Every finding on record at Normandy Nursing Center

Based on interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one resident, (Resident #2) with a history of falls, when staff left the resident unattended on the toilet. The resident attempted to transfer him/herself from the toilet to his/her wheelchair without assistance and fell. When the nurse assessed the resident, he/she guarded his/her right hip and complained of pain. X-ray results showed the resident sustained a fractured right hip. In addition, the facility failed to address falls on the care plan. The sample was four. The census was 95.Review of the facility's Fall Management policy, dated 02/28/23, showed:-Policy: To provide an environment free of accident hazards. The facility completed a Morse Fall Scale Evaluation on residents to determine fall risks, developed appropriate interventions, provided supervision and assistive devices to prevent/minimize further falls and/or reduce injuries;-Upon Admission, the charge nurse completed a Morse Fall Scale Evaluation, baseline care plan, identified risk factors related to the resident and implemented interventions which included the resident and/or resident representative;-Residents were evaluated for fall risk at admission/re-admission, post- fall, quarterly, annually, and significant change using the Morse Fall Scale Evaluation;-Residents with a Morse Fall Scale Evaluation score greater than 44 were considered at High Risk for falling;-Identified risk factors were addressed in the resident's care plan to ensure individualized interventions were implemented;-Risk factors: Gait/balance disorder, muscle weakness, confusion, incontinence, stroke, depression, previous falls, prescribed five or more antipsychotics (used to treat symptoms like delusions, hallucinations, paranoia, and confused thoughts), tricyclic antidepressants (used the treat major depressive disorder (persistent feeling of sadness, emptiness and loss of interests in activities), anxiolytics (used to treat symptoms of anxiety (persistent, excessive, and uncontrollable fear or worry that is out of proportion to the actual situation), sedatives (used to treat anxiety and sleep disorders), and hypnotic (used to treat insomnia and sleep disruptions) medications;-Staff completed a neurological evaluation post-fall on residents with potential head injury or unwitnessed fall;-If injury was known or suspected: -Provided emergency first aid treatment as applicable; -Notified physician, and resident representative. -Notified supervisor and Director of Nursing (DON); -Notified the Administrator when appropriate; -Investigated the circumstances and surroundings where the fall occurred; -Implemented interventions to reduce further occurrences; -Documented in the resident's medical record; -Completed an incident report; -Implemented post-fall evaluation/documentation;-The care plan was reviewed after every fall and updated with a new intervention;-Interdisciplinary team (IDT) reviewed post-fall residents within 24-72 hours during clinical meeting, evaluated circumstances/probable cause for fall, revised/modified care plan, implemented interventions according to treatment approach to minimize further falls and reduce injury, and reviewed accident/incident report in risk management to ensure completion;-The risk review committee members reviewed/documented residents post-fall for accident/incident documentation/completion, physician/resident representative notification, interventions, resident compliance/response and care plan/Kardex (provided a concise summary of the resident current care needs, medical diagnosis, medication, and treatments) review. Review of Resident #2's medical record, showed:-admitted [DATE];-Diagnoses included Alzheimer's disease, dementia with psychotic disturbance, history of stroke, muscle weakness, delusional disorder, depression, difficulty walking, hallucinations, history of falling, and communication deficit. Review of the resident's Fall Risk evaluation, dated 01/23/26, showed:-Intermittent confusion;-No falls in the last three months;-Chairbound;-Balance problem while walking and required use of assistive device;-The resident had three or more predisposed diseases;-At risk for falls. Review of the resident's progress notes, showed:-On 01/23/26 at 10:08 P.M., the resident was a new admit. He/She yelled out loud during evening shift. He/She refused all medication and refused to get in the bed. He/She got in the bed, but hung his/her legs out of the bed. The bed was in the lowest position, call light was within reach, and the fall mat was in place;-On 01/24/26 at 6:20 A.M., the resident yelled and tried to get out of bed. Staff gave the resident a PRN (as needed) medication (medication given unknown). The resident was at the nurse's station in his/her wheelchair. At 9:01 P.M., the resident yelled out. Staff entered the resident's room. The resident was on the floor, on the right side of his/her bed. The resident's bed was in the lowest position. The fall mat was on the left side of the bed. The nurse completed a head-to-toe assessment. The resident had a hematoma (a closed wound where blood collects and fills a space inside the body) on the right side of his/her head. Two staff assisted the resident back to bed. The physician and the resident's representative were notified. The physician gave an order to apply an ice pack to the hematoma. A fall mat was placed on the right side of the bed. The resident refused pain meds. Neurological (neuro) checks started;-On 01/26/26 at 9:29 A.M., the resident remained on observation for incident. He/She was alert, ignored staff when addressed, was non-compliant with medications (meds) and care. The resident was up in his/her wheelchair;-On 01/27/26 at 12:32 P.M., the Nurse Practitioner (NP) documented the resident was seen for a fall out of bed. The resident was agitated and kicked at staff. The resident refused meds and nursing assessments. The plan was for the bed to be in the lowest position, visual checks intermittently, and to position the resident where nursing staff were present for safety concern. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/05/26, showed:-Cognitive ability blank;-No behaviors exhibited;-Wheelchair used for mobility;-Totally dependent on staff for toileting, showers, and personal hygiene;-Totally dependent on staff for all transfers;-Always incontinent of bowel and bladder;-No falls since admission. Review of the resident's care plan, in use during the survey, showed no documentation of the resident's fall, fall risk status, identified risk factors and fall interventions. Review of the resident's progress notes, showed:-On 04/26/26 at 11:05 P.M., Licensed Practical Nurse (LPN) D documented at approximately 7:40 P.M., the resident attempted to transfer him/herself from toilet to the wheelchair without assistance and fell on his/her right side. Upon assessment, the resident had an abrasion to his/her right elbow and right buttock. The areas were cleansed, and ointment was applied. The resident was assisted back to his/her wheelchair. The resident guarded his/her right leg and complained of pain. LPN D could not assess range of motion due to guarding and refusal. No bruising/discoloration or swelling noted. No obvious deformity noted. The physician was notified. New order obtained for x-rays of right hip, right femur, and right knee. The resident's representative and the DON were notified. The resident rested in bed and was easy to arouse. The call light was within reach;-On 04/27/26 at 9:58 A.M., LPN A documented the resident was in his/her room in the bed. He/She yelled and screamed when touched. The x-ray technician (tech) was onsite to perform x-ray. The resident said he/she was high on morphine (used to manage moderate to severe acute or chronic pain). The resident was not prescribed morphine. Some hallucinations were noted. Neuro checks were ongoing. At 11:20 A.M. the resident refused the x-rays. The resident was noncompliant with the x-ray tech and LPN A. Review of the resident's x-ray order showed it was received on 04/26/26 at 8:35 P.M. and cancelled on 04/27/26 at 3:00 A.M., due to the resident's refusal. Review of the NPs progress note dated 04/27/26, time unknown, showed the resident was seen for a fall with right thigh pain. The resident refused movement of his/her right leg. He/She said I cannot, I am high on Morphine. The resident was a poor historian. Staff reported the resident refused all medications. Staff reported the resident fell out of bed and guarded his/her right upper thigh/leg. The resident refused the x-ray. Staff reapproached and completed the x-ray with coaching and reassurance. A right femur fracture was indicated. Directive given to transfer the resident to the emergency room for evaluation. Review of the resident's care plan in use during the survey showed no documentation of the fall, updated fall status or new fall interventions. Review of the resident's progress notes, showed on 04/28/26 at 9:44 A.M., LPN A documented the resident remained on observation for incident. He/She was alert, quiet, and non-compliant with meds. The resident's family was aware. He/She remained on neuro checks. No acute distress noted. At 1:00 P.M., LPN E documented the resident refused all x-rays on the previous day. The Nurse Practioner (NP) and physician were notified. No new orders given. The resident was in his/her wheelchair at the nurse's station. He/She required extensive assistance with activities of daily living (ADLs) and transfers. No acute changes in medical needs noted. He/She continued to refuse meds. Review of the resident's x-ray results, showed:-Completed on 04/29/26 at 10:58 A.M.;-Results reported to facility on 04/29/26 at 2:00 P.M.;-Findings: Nondisplaced impaction fracture of the right femoral neck (a stable crack in the narrow region of the right thighbone just below the hip ball. It caused mild to moderate, deep ache in the groin or pain radiating toward the upper knee or thigh. Those affected could sometimes still walk or stand, though it caused significant discomfort. The leg typically did not show outward shortening or abnormal sideways rotation, because the bone had not shifted). Review of the resident's progress notes, showed on 04/29/26 at 9:58 A.M., LPN A documented the resident transferred to his/her wheelchair without difficulty. The resident's skin on his/her right hip was normal without bruising. The resident denied pain. LPN A offered pain meds and the resident refused. Neuro checks continued. At 11:30 P.M., LPN E documented the resident refused all care, vital signs, meals and medication on his/her shift. The DON and Assistant Director of Nursing (ADON) were notified. X-ray results were obtained. The physician and NP were notified. New order received to send the resident to the hospital for evaluation. The resident was transported to the hospital via ambulance at 11:21 P.M. During an interview on 06/30/26 at 11:06 A.M., LPN A said on 04/27/26 the resident yelled when an aide tried to get him/her out of bed. The resident refused to allow the x-ray tech to touch him/her. Sometimes the resident complained of pain and sometimes he/she did not. He/She refused pain meds. The resident did not have any bruising. His/Her leg was not warm to the touch. On 04/28/26, LPN A rubbed the resident's leg and asked him/her if it hurt. The resident said no. The physician wanted the x-ray. The x-ray tech returned to the facility on [DATE]. LPN A coached the resident into getting the x-rays. The resident had a fractured hip. During an interview on 06/30/26 at 1:41 P.M., Certified Nurse's Aide (CNA) B said he/she was not assigned to the resident on 04/26/26. CNA B could not remember the CNA's name assigned to the resident, but the CNA assigned to the resident told CNA B he/she put the resident on the toilet and left the room. The CNA went back to check on the resident and left the room again. CNA B and other staff heard the resident yelling. Staff entered the resident's bathroom and found him/her on the floor. The nurse said he/she wanted an x-ray, because the resident exaggerated his/her symptoms. He/She did not remember any other details. During an interview on 06/30/26 at 3:15 P.M., the Assistant Director of Nursing (ADON) said she was told by unknown staff that the resident fell when he/she attempted to transfer him/herself from the toilet to wheelchair. Staff, unknown, said he/she observed the resident on the floor. Staff, unknown, said he/she transferred the resident from the floor to the wheelchair. CNA C was assigned to the resident. The ADON was not sure what happened after staff got the resident off the floor. She would have expected the nurse to give the resident pain meds, notify the physician and request an x-ray order. Residents should never be left unattended in the bathroom. The resident did have a previous fall. The resident was resistive to care. The NP's note was a late entry. The x-ray was ordered on 04/26/26 and the resident refused it. On 04/28/26 the IDT decided to order the x-ray stat (immediate) and the x-ray was completed on 04/29/26. The NP said an x-ray was not necessary to send the resident to the hospital. The physician could have given an order to send the resident to the hospital. Staff were instructed to contact the NP first. He/She believed the physician would have sent the resident out. The resident could voice pain, but he/she always said no to everything. At baseline, the resident yelled curse words at staff. During an interview on 06/30/26 at 3:43 P.M., the Administrator said she would have preferred the aide to stay with the resident during toileting. She did not know what was going on when the aide left the resident. She has not interviewed the aide. During an interview on 06/30/26 at 11:39 A.M., the NP said he/she saw the resident on 04/27/26 for a fall with right thigh pain. The resident would not allow the NP to move his/her leg. The resident said he/she was high on morphine, however, the resident did not take morphine. The fall occurred on 04/26/26. The initial x-ray was ordered on 04/27/26, by the physician. The resident refused the initial x-ray. He/She did not order a new x-ray on 04/27/26, because he/she thought staff said the initial x-ray was completed. He/She ordered a stat x-ray on 04/29/26. When asked why his/her note preceded the nurses' notes, he/she said he/she must have entered the wrong date. The NP said x-ray did not have to be completed to send the resident to the hospital. The resident yelled and resisted care at his/her baseline. The resident was a fall risk. The NP said the resident did not get out of bed and he/she would not have expected staff to get the resident up to toilet him/her. 3002514

Based on interview and record review, the facility failed to notify a resident's (Resident #2) representative after the resident had a change in condition. The resident had an unwitnessed fall on 04/26/26. The resident complained of pain. The physician ordered x-rays on 04/26/26. The resident refused the x-rays on 04/27/26. The x-rays were reordered on 04/29/26. The x-rays showed the resident had a fractured right hip. The resident was sent to the hospital on [DATE] for evaluation. Staff did not notify the resident's POA of the x-ray refusal, results and transfer to the hospital. The sample was four. The census was 95.Review of the facility's Notification of Change in Condition policy, revised 01/20/26, showed:-Policy: The attending physician/physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) and the resident representative would be notified of a change in a resident's condition, according to standards of practice and federal and/or state regulations;-Responsibility: All licensed nursing personnel, nursing administration, and Director of Nursing (DON);-Guideline for notification of physician/resident representative (not all inclusive): -Significant change in medical or cognitive baseline; -Accident/incident; -Abnormal laboratory results in conjunction with a change in condition; -Significant weight loss/gain; -Refusal to take prescribed medications; -Missing resident;-Document in the Interdisciplinary Team (IDT) notes: -Resident change in condition; -Physician/physician extender notification; -Notification of resident representative. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/14/26, showed:-admission date: 01/23/26;-Severe cognitive impairment;-Diagnoses included Alzheimer's disease, dementia with psychotic disturbance, history of stroke, muscle weakness, delusional disorder, depression, difficulty walking, hallucinations, history of falling, and communication deficit. Review of the resident's face sheet showed Power of Attorney (POA) contact information including phone numbers. Review of the resident's progress notes showed on 04/27/26 at 9:58 A.M., Licensed Practical Nurse (LPN) A documented the resident was in his/her room in the bed. He/She yelled and screamed when touched. The x-ray technician was onsite to perform an x-ray. At 11:20 A.M., the resident refused x-rays this morning. The resident was noncompliant with technician and LPN A. Review of the resident's x-ray results, dated 04/29/26 at 10:58 A.M. and reported at 2:00 P.M., showed a nondisplaced impaction fracture of the right femoral neck (a stable crack in the narrow region of the right thighbone just below the hip ball). Review of the resident's progress notes, showed on 04/29/26 at 11:30 P.M., LPN E documented the resident refused all care, vital signs, meals and medication on his/her shift. The DON and Assistant Director of Nursing (ADON) were notified. X-ray results obtained and the physician and NP were notified. New order received to send the resident to the hospital for evaluation. The resident was transported to the hospital via ambulance at 11:21 P.M. Review of the resident's medical record showed no documentation the resident's POA was notified of the resident's refusal to complete the x-rays, the x-ray results and the resident's transfer to the hospital. During an interview on 06/30/26 at 11:06 A.M., LPN A said the resident's POA was onsite on 04/27/26 and he/she notified the POA of the resident's x-ray refusal. The POA said You know the resident could be resistant. He/She should have documented the notification. During an interview on 06/30/26 at 3:15 P.M., the ADON said the risk management note showed the resident's POA was notified of the x-ray results and the fracture. She could not locate the risk management note when asked for the documentation. During an interview on 06/30/26 at 3:43 P.M., the Administrator said she would have expected the nurses to notify the POA of the resident's change of condition. 3002514

Based on interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1) when the facility failed to provide follow up care and treatment after Resident #1 had an abnormal lab result which showed an acute hepatitis C infection (viral infection that causes liver swelling, called inflammation. Hepatitis C can lead to serious liver damage). The sample size was 7. The census was 96. Review of the facility's Change in Condition Policy, revised 2/6/25, showed:-Policy: The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, per Standards of Practice and Federal and/or State Regulations;-Responsibility: All Certified Medication Aides, Licensed Nursing Personnel, Nursing Administration, and Director of Nursing;-Procedure: Guideline for Notification of Physician/Resident Representative (not all inclusive): Abnormal Laboratory Results in conjunction with a change in condition;-Document in the Interdisciplinary Team (IDT) Notes: -Resident Change in Condition; -Physician/Physician Extender Notification; -Notification of Resident Representative.Review of the Centers for Disease Control and Prevention (CDC) guidelines, showed a reactive Hepatitis C (HCV) antibody test along with a detectable HCV Ribonucleic Acid (RNA, the genetic material of the hepatitis C virus itself) of 2.73 indicates a current HCV infection. The RNA level of 2.73 log international units (IU)/milliliters (ml) (normal undetected) signifies the presence of the virus and confirms an active infection:-Breakdown of the guidelines and recommendations: Diagnosis confirmation: A reactive HCV antibody test followed by a positive HCV RNA test a current HCV infection. No need to delay treatment: You do not need to wait for potential spontaneous resolution of the infection. Treatment is recommended for most people with detectable HCV RNA;-Treatment options: Direct-acting antiviral (DAA) medications are the current standard of care for Hepatitis C treatment: -These medications are taken orally (as pills); -They are highly effective, curing over 95% of people within 8-12 weeks; -They generally have very few side effects.Review of the CDC interpretation of results of tests for HCV Infection and Further Actions included:-Test Outcome: HCV antibody reactive, HCV RNA detected;-Interpretation: Current HCV infection; -Further Actions: Provide person tested with appropriate counseling and link person tested to care and treatment.Review of the Resident #1's electronic medical record (EMR) showed:-admission: [DATE];-discharge: [DATE];-Diagnoses included Chronic Obstructive Pulmonary Disease (lung disease, COPD), viral hepatitis C, schizophrenia, depression, and anxiety.Review of the resident's lab results, dated 2/14/24, showed:-Hepatitis C Virus (HCV)-Reactive (Presumptive evidence of antibodies to HCV; test for HCV RNA to identify current infection. A reactive HCV Antibody test with HCV Ribonucleic Acid (RNA, the genetic material of the hepatitis C virus itself). Detected indicates current HCV Infection. A reactive HCV Antibody test with HCV RNA Not Detected indicates no current HCV Infection.);-Hep C, RNA-Pending.Review of the resident's lab results, dated 2/19/24, showed HCV RNA Polymerase Chain Reaction (PCR) 2.73 High.Review of the resident's provider progress notes dated 2/19/24, showed:-Subjective: Resident with abnormal labs. Resident noted to have active hepatitis c;-Objective: Respirations even and nonlabored. No distress noted;-Lab: Hepatitis c virus AB reactive, Hep c RNA [NAME] 531 elevate;-Plan: Resident to follow up at clinic in regard to see about medication regime to start;-Active diagnosis: Acute hepatitis C without hepatic coma.Review of the resident's provider progress note dated 3/15/24, showed: -Subjective: Resident with complaints of vision issues and lab. Resident to wear glasses but does not have at the moment and due for eye exam;-Objective: labs reviewed hepatitis C history;-Plan: Will follow up on referral for hepatitis clinic;-Active diagnosis: High blood pressure, hypocalcemia, and muscle weakness (generalized).During an interview on 8/21/25 at 9:50 A.M., the Assistant Director of Nursing (ADON) said she was employed at the facility when the resident resided at the facility. She does not remember any diagnosis except schizophrenia. She does not remember a hepatitis diagnosis but the resident left on his/her and family's own choice. The resident was transferred to a different facility last year. During an interview on 8/21/25 at 1:45 P.M., the Director of Nursing (DON) said she was not employed at the facility when the resident resided at the facility. She is not sure if the resident had an appointment set up with the hepatis clinic or if the provider followed up. The provider is also not at the facility anymore. During an interview on 8/21/25 at 2:00 P.M., the DON and ADON said they would expect staff to follow up on lab results and recommended treatment for a resident that has the reactive Hepatitis C because it is standard nursing practice. When they transferred the resident, the information should have been sent to the new facility. During an interview and record review on 8/25/25 at 10:55 A.M., the Administrator provided the documents sent to the resident's new facility as well as several emails. Review of the records, showed there was no order for hepatitis C follow up on the order sheet that was sent. There was no mention of the hepatitis C lab results or recommended follow up. The progress note from the provider was included. The Administrator said the medical director that was at this facility was also at the resident's new facility and has been the resident's provider since 2016. She also said the social worker and the transportation staff member involved at that time are no longer with the facility, so she is unable to verify whether follow-up arrangements were made with the infectious disease clinic. She attempted to reach out to the hospital regarding this, but so far has notreceived a call back. 2570330

Based on observation, interview and record review, the facility failed to ensure 8 sampled residents, who were involved in resident-to-resident incidents were free from physical abuse (Residents #27 and #37, Residents #39 and #65, Residents #4 and #1 and Residents #86 and #49). The resident-to-resident altercations resulted in injuries. The sample was 19. The census was 95. Review of the Abuse Prevention policy, revised 10/21/22, showed: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and other staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual; -Definitions: -Abuse: Willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, mental anguish, or emotional distress. Abuse may be resident-to-resident; -Procedure: -Screening: The facility will pre-screen all potential residents for a history of abusive behaviors; -Prevention: -When an incident of resident abuse is suspect of determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in the policy; -The subject of abuse will be routinely and openly discussed. Residents and/or representatives will be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents upon admission and at least annually thereafter; -Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility; -Identification: -Identify events, such as occurrences, patterns and trends that may constitute abuse. Review of the undated Behavior Modification Program Protocol, showed: -Program objective: to reduce physical altercations between residents by implementing individualized behavior strategies, environment modifications and staff training, while preserving dignity and safety; -Assessment and resident history review: -Behavior tracking: log incidents: date, time, location, individuals, staff present and response used; -Identify triggers: common triggers include overstimulation, cognitive impairment, personal space violations and unmet care needs; -Resident profiles: review cognitive status, mental health history, medications, communication ability; -Prevention strategies: -Environmental modifications: maintain personal space and reduce clutter, use calming lighting and sound and clearly label rooms and personal areas; -Daily routine and structure: keep routines predictable, schedule calming activities before high-risk times; -Resident engagement: offer meaningful activities like music therapy and match tasks to abilities; -Staff training: recognize agitation signs, apply trauma informed and dementia sensitive care and use respectful and non-verbal cues; -Intervention techniques: early de-escalation, approach calmly, redirect, offer soothing activity, behavior protocols and use care plans, conflict resolution by mediate and support healthy expression of concerns; -Reinforcement and positive support: praise and acknowledgement by reinforcing calm behavior, token or reward system staff use appropriate incentives such as favorite activities and music, personalized motivation such as tailor rewards to individual interests; -Crisis prevention institute management: individualized crisis plans and strategies per resident, safe interventions like trained staff only and follow guidelines, interdisciplinary team (IDT) review staff debrief, update care plans and inform family if needed; Monitoring and evaluation: weekly review meetings and IDT tracks progress, behavior tracking review and family involvement to engage family in support and reassurance. 1. Review of Resident #27's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/2/25, showed: -Moderate cognitive impairment; -Physical Behaviors: 0 -Behavioral Symptoms: Verbal behavior toward others (1-3) days; -Other behavior symptoms not directed toward others (1-3) days; -No rejection of care; -Uses wheelchair for mobility, upper and lower body impairment one side; -Received routine antidepressant medication. No antipsychotic medication; -Diagnoses include stroke, dementia, psychiatric disorder and hemiplegia (one sided weakness). Review of the resident's care plan, in use during the survey, showed: -Focus: Resident is at risk for decline with cognitive function and/or is dependent on staff for cognitive stimulation; -Goal: Resident will maintain current level of cognitive function now through next review; -Interventions: Avoid overstimulation. Shorten conversation if resident becomes restless, agitated, and resume at a later time. Move to a quiet area and limit sensory distractions as possible. -Focus: Resident is at risk for disorganized thought process and ineffective social interaction related to diagnosis of schizophrenia (a serious mental health condition that affects how people think, feel and behave). On 5/12/25 involved in resident/resident altercation: This resident was the aggressor. On 4/6/25 Resident to resident altercation: This resident was the aggressor; -Goal: Resident will remain free of complications related to diagnosis of schizophrenia now through next review; -Interventions: Follow up with physician and psychiatric provider as needed. Medication review quarterly and as needed, provide redirection as needed. Review of the progress notes, showed: -On 5/12/25 at 2:31 P.M., Tylenol Oral Tablet 325 milligram (mg), give 650 mg by mouth every 8 hours as needed (PRN) for mild pain and discomfort. The resident requested for pain; -On 5/12/25 at 2:57 P.M., the resident was involved in a resident/resident, he/she noted as the aggressor. New order for diphenhydramine HCl (antihistimine) Injection Solution. Inject 25 mg intramuscularly (deep muscle) every 8 hours PRN for agitation for 14 days and Haldol (antipsychotic) injection solution 5 mg/milliliter (ml), inject 5 mg intramuscularly every 8 hours PRN for agitation for 14 days. The resident's representative aware of the new orders; -On 5/12/25 at 5:53 P.M., the resident continued to be monitored post altercation with another resident, (Resident #37) without any sign of injury, alert and oriented x 4 (to person, place, time and situation) regular breathing. Ambulating in his/her room, adjusting well to new room, teaching done about ways to ask for help if feeling attacked or offended. No changes noted in mental status, no seizure activities this shift, neurological assessment continues per protocol. Pupils dilated to light reactions, moves all extremities as previously operated, encouraged to voice any discomforts. Reminded to knock on the bathroom door in his/her room before letting him/herself in because it is a shared bathroom, responded: okay monitor safety, now sitting on his/her bed eating supper, remains calm and very pleasant, no behavior issue noted, no distress; -On 5/12/25 at 6:20 P.M., resident involved in resident to resident physical altercation. Staff arrived to resident room after being informed by another resident that it was a fight. Resident along with another resident were on floor tangled and attempted to grab at each other. The residents immediately separated but remained verbally aggressive. The resident stated that he/she was using the shared restroom when other resident walked in the restroom and stated that he/she needed to use restroom. The resident stated that he/she made other resident aware that he/she was using the restroom, resident states that other resident continued to rush him/her out of the restroom stating that he/she needed to use the restroom. The resident stated he/she struck other resident, and in return, the other struck him/her and caused the physical altercation. Pain and skin assessments completed. Physician notified and updated. New orders received and noted. PRN injection administered. Resident room change completed. Family notified and updated. Neurological assessments initiated. The resident denied any feeling of fearfulness. He/She remained at baseline level of consciousness and functioning; -On 5/13/25 at 4:05 A.M., the resident continued to be monitored post altercation with another resident, alert and oriented x 4 regular breathing in room air, voices any discomforts up ad lib (independently) ambulating in his room, no changes noted, neuro assessment continues per protocol, pupils dilated to light reactions, moves all extremities, resting quietly with both eyes closed, no distress, will continue to monitor; -On 5/13/25 at 8:33 A.M., Social Services Assistant (SSA) completed a follow up with the resident about resident to resident on 5/12/25. The resident states he/she is doing well. He/She said he/she is not angry nor have any fear. Will reach out to social services if he/she needs to talk; -On 5/13/25 at 1:39 P.M., the resident continued to be monitored for resident/resident, denied any feelings of fearfulness/denies pain or discomfort, appetite good, he/she has been calm and quiet this shift watching television while resting in bed, no concerns voiced at this time; -On 5/13/25 at 8:22 P.M., the resident continued to be monitored for resident/resident, denies any pain or discomfort and any feeling of fearfulness, resident calm and quiet watching television with call light, hydration, and personal items in reach; -On 5/14/25 at 4:52 A.M., the resident is on observation for Resident to Resident. No signs of fearfulness, distress, or discomfort noted. He/She denied any pain at this time. Vital signs and range of motion within normal limits. He/She remained in bed all night and appears to be resting; -On 5/14/25 at 1:20 P.M., the resident continued to be monitored per 15 minute checks for resident/resident, denied any feelings of fearfulness/pain/or discomfort, he/she is calm and quiet, no behaviors noted this shift, no other concerns voiced at this time, he/she rested quietly in bed watching television with call light hydration and personal items in reach; -On 5/14/25 at 6:44 P.M., the resident remained on observation for resident to resident. No fearfulness noted resting in room at this time; -On 5/15/25 at 3:18 A.M., the resident remained on observation for Resident to Resident. No signs of distress, fearfulness, or discomfort noted. He/She denied any pain at this time. Vital signs and range of motion within normal limits. He/She rested in bed all night. Review of the physician visit note, dated 5/13/25 at 5:52 P.M., showed: -Chief complaint: the resident with a history of dementia, left sided weakness status post stroke, psychotic disorder with hallucination seen following an altercation with resident with resident noted as the aggressor; -Plans: Restlessness and agitation. Vascular dementia, moderate, with agitation. -Problem: Physical aggression, yelling; -Problem Status: Worsening - Mild Exacerbation Problem Is: Established; -Problem Type: Acute - Medium Risk; -Plan: staff encourage verbal de-escalation, he/she will be maintained on PRN Haldol for agitation. Review of the May 2025 Medication Administration Record (MAR), on 5/16/25, showed no administration of the Diphenhydramine 25 mg IM injection or Haldol 5 mg IM injection for the resident. Review of Resident #37's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Physical Behaviors: 0 -Behavioral Symptoms: Verbal behavior toward others (1-3) days; -Other behavior symptoms not directed toward others (1-3) days; -1-3 days rejection of care; -Does not receive routine antidepressant or antipsychotic medication; -Diagnoses include stroke, dementia, seizure, traumatic brain injury (TBI) and depression. Review of the care plan, in use during the survey, showed: -Focus: Resident has the potential to be physically aggressive related to dementia. 5/12/25 Resident/resident altercation: He/She was not the aggressor. 1/30/25 Resident to resident altercation: He/She was not the aggressor; -Goal: Will demonstrate effective coping skills through the review date. Will have less than 3 episodes a month of aggressive behavior through the next review date. Will not harm self or others through the review date; -Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Document observed behavior and attempted interventions in behavior log. Give as many choices as possible about care and activities. Observe/document/report PRN any signs/symptoms of resident posing danger to self and others. Tolerates minimal people at a time. Needs 3 feet of personal space. Reacts to touch by startle hollering and potentially striking out. When becomes agitated, intervene before agitation escalates. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. -Focus: Resident has impaired cognitive function/dementia or impaired though processes Dementia, head injury; -Goal: Resident will be able to communicate basic needs on a daily basis through the review date. Will maintain current level of cognitive function through the review date. Will maintain current level of decision making ability by maintaining Brief Interview for Mental status (BINS, a brief screener of cognition) through the review date. -Interventions: Administer medications as ordered. Cue, reorient, and supervise as needed. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Observe/document/report PRN any changes in cognitive function. Review of the progress notes, showed: -On 5/12/25 at 3:43 P.M., the resident was involved in a resident/resident altercation, he/she was not the aggressor. Resident has new order for diphenhydramine HCl Injection Solution and Haldol injection solution 5 mg/ml. The resident representative aware of new orders. -On 5/12/25 at 5:43 P.M., Continued to be monitored post altercation with another resident with facial abrasion, alert and oriented x 4, regular breathing, voices any discomforts up ad lib ambulating in hallways no changes noted, neuro assessment continues per protocol, pupils dilated to light reactions, moves all extremities, encouraged to voices any pain or changes, reminded to knock on the bathroom door in his/her room before letting him/herself in, because it is a shared bathroom, responded: okay okay bla bla bla disregarded instruction, treatment applied to facial skin abrasion per protocol monitor safety now in the dining room, very pleasant and calm no behavior issue noted; -On 5/12/25 at 6:54 P.M., the resident involved in physical resident to resident altercation, resident not the initiator. Staff arrived to resident room after being informed by another resident that it was a fight happening in room. Staff arrived to find resident on floor alongside another resident (Resident #27) entangled. Both residents yelling and attempting to grab at each other. Staff immediately intervened and separated the residents. He/She noted to have some redness and bloody areas to face. Denied any pain or discomforts. Staff assisting resident from room to nurse station for treatment. Resident states that he/she went into restroom and informed other resident that he/she needed to use restroom, resident stating that he/she continued to stand in doorway and that's when other resident stood from sitting on toilet and struck him. Resident stating, he/she then struck resident back. Neuro checks initiated. Resident remains anxious, PRN administered. Physician office notified. Call placed to family to update; no concerns voiced. Resident remains on 15 minute checks at this time; -On 5/13/25 at 4:03 A.M., continued to be monitored post altercation with another resident with facial abrasion, alert and oriented x 4 regular breathing in room air, voices any discomforts, up ad lib ambulating in hallways no changes noted, neuro assessment continues per protocol, pupils dilated to light reactions, moves all extremities, resting quietly with both eyes closed, no changes noted, no distress will continue to monitor; -On 5/13/25 at 8:25 A.M., SSA made a follow up on resident to resident from 5/12/25. The resident said he/she is doing well. No fear just resting getting ready to have some coffee. SSA asked was there anything needed? No, he/she replied. SSA will continue to check on wellbeing of resident to make sure his/her needs are met and he/she continues to feel no fear; -On 5/13/25 at 1:43 P.M., the resident continued to be monitored for resident/resident, denied having any feelings of fearfulness/pain/discomfort, resident is calm and quiet. No behaviors noted, appetite very good today, in the dining room for on the floor group activities, resident is now in his/her room doing his artwork at bedside, no concerns voiced at this time; -On 5/13/25 at 8:24 P.M., the resident continued to be monitored for resident/resident, denies having any pain or discomfort, and any feelings of fearfulness, resident is now resting in bed calm and quiet with call light, hydration, and personal items in reach, no concerns voiced at this time; -On 5/14/25 at 4:54 A.M., Resident is on observation for Resident to Resident. No signs of distress, fearfulness. or discomfort noted. Vital signs and range of motion within normal limits. Resident denies any pain. Resident slept throughout the night; -On 5/14/25 at 1:42 P.M., the resident continues to be monitored for resident/resident, denies having any feelings of fearfulness/pain/or discomfort at this time, up ad lib on the nursing unit with a steady gait, appetite very good, resident has been calm and quiet this shift, no behaviors concerns observed, resident is now resting in bed with call light, hydration, and personal items in reach; -On 5/14/25 at 6:45 P.M., Remained on observation for resident to resident no fearfulness noted. In room at this time resting comfortable no acute distress noted; -On 5/15/25 at 3:25 A.M., Resident continue on observation for Resident to Resident. No signs of fearfulness, distress, or discomfort noted. Resident denies any pain. Range of motion and vital signs within normal limits. Review of the May 2025 MAR, on 5/16/25, showed no administration of the Diphenhydramine 25 mg IM injection or Haldol 5 mg IM injection for the resident. Review of the physician note, dated 5/13/25 at 4:27 P.M., showed: -Chief complaint: the resident seen following an altercation with another resident. Resident was reportedly not the aggressor. Staff found the resident and aggressor on the floor with minor facial scratches to the resident's face. Resident denied head injury or LOC; -Diagnoses: Restlessness and agitation. Dementia, moderate, with agitation; -Problem: Restlessness and agitation; -Problem Status: Worsening - Mild Exacerbation; -Problem Is: Established; -Problem Type: Acute - Medium Risk; -Plan: The other (resident) has been transferred to another room, encourage verbal de-escalation of conflict, maintain resident on PRN Haldol; -Diagnosis: Abrasion of other part of head, initial encounter; -Problem: Fall with Superficial facial scratch injuries; -Problem Status: Worsening - Mild Exacerbation Problem Is: New; -Problem Type: Acute - Low Risk; -Plan: Resident will be maintained on triple antibiotic ointment to facial injuries. Review of the facility's investigation, showed: -Occurrence: 5/12/25 at approximately 2:10 P.M.; -Description: Another resident reported that Residents #27 and #37 were fighting in the bathroom. Resident #37 entered the bathroom several times while Resident #27 was using the restroom. Resident #27 became angry and stood from the sitting position and hit Resident #37. Residents were found on the floor fighting. -Assessments: skin and pain assessments completed for both residents. -Steps taken to protect residents: the residents were placed on 15 minute checks for 72 hours, medication reviews were completed, behavior tracking, reminder signs on bathroom doors, room change for Resident #27, Social services 1-1, and updated the care plans. -Findings: upon completion of the investigation the facility substantiated a physical altercation had occurred. Observation and interview on 5/12/25 at 2:42 P.M., showed Resident #37 sat in the hallway in a chair. The resident's eyes appeared to be wet. He/She had a red spot on his/her white shirt and appeared to have several scratches on his/her face. Resident #37 said Resident #27 walked up naked and attacked him/her while he/she used the bathroom. Resident #37 said, They are going to move me and its crazy, I did not do anything. He/She stated no current pain and the other resident tried to punch him/her in mouth and he/she stood up to him/her. He/She was going to the bathroom and he/she knocked me out of my socks. Resident #37 said he/she is not sure why it happened. He/She felt safe, he/she just did not want to move rooms. During an interview on 5/12/25 at 2:43 P.M., Resident #37's roommate said Resident #37 was going to the bathroom. Resident #27 was in bathroom first. He/She does not think Resident #37 was confused. During an interview on 5/12/25 at 2:55 P.M., Certified Nursing Assistant (CNA) L said he/she was in a different bathroom when the incident happened. CNA L did not see or hear anything. When he/she came out, the other staff told him/her what happened. There were no problems between those two residents before today. After an incident, staff move the residents and separate them. Another CNA helped and each staff member took one resident to help calm them down. They move the residents to different rooms and report any change to the nurse. Staff check residents every two hours, but if there is an altercation then maybe every 30 minutes. CNA L is not aware of any previous resident to resident incidents for either of these residents. During an interview on 5/12/25 at 2:57 P.M., CNA K said he/she worked the other hall and had been charting at the nurses station when the incident occurred. He/She did not hear anything but Resident #37's roommate came and reported it. CNA K said he/she heard the residents and went to the commotion (Refuting what he/she originally said). Resident #27 was in the bathroom and felt like his/her space was invaded. Resident #37 did not know Resident #27 was in the bathroom and it escalated from there. Staff separated them. When a resident to resident occurred, staff announce a code purple, call the nurse, and do not leave the involved residents alone. Staff take vitals every 15 minutes and write a statement. Staff also separate the residents by putting one on a separate floor. The resident who moves floors usually remained on the new floor for 30 days. Resident #27 does not come out of his/her room. Resident #27 is very sweet and keeps to himself/herself. Resident #37 can be harsh. During an interview on 5/12/25 at 3:01 P.M., Nurse A said he/she was off the unit on lunch break at the time of the incident. Assistant Director of Nursing (ADON) X was aware he/she needed to cover the floor. The Certified Medication Technician (CMT) and two CNAs were also on the unit. Nurse A said if he/she would have been at the nurses station, then he/she would have been able to hear the commotion if it was quiet. Both Resident #37 and Resident #27 are very loud. Nurse A spoke to Resident #27 and will talk to Resident #37. He/She did a skin assessment on Resident #27 and he/she has a small skin tear to his/her left elbow. Resident #27 told Nurse A while he/she was on the toilet, Resident #37 entered the bathroom and demanded he/she get off toilet. When a resident to resident occurs, staff intervene immediately and provide resident separation, conduct interviews, and check for injury. Staff checks to see if there is a PRN medication to administer. Nurse A said he/she will get a treatment order for Resident #27's elbow and will decide which resident will move to a different floor. Nurse A created signs for the bathroom for when the bathroom is in use. Resident #27 was down the hall before but needs access to the bathroom so he/she was not sure where to move him/her. Resident #37 has a diagnosis of dementia and is up and down with episodes of confusion. Nurse A showed neurochecks and 15 minute checks were started for both residents. Resident #27 reported pain after the incident and was given Tylenol. During an interview on 5/12/25 at 3:08 P.M., ADON X said he/she was aware Nurse A was at lunch. He/She was in his/her office with ADON Y and the Director of Nursing (DON). He/She heard Resident #37's roommate scream for help and then heard commotion and they all came out of the office and went to the room. During an interview on 5/12/25 at 3:10 P.M., ADON Y said he/she was in ADON X's office with the DON and they were going over staffing. Resident #37's roommate came down the hall and said there was a fight in his/her room. They went down there to check on them. It was in the bathroom. Resident #27 was in there on the toilet and said Resident #37 went in there to use the bathroom. When Resident #27 stood up to wipe, Resident #37 thought he/she was getting up. There is a history of resident to resident for both of them but not with each other. They will do a couple room changes, new PRN meds, and treatment orders started on Resident #27. Resident #27 will be moving rooms and is ok with that. ADON Y said he/she was not sure on the room, they may have to move other people. During an interview on 5/13/25 at 12:15 P.M., Nurse A said Resident #27 has been involved in a couple resident to resident incidents. One was not long ago. Nurse A said he/she followed up with Resident #27 on yesterday's incident and he/she seems ok with the move. He/She always has the television on. There was one resident that he/she got along with but that resident passed away. Resident #27 does not go back and revisit things and does not retaliate. Nurse A said yesterday he/she saw the resident fist bump another resident that he/she had a prior incident with. There are no bad feelings and most of the time he/she is redirectable. Sometimes they do IM injections to calm them down. They got orders for both residents yesterday but didn't have to use it. Resident #27 was moved to a room with two other residents. They were getting along and watching TV. Nurse A monitored them yesterday to make sure it was a good fit. Resident #27 is territorial about what belongs to him/her and does not like his/her stuff messed with by others. Nurse A told Resident #27's new roommates that and they understood. Yesterday, before he/she went to lunch, Nurse A said he/she checked on Resident #27 to do follow up because he/she fell against the wall the day before. Nurse A does not understand what happened. He/She has different chairs set up around the nurses station and hall to give them space when needed. He/She sits out there to so he/she can see everything. During an interview on 5/15/25 at 11:45 A.M., the Administrator said they have coverage when a nurse goes to lunch. She would not have expected the manager covering for the nurse to be out in the open. When the nurse is on lunch, the CMT and 2 CNAs were out on the unit to provide coverage and they have some strong CMTs. A manager is on the floor who is there if they need anything, they can go to them. 2. Review of Resident #39's quarterly MDS, dated [DATE], showed: -Able to make needs and wants known; -No behaviors; -No rejection of care; -Received routine antipsychotic and antidepressant medication; -Diagnoses included viral hepatitis C (viral infection that causes liver swelling, called inflammation. Hepatitis C can lead to serious liver damage), seizure disorder, bipolar disorder (a mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), schizophrenia, post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) anxiety and depression. Review of the care plan, in use during the survey, showed: -Focus: History/potential for behavioral problem; -Goal: Will have no behavior problems; -Interventions: On 11/3/24 experienced a resident to resident altercation. He/She was not the aggressor, on 4/27/25 involved in resident to resident altercation he/she was the aggressor, administer medications anticipated and attempt to meet needs, assist to develop more appropriate methods of coping and interacting and expressing feelings appropriately, explain procedures, intervene as needed to protect the rights as safety of others, observe behavior episodes and attempt to determine underlying cause- consider location, time of day, involved persons and the situation. Document behaviors and potential causes. Review of the progress notes, showed: -No documented notes regarding resident to a resident altercation on 4/27/25; -On 4/30/25 at 1:45 P.M., a social service note: the resident is calm, pleasant and talkative. He/She expressed struggling with anger at times. Writer expressed the importance of appropriate communication and removing self from the situation that could be triggering. He/She wished to be moved back to the first floor when the IDT team felt appropriate. He/She had appropriately communicated with others since the incident. He/She planned to work on his/her anger and removing self from triggering situations; -On 4/30/25 at 2:30 P.M., a nurse note: the resident continued to be monitored for resident to resident initiation. No behaviors noted this shift. He/She had been calm and quiet and mostly in his/her room. The resident did attend an off the floor activity without any behaviors. Review of Resident #65's quarterly MDS, dated [DATE], showed: -Able to make needs and wants known; -No behaviors; -Does not refuse care; -Diagnoses included: Parkinson's (a movement disorder of the nervous system that worsens over time causing difficulty in walking and balance), muscle weakness and schizophrenia; -Routinely takes antipsychotic medications. Review of the care plan, in use during the survey, showed: -Focus: Potential for behavior problems; -Goal: No evidence of behavior problems; -Interventions: On 4/27/25 experienced a resident to resident altercation, the resident was not the aggressor. He/She approached the nurses station and said he/she was struck in the face by Resident #39. Upon assessment the resident noted to have a busted nose. Sent to the hospital for evaluation. Staff administer medication as ordered, assist to develop more appropriate methods of coping and interacting and encourage to express feelings appropriately, provide opportunity for positive interaction and attention, discuss disruptive behaviors, staff intervene when needed to protect others and observe behavior episodes and attempt to determine underlying cause. Review of the facility investigation, showed: -Occurrence: 4/27/25 at 6:45 P.M.; -Description: Residents #39 and #65 reported to have an argument over cleaning the toilet in the bathroom, when Resident #39 struck Resident #65 with a closed hand in Resident #65's face. The strike caused Resident #65 to fall; -Alleged victim: skin and pain assessments completed. Resident #65 called emergency services and requested to go to the hospital for evaluation; -Steps taken to protect residents: placed on 15 minute checks, psychiatric nurse practitioner (NP) notified and will conduct a medication review. Resident #39 moved to the third floor; -Findings: upon completion of the investigation the facility substantiated a physical altercation occurred. Review of the progress notes, showed: -On 4/27/25 at 7:02 P.M., the resident called emergency services himself/he

