Every finding on record at North Village Park

Based on interview and record review, the facility failed to timely assess one resident (Resident #20), in a review of 27 sampled residents, following an unwitnessed fall with a resulting head laceration and a change in the resident's mental status. On the morning of 8/15/26, staff found the resident on the floor, picked the resident up from the floor without assessing him/her, placed the resident in his/her bed and did not notify the charge nurse the resident fell or was found on the floor. More than six hours later, staff checked on the resident, found blood on the resident's pillow, and notified the charge nurse, Licensed Practical Nurse (LPN) G. LPN G assessed the resident, notified the resident's physician and sent the resident by ambulance to the hospital. The resident's head laceration required four staples. The facility census was 156.Review of the facility's Fall Prevention Program policy, dated 10/31/24, showed when any resident experiences a fall, the facility will assess the resident, initiate neurological checks (assessment used to monitor brain function and detect sudden changes in neurological status), notify the physician and family, document all assessments and actions, and obtain witness statements in the case of injury. 1. Review of Resident #20's undated Face Sheet showed his/her diagnoses included paranoid schizophrenia (psychotic mental illness), dementia, unsteadiness on feet, and lack of coordination. Review of the resident's Baseline Care Plan, dated 08/04/26, showed the following:-Alert and cognitively impaired;-The resident could communicate but did not understand staff;-Required a wheelchair for mobility. Review of the resident's Fall Risk Assessment, dated 08/04/26, showed the following:-Disoriented at all times;-Chairbound and incontinent;-One to two predisposing diseases that contributed to falls;-Recent hospitalization in the last 30 days;-Balance problem while standing and walking;-Required use of assistive device;-Took one to two medications that contributed to falls;-Scored 13 points, score of 10 or higher indicated high risk of falls. Review of the resident's Nurses' Note, dated 08/05/26 at 10:00 A.M., showed the resident fell after standing from the wheelchair and attempted to walk independently. He/She landed on his/her buttocks. No injuries noted. Staff assisted the resident to the wheelchair and moved him/her to the nurses' desk for monitoring. Review of the resident's Nurses' Note, dated 08/15/26 at 6:04 P.M., showed LPN G documented staff found the resident after an unwitnessed fall with a scalp laceration and bleeding. Staff cleaned the laceration and applied pressure. Staff notified the resident's responsible party and physician of the fall and laceration. The physician ordered staff to transfer the resident to the emergency department for evaluation and treatment. Review of the resident's Nurses' Note, dated 08/15/26 at 8:10 P.M., showed staff called emergency medical services (EMS) at 7:55 P.M. to transport the resident to the emergency department. EMS arrived and transported the resident by stretcher from the facility to the ambulance. Review of the resident's EMS Transport Record, dated 08/15/26, showed the following:-At 7:59 P.M., dispatch received a call from the facility for transport. EMS staff arrived at the facility at 8:06 P.M.;-Dispatched to facility for a resident who fell earlier in the day. Arrived on scene and found the resident in a wheelchair in the hallway with his/her head slumped over. Staff said the resident had an unwitnessed fall earlier in the day. The laceration to the back of the resident's head was not found until staff change for the night shift. The resident was not responding verbally to EMS staff. Review of the resident's Hospital Emergency Services Note showed the following:-Service provided on 08/15/26 at 8:58 P.M.;-The resident presented with a fall with laceration to the posterior (back) of the scalp. Review of the resident's Nurses' Note, dated 08/16/26 at 5:41 A.M., showed the resident returned to the facility with four staples to the back of his/her head. During an interview on 09/02/26 at 3:35 P.M., LPN G said the following:-On 08/15/26, he/she was the charge nurse;-Certified Nurse Assistant (CNA) H notified him/her that he/she found blood on the resident's pillow while providing the resident personal care around supper time (5:00 P.M.);-He/She immediately assessed the resident and found a bloody gash on the back of the resident's head. The resident was not responding well;-He/She called EMS who transferred the resident by ambulance to the emergency room for treatment;-CNA I cared for the resident that day;-After CNA H found the bloody gash on the resident's head around 5:00 P.M., CNA I told him/her (LPN G) that he/she found the resident on the floor earlier that morning (before lunch time), picked up the resident, and placed the resident into bed.-CNA I did not notify him/her at the time he/she found the resident and staff did not assess the resident for injuries or initiate immediate neurological checks;-He/She was not sure how long the resident was on the floor before CNA I found the resident and transferred him/her back to bed;-It was several hours later, from morning to supper time, before he/she was aware the resident fell;-CNA I should have immediately notified him/her the resident was on the floor and should not have moved the resident;-Staff should assess the resident for injuries and provide treatment before transferring the resident off the floor. During an interview on 09/03/26 at 1:10 P.M., CNA H said the following:-About supper time on 08/15/26, he/she turned the resident onto his/her side and found blood on the resident's pillow;-He/She notified the charge nurse, LPN G, of the blood;-LPN G assessed the resident and found a laceration on the back of the resident's head, called the ambulance and sent the resident to the emergency room;-CNA I cared for the resident that day. After LPN G assessed the resident at supper time, he/she spoke with CNA I. CNA H overheard CNA I tell LPN G that he/she had found the resident on the floor in his/her room that morning, picked the resident up, and put him/her back in bed;-Staff should immediately inform the nurse of a fall and not move a resident after a fall. The charge nurse should assess the resident and determine the treatment. During an interview on 09/03/26 at 2:00 P.M., CNA I said 08/15/26 was the last day he/she worked at the facility and did not remember anything that happened that day. He/She did not know how the resident got a laceration to the back of his/her head. CNA I did not know what happened to the resident. He/She did not remember if the resident fell or if he/she found the resident on the floor and placed the resident back into bed. If a resident fell, he/she should notify the charge nurse. During an interview on 09/03/26 at 2:15 P.M., the Director of Nursing (DON) said the following:-Following a fall, staff should not move the resident, immediately notify the charge nurse and follow the facility policy following a fall;-The charge nurse should implement treatment, immediately initiate neurological checks, call EMS, if necessary, notify the physician and family of the fall and the resident's condition;-If a resident hits his/her head, staff should send the resident to the emergency room for evaluation;-She was not aware staff found the resident on the floor that morning (08/15/26) and was not aware staff did not notify the charge nurse until supper time when CNA H found blood on the resident's pillow;-The staff who found the resident on the floor should have immediately notified the charge nurse and not moved the resident;-Staff should never transfer the resident off the floor before the charge nurse completed an assessment for injuries. During an interview on 09/03/26 at 2:50 P.M., the Administrator said staff should follow the facility fall policy. Staff should notify the charge nurse when a resident fell or if a resident was found on the floor. The charge nurse should assess the resident and implement treatment or call EMS for transfer to the emergency department. During an interview on 09/08/26 at 10:27 A.M., the resident's physician said staff should immediately assess a resident after a fall and provide treatment accordingly. Staff should not pick up a resident found on the floor and place the resident back in bed without evaluating the resident's condition, assessing the resident's vital signs, neurological status and ensure no alteration in mental status following an unwitnessed fall with a head injury and laceration. Staff should have notified him of the resident's fall and laceration to the head at the time of the fall.

Based on interview and record review the facility failed to provide medically related social services to attain the highest practical, physical, mental and psychosocial wellbeing and assure adequate social services were implemented for three residents (Resident #9, #10 and #11), in a review of 11 sampled residents. The facility failed to make arrangements for a transfer to another facility for Resident #9 and #11 and failed to assist Resident #11 with transition of care arrangements to the other facility, assuring post discharge medications were available. The facility also failed to provide Resident #10 with a written response of actions taken to resolve his/her grievance. The facility also failed to employee a qualified social worker since 06/22/26. The facility census was 160. During an interview on 07/22/26 at 1:30 P.M. the Administrator said the facility did not have a policy related to social services. She would expect the facility to follow the regulation regarding social services. Review of the facility's policy, titled Grievance Policy-Residents, dated 12/27/24, showed the following:-The facility wants to hear and address any concern of a resident. A resident or their legal representative can bring concerns to a staff member, the resident concern group or call the compliance hotline. Additionally, each resident had the right to use the formal grievance process;-The grievance official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; issuing written grievance decisions to the resident;-The social service director shall serve as the grievance officer and may be reached at the facility address and phone number. If the facility does not have a social service director, the Administrator shall appoint someone to serve as the grievance officer;-The grievance official will take steps to resolve the grievance, and record information about the grievance and those actions on the grievance form;-In accordance with the resident's rights to obtain a written decision regarding his/her grievance, the grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum the date the grievance was received, the steps taken to investigate the grievance and a summary of the pertinent findings or conclusions regarding the resident's concerns. 1. Review of Resident #9's undated Face Sheet showed the following:-The resident was his/her own responsible party; -Diagnosis of malignant neoplasm (cancerous mass) of esophagus (the muscular tube that carries food and liquid from your throat down to your stomach), secondary malignant neoplasm of the lung and pharynx. Review of the resident's Care Plan, last revised 06/13/25, showed the resident and/or guardian decided they would like to explore other care options or living arrangements, staff would provide information and referral to facility of resident's choice. The resident and his/her family member would like the resident closer to a specific location. During an interview on 07/22/26 at 3:38 P.M. the resident said the following:-The resident found out he/she had terminal cancer and had only a few months to live;-The resident and his/her family spoke to the Assistant Administrator about moving closer to his/her family due to his/her terminal diagnosis. The resident's family was over four hours away;-The resident had not heard back from anyone at the facility regarding his/her transfer or if referrals had been sent or not;-He/She was not sure if the facility had a social worker or not. During an interview on 07/22/26 at 12:45 P.M. the resident's family member said the following:-He/She had requested the facility send out referrals to other facilities closer to where he/she lived for approximately a year and had no follow-up from the facility;-The resident was diagnosed with terminal cancer and had two to three months to live;-He/She had left several messages for the previous social worker and never got a response;-He/She spoke to the Assistant Administrator in person on 7/2/26 about referrals and he/she had not heard back from anyone at the facility;-The family lived several hours away from the current facility and wanted the resident closer to them. During an interview on 07/22/26 at 3:10 P.M. Certified Medication Technician (CMT) S said the following:-He/She was aware the resident wanted to transfer to a facility closer to family;-The facility did not have a current social worker, and he/she did not know who he/she would go to about issues like that if there was not a current social worker. 2. Review of Resident #11's physician order sheet (POS), dated 07/1/26, showed the resident may have social services as needed (order dated 09/17/25). Review of the resident's Progress Note, dated 7/9/26 at 12:19 P.M., showed discharge to other facility. The note provided no other information regarding the discharge process including mode of transfer, medications sent with the resident or any specific discharge instructions. Review of the resident's POS showed there was no written order for discharge on [DATE]. Review of the resident's Discharge Recapitulation, undated, showed the following:-Reason for discharge, section was not completed by staff;-Where was resident discharged to at the time of discharge: staff checked all of the following, private residence, apartment, retirement apartment, and assisted living;-Discharge goal barriers: staff checked medication management;-The medication reconciliation section was not completed by staff;-Had medication reconciliation been completed according to your organization's policy and procedure, staff did not complete this section;-Has post discharge medication list been discussed with the resident/family, staff did not complete this section;-Has post-discharge medication list been provided to resident/family, staff did not complete this section. During an interview on 7/23/26 at 8:45 A.M. the resident's guardian said the following:-There had not been a social worker onsite for months at the facility. It was difficult to get anything done regarding resident transfers;-He/She reminded the facility repeatedly to send resident referrals to other facilities and it was never done; -Now, he/she had the facility to send the referral packet information directly to his/her office and he/she would send the referrals to other facilities directly to ensure it was being done;-The facility social worker was to be the point of contact person at the facility. Many things were not being completed due to the facility's lack of a social worker;-The resident was discharged from the facility on 07/09/26 and was without several of his/her medications and nothing was prepared in advance, and the discharge process was not completed correctly. 3. Review of Resident 10's Care Plan, revised on 10/03/23, showed social service consultation as needed and requested. Offer support/encouragement as needed and requested. Review of the resident's Grievance Form, dated 07/15/26, showed the following:-Completion of this form will assist in prompt investigation of your grievance;-The grievance (handwritten by the resident): There is no communication with staff. Needed to be an open-door policy. He/She did call state and would do so again. There was no Boost (nutritional supplement drink). He/She needed a referral packet sent to a facility;-Actions taken to resolve the situation (if any) for staff to fill out was left blank; -Staff did not include a written response or any actions taken on the grievance form. During an interview on 7/22/26 at 12:16 P.M the resident said the facility did not follow up on his/her grievances. Staff did not offer him/her a copy of his/her grievance with any follow-up or a resolution. 4. During an interview on 07/22/26 the Social Service Designee T said the following:-He/She was not sure if Resident #10 had requested a transfer to another facility;-He/She met with the residents regarding their grievances;-He/She was not a licensed social worker and did not have any formal training;-He/She had not received much training from the previous social worker to be familiar with the grievance process;-He/She provided the residents with a copy of their grievances and a written follow-up if the resident requested it;-He/She just did the best he/she could. During an interview on 7/22/26 at 4:00 P.M. the Assistant Administrator said the following:-He/She had been working with Social Service Designee T and filling in as the social worker as the facility did have a current licensed social worker;-Social Service Designee T was following up on resident grievances;-He/She had spoken with the admissions coordinator with their corporate office regarding Resident #9 going to a sister facility closer to family. He/She had not heard back from the admissions coordinator. During an interview on 07/22/26 at 3:35 P.M. the Administrator said the following:-She would expect the facility to have a social worker on staff;-The social worker would be responsible for sending referrals to other facilities if a resident requested a transfer or the provider recommended a lower level of care;-She would expect the social worker to contact the guardian to discuss the provider's recommendations;-The facility had been without a licensed social worker since 06/22/26;-She expected the facility to follow the facility's policy regarding grievances. During an interview on 7/22/26 at 10:35 A.M. Psychiatric Nurse Practitioner I said the following:-The facility did not have a current, licensed social worker;-She had recommended on several residents' mental status exams for the facility to discuss a less restrictive level of care with the guardian, facility and interdisciplinary team. She continued to recommend this on residents' mental status exams without any follow-up by the facility. 309441230935293084102

Based on interview and record review, the facility failed to accurately obtain, evaluate, and monitor blood pressures, administer blood pressure medications as ordered, and notify the physician with abnormal blood pressures per the resident's plan of care for one resident (Resident #16), in a review of 27 sampled residents. Staff routinely documented the same blood pressure reading on the resident's medication administration record across multiple days, did not administer the resident's as needed blood pressure medication as ordered when his/her documented blood pressure was outside the ordered parameters, and did not notify the resident's physician when the resident's documented blood pressures were abnormal. The resident reported staff did not take his/her blood pressure daily as ordered. The facility census was 156. Review of the facility policy, Notification of Changes, revised 05/14/24, showed the following:-Purpose: To ensure the facility promptly consults the resident's physician and notifies when there is a change requiring notification;-Circumstances requiring notification: -Significant change in the resident's physical condition such as deterioration in health; this may include clinical complications; -Circumstances that require a need to alter treatment; this may include new treatments or discontinuation of current treatment due to acute condition or exacerbation of a chronic condition. Review of the facility policy, Transcription of Orders/Following Physician's Orders, revised 05/18/24, showed the following:-The nurse or certified medication technician (CMT) in charge of medication administration must review all their designated medication administration records (MARs) prior to the end of their shift to ensure all medications scheduled to be given on their shift were administered according to the physician's order and all necessary interventions were taken in the event of an omission. Review of the facility policy, Medication Administration, revised 06/26/24, showed the following:-Purpose: To ensure the safe and effective administration of all medications by utilizing best practice guidelines;-Obtain and record vital signs, when applicable or per physician orders;-Review MAR to identify medications to be administered;-For those medications requiring vital signs, record the vital signs onto the MAR;-Medications requiring vital signs prior to administration: anti-hypertensives (medications used to treat high blood pressure). 1. Review of Resident #16's care plan, revised 07/02/25, showed the following:-He/She was at risk for unstable/fluctuating blood pressures related to his/her diagnosis of hypertension (high blood pressure);-Administer medications as ordered;-Evaluate blood pressure;-Monitor for increased weakness, confusion, headache, dizziness, mental status changes and report to primary care physician;-Obtain vital signs as ordered. Report abnormal findings to primary care physician. Review of the resident's physician order sheet (POS), dated June 2026, showed the following:-Diagnoses of hypertension and abdominal aortic aneurysm without rupture (a dangerous balloon-like bulge in the lower part of the aorta, the main blood vessel that supplies blood to the body);-Amlodipine besylate (a medication used to treat high blood pressure) 5 milligram (mg) one time a day (7:00 A.M.) for hypertension. Hold if blood pressure was less than 100/60 or pulse was less than 60 and notify physician; start date 10/24/2025;-Clonidine hydrochloride (HCI) (a medication used to treat high blood pressure) 0.1 mg every eight hours as needed (PRN) for hypertension for systolic blood pressure (SBP, top number on a blood pressure reading) greater than 170 (normal range: 90-120) or diastolic blood pressure (DBP, bottom number) greater than 100 (normal range: 60-80); start date 06/01/26. Review of the resident's Medication Administration Record (MAR), dated 06/02/26, showed Certified Medication Technician (CMT) A documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/03/26, showed CMT B documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/04/26, showed CMT B documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/05/26, showed CMT A documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/06/26, showed CMT A documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/07/26, showed CMT A documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/08/26, showed CMT B documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/09/26, showed CMT B documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. Review of the resident's MAR, dated 06/10/26, showed CMT A documented the resident's blood pressure was 172/80 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170. (Review of the resident's MAR, dated 06/02/26 through 06/10/26, showed staff documented the same blood pressure and pulse nine days in a row.) Review of the resident's progress notes, dated 06/02/26 through 06/10/26, showed no documentation staff notified the resident's physician of the resident's elevated blood pressure. Review of the resident's MAR, dated 06/11/26 at 7:00 A.M., showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. Review of the resident's progress note, dated 06/11/26 at 7:49 A.M., showed the following:-Staff called Licensed Practical Nurse (LPN) C to the resident's room. The resident was pale, had clammy skin, wide eyes, and constricted pupils; -The resident's blood pressure was 185/102;-Staff administered clonidine;-The nurse practitioner (NP) gave a new order to send the resident to emergency room for evaluation. Review of the resident's progress note, dated 06/11/26 at 8:23 A.M., showed LPN C sent a SBAR (situation, background, assessment, and request) communication to the physician that included the following:-Situation: The resident was hypertensive, skin was pale, clammy to touch, hallucinating, and appeared anxious;-Background: The resident started Ambien (prescription medication for insomnia) a month ago with similar episodes;-Assessment: The resident was hypertensive, skin was pale, clammy to touch, hallucinating, and appeared anxious. The resident's blood pressure was 185/102;-Request: NP notified and the resident was sent to the emergency room for evaluation and treatment. Review of the resident's hospital discharge paperwork, dated 06/11/26, showed the following:-The resident presented to the emergency department at 9:16 A.M. with complaints of hypertension;-The resident's blood pressure was 159/91 upon arrival;-The resident had slurred speech, a generalized headache, and ringing in his/her ears;-The resident said the symptoms happened when his/her blood pressure was elevated;-Discharge diagnoses included essential (primary) hypertension, dysarthria (motor speech disorder caused by weakness, paralysis, or poor coordination of the muscles used for speaking), anarthria (a severe motor speech disorder where a person completely loses the ability to articulate or produce any spoken words), and positive for headache and tinnitus (ringing in the ears). Review of the resident's MAR, dated 06/12/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/13/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/14/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/15/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/16/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/17/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/18/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/19/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/20/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/21/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/22/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/23/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/24/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/25/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/26/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/27/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/28/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/29/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 06/30/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 88. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. (Review of the resident's MAR, dated 06/11/26 through 06/30/26, showed staff documented the same blood pressure and pulse 20 days in a row.) Review of the resident's progress notes, dated 06/12/26 through 06/30/26, showed no documentation staff notified the physician of the resident's elevated blood pressure. Review of the resident's POS, dated July 2026, showed the following:-Amlodipine besylate 5 mg tablet (7:00 A.M.) by mouth one time a day for hypertension; hold if blood pressure was less than 100/60 or pulse was less than 60 and notify physician; -Clonidine HCL 0.1 mg every eight hours PRN for hypertension for SBP greater than 170 or DBP greater than 100. Review of the resident's MAR, dated 07/01/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 88 (21 days of continued documentation of the same blood pressure and pulse). No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 07/02/26, showed CMT B documented the resident's blood pressure was 185/102 and his/her pulse was 82. No documentation CMT B administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 07/03/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 82. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 07/04/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 82. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's MAR, dated 07/05/26, showed CMT A documented the resident's blood pressure was 185/102 and his/her pulse was 82. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. (Review of the resident's MAR, dated 07/02/26 through 07/05/26, showed staff documented the same blood pressure and pulse four days in a row.) Review of the resident's MAR, dated July 2026, showed the following:-On 07/06/26 and 07/07/26, CMT B documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/08/26 and 07/09/26, CMT A documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/10/26, 07/11/26 and 07/12/26, CMT B documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/13/26 and 07/14/26, CMT A documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/15/26 and 07/16/26, CMT B documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/17/26, 07/18/26, and 07/19/26, CMT A documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/20/26 and 07/21/26, CMT B documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/22/26 and 07/23/26, CMT A documented the resident's blood pressure was 138/78 and his/her pulse was 82;-On 07/24/26, 07/25/26, and 07/26/26, CMT B documented the resident's blood pressure was 138/78 and his/her pulse was 82.-On 07/27/26, CMT A documented the resident's blood pressure was 138/78 and his/her pulse was 82. Review of the resident's progress notes, dated 07/27/26 at 12:02 P.M., showed the resident had a follow up with the cardiologist today, and Amlodipine was increased to 10 mg daily. New order for Losartan (a medication to treat high blood pressure) 25 mg was started to help protect aorta. Review of the resident's MAR, dated 07/28/26, showed CMT A documented the resident's blood pressure was 138/78 and his/her pulse was 82. (Review of the resident's MAR, dated 07/06/26 through 07/28/26, showed staff documented the same blood pressure and pulse 23 days in a row.) Review of the resident's POS, dated July 2026, showed new orders on 07/28/26 for the following:-Amlodipine besylate 10 mg one time a day (7:00 A.M.) for hypertension; hold if blood pressure was less than 100/60 or pulse was less than 60 and notify physician; -Losartan potassium 25 mg one time a day (7:00 A.M.) for hypertension; hold if blood pressure was less than 100/60 or pulse was less than 60 and notify physician. Review of the resident's progress note, dated 07/30/26 at 5:10 A.M., showed the following:-LPN E documented the resident came to staff and complained of a headache;-Staff checked his/her blood pressure and it was 200/111;-The resident requested his/her PRN Tylenol and staff administered it per the order;-Staff suggested the resident relax and put up his/her feet. Review of the resident's MAR, dated 07/30/26 at 5:10 A.M., showed no documentation staff administered clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the resident's progress note, dated 07/30/26 at 6:41 A.M., showed the following:-LPN E rechecked the resident's blood pressure and it was 189/106;-LPN E left the physician a voicemail message regarding the resident's blood pressure and asked for a return phone call. Review of the resident's MAR, dated 07/30/26 at 6:41 A.M., showed no documentation staff administered clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. During an interview on 09/03/26 at 10:13 A.M., LPN E said the following:-He/She was the nurse on duty the morning of 07/30/26 when the resident complained of a headache and had an elevated blood pressure;-He/She normally looked at the resident's medication list to see if he/she had any medications ordered for hypertension; -He/She normally worked 7:00 P.M. to 7:00 A.M., so at that time of morning, he/she left his/her laptop in a different area and didn't have the resident's medication list in front of him/her;-He/She contacted the physician, and the physician told him/her to monitor the resident;-If he/she would've seen the PRN clonidine, he/she would have administered it. Review of the resident's MAR, dated 07/30/26 at 7:00 A.M., showed CMT A documented the resident's blood pressure was 189/106 and his/her pulse was 66. No documentation CMT A administered PRN clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100. Review of the physician progress note, dated 07/30/26 at 10:00 A.M., showed the following:-The physician came in the facility and saw the resident to follow up for chronic condition of management with severely elevated blood pressure, headaches, blurred vision, and abdominal aortic aneurysm;-Given the resident's symptomatic severe hypertension, immediate treatment and close monitoring were required;-Assessment: hypertensive urgency, essential hypertension, abdominal aortic aneurysm. Patient presented with severe symptomatic hypertension with blood pressure readings of 189/105 and 200/110 accompanied by headache and blurred vision. Immediate treatment and close follow up were warranted; -Plan: Increase losartan 100 mg daily, decrease amlodipine to 5 mg daily, start Bystolic (a medication to treat high blood pressure) 5 mg daily, administer clonidine immediately and monitor blood pressure response and improvement in headache and blurred vision. If symptoms or blood pressure do not improve after treatment, send the patient to the emergency department for further evaluation and management. Monitor blood pressure closely and report any worsening symptoms immediately;-Procedure: Administer clonidine for acute blood pressure reduction;-Follow up in one week. Review of the resident's progress note, dated 07/30/26 at 1:08 P.M., LPN F documented he/she told CMT A to give clonidine to the resident now. Review of the resident's MAR, dated 07/30/26 at 3:43 P.M., showed CMT A documented the resident's blood pressure was 217/116, and he/she administered clonidine. Review of the resident's progress note, dated 07/30/26 at 6:07 P.M. (two hours and 24 minutes after administering PRN clonidine), showed CMT A documented the clonidine was effective, and the resident's blood pressure was 125/72. During an interview on 09/03/26 at 10:21 A.M., LPN F said the following:-He/She accompanied the resident to see the physician sometime before noon on 07/30/26;-He/She looked in the resident's medical record and let the physician know the resident had a PRN order for clonidine. The physician said to give the clonidine now;-He/She escorted the resident back to his/her unit and told CMT A (who was on another hall at the time) to administer the PRN clonidine now;-He/She put the progress note in the computer once he/she was able to get to a computer (at 1:08 P.M.). -He/She expected staff to follow up within an hour of giving the PRN clonidine and to document the blood pressures;-He/She expected staff to let him/her know if the blood pressure was still high so he/she could assess the resident and notify the physician.(The physician told staff to immediately administer PRN clonidine prior to noon on 07/30/26. CMT A did not document he/she administered the PRN clonidine until 3:43 P.M. at which time he/she documented the resident's blood pressure was 217/116. Review showed no documentation CMT A notified LPN F of the resident's elevated blood pressure at 3:43 P.M.) During an interview on 09/10/26 at 3:50 P.M., CMT A said the following:-On 07/30/26, he/she informed the nurse about the resident's elevated blood pressure;-The resident complained of a headache for a few weeks;-He/She was aware of the resident's PRN clonidine order, but did not administer it until later in the day because he/she had not heard back from the nurse to give it until then;-He/She believed he/she administered the PRN clonidine earlier in the day and didn't chart it until later;-He/She should have followed up with another blood pressure check an hour after administering the PRN clonidine;-He/She was under the impression that an aide took the resident's blood pressure so that previously charted blood pressure was the blood pressure reading he/she charted. Review of the resident's MAR, dated 07/31/26 at 7:00 A.M., showed the following:-CMT A documented the resident's blood pressure was 217/116 and his/her pulse was 66;-No documentation CMT A administered clonidine HCL as ordered when the resident's systolic blood pressure was greater than 170 and his/her diastolic blood pressure was greater than 100.(Review of the resident's MAR, dated 07/30/26 through 07/31/26, showed staff documented the same blood pressure and pulse on both days.) Review of the resident's progress notes, dated 07/31/26, showed no documentation staff notified the resident's physician of the elevated blood pressure. Review of the resident's MAR, dated August 2026, showed CMT A documented the resident's blood pressure was 142/77 and his/her pulse was 64 on 08/01/26, 08/02/26, and 08/03/26. (CMT A documented the same blood pressure and pulse three days in a row.) During an interview on 09/03/26 at 9:58 A.M., CMT A said the following:-He/She always took the resident's blood pressure prior to administering blood pressure medications with ordered perimeters;-He/She never copied/pasted a previous blood pressure reading; -He/She was unsure how the same blood pressure and pulse would be charted; -If the resident had a PRN medication that needed administered, he/she would give it and let the charge nurse know it had been administered. During an interview on 09/03/26 at 10:03 A.M., CMT B said the following:-He/She always checked the resident's blood pressure prior to administering blood pressure medications that had perimeters;-There would be no reason for him/her to copy/paste previous readings;-If there was an exact reading documented, the resident's blood pressure was the same or he/she might have charted it wrong;-He/She would notify the nurse and administer the PRN medication if the resident's blood pressure was out of the parameters. During an interview on 09/03/26 at 11:16 A.M., the resident said the following:-He/She had high blood pressure symptoms, including blurred vision, ears ringing like a banshee, and feeling like his/her head was going to blow off frequently; -Staff were not checking his/her blood pressure daily;-Staff very rarely checked his/her blood pressure;-When the physician told staff to give the clonidine on 07/30/26, no one even knew he/she had the order; -After the physician told staff to give the clonidine now (on 07/30/26), it took several hours for staff to administer the medication. He/She told the physician when he/she saw him in the hall later that day that staff had not administered the clonidine from his/her visit earlier in the day when the physician told staff to administer it now. Staff finally administered the medication shortly after he/she spoke with the physician. During an interview on 09/03/26 at 2:20 P.M., the Director of Nursing (DON) said the following:-She expected staff to obtain and document blood pressures accurately; -She would not expect to see the exact same blood pressure and pulse readings documented;-It was not okay for staff to copy and paste a previous blood pressure and/or pulse;-If a blood pressure was out of range, she expected staff to check the blood pressure manually; -She expected CMTs to notify the nurse if there were any issues with a resident's blood pressure; -She expected nurses to notify the physician if there were any issues with a resident's blood pressure;-If the resident's blood pressure was high, she expected staff to give the PRN medication and to follow up and document the blood pressures. During an interview on 09/03/26 at 3:45 P.M., the Administrator said she expected staff to follow the facility policies and procedures. During an interview on 09/08/26, at 10:27 A.M., the resident' physician said the following:-He expected staff to obtain and document blood pressures prior to administering a blood pressure medication with parameters;-He did not expect staff to copy/paste the same blood pressure readings; staff should be carefully monitoring the blood pressures;-He expected staff to notify him if the blood pressure readings were above or below the parameters or when they needed to administer the Clonidine so he/she could adjust orders as needed or send the resident to the emergency room for evaluation and treatment; -He would have expected staff to administer the PRN clonidine as ordered if the resident's systolic blood pressure was above 170;-He considered symptoms of blurred vision, headache, and slurred speech an urgent or emergent hypertensive crisis and would have sent the resident to the emergency room for further evaluation and treatment; -He expected staff to follow physician orders.

Based on observation, interview and record review, the facility failed to ensure two residents with mental disorders (Resident #2 and #1), in a review of 11 sampled residents, received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. Resident #2 had poor insight and judgement, a history of verbal and physical aggression and was at risk for self-harm as indicated on his/her Preadmission Screening and Resident Review (PASRR, a screening for serious mental illness and intellectual or developmental disabilities to ensure the most appropriate placement setting) and Care Plan. Staff failed to provide one on one monitoring, keeping the resident within line of site per the facility policy as one staff was outside the room with the door closed and another staff member was later found to be asleep on the floor while assigned the resident's one on one monitoring following a resident-to-resident altercation where Resident #2 punched Resident #4 on the left side of the face. Resident #4 sustained an abrasion to his/her top lip, scratches to his/her chest and red marks around his/her neck. Staff failed to implement coping skills and interventions, per facility policy and the resident's Care Plan when the resident yelled and pounded on walls and failed to notify the physician of the resident's increased behaviors, timely. The facility also failed to adequately monitor Resident #1 per facility policy and direction from the psychiatric provider following a recent reduction of his/her antipsychotic medication and failed to notify the psychiatric provider when Resident #1 was involved in several Code Greens (behavioral emergencies), exhibited aggressive behaviors and attempted to assault another resident. Resident #1 injured his/her ankle and fell while attempting to assault another resident. The facility census was 160. Review of the facility policy titled, Behavioral Health Services, dated 10/31/24, showed the following:-It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;-Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders;-The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to depression, anxiety, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves that can cause hallucinations, delusions and disorganized thinking including paranoia), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs);-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Staff will monitor the resident closely for expressions or indications of distress, evaluate whether the resident's distress was attributable to their clinical condition and that the change in behavior was unavoidable, utilize Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff) and care area assessments, assess and develop a person-centered care plan for concerns identified, share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnoses, accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record, ensure appropriate follow up assessments, discuss potential modifications to the care plan, and evaluate the resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-The care plan shall have interventions that are person-centered, evidence based, culturally competent, trauma-informed, and in accordance with professional standards of practice, provide meaningful activities which promote engagement and positive, meaningful relationships, and meet the needs of the residents. Review of the facility policy titled, Behavioral Emergency, dated 09/23/25, showed the following: -Care will be directed by the resident's plan of care and will help to respond to difficult behaviors in the safest and most effective way possible;-The Interdisciplinary Team (IDT) will ensure the care plan is updated if appropriate;-The facility will notify the physician and/or the psychiatrist of the behavioral emergency. The guardian, family or responsible party will be notified of the situation, including current status, hospitalization or other specifics;-Proactive management for residents is the best plan;-All staff should recognize when the resident has become, or can become, a danger to themselves or others;-De-escalation techniques should be utilized first;-At regular intervals, the company will review incidents to obtain root cause analysis which will facilitate improvements of care management and further prevention of incidents. Review of the facility policy, titled Intensive Monitoring, dated 4/30/24, showed the following:-Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal or physical aggression, elopement ideations, suicidal or homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-to-one or two-to-one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor;-The facility's interdisciplinary team will address the resident's behavioral concerns and ensure interventions are in place to address residents' needs (psychiatry follow up, counseling, medical needs, etc.). 1. Review of Resident #2's Preadmission Screening and Resident Review, dated 02/19/21, showed the following:-Psychiatric diagnoses included bipolar affective disorder (a chronic mental health condition characterized by extreme cyclical shifts in mood, energy and activity levels) with severe psychotic features, depressive disorder, dysthymic disorder (a long lasting form of depression characterized by chronic low mod, fatigue and feelings of hopelessness), severe mixed bipolar I disorder (the simultaneous presence of manic and depressive symptoms) and schizoaffective disorder (a chronic mental health condition marked by a combination of symptoms like hallucinations or delusions and major mood disorder symptoms such as depression or mania);-History of drug abuse including methamphetamine and heroin (illicit drugs);-Prior history of suicide attempts. Denied current suicidal ideations;-Records indicated poor insight and judgement;-Impulsive actions and poor decision making skills;-If admitted to a nursing facility, the resident needed behavior monitoring with every 15-minute checks, line of sight recommended when around vulnerable individuals;-The resident's crisis plan should identify clear steps that will be taken to support the resident during a crisis situation, specify who to contact for assistance, how staff should work with the resident during a crisis, as well as identify when the physician, emergency medical services and/or law enforcement should be contacted;-Close monitoring and supervision were needed. Review of the resident's Care Plan, last revised 07/02/25, showed the following:-The resident was at risk for altered mental status and mood swings due to bipolar disorder;-Staff will report any new behaviors to the resident's physician as needed;-Staff will encourage the resident to discuss any negative thoughts;-The resident currently required a secured unit due to being a risk to others;-Staff will allow the resident to express feelings and give the resident privacy when needed and able to safely do so;-The resident had a history of behavioral challenges that require protective oversight in a secure setting. The resident had a history of drug abuse and increased anger with issues controlling his/her anger. Multiple hospitalizations for delusions, paranoia, periods of anxiety and aggression. Behaviors included verbal and physical aggression, pacing, anxiety, and delusions;-Coping skills included walking the halls, alone time and listening to music, talking with friends, reading, television, dancing meditation, one-on-one and pharmaceutical interventions as needed. The resident loved space when he/she was upset and mad;-Staff would refer to coping skills and redirect behavior immediately if they observed the resident exhibit any listed behaviors;-The resident was at risk for self-harm related to a history of suicidal ideation;-If the resident posed a potential threat to injury himself/herself or others, staff would notify the provider;-Staff to monitor for suicidal or homicidal ideations and help the resident choose activities to redirect their emotions and provide education and support;-What worked well for the resident in past crisis moments included music, television, socializing and working out;-Staff should calmly redirect the resident's inappropriate behavior and decrease stimulation when he/she displayed signs of anxiety;-Staff should notify the charge nurse if the resident experienced hallucinations, delusions, irritability, anxiety or aggression. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 07/20/26, showed the following:-The resident was cognitively intact;-No behaviors;-He/She received antipsychotic (used to treat and manage symptoms for several psychiatric disorders), antianxiety (prescription drugs that help manage symptoms of anxiety like panic, extreme worry, and restlessness by calming the nervous system), and antidepressant (help restore the normal balance of brain chemicals called neurotransmitters and help regulate the affected person's mood) medications. Review of the resident's Progress Note, dated 07/21/26 at 1:00 P.M., showed the following:-Staff reported the resident was agitated with a peer. The Assistant Administrator talked to the resident on the unit and took the resident off the unit for fresh air. The resident was allowed to charge his/her phone, vent and verbalize his/her feelings;-The resident said he/she did not have an issue with his/her peer (Resident #4). The resident thought his/her boyfriend/girlfriend, who resided in another facility, and his/her roommate (Resident #4) were either talking to each other or liked each other;-He/She did not want a room change and did not want to hurt his/her roommate (Resident #4);-Resident #2 asked if the Assistant Administrator would talk to his/her roommate and tell him/her how he/she was feeling;-Resident #2 asked for an as needed (PRN) medication. The resident was left with the charge nurse while he/she received his/her PRN medication;-Staff notified Psychiatric Nurse Practitioner I;-The resident's roommate said he/she did not know why the resident thought he/she liked the resident's boyfriend/girlfriend and said this was not true;-Room move was figured out. The roommate was in the process of moving to a different room when the Assistant Administrator left the resident. There were no signs of further issues or concerns. Review of the resident's progress note, dated 07/21/26 at 1:24 P.M., showed the following: -Staff notified the resident's primary care physician of the resident assaulting his/her peer. No new orders given; -Psychiatric Nurse Practitioner I gave orders for tele psych visit and to send the resident out for mental health evaluation if needed. Review of the resident's progress note, dated 07/21/26 at 2:00 P.M., showed the following:-Code [NAME] was called. Staff reported to the nurse that the resident assaulted his/her roommate while he/she was trying to move out of the room. Three staff members separated the residents. Staff took the peer off the hall; -During the separation of the struggle, Resident #2's top lip started bleeding. It was thought somebody's elbow hit the resident in the mouth;-Resident #2 was mumbling about Resident #4 trying to talk to his/her boyfriend/girlfriend;-The resident was taken to the front office with the Assistant Administrator. The police were called and took statements. Psychiatry, primary care physician, administration and the guardian were notified. Review of the resident's Registered Nurse Investigation (RNI), dated 07/21/26, showed the following: -Date and time of incident: 07/21/26 at 2:00 P.M.;-Persons Involved: Resident #2 and Resident #4;-Code [NAME] was called. Resident #2 struck Resident #4 because he/she thought Resident #4 and his/her boyfriend/girlfriend liked each other;-Staff immediately separated the residents;-Resident #4 was exiting the shared room when Resident #2 walked in and punched him/her on the left side of the face. Resident #4 reported Resident #2 scratched his/her chest, hit him/her in the face and put his/her hands around Resident #4's neck;-Resident #4 sustained an abrasion to his/her top lip, scratches to chest and red marks around his/her neck;-Resident #4 reported he/she felt safe;-There was no previous issue or aggression prior to this incident between the two residents;-The facility concluded the physical altercation occurred and mediated between the two residents;-Staff placed Resident #2 on one-on-one monitoring;-Resident #2 refused transfer to the acute psychiatric hospital. The facility worked on obtaining a 96-hour hold through the court for the resident;-Staff offered counseling and Resident #2 declined. Review of the resident's Psychosocial Post-Incident Impact Questionnaire, dated 07/21/26, showed the following:-Resident #2 was the aggressor in the incident;-Coping skills included listening to music, talking to peers, spending one-on-one time with the Assistant Administrator and talking to family;-The resident said he/she did not want to have conflict with the other resident but felt like there was nothing he/she could have done better. Review of the resident's Care Plan, revised 07/21/26, showed the resident had a physical altercation with another resident due to thinking the other resident liked his/her boyfriend/girlfriend. Staff provided one-on-one monitoring and an acute telehealth psychiatric visit was completed. The resident would begin anger management classes. Counseling was offered and the resident declined. Staff worked on getting a 96-hour psychiatric hold completed for the resident. During an interview on 07/22/26 at 9:00 A.M., Housekeeping Staff G said the following:-On 7/21/26, he/she and Housekeeping Staff K gathered up items from Resident #4's room to move him/her to another room;-Resident #2 walked up to Resident #4 and punched him/her in the face;-Housekeeping Staff G and Housekeeping Staff K were on the other side of the room;-He/She placed Resident #4 in a CPI hold and Housekeeping Staff K placed Resident #2 in a CPI hold;-He/She yelled, staff responded, and a Code [NAME] was called. During an interview on 07/22/26 at 2:25 P.M. Hospitality Aide P said the following:-He/She was not sure what the physical altercation between Resident #2 and Resident #4 was regarding on 07/21/26;-He/She was in another resident's room on the opposite hall when he/she heard staff yell Code Green and he/she responded but did not witness anything;-He/She was assigned the resident's hall today (07/22/26);- He/She heard the resident yelling inside his/her room but didn't hear banging on the walls. During an interview on 07/22/26 at 2:30 P.M. Hospitality Aide O said the following;-He/She was assigned Resident #2's hall today (07/22/26);-He/She was not aware the resident was yelling and hitting the walls;-Another staff member was assigned to provide one on one monitoring for the resident at that time;-Usually, the one-on-one staff took care of the oversight of the resident who was one on one; -Coping skills for the resident were rap music and putting on skits. Review of the resident's one-on-one form, dated 07/22/26 for 7:00 A.M. to 10:50 A.M., showed the following: -Reason for one-on-one aggression/fighting;-Current behaviors included verbal aggression, physically aggressive, pacing, insomnia, anxiety, false allegations, delusions, defend specific staff;-Crying, screaming and hitting wall and talking to his/her family member on the phone (a handwritten note added to form under current behaviors);-Triggers: yelling, people laughing in his/her face, people talking recklessly to him/her, staff's tone when approaching him/her about an incident, being asked the same questions over and over again, staff thinking they are better than him/her, others being disrespected;-Triggers are talking to his/her family member on the phone (a handwritten note was added to form under triggers);-Coping skill: CMT J tried to talk to him/her and calm him/her down;-Your one-on-one should always be within arm's reach;-Your responsibility when assigned one-on-one was to provide protective oversight for that individual;-Before taking responsibility for one-on-one, understand the purpose behind the resident being on the one-on-one so that you are fully aware of what you should be monitoring;-Keep in mind that a resident was placed one-on-one due to emergent reasons (falls, altercations, self-harm, etc.) you must take each one on one assignment seriously;-Signing the bottom of the form means you have read the form, understood, and completed the above information. Failure to do so will result in termination due to failure to protect the resident;-Floor Care H, who was assigned to provide one-on-one for the resident, signed his/her name to bottom of the form (indicating he/she read the form and understood and completed the information). Under the section updates, Floor Care Staff H added a hand written note with the words mad, angry and irate, referring to the resident, and signed his/her name. Observation on 07/22/26 at approximately 8:30 A.M. showed the following:-Floor Care Staff H, assigned to provide one-on-one for the resident, was seated on a chair outside the resident's room. The door to the resident's room was closed;-Sounds of heavy pounding on the walls, loud yelling and profanity came from inside the room. Review of the facility's CPI training record showed Floor Care staff H completed CPI training on 08/11/25. During interview on 07/22/26 at 8:36 A.M. and 07/30/26 at 8:36 A.M. and 11:50 A.M., Floor Care Staff H said the following: -The resident was on the phone and had been hitting the wall, crying, and yelling for a while;-He/She questioned the surveyor if he/she should go into the resident's room when the resident was hitting the wall and yelling. He/She knew the resident was on the phone but wasn't sure if he/she should check on him/her;-If the resident got too out of hand, he/she would let someone know; -He/She opened the door about every hour to check on the resident;-He/She was frequently assigned to be on a one-on-one because the facility was short staffed;-He/She knew the resident had been in a fight and could fly off the handle;-He/She was CPI trained; -He/She was not sure how far behaviors should go with the resident before he/she called a Code Green. Observation on 07/22/26 at approximately 8:52 A.M. showed CMT J entered the resident's room and closed the door. Sounds of heavy pounding on the walls and loud yelling continued to be heard from outside of the room through the closed door in the hallway. During an interview on 07/22/26 at 9:02 A.M., CMT J said he/she administered the resident's routine medications and tried to calm him/her down. The resident was on the phone with his/her family member. During an interview on 07/22/26 at 9:06 A.M., Floor Care Staff H said after CMT J administered the resident's medications and talked to the resident, he/she calmed down for a second. Review of the resident's one-on-one form, dated 07/22/26 for 10:50 A.M. through 3:40 P.M., showed the following:-Aggression was the reason for the one-on-one;-Current behaviors included verbal aggression, physically aggressive, pacing, insomnia, anxiety, false allegations, delusions, and defending specific staff;-Triggers: yelling, people laughing in his/her face, people talking recklessly to him/her, staff's tone when approaching him/her about an incident, being asked the same questions over and over again, staff thinking they are better than him/her, and others being disrespected;-Your one-on-one should always be within arm's reach;-Your responsibility when assigned one-on-one was to provide protective oversight for that individual;-Before taking responsibility for one-on-one, understand the purpose behind the resident being on the one-on-one so you are fully aware of what you should be monitoring;-Keep in mind the resident was placed on one-on-one due to emergent reasons (falls, altercations, self-harm, etc.). You must take each one-on-one assignment seriously;-Signing the bottom of the form means you have read the form, understood, and completed the above information. Failure to do so will result in termination due to failure to protect the resident;-Floor Care Staff C signed the bottom of the form. Observation on 7/22/26 at 2:54 P.M. showed the door to the resident's room was partially open, and the resident was in bed resting with his/her eyes closed. One-on-one staff, Floor Care C, was seated on the floor outside the resident's room with his/her head down and eyes closed. Observation on 7/22/26 at 2:55 P.M. showed Floor Care Staff C was startled when the surveyor asked if he/she was the one-on-one staff for the resident During interview on 7/22/26 at 2:55 P.M., Floor Care Staff C said the following:-Floor Care Staff C quickly stood up and said he/she had dozed off and this was not his/her normal role;-The resident was upset, hitting the walls and yelling, when he/she first started his/her one-on-one assignment around 11:00 A.M.;-He/She was not familiar with the resident's care plan. He/She just kept an eye on the resident. If the resident got irate, he/she made sure the resident did not hurt himself/herself;-He/She had completed CPI training. Review of the facility's CPI staff training record showed Floor Care Staff C completed CPI training on 02/02/26 During an interview 07/23/26 at 11:10 A.M., the resident's family member/guardian said the following: -The facility notified him/her of the altercation on 7/21/26 involving the resident;-The resident needed psychiatric help;-The resident had not been aggressive for a very long time. The resident had routine home visits on the weekends and had been doing very well;-The resident was on the phone with the family member off and on all day yesterday. The resident was very upset yelling and hitting things;-The resident was upset because he/she thought his/her roommate (Resident #4) was talking to his/her boyfriend/girlfriend;-The resident broke his/her hand in the past from hitting the wall when he/she was upset and angry. During an interview on 07/22/26 at 12:20 P.M., Resident #4 said the following:-Resident #2 was his/her previous roommate. He/She was sore from the altercation the day before;-He/She and Resident #2 were in their room alone while two of the housekeeping staff moved things out of the room. There were no other staff in the area;-Resident #2 put his/her hands around his/her neck and tried to choke him/her out. Resident #2 thought he/she had been talking to his/her girlfriend/boyfriend. Staff came running and grabbed ahold of Resident #2;-He/She felt safe while he/she remained on the current hall, but he/she did not want to go on the hall where Resident #2 was located. Resident #2 continued to make threats against him/her;-He/She informed the Assistant Administrator, and he/she said to block the text messages from Resident #2. Review of Resident #4's phone text message from Resident #2, dated 7/22/26 at 6:52 A.M. showed the following;-If nobody was there to keep him/her (Resident #2) off your bitch ass, soft ass he/she would beat him/her so bad he/she would go to jail for life. Fuck you. If Resident #2 crossed him/her (Resident #4) in the hall, the pain he/she had over his/her boyfriend/girlfriend was getting released on him/her (Resident #4);-He/She wished the two of them were on the other side of the fence. During an interview on 07/22/26 at 9:50 A.M., and 07/22/26 at 4:10 P.M. Corporate Support Staff Q said the following:-Resident #2 remained on one-on-one supervision as an intervention;-He had to protect the facility staff, so when the resident was acting out and hitting walls, he/she would not expect staff to enter the resident's room because the resident could hit the staff;-If the resident broke his/her hand, then the resident broke his/her hand. He/She had to protect the facility staff;-The police would not take the resident;-The facility was actively trying to pursue a 96-hour hold for the resident;-The facility had been in contact with Psychiatric Nurse Practitioner I regarding the resident's continued behaviors;-It was clinically inappropriate for staff to enter the resident's room when he was having behaviors;-When the surveyor asked him to elaborate on why, he did not provide a response. During an interview on 07/22/2026 at 2:35 P.M. Registered Nurse B said the following:-He/She was not aware Resident #2 had been hitting the wall and yelling inside his/her room earlier that day;-The Director of Nursing called RN B around 10:00 A.M. to 11:00 A.M. and told him/her to go check on the resident as he/she was having behaviors;-He/She received an order for Thorazine (antipsychotic medication) intramuscular injection and a drug urinalysis from Psychiatric Nurse Practitioner I. The resident refused the urinalysis;-The primary care physician ordered Benadryl (an antihistamine that can be used to treat insomnia) because the resident said he/she had not slept for a couple days;-Staff should open the door and check on a resident if a resident was hitting the walls and yelling and notify the charge nurse of the behaviors. During an interview on 07/22/26 at approximately 3:35 P.M., the Administrator said she would have expected staff to go into Resident 2's room and check on him/her if he/she was hitting the wall and yelling to assure the resident was safe or call a Code Green. Once she was made aware of Resident 2's behaviors (hitting walls and yelling), she went to the resident's room and checked on the resident. She notified the DON to make sure staff checked on the resident. She expected staff to follow the behavioral health policies. Staff should not ask the surveyor what to do when the resident was hitting the walls and yelling. Staff should not be sitting on the floor or asleep when they provided one-on-one monitoring for a resident. The resident did get upset when someone was in the room all the time. The Assistant Administrator notified her Resident #2 was sending threatening text messages to Resident #4, and the Assistant Administrator instructed Resident #4 to block Resident #2's text messages. During an interview on 07/22/26 at 10:35 A.M., Psychiatric Nurse Practitioner I said the following:-Resident #2 was typically not aggressive. On 07/21/26, staff notified him/her of the physical altercation that occurred on 07/21/26 between the two residents and the facility was working on obtaining a 96-hour psychiatric hold for the resident; -Staff should not leave the resident in his/her room alone with the door closed while the resident yelled and hit the wall;-The door should remain open so staff could monitor the resident to ensure his/her safety;-Staff should call a Code [NAME] or continue notifying the police if they were unable to handle the situation to assure the resident's safety;-On 07/22/2026, at approximately 10:11 A.M. on 7/22/26 the facility notified her the resident was hitting the walls and yelling inside his/her room. She gave staff a verbal order for Thorazine 25 milligrams (mg) and a urine drug screen to be obtained due to his/her aggression and agitation which was not typical for the resident. 2. Review of Resident #1's PASRR, dated 04/06/26, showed the following:-The resident had a chronic history of mental illness with multiple psychiatric diagnoses;-The resident's current hospital admission was precipitated by suicidal ideation and aggressive behavior;-The resident's limitations included impaired judgment, medication non-compliance, impaired impulse control and emotional regulation, history of substance use and intellectual disability;-A crisis plan should be developed to create clear steps to be taken to support the resident during a behavioral health crisis and how to determine when the crisis was over. The plan should also identify a physician and emergency medical services that should be contacted;-The resident needed health behavior assessment and intervention and monitoring of behavioral symptoms. Assess and plan for the level of supervision required to prevent harm to self or others. Review of the resident's Care Plan, last revised 05/13/26, showed the following:-Attention-deficit/hyperactivity disorder (ADHD) related to impaired attention span and impulsivity;-Maintain a structured, consistent daily routine to promote focus;-Monitor behavior and report any significant changes to the provider;-Redirect impulsive or restless behaviors calmly and respectfully;-The resident was at risk for the following signs and symptoms related to diagnosis of bipolar disorder, may change clothes multiple times a day, may display high emotions and low emotions, and may have increased signs and symptoms of depression;-Assist the resident with staying on task;-Be consistent. Keep routine consistent as much as possible;-Calmy redirect inappropriate behavior. Decrease stimulation around the resident when the resident displayed signs of anxiety;-Do not get into a power struggle with the resident;-Offer warm baths or soothing music to decrease restlessness;-Provide activities that only require short attention span;-The resident used psychotropic medications related to behavior management;-Administer psychotropic medications as ordered by the physician. Monitor for side effects or effectiveness each shift. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-The resident was cognitively intact;-No behaviors;-He/She received antipsychotic medication. Review of the resident's Mental Status Exam, dated 06/06/26, showed the following:-Seen today for initial psychiatric evaluation and medication management. This was the first encounter with the provider;-The resident reported overall psychiatric stability and denied current mood swings , depression, anxiety, hallucinations, paranoia or other acute psychiatric concerns;-The resident reported compliance with prescribed medications and denied current medication side effects other than excessive sedation from Seroquel (antipsychotic medication). The resident reported the current does was too much and requested a dose reduction. The resident requested a trial of a lower dose;-Given current psychiatric stability and patient request, a gradual dose reduction trial is clinically appropriate to determine the lowest effective dose while maintaining symptom control;-Monitor closely for recurrence of mood swings, irritability, insomnia, anxiety, psychosis or behavior changes, substance use concerns or safety concerns. Nursing staff to notify psychiatry of worsening mood symptoms, insomnia (common sleep disorder that involves trouble falling asleep, staying asleep or waking up too early) medication, intolerance, behavioral changes, substance use concerns, or safety concerns. Seroquel will be reduced from 150 mg to 100 mg at bedtime with close monitoring for symptom recurrence;-Bipolar disorder current episode manic without psychotic features mild, actively monitoring;-Intermittent explosive disorder (a mental