Based on observation, interview and record review, the facility failed to store food properly in the walk-in cooler and freezer by stacking smashed and wet boxes on top of each other. Staff failed to ensure food items on the menu were consistently available. This resulted in residents receiving alternate meals not equal in nutritional value due to inadequate inventory and improper food storage practices. This had the potential to affect all residents. The sample was 19. The census was 95. Review of the facility's walk-in cooler food storage chart, showed: -Chart showed photos of which food items stored on each shelf; -Top shelf showed ready to eat fruit and vegetables; -The second shelf showed fish, pork and beef; -The third shelf showed ground meats; -The fourth shelf showed chicken and poultry; -The bottom shelf showed thawing foods. 1. Observation on [DATE] at 12:50 P.M. and 3:47 P.M., [DATE] at 9:43 A.M. and 9:56 A.M., [DATE] at 11:14 A.M. and [DATE] at 12:17 P.M., of the inside of the walk-in cooler, on the right side, showed a four tier, wire metal shelving unit. On the top shelf there were several blue unopened boxes. There were plastic containers with handles, holding liquids and food including pasta, creamy salad dressings and sauces. On the middle shelf, there were four cardboard produce boxes containing cherry tomatoes. There were at least two smashed cherry tomatoes in the box. There were at least two large unopened packages of American sliced cheese. The shelf below, contained more cardboard boxes and a large unopened box labeled spread. There was a visible collapsed box on the shelf that was torn and soiled. There were several unopened packages of sliced meat and one pack of sliced meat that was wrapped in plastic without a label. There was a large bag of shredded cheese behind the collapsed box. The bottom shelf showed two large, unopened boxes. There were two, large ribs inside a metal pan. The boxes lay on top of one side of the metal pan with the ribs on the other side. The left side of the walk in cooler showed several boxes stacked on top of each other. The boxes sat on milk crates with several rows of boxes, stacked two or three boxes high. Inside the boxes were milk and health shakes. The door to the walk in freezer was in the back of the cooler. The entrance to the walk in freezer, showed two, four tier, wire metal shelves. There were approximately 40 boxes stacked in the freezer. Many boxes were smashed; -On [DATE] at 12:50 P.M., the walk in cooler showed a box of 2% milk with an expiration date of [DATE]. There were approximately 20 cartons of milk in the box. At 3:47 P.M., there was a baggie of red onions inside a box with unopened sliced meat without a label. Observation and interview on [DATE] at 11:20 A.M., showed the Dietary Manager cleaning out the walk in cooler. There were boxes and a cart outside of the walk-in cooler. The Dietary Manager said they do not have a lot of room. They delivered boxes and they put the boxes of food that were coming up on the menu in front. Then they rotate them. During an interview on [DATE] at 9:27 A.M., the Dietary Manager said they try to place the boxes on top of milk crates. They try to place the same size boxes on top of each other. They stack things in the corner, so it does not get smashed. When the delivery comes, they put the food that will be coming up on the menu in the front. They write the dates on the outside of the box. They date the bag if there is a bag left. If something like a box is damaged when it comes in, they will send it back. The food that has been inside a smashed box should be thrown out. They train staff on cross contamination. In the morning, staff are expected to remove anything that is outdated or undated. On the right side of the cooler, the meat is stored. On the left, juice and milk are stored. The vegetables can be stored on either side. No fruit or vegetables are stored with meat. They put that above the meat on the shelf. The night shift is supposed to make sure everything is straightened up. They have to often take boxes out of the cooler to remove other items. They have to make sure the food is not outside of the cooler or freezer for a significant time. It is difficult to access the boxes. The kitchen does not have another refrigerator. They have discussed whether or not limited space in the walk-in cooler/freezer contributes to improper food storage. They offered a widget freezer. It would be so helpful. All food should be dated and labeled. All staff are responsible for ensuring it is dated. The Dietary Manager said she removed the expired milk from the cooler. It should have been removed on the 10th. 2. Review of the facility's menu, dated [DATE], showed: -Lunch: Herbed turkey, baked potato, sour cream, sugar snap peas and dinner roll; -No alternate listed. During an interview on [DATE] at 11:21 A.M., [NAME] J said the alternate meal for lunch was grilled cheese and potato chips. If they ask for something else, they will make it. It keeps the residents happy. Observation on [DATE] at 12:07 P.M., showed dietary staff prepared grilled cheese sandwiches in a large skillet. At 12:26 P.M., staff prepared more grilled cheese sandwiches in the large skillet. Observation of the ground floor main dining room on [DATE], showed: -At 12:52 P.M., approximately ,d+[DATE] residents sat at various dining room tables. A resident said the noon meal was late and said they were hungry, they were looking forward to the noon meal of turkey; -At 1:38 P.M., nursing staff served the main dining room residents grilled cheese sandwiches, mashed potatoes, two Brussel sprouts in a bowl and ice cream. Ten residents verbalized disappointment in receiving grilled cheese instead of turkey. Nursing staff were noted to shrug shoulders and said Maybe they ran out of turkey and continued to serve the remaining residents in the dining room. 3. Review of the facility's menu, dated [DATE], showed: -Breakfast: Cereal of choice, egg, bacon, fresh fruit and diet yellow cake. Observation on [DATE] at approximately 7:30 A.M., showed residents were served toast and gravy for breakfast. During an interview on [DATE] at 8:00 A.M., [NAME] L said breakfast called for bacon, fresh fruit and crumb cake. They did not have oranges or bacon. The residents got biscuits and gravy, hot cereal, and scrambled eggs. [NAME] L was asked if they used biscuits. He/She said biscuits were not used. They did not have biscuits. 4. During an interview on [DATE] at 9:27 A.M., the Dietary Manager said they do have enough food for the most part. They do run out. Most of the time, residents ask for something that's not on the menu and they try to give it to them to keep them happy. They did not have sugar snap peas. There were not enough Brussel sprouts served. There should have been some lima beans prepared if there was not enough. On ,d+[DATE], they were serving lunch when it was determined they did not have enough. The grilled cheese was the alternate, but it was served to the residents in the dining room. Sometimes there are chicken tenders, salad, or burgers, but they did not have lettuce. The residents were served sandwiches in a hurry to get them fed. The biscuits were used for another meal, so they were not available for biscuits and gravy. Sometimes residents ask for biscuits and sausage instead of what was on the menu. She told staff not to do that unless it is the next day because they may not have the food available. 5. During an interview on [DATE] at 12:26 P.M., the Administrator said they can substitute the menu, but they would need approval from the Dietician first. If the food is available, they can find a substitute and still log it. If they did not have a food item that was on the menu, she expected dietary staff to notify her. If biscuits were not available, using toast was not appropriate. She could order food from a vendor and it would be delivered within three hours. She expected alternates to be equal or of similar nutritional value. There should be real substitutes. They order food for 100 residents so there should be enough food. The storage is small. They are expected to move the food to the front that is going to be served. There is not adequate space. She's been aware of this issue. They would like there to be a reach in refrigerator and freezer.

Based on observation and interview the facility failed to provide a safe, and comfortable environment for residents, staff and the public by failing to maintain resident rooms, resident use areas, and public use areas air temperatures below 80 degrees Fahrenheit (F) on the second and third floors. The census was 95. During an interview on 5/13/25 at 9:53 A.M., Resident #33 said the building is always warm it seems, and he/she would like it to be cooler for it to be comfortable for him/her. During an interview on 5/14/25 at 11:00 A.M., Nurse B said the building is always hot and there is always trouble with the chiller system because the building is old. He/She would like it to be cooler inside the building. Observation on 5/14/25 at 9:50 A.M., showed the facility internal air temperature in the hallway outside of resident room [ROOM NUMBER] measured 81 degrees F with a digital thermometer. At 12:10 P.M., room [ROOM NUMBER] measured 82.8 degrees F. Observation on 5/14/25 at 9:54 A.M., showed air temperatures at the end of the third-floor hallway measured 81.4 degrees F outside of resident room [ROOM NUMBER]. Observation on 5/14/25 at 9:55 A.M., showed the air temperature measured 83.1 degrees F in the hall outside resident room [ROOM NUMBER] and 80.4 degrees F inside resident room [ROOM NUMBER]. Observation on 5/14/25 at 10:00 A.M., showed the air temperature measured 82.9 degrees F inside resident room [ROOM NUMBER]. Observation on 5/14/25 at 10:15 A.M., showed the air temperature taken with a digital thermometer measured 82.6 inside resident room [ROOM NUMBER] and 81.5 degrees F at the nurses station. At 11:50 A.M. it was 81.6 degrees F in resident room [ROOM NUMBER]. Observation on 5/14/25 At 11:45 A.M. showed the air temperature inside room [ROOM NUMBER] measured 81 degrees F. Observation on 5/14/25 at 11:55 A.M., the air temperature inside resident room [ROOM NUMBER], measured 81.6 degrees F. Observation on 5/14/25 at 12:00 P.M., the air temperature inside resident room [ROOM NUMBER] measured 81.7 degrees F. Observation on 5/14/25 at 12:05 P.M., showed the air temperature inside room [ROOM NUMBER] measured 82.7 degrees F. During an interview on 5/16/25 at 12:45 P.M., the Administrator said the facility has issues maintaining air temperatures at comfortable levels due to the facility's chiller system being old. The system fails every time it's changed from heating to cooling modes. They are contracted with a service provider who brought in portable air conditioners (5/15/25) until the chiller could be fixed. The chiller is working properly now.

Based on observation, interview, and record review the facility failed to maintain an environment free of accident hazards by not maintaining proper body mechanics while transferring a dependent resident (Resident #18). In addition, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents for one of one housekeeping closet on the first floor. This had the potential to affect all residents with access to the first floor. The sample was 19. The census was 95. 1. Review of the facility's Gait belt policy, reviewed 10/22, showed: -Position your body close to the resident face to face; -Transfer resident by grasping the gait-belt using an underhand grip; -Allow resident to stand for a moment to gain his/her balance; -Instruct resident to pivot to bear weight; -Maintain contact between the destination surface and the resident's legs; -Perform hand hygiene. Review of Resident #18's diagnoses list, included muscle wasting and atrophy (size decrease and weakness of the muscles), shoulder pain, muscle weakness generalized, unsteadiness on feet, lack of coordination, pain in right knee, repeated falls, abnormal posture, left shoulder pain, need for assistance with personal care, cerebral palsy (body impairment related to muscles movement, tone, and posture), other abnormalities of gait and mobility, and epilepsy (seizures). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/6/25, showed: -Cognitively intact; -Used a wheelchair; -Range of motion impaired on both sides. Review of the resident's care plan, in use at the time of the survey, showed care directions for Hoyer (mechanical lift) transfer discontinued on 9/15/22. No current directions for the resident's transfer status. During an observation on 5/13/25 at 1:37 P.M., staff assisted the resident to transfer to bed for care. Certified Nursing Assistant (CNA) H applied a gait belt around the resident's chest region. The resident sat in a wheelchair at the bedside. CNA H held onto the gait belt, lifted the resident up and twisted and swung the resident into bed. CNA H said, you almost made me fall. CNA H provided care to the resident and said you know how to use your legs to the resident. Observation on 5/14/25 at 10:38 A.M., showed the resident in a wheelchair near the bed. The wound nurse wrapped a gait belt above the resident's naval (belly button), with two finger width between the gait belt and the resident. The Wound Nurse attempted to transfer the resident by themselves but was unable and set the resident back down. The resident said he/she will wrap his/her arms around the wound nurse's neck and then try again. The wound nurse said that is not safe and would need to get additional assistance. The wound nurse returned at 10:43 A.M. with a CNA F. Both employees stood on each side of the resident, then looped their arms underneath the resident's arm pits to lift him/her to his/her feet before transferring the resident to the bed. CNA F said he/she felt the resident was improving with mobility and does not see a decline in their ability to transfer. During an interview on 5/14/25 at 12:31 P.M., CNA G said the resident transfers x 2 assistance. He/She cannot pivot on his/her own. Two person assist is how CNA G transfers this resident. During an interview on 5/14/25 at 9:04 A.M., the Director of Physical Therapy/Occupational Therapy (PT/OT) said gait belts should be slightly above the naval, and 2 fingers width within the gait belt. Resident #18 was last seen by therapy on 2/12/25 with discharge of service transfer instructions of swing and pivot with one assist. A review is due every three months or when staff initiates a concern regarding difficulty of a transfer with current orders. With a swing pivot where a resident can bare weight on their legs, but staff swings them to a safe surface. If a staff makes comments like you almost made me fall or you can use your legs this should prompt staff to seek additional support when transferring with a note to the physical therapy department. She denied receiving any comments or concerns regarding Resident #18 this week. Resident #18 is due for evaluation since it is over three months from his/her last physical therapy evaluation. Therapy notes received showed on evaluation he/she had impaired upper and lower extremities range of motion in October 2024. Upon discharge records showed he/she reached maximum capacity and referral was made to the restorative range of motion program. At 9:28 A.M., the Restorative Director said restorative therapy is completed daily and there have been no concerns noticed, seen or shared with them regarding the resident. They have weekly meetings to discuss residents' care, and the Restorative Director cannot recall any relevant concerns from February to current pertaining to resident. During an interview on 5/16/25 at 11:25 the Director of Nursing (DON) said residents should never be wing lifted. She added that residents should never be lifted under the arm pits, as this can cause injury to the shoulder and staff risk dropping the resident. 2. Observation on 5/12/25 between 12:50 P.M. to 2:38 P.M., showed the housekeeping closet, located between the elevator and the activity/dining room on the first floor was unlocked and opened approximately a half inch from the door jam. Further observation showed four bottles of toxic or poisonous material sat on the floor inside the closet. Review of the chemical bottles and the facility's Material Safety Data Sheets (MSDS) on 5/16/25 at 9:00 A.M., showed: -Two of the four bottles from the unlocked closet contained material Clean on the GO disinfectant. The MSDS and warning label on the bottle showed DANGER can cause severe skin burns, serious eye damage, and harmful if swallowed; -One bottle of Sparclean Sure Step (59), cleaning agent, and the MSDS showed Warning: keep out of reach of children, harmful if swallowed, may cause skin irritation, and causes eye irritation, and may induce respiratory sensitization; -The other bottle contained material Clean on the GO Xelente (24). The MSDS showed the warnings harmful if swallowed, keep out of reach of children and can cause skin irritation, and can cause serious eye damage. Observation on 5/13/25 at 9:54 A.M., showed the same housekeeping closet unlocked and the same toxic or poisonous material in plastic bottles remained in closet. Observation on 5/14/25, showed the housekeeping closet was unlocked, and the same toxic or poisonous material remained in the closet from 10:00 AM until 3:00 PM. During an interview on 5/16/25 at 10:30 A.M., the housekeeping supervisor verified the material in the bottles as Clean on the GO products and Sparclean. The housekeeping supervisor said all chemicals are to be locked up and not accessible to residents. The chemicals are to be locked up either in the house keeping closets or in his office/supply room. During an interview on 5/16/25 at 10:54 A.M., the Administrator said the facility's policy is that all chemicals are to be locked up and not accessible to residents.

Based on observation, interview and record review, facility staff failed to ensure appropriate infection control practices during perineal care (cleansing from the front of the hips, between the legs and buttocks) for one resident (Resident #26). Staff also failed to follow the facility policy on transporting laundry when staff pressed a resident's clean laundry against their uniform. The sample was 19. The census was 95. 1. Review of the facility's incontinent care policy, dated 7/21/22, showed: -Policy: the facility will provide incontinent care as directed by the plan of care. Care will promote hygiene and prevent infection; -Procedure: -Perform hand hygiene and apply gloves; -Remove soiled brief; -Cleanse the perineal area; -Use a clean wipe for each area; -Remove soiled gloves, perform hand hygiene and apply clean gloves; -Apply ointment, remove gloves, sanitize hands, apply clean gloves. Review of Resident #26's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 4/17/25, showed: -Cognitively intact, able to make needs and wants known; -Physical impairments to both lower extremities; -Staff provide total assistance for toileting, daily hygiene, and dressing; -Always incontinent of bowel and bladder. Review of the resident's care plan, in use during the survey, showed: -Focus: The resident required assistance with daily care tasks due to weakness; -Goal: Will remain free from complications related to immobility; -Interventions: The resident does not walk, staff provide care and observe for complications. During an observation and interview on 5/13/25 at 2:45 P.M., Certified Nursing Assistant (CNA) E entered the resident's room and explained care. CNA E applied gloves and did not first sanitize or wash his/her hands. CNA E unfastened the urine saturated brief and tucked the brief between the resident's legs. CNA E obtained a wet wipe and used the same wipe and cleaned the front thigh folds in a downward motion. CNA E used the same gloved hands and assisted the resident onto his/her side and removed the saturated brief. CNA E obtained another wipe and used the same wipe and cleaned the lower buttocks. CNA E used the same gloved hands and applied a clean brief and secured the brief in place. CNA E said he/she was rushed to complete care before the next shift started. CNA E said he/she did not sanitize, wash hands, or change gloves during care. He/She should have washed or sanitized his/her hands and changed gloves during care, not doing so placed the residents at risk for infection. During an interview on 5/16/25 at 11:25 A.M., the Director of Nursing said when staff provide perineal care (cleansing from the front of the hips, between the legs and buttocks), the staff should sanitize or wash hands between dirty to clean surfaces and change gloves. If staff do not sanitize, wash hands or change gloves staff could spread infections. 2. Review of the facility's Handling line/Laundry Policy and Procedure dated 7/2/24, showed: -Linen/laundry includes residents personal clothing, sheets, blankets, pillows; -Employees shall be educated in proper techniques to handle, store, and transport both soiled and clean linens and laundry; -If no leakproof container with lid is available, the laundry shall be bagged before placing in open container; -Clean linen/laundry shall be covered during transport to ensure cleanliness and protect against dust and soilage. During an observation on 5/16/25 at approximately 10:00 A.M., CNA G exited the laundry room with a resident's cloths draped over their arm. CNA G waited on the ground level by the elevator until it arrived. Once the elevator arrived CNA G went to their assigned unit. During an interview on 5/16/25 at 10:13 A.M., the Wound Nurse said she expects staff to bring clothing to residents in a covered cart. Staff should never carry resident's cloths pressed against themselves while in their work attire, which could be carrying pathogens from other residents. This is an infection control concern for the entire facility. During an interview on 5/16/25 at approximately 11:00 A.M., CNA G he/she is unfamiliar with the laundry policy but said soiled/clean items should be in a bag when transported. 52419

Based on observation, interview and record review, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. The facility failed to provide curtains and/or blinds in a resident room and failed to maintain ceiling tiles in good repair for one of 19 sampled residents (Resident #33). The census was 95. Review of Resident #33's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/25, showed the resident was cognitively intact. Review of the resident's medical record, showed diagnoses of schizoaffective disorder (mood disorder) and morbid obesity. Observation on 5/13/25 at 9:00 A.M., showed the resident's private room without blinds or curtains over the window. The window measured approximately 5 feet by 5 feet and allowed for sunshine constantly in the room Observation on 5/14/25 at 9:30 A.M., 5/15/25 at 9:10 A.M., and 5/16/25 at 9:10 A.M., showed the resident's room remained without curtains or blinds. The resident's bathroom contained two brown stained ceiling tiles. Each tile had a stained area of approximately 2 feet by 2 feet. During an interview on 5/13/25 at 9:53 A.M., the resident said the room becomes very warm with the sun shining in the room through the window without curtains or blinds. If he/she wants to take a nap, it is impossible because of the sun shining so brilliantly in his/her room. During an interview on 5/14/25 at 12:39 P.M., Licensed Practical Nurse (LPN) B said the resident room issues were reported verbally to maintenance approximately three weeks ago. There used to be a requisition book kept at the nurses' station and this was used to report issues to maintenance and tracking of requests. LPN B was not sure where it is now and hasn't seen the book since painting happened at the nurses' station. LPN B could not remember when the painting started. During an interview on 5/16/25 at 10:00 A.M., the Maintenance Director there is a book kept at the nurses' station and this is how he finds out what needs repaired or serviced. He could not locate the book immediately and after searching, found the book. Review of the book, showed the last requisition was made on 8/24/24. He also said he has known of Resident #33's room issues and has known for about two weeks. During an interview on 5/16/25 at 12:30 P.M., the Administrator said all residents room windows should have blinds and or curtains.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #74), who chose to perform services for the facility, had a care plan developed to address the services to be provided and the decision for these services to be paid or unpaid. The census was 95. Review on of Resident #74 quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 4/17/25, showed: -Cognitively intact -Diagnosis of Schizophrenia. Review of the resident's care plan, dated 4/17/25 and in use at the time of the survey, showed: -No documentation of the resident's desire for work; -No plan specified regarding the nature of the services performed and whether the services are voluntary or paid; -Do documentation if there is payment or if the work is voluntary. Observation on 5/12/25 at 12:50 P.M., showed the resident in the kitchen. He placed plastic utensils inside the envelope/sleeve and placed it on the tray. During an interview on 5/12/25 At 2:48 P.M., the resident said he/she was in the kitchen earlier. He/she works in the kitchen. He/She transports the trays to the resident halls and back to the kitchen. He/She has been doing it for about a year. He/She works typically when they have had a call in. Observation on 5/13/25 at 9:46 A.M., showed the resident entered the dining room. He/She moved a cart from the closet and exited the kitchen. At 12:07 P.M., staff prepped the meal. The resident present at the cart with the meal tickets. He/She placed plastic utensils in the envelopes. During an interview on 5/16/25 at 9:27 A.M., the Dietary Manager said the resident does one thing, he/she bags plasticware and brings the dirty carts down. Sometimes he/she operates the dish machine. He/She has had training and receives the same training as the dietary staff. She does not have a policy regarding residents working in kitchen, just a workflow or job description. The Administrator determines what tasks the resident is safe to do. They do not allow the resident to do anything except what was discussed. During an interview on 5/16/25 at 12:26 P.M., the Administrator said the Interdisciplinary Team (IDT) decides if a Resident is appropriate to volunteer at the facility and explained the numerous benefits per the Administrator. The jobs the resident performs are taking the meal cart up to the floor, rolling up silverware, cleaning tables in the dining room, and wiping the tables clean. It has been positive for his/her behavior modification. The resident is rewarded through Walmart or Amazon gift cards. He/She does not get cash. He/She gets five dollars for each completed time sheet. She expects this to be care planned and acknowledged there was no care plan items addressing resident working in the kitchen.

Based on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion for one resident (Resident #45). The facility failed ensure policies and procedures were developed with clinical criteria for placement on the secured unit and to ensure residents who resided on the secured unit were assessed for appropriateness. As a result, the resident had been placed on and remained on the secured unit without clinical rationale. The facility staff failed to notify the resident's next of kin of the relocation from the first floor to the secured unit. The facility failed to assess continued appropriateness of the placement following the move on to the secured unit. Staff were unaware of the rationale for the resident's placement onto the secured unit. During the survey, the resident expressed desire to move back onto the first floor because he/she had friends on the first floor. The sample was 19. The census was 95. Review of the facility's Abuse Prevention policy, revised 10/21/22, showed: -Policy: the facility is committed to protecting the residents from abuse by anyone; -Definitions: Involuntary seclusion: separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/25, showed: -Diagnoses included stroke, aphasia (difficulty speaking), paralysis, seizures, anxiety, depression, and bipolar disease; -Severe cognitive impairment; -No behaviors, experienced daily inattention and disorganized thinking; -Moderate depression; -Required staff assistance with toileting and hygiene. Review of the resident's care plan, in use during the survey, showed: -Focus: Resident is highly functional but does require some assistance, supervision and set up for Activities of Daily Living (ADL) task: -Goal: Resident will maintain his/her current level of ADL functions; -Interventions: Allow time to complete task and intervene as needed; Monitor for decline in functions; Provide assistance, set up and supervision as needed; -Focus: The resident was at risk for alternation in health and injury related to behaviors of rejection of care and medication: -Goal: The resident will remain free of complications related to behaviors of rejection of care and medication now through next review; -Interventions: Follow up with Medical Director (MD) and Psychiatrist as needed. Review of the resident's progress notes, showed: -On 9/4/24 at 12:14 P.M., the resident is self-responsible and has no significant behavioral issues; -On 9/23/24 at 1:16 P.M., 12/3/24 at 4:25 P.M., 2/18/25 at 2:09 P.M., and 3/5/25 at 9:02 A.M., the resident's elopement assessment score was 0.0 (not an elopement risk); -On 2/18/25 at 1:37 A.M., resident oriented x three (oriented to person, place and time) about to make needs known; non-English speaking (resident is Vietnamese); -On 3/5/25 at 12:14 P.M., the resident did not attend care plan meeting. The resident had no significant behavioral issues and isolates in his/her room and is quiet in groups; -On 4/3/25 at 3:22 P.M., review of prior hospital paperwork, it was noted that schizophrenia diagnosis was added after a single incident at a previous skilled nursing facility. The resident had no prior psychiatric history and no psychiatric medications were administered during that time. The psychiatric nurse practitioner (NP) notified and the diagnosis was removed. Observation on 5/13/25 at 9:37 A.M. and 5/14/25 at 1:46 P.M., showed the resident in his/her room on the secure unit, lay in bed and stared at the ceiling. No visible entertainment items or noted communication cards were visible. During an interview on 5/14/25 at 8:45 A.M., Certified Nurse Aide (CNA) I said the resident will do for him/herself and point to what he/she wants. Most days the resident just pushes him/herself around the unit in a wheelchair and stays to him/herself. During an interview on 5/14/25 at 8:45 A.M., CNA J said the resident was independent with care and does not have any behaviors. During an interview on 5/14/25 at 9:05 A.M., CNA K said the resident cared for him/herself and does not require much staff assistance. During an interview on 5/14/25 at 12:27 P.M., the Activity Director said the resident has very limited English and preferred his/her own language. He/She will point at needed items. Prior to the move to the secured unit, the resident was very social. Socialization opportunities are difficult due to residing on the secured unit. The activity director was unaware why resident was moved from the first floor to the secured unit. During an interview on 5/14/25 at 12:45 A.M., the MDS Coordinator/Restorative Director said resident was moved to the secure unit because he/she needed more assistance. The facility does not have a policy or use an assessment for placement on the secure unit. Placement is based on how much ADL assistance is needed. Those with a higher acuity (needing more assistance) go up the secure unit or if they are at risk for elopement. During an interview on 5/14/25 at 1:05 A.M., the Social Worker said the resident does not have any behavior issues and is on the secure unit because that floor is used to help those residents needing more assistance with their ADLs or who are an elopement risk with dementia or Alzheimer's disease. The facility does not have a policy or use an assessment for placement on the secure unit. During an interview on 5/14/25 at 1:33 P.M., the Administrator said the facility does not have a policy nor uses an assessment for residents that are admitted on the secured unit. The interdisciplinary team (IDT) identified residents who may be an elopement risk. Newly admitted residents are placed on the secured unit until elopement and behaviors status can be evaluated. Residents that required more staff assistance with care are placed on the secured unit. During an interview on 5/14/25 at 6:32 P.M., the resident's family said the resident was unable to speak or understand English. The family moved to the United States back in 2000 and the resident did not learn the English language. The resident may be able to repeat a word, but he/she does not understand the meaning of the word. Due to the language barrier, the family bought the resident a television (TV) so he/she would have something to do. When visiting, the family would find the resident's TV off because the resident's remote would be missing. The resident was unable to ask the staff for help. He/She was unaware the resident lived on a secure unit and was not notified when the resident was moved. The family would find out during visits if they cannot locate the resident. During an interview on 5/15/25 at 10:15 A.M., License Practical Nurse (LPN) A said the resident was on first floor and discharged to the hospital. At the time of re-admission, he/she was admitted to the secured unit. The resident does better on the secure unit because it is not so busy. The resident had no history or attempted elopements and no behaviors. The resident did not require full staff assistance for care. The resident enjoyed watching and listening to music on his/her television. He/She does not have a TV and LPN A did not know the location of the TV. During an interview on 5/15/25 at 1:39 P.M., with the use of a translator application, the resident said his/her TV had been missing for five days and he/she was unable to ask the staff for help or call his/her family. He/She was unaware what happened to his/her television and began to count out loud, in his/her language, the days the television had been missing. The resident said he/she cannot understand the staff, so he/she just takes whatever medication the staff hands him/her. He/She does not know why he/she was moved to the secure unit; the third floor. He/She does not like it and wants to return to the first floor where he/she had friends. The Resident was unaware it was a secure locked unit, only that he/she could not leave the floor. During an interview on 5/15/25 at 1:55 P.M., with the resident and the resident's family member, the resident's family member, who spoke English, confirmed the accuracy of the translator application. The resident had not been able to ask for help due to a language barrier. The resident said he/she wanted to return to the first floor since he/she had friends there.

Based on observation, interview and record review, the facility failed to have a communication policy, clinical assessment, and individualized criteria in place to ensure that a resident's abilities in activities of daily living do not diminish when staff failed to accommodate one resident's communication needs (Resident #45). The sample was 19. The census was 95. Review of the facility's Residents' [NAME] of Rights policy, revised 6/23, showed: -Policy: Get Proper Medical care; -Definitions: To be fully informed about your total health status in a language resident understands. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/25, showed: -Diagnoses included stroke, aphasia (difficulty speaking), paralysis, seizures, anxiety, depression, and bipolar disease; -Severe cognitive impairment; -No behaviors, experienced daily inattention and disorganized thinking; -Moderate depression; -Required staff assistance with toileting and hygiene. Review of the resident's care plan, dated 3/20/25, showed: -Focus: Resident displays a deficit in communication related to aphagia following a stroke and poor English. Resident often refuses interviews with staff pretending he/she cannot speak English: -Goal: Resident will continue to have effective communication now through next review; -Interventions: Allow time to voice feelings and concerns as needed; Speak in slow, simple communication; Therapy to screen quarterly and PRN (as needed); -Focus: The resident was at risk for alternation in health and injury related to behaviors of rejection of care and medication: -Goal: The resident will remain free of complications related to behaviors of rejection of care and medication now through next review; -Interventions: Follow up with Medical Doctor (MD) and Psychiatrist as needed; -Focus: Resident is at risk for unplanned, unexpected weight gain or loss related to refusals of monthly weights; 11/2024 resident refused monthly weights three times, 12/2024 refused monthly weights, 2/2025 refused monthly weights, 3/2025 refused monthly weights, 4/2025 refused monthly weights multiple attempts by multiple staff, and on 5/2025 refused monthly weights on three attempts: -Goal: Resident consume 50% of two of three meals a day; -Interventions: Resident refused monthly weight multiple attempts by multiple staff members; Alert dietician if consumption is poor for more than 48 hours; Give the resident supplements as ordered. Alert nurse/dietitian if not consuming on a routine basis; Labs ordered. Report results to physician and ensure dietician is aware. Review of the resident's Activity Interview for Daily and Activity Preferences, dated 4/1/25, showed: -Resident able to communicate; -No response or non-responsive for daily and activity preferences; -Resident indicated as primary respondent for daily and activity preferences. Review of the resident's progress notes, showed: -On 9/4/2024 at 12:14 P.M., the resident is self-responsible and has no significant behavioral issues. -On 9/4/24 at 12:14 P.M., care conference held. The resident is responsible for self and not in attendance. The resident remains calm and cooperative with staff. Compliant with medication. No issues or concerns noted by interdisciplinary team (IDT); -On 12/4/24 at 1:51 P.M., care conference held. The resident responsible for self and not in attendance. The resident remains calm and cooperative with staff. Compliant with medication. The resident does not have verbal or physical behaviors but will pretend he/she does not understand English to avoid talking to an individual. No issues or concerns noted by IDT; -On 12/5/24 at 1:25 P.M., brief interview for mental status (BIMS) conducted and indicated the following: -Number of words repeated after first attempt: None; -Able to report correct year: missed by >5 years or no answer; -Able to report correct month: missed by >1 month or no answer; -Able to report correct week: Incorrect or no answer; -Able to recall sock: No, could not recall; -Able to recall bed: No, could not recall; -Able to recall blue: No, could not recall; -BIMS summary score: 0.0 (resident has severely impaired cognition); -On 2/18/25 at 1:37 A.M., resident oriented x three (oriented to person, place and time) about to make needs known; non-English speaking (resident is Vietnamese); -On 2/27/25 at 7:51 A.M.; 3/7/25 at 2:33 P.M.; 3/13/25 at 10:44 A.M.; 4/21/25 at 12:52 P.M.; and 5/8/25 at 3:38 P.M., resident refused monthly weights multiple attempts made by multiple staff members; -On 3/5/25 at 8:51 A.M., BIMS indicated resident has severely impaired cognition; -On 3/5/25 at 12:14 P.M., the resident did not attend care plan meeting. The resident had no significant behavioral issues and isolates in his/her room and is quiet in groups; -On 3/7/25 at 2:17 P.M. the resident walks short distances and uses a wheelchair for long distances. The resident continues to pretend he/she does not understand English when he/she does not want to speak to staff. The resident only participates in activities with Vietnamese peers. No further issues or concerns noted by the IDT. Observation on 5/13/25 at 9:37 A.M., showed the resident his/her room on the secure unit, lay in bed and stared at the ceiling. No visible entertainment items or communication cards were visible. Observation on 5/14/25 at 1:46 P.M., showed the resident in his/her room on the secure unit, lay in bed and stared at the ceiling, no visible entertainment items or communication cards visible. The Administrator stopped by the resident's door, waved and said Hi, how are you?. The resident waved back at the administrator who said See, I told you he/she understands English. During an interview on 5/14/25 at 8:15 A.M., Certified Medication Technician (CMT) B said the facility does not use a communication board because the resident can speak English but pretends, he/she cannot. The resident does his/her own toileting, hygiene, bathing and will point to his/her finger if he/she wants his/her blood sugar check and uses hand gestures. During an interview on 5/14/25 at 8:45 A.M., Certified Nurse Aide (CNA) I said the resident will do for him/herself and point to what he/she wants. Most days the resident just pushes him/herself around in a wheelchair and stays to him/herself. During an interview on 5/14/25 at 8:45 A.M., CNA J said the resident does for him/herself. There is no communication devices being used because the resident can understand and speaks English, he/she just pretends he/she does not understand. The resident prefers to communicate by doing hand gestures or pointing to what he/she wants. During an interview on 5/14/25 at 9:05 A.M., CNA K said the resident cares for him/herself and just points to what he/she wants. The resident does not talk but he/she understands English. During an interview on 5/14/25 at 12:27 P.M., the Activity Director said the resident has very limited English and just likes his/her own language, so he/she points. When the resident lived on the first floor, he/she interacted with a group of residents, one who is also Vietnamese, who all watched television together. During an interview on 5/14/25 at 12:45 A.M., the MDS Coordinator/Restorative Director said the resident does not have family, but he/she can understand and speak English and at times just pretends he/she does not. During an interview on 5/14/25 at 1:05 A.M., the Social Worker said the resident can understand English but can only say a few words, so he/she just points. He/She speaks very slowly and needs to have patience. During an interview on 5/14/25 at 1:33 P.M., the Administrator said the resident can understand and speak enough English that the staff and resident can communicate. At times the resident pretends he/she does not understand but really does. The facility does not have a communication policy or use communication cards for those residents that English is not their native language because all the residents understand and speak English. During an interview on 5/14/25 at 6:32 P.M., the resident's family said the resident was unable to speak or understand English. The family moved to the United States back in 2000 and the resident did not learn the English language. The resident may be able to repeat a word, but he/she does not understand the meaning of the word. Due to the language barrier, the family bought the resident a television (TV) so he/she would have something to do. When visiting, the family would find the resident's TV off because the resident's remote would be missing. The resident was unable to ask the staff for help. During an interview on 5/15/25 at 10:15 A.M., License Practical Nurse (LPN) A said the resident does hand gestures or points to his/her finger if he/she wants, his/her blood sugar check or points to a shirt if he/she wants changed. The resident is easy care and does his/her own toileting, hygiene and bathing. The family is big on coming up to visit him/her. The resident receives meal trays and usually eats what is served. If the resident does not want what is served, he/she will not eat it. During snacks, the staff will show him/her options and he/she will pick out what he/she wants. The resident loves watching and listening to American music on his/her television but currently does not have a TV. He/she was not sure what happened to the resident's television but believes it was ordered by the Administrator. LPN A does not recall how long the resident has been without a TV. During an interview on 5/15/25 at 1:39 P.M., with the use of a translator application, the resident said his/her TV had been missing for five days and he/she was unable to ask the staff for help or call his/her family. He/She was unsure what happened to his/her television and began to count out loud, in his/her language, the days the television had been missing. The resident said he/she cannot understand the staff, so he/she just takes whatever medication the staff hands him/her. During an interview on 5/15/25 at 1:55 P.M., with the resident and the resident's family member, the resident's family member, who spoke English, confirmed the accuracy of the translator application. The resident's family said the TV had been missing for five days. The resident had not been able to ask for help due to a language barrier. The resident said he/she wanted to return to the first floor since he/she had friends there. The family member said about a month ago when he/she was visiting the resident, his/her roommate threatened the family member, the resident, and another roommate but that resident has since moved out. The family member said he/she told the staff he/she was afraid for the resident's safety because of the language barrier and the resident could not ask for help. The resident denied anyone had hurt him/her.

Based on observation, interview and record review, the facility failed to ensure appropriate perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) for two of two perineal care observations (Resident #26 and Resident #18). The sample was 19. The census was 95. Review of the facility's Incontinent Care policy, dated 7/21/25, showed: -Policy: the facility will provide incontinent care as directed by the plan of care. Incontinent care will promote hygiene; -Procedure: -Staff cleanse the perineal area with cleanser; -For female residents: separate the skin, cleanse one side and then the other, then cleanse down the center of the skin in a front to back manner; -Cleanse the thighs, area between the buttocks. 1. Review of Resident #26's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/17/25, showed: -Cognitively intact, able to make needs and wants known; -Does not refuse care; -Physical impairments to both lower extremities; -Staff provide total assistance for toileting, daily hygiene and dressing; -Always incontinent of bowel and bladder. Review of the care plan, in use during the survey, showed: -Focus: the resident required assistance with daily care tasks due to weakness; -Goal: will remain free from complications related to immobility; -Interventions: the resident does not walk, staff provide care and observe for complications. During an observation and interview on 5/13/25 at 2:45 P.M., Certified Nurse Aide (CNA) E entered the resident's room and explained care. CNA E applied gloves and unfastened the urine saturated brief and tucked the brief between the resident's legs. CNA E obtained a wet wipe, wiped in a downward motion on each thigh fold and disposed of the wipe. CNA E assisted the resident onto his/her side and removed the brief. CNA E obtained a wipe and wiped the lower buttocks. CNA E applied a clean brief and secured the brief in place. CNA E said he/she provided care at 10:00 A.M. The resident's brief was urine saturated at 2:45 P.M., and CNA E was rushed to complete care before the next shift started. CNA E did not provide care between the resident's legs or buttocks. During an interview on 5/13/25 at 3:20 P.M., the resident said he/she did not feel clean after the provided care. He/She is incontinent of bowel and bladder and it had been several hours since he/she received care. CNA E did not clean between his/her legs or buttocks. 2. Review of Resident #18's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Used a wheelchair for mobility; -Range of motion impaired on both sides; -Required staff assistance with toileting and personal hygiene; -Frequently incontinent of urine; -Always incontinent of bowel; -Diagnoses included muscle wasting atrophy (weakness and muscle loss), urinary tract infections (UTIs) and overactive bladder. Review of the care plan, in use during the survey, showed: -Focus: Activities of daily living (ADL) deficit related to impaired balance and limited mobility; -Goal: Maintain current level of ADL function; -Interventions: Required total assistance with personal hygiene. During an observation and interview on 5/13/25 at 1:40 P.M., CNA H entered the resident's room. CNA H applied gloves and unfastened the wet brief. CNA H used a wet wipe, cleaned the groin and the crease of the buttocks. CNA H did not clean the area of the hips, outer buttocks, or the inner thighs. CNA H obtained and applied barrier ointment to the resident's buttock crease. CNA H said the last time the resident received hygiene care was at 10:00 A.M. 3. During an interview on 5/16/25 at 11:25 A.M., the Director of Nursing said perineal care should be provided in a top to bottom motion and front to back. All areas of the skin in contact with moisture or soiled areas should be cleaned. If staff did not provide through cleaning, the resident could develop infection, odors or sores. 52419

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to treat wounds for one of two sampled residents found to have wounds by the certified nursing assistant (CNA) and the wounds were not reported to the nurse and treatments not ordered timely (Resident #18). The sample was 19. The census was 95. Review of the facility's Wound Management policy, dated 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatment sin accordance with current standards of practice and physician order; -The charge nurse will notify the physician if the absence of treatment orders. Review of Resident #18's diagnoses list included peripheral vascular disease (reduced blood flow to the upper/lower extremities), muscle wasting and atrophy (decrease in size and weakness of the muscles), urinary tract infections (UTIs), overactive bladder (frequently feeling the urge to urinate), need for assistance with personal care, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), and other abnormalities of gait and mobility. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 3/6/25, showed: -Cognitively intact; -Used a wheelchair; -Range of motion coded impaired on both sides; -Dependent with toileting and personal hygiene; -Frequently incontinent of urine and always incontinent of bowel. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: activities of daily living (ADLs) deficit related to impaired balance, limited mobility: -Goal: Maintain current level of ADL function; -Interventions: Requires total assistance with personal hygiene; -Focus: Has a skin tear/potential skin tear/self-inflicted injury related to seeking behavior. Self-inflicted scratches, picks at skin and scalp; -Goal: will be free from skin tears; -Interventions: Treat skin tears per facility policy, keep nails shorter to reduce risk of scratching or picking wounds. Review of the resident's physician orders and medication administration record, showed an order dated 7/29/24 for skin assessment by a licensed nurse every Tuesday on evening shift, last assessment 5/6/25, missed assessment 5/13/25. Review of the resident's skin assessments, showed: -On 4/22/25 within normal limits (WNL) (free from bruises, wounds, scrapes or discoloration, no redness, warmth or swelling), with scabs on feet healing; -On 4/29/25 skin assessment showed Skin WNL, dry scabs on feet healing; -On 5/6/25, skin is clean, dry and intact with no redness, warmth or swelling. Review of the resident's shower sheet, dated 5/14/25 at 8:30 A.M., showed no skin concerns. During an observation on 5/14/25 at 10:38 A.M., the wound nurse identified the following wounds on the resident: -A left posterior inner thigh open, pink area. The wound nurse said it is from moisture; -A cluster of scratches between the shoulder blades. Some open with sanguinous fluid (bloody drainage) with a large brown scab cover the rest, measured 20 cm by 8 cm. During an interview on 5/14/25 at 10:50 A.M., CNA F said he/she saw the wounds on the resident's inner thigh and the scratches on the back when he/she gave the resident a shower at 8:30 A.M. that morning, but believed they were not open, or leaking, or bleeding; therefor he/she did not report them to the nurse due to them being old. During an interview on 5/14/25 at 11:22 A.M., the Wound Nurse said she expected staff to report the injuries on the resident to the nurse on shift and document them on the shower sheet. Review of the resident's physician orders, showed: -An order dated 5/14/25, for left upper posterior leg skin tear, cleanse with wound cleanser then apply zinc ointment one time daily for wound management; -An order dated 5/15/25, for upper back cluster, apply triple antibiotic ointment one time a day for wound management until healed. During an interview on 5/14/25 at 11:47 A.M., the DON said the CNAs are expected to report any skin changes to the nurse assigned to the hall, if the nurse is unable to view them, then contact the wound nurse or DON. The DON said any skin changed should be report immediately. The staff are educated monthly not to assume wounds are old, they would expect staff to keep charting on the wounds until healed. The wounds are not healed if a scab is visible.

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to treat pressure related wounds for one of one sampled resident found to have wounds by the certified nursing assistant (CNA) and the wounds were not reported to the nurse and treatments not ordered timely (Resident #18). The sample was 19. The census was 95. Review of the facility's Wound Management policy, dated 11/15/22, showed: -Policy: To promote wound healing of various types of wounds, the facility will provide evidence-based treatment sin accordance with current standards of practice and physician order; -The charge nurse will notify the physician if the absence of treatment orders. Review of Resident #18's diagnoses list included peripheral vascular disease (reduced blood flow to the upper/lower extremities), muscle wasting and atrophy (decrease in size and weakness of the muscles), urinary tract infections (UTIs), overactive bladder (frequently feeling the urge to urinate), need for assistance with personal care, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), and other abnormalities of gait and mobility. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 3/6/25, showed: -Cognitively intact; -Used a wheelchair; -Range of motions coded impaired on both sides; -Dependent with toileting and personal hygiene; -Frequently incontinent of urine and always incontinent of bowel. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: activities of daily living (ADLs) deficit related to impaired balance, limited mobility: -Goal: Maintain current level of ADL function; -Interventions: Requires total assistance with personal hygiene; -Focus: Has a skin tear/potential skin tear/self-inflicted injury related to seeking behavior. Self-inflicted scratches, picks at skin and scalp; -Goal: will be free from skin tears; -Interventions: Treat skin tears per facility policy, keep nails shorter to reduce risk of scratching or picking wounds. Review of the resident's physician orders and treatment administration record, showed an order dated 7/29/24 for skin assessment by a licensed nurse every Tuesday on evening shift, last assessment 5/6/25, missed assessment 05/13/2025. Review of the resident's skin assessments, showed: -On 4/22/25 within normal limits (WNL) (free from bruises, wounds, scrapes or discoloration, no redness, warmth or swelling), with scabs on feet healing; -On 4/29/25 skin assessment showed Skin WNL, dry scabs on feet healing; -On 5/6/25, skin is clean, dry and intact with no redness, warmth or swelling. Review of the resident's shower sheet, dated 5/14/25 at 8:30 A.M., showed no skin concerns. During an observation on 5/14/25 at 10:38 A.M., the wound nurse identified the following wounds on the resident: -Left foot lateral (side), shaped oval, open with scrapes, blanchable (good blood return when pressed) measured 1.0 by 1.5 centimeter (cm), edges opened, pressure ulcer stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. May also present as an intact or open/ruptured blister); -Left dorsal (posterior, back side) foot at the ankle 2.0 by 2.0 cm undefined, blanching pressure ulcer stage 2. Review of the resident's physician orders, showed: -An order dated 5/14/25, for left back ankle- cleanse with wound cleanser. Apply medi-honey and dry dressing one time a day for wound management unit healed; -An order dated 5/14/25, for left dorsal foot- cleanse with wound cleanser and apply Zinc one time a day for wound management until healed; -No left dorsal or left lateral treatment order prior to 5/14/25. During an interview on 5/14/25 at 10:50 A.M., CNA F said he/she saw the wounds on the resident's left foot when he/she gave the resident a shower at 8:30 A.M. that morning but believed they were not open, leaking, or bleeding; therefor he/she did not report them to the nurse due to them being old. During an interview on 5/14/25 at 11:22 A.M., the Wound Nurse said she expected staff to report the injuries on the resident to the nurse on shift and document them on the shower sheet. During an interview on 5/14/25 at 11:47 A.M., the DON said the CNAs are expected to report any skin changes to the nurse assigned to the hall. If the nurse is unable to view them, then contact the wound nurse or DON. The DON said any skin changes should be report immediately. The staff are educated monthly not to assume wounds are old, they would expect staff to keep charting on the wounds until healed. The wounds are not healed if a scab is visible.

44950 Based on observation, interview and record review, the facility failed to provide dialysis agreements between the dialysis center and the facility for residents that receive dialysis (the process of filtering toxins from the blood in individuals with kidney failure). The facility identified two residents who receive dialysis. Both receive dialysis at different outside dialysis centers. Both were included in the sample and concerns were identified with both residents (Residents #35 and #60). The sample was 19. The census was 95. During an interview on 5/16/25 at 10:00 A.M., the Administrator said they do not have a dialysis policy. They just use the dialysis pre and post assessment forms. 1. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff MDS, dated [DATE], showed: -admitted : 3/14/25; -The resident received dialysis; -Diagnoses included end stage renal disease (ESRD), stroke, and seizure disorder. Review of the resident's electronic Physician Order Sheet (ePOS), showed an order, dated 4/23/25, dialysis days Tuesday, Thursday, and Saturday. During an interview on 5/12/25 at 11:50 A.M., the Administrator said they do not have a dialysis contract with the dialysis center for Resident #35. 2. Review of Resident #60's quarterly MDS, dated [DATE], showed: -admitted : 1/7/25; -The MDS did not show the resident receives dialysis; -Diagnoses included ESRD, viral Hepatitis (inflammation of the liver caused by viruses), dementia, diabetes, and seizure disorder. Review of the resident's ePOS, showed an order, dated 1/7/25, dialysis days Tuesday, Thursday, and Saturday. During an interview on 5/15/25 at 10:30 A.M., the Administrator said they do not have a dialysis contract with the dialysis center for Resident #60.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, three errors occurred, resulting in a 11.11% error rate (Resident #60 and Resident #1). The census was 95. 1. Review of the facility's Medication Administration policy, revised 8/14, showed: -Policy: medication are administered as prescribed in accordance with good nursing principles and practices; -Procedures: -Preparation: -Five rights: right resident, right dose, right drug, right route, right time are applied for each medication being administered; -Prepare the dose, the dose is removed from the container and verified against the label and Medication Administration Record (MAR); -If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. Review of the facility's Injectable Medication Administration policy, revised 9/18, showed: -Purpose: to administer medication via subcutaneous (under the skin) in a safe, accurate and effective manner; -Sites for administration: abdomen, upper arm (fatty tissue), top of the thigh (fatty tissue upper thigh); -Procedures: prepare the medication, withdraw the appropriate amount of medication from the vial; -The policy did not address insulin needle priming. 2. Review of Resident #60's medical record, showed: -Diagnoses included diabetes; -An order, dated 1/8/25: Novolog (fast acting insulin) give 5 units with meals. Observation and interview on 5/14/25 at 11:36 AM, showed Nurse A obtained an insulin syringe and drew up 5 units of Novolog from the resident's insulin vial. Nurse A removed air bubbles, cleansed the administration site and administered the insulin to the resident. He/She verified the resident's comfort, disposed of the insulin syringe and documented the administration into the medical record. Nurse A said he/she did not prime the insulin syringe needle and had not received training to prime the needle. Not priming the needle would result in a lower insulin dose administered to the resident. 3. Review of Resident #1's medical record, showed: -Diagnoses included high blood pressure and seasonal allergies; -An order dated, 3/21/25: Coreg (used for high blood pressure) 12.5 milligram, take one tablet twice a day. Scheduled at 9:00 A.M., and 5:00 P.M.; -An order dated, 1/25/25: Flonase (used to treat nasal congestion) nasal spray. Administer one spray in both nostrils once a day. Scheduled at 9:00 A.M. Observation and interview on 5/14/25 at 9:00 A.M., showed Certified Medication Technician (CMT) A greeted the resident and obtained the resident's morning medication from the prefilled medication packs. CMT A said the resident was out of Coreg and Flonase and he/she would have to call the pharmacy to have the medication sent. Review of the May, 2025 MAR on 5/14/25 at 11:45 A.M., showed: -Coreg 12.5 mg, documented as not available; -Flonase nasal spray, not administered. 4. During an interview on 5/15/25 at 11:59 A.M., the Director of Nursing said all insulin needles should be primed with 2 units of insulin prior to administration. If the nurse does not prime the needle, the resident did not receive the full ordered dose of insulin. All medications should be administered as ordered. If a medication is not available, the staff should notify the nurse and check the emergency supply kit. Coreg is available on the e-kit. Medications can be administered no more that an hour before or an hour after the ordered administration time.

Based on observation, interview and record review, the facility failed to ensure residents were provided therapeutic diets as prescribed by the attending physician and/or according to their care plan, for one resident with an order for renal diet (Resident #35). In addition, the facility failed to ensure residents with orders for a mechanical soft diet received the appropriate texture after residents were served grilled cheese. This had the potential to affect all residents. The sample was 19. The census was 95. 1. Review of Resident #35's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/25/25, showed: -Severe cognitive impairment; -Receives dialysis; -Diagnoses included deep venous thrombosis (blood clots), heart failure, hypertension (high blood pressure), renal failure, hyperkalemia (high electrolyte potassium in the blood), thyroid disorder, hyperlipidemia (high level of fat particles in the blood), stroke, seizure disorder, schizophrenia (disorder that affects a person's ability to think, behave, or feel clearly), post traumatic stress disorder and respiratory failure. Review of the resident's care plan, in use during survey, showed: -Focus: The resident has nutritional problem or potential nutritional problem related to diet restrictions. Resident is noncompliant with diet. Resident receives adult renal diet; -Goal: The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility; -Interventions: Explain and reinforce the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors; -Provide and serve diet as ordered. Review of the resident's Physician's Orders Sheet (POS), dated May 2025, showed: -An order, dated 4/23/25, no added salt (NAS) diet. Regular texture, thin consistency, renal precautions. No orange juice (OJ)/oranges, bananas tomatoes, and potatoes; -An order, dated 4/23/25, dialysis center on Tuesday, Thursday and Saturday. Observation on 5/14/25 at 12:14 P.M., showed the resident knocked on the kitchen door to notify staff he/she was eating in the dining room. Observation and interview on 5/14/25 at 12:43 P.M., showed the resident was served his/her meal. He/She was served pork cutlet, broccoli, scalloped potatoes and a roll. The resident immediately told staff he/she was not supposed to have potatoes. The resident's meal ticket showed no potatoes. At 12:44 P.M., the resident received his/her plate with rice instead of scalloped potatoes. 2. During an interview on 5/13/25 at 11:21 A.M., [NAME] J said the alternate meal was grilled cheese sandwiches. Observation on 5/13/25 at 12:07 P.M., showed staff prepping several grilled cheese sandwiches in the pan. At 12:26 P.M., more grilled cheese sandwiches were placed in the pan to cook. At 12:45 P.M., [NAME] J cut a grilled cheese sandwich into 6 pieces. The cut up grilled cheese was served with mashed potatoes and Brussels sprouts. The Brussels sprouts were easily mashed with a ladle. Additional plates were prepared with grilled cheese that was cut into several pieces. During an interview on 5/13/25 at 2:28 P.M., Dietary Aide K said the residents with mechanical soft diet orders were served turkey that was ground up. Dietary Aide K was not sure if they can eat meat. There are five residents on the third floor and two residents on second floor who were on a mechanical soft diet. During an interview on 5/13/24 at 2:50 P.M., [NAME] L said the residents on a mechanical soft diet were served grilled cheese. Review of the facility's menu, showed: -No menu information for renal diet; -No menu information for mechanical soft diet; -No alternate meal information. 3. During an interview on 5/16/25 at 9:27 A.M., the Dietary Manager said she expected staff to read every ticket. The Dietary Manager was aware residents on a mechanical soft diet were served grilled cheese. Grilled cheese is not appropriate for mechanical soft. The cook did not know it was not appropriate. The residents should have been served what was on the menu. They are expected to put the food into a blender. 4. During an interview on 5/16/25 at 12:26 P.M., the Administrator said she expected staff to follow diet orders. They can substitute, but there is a process for that. They would need approval from the dietician and log it. Grilled cheese is not an appropriate food for mechanical soft. It sounds like finger food, not mechanical soft.

Based on observation and interview, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution when staff failed to keep the kitchen equipment and floors clean, free of dust, grease, and grime. Additionally, the facility failed to keep soap dispenser in the main kitchen filled. These deficient practices had the potential to affect all residents who consumed food from the facility's kitchen. The sample was 10. The census was 97. Review of the facility's Nutritional Service Sanitation policy, revised 11/21/24, showed: -Policy: Nutritional service shall ensure a clean and sanitary work environment; to promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety; -Responsibility: Dietary Aide, Dietary Cook, Registered Dietitian, and Dietary Manager; -Procedure: -Personnel shall be responsible for daily, weekly, and monthly cleaning assignment as determined by the dietary manager and/or his/her designee; -Cleaning assignments may include but not limit to dining room tables, equipment, cabinets, storage areas, walls, food service-related carts, and refrigeration units. Frequency of completion shall be in conjunction with food safety regulation and with consideration of manufacturer guidelines; -Cleaning of equipment condensers, lights, vents/fans, ceiling, ice machine, etc. shall be completed by the maintenance department as determined by the Administrator and in accordance to meet minimum standards of Federal, State, and Local guidelines and ordinances governing food service; -Equipment shall be cleaned, sanitized, delimed, etc. in accordance with manufacturer recommendations. Review of the facility's Daily Kitchen Checklist, (no date) showed: -Daily or after each use: -All dishes, pots, pans, and utensils are cleaned and stored properly after each meal and snack; -All work counters/tables are cleaned and sanitized after use, to include prep table/counter; -Steam table is cleaned and sanitized after each use; -Floors swept and mopped daily; -Clean steamer and steam table after each use; -All hand sinks cleaned and restocked. Review of the facility's Weekly Kitchen Checklist, (no date) showed: -Clean pantries, shelves, and food canisters; -Polish all stainless-steel surfaces. Review of the facility's Monthly Kitchen Checklist, (no date), showed: -Underneath all prep stations deep cleaned; -Clean all baseboards; -Floors deep cleaned; -Underneath cook's area deep cleaned. Review of the facility's Essential Functions of Dietary Cook, revised 5/2022, showed: -Maintain a clean and organized kitchen; -Perform all other tasks and duties as assigned. Review of the facility's Essential Functions of Dietary Aide, revised 5/2022, showed: -Maintain tray line in a clean, neat, and organized manner; -Put clean dishes and utensils away; -Mop floors as scheduled and as necessary; -Perform special cleaning duties as assigned by the dietary supervisor; -Always observe infection prevention and control practices; -Perform other task and duties as assigned. 1. Observation of the main kitchen area on 2/3/25 at 10:23 A.M., showed the following: -Soot build up on the front part of the silver steam table; -Pots and pans stored underneath the steam table on shelves. Visible debris, dust, crumbs, and unknown dried material/substances on the shelves and knobs; -One of two cabinet drawers connected to the steam table contained one can opener, one small black pair of tongs, and one long fork, along with old torn, stained paper and dried black grime and debris in the very back of the drawer. During an interview with [NAME] E and [NAME] F on 2/3/25 at 10:32 A.M., [NAME] E said the equipment was supposed to be cleaned daily and he/she thought at least two times a week. [NAME] F said the kitchen should be cleaned every two to three days and/or as needed. Both [NAME] E and [NAME] F said they didn't know the cabinet drawer was there and never used the drawers on the steam table before. 2. Observation of the dish room on 2/3/25 at 10:18 A.M., showed the following: -Two white bait traps broken apart, small clear plastic bag, one wadded paper towel, soot and grime on the floor underneath the dishwasher/table; -Two small blue sauces saucers? filled with dried food and debris, one small black bowl, filled with dried food and debris, one small clear bowl, and one small clear four ounce cup on the floor in the corner of the kitchen. Additional food, trash, grime, and other debris visibly scattered on the floor in the same area as the dishes; -Green corrosion and brown splatters on the white wall just above the dishes and debris in the corner on the floor in the kitchen; -Missing ceiling tiles; -Large globs of black grime underneath the silver table in the kitchen near the wall and inside the floor grout. During an interview on 2/3/25 at 10:20 A.M., [NAME] E said everyone was responsible for cleaning the areas in the kitchen. He/She said whoever saw whatever was dirty, should clean it up. He/She said Dietary Aides were back in the dishwasher side of the kitchen most of the time. 3. Observation of the kitchen on 2/3/25 at 10:12 A.M., showed the soap dispenser at the white handwashing sink, near the microwave, was empty. During an interview on 2/3/25, 10:12 A.M., Dietary Aide C said he/she guessed the soap dispensers were refilled by dietary but thought there was none. During an interview on 2/3/25, 10:12 A.M., Dietary Aide D said housekeeping was responsible to put soap in the soap dispensers. He/She said they checked every morning but guessed it slipped their minds today. During an interview on 2/4/25 at 11:54 A.M., the Housekeeping Supervisor said housekeeping was responsible for refilling all soap dispensers. He expected housekeeping staff to refill the soap dispensers. 4. During an interview on 2/4/25 at 11:38 A.M., the Dietary Manager said the Dietary Aides and Cooks have a daily cleaning schedule. She expected them to follow the cleaning schedule every day. She said the kitchen equipment was supposed to be wiped down after each meal. Rubbish, debris or dishes should not have been on the floor in the corner or anywhere in the kitchen. She expected staff to follow the facility's Nutritional Sanitation policy. 5. During an interview on 2/4/25 at 1:30 P.M., the Administrator said she expected the kitchen to be cleaned daily, weekly, monthly, and as need. She expected soap to be in all dispensers, and all dietary staff to follow the facility Nutritional Sanitation policy and kitchen cleaning schedules. MO00248497

Based on observation, interview and record review, the facility failed to provide a clean, comfortable, home-like environment when staff did not keep one resident's (Resident #5) shower clean and free of feces and failed to clean his/her bathroom, prior to the resident's bathroom being locked for service repair. The facility failed to maintain resident showers in good condition and/or repair by not having all sides of the shower wall finished (Resident #4) and failed to replace/repair the cove base that had separated from the wall of the shower in another resident's room (Resident #1). Additionally, the facility failed to keep clean the community bathroom and clean utility room sink on the 3rd floor. The sample size was 10. The census was 97. Review of the facility's essential functions of the Housekeeping Supervisor, revised 05/2022, showed: -The Housekeeping Supervisor will oversee and schedule a team responsible for creating a clean and comforting home for residents in long-term care. In addition to directing, training, and leading the team, the supervisor will also participate in environmental functions including: -Sweeping, mopping, and other floor care including spill clean-up and regular maintenance; -Dusting and general pick-up of common areas; -Arrange furniture and disinfect surfaces; -Launder linens for residents; -Prepare bedding; -Generally clean furniture, equipment, fixtures, and hardware; -Other duties as assigned. Review of the facility's essential functions of Housekeeping Assistant, reviewed 05/2022, showed: -Sweep and mop floors; -Clean furniture, equipment, fixtures, and hardware; -Other duties as assigned. Review of the facility's essential functions of the Maintenance Supervisor, revised 05/2022, showed: -Report to the Administrator regarding the physical and structural conditions of the center and the status of work in progress; -Coordinate the repair of equipment or recommend the replacement of or additions to equipment or center as necessary; -Negotiate priorities, plan work schedules, make job assignments, order needed materials, supplies and parts; -Schedule and supervise maintenance repair work, alterations, remodeling, minor construction; -Maintain an inventory of parts and supplies to maximize the operational readiness of hospital building systems and equipment with due respect to the limitations of cost, regulations, and relative priorities; -Responsible for developing the annual operating budget, which includes equipment, materials, and supply needs; -Other duties as assigned. Review of the facility's essential functions of a Certified Nurse Aide (CNA), revised 01/2024, showed: -Assures all infection control protocols are followed at all times; -Follows all company policies and procedures; -Other duties as assigned. 1. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/24, showed the following: -Severe cognitive impairment; -Diagnoses included anemia (lack of blood), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), renal failure or end-stage renal disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids) and stroke; -Functional limitation in range of motion: impairment on one side, both upper and lower extremity; -Roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed): Supervision or touching assistance. Review of the resident's physician order, dated 4/30/24, showed an order for Lasix oral tablet 20 milligrams (mg), give 1 tablet by mouth 1 time a day related to hypertensive heart disease without heart failure. Observation of the resident's bathroom on 2/3/25 at 12:13 P.M., showed the door was locked. A formed dark colored substance/material (feces) and strings of hair inside of and to the left of the entrance of the shower and black/dark colored grout in between the dark and light gray shower tiles. The shower floor was wet inside. During an interview on 2/3/25 at 12:13 P.M., the resident the facility wouldn't fix the toilet, so they locked the door. Whenever he/she needed the bathroom, the resident said he/she had to use the bathroom in the common area on his/her floor. The resident said he/she went to the bathroom a lot and had had accidents because other people were in the bathroom when he/she needed to go. He/She wanted the bathroom in his/her room to work and didn't want to have to use bathrooms in other places. The resident said he/she was able to use his/her shower. He/She didn't know when or if housekeeping had cleaned it. The resident said he/she moved out once the bathroom toilet door was locked by maintenance for repair. During an interview on 2/3/25 at 12:53 P.M., the Maintenance Director said they were working on the toilet. The water constantly ran, and that was the only reason the bathroom had been locked. They were waiting for parts to come in. He said the bathroom had been locked for about a month. The water couldn't be shut off only in that room because the building system was old. The Maintenance Director expected the resident to have access to the toilet in his/her room but said there were other bathrooms on the floor the resident could use. The Maintenance Director could not provide documentation for any ordered parts or materials on order to repair the resident's toilet. During an interview on 2/4/25 at 10:06 A.M., the resident said he/she didn't like not being able to use the bathroom in his/her room. He/She said it bothered him/her because he/she had sudden urges to go the bathroom. He/She said it felt terrible to have to wait for other people to come out of the bathroom before he/she could go. Observation on 2/4/25 at 11:05 A.M., showed the resident's bathroom door unlocked, with feces behind the base of the toilet, dried brown substance/material splattered on the blue wall tile, and on the floor below it. During an interview on 2/4/25 at 10:07 A.M., Housekeeper B said he/she reported maintenance issues by completing a form and putting it in the mail slot for maintenance. The mail slot was downstairs. He/She said the main Housekeeper assigned to the floor was responsible to clean bathrooms, resident rooms, and common areas. During an interview on 2/4/25 at 12:21 P.M., the Maintenance Director said he had the parts to repair the resident's bathroom and he expected the bathroom to be fixed today and if not today, by the end of the week. He expected the resident to be able to use the toilet in his/her room. He said he didn't know the bathroom was soiled the way it was and said housekeeping was responsible to clean the bathroom. The Maintenance Director said he did visual walk throughs of resident rooms during the monthly bed inspections. The facility had an electronic system for maintenance concerns, but there were paper maintenance request forms available for staff and/or residents to use. He said there were mailboxes on each floor and near the maintenance office where the forms could be dropped in. He expected all equipment maintenance was responsible for to be in good working/functioning condition. He said they tried to promptly address maintenance concerns. During an interview on 2/4/25 at 1:30 P.M., the Administrator said she expected housekeeping to clean resident rooms and other assigned areas. She said the resident's bathroom had been locked because the water needed to be turned off to complete the work and the water was leaking down to the 1st floor. The work required a complete water shutoff and it had been too cold to do that. The Administrator thought the bathroom had only been locked a couple of weeks. She expected the bathroom to have been cleaned before it was locked but said the way it looked didn't happen in one day. She said the Housekeeping Supervisor told her about the bathroom today. 2. Review of Resident #4's annual MDS, date 12/23/24, showed: -Cognitively intact: -No range of motion functional limitations upper or lower extremities; -Daily preference: very important to choose between a tub bath, shower, bed bath, or sponge bath; -Diagnoses included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problems), anxiety disorder, depression. Observation of the resident's shower on 2/3/25 at 11:50 A.M., showed the shower had no finished shower walls. Torn brown cardboard and cardboard like material was on the shower wall and covered a different layer of the shower wall. On some areas of the wall there was torn white paperlike material on top of the torn brown cardboard material. There was a disconnected white shower hose on the shower floor. The floor tiles were a mixture of dark and light gray. During an interview on 2/3/25 at 11:50 A.M., the resident said his/her shower didn't work and the shower didn't have any finished walls. He/She was disgusted for having to live there. He/She didn't like using the community shower because there was no privacy and he/she was afraid of germs and of getting a disease. The resident said he/she was particular about taking showers and being clean. During an interview on 2/3/25 at 12:53 A.M., the Maintenance Director said the resident's shower floor had been re-done and they needed to put in the shower walls to complete the work. He said the shower had been down for about two months. They had other issues in the building and that's why it had taken so long to complete. The Maintenance Director said they were waiting for curtains, rings for the shower curtain and handles. He said the resident could use the main shower in the common area to take a shower. They ordered privacy curtains for that shower but none of the privacy curtains had been put up yet in the community shower on 3rd floor. He had some in the pack and some on order. The Maintenance Director said he expected the resident to have access to the shower in his/her room. The Maintenance Director could not provide documentation for any ordered shower room materials on order. During an interview on 2/4/25 at 12:21 P.M., the Maintenance Director said he had one of his maintenance workers working on the shower today. He said the material was here. He expected all equipment that maintenance was responsible for to be in good repair and properly functioning. During an interview on 2/4/25 at 1:30 P.M., the Administrator said she didn't know the resident's shower was still not completed. She thought it was finished. She expected the resident's bathroom shower to be finished. 3. Review of Resident #1's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Daily preference: very important to choose between a tub bath, shower, bed bath, or sponge bath; -No range of motion functional limitations upper or lower extremities; -Asthma (condition in which a person's airway becomes inflamed, narrow, and swell, and produce extra mucus, which makes it hard to breath) and COPD. Observation on 2/4/25 at 10:12 A.M., showed the cove base separated from the base of the shower wall in the resident's room. He/She had a regular wooden high back chair with soft cushion inside of the shower being used as a shower chair. The resident said he/she used the chair for his/her showers. During an interview on 2/4/25 at 12:21 P.M., the Maintenance Director said he didn't know the cove base had fallen down in the resident's shower. He said the facility had the materials available to the cove base. He did monthly visual walk-through of rooms. He expected the resident's shower to be in good repair and working properly. They try to promptly address concerns. During an interview on 2/4/25 at 1:30 P.M., the Administrator said she didn't know the cove base in the resident's shower was in disrepair. She said she had seen some other places in the building before with that issue, so she had materials ordered. She knew who was assigned to work on the cove base. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) all said the facility had plenty of shower chairs and thought the resident had put the regular cushioned chair in his/her shower. 4. Observation on 2/3/25 at 10:42 A.M., showed the bathroom across from/near room [ROOM NUMBER] had brown substance/material smeared on the toilet seat and no hand soap in the soap dispenser. Observations of the 3rd floor on 2/3/25 at 11:18 A.M., showed: -The clean utility room had sink without a faucet, contained dried trash, corn, and other debris; -A strong/offensive urine odor near the nurse station and room [ROOM NUMBER]; -The common bathroom, across from room [ROOM NUMBER] had dark yellow colored urine and formed feces inside the toilet, with toilet seat raised. A very strong smell of ammonia filled the bathroom and an ammonia odor seeped into the hallway. There was no soap in the soap dispenser. During an interview on 2/3/25 at 11:26 A.M., Licensed Practical Nurse (LPN) A said whomever walked past the bathroom and observed it was dirty/soiled was responsible to flush the toilet and/or clean the bathroom. Observation showed he/she stood at/near/in front of the entrance of the open bathroom door and looked inside as he/she put his/her gloves on to go into the dirty bathroom. During an interview on 2/4/25 at 10:30 A.M., the Administrator said some of the residents do mean things to the third floor bathroom. 5. During an interview on 2/4/25 at 11:54 A.M., the Housekeeping Supervisor said it was housekeeping's responsibility to clean the resident bathrooms and the bathrooms in the hallway. When housekeeping staff first come to work, they clean all the resident rooms and then the hallway bathrooms, and showers. Those are the areas with the most traffic. Nursing was supposed to clean up any feces and urine that was not in the toilet with a bucket that was stored in the soiled utility room. Nursing staff were then supposed to tell the housekeeper so they could clean and sanitize the area. The Housekeeping Supervisor expected staff to follow all the facility's daily, weekly, and monthly cleaning schedules. 6. During an interview on 2/4/25 at 1:30 P.M., the Administrator said she expected housekeeping to clean resident rooms including showers and toilets and common areas. She expected staff to follow all of the facility's daily, weekly, and monthly cleaning schedules and maintenance to complete repairs timely and as needed and visually inspect resident rooms. MO00248497