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 42 sampled residents, was free from abuse when Resident #2 struck Resident #1 in the head and face with a closed fist after pinning Resident #1 against the wall in their shared bedroom. Resident #1 sustained injuries including pain, two chipped lower teeth, a laceration to his/her lower lip, and lost a tooth, which required medical treatment. The facility census was 165. The administrator was notified of the past noncompliance on 03/26/26, which occurred on 03/14/26. After the incident on 03/14/26, the facility moved Resident #2 from the shared room to another secured unit, provided one-on-one monitoring for Resident #2, began an investigation of the incident, identified the root cause of the abuse, and in-serviced staff on the facility abuse policy and vape pen (a handheld electronic device used to inhale vapor, commonly containing nicotine) expectations per education, which began for those currently in the building and then before other staff's next shift. This deficiency was corrected on 03/16/26. Review of the facility's Abuse and Neglect Policy, last revised 06/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident and resident to resident altercations;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner;-Physical abuse also includes but is not limited to hitting, slapping, punching, biting, and kicking;-Residents who allegedly mistreat another resident will be removed from contact with the resident during the investigation. 1. Review of Resident #2's undated face sheet showed the following:-He/She had a guardian;-Diagnoses include schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves), anxiety disorder (persistent, excessive fear or worry that interferes with daily life, going beyond normal stress), and paranoid schizophrenia (a subtype of schizophrenia characterized primarily by delusions and auditory hallucinations). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/10/26, showed the following:-Cognitively intact;-No behaviors;-Independent with walking and transfers. Review of the resident's nursing progress notes, dated 03/14/26 at 1:30 A.M., showed the following:-Staff called the nurse to the hall concerning a resident-to-resident altercation;-The resident was sitting at a table in the dining room;-No apparent injury noted, and the resident appeared calm;-The resident said he/she did not want to talk to his/her roommate (Resident #1), so he/she tried to leave the room. Resident #1 closed the bedroom door, hitting him/her with the door;-He/She became angry, so he/she struck Resident #1 several times in the mouth and head;-Staff immediately separated the resident from Resident #1;-Administration notified and arrangements made to move the resident off the hall;-Root cause appears to be conflict within relationship but also may be connected to a vape pen. Review of the resident's written statement, provided by the facility, dated 03/14/26 at 12:20 A.M., showed he/she and Resident #1 began to argue so he/she tried to leave the room. When he/she got to the door, Resident #1 punched him/her in the shoulder and grabbed him/her. He/She pushed Resident #1 away and punched him/her. Review of the resident's nursing progress notes, dated 03/14/26 at 2:02 A.M., showed the resident moved to another locked unit in the facility and was under one-on-one supervision. Review of the resident's nursing progress notes, dated 03/14/26 at 3:44 A.M., showed the resident now states the reason he/she did not want to talk to his/her roommate (Resident #1) was because his/her roommate took his/her vape pen and would not give it back to him/her. Review of the resident's electronic health record (EHR), Psychosocial Post-Incident Impact Questionnaire, dated 03/14/26 at 10:55 A.M., showed the following:-Psychosocial Impact:1. Was resident a witness, aggressor or victim in incident? Aggressor;2. Why were you trying to hurt yourself or others? The resident was not trying to hurt his/her peer, just trying to leave the room;5. What do you feel you could have done differently in the situation? He/She should not have hit his/her peer. He/She should have left the vape pen in the smoke box;. Review of the resident's care plan, updated on 03/14/26, showed the following:-On 03/14/26, Code [NAME] (staff's response to a behavioral emergency) initiated related to physical aggression;-Desired outcome: The resident will maintain behavioral stability with use of coping skills, medication management and supportive approaches by staff. Protective oversight will be maintained;-Immediate action: per reporting nurse, resident was immediately separated from roommate. Administration notified and arrangements made to move resident off the hall. During an interview on 03/24/26 at 2:45 P.M., the resident said the following:-On 03/14/26, he/she and Resident #1 had a disagreement over a vape pen;-Resident #1 had his/her vape pen, and he/she wanted it back;-Resident #1 gave the vape pen back, and he/she attempted to leave the room;-Resident #1 tried to shut the bedroom door, and he/she kicked a chair out to prevent the door from closing;-Resident #1 hit him/her in the shoulder, and he/she blacked out in a fit of rage because Resident #1 hit him/her while his/her back was turned;-After the incident, he/she moved off the unit. 2. Review of Resident #1's undated face sheet showed the following: -He/She had a guardian;-Diagnoses include bipolar disorder (mood disorder that can cause intense mood swings), autistic disorder (a condition related to brain development that affects how people see others and socialize with them), attention deficit hyperactivity disorder (a neurodevelopmental disorder marked by persistent inattention, hyperactivity, and impulsivity), impulse disorder (a mental health condition where individuals struggle to resist impulses or urges) and oppositional defiant disorder (a behavioral disorder characterized by persistent [NAME] of angry/irritable mood, argumentative/defiant behavior, or vindictiveness). Review of the resident's nursing progress notes, dated 03/14/26 at 1:34 A.M., showed the following: -Floor staff called the nurse to the resident's hall concerning a resident-to-resident altercation;-The resident was in his/her room sitting on the bed, visibly upset and stating his/her roommate (Resident #2) struck him/her several times;-A staff member gave the nurse a tooth, and the nurse examined the resident's mouth for injury;-One lower front tooth was broken out, another tooth was loose, and a third tooth was chipped;-The resident had a small laceration inside the lower lip where the resident was missing a tooth;-The resident had multiple red areas to the sides and top of his/her head with one at the left, front hairline that was particularly dark and lightly swollen;-The resident said he/she was trying to talk to his/her roommate who became angry and pinned him/her against the door;-His/Her roommate then began punching him/her in the face and head, knocking his/her teeth out;-The resident said he/she did not hit or kick back at his/her roommate;-Staff immediately separated the resident from his/her roommate and placed him/her with nursing for neurological checks (assessment of the nervous system used to detect changes in the brain function, mental status and physical coordination) and observation;-Staff notified the resident's physician and psychiatric nurse practitioner and received orders from the physician to continue neurological checks and to send to the emergency room if any changes to assessment;-Administrator and guardian notified.Review of the resident's care plan, updated on 03/14/26, showed the following: -Code [NAME] initiated related to physical aggression;-Injuries observed to the resident's lips/mouth at the time of incident and a bruise to left forehead post incident;-Desired Outcome: The resident will maintain behavioral stability with use of coping skills, medication management, and supportive approaches by staff. Protective oversight will be maintained; -Immediate Action Taken: Per the reporting nurse, staff gave him/her a tooth and then he/she examined the resident's mouth for injury. One of the resident's lower front teeth was broken out, another tooth was loose, and a third tooth was chipped. The resident had a small laceration inside his/her lower lip where he/she was missing the tooth. Review of the resident's written statement, provided by the facility, dated 03/21/26, showed he/she was trying to talk to Resident #2 calmy. Next thing he/she knew, Resident #2 had him/her pinned against the door and started punching him/her in the head and knocked his/her teeth out. He/She did not hit or kick back at Resident #2. During an interview on 03/24/26 at 12:10 P.M., the resident said the following:-He/She and Resident #2 were roommates;-He/She and Resident #2 had a disagreement over a vape pen. He/She had Resident #2's vape pen, and Resident #2 wanted it back; -He/She gave the vape pen back and wanted to talk to Resident #2, so he/she went to shut the bedroom door to have a private conversation;-Resident #2 opened the door and pinned him/her between the door and the wall in the corner and started hitting him/her;-He/She lost a tooth and chipped two teeth from where Resident #2 hit him/her in the face and head;-Staff immediately intervened and took Resident #2 out of the room and moved Resident #2 from the hall;-He/She did not want to go to the hospital after the incident occurred but later went when his/her teeth were still hurting. Review of the resident's nursing progress notes, dated 03/14/26 at 2:35 A.M., showed the resident complained of head pain with a pain score of five (out of a zero to ten scale, with zero being no pain to ten being the most pain) and aching. Staff administered as needed medication. Review of the resident's nursing progress notes, dated 03/14/26 at 10:11 A.M., showed a new order received to send the resident to urgent care for unresolved dental pain. Review of the resident's EHR showed a report of consultation for the resident's dental appointment, dated 03/16/26, with recommendations and treatment plan for root canal and crown or extraction of two lower anterior broken teeth. 3. During an interview on 03/26/26 at 12:30 P.M., Hospitality Aide B said the following: -On the night of 03/14/26 around 12:20 A.M., he/she was charting and heard a shuffling sound and heard someone say, staff; -When entering the room, he/she saw both residents were behind the door, and Resident #2 had Resident #1 pinned against the wall in the corner;-As he/she separated the residents, Resident #2 reached over him/her and hit Resident #1 one time; -Hospitality Aide C removed Resident #2 from the room and took Resident #1 to the nurse for evaluation; -Resident #1 told him/her Resident #2 broke his/her tooth. During an interview on 03/26/26 at 12:42 P.M., Licensed Practical Nurse (LPN) A, said the following: -He/She was on another unit and was called to the 100/200 hall when staff called a Code Green;-When he/she arrived on the unit, Resident #2 was sitting in the dining room and Resident #1 was sitting on his/her bed in his/her room;-Resident #2 said he/she was angry and tried to leave his/her room;-Resident #1 shut the door and everything escalated from there;-Resident #1 had a cut inside his/her lower lip where a tooth had cut his/her lip, and had a knocked-out tooth and a couple of chipped teeth;-Staff immediately separated both residents and kept Resident #2 in line of sight until they could move him/her to a different room;-Staff moved Resident #2 to another locked unit;-He/She was told later the altercation was about a vape pen that belonged to Resident #2 that Resident #1 had, and Resident #2 wanted it back. During interviews on 03/26/26 at 8:58 A.M. and email communication on 03/31/26 at 4:18 P.M., the Administrator said following: -Abuse/Neglect education and vape management education began on 03/14/26 and was completed on 03/16/26; -All residents were educated on the vape rules that vapes must stay with the cigarette box and not on their person at any time. Complaint #2804276

Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #5) in a review of nine residents, when Resident #5 eloped through the service hall exit door without staff knowledge. On 2/25/26 at 11:32 A.M., Floor Tech A turned the service hall exit door alarm off, entered the door lock code, exited the door without ensuring a spotter (a second staff member to monitor the exit door while unalarmed) was in place. Floor Tech A did not reenter the building through the service hall exit door but entered through a different door later, leaving the service hall exit door unalarmed. On 2/25/26 at 11:35 AM, Resident #5 entered the service hall from the Hangout (supervised common area used by residents for activities and meals)) passed the vending machines (accessible to residents and staff), and attempted to open the service hall exit door without success. The resident returned at 11:50 A.M., pushed on the door handle and the service hall exit door opened. Resident #5 exited the facility to the back of the building, walked around the south side of the building and approximately two blocks down the street, crossed a four-lane highway within the city limits and sat in the grass at a local coffee shop near dumpsters. Facility staff was unaware the resident exited the building. The local police department notified the facility Resident #5 was at the coffee shop 30 minutes after the resident exited the service hall exit door. The facility census was 165. On 3/4/26 at 12:15 P.M. the Administrator was notified of the Past Non-Compliance which occurred on 2/25/26. On 2/25/26, the Administrator identified Resident #5 eloped from the facility through the service hall exit door. Floor Tech A exited the door prior to the resident and did not ensure a second staff member (spotter) was present and left the door unalarmed. Upon discovery, Resident #5 was located and returned to the facility. The resident was placed on increased face to face monitoring checks and re-evaluated for elopement risk. The resident's physician and guardian were notified, and the resident was evaluated by psychiatric services. The resident was unharmed. Additional interventions were implemented to ensure the resident's verbalized need to see the grass and trees was implemented as well as increased staff monitoring of the resident's location and activity. The service hall exit door was secured as well as all exit doors. Staff were educated on use of the service hall exit door and the number of alarm keys was reduced to the Maintenance Director, the charge nurse, the Director of Nursing and the Administrator. Floor Tech A no longer had a key for the service hall exit door. Floor Tech A and all staff were educated on the procedure of utilizing a spotter when exiting an alarmed exit door and ensuring the exit door was always secured. The deficiency was corrected on 2/26/25. Review of the facility Elopement and Wandering Residents policy, dated 6/12/24, showed the following:-The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care, addressing the unique factors contributing to wandering or elopement risk;-Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so;-The facility is equipped with door locks/alarms to help avoid elopements;-Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner;-The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment or risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary;-Adequate supervision will be provided to help prevent accidents or elopements;-A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults following a resident elopement;-The resident and family/authorized representative will be included in the plan of care;-Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. 1. Review of Resident #5's undated face sheet showed the following:-admission date of 11/5/25;-Diagnoses of paranoid schizophrenia (mental illness exhibiting intense irrational belief the person is being watched, plotted against or controlled with delusions or believing others are plotting against them or being persecuted and hallucinations or seeing and hearing things that are not real), chronic pain, and generalized anxiety disorder (intense anxiety). Review of the resident's elopement risk assessment, dated 11/6/25, showed the resident did not have a previous history of elopement or an attempted elopement while at home or in a facility. He/She had not expressed the desire to go home, packed belongings to go home or stayed near an exit door. The resident did not wander. Low risk for elopement. Review of the resident's care plan, dated 11/6/25, showed the following:-The resident was at risk for moving around or frequently getting up and down from the chair, nervousness, pacing on the unit and restlessness related to anxiety disorder. Staff should offer activity to keep from getting bored and provide opportunity to release energy in a healthy way;-The resident was independent with Activities of Daily Living (ADLs) with supervision. Staff should provide protective oversight and assist when needed. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 12/25/25, showed the following:-Cognitively intact;-No wandering;-No functional limitation in movement;-Independent in ambulation and mobility. Review of the resident's hourly face check documentation (located in the resident's electronic medical record), dated 2/25/26 showed staff documented at 9:41 A.M.,10:40 A.M. and11:45 A.M., the resident was in the building. Review of the resident's nurses' note, dated 2/25/26 at 1:41 P.M., showed the Administrator documented at about 12:20 P.M. administration received a call from the local police department. The dispatcher advised one of the residents was located across the street behind the dumpsters of a local coffee shop. At 12:25 P.M. the Administrator arrived at the location behind the coffee shop and confirmed it was Resident #5. The resident sat behind the dumpster area. Staff called to assist in encouraging the resident to return to the facility. At 12:50 P.M. the resident returned to the facility. A full skin assessment was completed with no immediate concerns noted. Observation on 3/3/26 at 9:30 A.M., showed the service hall exit door was located opposite the dietary employee entrance door and next to a locked walk-in cooler and freezer space. The service hall also contained vending machines accessible to residents and staff from the unlocked Hangout area. The service hall led to two different, locked resident units. The exit door was equipped with a coded keypad used to unlock and release the door and a security alarm. Unlocking the exit door required a key for the alarm box located above the door and a code entry on the keypad attached to the wall beside the door. The exit door opened to a covered area and then opened to the back parking lot and perimeter of the facility with access to a side street. The side street was without sidewalks with business along the street and connected to a four lane highway through town. The coffee shop was across the four-lane highway with no stoplights or crosswalks for pedestrians. During an interview on 3/3/26 at 9:35 A.M. the Assistant Administrator said he/she watched the 2/25/26 video footage of the service hall. At 11:32 A.M. he/she saw Floor Tech A turn the keyed alarm off, enter the keypad code, open the door and exit the facility. There was no spotter near the door monitoring the exit door or turning the alarm back on. At 11:35 A.M. Resident #5 tried the door (pushed down the handle) and it did not open, the resident walked away. At 11:50 A.M. Resident #5 tried the door again, the door opened, and the resident exited the door to the back of the facility. The service hall exit door did not alarm. Floor Tech A did not reenter the facility through the service hall exit door on the video footage. No other staff or resident tried to exit the door on the video footage between the time Floor Tech A exited the door at 11:32 A.M. and Resident #5 exited the door at 11:50 A.M. During an interview on 3/3/26 at 9:50 A.M. the Maintenance Director said the service hall exit door was used for vendor deliveries, access to the trash dumpster located behind the facility, access to the back parking lot and access to the storage unit. The service hall was accessible to residents from the Hanout area. Residents and staff utilized the service hall for the vending machines, access to the kitchen, kitchen storage areas and access to locked resident halls. The service hall exit door required a code entered on a keypad on the wall to unlock the door and required a key to turn the door alarm off prior to opening the door. Staff turned the alarm off first with the alarm key, entered the keypad code and then pushed the handle opening the door. If the door banged shut and bounced off the frame it might not have latched leaving the door unlocked or the mechanism failed at the time and the door lock did not engage when Floor Tech A went out the door. The Maintenance Director was not sure how the door opened when Resident #5 pushed on the handle the second time he/she tried the door. The resident did not have the keypad code. Staff should have a spotter every time staff exited the door or when going in and out the door taking trash to the dumpster or unloading deliveries. During an interview on 3/3/26 at 11:15 A.M. Licensed Practical Nurse (LPN) B said he/she was the charge nurse on 2/25/26. He/She was unaware the resident was missing until the administrator called and said the resident was at the local coffee shop across the road. LPN B went to get the resident who sat in the grass behind the coffee shop near the dumpster. The resident wore shoes, appropriate clothing and a sweater. It was not cold outside or raining. Staff had not reported the resident had any behaviors that morning. During an interview on 3/3/26 at 1:15 P.M. Certified Nurse Assistant (CNA) C said he/she worked the resident's hall on 2/25/26. The resident was his/her normal base line that morning, was on one-hour checks and was not a high risk for elopement. CNA C saw the resident all morning on the hall and in the Hangout. The resident did not normally exit seek. Staff were unaware the resident was gone until the police department called and informed the administrator the resident was at the coffee shop in the grass by the dumpster. CNA C completed the resident face checks on 2/25/26 and saw the resident at 11:45 A.M. in the Hangout while doing rounds. The resident was not in the service hall at 11:45 A.M. During an interview on 3/3/26 at 9:00 A.M. Floor Tech A said the following:-He/She exited the service hall exit door many times per day to dump trash, unload trucks and access the storage building. The service hall exit door required a code entered in the keypad located next to the door on the wall and a key to turn off the alarm located above the door. He/She knew the keypad code and had a key for the alarm on his/her work key ring fastened to his/her jeans while working;-On 2/25/26 after finishing the trash run between 10:00 A.M. and 12:00 P.M., he went out the service hall exit door to his/her car on the south side of the building. He/She entered the keypad code and pushed the door open. He/She thought the door alarm was already off, and he/she did not remember using the alarm key turning the alarm off before exiting the door. The alarm did not sound;-He/She did not reenter the facility through the service hall exit door, he/she came back in the facility through the front door (on the opposite side of the facility as the service hall exit door);-He/She did not have a spotter when he/she exited the door and did not make sure the door was secured and alarmed after exiting the door. During an interview on 3/3/26 at 11:30 A.M. the resident said he/she went to see the green grass, looked both ways before crossing the street and sat in the grass by a dumpster. He/She was not injured, did not like the facility and wanted to go home. He/She tried the door twice and it opened the second time. He/She went out the door, around the building and crossed the street. No one saw him/her leave the building. During an interview on 3/3/26 at 10:00 A.M. and 2:05 P.M. the Administrator said the service hall exit door was used many times per day by staff to access the trash dumpster, receive and unload deliveries and access the storage barn. The exit door had a keypad code to unlock the door and required a key to turn the door alarm off prior to opening the door. Staff should have another staff member present as a spotter before exiting the door to ensure the door remained secured and residents were unable to exit the door when opened and unalarmed. Floor Tech A went out the service hall exit door without ensuring a spotter monitored the door and left the door unalarmed. Floor Tech A did not return through the service hall door. The resident went out the opened door, the local police department found the resident 20 minutes after exiting the facility at the local coffee shop. Staff were unaware the resident had eloped from the facility. MO#2790713

Based on interview and record review, the facility failed to ensure one resident (Resident #13), in a review of 16 sampled residents, was free from abuse by Housekeeper N. Resident #13 had diagnoses that included personality disorder (mental health condition characterized by long-term, rigid, and unhealthy patterns of thinking, feeling, and behaving that differ significantly from cultural norms), major depressive disorder, recurrent severe without psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and severe methamphetamine use disorder. The resident reported to his/her emergency contact that he/she had observed Housekeeper N smoking methamphetamine (a powerful, illicit, stimulant that is highly addictive and can cause anxiety, paranoia, agitation, stroke or death and is typically snorted, smoked or injected), out of a glass pipe in a facility shower room, and the resident approached Housekeeper N about the methamphetamine. Housekeeper N then provided methamphetamine to the resident on four occasions. The resident tested positive for methamphetamine at a pre-operative surgical appointment on 02/12/26. The facility census was 171. The administrator was notified on 02/18/26 at 3:40 P.M. of an Immediate Jeopardy (IJ) which began on 02/08/26. The IJ was removed on 02/13/26, per surveyor onsite verification. Review of the facility policy, Abuse and Neglect, dated 06/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations;-As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Review of the facility policy, Illegal Drug Use, dated 12/27/24, showed the following:-The facility is an illegal drug-free facility;-Illegal drugs are defined for the purpose of this policy as the use, possession or distribution of any substance which is unlawful under the Controlled Substance Act;-No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of the facility;-No one is allowed to sell, buy, transfer, distribute or use said illegal drugs on the premises of the facility;-No one is allowed to sell, buy, transfer, distribute or use any drug paraphernalia (equipment that is used to produce, conceal, and consume illicit drugs) on the premises of the facility. Review of the facility policy, Code of Conduct, dated 04/18/25, showed the following:Controlled Substances:-The facility prohibits the unlawful possession, use, manufacture or distribution of illegal drugs and alcohol on its property or as part of any of the facilities it manages sponsored activity;-All employees shall refrain from illegal conduct in both personal and business matters. 1. Review of Resident #13's Pre-admission Screening and Resident Review (PASARR), dated 10/31/25, showed the following:-Numerous hospitalizations for suicidal ideations;-History of possession charges;-Prison release in 2022;-Endorsed methamphetamine use disorder, severe intravenous (IV) drug use;-Suicide attempts: endorsed three to four times, most recently reported attempted drug overdose which failed followed by attempted hanging with a belt;-The resident was living at a homeless shelter prior to discharge;-The plan is for inpatient physical therapy (PT)/occupational therapy (OT) and then to a long-term care facility to finish antibiotics and then return to the community. Review of the resident's undated Face Sheet showed the following:-The resident admitted to the facility on [DATE];-The resident was his/her own responsible party;-His/Her diagnoses included severe methamphetamine use disorder, stimulant use disorder, antisocial personality disorder, and major depressive disorder. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/25, showed the following:-Cognitively intact;-No behaviors or rejection of care;-Taking antibiotic, antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. Review of the resident's Care Plan, dated 12/13/25, showed the following:-The resident has a history of stimulant dependence;-Monitor for cravings and relapse warning signs;-Encourage participation in recovery programs;-Teach coping and stress-management skills;-Assess the resident for safety;-The resident uses psychotropic medications;-Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift;-Behaviors per PASARR:1.Substance abuse;2. Homelessness;3. Paranoid/suspicious of others;4. Suicide attempt;5. Suicidal ideations;6. Methamphetamine intoxication/psychiatric hospital stay 09/21/25;7. History of possession of illegal substances charges;8. Expressed thoughts of self-harm;9. Depression/mania/anxiety;10. History of incarceration/prison;11. Antisocial personality disorder. Review of the resident's February 2026 Physician's Orders showed the following:-Abilify (antipsychotic medication) 10 milligrams (mg) by mouth two times daily;-Biktarvy (anti-viral medication) 30-120-16 mg by mouth once daily;-Celebrex (medication used to treat mild to moderate pain and inflammation), 200 mg by mouth once daily;-Gabapentin (medication used to treat nerve pain and manage partial-onset seizures), 400 mg by mouth three times daily;-Tizanidine (muscle relaxant) 2 mg by mouth two times daily;-Seroquel (antipsychotic medication) 200 mg by mouth daily. Review of the resident's Progress Notes, dated 02/12/26 at 6:28 P.M., showed the following:-Resident scheduled for surgery this morning;-Staff received report the resident was unable to have surgery due to positive urine drug screen;-When resident returned to the facility, assessment and vital signs obtained;-Resident was very tearful at that time. Review of the resident's Progress Notes, dated 02/12/26 at 6:38 P.M., showed the following:-Contacted Psychiatric Nurse Practitioner (NP) to notify her the resident's scheduled surgery was canceled due to a positive methamphetamine result on the drug screen obtained at the appointment;-NP provided an order for hydroxyzine (antihistamine medication used to treat itching from allergies and managing anxiety and tension), 50 mg by mouth twice daily as needed for 14 days for anxiety;-Suicide precautions (safety measures designed to prevent self-harm in high-risk individuals, involving constant, direct observation (1:1), removal of dangerous items (belts, cords, sharp objects and medication) and securing the environment) initiated per facility protocol; -Staff assigned to maintain continuous line-of-sight supervision. Review of the resident's Urine Drug Screen (UDS), dated 02/12/26, showed positive for methamphetamine. Review of the facility Admin/Registered Nurse Investigation (RNI), dated 02/12/26 at 8:22 P.M., regarding Resident #13 and Housekeeper N, showed the following:-The investigative narrative note showed the facility received a report from the Social Services Director (SSD) who said she was contacted by the resident's emergency contact reporting the resident was unable to undergo a scheduled surgery after testing positive for methamphetamine;-The resident's emergency contact said the resident informed him/her that he/she received methamphetamine from a facility employee, identified as Housekeeper N, and the resident had consumed the substance on 02/08/26;-Housekeeper N denied providing drugs to the resident but documented that he/she refused to take a drug test because he/she used methamphetamine twice within the past 30 days;-The resident provided a statement alleging Housekeeper N, and no one else, provided him/her methamphetamine four to five times over a two-week period, delivering small amounts in clear bags to his/her bedroom;-The resident said he/she had paraphernalia in his/her room and willingly told administration where it was located;-Confiscated a straw and a few clear bags; -Resident placed on 1:1;-Local police were called and interviewed both Housekeeper N and Resident #13;-Conclusion/Outcomes of the Investigation: -The investigation substantiated serious concern. The employee admitted to recent methamphetamine use and refused drug testing; the resident tested positive for methamphetamine. Given these findings, immediate corrective action was taken, including protective supervision of the resident, notification of law enforcement and Department of Health and Senior Services and termination of Housekeeper N;-This was a result of abuse. Review of the resident's Progress Notes, dated 02/12/26 at 5:29 P.M., showed the following:-Interdisciplinary Team (IDT) met with the resident regarding allegation the resident received methamphetamine from a staff member;-The resident said he/she started receiving drugs from the staff member approximately two weeks ago;-The resident said he/she received multiple baggies from the staff member in a two-week time period and informed IDT where the baggies were located in his/her room and gave consent to search his/her room;-Resident was asked how the relationship with staff started regarding drugs;-The resident said he/she was going into the shower room located on his/her unit when he/she saw a staff member smoking methamphetamine;-The resident said he/she approached the staff member and asked the staff member to bring him/her methamphetamine;-The resident was tearful and apologetic regarding his/her actions and verbalized understanding the risk of potential harm that he/she could have caused him/herself;-Law enforcement called and arrived at the facility to take the resident's statement;-Resident gave consent to the officers to search his/her room, no additional contraband was located, all items were taken into custody for evidence. Review of the resident's Care Plan, revised 02/12/26, showed the following:-The resident tested positive for methamphetamine during routine drug screen prior to having surgery;-Root cause: The resident's mental health challenges, including anxiety, depression, difficulty sleeping, and struggles with substance abuse, made it hard for him/her to manage impulses and make safe choices. These challenges contributed to the resident's decision to use methamphetamine within the facility, despite knowing it could put his/her health and treatment at risk allegedly. During interviews on 02/17/26 at 11:08 A.M. and 02/18/26 at 10:05 A.M., the resident said the following:-He/She had a history of methamphetamine use and he/she had been clean (abstaining from using drugs) for eight months;-Three to four weeks ago, he/she went into the resident shower/bathroom and saw Housekeeper N smoking methamphetamine from a glass pipe; -When he/she saw Housekeeper N smoking methamphetamine, it just made him/her want to do methamphetamine;-A week later, he/she approached Housekeeper N and asked for some methamphetamine;-Housekeeper N brought him/her three to four plastic bags of methamphetamine. Housekeeper N brought the methamphetamine to his/her room;-He/She used the methamphetamine because he/she was bored and using methamphetamine makes him/her feel normal; -He/She last received methamphetamine from Housekeeper N on Sunday, 02/08/26; -He/She had a urine drug screen on 02/12/26, prior to surgery, and tested positive for methamphetamine;-He/She was previously incarcerated due to methamphetamine use and he/she was unsure what would happen to him/her after using and testing positive for methamphetamine. During an interview on 02/17/26 at 2:17 P.M., the resident's emergency contact said the following:-The resident's drug of choice was methamphetamine;-The resident told him/her the last time he/she used methamphetamine was 02/08/26;-When he/she visited the resident on 02/08/26, the resident pointed out Housekeeper N as the staff member who gave the resident methamphetamine;-The resident told him/her that Housekeeper N gave him/her methamphetamine a handful of times;-The resident missed a major surgery on 02/12/26 and all the resident's plans for surgery and rehabilitation were postponed;-The resident's surgery was cancelled because he/she tested positive for methamphetamine;-The resident had been clean for six months. During an interview on 02/18/26 at 8:40 A.M., the Director of Nurses said the following:-The resident's emergency contact reported to the SSD on 02/12/26 the resident got methamphetamine from Housekeeper N;-Staff giving a resident methamphetamine (or any illegal drugs) would be considered abuse. During interviews on 02/17/26 at 3:10 P.M. and 02/18/26 at 2:54 P.M., the Administrator said the following:-Housekeeper N violated the facility's Abuse and Neglect policy and was terminated;-Housekeeper N admitted he/she used methamphetamine while an employee;-Baggies and paraphernalia were found in the resident's room; -The facility substantiated that abuse occurred; -Staff providing a resident with illegal substances would be considered abuse. During an interview 03/03/26 at 9:28 A.M., the resident's physician said the following:-He was aware the resident tested positive for methamphetamine;-It is not good for anyone to use methamphetamine;-The resident took a great deal of medications that deal with neurotransmitters (chemical messengers in the nervous system that influence mood, muscle movement, heart rate and many other functions) which could cause adverse effects when also using methamphetamine;-Staff should not bring illegal drugs in for residents. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).MO2742762

Based on observation, interview and record review, the facility failed to perform a thorough review of one resident's (Resident #1) behavioral health emergencies and take steps to develop person-centered behavioral care plans to support the resident's changing behavioral health care needs. The facility failed to and revise behavioral care plans to include effective interventions for the resident. On 1/27/26, the resident was hospitalized after exhibiting behaviors including threatening another resident and throwing a wet floor sign, which injured a staff member. The resident was hospitalized and returned to the facility 1/29/26. There was no documentation of the interdisciplinary team meeting involving Resident #1, including steps taken to determine potential underlying cause of the negative behavior and steps taken to address, including reviewing and revising the resident's individualized care plan interventions based on that determination. On 1/31/26, the resident, who was assessed the day prior as not being an elopement risk, left the secured unit, went to the facility family room, put his/her hand through a glass window, breaking the glass and in an attempt to leave the facility. The resident sustained injuries which required emergency room care for treatment of lacerations, requiring 20 sutures. The resident was then admitted to the psychiatric hospital. The resident returned to the facility on 2/5/26. There was no documentation to show the facility reviewed the incident for underlying causes or developed a person-centered care plan to support the resident's behavioral health care needs related the resident's new elopement behavior. Observation showed the resident left the secured unit on 2/9/26 and went to the front entrance, demanding to leave requiring a behavioral emergency response from staff. Staff failed to notify the resident's physician of the continued behaviors following his/her readmission on [DATE] and failed to timely update the resident's care plan with interventions to address continued behavioral emergencies. The resident had five Code Greens (behavior emergency) called over a 10-day period at the facility. On 1/27/25 he/she had physical aggression towards a staff member, on 1/31/26 he/she was verbally aggressive and self-harmed, on 2/6/26 and 2/9/26 he/she was verbally aggressive and on 2/10/26 during two incidents he/she was verbally aggressive toward other residents. Residents relayed they were fearful of Resident #1 due to the erratic outbursts and not knowing if the resident would hurt them. The facility census was 171.Review of the facility policy, Behavioral Health Services, dated 10/31/2024, showed the following:-It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;-Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders;-The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Conditions that are frequently seen in nursing home residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to depression, anxiety, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves that can cause hallucinations, delusions and disorganized thinking including paranoia), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs);-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Staff will monitor the resident closely for expressions or indications of distress, evaluate whether the resident's distress was attributable to their clinical condition and that the change in behavior was unavoidable, utilize Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff) and care area assessments, assess and develop a person-centered care plan for concerns identified, share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnoses, accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record, ensure appropriate follow up assessments, discuss potential modifications to the care plan, and evaluate the resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-The care plan shall have interventions that are person-centered, evidence based, culturally competent, trauma-informed, and in accordance with professional standards of practice, provide meaningful activities which promote engagement and positive, meaningful relationships, and meet the needs of the residents. Review of the facility policy, Behavioral Emergency, dated 09/23/25, showed the following:-Care will be directed by the resident's plan of care and will help to respond to difficult behaviors in the safest and most effective way possible;-The Interdisciplinary Team (IDT) will ensure the care plan is updated if appropriate;-The facility will notify the physician and/or the psychiatrist of the behavioral emergency. The guardian, family or responsible party will be notified of the situation, including current status, hospitalization or other specifics;-Proactive management for residents is the best plan;-All staff should recognize when the resident has become, or can become, a danger to themselves or others;-De-escalation techniques should be utilized first;-At regular intervals, the company will review incidents to obtain root cause analysis which will facilitate improvements of care management and further prevention of incidents. Review of the facility policy, Intensive Monitoring, dated 4/30/24, showed the following:-Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal or physical aggression, elopement ideations, suicidal or homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-to-one or two-to-one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor;-The facility's interdisciplinary team will address the resident's behavioral concerns and ensure interventions are in place to address residents' needs (psychiatry follow up, counseling, medical needs, etc.). 1. Review of Resident #1's Pre admission Screening and Resident Review (PASRR, a federally required assessment to evaluate individuals for serious mental disorders and/or intellectual disability so that these individuals be offered the most appropriate setting for their needs and those individuals receive needed services in these settings) dated 12/10/18, located in the resident's electronic health record containing only odd numbered pages, one through 15, for a total of eight pages, showed the following:-The resident had a legal guardian;-The resident had psychiatric diagnoses of schizophrenia, psychosis, major depressive disorder, and mood disorder;-The resident was confused at times during the day and night;-The resident had short term and long term memory loss;-The resident had a history of wandering without knowing where he/she was;-The resident had poor judgement and insight;-The resident did not make good decisions;-The resident had below average intellectual functioning;-The resident was easily frustrated;-The resident had difficulty interacting appropriately and/or communicating effectively with others;-The resident manifests agitation;-The resident required interventions by mental health and or judicial systems;-The resident would benefit from recreational therapy/activities evaluation, grief/loss/adjustment counseling/emotional support, medical and psychiatry follow up, development of personal support networks, and monitoring to change inappropriate behavior or alter manifestations of psychiatric illness. Review of the resident's complete PASRR (16 pages provided by the state agency), dated 12/10/18, showed additional information about the resident that would assist in directing his/her plan of care), as follows: -The resident had substantial cognitive impairment;-The resident needed medication therapy, administration and monitoring, and outpatient psychiatric follow up;-The resident required a secured behavioral unit due to his/her short term memory problems, poor insight and judgement, and insistence on leaving the facility. The resident wanted to go home but did not know where home was;-The resident had a history of auditory and visual hallucinations;-The resident had a history of drug and alcohol abuse;-The resident had periods of assaultive behaviors and agitation;-The resident required monitoring at a skilled nursing facility level to ensure safety and needed a structured environment due to his/her memory problems would pose a risk to his/her safety in a less restrictive setting. Review of the resident's Care Plan, dated 4/17/25, showed the following:-The resident displays manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include verbal aggression;-Assist the resident in addressing root cause of change in behavior or mood as needed;-If the resident disturbs others, encourage him/her to go to a more private area to voice concerns/feelings;-Non-pharmacological interventions include meet with administration/staff member the resident is comfortable with, encourage the resident to attend outdoor activities, play music, and provide one-on-one time to talk to a trusted person/staff;-The resident displays impaired thought processes related to a traumatic brain injury;-The resident had confusion and forgetfulness at times;-Monitor and document the resident's behaviors as needed. Report significant changes in cognitive functioning to physician promptly;-Ongoing assessment for changes in mental status, behavioral emergencies and impaired cognitive functioning to physician promptly;-One-on-one intensive monitoring as needed/warranted for protective oversight;-Assist the resident in using coping skills as needed;-Attempt to ascertain what the resident would accept/need to calm down and provide as able;-The resident had triggers that included yelling, being denied toilet paper, and smoking;-Staff and peers should avoid following triggers. If staff observe a trigger is happening to the resident immediately refer to the resident's preferred coping skills and redirect his/her behavior;-The resident had current behaviors that included agitation, mood swings, anxiety and aggression;-If staff see the resident exhibiting behaviors listed in the current behaviors section, refer to the preferred coping skills immediately;-The resident's coping skills include watching tv, sleeping, visiting with peers and group activities;-If the resident is having behaviors and preferred coping skills are not being effective refer to Crisis Alleviation Lessons and Methods (CALM, a system of interventions including de-escalation and physical holds to manage residents in crisis), de-escalation protocols (this protocol had not been used by the facility since 2024 but remained part of the resident's plan of care);-This is my (the resident's) safety plan: not sure;-Please list my personal goal not sure;-I feel like my warning signs are yelling, not being listened to;-My past crisis moments include none;-These are items I want to work on nothing;-The resident was at risk for elopement;-Smoking was not listed as a coping skill for the resident. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 1/6/26, showed the following:-The resident's cognition was moderately impaired;-The resident had no inattention, disorganized thinking, hallucinations, or delusions;-The resident had no physical, verbal or other behaviors towards others. Review of the resident's Progress Note, dated 1/27/26 at 4:02 A.M., showed the following:-The resident approached the nurse's station yelling and using profane language toward staff;-Staff immediately removed any items from the nurse's station that could potentially be thrown;-A peer located down the hall was yelling at and antagonizing Resident #1;-The resident redirected his/her attention toward the peer and began moving in the peer's direction;-Staff immediately intervened by positioning themselves between the resident and the peer, with another staff member standing next to the resident;-A Code [NAME] (behavioral emergency requiring staff intervention) was initiated;-The peer retreated into his/her room and another staff member stood in the peer's doorway to maintain separation between residents;-The resident then threw a wet floor sign directly at staff, striking the staff member in the face;-As additional support staff arrived, the resident moved to the front of the nurse's station and was calm at that time;-911 called. The fire department and police arrived first, followed by EMS (emergency medical services). EMS assessed the injured staff member and transported the staff member to the hospital for further evaluation;-The resident became aggressive again and the police placed the resident in handcuffs and escorted him/her out of the building to the psychiatric hospital;-The resident refused vitals and a skin assessment;-The Director of Nurses (DON), Administrator, primary care physician, and psychiatric nurse practitioner were made aware. Call placed to the guardian's emergency number and was told to leave a voice mail for the guardian. An email was sent that included the progress note;-The nurse spoke with the physician at the psychiatric hospital. Review of the resident's Registered Nurse Investigation (RNI), dated 1/27/26, showed the following:-Date and approximate time of incident: 1/27/27 at 2:30 A.M.;-Type of incident: Physical aggression not involving head;-Persons involved: Resident #1 and Resident #4;-On 1/27/24 an incident occurred involving Resident #1, resulting in staff injury. Resident #1 was observed yelling loudly in his/her room, creating a disturbance on the unit. Staff initiated interventions to maintain safety, including blocking off the nurse's station. Resident #1 then exited his/her room and began moving down the hallway, continuing escalated behavior. He/She was observed was observed threatening staff and verbally aggressive. Staff members followed Resident #1 in an attempt to de-escalate the situation and prevent further disruption. As Resident #1 approached the hallway near Resident #4's room, staff positioned themselves between Resident #1 and other residents to prevent confrontation. During this time, Resident #1 picked up a wet floor caution sign and threw it down the hallway. The sign struck a staff member in the face, causing the staff member to fall to the floor. A green alert was immediately initiated. Resident #4 had returned to his/her room at the time the sign was thrown and was not struck. Resident #4 later reported that prior to the incident, Resident #1 has been threatening staff and verbally provoking Resident #4, stating phrases such as, you want to fight, while advancing down the hallway. Staff intervened by positioning themselves between the two individuals. The wet floor sign initially struck Resident #4's arm and face before striking the staff member allegedly;-Police, physician, guardian notified;-The incident occurred due to unpredictable resident behavior. Staff responded promptly by intervening, initiating emergency protocols, and preventing further escalation. Ongoing focus will remain on de-escalation strategies. It was deemed that Resident #4 was never harmed or put in harm's way. Resident #4 was not close to the resident who struck staff and was roughly 20 yards away;-Residents immediately separated. Allowed 1:1 time to vent and verbalize feelings. Interdisciplinary (IDT) meeting in progress. Peer meeting completed. Education on abuse/neglect. Skin assessment complete. No injections. No missed medications. No abnormal labs. PASSR reviewed. Resident reviewed by primary care physician (PCP). Counseling offered. Legal guardian/PCP/Psych/Management/Administrator all notified;-The plan of care must reflect new interventions as the result of this behavior emergency crisis. List two interventions: See above;-Signed by the administrator as the person completing the investigation and dated 1/25/26. Review of the resident's Care Plan, listed as Resolved and dated 1/27/26, showed the following:-Problem: RESOLVED. The resident displayed physical aggression, resulting in an investigation;-Desired outcome: protective oversight will be maintained through the next review (2/24/26);-Interventions included residents immediately separated, Resident #1 was allowed one-on-one time to vent and verbalize feelings, the IDT team meeting was in progress, P2I2 (psychosocial questionnaire for residents) meeting completed, no injections were given, no as needed medications were given, the resident was not placed on a one-on-one monitoring; PASRR was reviewed, the resident was reviewed by the physician, counseling was offered;-The resident's guardian, physician, psychiatrist, management/administration were notified;-This care plan problem was marked as resolved on 2/1/26;-Problem: the resident became physically aggressive towards staff;-Desired outcome: ensure protective oversight is provided through next review and the resident will have fewer episodes of physical aggression by the review date (2/24/26);-Interventions included 911 was called and the resident was transported to the hospital by the police, nurses attempted to assess the resident, but he/she refused;-The resident's guardian, DON, psychiatrist, and administration were notified;-The care plan problem was resolved on 1/27/06. The resident's care plan, progress notes, and RNI dated 1/27/26, showed no documentation of the interdisciplinary team meeting involving Resident #1, including steps taken to determine the underlying cause of the negative outcome and steps taken to address, including reviewing and revising individualized interventions based on that determination. One problem, physical aggression that resulted in injury to staff, was noted as resolved on the care plan on the same day it was initiated and before the resident had returned from the hospital. Review of the resident's Progress Note, dated 1/30/26 at 10:45 A.M., showed the resident had no history of elopement. Review of the resident's Progress Notes, dated 1/31/26 at 9:53 A.M., showed the following:-The resident was in his/her wheelchair at the front of the building;-The resident attempted to get through the door;-When the front door was not opened, the resident went into the family area across from the front office and then staff heard glass shattering;-Staff were with the resident when he/she attempted to get out of the window;-Staff called 911 and asked for police and ambulance to the facility;-The Administrator and DON were called with an update;-Once EMS arrived the resident allowed them to address his/her wound and the resident was transported to the hospital;-The resident's guardian was notified. Review of the resident's Hospital Records, dated 1/31/26, showed the following:-The resident required six sutures to the left ring finger;-The resident required five sutures to the outer side of the left hand;-The resident required four sutures to the left wrist;-The resident required five sutures to the left forearm, 20 sutures total;-The hospital called the facility to discharge the resident back to the facility;-When the resident was prepared to return to the nursing home and staff arrived to transport him/her the resident became violent/explosive and refused to return to the facility;-The facility said the resident was to go to a psychiatric hospital for admission because they did not feel comfortable taking the resident back due to his/her violent behavior and aggression towards staff;-EMS staff were never told about the resident's violent behavior or the need for a psychiatric evaluation. Review of the resident's progress notes, dated 1/31/26 at 11:45 A.M., showed the following:-The facility received a call from the local hospital stating the resident was ready to discharge;-The facility said they told EMS to take the resident to a psychiatric hospital about 30 miles south of the facility;-The local hospital said they could not transport the resident to the psychiatric hospital and that the facility would have to transport the resident;-The DON was notified. Review of the resident's Care Plan, listed as Resolved, dated 1/31/26, showed the following:-Problem: RESOLVED. The resident sustained a self-inflicted injury as a result of breaking a window;-Desired outcome: ensure protective oversight is provided through next review (2/24/26);-Interventions included police and emergency medical services (EMS) were called, staff stayed beside resident until police and EMS arrived;-The resident's guardian, DON, physician, and administration were notified;-A psychosocial post-incident impact questionnaire and skin assessment were completed per facility protocol;-The care plan problem was listed as resolved on 2/1/26. Review of the resident's care plan showed no documentation the facility identified a root cause of the resident's behavior or interventions based on the root cause to address the behavior. The resident's record showed no documentation of the interdisciplinary team meeting involving Resident #1, including steps taken to determine the underlying cause of the negative outcome and steps taken to address the new behavior of attempting to elope, including reviewing and revising individualized interventions based on that determination. The problem was listed as resolved before the resident had returned to the facility from the psychiatric hospital. During an interview on 2/9/26 4:00 P.M. Nursing Assistant (NA) J said the following:-On 1/31/2026, he/she arrived on duty on the secured unit where the resident resided;-As he/she got report from night shift, Resident #1 came up and asked to go smoke because he/she did not smoke at the 5:30 A.M. smoke break. The night shift staff ignored the resident and continued to give report;-NA J did not know if the resident was asleep and missed the smoke break or why he/she missed smoking;-A little bit later the Certified Medication Technician (CMT) gave the resident his/her medication and the resident calmed down. During an interview on 2/9/26 at 1:08 P.M. Certified Nurse Aide (CNA) K said the following:-On 1/31/26, the resident wheeled himself/herself very fast down the hallway towards the front entrance in his/her wheelchair;-The resident did not yell or say anything when he/she passed CNA K, but CNA K knew something was going on because the resident was going so fast;-CNA K used his/her walkie talkie to call a Code Green. By the time he/she called the Code [NAME] the resident was already around the corner and at the front entrance. During an interview on 2/9/26 at 2:23 P.M. CNA C said the following:-On 1/31/26, when CNA C went on duty at 7:30 A.M. on the secured unit where the resident resided, the resident was yelling I want out of this mother fucking place, I want to leave!;-When the door of the secured unit was opened to let residents out to eat breakfast in the assist to dine dining room, Resident #1 burst out of the door and wheeled himself/herself to the front entrance;-CNA C went up to the front entrance for the Code [NAME] but he/she stayed in the office because he/she was afraid of Resident #1;-Other residents were also afraid of Resident #1. During an interview on 2/9/26 at 1:12 P.M. CMT L said the following:-On 1/31/26 he/she was on the hall just outside the secured unit where Resident #1 resided when the resident was let off the secured unit by CMT M;-CMT L asked the resident how he/she was doing and the resident said he/she was mad and kept going in his/her wheelchair;-CMT L asked CMT M why he/she let the resident off the unit, CMT M did not answer but did say the resident was about to go off;-CMT L looked around the corner and the resident was already down the hallway towards the front entrance, the resident was moving fast in his/her wheelchair;-CMT L heard a Code [NAME] called over the walkie talkie and went to the front;-When he/she got to the front he/she heard a window shatter and when CMT L got to the family room the resident had a leg out of the broken window;-The resident yelled Fuck you, get out of my way!;-CMT L, Floor Technician D, and the Activity Director tried to redirect the resident and had to pull the resident back into his/her wheelchair and hold the resident in the wheelchair until the ambulance arrived. During an interview on 2/9/26 at 2:49 P.M. Receptionist E said the following:-He/She was in the office and heard Resident #1 coming to the front entrance. The resident was yelling and cussing;-The resident went to the secured front door and beat on it with both fists and said let me out of here. The resident beat on the door several times before Receptionist E told the resident he/she could not leave;-The resident turned around and Licensed Practical Nurse (LPN) H was there so the resident went into the family room (a room directly across from the reception window);-Receptionist E did not see anything after the resident went into the family room but he/she did hear glass shatter;-Staff went outside to keep the resident from climbing out of the broken window and other staff were in the family room trying to calm the resident down. During an interview on 2/9/26 at 3:06 P.M. and 5:10 P.M., Floor Technician D said the following:-He/She was in the front office when a Code [NAME] was called on Resident #1;-He/She went into the family room where Resident #1 had already broken a window and was attempting to crawl out the window with his/her arms, then the resident tried to lift himself/herself out of the window on his/her buttock;-He/She and other staff had to hold the resident in his/her wheelchair to prevent him/her from going out of the window;-The resident's arm was badly cut. Review of the resident's Progress Note, dated 2/5/26, showed the resident returned to the facility from the psychiatric hospital where he/she had been admitted from 1/31/26 to 2/5/26. Review of the resident's record showed no documentation the facility identified a root cause of the resident's behavior on 1/31/26. The resident's record showed no documentation of the interdisciplinary team meeting involving Resident #1, including steps taken to determine the underlying cause of the negative outcome and steps taken to address the new behavior of elopement, including reviewing and revising individualized interventions based on that determination. The problem was listed as resolved before the resident had returned to the facility from the psychiatric hospital. Review of the resident's progress notes, dated 2/6/26 at 5:26 P.M. and 5:31 P.M., showed the following:-The resident was washing his/her face and hands at the sink in his/her room and became agitated;-The resident yelled and told staff to Get the fuck away from me!;-Staff called a Code Green;-A staff member asked the resident if he/she would like to smoke, if that would help;-The resident was agreeable;-The nurse bandaged the resident's hand and helped wash the resident's face;-The resident went to smoke and was calm afterwards. No further behaviors at that time;-There was no documentation to show staff notified the physician, as directed in facility policy;-Staff left a message for the guardian the resident had a behavioral code called but he/she was redirectable and calm with no medication interventions. During an interview on 2/9/2026 at 9:46 A.M., 10:15 A.M., and 12:06 P.M. CNA A said the following:-There was no specific monitoring in place for Resident #1;-The resident ate his/her meals off the secured unit in the assist- to-dine dining room;-There was no redirection that worked for the resident when he/she got upset besides letting the resident smoke;-Some residents had made comments that they were afraid of Resident #1. Observation on 2/9/26 at 9:47 A.M. showed CNA A opened the secured door on the unit where Resident #1 resided when the resident asked to get coffee in the assist-to-dine dining room. The resident left the unit without staff. Observation on 2/9/26 at 9:49 A.M., showed staff called a Code Green:-Resident #1 was at the facility front entrance with multiple staff around him/her including the Administrator and Assistant Administrator;-The Administrator stood between the resident and the front door and blocked the doorway to the family room;-The resident yelled and cussed and said, I want the [expletive] out of here! How hard is it to open the [expletive] door and let me out of here! as the resident waved both arms above his/her head;-The Assistant Administrator tried to calm the resident and asked the resident if he/she would like to smoke. The resident continued to yell he/she wanted out of the facility;-After several minutes the resident calmed down and agreed to go smoke with the Assistant Administrator;-The Assistant Administrator took the resident to the secured unit where he/she resided to the indoor smoking room for about 30 minutes and let the resident talk and smoke;-The resident returned to his/her room. During an interview on 2/9/26 at 10:15 A.M. CNA A said the following:-The resident had behaviors almost every day;-The resident returned from the hospital on 2/5/26 and had a behavior on 2/6/26;-A Code [NAME] was called related to the resident on 2/6/26 in his/her room;-The resident got upset when a resident in the neighboring room knocked on the bathroom door;-The resident began yelling and cussing when CNA A was down the hall helping another resident;-CNA A got to the resident's room and he/she was out of his/her wheelchair, at the sink, putting soap on his/her hands and slapping them together;-The resident continued to yell and cuss and slap his/her hands together and his/her hand began to bleed from the area that had stitches. Some of the stitches busted open;-The resident finally calmed down and was taken to smoke and wrap his/her hand to keep to stop the bleeding. Review of the resident's Progress Note, documented by the Assistant Administrator, dated 2/9/26 at 11:33 A.M., showed the following:-The Assistant Administrator met with the resident during and after his/her behavior;-The resident was allowed time to vent and verbalize feelings;-The resident and Assistant Administrator discussed calling the Assistant Administrator before he/she got upset;-The resident was smiling and laughing with the Assistant Administrator after the incident;-The resident had no further concerns;-The record did not contain documentation to show the physician or guardian were notified, as directed in policy. During an interview on 2/9/26 at 2:36 P.M. the resident said the following:-He/She wanted to leave, he/she was tired of living at this facility;-On 1/31/26, he/she busted the window to try to get out of the facility;-None of the staff had asked the resident what he/she wanted or why he/she wanted to leave the facility;-He/She wanted to go to live on his/her own in the city;-The resident refused to talk any further. Review of the resident's Care Plan, revised 2/9/26, showed the following:-Problem: On 2/9/26 the resident displayed verbal aggression, unprovoked, wheeling himself/herself to the front door stating he/she wanted to leave the facility;-Desired Outcome: Resident will use coping skills once he/she feels agitated until the next review;-Interventions: This portion of the care plan was blank. The resident's care plan showed no evidence of root cause a

Based on interview and record review, the facility failed to ensure one resident (Resident #7), in a review of 15 sampled residents, was free from sexual abuse when Certified Nurse Aide (CNA) B sent sexual content via text messages and pictures to the resident's cell phone. The resident reported he/she and CNA B had kissed and had a sexual relationship including touching each other's genitals. The facility census was 177.On 1/14/26 at 4:11 P.M., the Administrator was notified of the past noncompliance which occurred on 1/4/26. On 1/4/26, the Administrator became aware of the employee to resident sexual abuse allegation involving CNA B and Resident #7. Upon discovery, the facility suspended CNA B, separated Resident #7 from the other residents to allow one on one time for the resident to vent and verbalize feelings. The nurse completed a skin assessment on the resident which showed no injury. The counselor, who provided bi-weekly counselling was notified of the incident. The legal guardian, physician, police department, and psychiatric provider were notified of the incident. Staff began interviews of the residents on the 900 Hall and Homestead Hall to determine how many residents were affected. Before the start of their shift, all staff received education on the Abuse/Neglect policy, Social Media policy, and Relationship with Residents policy. On 1/5/26, the facility provided a Resident Council Meeting on all the halls of the facility regarding therapeutic relationships. The deficiency was corrected on 1/5/26. Review of the facility's Sexual Activity/Abuse and Neglect policy, revised on 9/29/25, showed the following:-Residents that are wishing to engage in sexual activity/intercourse will be allowed to participate in these activities as long as both parties consent and have the ability to consent;-If the resident has a guardian or a physical and/or cognitive impairment an assessment should be completed to determine the resident's ability to consent;-The resident's guardian will be invited to provide their guidance/opinion to the Interdisciplinary Care Team. Family members may be involved in the assessment as appropriate;-If a resident has been deemed unable to provide consent to sexual activity based on criteria within, guardian involvement will be taken into advisement if the resident wishes to have a sexual engagement but may not understand the risk and benefits associated. Review of the facility's Employee Dating Residents policy, dated 7/31/23, showed the following:-Employees are not allowed to have a dating relationship with residents of the facility;-This policy is in effect at all times while a resident is living at the facility;-The employer will determine what constitutes a dating relationship;-Employees who participate in a dating relationship may be disciplined up to and including termination for the first offense. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed the following:-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes sexual abuse facilitated or enabled through the use of technology;-Sexual abuse is non-consensual contact of any type with a resident;-Taking sexually explicate photographs and/or audio/video recordings of a resident and maintaining and/or distributing them (e.g., posting on social media);-Any photograph or recording of residents that contain nudity, sexual/intimate relations, directing a resident to use inappropriate language, or showing a resident in a compromising position is a violation of this policy. 1. Review of Resident #7's Preadmission Screening and Resident Review (PASARR) MentalIllness Level II Evaluation, dated 5/2/23, showed the following:-The resident had an onset of symptoms at age nine that included anxiety (feeling of fear, dread, and uneasiness), sleep disturbances, depression (common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), mood change, manic episodes (period of abnormally elevated mood and high energy, often accompanied by erratic behavior), poor impulse control and poor concentration;-The resident left the residential care facility and stayed out overnight with another resident, returning the next morning, because the resident was angry because of restrictions over little things such as, going out on dates with the opposite sex;-The resident put self in dangerous situations, poor decision making, poor social boundaries, irritable, and elevated mood;-If admitted to a nursing facility, the resident needed or continued to need services indicated below:Individual, group and family psychotherapy;Drug therapy and monitoring for side effects and effectiveness of medications;Structured socialization activities to dimmish tendencies toward isolation and withdrawal, difficulty with maintaining healthy relationships;Development of appropriate personal support networks;Implementation of systemic plans to change inappropriate behavior;Provision of a structured environment. The resident was immature, requires redirection as needed;Physician services;Medically related social services;-The resident may benefit from the following additional services, if available:Guardianship/conservatorship;Secured unit/facility. Review of the resident's face sheet, undated, showed the following:-The resident was readmitted on [DATE];-He/She had a guardian. Review of the resident's Care Plan, updated 9/6/25, showed the following:-The resident had a PASRR history of anxiety, onset at the age of nine. He/She had a history of sleepdisturbances, depression, mood changes, manic episodes. The resident lived with his/her familyfor a long time up until a few years ago when he/she went to several different residential care facilities (RCF) and had a failed history at an RCF. He/She had many failed short term employments. The resident had poor impulse control;-Behaviors included: manic episodes, poor impulse control, having a behavior then stating he/she didn't remember it happening, physical aggression, destruction of property, false allegations when the resident ran out of his/her vape about peers and staff, verbal outbursts, and fixating when things don't go his/her way. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 12/22/25, showed the following:-The resident was cognitively intact;-No behaviors;-He/She required supervision with walking;-He/She received antipsychotic (used to treat and manage symptoms for several psychiatric disorders), antianxiety (prescription drugs that help manage symptoms of anxiety like panic, extreme worry, and restlessness by calming the nervous system), and antidepressant (help restore the normal balance of brain chemicals called neurotransmitters and help regulate the affected person's mood) medications. Review of the resident's Nurse's Note, dated 1/4/26 at 8:40 A.M., showed the following:-Staff called Registered Nurse (RN) A to the unit due to the resident flipping tables and chairs;-When RN A responded, the resident was vaping in the common area;-The resident said the medications were not working, and he/she was tired of the same routine every day;-RN A offered to move the resident to a different unit, but the resident declined;-RN A offered to send the resident to psychiatric hospital, but the resident declined;-The resident requested an injection;-He/She did take the morning medications;-He/She walked away to his/her room;-RN A instructed staff to monitor and report abnormal behaviors;-RN A left a voice message for the resident's guardian, physician, and the facility administrator. Review of the resident's Nurse's Note, dated 1/4/26 at 5:20 P.M., showed the resident told staff a staff member of the opposite gender sent him/her pictures. Staff notified the director of nursing, administrator, management, the resident's legal guardian, physician, psychiatric services, state agency and local police department. Review of the facility's Administration/Registered Nurse investigation, dated 1/4/26 at 9:32 P.M., showed the following:-On 1/4/26, Resident #7 told staff he/she had been communicating with a staff member of the opposite gender via text messages and video exchanges and alleged inappropriate physical contact with the staff member;-The resident said he/she asked CNA B for his/her cell phone number, which CNA B entered in the resident's phone;-The resident and CNA B started texting and sending videos, became closer, and engaged in physical contact including kissing and touching;-The encounters occurred in the resident's room and in the linen closet;-CNA B instructed the resident to delete the messages;-The Activity Director responded to a code (behavioral emergency), calmed the resident, and escorted the resident to his/her office;-The resident disclosed to the Activity Director that he/she was upset due to texting and video communication with CNA B who told the resident to erase the messages;-The resident showed the Activity Director the texts and videos on his/her phone;-The root cause of the incident was the staff member crossing professional boundaries with the resident including, sharing a personal phone number, texting, sending videos, and engaging in physical contact;-These actions were not allowed and went against facility policy and staff training;-This was a result of abuse. Review of the Activity Director's witness statement, provided by the facility, dated 1/4/26, showed the following:-He/She responded to a code on Resident #7's hall, calmed the resident down, and asked the resident if he/she wanted to go to his/her office to calm down;-The resident said, he/she was upset because he/she was texting CNA B and videoing him/her;-CNA B told the resident to erase all the messages;-The resident showed the Activity Director the text messages and videos on his/her phone;-The Activity Director called the Administrator around 5:20 P.M. Review of the resident's statement, provided by the facility, dated 1/4/26, showed the following:-The resident asked CNA B for his/her phone number and the staff member typed it in the resident's phone;-Resident #7 and CNA B started texting and sent videos, then they became closer and being physical like kissing and touching;-The resident and CNA B touched and kissed in his/her room and in the linen closet;-Where the cigarettes were located, the resident and CNA B touched each other's genitals, and this occurred again in the resident's room. Review of the resident's phone text photos, obtained on 1/4/26 by the facility, showed the following:-The resident had a text conversation with CNA B on 12/6/25 at 8:39 A.M.;-Text message from CNA B to the resident showed, to answer your question about what I thought about your video.I like to give hand jobs. Feel how hard I can make it using my;-CNA B sent a photo of himself/herself in underwear to the resident on 12/6/25 at 3:28 P.M During an interview on 1/13/26 at 12:04 P.M., Resident #7 said the following:-CNA B was sexual with him/her;-The resident asked for CNA B's phone number, and he/she put it in the resident's phone;-They started out by sending text messages and videos, then started fooling around in his/her room and the linen closet;-Fooling around meant touching each other's genitals in a sexual manner;-CNA B waited until the other residents went outside for a smoke break before approaching him/her;-[NAME] another resident knocked on the door, CNA B left to help the other resident and then came back to him/her to finish. During an interview on 1/13/26 at 4:04 P.M., the resident's guardian said the following:-Resident #7 did not have the ability to consent to sexual activity;-In the court of law, the resident was determined incapacitated and disabled;-The resident had poor impulse control and decision making;-From discussing the situation with the facility staff, the reason the resident reported what happened was because the staff member stopped communicating with him/her. During an interview on 1/13/26 at 4:50 P.M. and 1/21/26 at 1:18 P.M., the Administrator said the following:-His expectation was the staff members to have a professional, therapeutic relationship with the residents inside the facility;-His expectation was the staff members followed the policy about not having a relationship with residents while in the facility;-His expectation was the staff members did not provide residents with their personal phone number to communicate outside the facility;-The incident between CNA B and Resident #7 was abuse;-CNA B did not follow the policies and had an inappropriate relationship with Resident #7. 2706891

Based on interview and record review, the facility failed to convey resident funds within 30 days of discharge to the resident and/or responsible party for one resident (Resident #11), in a review of 15 sampled residents. The facility census was 177.Review of the facility's Resident Trust policy, revised on 9/21/25, showed the following:-Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident's trust account balance;-The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge. The Resident Trust Clerk shall provide a complete accounting record of the funds along with the check. Review of email correspondence sent to the facility by Resident #11's guardian to the Social Services Director and the Administrator) provided by the resident's guardian, dated 11/25/25 at 10:16 P.M., showed the following:-The email served as a formal notice that Resident #11 would not return to the facility;-The resident's guardian requested a call back to discuss the funds remaining in the resident's trust account. Review of the facility's Trust Transaction History report, dated 11/24/25, showed the resident's trust fund balance was $103.99. Review of the resident's record and trust account showed no documentation the facility returned the resident's funds to the resident or the resident's responsible party. During an interview on 1/15/26 at 1:27 P.M., the Business Office Manager/Resident Trust Clerk, said the following:-She was in charge of the resident trust account;-She was unaware the resident had discharged from the facility. During an interview on 1/15/26 at 1:53 P.M., the Social Services Director said, she had just found an email from the resident's guardian reporting the resident was not returning to the facility, dated 11/25/25. During an interview on 1/15/26 at 2:33 P.M., the Administrator said his expectation was remaining resident trust funds were sent to the resident/family within five days of discharge. 2714640

Based on interview and record review, the facility failed to ensure staff obtained a lithium level (a laboratory test to monitor the concentration of lithium (mood stabilizing medication to treat bipolar disorder (mental illness) in the blood) for Resident #24 as ordered by the psychiatric Nurse Practitioner in October 2025. Resident #24 had a physician order for lithium 600 milligrams twice daily with an order start date of 09/20/24. Review showed Resident #24 was found in his/her room unresponsive on 11/24/25. The resident had vomited and was incontinent (abnormal for this resident). The resident's color was pale (normal color pink) and yellow. The resident's heart rate was 111 beats per minute (normal 60-100) and his/her oxygen saturation (blood oxygen level) was 70 percent (%) on room air (normal 95-100%). The resident was transferred to the hospital where he/she was found to have a critically high lithium level of 3.6 (normal is 0.6 - 1.2) and required intubation (a procedure where a tube is inserted through the mouth into the trachea to secure an open airway to support breathing) and was dialyzed (a life-sustaining treatment that filters waste products from the blood) four times to lower the lithium level. Further review showed the facility failed to obtain ordered blood work, including complete blood counts (CBC) (blood cell count including measure of white blood cells (WBC), that may indicate infection) and comprehensive metabolic panels (CMP) (blood test that checks the chemical balance of the blood, including Blood Urea Nitrogen (BUN, a test to assess how well the kidneys and liver are functioning) and Creatinine (a component to test how well the kidneys are filtering waste from the body). Upon the resident's emergency medical care, he/she was found to have elevated BUN and Creatinine levels as well as an elevated WBC. Review of hospital records and interview with the physician showed the resident suffered acute kidney failure and concerns with lack of oxygen to the brain. At the time of the survey exit, the resident remained hospitalized , 19 days following admission. The facility census was 172. The administrator was notified of the Immediate Jeopardy (IJ) on 12/10/25 at 12:30 P.M. which began on 11/24/25. The IJ was removed on 12/10/25 as confirmed by the surveyor onsite. Review of the facility policy, Transcription of Orders/Following Physician's Orders, revised on 05/18/24, showed the following:-The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical record (EMR) in orders section;- After laboratory testing, diagnostic testing or other services are ordered, the nurse will document orders in the resident's EMR (electronic medical record) and will fill out the corresponding requisition for the specific services to be obtained (or follow protocol set forth by individual lab company). Review of the facility policy, Diagnostic Testing Services Policy, revised on 06/26/24, showed the following:-This facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with state and federal guidelines;-The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. Review of www.drugs.com showed the following: -Lithium is a mood stabilizing medication used to treat or control the manic episodes of bipolar disorder (brain disorder causing extreme shifts in mood, energy and activity, also known as manic depression); -Lithium toxicity can cause death. Lithium is a medicine with a narrow range of safety and toxicity can occur if you take only slightly more than a recommended dose;-Early signs of toxicity include vomiting, diarrhea, drowsiness, muscle weakness, or loss of coordination. Review of Resident #24's undated diagnoses list showed the following:-Bipolar disorder, current episodic manic without psychotic features.-Attention-deficit hyperactivity disorder (disorder that impacts attention, focus, hyperactivity and impulsivity);-Mild intellectual disabilities.-Major depressive disorder, recurrent.-Post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event). Review of the resident's Physician's Order Sheet (POS), dated 9/20/24, showed an order for lithium carbonate 600 milligrams (mg) one tablet by mouth twice daily. Review of the resident's Care Plan dated 9/20/24, showed the following: -The resident uses psychotropic medications related to behavior management;-The resident has a behavior problem related to depression;-Arrange for psychiatric consult, follow up as indicated;-Drug therapy and monitoring;-Monitor/document for side effects and effectiveness;-The plan included no specific interventions regarding monitoring for side effects of lithium, signs of toxicity, or monitoring lithium levels. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/26/24 showed the following:-Cognitively intact;-Diagnoses of depression, Bipolar disorder, Post Traumatic Stress, and autism (a condition related to brain development that affects how people see others and socialize with them). Review of the resident's medical record, dated 11/21/24, showed the following:-BUN 8 (normal 7-25);-Creatinine 1.0 (normal 0.7-1.3);-Lithium level 1.0 mmol/L (normal 0.6-1.3). Review of the resident's Care Plan dated 12/19/24 included no specific interventions regarding monitoring for side effects of lithium, signs of toxicity, or monitoring lithium levels. Review of the resident's medical record dated 03/20/25 showed the following:-BUN 5;-Creatinine 0.8;-Lithium level 1.0. Review of the resident's POS, dated 05/15/25, showed an order for a lithium level (laboratory test) every three months. Review of the resident's medical record showed no documentation staff attempted and obtained, or the resident refused the ordered lab work on 5/15/25. Further review showed no documentation staff notified the resident's physician the ordered lab work had not been obtained. Review of the resident's laboratory results dated [DATE] showed the following:-BUN 11;-Creatinine 0.9;-Lithium level 0.5 mmol/L (normal 0.6-1.3). Review of the resident's Care Plan, revised 09/06/25, showed the following:-Encourage adherence to prescribed medications (antidepressants, mood stabilizers, and antipsychotics as prescribed);-No specific interventions regarding monitoring for side effects of lithium, signs of toxicity, or monitoring lithium levels. Review of the resident's POS, dated 09/12/25, showed an order for a CBC monthly starting on the 13th. Review of the resident's medical record dated September 2025 showed no documentation staff obtained, or the resident refused the ordered lab work. Further review showed no documentation staff notified the resident's physician the ordered lab work had not been obtained. Review of the resident's October 2025 POS showed the following:-On 10/20/25 an order for lithium serum level and CMP;-On 10/21/25, an order for CBC;-On 10/22/25, lithium level, CMP and CBC, SENT Uncollected. Review of the resident's Medication Administration Record (MAR) dated October 2025, showed staff documented administering the resident his/her scheduled lithium carbonate 600 mg by mouth twice daily as ordered with no documentation to support the resident had been refusing the medication. Review of the resident's medical record dated October 2025 showed no documentation staff obtained, or the resident refused the 10/20/25 and 10/21/25 ordered lab work. Further review showed no documentation staff notified the resident's physician the ordered lab work had not been obtained. Review of the resident's Physician Progress Notes, dated 10/23/25, showed the following:-The resident's mental health was being actively managed with psychotropic medications;-Autistic disorder: Followed and managed by psychiatric services;-Major depressive disorder: Followed and managed by psychiatric services;-Adjustment disorder: Followed and managed by psychiatric services.-No documentation regarding the resident refusing medications or experiencing side effects of lithium. Review of the resident's POS, dated November 2025, showed an order for lithium carbonate 600 mg by mouth twice daily. Review of the resident's POS, dated 11/11/25, showed an order for a CMP every three months. Review of the resident's medical record dated November 2025, showed no documentation staff obtained, or the resident refused ordered lab work of 11/11/25. Further review showed no documentation staff notified the resident's physician the ordered lab work had not been obtained. Review of the resident's MAR, dated 11/01/25 through 11/14/25, showed staff documented administering the resident his/her scheduled lithium carbonate 600 mg by mouth twice daily as ordered with no documentation to support the resident had been refusing the medication. Review of the resident's Mental Status Exam, completed by the Psychiatric Nurse Practitioner, dated 11/14/25, showed the following:-Reason for visit: Elevated lipids, valproic acid (antiseizure medication) level low, refusing medications at times;-Symptoms: resident is on six psychotropic medications;-Labs are up to date, lipids are elevated. Review of the resident's MAR, dated 11/15/25 through 11/20/25, showed staff documented administering the resident his/her scheduled lithium carbonate 600 mg by mouth twice daily as ordered with no documentation to support the resident had been refusing the medication. Review of the resident's Physician Progress Note, dated 11/20/25, showed the following:-Chief complaint: Resident evaluated for chronic psychiatric, neurologic, and gastrointestinal conditions with emphasis on acute nausea and vomiting;-Resident not doing well today;-Nursing reports he/she vomited twice and was experiencing intermittent nausea;-Appetite reduced but tolerating fluids;-The resident was already on Zofran (anti-nausea medication) four milligrams as needed, and staff will administer upon the resident's request;-Treatment: Encourage fluid intake. Continue Zofran by mouth as needed for nausea and vomiting. Monitor for dehydration and worsening gastrointestinal symptoms. Review of the resident's progress notes dated 11/20/25-11/21/25 showed no documentation regarding the resident experiencing nausea and/or vomiting. Review of the resident's MAR, dated 11/21/25 through 11/22/25, showed staff documented administering the resident his/her scheduled lithium carbonate 600 mg by mouth twice daily as ordered with no documentation to support the resident had been refusing the medication. Review of the resident's Behavior Symptoms and Cognitive Performance Assessment completed by facility staff and dated 11/22/25 showed the following:-No behavior symptom presence;-No rejection of care, including bloodwork;-Current behavior: same. Review of the resident's progress notes dated 11/22/25-11/23/25 showed no documentation regarding the resident experiencing nausea and/or vomiting. Review of the resident's MAR dated 11/23/25, showed staff documented administering the resident his/her scheduled lithium carbonate 600 mg by mouth twice daily as ordered with no documentation to support the resident had been refusing the medication. Review of the resident's Progress Notes, dated 11/24/25 at 1:45 A.M., showed the following:-Resident was found by staff after an aide heard a noise and a smell coming from the resident's room;-Upon entering the room, the resident was noted to have vomited and was incontinent;-The resident's color appeared pale and the resident was not responding to nursing staff;-Resident's pupils were noted to have poor dilation response;-Resident's lung sounds were hard to hear due to gurgling respirations (normal respiration sound is soft, low pitched);-Due to altered responsiveness, abnormal discoloration, low oxygen saturation, and significant change from baseline, Emergency Medical Services (EMS) notified;-Resident was transported to a local hospital for further evaluation and treatment. Review of the resident's emergency room record, dated 11/24/25, showed the following:-Presenting complaint: Possible aspiration of stomach contents. Received report from nurse at facility during every two hour rounds, there was a foul smell present in the resident's room. Upon turning on the lights, found resident to be covered in yellow emesis, nonreactive to painful stimuli, and having gurgling respirations. Oxygen saturation (measures the percentage of oxygen in the blood) 82 percent (%) (normal is 95 - 100%) on room air, placed on oxygen via nasal cannula (prongs placed in the nares that deliver oxygen) at facility. EMS unable to get intravenous (IV) (within the vein) or intraosseous (IO) (emergency technique for giving fluids/medications directly into the bone marrow when the veins fail) access. Resident on nonrebreather mask (medical device that delivers a high concentration of supplemental oxygen) at 15 liters per minute (a high flow rate often used for severe, critical conditions). Resident became hypotensive (low blood pressure) enroute 83/43 (normal blood pressure 120/80) and tachycardic (elevated heart rate);-General: Appears distressed;-Neuro: Level of consciousness unresponsive. Pupils are sluggish;-Respiratory: Respiratory pattern is tachypnea (fast respirations). Breath sounds with crackles bilaterally (normal clear);-The resident's creatinine was greater than three, concerning for acute kidney injury, however no baseline labs are available at this time;-Resident with an elevated lithium level concerning for lithium toxicity. The lithium level is 3.6. The resident will need transfer to a Medical Intensive Care Unit (MICU) for emergent treatment of lithium toxicity;-BUN 60;-Creatinine 3.02;-WBC 19.4 (normal 4.5-11.0);-The resident was intubated upon arrival for hypoxia (low oxygen level) and altered mental status;-Transferred by EMS ground to outlying hospital. Review of the resident's Outlying Hospital admission Note, dated 11/24/25, showed the following:-Severe lithium toxicity with lethargy/coma;-Acute hypoxemia respiratory failure on mechanical ventilation (a life-supporting treatment using a machine (ventilator) to help or fully control breathing for someone unable to breathe adequately on their own);-Acute renal (kidney) failure;-Lithium at outside hospital was 3.6, now 3.2. Nonetheless, the resident continued to be minimally responsive while off sedation;-Consulted nephrology (kidney specialist) for consideration of hemodialysis (a life-sustaining treatment for kidney failure that uses a machine with a filter to clean waste and toxins from the blood) (despite level being below 4, his/her mental status was really impacted.) Review of the resident's Nephrology Consultation Note, dated 11/24/25, showed the following:-The resident's lithium dose had been reportedly stable since September 2024;-The resident's Ativan (anti-anxiety medication) dose was recently decreased due to increased somnolence;-Facility staff denies him/her having any recent illness, diarrhea, abnormal behavior or poor oral intake recently;-Assessment/Plan: Lithium level was found to be significantly elevated though it is not clear what precipitated this abrupt increase. His/Her encephalopathy (disturbance of the brain's functioning) is likely related to lithium toxicity. Review of the resident's Hospital Progress Note, dated 12/01/25, showed the following:-The resident's encephalopathy was likely related to lithium toxicity and he/she received four sessions of dialysis and lithium level within normal limits (WNL) now;-The medical intensive care unit (MICU) team will discuss with poison control and determine if more dialysis is needed for Silent Lithium Syndrome (a rare, severe complication of lithium treatment where neurological damage persists long after lithium levels normalize, causing lasting issues like tremors, balance problems, slurred speech and cognitive decline, often linked to acute toxicity episodes). During an interview on 12/08/25 at 1:16 P.M., the resident's guardian said the following:-He/She had received no communication from the facility regarding the resident refusing labs or medications;-The resident was still hospitalized and was intubated;-The resident had failed several extubating (removal of the tube in the windpipe) attempts and had been minimally responsive;-A Magnetic Resonance Imaging (MRI) (a noninvasive scan that creates detailed internal pictures of the body that helps diagnose diseases and plan treatments) was done at the hospital which showed concern for oxygen loss to the brain;-The resident required four rounds of dialysis to clear the excess lithium from his/her system. During an interview on 12/09/25 at 10:00 A.M., Nurse Aide (NA) QQ said the following:-For a few weeks prior to the resident going to the hospital, the resident was staying in bed more and was groggy when he/she woke up;-The charge nurses were aware of the resident sleeping more and thought it was one of the resident's medications. During an interview on 12/09/25 at 7:49 P.M, Certified Medication Technician (CMT) PP said the following:-Prior to the resident's hospitalization, the resident was sleeping more;-Usually the resident would take his/her medications;-Staff would have to wake the resident up for meals and he/she seemed unsteady when he/she got up out of bed. During an interview on 12/09/25 at 10:03 A.M., Licensed Practical Nurse (LPN) HH said the following:-The resident normally slept in and was groggy when staff woke him/her;-The Psychiatric Nurse Practitioner had recently decreased some of the resident's medications in hopes to decrease the resident's sleepiness;-When the physician ordered lab work, Registered Nurse (RN) A took the new orders and entered them into the computer. During an interview on 12/09/25 at 11:25 A.M., RN A said the following:-The providers send a list of lab orders to the Director of Nursing (DON), and it was his/her responsibility to schedule the labs in the computer.-If the lab noted SENT uncollected there was a loss of Internet, or the resident refused. During interviews on 12/09/25 at 11:29 A.M., 1:49 P.M. and 3:30 P.M., DON #1 said the following:-Providers (physician and nurse practitioners) can enter lab orders directly into the computer but were not able to schedule labs.-Only facility staff can schedule labs. This was how the lab technician knew which residents needed blood work when they came to the facility.-RN A does rounds with the physician and enters new orders into the computer, including lab orders.-The Psychiatric Nurse Practitioner (NP) enters her new orders into the computer and sends a list of new orders to her.-The way the Psychiatric NP entered the labs into the computer did not schedule the labs to be drawn.-The providers can order labs in the computer but can't confirm the orders, only staff can confirm the orders which sends the order to the lab company.-Only facility staff can schedule resident lab work.-She was not aware of the 10/20/25 and 10/21/25 lab orders.-She gives the list of new orders to RN A to schedule in the computer.-There was no documentation in the resident's medical record the resident refused blood work in October.-The resident's last lithium level was drawn 08/19/25.-The resident had altered mental status and was sent to the hospital (on 11/24/25).-There used to be a Resident Care Coordinator (RCC) that would monitor to make sure lab orders were carried out, there had not been an RCC for a long time.-The RCC used to do a lab audit every month and if a lab was not collected, they would reorder the lab.-The resident has not had labs drawn since August.-There had been an ongoing issue with the lab company that lab orders were not being received by the lab, so they had started to double check orders for completion.-Labs should be obtained as ordered. During interview on 12/09/25 at 2:43 P.M., the resident's psychiatric NP said the following:-The resident had been on lithium for over two years, and the resident was stable.-She had recently decreased several of the resident's medications.-The resident had not had any behaviors recently.-Labs must be monitored on residents receiving multiple medications including lithium.-She placed an order for the lithium level to be drawn in October 2025 and would expect that lab to have been drawn.-She placed more than one order for the resident to receive labs and none of the labs were drawn.-When she ordered labs, she entered the order in the computer and emailed a list of new orders to the DON.-It had been an ongoing problem with the facility not getting labs as ordered.-If staff would have obtained the lithium level as ordered, the resident's critical high lithium level could have been detected sooner and addressed. During interview on 12/09/25 at 1:10 P.M., the resident's physician said the following:-Staff should follow physician's orders and obtain labs as ordered.-He examined the resident on 11/20/25 and the resident complained of nausea and vomiting but was otherwise stable.-It was very important to monitor lithium levels closely, as the range of toxicity with lithium was very small.-The resident was receiving a lot of lithium.-Lithium levels should have been obtained and monitored by psychiatry.-Sometimes it can take a person years to recover from lithium toxicity. During an interview on 12/09/25 at 4:00 P.M., the resident's hospital physician said the following:-When the resident admitted to the hospital, he/she was unresponsive.-It took four rounds of dialysis to lower the resident's lithium level.-Usually, residents are not dialyzed until the lithium level was 5.5, but the resident was persistently somnolent (a strong, continuous feeling of drowsiness or an overwhelming urge to sleep, even after getting sufficient sleep at night. It is considered a pathological condition or a symptom of an underlying medical issue) when sedation was weaned.-Hospital staff were concerned about Toxic Lithium Syndrome and had been in contact with poison control.-The resident was currently able to answer simple questions. There was concern about lack of oxygen to the resident's brain. NOTE: At the time of the recertification survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). #2669559#2676987#2679510

Based on observation, interview and record review, the facility failed to maintain walls, flooring, resident sleeping rooms, resident restrooms, resident common areas, light fixtures, ceilings, shower and toilet rooms, plumbing fixtures, window blinds, heating/ventilation units, exhaust fans, and room fixtures such as call lights, soap dispensers, and paper towel dispensers throughout the facility to be clean and good repair. The facility census was 172. Review of the undated facility Resident Agreement (part of the admission packet) showed the facility will provide basic maintenance, replacement and repair to the resident's room as required by normal wear and tear. 1. Observation and interview on 12/08/25 at 6:18 P.M. in two of two public restrooms near the main entrance, showed a heavy buildup of fuzzy debris on both exhaust fans. The Maintenance Director said maintenance staff dusted all fans weekly. 2. Observation and interview on 12/08/25 at 3:21 P.M. in occupied resident room [ROOM NUMBER] showed two square holes in the wall next to the vanity and one hole in the blue wall. The Maintenance Director said a resident threw a chair at the wall. 3. Observation on 12/08/25 at 3:20 P.M. in occupied resident room [ROOM NUMBER] showed the ceiling light fixture was missing. 4. Observation on 12/08/25 at 2:57 P.M. in occupied resident room [ROOM NUMBER] showed the window blinds were broken with large sections missing or hanging from the window. The soap dispenser and paper towel dispenser were missing from the vanity wall. The switch plate cover was loose on the wall. 5. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 3:20 P.M. and 12/08/25 at 3:03 P.M., showed a missing paper towel holder near the sink. The area by the bathroom sink had several screw holes and a different paint color where the towel dispenser used to be. Three ceiling tiles were discolored with areas that were black in appearance. During an interview on 12/07/25 at 3:20 P.M., the resident who resided in this room said it would be nice to have a paper towel holder in his/her room. It had been gone for quite a long time. 6. Observation on 12/07/25 at 3:42 P.M. and 12/08/25 at 3:14 P.M., showed the following:-Four holes on the wall above bed A in occupied resident room [ROOM NUMBER] where a television had previously been mounted;-Ten open holes on the white wall and four large open holes on the blue wall. The towel bar was missing from the wall. 7. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 3:25 P.M. and 12/08/25 at 3:07 P.M. showed the following:-Multiple areas of the wall behind bed #1 repaired with dry wall mud and left unpainted with one hole approximately the size of a golf ball; -Large areas of dry wall compound on the blue wall behind the bed. The overbed light fixture was not functional and a fist-sized hole was visible on the vanity wall. The Maintenance Director said the dry wall compound had been there for quite a while, and the wall needed to be finished and painted. 8. Observation on 12/08/25 at 3:11 P.M. in occupied resident room [ROOM NUMBER] showed the overbed light was not secure to the wall and hung diagonally from the wall. 9. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 3:25 P.M., showed the following;-The soap dispenser near the sink was taped shut to hold it together; -The bathroom door handle was loose. During an interview on 12/07/25 at 3:25 P.M., the resident who resides in this room said the following:-He/She would like the paper towel dispenser fixed; every time the bathroom door shut the cover falls open;-He/She had to tape the soap dispenser shut because every time it was used it would pop open;-The bathroom door handle was very loose and did not allow the door to shut securely;-He/She had reported his/her concerns but was not sure to who or when. 10. Observation and interview on 12/08/25 at 2:36 P.M. in the single shower room on the 200 hall showed, black areas and peeling ceiling paint inside the shower stall. The light fixture in the shower was rusty. The wall and ceiling over the toilet in the shower room had black mold-like areas and moisture. The Maintenance Director said the chiller lines had leaked over the toilet area and caused mold and wet areas. 11. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 12:46 P.M., showed the following:-Multiple scraped areas on the wall exposing previous paint above bed #1;-The shared bathroom door had a tennis ball size hole, that went completely through from one side to the other; toilet paper had been stuffed in the hole;-The toilet stool was loose and not secure to the floor; -A small amount of water was observed around the base of the toilet stool;-Multiple pieces of rubberized flooring were missing from the bathroom floor, one approximately 1 inch wide by 2-3 inches long in a half-moon shape, and 8+ cracked areas in a half-moon crescent shape; -An area on the ceiling, near the wardrobe of bed two, had a soccer ball size black mold like area on the ceiling tile with a black ring around the area;-The entry door had multiple scrapes, exposing the previous paint layers underneath the top layer, as well at the metal door. During an interview on 12/07/25 at 12:45 P.M., the resident who resided in this room said the following:-Someone hit the bathroom door and put a hole in it, and it had been that way for a while;-The toilet stool was slightly loose. 12. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 1:03 P.M., showed the following:-Multiple bath blankets laying on the floor from the doorway across the room, in an area approximately seven feet long and four feet wide;- An area near the base trim, at the wall by the bathroom sink, had a small amount of water coming out from under the base trim; -The bathroom vent had a large amount of dust accumulation;-The bathroom ceiling had part of the tile missing around the light fixture;-Part of the wall trim entering the bathroom was missing and the strike plate for the bathroom door handle was missing. 13. Observation on 12/08/25 at 2:30 P.M. in occupied resident room [ROOM NUMBER] showed the restroom light fixture globe was cracked and ceiling tiles were missing around the light fixture. 14. Observation and interview on 12/08/25 at 2:34 P.M in the shower room across from resident room [ROOM NUMBER], showed both showers had a heavy buildup of black mold like areas on the ceilings. One water control handle for the shower was missing. Four large holes were visible in the shower room wall near the sink. The Maintenance Director said maintenance had painted Kilz on the ceilings a few months ago, but the mold returned quickly. The holes in the wall were from a previous soap dispenser. 15. Observation on 12/08/25 at 2:26 P.M. in occupied resident room [ROOM NUMBER] showed the soap dispenser was missing from the vanity wall, and a black mold-like area was visible on the ceiling tiles. 16. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 10:16 A.M. and 12/08/25 at 1:37 P.M. showed the following:-The vented area above the closet had multiple black areas, with a mold like appearance, and previous water leaks directly below the vented area and on the ceiling tile above the door entry; -Paint missing from multiple areas on the walls and showing the white drywall beneath the paint;-The bathroom vent had a large amount of dust accumulation;-The bathroom floor was missing pieces of the flooring and had multiple cracked areas; -The light fixture cover was missing. 17. Observation of occupied room [ROOM NUMBER] on 12/07/25 at 11:50 A.M. and 12/08/25 at 2:23 P.M. showed the following:-Two large holes in the window screen on the right double window;-A ceiling tile was missing in the corner above bed two;-The exhaust fan did not work in the bathroom. -The paper towel dispenser was missing from the vanity wall. During an interview on 12/07/25 at 11:50 A.M., the resident who resided in this room said the following:-He/She did not know how long the bathroom exhaust fan had not worked;-He/She had asked staff to put in work orders for the screen, ceiling tile and bathroom fan, but was unsure who he/she told or how long ago. 18. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 10:26 A.M. and 12:07 P.M. and 12/08/25 at 2:15 P.M., showed the following:-The paper towel dispenser was missing from the vanity wall. The area by the bathroom sink had seven screw holes and a different paint color where the towel dispenser used to be;-The bottom trim was missing around the wall between the bathroom and sink;-Two large round holes in the cream-colored wall and two large holes in the blue wall. 19. Observation and interview on 12/08/25 at 2:14 P.M. in occupied resident room [ROOM NUMBER] showed the restroom light was not functional, and there was a black mold like area on a ceiling tile in the room. The resident said the light in the restroom had not worked for two or three months. The Maintenance Director said the light in the restroom was a temporary replacement light that had been installed while waiting for the appropriate light for the restroom to come in. The bulb in the current light had burned out. 20. Observation on 12/8/25 at 1:55 P.M. in occupied resident room [ROOM NUMBER] showed a floor tile was missing underneath the leg of the bed by the door, and the paper towel dispenser was broken and in pieces. 21. Observation on 12/8/25 at 2:06 P.M. in occupied resident room [ROOM NUMBER] showed the wall light switch plate was broken and had jagged edges. 22. Observation on 12/8/25 at 2:02 P.M. in occupied resident room [ROOM NUMBER] showed the restroom exhaust fan was covered in heavy debris and was not functional. A fist-sized hole was visible in the blue wall near the head of the bed. 23. Observation and interview on 12/07/25 at 12:30 P.M. and 12/08/25 at 2:00 P.M. and at 3:30 P.M. in occupied resident room [ROOM NUMBER] showed the temperature in the room felt very hot. The resident said he/she was unable to adjust the temperature, and the room was always hot. The heat was either on full heat or had to be turned completely off and he/she had reported it many times to maintenance. The Maintenance Director said an HVAC vendor had already come to the facility and replaced the thermostat parts, but it still wasn't working properly. The thermostat had been installed backwards, and the vendor would need to return to fix the thermostat 24. Observation on 12/08/25 at 8:27 A.M. in the Homestead Dining Room showed the following:-Dried food spills on the wall under the window by the fire doors; -The blue paint trim around the windows had black discoloration; -There were dried brown liquid/food splatters on the wall behind the trash can; -There were gray-black scuff marks along the wall horizontally on both sides of the electrical outlet; -There were dried orange liquid stains on the tile floor behind the trash can near the windows. 25. Observation on 12/09/25 at 8:41 A.M. in the Homestead Big Shower Room showed the following:-The tile floor in the shower stall was dark and dingy;-There were scuffs in the gray paint near the light switch beside the hand sanitizer with brown paint and drywall underneath;-There was a rust color stain approximately six inches long on the wall under the electrical outlet near the hand sanitizer dispenser;-There were dried feces on the floor near the sink;-There was a rust colored discoloration on the tile near the sink;-There was dried brown debris on the wall beside and behind the toilet; -There was a brown discoloration at the base of the toilet; -There was dried fecal matter on the handrail beside the toilet; -There was chipping paint from the handrail near the toilet exposing brown and black paint underneath;-There were multiple areas of missing paint on the wall near the light switch. 26. Observation on 12/08/25 at 11:12 A.M. in occupied resident room [ROOM NUMBER] showed the heating/ventilation unit was not equipped with a vent cover. 27. Observation on 12/08/25 at 11:10 A.M in the shared restroom between occupied resident rooms [ROOM NUMBERS] showed the ceiling light fixture was not functional. 28. Observation on 12/08/25 at 11:19 A.M. in occupied resident room [ROOM NUMBER] showed the night light was not functional. The dry wall around the night light was loose, crumbling and rusted. 29. Observation and interview on 12/08/25 at 11:18 A.M. in occupied resident room [ROOM NUMBER] showed the night light was not functional. The dry wall around the night light was loose, crumbling and rusted. The Maintenance Director said the night light bulb was burned out. 30. Observation and interview on 12/08/2 at 11:20 A.M. in occupied resident room [ROOM NUMBER] showed four large holes in the dry wall (wall painted brown) and five large holes in the dry wall (wall painted white). The Maintenance Director said the holes were created from a previous wall mounting of a television and wall decor. 31. Observation on 12/07/25 at 10:51 A.M. and 12/08/25 at 11:21 A.M., in occupied resident room # 408 showed the following:-There was black discoloration on the floor tiles;-The toilet seat was loose;-There was a buildup of lint on the ceiling vent in the bathroom;-The light fixture in the bathroom was dusty and appeared dirty;-There were black scuff marks on the bathroom doors exposing bare wood;-There was dried fecal material on the wall in the bathroom;-There was a black discoloration around the base of the toilet; -There was clear liquid on the floor in front of the toilet; -There was a dried black discoloration on the wall behind the toilet;-The black kick plate was missing under the sink, exposing brown wood and drywall underneath;-There were scuff marks on the door frames exposing bare wood;-The call light at the bedside was not functional when the button was activated. During an interview on 12/07/25 at 10:53 A.M. and 12/08/25 at 11:21 A.M. with the resident who resided in room [ROOM NUMBER] showed the following:-Other residents in the adjoining room leave blood and feces on the toilet seat and urinate on the floor;-He/She tells staff, but they don't clean it up;-Staff has given him/her disinfectant wipes to clean the toilet him/herself;-Housekeeping doesn't clean the room or the bathroom unless there was a problem;-The only way the call light worked was if he/she pulled it out of the wall. 32. Observation and interview on 12/08/25 at 11:37 A.M. and 12/09/25 at 12:26 P.M. in occupied resident room [ROOM NUMBER] showed the following:-Three holes in the wall. Maintenance Staff W said the wall were created by mounting a previous television on the wall;-The black strip below the built-in drawers hung loose towards the floor;-The black kick plate between the sink and the bathroom door was missing, exposing tan drywall;-There was a black discoloration on the floor tiles;-There was dried brown debris on the wall in the bathroom;-There were scrape marks on the bathroom door frame revealing brown paint. 33. Observation on 12/08/25 at 11:35 A.M. in occupied resident room [ROOM NUMBER] showed the cove base below the vanity sink lay on the floor and was not attached to the wall. 34. Observation on 12/08/25 at 10:59 A.M. in occupied resident room [ROOM NUMBER] showed a hole in the exterior wall next to the heating/ventilation unit. 35. Observation on 12/08/25 at 10:38 A.M. and 12/08/25 at 12:23 P.M. in occupied resident room [ROOM NUMBER] showed the following:-The bathroom baseboard heating unit was not equipped with a cover and the heating elements were exposed;-There were dried brown liquid spills on the floor;-There was dried brown liquid on the resident's bed frame;-There was dried brown stains on the floor below the air conditioning unit;-The paint was peeling off the windowsill exposing the wood below;-There were black scuffs in the paint along the wall in between the sink and the bathroom;-The paint was missing on the edge of the wall by the sink exposing the drywall underneath;-The floor tiles under the sink were dingy and brown;-A light bulb was missing above the sink;-There was white discoloration on the bathroom floor. 36. Observation on 12/07/25 at 9:40 A.M. in occupied resident room [ROOM NUMBER] showed the following:-The floor was sticky;-The room had a urine smell;-There was a brown stain on the bedspread (Bed A). 37. Observation on 12/07/25 at 9:38 A.M. and 12/08/25 at 10:52 A.M. in occupied resident room [ROOM NUMBER] showed the following:-The resident lay awake in bed. There was a brown discoloration on his/her pillow;-The black trim was pulled away from the wall between the sink and the bathroom. 38. Observation on 12/09/25 at 9:38 A.M. and 12:30 P.M. in occupied resident room [ROOM NUMBER] showed the following:-There was a strong urine odor in the room;-The floor in the room and bathroom was sticky;-There was fecal matter on the bedspread of occupied Bed B;-There were black marks on the tile floor near the door;-There was brown discoloration around the sink;-In the bathroom there were multiple missing standard square floor tiles. There was a gray discoloration at the base of the toilet and black discoloration near the threshold of the bathroom door. There was brown discoloration on the base of the toilet. 39. Observation on 12/07/25 at 9:31 A.M. in occupied resident room [ROOM NUMBER] showed the following:-There was a strong stale smell in the room;-There was a brown discoloration on the bed sheet (Bed A). 40. Observation and interview on 12/07/25 at 9:30 A.M. and 12/08/25 at 10:48 A.M. in occupied resident room [ROOM NUMBER] showed the following:-There was a strong urine smell;-There was a cloth incontinence pad on the floor with fecal matter on it;-The window blinds had multiple broken slats. He was aware of the broken blinds, and they needed to be replaced. 41. Observation on 12/08/25 at 9:36 A.M. in occupied resident room [ROOM NUMBER] showed the cove base was missing next to the sink. 42. Observation of occupied resident room [ROOM NUMBER] on 12/07/25 at 10:48 A.M. and 12/08/25 at 9:45 A.M. showed the following:-The four-inch, black, floor baseboard in the bathroom was pulled away from the bottom of the wall behind the toilet the entire length of the wall;-There was a hole at the bottom of the wall, measuring four-inches by two feet;-Six, twelve by twelve (12 X 12) floor tiles were loose and not affixed to the floor.-The overbed light fixture was not level and hung diagonally on the wall. During an interview on 12/07/25 at 10:48 A.M., one of the residents who resided in the adjoining room said the following:-The bathroom had been that way since he/she had resided in the room;-He/She had told maintenance staff, but nothing had been done to fix the bathroom. 43. Observation and interview on 12/08/25 at 8:50 A.M. in the 700 Hall shower room on Meadowbrook showed large black mold-like areas surrounded the ceiling heating vent. The Maintenance Director said he was unaware of the mold in the shower room. 44. Observation on 12/08/25 at 8:46 A.M. in occupied resident room [ROOM NUMBER] showed the vanity hot water faucet handle spun around in circles and the hot water would not consistently run. The resident who lived in the room said the hot water knob would not stay on. He had lived at the facility for two years and this had always been a problem. 45. Observation on 12/08/25 at 8:18 A.M. in occupied resident room [ROOM NUMBER] showed the heating/ventilation unit with a broken vent cover. 46. Observation and interview on 12/08/25 at 4:38 P.M. in the social services and business office on the 800 Hall showed the ceiling light fixture was missing. The Maintenance Director said there had been a roof leak in the last year and the light fixture had not been replaced. 47. Observation on 12/08/25 at 5:21 P.M. of the 800 Hall resident telephone room showed a large round hole in the wall behind the door. 48. Observation on 12/08/25 at 5:28 P.M. of the 800 Hall snack room showed a large round hole in the wall behind the door. 49. Observation on 12/08/25 at 5:29 P.M. of the 800 Hall shower/tub room showed the knob for shower water temperature control was missing. 50. Observation on 12/08/25 at 5:07 P.M. in occupied resident room [ROOM NUMBER] showed the vent cover on the heating/ventilation unit was missing. 51. Observation on 12/08/25 at 5:00 P.M. in occupied resident room [ROOM NUMBER] showed the overbed light fixture bulbs had burned out (three separate bulbs) and were not functional. The night light bulb was burned out and was not functional. 52. Observation on 12/08/25 at 4:58 P.M. in occupied resident room [ROOM NUMBER] showed the toilet paper spring bar (that holds the toilet paper roll) was missing. 53. Observation on 12/08/25 at 4:59 P.M. in occupied resident room [ROOM NUMBER] showed the light over the vanity was not equipped with a cover. 54. Observation in occupied resident room [ROOM NUMBER] on 12/07/25, at 3:22 P.M., showed the toilet tank cover was missing on the back of the toilet in the bathroom. 55. Observation in occupied resident room [ROOM NUMBER] on 12/07/25 at 1:24 P.M. and 12/08/25 at 4:50 P.M. showed the following:-A section of the corner wall below the sink had been repaired with dry wall mud and left unpainted;-An area of the corner wall was damaged. An area of the sheet rock was missing and the wall surrounding this was stained a brown color.-The night light was not functional;-The bottom to the second drawer in the resident's dresser was missing;-The resident said the light shorted out, wouldn't work and he/she would like a working light;-He/She said the dresser drawer was not useable since there was no bottom to the drawer. 56. Observation on 12/8/25 at 5:36 P.M. in occupied resident room [ROOM NUMBER] showed a large area of dry wall compound on the wall that had not been painted. 57. Observation in occupied resident room [ROOM NUMBER] on 12/7/25, at 1:15 P.M., showed multiple tiles on the bathroom floor beside and behind the toilet were discolored brown and the grout was missing between the tiles. 58. During an interview on 12/11/25 at 2:10 P.M. Housekeeper VV said the following:-Housekeeping cleans rooms daily;-Nursing staff should also check the rooms for cleanliness and address as needed;-Nursing staff have access to cleaner and disinfectant in between housekeeper visits. During an interview on 12/10/25 at 10:33 A.M., Maintenance Staff W said the facility used work orders as a way of identifying issues needing repair in the building. Staff or residents could fill out a work order. Each area in the building was a little different as to where the requested work order should go (location of a mailbox, etc.) Each hall has a designated area where staff or residents should place a work order request. Maintenance Staff W said he walked around the facility and collected work orders daily at a minimum. Once a work order was received, the repair was typically completed within a week or so. The resolution/repair was documented on the work order written form. The forms were retained for future reference. During an interview on 12/10/25 at 10:38 A.M. and 12/12/25 at 8:47 A.M., the Maintenance Director said the following:-Department heads are supposed to walk around the facility daily to identify any building issues that need correction or repair, but daily rounds don't always get completed due to emergencies, staffing, etc.;-Maintenance was usually made aware of an issue in a resident's room or in the building verbally by the staff or resident;-Maintenance had asked the staff/resident to ensure a maintenance request was completed;-Maintenance requests were available on every unit;-Maintenance staff picked up the maintenance request sheets every day. During an interview on 12/10/25 at 3:27 P.M., the Administrator said daily walking rounds were conducted by department heads to identify any building issues. A work order process was already in place to address identified issues. #2630303#2640327#2664663#2646556#2652518#2686163