Based on observation, interview and record review, the facility failed to ensure the safety of one of two sampled residents (Resident #1) when a cognitively impaired resident, whose diagnoses included schizophrenia and vascular dementia, left the building unaccompanied. Staff last saw the resident on 10/12/23 at approximately 11:00 P.M. The resident left pillows and clothing in a form under the blankets. Staff did not visualize the resident. Staff did not administer ordered morning medications or provide breakfast. On 10/13/23 at approximately 12:30 P.M., a nurse pulled the covers back, and saw the resident was not there. The resident was found on 10/13/23 at a homeless shelter. He/She tried to find a bus station, but became confused and went to the shelter. The census was 85. The Administrator was informed on 10/20/23 at 3:05 P.M., of an Immediate Jeopardy (IJ) past noncompliance which began on 10/13/23. The facility conducted an investigation and immediately in-serviced all staff on 10/14/23 regarding knowing a resident's location, scheduling door code changes, moving the resident to a secured unit and scheduling an appointment with the Nurse Practititioner. The IJ was corrected on 10/14/23. Review of the facility's Missing Resident/Elopement Policy, revised date 4/26/23, showed the following: -Policy: The Charge Nurse is responsible for knowing the location of their assigned residents. Residents who are participating in various programs such as physical therapy, recreational activities and dining, the employees in these programs will be responsible for the location of their participants; -Responsibility: All Employees, Nursing Administration, Director of Nursing (DON) and Administrator; Procedure: 1. It is the responsibility of all Employees to report any resident attempting to leave the premises, or suspected of being missing to the charge nurse immediately; 2. Should an employee discover that a resident is missing from the Facility, he/she should: -Determine if the resident is on authorized Leave of Absence/Pass and if not; -Make a thorough search of the building and premises. If not located; -Notify the Administrator and DON; -Notify the resident's legal representative; -Notify the attending physician; -Notify local law enforcement officials; -Provide search teams with resident identification information; -Complete an extensive search of the surrounding areas. 3. At any time in which a resident is determined missing, the following procedure will be followed: -Alert: The Supervisor/Charge Nurse will alert all other personnel by all-paging Code Gray (an overhead page that notifies all staff that one of the residents cannot be located). Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/4/23, showed the following: -Severe cognitive impairment; -No moods or behaviors; -No wandering exhibited; -Diagnoses of high blood pressure, dementia and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's Elopement Risk Evaluation, dated 9/9/23, showed the following: -Score of nine; -9-10 Moderate risk: Implement/Continue with interventions from the optional moderate risk or add and implement additional intervention in summary section. Review of the resident's care plan, undated, showed the following: -Focus: Resident is at risk for elopement; -Goal: Resident will have no episodes of elopement through next review; -Intervention: Encourage attendance in activities that provide physical exercise, musical entertainment or recreational activities that resident enjoys. Inform the Charge Nurse and Director of Nursing (DON) immediately of any attempts to exit the facility unsupervised. Make sure the resident is on a floor where all exits and doors leading to a stairwell are alarmed and redirect the resident away from exits. Resident to live on geri-psych floor. Review of the resident's Order Summary Report, dated October 2023, showed the following: -6/22/23, memantine HCI oral tablet 10 milligrams (mg) (treatment for dementia), give one tablet by mouth in the morning with related to vascular dementia; -6/22/23, quetiapine fumarate oral tablet 25 mg (treatment for schizophrenia) give one tablet by mouth one time a day; -8/1/23, divalproex sodium oral capsule delayed release sprinkle 125 mg (treatment for seizures), give two capsules by mouth three times a day related to unspecified convulsions; -8/7/23, amlodipine besylate oral tablet five mg (treatment for high blood pressure), give one tablet by mouth one time a day. Review of the resident's Medication Administration Record (MAR), dated 10/13/23, showed the following: -7:00 A.M. to 11:00 A.M., memantine HCI oral tablet 10 mg, showed a number five with staff initials; -8:00 A.M., divalproex sodium oral capsule delayed release sprinkle 25 mg, showed a number five with staff initials; -9:00 A.M., amlodipine besylate oral tablet 5 mg, showed a number five with staff initials; -9:00 A.M., quetiapine fumarate oral tablet mg, showed the number five with staff initials. Review of the resident's MAR charting symbols, showed the number five meant the resident was out of the building. Review of the resident's nurse's note, dated 10/13/23, showed the following: -4:23 P.M., a Code Gray was called at 12:34 P.M., a search of the entry building and perimeter completed. 100% of the doors were checked and were secured. A notification to the resident's guardian and physician was made. The video surveillances were reviewed and the resident was noted opening the patio door at 12:40 A.M. and jumping over the fence and running past the front door. A search team was sent out to look at the bus stations, homeless shelters and downtown area. The resident's room was searched and the bed was noted with clothing under the blanket to resemble as if a resident was in bed; -4:43 P.M., spoke with the resident's guardian and was informed the resident has a history of elopement and is normally located at local shelters and hospitals. Six local hospitals were contacted and the resident was not noted at any location. During an interview on 10/19/23 at 1:47 P.M., Certified Medication Technician (CMT) A said he/she was pulled to pass medications, including morning medications about 10:00 A.M. on 10/13/23, on the resident's floor which is the first floor. CMT A said when it came time to give the resident his/her medication, he/she could not find the resident. CMT A said he/she probably should have looked for the resident and then would have found out the resident was not in the building. CMT A charted the number five later in the evening as instructed by the Regional Nurse so there would not be blank spots on the MAR. During an interview on 10/20/23 at 11:52 A.M. Certified Nurse Aide (CNA) B said he/she was on the third floor and came down to the first floor to work from 11:00 P.M. to 7:00 A.M. 10/12-13/23. CNA B said he/she did see a body silhouette in the resident's bed, but did not see the resident's face. CNA B said he/she did rounds about every two hours and did not notice the resident get up during the rounds. He/She did not see the resident's face in bed. CNA B said he/she should have looked at the resident's face to ensure the resident was in bed. CNA B said he/she was inserviced on making sure the doors are secured and checking to see if you see the resident. During an interview on 10/20/23 at 1:23 P.M., Nurse D said he/she worked 7:00 P.M. to 7:00 A.M. (10/12-10/13/23) Nurse D said he/she last saw the resident approximately 11:00 P.M. on 10/12/23 walking from the elevator to his/her room on the first floor and the resident did not say anything. Nurse D said he/she left the first floor and went to the third floor. Nurse D said he/she was covering both floors as the nurse. CNA B was left alone on the first floor. Nurse D said during rounds, he/she would use his/her camera light to look in the rooms. Nurse D said he/she never went in the rooms to look at the residents. Nurse D said he/she did not know the resident was gone. The first floor is an unsecured floor. During an interview on 10/20/23 at 12:44 P.M., CNA C said he/she worked the 7:00 A.M. to 3:00 P.M. shift on 10/13/23 on the first floor. CNA C said he/she went into the resident's room to change the resident's roommate. CNA C said he/she looked over and saw a body silhouette in the resident's bed. CNA C said he/she did not see the resident's face. CNA C said the resident usually slept with the covers over his/her head. CNA C said he/she should have looked at the resident's face to ensure the resident was in bed. The resident did not express wanting to get out of the facility previously. During an interview on 10/23/23 at 10:45 A.M., CNA E said he/she does restorative duties and went to get the resident's weight on the first floor about the middle of the day on 10/13/23. CNA E went to the resident's room and pulled back the sheets and realized the resident was not there. CNA E reported this to the ADON immediately and a Code Gray was called. During an interview on 10/23/23 at 10:36 A.M., the Assistant Director of Nursing (ADON) said he/she came to work about 10:00 A.M. on 10/13/23. CNA E came to him/her and was looking for the resident. The ADON said they both went into the resident's room and realized the resident was not there. The ADON called a Code Gray about 12:00 P.M. Review of the resident's nurse's note, dated 10/14/23 at 12:00 P.M., showed the resident returned to the facility with staff. The resident initially was tearful stating he/she was happy to be back. The resident had no acute distress or discomfort noted. The nurse assisted the resident to a smoke break and asking how the resident managed to get out. The resident went over to the key pad and entered the security code. Once outside, this nurse asked the resident how he/she made it through or over the gate. The resident said he/she never left the facility and that he/she is just confused and does not remember leaving the facility. The resident insisted he/she never left the facility. The resident then contradicted him/herself by saying someone gave him/her a ride downtown so he/she could get a bus. During an interview on 10/20/23 at 10:08 A.M., the resident said he/she jumped the fence on the patio. The resident said he/she was trying to go to another state and see his/her family. The resident said he/she did not remember how he/she got out to the patio. Observation on 10/20/23 at 10:15 A.M., showed the first floor was an unsecured unit. An elevator to the ground floor showed approximately 40 steps to the door towards the patio. The second door to enter the patio was secured and needed a code to enter the patio. The DON entered the code to the door and it was approximately 20 steps to the approximate 10 foot fence. During an interview on 10/20/23 at 2:10 P.M., the Administrator and DON said there was a flaw in the system. The Administrator said going forward, staff are to physically see the resident's face and not assume the resident is in bed. The Administrator said previously there was no schedule of changing the door codes. They were only changed when the codes may have been compromised, meaning the residents may have figured out the door code. MO00226066

Based on interview and record review, the facility failed to keep residents free from physical abuse when Resident #2 and Resident #3 had a verbal altercation which escalated into a physical altercation during a smoke break. Two staff were present during the incident, which lasted approximately five minutes, and neither staff intervened. Resident #3 sustained an orbital (bones around the eyeball) fracture. The facility also failed to keep residents free from physical abuse when Nurse A poured a pot of cold coffee on Resident #1 when he/she became agitated and aggressive toward Nurse A. Nurse D was present and witnessed the incident but did not intervene. Nurse A returned to work the next day for an entire shift and worked on the same hall as Resident #1. The resident sample was 11. The census was 61. The administrator and regional nurse were notified on 11/4/22 at 1:48 P.M. of an Immediate Jeopardy (IJ) which began on 10/1/22. The IJ was removed on 11/11/22, as confirmed by surveyor onsite verification on 11/14/22. Review of the facility's Abuse Prevention policy, reviewed 4/28/21, showed: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; Definitions: Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident; Physical Abuse: -An employee purposefully beating, striking, wounding, or injuring any consumer; -In any manner whatsoever, an employee mistreating or maltreating a consumer in a brutal or inhumane manner; -An employee handling a consumer with any more force than is reasonable for a consumer's proper control. treatment, or management; Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation including staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/25/22, showed: -Cognitively intact; -Behaviors: None exhibited; -Diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), hypertension (high blood pressure) and chronic obstructive pulmonary disorder (COPD, lung disease). Review of Resident #2's care plan, in use during the survey, showed: -Focus: Resident has issues with boundaries and will often get in people's faces when he/she is upset or believes he/she is being misunderstood. The resident will yell and curse at staff when he/she is upset. 10/14/22: Actual resident to resident with aggression; -Goal: The resident will be receptive to redirection through the next review date; -Interventions: 10/14/22: Send to the emergency room (ER) for psychiatric (psych) evaluation and further evaluation. Group. Future appointment for the independent center, visits a couple of days per week, club house visits. 15 minute checks times 72 hours. Speak to the resident in a normal, firm tone when he/she gets up close when he/she is upset. Staff to redirect the resident and explain why his/her behavior is not acceptable. Review of Resident #2's progress notes, showed: -On 10/14/22 at 8:29 P.M., Nurse D was summoned to the smoke yard during the last smoke break due to Resident #2 arguing with Resident #3. Nurse E, on the third floor, witnessed the resident verbally and physically assault Resident #3. Nurse E stated he/she observed Resident #2 strike Resident #3 in the face several times. An ambulance was called for transportation. Nurse E said Resident #2 went to a local hospital. -On 10/15/22 at 5:45 A.M., the resident returned from the local hospital with no new orders; -On 10/17/22 at 12:57 P.M., the administrator documented that she spoke with resident regarding altercation. The resident was remorseful and set new goals to avoid potential problems in the future. The resident will call his/her sibling if he/she started feeling overwhelmed. The resident agreed to leave any area that Resident #3 was already occupying. Resident #2 agreed to have no contact with Resident #3 and both would be on 15 minute checks when Resident #3 returns. The resident expressed still wanting to connect with the independence center and eventually getting placement in one of their residential care facilities (RCF's). -On 10/17/22 at 5:03 P.M. the administrator documented Resident #2 went to his/her door accompanied by Resident #3. Both residents professed forgiveness. They requested that they be allowed to be in the same room. 15 min checks to continue. Review of Resident #3's admission MDS, dated [DATE], showed: -Cognitively intact; -Behaviors: None exhibited; -Diagnoses included hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), depression and COPD. Review Resident #3's care plan, in use during the survey, showed: -Focus: Resident has the potential to be physically aggressive. History of harm to others. 10/14/22: Actual resident to resident encounter without aggression with right orbital eye injury; -Goal: will not harm self or others through the review date. Will seek out staff/caregiver when agitation occurs through the review date; -Interventions: 10/12/22: Group, social services one to one, diversional activity, education when thoughts of anger occur and coping mechanisms addressed. 10/14/22: Send to ER for further evaluation, treatment to right eye daily until healed, room change to private room, monitor for signs and symptoms of fearfulness. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers and what de-escalates behavior and documents. Give as many choices as possible about care and activities. Observe/document/report as needed (PRN) any signs or symptoms of the resident posing danger to self and others. Psychiatric/psychogeriatric consult as needed. Review Resident #3's progress notes, showed: -On 10/14/22 at 8:49 P.M., Nurse D was summoned to the smoke yard due to the resident being physically assaulted by Resident #2 after verbally assaulting him/her. Nurse E said he/she she witnessed Resident #2 striking Resident #3 in the face several times. Assessment completed; Noted and observed bleeding to the left eyebrow. 911 was called and the resident was sent to the local hospital to be evaluated. Family member of the resident called. Message left on the voice mail; -On 10/16/22 at 1:56 A.M., the resident was discharged to a sister facility with medication reconciliation record via an ambulance company, accompanied by two attendees; -On 10/17/22 at 5:06 P.M., the administrator met with the resident upon his/her return from the sister facility. He/she stated he/she did not want to press charges against the other resident. The resident stated he/she may have provoked the situation. Both residents professed to be friends from the streets and that there are no hard feelings. Both residents placed on 15 minutes checks times 72 hours; Review of Resident #3's hospital discharge paperwork dated 10/15/22, showed diagnoses of closed fracture of left orbital floor and traumatic iritis (inflammation of the iris (the circular pigmented membrane that surrounds the pupil.)). Review of the facility's investigative summary, dated 10/15/22, showed: -Incident involving Resident #2 and Resident #3: -On 10/15/22 at approximately 8:00 PM, staff witnessed during smoke break, Resident #2, unprovoked punched Resident #3 on the left side of his/her face. Staff immediately separated residents and the charge nurse assessed Resident #3 for injury; pain/skin evaluations were completed with noted left orbital edema. Physician, resident representative, and Department of Health and Senior Services (DHSS) were made aware of the incident. An investigation was initiated with the following completed immediately: physician and resident representative notification, Resident #3 was sent to emergency room (ER) for evaluation and treatment, Resident #2 was sent to ER for psych evaluation and treatment, administrator and DHSS notification, pain/skin evaluation completed, physician order sheet (POS) reviewed, nurse's notes reviewed, care plan/MDS reviewed, appropriate staff interviewed; -Upon completion of the investigation the facility substantiated the altercation did occur. During interviews with the residents, including Resident #2 and Resident #3, Resident #2 said Resident #3 said some bad stuff about his/her father. During an interview with Resident #3, he/she said, he/she did in fact say some things about Resident #2's family. Social Services was to conduct 1:1 visits with both residents. Interventions have been put into place to prevent further occurrences. Residents #2 and #3 remained at their baseline and staff will continue their plan of care. Appropriate interventions have been put in place to prevent further occurrences. During an interview on 10/28/22 at 3:10 P.M., Resident #2 said this was self-defense. It was a misunderstanding with Resident #3 talking about his/her dad. He/she did not know Resident #3 before this incident. Resident #3 swung on him/her first. He/she hit Resident #2 in the jowl. They sent both of them out and they both came back the same night. The two residents get along now. During an interview on 11/14/22 at 4:05 P.M., Resident #3 said there was an altercation between him/her and Resident #2. Resident #2 jumped on Resident #3. No one broke up the fight. There were two activities staff present. They were trying to say stop. Resident #2 kept going toward him/her, but no one grabbed him/her or intervened. Staff told him/her that they would have stopped it, but they were told not to stop fights. The fight went on for about three minutes. Resident #3 now has a fractured eye. Resident #2 eventually stopped hitting him/her. Resident #3 slipped and fell . He/she was on the ground the entire time Resident #2 was hitting him/her. Resident #3 said he/she did not fight back because he/she did not want to get in trouble. He/she and Resident #2 have made amends and are okay now. During an interview on 10/28/22 at 1:50 P.M., Resident #11 said he/she witnessed the resident to resident altercation between residents #2 and #3. The incident may have happened about 7:30 P.M.-8:00 P.M. He/she does not smoke but went outside to get some fresh air. He/she did not know exactly what happened or who started the fight. There had been an argument and it got out of control. Resident #2 jumped up on the table, then jumped off of it, and then Resident #2 and Resident #3 started going at it. One resident was going to break it up, but staff told him not to and to leave it alone. A staff member (maybe an aide) said that was enough, and stopped the fight. During interviews on 10/28/22 at 1:57 P.M. and 11/3/22 at 11:53 A.M., AA B said he/she was at work when the resident to resident altercation happened between Resident #2 and Resident #3. The altercation happened during a smoke break on the patio. He/she was at the front table, so he/she really could not hear what the residents were saying. He/she and AA C heard yelling. They walked down to the end of the patio to see what the yelling was about. When the yelling got a little more aggressive, that's when he/she and AA C intervened. He/she did not see who started it. He/she just saw the altercation. It got too aggressive for him/her, so he/she grabbed another nurse, Nurse D. He/she was able to get the residents separated. The residents fought for about five minutes because he/she had to run and get Nurse D. The front desk staff person called 911. When he/she returned, they weren't fighting anymore. Nurse D took Resident #2 upstairs and he/she and AA C stayed out on the patio with Resident #3. Resident #3 had a puffy eye. Both residents were sent out. He/she has been CPI certified for seven months, and the certification is still good for a year. If a fight breaks out and even if you are not CPI certified, you are still expected to intervene. You try to calm them down and separate them as soon as possible. No residents to his/her knowledge tried to break it up. Any issues of abuse and neglect are reported to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) as soon as it happens. During an interview on 11/2/22 at 10:59 A.M., AA C said he/she had been employed at the facility for two months. He/she is familiar with Resident #2 and Resident #3. Resident #2 had no prior aggressive history of which he/she was aware. Resident #3 never had any prior aggressive issues either and had been there about two to three weeks. The incident occurred outside. The residents were fine at first, sitting together, talking and socializing. The two residents began arguing. Resident #2 got in Resident #3's face, and they argued back and forth. Resident #3 told Resident #2 to stop putting his/her finger in his/her face. Resident #2 stood up on the bench. He/she was cussing Resident #3 out and Resident #3 flinched at him/her. Resident #2 jumped down off the bench. One thing led to another, and the two residents started fighting. When the fight started, the staff did not intervene. None of them had their CPI training so none of them could do anything to stop it. Eventually the residents stopped fighting. The fight went on for five minutes at the most. After they stopped fighting, AA C went to check on Resident #3 because Resident #2 beat him/her up pretty bad. Resident #3 had to go to the hospital because his/her eyeball was leaking pretty badly. Some of the nurses called the ambulance immediately. Resident #2 was taken to a local hospital, but he/she came right back. He/she thinks AA B was told not to intervene. AA C was going to try to break it up, but somebody (does not remember who) told him/her not to break it up because he/she did not have his/her CPI training. He/she didn't think it was a rule, but was told that if they don't have CPI training, to not break up fights. During an interview on 11/3/22 at 7:39 A.M., Nurse D said he/she is familiar with both residents, but he/she was not around them when the altercation started. The incident happened close to 7:00 P.M., because this was the last smoke break. The staff down there at the time were Nurse E, who was smoking outside the front entrance and AA B and AA C. Nurse D was paged to the smoking area and went to see what was going on. When he/she got there, the fight was over. He/she did not hear any conversation about what AA B and AA C did regarding breaking up the fight. If residents fight, staff are expected to break up the fight. They will separate the residents, each one will go to a separate area, and then will report it to the administration. After the incident, Resident #2 and Resident #3 were sent to the hospital. Nurse D just had the CPI course about two or three weeks ago. He/she would not say he/she was familiar with CPI because he/she does not think any of the staff knows it. He/she does not know if any of the staff present during the fight were CPI certified. They did have CPI training last month on 10/18/22 and 10/19/22. Even if staff are not CPI certified, they are expected to break up fights because that is part of abuse training. Staff are still expected to break up residents, separate them and report the incident within two hours. During an interview on 11/4/2022 at 10:08 A.M., Nurse E said on the day of the incident, he/she was in the front of the building taking a smoke break when he/she heard a commotion. He/she looked around and he/she saw the residents in a smoking area. He/she saw Resident #2 fussing,cussing and threatening Resident #3. He/she then saw Resident #2 stand up on the table bench. Then he/she got down off the table, ran and punched Resident #3, hitting him/her in the face. Then Resident #3 fell . Resident #2 continued hitting and punching Resident #3. Resident #3 did not fight back at all. It blew up; Resident #2 was in a full blown rage. He/she wasn't going to stop. The fight went on for approximately five to ten minutes. Nurse E told the receptionist to call code purple (resident behavior call). He/she called for help for more staff to come out. Two were already out there. AA B and AA C were telling Resident #2 No. Both AA's tried to intervene. They moved closer, telling Resident #2 to stop and calm down. They told the other residents to go inside of the building. At that time, some of the other staff members came out. Nurse E also had the receptionist call 911. When there is a fight, Nurse E said he/she is confused on whether to intervene. Some staff told him/her when residents are fighting, you are not supposed to get involved. They call for back up and call for police. They intervene by trying to break them up. They took a CPI class last week. Four CPI classes have been offered recently. In the CPI class, they were told what they could and could not do. During interviews on 10/28/22 at 12:30 P.M. and on 11/2/22 at 3:07 P.M., the administrator said the residents were never roommates. Staff sent Resident #3 to the hospital for evaluation, but he/she was sent right back. He/she had a black eye, and maybe a bruise or two. An x-ray was completed on Resident #3's face. He/she had a fracture of the orbital bone. He/she was hit only with Resident #2's fist. The incident happened during a smoke break. The two residents know each other from the community. When they first realized they knew each other, the two residents hugged. There were no issues prior to the fight. Resident #3 said something about Resident #2's dad. Resident #3 told the administrator, that may have caused the fight, and he/she should have kept his/her mouth shut. The staff did break up the fight. She did not know exactly how long the fight lasted. It was over so quickly. Resident #2 went after Resident #3 and punched him/her. The fight broke up naturally. As staff went toward the residents, the fight broke up. It was her expectation for the staff to break up the fight. She would expect for the staff to do everything in their power to break it up, short of getting beat up themselves. It is the expectation for staff to break up or intervene on resident to resident altercations, but AA B is small . The staff called for help because they wanted some men to come out. She did not think AA C was someone who would break up a fight. AA B did what the administrator expected him/her to do, which is to call for help, a code purple. With a code purple, staff drop what they are doing and respond. Staff called for help and the front office called 911. She knew staff called for Nurse D. There is not a policy for all staff to be CPI certified, but she would like them to be. This is just her goal due to the population they serve. Resident #2 and Resident #3 are best friends now. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Cognitively impaired; -Behaviors: None exhibited; -Diagnoses: schizophrenia, diabetes, chronic obstructive pulmonary disease (COPD) and epilepsy (seizure disorder). Review of the resident's care plan, in use during the survey, showed: -Focus: Resident has the potential to be physically aggressive. 4/27/22: Resident slapped another resident, related to the resident making a hand gesture towards him/her. 4/28/22: Resident involved in resident to resident altercation; -Goal: The resident will have less than three episodes a month of aggressive behavior through the next review date; -Interventions: 4/27/22: Notify administration, legal guardian, DON, DHSS of allegation. Notify psych, notify medical director, skin/pain evaluation. 4/28/22: Notify administration, legal guardian, DON, DHSS of allegation. Notify psych, notify medical director, skin/pain evaluation. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Observe/document/report as needed any signs and symptoms of resident posing danger to self and others. Psychiatric/Psychoneurotic consult as indicated. When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress, engage calmly in conversation, if response is aggressive, staff should walk away. Review of the resident's progress notes, showed: -On 10/2/22 at 1:03 P.M., staff documented the resident remained on incident follow up (IFU) from having an altercation with Nurse A yesterday. No complications from the incident; -On 10/5/22 at 1:12 P.M., Social Services (SS) documented he/she spoke with the resident regarding the altercation with Nurse A. SS asked the resident if he/she felt safe and he/she said yes, the nurse was being mean. The resident was reminded of his/her rights (to be treated with respect and the right to be free from abuse). SS was to follow up; -No documentation regarding the incident on 10/1/22 following the altercation with the staff member; -No documentation regarding notification to DHSS. Review of the facility's investigative summary, dated 10/5/22, showed: -Allegation regarding Resident #1 and Nurse A: -On 10/5/22, staff reported that the resident attacked Nurse A on Saturday 10/1/22. An investigation was initiated with the following completed immediately: Administrator and DHSS notified, staffing agency notified and Nurse A was placed on the do not return (DNR) list, skin assessments and pain evaluations completed; physician order sheet (POS) reviewed, nurse's notes reviewed, care plan/MDS reviewed, appropriate staff and appropriate residents interviewed; -Upon completion of the investigation, the facility determined that resident had attacked Nurse A. Nurse A had in fact poured a cold carafe of coffee on the resident to try to get the resident off of him/her. During interviews, the resident was unable to articulate any parts of the altercation, just shaking his/her head. Nurse A said the resident lunged toward him/her trying to grab him/her. He/she tried to get away from the resident, and when he/she could not, he/she grabbed the coffee and poured it on the resident. He/she was scared and knew the coffee was cold. Skin and pain assessments were conducted by Nurse D with negative findings. Video surveillance was unable to be reviewed. As a result of the investigation, appropriate interventions were put in place to prevent further occurrences. Further review of the residents medical record, showed: -On 10/1/22: skin assessment completed which yielded negative results; -On 10/1/22: pain assessment completed which yielded negative results. Review of Nurse A's agency time sheet, showed; -On 10/1/22, hours worked: 7:00 A.M. 3:00 P.M.; -On 10/2/22, hours worked: 7:00 A.M. 3:00 P.M. During an interview on 10/5/22 at 12:28 P.M., the administrator said this morning in the morning meeting, she heard rumors going around that over the weekend there was an incident involving staff to resident abuse with Nurse A and Resident #1. Based on what she heard, she had corporate give her access to possible video footage, which she viewed. Nurse A hit the resident with a coffee pot. They are trying to get into contact with Nurse A. The administrator said the first thing she did was call the staffing agency company that he/she works for to stop him/her from going to other places. When the resident went toward Nurse A, he/she hit the resident with the coffee pot. There was an opening on both sides of the nurses' station, and Nurse A could have removed him/herself. There was no excuse for what happened. The incident happened on 10/1/22. She is not sure who witnessed the incident. She just found out about the incident minutes before this surveyor walked into the building. During an interview on 10/11/22 at 10:43 A.M., Nurse A said he/she worked for a local staffing company. He/she had been working the night shift at the facility for a couple of months. He/she is familiar Resident #1. On 10/1/22, before the incident, the resident had asked for Tylenol about 2:30 P.M. He/she told the resident that his/her certified medication technician (CMT) was on break. He/she didn't have the key and when the CMT returned, he/she would give him/her the medication. The CMT cart was locked. The resident came back around about 2:45 P.M., and again asked for the Tylenol. He/she told the resident again that the CMT still had not returned, and he/she did not have the key. By this time, the resident was upset. Nurse A was giving report to Nurse D, who was the nurse who was relieving him/her. He/she was telling Nurse D what was going on with the resident, and then the resident reached over the nurses' station and grabbed and scratched Nurse A's arm. Nurse A put a chair between them. The resident continued grabbing at him/her. He/she couldn't get away because the resident was in front of him/her. He/she had a chair blocking in front of him/her to keep a barrier between them. Nurse D was behind Nurse A. Nurse A saw the coffee pot and he/she poured coffee on him/her. The coffee was not hot, but he/she knew it was not right. Another resident saw Resident #1 attacking him/her, and he/she came and grabbed the resident and pushed him/her. That is when Nurse D decided to intervene with the resident and break it up. Then Resident #1 attacked Nurse D. At that time, Nurse A called the Assistant Director of Nurses (ADON) but got her voicemail, and then he/she called the administrator. The administrator said she was dealing with another incident and asked him/her if he/she could just write a statement and stick it under her door. The next day, he/she returned to work because he/she was scheduled to work. He/she came to work and they told him/her that he/she was the only nurse in the building. The incident happened on Saturday, 10/1/22 at about 2:48 P.M. He/she returned to work on Sunday and worked 7:00 A.M. to 3:00 P.M. He/she called the administrator on Sunday, 10/2/22 and told her that he/she was the only nurse in the building, and the administrator gave him/her a bonus for being the only nurse there. When he/she worked on 10/2/22, the resident asked Nurse A for Tylenol. Because he/she didn't want the same thing to happen, he/she had the Tylenol ready. Nurse A was unaware that it was an issue for him/her to work from 10/2/22 until 10/5/22, when he/she received a call from the staffing agency. The staffing agency told him/her that they had a received a report of abuse by the facility, and that he/she was fired. During an interviews on 10/5/22 at 3:13 P.M. and 10/28/22 at 2:50 P.M., Nurse D said he/she was at work the day of the incident, 10/1/22. His/her shift begins at 3:00 P.M., and he/she came in 15 minutes early, so the incident happened about 2:45 P.M. The resident came to the nurses desk and asked Nurse A for some Tylenol. Nurse A told the resident that the CMT was off the floor with the key so he/she didn't have access to the medication. The resident was persistent and returned again. At that time, Nurse A repeated that he/she the CMT is off the floor and that he/she could not give the resident anything. The resident then started calling Nurse A curse words and then Nurse A called the resident curse words back. At that point, the resident was highly upset, and Nurse A was highly upset, so Nurse D came around the resident to approach Nurse A. Nurse D was in the middle of them. He/she saw Nurse A get the coffee pot. Nurse D said he/she took a chair and wedged it between the resident and Nurse A to diffuse the situation. Nurse A poured coffee on the resident. He/she did not notice any hitting but knew Nurse A poured coffee on the resident. Nurse A made the statement that he/she poured coffee on the resident to get the resident off him/her. The resident never went toward Nurse A. Nurse D did not recall what happened after that. He/she reported the incident to the administrator. Nurse D said any abuse issues are to be reported within two hours. Abuse and neglect incidents are reported by way of chain of command, but since the administrator was in, he/she called her first. During an interview on 10/28/22 at 3:00 P.M., Nurse E said he/she was at work on 10/1/22 when Nurse A and the resident had the altercation. The incident happened at the change of shift. He/she was not on the same floor as Nurse A and the resident. He/she said Nurse A told him/her about the incident. Nurse A showed him/her a couple of scratches on his/her arm. Nurse A told him/her the resident scratched him/her and Nurse D on the arms, and that the resident had cursed him/her out. After the incident, Nurse A called the administrator and he/she said he/she was going to call the former DON at that time. Nurse E said any abuse and neglect situations have to be reported right away. The staff involved is sent home. Nurse A was not sent home. He/she was on his/her way out anyway since it was the end of Nurse A's shift. Nurse E told Nurse A that he/she could not return to work until he/she talked to management. Nurse A returned to work the next day. He/she knew Nurse A was scheduled for the weekend. He/she assumed whoever had talked to Nurse A had told him/her that he/she could not return back. With abuse cases, the person cannot return to work until the investigation is finished. During an interview on 11/2/22 at 10:30 A.M., the ADON said she was not at work on 10/1/22 during the time Nurse A and the resident had their altercation. No one contacted her when the incident happened. She was out and found out about this incident when she returned to work. She looked at her notes and found out it was an incident with Nurse A and the resident. The clinical staff talked about it. She found out on Tuesday (10/4/22) when she returned to work. During interviews on 10/28/22 at 12:45 P.M., 11/3/22 at 1:48 P.M. and on 11/4/22 at 9:08 A.M., the administrator said she was unable to get the entire video of the altercation between Nurse A and the resident. She substantiated that the incident happened. Nurse A could have done something different. When there is a staff to resident altercation, they suspend the staff until they complete an investigation, always. The problem with this situation was there was miscommunication in the reporting of the incident. The second the administrator became aware of what was going on, she had one of her staff call the staffing agency and tell them to not send Nurse A back until the facility completed their investigation. They subsequently said to put him/her on the do not return list. Nurse A should not have worked the next day. The incident needed to be reported to her right away. Note: At the time of the investigation/abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the on-site 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. Note: At the time of the 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). MO00209061MO00207955