Based on observation, interview, and record review, the facility failed to follow current infection control standards for two residents (Residents #14 and #4), in a review of 47 sampled and five additional residents (Resident #23, #110, #180, #172 and #72). The facility failed to follow infection control practices while performing blood glucose monitoring (also known as accu check, a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for two residents (Resident #23 and #110) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for sugar it contains) after use to protect against contamination. The facility failed to review their Legionella risk assessment, follow interventions, test residents diagnosed with pneumonia for Legionnaire's Disease, and retest water samples when an outside laboratory found Legionella pneumophila in water samples provided by the facility. The facility failed to follow infection control practices for Enhanced Barrier Precaution (EBP) when staff did not wear personal protective equipment (PPE) during personal care for two residents (#180 and #4) who required EBP use, failed to ensure staff washed their hands and changed their gloves after they became soiled during direct care and before touching the resident and/or clean items for one resident (Resident #4), failed to ensure catheter (a tube used to drain urine from the bladder) bags (a bag attached to the catheter, used to collect urine) and catheter tubing (tube used to drain urine from the bladder into a collection bag) did not lay on the floor for two residents (Resident #180 and #172) and failed to ensure a blood glucose monitor was not sat directly on a surface without a barrier while in use for one resident (Resident #72). Additionally, the facility failed to follow infection control practices for storage of oxygen tubing when not in use for one resident (Resident #14). The facility census was 172. Review of the Centers for Disease Control (CDC), Considerations for Blood Glucose Monitoring, showed the following:-Assign blood glucose meters to a person unless the device is designed for use in professional settings and is cleaned and disinfected after every use;-Clean and disinfect blood glucose meters after every use per the manufacturer's instructions, to prevent the spread of blood and infectious agents. Review of the facility policy, Glucometer Disinfection, revised 4/30/24, showed the following:-The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use;-Glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, hepatitis B and hepatitis C;-Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use;-Obtain needed equipment and supplies (gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips and disinfecting wipes);-Wash hands, explain procedure to the resident, provide privacy, put on gloves and obtain blood glucose sampling according to facility policy;-Remove and discard gloves, perform hand hygiene prior to exiting room;-Reapply gloves if there is visible contamination of the device or if the resident is HIV or hepatitis B or C positive;-Retrieve disinfectant wipes from container, using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer;-After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions;-Allow the glucometer to air dry;-Discard wipes and perform hand hygiene. Review of the [NAME] True Metrix Blood Glucose Monitoring System user manual, showed the following:-Wash hands thoroughly with soap and water;-Wear a clean pair of gloves;-To clean the meter, use a Super Sani Cloth wipe or any disinfectant product with EPA* reg.no. of 9480-4;-Rub the entire outside of the meter with the cloth using three circular wiping motions with moderate pressure on the front, back, left, right, side, top and bottom of the meter;-Repeat as needed until all surfaces are visibly clean;-Discard used wipes;-To disinfect the meter, use a fresh wipe and make sure all outside surfaces of the meter remain wet for two minutes;-Let the meter air dry thoroughly before using to test. Review of the Medline EvenCare G2 Blood Glucose Monitoring System User Manual, showed the following:-To clean the meter, use a moist lint-free cloth dampened with mild detergent and wipe all external areas of the meter;-To disinfect the meter, use a U.S. Environmental Protection Agency (EPA) registered disinfecting wipe;-Wipe all external areas of the meter until visibly clean;-Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use;-Wipe meter dry or allow to air dry. Review of the CaviWipes Disinfecting Towelettes label showed the following:-CaviWipes is a two-step disinfectant product;-One wipe is required to pre-clean then a second wipe is required to disinfect;-Wipe surface completely to preclean surface of all visible debris;-Wipe surface with second wipe to ensure that the surface remains visibly wet for 2 minutes at room temperature;-This product protects against human immunodeficiency virus (HIV) (virus that is transmitted by contact with infected blood), hepatitis B (virus commonly spread by exposure to infected bodily fluids), and hepatitis C (virus that is spread by contact with contaminated blood) when the surface remains visibly wet for 2 minutes at room temperature. Review of the facility policy, Hand Hygiene, revised 6/26/24, showed the following:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors;-Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice;-Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations;-Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom;-The use of gloves does not replace hand hygiene;-If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1. Review of Resident #23's undated Face Sheet showed the resident's diagnoses included Type 2 diabetes mellitus (a chronic condition where your body either doesn't produce enough insulin or doesn't use insulin effectively (insulin resistance), leading to high blood sugar). Review of the resident's Physician Orders, dated 4/27/25, showed to monitor blood every morning and evening. Observation on 12/9/25 at 9:00 P.M., showed the following:-Licensed Practical Nurse (LPN) S put on gloves without performing hand hygiene;-LPN S took a [NAME] True Metrix glucometer out of the treatment cart that was labeled with Resident #23's name and placed it on top of the cart on a barrier;-LPN S obtained the blood sample from the resident's finger, performed the blood glucose check procedure by placing a blood-filled test strip in the glucometer, obtained the result and then removed the blood-filled test strip from the glucometer;-LPN S cleaned the glucometer with an alcohol wipe and placed the glucometer back into the treatment cart drawer; -LPN S removed his/her gloves and did not wash hands or perform hand hygiene. 2. Review of Resident #110's diagnosis report, showed the resident's diagnoses included Type 2 diabetes mellitus. Observation on 12/9/25 at 8:48 P.M., showed the following:-LPN S could not locate the resident's glucometer in the treatment cart;-LPN S went to another treatment cart and obtained an extra glucometer to use for Resident #110; -LPN S applied gloves without first performing hand hygiene;-LPN S placed the EvenCare G2 glucometer on top of the treatment cart on a barrier;-LPN S obtained the blood sample from the resident's finger, performed the blood glucose check procedure by placing a blood-filled test strip in the glucometer, obtained the result, and removed the blood-filled test strip;-LPN S cleaned the glucometer with an alcohol wipe and placed the glucometer back in the treatment cart drawer;-LPN S removed his/her gloves and did not wash hands or perform hand hygiene. During an interview on 12/9/25 at 9:10 P.M., LPN S said the following:-She should perform hand hygiene between glove changes; -She should use disinfecting wipes to clean the glucometer before putting it back into the cart;-There were no disinfecting wipes on the cart, so he/she cleaned the glucometer with an alcohol wipe. 3. Review of Resident #72's face sheet showed he/she had a diagnosis of type 2 diabetes mellitus. Review of the resident physician orders, dated December 2025, showed Accu check (a finger stick procedure where a droplet of blood is obtained to check the amount of sugar in the blood using a blood glucometer device) before meals at bedtime for diabetes. Observation on 12/09/25 at 4:42 P.M., showed the following:-Certified Medication Technician (CMT) II entered the resident's room and placed the resident's personal glucometer on the resident's countertop without a barrier while he/she washed his/her hands; -He/She applied gloves, picked up the glucometer and held it in his/her gloved hand. He/She obtained blood from the resident's finger using a lancet and applied the resident's blood to the test strip in the glucometer; -He/She left the room wearing soiled gloves, carrying the blood glucometer and used test strip still in the glucometer. He/She placed the glucometer directly on the medication cart with no barrier;-CMT II removed his/her gloves and used hand sanitizer for hand hygiene;-He/She gathered the resident's insulin from the medication cart, prepared the resident's insulin dose, entered the resident's room, washed his/her hands with soap and water and applied gloves. He/She administered the resident's insulin, removed his/her gloves, washed his/her hands with soap and water and then returned to the medication cart; -He/She documented the blood sugar reading and the insulin administration into the resident's electronic health record;-He/She put on gloves, picked up the glucometer, removed the blood filled test strip from the glucometer and put the soiled test strip into the sharp's container;-He/She cleaned the blood glucometer with a Sani wipe, waited until the glucometer was dry and put it back into the medication cart.;-He/She then removed his/her gloves and used hand sanitizer. During an interview on 12/19/25 at 8:31 A.M., CMT II said the following:-Each resident has their own glucometer;-He/She sat the glucometer on the counter by the sink and on the medication cart without a barrier;-The glucometer should be placed on a surface with a barrier;-He/She should not have left the glucometer on the cart without a barrier and the soiled test strip in the machine;-Hands should be washed with soap and water after the removal of gloves. During interview on 12/12/25 at 3:42 P.M., Licensed Practical Nurse (LPN) HH said the following:-Glucometers should not sit directly on a surface without a barrier;-A glucometer should not be left sitting directly on the medication cart with the blood-filled test strip in the machine. As soon as a blood sugar was read, staff should document the reading in the computer and the strip should be discarded and the glucometer cleaned and put back into the medication cart. During an interview on 12/12/2025 3:39 P.M., Corporate Registered Nurse/Interim DON #2 said the following: -She expected staff to have disinfecting wipes and to set up a clean field (barrier) when performing Accu checks; -She expected staff to clean glucometers with an acceptable product before and after use and before they stored the glucometers;-Staff should not clean the glucometers with alcohol wipes;-She expected staff to wash their hands before and after providing any care or performing a procedure;-She expected staff to wash their hands before and after they use a glucometer;-Staff should wash their hands with soap and water after the removal of gloves; just using hand sanitizer was not appropriate, especially after performing a procedure where blood was collected; -She expected staff to place a barrier between the surface and glucometer when checking a blood sugar. 4. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following:-The bacterium Legionella can cause a serious type of pneumonia called Legionnaire'sDisease (LD) in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains;-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;-Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;-Specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. 5. Review of the facility's Legionella Surveillance Policy, revised 6/26/24, showed the following:-Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems;-In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies;-Principles of Legionella transmission: -Legionella grows best in water temperatures of 77 degrees Fahrenheit (F) to 108 degrees F, particularly in water that is not moving or that does not have enough disinfectant (i.e. pH 6.5-8.5) to kill germs.-Legionella can make people sick when the germs spread in droplets small enough for people to breathe in. Medical devices, cooling towers, showers, hot tubs, and fountains create aerosols; - Signs and symptoms of Legionnaires' disease are similar to pneumonia by other pathogens and include cough, fever, positive chest radiograph, sputum production, and new/changed lung examination abnormalities;-Primary prevention strategies:-Diagnostic testing: -The facility shall use the McGeer criteria when diagnosing pneumonia; -Residents with healthcare associated pneumonia or who have failed antibiotic therapy for community-acquired pneumonia shall be tested for Legionella using both culture of lower respiratory secretions and the Legionella urinary antigen test. -Investigation for a facility source of Legionella, may include culturing of facility water for Legionella:-The Infection Preventionist will investigate all cases of definite healthcare associated Legionnaires Disease (LD) for the source of Legionella; -The Infection Preventionist will also investigate for the source of Legionella when two or more possible healthcare-associated LD was identified.-Physical controls: -Cooling towers and potable water systems shall be routinely maintained; - At risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations; -Non-potable water systems shall be routinely cleaned and disinfected; -Nebulization devices shall be filled only with sterile fluid (e.g., sterile water or aerosol medication).-Temperature controls: -Cold water shall be stored and distributed below 68 degrees Fahrenheit; -Hot water shall be stored above 140 degrees Fahrenheit and circulated at a minimum return temperature of 124 degrees Fahrenheit. 6. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F.-Generally, a result of greater than 1 Most Probable Number (MPN) per 100 milliliters (mL) (statistical estimate of the bacterial concentration in a water sample) or greater than 100 CFU/L (equivalent to less than10 MPN/100mL) suggests that Legionella growth is well controlled; -Low Level Contamination (e.g., greater than 100 CFU/L or greater than 10 MPN/100mL in general systems may indicate a need for further investigation, system resampling, or a review of control measures;-Amplification Occurred (e.g., greater than 10 CFU/mL or greater than 10,000 MPN/100mL in general systems usually indicate that immediate corrective action, such as disinfection of the system, is required-Follow these steps when Legionella laboratory results aren't indicative of well-controlled growth:-Review for potential errors in sample collection, hauling, and testing;-Examine equipment to confirm that systems in good working order and functioning as intended;-Review records to confirm that the Water Management Plan was implemented as designed (verification);-Review assumptions about operating conditions, such as physical and chemical characteristics of incoming water;-Re-evaluate the Water Management Plan, including analysis of:-Chemical treatment;-Cleaning;-Hazardous conditions;-Maintenance procedures; -Adjust Water Management Program as necessary to address any deficiencies identified; -Consider whether remedial treatment is needed only after completing prior steps; -Re-test: After performing any remediation, wait at least 48 hours after the system returns to normal operating conditions. Then test representative samples to confirm the response's effectiveness. 7. Review of the facility's Infection Control Log, dated 8/1/25 through 8/31/25, showed the following:-Resident #50 developed pneumonia; the infection control log and the resident's medical record did not contain any testing for Legionella;-Resident #59 developed pneumonia; the infection control log and the resident's medical record did not contain any testing for Legionella. 8. Review of the facility's Infection Control Log, dated 9/1/25 through 9/30/25, showed the following:-Resident #142 developed pneumonia; the infection control log and the resident's medical record did not contain any testing for Legionella;-Resident #157 developed pneumonia; the infection control log and the resident's medical record did not contain any testing for Legionella. 9. Review of the facility's analytical results for 22 samples received by the contracted laboratory for Legionella testing, dated 9/5/25, showed the following:-Sample obtained at the 700 Hall Nurse Station had 4,920 MPN (most probable number)/100 milliliters (ml) of Legionella pneumophila (type of bacteria that causes Legionnaires' disease, a severe pneumonia, and a milder flu-like illness called Pontiac fever, thriving in warm water systems like cooling towers and hot tubs);-Sample obtained at the Meadow [NAME] Dining Room had greater than 2,272.6 MPN/100 ml of Legionella pneumophila;-Sample obtained from room [ROOM NUMBER] had 854 MPN/100 ml;-Sample obtained from room [ROOM NUMBER] had 19,200 MPN/100 ml;-Sample obtained from room [ROOM NUMBER] had 534 MPN/100 ml. 10. Review of the facility's Infection Control Log, dated 10/1/25 through 10/31/25, showed the following:-Resident #8 developed pneumonia; the infection control log and the resident's medical record did not contain any testing for Legionella;-Resident #116 developed pneumonia; the infection control log and the resident's medical record did not contain any testing for Legionella. During an interview on 12/18/25 at 3:39 P.M., the Director of Nursing (DON #1) said the facility did not test any residents with pneumonia for Legionella. 11. Observation on 12/12/25 at 12:25 P.M. through 1:20 P.M., showed the following:-In the Meadowbrook dining room, the temperature of the hot water at the handwashing/drinking water sink was 107.8 degrees Fahrenheit (F); -In occupied resident room [ROOM NUMBER], the temperature of the hot water at the handwashing/drinking water sink was 100.2 degrees F; -In occupied resident room [ROOM NUMBER], the temperature of the hot water at the handwashing/drinking water sink was 110. 4 degrees F;-During the temperature checks, the water pressure fluctuated from strong to weak pressure. During an interview on 12/12/25 at 8:28 A.M. and 9:34 A.M., the Maintenance Director said the following:-The temperature parameters for hot water were 105 to 120 degrees F and cold water temperatures not over 80 degrees F;-He checked water temperatures in four rooms per day and documented it on a log;-He visually inspected faucet aerators for calcium build up once a month;-There was no process in place to ensure there was no sediment or biofilm in the water system or appropriate chlorine levels as the water coming in from the city was already chlorinated;-If the temperatures were not within range, then he checked the hot water heaters and if not functioning correctly called a plumber. He also tried to adjust the temperature valve;-He was not part of the infection control committee and didn't know if there was a Water Maintenance Committee;-The facility had water softeners for incoming water, but they didn't work;-He emailed the Legionella pneumophila microbiology report to the Corporate Maintenance Director as soon as it was received;-The Corporate Maintenance Director determined the corrective measures from the report;-He was told to check the faucet aerators throughout the facility and change out the ones that had a calcium build up, then use the ordered water testing kits when they arrived;-He didn't know how to perform the water tests, so he requested assistance from the Corporate Maintenance Director, who assigned the Regional Maintenance Director to show the facility's Maintenance Director how to use the tests;-The Regional Maintenance Director came to the facility two months ago to pick up a kit and left. The Regional Maintenance Director was in the facility once since that time and still didn't show him how to perform the tests, so the tests were not completed. During an interview on 12/12/25 at 9:25 A.M., the Corporate Maintenance Director said the following:-Once he received the microbiology report on 9/8/25, he ordered eleven water testing kits for the facility;-He told the Maintenance Director to flush the lines and aerators, change aerators on the affected faucets as needed, then use the new kits to retest the water;-The facility's Maintenance Director was supposed to use five test kits on the hot water samples and five test kits on the cold water samples, then use one on the sprinkler system;-He didn't have the results from the retesting the facility's Maintenance Director was supposed to complete, so he couldn't show it was completed. During an interview on 12/12/25 at 1:19 P.M., the Corporate Registered Nurse/Interim (DON #2) and Administrator said the following:-The Maintenance Director along with the Administrator were part of the Infection Control Committee;-The Maintenance Director, Administrator and Corporate Maintenance Director were the Water Management Committee;-Neither one knew about the Legionella pneumophila testing results in August 2025 or what the interventions were put in place following the test;-The Administrator said the facility sent out water samples yearly. Record review showed the facility did not have a policy in place for flushing and descaling the faucets on a regular basis. The Maintenance Director did not have documentation showing at least once weekly and descaling monthly. There was no documentation for monitoring chlorine levels or development of a protocol for when levels were too low and no documentation of specific actions to take in response to a Legionella positive water sample. The policy did not address backflow prevention device inspection frequency. A schedule of preventative maintenance for all potable water fixtures was not described in the water management plan. 12. Review of the Center for Disease Control website, Guidelines for Prevention of Catheter- Associated Urinary Tract Infections last updated 06/06/2019, showed proper techniques for urinary catheter maintenance included not resting the urine collection bag or catheter on the floor. 13. Review of the facility policy, Enhanced Barrier Precautions, reviewed and revised on 05/18/24, showed the following:-It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms;-Enhanced Barrier Precautions (EBP) is a strategy to decrease transmission of Centers for Disease Control and Prevention (CDC) -targeted and epidemiologically important multidrug-resistant organisms (MDROs) when contact precautions do not apply. EBP uses personal protective equipment (PPE) and recommends gown and glove use for certain residents during specific high contact resident care activities associated with MDRO transmission. EBP expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. EBP uses gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing:-EBP (gown and gloves) must be used for high-contact resident care activities for residents (dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care) with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO;- Indwelling Medical Device: Indwelling medical devices include, but are not limited to, central lines, urinary catheters, feeding tubes, and tracheotomies;- The facility should ensure that all staff and other health care providers know which residents require EBP. 14. Review of Resident #180's face sheet showed diagnoses that included neuromuscular dysfunction of the bladder (when nerve damage to the brain disrupts the signals controlling bladder function, causing problems holding or releasing urine, leading to issues like incontinence, retention, or frequent urination). Review of the resident's physician orders, dated 11/19/25, showed the following:-Change catheter for leakage, blockage or becoming dislodged as needed;-Monitor catheter for signs and symptoms of infection, adequate output and empty every shift;-Check and secure urinary catheter with tube holder. Review of the resident's care plan, dated 11/20/25, showed the following:-The resident had a catheter related to neuromuscular dysfunction of bladder;-No documentation shown for EBP. Observation on 12/07/25 at 10:29 A.M., showed the following:-The resident lay in bed with the bed in the low position;-The resident's catheter bag and tubing lay directly on the floor; the urine collection bag was not in a dignity bag. The urine in the bag was dark in color (normal urine color is clear, pale yellow to amber in color). Observation on 12/09/25 at 8:38 A.M and 11:03 A.M., showed the following:-The resident lay in bed;-His/Her catheter tubing lay directly on the floor;-The urine in the tube was dark yellow in color. Observation on 12/09/25 at 11:08 A.M., showed the following:-The resident lay in bed;-There was an EBP sign on the resident's door; -Certified Nurse Aide (CNA) FF entered the resident's room, washed his/her hands with soap and water and donned gloves;-CNA FF did not put on a gown;-CNA GG entered the resident's room, washed his/her hands with soap and water and donned gloves;-CNA GG did not put on a gown; -CNA FF performed peri-care and catheter care for the resident. During interview on 12/11/25 at 3:02 P.M., CNA FF said the following:-He/She did not wear EBP while providing peri care and catheter care for the resident;-He/She did not realize EBP should be worn if a resident had a urinary catheter;-He/She thought EBP should be worn if a resident required wound care or had a roommate that required wound care;-He/She had been educated on EBP, but did not wear EPB while helping with peri care. During interview on 12/12/25 at 3:36 P.M., CNA GG said the following:-He/She did not wear EBP while providing peri care and catheter care for the resident;-He/She thought EBP had to be worn in the rooms with residents who had wounds;-He/She had been educated on when to wear EBP, but had not had a lot of residents with catheters to care for in the past;-He/She should have worn EBP while providing peri care and catheter care for the resident;-Catheter bags and tubing should not be directly on the floor. It could increase the risk of infection. During interview on 12/12/25 at 3:42 P.M., LPN HH said the following:-All staff should wear EBP when providing cares for a resident who had a urinary catheter;-All urinary catheter bags and tubing should be off the floor to prevent the risk of infection. During an interview on 12/09/25 at 8:57 P.M., the Resident Care Coordinator said the following:-EBP was not new to the facility;-Staff had been trained on when to use EBP;-If there was an EBP sign on the door, staff were to use EBP for both residents in the room. During an interview on 12/12/25 at 3:39 P.M., the Corporate Registered Nurse/Interim DON #2, said the following:-She expected staff to use EBP when any resident has an artificial opening in their body;-Staff should wear gloves and gowns when providing cares and face shields if needed;-Catheter bags and tubing should not be on the floor. 15. Review of Resident #172's face sheet showed on 11/12/25 the resident was diagnosed with a closed fracture of the left femur (break in the thigh bone but the skin over the break remains intact). Review of the resident's physician order summary, dated December 2025, showed an order to change the resident's urinary catheter as needed, start date 11/17/25. Observation on 12/07/25 at 11:54 and 3:17 P.M., showed the following:-The resident sat in a wheelchair in the dining room;-His/Her catheter bag and tubing sat directly on the floor under the wheelchair; the urine collection bag was not in a privacy bag; staff were in the dining room assisting residents; -There was dark yellow urine in the catheter bag. Observation on 12/07/25 at 4:54 P.M. showed the following:-The resident sat in a wheelchair and self-propelled down the hallway; -The resident's catheter bag and tubing dragged the[TRUNCATED]

Based on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, or date food items. Staff did not practice proper hand and glove hygiene and did not properly wear hair restraints in the kitchen. Staff did ensure personal beverages were not consumed in the food preparation areas. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris. Staff did not maintain range hood baffle filters free from an excess buildup of grease. Staff failed to ensure an air gap was present at the facility's ice machine drain to prevent possible backflow from the drain back into the ice machine. The facility census was 172. 1. Review of the facility policy, Resident Food Storage: Food from Outside Sources, revised on 11/28/24, showed the following:-Facility staff will monitor the snack refrigerators on a daily basis;-Refrigerators will be kept clean;-Food items will be dated after opening. Observation on 12/7/25 at 9:25 AM, in the facility's reach-in refrigerator in the kitchen, showed unlabeled and undated containers of pimento cheese spread, shredded cheese, cranberry juice, and pickle relish. Observation on 12/8/25 at 3:48 P.M., in the 600/700 hall snack room (located next to the nurses' station on the 700 hall side), showed the following:-In the freezer portion of the refrigerator, there was an uncovered, unlabeled, and undated clear container of a frozen pink substance and a plate of a white- and brown-colored frozen substance;-In the refrigerator, there were two undated, unlabeled boxes of pizza. There was a cottage cheese container that contained a yellowish-red substance that was undated and unlabeled to its contents;-On the shelves, there were pieces of popcorn that were scattered across the shelf surface. There was an unwrapped chocolate candy bar and had approximately 50% of the outer coating of chocolate missing from the bar. The candy bar wrapper sat approximately six inches away and there were flakes of brown chocolate from the candy bar on the shelf surface;-A sign posted on the food storage cabinet read, 'Please ensure you date/label items upon opening!!!' Observation on 12/9/25 at 9:44 A.M., in the facility's dry storage room, showed two large bags of spaghetti were unsealed and exposed to the air. A 25-pound box of food thickener had the inner plastic bag unsealed and exposed to the air. During an interview on 12/9/25 at 2:08 P.M., the Dietary Manager said she expected food items to be sealed, labeled and dated. Dietary staff did not clean or discard expired items from satellite snack rooms or refrigerators. 2. Review of the undated facility policy, Hand Washing and Glove Use, showed the following:-Hand washing is a priority for infection control;-Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food substances such as raw chicken to fresh fruit, following contact with any unsanitary surface such as touching hair, sneezing, opening doors etc.;-Washing procedure: wet hands, apply soap, lather vigorously rubbing hands together for approximately 20 seconds, rinse hands to remove soap and debris, dry hands with a disposable paper towel, utilize paper towels to turn off the faucet, discard paper towel in a foot pedal trash can;-Gloves may be used when working with food to avoid contact with hands;-Gloves must be worn when touching any ready-to-eat food;-When gloves are used, hand washing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed. Gloves may be used for one task only;-It's important to remember that gloves can often give a false sense of security and can carry germs same as our hands. Observation on 12/8/25 at 8:01 A.M., in the kitchen, showed no hot or cold faucet handles on the handwashing sink. There were no handles just the circular metal components under where the handles should be attached - the sink could be used and water turned on by turning the circular components, making it more challenging to turn on/off the water using the metal components because they were not easy to grip. Observation on 12/8/25 from 11:53 A.M. to 12:10 P.M., in the kitchen, showed the following:-Dietary Aide Z wore gloves and prepared sandwiches at the food preparation counter;-He/She left the kitchen and returned to the kitchen with no gloves on his/her hands;-Without washing his/her hands, he/she used his/her bare hands to touch and place sandwiches into individual bags;-He/She further contaminated his/her bare hands by touching/opening the reach-in refrigerator used his/her bare hands;-Without washing his/her hands, he/she put on gloves and placed unwrapped cheese slices from the preparation counter into the package of cheese (obtained from the reach-in refrigerator);-He/She placed the package of cheese back into the reach-in cooler and discarded his/her gloves;-Without washing his/her hands, he/she touched his/her face and used his/her bare hands to move clean plates from the dishwashing area to the food preparation counter. As he/she grasped the plates, he/she used his/her thumb to touch the eating surface of the plates. Observation on 12/8/25 from 12:11 P.M. to 12:18 P.M., in the kitchen, showed the following:-Dietary Aide X used a paper towel to wipe the floor around the handwashing sink; -He/She washed his/her hands at the handwashing sink, turned the faucet off with his/her clean hands, and discarded the used paper towel into the trash can by lifting the trash can lid with his/her clean hands; -He/She scooped ice from the ice machine into an open cup and drank from the cup as he/she walked across the kitchen near the steam table where staff prepared and placed food items into the steam table for the lunch meal service;-He/She sat the cup on the top shelf of the food preparation counter located near the fryer; -He/She touched his/her hair restraint, washed his/her hands at the handwashing sink, and turned the faucet off with his/her clean hands;-He/She carried the used paper towel (from washing his/her hands) across the kitchen and used it to wipe the surface of the food preparation counter located near the fryer;-He/She touched his/her hair restraint, obtained an empty pan, put parchment paper in the pan, and emptied food from the fryer basket into the pan and placed the pan of fried food into the steam table. Observation on 12/8/25 5:13 P.M., in the kitchen, showed the following:-Dietary Aide Z served food from the steam table to residents' plates during the dinner meal service;-He/She used his/her bare hands to grasp utensil handles, touch his/her hair restraint, and touch paper meal tickets;-Without washing his/her hands, he/she put on gloves and grabbed a vegan patty, bun, and handful of potato cubes and placed the food items onto a resident's plate. During an interview on 12/9/25 at 2:08 P.M., the Dietary Manager said the following:-Staff should not drink personal beverage items in the kitchen and should use the provided drink station area located at the side of the kitchen;-She expected staff to practice appropriate hand washing and gloving and not to turn the hand washing sink faucet off using clean hands;-Changing gloves did not substitute the need for staff to wash their hands;-Staff should use clean gloves when touching ready-to-eat food items;-Staff should handle clean dishes by the non-eating surfaces of those items;-The faucet handles to the hand washing sink had been missing a few months. She told the maintenance staff about the missing handles a couple of weeks ago, but the facility had started a new work order system, and she was unsure of the status of the replacement handles. 3. During an interview on 12/7/25 at 12:46 P.M., Resident #119 said he/she found a hair in his/her soup today. Observation on 12/8/25 from 11:53 A.M. to 12:10 P.M., in the kitchen, showed Dietary Aide Z prepared sandwiches at the food preparation counter. He/She wore a ballcap and one-inch long sections of uncovered hair stuck out around Dietary Aide Z's forehead. During an interview on 12/9/25 at 2:08 P.M., the Dietary Manager said she expected staff to wear hair restraints that contained all hair in the hair restraint. 4. Observation on 12/7/25 at 9:25 AM, during the initial kitchen tour of the facility, showed the following:-A used glove was in the eyewash sink and the sink was very dirty and corroded;-The walls in the dishwashing area were very dirty and splattered with debris;-There were broken and missing tiles on the wall behind the water sprayer at the dishwashing sink;-The ceiling above the dishwashing machine was patched and not painted;-There was an excess buildup of dust and debris around the door and frame of the west kitchen door (that led to the hallway near the locked men's unit and walk in cooler and freezer). This door also had chipped and missing paint on the door's metal frame;-The vent located above the preparation table next to the dishwashing area had an excess buildup of dust and debris;-The lower shelves of the food preparation tables had an excess buildup of food crumbs and debris;-There was an accumulation of debris on the can opener mounted to the food preparation table located by the ovens;-The six burner stove had an accumulation of grease buildup, including on the back guard of the stove and the shelf above the stove;-The fryer had a large accumulation of debris and buildup at the front and back of the unit, including in the fryer baskets;-The wall behind the clean pan storage area was patched and unpainted in some areas and had gray marks on the wall. The tape was coming off the pipe insulation located in this area. Observation on 12/8/25 from 9:27 A.M. to 11:10 A.M., in the kitchen, showed the following:-No handles on the faucet of the handwashing sink; -An approximately 3-inch by 6-foot area of ceiling, located in the top middle portion of the ceiling above the reach-in cooler, was cracked and loose in several areas;-An approximately 4-inch by 12-inch patched area of ceiling, located above the preparation tables by the stove, was cracked with flaking paint;-An approximately 3-foot by 5-foot area of ceiling, located above the dishwashing machine, had flaking paint;-An approximately 3-foot diameter fan had a moderate buildup of dust and debris on the surface of the fan guard. The fan was on the preparation counter and was blowing air on approximately 140 clean plates drying near the dishwashing area;-An approximate 2-inch by 12-inch area of tile backsplash, located above the dishwashing sink and faucet sprayer, was broken and missing tiles. There was loose caulk around the counter by the dishwashing area. Paint was flaking on the wall in this area and there were black spots visible along the edge of the caulk and trim;-The cover of the light fixture, located on the ceiling in front of and above the three-compartment sink and preparation counter, was cracked with a 1-inch by 2-inch piece of the cover missing. An approximately 0.5-inch by 2-inch piece of plastic sat loose on the top of the light fixture cover;-The floors under the cooking equipment, beverage counter, and dishwashing area had an excess buildup of black residue, debris, and pieces of food and trash;-An approximately 3-foot by 6-foot area of tile was missing under the dishwashing area and there was a heavy accumulation of debris and trash in this area;-On the top side of the reach-in cooler, there was a thick layer of dust and crusty whitish-brown buildup on the cooler's fan, piping, and other components. Observation on 12/9/25 at 9:44 A.M., in the facility's dry storage room, showed chip crumbs, food items, debris, and trash were on the floor and under the food storage shelves. During an interview on 12/9/25 at 2:08 P.M., the Dietary Manager said the following:-She expected food to be stored, prepared, and served in a safe and sanitary manner;-There were a lot of new dietary staff who were still learning expectations of cleaning and sanitation in the kitchen. 5. Review of the facility's maintenance records showed the most recent kitchen range hood cleaning was conducted on 11/3/25. The section 'Hood Filters Cleaned' showed 'Not Applicable.' Observation on 12/8/25 at 1:36 P.M. in the kitchen showed the following:-A range hood that protected a double fryer and griddle had a heavy buildup of yellow grease on three of eight baffle filters;-The other range hood protected a six-burner stove and had a moderate buildup of yellow grease on two of eight baffle filters;-A sticker on the exterior of the range hood showed the hoods were professionally cleaned in November 2025. During an interview on 12/8/25 at 1:30 P.M., the Dietary Manager said dietary staff did not regularly clean the range hood filters. She was unaware there was a buildup of yellow grease in the range hood. During an interview on 12/8/25 at 1:36 P.M., the Maintenance Director said maintenance staff were not responsible for cleaning the range hood or the filters. A professional company cleaned the range hood every six months. During an interview on 12/19/25 at 11:36 A.M., the range hood cleaning vendor said the following:-Their staff (vendor staff) clean the baffle filters each time they cleaned the range hood;-He/She was unsure why the staff who conducted the 11/3/25 cleaning marked 'not applicable' on the form;-It was possible the staff overlooked the step of cleaning the baffle filters after replacing them in the range hood. 6. Review of the Food and Drug Administration Food Code, dated 2013, showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture or equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Observation on 12/8/25 at 2:24 P.M., of the ice machine in the kitchen, showed there was no air gap at the drain. A flexible drain hose went from the ice machine drain to an approximately 1.5-inch diameter by 10-foot long PVC pipe that went to a floor drain located under the beverage counter. The end of the PVC pipe had an elbow that extended approximately 0.25-inches below the flood rim level of the floor drain. During an interview on 12/8/25 at 1:28 P.M., the Maintenance Director said he was unaware an air gap was needed for the ice machine. He thought the drainpipe was a 0.75-inch diameter pipe. During an interview on 12/9/25 at 2:08 P.M., the Dietary Manager said she expected there to be an adequate air gap at the ice machine drain. During an interview on 12/9/25 at 3:15 P.M., the Administrator said he expected there to be an air gap at the drain to prevent potential back flow from the drain back into the machine and was unaware that the ice machine in the kitchen did not contain an air gap. #2646556

Based on record review and interview, the facility failed to ensure checking account fees deducted from the resident trust account were replaced by the facility. This affected 127 residents for which the facility managed funds. Further review showed the facility failed to ensure residents had reasonable access to their personal funds. Residents were unable to gain access to their funds unless it was between the hours of 10:30 A.M. and 2:00 P.M. Monday-Friday. The facility census was 172. Review of the facility's policy, titled Resident Trust, last revised 09/21/2025 showed the following:-The facility shall allow the residents access to their personal possessions and funds during regular business hours, Monday through Friday; (there were no specific hours listed, and Saturday availability was not mentioned)-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete accounting principles;-The facility shall reimburse the resident trust account for any service charges or new check order charges;-The management accountant will fill out a check request to the trust account for any items that are to be funded by the facility. Review of the facility's undated Resident Agreement (part of the admission packet) showed the following:-1. Management of Resident Funds:-Funds may be deposited or withdrawn by the resident to meet the resident's personal needs upon written request and in accordance with the facility's procedures;-The facility will ensure that the resident's funds are accessible, at a minimum, during regular business hours, Monday through Friday, excluding banking holidays (Saturday availability was not mentioned). 1. Review of the facility monthly reconciliations of the resident trust fund showed the following:Month Amount Description11/2024 $103.52 September (Sept) Deposit Slip Order 11/2024 $48.00 Sept Check Order12/2024 $103.52 Sept Deposit Slip Order12/2024 $48.00 Sept Check Order01/2025 $103.52 Sept Deposit Slip Order01/2025 $48.00 Sept Check Order02/2025 $103.52 Sept Deposit Slip Order02/2025 $48.00 Sept Check Order03/2025 $103.52 Sept Deposit Slip Order03/2025 $48.00 Sept Check Order04/2025 $103.52 Sept Deposit Slip Order04/2025 $48.00 Sept Check Order05/2025 $103.52 Sept Deposit Slip Order05/2025 $48.00 Sept Check Order06/2025 $103.52 Sept Deposit Slip Order06/2025 $48.00 Sept Check Order07/2025 $103.52 Sept Deposit Slip Order07/2025 $48.00 Sept Check Order08/2025 $103.52 Sept Deposit Slip Order08/2025 $48.00 Sept Check Order09/2025 $103.52 Sept Deposit Slip Order09/2025 $48.00 Sept Check Order10/2025 $103.52 Sept Deposit Slip Order10/2025 $48.00 Sept Check Order The facility was not able to provide any documentation to show the resident trust fund had been reimbursed for the September deposit slip order or the September check order. During an interview on 12/09/25 at 11:00 A.M., the Business Office Manager, (BOM), also the Resident Trust Clerk, said the following: -She was in charge of the resident trust account;-She did not know why the resident trust reconciliations listed September Deposit Slip order and September Check Order to be reimbursed. The Corporate Accounts Payable (AP) staff documented that. During an interview on 12/09/25 at 2:00P.M., the Corporate Business Office Manager said the following: -The entries on the Resident Trust Reconciliation form showing the September Deposit Slip order and September Check Order were on the form as a reminder that this money was due to be reimbursed to the resident trust account. The staff member who documented that on that form was the Corporate AP, who was the management company accountant;-There were several factors as to why the resident trust reimbursements were not done timely;-The Corporate AP was terminated, and emails were still going to her email that no one had access to; -The deposit slip and check orders automatically come out of the resident trust account, then the facility reimburses the resident trust account; -It would have been the Corporate AP's responsibility to fill out a check request for reimbursement to the resident trust; -They started using new software in October 2024, and they got behind;-She was unaware that these amounts to be reimbursed had not been reimbursed. During an interview on 12/12/25 at 3:48 P.M., the administrator said there should not be any operating expenses, like deposit slips and check orders, in the resident trust fund. 2. Review of the facility Resident Trust-Current Account Balance dated 12/7/25 showed the following:-Resident #167 had a balance of $100.94;-Resident #132 had a balance of $1367.67. Review of Resident #167's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/25 showed the resident was cognitively intact. During an interview on 12/11/25 at 12:22 P.M., the resident said the following:-He/She had funds in the resident trust account;-Monday-Friday, the BOM brings around the list of residents with money in the trust account and the Certified Nurse Aides (CNAs) must go to each resident and ask if they want to withdraw money;-Often the list of residents with money doesn't come to his/her unit until around 10:30 A.M. and was picked up around 11:00 A.M. This was the only opportunity to request money each day;-If your request was not in during this specific time, you could not request money until the next day;-The BOM was only available from 10:30 A.M. to 2:00 P.M. Monday-Friday;-He/She was upset because he/she could not access his/her funds on the same business day. Review of Resident #132's Quarterly MDS dated [DATE] showed the resident was cognitively intact. During an interview on 12/11/25 at 2:25 P.M., the resident said the following:-He/She had money in the resident trust account;-He/She must tell the aide by 10:00 or 10:30 A.M. in the morning if he/she wanted money from his/her account or he/she could not get money until the next day;-Sometimes he/she needs money on the same day and can't get his/her money. During an interview on 12/11/25 at 12:30 P.M., Nurse Aide (NA) UU said the following:-Staff only have the list of residents with money in the trust account for a short period of time each day and then the list was picked up;-If money was not requested during this time, a resident could not request money until the next day. During an interview on 12/11/25 at 1:35 P.M., the BOM said the following:-She only worked Monday through Friday, from 8:00 A.M. to 4:00 P.M.; resident funds were only accessible from 10:30 A.M. to 2:00 P.M.;-At 10:30 A.M., she sent a list of residents to each unit showing the resident's balance in the trust account;-CNA staff were responsible for taking the list around to the residents on the unit and asking if they wanted to withdraw money. During an interview on 12/11/25 at 1:35 P.M., the Administrator said resident funds should be available per facility policy. #2655329