See Event ID MQ6T12. Based on observation, interview and record review, the facility failed to ensure staff followed physician orders by failing to administer accu-checks (blood sugar checks) and insulin, and by failing to notify the physician when blood glucose levels exceeded parameters and when a resident refused accu-checks and/or insulin. The facility identified 10 residents receiving insulin. Of those 10, two had blood glucose levels that exceeded physician orders/and or nursing standards of practice, in accordance with the Assistant Director of Nursing's (ADON) expectations for blood glucose parameters (Residents #20 and #19). Resident #20 was transferred to the hospital with a diagnosis of hyperglycemia (high blood sugar). In addition, two residents had inconsistent documentation of insulin and accu-check administration (Residents #2 and #28). The census was 58. Record review and interview during the survey showed the facility did not have a policy and procedure for insulin administration or care for the diabetic resident. 1. Review of Resident #20's Prospective Payment System (PPS) 5 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/27/22, showed: -admitted [DATE]; -Cognitively intact; -Rejection of care not exhibited; -Diagnoses included diabetes; -Insulin injections received seven of seven days. Review of the resident's electronic physician order sheet (POS), showed: -An order, dated 4/20/22, for insulin aspart solution (Novolog, an injectable rapid-acting insulin) 100 unit/milliliters (ml), inject 6 unit subcutaneously (under the skin) four times a day for diabetes, every six hours; -An order, dated 4/20/22, for insulin detemir solution (Levemir, a long-acting insulin) pen-injector 100 unit/ml, inject 32 units one time a day for diabetes, every morning. -Further review of the resident's electronic POS, showed an order, dated 5/4/22, to record accu-checks three times daily for diabetes. Review of the resident's electronic medication administration record (eMAR, used by the nurses at the time of administration), showed Novolog scheduled administration times at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M., with spaces for staff to input the resident's blood sugars prior to or upon administering Novolog. Review of the resident's April 2022 and May 2022 eMARs, blood sugar summary reports and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars with no documentation showing if the resident's physician had been notified: -On 4/29/22: -At 6:27 A.M., blood sugar 445 (normal 80-130); -12:00 P.M. and 6:00 P.M. blood sugars and Novolog not documented; -On 4/30/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugars and Novolog not documented; -On 5/1/22, blood sugars, Levemir, and all doses of Novolog not documented; -On 5/2/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugars and Novolog not documented; -At 6:09 P.M., blood sugar 575; -At 6:31 P.M., blood sugar 442; -On 5/4/22: -At 1:14 P.M., blood sugar 470; -At 6:00 P.M., blood sugar and Novolog not documented. Further review of the resident's May 2022 eMARs, blood sugar summary reports and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars and resident refusals of insulin with no documentation if the resident's physician had been notified, unless indicated: -On 5/5/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 8:35 A.M., blood sugar 425; -At 3:11 P.M., blood sugar 427; -At 6:00 P.M., blood sugar and Novolog not documented; -On 5/6/22: -Levemir not documented; -Blood sugars and all doses of Novolog not documented; -On 5/7/22: -At 7:04 A.M. and 9:15 A.M., blood sugar 408; -6:00 P.M. blood sugar and Novolog not documented; -On 5/8/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 2:10 P.M., blood sugar 440; -On 5/9/22: -Levemir not documented; -12:00 A.M., 6:00 A.M., and 12:00 P.M. blood sugar and Novolog not documented; -On 5/11/22; -12:00 A.M., blood sugar and Novolog documented as refused; -At 6:00 A.M., blood sugar 400; -At 12:00 P.M., blood sugar 414; -6:00 P.M. blood sugar and Novolog not documented; -On 5/12/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 8:50 A.M., blood sugar 431; -At 6:00 P.M., blood sugar and Novolog not documented; -On 5/13/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 8:53 A.M., blood sugar 423; -On 5/14/22: -12:00 A.M. blood sugar and Novolog documented as refused; -6:00 P.M. blood sugar and Novolog not documented; -On 5/15/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -12:00 P.M. Novolog documented as refused; -6:00 P.M. blood sugar and Novolog not documented -On 5/16/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -12:00 P.M. Novolog documented as refused; -At 1:09 P.M. staff documented the resident requested to be evaluated for hospice. Physician was notified and issued order for consult; -At 1:27 P.M. blood sugar 461; -At 3:05 P.M., staff documented the resident refused blood sugar check and insulin twice during the shift. Resident presented to nurse with complaints of tasting and smelling ammonia. Physician notified. Resident sent to the hospital for evaluation and treatment; -At 9:13 P.M., staff documented a call received from the emergency room nurse, who reported the resident's blood sugar was 438, and he/she was being treated with intravenous (IV) fluids. Review of the resident's hospital after visit summary, dated 5/16/22, showed the resident was diagnosed with hyperglycemia. Review of the resident's progress note, dated 5/16/22 at 9:56 P.M., showed staff documented the resident returned to the facility. Further review of the resident's May 2022 eMARs, blood sugar summary reports and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars with no documentation showing the resident's physician had been notified: -On 5/17/22: -Levemir not documented; -At 4:58 A.M., blood sugar 502; -6:00 A.M. and 6:00 P.M. blood sugar and Novolog not documented; -On 5/18/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 1:10 P.M., blood sugar 475; -On 5/19/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 9:01 A.M., blood sugar 473. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Has diabetes. Goal and interventions: blank; -The care plan did not identify resident-specific interventions to address the resident's diabetes, and did not identify the resident as having a history of refusing medications. During an interview on 5/19/22 at 9:19 A.M., the resident said he/she has been at the facility for a month. He/she is not getting his/her insulin consistently and staff is not checking his/her blood sugars regularly like they should. He/she will ask staff to check his/her blood sugar and they say they're busy and then never get back to him/her. During an interview on 5/20/22 at 12:04 P.M., the resident said he/she refused to take insulin one time because he/she felt nauseous. He/she denied any other refusals and said if that's what his/her record shows, it's not true. He/she knows not having insulin could make him/her very sick. The facility has run out of his/her medication. During an interview on 5/20/22 at 3:04 P.M., Pharmacy Technician K said the pharmacy does not have an active order for Resident #20's Novolog. The pharmacy dispensed the resident's Levemir on 4/20/22 and 5/12/22. Levemir is a 31 day supply, but it's only good for 28 days. Observation and interview on 5/20/22 at 2:04 P.M., showed Licensed Practical Nurse (LPN) A removed Resident #20's 10 ml vial of Levemir. Approximately 1/10 of the liquid remained in the vial. The vial was labeled with the resident's name, administration instructions, and date of 4/20/22. The LPN checked the nurse medication cart for Resident #20's Novolog and did not find it. He/she checked the refrigerator in the medication storage room behind the nurse's station and the certified medication technician (CMT) cart, but could not find the Novolog. He/she checked the computer, which showed the last dose of Novolog was administered earlier that day, at 1:55 P.M. LPN said ideally, the person who administered the last dose should reorder the insulin. If insulin or any medication is not administered for whatever reason, the nurse or insulin certified CMT should indicate the reason on the resident's MAR. There is a code to use if the resident's insulin needs to be held because of their blood sugar, if the resident refused, or if they are out in the hospital. There is no reason to leave it blank on the MAR. If a space is blank, you can't tell if the medication was administered or not. During an interview with Resident #20's physician on 5/26/22 at 9:58 A.M., Physician G said he would expect licensed nursing staff to follow physician orders. Insulin is administered to treat and prevent diabetic complications. He would expect the nurse to notify him of a resident's refusal of insulin. He would expect the nurse to notify him of blood sugars that are outside of normal parameters. Blood sugar parameters are usually in writing and they vary based on the individual. High blood sugars would be considered over 350 or 400, based on the individual. The facility might have notified him of Resident #20's refusal of insulin and high blood sugars, but he cannot recall specifically. It might be good for the facility to have written policies to provide guidance on blood sugar parameters. He would expect staff to document physician notification and resident refusal in the resident's medical record. 2. Review of Resident #19's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -Rejection of care not exhibited; -Insulin injections received seven of seven days. Review of the resident's medical record, showed diagnoses included diabetes with diabetic neuropathy (nerve damage) and cognitive communication deficit. Review of the resident's electronic POS, showed: -An order, dated 4/7/22, to check accu-checks before meals and at bedtime for diabetes. Notify physician over 400; -An order, dated 4/14/22, for insulin glargine solution (Lantus, a long-acting insulin) 100 unit/ml solution pen-injector, inject 55 units subcutaneously twice daily for diabetes. Review of the resident's April 2022 eMARs, blood sugar summary reports, and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars with no documentation if the resident's physician had been notified: -On 4/13/22, blood sugar checked three of four opportunities. At 2:43 P.M., blood sugar 451; -On 4/14/22, blood sugar checked three of four opportunities; -On 4/15/22, evening Lantus not documented; -On 4/16/22, blood sugar checked two of four opportunities. Morning and evening Lantus not documented; -On 4/17/22, blood sugar checked three of four opportunities. Evening Lantus not documented; -On 4/18/22, blood sugar checked three of four opportunities; -On 4/19/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/20/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/21/22, blood sugar checked three of four opportunities; -On 4/22/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/24/22, morning and evening Lantus not documented; -On 4/25/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/26/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/27/22, at 12:30 P.M., blood sugar 462; -On 4/28/22, blood sugar checked three of four opportunities. At 2:16 P.M., blood sugar 427. Evening Lantus not documented; -On 4/29/22, blood sugar checked one of four opportunities. Morning and evening Lantus not documented; -On 4/30/22, blood sugar checked three of four opportunities; -On 5/1/22, blood sugar checked two of four opportunities. Morning and evening Lantus not documented; -On 5/2/22, blood sugar checked three of four opportunities; -On 5/3/22, blood sugar checked three of four opportunities. Evening Lantus not documented; -On 5/4/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/5/22, blood sugar checked one of four opportunities. Evening Lantus not documented; -On 5/6/22, blood sugar checked two of four opportunities. Morning Lantus not documented; -On 5/7/22, blood sugar checked two of four opportunities. At 9:07 A.M., blood sugar 457. Evening Lantus not documented; -On 5/8/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/9/22, blood sugar checked one of four opportunities. Morning Lantus not documented; -On 5/11/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/12/22 and 5/13/22, blood sugar checked one of four opportunities. Evening Lantus not documented; -On 5/14/22 and 5/15/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/16/22, blood sugar checked three of four opportunities; -On 5/17/22, blood sugar checked two of four opportunities. Evening Lantus not documented. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Has diabetes; -Goals: Will be free from any signs/symptoms of hyperglycemia and hypoglycemia (low blood sugar). Will not have complications related to diabetes; -Interventions: blank; -The care plan did not identify resident-specific interventions to address the resident's diabetes. During an interview on 5/20/22 at 3:06 P.M., the resident said he/she receives his/her medications and insulin. The resident provided no response when asked about his/her blood sugars. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care exhibited daily; -Insulin injections received five of seven days. Review of the resident's medical record, showed diagnoses included diabetes. Review of the resident's electronic POS, showed: -An order, dated 6/25/22, for Lantus 100 unit/ml, inject 10 unit subcutaneously at bedtime for diabetes; -An order, dated 6/25/21, for Novolog 100 unit/ml, inject as per sliding scale scale: If 0 - 150 = 0; 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 8 units; 301 -350 = 10 units; 351 - 400 = 12 units, subcutaneously before meals for diabetes. Blood sugar over 400, notify physician. Review of the resident's eMAR, showed Novolog scheduled administration times at 6:00 A.M., 11:00 A.M. and 4:00 P.M. with spaces for staff to input the resident's blood sugars prior to or upon administering Novolog. Review of the resident's May 2022 eMARs and blood sugar summary reports, showed the following: -On 5/1/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/2/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/4/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/5/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/6/22, Lantus not documented. 6:00 A.M., 11:00 A.M., and 4:00 P.M. blood sugar and Novolog not documented; -On 5/7/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/8/22, Lantus not documented. 6:00 A.M. blood sugar and Novolog not documented; -On 5/9/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/11/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/12/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/13/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/14/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/15/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/16/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/17/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/18/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/19/22, 6:00 A.M. blood sugar and Novolog not documented. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Has diabetes; -Goal: Will be free from any signs/symptoms of hypoglycemia and hyperglycemia. Will have no complications related to diabetes; -Interventions included: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Observation and interview on 5/20/22 at 2:04 P.M., LPN A said he/she ordered Resident #2's Novolog earlier today because he/she did not have any. During the interview, the nurse ordered Resident #2's Lantus on the computer. He/she said the facility had plenty of Lantus on hand, just not Resident #2's. His/her last dose of Lantus was administered 5/19/22 at 9:21 P.M. 4. Review of Resident #28's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -No behaviors or rejection of care; -Diagnoses included diabetes. Review of the resident's care plan, undated, showed: -Focus: The resident has diabetes; -Goal: Will be free from any signs and symptoms of hyperglycemia through the review date. Will be free from any signs and symptoms of hypoglycemia through the review date; -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Fasting serum blood sugar as ordered by the physician. If infection is present, consult physician regarding any changes in diabetic medications. Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Monitor/document/report as needed any signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing (deep, rapid breathing), acetone breath (smells fruity), stupor, coma. Monitor/document/report as needed any signs and symptoms of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, staggering gait. Monitor/document/report as needed any signs and symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation. Offer substitutes for foods not eaten. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Wash feet daily with mild soap and water. Dry thoroughly. May use a light dusting powder or lotion. Do not apply lotion or powder between the toes. Review of the resident's April 2022 electronic physician order sheet (ePOS), included: -An order, dated 4/13/22, end date 4/28/22, for accu check with meals, notify the physician over 400, for diabetes; -An order, dated 4/28/22, end date 5/23/22, for accu check with meals, notify the physician over 400, for diabetes; -An order, dated 4/13/22, end date 5/13/22, to administer Lantus Solution 100 unit/ml , inject 100 unit, one time a day for diabetes. Review of the resident's medication administration record (MAR) for the dates 4/1/22 to 4/30/22, showed: -An order for accu check with meals, notify the physician over 400, for: diabetes -At 8:00 A.M., blank, one of seventeen opportunities; -At 12:00 P.M., blank, one of seventeen opportunities; -At 5:00 P.M., blank, eight of seventeen opportunities. -An order to administer Lantus Solution 100 unit/ml, inject 100 unit subcutaneously one time a day: -At 6:00 A.M., blank, seven of seventeen opportunities. -There was no explanation on the MAR showing why the accu checks and insulin administration were not done as ordered. 5. Review of the facility's in-servicing, dated 5/20/22, showed nurses and CMTs educated on diabetic protocols. Review of the facility's diabetic protocol in-service record for nurses, showed: -Subject: Residents should have parameters notify below and notify above. Snacks at bedtime. Notification to physician and resident representative of outside parameters, refusals. Storage and labeling of insulin. Ordering insulin and vials; -Policy reviewed: blank; -Title of staff performing in-service: Assistant Director of Nursing (ADON). Review of the facility's diabetic protocol in-service record for CMTs, showed: -Subject: Order insulin, add sliding scale, blood sugar parameters, notification to charge nurse, location of administration of insulin. 28 day usage, dating insulin vials, pens, reorder insulin; -Policy reviewed: blank; -Title of staff performing in-service: ADON. Review of the facility's missed medications in-service for nurses and CMTs, dated 5/20/22, showed: -Subject: Any medication not available in cart. Check for pharmacy for medications. Call pharmacy. Notify physician if medication not given; -Policy reviewed: Medication administration; -Title of staff performing in-service: ADON. Review of the facility's missed medication unavailable medication audit sheet in-service for nurses and CMTs, dated 5/20/22, showed: -Subject: Must be completed at end of shift; -Policey reviewed: Medication administration; -Title of staff performing in-service: blank. 6. During an interview on 5/23/22 at 10:05 A.M., LPN A said nurses and insulin certified CMTs can check blood sugars and administer insulin. The purpose of checking the blood sugar is to determine if a resident is hypoglycemic or hyperglycemic. Staff should follow physician orders for checking blood sugars. They should document blood sugars on the MAR. If there are no orders for checking blood sugars, but the resident has orders for insulin several times a day, the blood sugar should be checked. The standard nursing practice is to notify the physician if the resident's blood sugar is over 400 or under 70. Physician notification should be documented in the resident's medical record. If a resident refuses to take their insulin, staff should encourage them and educate them on its importance. Staff should try again later, a couple times, then document the refusal. The physician should be notified of ongoing refusals. The LPN was not sure if Resident #20 had a history of refusals. Residents #19 and #2 did not have a known history of refusals. 7. During an interview on 5/23/22 at 10:27 A.M., Registered Nurse (RN) D said nurses are responsible for checking blood sugars. Depending on the doctor, a resident may or may not have orders for accu-checks. If a resident receives insulin on a routine basis, it is standard nursing practice to check their blood sugar. The purpose of checking blood sugars is to see if a resident's blood sugar is too high or low. Normal blood sugar parameters are between 70 and 300. 300 is abnormal, but a blood sugar over 400 is a problem If a resident's blood sugar is over 400, it is nursing standard of practice to call the physician and ask them if they want to monitor the resident or administer medication. Physician orders can be customized to include specific parameters. Blood sugars should be documented on the MAR and the medial record. If a resident cannot receive medication for whatever reason, staff should document the reason on the MAR using the appropriate code. Staff should not leave a MAR blank because there is no way to tell what happened with the medication. If a resident refuses to take their insulin, staff should try again later and ask a few times. If the resident continues to refuse, staff should notify the physician. Staff should order another bottle of insulin when they open a vial or if they are halfway through one. All refusals should be documented in the resident's progress notes and care plan. 8. During an interview on 5/23/22 at 1:41 P.M., the ADON said insulin certified CMTs and licensed nurses are responsible for checking blood sugars and administering insulin. She would expect staff to follow physician orders for medication administration and accu-checks. The purpose of checking blood sugars is to get an accurate measure of the resident's glucose levels. Sliding scale insulin will have physician orders for accu-checks, and should have parameters for staff to notify the physician. Routine insulin that is not sliding scale might have a space on the eMAR for staff to input the resident's blood sugar, and in that case, the resident's blood sugar should be checked before administering insulin. Blood sugar parameters depend on the residents and there is no standard sliding scale. When there is no order specifying parameters to notify the physician, licensed nurses and insulin certified CMTs should refer to nursing standards of practice, which is to notify the physician of blood sugars over 400 or under 70. Staff should document insulin administration and accu-checks on the eMAR. If the resident is unable to take a medication, staff should document the reason why on the eMAR, using the appropriate code. There should not be blank spaces on the eMAR, because that would not indicate whether or not a medication was administered. If the resident refuses to take their medication, staff should try to encourage them to take it and attempt administering it later. If the resident continues to refuse, staff should notify the physician and document the refusal and communication in the resident's record. Initially, Resident #20 did not have orders for accu-checks. He/she approached the ADON about this a while ago and the ADON spoke with the resident's physician, who gave orders for accu-checks. The ADON found out Resident #20 refused to take his/her insulin on 5/16/22, when the resident was sent out to the hospital. The ADON was not aware the resident refused to take his/her insulin the days prior to 5/16/22. She would have expected staff to notify the physician of the resident's refusals. She was not aware the resident had not been getting his 12:00 A.M. and 6:00 A.M. doses of insulin. The blank spaces on the eMAR do not show if the insulin was not administered or if the resident refused. Seeing the pattern of the resident's missed medications might mean taking the medication at those times does not work for the resident. A care plan meeting should be held to educate the resident and discuss his choices, such as potentially taking medication at a different time. She was not aware of the resident's blood sugars over 400. She would have expected staff to notify the physician of this. She was not aware the pharmacy did not have an active order for the resident's Novolog. She would expect nurses to communicate physician orders to the pharmacy and will look into the resident's Novolog. She would have expected staff to follow Resident 19's physician order by notifying the doctor when the resident's blood sugars were over 400. Resident #2 should be getting accu-checks before his/her Novolog administration. Recently, the ADON identified an issue with accu-checks, insulin administration, insulin storage, ordering insulin, missed medications, and physician notification of blood sugars outside of parameters. The ADON in-serviced nurses and insulin-certified CMTs on accu-checks, insulin administration, insulin storage, ordering insulin, missed medications, and physician notification of blood sugars outside of parameters in February 2022. Copies of in-services were requested. Policies regarding insulin administration, accu-checks, and physician notification were requested. The ADON said the facility has a diabetic program covering all of this that she can print out. 9. During an interview on 5/23/22 at 2:52 P.M., the administrator said she would expect nurses to communicate physician orders to the pharmacy to ensure medications were on hand. She would expect staff to follow physician orders for medication administration and accu-checks, which should be documented on the MAR. If a medication cannot be given, staff should document the reason on the MAR. There should not be blanks on a MAR. If a resident refuses, staff should give them a while and try again later. If the resident continues to refuse, staff should document the refusal. For continued refusals, the physician should be notified. She would expect the nurse to notify the physician of blood sugars outside of parameters in accordance with nursing standards of practice. Resident #20 was usually pretty good about taking his/her insulin, but stopped taking his/her insulin for days and told the administrator he/she wanted to be put on hospice. The administrator tried explaining why taking the insulin was important. She isn't sure if nursing staff notified the physician of the resident's ongoing refusals, but they should have. Once in a while, Resident #19 might refuse things if he/she is in a mood, but most of the time, he/she is agreeable. Residents #19 and #20 can be re-approached at a later time. Care plans should identify resident-specific interventions for identified care areas. 10. During an interview on 5/23/22 at 4:27 P.M., the Regional Nurse Consultant (RNC) said the facility does not have a policy regarding a diabetic program or accu-checks. For checking blood sugars, different doctors have different parameters. Nurses should follow the basic procedures based on nursing standards of practice to notify the physician of blood sugars below 70 and above 400. In-servicing regarding blood sugars and insulin administration was provided. 11. During an interview on 5/24/22, 12:03 P.M., Physician H said he is the facility's medical director. Physician G works in the same practice and sees the residents in the facility. Physician H would expect licensed nursing staff to follow physician orders for obtaining accu-checks and administering insulin. The facility has protocols for blood sugar parameters. Nurses should follow physician orders for notifying the physician if a resident's blood sugars are outside of their specified parameters. If a resident does not have orders for specific blood sugar parameters, the nurse should rely on the facility's protocols. If the nurse is unsure of the facility protocols, they should notify the physician. If a resident refuses their insulin for consecutive sessions or days, the nurse should notify the physician and document the resident's refusals. If staff observe the resident has a pattern of refusal, they should notify the physician and the physician would talk to the resident about their medication. MO00200394 MO00200325 MO00200232

Based on observation, interview and record review, the facility failed to ensure staff followed physician orders by failing to administer accu-checks (blood sugar checks) and insulin, and by failing to notify the physician when blood glucose levels exceeded parameters and when a resident refused accu-checks and/or insulin. The facility identified 10 residents receiving insulin. Of those 10, two had blood glucose levels that exceeded physician orders/and or nursing standards of practice, in accordance with the Assistant Director of Nursing's (ADON) expectations for blood glucose parameters (Residents #20 and #19). Resident #20 was transferred to the hospital with a diagnosis of hyperglycemia (high blood sugar). In addition, two residents had inconsistent documentation of insulin and accu-check administration (Residents #2 and #28). The census was 58. Record review and interview during the survey showed the facility did not have a policy and procedure for insulin administration or care for the diabetic resident. 1. Review of Resident #20's Prospective Payment System (PPS) 5 day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/27/22, showed: -admitted [DATE]; -Cognitively intact; -Rejection of care not exhibited; -Diagnoses included diabetes; -Insulin injections received seven of seven days. Review of the resident's electronic physician order sheet (POS), showed: -An order, dated 4/20/22, for insulin aspart solution (Novolog, an injectable rapid-acting insulin) 100 unit/milliliters (ml), inject 6 unit subcutaneously (under the skin) four times a day for diabetes, every six hours; -An order, dated 4/20/22, for insulin detemir solution (Levemir, a long-acting insulin) pen-injector 100 unit/ml, inject 32 units one time a day for diabetes, every morning. -Further review of the resident's electronic POS, showed an order, dated 5/4/22, to record accu-checks three times daily for diabetes. Review of the resident's electronic medication administration record (eMAR, used by the nurses at the time of administration), showed Novolog scheduled administration times at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M., with spaces for staff to input the resident's blood sugars prior to or upon administering Novolog. Review of the resident's April 2022 and May 2022 eMARs, blood sugar summary reports and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars with no documentation showing if the resident's physician had been notified: -On 4/29/22: -At 6:27 A.M., blood sugar 445 (normal 80-130); -12:00 P.M. and 6:00 P.M. blood sugars and Novolog not documented; -On 4/30/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugars and Novolog not documented; -On 5/1/22, blood sugars, Levemir, and all doses of Novolog not documented; -On 5/2/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugars and Novolog not documented; -At 6:09 P.M., blood sugar 575; -At 6:31 P.M., blood sugar 442; -On 5/4/22: -At 1:14 P.M., blood sugar 470; -At 6:00 P.M., blood sugar and Novolog not documented. Further review of the resident's May 2022 eMARs, blood sugar summary reports and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars and resident refusals of insulin with no documentation if the resident's physician had been notified, unless indicated: -On 5/5/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 8:35 A.M., blood sugar 425; -At 3:11 P.M., blood sugar 427; -At 6:00 P.M., blood sugar and Novolog not documented; -On 5/6/22: -Levemir not documented; -Blood sugars and all doses of Novolog not documented; -On 5/7/22: -At 7:04 A.M. and 9:15 A.M., blood sugar 408; -6:00 P.M. blood sugar and Novolog not documented; -On 5/8/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 2:10 P.M., blood sugar 440; -On 5/9/22: -Levemir not documented; -12:00 A.M., 6:00 A.M., and 12:00 P.M. blood sugar and Novolog not documented; -On 5/11/22; -12:00 A.M., blood sugar and Novolog documented as refused; -At 6:00 A.M., blood sugar 400; -At 12:00 P.M., blood sugar 414; -6:00 P.M. blood sugar and Novolog not documented; -On 5/12/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 8:50 A.M., blood sugar 431; -At 6:00 P.M., blood sugar and Novolog not documented; -On 5/13/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 8:53 A.M., blood sugar 423; -On 5/14/22: -12:00 A.M. blood sugar and Novolog documented as refused; -6:00 P.M. blood sugar and Novolog not documented; -On 5/15/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -12:00 P.M. Novolog documented as refused; -6:00 P.M. blood sugar and Novolog not documented -On 5/16/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -12:00 P.M. Novolog documented as refused; -At 1:09 P.M. staff documented the resident requested to be evaluated for hospice. Physician was notified and issued order for consult; -At 1:27 P.M. blood sugar 461; -At 3:05 P.M., staff documented the resident refused blood sugar check and insulin twice during the shift. Resident presented to nurse with complaints of tasting and smelling ammonia. Physician notified. Resident sent to the hospital for evaluation and treatment; -At 9:13 P.M., staff documented a call received from the emergency room nurse, who reported the resident's blood sugar was 438, and he/she was being treated with intravenous (IV) fluids. Review of the resident's hospital after visit summary, dated 5/16/22, showed the resident was diagnosed with hyperglycemia. Review of the resident's progress note, dated 5/16/22 at 9:56 P.M., showed staff documented the resident returned to the facility. Further review of the resident's May 2022 eMARs, blood sugar summary reports and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars with no documentation showing the resident's physician had been notified: -On 5/17/22: -Levemir not documented; -At 4:58 A.M., blood sugar 502; -6:00 A.M. and 6:00 P.M. blood sugar and Novolog not documented; -On 5/18/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 1:10 P.M., blood sugar 475; -On 5/19/22: -Levemir not documented; -12:00 A.M. and 6:00 A.M. blood sugar and Novolog not documented; -At 9:01 A.M., blood sugar 473. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Has diabetes. Goal and interventions: blank; -The care plan did not identify resident-specific interventions to address the resident's diabetes, and did not identify the resident as having a history of refusing medications. During an interview on 5/19/22 at 9:19 A.M., the resident said he/she has been at the facility for a month. He/she is not getting his/her insulin consistently and staff is not checking his/her blood sugars regularly like they should. He/she will ask staff to check his/her blood sugar and they say they're busy and then never get back to him/her. During an interview on 5/20/22 at 12:04 P.M., the resident said he/she refused to take insulin one time because he/she felt nauseous. He/she denied any other refusals and said if that's what his/her record shows, it's not true. He/she knows not having insulin could make him/her very sick. The facility has run out of his/her medication. During an interview on 5/20/22 at 3:04 P.M., Pharmacy Technician K said the pharmacy does not have an active order for Resident #20's Novolog. The pharmacy dispensed the resident's Levemir on 4/20/22 and 5/12/22. Levemir is a 31 day supply, but it's only good for 28 days. Observation and interview on 5/20/22 at 2:04 P.M., showed Licensed Practical Nurse (LPN) A removed Resident #20's 10 ml vial of Levemir. Approximately 1/10 of the liquid remained in the vial. The vial was labeled with the resident's name, administration instructions, and date of 4/20/22. The LPN checked the nurse medication cart for Resident #20's Novolog and did not find it. He/she checked the refrigerator in the medication storage room behind the nurse's station and the certified medication technician (CMT) cart, but could not find the Novolog. He/she checked the computer, which showed the last dose of Novolog was administered earlier that day, at 1:55 P.M. LPN said ideally, the person who administered the last dose should reorder the insulin. If insulin or any medication is not administered for whatever reason, the nurse or insulin certified CMT should indicate the reason on the resident's MAR. There is a code to use if the resident's insulin needs to be held because of their blood sugar, if the resident refused, or if they are out in the hospital. There is no reason to leave it blank on the MAR. If a space is blank, you can't tell if the medication was administered or not. During an interview with Resident #20's physician on 5/26/22 at 9:58 A.M., Physician G said he would expect licensed nursing staff to follow physician orders. Insulin is administered to treat and prevent diabetic complications. He would expect the nurse to notify him of a resident's refusal of insulin. He would expect the nurse to notify him of blood sugars that are outside of normal parameters. Blood sugar parameters are usually in writing and they vary based on the individual. High blood sugars would be considered over 350 or 400, based on the individual. The facility might have notified him of Resident #20's refusal of insulin and high blood sugars, but he cannot recall specifically. It might be good for the facility to have written policies to provide guidance on blood sugar parameters. He would expect staff to document physician notification and resident refusal in the resident's medical record. 2. Review of Resident #19's admission MDS, dated [DATE], showed: -Moderate cognitive impairment; -Rejection of care not exhibited; -Insulin injections received seven of seven days. Review of the resident's medical record, showed diagnoses included diabetes with diabetic neuropathy (nerve damage) and cognitive communication deficit. Review of the resident's electronic POS, showed: -An order, dated 4/7/22, to check accu-checks before meals and at bedtime for diabetes. Notify physician over 400; -An order, dated 4/14/22, for insulin glargine solution (Lantus, a long-acting insulin) 100 unit/ml solution pen-injector, inject 55 units subcutaneously twice daily for diabetes. Review of the resident's April 2022 eMARs, blood sugar summary reports, and nurse's notes, showed inconsistent documentation of insulin administration and blood sugar checks, as well as the following blood sugars with no documentation if the resident's physician had been notified: -On 4/13/22, blood sugar checked three of four opportunities. At 2:43 P.M., blood sugar 451; -On 4/14/22, blood sugar checked three of four opportunities; -On 4/15/22, evening Lantus not documented; -On 4/16/22, blood sugar checked two of four opportunities. Morning and evening Lantus not documented; -On 4/17/22, blood sugar checked three of four opportunities. Evening Lantus not documented; -On 4/18/22, blood sugar checked three of four opportunities; -On 4/19/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/20/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/21/22, blood sugar checked three of four opportunities; -On 4/22/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/24/22, morning and evening Lantus not documented; -On 4/25/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/26/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 4/27/22, at 12:30 P.M., blood sugar 462; -On 4/28/22, blood sugar checked three of four opportunities. At 2:16 P.M., blood sugar 427. Evening Lantus not documented; -On 4/29/22, blood sugar checked one of four opportunities. Morning and evening Lantus not documented; -On 4/30/22, blood sugar checked three of four opportunities; -On 5/1/22, blood sugar checked two of four opportunities. Morning and evening Lantus not documented; -On 5/2/22, blood sugar checked three of four opportunities; -On 5/3/22, blood sugar checked three of four opportunities. Evening Lantus not documented; -On 5/4/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/5/22, blood sugar checked one of four opportunities. Evening Lantus not documented; -On 5/6/22, blood sugar checked two of four opportunities. Morning Lantus not documented; -On 5/7/22, blood sugar checked two of four opportunities. At 9:07 A.M., blood sugar 457. Evening Lantus not documented; -On 5/8/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/9/22, blood sugar checked one of four opportunities. Morning Lantus not documented; -On 5/11/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/12/22 and 5/13/22, blood sugar checked one of four opportunities. Evening Lantus not documented; -On 5/14/22 and 5/15/22, blood sugar checked two of four opportunities. Evening Lantus not documented; -On 5/16/22, blood sugar checked three of four opportunities; -On 5/17/22, blood sugar checked two of four opportunities. Evening Lantus not documented. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Has diabetes; -Goals: Will be free from any signs/symptoms of hyperglycemia and hypoglycemia (low blood sugar). Will not have complications related to diabetes; -Interventions: blank; -The care plan did not identify resident-specific interventions to address the resident's diabetes. During an interview on 5/20/22 at 3:06 P.M., the resident said he/she receives his/her medications and insulin. The resident provided no response when asked about his/her blood sugars. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Rejection of care exhibited daily; -Insulin injections received five of seven days. Review of the resident's medical record, showed diagnoses included diabetes. Review of the resident's electronic POS, showed: -An order, dated 6/25/22, for Lantus 100 unit/ml, inject 10 unit subcutaneously at bedtime for diabetes; -An order, dated 6/25/21, for Novolog 100 unit/ml, inject as per sliding scale scale: If 0 - 150 = 0; 151 - 200 = 3 units; 201 - 250 = 5 units; 251 - 300 = 8 units; 301 -350 = 10 units; 351 - 400 = 12 units, subcutaneously before meals for diabetes. Blood sugar over 400, notify physician. Review of the resident's eMAR, showed Novolog scheduled administration times at 6:00 A.M., 11:00 A.M. and 4:00 P.M. with spaces for staff to input the resident's blood sugars prior to or upon administering Novolog. Review of the resident's May 2022 eMARs and blood sugar summary reports, showed the following: -On 5/1/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/2/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/4/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/5/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/6/22, Lantus not documented. 6:00 A.M., 11:00 A.M., and 4:00 P.M. blood sugar and Novolog not documented; -On 5/7/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/8/22, Lantus not documented. 6:00 A.M. blood sugar and Novolog not documented; -On 5/9/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/11/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/12/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/13/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/14/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/15/22, Lantus not documented. 6:00 A.M. and 4:00 P.M. blood sugar and Novolog not documented; -On 5/16/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/17/22, Lantus not documented. 4:00 P.M. blood sugar and Novolog not documented; -On 5/18/22, 6:00 A.M. blood sugar and Novolog not documented; -On 5/19/22, 6:00 A.M. blood sugar and Novolog not documented. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Has diabetes; -Goal: Will be free from any signs/symptoms of hypoglycemia and hyperglycemia. Will have no complications related to diabetes; -Interventions included: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Observation and interview on 5/20/22 at 2:04 P.M., LPN A said he/she ordered Resident #2's Novolog earlier today because he/she did not have any. During the interview, the nurse ordered Resident #2's Lantus on the computer. He/she said the facility had plenty of Lantus on hand, just not Resident #2's. His/her last dose of Lantus was administered 5/19/22 at 9:21 P.M. 4. Review of Resident #28's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -No behaviors or rejection of care; -Diagnoses included diabetes. Review of the resident's care plan, undated, showed: -Focus: The resident has diabetes; -Goal: Will be free from any signs and symptoms of hyperglycemia through the review date. Will be free from any signs and symptoms of hypoglycemia through the review date; -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Fasting serum blood sugar as ordered by the physician. If infection is present, consult physician regarding any changes in diabetic medications. Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Monitor/document/report as needed any signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing (deep, rapid breathing), acetone breath (smells fruity), stupor, coma. Monitor/document/report as needed any signs and symptoms of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, staggering gait. Monitor/document/report as needed any signs and symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation. Offer substitutes for foods not eaten. Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Wash feet daily with mild soap and water. Dry thoroughly. May use a light dusting powder or lotion. Do not apply lotion or powder between the toes. Review of the resident's April 2022 electronic physician order sheet (ePOS), included: -An order, dated 4/13/22, end date 4/28/22, for accu check with meals, notify the physician over 400, for diabetes; -An order, dated 4/28/22, end date 5/23/22, for accu check with meals, notify the physician over 400, for diabetes; -An order, dated 4/13/22, end date 5/13/22, to administer Lantus Solution 100 unit/ml , inject 100 unit, one time a day for diabetes. Review of the resident's medication administration record (MAR) for the dates 4/1/22 to 4/30/22, showed: -An order for accu check with meals, notify the physician over 400, for: diabetes -At 8:00 A.M., blank, one of seventeen opportunities; -At 12:00 P.M., blank, one of seventeen opportunities; -At 5:00 P.M., blank, eight of seventeen opportunities. -An order to administer Lantus Solution 100 unit/ml, inject 100 unit subcutaneously one time a day: -At 6:00 A.M., blank, seven of seventeen opportunities. -There was no explanation on the MAR showing why the accu checks and insulin administration were not done as ordered. 5. Review of the facility's in-servicing, dated 5/20/22, showed nurses and CMTs educated on diabetic protocols. Review of the facility's diabetic protocol in-service record for nurses, showed: -Subject: Residents should have parameters notify below and notify above. Snacks at bedtime. Notification to physician and resident representative of outside parameters, refusals. Storage and labeling of insulin. Ordering insulin and vials; -Policy reviewed: blank; -Title of staff performing in-service: Assistant Director of Nursing (ADON). Review of the facility's diabetic protocol in-service record for CMTs, showed: -Subject: Order insulin, add sliding scale, blood sugar parameters, notification to charge nurse, location of administration of insulin. 28 day usage, dating insulin vials, pens, reorder insulin; -Policy reviewed: blank; -Title of staff performing in-service: ADON. Review of the facility's missed medications in-service for nurses and CMTs, dated 5/20/22, showed: -Subject: Any medication not available in cart. Check for pharmacy for medications. Call pharmacy. Notify physician if medication not given; -Policy reviewed: Medication administration; -Title of staff performing in-service: ADON. Review of the facility's missed medication unavailable medication audit sheet in-service for nurses and CMTs, dated 5/20/22, showed: -Subject: Must be completed at end of shift; -Policey reviewed: Medication administration; -Title of staff performing in-service: blank. 6. During an interview on 5/23/22 at 10:05 A.M., LPN A said nurses and insulin certified CMTs can check blood sugars and administer insulin. The purpose of checking the blood sugar is to determine if a resident is hypoglycemic or hyperglycemic. Staff should follow physician orders for checking blood sugars. They should document blood sugars on the MAR. If there are no orders for checking blood sugars, but the resident has orders for insulin several times a day, the blood sugar should be checked. The standard nursing practice is to notify the physician if the resident's blood sugar is over 400 or under 70. Physician notification should be documented in the resident's medical record. If a resident refuses to take their insulin, staff should encourage them and educate them on its importance. Staff should try again later, a couple times, then document the refusal. The physician should be notified of ongoing refusals. The LPN was not sure if Resident #20 had a history of refusals. Residents #19 and #2 did not have a known history of refusals. 7. During an interview on 5/23/22 at 10:27 A.M., Registered Nurse (RN) D said nurses are responsible for checking blood sugars. Depending on the doctor, a resident may or may not have orders for accu-checks. If a resident receives insulin on a routine basis, it is standard nursing practice to check their blood sugar. The purpose of checking blood sugars is to see if a resident's blood sugar is too high or low. Normal blood sugar parameters are between 70 and 300. 300 is abnormal, but a blood sugar over 400 is a problem If a resident's blood sugar is over 400, it is nursing standard of practice to call the physician and ask them if they want to monitor the resident or administer medication. Physician orders can be customized to include specific parameters. Blood sugars should be documented on the MAR and the medial record. If a resident cannot receive medication for whatever reason, staff should document the reason on the MAR using the appropriate code. Staff should not leave a MAR blank because there is no way to tell what happened with the medication. If a resident refuses to take their insulin, staff should try again later and ask a few times. If the resident continues to refuse, staff should notify the physician. Staff should order another bottle of insulin when they open a vial or if they are halfway through one. All refusals should be documented in the resident's progress notes and care plan. 8. During an interview on 5/23/22 at 1:41 P.M., the ADON said insulin certified CMTs and licensed nurses are responsible for checking blood sugars and administering insulin. She would expect staff to follow physician orders for medication administration and accu-checks. The purpose of checking blood sugars is to get an accurate measure of the resident's glucose levels. Sliding scale insulin will have physician orders for accu-checks, and should have parameters for staff to notify the physician. Routine insulin that is not sliding scale might have a space on the eMAR for staff to input the resident's blood sugar, and in that case, the resident's blood sugar should be checked before administering insulin. Blood sugar parameters depend on the residents and there is no standard sliding scale. When there is no order specifying parameters to notify the physician, licensed nurses and insulin certified CMTs should refer to nursing standards of practice, which is to notify the physician of blood sugars over 400 or under 70. Staff should document insulin administration and accu-checks on the eMAR. If the resident is unable to take a medication, staff should document the reason why on the eMAR, using the appropriate code. There should not be blank spaces on the eMAR, because that would not indicate whether or not a medication was administered. If the resident refuses to take their medication, staff should try to encourage them to take it and attempt administering it later. If the resident continues to refuse, staff should notify the physician and document the refusal and communication in the resident's record. Initially, Resident #20 did not have orders for accu-checks. He/she approached the ADON about this a while ago and the ADON spoke with the resident's physician, who gave orders for accu-checks. The ADON found out Resident #20 refused to take his/her insulin on 5/16/22, when the resident was sent out to the hospital. The ADON was not aware the resident refused to take his/her insulin the days prior to 5/16/22. She would have expected staff to notify the physician of the resident's refusals. She was not aware the resident had not been getting his 12:00 A.M. and 6:00 A.M. doses of insulin. The blank spaces on the eMAR do not show if the insulin was not administered or if the resident refused. Seeing the pattern of the resident's missed medications might mean taking the medication at those times does not work for the resident. A care plan meeting should be held to educate the resident and discuss his choices, such as potentially taking medication at a different time. She was not aware of the resident's blood sugars over 400. She would have expected staff to notify the physician of this. She was not aware the pharmacy did not have an active order for the resident's Novolog. She would expect nurses to communicate physician orders to the pharmacy and will look into the resident's Novolog. She would have expected staff to follow Resident 19's physician order by notifying the doctor when the resident's blood sugars were over 400. Resident #2 should be getting accu-checks before his/her Novolog administration. Recently, the ADON identified an issue with accu-checks, insulin administration, insulin storage, ordering insulin, missed medications, and physician notification of blood sugars outside of parameters. The ADON in-serviced nurses and insulin-certified CMTs on accu-checks, insulin administration, insulin storage, ordering insulin, missed medications, and physician notification of blood sugars outside of parameters in February 2022. Copies of in-services were requested. Policies regarding insulin administration, accu-checks, and physician notification were requested. The ADON said the facility has a diabetic program covering all of this that she can print out. 9. During an interview on 5/23/22 at 2:52 P.M., the administrator said she would expect nurses to communicate physician orders to the pharmacy to ensure medications were on hand. She would expect staff to follow physician orders for medication administration and accu-checks, which should be documented on the MAR. If a medication cannot be given, staff should document the reason on the MAR. There should not be blanks on a MAR. If a resident refuses, staff should give them a while and try again later. If the resident continues to refuse, staff should document the refusal. For continued refusals, the physician should be notified. She would expect the nurse to notify the physician of blood sugars outside of parameters in accordance with nursing standards of practice. Resident #20 was usually pretty good about taking his/her insulin, but stopped taking his/her insulin for days and told the administrator he/she wanted to be put on hospice. The administrator tried explaining why taking the insulin was important. She isn't sure if nursing staff notified the physician of the resident's ongoing refusals, but they should have. Once in a while, Resident #19 might refuse things if he/she is in a mood, but most of the time, he/she is agreeable. Residents #19 and #20 can be re-approached at a later time. Care plans should identify resident-specific interventions for identified care areas. 10. During an interview on 5/23/22 at 4:27 P.M., the Regional Nurse Consultant (RNC) said the facility does not have a policy regarding a diabetic program or accu-checks. For checking blood sugars, different doctors have different parameters. Nurses should follow the basic procedures based on nursing standards of practice to notify the physician of blood sugars below 70 and above 400. In-servicing regarding blood sugars and insulin administration was provided. 11. During an interview on 5/24/22, 12:03 P.M., Physician H said he is the facility's medical director. Physician G works in the same practice and sees the residents in the facility. Physician H would expect licensed nursing staff to follow physician orders for obtaining accu-checks and administering insulin. The facility has protocols for blood sugar parameters. Nurses should follow physician orders for notifying the physician if a resident's blood sugars are outside of their specified parameters. If a resident does not have orders for specific blood sugar parameters, the nurse should rely on the facility's protocols. If the nurse is unsure of the facility protocols, they should notify the physician. If a resident refuses their insulin for consecutive sessions or days, the nurse should notify the physician and document the resident's refusals. If staff observe the resident has a pattern of refusal, they should notify the physician and the physician would talk to the resident about their medication. MO00200394 MO00200325 MO00200232 40291