Based on interview and record review, the facility failed to ensure residents (Resident #131 and #178) who participated in group interview, received mail on regular mail delivery days as identified by the United States Postal Service, including Saturdays. The facility census was 172. Review of the facility's policy, Resident Rights, revised 09/21/25, showed the resident has the right to privacy in written communications, including the right to send and promptly receive mail that was unopened. Request was made for, but the facility did not provide a policy regarding mail delivery at the facility. 1. Resident council/group interview on 12/09/25 at 9:59 A.M. showed the following: -Residents said mail comes on Saturday, but was not delivered that day because there was no mail delivery on weekends;-Resident #131 said he/she would like to receive his/her mail on Saturday;-Resident #178 said he/she would like to receive his/her mail on Saturday. During an interview on 12/12/25 at 2:45 P.M, the activity director said the following:-Activity staff are responsible for delivering mail to the residents;-Mail gets delivered to the residents on Saturday if it was picked up by 5:30 P.M.; -If staff pick the mail up later than that, the mail was not delivered until Monday. During an interview on 12/12/25 at 1:08 P.M., the administrator said the following:-Mail was picked up on Saturday by whatever department manager was on duty;-He would expect mail to be delivered to the residents on Saturday by the department manager on duty.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for six residents (Residents #11, #20, #103, #179, #45, and #167), in a review of 47 sampled residents. The facility census was 172. Review of the facility policy, MDS 3.0, care assessment summary and individualized care plans, revised on 11/6/23, showed the following:-The purpose is to understand the changes presented by CMS for the MDS 3.0;-To define the intent of each section of the MDS 3.0;-To ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties;-The MDS 3.0 with the Care Area Assessment Summaries is a much more user-friendly assessment tool that addresses the wholistic person, including functional status, quality of life and individual plan of care to address and meet the needs of the individual resident;-Section K is to be completed by Dietary Manager. This section addresses nutritional and swallowing status;-Used to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration;-Monitors for triggered weight gains or losses;-Triggered gains or losses are: 5% in 30 days, 7.5% in 90 days or 10% in 180 days;-Section N is to be completed by nursing staff;-This section focuses on the medications the resident has received in the last 7 days or since admission or re-entry if less than 7 days;-Used to record the number of days that the resident receives any type of injection, insulin and/ or specific oral medications;-MDSs must be kept current and up to date. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed the following:-Swallowing/Nutritional status: Diminished nutritional and hydration status can lead to debility that can adversely affect health and safety as well as quality of life;-Height and weight measurements assist staff with assessing the resident's nutrition and hydration status by providing a mechanism for monitoring stability of weight over a period of time;-The measurement of weight is one guide for determining nutritional status;-Base weight on the most recent measure in the last 30 days;-If the resident's weight was taken more than once during the preceding month, record the most recent weight;-If significant weight loss is noted, the interdisciplinary team should review for possible causes of changed intake, changed caloric need, change in medications or changed fluid volume status;-Weight loss should be assessed at the time of detection and not delayed until the next MDS assessment;-Medications: High Risk Drug Classes: Residents taking medications in these medication categories and pharmacologic classes are at risk of side effects that can adversely affect health, safety and quality of life;-Code question N0415E2, Anticoagulant: Check is there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than seven days);-Anticoagulants must be monitored with dosage frequency determined by clinical circumstances and duration of use;-Certain anticoagulants require monitoring via laboratory results. 1.Review of Resident #45's Weights and Vitals dated 05/12/25 showed the resident weighed 161 pounds. Review of the resident's Care Plan dated /13/25 showed the following:-The resident was on a regular diet;-Dietary department will monitor diet monthly to ensure proper dietary recommendations;-Dietician will review chart quarterly to ensure regular diet is still proper diet for resident. Review of the resident's admission MDS, dated [DATE], showed the following:-Short and long term memory problems;-Diagnoses of dementia and psychotic disorder;-Weight 161 pounds. Review of the resident's facility Weights and Vitals Record showed staff documented the resident's weight as the following:-06/4/25, 153.8 pounds; -07/9/25, 151 pounds.-08/5/25, 149 pounds. Review of the resident's facility Quality Assurance (QA)/Weight Note, dated 08/13/25, showed the resident's weight was 149 pounds. This was down two pounds in one month and down 12 pounds in three months. Review of the resident's Quarterly MDS, dated [DATE], showed the following:-Severely impaired cognition;-Weight 149 pounds; (loss of 12 pounds or 7% in three months). -No weight loss. (This was not an accurate assessment as the resident had weight loss.) Review of the resident's facility Weights and Vitals Record, dated 09/04/25, showed the resident weighed 148 pounds. Review of the resident's Weight Note (completed by the Registered Dietitian), dated 10/13/25, showed the resident's weight was 141 pounds on 10/08/25, this was down seven pounds in one month, down nine pounds in three months, and down 20 pounds in five months. Review of the resident's facility Weights and Vitals Record showed the following:-10/14/25, the resident weighed 140 pounds;-11/05/25, the resident weighed 138 pounds (23 pound weight loss or 14.2% in six months). Review of the resident's QA/Weight Note, dated 11/10/25, showed the resident's weight was 138 pounds on 11/05/25, this was down three pounds in one month, down 11 pounds in three months, and down 23 pounds in six months (14.2% loss). Review of the resident's Significant Change MDS, dated [DATE], showed the following:-Severely impaired cognition;-Weight 149 pounds recorded by staff. (The resident's Weights and Vitals Record showed the resident weighed 138 pounds on 11/05/25);-No weight loss recorded by staff (Review of the RD notes and review of the resident's Weight and Vitals Record showed a loss of 23 pounds in 6 months or 14.2% );-Review of the resident's Significant Change MDS showed inaccurate documentation regarding the resident's current weight and weight loss. 2. Review of Resident #103's care plan, revised 11/04/24, showed the following:-He/She had a communication problem related to difficulty hearing;-He/She was independent with activities of daily living (ADLs). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact;-Section B, staff documented the resident's hearing was adequate, no difficulty in normal conversation, social interaction, listening to TV;-Ability to understand others, understands-clear comprehension;-Section GG, staff documented the resident needed supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity. Assistance may be provided throughout the activity or intermittently for eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing including putting on and taking off footwear, personal hygiene, roll left and right in bed, sitting on side of bed to lying flat in bed, lying in bed to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, toilet transfer, tub/shower transfer, walking 10 feet, walking 50 feet with two turns and walking 150 feet. Observation and interview on 12/07/25 at 12:30 P.M., showed the following:-Music was playing loudly in the resident's room;-The resident apologized for his/her music being loud and said he/she was hard of hearing and turns the music up to hear it;-He/She was independent in all his/her ADLs (items referenced in section GG);-He/She takes his/her own shower, gets dressed without cues, transfers to and from bed/chairs independently and walked to and from all areas in the building unassisted;-He/She did not need assistance from staff to complete any tasks except getting medication and cigarettes during smoking times. During an interview on 12/10/25 at 10:30 A.M., Nurse Aide (NA) M said the resident was independent and if he/she needed something, the resident would ask staff. 3. Review of Resident #179's quarterly MDS, dated [DATE], showed the following: -Cognitively intact;-Section GG, staff documented the resident needed supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity. Assistance may be provided throughout the activity or intermittently for eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing including putting on and taking off footwear, roll left and right in bed, sitting on side of bed to lying flat in bed, lying in bed to sitting on side of bed, sitting to standing, chair/bed-to-chair transfers, toilet transfer, tub/shower transfer, walking 10 feet, walking 50 feet with two turns and walking 150 feet;-Independent with personal hygiene;-Indwelling catheter (a tube inserted directly into the bladder to drain urine) present. During an interview on 12/09/25 at 8:39 A.M., the resident said the following:-He/She has a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder) he/she plugs because the physician wanted to try to stretch his/her bladder;-He/She does all his/her catheter care independently and has been doing so for years;-He/She was independent in all his/her ADLs and only needed staff assistance to take him/her to the dining room as he/she needed supervision for meals;-He/She walked independently and will ask staff for any needs. Staff administer his/her medications, otherwise staff does not do anything to help him/her. During an interview on 12/10/25 at 10:30 A.M., NA M said the resident was independent and if he/she needed something, the resident would ask staff. 4. Review of Resident #20's Care Plan, revised 10/27/24, showed the following:-The resident had an ADL self-care performance deficit related to activity intolerance. He/She did need assistance with ADLs;-No direction towards staff regarding assistance required for hygiene, transfers and ambulation. Review of the resident's Quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnosis of depression;-Required staff supervision or touch assistance for oral hygiene, toileting hygiene, dressing and personal hygiene;-He/She also required staff supervision or touch assistance for rolling left to right, sit to lying transfers, sit to stand, chair/bed-to-chair transfers and walk 10 feet. During an interview on 12/09/25 at 9:39 A.M., the resident said he/she can do all his/her own self-care except for trimming his/her nails and shaving as that was done with staff supervision. During an interview on 12/11/25 at 12:30 P.M., NA UU said the resident is independent with all cares. 5. Review of Resident #167's Care Plan, revised 07/02/25, showed the following:-The resident displayed impaired thought processes related to delusions/hallucinations/poor insight/judgment;-The resident had a legal guardian who assisted with decision making;-The resident was independent with ADLs and required set-up help only for all meals and prompting for personal hygiene;-Provide assist and supervision as needed/requested. Encourage resident to do as much for him/herself as possible. Review of the resident's Quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnosis of schizophrenia (mental illness);-Required supervision or touch assistance for oral hygiene, toileting hygiene, shower/bathing and upper and lower body dressing;-The resident also required supervision or touch assistance for rolling left to right, sitting to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 50 feet with two turns and walk 150 feet. During an interview on 12/11/25 at 12:22 P.M., the resident said the following:-He/She received no ADL assistance from staff;-He/She walked independently, dressed him/herself and takes him/herself to the bathroom without any prompting or assistance from staff. During an interview on 12/11/25 at 12:30 P.M., NA UU said the resident was independent with all cares. 6. Review of Resident #11's Physician's Orders, dated 8/15/25, showed Apixaban (a blood thinner medication used to prevent and treat blood clots) was discontinued on this date. Review of the resident's Physician's Orders, dated October 2025, showed no order for an anticoagulant. Review of the resident's quarterly MDS, dated [DATE], showed the resident received an anticoagulant in the last seven days. Review of the resident's current care plan, initiated date of 8/21/24 and last revised on 7/2/25, showed the resident received an anticoagulant. During an interview on 12/11/25 at 11:30 A.M., Registered Nurse A said the following:-The resident was on the blood thinner from 9/20/24 to 8/15/25;-The anticoagulant should not be marked on the MDS after the end date. 7. During an interview on 12/19/25 11:48 A.M., the Nurse Assessment Coordinator said the following:-She completed the nursing assessment for the MDS;-She talked to the resident in-person and does section GG;-She does not enter anything into the MDS specifically; -She only does the assessments and passes them on to the MDS coordinator;-She was made aware of the current condition of a resident related to how they bathe, ambulate, transfer and what medications are ordered by laying eyes on the residents and doing the assessment for section GG;-Supervision in section GG means verbal cues, eyes on the resident, cues for them to complete tasks or any cues or assistance provided;-No staff assistance or cueing would be considered independent;-She did not feel like anyone at the facility would be coded as independent as cues are given daily as well as supervision daily;-Everything about the resident should be on the MDS. During an interview on 12/19/25 11:38 A.M., the facility MDS Coordinator said the following:-She expected assessments to be accurate regarding current medications such as anticoagulants, weights, catheters and level of care provided in section GG;-The nurse assessment coordinator went into facilities and completed the hands-on assessment for the completion of portions of the MDS;-Medications were reviewed on the MAR/treatment administration record (TARs);-Supervision in section GG meant the resident was only able to complete tasks with cues;-Touch assistance would be supervision;-Independent was when the resident did not have any staff assistance provided;-She used the RAI manual for MDS completions. During an interview on 12/12/25 at 3:39 P.M., Director of Nursing #2 said the MDS should be accurate and reflect the most current level of care for a resident. During an interview on 12/18/25 at 1:08 P.M., the Corporate MDS Coordinator said the following:-She had been the facility MDS coordinator until about September of this year, and now she was the corporate MDS coordinator; -She expected assessments to be accurate regarding current diet orders, medications such as anticoagulants, weights, catheters and level of care provided in section GG;-When she completed the MDS for the facility, she spoke to the nurse managers to get the assessment of current condition to complete the MDS;-The nurse assessment coordinator went into the facilities and completed the hands-on assessment for the completion of portions of the MDS;-The medication administration record (MAR) was reviewed for the medication section; -Supervision in section GG meant verbal cues, eyes on the resident and cues for them to complete the tasks;-No staff assistance or cueing would be considered independent;-She used the RAI manual for MDS completions.

Based on interview and record review, the facility failed to provide a written notice of transfer discharge to seven residents (Resident #85, #113, #30, #38, #5, #6, #75) or the resident representatives, in a sample of 47 residents reviewed, that included the reason for discharge/transfer, location being discharged to, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocacy for residents with mental illness. Further review showed the facility did not provide a bed hold policy to one resident (Resident # 113) or their representative at the time of their transfer. The facility census was 172. Review of the facility policy, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 4/28/25, showed the following:-With the exception of ceasing to operate, the resident's medical record must be documented with the reasons for any transfer or discharge;-When a resident is discharged or transferred, the Interdisciplinary Discharge Summary (recapitulation) must be completed in Point Click Care;-Before any resident is transferred or discharged , the facility must notify the resident and the resident representative of the reason for the transfer or discharge in writing in a manner they understand;-The written notice shall include the following information:-Reason for the transfer or discharge;-Effective date of the transfer or discharge;-Location to which the resident is being transferred or discharged , including specific address;-Resident's right to appeal the transfer or discharge notice within 30 days of the receipt of the notice and the address to which the request shall be sent;-That if the resident files an appeal, they can remain in the facility unless and until a hearing official finds otherwise;-The name, address, e-mail, and telephone number of the designated regional long-term care Ombudsman office;-For residents with development disabilities, the mailing address, e-mail, and telephone number of tile agency responsible for the protection and advocacy of individuals with developmental disabilities;-For residents with a mental disorder or related disabilities, the mailing address, e-mail, and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder;-If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available;-In the case of an emergency or immediate transfer or discharge, the notice shall be as soon as practicable before the transfer/discharge;-Emergency or immediate discharge is permitted if it specifically alleged in the notice that:-Immediate transfer or discharge is required by resident's urgent medical needs; or-The administrator, social service manager or their designee is responsible for drafting the transfer/ discharge letter;-This letter shall be sent to the facility Chief Compliance Officer for view;-The legal review will ensure that the letter meets all the legal requirements, but the decision to discharge the resident and where to discharge the resident is fully the facility's decision. Review of the facility policy, Notice of Bed Hold Policy, revised 04/28/25, showed the following:-When a resident is transferred to the hospital or other location or when the resident goes on therapeutic leave, the facility must provide to the resident or their legal representative, a written copy of the bed hold policy;-This notice must be given at the time of transfer or therapeutic leave. For emergency transfers, the notice must be given within 24 hours of transfer:-If the emergency transfer was to a hospital, the facility may send copy of bed hold policy to the resident in the hospital if a hospital representative such as a social worker, agrees and will confirm resident received the copy in an e-mail that will be kept in the medical record;-In the case of an emergency transfer, if the resident returns to facility within 24 hours, the facility may document in the medical record that the notice was not issued due to resident returning within 24 hours;-If the Facility is unable to provide a copy to the resident's legal representative, the facility should document the multiple attempts to reach the resident's representative;-Documentation that the bed hold policy was provided must be put in the resident's medical record. This documentation shall include how and when the notice was issued;-The bed hold policy must provide information to the resident that explains the duration of bed hold, if any, and the reserve bed payment policy. It also addresses permitting the return of residents to the next available bed. 1. Review of Resident #85's face sheet showed the resident had a guardian. Review of the resident's progress note, dated 11/20/25 at 5:31 P.M., showed the following:-The resident was in pain related to could not urinate since yesterday at 1:00 P.M.;-The resident was yelling and kicking doors and said he/she was in pain;-Physician contacted and order received to send to the hospital;-Transported by facility van. Review of the resident's progress note, dated 11/22/25 at 3:58 P.M., showed the social services director (SSD) sent the bed hold to the guardian via email for signature. There was no documentation staff provided a written notice of transfer. Review of the resident's progress note, dated 11/24/25 at 3:19 P.M., showed the resident arrived back to the facility from the hospital via facility van. Review of the resident's electronic health record (EHR) showed no documentation the facility gave the resident, or the resident's representative, a written notice of transfer to the hospital when the resident was transferred to the hospital on [DATE]. 2.Review of Resident #113's face sheet showed the resident had a guardian. Review of the progress note, dated 12/7/25 at 7:28 P.M., showed the following:-The resident complained of right upper abdominal pain;-PRN (as needed) pain medication given per orders, and the resident reported it was not effective;-Physician notified and order received to send the resident out for evaluation and treatment. Review of the resident's progress note, dated 12/7/25 at 7:32 P.M., showed the resident left the facility to go to the hospital. Review of the resident's progress note, dated 12/8/25 at 6:21 A.M., showed the resident returned to the facility on [DATE] at 10:40 P.M. Review of the resident's EHR showed no documentation the facility provided the resident, or the resident's representative, a written notice of transfer to the hospital or the bed hold policy for the resident's 12/7/25 transfer. 3. Review of Resident #30's face sheet showed he/she had a guardian. Review of the resident's census list showed the resident transferred to the hospital and was hospitalized from [DATE] through 09/10/25 and again on 12/10/25. The resident remained hospitalized on [DATE]. Review of facility documentation from the SSD showed a bed hold notice had been emailed to the resident's guardian on 08/15/25 and 12/10/25. There was no documentation the facility provided a written notice of transfer. Review of the resident's EHR showed no documentation the facility issued the resident, or the resident's representative, a written notice of transfer to the hospital for his/her 08/12/25 or 12/10/25 transfer. 4. Review of Resident #38's face sheet showed he/she had a guardian. Review of the resident's census list showed the resident transferred to the hospital and was hospitalized from [DATE] through 10/21/25. Review of documentation from the SSD showed a bed hold notice had been emailed to the resident's guardian on 10/13/25. There was no documentation the facility provided a written notice of transfer. Review of the resident's EHR showed no documentation the facility issued the resident, or the resident's representative, a written notice of transfer to the hospital for his/her 10/12/25 transfer. 5. Review of Resident #6 face sheet showed the resident was his/her own responsible party. Review of the resident's nurse's notes, dated 10/13/25 at 6:28 P.M., showed the resident admitted to the Intensive Care Unit (ICU) at the hospital for shortness of breath. Review of the resident's medical record showed no documentation staff informed the resident in writing of the transfer notice prior to transfer to the hospital on [DATE]. Review of the resident's nurse's notes, dated 10/24/25 at 6:46 P.M., showed the resident readmitted to the facility (from the hospital). Review of the resident's nurse's notes, dated 11/12/25 at 1:20 P.M., showed the resident was sent to the emergency room for evaluation and treatment for shortness of breath. Review of the resident's medical record showed no documentation staff informed the resident in writing of the transfer notice prior to transfer to the hospital on [DATE]. Review of the resident's nurse's notes, dated 11/14/25 at 8:18 P.M., showed the resident was readmitted to the facility (from the hospital). 6. Review of Resident #75 face sheet showed the resident had a guardian (power of attorney). Review of the resident's nurse's notes, dated 07/13/25 at 2:36 P.M., showed the following:-The resident was delusional;-He/She was throwing things and trying to hit staff;-The psych hospital called, and the resident could be admitted on [DATE];-The resident's guardian had been notified. Review of the resident's nurse's notes, dated 07/14/25 at 1:12 P.M., showed the resident was sent to the hospital for evaluation. Review of the resident's medical record showed no evidence facility staff informed the resident's guardian (POA) in writing of the transfer and the reason for transfer to the hospital on [DATE]. 7. Review of Resident #5 face sheet showed the resident had a guardian (POA). Review of the resident's nurse's notes, dated 10/09/25 at 5:22 P.M., showed the following:-The resident was being seen by the physician;-He/She was pale in color and unable to transfer himself/herself;-His/Her blood sugar was elevated, and he/she had altered mental status;-The physician ordered staff to send the resident to the hospital for evaluation and treatment. Review of the resident's medical record showed no evidence facility staff informed the resident's guardian (POA) in writing of the transfer and the reason for transfer to the hospital on [DATE]. Review of the resident's nurse's notes, dated 10/12/25 at 11:45 A.M., showed the resident was readmitted to the facility (from the hospital). 8. During an interview on 12/11/25, at 1:30 P.M., the SSD said the following:-She sends the bed hold notice to the resident's responsible party/guardian on each transfer to the emergency room, but she does not send the discharge/transfer notice and has not sent it in the past on any transfer;-She was unaware that a written transfer notice needed to be sent. During an interview on 12/11/25, at 1:30 P.M., Director of Nursing (DON) #2 said the following:-A written transfer notice was required to be given to the resident/resident's responsible party with every hospital transfer and has very specific information required on the transfer notice;-The admitting nurse starts the packet, but the SSD was responsible for ensuring the written transfer agreement and bed hold notice was given to the resident/resident's representative;-The written transfer notice and bed hold notice was part of a packet to be completed with each transfer.

Based on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (this indicator disqualifies an individual from working in the facility) for three of ten newly hired employees (Maintenance Assistant I, Certified Nurse Aide (CNA) J and Dietary Aide L) reviewed. The facility also failed to check the Employee Disqualification List (EDL) for three of ten newly hired employees (Maintenance Assistant I, Dietary Aide L and Licensed Practical Nurse (LPN H) reviewed. The facility census was 172. Review of the facility's policy, Screening-Applicant, Employee, Volunteer and Vendor, revised 06/12/25 showed the following:-Human Resources (HR) department will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State health care programs, is eligible to work in the United States, and, if applicable, is duly licensed or certified to perform the duties of the position for which they applied;-Applicant shall complete a Request for Criminal Records Check and Request for Consent to EmployeeDisqualification Check Form. Human Resources Staff will conduct the following screens on potential employees prior to hire;-The results of each background check must be maintained in the applicant's file;-Family Care Safety Registry (FCSR) - this screening will check the sex offender, employee disqualification list, and other Missouri databases automatically. Enter the applicant Social Security Number, and print, date and initial the results. If the applicant's Social Security Number is not found in the database, then the applicant needs to be registered with the FCSR. The company should ensure that the applicant submits the paperwork and the fee to the FCSR. For the convenience of the applicant, the fee can be paid by the company and deducted from the applicant's first paycheck. Registration can be done online or mailed to the Department of Health and Senior Services (DHSS). Registration and background check must be completed within fifteen days of the first date of employment and a copy placed in the employee's file;-The Missouri Employee Disqualification List (EDL) must be checked for every applicant. Log in to the EDL at http://health.mo.gov/safety/edl/index.php. If a record is found, the applicant is on the EDL and may not be hired. A copy of that information must be put in the employee's file. If no record is found, the applicant may be hired. The results must be placed in the employee's file;-The CNA Registry must be checked for all applicants regardless of the position for which they are applying. Any applicant listed with background problems, or a federal indicator may not be hired for any position;-Any applicant being hired for a CNA or Certified Medication Technician (CMT) position must have an active (not inactive or suspended) certification before beginning employment. The results must be placed in the Employee File. 1.Review of Maintenance Assistant I's employee file showed the following:-Date of hire 08/12/25;-No documentation the facility completed a Nurse Aide Registry check;-No documentation the facility completed an EDL check;-A Family Care Safety Registry letter dated 12/09/25, 120 days after the employee's date of hire. 2.Review of CNA J's employee file showed the following.-Date of hire 11/19/25;-No documentation the facility completed a Nurse Aide Registry check. 3.Review of Dietary Aide L's employee file showed the following:-Date of hire 08/11/25;-No documentation the facility completed a Nurse Aide Registry check;-No documentation the facility completed an EDL check;-A Family Care Safety Registry letter dated 12/09/25, 121 days after the employee's date of hire. 4.Review of LPN H's employee file showed the following:-Date of hire 10/23/25;-No documentation the facility completed an EDL check;-No documentation of a Family Care Safety Registry check. During an interview on 12/10/25 at 1:30 P.M., Human Resources (HR) staff said the following-He/She had been in this position since September 8, 2025 and had been trained to obtain the background checks, EDLs, and the Nurse Aide Registry and was told this was part of his/her job;-The previous administrator took care of human resource duties including checking the Family Care Safety Registry, EDL, and Nurse Aide Registry prior to September when she started the HR position; -Corporate HR was in charge of running the background checks, EDL and Nurse Aide Registry on all new hires;-The background checks and Nurse Aid Registry checks were all uploaded to a computer program by corporate and HR was to print the results of the background checks and Nurse Aide Registry checks and put them in the employee files;-With so many changes in HR personnel, the results of the background checks and Nurse Aide Registry checks did not get printed off and put in the employee file and the facility no longer had access to the computer program;-He/She said he/she had recently been doing an audit and caught a few missing pieces but had not finished the audit yet. During an interview on 12/12/25 at 3:48 P.M., the administrator said Nurse Aide Registry check and EDL check should be completed upon hire, before actual starting work and before resident contact.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility managed funds for 127 residents. The facility census was 172. Review of the facility's policy, titled Resident Trust, last revised 09/21/2025 showed the following:-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete accounting principles;-A reconciliation of the bank statement, checkbook, and the Point Click Care (PCC) Trust Funds module must be completed monthly. This will be completed by the management company staff accountant responsible for the facility's financials. The reconciliation must be done by someone other than the Resident Trust Clerk;-On the first day of every month, the Resident Trust Clerk must reconcile a list of all checks that were written from the resident trust account during the prior month. The list should include the date, check number, payee and amount of the check. This list should be kept on the Public P drive under your facility named folder in a trust folder. An email will be sent to the management company staff accountant responsible for your facility's reconciliation once it is updated. The bank statement should be sent as soon as it is received to account as soon as it is received;-As the management accountant finds errors, he/she will email the Resident Trust Clerk on or before the 5th of each month to obtain information on the discrepancies to make accurate corrections. The Administrator should be copied on the email. The Resident Trust Clerk must respond the same day to ensure a timely reconciliation of the trust funds. For any issues preventing this the Resident Trust Clerk must reach out to the Regional Business Office team for assistance and get it resolved no later than the 7th of each month;-When the reconciliation is complete, the management accountant will send to the Resident Trust Clerk a copy of the completed reconciliation and bank statement, which should be filed in the monthly resident trust folder or Binder. 1. Review of the facility monthly reconciliation of the resident trust fund showed the following:Month Amount Description11/2024 $2829.56 Reconciled difference to be reimbursed 12/2024 $2829.56 Reconciled difference to be reimbursed01/2025 $2829.56 Reconciled difference to be reimbursed02/2025 $2829.56 Reconciled difference to be reimbursed03/2025 $350.00 September (Sept) shortage to be reimbursed 04/2025 $350.00 Sept shortage to be reimbursed05/2025 $350.00 Sept shortage to be reimbursed05/2025 $650.00 Reconciled difference to be reimbursed06/2025 $350.00 Sept shortage to be reimbursed06/2025 $650.00 Reconciled difference to be reimbursed07/2025 $350.00 Sept shortage to be reimbursed07/2025 $650.00 Reconciled difference to be reimbursed08/2025 $350.00 Sept shortage to be reimbursed08/2025 $650.00 Reconciled difference to be reimbursed09/2025 $350.00 Sept shortage to be reimbursed09/2025 $650.00 Reconciled difference to be reimbursed10/2025 $350.00 Sept shortage to be reimbursed10/2025 $650.00 Reconciled difference to be reimbursed 2. Review of the facility maintained attempted reconciliation forms, for the period 11/01/24 through 10/31/25, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of reconciliation by inserting an amount with Reconciled difference to be reimbursed and/or Sept shortage to be reimbursed.3. During an interview on 12/09/25 at 11:00 A.M., the Business Office Manager, who is the Resident Trust Clerk, said the following: -She was in charge of the resident trust account;-She did not know why the resident trust reconciliations listed September shortage to be reimbursed or reconciling difference to be reimbursed. The Corporate Accounts Payable (AP) staff documented that. During an interview on 12/09/25 at 2:00P.M., the Corporate Business Office Manager said the following:-The entries on the Resident Trust Reconciliation form stating Sept shortage to be reimbursed and reconciled difference to be reimbursed were on the form as a reminder that this money was due to be reimbursed to the resident trust account;-The reconciled difference to be reimbursed and September shortage to be reimbursed were due to the previous business office manager having some posting errors, and not keeping track of purchases correctly;-The previous Corporate Accounts Payable (AP) staff, who was the management company staff accountant, should have addressed this, but there were several factors as to why it had not been;-The corporate AP was terminated, and emails were still going to her email that nobody had access to; -They started using new software in October 2024, and they got behind;-She was unaware these amounts to be reimbursed had not been reimbursed. During an interview on 12/12/25 at 3:48 P.M., the administrator said the resident trust fund statements should be reconciled accurately monthly.

Based on interview and record review, the facility failed to follow physician orders for a mechanical soft diet (foods that are chopped or ground to be easily chewed and swallowed to prevent choking) for one resident (Resident #8), who had a history of choking and was on an assist to dine program, when staff prepared and served the resident a regular diet tray including pork loin for the resident's lunch on 11/30/25. The resident choked while eating the meal and became unresponsive and stopped breathing. Staff began cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) and called Emergency Medical Services (EMS). The resident was transferred to the hospital where he/she later expired, with a cause of death of food aspiration (the accidental inhalation of food or liquids into the airway), respiratory failure (insufficient oxygen to the lungs), with unspecified hypoxia (insufficient oxygen reaching the body's tissues, vital organs or the brain). The facility census was 174.On 12/4/25 the Administrator was notified of the past noncompliance IJ that occurred on 11/30/25. The facility began an investigation and corrective measures on 11/30/25. Education was completed on diet policy, supervision of dining rooms, and preparation of therapeutic diets. The facility initiated a system of pictures of all three meals showing therapeutic diet consistencies which were sent to and approved by the dietary manager prior to serving any meals. Dietary staff send a daily menu to all units showing alternatives for all regular and mechanically altered diets. All food substitutions will be approved by the dietary manager. The facility began daily briefings regarding diets/meals between the dietary manager and charge nurse/Director of Nursing (DON). Menus are sent to all units and posted on each unit, followed by documented communication from charge nurse/DON to floor staff of any changes. The facility reviewed all resident's diagnoses, diet orders, and aspiration risk on 12/1/25. The IJ was corrected on 12/1/25. Review of the facility's policy, Supervision of Dining Rooms, Cleanliness and Preparedness of Dining, revised 5/23/24, showed the following:-To ensure that all residents are provided the prescribed diet by the physician and that accurate intakes of food are recorded;-The charge nurse and/or designated department head, and or designated nursing staff assigned to the dining room, will supervise and ensure dining rooms are adequately staffed to direct self-help dining procedures; to ensure that each resident is served the correct ordered physician diet; to ensure that each resident receives enough food; to ensure that each resident eats in a manner consistent with his/her developmental level and ensure that each resident eats in a upright position, unless otherwise specified by the interdisciplinary team or a physician; -Prior to serving the tray the nurse assistant or department head must first read the card to ensure that the resident will receive the correct tray, diet and fluids are placed on the tray;-If any question or if the tray is incorrect, the charge nurse or Registered Nurse supervisor must be notified immediately, and the tray will not be served until corrected. Review of the facility's policy Transcription Orders/Following Physician's Orders, revised 5/18/24, showed the purpose of this policy is to outline procedures in accurately transcribing orders and to ensure that all physician's orders are followed. Review of the facility's Diets policy, revised on 7/5/23, showed the following:-Nursing will check all diet orders received to see that they coincide with diets available;-The physician will be notified if there is any discrepancy to ensure appropriate accommodation to facility diets ordered;-Therapeutic diets are prepared and served as prescribed by the attending physician;-Therapeutic diets are planned, prepared, and served with supervision or consultation from a registered dietician;-Persons responsible for therapeutic diets have sufficient knowledge of food values to make appropriate substitutions when necessary;-A therapeutic diet is defined as any deviation from the regular diet;-The charge nurse is responsible for clarifying diet orders when necessary;-Mechanical soft (chopped);-Mechanically altered diets are planned, prepared and served with supervision of a registered dietician. 1. Review of Resident #8's undated face sheet showed the following:-The resident had a guardian;-Diagnoses included hypoxia with respiratory failure, gastroesophageal reflux disease without esophagitis (a chronic digestive disorder where stomach acid frequently flows back into the esophagus (connection between the mouth and stomach) and personal history of sudden cardiac arrest (sudden loss of heart function, breathing and consciousness). Review of the resident's registered dietician assessment for swallow recommendations, dated 5/9/25, showed the following:-Diet, mechanical soft;-The resident was an aspiration risk (at risk for inhaling material like food or fluids into the lungs) and an assist to dine (dining area staffed by a licensed nurse and certified nursing aides to monitor and assist residents who have been identified as an aspiration risk);-The resident was to empty his/her mouth before the next bite, take small bites, slow down, and remain upright for 30-60 minutes after meals. Review of the resident's physician orders, dated November 2025, showed the following:-Speech therapy to evaluate and treat; date ordered 5/1/25;-Mechanical soft diet texture, thin/regular consistency and diabetic precautions; date ordered 5/12/25;-The resident was a full code (the resident wanted all possible life-saving measures used if his/her heart stopped beating or the resident stopped breathing). Review of the resident's care plan, dated 11/30/25, showed the following:-The resident was on a regular, mechanical soft diet. Dietary department will monitor diet monthly to ensure proper dietary recommendations;-On 11/30/25, the resident was involved in a choking incident and expired. Review of the mechanical soft lunch menu recipe for ground, herb roasted, pork loin with gravy, dated 11/30/25, showed the following:-Pork loin boneless, place in roasting pan with nonstick cooking spray, bake for 35-45 minutes;-After pork loin rests for 10-15 minutes, place the number of servings into a clean and sanitized food processor and pulse to achieve ground/minced consistency. Add a small amount of prepared gravy, broth, or appropriate liquid to ensure all pieces are moistened;-Serve ground meat portion and top with an appropriate gravy/sauce to keep food moist. Review of the resident's progress note completed by Registered Nurse (RN) D, dated 11/30/25 at 12:20 P.M., showed the following:-Around 12:30 P.M. responded to the dining room to inform resident when he/she finished lunch he/she had a telehealth (the use of digital technology to provide healthcare services remotely) call. The resident did not respond to the nurse's question, observed the resident attempting to talk but was unsuccessful, Heimlich maneuver given;-Food came out of the resident's mouth, but resident continued to choke. The Heimlich was attempted several more times with food coming out, but unable to completely clear airway;-The resident became cyanotic (a bluish discoloration of the skin), eyes glassy, breathing shallow. CPR initiated and 911 called times two. When EMS arrived, they took over CPR and transported the resident to the hospital. Review of the resident's ambulance transport narrative, dated 11/30/25, showed the following:-Received call at 12:21 P.M.-Dispatch at 12:21 P.M.-Enroute at 12:21 P.M.-At patient at 12:25 P.M.-Called to report of choking at facility. The resident reported to be eating lunch at 12:05 P.M. and started choking. Started with back blows while the resident was in the chair and the resident was reported to go unresponsive and was lowered to the floor. Staff started CPR and was not able to dislodge. The resident was pulseless and apneic (a state where someone stops breathing) upon arrival;-The resident was found on the floor in the facility dining room with staff doing CPR and bagging resident with bag-valve mask device (BVM) with oxygen attached. Defibrillator pads were attached, and asystole (heart not beating) was seen on the monitor;-First attempt of intubation failed. Second attempt was made and able to dislodge the obstruction and removed a large amount of food from the airway;-Final acuity, dead with resuscitation efforts. Review of the resident's emergency department physician documentation, dated 11/30/25 at 2:20 P.M., showed the following:-Presenting complaint, the resident choked on meat at the nursing home, resident was in cardiac arrest when EMS arrived. Food bolus was removed from the trachea by EMS and CPR continued;-The resident presented to the emergency department in respiratory failure secondary to a choking episode leading to cardiac arrest;-The resident expired. Diagnosis of respiratory conditions due to unspecified external agent, aspiration of food, respiratory failure with hypoxia. During an interview on 12/3/25 at 10:00 A.M., Dietary [NAME] F said the following:-On 11/30/25 he/she was the cook for the noon meal;-Staff were to serve pork loin for regular, mechanical soft and pureed diets;-When the pork loin came out of the oven, he/she thought it was dry and tough;-He/She could not get the mechanical soft diet or pureed diets to the appropriate consistency and made the decision to make a substitution;-The mechanical soft diets would receive a pimento cheese sandwich in place of the pork loin;-He/She did not feel comfortable serving the pork loin for therapeutic diets and was concerned the residents could choke on the meat;-He/She told Dietary [NAME] A the pork loin was not the correct consistency for the mechanical soft diet and notified him/her pimento cheese sandwiches should be served to residents on a mechanical soft diet;-He/She prepared 16 pimento cheese sandwiches and put them in plastic bags on the cart. During an interview on 12/3/25 at 4:00 P.M., Dietary [NAME] A said the following:-He/She served the noon meal on 11/30/25;-He/She and Dietary [NAME] F discussed the pork loin consistency for mechanical soft diets and did not feel it was the correct consistency, so they made the decision to serve pimento cheese sandwiches in place of the pork loin for residents with a mechanical soft diet;-He/She prepared one regular tray and two mechanical soft diet trays for service. Licensed Practical Nurse (LPN) B asked if the regular tray was for Resident #8, and he/she told LPN B it was;-He/She made a mistake. The dining room was busy, and he/she plated the wrong diet for the resident. During an interview on 12/3/25 at 7:45 A.M., LPN B said the following:-On 11/30/25 he/she was in the assist to dine dining room serving lunch;-He/She confirmed with Dietary [NAME] A the tray prepared on the cart was Resident #8's and was a mechanical soft diet. The resident's card was with the tray. The tray consisted of the regular diet of shredded meat with a liquid covering the meat and mashed potatoes, the resident had refused the vegetable; -LPN B passed the tray to the resident;-RN D came into the dining room a little later and tried to speak to the resident and identified the resident was choking;-LPN B started the Heimlich maneuver on the resident and was able to get a chunk of food particles out of the resident's mouth a couple of times;-The resident became unresponsive, and staff lowered the resident to the floor and started CPR;-Staff called a Code Blue (medical emergency) within seconds of the resident choking and called 911;-After the resident choked, Dietary [NAME] A said the resident was to receive a pimento cheese sandwich and not the pork loin, as the pork loin was for the regular diet tray;-LPN B did not know the tray he/she passed was the incorrect diet. During an interview on 12/3/25 at 1:20 P.M., RN D said the following:-On 11/30/25 during lunch he/she went to Resident #8 to inform him/her of a telehealth phone call;-The resident's plate had shredded meat on it with a brown gravy or liquid on the meat;-The resident appeared to be trying to swallow, but could not. When he/she spoke to the resident the resident did not respond. RN D identified the resident was choking;-LPN B started the Heimlich maneuver on the resident and was able to remove a little food;-He/She tried the Heimlich maneuver on the resident and was to get up a little food;-The resident started turning blue and did not have a pulse. Staff lowered the resident to the floor and started CPR. Staff had already called 911;-Staff continued CPR until EMS arrived;-The resident was an aspiration risk and ate in the assist to dine dining room. During an interview on 12/3/25 at 12:15 P.M., the Dietary Manager said the following:-On 11/30/25 Dietary [NAME] F made a protein substitution and served a pimento cheese sandwich in place of the pork loin;-Dietary [NAME] F did not feel the pork loin was the appropriate consistency for a mechanical soft diet after it was prepared. The meat clumped and balled up;-Dietary [NAME] F informed Dietary [NAME] A, who was to plate the meals, that pimento cheese sandwiches were to be served for all mechanical soft diets instead of the pork loin. During an interview on 12/3/25 at 12:00 P.M., Registered Dietician G said the following:-He/She was aware of the substitution for pork loin for the lunch meal on 11/30/25;-Pimento cheese on regular white bread was an appropriate protein substitution for pork loin for residents on a mechanical soft diet. He/She approved the substitution; -If staff did not like the consistency of the pork loin on a weekend, close to serving time, it was appropriate to substitute as needed as long it was a similar protein substitution;-Serving regular pork loin to Resident #8 instead of a pimento cheese sandwich, was a mistake or accident. During an interview on 12/3/25 at 1:00 P.M., Speech Therapist H said the following:-The resident choked around April 2025 and the facility placed the resident on a pureed diet until he/she could do an evaluation of the resident;-Several diet trial observations were made, and the resident did well with a mechanical soft diet and was able to upgrade his/her diet;-The resident was alert and oriented and followed direction well, the resident did eat fast and needed to be reminded on occasion to slow down and alternate bites of food with a drink;-The resident should have ground or minced meat or meat was to be cut up in bite size pieces less than the size of a dime;-Serving the resident shredded pork that was not in bite size pieces would not be considered a mechanical soft diet. During an interview on 12/4/25 at 1:20 P.M., the DON said the resident was served the incorrect diet, a regular diet was served when the resident should have received a mechanical soft diet. The resident choked and expired as a result. She would expect staff to follow the physician ordered diet and policy for mechanical soft diets. During an interview on 12/4/25 at 1:15 P.M., the Administrator said staff served the resident the incorrect diet and the resident expired as a result. He would expect staff to follow the physician's order for the resident's diet and the facility policy for mechanical soft diet. Intake ID: 2679901

Based on observation, interview and record review, the facility failed to ensure one resident, (Resident #1), in a review of eight sampled residents, was free from abuse when Resident #2 pushed Resident #1 to the ground and kicked Resident #1's head while Resident #1 was down. Resident #1 was sent to the emergency room for right arm pain and was diagnosed with a nondisplaced spiral fracture of the right humerus (a spiral break in the upper arm). The facility census was 174. The administrator was notified of the past noncompliance on 12/04/25, which occurred on 11/28/25. Immediately after the incident, the facility placed Resident #2 on one-on-one monitoring. The facility began their investigation into the allegation and in-serviced staff on duty at the time on abuse, behavioral health services and behavioral emergency policies. Behavioral mediation agreements were completed with both residents. All other staff were to be in-serviced before the start of their next shift. Resident #1 was sent out for medical evaluation. This deficiency was corrected on 12/1/25. Review of the facility's Abuse and Neglect Policy, last revised on 6/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident and resident to resident altercations;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner;-Physical abuse also includes, but is not limited to hitting, slapping, punching, biting, and kicking. 1.Review of Resident #1's undated face sheet showed the following:-Diagnoses included schizophrenia (a mental health condition that affects how you think, feel and behave), post-traumatic stress disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event), autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn and behave), schizoaffective disorder, bipolar type (a chronic mental illness blending symptoms of schizophrenia with mood swings), generalized anxiety disorder, and attention deficit hyperactivity disorder, unspecified type ( a condition that can make it hard for a person to sit still, control behavior and pay attention). Review of the resident's Preadmission Screening and Resident Review, dated 6/18/25 showed the following:-Historical and current psychiatric and intellectual disability (ID) and developmental disability (DD) diagnoses included schizophrenia, unspecified mood disorder, autistic disorder, pervasive developmental disorder (severe impairments in social interaction, communication and behavior affecting how a child develops and processes information), learning disorder, anxiety disorder, Asperger's disorder ( a condition that affects how people see others and socialize with them), Tourette's disorder (neurological disorder causing involuntary repetitive movements or sounds), ADHD, PTSD, mild intellectual disability (limitations in intellectual functioning);-Behaviors in the last 30 days included being intrusive, invades others' space, cursing/swearing, injures self;-Psychosocial assessment showed assistance needed to complete activities of daily living, medical treatment and/or monitoring for chronic conditions with treatment services needed on a regular basis in nursing facility setting, 24-hour protective oversight needed due to severity of behaviors or mental illness symptoms. Individual cannot be without supervision at any time. Review of the resident's care plan, dated 11/28/25, showed the following:-The resident had a history of PSTD; this affected the resident's symptoms and may flare up without any known trigger. Alterations in reactivity from the traumatic even, including aggressiveness, and self-destructive behavior;-Encourage the resident to verbally identify current ineffective coping techniques. Help the resident understand their current behaviors that may be preventing healing or treatment and establish trust with the resident. Listen to what the resident is saying and behave in a calm manner, especially when resident has a high level of anxiety, establishing trust can help the client calm down and make treatment more effective;-The resident is at risk for signs and symptoms related to anxiety disorder including, cursing, nervousness, restlessness and sweating. Be aware of your body stance and facial expressions when you approach the resident. Closely watch the resident for signs of anxiety and act before the resident loses control. Do not argue or tell the resident that they are wrong when he/she is upset;-The resident is at risk for aggression, anxiety cannot make decisions; delusions (fixed false beliefs, that can't be reasoned with), hallucinations (hearing, seeing, feeling, smelling things that are not there) and irritability due to schizophrenia;-On 11/28/25 the resident was involved in a physical altercation with another peer resulting in the resident sustaining injuries. Review of the resident's progress note, dated 11/28/25 at 10:33 P.M., showed the following:-Code [NAME] (behavioral emergency) was called on Resident #1 and another resident. When staff arrived, the resident was on the floor and the other resident (Resident #2) was already removed from the situation by staff. The resident was immediately assessed and had red marks on the left side of his/her forehead, right elbow slightly red with no swelling at the present time. Rates pain in his/her right elbow an 8, on a 0 to 10 scale with 10 being the worse possible pain. The resident said he/she was unable to bend his/her right elbow. Received order to send out via transport for further evaluation. Review of the resident's emergency department discharge instructions, dated [DATE] at 5:13 A.M., showed the following:-Diagnosis of nondisplaced spiral fracture of shaft of right humerus;-Orthopedics will call you to schedule a follow-up appointment to evaluate the arm fracture further and discuss surgery. During an interview on 12/3/25 at 2:20 P.M., Resident #1 said the following: He/She and Resident #2 got into it over trading a cigarette for a soda;-He/She was on the hall and the next thing he/she was on the floor. Resident #2 shoved him/her to the ground and stomped on his/her head;-His/Her right arm was broken, and he/she had to have surgery. 2. Review of Resident #2's undated face sheet showed the following:-admission date of 10/1/25;-Diagnoses included schizophrenia, hallucinations (an experience involving the apparent perception of something not present), anxiety disorder and impulse disorder (a condition that affects the ability to control impulses and behaviors). Review of the resident's Preadmission Screening and Resident Review, dated 1/20/25, showed the following:-Historical and current psychiatric diagnoses included Bipolar I disorder, mixed, schizoaffective disorder, schizophrenia, obsessive-compulsive disorder, unspecified psychosis, anxiety, depressive disorder, obsessive control disorder (a disorder characterized by unwanted thoughts and fears), PTSD and mood disorder (a mental health condition affecting your persistent emotional state);-Recent aggressive/threatening behavior to family members making verbal threats, hallucinations. Barricaded self in room when the police arrived. Incident three weeks ago in which he/she tried to strike a nurse, when public safety officers intervened, he/she put one of them in a choke hold. Continues to be agitated at times, slams doors, kicked a window. No physical aggression to peers, continues to be verbally abusive to staff at times;-Overt behaviors include refuses medication, verbally abusive and threatening, cursing/swearing, physically threatening, strikes others unprovoked, and suspicious of others;-Individual's limitations include poor insight and judgement, history of poor impulse control, history of aggressive behaviors;-History of aggression, homicidal ideations, suicidal ideations, self-injurious behaviors, impulsive, limited insight, poor judgement, and poor decision-making skills. Review of the resident's progress note completed by Licensed Practical Nurse (LPN) J, dated 11/28/25 at 10:30 P.M., showed the following:-Staff called a Code [NAME] on the resident. When writer arrived, Resident #1 was laying on the floor and Resident #2 was already removed from the incident for safety by staff. LPN J was informed that Resident #2 pushed Resident #1, open handed, causing him/her to fall and Resident #2 hit Resident #1 in the head with his/her foot. Review of the resident's care plan, dated 11/29/25, showed the following:-The resident was a risk for aggression, anxiety, delusions, hallucinations and irritability. Avoid arguing or getting defensive with the resident. Always be respectful, honest and non-judgemental with the resident. During an interview on 12/3/25 at 4:30 P.M., Nurse Aide (NA) L said the following:-On 11/28/25 he/she was taking a break when a Code [NAME] was called on his/her walkie on the 100 and 200 hall where he/she was assigned to work; -He/She responded to the Code [NAME] and saw Resident #1 on the floor and Resident #2 kicking him/her in the head. During an interview on 12/4/25 at 10:15 A.M. NA I said the following:-On 11/28/25 around 10:30 P.M. he/she was completing room checks on the 200 hall and heard a commotion; -He/She headed up the hall quickly and observed Resident #2 pushing Resident #1 in the chest and Resident #1 fell to the floor; -He/She called a Code [NAME] on the walkie talkie as he/she was approaching the altercation;-NA L arrived at the Code [NAME] about the same time he/she (NA I) did. NA K showed up too, but NA I was not sure where he/she was located;-Resident #2 started stomping on Resident #1's head and arm as NA I approached;-He/She and NA L pulled Resident #2 off Resident #1. During an interview on 12/4/25 12:25 P.M., LPN J said the following:-He/She was working on 11/28/25 when the altercation took place between Resident #1 and Resident #2;-Around 10:30 P.M. a Code [NAME] was called, and he/she responded;-He/She assessed Resident #1 and observed red marks on his/her left forehead, his/her right elbow was red and swollen and he/she rated pain to the elbow;-He/She notified administration, and the facility van transported Resident #1 to the local hospital for evaluation and was later transported by ambulance to another hospital for evaluation by an orthopedic specialist due to his/her right arm fracture. During an interview on 12/4/25 at 1: 20 P.M., the Director of Nursing said the following:-The physical altercation between the two residents was considered abuse;-Staff were not aware of the issue with the two residents trading items until after the physical altercation occurred;-Resident #1's arm was fractured, and he/she was scheduled to have surgery to repair the fracture. During an interview on 12/4/25 at 1:15 P.M., the Administrator said the following:-Resident #1 and Resident #2 were in a physical altercation;-What occurred between Resident #2 and Resident #1 was considered abuse;-Resident #2 was placed on one on one monitoring and Resident #1 was sent to for a medical evaluation of his/her arm;-Resident#1's arm was broken. Intake ID: 2680751