See event ID SZJW14 Based on interview and record review, the facility failed to ensure residents were free from physical abuse. Two residents were involved in a resident to resident altercation (Resident #1 and Resident #414), which resulted in Resident #1's nose being fractured. Upon Resident #1's return from the hospital, he/she was moved into a room with a third resident (Resident #415), whom the facility admitted with behaviors and identified as aggressive with thoughts of violence and a danger to others. Resident #415 hit Resident #1 in the face multiple times, resulting in the resident's re-hospitalization . Nineteen residents were sampled. The census was 38. Review of the facility's Abuse Prevention Policy, dated 8/30/12 and revised on 4/28/21, showed the following: -Abuse Prevention: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Definition: Abuse, is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident; -Neglect: Failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presents either imminent danger to the health, safety, or welfare of a consumer or a substantial probability that death or serious physical injury would result. This would include, but is not limited to, failure to provide adequate supervision during an event in which one consumer causes serious injury to another consumer; -STEPS TO PREVENT, DETECT AND REPORT; -SCREENING: -The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property. -The facility will pre-screen all potential new employees and residents for a history of abusive behavior; -IDENTIFICATION: - Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident; -Reporting: Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an 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. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency, and local law enforcement as required); -PROTECTION: It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed; -Implementation of this policy: -All residents/family members will be made aware of the prohibition of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of resident's property upon admission; -This subject and these items shall be reviewed no less than annually at resident council, family council, and general staff meeting; -All residents and family members will be interviewed during other times, for example, at care planning conferences to determine whether complaints or suspected events of abuse or neglect have been reported and investigated. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/21, showed the following: -admitted : 1/20/21; -Brief interview for mental status (BIMS) score of 8 out of a possible score of 15, indicated moderately impaired; -Required assistance of two staff with transfers, -Required assistance of one staff for dressing, bed mobility, toileting and personal hygiene; -Wheelchair for mobility; -Behaviors, Hallucinations (perceptual experiences in the absence of real external sensory stimuli); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, showed: -Focus: At times, will use call-light in an excessive manner; -Interventions: Please allow time to express needs. Please allow time to vent any frustration. Staff to re-direct resident as tolerated. Please offer snacks or diversion activities; -Focus: At times will demonstrate attention seeking behavior; -Interventions: Staff to provide re-direction as needed. Offer social services 1:1 (one staff person per one resident) as needed. Allow time to express needs and feelings. Offer resident time to call his/her spouse in efforts to reduce behaviors. Offer snacks and divisional activities; -Focus: At times can be verbally abusive towards staff and make verbal threats; -Interventions: Social service 1:1 as needed. Please provide, redirection. Please remind of appropriate behavior and how to be courteous to others; -Focus: Resident has a potential for psychosocial well-being problem due to, 7/29/21, being in a physical altercation with another resident; -Interventions: Allow resident time to answer questions and to verbalize feelings, perceptions and fears as needed. When conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. Review of Resident #414's quarterly MDS, dated [DATE], showed: -Short and long term memory problems; -Behaviors, rejection of care, 1 to 3 days a week; -Required one staff person's assistance for transferring, dressing, toileting and personal hygiene; -Upper extremity impairment, on one side; -Lower extremity impairment, on one side; -Wheelchair for mobility; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate or delayed symptoms may include confusion, blurry vision and concentration difficulty), dementia and [CONDITION(S)]. Review of Resident#1's nurse's notes, showed: -On 7/29/2021 at 1:44 P.M., Incident Note, Late Entry: Note Text: Resident involved in physical altercation with another resident. Resident was struck in face while sitting in geri-chair (reclining wheeled chair), staff immediately intervened. Resident separated from other resident involved in incident and assessed for injury, has noted laceration to left eye, resident received first aid. Resident denies pain at this time voicing would like to go out and smoke. Resident's physician and responsible party (RP) notified of incident at this time; -On 7/30/2021 at 3:30 P.M., resident returned from the hospital at this time, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was admitted from the hospital via ambulance on stretcher per two attendants. Resident alert and oriented x's 2-3 (cognitive status, oriented to person, place, and time). No pain or discomfort voiced at this time. Call light within reach. Review of the facility Resident to Resident Abuse Self-Report Investigation, dated 7/29/21, showed: -Summary of incident, Resident #414 had an episode of [CONDITION(S)] (a mental disorder characterized by a disconnection from reality) and charged at residents and staff, striking multiple staff members who were attempting to stop him/her from hitting other residents. Resident #414 struck Resident #1 in the eye before staff could intervene. Both residents were separated; -Upon completion of the investigation, the facility was able to substantiate the incident did occur. Resident #414 was placed on a 1:1 until he/she was sent to the hospital for evaluation and treatment and was admitted for a psychiatric evaluation. Resident #1 was sent to the hospital for evaluation and treatment in which he/she returned to the facility with a left eyelid laceration and closed nasal fracture. During an interview on 8/24/21 at 11:54 A.M., the assistant director of nurses (ADON) said Resident #1 has behaviors of yelling out and is very demanding. Resident #1 was yelling out and Resident #414 attacked him/her, as well as a couple of staff. Resident #414 was sent to the hospital for a psychiatric evaluation. Resident #1 suffered a fractured nose from the incident and when he/she returned from the hospital, he/she was moved to a new room, away from Resident #414 and he/she was placed in a room with Resident #415. Review of Resident #415's medical record, showed -admitted : 7/8/21; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #415's hospital discharge instructions, dated 7/8/21, showed: -Reason for admission, danger to others; -Precipitating factors, aggression/thoughts of violence; -Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #415's nurse's admission screen, dated 7/8/21, showed: -Reason for admission, nursing supervision; -Reason for admission from paperwork, blank; -Mood and behavior concerns, disorganized thinking; -Independent with all activities of daily living. Review of Resident #415's care plan, undated in use during the survey, showed: -Focus: Uses [CONDITION(S)] medications, due to [CONDITION(S)] and potential for injury to self and others; -Interventions: Administer medications as ordered. Consult with pharmacy, physician to consider dosage reduction when clinically appropriate. Monitor/record target behavior symptoms, monitor for side effects and adverse reactions; -Focus: Use of anti-depressant medications due to depression and [CONDITION(S)]; -Interventions: Give medications as ordered. Monitor/document/report ongoing symptoms unaltered by medication; -Focus: Potential to be physically aggressive. History of harm to others. Poor impulse control and confusion. 8/1/21, hit roommate in the face; -Interventions: Administer medications as ordered. Known triggers or physical aggression are deescalated by: (not defined on care plan). Further review of Resident #1's nurse's notes, showed: -8/1/2021 at 1:12 P.M., resident remains on antibiotics, complaints of broken nose and laceration to left eye. No pain or discomfort noted. Call light within reach; -8/1/21 at 9:23 P.M., this writer was called to resident room by medics and police officers. The police informed this writer Resident #1's spouse called and stated the resident had been hit in the face by another resident. Examined resident and he/she had blood coming from the top of his/her nose. Explained to resident and tried telling spouse that a portable x-ray could be sent out to the test and medics was saying he/she did not need to go to the hospital. Since the spouse is his/her guardian, they had to take him/her. Resident left facility with 911 medics. Administrator was notified and tried calling interim DON. Review of Resident #415's nurse's notes, showed: -On 8/1/21 at 9:43 P.M., resident in bed upon entering room. He/she seemed like he/she didn't know what this writer was talking about. Resident was moved to another room; -On 8/4/21 at 12:48 P.M., spoke with resident's parent about the behavior and he/she stated he/she was not surprised. Review of the facility resident to resident abuse self-report investigation, dated 8/1/21, showed: -Fax received on 8/1/21 at 8:51 P.M., Date and time of incident, no date noted, time, 7:30 P.M., resident stated he/she was hit in the face by another resident; -On 8/1/21 at approximately 8:15 P.M., it was reported Resident #415 and Resident #1 had a physical altercation. Upon completion of investigation the facility, was able to substantiate the incident did occur. During resident interview with Resident #1, he/she stated that Resident #415 hit him/her in the face multiple times. During an interview, Resident #415 admitted to hitting Resident #1 because he/she would not stop talking. Resident #1 called his/her significant other and he/she called emergency medical services (EMS). When employee and the EMS went into the room, Resident #1 said what had occurred. He/she was on the phone with his/her significant other and he/she requested him/her to go to the hospital. Resident #1 was assessed by EMS and they stated that he/she did not need to go to the hospital, but when the power of attorney (POA) demanded he/she go, they took Resident #1 to the hospital. During an interview on 8/24/21 at 11:56 A.M., the ADON said Resident #415 had previously lived at home with his/her parents. He/she had become violent with his/her parents, police were called and he/she was taken to the hospital. Noise makes him/her irritated. Resident #1's yelling out upset the resident and he/she attacked him/her, punching him/her a couple times. Resident #1 called EMS him/herself without staff being aware of the incident. They were made aware when EMS and the police arrived. Resident #1 had a prior incident with another resident that didn't like noise, he/she suffered a broken nose from that incident. During an interview on 8/24/21 at 11:36 A.M., Licensed Practical Nurse (LPN) C said the resident liked to stay in bed, he/she can't share a room due to an altercation with Resident #1. Resident #1 had facial injuries from a previous incident. Resident #1 has behaviors, yells and calls out all the time, day and night, and it upsets people who are sleeping. During an interview on 8/25/21 at 1:16 P.M., Certified Nurse Aide (CNA) X said Resident #1 called out a lot. Once he/she knew your name, he/she would call it out constantly. His/her behaviors would irritate other residents, and he/she was like that ever since he/she arrived. He/she is very impatient, and would yell out, Help, help, help! or a staff person's name if he/she knew it. During an interview on 8/26/21 at 8:30 A.M., the resident's roommate who lived in the same room with Resident #1 and Resident #415 at the time of the incident, said Resident #1 was irritating, he/she would call for the nurse constantly, yelled out, and was a pain to be around. He/she did not witness the incident. He/she heard a noise and Resident #1 said Resident #415 hit him/her like five times. Resident #415 slept most of the time, and is alright to be around. He/she just got irritated by Resident #1. During an interview on 8/26/21 at 1:06 P.M., the former administrator said she wasn't aware of the resident's reason for admission to the hospital prior to being admitted to the facility. She said she would have to look at the hospital paperwork. She said the hospital paperwork is reviewed during the morning team meeting when they know an admission is coming. She said the marketer reviews potential residents and determines if they are appropriate for placement with the facility. The marketer is a CNA, who follows a decision tree that utilizes a red light/yellow light/green light system to determine if a resident can be admitted . The DON or ADON reviews the admission packet with 24 to 48 hours to determine if the resident is an appropriate placement. MO 3 MO 1 MO 5

Based on interview and record review, the facility failed to ensure residents were free from physical abuse. Two residents were involved in a resident to resident altercation (Resident #1 and Resident #414), which resulted in Resident #1's nose being fractured. Upon Resident #1's return from the hospital, he/she was moved into a room with a third resident (Resident #415), whom the facility admitted with behaviors and identified as aggressive with thoughts of violence and a danger to others. Resident #415 hit Resident #1 in the face multiple times, resulting in the resident's re-hospitalization . Nineteen residents were sampled. The census was 38. Review of the facility's Abuse Prevention Policy, dated 8/30/12 and revised on 4/28/21, showed the following: -Abuse Prevention: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Definition: Abuse, is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident; -Neglect: Failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presents either imminent danger to the health, safety, or welfare of a consumer or a substantial probability that death or serious physical injury would result. This would include, but is not limited to, failure to provide adequate supervision during an event in which one consumer causes serious injury to another consumer; -STEPS TO PREVENT, DETECT AND REPORT; -SCREENING: -The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property. -The facility will pre-screen all potential new employees and residents for a history of abusive behavior; -IDENTIFICATION: - Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The Administrator and Director of Nursing (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident; -Reporting: Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of an 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. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, are reported immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility and to other officials (including State Survey Agency, and local law enforcement as required); -PROTECTION: It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed; -Implementation of this policy: -All residents/family members will be made aware of the prohibition of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of resident's property upon admission; -This subject and these items shall be reviewed no less than annually at resident council, family council, and general staff meeting; -All residents and family members will be interviewed during other times, for example, at care planning conferences to determine whether complaints or suspected events of abuse or neglect have been reported and investigated. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/21, showed the following: -admitted : 1/20/21; -Brief interview for mental status (BIMS) score of 8 out of a possible score of 15, indicated moderately impaired; -Required assistance of two staff with transfers, -Required assistance of one staff for dressing, bed mobility, toileting and personal hygiene; -Wheelchair for mobility; -Behaviors, Hallucinations (perceptual experiences in the absence of real external sensory stimuli); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, showed: -Focus: At times, will use call-light in an excessive manner; -Interventions: Please allow time to express needs. Please allow time to vent any frustration. Staff to re-direct resident as tolerated. Please offer snacks or diversion activities; -Focus: At times will demonstrate attention seeking behavior; -Interventions: Staff to provide re-direction as needed. Offer social services 1:1 (one staff person per one resident) as needed. Allow time to express needs and feelings. Offer resident time to call his/her spouse in efforts to reduce behaviors. Offer snacks and divisional activities; -Focus: At times can be verbally abusive towards staff and make verbal threats; -Interventions: Social service 1:1 as needed. Please provide, redirection. Please remind of appropriate behavior and how to be courteous to others; -Focus: Resident has a potential for psychosocial well-being problem due to, 7/29/21, being in a physical altercation with another resident; -Interventions: Allow resident time to answer questions and to verbalize feelings, perceptions and fears as needed. When conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. Review of Resident #414's quarterly MDS, dated [DATE], showed: -Short and long term memory problems; -Behaviors, rejection of care, 1 to 3 days a week; -Required one staff person's assistance for transferring, dressing, toileting and personal hygiene; -Upper extremity impairment, on one side; -Lower extremity impairment, on one side; -Wheelchair for mobility; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate or delayed symptoms may include confusion, blurry vision and concentration difficulty), dementia and [CONDITION(S)]. Review of Resident#1's nurse's notes, showed: -On 7/29/2021 at 1:44 P.M., Incident Note, Late Entry: Note Text: Resident involved in physical altercation with another resident. Resident was struck in face while sitting in geri-chair (reclining wheeled chair), staff immediately intervened. Resident separated from other resident involved in incident and assessed for injury, has noted laceration to left eye, resident received first aid. Resident denies pain at this time voicing would like to go out and smoke. Resident's physician and responsible party (RP) notified of incident at this time; -On 7/30/2021 at 3:30 P.M., resident returned from the hospital at this time, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was admitted from the hospital via ambulance on stretcher per two attendants. Resident alert and oriented x's 2-3 (cognitive status, oriented to person, place, and time). No pain or discomfort voiced at this time. Call light within reach. Review of the facility Resident to Resident Abuse Self-Report Investigation, dated 7/29/21, showed: -Summary of incident, Resident #414 had an episode of [CONDITION(S)] (a mental disorder characterized by a disconnection from reality) and charged at residents and staff, striking multiple staff members who were attempting to stop him/her from hitting other residents. Resident #414 struck Resident #1 in the eye before staff could intervene. Both residents were separated; -Upon completion of the investigation, the facility was able to substantiate the incident did occur. Resident #414 was placed on a 1:1 until he/she was sent to the hospital for evaluation and treatment and was admitted for a psychiatric evaluation. Resident #1 was sent to the hospital for evaluation and treatment in which he/she returned to the facility with a left eyelid laceration and closed nasal fracture. During an interview on 8/24/21 at 11:54 A.M., the assistant director of nurses (ADON) said Resident #1 has behaviors of yelling out and is very demanding. Resident #1 was yelling out and Resident #414 attacked him/her, as well as a couple of staff. Resident #414 was sent to the hospital for a psychiatric evaluation. Resident #1 suffered a fractured nose from the incident and when he/she returned from the hospital, he/she was moved to a new room, away from Resident #414 and he/she was placed in a room with Resident #415. Review of Resident #415's medical record, showed: -admitted : 7/8/21; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #415's hospital discharge instructions, dated 7/8/21, showed: -Reason for admission, danger to others; -Precipitating factors, aggression/thoughts of violence; -Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #415's nurse's admission screen, dated 7/8/21, showed: -Reason for admission, nursing supervision; -Reason for admission from paperwork, blank; -Mood and behavior concerns, disorganized thinking; -Independent with all activities of daily living. Review of Resident #415's care plan, undated in use during the survey, showed: -Focus: Uses [CONDITION(S)] medications, due to [CONDITION(S)] and potential for injury to self and others; -Interventions: Administer medications as ordered. Consult with pharmacy, physician to consider dosage reduction when clinically appropriate. Monitor/record target behavior symptoms, monitor for side effects and adverse reactions; -Focus: Use of anti-depressant medications due to depression and [CONDITION(S)]; -Interventions: Give medications as ordered. Monitor/document/report ongoing symptoms unaltered by medication; -Focus: Potential to be physically aggressive. History of harm to others. Poor impulse control and confusion. 8/1/21, hit roommate in the face; -Interventions: Administer medications as ordered. Known triggers or physical aggression are deescalated by: (not defined on care plan). Further review of Resident #1's nurse's notes, showed: -8/1/2021 at 1:12 P.M., resident remains on antibiotics, complaints of broken nose and laceration to left eye. No pain or discomfort noted. Call light within reach; -8/1/21 at 9:23 P.M., this writer was called to resident room by medics and police officers. The police informed this writer Resident #1's spouse called and stated the resident had been hit in the face by another resident. Examined resident and he/she had blood coming from the top of his/her nose. Explained to resident and tried telling spouse that a portable x-ray could be sent out to the test and medics was saying he/she did not need to go to the hospital. Since the spouse is his/her guardian, they had to take him/her. Resident left facility with 911 medics. Administrator was notified and tried calling interim DON. Review of Resident #415's nurse's notes, showed: -On 8/1/21 at 9:43 P.M., resident in bed upon entering room. He/she seemed like he/she didn't know what this writer was talking about. Resident was moved to another room; -On 8/4/21 at 12:48 P.M., spoke with resident's parent about the behavior and he/she stated he/she was not surprised. Review of the facility resident to resident abuse self-report investigation, dated 8/1/21, showed: -Fax received on 8/1/21 at 8:51 P.M., date and time of incident, no date noted, time, 7:30 P.M., resident stated he/she was hit in the face by another resident; -On 8/1/21 at approximately 8:15 P.M., it was reported Resident #415 and Resident #1 had a physical altercation. Upon completion of investigation the facility, was able to substantiate the incident did occur. During resident interview with Resident #1, he/she stated that Resident #415 hit him/her in the face multiple times. During an interview, Resident #415 admitted to hitting Resident #1 because he/she would not stop talking. Resident #1 called his/her significant other and he/she called emergency medical services (EMS). When employee and the EMS went into the room, Resident #1 said what had occurred. He/she was on the phone with his/her significant other and he/she requested him/her to go to the hospital. Resident #1 was assessed by EMS and they stated that he/she did not need to go to the hospital, but when the power of attorney (POA) demanded he/she go, they took Resident #1 to the hospital. During an interview on 8/24/21 at 11:56 A.M., the ADON said Resident #415 had previously lived at home with his/her parents. He/she had become violent with his/her parents, police were called and he/she was taken to the hospital. Noise makes him/her irritated. Resident #1's yelling out upset the resident and he/she attacked him/her, punching him/her a couple times. Resident #1 called EMS him/herself without staff being aware of the incident. They were made aware when EMS and the police arrived. Resident #1 had a prior incident with another resident that didn't like noise, he/she suffered a broken nose from that incident. During an interview on 8/24/21 at 11:36 A.M., Licensed Practical Nurse (LPN) C said the resident liked to stay in bed, he/she can't share a room due to an altercation with Resident #1. Resident #1 had facial injuries from a previous incident. Resident #1 has behaviors, yells and calls out all the time, day and night, and it upsets people who are sleeping. During an interview on 8/25/21 at 1:16 P.M., Certified Nurse Aide (CNA) X said Resident #1 called out a lot. Once he/she knew your name, he/she would call it out constantly. His/her behaviors would irritate other residents, and he/she was like that ever since he/she arrived. He/she is very impatient, and would yell out, Help, help, help! or a staff person's name if he/she knew it. During an interview on 8/26/21 at 8:30 A.M., the resident's roommate who lived in the same room with Resident #1 and Resident #415 at the time of the incident, said Resident #1 was irritating, he/she would call for the nurse constantly, yelled out, and was a pain to be around. He/she did not witness the incident. He/she heard a noise and Resident #1 said Resident #415 hit him/her like five times. Resident #415 slept most of the time, and is alright to be around. He/she just got irritated by Resident #1. During an interview on 8/26/21 at 1:06 P.M., the former administrator said she wasn't aware of the resident's reason for admission to the hospital prior to being admitted to the facility. She said she would have to look at the hospital paperwork. She said the hospital paperwork is reviewed during the morning team meeting when they know an admission is coming. She said the marketer reviews potential residents and determines if they are appropriate for placement with the facility. The marketer is a CNA, who follows a decision tree that utilizes a red light/yellow light/green light system to determine if a resident can be admitted . The DON or ADON reviews the admission packet with 24 to 48 hours to determine if the resident is an appropriate placement. MO 3 MO 1 MO 5

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #6), who exhibited behaviors of confusion and had a history of [REDACTED]. The resident resided in a room not visible from the nurse's station and near a stairwell exit that was not visible from the nurse's station. On 6/26/18 at 2:40 A.M., the resident exited the stairwell on the third floor and fell down to the bottom of the first landing. Two Certified Medication Technicians (CMTs) assisted the resident back to the third floor prior to him/her being assessed by the nurse. The fall resulted in the resident being sent out to the hospital with a [DIAGNOSES REDACTED]. The census was 89. Review of Resident #6's Nursing Admission Screening/History form, dated 5/21/18, showed the following: -The resident was discharged from the hospital and admitted to the facility on [DATE]; -He/she was alert and oriented to person and place; -Motor control consisted of a normal gait, tremors and a history of falls; -Cognition was intact, exhibited short-term memory problems and delusions; -Exhibited aggressive behaviors and disorganized thinking; -Independent with walking. Review of the resident's nurse's note, dated 5/22/18 at 11:17 P.M., showed the resident was admitted to the facility on [DATE]. The resident was very confused and could become very combative with staff when trying to redirect. The resident kept going into other residents' rooms and bothering their belongings. Will continue to monitor the resident. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/25/18, showed the following: -Unplanned discharge with a return to the facility anticipated; -Rarely/never understood; -Exhibited long and short-term memory problems; -Severely impaired cognition regarding tasks of daily life; -Exhibited behaviors not directed towards others such as pacing and rummaging one to three days per week; -Exhibited wandering behavior four to six days per week; -Required extensive assistance of one staff for walking in his/her room, walking in the corridor, locomotion on and off the unit and transfers; -Balance during transfers and walking was not steady; -No history of falls. Review of the resident's undated physician's orders [REDACTED]. Review of the resident's Physical Therapy Plan of Care, dated 6/5/18, showed the following: -Reason for Referral: The resident was readmitted to the facility with a decline in function and walking mobility. The evaluation examination identified five performance deficits with transfers, bed mobility, gait, balance and safety that resulted in activity limitation and or participation. Moderate assistance task modification is necessary to enable the resident to complete the evaluation component. The patient and/or family concerns related to engaging daily life activities include to safety performance of functional mobility; -Therapy Necessity: Therapy was necessary for the recent readmission due to exacerbation of muscle weakness, decline in functional transfers and mobility, gait and balance. Without therapy, the patient was at risk for immobility and falls; -Medical History Related to Diagnosis/Condition: [MEDICAL CONDITION], dementia with behavioral disturbances, [MEDICAL CONDITION] and [MEDICAL CONDITION]; -Precautions: Fall risk and dementia with behavioral disturbances. During an interview on 7/3/18 at 11:13 A.M., the Director of Therapy said the resident received physical and occupational therapy. He/she was a fall risk and did not have a steady gait. She was not sure why therapy was ordered for the resident, because she was not the evaluating therapist. However, the resident had a qualifying stay at the hospital of general weakness and a functional decline. The resident began therapy after the physician ordered physical and occupational therapy. Review of the resident's undated care plan, showed the following: -Focus: The resident was at risk for decline with cognition function and dependent on staff for cognitive stimulation; -Goal: The resident will receive care that provides positive experiences; -Interventions: Assess the resident's degree of disorientation to person, place, time and situation frequently. Monitor for factors that may contribute to or worsen cognitive function; Focus: The resident will wander into other resident's room and other areas due to cognitive loss; -Goal: The resident will wander safely without risk or injury to self; Interventions: Monitor the resident's movement on the unit and in the facility. If the resident attempts to leave the facility, redirect and involve him/her in another activity. Monitor per policy and respond to door alarm promptly. -Focus: The resident was at risk for falls due to poor safety awareness, wandering and cognitive loss. On 6/25/18, the resident slipped to the floor from the bed. On 6/26/18, the resident fell on the stairs resulting in injury and hospitalization . Review of the resident's nurse's notes, showed the following: -No documentation regarding the fall on 6/25/18; -On 6/26/18 at 5:15 A.M., a late entry note showed staff spoke with the resident's Power of Attorney (POA) about his/her recent incident and transfer to the hospital. Explained the situation and the circumstances of the resident's fall. POA inquired about patient safety and asked why the facility did not restrain or lock the resident in his/her room or on his/her unit. POA was explained the intent and reasoning for resident rights. Explained a room move was upon resident's return likely; to place him/her near the nurse's station for close observation on movement and safety; -On 6/26/18 at 10:40 A.M., a late entry note showed it was reported to the nurse the resident had a fall on the night shift. The resident was reported to be found by staff in the stairwell laying on the floor. Nurse was called to the floor by staff. Staff stated the stairwell alarm began to sound, and they responded immediately. The resident was reported to have a large hematoma (bruise), painful to touch to the back of the head. The resident was assisted to the wheelchair by staff and neurochecks (a check for a level of consciousness) were initiated. Call was placed to the physician and an order was given for the resident to be sent to the nearest hospital. The resident left the facility in stable condition. Review of the staffing pattern, dated 6/25/18 for the third shift working from 11:00 P.M. on 6/25/18 until 7:00 A.M. on 6/26/18, showed Nurse I and one Certified Nursing Assistant (CNA) on the first floor, Nurse D and CNA A were assigned to the second floor and CMT F and CMT L were assigned the third floor, where Resident #6 resided. During an interview on 6/29/18 at 10:56 A.M., a representative of Resident #6 said he/she received a call from staff at the facility. From his/her understanding, the resident was up during the night, left his/her room and walked in the wrong direction toward the alarmed door. Staff heard the alarm go off and couldn't get to the resident in time. When they got to him/her, he/she was laying at the bottom of the stairs. Prior to the resident's admission into the facility, he/she was at several facilities and was known to wander, was a fall risk and had no definite sleep pattern, so it was not out of the ordinary for the resident to be up at 2:00 A.M. The representative expressed his/her concern to staff two weeks prior to the resident's fall, because the resident was so far from the nurse's station and on the psych floor. The representative wanted the resident moved to the Alzheimer's floor. He/she was told due to the resident's aggressive behavior, he/she would have to stay on the unit he/she resided on. After the resident fell , he/she was sent to the hospital. He/she was in the intensive care unit and was diagnosed with [REDACTED]. He/she had a feeding tube due to swallowing difficulties following the fall. During an interview on 6/29/18 at 9:50 A.M., Hospital Nurse M said the resident was admitted from the emergency room to the geriatric trauma unit with a [DIAGNOSES REDACTED]. The resident was not able to eat by mouth due to his/her injuries and received nutrition through a gastric tube and would receive a swallow study. During an interview on 6/28/18 at approximately 12:00 P.M., Certified Medication Technician (CMT) F said he/she worked with CMT L on the third shift 6/26/18. The resident ambulated independently, had a wheel chair but did not use it, was unsteady on his/her feet and had a history of [REDACTED]. Wherever there was a door, he/she would try to go through it. CMT F did not know why the resident resided on this unit, because the resident was a high risk Big time. CMT F sat at the nurse's station during the night of the incident while CMT L did a one on one with another resident. CMT L called out There he/she (Resident #6) goes, he/she is going for the door. He/she is out the door. CMT F then heard the door alarm sound and ran towards the door. Before he/she could reach the resident, he/she had already gone through the door. When CMT F opened the door, he/she saw the resident at the bottom of the stairs on the floor. The nurse assessed the resident, and he/she was sent to the hospital for an evaluation. Observation on 6/29/18 at 5:05 A.M. of the unit the resident resided on, showed no staff present upon arriving on the unit. The nurse's station was located at the front of the unit to the left of the elevator. What appeared to be blankets were piled on the counter of the nurse's station. An unknown resident wandered in the area where Resident #6 resided before he/she fell . Resident #6's room was located to the right of the nurse's station and out of view of the nurse's station. The room was diagonal from the alarmed non egress door that lead to a set of stairs. After returning to the nurse's station approximately two minutes later, the blanket at the nurse's station moved. Upon further observation, Certified Nursing Assistant (CNA) A was observed with the blanket covering his/her body as he/she slept. At 5:15 A.M., CMT L arrived off the elevator, turned the lights on and yelled, Hey, hey, how are you all doing. CNA A woke up and stood up from the nurse's station chair where he/she slept. During an interview on 6/29/18 at 5:15 A.M., CMT L said he/she worked the night shift on 6/26/18 when Resident #6 fell . He/she was assigned to conduct one on one observation with Resident #14. The room he/she conducted the one on one was approximately four doors down from Resident #6's room. Around 2:00 A.M., Resident #14 was asleep. CMT L stood in the hallway to the left and around the corner from Resident #14's room and spoke with other residents. The hallway was located behind the nurse's station and a wall separated the area from view of the nurse's station and the hallway from Resident #14, Resident #6's room and the alarmed door. He/she heard the alarm to the door go off. Instead of walking back to the right, toward Resident #14's room, he/she continued to the left and ended up on the right side of the nurse's station. CMT F was at the nurse's station and got up to check the alarm. CMT F and CMT L went to the front right of the nurse's station and walked past the resident's room. They opened the alarmed stairwell door and saw the resident at the bottom of the stairs. CMT L denied seeing the resident going towards the door prior to him/her going through the door. They called for a stat over the intercom. Nurse D was the nurse on duty. He/she arrived and assessed the resident. CMT L and CMT F were assigned to the floor the night of the incident. They were expected to do rounds every two hours. CMT L was familiar with Resident #6 and said he/she wandered all the time. He/she was not sure if the resident was a fall risk. During an interview on 6/29/18 at 1:07 P.M., Nurse D said he/she worked the night shift on 6/26/18 and was the nurse on a different floor. He/she was familiar with the resident and said he/she was alert and oriented to him/herself, was considered a fall risk, wandered and needed to be on a secured unit and required more assistance. The resident was also exit-seeking. At approximately 2:20 A.M., he/she heard the page over the intercom. Nurse D went to the elevator, but it took too long so he/she went up the stairs. When he/she arrived at the stairwell, he/she saw the two CMTs had already stood the resident up and was in the process of walking him/her back up the stairs. It was difficult to communicate with the resident. He/she could not respond, but pointed to the back of his/her head. Nurse D saw a hematoma (bruise). Nurse D contacted the physician and received an order to send the resident out immediately. He/she was not the charge nurse for the floor. He/she was not sure who was in charge of the unit, but assumed it was the CMT. He/she would not have the responsibility of two floors. The two CMTs should not have lifted the resident. When the resident fell , they should have notified the nurse immediately. During an interview on 6/29/18 at 5:45 A.M. and 6:38 A.M., Nurse P said he/she was the nurse on duty for one floor. There were two CNAs present on his/her floor. On the next floor was a nurse and one CNA. The last floor (Where Resident #6 resided) CNA A and CMT L were assigned. Although all nurses were responsible for the nursing duties, Charge CMTs were in charge of some units if there was not a nurse on the floor. He/she expected the CNAs to conduct rounds every two hours. If the residents were asleep, CNAs were expected to clean wheelchairs, fold towels and make sure water was available. Staff should not be asleep at the nurse's station. During an interview on 6/29/18 at 8:16 A.M. and 9:40 A.M., the administrator, Director of Nursing (DON), and regional nurse said there were 31 residents on the floor Resident #6 resided on 6/25/18, going into 6/26/18. They identified 16 residents who exhibited wandering behaviors, 29 residents at risk for falls and six residents at risk for elopement. Resident #6 was included on the fall and wandering list. Resident #14 was identified as the only resident receiving one on one care and the staffing pattern on 6/25/18 going into 6/26/18 was correct. Nurse D was the charge nurse on one floor, but was expected to also work the floor Resident #6 resided on. The CNAs and CMTs were expected to conduct rounds on residents every two hours. During their down time or if residents were asleep, they were expected to monitor the hallways, clean the wheelchairs and check the stairwells. They should not be asleep at the nurse's station while on duty. The administrator said there wasn't a fall risk assessment done on Resident #6, because he/she had no falls, was not a wanderer and was not at risk for elopement. The regional nurse said Resident #6 was a wanderer, but did not exhibit exit-seeking behaviors. The DON said Resident #6 would wander in and out of other residents' rooms, but was easily redirected and did not attempt to go toward doors. They did not have a policy regarding providing care for residents exhibiting wandering or exit-seeking behavior. The DON would expect the CMTs to notify the nurse and the nurse would assess the resident before a resident was moved following a fall. During an interview on 7/3/18 at 2:26 P.M., the resident's representative said the resident returned to the facility from the hospital on [DATE]. The representative was on his/her way to the facility and received a call stating the resident fell and hit his/her head again. Staff was walking with the resident, turned around to do another task and the resident lost his/her balance. The resident had a bruise on the forehead. He/she was sent to the hospital and was in the trauma unit. *NOTE: At the time of the abbreviated 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 violation at the time. During the onsite visit, the administrator and DON began immediately re-educating staff on fall management and wandering for residents and performing hallway rounds as well as facility expectations. The administrator placed a stop sign on the alarmed doors as an attempt to redirect residents from going through the door. Resident #6's room was moved near the nurse's station for observation and monitoring. He/she would be re-evaluated for wandering and fall risks upon return from the hospital. Therapy would perform an evaluation and treat as ordered by the physician. The facility identified residents at risk for falls and exhibiting wandering behaviors. The facility still needs to ensure the residents who wander and are at risk for falls have the appropriate care plans in place. The residents will be re-evaluated as needed and quarterly. Licensed nurses on duty will be assigned specific floors to monitor for each shift. The CNAs and CMTs will perform hallway checks during their rounds every two hours. These rounds will include checking on the residents in their rooms, checking exit doors to ensure alarms are armed and stop signs are in place. If a resident falls, the nurse on duty for the floor will assess the resident for injury prior to moving the resident if deemed safe to move. The nurse will direct moving of the resident. The installation of delayed release locks on the egress doors to the stairwells will be completed on 7/10/18. The DON, Assistant Director of Nursing (ADON) and administrator will be responsible for ensuring these corrections are in place and continued to be utilized. 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 violations. MO 156