Based on observation, interview, and record review, the facility failed to ensure one resident, (Resident #2), in a review of seven sampled residents, was free from abuse when Resident #3 attempted to strike Resident #2, then grabbed Resident #2 by the hair and pulled him/her to the ground causing Resident #2 to strike her head on the ground, and then striking the resident in his/her side. Resident #2 was sent to the emergency room for a closed head injury after he/she developed a large knot on his/her head. The resident experienced headaches, a bruised knot on his/her forehead, a black eye, a bruise on his/her right hip, and rib pain. The facility census was 176. The administrator was notified of the past noncompliance on 12/04/25, which occurred on 11/12/25. After the incident on 11/12/25, the facility put Resident #3 on one-on-one monitoring, initiated an investigation, and began in-servicing staff on abuse. The facility continued staff inservicing before staff started their next shift. This deficiency was corrected on 11/16/25.Review of the facility's Abuse and Neglect Policy, last revised 06/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident and resident to resident altercations;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner;-Physical abuse also includes but is not limited to hitting, slapping, punching, biting, and kicking. 1. Review of Resident #2's Preadmission Screening and Resident Review, dated 09/14/21, showed diagnoses including watershed brain damage (occurs when blood flow is reduced or blocked in the border zones between the major arteries supplying the brain) from seizures at the age of five years old, bipolar disorder (periods of mania and depression), anxiety, impulse control disorder, major depressive disorder, attention deficit and hyperactivity disorder (ADHD), oppositional defiant disorder (ODD is a condition where a person is defiant/argumentative), borderline intellectual functioning (having a low IQ); Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 04/13/25, showed the following:-Cognitively intact;-Moderate symptoms of depression;-No hallucinations, delusions, behaviors, or rejection of care;-Required supervision from staff for Activities of Daily Living (ADL). Review of the resident's Care Plan, updated 04/22/25, showed the following:-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-Behaviors include anxiety, poor decision-making, bad judgement, depression, agitation, and suicidal ideation.Review of the resident's Nursing Progress Notes, dated 11/12/25, at 10:49 P.M. and 10:55 P.M., showed the following:-Resident was sitting at the table next to him/her (LPN E) when a peer came up and reached his/her hand in the resident's pocket and start calling out Resident #2's name saying he/she stole peer's $3.00 and wanted it back immediately;-The resident's peer said the resident has stolen his/her money. The peer called the resident a bitch and walked away;-The resident called the peer a racial slur as Licensed Practical Nurse (LPN) E stood in the middle of the residents;-The peer reached around LPN E and grabbed the resident by his/her hair and pulled him/her to the ground;-The resident got up and had a hematoma on the resident's left temple. New skin issue #001: left temporal area, hematoma (a solid swelling of clotted blood within the tissues), measures 4 centimeters (cm) in length and 3 cm in width. New skin issue #002 rear right trochanter (hip), bruising 2 cm in length, and 1 cm in width. Review of the resident's Nursing Progress Notes, dated 11/12/25, at 11:15 P.M., showed the following:-Pain issue: left temporal area;-Pain score: 7 out of 10 (10 being worst pain), aching. Review of the resident's Nursing Progress Notes dated 11/12/25, at 11:25 P.M., showed the resident was sent to the emergency room for complaints of pain to the head from a physical altercation. Review of the resident's emergency room Nurse Notes, dated 11/13/25, at 1:02 A.M., the resident presents with complaints of a severe headache after a fall, being pushed by another resident. Resident complains of headache on the left and describes, as the worst ever. Review of the resident's Radiology CT (computerized tomography scan) head without contrast Report, dated 11/13/25, at 2:03 A.M., showed left temporal scalp acute hematoma. Review of the facility's Admin/Registered Nurse Investigation, dated 11/13/25, at 1:36 A.M., showed the following:-On 11/13/25 (should be 11/12/25 typo by facility) at 9:00 P.M., there was an incident of physical aggression involving head;-Resident #2 and Resident #3 were involved in the incident;-LPN E and Nurse Aide (NA) F witnessed the incident;- Resident #3 reports he/she was in his/her room with Resident #7 and Resident #2. Resident #7 gave Resident #2 $10.00 to get breakfast the next morning. Resident #7 then gave Resident #3 $3.00 for cigarettes for the next day. Resident #3 put $3.00 on the table and left the room. When Resident #3 returned, the $3.00 was gone. Resident #7 told Resident #3 Resident #2 had just been in his/her room. Resident #3 went to Resident #2 and asked where his/her money was. Resident #2 denied having the $3.00. Resident #3 then searched Resident #2's pockets. Resident #3 said Resident #2 told Resident #3, I don't have your money again, bitch. Resident #3 then pulled Resident #2 to the ground and Resident #2 on his/her side. LPN E was between the residents when Resident #3 tried to strike Resident #2 the first time. When LPN E was in Resident #3's way, Resident #3 grabbed Resident #2 by the hair, and swung him/her to the ground. Review of LPN E's written statement, dated 11/12/25, showed the following:-Resident #3 stood behind Resident #2. Resident #3 started yelling at Resident #2, saying he/she stole his/her $3.00. Resident #3 tried to reach in Resident #2's pockets. Resident #3 was told to stop and back away; he/she was name calling Resident #2. Resident #2 started calling Resident #3 names back and Resident #3 went to swing at Resident #2. LPN E stood in the middle of both residents to prevent any injuries or physical resident-to-resident (contact). Resident #3 reached around and grabbed Resident #2 by the hair, slung him/her to the ground and hit him/her in the rib area. LPN E hovered over Resident #2 to prevent any more physical aggression and told Resident #3 to back up and leave. Resident #3 backed away and walked down the hall. LPN E stayed hovering over Resident #2 until he/she felt it was safe to get Resident #2 up. Once he/she got Resident #2 up he/she noted the resident had a knot on the left temple area. Review of Nurse Aide (NA) F's written statement, dated 11/12/25, showed he/she was in the common area, heard a commotion and saw Resident #3 reaching in Resident #2's pocket demanding $3.00. LPN E went to get between the residents. At the same time, he/she went to assist. Before he/she was able to reach them Resident #3 was able to grab Resident #2's hair and pull the resident to the ground. Review of Resident #2's written statement, dated 11/12/25, showed he/she was sitting at the table when Resident #3 came up and said, I know you stole my money, where's my money bitch? LPN E was in the middle between him/her and Resident #3. Resident #3 put his/her hands in Resident #2's pockets. Resident #3 reached around LPN E and grabbed Resident #2 by the hair and swung him/her down to the ground. During an interview on 11/16/25, at 3:39 P.M. and 4:45 P.M. and 11/18/25 at 11:40 A.M., Resident #2 said the following:-Resident #3 attacked him/her because he/she thought Resident #2 took his/her $3.00;-LPN E got between the two of them and Resident #3 reached over LPN E to hit Resident #2, but LPN E blocked most of it;-Then Resident #3 reached around LPN E and pulled him/her by the hair to the ground;-The resident hit the floor really hard;-Resident #3 also hit him/her in the side and hit his/her hip which was now bruised;-His/Her ribs hurt, and he/she thought they were broken because Resident #3 hit him/her in the side. During an interview on 11/16/25, at 1:30 P.M., Resident #3 said the following:-He/She tried to hit Resident #2, but staff was in the way;-He/She grabbed Resident #2 by the hair and pulled the resident to the floor; once Resident #2 was on the floor he/she struck the resident in the side;-He/She attacked Resident #2 because he/she thought Resident #2 stole his/her $3.00. Review of Resident #12's written statement, dated 11/14/25, showed he/she took Resident #3's $3.00. He/She didn't think Resident #3 would put hands on Resident #2. Observation on 11/16/25, at 3:39 P.M., showed Resident #2 with half dollar sized knot on the left temporal region of his/her forehead with purple spots in the center of the knot, yellow discoloration was present on his/her forehead from the knot down to his/her left eye. The resident's left eye is bruised dark purple on his/her eye lid from the edge of the eye lid to the eyebrow, and dark purple under the residents left eye approximately 1.5 cm. Observation on 11/18/25, at 11:45 A.M., showed the resident's right hip with a large bruise with a dark purple oval area, surrounded by green and yellow discoloration. The area was the size of the resident's palm and oval in shape. No discoloration was noted on the resident's left ribs, but he/she said they were sore. 4. During an interview on 11/16/25, at 3:15 P.M. the Assistant Administrator (AADM) said Resident #3 grabbed Resident #2 by the hair and pulled Resident #2 to the ground. This was witnessed by staff and an investigation was completed by himself and the Administrator. During an interview on 11/17/25, at 10:16 A.M., and 11/18/25, at 11:30 A.M., the Administrator said Resident #3 grabbed Resident #2 by the hair and pulled Resident #2 to the ground. This was witnessed by staff and an investigation was completed by himself and the Assistant Administrator. They did not think Resident #3 was truly trying to harm Resident #2. When Resident #3 pulled Resident #2 to the ground by his/her hair, Resident #3 could have hit Resident #2 in the face, but he/she restrained himself/herself. Resident #3 could have hurt Resident #2 and struck him/her in the face, but he/she did not. Complaint #2669277

Based on observation, interview, and record review, the facility failed to ensure one resident with mental disorders (Resident #3) of 22 sampled residents, received individualized treatment and services to meet the resident's needs. The facility failed to implement interventions consistent with Resident #3's plan of care to address his/her behaviors and psychosocial needs. The resident refused medications off and on for a few months and became easily irritated and aggressive. This resulted in verbal and physical altercations with other residents. On 8/10/25, the resident threatened a staff member and another resident got involved. A physical altercation occurred between the two residents and Resident #3 sustained a fracture of the medial orbital wall (eye socket nearest the nose) on the right side. Staff failed to consistently identify the root cause for the resident's behaviors and implement interventions to meet the resident's psychosocial needs. The facility census was 174.Review of the facility policy Behavioral Health Services, dated 10/13/24, showed the following:-The purpose of the policy is to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;-Mental disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities;-Non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being;-Behavioral health encompasses a residents' whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders;-The facility must ensure behavioral health services are provided;-The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Conditions that are frequently seen in residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to depression, anxiety and anxiety disorders, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves that can cause hallucinations, delusions and disorganized thinking including paranoia), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs);-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Staff will monitor the resident closely for expression or indication of distress, evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable; assess and develop a person-centered care plan for concerns identified in the resident's assessment, share concerns with the Interdisciplinary Team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis, accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record, ensure appropriate follow up assessments if needed, and evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-The care plan shall have interventions that are person-centered, evidence based, trauma informed, and in accordance with professional standards of practice;-Non-pharmacological interventions include exercise, individualizing sleep and dining routines, supporting the resident through meaningful activities that match his/her individual abilities, interests and needs, focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities, offering verbal reassurance, especially in terms of keeping the resident safe and acknowledging the resident's experience is real to him/her, assisting residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem solving therapy, and providing support with skills related to verbal de-escalation, coping skills, and stress management. 1. Review of Resident #3's undated face sheet showed the resident had diagnoses that included insomnia (inability to sleep) due to other mental disorders, unspecified psychosis (a mental state where a person loses contact with reality, experiencing symptoms like hallucinations (seeing or hearing things not there) and delusions (false beliefs), along with disorganized thinking and speech) not due to a substance or known physiological condition, generalized anxiety disorder, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder, depressive type (a combination of symptoms of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and mood disorder, such as depression). Review of the resident's Preadmission Screening and Resident Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 11/15/19, showed the following:-The resident had a serious mental illness;-The recommended services were to implement plans to change inappropriate behavior, provision of a structured environment, drug therapy and monitoring, and crises intervention services;-Current psychiatric diagnoses of schizophrenia and schizoaffective disorder;-The resident was put under guardianship when he/she tried to poison a family member and walked around with a machete;-The resident had sleep disturbances, decreased concentration, isolation, grandiosity, anhedonia (inability to experience joy or pleasure), intrusive thoughts, hallucinations, thought disorganization, thought blocking, delusions, and paranoia;-The resident did not make good decisions, did not follow complex directions, could not stay on task or complete assignments;-The resident was dependent on staff for medication monitoring;-The resident had very little insight and he/she was in complete denial of his/her issues;-The resident should be monitored in a skilled nursing facility for refusal of food, refusal of cooperativeness with activities of daily living (ADLs), increase isolative behaviors, anger outbursts, and an increase in paranoia/psychosis that may signal an exacerbation of his/her illness. Promptly report to the resident's psychiatrist;-The resident should be monitored for the following; medication administration, address, report and implement a plan to manage the resident's refusal or noncompliance;-A secured unit was recommended. Review of the resident's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/13/25, showed the following:-The resident was cognitively intact;-The resident had moderate depression;-The resident had no verbal, physical or other behaviors toward others;-The resident had no delusions or hallucinations;-The resident did not reject cares. Review of the resident's Physician Order Sheet (POS) showed the following orders:-Ariprprazole 10 milligrams (mg) for schizophrenia two times a day at 7:00 A.M. and 4:00 P.M., start date 10/28/24;-Buspirone 20 mg for general anxiety three times a day at 7:00 A.M., 11:00 A.M., and 4:00 P.M., start date 10/28/24;-Melatonin 3mg for insomnia due to other mental disorders in the evening, start date 3/16/25; -Quetiapine 50 mg for schizophrenia in the evening, start date 3/16/25;-Trazodone 50 mg for insomnia due to other mental disorders in the evening, start date 3/16/25. Review of the resident's Psychiatric Nurse Practitioner's note, dated 6/28/25, showed the following:-The resident was seen for follow up management of schizophrenia and anxiety;-The resident refused medications per the staff and refused care at times;-The resident reported to the Psychiatric Nurse Practitioner he/she was poisoned at his/her last visit to the hospital. The resident was responding to internal stimuli;-The resident was anxious, irritable/angry;-The resident had increased hallucinations, worsened delusions, fair to good judgement and limited to poor insight. Review of the resident's Medication Administration Record (MAR), dated 7/14/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 7/17/25, showed the resident did not exhibit any behaviors. Review of the resident's progress note, dated 7/19/25, showed the following:-A behavior symptoms and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's MAR, dated 7/20/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 7/22/25, showed the following:-The staff heard the resident yelling at his/her roommate in their room;-Staff responded immediately. The roommate sat on his/her bed and Resident #3 said the roommate stood at his/her bedside;-A proactive Code [NAME] (an overhead page that alerted staff a resident was having a behavioral emergency) was called because Resident #3 continued to yell and scream;-Resident #3 and his/her roommate were separated. Resident #3 was calmed down by staff. The roommate requested to move to another room;-No further concerns and no physical contact were made by either resident;-There was no documentation staff notified the Director of Nursing (DON), Administrator, physician, or guardian. Review of the resident's MAR, dated 7/23/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR, dated 7/24/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 7/26/25 at 4:38 A.M., showed the following:-A behavior symptom and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's progress note, dated 7/26/25 at 3:00 P.M., showed the following:-A Code [NAME] was called about 3:00 P.M.;-Resident #3 made verbal threats towards another resident because the other resident stared at Resident #3 and then he/she pushed the other resident;-The two residents were separated;-Resident #3 was redirected but he/she made delusional and irrational statements, had a loss of cognitive thought, paced back and forth, and continued to make verbal threats toward the other resident;-The psychiatric physician was called, and an order obtained to send the resident to the hospital for evaluation;-The resident left the facility about 6:00 P.M. Review of the resident's progress notes showed no documentation the resident returned to the facility, or if there were any new orders received, that staff completed an assessment of the resident or staff provided any additional monitoring of the resident upon return to the facility. Review of the resident's progress note, dated 7/27/25 at 11:13 A.M., showed the resident refused to meet with the Interdisciplinary Team (IDT) and no other attempts were made to meet with the resident. Review of the resident's MAR, dated 7/28/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record the staff notified the physician resident refused medication. Review of the resident's care plan, dated 7/30/25, showed the following:-The resident displayed impaired thought process related to mental illness;-Administer medications as ordered;-Intensive monitoring per unit protocol to ensure protective oversight;-Physician/psychological consult as needed;-Provide one-on-one visits as needed/requested for verbalization of feelings and concerns related to room, roommate, unit, and placement and attempt to resolve areas of upset promptly as needed/able;-The resident was at risk for alteration in mood/behavior related to schizophrenia. He/She had a history of auditory and visual hallucinations, delusional thoughts that his/her food was being poisoned, paranoid/angry, physically threatening, poor hygiene and medication noncompliance;-Attempt to redirect negative behavior to more positive behavior choices;-Monitor mood/behavior changes, report to physician as needed;-Notify guardian, physician, administration if behavioral emergencies occur;-The resident preferred morning medications administered at 11:00 A.M., evening medications administered at 4:00 P.M. and evening medications administered at 11:00 P.M.;-The resident had a history of behavioral challenges that require protective oversight in a secure setting;-Coping skills were sleeping, watching TV, and listening to music;-Non-pharmacological interventions were one-on-one as needed, listening to music, Xbox, outdoor activities, alone time in his/her room, and smoking;-Pharmaceutical interventions as needed;-The resident's safety plan included: warning signs are starting to get angry, review medications with the resident to ensure he/she understood what medication he/she took and why, review the symptoms of his/her diagnoses to ensure that the resident understood them and may be able to identify them, review the resident's diagnosis and provide education if he/she didn't understand, movies are a distraction and a method of comfort, the resident liked to read to expand his/her learning and work toward goals, exercising worked in the past during a crisis moment;-Closely watch the resident for signs of anxiety and act before he/she lost control;-Staff should avoid the following triggers; too much stimuli, yelling, verbal threats from peers, being told no, taking accountability, being told what to do, and having to clean his/her room;-The resident displayed manifestations of behaviors related to his/her schizophrenia that may create disturbances that affect others;-Assist the resident to address the root cause of change in his/her behavior or mood as needed;-Resident was listed as part of the focus interviews with administration; Review of the resident's progress note, dated 7/31/25 showed the following:-A proactive Code [NAME] was called;-Resident #3 was upset with another resident about a lost speaker and a phone that Resident #3 had traded;-Environmental rounds were completed and the phone and speaker found and given back to Resident #3;-No more concerns;-There was no documentation staff notified the DON, Administrator, physician, or guardian. Review of the resident's progress note, dated 8/1/25, showed the following:-During a care plan meeting the resident walked out of the meeting because he/she did not get approved to leave the facility;-There was no documentation staff attempted to talk to the resident about being upset or attempted to help the resident calm down and use his/her coping skills. Review of the resident's MAR, dated 8/1/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/2/25, showed the following:-A behavior symptom and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's MAR, dated 8/2/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR dated 8/5/25, showed the following:-Aripiprazole was on order and not available for administration; -The resident refused to take buspirone 20 mg at 11:00 A.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR, dated 8/6/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, entered on 8/13/25 at 4:25 A.M. as a late entry, for a Code [NAME] that occurred on 8/7/25, showed the following: -Licensed Practical Nurse (LPN) C responded to a Code [NAME] for Resident #3;-When LPN C arrived, Resident #3 paced on the hall and the other resident was behind closed double doors in the TV/dining room;-LPN C tried to calm Resident #3 down. Resident #3 was upset because the other resident changed the channel on the TV;-Resident #3 yelled at staff, went to his/her room, and slammed the door;-Ten minutes later Resident #3 was in the dining room to eat dinner and showed no aggression;-There was no documentation staff notified the DON, Administrator, physician, or guardian. Review of the resident's progress notes, dated 8/7/25 at 4:40 P.M. as a late entry, showed the following:-Resident #3 was the aggressor in an incident;-Staff asked the resident if he/she felt safe, and the resident said yea;-Staff asked the resident if he/she needed to talk with someone, and the resident said no;-Staff asked the resident if he/she could name at least one staff member the resident felt safe to share his/her thoughts and the resident said none of you;-Staff asked the resident if he/she had any aftereffects from the incident and the resident said No, leave me alone. I am going to my room;-Staff asked the resident if he/she had any other needs/items that he/she would like addressed and the resident said no. Review of the resident's MAR, dated 8/7/25, showed the following: -The resident refused to take aripiprazole 10 mg at 7:00 A.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/8/25, showed the following:-A behavior symptoms and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's MAR, dated 8/8/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take Trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR, dated 8/9/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/10/25, showed the following:-A Code [NAME] was called on Resident #3;-Resident #3 threatened CMT R and said he/she was going to hit CMT R and walked towards the CMT;-Resident #4 told Resident #3 to calm down and that is when Resident #3 went towards Resident #4 and swung at him/her. Resident #3 did not make contact with Resident #4. Resident #4 swung and hit Resident #3 in the right eye;-Resident #4 was escorted off the hall;-Resident #3 was assessed but refused a complete skin assessment;-Resident #3 was sent to the hospital about 3:30 P.M. for a psychiatric evaluation. Review of the resident's Psychiatric Nurse Practitioner's note, dated 8/10/25, showed the following:-The resident was seen for follow up management of schizophrenia and anxiety;-The resident was paranoid, delusional, physically aggressive and refused medications;-The resident denied mental illness diagnosis, reported no insight into his/her psychiatric condition and was a poor historian;-During evaluation the resident responded to internal stimuli and displayed overt paranoia and delusional thinking;-After the Psychiatric Nurse Practitioner left the resident's unit, staff reported Resident #3 approached Certified Medication Technician (CMT) R in an aggressive manner. The resident yelled and accused CMT R of poisoning another resident;-Another resident attempted to de-escalate the situation and Resident #3 swung at the other resident. The other resident swung and hit Resident #3 above the right, upper eyelid;-Due to continued acute psychosis, poor insight, noncompliance with medication, and escalating aggression toward staff and residents, Resident #3 was transferred to the hospital for further stabilization;-The resident's refusal of all prescription medications contributed to an acute psychiatric decompensation. His/Her current symptoms were paranoia, delusions, responding to internal stimuli, and impaired judgement;-The resident's conditions and symptoms showed imminent intent (a situation where there's a significant possibility that serious physical or mental harm, death, or severe injury could occur at any moment), increasing hallucination, worsened delusions, and deterioration. Review of the resident's hospital discharge note, dated 8/10/25 at 5:59 P.M. showed the resident had a fracture of the medial orbital wall (eye socket nearest the nose) on the right side. Review of the resident's MAR, dated 8/10/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/11/25 at 2:00 A.M., showed the resident returned to the facility. The hospital reported a fracture to the resident's right orbital lobe (eye socket). Review of the resident's progress note, dated 8/11/25 at 9:36 A.M., showed the following:-The DON spoke with the resident about medication refusals and the incident from the weekend;-The resident's right eye was purple and swollen;-The resident was calm when the DON educated him/her on the importance of taking his/her medication;-The resident did not make sense when he/she answered the DON's questions;-The DON asked the resident to take his/her morning medication and the resident said he/she did not need to take them all the time because there was nothing wrong with him/her and he/she had no psychological issues;-The resident stopped talking to the DON. Review of the resident's progress note, dated 8/11/25 at 11:36 A.M., showed the resident was sexually inappropriate with the couch and was educated on appropriate behavior. Review of the resident's progress note, dated 8/11/25 at 12:49 P.M., showed the guardian was notified by email and in person of the resident's medication refusals. Review of the resident's progress note, dated 8/11/25 at 3:30 P.M., showed the following:-Resident #3 was the aggressor in an incident;-Staff asked the resident if he/she felt safe, and the resident refused to answer;-Staff asked the resident if he/she needed to talk with someone, and the resident refused to answer;-Staff asked the resident if he/she could name at least one staff member the resident felt safe to share his/her thoughts and the resident said leave me alone;-Staff asked the resident if he/she had any aftereffects from the incident and the resident said leave me alone;-Staff asked the resident if he/she had any other needs/items that he/she would like addressed and the resident said, leave me alone. Review of the resident's progress note, dated 8/11/25 at 3:34 P.M., showed the following:-The IDT attempted to meet with the resident about the incident that took place with him/her and Resident #4 and Resident #3's medication refusals;-Resident #3 told the IDT he/she did not have any psychological diagnoses and therefore he/she did not need any medication;-The facility will continue to attempt medication administration. Review of the resident's care plan, dated 8/11/25, showed the following:-The resident had a physical altercation where he/she was the aggressor;-The resident was one-on-one until he/she was sent to the hospital;-Allowed time for resident to vent and verbalize feelings;-The resident was educated on appropriate behavior and social skills;-The resident randomly refused medications, not with a particular staff member. He/She said they poison him/her and the resident only needed to take them sometimes because he/she was not a psychotic. The resident said the physician said he/she did not have to take his/her medications;-The resident was offered counseling and refused;-No as needed medications were utilized. Observation of Resident #3 on 8/11/25 at 3:58 P.M. showed the following:-The resident had a swollen right eye with purple bruising extending around his/her eye, to above the eyebrow and onto his/her nose;-The resident had about a quarter inch size cut on his/her left lower lip. During an interview on 8/11/25 at 3:58 P.M., Resident #3 said the following:-He/She tried to turn in an inhaler to CMT R;-CMT R got upset because he/she knew a physician wouldn't let CMT R touch the inhaler;-Resident #4 hit him/her in the face and Resident #4's twin stepped on his/her belly and tried to rip it open (Resident #4 did not have a twin in the facility). Review of the resident's MAR, dated 8/11/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record the staff notified physician the resident refused medication. Review of the resident's progress note, dated 8/12/25 at 11:07 A.M., showed the following:-The IDT met with the resident;-The resident expressed delusions. Review of the resident's MAR, dated 8/12/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M. Review of the resident's progress note, dated 8/12/25 at 2:50 P.M., showed the following:-The facility received notice the resident was accepted for an inpatient psychological evaluation;-Staff informed the resident and he/she immediately became aggressive. The resident was very delusional and talked in different voices;-The resident did finally agree to go to the hospital and left with a driver and two other staff members. During an interview on 8/12/25 at 9:34 A.M. Resident #4 said the following:-He/She and Resident #3 had each other by the shirt and swung at each other;-He/She hit Resident #3;-He/She did not have a problem with Resident #3, he/she just defended himself/herself. During an interview on 8/13/25 at 8:30 A.M. Nursing Assistant (NA)/Housekeeper I said the following:-Resident #3 has cussed NA I out and not let him/her clean Resident #3's room;-When Resident #3 did not take his/her medications, he/she yelled, cussed, would not let housekeeping clean his/her room and walked down the hallway and randomly hit others. During an interview on 8/13/25 at 8:41 NA H said the following:-Resident #3 acted aggressive and snapped at the littlest of things on 8/4/25;-Resident #3 got upset when Resident #15 kept changing the channel on the TV;-Resident #14 stood up and took off his/her jacket and Resident #3 thought Resident #14 was going to hit him/her;-NA S walked Resident #14 to his/her room and Resident #3 followed but nothing happened between them;-Resident [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure one resident, Resident #5, in a review of 17 sampled residents, was free from abuse when staff physically took the resident down to the ground and caused injury. The resident sustained injuries including a bruised chin, a swollen sprained right ankle, and bruising to the right knee. The resident felt staff abused him/her. The facility census was 177. Review of the facility's Abuse and Neglect Policy, last revised 06/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident and resident to resident altercations;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner;-Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment, or management;-Physical abuse also includes but is not limited to hitting, slapping, punching, biting, and kicking;-Physical abuse also includes corporal punishment, which is physical punishment used to correct or control behavior. Review of the facility's policy Behavioral Emergency Policy, dated 06/26/24, showed the following:-The facility is to provide safe treatment and humane care to the resident in a behavioral crisis;-Staff is to follow steps to ensure they correctly care for the resident in a behavioral crisis to ensure that the resident is not being coerced, punished, or disciplined for staff convenience;-Any emergency interventions have the potential for (re)traumatizing individuals;-Despite best intentions, decisions concerning the use of physical holds, and the administration of medication are necessarily made under less-than-ideal circumstances (i.e., emergencies), and involve the urgent weighing of significant risks versus the benefits of physical safety;-Therefore, such emergency interventions as the use of physical holds and the administration of medication are to be avoided as possible.-Use of physical holds and the administration of medication is seen as a safety intervention of last resort, rather than a treatment intervention per se, and its usage should be a crisis event;-An organizational philosophy of giving the highest priority to all non-violence is to be articulated in all policies, procedures, and practices;-Practices that are sensitive to those with a history of trauma are to be in place;-Non-Physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention;-The facility's approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible;-Care will be guided by the resident's plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. Review of the facility's Crisis Assessment Linkage and Management (CALM) training manual, undated, showed the following:-Before beginning a discussion on the use of restraints it is important to consider the potential negative outcomes;-When it becomes necessary to physically control a client, the risk of physical and emotional trauma to both the resident and staff member was significant;-Without question the therapeutic relationship would suffer;-Careful consideration was necessary before involving the use of restraints;-Methods to prevent the use of restraint needed to be included in the policies as well as the expected behaviors of staff members;-Control positions, Seclusion or Restraint are never to be used for punishment. Review of the facility's Crisis Prevention Institute (CPI) training manual, dated 2023, showed the manual included no direction for staff to physically take a resident to the floor. 1. Review of Resident #5's Preadmission Screening and Resident Review, dated 09/14/21, showed the following:-Diagnoses included watershed brain damage (occurs when blood flow is reduced or blocked in the border zones between the major arteries supplying the brain) from seizures at the age of five years old, bipolar disorder (periods of mania and depression), anxiety, impulse control disorder, major depressive disorder, attention deficit and hyperactivity disorder (ADHD), oppositional defiant disorder (ODD is a condition where a person is defiant/argumentative), borderline intellectual functioning (having a low IQ);-The resident had self-harming behaviors and was aggressive with staff;-The resident has poor impulse control;-The resident can be verbally and physically aggressive towards the staff and others and required supervision;-The resident required behavioral therapy two times per week;-The resident required a Crisis Plan that should identify clear steps that will be taken to support individual during a crisis, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services and/or law enforcement should be contacted.-The facility may also wish to utilize DMH Behavioral Health Crisis Hotline: https://dmh.mo.gov/mentalillness/progs/acimap.html Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 04/13/25, showed the following:-Cognitively intact;-Moderate symptoms of depression;-No hallucinations, delusions, behaviors, or rejection of care;-Required supervision from staff for Activities of Daily Living (ADL);-Resident was 63 inches in height and weighed 139 pounds. Review of the resident's Care Plan, updated 04/22/25, showed the following:-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-Can be verbally and physically aggressive;-CALM technique, if needed;-Coping skills included karaoke, bingo, yoga, and calls from family;-Non pharmaceutical interventions: One-on-one;-Pharmaceutical interventions as needed;-Behaviors include anxiety, poor decision-making, bad judgement, depression, agitation, and suicidal ideation;-If you see the resident exhibiting any behaviors listed in the current behaviors section, refer to preferred coping skills immediately;-Warning signs for the resident included the resident may start popping off at the mouth, saying I don't care, saying mean things to hurt others;-His/Her crisis moments are triggered when he/she was told no;-The resident can be distracted and comforted with sleeping, playing cards, or taking a shower;-The resident can expand his/her learning and work toward his/her goals by listening and coping;-During past crisis moments listening to music and watching the Golden Girls helped the resident;-Coping skills included watching television, listening to music, taking naps, word searches, and talking to his/her parent. Review of a facility surveillance video from 07/16/25 of an incident with the resident and staff showed the following:-The resident is seen standing and not showing signs of agitation; the resident appeared calm. The resident was not moving his/her body or displaying any type of threatening behavior with his/her body. The resident stood still. There was no sound, but there was no indication the resident was yelling or resisting staff in any way;- Night Shift Supervisor (NSS) D stood on the resident's left side next to the resident and had his/her right arm under the resident's left arm, NA G stood on the resident's right side with his/her left arm under the resident's right arm;-NA F came up behind the resident, knelt and held the resident's left leg (placement of his/her hands was not visible on the video);-Licensed Practical Nurse (LPN) H stood behind the resident and was not touching the resident.-NSS D looked behind the resident and nodded to NA F, then turned his/her head back around and nodded again;-At this time NSS D, NA G, and NA F moving quickly, all with hands on the resident, took the resident face down to the floor. The resident's head and right leg were not secured or protected by staff;After NSS D, NA G and NA F took the resident to the floor, LPN H quickly moved toward the resident. Review of the resident's Physician's Order Sheet, dated 07/16/25, at 10:45 P.M., showed an order for Chlorpromazine 25 milligrams/milliliter, inject 25 milligrams intramuscularly every 24 hours as needed for increased agitation/irritation for 14 days. During an interview on 08/06/25, at 1:43 P.M., the resident's family member said he/she met the resident at his/her physician appointment on 07/17/25. When the resident arrived at the appointment, the resident had a large bruise on his/her chin. The physician asked the resident about it several times and the resident seemed afraid to answer. The resident kept saying he/she didn't know how it happened. The resident told him/her later that NSS D did it when he/she took the resident to the floor and that the resident's right leg and ankle hurt. Review of the resident's Nursing Progress Notes dated 07/19/25, at 1:44 P.M., showed the resident had a new bruise on his/her chin that was acquired in house, it was unknown how long it had been present. Observation on 07/19/25, at 11:30 A.M., showed the resident in his/her room. The resident had a quarter to half dollar sized purple bruise on his/her chin; his/her right ankle was swollen from the lower shin to halfway down the resident's foot, his/her malleolus (ankle bone) was not visualized because of the swelling and his/her shoe caused an indentation into his/her skin due to swelling. During an interview on 07/19/25, at 11:30 A.M. the resident said the following:-He/She was mad and threw the cigarette box on the floor;-Staff called a code green (behavioral emergency);-NSS D, NA F, NA G, and LPN H were there;-The resident said NSS D told him/her, I dare you to do it again, and so he/she threw the cigarette box on the floor again because it made him/her angry;-That made NSS D angry;-NSS D and NA F took him/her down to the ground;-He/She hit the ground hard;-Staff did not protect his/her head or right leg;-When he/she went down it hurt his/her chin, right leg, and ankle because they put him /her down hard and he/she hit the floor hard;-He/She felt like NSS D did the take down hard on purpose, like he/she tried to hurt him/her to teach him/her a lesson;-He/She felt staff did not try to prevent his/her injury and that they were abusive to him/her. During an interview on 07/19/25, at 11:40 A.M. Resident #6 said the following:-He/She saw staff take Resident #5 to the floor, but was not close enough to hear what staff said;-Staff slammed the resident to the floor;-Staff used excessive force, and they didn't do it the right way;-Staff did not have hold of Resident #5's head and did not have one of the resident's legs;-It was too rough. During an interview on 07/19/25, at 11:44 A.M. Resident #7 said the following:-He/She saw NSS D, LPN H, NA F, and NA G take Resident #5 to the ground;-It looked like Resident #5 hit the floor hard. During an interview on 07/21/25, at 4:05 P.M., NA G said the following:-On the night of 07/16/25 the resident got upset because he/she wanted to smoke another cigarette;-The resident threw the cigarette box off the medication cart;-The resident threatened to throw the cigarette box and was yelling, he/she did not hear the resident threaten staff or other residents, just to throw stuff;-Someone called a code green;-NSS D and LPN H responded, NA G and NA F were already there;-He/She did not hear anyone attempt to offer the resident any of his/her coping mechanisms but he/she could not hear everything;-NSS D instructed staff to take the resident down;-NSS D had the resident's left arm and he/she had the resident's right arm;-LPN H and NA F were behind him/her to get the resident's legs but he/she could not visualize their position;-They are supposed to have five staff members to do a proper take down but there were four, there was no staff to secure the resident's head;-The resident went down faster than he/she was used to and might have hit the ground harder compared to other times h/she had been involved in a takedown maneuver;-He/She and NSS D, LPN H, and NA G held the resident on the ground for one minute;-The resident had not made a threat against other residents or staff. During an interview on 07/21/24, at 7:40 A.M., NSS D said the following:-He/She was called to the unit for a code green;-Staff reported Resident #5 wanted another cigarette and was throwing things;-When he/she arrived on the unit the resident attempted to go back into the smoke room, so he stood in front of the door;-The resident threated to knock off the cigarette box again;-That is when he/she took the resident's left arm, NA G took the resident's right arm;-They did a five person procedure and took the resident face first to the ground;-They held the resident on the ground for about a minute until the resident calmed down;- NA F, NA G, and LPN H were the other staff that performed the take down with him/her; five employees were not available for the procedure;-The team lead was supposed to secure the resident's head, but they did not have five staff;-The resident had not threatened staff or residents, but had a history of physical behaviors so he felt like the resident needed to be taken down for safety;-LPN H should have had the resident's right leg, NA F was expected to have the resident's left leg;-He/She did not think the resident hit his/her chin on the floor;-During the code green he/she was the only one speaking to the resident;-He/She was not aware of the resident having any type of crisis program and did not know what the resident's care plan directed for de-escalating behaviors. During an interview on 07/19/25, at 2:26 P.M. the Assistant Administrator (AADM) said the following:-He reviewed the video of staff taking the resident to the floor on 07/16/25;-Staff did not report to administration the code green or that they had physically taken the resident to the ground;-Review of the video showed three staff touching the resident during the take down;-He felt like staff did not execute the CALM five person take down as instructed in CALM training;-Staff are supposed to use CPI techniques but all the training was not done. During an interview on 07/19/25, at 3:07 P.M., and 07/24/25, at 10:25 A.M., the Administrator (ADM) said the following:-Staff had not reported the code green or take down;-NSS D said the resident had two cigarettes and wanted a third cigarette and, when staff denied the resident getting a third cigarette, the resident knocked the cigarette box off the medication cart;-NSS D made the call to take the resident to the ground;-LPN H then gave the resident an injection of Thorazine (antipsychotic medication);-Staff are expected to report code greens and use of physical and chemical restraints;-The staff did not report this incident to administration. Complaint #2565905 and #2570073

Based on observation, interview, and record review, the facility failed to follow physician's orders and administer medications for three residents (Resident #15, #12, and #17) in a review of 17 residents. Resident #15 had diagnosis of congestive heart failure (CHF) and missed several doses of medications for fluid retention prior to a hospitalization for fluid overload. Resident #12 experienced increased pain from missing ordered pain medications. The facility reported their pharmacy had not supplied the medications. Many of the medications were available in the facility's eKit (emergency medication supply), but staff did not use the available medications to ensure resident's received administration of ordered medications. The facility census was 177. Review of the facility's policy Transcription of Orders/Following Physician's Orders, dated 05/18/24, showed the following:-The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section;-The Licensed/Registered Nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. If the medication is not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication is unable to be started within 24 hours of the order, the prescribing physician will be notified, and further orders will be obtained. If a stat medication is ordered, the physician will be made aware of facility availability in the case that an alternative is needed;-The Licensed Nurse will review electronic Medication Administration Records (MARs) &electronic Treatment Administration Records (TARs) on a routine basis to monitor formedications that were not administered to the resident due to unavailability, refusal, omission, etc.-If a medication is marked as not given, the reasoning for not being given should beexplained in the progress notes and the RCC, the DON/ADON/RN, and the Administrator must be notified. The Physician and Legal Guardian (if applicable) must also be notified. The nurse's progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have.-For Electronic MARS/TARS: The medication will be documented as not given byselecting the corresponding chart code for the reason why it was not given, and aprogress note will be written.-If the medication is unavailable, the Licensed Nurse will contact the pharmacy and have the medication delivered. If the resident is not going to receive their scheduled medication per Physician's Order, the Licensed Nurse will contact the Director of Nursing, The Administrator, Physician and Legal Guardian, if applicable. The RCC/Unit Manager/Designated Nurse will then follow any further orders that may be provided by the Physician.-The facility may utilize a stat or emergency medication kit or back up pharmacy todeliver the medication to the resident before the primary pharmacy can deliver.-The Nurse or CMT in charge of medication administration must review all their designated MARs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physicians' order and that all necessary interventions were taken in the event of an omission.-The RCC/ Unit Manager/Designated Nurse will review all electronic MARs/TARs and compare all medications to the medications available for each resident in the facility weekly to ensure availability. Review of the facility's Emergency medication list (E-kit) inventory dated 07/24/25, showed the following available medications:- Bupropion (medication for depression) 75 milligram (mg) one on hand;- Cardizem (medication for blood pressure, irregular heartbeat) 30 mg six on hand-Clonazepam (medication for seizures and anxiety) 0.5 mg seven on hand;-Clonazapine (antipsychotic medication) 0 on hand;-Depakote Sprinkles (medication for seizures sometimes used as a mood stabilizer): DR 250 mg five on hand, ER 250 mg six on hand, ER 500 mg five on hand, sprinkles 125 mg six on hand and DR 500 mg seven on hand;-Farxiga (medication for heart failure, diabetes, and kidney failure) not available;-Furosemide (medication used to remove excess fluid) 20 mg eleven on hand;-Lyrica (medication used for nerve pain) 50 mg 15 on hand;-Metformin (medication used to control blood sugar) 500 mg seven on hand;-Metolazone (medication used to removed excess fluid) not available;-Montelukast (medication to treat seasonal allergies) not available;-Pantoprazole Sodium (medication to reduce stomach acid) not available;- Potassium (medication to replace potassium) 10 milliequivalent (mEq) six on hand;-Pravastatin (medication used to lower cholesterol) not available;-Spironolactone (medication which helps the kidneys remove excess salt and water from the body while retaining potassium) not available;-Sacubitril-Valsartan (medication used to treat congestive heart failure by reducing strain on the heart, and improved blood flow to the heart), not available;-Terazosin HCL (medication used for high blood pressure or enlarged prostate), not available;-Trazodone (antidepressant medication) 50 mg six on hand;-Vrayfar (antipsychotic medication for hallucinations, delusions, and mood stability), not available. 1. Review of Resident #15's Care Plan, updated 06/24/24, showed the following:-Resident is his/her own guardian;-Resident is highly functional and can take care of most of his/her needs;-Diagnosis include major depression, diabetes mellitus (inability to regulate blood sugar), high blood pressure, chronic ischemic heart disease, congestive heart failure;-Potential for fluid deficit related to diuretic (fluid medication) use;-Resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor;-Administer medications as ordered;-Monitor fluid intake and output per facility policy;-Monitor vital signs as ordered;-Notify physician of significant abnormalities;-Resident has impaired circulation related to edema;-Will be free from signs and symptoms of complications of poor circulation through next review. The resident's care plan did not include possible complications from fluid overload, or how to monitor fluid overload including giving diuretics as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/14/25, showed the following:-Cognitively intact;-Diagnoses included heart failure, high blood pressure, diabetes mellitus (inability to regulate blood sugar), depression, shortness of breath, swelling (edema), pain in ankle and foot, and chronic ischemic heart disease (a condition where the heart muscle doesn't receive enough blood flow due to narrowed or blocked coronary arteries); -Moderate to severe depression symptoms;-No hallucinations, delusions, behaviors, or rejection of care;-Requires supervision from staff for Activities of Daily Living (ADL). Review of the resident's Physician's Order Sheet (POS), dated 07/01/25, showed the following:-Metformin (medication used to manage blood sugar levels in people with type 2 diabetes) 1000 mg capsule two times daily morning and bedtime;-Metformin 500 mg capsule two times daily in the evening.-Spironolactone (medication which helps the kidneys remove excess salt and water from the body while retaining potassium) 50 mg daily for high blood pressure and heart failure;-Sacubitril-Valsartan (medication used to treat congestive heart failure by reducing strain on the heart, and improved blood flow to the heart) 24-26 mg one tablet every 12 hours for heart failure;-Bupropion (medication for depression) 300 mg capsule daily. Review of resident's weight record, dated 07/01/25-07/03/25, showed the following: -7/01/25 no weight;-7/02/25 498.2 pounds (lbs.);-7/03/25 501.2 lbs. Review of the resident's POS, dated 07/03/25, showed metolazone (medication used to treat fluid retention), 2.5 mg one time (administered on 07/04/25). Review of the resident's POS, dated 07/03/25, showed metolazone 2.5 mg 1 tablet by mouth before meals for weight gain for two days. Review of resident's weight record, dated 07/04/25-07/05/25, showed the following:-7/04/25 502.6 lbs.;-7/05/25 505.4 lbs. Review of the resident's Medication Administration Record (MAR), dated 07/05/25, showed the following:-Metolazone 2.5 mg capsule 12:00 P.M. dose not administered and marked 5 (hold/see progress note);-Metolazone 2.5 mg capsule 5:00 P.M. dose not administered 5 (hold/see progress note); Review of the resident's Nurses Note, dated 07/05/25 at 5:11 P.M., showed waiting on the pharmacy for the resident's metolazone. Review of the resident's POS, dated 07/06/25, showed metolazone 2.5 mg one time. Review of resident's weight record, dated 07/06/25-07/08/25, showed the following:-07/06/25 502.2 lbs.;-07/07/25 498.4 lbs.;-07/08/25 502.1 lbs. Review of the resident's Nurses Note, dated 07/08/25, at 5:23 P.M., showed notified the cardiologist of the resident's weight gain, received orders for labs. Resident is compliant with medications. Review of the resident's weight record showed staff documented no weight for 07/09/25. Review of the resident's MAR, dated 07/09/25, showed the following:-Metformin 1000 mg capsule 7:00 A.M. dose not administered 5 (hold/see progress note);-Metformin 500 mg capsule 5:00 P.M. dose not administered 5 (hold/see progress note);-Spironolactone 50 mg 7:00 A.M. dose not administered 5 (hold/see progress note);-Sacubitril-Valsartan 24-26 mg 9:00 A.M. dose not administered 5 (hold/see progress note); Review of the resident's Nurses Note, dated 07/09/25 at 11:00 A.M., showed waiting on the pharmacy for delivery of the resident's spironolactone, Metformin, and Sacubitril-Valsartan. Review of the resident's Nurses Note, dated 07/09/25, at 2:07 P.M., showed the primary care physician was notified that medications were currently not available in the facility due to a delay from the pharmacy. Contact made with pharmacy, who reported the medications were expected to arrive today. Director of Nursing, administration, management have been made aware. Review of the resident's Nurses Note, dated 07/09/25 at 4:15 P.M., showed waiting on the pharmacy for delivery of the resident's Spironolactone, Metformin, and Sacubitril-Valsartan. Review of the resident's weight record, dated 07/10/25, showed the resident weighed 503.4 lbs. Review of the resident's MAR, dated 07/10/25, showed bupropion 300 mg capsule 7:00 A.M. dose not administered 5 (hold/see progress note). Review of the resident's Nurses Note, dated 07/10/25 at 10:54 A.M., showed waiting on the pharmacy for delivery of the resident's bupropion. Review of the resident's Nurses Note, dated 07/10/25 at 11:19 A.M., showed the resident has been medication compliant. Review of the resident's weight record, dated 07/11/25, showed two weights documented for the resident 502.1 lbs. and 493.8 lbs. Review of the resident's weight record, dated 07/12/25, showed the resident weighed 504.4 lbs. Review of the resident's weight record, dated 07/13/25, showed the resident weighed 508.6 lbs. Review of the resident's Nurses Note, dated 07/13/25 at 9:13 A.M., showed the resident was short of breath while talking, with movement oxygen saturation dropped to the 7O's (normal oxygen saturations range from 95-100%). Resident refused oxygen. Resident has had significant weight gain in the last two days. Notified primary care physician and received orders to send out to be evaluated. Review of the resident's Nurses Note, dated 07/13/25 at 5:10 P.M., showed the resident was admitted to the hospital for fluid overload. Review of the resident's Hospital Physician Discharge summary, dated [DATE] at 10:05 A.M., showed the following;-Date of admission [DATE];-Presented with four-pound weight gain over his/her set limit of 505 lbs.;-admitted to cardiology service for treatment of his CHF exacerbation;-Received intravenous (medication give via a tube in a vein) medication to remove fluid;-Obtain weight daily taking weight at same time each day;-Continue medications for fluid;-Report any increase in symptoms or rapid weight gain;-Added medication for related to weight gain. Review of the resident's Nurses Note, dated 07/16/25 at 1:42 P.M., showed the resident returned to the facility. During an interview on 07/24/25, at 3:15 P.M., the resident said the facility kept running out of his/her medications. He/She had severe CHF, and the facility had been running out of the medications that keep the fluid off or had to wait a long time to get new medications ordered. He/She was hospitalized for CHF. It was miserable when he/she could not breathe from not having his/her medications. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses included bipolar disorder (a mood disorder), high blood pressure, anxiety, depression, post-traumatic stress disorder, chronic obstructive pulmonary disease, thyrotoxicosis (a condition in which there is an excessive amount of thyroid hormone in the body), pain, atrial fibrillation, and shortness of breath;-Moderate depressive symptoms;-No hallucinations, delusions, behaviors, or rejection of care;-Requires supervision from staff for Activities of Daily Living (ADL).-No scheduled pain medication, PRN medications used for pain, the resident denied having pain on the pain interview. Review of the resident's Care Plan, last updated 07/02/25, showed the following:-Diagnosis include fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), pain, gastro-esophageal reflux disease;-Resident reports fibromyalgia pain all over;-He/She has as needed pain medications he/she can request;-Administer medications as ordered;-Assist with diversional activities/distraction techniques as needed;-Report worsening pain symptoms and notify physician as needed;-Ongoing assessment of pain status;-Consult the physician as needed. Review of the resident's POS, dated 07/01/25, showed the following:-Lyrica 100 mg three times daily for acute (present or experienced to a severe or intense degree) pain;-Montelukast (medication to treat seasonal allergies) 10 mg daily;-Pantoprazole sodium (medication to reduce stomach acid) 20 mg daily;-Vrayfar (antipsychotic medication for hallucinations, delusions, and mood stability) 3 mg daily. Review of the resident's MAR dated 07/09/25, showed the following:-Montelukast 10 mg, 7:00 A.M. dose not administered 14 (awaiting medication);-Pantoprazole sodium 20 mg, 7:00 A.M. dose not administered 14 (awaiting medication);-Vrayfar 3 mg, 7:00 A.M. dose not administered 14 (awaiting medication); Review of the resident's Nurses Note, dated 07/09/25, at 2:01 P.M., showed the primary care physician was notified that medications were currently not available in the facility due to a delay from the pharmacy. Contact made with pharmacy, who reported the medications were expected to arrive today. Director of Nursing, administration, management have been made aware. Review of the resident's MAR dated 07/10/25, showed pantoprazole sodium 20 mg, 7:00 A.M. dose not administered 14 (awaiting medication); Review of the resident's Nurses Note, dated 07/10/25, at 3:07 P.M., showed the primary care physician was notified that medications are currently not available in the facility due to a delay from the pharmacy. Contact made with pharmacy, who reported the medications were expected to arrive today. Director of Nursing, administration, management have been made aware. Review of the resident's MAR dated 07/14/25, showed pantoprazole sodium 20 mg, 7:00 A.M. dose not administered 14 (awaiting medication); Review of the resident's MAR dated 07/19/25, showed the following: - Lyrica 100 milligram (mg) capsule at 7:00 A.M. dose not administered 14 (awaiting medication);- Lyrica 100 mg capsule 11:00 A.M. dose not administered 14 (awaiting medication);- Lyrica 100 mg capsule 4:00 P.M. dose not administered 14 (awaiting medication). Review of the resident's Nurses Notes dated 07/19/25, at 11:07 A.M., showed Lyrica 100 mg three times a day related to acute pain, medication was missing. Review of the resident's Nurses Notes dated 07/21/25, at 08:03 A.M., showed the resident had an appointment with the pain clinic on 07/18/25, with orders to refill Lyrica 100mg three times a day for 90 pills and follow up with the clinic in one month. Review of the resident's MAR dated 07/23/25, showed Vrayfar 3 mg, 7:00 A.M. dose not administered 14 (awaiting medication); During an interview on 07/24/25, at 3:52 P.M., the resident said the following:-He/She had been out of his/her inhalers and out of Lyrica all day on 07/19/25 (a Saturday); -He/She had fibromyalgia and did not get three doses of his/her Lyrica which left him/her in a lot of pain;-With Lyrica his/her pain was 4 (on a 1-10 scale with 10 being the worst pain), without the three doses of Lyrica his/her pain was an 8 or 9;-He/She ran out on Friday afternoon (07/18/25).-On 07/21/25 a nurse pulled two days' worth of Lyrica out of the Ekit, it was available over the weekend, but no one checked so he/she didn't get the medication all weekend. 3. Review of Resident #17's quarterly (MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses included high blood pressure, diabetes mellitus, schizophrenia (mental condition that causes racing thoughts, hallucinations and delusions at times), bipolar, chronic obstructive pulmonary disease, neuropathy (dysfunction of one or more peripheral nerves, typically causing numbness or weakness), and liver disease,-Moderate depressive symptoms;-No hallucinations, delusions, behaviors, or rejection of care;-Independent to supervision with all ADLs and transfers except requires substantial to maximum assistance with lower body dressing and bathing. Review of the resident's MAR, dated 07/09/25, showed the following:-Cardizem 60 mg, 11:00 A.M. dose not administered 5 (hold/see progress note);-Cardizem 60 mg, 4:00 P.M. dose not administered 5 (hold/see progress note);-Clonazapine 250 mg, 4:00 P.M. dose not administered, 5 (hold/see progress note);-Pravastatin 40 mg, 5:00 P.M. dose not administered, 5 (hold/see progress note);-Terazosin HCL 2 mg, 5:00 P.M. dose not administered, 5 (hold/see progress note);-Trazodone 200 mg, 5:00 P.M. dose not administered, 5 (hold/see progress note); Review of the resident's Nurses Notes/Administration Note, dated 07/09/25, at 10:45 A.M., showed the resident's Cardizem 60 mg was not administered, ‘waiting on delivery'. Potassium 20 mEq was not administered, ‘waiting on delivery'. Review of the resident's Nurses Notes/Health Status Note, dated 07/09/25, at 2:08 P.M., showed the resident's medications were currently not available in the facility due to a delay from the pharmacy. Contact made with the pharmacy who reported the resident's medications were expected to arrive today. Director of Nursing, administration and primary care physician have been made aware. Review of the resident's Nurses Notes/Administration Note, dated 07/09/25, at 3:24 P.M., showed the resident's Cardizem 60 mg was not administered, ‘waiting on delivery'. Clonazapine 100 mg administer 2.5 tablet (250 mg) was not administered, waiting on delivery. Potassium 20 mEq was not administered, ‘waiting on delivery'. Review of the resident's MAR, dated 07/10/25, showed the following:-Farxiga 10 mg daily, 7:00 A.M. dose not administered 5 (Hold/See Progress Notes);-Metolazone 5 mg daily, 7:00 A.M. dose not administered 5 (Hold/See Progress Notes);-Cardizem 60 mg, 7:00 A.M. dose not administered 5 (hold/see progress note);-Cardizem 60 mg, 11:00 A.M. dose not administered 5 (hold/see progress note). Review of the resident's Nurses Notes/Administration Note, dated 07/10/25, at 6:46 A.M., showed the resident's Farxiga 10 mg was not administered, ‘waiting on pharmacy to deliver'. Cardizem 60 mg was not administered, ‘waiting on delivery'. Metolazone 5 mg not administered, ‘waiting on pharmacy to deliver'.Review of the resident's Nurses Notes/Administration Note, dated 07/10/25, at 6:51 A.M., showed the resident received methocarbamol 750 mg because the resident was experiencing muscle spasms.Review of the resident's Nurses Notes/Administration Note, dated 07/10/25, at 12:00 P.M., showed the Cardizem 60 mg was not administered, ‘waiting on pharmacy to deliver'.Review of the resident's Nurses Notes/Health Status Note, dated 07/10/25, at 3:25 P.M., showed the resident's medications were currently not available in the facility due to a delay from the pharmacy. Contact made with the pharmacy who reported the resident's medications were expected to arrive today. Director of Nursing, administration and primary care physician have been made aware. Review of the resident's MAR dated 07/11/25, showed staff documented 14 (according to the codes on the [DATE] means ‘awaiting medication') for the resident's Clonazepam 0.5 mg tablet at 7:00 A.M. dose.Review of the resident's Nurses Notes/Administration Note, dated 07/11/25, at 4:14 A.M., showed staff administered two acetaminophen extra strength (generic Tylenol) 500 mg, for moderate pain all over his/her body; the resident rated his/her pain a seven on a one to ten scale (10 being worst pain ever felt). Review of the resident's Nurses Notes/Administration Note, dated 07/11/25, at 4:16 A.M., showed staff administered methocarbamol 750 mg for muscle spasms. Review of the resident's Nurses Notes/Administration Note, dated 07/11/25, at 10:37 A.M., showed ‘waiting on arrival from pharmacy', the note did not say what staff was waiting for from the pharmacy.Review of the resident's MAR, dated 07/16/25, showed the following:-Depakote Sprinkles 750 mg, 7:00 A.M. dose not administered, 14 (awaiting delivery);-Furosemide 40 mg, 7:00 A.M. dose not administered, 14 (awaiting delivery);-Depakote Sprinkles 750 mg, 4:00 P.M. dose not administered, 14 (awaiting delivery);-Furosemide 40 mg, 4:00 P.M., dose not administered, 14 (awaiting delivery); Review of the resident's Nurses Notes/Administration Note, dated 07/16/25, at 1:02 P.M., showed ‘waiting on arrival from pharmacy', the note did not say what staff was waiting for from the pharmacy.Review of the resident's Nurses Notes/Administration Note, dated 07/16/25, at 4:36 P.M., showed ‘waiting'.Review of the resident's Nurses Notes/Administration Note, dated 07/20/25, at 6:42 A.M., showed staff did not administer Vascepa 1 gram (gm), give two capsules for a dose of two grams, ‘waiting on pharmacy to deliver'.During an interview on 07/24/25, at 02:29 P.M., the resident said the following:-He/She has been out of medications three or four different days;-He/She did not receive his/her clonazepam one day, gabapentin one to two days and Depakote one day; -He/She had increased pain and anxiety; -The staff said it was a pharmacy problem and not their fault. 4. During an interview on 07/24/25, at 2:30 P.M., the Director of Nursing said the following:-She expected medications to be given as ordered;-Staff should use the e-kit if a resident needed a medication that was not available from the pharmacy;-Physician's orders should be followed;-If a medication was not available then staff were expected to notify the physician to see if any other orders or interventions were needed;-She has been working with the pharmacy to improve medication availability. During an interview on 07/24/25, at 4:45 P.M., the Administrator said the facility had been missing a lot of medications from the pharmacy. He expected staff to follow the facility policy for following physician orders. He expected the staff to utilize the Ekit for medications if they are needed. Complaint #2570073, #2560715 and #2566838