Based on observation, interview and record review, the facility failed to ensure one staff member maintained a professional relationship with a resident (Resident #8), who was diagnosed with [REDACTED]. The sample size was 16. The census was 89. 1. Review of the facility's Policy and Procedure on Abuse and Neglect Prevention, issued (MONTH) (YEAR) and revised in (MONTH) (YEAR), showed the following: -Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms; -Definitions: Abuse means 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. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Sexual abuse is non-consensual sexual contact of any type with a resident. 2. Review of Resident #8's annual history and psychiatric examination, dated 5/4/18, showed the following: -[DIAGNOSES REDACTED]. These symptoms often result in impulsive actions and problems in relationships), and [MEDICAL CONDITION] disorder, depressive type (a chronic mental health condition characterized primarily by symptoms of [MEDICAL CONDITION], such as hallucinations or delusions, and symptoms of mood disorder, such [MEDICAL CONDITION] depression); -Exhibited logical thought processes; -Oriented to person, place and time; -Exhibited a poor fund of knowledge; -History of sexual abuse by a family member. Review of the resident's physician's orders [REDACTED]. ECT causes change in brain chemistry that can quickly reverse symptoms of certain mental illnesses). Review of the resident's five day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/23/18, showed the following: -Brief interview of mental status (BIMS), a brief screener that aids in detecting cognitive impairment, score of 12 (Moderate cognitive impairment); -Exhibited no behaviors of [MEDICAL CONDITION]; -Physical and verbal behaviors directed towards others occurred one to three days per week; -Other behavior symptoms not directed toward others, such as hitting and scratching him/herself occurred one to three days per week; -Supervision required for locomotion on and off the unit. Review of the resident's nurse's notes, showed the following: -On 6/27/18 at 7:20 P.M., the resident reported an allegation to a staff member. The resident was immediately taken to safety and one on one with staff. The resident was taken to the administrator's office to give a statement to the administrator; -On 6/27/18 at 10:38 P.M., the resident was having a conversation with the nurse upon a skin assessment regarding the incident with alleged staff member. He/she stated he/she was inappropriately touched with sexual misconduct by the male staff. He/she reported the situation to staff and Department of Health and Senior Services (DHSS). He/she stated physical contact with hug and staff's hand touched and fondled his/her buttocks. The staff placed his/her hand on his private part. During an interview on 6/27/18 at 8:33 P.M., the resident said he/she had ECT earlier that day and felt nauseous and dizzy. He/she ate dinner around 5:30 P.M., read a book on an electronic device and spoke with his/her family member. Certified Nursing Assistant (CNA B) entered his/her room and asked how he/she was feeling. He/She told him he/she felt sick and dizzy. He told him/her to follow him. CNA B always joked around with him/her, but the resident would not cross boundaries. CNA B always made inappropriate jokes, but he/she would laugh and walk away. He pulled him/her to the back hall on the first floor by the drinking fountain. He hugged him/her and grabbed his/her butt. The resident said, Not right now. CNA B pulled him/her back by the hand and placed it on his private part. He/she told CNA B, That is naughty. He/she pulled his/her hand away, turned away and went downstairs to call a family member. After speaking with the family member, he/she went back upstairs. He/she was upset and the Director of Nursing (DON) approached him/her and asked if anything was wrong. He/she told the DON he/she did not want to talk. The DON asked if he/she would be comfortable talking with the administrative assistant. The administrative assistant came to his/her room to take him/her outside to smoke. As they were walking down the hall, CNA B approached him/her and said, What's the matter babe and tried to hug him/her. He/she told CNA B, I hear voices and pushed him away. He/she went outside with the administrative assistant and told her what happened. He/she was very afraid of CNA B and thought he would come to his/her room after the resident told staff what occurred. During the interview, a noise came from what appeared to be the vending machine. The sound startled the resident. During an interview on 6/27/18 at 7:55 P.M., (Certified Nursing Assistant) CNA B said he worked at the facility for five months and worked as a CNA for nine years. This situation was new to him. For the last week or so, this lady/man had been coming up to him asking for hugs. He usually won't hug people, but the resident had been going through some problems on the floor and he figured I could be a shoulder he/she could lean on. He decided to hug the resident, but would give a side hug. CNA B said he should have reported this, but last Thursday or Friday, the resident hugged him. After the resident released the hug, he/she grabbed CNA B's buttock. He described it as an intentional rub of the butt. We get to today, 6/27/18. The resident comes in for a hug. This was after dinner, around 7:00 P.M. The resident said he/she wanted to talk. CNA B asked the resident what was wrong. The resident came in for the hug. He gave the resident a side hug and said, You know you my girl/boy, right? After the resident released the hug, he/she grabbed my junk (penis). He/she then started stroking it. (As CNA B discussed this, he began to demonstrate what he alleged the resident did. He placed his hand on his penis and grabbed it three to four times.) When asked what he meant by stroking, he said, I don't want to say the word stroke, because that would be saying I wanted him/her to do it. It was more like a grab and pull. (CNA B grabbed at his penis, then pulled. He demonstrated this twice.) Even my gal (girlfriend) don't be doing that. After the resident grabbed his penis, he said, Whoa, you know you can't do this. The resident then left the area. Over the last week or so, the resident kept asking him for sex and trying to get him to come into his/her room. He should have reported this. He approached CNA C and told him/her what just occurred. He asked CNA C what he/she thought of the situation. CNA C told him to report it immediately. He went to the nurse's station to report the incident. The nurse was not there. He decided to go about his routine. While he was on the floor, he saw the resident walking with the administrative assistant. The resident was turning up (acting out). He approached the resident and asked him/her if he/she was okay. He tried to hug him/her and told the resident, If I can do anything, let me know. The resident said he/she was hearing voices and did not want to talk. Shortly after, the Director of Nursing (DON) approached him and said he had to suspend him. CNA B asked was it about Resident #8. He admitted he was not assigned to the resident but helped out with his/her care. During an interview on 6/27/18 at 8:24 P.M., CNA C said he/she worked at the facility for three years and was familiar with Resident #8. He/she was assigned to the resident. After dinner, CNA B approached him/her and said the resident approached him and said he/she wanted to have sex and asked, What do you think? CNA C told him to report it immediately if a resident made a statement like this. CNA B then asked if CNA C would assist him in transferring a resident directly across from Resident #8, because he wanted to have a witness in the event the resident made an accusation. CNA C was providing care to another resident and told him he/she would assist after he/she finished with the other resident, but suggested he tell the nurse what happened. CNA B never mentioned anything about the resident grabbing his penis. He/she was familiar with the resident and he/she never exhibited inappropriate behavior towards staff. The residents Mess around with each other and fight all the time. They be having they little boyfriend/girlfriend relationships, but nothing like this. That's why I told him (CNA B) to report this right away, because if the resident would say something like that, he/she could say anything. CNA C asked CNA B when the resident would have asked him for sex, because the resident had been sick throughout the afternoon and evening because he/she had ECT earlier that day. When he/she had ECT treatment, he/she was usually sick. CNA C actually took the resident's dinner to his/her room, because he/she wasn't feeling well. He/she was shocked the resident would ask the CNA for sex, because this was not his/her character. He/she was not aware of the resident making allegations of inappropriate behavior with any other staff. He/she worked with CNA B for about two to three months and was not aware of any other resident saying he was inappropriate. During an interview on 6/27/18 at 9:15 P.M., the administrative assistant said she was on the first floor by the smoking room when the DON approached her and asked her to speak with Resident #8. She approached the resident, who seemed distressed. The resident wanted to go outside and walked towards the elevators. As the resident walked toward the elevator, CNA B approached her and asked if there was anything he could do for him/her. He then tried to hug the resident. The resident said he/she couldn't talk and was hearing voices. The administrative assistant accompanied the resident on the elevator. He/she appeared fidgety. When they arrived downstairs, the resident began to cry. She asked him/her what was wrong. The resident said he/she was scared and did not want to get anyone in trouble and did not want anything to come back on him/her. CNA B came into his/her room and grabbed my ass. The administrative assistant asked the resident if CNA B ever said or did anything sexual prior to today. The resident replied, Yea, sort of. The resident cried and said when he/she pulled away, CNA B grabbed his/her hand and placed it on his crotch. She told the resident he/she needed to report this to the administrator immediately. During an interview on 6/27/18 at 8:52 P.M., Nurse I said he/she worked at the facility for [AGE] years and was familiar with the resident. The resident was very manipulative and cut him/herself. He/she accused staff in the past of being sexually inappropriate with him/her. He/she could not recall who the staff was, but the allegation was unsubstantiated. It happened about two months ago. The resident had threatened to make allegations in the past to get people fired. This was the first time he/she heard of an allegation of inappropriate behavior involving CNA B. He was usually polite and courteous to residents. No other female resident had made any allegations against CNA B. Resident #1 was known to make false allegations. During an interview on 6/27/18 at 9:30 P.M., the administrator, DON and regional nurse said they would suspend CNA B and place the resident on one on one observations. The resident told the administrator he/she was fearful of CNA B. During an interview on 6/27/18 at 9:35 P.M., the DON said CNA B told him the resident grabbed his penis. He did not tell the DON he and the resident had inappropriate contact the week prior to the incident, nor did he tell him he was a shoulder for the resident to lean on. He also did not tell him the resident allegedly grabbed his buttock the week prior. Review of the facility's completed investigation, dated 7/3/18, showed the following: -On 6/27/18 at approximately 7:05 P.M., the resident reported to the office assistant that CNA B hugged him/her, grabbed his/her buttocks, and placed his/her hand on his genitals on the evening of 6/27/18. The employee was immediately suspended pending an investigation; -Upon completion of the investigation, the facility unsubstantiated the alleged allegation of Resident #8 being forced to touch CNA B's genitals or grabbing the resident's buttocks. However, during the investigation, CNA B admitted to allowing the resident to hug him in the past. During the interview with CNA B, he denied the alleged allegation of grabbing the resident's buttock or placing his/her hand on his genitals. During the resident's interview, he/she reported CNA B attempted to hug him/her, grab his/her buttock and place his/her hand on his genitals. Staff interviews regarding CNA B's interactions with residents were negative for any findings. The resident remains at the facility at baseline and staff will continue to follow the resident's plan of care. Social services will complete one on ones as seeded. As a result of the facility's investigations, the CNA was terminated on 7/3/18 for unprofessional behavior and failure to report the resident's behavior; -Further review of the investigation showed no statement from CNA B. MO 216

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being of a resident experiencing a change in condition. The facility failed to notify the physician in a timely manner and monitor him/her to prevent further deterioration of his/her condition for one of four sampled residents (Resident #1). The census was 90. Review of Resident #1's care plan, updated 4/8/16, showed the following: -Insulin deficiency with inability to utilize nutrients; -Excessive intake in relation to metabolic needs; -Resident took food off used meal trays; -Court appointed guardian. Review of the resident's dietary nutritional assessment, dated 2/14/17 at 2:22 P.M., showed the resident was on a regular no added salt, no concentrated sweets diet and had no chewing or swallowing concerns. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/26/17, showed the following: -Cognitively intact; -[DIAGNOSES REDACTED]. -Required oversight, encouragement or cueing for ambulation without support; -Required setup help with supported ambulation; -Required oversight, encouragement or cueing when feeding self; -Required setup help with supported eating. Review of the resident's departmental notes, showed the following: -8/2/17 at 10:19 P.M., the resident was able to walk freely in the facility. He/she did not need any assistance with his/her activities of daily living. The resident regularly ate 100% of his/her dinner and seconds when offered. He/she was always compliant with taking medications; -8/14/17 at 1:00 P.M., staff performed a baseline assessment. The resident did not complain of any pain and did not exhibit any behavioral issues. Further review of the resident's departmental notes, showed staff did not document anything regarding the resident on 8/15/17 or 8/16/17. During an interview on 9/27/17 at 1:26 P.M., Nurse A said on 8/16/17, the resident skipped a meal and did not eat much but said that he/she was fine and not in pain. During an interview on 9/30/17 at 9:38 P.M., Certified Medication Technician (CMT) B said the resident's hands were never completely steady. However on the evening of 8/16/17, he/she had a pronounced tremor. The resident's nerves kept giving out, causing him/her to spill and drop things. He/she could not hold onto anything for very long. At the dinner table, he/she was drowsy and dozing off. CMT B kept waking the resident and fed him/her by putting food on a spoon and handing it to him/her. CMT B did not notify the charge nurse or doctor of his/her observations and did not document the observations. During an interview on 9/29/17 at 3:04 P.M., Nurse C said on the evening of 8/16/17, the outgoing staff did not report any concerns or pass on any instructions regarding the resident. He/she was the charge nurse for the first floor and also covered the second floor; when someone reported an issue with a resident. Nurse B also walked the second floor at regular intervals. No one reported anything to him/her about the resident. As far as Nurse B knew, the resident was fine. Review of the resident's nurse's note, dated 8/17/17 at 9:55 A.M., showed the resident's gait was unsteady and he/she was sleeping but easy to arouse. He/she did not complain of any pain. Staff contacted his/her primary care physician to inform him of the resident's mental status, and received an order to send the resident to the hospital emergency room for further evaluation. The resident's vital signs showed blood pressure 108/64 (BP, normal range, 90/60 millimeters (mm)/mm of mercury (Hg) to 120/80 mm/Hg), pulse 88 (P, normal range, 60-100 beats per minute), respiration 20 (R, normal range, 12-18 breaths per minute), temperature 97.7 (T, normal range, 97.8 to 99.1 degrees Fahrenheit (F), blood sugar 144 (normal range before breakfast, 90 and 130 milligrams (mg)/deciliters (dL)). Staff called an ambulance and had the resident transferred to the hospital at 10:15 A.M. Review of the resident's emergency medical services pre-hospital care report, dated 8/17/17, showed staff called for non-urgent advanced life support services for an altered level of consciousness at 9:22 A.M., and the ambulance arrived at 9:59 A.M. When the paramedics arrived, the resident was sitting upright in a wheelchair, slightly slumped over, and lethargic. The resident, who was typically alert and oriented times four, was alert and oriented times two. The chief complaint for him/her was an altered level of consciousness. According to nursing staff, the change in condition began during the previous night at around 6:00 P.M., and had gotten progressively worse. The resident was diabetic and the last blood glucose level (BGL) per staff was 164 that morning. He/she did not take any medications that morning, due to the inability to swallow food. The paramedics secured the resident to a stretcher and placed him/her on the cardiac monitor. His/her pulse oximetry blood oxygen saturation level reading (SPO2) was low and he/she was audibly wheezing. At that point, the resident was only responding to voice and pain. Paramedics placed the resident on two liters per minute (LPM) of oxygen per nasal cannula with carbon [MEDICATION NAME] (CO2) monitoring. The resident's SPO2 level rose to 84% on 2 LPM. An increase to 4 LPM resulted in his/her SPO2 level rising to 90%. Paramedics placed an 18 gauge intravenous (IV) line in the resident's right accessory cephalic vein (passes along the radial border of the forearm) then began to run normal saline wide open (opening the IV tubing roller clamp all the way to allow for maximal fluid delivery with the aid of gravity) due to low blood pressure. The resident's BGL was 114. Paramedics were unable to obtain a stroke scale, due to the resident's inability to follow commands. His/her blood pressure continued to drop and remained low in the hospital emergency department. Due to an altered level of consciousness, the resident was unable to sign for him/herself. Review of the resident's hospital records, dated 8/17/17 at 11:01 A.M., showed the resident presented at the hospital with an altered mental status. He/she could not answer any questions or provide any useful information. After receiving critical care, the resident was diagnosed with [REDACTED]. of heart injury/inflammation/weakening/congestive failure, or severe infections, or kidney disease). His/her blood pressure was 64/45. After aggressive fluid resuscitation, his/her blood pressure temporarily increased to 90s/40s and emergency room staff transferred the resident to the intensive care unit for pressure support (mechanical ventilation). The resident became unresponsive to painful physical stimuli including sternal rub and had to be intubated (placement of a flexible plastic tube in the windpipe) for airway protection. During an interview on 9/27/17 at 12:59 P.M., CMT D said his/her shift started at 7:00 A.M. On the morning of 8/17/17, the outgoing staff reported that the resident needed a little extra help getting dressed. He/she did not want to eat breakfast. Normally, the only time he/she did not want to eat a facility meal was when he/she was ordering out. When CMT D attempted to administer the resident's morning medications, he/she could not keep medication in his/her mouth. The pills came back out because the resident was confused about what he/she needed to do with them. CMT D noticed the resident's gait was off. The resident seemed okay, but found it increasingly difficult to walk and was breathing faster than normal. However, he/she was not panting or gasping. The resident had not previously experienced any respiratory issues like shortness of breath, persistent coughing or becoming short-winded with exertion. He/she liked to dance and his/her gait was normally steady. At around 8:45 A.M., CMT D asked the resident if he/she was okay and he/she said, yeah. However CMT D could tell by his/her expression that the question was not clicking and he/she did not understand what CMT D was saying. During an interview on 9/27/17 at 1:26 P.M., Nurse A said on the morning of 8/17/17, the outgoing charge nurse said the resident was fine. Nurse A was serving as charge nurse on the second floor. At 10:00 A.M., CMT D called the second floor. Nurse A went to the third floor to observe residents. Nurse A noticed that the resident's gait was unsteady. Nurse A took his/her vital signs, which were normal. The resident was still saying that he/she was fine and not feeling any pain. In order to be on the safe side, Nurse A contacted the resident's physician. Having provided care to the resident for several years, Nurse A was very familiar with his/her baseline. The resident's gait was normally steady and he/she did not previously have any swallowing issues. His/her breathing pattern remained unchanged. During an interview on 9/13/17 at 12:39 P.M., the Director of Nursing (DON) said the resident did not have any swallowing difficulties prior to 8/17/17. However, he/she did have a tendency to stuff his/her mouth full of food and gorge large quantities of food provided by a family member. The family member had recently brought the resident two cases of soda, gallon jars of pickles and two cases of ramen noodles, which the resident consumed in less than 48 hours. Three days later, he/she experienced a change in condition. Further review of the resident's care plan, updated 4/8/16, did not show identification or interventions for the resident's manner of consuming snacks. During an interview on 9/21/17 at 1:42 P.M., Deputy Public Administrator E said the resident's guardian was previously unaware of the large quantities of food being provided by the resident's family member. If the facility had notified the guardian, he would not have granted permission for the resident to consume such large quantities of snacks, due to the fact that the resident was diabetic and overweight. During an interview on 10/12/17 at 11:12 A.M. and 10/13/17 at 9:13 A.M., the DON said the CMTs supervising residents on the third floor were expected to act within their scope of practice. They did not receive any special training for their unit supervision duties. If CMTs noticed anything behaviorally or medically different in a resident or observed anything out-of-line, then they were expected to take that resident's vital signs and notify the second floor charge nurse to come the third floor. The CMT or charge nurse could document changes in condition. Notification of the resident's physician depended upon what occurred with the resident. If the resident could be maintained in the facility, then nursing staff were to notify the physician within the hour of the observed change in condition. If the resident's condition was life-threatening, staff should call 911 first, and then contact the physician. The second floor charge nurse was expected to conduct rounds on the third floor every two to three hours. He/she should visit the third floor twice during his/her shift and again, at the end of his/her shift. During an interview on 10/6/17 at 12:40 P.M., Physician F said staff should deal with a change in a resident's condition as the facility policy directed. However, he instructed staff not to hesitate to contact him with their concerns, especially for acute changes in condition. Staff had permission to send a resident to the hospital after a change in condition, and then secure the order from him. It was better to have a false positive, then to have the resident's condition deteriorate. On 8/17/17, CMT D notified Physician F that the resident had a change in condition that began that day. According to CMT D, the resident's gait/balance was unsteady and he/she was not eating much. Physician F expected staff to call when they noticed a change in the resident's condition on 8/16/17. A change in mental status could lead to transient aspirational issues, which could lead to aspiration pneumonia and develop into septic shock. Preventing those issues depended upon staff notifying Physician F of the resident's change in mental status early. Otherwise, a domino effect to his/her health could result. A urinary tract infection could lead to a change in mental status. Physician F preferred to be notified by staff as soon as one of them observed a change in condition. With timely notification, there was a 50/50 chance that Physician F could have prevented the negative outcome suffered by the resident. Review of the facility's undated policy titled, Change in Resident Condition, showed direction for facility staff to monitor, assess, and notify the physician and guardian/POA/listed family member of a change in a resident's condition. Staff was to document the telephone numbers called and times they made the notifications. A change in condition was defined as a resident displaying any change from a resident's baseline condition including but not limited to a change in skin integrity, refusal of medication more than one medication pass, change in sleep pattern, complaint of pain, abnormal vital signs from baseline. Nursing staff was to assess the resident, notify the physician and document in the resident's chart. The nursing staff must monitor and assess the resident, every 30 minutes, or more often as necessary, until the resident either stabilized or transferred to the hospital. Staff was to immediately notify the physician of the resident's change in condition. If he/she was unavailable or it was after office hours, then staff was to seek assistance from the on-call physician. If staff could not contact the on-call physician, they were to notify the director of nursing to contact the medical director. The chain of responsibility was CNAs and CMTs could record vital signs, a licensed nurse must complete the remainder of the assessment. Staff was expected to give report at the beginning of each shift, between oncoming and off going staff. Changes must be included on the 24 hour communication report and the nursing staff would provide verbal report to on-coming nursing staff. Any need to alter treatment (i.e. a need to discontinue or hold an existing form of treatment due to adverse consequences or to commence a new form of treatment). Or a decision to transfer or discharge the resident from the facility. MO 466

Based on interview and record review, the facility failed to provide protective oversight which prevented or minimized the possibility of resident-to-resident physical and mental abuse by an aggressive resident (Resident #2). The facility did not implement interventions which identified behavioral triggers or interventions for monitoring the hazardous behaviors exhibited by one of four sampled residents. The census was 90. Review of Resident #2's undated face sheet, showed an admission date of [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/13/17, showed the following: -Cognitively intact; -[DIAGNOSES REDACTED]. -Physical and verbal behavioral symptoms directed toward others. Review of the resident's departmental notes, showed the following: -8/6/17 at 8:34 P.M., during a smoke break, the resident was involved in a resident-to-resident verbal disagreement, got upset and struck the other resident in his/her face with a closed fist. Staff quickly intervened, but it took approximately 20 minutes to calm the resident down. Staff encouraged him/her to use his/her coping skills when agitated. Staff notified the resident's physician and did not receive any new orders. Review of the resident's physician's orders, dated September 2017, showed the following: -8/7/27, Prozac 20 milligrams (mg) daily for depression; -8/7/17, Haloperidol 5 mg tablet, take 1 tablet every 4 hours as needed (PRN) for agitation; -8/7/17, Haldol Decanoate 100 ampul, inject 100 mg intramuscularly (IM) every 28 days (for agitation); -8/7/17, Haldol 5 mg/ml (milliliters) ampul, inject 5 mg IM every 4 hours PRN for agitation; -8/7/17, Olanzapine 10 mg vial, inject 10 mg every 12 hours IM PRN for agitation. Further review of the resident's departmental notes, showed the following: -8/13/17 at 11:16 P.M., the resident shouted and cursed at the day shift nurse, threatening to beat him/her up. Staff redirected the resident who then went on a spiel about medications and chased the day shift nurse around the nurse's station until staff held the resident back and took him/her to another floor. Staff administered the resident's PRN Ativan injection. Throughout the evening shift, the resident spoke aggressively to other residents. Review of a document written by the Director of Nurses (DON), showed on 8/13/17 with no time documented, Ativan 2 mg PRN was administered for agitation. The time of administration was not documented. At the bottom of the document, the DON wrote the orders were not appearing on the Medication Administration Record (MAR) because they were one time orders and chart documentation. During an interview on 9/25/17 at 2:23 P.M., Nurse H said from the day of Resident #2's arrival at the facility, the resident incited confusion among other residents. When he/she began to act out, three to four additional residents would have negative behaviors daily. He/she was physically aggressive with residents, as well as staff and was hard to redirect. Staff could do nothing with the resident when he/she became aggressive. On 8/13/17, the resident chased a nurse into the medication room. Further review of the resident's departmental notes, showed the following: -8/14/17 at 7:17 A.M., the resident spoke aggressively to residents and staff; -8/19/17 at 8:59 P.M., the resident was threatening residents and yelling at staff in the main dining room. Staff redirected the resident back to the unit. While in the elevator, the resident threw his/her plate of food, and banged his/her head against the elevator wall. Staff administered a PRN Haldol injection. The resident cut his/her right foot on a piece of glass from the broken plate. His/her vital signs were body temperature 97.8 degrees Fahrenheit (T, normal range, 97.8 to 99.1 degrees Fahrenheit (F)), pulse 96 (P, normal range, 60-100 beats per minute), respirations 20 (R, normal range, 12-18 breaths per minute) and blood pressure (BP, normal range, 90/60 millimeters (mm)/mm of mercury (Hg) to 120/80 mm/Hg) 120/80. Further review of a document written by the DON, showed on 8/19/17 with no time documented, Ativan and Haldol were given as a one time order. No further assessment of effectiveness was documented. Further review of the resident's departmental notes, showed the following: -8/24/17 at 9:09 P.M., Resident #2 became anxious and agitated with another resident (Resident #3), and yelled that he/she would whip the other resident. Resident #2 ran and charged at the other resident (Resident #3), hitting the other resident twice on the leg and back. Staff redirected the resident (Resident #2) back to his/her room and noted that they would continue to monitor his/her behavior. Review of Resident #3's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms; -[DIAGNOSES REDACTED]. During an interview on 9/25/17 at 2:23 P.M., Nurse H said when Resident #2 attacked Resident #3 on 8/24/17, it took three staff members to physically separate the two residents. Even then, Resident #2 ran through three staff and struck Resident #3 a couple more times. That frustrated Resident #3 to the point that he/she beat his/her own hand against a wall and broke it. Resident #3 later explained that he/she was angry and fed up with being bullied by Resident #2. The other residents were afraid of Resident #2, who hit hard when he/she attacked them. His/her psychiatrist instructed nursing to administer a PRN medication when verbal redirection was ineffective. However, the PRN medications did not make the resident's behavior more manageable. Staff administering them only succeeded in further angering the resident. At times, he/she refused to take his/her PRN. He/she was a danger to the other residents but not him/herself. Resident #2 would say, I ain't gonna hurt myself, but I'll beat the[***]out the rest of these mother[***] s! The facility was not equipped for someone with his/her behavioral issues. Staff could not perform one-to-one supervision and the facility did not have a secured behavioral unit. The resident had no restrictions on where he/she was allowed to go in the building. Residents were allowed to leave the floor by elevator whenever they wanted. The resident would go from floor to floor and clown (act out). He/she was up all night roaming throughout the facility until 2:00 A.M. or 3:00 A.M. Nurse H bonded with the resident. However, Nurse H's efforts to redirect him/her and protect other residents from his/her aggression were still unsuccessful. At one point, Nurse H went to the DON and wanted to quit, because Nurse H could not keep the other residents safe from Resident #2. Further review of the resident's departmental notes, showed the following: -8/26/17 at 6:44 P.M., the resident continued to be demanding and verbally aggressive with other residents. Staff redirected him/her most of the shift. The resident continued to bully the other residents and told them when to talk or what to say. Staff frequently had to ask the resident to stop being demanding and bossy with residents; At 8:44 P.M., the resident was combative, unresponsive to redirection, ran and attempted to hit another resident. He/she cursed at staff and threatened to beat down the other resident. Staff made several unsuccessful attempts to redirect the resident, who refused his/her as needed medication. Staff notified Physician G and received an order to send the resident to the hospital for a psychiatric evaluation. Review of the resident's physician's orders, dated September 2017, included the following: -9/1/17 Geodon 40 mg twice a day for manic depression; -9/1/17 Depakote delayed release (treats manic episodes) 250 mg tablet, take 1 tablet 3 times daily. Further review of the resident's departmental notes, showed the following: -9/1/17 at 12:36 P.M., staff readmitted the resident to the facility. He/she said, You need to keep some damn patients away from me. I'm just saying. Staff redirected the resident, providedteaching and rationale; -9/3/17 at 10:16 A.M., the resident became very agitated and physically aggressive with staff and residents; -9/4/17 at 7:02 P.M., the resident was on the facility's ground floor and attempted to start a fight with another resident (Resident #4) over nothing. Resident #2 appeared to derive enjoyment from starting disturbances among the other residents. He/she pushed the resident (Resident #4) against a wall, causing him/her to hurt his/her leg. Resident #2 said, I don't care. Anybody call me a [***] or any other name is going to get their ass kicked. Staff notified Physician G and received an order to send the resident to the hospital for a psychiatric evaluation. Review of Resident #4's admission MDS, dated [DATE], showed the following: -Cognitively intact; -No behavioral symptoms. -[DIAGNOSES REDACTED]. During an interview on 9/25/17 at 2:23 P.M., Nurse H said Resident #2 had a crush on Resident #4. However, when Resident #2 attacked Resident #4 on 9/4/17, staff was unable to redirect Resident #2. He/she bragged, I got all these mother[***] s scared of me. During an interview on 9/8/17 at 11:22 A.M., Resident #4 said Resident #2 was aggressive with everyone, especially the weaker residents. Resident #2 made verbal threats and physically attacked residents. Prior to the incident on 9/4/17, the two of them had gotten along fine with one another. On two prior occasions, Resident #4 had to calm Resident #2 down. The resident got into four or five fights during his/her month at the facility. On the day of the incident, Resident #4 was giggling at things Resident #2 was saying. Resident #2 talked about beating up another resident. A staff person tried to calm Resident #2 down. Resident #2 said he/she didn't care if he/she was put out of the facility, he/she was going to do it. After the staff person walked away, Resident #2 got angry at Resident #4 for laughing. Resident #4 stood up, when Resident #2 got into his/her face. Resident #4 put his/her hands at Resident #2's throat after Resident #2 shoved him/her. Resident #2 hit Resident #4 in the face once and then kicked him/her in the leg. After the attack, Resident #4 felt pain in his/her legs worse than when he/she was struck by the car which originally fractured them. Staff administered pain mediation, but he/she still felt some pain. The next day, the resident's right knee was swollen. He/she had x-rays and was sent to the hospital. Hospital staff x-rayed him/her again and said there was fluid on the right knee. At the time of the interview, the resident could barely lift his/her right leg and stretch it out. The resident said, It feels like it's going to fall off. Review of Resident #2's care plan, updated 9/4/17, showed the following: -Combative with other residents; -Ensure safety of other residents when the resident makes physical threats; -Periodic bouts of confusion; -Resident initiated a physical altercation with another resident; -Verbal and physical threats to staff. Further review of the resident's care plan, showed no new behavioral interventions added prior to the incident on 9/4/17. No interventions were specified to address the perceptual and behavioral impact of his/her schizophrenia and intellectual disabilities. During an interview on 9/8/17 10:05 A.M., the DON said Resident #2 was difficult to calm down, once he/she was upset. Resident #2 knew that Resident #4's legs were broken, prior to the altercation. Resident #4 had just started to walk again. During the altercation on 9/4/17, Resident #2 stomped on Resident #4's leg. Afterwards, Resident #4's right knee was extremely swollen. Resident #2 was a bully and the other residents were afraid of him/her. On 10/12/17 at 11:12 A.M., the DON said if verbal redirection was ineffective with an aggressive resident, that resident's care plan should be updated with a new intervention. The care plan nurse was responsible for updating the care plan, but any nurse could update it. During an interview on 9/8/17 at 10:17 A.M., the social worker said Resident #2 was noncompliant with staff's encouragement for him/her to use his/her coping skills. The resident was fixated on getting into it with other residents. Resident #4 was not aggressive. During an interview on 10/10/17 11:33 A.M., the resident's psychiatrist said the resident got agitated very easily. Part of the issue was his/her intellectual disabilities. Once he/she became agitated, it was difficult to reason with him/her. Consequently, the resident tended to engage in verbal and physical altercations with people. Staff was instructed to send the resident to the hospital, once he/she became agitated and physically aggressive. Hospital staff had a different level of training than facility staff, some of whom were afraid of individuals like the resident. Once the resident injured someone, he/she became a danger and needed to be discharged from the facility immediately. During an interview on 10/11/17 at 11:06 A.M., Physician G said the resident was very immature, aggressive, difficult to control and hyperactive. Most facilities would have discharged the resident after the first time he/she became physically aggressive with someone. Safety became an issue after that occurred. The facility should have issued an immediate discharge at that point. When he/she attacked Resident #4, stomped on and kicked Resident #4 in the legs, he/she could have further damaged Resident #4's legs by dislodging the fixation plates holding the fractures in good alignment. If his/her PRN medication was ineffective, then he/she should have received a higher dose. Review of the facility policy titled, Procedures for Responding to Alleged/Possible Abuse, Neglect, or Mistreatment of [REDACTED]. Mental abuse included, but was not limited to, humiliation, harassment, threats of punishment or deprivation. Any employee who observed or otherwise became aware of possible mistreatment, abuse or neglect of a resident, or possible misappropriation of a resident's property, was to immediately take any reasonable measure to immediately protect the resident from mistreatment, abuse or neglect. That employee was to immediately make report to the administrator or DON. The member of administration to whom the problem was reported was expected to take any necessary further steps to try to stop any such mistreatment, abuse or neglect, to the extent reasonably possible, for not only that resident but for all residents within the facility. The suspected abuser was to be isolated from the residents to protect all residents either by removing that individual from the area (if remaining in the building the accused will be monitored by a staff person, in an area away from residents) or the building. MO 750

Based on observation, interview and record review, the facility staff failed to accurately assess, revise the plans of care and implement appropriate interventions to prevent weight loss for four of 21 sampled residents (Residents #2, #8, #12, and #18) whose records were reviewed. The facility census was 101 residents. 1. Review of Resident #8's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff and used for planning care, dated 11/12/11, showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 139 lbs; - No significant weight loss assessed. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 109 lbs; - No significant weight loss assessed. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 105 lbs; - No significant weight loss assessed. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 105 lbs; - No significant weight loss assessed; - Prefers snacks between meals. Review of the resident's Care Area Assessment (CAA), a portion of the Resident Assessment Instrument that is federally required as a piece of the care planning, dated 11/12/12, showed the resident's nutritional area should be care planned. Staff documented the following in the CAA: - Has weight loss over the past year; - Is very physically active and walks, paces, and/or runs almost constantly; - Will consume 100% of double portions; - Will take food from other residents; - Has "poverty of speech," did not "speak clear words," and "can only ramble along and cry out at times;" - Unable to make needs known; - Requires staff assistance with all activities of daily living; - Impaired insight and impaired judgement: - Attention span is short and he/she does not sit still for long periods of time. Review of the resident's Monthly Record of V/S and Weights showed staff recorded the following weights: - January 2012 - 134.2 lbs; - February 2012 - 118.9 lbs; - March 2012 - 116.2 lbs; - April 2012 - 109.2 lbs; - May 2012 - 104 lbs; - June 2012 - 108.6 lbs; - July 2012 - 105.2 lbs; - August 2012 - 100.8 lbs; - September 2012 - 100.4 lbs; - October 2012 - 109.4 lbs; - November 2012 - 104.0 lbs; - December 2012 - 100.6 lbs. Review of the resident's Care Plan Participation Log, dated 2/11/12 showed on 3/10/12 the dietary supervisor wrote the resident's current weight is 118 lbs. The resident is on a double portion regular diet. Staff provide the resident with three to four cans of Ensure (250 calories each can) daily. Resident likes to walk while eating. Staff will encouraged resident to eat foods on tray, monitor intake, and continue giving Ensure between meals. Review of the resident's Dietitian's Progress Record, dated 4/27/12, showed the RDLD documented the resident's April weight is 109 lbs and a possible 7 lbs (or 6%) weight loss in one month; down 25 lbs (19%) in three months; down 28 lbs (20%) in six months. The resident continues to receive a double portion regular diet, three to four cans of Ensure per shift. The resident is reported to have a good appetite of meals, Ensure, and snacks. He/She continues to be physically very active and usually does push ups after meals and spends the majority of his/her day walking. Recommend to monitor weight weekly for one month, change Ensure to Ensure Plus to provide additional calories. Review of the resident's Care Plan Participation Log, dated 5/12/12, showed on 5/26/12 the dietary supervisor wrote the resident's current weight is 109 lbs. The resident is on regular double portions diet. He/She gets three to four cans of Ensure per shift and also gets Two Cal (470 calories per can) Shakes "whenever (he/she) wants." Staff will encourage the resident to eat foods on trays. Resident likes to eat while walking. Staff assist with meals as needed and monitor intake. Review of the resident's Dietitian's Progress Record, dated 5/26/12, showed the RDLD documented the resident's May weight 104 lbs, down 5 lbs (5%) in one month, down 15 lbs (13 %) in three months and down 33 lbs (24 %) in six months. Resident is receiving Two Cal as supplement and the day shift charge nurse reports the resident drinks 4-5 cans on day shift along with multiple health shakes and consumes 100% of meals. The resident will also take food from other residents and consume this. The resident continues to spend the majority of his/her time walking and also does an exercise routine frequently. The resident is visually thin but does not appear any thinner than he/she was six months ago. Reason for inability to gain is unclear. Recommend supplement orders be changed to Two Cal HN one can each meal and Two Cal HN four times daily with medication pass to more accurately reflect what is occurring. Review of the Resident's Notes, dated 5/26/12 showed the dietary supervisor documented the resident weighed 109 lbs (pounds). Review of the resident's Dietitian's Progress Record, dated 8/17/12 showed the resident's August weight was 101 lbs. The resident's weight was down 4 lbs (4%) in one month; down 18 lbs (15%) in six months. The resident continues to receive Health Shakes, Two Cal HN one can each shift (three times daily) and will consume Ensure and additional shakes as needed. Per the medical doctor's note decline is expected and the goal is comfort. The resident continues to spend the majority of his/her time walking/pacing. No changes recommended. Review of the resident's plan of care, dated 10/9/12, showed staff failed to list weight loss as a problem for the resident. Under the Problem: 013 Staff documented "resident eats large amounts of food but moves constantly around unit, will take other resident and staff food and drink." Goal is listed as "resident will maintain ideal body weight." (According to the CDC.gov website the normal weight range for a female that is 5'6" is 115 to 154 lbs.) The plan of care showed interventions that included the following: - Encourage resident to sit and provide table activity; - Offer frequent snacks; - Redirect resident when attempting to take others food items; - Request additional snacks out of medication room for resident; - Assist with meals as needed; - Try to give meal tray first during all meals and offer extras. Further review of the plan of care showed the staff who attended the meeting did not include the dietitian, dietary supervisor, or any direct care staff who might have identified issues with the resident's weight loss. The staff who signed the Interdisciplinary Care Plan Review Sheet were; the MDS Coordinator, Director of Nurses, Social Services, and the Activity Director. Review of the resident's physician's progress notes, dated 10/23/12, showed the resident's physician documented the resident "eats and drinks a lot but is always moving." Review of the resident's Nutritional Assessment, dated 11/9/12, showed the Registered Dietitian/ Licensed Dietitian (RDLD) documented the following weights: - November 2011 - 137 lbs; - April 2012 - 109; - July 2012 - 105 lbs; and - September 2012 - 100 lbs. Further review showed the RDLD did not record a weight for October or November 2012. He/She documented the resident is "comfort measures." He/She receives a regular double portion diet and one can of Two Cal every shift. The dietitian documented the resident consumed 100% of breakfast, lunch, and dinner meals. He/She calculated the resident's needs as greater than or equal to 1750 calories per day. The dietitian further documented the resident with a weight loss trend over the past year, but stable for six months. The resident is physically very active and walks, paces or runs almost continuously. The resident will take other resident's food if not monitored. Staff give a minimum of three cans of Two Cal per day and he/she also receives health shakes as needed through out the day. The resident's body mass index (BMI) is 17.6. (According to the CDC.gov website below 18.5 Body Mass Index is underweight.) During an interview on 12/11/12 at 11:00 AM, the Assistant Director of Nursing (ADON) said the resident gets health shakes and has a very hardy appetite. He/She said the resident used to run track. He/She said the resident gets snacks but the snacks are not on a schedule. The resident "lets us know if (he/she) wants a drink." During an interview on 12/12/12 at 4:30 PM, FM A said the resident has been in a very steady decline and he/she could see the difference at every visit. He/She said the resident will not sit down and eat a tray of food. He/She said we don't know why, but he/she continues to lose weight. Review of the resident's physician's orders [REDACTED]. The POS did not contain orders for snacks or supplements for the resident. Review of the resident's monthly summary, dated 12/5/12, and signed by ADON, showed the resident feeds self but requires tray set up. The resident's weight was not recorded, but the box for stable next to weight was marked, indicating the resident's weight was stable. Review of the CMS Roster/Sample Matrix (Form CMS-802), provided by the facility on 12/10/12, showed facility staff did not identify the resident as having a concern in the area of weight loss. Observation on 12/10/12 at 1:10 PM showed staff held the resident back as he/she tried to take food from the trays on the tray cart in the hallway by the dining room door. Observation on 12/10/12 at 6:10 PM in the 200 hall dining room showed the resident tried to take food from other residents' trays. During an interview on 12/11/12 at 9:37 the DON said the resident constantly eats and walks. Observation on 12/11/12 at 10:11 showed the resident walking about on the floor. The resident did not have any food or drink as he/she paced up and down the hallways on the second floor. During an interview on 12/11/12 at 10:20 AM the ADON said on Tuesdays and Thursdays the residents with money can purchase soda and pizza from a local pizza place. Resident #8 did not have money to purchase pizza or soda. During an interview on 12/11/12 at 2:55 PM the MDS Coordinator said the resident eats everything in sight. He/She is on a double portion diet and gets shakes. His/Her behavior is to wander. His/Her attention span is about two minutes. Observation on 12/11/12 at 8:15 AM showed the ADON lead the resident into the dining room holding onto both hands. The resident's tray had two cartons of two percent milk and a juice, scrambled eggs and toast and cereal. CMT B assisted the resident with the tray set up. (Resident #8 was the last resident sitting in the dining room to get a tray.) At 8:25 AM the resident had left the dining room. CMT B said the resident ate about one piece of toast, half of his/her cereal, maybe one egg, and drank both the milks and shakes. During an interview on 12/11/12 at 8:40 AM CMT B said two residents on the second floor were loosing weight. He/She named two residents but did not name Resident #8. He/She said the Social Services Worker B brings up snacks and gives them to the residents who are not able to go downstairs to get snacks. Observation on 12/12/12 at 1:21 PM showed CNA B lead the resident into the 200 hall dining room. The resident's tray contained two cartons of two per cent milk, one health shake, two sloppy joe sandwiches, a side of pasta, one salad and one fruit cup. CNA B set up the resident's tray. At 1:37 PM the resident had left the dining room. He/She had consumed approximately 25% of the meal, one carton of two per cent milk, and 75% of the health shake. Review of the resident's intake records showed no snacks consumed during the days of December 1-12, 2012. Observation on 12/12/12 at 1:55 PM showed the resident walked up and down the hallway on the 200 hall. During an interview on 12/12/12 at 2:00 PM Social Services Worker B said Resident #8 should get snacks from the nurses. He/She said he/she did not bring snacks for the resident. He/She said the resident's family did bring snacks like soda for the resident when they came to visit, but not in large amounts. Social Services Worker B said the resident eats, but exercises. He/She said the resident ran track in high school and likes to jog around the unit. Social Services Worker B said there is really nothing for the resident to choose from (to eat) on the unit between meals. He/She said the snacks he/she brings to the unit are the snacks that the residents with money can purchase. During an interview on 12/12/12 the ADON said we have Ensure and peanut butter crackers for the resident in the second floor medication room. We do not document snacks for him/her and they are not scheduled. When he/she is hungry he/she comes to the medication room door and we give him/her something. We wait to feed him/her until after the other resident's have their trays. Observation on 12/13/12 showed the resident running up and down the hallways on the 200 hall. During an interview on 12/12/12 at 1:50 PM the dietary supervisor said snacks are only sent to the second floor (where Resident #8 resides) at bedtime. He/She said no snacks are sent up during the day for any residents. Nursing staff are supposed to let him/her know if they need something more for residents. Observation on 12/12/12 at 2:00 PM showed the resident up walking in the hallways on the 200 hall. At 2:45 PM the resident continued to walk about the hallways. During an interview on 12/13/12 the MDS Coordinator said the resident should receive frequent snacks. The MDS Coordinator said he/she did not think the resident was hungry because he/she would walk away from his/her tray. The MDS Coordinator said the plan of care did not specify what type of snacks or how often the resident should receive the snacks. Also there was not documentation to show how often the resident ate snacks and so it was very difficult to be sure how much the resident actually consumed. During an interview on 12/14/12 the RDLD said he/she did not participate in the resident's care plan meetings. She said she shared information through the chart and talking with the DON and the dietary supervisor. She said she sees the resident most months. She said the resident never stops moving and she thought that was part of the problem. She said the resident eats and has orders for Two Cal HN each shift. She said Two Cal is different from Ensure. Ensure has 250 calories, Two Cal has 475 calories and the house shakes have 200 calories. She said "We don't use Ensure here. We use Two Cal." She said this morning she discussed fortified foods with the facility staff and had not before because weight loss has not been the norm in this building. She said weight loss had only been a problem the last couple of months. She said if she did not have a current weight she used the weight from the month before to make her assessments and recommendations. She said they could begin to use fortified foods and have some planned snacks for specific people. During an interview on 12/14/12 at 11:20 AM the ADON said the resident receives Ensure for the Two Cal order and health shakes with his/her meals. Observation of the medication room at this time showed no Two Cal HN in the medication room. A flat of Ensure and a package of peanut butter crackers sat in the medication room. During an interview on 12/14/12 at 11:20 AM the dietary supervisor said he/she did not order Two Cal. He/She ordered Ensure. The nursing staff order Two Cal. 2. Record review of Resident #12's face sheet (personal data information) showed the following: -The resident was readmitted on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 03/22/12, showed a weight of 132 lbs. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident is rarely or never understood; -Has severe cognitive impairment and psychomotor [MEDICAL CONDITION]; -Behavioral symptoms not directed toward others (e.g. pacing, disrobing in public) -Total dependence with activities of daily living (ADL's); -Incontinent of bowel and bladder -Functional impairment of bilateral lower extremities; -Height 62 inches; -Weight 113 lbs, no significant weight loss assessed; -Mechanically altered diet; Review of the physician's orders [REDACTED]. -Health shakes three times a day with meals; -Double portions Review of Resident #12's food intake record for November and December 2012, showed 80%-100% of all 3 meals consumed. Review of the Plan of Care (POC) Nutritional status dated 05/08/12 showed the following; -Monitor meal consumption; -Monitor weight monthly; -Dietary consult as needed; -Mechanical soft diet; -Health shakes three times a day with meals; -Double portions. Review of the resident's Nutritional Assessments by the Registered Dietitian (RD), showed the following: -September 2011, 128 pounds; -March 2012, 129 pounds; -June 2012, 113.6 pounds; -August 2012, 106 pounds, caloric intake exceeds needs, question continued weight loss; -November 2012, 103 pounds, receiving a mechanical soft diet with double portions and a health shake three times a day with meals. Prevention of further weight loss is difficult as resident is physically active a large portion of the day. Observation of the resident during the survey week of 12/10/12-12/14/12, showed he/she was constantly moving in a crouching manner on his/her hands and knees. He/she had highly toned arm and back muscles. Observation on 12/11/12 at 8:05 AM showed the resident in the 200 hall dining room. The resident's tray contained one container of two percent milk and one small health shake. CNA B said the resident gets double portions and if he/she drinks all of the first milk he/she would get a second one. When the resident's tray was empty he/she picked up the empty health shake carton and tried to eat it. CNA B left the resident and the ADON sat down with him/her. The resident reached for another resident's food and ADON said "You already ate." During an interview on 12/11/12 at 8:35 AM the ADON said the resident would eat as long as you give her something to eat. During an interview on 12/11/12 at 8:40 AM CMT B said two residents on the second floor were losing weight. He/She named two residents but did not name Resident #8 or Resident #12. He/She said the Social Services Worker B brings up snacks and gives them to the residents who are not able to go downstairs to get snacks. Observation on 12/11/12 at 1:12 PM showed the ADON entered 200 hall dining room leading Resident #12 by both hands. CMT B fed the resident his/her meal. The resident consumed two personal size pizzas, two cartons of two percent milk, and one health shake. The ADON offered more pizza to the residents and Resident #12 ate another 2" slice of pizza. During an interview at 2:30 P.M. on 12/12/12, the Assistant Director of Nursing (ADON) said she monitors weight loss by the amount consumed, if consumption drops below 50% she will address it with the doctor. Resident #12 consumes 100% and does not receive snacks. During an interview at 10:15 A.M. on 12/14/12 the Director of Nursing (DON) said the IDT meets weekly on Thursdays for care planning and the RD attends quarterly. Restorative services weigh residents and if significant weight loss is noted the Dietary Supervisor, charge nurse or DON would notify the doctor and the RD. Recommendations from the RD would then be forwarded to the Dietary Supervisor. Weights are tracked in a data base, weight loss or gain is hi-lighted by the program. During an interview at 10:40 A.M. on 12/14/12, the RD said she was not actively participating in care planning. She gets a monthly weight log from the DON. Weight loss is unusual for this facility; weight gain is usually the concern. She discussed those residents with weight loss this morning with the Administrator and will recommend whole milk, fortified meals and snacks for Resident #12. 3. Record review of Resident # 2's comprehensive significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/26/12 showed: - Entry/admitted to facility was 06/26/12; - Memory problem; - Age is 58; - No falls; - Uses wheelchair; - Requires limited assistance to ambulate; - Weight is 120 pounds, height is 73 inches; - No significant weight loss; - Frequently incontinent (has little control over bowel and bladder); - Assessed at no risk for development of skin breakdown; - No skin/ulcer treatments provided; - No pressure reducing device for bed or chair; - No turning/repositioning program; - No hospice services. Record review of the resident's weight sheet showed: - July, 2012 weight 136 pounds; - August, 2012 weight 140 pounds; - September, 2012 weight 136 pounds; - October, 2012 weight 120 pounds; - November, 2012 weight 113 pounds; - December, 2012 weight 116 pounds. Record review of the resident's hospice progress note dated 10/26/12 showed: - Referred to hospice for dementia/weight loss; - Has a power of attorney (guardian) who is in agreement that no further aggressive treatment or hospitalization /feeding tube is in best interest of this patient. and is choosing hospice to maximize comfort and quality of life; - Extensive psychiatric history. Record review of the resident's unsigned wound report dated 11/02/12 showed: - Onset of skin breakdown to coccyx measuring 1.6 cm (centimeters) x 0.4 cm x 0 cm. No staging noted; - Apply [MEDICATION NAME] and santyl daily. Record review of the resident's Registered Dietician note dated 11/09/12 showed: - Weight loss and on hospice services; - "Prevention of further weight loss will probably not be possible as medical condition declines". Record review of the resident's physician orders [REDACTED]. - [DIAGNOSES REDACTED]. - Regular diet, double portions all meals; - Shakes three times a day; - Apply [MEDICATION NAME] and santyl (medicated ointments) with dry dressing daily to area on coccyx; - Hospice services. Record review of the resident's physician progress notes [REDACTED]. - Seen for significant wasting; - Weight loss despite eating well; - "Something else is using ...calories because is eating but wasting" - Plan is hospice/comfort. Record review of the resident's undated, unsigned care plan shows: - At risk for falls, use low bed, no mention of floor mat beside bed; - Dependent on wheelchair for mobility, no mention of Broda chair (specialized wheelchair to prevent skin breakdown); - Has adequate nutritional intake but continues to lose weight related to decline in health and hospice status. No mention of double portion diet or house supplement (shake) three times a day nor ensure; - No mention of skin breakdown or treatments provided; - Assure pressure cushion is in wheelchair; - Hospice services. Observation throughout the survey dates of 12/10/12 through 12/14/12 showed: - Bed in high position except on one occasion; - Floor mat on floor beside right side of bed all days; - Using a Broda wheelchair when up; - Pressure relieving cushion in Broda wheelchair on one occasion; - Fed self and ate 100% of double portioned meals; - House supplement served with meals; - No fortified foods provided; - No snacks provided to resident between meals other than a Pepsi on one occasion; - No snack cart passed offering food to residents between meals; - Pressure reducing cushion in Broda wheelchair on one occasion; - Hospice services being provided on 12/11/12. Review of the form CMS-802 Roster/Sample completed by staff and given to the surveyors during the survey process did not show Resident #2 as having a weight loss. During an interview on 12/11/12 at 9:25 A.M. the DON said: - Resident #2 was identified by facility as having weight loss. During observation and interview of on 12/11/12 at 9:30 A.M. Nurse A said: - Resident has a stage II ulcer to coccyx to which he/she applied [MEDICATION NAME] and santyl then dry dressing; - Resident is incontinent 90% of the time; - Resident likes to sit up and "keep pressure on"; - Resident is on hospice for dementia and weight loss; - Resident usually eats 90-100% of meals and receives health shakes with meals. Hospice provides ensure. During an interview on 12/11/12 at 11:20 A.M. the Hospice Nurse said: - Resident started hospice one month ago due to weight loss and dementia; - Pressure ulcer on coccyx is improving; - It is desirable not to use a pressure relieving cushion in a Broda chair as then the air cannot circulate between the straps on the seat; - Resident requested a milky way candy bar for Christmas so he/she brought him/her one. During an interview on 12/12/12 at 7:50 A.M. the MDS Coordinator said: - Resident's pressure ulcer was acquired at the facility due to weight loss. During an interview on 12/13/12 at 2:40 P.M. Nurse A said: - They keep health shakes and graham crackers at the nursing station for resident snacks; - There are no specific times that snacks are offered. During an interview on 12/14/12 at 10:45 A.M. the Registered Dietician said: - Resident eats 100% of food offered; - He/she was aware of the resident's significant weight loss; - A snack cart would not work with this population of psychiatric residents; - It would be possible for dietary to provide individualized between meal snacks or six meals per day for designated residents; - Currently no individualized between meal snacks were provided for the resident; - The facility does not currently provide fortified foods; - That morning he/she spoke with the administrator and dietary supervisor about providing fortified foods. During an interview on 12/14/12 at 11:00 A.M. the MDS Coordinator said: - Care plan meetings are held every Thursday; - The care plan team is responsible for reviewing and revising the care plans; - Members of the care plan team include himself/herself, social services, activities, dietary and restorative. 4. Record review of Resident #18's comprehensive admission MDS, dated [DATE] showed: - Entry/admitted to facility was 08/21/12; - Memory problem; - Weight 126 pounds; - Walks independently. Record review of the resident's weight sheet showed: - September, 2012 weight 126 pounds; - October, 2012 weight 121 pounds; - November, 2012 weight 113 pounds; - December, 2012 weight 112 pounds. Record review of the resident's Registered Dietician's notes dated 11/09/12 showed: - November weight 108 pounds , down 13 pounds, 11% in one month; - Resident first said wouldn't eat food "cause was poison" then said "foods all good"; - Prefers sweets, soda; - Recommended that all diet restrictions be stopped and add health shakes with all meals. Record review of the resident's physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - [DIAGNOSES REDACTED]. - Regular diet; - Shakes were originally ordered for three times per day then decreased to two times per day. Record review of the resident's undated, unsigned care plan showed: - No mention of weight loss; - Requires therapeutic diet of NCS/NAS (No Concentrated Sugars, No Added Salt); - No mention of providing house shakes with meals. Review of the form CMS-802 Roster/Sample completed by staff and given to the surveyors during the survey process did not show Resident #18 as having a weight loss. During an interview on 12/11/12 at 9:25 A.M. the DON said: - Resident #18 was identified by facility as having weight loss. During an interview on 12/13/12 at 2:40 P.M. Nurse A said: - They keep health shakes and graham crackers at the nursing station for resident snacks; - There are no specific times that snacks are offered. During an interview on 12/14/12 at 10:45 A.M. the Registered Dietician said: - He/she was aware of the resident's significant weight loss; - The resident frequently refused food; - A snack cart would not work with this population of psychiatric residents; - It would be possible for dietary to provide individualized between meal snacks or six meals per day for designated residents; - Currently no individualized between meal snacks were provided for the resident; - The facility does not currently provide fortified foods; - That morning he/she spoke with the administrator and dietary supervisor about providing fortified foods for this resident. During an interview on 12/14/12 at 11:00 A.M. the MDS Coordinator said: - Care plan meetings are held every Thursday; - The care plan team is responsible for reviewing and revising the care plans; - Members of the care plan team include himself/herself, social services, activities, dietary and restorative. - He/she was currently working on a significant change in status assessment for this resident (was due within 14 days of reentry from hospital: 12/12/12). 5. During a family interview on 12/12/12 at 6:30 P.M. the family member said: - He/she thinks some residents are hungry; - He/she purchases snacks for his/her resident from the grocery store so that the resident is not hungry.

Based on observation, record review and interview, the facility failed to ensure menus were adjusted to meet the caloric and nutrient intake needs of each resident in consideration of their individual needs, which resulted in continued weight loss for four (Residents #2, #8, #12, and #18) of 21 sampled residents whose records were reviewed. The facility census was 101. 1. Review of Resident #8's Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff and used for planning care, dated 11/12/11, showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 139 lbs; - No significant weight loss assessed. Review of the resident's Dietitian's Progress Record, dated 4/27/12, showed the RDLD documented the resident's April weight is 109 lbs and a possible 7 lbs (or 6%) weight loss in one month; down 25 lbs (19%) in three months; down 28 lbs (20%) in six months. The resident continues to receive a double portion regular diet, three to four cans of Ensure per shift. The resident is reported to have a good appetite of meals, Ensure, and snacks. He/She continues to be physically very active and usually does push ups after meals and spends the majority of his/her day walking. Recommend to monitor weight weekly for one month, change Ensure to Ensure Plus to provide additional calories. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 109 lbs; - No significant weight loss assessed. Review of the resident's Dietitian's Progress Record, dated 5/26/12, showed the RDLD documented the resident's May weight 104 lbs, down 5 lbs (5%) in one month, down 15 lbs (13 %) in three months and down 33 lbs (24 %) in six months. Resident is receiving Two Cal as supplement and the day shift charge nurse reports the resident drinks 4-5 cans on day shift along with multiple health shakes and consumes 100% of meals. The resident will also take food from other residents and consume this. The resident continues to spend the majority of his/her time walking and also does an exercise routine frequently. The resident is visually thin but does not appear any thinner than he/she was six months ago. Reason for inability to gain is unclear. Recommend supplement orders be changed to Two Cal HN one can each meal and Two Cal HN four times daily with medication pass to more accurately reflect what is occurring. Review of the Resident's Notes, dated 5/26/12 showed the dietary supervisor documented the resident weighed 109 lbs (pounds). Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 105 lbs; - No significant weight loss assessed. Review of the resident's Dietitian's Progress Record, dated 8/17/12 showed the resident's August weight was 101 lbs. The resident's weight was down 4 lbs (4%) in one month; down 18 lbs (15%) in six months. The resident continues to receive Health Shakes, Two Cal HN one can each shift (three times daily) and will consume Ensure and additional shakes as needed. Per the medical doctor's note decline is expected and the goal is comfort. The resident continues to spend the majority of his/her time walking/pacing. No changes recommended. Review of the resident's plan of care, dated 10/9/12, showed staff failed to list weight loss as a problem for the resident. Under the Problem: 013 Staff documented "resident eats large amounts of food but moves constantly around unit, will take other resident and staff food and drink." Goal is listed as "resident will maintain ideal body weight." (According to the CDC.gov website the normal weight range for a female that is 5'6" is 115 to 154 lbs.) The plan of care showed interventions that included the following: - Encourage resident to sit and provide table activity; - Offer frequent snacks; - Redirect resident when attempting to take others food items; - Request additional snacks out of medication room for resident; - Assist with meals as needed; - Try to give meal tray first during all meals and offer extras. Further review of the plan of care did not contain specifics for fortified foods, snacks, small frequent meals, or finger foods for the resident. The RDLD did not sign the resident's plan of care. Review of the resident's physician's progress notes, dated 10/23/12, showed the resident's physician documented the resident "eats and drinks a lot but is always moving." Review of the resident's Nutritional Assessment, dated 11/9/12, showed the Registered Dietitian/ Licensed Dietitian (RDLD) documented the following weights: - November 2011 - 137 lbs; - April 2012 - 109; - July 2012 - 105 lbs; and - September 2012 - 100 lbs. Further review showed the RDLD did not record a weight for October or November 2012. He/She documented the resident is "comfort measures." He/She receives a regular double portion diet and one can of Two Cal every shift. The dietitian documented the resident consumed 100% of breakfast, lunch, and dinner meals. He/She calculated the resident's needs as greater than or equal to 1750 calories per day. The dietitian further documented the resident with a weight loss trend over the past year, but stable for six months. The resident is physically very active and walks, paces or runs almost continuously. The resident will take other resident's food if not monitored. Staff give a minimum of three cans of Two Cal per day and he/she also receives health shakes as needed through out the day. The resident's body mass index (BMI) is 17.6. (According to the CDC.gov website below 18.5 Body Mass Index is underweight.) Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; - Decisions poor; - Requires cues and supervision; - Resident wanders daily; - Requires supervision with eating; - 65 inches tall (5'5"); - Weighs 105 lbs; - No significant weight loss assessed; - Prefers snacks between meals. Review of the resident's Care Area Assessment (CAA), a portion of the Resident Assessment Instrument that is federally required as a piece of the care planning, dated 11/12/12, showed the resident's nutritional area should be care planned. Staff documented the following in the CAA: - Has weight loss over the past year; - Is very physically active and walks, paces, and/or runs almost constantly; - Will consume 100% of double portions; - Will take food from other residents; - Has "poverty of speech," did not "speak clear words," and "can only ramble along and cry out at times;" - Unable to make needs known; - Requires staff assistance with all activities of daily living; - Impaired insight and impaired judgement: - Attention span is short and he/she does not sit still for long periods of time. Review of the resident's Monthly Record of V/S and Weights showed staff recorded the following weights: - January 2012 - 134.2 lbs; - February 2012 - 118.9 lbs; - March 2012 - 116.2 lbs; - April 2012 - 109.2 lbs; - May 2012 - 104 lbs; - June 2012 - 108.6 lbs; - July 2012 - 105.2 lbs; - August 2012 - 100.8 lbs; - September 2012 - 100.4 lbs; - October 2012 - 109.4 lbs; - November 2012 - 104.0 lbs; - December 2012 - 100.6 lbs. Review of the menus for Week 6 and provided by the facility staff showed the menus contained a column for fortified foods and for finger foods. During an interview on 12/11/12 at 11:00 AM, the Assistant Director of Nursing (ADON) said the resident gets health shakes and has a very hardy appetite. He/She said the resident used to run track. He/She said the resident gets snacks but the snacks are not on a schedule. The resident "lets us know if (he/she) wants a drink." During an interview on 12/12/12 at 4:30 PM, FM A said the resident has been in a very steady decline and he/she could see the difference at every visit. He/She said the resident will not sit down and eat a tray of food. He/She said we don't know why, but he/she continues to lose weight. Review of the resident's physician's orders [REDACTED]. The POS did not contain orders for snacks, supplements, fortified foods, or finger foods for the resident. During an interview on 12/11/12 at 9:37 the DON said the resident constantly eats and walks. Observation on 12/11/12 at 10:11 showed the resident walking about on the floor. The resident did not have any food as he/she paced up and down the hallways on the second floor. During an interview on 12/11/12 at 2:55 PM the MDS Coordinator said the resident eats everything in sight. He/She is on a double portion diet and gets shakes. His/Her behavior is to wander. His/Her attention span is about two minutes. Observation on 12/11/12 at 8:15 AM showed the ADON lead the resident into the dining room holding onto both hands. The resident's tray had two cartons of two percent milk and a juice, scrambled eggs and toast and cereal. CMT B assisted the resident with the tray set up. At 8:25 AM the resident had left the dining room. CMT B said the resident ate about one piece of toast, half of his/her cereal, maybe one egg, and drank both the milks and shakes. The tray did not contain fortified milk, supper cereal, jelly on the toast etc. as listed on the fortified foods menu. Observation on 12/12/12 at 1:21 PM showed CNA B lead the resident into the 200 hall dining room. The resident's tray contained two cartons of two per cent milk, one health shake, two sloppy joe sandwiches, a side of pasta, one salad and one fruit cup. CNA B set up the resident's tray. At 1:37 PM the resident had left the dining room. He/She had consumed approximately 25% of the meal, one carton of two per cent milk, and 75% of the health shake. The resident did not receive fortified milk with his/her meal. Review of the resident's intake records showed no snacks consumed during the days of December 1-12, 2012. Observation on 12/12/12 at 1:55 PM showed the resident walked up and down the hallway on the 200 hall. During an interview on 12/12/12 at 2:00 PM Social Services Worker B said Resident #8 should get snacks from the nurses. He/She said he/she did not bring snacks for the resident. He/She said the resident's family did bring snacks like soda for the resident when they came to visit, but not in large amounts. Social Services Worker B said the resident eats, but exercises. He/She said the resident ran track in high school and likes to jog around the unit. Social Services Worker B said there is really nothing for the resident to choose from (to eat) on the unit between meals. He/She said the snacks he/she brings to the unit are the snacks that the residents with money can purchase. During an interview on 12/12/12 the ADON said we have Ensure and peanut butter crackers for the resident in the second floor medication room. We do not document snacks for him/her and they are not scheduled. When he/she is hungry he/she comes to the medication room door and we give him/her something. We wait to feed him/her until after the other resident's have their trays. Observation on 12/13/12 showed the resident running up and down the hallways on the 200 hall. During an interview on 12/12/12 at 1:50 PM the dietary supervisor said snacks are only sent to the second floor (where Resident #8 resides) at bedtime. He/She said no snacks are sent up during the day for any residents. Nursing staff are supposed to let him/her know if they need something more for residents. Observation at 2:00 PM showed the resident up walking in the hallways on the 200 hall. At 2:45 PM the resident continued to walk about the hallways. During an interview on 12/13/12 the MDS Coordinator said the resident should receive frequent snacks. The MDS Coordinator said he/she did not think the resident was hungry because he/she would walk away from his/her tray. The MDS Coordinator said the plan of care did not specify what type of snacks or how often the resident should receive the snacks. Also there was not documentation to show how often the resident ate snacks and so it was very difficult to be sure how much the resident actually consumed. During an interview on 12/14/12 the RDLD said he/she did not participate in the resident's care plan meetings. She said she shared information through the chart and talking with the DON and the dietary supervisor. She said she sees the resident most months. She said the resident never stops moving and she thought that was part of the problem. She said the resident eats and has orders for Two Cal HN each shift. She said Two Cal is different from Ensure. Ensure has 250 calories, Two Cal has 475 calories and the house shakes have 200 calories. She said "We don't use Ensure here. We use Two Cal." She said this morning she discussed fortified foods with the facility staff and had not before because weight loss has not been the norm in this building. She said weight loss had only been a problem the last couple of months. She said if she did not have a current weight she used the weight from the month before to make her assessments and recommendations. She said they could begin to use fortified foods and have some planned snacks for specific people. During an interview on 12/14/12 at 11:20 AM the ADON said the resident receives Ensure for the Two Cal order and health shakes with his/her meals. Observation of the medication room at this time showed no Two Cal HN in the medication room. A flat of Ensure and a package of peanut butter crackers sat in the medication room. During an interview on 12/14/12 at 11:20 AM the dietary supervisor said he/she did not order Two Cal. He/She ordered Ensure. The nursing staff order Two Cal. 2. Record review of Resident #12's face sheet (personal data information) showed the following: -The resident was readmitted on [DATE]; -[DIAGNOSES REDACTED]. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 03/22/12, showed a weight of 132 lbs. Record review of Resident #12's quarterly MDS dated [DATE], showed the following: -Resident is rarely or never understood; -Has severe cognitive impairment and psychomotor [MEDICAL CONDITION]; -Behavioral symptoms not directed toward others (e.g. pacing, disrobing in public) -Total dependence with activities of daily living (ADL's); -Incontinent of bowel and bladder -Functional impairment of bilateral lower extremities; -Height 62 inches; -Weight 113 lbs, no significant weight loss assessed; -Mechanically altered diet; Observation of Resident #12 during the survey week of 12/10/12-12/14/12, showed he/she was fed double portions, a health shake and 2% milk at all 3 daily meals. Resident #12 was observed constantly moving in a crouching manner on his/her hands and knees, resulting in highly toned arm and back muscles. Review of the physician's orders [REDACTED]. -Health shakes three times a day with meals; -Double portions Review of Resident #12's food intake record for November and December 2012, showed 80%-100% of all 3 meals consumed. Review of the Plan of Care (POC) Nutritional status dated 05/08/12 showed the following; -Monitor meal consumption; -Monitor weight monthly; -Dietary consult as needed; -Mechanical soft diet; -Health shakes three times a day with meals; -Double portions. Review of Resident #12's Nutritional Assessments by the Registered Dietary Consultant (RD) showed the following: -September 2011, 128 pounds; -March 2012, 129 pounds; -June 2012, 113.6 pounds; -August 2012, 106 pounds, caloric intake exceeds needs, question continued weight loss; -November 2012, 103 pounds, receiving a mechanical soft diet with double portions and a health shake three times a day with meals. Prevention of further weight loss is difficult as resident is physically active a large portion of the day. During an interview at 2:30 P.M. on 12/12/12, the Assistant Director of Nursing (ADON) said she monitors weight loss by the amount consumed, if consumption drops below 50% she will address it with the doctor. Resident #12 consumes 100% and does not receive snacks. During an interview at 10:40 A.M. on 12/14/12, the RD said she was not actively participating in care planning. She said she gets a monthly weight log from the DON. She would recommend whole milk, fortified meals and snacks for Resident #12. 3. Record review of Resident # 2's comprehensive significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 10/26/12 showed: - Entry/admitted to facility was 06/26/12; - Memory problem; - Age is 58; - No falls; - Uses wheelchair; - Requires limited assistance to ambulate; - Weight is 120 pounds, height is 73 inches; - No significant weight loss; - Frequently incontinent (has little control over bowel and bladder); - Assessed at no risk for development of skin breakdown; - No skin/ulcer treatments provided; - No pressure reducing device for bed or chair; - No turning/repositioning program; - No hospice services. Record review of the resident's weight sheet showed: - July, 2012 weight 136 pounds; - August, 2012 weight 140 pounds; - September, 2012 weight 136 pounds; - October, 2012 weight 120 pounds; - November, 2012 weight 113 pounds; - December, 2012 weight 116 pounds. Record review of the resident's hospice progress note dated 10/26/12 showed: - Referred to hospice for dementia/weight loss; - Has a power of attorney (guardian) who is in agreement that no further aggressive treatment or hospitalization /feeding tube is in best interest of this patient. and is choosing hospice to maximize comfort and quality of life; - Extensive psychiatric history. Record review of the resident's unsigned wound report dated 11/02/12 showed: - Onset of skin breakdown to coccyx measuring 1.6 cm (centimeters) x 0.4 cm x 0 cm. No staging noted; - Apply [MEDICATION NAME] and santyl daily. Record review of the resident's Registered Dietician note dated 11/09/12 showed: - Weight loss and on hospice services; - "Prevention of further weight loss will probably not be possible as medical condition declines". Record review of the resident's physician orders [REDACTED]. - [DIAGNOSES REDACTED]. - Regular diet, double portions all meals; - Shakes three times a day; - Apply [MEDICATION NAME] and santyl (medicated ointments) with dry dressing daily to area on coccyx; - Hospice services. Record review of the resident's physician progress notes [REDACTED]. - Seen for significant wasting; - Weight loss despite eating well; - "Something else is using ...calories because is eating but wasting" - Plan is hospice/comfort. Record review of the resident's undated, unsigned care plan shows: - At risk for falls, use low bed, no mention of floor mat beside bed; - Dependent on wheelchair for mobility, no mention of Broda chair (specialized wheelchair to prevent skin breakdown); - Has adequate nutritional intake but continues to lose weight related to decline in health and hospice status. No mention of double portion diet or house supplement (shake) three times a day nor ensure; - No mention of skin breakdown or treatments provided; - Assure pressure cushion is in wheelchair; - Hospice services. Observation throughout the survey dates of 12/10/12 through 12/14/12 showed: - Bed in high position except on one occasion; - Floor mat on floor beside right side of bed all days; - Using a Broda wheelchair when up; - Pressure relieving cushion in Broda wheelchair on one occasion; - Fed self and ate 100% of double portioned meals; - House supplement served with meals; - No fortified foods provided; - No snacks provided to resident between meals other than a Pepsi on one occasion; - No snack cart passed offering food to residents between meals; - Pressure reducing cushion in Broda wheelchair on one occasion; - Hospice services being provided on 12/11/12. Review of the form CMS-802 Roster/Sample completed by staff and given to the surveyors during the survey process did not show Resident #2 as having a weight loss. During an interview on 12/11/12 at 9:25 A.M. the DON said: - Resident #2 was identified by facility as having weight loss. During observation and interview of on 12/11/12 at 9:30 A.M. Nurse A said: - Resident has a stage II ulcer to coccyx to which he/she applied [MEDICATION NAME] and santyl then dry dressing; - Resident is incontinent 90% of the time; - Resident likes to sit up and "keep pressure on"; - Resident is on hospice for dementia and weight loss; - Resident usually eats 90-100% of meals and receives health shakes with meals. Hospice provides ensure. During an interview on 12/11/12 at 11:20 A.M. the Hospice Nurse said: - Resident started hospice one month ago due to weight loss and dementia; - Pressure ulcer on coccyx is improving; - It is desirable not to use a pressure relieving cushion in a Broda chair as then the air cannot circulate between the straps on the seat; - Resident requested a milky way candy bar for Christmas so he/she brought him/her one. During an interview on 12/12/12 at 7:50 A.M. the MDS Coordinator said: - Resident's pressure ulcer was acquired at the facility due to weight loss. During an interview on 12/13/12 at 2:40 P.M. Nurse A said: - They keep health shakes and graham crackers at the nursing station for resident snacks; - There are no specific times that snacks are offered. During an interview on 12/14/12 at 10:45 A.M. the Registered Dietician said: - Resident eats 100% of food offered; - He/she was aware of the resident's significant weight loss; - A snack cart would not work with this population of psychiatric residents; - It would be possible for dietary to provide individualized between meal snacks or six meals per day for designated residents; - Currently no individualized between meal snacks were provided for the resident; - The facility does not currently provide fortified foods; - That morning he/she spoke with the administrator and dietary supervisor about providing fortified foods. During an interview on 12/14/12 at 11:00 A.M. the MDS Coordinator said: - Care plan meetings are held every Thursday; - The care plan team is responsible for reviewing and revising the care plans; - Members of the care plan team include himself/herself, social services, activities, dietary and restorative. 4. Record review of Resident #18's comprehensive admission MDS, dated [DATE] showed: - Entry/admitted to facility was 08/21/12; - Memory problem; - Weight 126 pounds; - Walks independently. Record review of the Resident's weight sheet showed: - September, 2012 weight 126 pounds; - October, 2012 weight 121 pounds; - November, 2012 weight 113 pounds; - December, 2012 weight 112 pounds. Record review of Registered Dietician's notes dated 11/09/12 showed: - November weight 108 pounds, down 13 pounds, 11% in one month; - Resident first said wouldn't eat food "cause was poison" then said "foods all good"; - Prefers sweets, soda; - Recommended that all diet restrictions be stopped and add health shakes with all meals. Record review of the Resident's physician's orders [REDACTED]. - [DIAGNOSES REDACTED]. - [DIAGNOSES REDACTED]. - Regular diet; - Shakes were originally ordered for three times per day then decreased to two times per day. Record review of the Resident's undated, unsigned care plan showed: - No mention of weight loss; - Requires therapeutic diet of NCS/NAS (No Concentrated Sugars, No Added Salt); - No mention of providing house shakes with meals. Review of the form CMS-802 Roster/Sample completed by staff and given to the surveyors during the survey process did not show Resident #18 as having a weight loss. During an interview on 12/11/12 at 9:25 A.M. the DON said: - Resident #18 was identified by facility as having weight loss. During an interview on 12/13/12 at 2:40 P.M. Nurse A said: - They keep health shakes and graham crackers at the nursing station for resident snacks; - There are no specific times that snacks are offered. During an interview on 12/14/12 at 10:45 A.M. the Registered Dietician said: - He/she was aware of the resident's significant weight loss; - The resident frequently refused food; - A snack cart would not work with this population of psychiatric residents; - It would be possible for dietary to provide individualized between meal snacks or six meals per day for designated residents; - Currently no individualized between meal snacks were provided for the resident; - The facility does not currently provide fortified foods; - That morning he/she spoke with the administrator and dietary supervisor about providing fortified foods for this resident. During an interview on 12/14/12 at 11:00 A.M. the MDS Coordinator said: - Care plan meetings are held every Thursday; - The care plan team is responsible for reviewing and revising the care plans; - Members of the care plan team include himself/herself, social services, activities, dietary and restorative. - He/she was currently working on a significant change in status assessment for this resident (was due within 14 days of reentry from hospital: 12/12/12). 5. During a family interview on 12/12/12 at 6:30 P.M. the family member said: - He/she thinks some residents are hungry; - He/she purchases snacks for his/her resident from the grocery store so that the resident is not hungry.