Based on observation, interview, and record review, the facility failed to recognize behavior triggers and provide early interventions of coping skills for two residents (Residents #13 and #14), in a review of 17 sampled residents, with mental disorders and who lived on a secured behavioral unit. Staff witnessed both residents in an argument during a smoke break and did not intervene or initiate coping skills. The residents left the smoke room and a verbal altercation ensued which led to a physical altercation where the residents hit each other. Resident #13 hit Resident #14 over the head with a laptop computer. Resident #14 obtained a laceration to his/her nose, a swollen and bruised eye, and an abrasion over his/her eyebrow. Resident #13 sustained a laceration on his/her finger. The facility census was 177. Review of the facility's Behavioral Emergency Policy, dated 06/26/24, showed the following:-The facility is to provide safe treatment and humane care to the resident in a behavioral crisis;-The facility's approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible;-Care will be guided by the resident's plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. 1. Review of Resident #13's Preadmission Screening and Resident Review (PASSAR), dated 08/13/20, showed the following:-The resident had a long history of aggression;-Diagnoses included attention deficit hyperactivity deficit (ADHD - a chronic condition including attention difficulty, hyperactivity and impulsiveness), conduct disorder, schizophrenia (mental illness with racing thoughts and hallucination and/or delusions), mild intellectual disorder, bipolar disorder (mental illness with mood swings from manic to depressive), mood disorder, post-traumatic stress disorder (PTSD; a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -The resident had delusions, confusion, and history of auditory hallucinations;-The nursing facility needed planning and case management to handle an immediate crisis;-Work with resident to develop a safety plan;-Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance, and how staff should work together with individual during the crisis. Review of the resident's Care Plan, last revised 04/22/25, showed the following:-The resident was at risk for alteration in mood related to diagnoses that include schizophrenia; -Goal: The resident will not cause harm to self or others through next review;-Behaviors included verbal aggression, physical aggression, poor insight, judgement, and impatience;-The resident suffered from auditory and visual hallucinations and was delusional;-If you see the resident exhibiting any behaviors listed in this section, refer to preferred coping skills and redirect behavior immediately;-Re-direct as able/needed to encourage positive behavior choices;-One-on-one intensive monitoring as needed/warranted for protective oversight;-One-on-one visits as needed/requested for verbalization and ventilation of concerns/feelings;-The resident's safety plan included reminding the resident of his/her diagnosis, validating his/her feelings, and allowing him/her to color;-Triggers for the resident were cigarettes, loud environment, and peers arguing/fighting;-If you observe a trigger happening to the resident, immediately refer to resident's preferred coping skills and redirect behavior;-Coping skills: Listens to music, talking with peers, doing his/her or peer's hair, walking, finding a quiet space/going to his/her room, and calling his/her family support;-If the resident was having behaviors and preferred coping skills were NOT effective, refer to CALM (Crisis Alleviation Lessons and Method, program for managing behaviors), de-escalation protocols. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 06/12/25, showed the following:-Cognitively intact;-No hallucinations, delusions, or behaviors directed toward self or others. Review of the resident's Nurses Notes, dated 07/23/25 at 6:38 A.M., showed residents (Resident #14 and another peer) were in the smoke room talking about how they thought some of their cigarettes were missing. They were not saying anyone's name, but the resident (Resident #13) thought they were talking about him/her. The peer (Resident #13) said something to the other residents about he/she had not stolen anything. One of the residents (Resident #14) told him/her (Resident #13) they were not talking about him/her. Resident #13 left the smoke room. The resident went into a peers' (Resident #18) room to talk to the peer. A few minutes later, peer (Resident #14) that was in the smoke room came into the room and called the resident (Resident #13) a name. A code green (facility alert for a behavioral crisis required response from staff) was called. Resident #13 struck Resident #14 with an object and Resident #14 struck Resident #13. Support staff arrived and residents were separated. Resident #13 immediately placed on one-on-one. Head to toe skin assessment completed with abrasion noted to the resident's finger. Review of the resident's Nurses Notes, dated 07/23/25 at 8:26 A.M., showed the resident said he/she thought his/her peers were accusing him/her of stealing their cigarettes and got into a verbal disagreement with them in the smoke room. The resident said he/she removed himself/herself from the situation because he/she didn't want to fight with anyone. Review of written statement, dated 07/23/25, provided by the facility, signed by the resident showed the residents were in the smoke room at 6:00 A.M. Resident #14 made some comments about how he/she was going to beat someone up if they kept trying to smoke his/her cigarettes. I said you ain't going to beat me up. I'm not smoking your cigarettes. Resident #14 said, you good then. Another resident did the crazy signal about me. I yelled at him/her and said, I'm not crazy and we argued. I said he/she was done and walked out of the smoke room and went to a friend's room. I was talking to his/her friend and heard Resident #14 yelling and looking for me. Resident #14 called me a bitch. Resident #14 saw me in his/her friend's room and walked in and hit me. I had my friend's laptop in my hand. After Resident #14 hit me, I hit him/her back with the laptop. We started fighting. Resident #14 threw me on the floor. More staff came and got Resident #14 out of the room. During an interview on 07/24/25 at 2:30 P.M., the resident said the following:-He/She and Resident #14 got into an argument; -He/She and Resident #14 ended up in Resident #18's room;-He/She hit Resident #14 over the head with Resident #18's laptop hard;-They both punched each other several times;-Resident #14 threw him/her on the floor;-He/She received a small cut on his/her finger from where he/she hit Resident #14 in the eye. Observation on 07/24/25 at 2:30 P.M. showed the resident had a small laceration on his/her right middle finger by his/her second knuckle. 2. Review of Resident #14's PASSAR, dated 07/29/20, showed the following:-Diagnoses included bipolar disorder, intellectual disorder, personality disorder, major depressive disorder, schizophrenia, and psychosis (mental condition with loss of reality);-Records state he/she traditionally displays angry outbursts, temper tantrums, yells, screams, and jumps up and down when he/she does not get his/her way;-Symptoms include mood lability (rapid and often unpredictable shifts in mood or emotional expression, hyperkinesis (excessive movement of muscles), rapid speech, mild flight of ideas, distractibility, impulsivity, intrusiveness, severely impaired insight, and judgment;-The resident had a history of episodes of paranoid ideation and verbal/physical aggression directed toward others;-The resident required daily nursing assessment of mood, thought process, behaviors to identify early changes that could lead to aggressive behaviors or agitation; -The resident required nursing assessment each shift in regard to mood, thought process, behaviors to identify any signs of psychotic thought process, and to identify any signs of increasing irritability or agitation; -Nursing facility to establish a behavior plan to address any verbal or physical aggression. Plan should include how to support client during a behavioral crisis, how to assure safety for client and others, de-escalation techniques, parameters for use of prn medications, one-on-one staff supervision until he/she calms. Review of the resident's Care Plan, updated on 02/06/23, showed the following:-The resident was at risk for alteration in mood related to diagnosis of schizoaffective disorder (bipolar, mental illness with periods of depression and periods of mania) and a history of medication non-compliance that can also lead to him/her becoming physically aggressive;-One-on-one intensive monitoring as needed/warranted for protective oversight;-One-on-one visits as needed/requested for verbalization and ventilation of concerns/feelings;-Allow resident to speak with someone of importance to him/her;-Assist the resident in using his/her coping skills;-Attempt to ascertain what the resident would accept/need to calm down and provide as able;-Re-direct as able/needed to encourage positive behavior choices;-Ongoing assessment for changes in mental status, behavior emergencies and impaired cognitive functioning;-The resident had a history of behavioral challenges that require behavioral challenges that require protective oversight in a secure setting;-Current behaviors: violently aggressive, temper tantrums, bizarre/erratic behaviors;-Behaviors from PASSR included anxiety, impatient/demanding, intrusive, verbally aggressive, verbally/physically threating, and paranoid;-Triggers for the resident include loud environments, arguing, and smoking;-If you observe trigger happening to resident, immediately refer to resident's preferred coping skills and redirect behavior; -If you see resident exhibiting any behaviors listed in this section, refer to preferred coping skills and redirect behavior immediately; -Coping Skills: Watching television, listening to music, hangout, coloring, watching unsolved mysteries, and talking with the other residents;-CALM technique if needed;-Pharmaceutical and non-pharmaceutical interventions as needed. Review of the resident's annual MDS, dated [DATE], showed the following:-Cognitively intact;-No hallucinations, delusions, or behaviors directed toward self or others. Review of the resident's Nurses Notes, dated 07/23/25 at 6:38 A.M., showed residents were in the smoke room talking about how they thought some of their cigarettes were missing. They were not saying anyone's name, but Resident #13 thought they were talking about him/her. Resident #13 said something to the other residents about he/she had not stolen anything. Resident #14 told Resident #13 they were not talking about him/her and Resident #13 left the smoke room. Resident #14 went out in the hall a few minutes later, and staff noted him/her to be calm. When Resident #14 went out in the hall, he/she went into a different resident's room (Resident #18) and called Resident #13 a name. It was reported that Resident #14's voice started rising. Code green was called, and staff attempted to get between the residents (Resident #13 and Resident #14). Resident #13 struck Resident #14 with an object and Resident #14 struck Resident #13. Head to toe skin assessment completed with abrasion noted to bridge of Resident #14's nose and swelling to right eyebrow with abrasion noted above eyebrow. Review of a typed statement, dated 07/23/25, provided by the facility, signed by Resident #14, showed he/she was sitting in the smoke room at the 6:00 A.M. smoke break. He/She discussed missing cigarettes with another resident. Resident #13 then stated he/she didn't smoke the cigarettes and had nothing to do with it. The resident told Resident #13 that they didn't say his/her name, and he/she was being paranoid. Resident #13 started arguing with Resident #14. Resident #13 left the smoke room. Then Resident #14 walked out of the smoke room and started walking down the hall. Resident #14 was upset because Resident #13 was yelling and cussing at the residents. When Resident #14 went down the hall and saw Resident #13 in another resident's room, he/she went in. Resident #14 was cursing at Resident #13, and they argued back and forth. Resident #13 grabbed a laptop and hit Resident #14 over the head with it. Resident #13 and Resident #14 started hitting each other. Staff were trying to separate them. Resident #14 knocked Resident #13 down a couple times. More staff came in and separated them. He/She was not trying to cause Resident #13 harm, he/she was just upset and let his/her temper get to him/her. During an interview on 07/24/25 at 3:49 P.M., the resident said the following:-The residents were in the smoke room, and he/she and his/her friend were talking about missing cigarettes;-Resident #13 was paranoid and thought they were talking about him/her but they were not. Resident #13 started yelling and cursing at them;-Resident #13 left the smoke room, and then he/she left the smoke room; -When he/she walked down the hall, Resident #13 was waiting for him/her by Resident #18's room, so he/she began yelling at Resident #13 and cursing at him/her; -Resident #13 went into Resident #18's room. Resident #13 grabbed Resident #18's laptop and hit him/her over the top of the head with the laptop. It shattered the screen of the laptop;-Resident #13 punched him/her in the eye and the nose which caused injuries; he/she also punched Resident #13 several times; -He/She then threw Resident #13 on the ground;-The staff called a code green but never tried to physically intervene until the fight was over. By the time the other staff responded and arrived at the unit, the fight was over; -The staff didn't intervene;-The Director of Nursing made him/her sign a statement that he/she and Resident #13 are friends and that everything was okay; -He/She was not Resident #13's friend and never has been. They don't hate each other but they are not friends;-Staff kept he/she and Resident #13 separated and then told them it was in their best interest to sign the statements. Review of the resident's Nurses Notes showed the following:-On 07/23/25 at 12:29 P.M., staff notified the physician regarding the resident's right eye swelling shut. Received orders to obtain facial x-rays. The resident was able to see out of the right eye when his/her eye lid was pulled up. The resident had an ice pack to his/her eye and denied pain at this time;-On 07/24/25 at 11:46 A.M., the resident's eyelid was swollen and reddish/purple. Abrasion to bridge of nose. Observation on 07/24/25 at 3:49 P.M., showed the resident in his/her room. The resident's right eye lid was red, purple, and swollen. His/Her eyelid protruded out from the swelling. The resident had an abrasion above his/her right eyebrow, and a laceration across the bridge of his/her nose. 3. Review of written statement, dated 07/23/25, provided by the facility, signed by Resident #18 (statement was typed and the resident signed it), showed the resident relayed he/she was laying in my bed, dozing off when Resident #13 came into my room and told me that I better not let them roll up on me. I asked him/her what he/she was talking about, and then I heard Resident #14 yelling and looking for Resident #13. Resident #14 came to my door, and they (Resident #13 and Resident #14) started yelling and cussing at each other. Resident #13 grabbed my laptop off my bed and hit Resident #14 on the head. They both started fighting and hitting each other. Staff had already called a code green. 4. Review of a written statement, dated 07/23/25, provided by the facility, signed by Nurse Assistant (NA) I, showed he/she wrote he/she had residents gathered for 6:00 A.M. smoke break, Resident #14 was discussing with his/her friend about people taking their things. While they were talking, Resident #13 thought they were discussing him/her. The residents tried to tell Resident #13 they were not talking about him/her. He/She let Resident #13 out of the smoke room. Then Resident #14 left the smoke room. NA F called a code. When he/she came out of the smoke room and went down the hall, Resident #14 was coming out of a resident room with a small cut across his/her nose. 5. Review of written statement, dated 07/23/25, provided by the facility, signed by NA F showed he/she was in the dining room when Resident #13 said Resident #14 and his/her friend were saying he/she stole their cigarettes. Resident #13 went to a peer's room (Resident #18). Resident #14 came out of the smoke room. Resident #14 was yelling looking for Resident #13. Resident #14 kept calling Resident #13 a bitch, and Resident #13 yelled back bitch. He/She was already calling a code and staying/walking with Resident #14 until support staff arrived. Resident #14 saw Resident #13, and they started fighting. Resident #13 had a laptop and hit Resident #14 to the face area and then they started exchanging blows and Resident #14 tossed Resident #13 to the floor. 6. During an interview on 07/24/25 at 10:14 A.M. and 4:40 P.M., the Director of Nursing (DON) said the following:-She investigated the resident-to-resident altercation between Resident #13 and #14 and felt like there was nothing the staff should have done differently;-She was not sure if the staff identified the residents' triggers or offered coping mechanisms for the residents prior to the physical altercation. During an interview on 07/24/25 at 4:40 P.M., the Administrator said the following:-He expected staff to recognize triggers for residents who had behaviors and respond with offering coping skills as instructed in the resident's care plan;-If there was a physical altercation, staff may have to wait for back up, but were to physically intervene to protect residents;-He expected staff to follow their training on how to deal with behavioral crisis. Complaint #2565905

Based on observation, interview and record review, the facility failed to provide protective oversight and a safe environment for one resident (Resident #1) who was assessed to be an elopement risk, had a history of a previous elopement from the facility, and resided on a secured behavioral unit. Staff allowed the resident into the exterior courtyard unsupervised, and failed to ensure the door was securely latched when the resident returned inside the facility. The resident went back out this unlatched door and left the premises without staff knowledge. Staff failed to complete hourly face checks on the resident from 7:30 P.M. until approximately 11:30 P.M. per facility policy. The resident was missing for over 12 hours before being located by staff. The facility census was 178. On 4/17/25 at 4:30 P.M., the administrator was notified of the immediate jeopardy (IJ) past non-compliance that occurred on 4/16/25. Corrective measures and an investigation began immediately. Resident #1's guardian, physician and law enforcement were notified of the elopement. The resident was assessed, placed under supervision of two staff members and transported to a acute psychiatric center for evaluation and treatment. Education was provided to staff and policies were reviewed on Protective Oversight, Face Checks, Code [NAME] Procedure, When to Notify, and Abuse and Neglect, to all staff. One on one education was provided to the staff directly involved and those staff members were suspended pending the investigation. All residents were audited for elopement risk and care plans updated. Maintenance staff completed door inspections to identify doors that did not latch and review of any outside areas that could be utilized to climb onto the building with. The door identified to the courtyard was marked as a fire exit only. The IJ was corrected on 4/17/25. Review of the facility policy, Intensive Monitoring/Visual Checks, revised 4/30/24, showed the following: -To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues; -Residents who require more intensive monitoring due to crisis, behavioral/psychiatric symptoms will be monitored by facility staff; -Intensive monitoring is defined as a periodic (hourly, every two hours or every shift) check by a facility staff member; -Residents may require more intensive monitoring based on their crisis, behavioral, psychiatric issues. The level of intensive monitoring shall be identified by the specific situation or resident assessment; -Residents who have poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal/physical aggression, elopement ideations, suicidal/homicidal ideations and decompensation mentally or crisis may be placed on intensive monitoring or one to one or two to one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor; -The facility staff will document the intensive monitoring in the residents' electronic medical record. Review of the facility policy, Elopements and Wandering Residents, revised on 6/12/24, showed the following: -The facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care, addressing the unique factors contributing to wandering or elopement risk; -The facility is equipped with door locks/alarms to help avoid elopements; -The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -The interdisciplinary team will evaluate the unique factors contributing to risk to develop a person-centered care plan; -Interventions to increase staff awareness of the resident's risk, modify the residents' behavior, or to minimize risks associated with hazards will be added to the residents' care plan and communicated to appropriate staff; -Adequate supervision will be provided to help prevent accidents or elopements; -Staff will be educated on the reasons for the elopement and possible strategies for avoiding such behavior; -When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred to alternate placement in an appropriate facility. Review of Resident #1's undated, Face Sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident had a legal guardian. Review of the resident's Care Plan, revised 3/15/24, showed the following: -The resident was at risk of elopement due to a history of elopement from the facility and/or expresses a desire to elope from the facility; -Complete elopement assessment on admission, readmission, and quarterly; -Face Checks/Intensive Monitoring will be completed per facility policy; -Resident's photo and information will be kept in elopement book; -Maintenance will make improvement to fence to prevent residents from climbing over; -All non-bolted chairs are to be removed from all smoke areas; -Door code changed; -The resident had a guardian to assist in decision making due to mental illness. Review of the resident's Elopement Evaluation, dated 3/5/25, showed the following: -History of elopement or an attempted elopement while at home: Yes; -History of elopement or attempted leaving the facility without informing staff: Yes; -Verbally expressed the desire to go home, packed belongings or stayed near an exit door: Yes; -Does the resident wander: Yes; -Wandering behavior a pattern, goal directed: Yes; -Risk for wandering/elopement identified. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 3/6/25, showed the following: -Cognitively intact; -Makes self-understood and understands others; -No signs or symptoms of delirium; -No behavioral symptoms exhibited; -No psychosis exhibited; -No wandering behaviors exhibited; -Required supervision with eating, oral hygiene, toilet hygiene, showering and walking; -Independent with upper and lower body dressing, moving from a lying to a sitting position on the side of the bed, moving from a sitting to standing position, chair/bed to chair transfer. Review of the resident's Preadmission Screening and Resident Review (PASRR) Mental Illness Level II Evaluation, dated 3/10/25, showed the following: -Reason for nursing facility application was for Resident Review/Department of Mental Health/ Re-determination; -Diagnoses included post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it), antisocial personality disorder (a mental health disorder characterized by disregard for other people), bipolar disorder-manic with psychotic features (intense or prolonged mood episodes or psychotic symptoms), schizoaffective disorder (a mental illness characterized by a combination of psychotic symptoms (like hallucinations and delusions) and mood disorder symptoms (like depression or mania)), cannabis abuse, hallucinogenic abuse, cocaine abuse, methamphetamine use disorder moderate, in sustained remission; -The resident's updated mental status, per referral, showed anxiety, verbal/physical aggression, irritability, insomnia, minimal suspiciousness, paranoia, hallucinations, and delusions. Moderate abnormal thought processes. Maximum aggression. Alert and oriented. No memory impairments noted; -Current psychiatric support/services psychiatric follow-up/consultation, medication administration/ management/monitoring and a secured/behavioral unit; -Referral indicates maximum aggression no aggressive episodes noted in February or March; -Behaviors included refuses medications, uncooperative with medical/nursing care or treatments; -Reason for nursing facility application/continued stay included assistance needed with activities of daily living (ADLs), behavioral difficulties and or mental illness requiring 24-hour monitoring/management, housing instability/homeless; -Discharge planning from March 15, 2024, the resident's guardian wanted the resident to remain in his/her current facility until the desired level of independence was achieved; -Barriers to returning home include history of medication non-compliance, finances, and history of severe polysubstance abuse; -At this time, his/her guardian had no plan of discharge given his/her recent noncompliance with medications and his/her inability to care for himself/herself without oversight from staff; -Individual limitations include limited insight, poor judgment, history of medication non-compliance and limited support system. Review of the resident's Progress Note, dated 3/24/25 at 4:39 P.M., showed the resident refused his/her Invega (antipsychotic medication used to treat schizophrenia) injection. Psychiatric provider was notified, and he/she will review his/her medications and evaluate the resident on Friday. The resident's legal guardian was notified. Review of the resident's Mental Status Exam Note, dated 3/28/25, untimed, showed the following: -The resident was seen for follow up assessment and reports doing ok but appears delusional and expresses desire to leave the facility. The resident demonstrates significant treatment non-adherence, refusing to take his/her prescribed medication or undergo lab tests, believing they are unnecessary; -Despite education on the importance of compliance, his/her delusional thinking interferes with his/her understanding of his/her treatment plan. His/Her current mental state and resistance to treatment suggest a potential decline in his/her psychiatric stability. Despite continuing education on the importance of medication compliance, lab monitoring and treatment adherence to prevent relapse, the patient maintains his/her belief that he/she does not need these interventions; -Plan: continue educating patient on importance of medication compliance and lab monitoring to prevent relapse; -Provide psychoeducation on good coping skills to improve mood. Continue current medication regime. Closely monitor the resident's mental status and risk for leaving facility against medical advice. Re-evaluate the resident's mental stability; -The resident has refused his/her Invega injection and shows signs of disorganized thinking indicative of delirium. Review of the resident's Hourly Face Checks, dated 4/16/25, showed staff did not document completion of hourly face checks from 7:30 P.M. through 11:30 P.M. Review of the resident's Behavioral Note, dated 4/16/25 at 11:51 P.M., showed the following: -It was reported to the writer, staff were unable to locate the resident. Staff immediately started searching throughout the unit and the building; -A Code [NAME] was called, and support staff arrived at the building and a search in the community started. Law enforcement was notified. Social Service Director (SSD) left a message for the legal guardian and the physician; -The Director of Nursing (DON) and the Administrator were made aware. Review of the initial reporting by the facility to the Department of Health and Senior Services, dated 4/17/25 at 4:29 A.M. showed the following: -On 4/16/25 at 11:45 P.M., it was reported to the Administrator the resident was not present on his/her unit. The Administrator instructed staff to begin room searches within the facility and the Code [NAME] procedure was implemented, after staff were unsuccessful with locating the resident; -Video footage showed the resident left the facility at 7:45 P.M. after using a post to scale the side of the building; -Notified law enforcement and a missing person's report was sent out for the surrounding area; -Voicemail was left for the resident's guardian, will try to reach the guardian first thing in the morning. -All areas of building checked to ensure no objects are present that can be used to scale building. Review of recorded facility camera footage, dated 4/16/25, showed the following: -At 7:30 P.M., Resident #1 walked outside into the courtyard area, no staff members were observed in the courtyard. The resident walked around briefly in the courtyard and reentered the door to the facility; -At approximately 7:40 P.M., the resident exited the building again and walked around the courtyard area, no staff members were observed in the courtyard; -At 7:48 P.M., the resident climbed up the punching bag base onto the roof of the building. During an interview on 5/5/25 at 10:30 A.M. the Administrator said the following: -The resident was located by Certified Nurse Assistant (CNA) A when he/she was driving home from work. The resident was observed walking on a sidewalk approximately a mile from the facility; -CNA A was directed to wait until additional staff arrived on scene and to not approach the resident; -The Administrator, Social Service Director (SSD), and Assistant Administrator went immediately to the location where the resident was found; -The resident had turned onto a side street and was walking along the side of the street when the Administrator and the other staff arrived; -Staff got out of the vehicle and the resident ran approximately 100 feet and jokingly said, you found me, but got right into the vehicle when directed by staff; -The resident was wearing a sweatshirt and sweatpants, and no injury was noted. Observation on 4/17/25 at approximately 11:00 A.M., of the route the resident would have taken from the facility to where he/she was found, showed the following: -The resident would have walked approximately 1.3 miles from the facility, through a traffic light with a busy intersection, turned left where he/she would have crossed a four-lane intersection, with traffic speed of 35 miles per hour; -The street was well lit with sidewalks along the route and no curves or hills. Review of the [NAME].ground (a weather website service that lets you access real-time weather information) showed the lowest the temperature recorded from 4/16/25 at 7:45 P.M. until the morning of 4/17/25 at approximately 8:00 A.M. was 55 degrees Fahrenheit. During an interview on 4/23/25 at 9:30 A.M. the resident said he/she sustained no injuries from the elopement and did not want to discuss it any further. He/She was being transferred to another facility and was ready to go. Review of the resident's Progress Note, dated 4/23/25 at 10:17 A.M., showed the resident was discharged to another facility via facility transport. During an interview on 5/1/25 at 11:25 A.M. the resident's guardian said the following: -The facility had reported the resident's elopement to him/her; -He/She had a meeting with the resident along with the Administrator a couple months ago; -At that time, the resident said he/she did not feel he/she had any mental health conditions; -The resident said he/she was not sure why he/she was in the facility and wanted to go home; -The resident became very upset during the conversation, cursed and abruptly left the room; -She agreed for the resident to be transferred to another facility after the elopement. The resident had eloped from the facility before. During an interview on 4/21/25 at 1:45 P.M., Nurse Aide (NA) C said the following: -He/She had worked at the facility for a few weeks. He/She was aware Resident #1 had eloped in the past; -Earlier in the evening, CNA A was joking around with another resident and Resident #1 took it as a threat towards the other resident and got upset; -Resident #1 got upset, face was red, and he/she was screaming at CNA A about the situation; -The resident was making comments about someone watching him/her, and wanted his/her bible; -Certified Medication Technician (CMT) B took Resident #1 outside to calm him/her down and Resident #1 apologized to CNA A; -It was his/her and CNA A's responsibility to do hourly face checks on each of the residents and document it; -It was a busy night and NA C and CNA A did not complete face checks like they were supposed to that night; -Around 11:30 P.M., he/she realized the resident was gone; -He/She looked everywhere for the resident and when he/she could not find Resident #1, Licensed Practical Nurse (LPN) D was notified. During an interview on 4/21/25 at 3:35 P.M., CNA A said the following: -He/She had worked at the facility for a few weeks and wasn't very familiar with the residents; -On the evening of 4/16/25, he/she was joking around with another resident about their hat; -Resident #1 got upset and said, if you are going to fight him/her you will have to fight me. CMT B took Resident #1 outside to calm him/her down; -When Resident #1 came back inside, Resident #1 and CNA A apologized to each other about the situation and the misunderstanding; -CNA A felt bad about the situation, so he/she offered to take the resident outside to smoke; -CNA A opened the door to the outside courtyard area for the resident to go outside while CNA A went to get the resident a cigarette inside the facility; -The resident was already walking back inside before CNA A got back outside, and the resident decided to smoke inside instead; -He/She assumed the door latched, but did not check the door to assure it was latched; -He/She did not do face checks that night, he/she thought NA C was doing them; -He/She was not aware the resident was an elopement risk or had eloped before; -He/She and NA C could not locate the resident later in the night, CNA A and NA C searched for the resident and when they couldn't locate him/her they reported it to the charge nurse. During an interview on 4/17/25 at 12:00 P.M., CMT B said the following: -On 4/16/25 he/she worked the day shift (7:30 A.M. to 7:30 P.M.) -CNA A and another resident were talking and Resident #1 got upset about the situation and started yelling at CNA A; -CMT B took Resident #1 outside to calm him/her down; -He/She did not report the situation to LPN D because the resident had calmed down; -He/She left work around 8:00 P.M. that night. During an interview on 4/21/25 at 2:45 P.M., LPN D said the following: -On 4/16/25 he/she was working 7:30 P.M. to 7:30 A.M. as the charge nurse and was responsible for four units, which included the unit where Resident #1 was; -He/She was not aware of any issues with Resident #1 during the evening on 4/16/25; -A little before 11:30 P.M. NA C called him/her and said that they could not locate Resident #1; -He/She called the other charge nurse in the building and told everyone to search for the resident; -About 10 to 15 minutes later, he/she talked to the Administer about the situation, a Code [NAME] was called and staff continued to search for the resident outside; -He/She was educated before he/she left that morning that as a charge nurse it was his/her responsibility to assure face checks were being done and he/she was responsible for the staff working on the units, also he/she should be checking in with staff routinely. During an interview on 4/17/25 at 10:00 A.M., the DON said the following: -The resident was very delusional on the evening of 4/16/25 and had an issue with a peer, but the peer was unaware of any issue between the two of them. Also, CNA A was joking around with another resident and Resident #1 got upset and thought the staff member was being disrespectful to the other resident. Resident #1 started yelling at CNA A; -CMT B took the resident outside to calm him/her down, the resident came back inside, was calm and apologized to CNA A about the situation; -CNA A felt bad about the situation and offered to take the resident out for a cigarette. CNA A opened the door to the outside courtyard and left the resident outside alone while CNA A went back inside of the facility to get the resident a cigarette. Before CNA A made it back outside, the resident was walking back inside the facility; -CNA A didn't check the door to assure it was latched after Resident #1 came back inside; -In the past there had been some issues with the door, staff or residents had propped the door open with a rock. The door could look like it was shut when it was not; -Later, the resident exited the unlatched door and eloped from the facility using the punching bag base to climb up onto the roof and off the backside of the roof; -CNA A was driving home following his/her shift on 4/17/25 at approximately 8:00 to 8:30 A.M. and observed the resident walking on a sidewalk approximately a mile from the facility; -CNA A notified the facility and continued to follow the resident in his/her car until additional staff responded and transported the resident back to the facility, without any issues; -The resident said he/she tried to come back to the facility and got turned around and slept in the woods last night; -The resident made homicidal and suicidal comments when he/she got back to the facility and was sent out for a psychiatric evaluation. Two staff members accompanied the resident to the psychiatric facility due to the comments the resident made. During interviews on 4/17/25 at 11:35 A.M. and at 2:00 P.M., the Administrator said the following: -It was reported to him that earlier in the evening on 4/16/25 the resident was upset with CNA A who was joking around with another resident. Resident #1 thought the staff member was being serious, and being disrespectful to the other resident; -CNA A and Resident #1 apologized later after the incident. CNA A allowed the resident outside into the outside courtyard area while CNA A went back inside the facility to get the resident a cigarette; -The resident reentered the building and didn't latch the door behind him/her. CNA A didn't check to assure the door was closed after the resident entered the building; -There had been some issues with this door in the past and it not getting shut like it should when the residents came back inside the facility; -The resident exited the unlatched door at approximately 7:48 P.M. and climbed up the punching bag base onto the roof of the facility, jumped down onto the backside of the facility and left the premises per video footage obtained by the facility; -The punching bag and the base were not bolted down and it was positioned close to the building; -The night supervisor called around 11:45 P.M. and said they could not locate the resident and were looking for him/her; -At 11:48 P.M. LPN D called and said the resident was unable to be located and they were still searching rooms; -At 11:57 P.M. a text went out to all department heads, corporate and a Code [NAME] was issued; -The resident was to be on hourly face checks and upon review of the hourly face check documentation, hourly face checks were not completed on 4/16/25 from 7:30 P.M. through 11:30 P.M. -The resident was located by CNA A when he/she was driving home from work. The resident was observed walking on a sidewalk approximately a mile from the facility; -The resident said he/she slept under a tree throughout the night; -The resident was brought back to the facility and upon returning made comments regarding homicidal and suicidal, the resident was sent out for a Psychiatric Evaluation; -Staff should have notified the charge nurse Resident #1 had a change in his/her baseline during the evening of 4/16/25; -The resident should not have been allowed in the outside courtyard unsupervised. Staff should have checked to assure the door was latched when the resident reentered the building from the courtyard; -He would expect staff to complete face checks hourly on all residents and documented. MO252874 MO252991

Based on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 18 sampled residents, received care and treatment in accordance with professional standards of practice. Staff failed to assess and obtain treatment for seven days following the resident's complaints of urinary urgency (a sudden and strong need to urinate) and dysuria (difficulty urinating) and failed to obtain a urinalysis (a diagnostic laboratory procedure used to determine urinary changes and infection) as ordered by the physician. The resident was admitted to the hospital with acute pyelonephritis (a bacterial infection of the kidneys that caused inflammation. A severe urinary tract infection), and complicated urinary tract infection. Upon readmission staff failed to obtain and administer four doses of the physician ordered antibiotic for the resident. The facility census was 181. Review of the facility policy Notification of Changes, dated 5/14/24, showed the following: -The purpose was to ensure the facility promptly informed the resident and consulted the resident's physician when there was a change requiring notification; -Circumstances requiring notification were accidents, significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status that may included life-threatening conditions or clinical complications. Review of the facility policy Transcription of Orders/Following Physician Orders, dated 5/18/24, showed the following: -The purpose was to outline procedures in accurately transcribing physicians' orders and to ensure all physicians' orders were followed. To ensure a process was in place to monitor nurses in accurately transcribing and following physicians' orders; -Upon receiving a physician's order, it would be documented in the resident's electronic medical record in the order section; -The licensed nurse would check the emergency kit to verify if the medication was present in the facility to begin immediately. If the medication was not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication was unable to be started within 24 hours of the order, the prescribing physician would be notified, and further orders would be obtained. If a stat (without delay) medication was ordered, the physician would be made aware of facility availability in the case an alternative was needed; -After laboratory testing, diagnostic testing or other services were ordered, the nurse would document orders in the resident's electronic medical record and fill out the corresponding requisition for the specific services to be obtained; -The licensed nurse would review electronic Medication Administration Records (MARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. If a medication was marked as not given, the reasoning for not being given should be explained in the progress notes and Director of Nursing or supervising nurse and the Administrator must be notified. The physician must also be notified. The nurses' progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have. For electronic MARs the medication would be documented as not given by selecting the corresponding chart code for the reason why it was not given, and a progress note would be written; -If the medication was unavailable, the licensed nurse would contact the pharmacy and have the medication delivered. If the resident was not going to receive their scheduled medication per the physician's orders, the licensed nurse would contact the Director of Nursing (DON), the Administrator, and the physician. The nurse would then follow any further orders provided by the physician. 1. Review of Resident #10's annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 6/21/24, showed the following: -Cognitively intact; -Independent in activities of daily living; -Continent of bowel and bladder. Review of the resident's Care Plan, updated 6/24/24, showed the following: -Diagnoses of depression, shortness of breath, and urinary incontinence; -The resident was highly functional and able to complete activities of daily living with supervision. Staff should provide assistance as needed. Review of the resident's Care Plan showed the resident's urinary incontinence diagnosis was not addressed. Review of the resident's Physician Order Sheet (POS), dated 9/15/24, showed to obtain urinalysis with culture and sensitivity (diagnostic lab procedure used to identify the type of bacteria causing an infection). Review of the resident's nurses note, dated 9/17/24 at 1:32 P.M., showed staff documented the resident currently complained of urgency and dysuria. A urinalysis with culture and sensitivity was ordered and urine sample sent to the laboratory on 9/16/24. The results were currently not available. Review of the resident's nurses' notes showed staff documented the following: -On 9/18/24 at 1:00 P.M. the resident was continent of bowel and bladder; -On 9/19/24 at 1:45 P.M. the resident was continent of bowel and bladder, able to make needs and concerns known; -On 9/21/24 at 9:37 A.M. the resident believed an antibiotic was ordered on 9/19/24 for a possible urinary tract infection. No physician orders noted for an antibiotic, attempted to reach the physician at number provided with no answer and no voice mail set up; -On 9/21/24 at 11:28 A.M. attempted to reach the physician again with no answer and unable to leave a message. Review of the resident's POS, dated 9/21/24, showed an order from the resident's physician for Bactrim DS (antibiotic medication) 800/160 milligrams (mg) one tablet two times daily for urinary tract infection for seven days. Review of the resident's Medication Administration Record (MAR) dated September 2024 showed the following: -On 9/21/24 no documentation staff administered Bactrim DS 800/160 mg as ordered two times daily; -On 9/22/24 no documentation staff administered Bactrim DS 800/160 mg as ordered two times daily; -On 9/23/24 staff documented Bactrim DS 800/160 mg administered at 7:00 A.M. and 4:00 P.M. Review of the resident's nurses' notes showed staff documented the following: -On 9/23/24 at 8:55 P.M., the resident wanted to be sent out to the hospital, he/she did not feel right, was short of breath and his/her abdomen hurt due to a urinary tract infection. Temperature of 101.8 degrees (normal 98.6 degrees), blood pressure 141/111 (normal 120/80), heart rate 92 beats per minute (normal 60 to 80), respirations 18 breaths per minute (normal 12-18). Resident was sent by ambulance to the local hospital; -On 9/24/24 at 2:04 P.M., the resident was transferred from the local hospital to a regional hospital and admitted with fluid overload and urinary tract infection. Review of the resident's hospital discharge summary, dated 9/28/24, showed the following: -Diagnoses of acute pyelonephritis (a bacterial infection of the kidneys that caused inflammation. A severe urinary tract infection), complicated urinary tract infection, hematuria (blood in the urine) likely secondary to infection, electrolyte derangements (imbalance of the electrolyte levels in the blood); -Intravenous (IV) ceftriaxon (antibiotic medication) treatment from 9/24/24 to 9/28/24; -Transition to cefpodoxime (oral antibiotic medication) on 9/28/24 to complete a 14-day course of treatment, end date of 10/7/24; -New medications cefpodoxime 200 mg, one tablet every 12 hours for ten days. Review of the resident's nurses note, dated 9/28/24 at 3:42 P.M., showed staff documented the resident returned from the hospital. Review of the resident's clinical admission note, dated 9/28/24 at 4:33 P.M., showed staff documented the resident arrived back at the facility. Denies urinary complaints, urine clear yellow. Currently on antibiotics. Review of the resident's POS, dated 9/28/24, showed cefpodoxime 200 mg one tablet every 12 hours for pyelonephritis for ten days. Review of the resident's MAR, dated September 2024, showed the following: -On 9/28/24 no documentation staff administered cefpodoxime 200 mg at 9:00 P.M.; -On 9/29/24 at 9:00 A.M. staff documented cefpodoxime 200 mg was not administered, see progress (nurses note) notes. Review of the resident's nurses notes dated 9/29/24 at 10:13 A.M., showed staff documented cefpodoxime 200 mg not administered, the medication had not arrived from the pharmacy. Review of the resident's MAR dated September 2024 showed on 9/29/24 at 9:00 P.M. staff documented cefpodoxime 200 mg not administered, see progress notes. Review of the resident's nurses note, dated 9/29/24 at 9:38 P.M., showed staff documented cefpodoxime 200 mg not administered, the medication had not arrived from the pharmacy. Review of the resident's MAR dated September 2024 showed on 9/30/24 at 9:00 A.M., staff documented cefpodoxime 200 mg not administered, see progress notes. Review of the resident's nurses note, dated 9/30/24 at 10:30 A.M., showed staff documented cefpodoxime 200 mg not administered, the medication had not arrived from the pharmacy. Pharmacy notified of missing medication. Review of the resident's medical record showed no documentation staff notified the resident's physician cefpodoxime 200 mg was not administered on 9/28/24 at 9:00 P.M., on 9/29/24 at 9:00 A.M. and 9:00 P.M. or 9/30/34 at 9:00 A.M. Review of the resident's nurses note, dated 9/30/24 at 7:20 P.M., showed the physician made rounds, discussed the antibiotic orders. Antibiotic changed to Cipro (oral antibiotic) for pyelonephritis. Review of the resident's POS, dated 9/30/24, showed the following: -Discontinue cefpodoxime 200 mg twice daily; -Cipro 500 mg two times daily for acute pyelonephritis for seven days. During an interview on 10/3/24 at 9:50 A.M., the resident said he/she had urinary symptoms about three weeks ago of burning and hematuria. He/She told staff and a urine sample was obtained. Two days later staff said the urine sample was sent to the wrong laboratory and he/she had to start over. Staff said an antibiotic was ordered but did not come from the pharmacy. After a few days the resident asked staff to call the physician for another antibiotic order which he/she did not receive. His/Her urinary symptoms continued to get worse. The resident did receive one dose of an antibiotic, was not improving, and asked to go to the hospital for treatment. The resident felt short of breath, his/her kidneys were not working very well, and his/her abdomen was hard. The resident felt like fluid was backing up in his/her kidneys and abdomen. Staff sent the resident to the hospital by ambulance. He/She did not receive the new antibiotic ordered on discharge from the hospital. The pharmacy did not send the antibiotic because his/her insurance did not cover the cost. The resident's physician changed the antibiotic that was started a few days after his/her hospital discharge. Staff did not assess the resident and try to get him/her treatment for the urinary symptoms and did not arrange for hospital transfer until the resident asked to go to the hospital. During an interview on 10/3/24 at 3:00 P.M. the DON said staff should have assessed and documented the resident's condition and complaints of urinary urgency and dysuria. Staff should have called the physician and obtained treatment and not delayed treatment. If a urinalysis was obtained and treatment provided, hospitalization might have been prevented. The resident had history of urinary tract infections. He expected staff to assess a resident's condition and obtain treatment orders from the physician. Staff should document the assessments, findings, and communication with the physician. If the physician was not reached, staff should notify the administrative nursing staff for assistance. The resident should have received treatment much sooner. During an interview on 10/3/24 at 3:15 P.M. the Administrator said he expected staff to assess residents for change in condition, call the physician and obtain treatment as indicated. Staff should document assessments, communication with the physician, and follow up assessments. Staff should have obtained a urinalysis for the resident as ordered by the physician and followed up with treatment to prevent hospitalization . The resident was aware of his/her symptoms and told staff. Staff should not delay a resident's treatment. During an interview on 10/10/24 at 8:15 A.M. the facility Medical Director said he was on call for the previous month and had not received notification of the resident's urinary symptoms. He expected staff to notify him of any change in a resident's condition in order to obtain testing and implement treatment as soon as possible. Staff should not delay a resident's treatment. He was not aware the resident had urgency and dysuria and not aware staff had not completed the urinalysis. Staff should have called and notified him of the resident's condition, obtained the urinalysis, and started treatment to prevent hospitalization and worsening of the resident's condition. MO 00242406

Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident # 3) with psychiatric diagnoses, and a history of suicidal ideation, who lived on a secured behavioral unit, when the resident obtained a disposable razor on 7/23/24 from another resident (Resident #8) and cut his/her wrist several times. The facility census was 178. The Administrator was notified on 7/24/24 at 2:45 P.M. of the Immediate Jeopardy (IJ), which began on 7/23/24. The IJ was removed on 7/25/24, as confirmed by surveyor onsite verification. Review of the facility's Behavioral Emergency Policy, dated 6/26/24, showed the following: -It is the policy of the facility to provide a safe environment and provide humane care to all residents; -Care will be guided by the resident's plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. The facility did not have a policy specific to the use of razors by residents, how staff were to handle/dispose of resident razors, or how staff were to ensure razors were accounted for/safely managed. 1. Review of Resident #3's Preadmission Screening and Resident Review (PASARR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 1/18/22, showed the following: -The resident had a history of abuse and neglect by his/her parents and an unstable childhood; -The resident had current diagnoses that included bipolar disorder (causes extreme mood swings that include emotional highs and lows), schizoaffective disorder (a combination of symptoms of schizophrenia, a serious mental illness that affects how a person thinks, feels, and behaves, and mood disorder, such as depression), borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life. It includes a pattern of unstable, intense relationships, as well as impulsiveness and an unhealthy way of seeing themselves. Impulsiveness involves having extreme emotions and acting or doing things without thinking about them first), post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest); -The resident had a history of being involved in satanic cult ceremonies which he/she was the recipient of multiple lacerations by religious knives; -The resident had historical behaviors of suicidal ideations, depression, impulsiveness, poor judgement and insight, impulsive suicidal act, feelings of hopelessness and helplessness, and auditory and visual hallucinations; -At the time of the evaluation the resident had superficial lacerations to his/her left forearm, left bicep and across his/her anterior neck; -The resident had a history of cutting himself/herself with an onset at age 13. Review of the resident's care plan, dated 8/22/22, showed the following: -The resident had current behaviors that included anxiety, poor impulse control, poor judgement, verbal and physical aggression, racing thoughts, abnormal thought process, suicide ideation/attempt, self-harm and poor boundaries; -The resident did not always think about the consequences before he/she acted and acted on impulse without thinking about his/her safety. Review of the resident's care plan, dated 2/6/23, showed the following: -The resident had a behavior problem related to bipolar disorder; -Monitor behavior episodes and attempt to determine the underlying cause. Review of the resident's care plan, dated 4/30/23, showed the following: -The resident's PASARR showed the resident had a history of abuse and neglect by family, and a history of behavioral challenges that required protective oversight in a secure setting; -Current behaviors were anxiety, depression, agitation, poor impulse control, poor judgement and mania. Review of the resident's care plan, dated 6/26/23, showed behavior per the resident's PASARR showed suicidal ideations, depression, labile (something that can change quickly and spontaneously) and impulsive. Review of the resident's care plan, dated 11/21/23, showed the following: -The resident was at risk for lack of motivation, interest and self-harm related to a history of suicidal ideation; -Implement safety measures; -Provide education and support; -Monitor for suicidal and homicidal ideations. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/24/24, showed the following: -The resident admitted to the facility on [DATE]; -The resident was cognitively intact; -The resident had diagnoses that included medically complex conditions, schizophrenia and bipolar disorder. During an interview on 7/24/24 at 9:27 A.M., Resident #8 said the following: -He/She had a razor in his/her room for about three or four weeks; -He/She got the razor when showering and there was no staff to give it back to, so he/she took it to his/her room and continued to use it; -Resident #3 asked if he/she could use the razor to shave, so Resident #8 gave the razor to Resident #3 to borrow on 7/23/24; -Before the 6:00 A.M. smoke break, Resident #3 told Resident #8 he/she had cut his/her arm with the razor he/she borrowed, because he/she was upset about breaking up with Resident #13; -Resident #8 helped Resident #3 clean up his/her arm. Resident #8 used a paper towel to wipe the blood from Resident #3's arm; -Residents #8 and #3 went to smoke. Resident #1 was in the smoke room and heard them talking about Resident #3 cutting his/her arm; -Residents #8 and #3 went to Resident #3's room. Resident #8 got the razor from Resident #3. Resident #3 had taken the razor apart; -Hall Monitor G came to Resident #3's room and Resident #8 gave the razor to Hall Monitor G; -Hall monitor G put the razor in the sharps box. During an interview on 7/29/24 at 1:40 P.M., Resident #3 said the following: -He/She and Resident #13 got into an argument during the night; -He/She did not try to commit suicide, only hurt himself/herself; -He/She got the razor from Resident #8; -He/She told Resident #8 he/she wanted to shave without staff watching, not that he/she was going to hurt himself/herself; -He/She had been thinking about cutting for a few days; -He/She told Resident #8 after he/she cut his/her arm; -He/She cut his/her left forearm 18 times; -He/She went to smoke at 6:00 A.M. and told Resident #1 about cutting his/her arm; -Resident #1 reported the cutting to Hall Monitor G. During an interview on 7/25/24 at 12:54 P.M. Hall Monitor G said the following: -After the 11:00 P.M. smoke break on 7/23/24, Resident #3 sat in the commons area and watched television for awhile and then went to bed and stayed in his/her room; -After the 6:00 A.M. smoke break on 7/24/24, Resident #1 told Hall Monitor G Resident #3 got a razor and cut his/her arm; -Resident #1 said Resident #3 got the razor from Resident #8; -Hall Monitor G went to Resident #3's room and Resident #3 showed Hall Monitor G his/her arm where it had been cut several times; -Resident #3 said he/she got the razor from Resident #8; -Resident #8 was in the room and gave the razor to Hall Monitor G who then put the razor in a sharps container; -Hall Monitor G called the night shift supervisor and reported the incident; -Resident #8 could not remember which staff member gave him/her the razor. During an interview on 7/24/24 at 4:25 P.M., the night shift supervisor said the following: -Hall Monitor G called and reported Resident #3 had taken a razor apart and cut his/her arm; -Hall Monitor G said Resident #3 got the razor from Resident #8; -Resident #3 said he/she wasn't suicidal, he/she just liked the feeling of cutting; Review of a picture on 7/24/24 at 11:35 A.M. on the administrator's phone showed a picture of Resident #3's left forearm with approximately 15 to 20 superficial cuts in about a four inch span from his/her wrist towards his/her elbow. Review of Resident #3's hospital records, dated 7/25/24, showed the following: -The resident self-harmed by superficial cutting on his/her arm in attempt to feel better; -The resident had suicidal ideations without intent or plan; -The resident had depression symptoms for the last few months; -The resident had emotional reactivity (to experience frequent and intense emotional arousal - to be in a state of fight or flight) and dysregulation (a mental health symptom that involves trouble controlling your emotions and how you act on those feelings) after a breakup with Resident #13; -The resident continued to endorse suicidal ideations with a plan to cut his/her wrists and bleed to death; -The resident reported experiencing worsening depression symptoms for the last few months, including decreased appetite, feeling low, and hopeless; -The resident said he/she had nightmares of past trauma that felt like flashbacks. The nightmares had increased due to stressors with Resident #13. During an interview on 7/24/24 at 11:35 A.M., 2:45 P.M. the administrator said the following: -Resident #8 should not have had the razor in her possession after shaving; staff should have taken the razor; -Residents should be supervised at all times with a razor and after each use the razor should go to the sharps container; -Staff are educated about resident use of razors during orientation; -Staff should monitor residents when they give them a razor to shave and ensure the razor was returned to staff when residents are finished shaving; -The facility did not have a system in place to keep track of razors or count razors. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #4) of 13 sampled residents, with mental disorders who lived on a secured locked unit, received individualized treatment and services to meet the resident's needs. The facility failed to ensure the resident received timely and appropriate treatment or services, including administering medications that were prescribed by the physician. The facility census was 178. Review of the facility policy Behavioral Health Services, dated 6/26/24, showed the following: -It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning; -Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders; -Staff will monitor the resident closely for expressions or indication of distress, assess and develop a person-centered care plan for concerns identified in the resident's assessment; -The care plan shall have interventions that are person-centered, evidence based, culturally competent, trauma informed, and in accordance with professional standards of practice, reflect the resident's goals, use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. 1. Review of Resident #4's care plan, dated 9/23/23, showed the following: -The resident was perseverated (to intently focus one's attention on a thought) on medications; -The resident had a behavior problem of becoming verbally and physically aggressive and had a history of suicide attempts related to bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); -Administer medications as ordered. Monitor/document for side effects and effectiveness; -Anticipate and meet the resident's needs; -The resident's coping skills included smoking and listening to music. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 6/23/24, showed the following: -The resident was cognitively intact; -The resident had diagnoses that included medically complex conditions, paranoid (paranoia is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia, bipolar disorder, and traumatic brain injury (TBI - a brain injury that was caused by an outside force that can cause problems with how a person thinks, understands, moves, communicates and acts). Review of the resident's progress notes, dated 6/8/24, showed the following: -At 8:04 A.M., Wellbutrin XL (used to treat depression) oral tablet extended release 300 mg was not available and the facility was waiting on a preauthorization from insurance; -At 10:03 A.M., staff called a code green (behavioral emergency) because the resident was agitated because his/her morning dose of Wellbutrin was not available. Staff educated to obtain the Wellbutrin from the Omnicell (automated emergency medication system) so the resident would not miss a dose. The pharmacy reported the resident's insurance would not pay for Wellbutrin because they needed a prior authorization form. The Director of Nursing (DON) was notified of the same concerns and reports on 6/7/24. Review of the resident's progress notes, dated 6/8/24 at 10:45 A.M. showed the resident was tearful and apologetic for becoming aggressive over his/her medications. Review of the resident's Medication Administration Record (MAR), dated 6/8/24, showed no documentation staff administered Wellbutrin XL oral tablet extended release 300 mg to the resident. Review of the resident's psychiatrist's notes, dated 6/10/24, showed the following: -The resident was seen for evaluation of sleep, mood, anxiety, delusions and medication; -The resident endorsed auditory hallucination (sensory perceptions of hearing in the absence of an external stimulus) without details; -No recent behaviors or concerns were reported; -Diagnosis of paranoid schizophrenia; review of safety precautions with cognitive decline. Review of medications showed Abilify extended release (a medication used to treat certain mental/mood disorders), maintenance injection 400 mg once every 28 days. Review of the resident's psychiatrist's notes, dated 6/17/24, showed a nurse practitioner's (NP) visit encounter that showed the following: -The resident was seen for a medication follow up; -Medication list was updated on 6/14/24 that included Abilify extended release maintenance injection 400 mg once every 28 days and Wellbutrin XL extended release 24 hour, 300 mg; -The resident was seen for medication reconciliation for re-evaluation of paranoid schizophrenia, depression, and anxiety; -The resident resided in a long term care facility locked unit due to the need for ongoing nursing care and medication monitoring; -No acute changes reported; -Paranoid schizophrenia was stable and continue Abilify maintenance extended release 400 mg maintenance injection, 400 mg once every 28 days; -Severe episodes of recurrent major depressive disorder without psychotic features, no acute signs or symptoms, continue Wellbutrin XL 300 mg daily. Review of the resident's progress notes, dated 6/18/24, showed a plan of care note by the resident's primary care physician that showed the following: -The resident was seen for evaluation of sleep, mood, anxiety, delusions and medication reconciliation; -The resident endorsed auditory hallucination without details; -Paranoid schizophrenia in exacerbation (an acute increase in the severity of a problem, illness, or bad situation); -Review of safety precautions with cognitive decline; -Review of medications: Abilify extended release maintenance injection 400 mg once every 28 days. Review of the resident's MAR, showed Abilify extended release 400 mg intramuscularly (IM) one time a day every 28 days related to schizophrenia scheduled to be administered on 06/19/24. Staff left the date blank which indicated staff did not administer the medication. Review of the resident's progress notes, dated 6/27/24, showed an order administration note: Wellbutrin XL extended release 24 hour, 300 mg by mouth one time day for depression, medication not available, too soon to reorder. Review of the resident's MAR, dated 6/27/24, showed staff did not administer Wellbutrin XL. Review of the resident's progress notes, dated 6/30/24, showed a behavior note the resident pulled the fire alarm. The resident said he/she pulled the alarm because he/she was upset about medication concerns. Review of the resident's MAR, dated June 2024, showed the following: -The resident missed two doses of Wellbutrin XL on 6/8/24 and 6/27/24; -The resident missed his/her monthly injection of Abilify on 6/19/24. Review of the resident's progress notes, dated 7/6/24, showed the following: -At 4:15 P.M., a behavior note showed the resident was observed to be verbally aggressive towards the certified medication technician (CMT). Immediate staff intervention and separation from peers. The resident was not easily redirected and continued to be verbally aggressive to staff and peers; -Staff contacted long term psychological management and got a new order for olanzapine (used to treat schizophrenia) 10 mg injection, one time only. Staff administered the injection and the resident calmed down. Staff will continue to monitor for protective oversight; -At 4:51 P.M., the resident rested in bed and said he/she was sorry for his/her behavior. Review of the resident's progress notes, dated 7/7/24, showed the following: -At 1:06 P.M., the resident told the nurse he/she felt anxious and requested an as needed (PRN) medication; -At 1:11 P.M., staff gave the resident PRN olanzapine 10 mg by mouth. Review of the resident's MAR, dated 7/7/24, showed a new order for olanzapine 10 mg by mouth every eight hours as needed for agitation/anxiety for 14 days. Review of the resident's progress notes dated, 7/9/24, showed the following: -The resident said he/she was extremely anxious and wanted a PRN medication; -Staff walked the resident through coping skills and once done the resident said the coping skills were ineffective. The resident was pacing aimlessly and talking fast; -The staff administered a PRN olanzapine 10 mg by mouth. Review of the resident's progress notes dated, 7/10/24, showed the following: -At 8:21 A.M., the resident said he/she was extremely anxious and wanted an as needed medication; -The resident said he/she had some anxiety; -The resident said he/she had been having dreams where he/she felt stuck; -Staff talked the resident through his/her coping skills and then would check in with the resident in an hour; -At 10:27 A.M., the resident said his/her coping skills were ineffective and he/she wanted a PRN medication because he/she was still anxious and did not want to blowup later. The resident wanted to have a good day; -Staff administered a PRN olanzapine 10 mg by mouth. Review of the resident's progress notes dated, 7/11/24, showed the following: -At 4:01 A.M., the resident requested a PRN medication because he/she had anxiety; -At 4:03 A.M., staff administered PRN olanzapine 10 mg by mouth and encouraged the resident to use coping skills. Review of the resident's progress notes dated, 7/17/24, showed the resident's Wellbutrin XL 300 mg was not available. Review of the resident's MAR, dated 7/17/24, showed the following: -Staff did not administer the resident's Wellbutrin XL 300 mg; -Abilify extended release 400 mg intramuscularly one time a day every 28 days related to schizophrenia was scheduled to be administered. The date was left blank which indicated staff did not administer the medication. During an interview on 7/30/24 at 4:18 P.M., Licensed Practical Nurse (LPN) H said the following: -Resident #4's Abilify probably wasn't available; -LPN H did call the pharmacy and they said it would be delivered the next day and that is why he/she did not chart anything, so that the next nurse would know to administer the medication. Or the pharmacy said it wasn't covered by insurance; -LPN H was not for sure what the pharmacy said; -LPN H would have reported the missed medication to the nurse that came on the next shift and he/she would have reported it in the nurse's meeting; -Resident #4 was loud and agitated and pulled the fire alarm; -If Resident #4 asked for a PRN medication it was usually because he/she was anxious. Review of the resident's progress notes dated, 7/18/24, showed the resident's Wellbutrin XL 300 mg was not available. Review of the resident's MAR, dated 7/18/24, showed staff did not administer the resident's Wellbutrin XL 300 mg. Review of the resident's progress notes dated, 7/19/24, showed the following: -At 8:26 A.M., the resident's Wellbutrin XL 300 mg was not available and staff would follow up with the pharmacy; -At 8:50 A.M., noted that the resident missed a dose of his/her Wellbutrin XL 300 mg. The resident's physician was notified. Wellbutrin was in the building and would be administered per schedule; -At 8:56 A.M., long term psych management notified the resident missed his/her Wellbutrin XL 300 mg; -At 6:00 P.M.,staff removed the Wellbutrin from the Omnicell for the morning dose. Review of the resident's MAR, dated 7/19/24, showed staff did not administer the resident's Wellbutrin XL 300 mg at any time that day. Review of the resident's progress notes dated, 7/25/24, showed the following: -Housekeeping attempted to deep clean the resident's room when the resident began screaming at and threatening the housekeeper; -A code green was called. Review of the resident's progress notes, dated 7/27/24, showed the following: -At 3:40 A.M., the resident reported to the staff he/she did not receive his/her monthly injection; -Staff told the resident they would have to look it up and let the resident know why he/she did not get his/her injection; -Five minutes later the fire alarm went off; -Staff said Resident #4 pulled the fire alarm because staff took too long to give him/her the injection; -The resident yelled and it upset the other residents. Staff separated all the residents but Resident #4 continued to yell; -Resident #4 could not utilize his/her coping skills and could not be redirected; -Staff obtained an order for Thorazine (used to treat schizophrenia and bipolar disorder) 50 mg injection; -At 4:50 A.M., staff administered PRN Thorazine 50 injection to the resident; -At 12:00 P.M., the resident pulled the fire alarm two times, he/she was delusional and said everyone was trying to kill him/her. Staff obtained an order to send the resident to the hospital for evaluation. Review of the resident's care plan, dated 7/28/24, showed the following: -Problem: this is my safety plan; -My personal goal is: make healthy decisions; -Interventions: the resident had one PRN (as needed) medication if he/she needed it, his/her warning sign was anxiousness, review the resident's medication with him/her to ensure he/she understood what medications the resident took and why, the following are ways the resident could be distracted or methods that comfort him/her including smoking, TV, games, group, and phone calls, the following worked well for the resident during his/her past crisis moments: sleeping and talking. Review of the resident's physician order sheet (POS), dated 7/29/24, showed the following: -Abilify extended release 400 mg injection once every 28 days start on 4/24/24; -Thorazine 50 mg injection every 12 hours as needed for agitation/anxiety related to paranoid schizophrenia and bipolar disorder start on 7/27/24; -Wellbutrin XL extended release 300 mg by mouth one time a day for depression start on 5/27/24. Review of the resident's MAR, dated July 2024, showed the following: -The resident missed three consecutive doses of Wellbutrin XL on 7/17/24, 7/18/24, and 7/19/24; -The resident missed his/her monthly injection of Abilify on 7/17/24. During an interview on 7/9/24 at 3:08 P.M., Licensed Practical Nurse (LPN) A/Resident Care Coordinator said the following: -The pharmacy said Resident #4's Abilify was not covered by insurance; -If a medication is not available on the medication cart for a resident, staff should call the pharmacy to check on it, call the physician, and notify the DON. During an interview on 7/29/24 at 5:19 P.M. the Assistant Director of Nursing (ADON) said the following: -If a medication was not available she would expect the staff to chart that on the MAR; -She would expect staff to call the pharmacy and find out why the medication wasn't at the facility; -She would expect the nurse to call the physician and get an alternative medication if the one prescribed was not covered by insurance. During an interview on 7/29/24 at 5:19 P.M. the Assistant Director of Nursing (ADON) said the following: -If a medication was not available she would expect the staff to chart that on the MAR; -She would expect staff to call the pharmacy and find out why the medication wasn't at the facility; -She would expect the nurse to call the physician and get an alternative medication if the one prescribed was not covered by insurance. Review of the resident's psychiatric hospital discharge records, dated 8/3/24, showed the following: -Arrival to hospital 7/27/24; -Chief complaint: the resident came from a skilled nursing facility for a mental health evaluation. The resident made suicidal statements and had exhibited increasing paranoia; -Admission Impression: the resident was not safe for discharge and was admitted to inpatient with suicidal ideations due to voices that told him/her to kill himself/herself; -Duration of symptoms prior to arrival: days prior to admission; -On 8/3/24 the resident was ready and agreeable to discharge to the skilled nursing facility. During an interview on 8/6/24 at 9:38 A.M., and 8/8/24 at 9:20 A.M. the DON said the following: -There were no medications pulled from the Omnicell for Resident #4 during the months of June and July 2024; -She did not recall LPN H ever reporting in a nursing meeting that the resident's Abilify or Wellbutrin were not available for administration; -She expected nurses to call the pharmacy and the physician when a medication was not available to a resident; -If she was notified a medication was not available, she called the physician to notify them and to get a new order, either to put the medication on hold or get an alternative; -She was made aware that the resident missed his/her Abilify monthly injections for June and July 2024 on the day the resident was sent to the hospital (7/27/24); -She did not know why the resident pulled the fire alarm, the resident just did that when he/she was cycling. During an interview on 8/8/24 at 8:33 A.M., the resident said the following: -He/She pulled the fire alarm at the facility to get attention because he/she didn't get medications; -The resident felt he/she was neglected; -He/She doesn't get to see the psychiatrist, he/she had not seen the psychiatrics in two months. During an interview on 8/8/24 at 9:11 A.M., the Administrator said the following: -He expected staff to contact the resident's physician when his/her medications were not available; -He expected staff to contact the psychiatric physician for an appointment when the resident was having behaviors; -The resident was on a schedule with the psychiatric physician/NP for regular visits. He did not know for sure how often the resident was seen; -If the resident did not get his/her regimen of prescribed medications it could increase his/her behaviors and actions. MO239610

Based on interview and record review, the facility failed to ensure one resident (Resident #2) in a review of 13 sampled residents, who was monitored one on one by Certified Nurse Aide (CNA) F, was free from abuse when Resident #1 entered Resident #2's room and started a verbal argument. The verbal argument escalated and CNA F did not intervene. Resident #1 hit Resident #2 in the head and neck repeatedly with a closed fist which resulted in the resident being sent to the hospital where he/she was diagnosed with a neck contusion (bruising). Resident #2 remained fearful and scared of Resident #1 and was moved to another hall for his/her safety. The facility census was 178. Review of the facility Abuse and Neglect policy, dated 6/12/24, showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -Physical abuse is purposefully beating, striking, wounding, or injuring any resident in any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner; -Physical abuse also includes but is not limited to hitting, slapping, punching, biting and kicking; -The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; -The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -New employees will be educated by the department manager or designee on issues related to abuse prohibition practices during initial orientation and annually; -The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur; -During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs and what constitutes physical, sexual, verbal and mental abuse, and how to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his/her safety, as well as the safety of other residents in the facility. 1. Review of the facility Administrative/Registered Nurse Investigation, dated 7/15/24, showed the following: -Date of incident was 7/15/24; -Type of incident; physical aggression involving the head; -Person(s) involved in the incident: Resident #1, #2, #3, and #12; -There was a physical altercation between Resident #1 and #2; -Certified Nurse Aide (CNA) F was one-on-one with Resident #2 when Resident #1 came into Resident #2's room yelling; -CNA F said he/she tried to redirect Residents #1, #3, and #12; -Hall Monitor I heard the commotion and went to Resident #2's room and tried to redirect Resident #1; -Resident #1 pushed past Hall Monitor I and struck Resident #2 with a closed fist; -The facility concluded Resident #1 did strike Resident #2 with a closed fist; -The facility concluded Resident #1 had diagnoses of oppositional defiant disorder and intellectual disabilities with a history per his/her Preadmission Screening and Resident Review (PASARR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) of poor impulse control. When Resident #1 heard that Resident #2 made negative comments about Resident #12, Resident #1 responded by striking Resident #2; -Resident #2 complained of pain in the head and was sent to the hospital for evaluation. Resident #2 returned from the hospital with a diagnosis of a neck contusion (bruising). 2. Review of Resident #1's care plan, dated 9/25/23, showed the following: -Special Instructions: High behavior resident/resident behaviors: physical aggression towards others, assaultive behaviors, biting others and anger management. Effective coping skills included coloring and listening to music; -The resident was at risk for altercation in mood and delusional thought process related to bipolar disorder (a mental illness that causes extreme mood swings that include emotional highs and lows); -Monitor for changes in mood and behaviors, provide a calm environment and redirect as needed; -The resident had a history of behaviors related to his/her mental health including verbal aggression, emotional disturbances, poor impulse control, aggressiveness, combative behaviors, poor judgement, intrusive, anger management, poor social skills, homicidal ideations, assaultive behaviors, auditory and visual hallucinations, poor boundaries with others and was child-like (functions at the level of a [AGE] year old); -The resident had a history of behavioral challenges that required protective oversight in a secure setting that included physically aggressive, threatening behavior, verbally aggressive, and poor impulse control; -The resident had a history of post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances. -Assess the resident for suicidal or homicidal ideations to ensure the safety of the resident and others; -Remain with the resident at all times when levels of anxiety are high. Review of the resident's care plan, dated 5/6/24, showed the resident returned to the facility from jail after assaulting a staff member. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/16/24, showed the following: -The resident was cognitively intact; -The resident had diagnoses that included medically complex conditions, depression, oppositional defiant disorder (ODD, a type of disruptive behavior disorder in which people frequently defy authority with hostility, leading to serious disturbances in their daily life), bipolar disorder, intellectual disabilities (ID, a term used when a person has certain limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills) and mood disorder (mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination of these). Review of Resident #1's facility acquired written statement, dated 7/15/24, showed the following: -Resident #1 said he/she was told Resident #2 talked bad about Resident #12 who was Resident #1's friend. That upset Resident #1; -Resident #1 went to Resident #2's room and yelled at him/her and told Resident #2 to stop talking about Resident #12; -Resident #1 said he/she hit Resident #2 a few times in the head area and walked out of the room; -A code green (a code called when a behavioral event occurs and trained staff respond to assist to deescalate a situation) was called, and Resident #1 did not remember who was in the room, it all happened fast. During an interview on 7/29/24 at 12:17 P.M., the resident said the following: -Resident #3 told him/her Resident #2 talked bad about Resident #12; -Resident #1 did not like people talking bad about his/her friends and it made him/her mad; -Resident #1 went to Resident #2's room and they argued; -Resident #1 threw Resident #2's blankets at Resident #2 and then Resident #1 hit Resident #2; -Hall Monitor I came in the room and separated the two residents; -Resident #2's one-on-one staff (CNA F) was in the room at the time, but he/she did not do anything or say anything. 2. Review of Resident #2's care plan, dated 9/20/23, showed the resident had a history of behavioral challenges that required protective oversight in a secure setting. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident had diagnoses that included anxiety, depression, borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life. It includes a pattern of unstable, intense relationships, as well as impulsiveness and an unhealthy way of seeing themselves. Impulsiveness involves having extreme emotions and acting or doing things without thinking about them first), and schizophrenia (a chronic mental disorder characterized by delusions, hallucinations, disorganized speech and behavior, and decreased emotional expression and motivation); -The resident did not have any behaviors. Review of the resident's progress notes, dated 7/15/24, showed the following: -At 4:25 P.M. the resident told staff he/she felt suicidal and was immediately placed on one-on-one with staff; -At 8:15 P.M. the resident was one-on-one with staff when a peer entered his/her room and became verbally abusive and punched the resident in the head. Review of the resident's facility acquired written statement, dated 7/15/24, showed the following: -Resident #1 went into Resident #2's room and told him/her to stop talking about Resident #12; -Resident #2 told Resident #1 it was none of his/her business and to leave the room; -Resident #1 did not leave Resident #2's room even after being asked a second time by Resident #2; -A staff member came into Resident #2's room and stood between Resident #1 and #2; -Resident #1 went around the staff member and started hitting Resident #2 in the head. Resident #1 hit Resident #2 six times in the head; -Staff got between the two residents and Resident #1 left the room. During an interview on 7/24/24 at 9:18 A.M. and 7/29/24 at 11:18 A.M., the resident said the following: -Resident #1 came into his/her room and asked why he/she was talking about Resident #12; -He/She and Resident #1 argued and yelled at each other; -He/She asked Resident #1 to leave his/her room, but Resident #1 did not leave; -Resident #1 hit Resident #2 in the head and neck six times; -Resident #12, #3, and another peer blocked the doorway so Resident #2's one-on-one staff could not get out -CNA F did not do anything at all to help the resident when Resident #1 came in his/her room; -He/She had trouble sleeping since the incident with Resident #1 and was supposed to get moved to another room, because he/she just didn't feel safe around Resident #1. Review of the resident's hospital discharge records, dated 7/15/24, showed the following: -The resident was discharged to the facility on [DATE]; -The resident had a neck contusion. During an interview on 8/1/24 at 9:50 A.M. Resident #2's guardian said the following: -She went to the facility the day of the altercation between Resident #1 and #2; -She filed charges with the police department because this was not the first incident with Resident #1; -Resident #2 was moved to another hall on 7/29/24 because he/she was scared of Resident #1 even though Resident #1 was on one-on-one supervision. During an interview on 7/25/24 at 8:30 A.M., CNA F said the following: -He/She was hired around July 1, 2024; -He/She did not get any training about being one-on-one with residents or how to handle physical aggression by residents; -He/She was one-on-one with Resident #2 on 7/15/24; -He/She did not intervene or get in between Resident #1 and Resident #2; -CNA F said he/she was not going to get in the middle of all that mess; -He/She went to get someone to help and Resident #12 was blocking the doorway; -Another staff was across the hall and came to help. During an interview on 7/30/24 at 2:57 P.M., Hall Monitor I said the following: -Hall Monitor I was across the hall from Resident #2's room with another resident when he/she heard yelling and arguing; -Hall Monitor I went to Resident #2's room and saw Resident #1 and #2 arguing with each other: -CNA F was in the room just standing there watching and doing nothing; -Hall Monitor I tried to calm Resident #1, but the resident went around him/her and started hitting Resident #2 in the head; -Other residents were in the hallway outside Resident #2's room but none of them were blocking the doorway. During an interview on 7/24/24 at 3:33 P.M., 7/29/24 at 5:38 P.M. and 8/1/24 at 1:31 P.M., the Administrator said the following: -He would expect one-on-one staff to intervene in any verbally or physically aggressive situation; -Staff should protect the residents; -CNA F would have had training during orientation that would have covered one-on-one supervision situations, abuse and neglect, intervening when needed and resident to resident altercations. -Resident #2 was moved to another hall to keep him/her away from Resident #1 and to help Resident #2 feel safe. -The facility concluded Resident #1 hit Resident #2 and this was considered abuse by Resident #1. MO239016

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1), who had behavioral difficulties and required 24-hour monitoring and management and was at risk for elopement per the resident's Pre-Admission Screening and Resident Review (PASARR), and resided on a secured behavioral unit. On 3/15/24, Hall Monitor A left residents unattended in the gated courtyard during the 9:00 PM smoke break. Resident #1 placed a chair in the corner of the courtyard next to a 12 foot tall fence and used the chair to climb up and over the fence. The resident left the facility without staff knowledge and walked for approximately two miles, crossing a busy four lane highway intersection, then along an outer road before he/she was located at approximately 10:00 P.M. Staff were not aware the resident had left the facility until another resident reported at approximately 9:30 P.M., the resident had left. The facility also failed to consistently implement and communicate interventions to prevent falls for one resident (Resident #7) with a history of falls, including falls with injury. A sample of 16 residents was selected for review. The facility census was 178. The administrator was notified on 3/20/24 at 2:55 P.M. of an Immediate Jeopardy (IJ) which began on 3/15/24. The IJ was removed on 3/22/24, per surveyor onsite verification. The facility did not have a specific policy that addressed monitoring residents during smoke breaks. Review of the facility policy, Intensive Monitoring/Visual Checks, dated 6/30/23, showed the following: -To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues; -All residents on each unit will be monitored by visual checks at least every two hours or may be provided more intensive monitoring every hour; -Special care units will not be left unattended at any time. 1. Review of Resident #11's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's PASARR Mental Illness Level II Evaluation, dated 9/27/23, showed the following: -Reason for nursing facility application, admission was behavioral difficulties and/or mental illness requiring 24-hour monitoring and management; -Diagnoses included post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it), antisocial personality disorder (a mental health disorder characterized by disregard for other people), cluster B personality disorder (characterized by overly dramatic, emotional, erratic thinking), bipolar disorder-manic with psychotic features (intense or prolonged mood episodes, psychotic symptoms, or hospitalization ), schizoaffective disorder (a mental health disorder marked by symptoms such as hallucinations or delusions and mood disorder symptoms such as depression or mania), cannabis abuse, hallucinogenic mushroom, cocaine use disorder, methamphetamine use disorder moderate, in sustained remission; -The resident has a long history of mental health symptoms, he/she was non-compliant with medications, takes a variety of drugs, becomes manic and threatening and ends up in the hospital. The resident lacks the executive functioning skills necessary to make safe decisions; -Current psychiatric support/services inpatient psychiatric treatment, medication administration/management/monitoring, secured behavioral unit, safety precautions 15-minute checks, individual therapy/counseling, group therapy counseling; He/She has previously jumped in front of a car in a suicide attempt, punched himself/herself and pulled his/her hair out; -Overt behaviors included refuses activities, impatient and demanding, wandering, physically threatening, strikes others when provoked; -Initially required frequent intervention, but now that he/she is on medications is doing better, and he/she is less argumentative with staff; -Orientation to person, place, circumstance, and time; -Limitations include poor coping skills, little actual support outside the hospital, he/she is non- complaint with medications and follow-up treatment; -Strengths include has a guardian, no medical problems, he/she is young, has good verbal skills, able to express needs and independence with activities of daily living (ADLs); -The resident's individual needs can be met in a nursing facility at this time; -He/She requires supervision to stay on his/her medications and make sure he/she does not become manic, requires 24/7 supervision until he/she has been on medications for a stabilizing period; -The individual needs or continues to need the following supports and services include provision of specific services to address individual mental health and behavioral needs; -Obtain individual support plan (ISP), individualized treatment plan (ITP), behavioral support plan (BSP) from department of mental health community mental health center and or developmental disability regional office; -Provision of a structured environment include maintain environment with low stimulation, maintain environment with a minimum of visual/auditory distractions, provide instructions at the individuals level of understanding, environmental supports to prevent elopement, assess and plan for the level of supervision required to prevent harm to self and others, provide for individual personal space, provide sensory supports, and establish consistent routines; -Crisis intervention services to include suicidal precautions, assault precautions and elopement precautions; -Monitor his/her behavior for signs and symptoms that he/she is becoming less stable, manic and report immediately. Review of the resident's nursing note dated 1/20/24 at 6:45 P.M., showed the resident reported it upset him/her that he/she must live in the facility due to not being able to hold a job, take classes or jog. The resident felt like the medication was not helping enough for his/her anger. The resident was made aware he/she would meet with administrator regarding his/her concerns, as well as Long-Term Care Psychiatric Management (LTPM) and the Assistant Director of Nursing (ADON) was notified. Review of the resident's care plan revised 1/31/24 showed the following: The resident has a guardian to assist in decision making due to mental illness. Ensure guardian wishes are followed; -Triggers included missing family, being yelled at and loud noises. The resident's care plan did not address elopement risk or smoking precautions. Review of the resident's Elopement Evaluation, dated 1/31/24, showed the following: -History of elopement while at home: No; -Wandering behavior, a pattern or goal directed: No; -Wanders aimlessly or non-goal directed: No; -Wandering behavior likely to affect the privacy of others: No; -Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No; -Elopement Score: not at risk for elopement. Review of the resident's PASRR/ Mental Illness Level II Evaluation, dated 2/16/24, showed the following: -Specific reason for nursing facility application admission or continued stay includes behavioral difficulties and/or mental illness symptoms requiring 24-hour monitoring/management, lack of community/family supports to maintain functioning at home, and alternate care options are unavailable (waiting lists, etc.); -Living situation since last evaluation has been at the facility since September 2023; -The individual's mental status, psychiatric symptoms and behaviors include anxiety, verbal and physical aggression, irritability, and sleep disturbances. He/She has been suspicious and paranoid and has had abnormal thought processes. The resident said they (the facility) told him/her six months to a year, and he/she thought he/she would listen to them. They lie to people and don't let them out. If they will let me out it will be good. This place (the facility) makes him/her want to go to prison. He/She was prepared to be in a place to better himself/herself; -Psychiatry, counseling staff relay the resident has requested a therapist and is on a waiting list to see one; -Current psychiatric support/services include psychiatric follow-up/consultation, individual therapy/counseling, and a secured behavioral unit; -Groups are offered but the resident refuses to go to a lot of them. He/She spends most of his/her day in bed, and prefer to stay up in the evening and at night; -The resident has continued to have behavioral problems, mood instability and irrational thinking processes. He/She spent a few weeks in a psychiatric center and can sleep better, although he/she likes to stay up at night; -He/She has a history of medication noncompliance and has a history of drug use; -He/She has previously jumped in front of a car in a suicide attempt, punched himself/herself and pulled his/her hair out; He/She has a history of cutting himself/herself and trying to strangle himself/herself with a tie. He/She has a history of poor coping skills; -Nursing facility/Community Interest: I don't like it at this place. There is a bunch of fights. I would rather be in a faith-based program. I wish I was in a rehab program in a faith-based program. I have wasted six months here. -Individual limitations include ongoing behavioral problems, elevated mood and irritability and irrational thinking processes. He/She lacks insight and judgement; -Provision of a structured environment includes environmental supports to prevent elopement, assess and plan for the level of supervision required to prevent harm to self and others, provide individual personal space, consistent routines, and a schedule for daily tasks/activities; -Needs and rationale as well as level of supervision needed, history of self-injury and elopement risk; -Crisis interventions services include suicidal precautions, assault precautions and elopement precautions; -History of self-harm and aggression. It is recommended that a safety plan be in place that addresses interventions should these issues occur; -Long term skilled care is not the overall goal. The resident seems confused about the specifics regarding what he/she needs to do to get out. He/She seems unaware of his/her goals regarding discharge. Review of the resident's care plan showed no evidence the facility updated the care plan with interventions for elopement risk precautions as indicated on the PASRR/Mental Illness Level II Evaluation on 9/27/23 and the PASRR/Mental Illness Level II Update dated 2/16/24. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 3/15/24, showed the following: -Cognitively intact; -Makes self-understood and understands others; -No behavioral symptoms exhibited; -No psychosis exhibited; -No wandering behaviors exhibited; -Feeling down, depressed, or hopeless occurred two to six days of the seven day look back period; -Independent ADLs. Review of the resident's progress note dated 3/15/24 at 10:56 P.M., showed it was reported to Registered Nurse (RN) F on 3/15/24 after the 9:00 P.M. smoke break the resident was not able to be located on the unit. Hall monitor E called a Code [NAME] (call to respond to an elopement or anytime a resident is missing from the facility or there was a possibility that a resident left the facility without appropriate supervision). The nurse notified the Administrator. Immediate staff intervention, face checks to every room, all residents accounted for except for this resident. The police were notified about the elopement and responded to the facility. Demographics and a picture of the resident provided to law enforcement officer. The resident was found outside the facility and was returned to the facility by a department head staff. The resident was alert and oriented. The resident was agitated and yelling at staff members. The Director of Nursing (DON) and Long-term Psychiatric Management (LTPM) obtained an order to give Thorazine by mouth (PO) or intramuscular (IM). Obtained an order to send out for further medical and psychiatric evaluation. Physician on call notified. Guardian was notified. During an interview on 3/20/24 at 11:45 A.M., the resident said his/her guardian told him/her to try and give the facility six months and he/she did. He/She left on his/her terms after six months. He/She had planned it out well and the way it was planned out, no one would catch him/her. After the 9:00 P.M. or 11:00 P.M. smoke break (he/she did not remember which one) (on 3/15/24), he/she hid around the corner in the dark and once everyone went back inside, he/she climbed over the fence. It wasn't hard to do. He/She did not want to be at the facility. He/She wanted to have his/her own place and get a job. The facility wasn't doing anything to help him/her get better. During an interview on 3/21/24 at 3:20 P.M. the resident's guardian said the following: -The facility had reported the resident's elopement to him/her; -He/She was new as the resident's guardian, and was not real familiar with him/her yet; -The resident had not been in contact with him/her about wanting to leave the facility. Review of the initial reporting form, dated 3/16/24 at 11:57 A.M. showed the following: -Date and time the alleged incident occurred: 3/15/24 at 9:29 P.M.; -It was reported to administration on 3/15/24 at 9:35 P.M. the resident was noted missing from the unit after 9:00 P.M. smoke break, a Code [NAME] procedure was immediately started. Staff began checking all rooms and when staff went to the smoke area a chair was found wedged in the corner of the smoke yard that the resident used to scale the fence and elope. Staff immediately started looking offsite for the resident. At 10:05 P.M. the resident was found on an outer road about two miles from the facility. The resident was returned to the facility, skin assessment completed and no injuries, order given for the resident to be sent out for psychiatric evaluation. Review of the resident's progress note dated 3/16/24 at 2:20 A.M. showed the resident was admitted to a psychiatric center. During an interview on 3/19/24 at 3:00 P.M. Hall Monitor E said the following: -He/She had worked at the facility for approximately two years; -He/She worked routinely on the hall where Resident #1 resided; -When he/she took the residents outside to smoke, he/she would prop the door open and try to position himself/herself between the door (to the outside gated courtyard) and the inside of the facility, so he/she could monitor the hall at the same time residents were outside smoking; -He/She could not see around the side of the building when residents were outside smoking, he/she tried to watch the residents the best he/she could; -When it was dark, there was only one light on the outside (in the courtyard), and it was over the door; -On 3/15//24 at the 9:00 P.M., he/she did not see the resident come out for smoke break at all that night, normally the resident said he/she didn't smoke; -A call light came on (during the 9:00 P.M. smoke break), so he/she went inside to answer the call light. RN F watched the smoke area for a few minutes (he/she thought), while he/she answered the call light inside; -Resident #9 came to him/her (Hall Monitor E) after the smoke break (approximately 9:30 P.M.) and said Resident #11 had escaped. This was how he/she found out the resident was missing; -Resident #9 showed Hall Monitor E where a chair was positioned by the fence outside in the outside smoke area, he/she believed the resident used the chair to get over the fence; -He/She immediately called a Code [NAME] and started looking for the resident; -He/She thought maybe 12 residents went out to smoke that night, but it was different every break, he/she didn't document how many residents went out to smoke or how many came back in; -He/She completed hourly face checks on each resident on the hall; -The facility was always short staffed so he/she often would take the residents outside to smoke and try to watch the hall for call lights at the door while he/she was smoking the residents. It was difficult to do both at the same time. During an interview on 3/19/24 at 12:30 P.M. RN F said the following: -He/She was the charge nurse for the 300 hall the night of 3/15/24 when the resident eloped, he/she found out the resident had eloped after the 9:00 P.M. smoke break; -An overhead Code [NAME] was called for the 300 hall sometime after 9:00 P.M.; -He/She responded to the hall and was notified by Hall Monitor E the resident was missing, he/she immediately completed a room search of every room in the building (including closets, bathrooms etc.) -Face checks were completed on all residents in the facility to ensure all other residents were accounted for and no one else was missing; -He/She notified the Administrator the resident could not be located after face checks were all completed; -Only one hall monitor was scheduled to work on the 300 hall (this was routine), a hall monitor from another hall was to come to 300 hall and supervise the floor (answer lights etc.) when the hall monitor assigned the 300 hall took the residents outside to smoke. He/She could also supervise the hall if needed while the hall monitor took residents outside to smoke; -He/She did not go to the 300 hall that night and supervise the hall while the residents went outside to smoke; -The hall monitor was never to leave the outside smoke area unattended to answer a call light inside. Observation on 3/19/24 at approximately 8:00 A.M., of the route the resident would have taken from the facility where he/she was found, showed the following: -The city street in front of the facility a two-lane black top; -The resident would have walked approximately one tenth of a mile to an intersection after dark where he/she would have crossed a busy four lane intersection, with traffic speed of 40 miles per hour and turned left then back right onto an outer road; -Once on the outer road, a two-lane black top with traffic speed of 45 mph, the resident would have walked approximately two miles on an unlit road with several curves, a hill and moderate traffic. There were no sidewalks along the route. Review of the [NAME].ground (a weather website service that lets you access real-time weather information) showed the temperature on 3/15/24 at approximately 10:00 P.M. was 45 degrees Fahrenheit. Observation on 3/19/24 at approximately 12:00 P.M. (on the 300 hall) showed the following: -Hall Monitor G opened the door from the 300 hall into the gated outside courtyard. Hall monitor G positioned himself/herself directly outside the door while he/she lit each resident's cigarette one by one (10 residents total); -Various residents walked around the gated courtyard (outside of Hall Monitor G's line of sight); -Hall Monitor G questioned one of the residents, if he/she was on the correct hall, (as he/she thought this resident did not belong on the 300 hall), another resident spoke up and said, yes, the resident was on the correct hall; -Hall Monitor G said he/she did not know the residents on this hall as well; -Hall monitor G walked to the side of outside smoke area once during the smoke break, but did not check the area before going back inside; -Hall Monitor G did not document/log who came out to smoke or who returned inside the building once smoke break was completed. During an interview on 3/19/24 at 1:15 P.M. Hall Monitor G said he/she had worked at the facility for a couple months and wasn't very familiar with the residents on the 300 hall. He/She was covering the outside smoke break on the 300 hall today. He/She did not participate in the in-service following Resident # 11's elopement. He/She always lit the residents' cigarettes by the door. It was hard to see around the side of the building to supervise all the residents when they were outside smoking. He/She tried to keep an eye on them the best he/she could. He/She thought 10 to 15 residents went out to smoke today on the smoke break he/she supervised. During an interview on 3/20/24 at 9:45 A.M. Licensed Practical Nurse (LPN) A said he/she was the charge nurse today on the 100, 200 and 300 halls. He/She heard a resident got out of the facility on the night shift. The facility would probably schedule an in-service soon (regarding the elopement), but it had not been scheduled yet. He/She heard the residents were not to smoke outside after dark. During an interview on 3/19/24 at 9:35 A.M. the DON said the following: This was the resident's first placement, the resident was just placed under guardianship prior to admission to the facility; -The resident had made no comments about wanting to leave, the resident had not been identified as an elopement risk; -The PASARR had something documented about the resident being an elopement risk, but it got missed or wasn't seen; -The resident left on 3/15/24 around 9:30 P.M., she was not working, but was told a Code [NAME] was called, room searches were completed and most likely the police were notified; -The resident was found on a side street walking; facility staff found the resident and brought him/her back; -The resident had no injuries and was sent out for psychiatric evaluation; -Staff should never leave the smoke area unsupervised. During an interview on 3/27/24 at 5:35 P.M. the Administrator said the following: -He would expect the facility staff to position themselves in the outside smoke area, where all residents are within line of sight, staff should not stand at the door; -Staff should never leave the outside smoke area unattended; -On 3/15/24 during the 9:00 P.M. smoke break, Hall Monitor E left the outside smoke area unattended to answer a call light inside, he/she should have never left the outside smoke area unattended. 2. Review of the facility policy, Post Fall Protocol, last revised 6/30/23, showed the following: -The purpose of the policy was to ensure that all residents who have had a fall have accurate assessment and follow through to prevent further injury and the recurrence of falls; -A fall is any event, not purposeful, and not from external force that results in the resident coming in contact with the next lower surface; -The LPN or RN on duty will perform a full head to toe assessment of affected resident immediately when informed of a fall; -Immediate vital signs are taken. Neurological assessments will be completed if the fall is unobserved, if the resident hits any part of their head or if the resident is cognitively impaired; -Stabilization/first aide of any injuries. Call 911 if needed; -Notify physician of incident and any injuries immediately upon discovery; -Notify the responsible party of the incident; -Documentation of the resident fall must be completed in the risk management section and include, but not limited to, the time, location, equipment involved if any, resident ' s activity at the time of the incident, description of any injuries, any action taken, resident ' s condition at the time of the incident, and details of the incident, including but not limited to immediate actions taken and actions taken to minimize recurrence; -Update care plan to include individualized interventions with date; -Refer to therapy department for screens and evaluation and treatment to prevent recurrence. Review of the facility policy, Focus Risk Assessment Plan Scope/Severity for Falls (FRAPSS), revised 6/29/23, showed the following: -Purpose: To assess all residents for potential for falls in the facility. To ensure a comprehensive interdisciplinary plan of care is established for all residents who are identified for increase risk of falls. To identify precipitating factors for fall risk and to be proactive in implementing interventions to prevent or reduce the incident of further falls; -Resident will be assessed using the FRAPSS form for fall risk upon admission, quarterly and in an acute situation where a resident has fallen; -Every resident who has a fall including those without injury will be screened by the therapy department and nursing interventions will be put in place to reduce the risk of further falls; -A FRAPSS Level 1 score of 0-15 indicates minimal risk for falls; -A FRAPSS Level 2 score of 16-25 indicates potential for more than minimal harm; -FRAPSS Level 3 score of 26-34 indicates potential for actual harm; -FRAPSS Level 4 score of 35 and up indicates immediate jeopardy with two or more falls with one or more resulting in a significant injury. Additional interventions may include, based on the IDT, hospitalization , 30 day discharge letter sent to the legal guardian if the facility feels the resident ' s needs cannot continue to be met, 1:1 supervision while awake with body alarm on the resident, and bed alarms on resident while asleep, including other individualized plans of care as assessed by the IDT. The administrator, DON, and therapy director will meet and establish interventions and plan of care that will reduce the risk of resident falling and ensure that protective oversight of the resident is a priority. The DON will continue to assess the resident as a high priority resident in the facility and the plan of care will be modified to ensure the highest level of safety is on place for the resident; -Nursing interventions will be individualized and addressed on the plan of care for the resident. Review of Resident #7's diagnoses list showed the resident had diagnoses that included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), heart failure, dementia, major depressive disorder, arthritis, glaucoma, mild intellectual disabilities and need for assistance with personal care. Review of the resident's care plan, last reviewed 1/17/24, showed the following: -The resident displayed impaired thought processes related to senile dementia; -The resident had impaired vision and wore glasses. The resident was also hard of hearing but refused to wear his/her hearing aides; -The resident required assistance of one staff with all activities of daily living (ADLs) and required consistent queuing. Provide protective oversight and assist where needed; -The resident was at risk for falls related to weakness and side effects of medications. The resident had a history of falls; -Encourage the resident to ask for assistance when walking and transferring as needed; -Focus Risk Assessment Plan Scope/Severity (FRAPSS) for Falls assessment quarterly and as needed; -Ensure appropriate footwear and clothing; -Ensure adequate lighting; -One staff to provide limited assistance with mobility/transfers as needed/requested; -Monitor for weakness, dizziness, blurred vision, unsteady gait/balance and report to the physician as needed; -Therapy evaluation/treatment as needed; -On 4/6/23 the resident sat self on floor and was upset and said, my favorite nurse doesn't work here anymore. The resident was educated on how to voice feelings and concerns. The resident was assessed and stable. Administrator, DON and physician were notified; -On 4/23/23 the resident slid out the chair onto the floor. The resident was assessed with no injuries. The resident was monitored by staff. The resident was placed on the list for provider rounds. Administrator, DON and physician were notified. Review of the resident's nurse's notes showed the following: -On 2/18/24 at 3:08 A.M., staff witnessed the resident asleep and fall forward from the wheelchair. Assessment completed and the resident assisted back to his/her room. Vital signs were within normal limits. A skin tear was noted to the left wrist which was cleaned and covered. Guardian, assistant DON, DON, administrator, and physician on call were notified. Education was provided to the resident on call light use and resident safety; -On 2/25/24 at 11:13 A.M., the resident had an unwitnessed fall. The resident was sitting on his/her buttocks on the floor in the dining room. There was a laceration to the right eye that was actively bleeding. The resident said a chair would not move when he/she attempted to sit down and the resident fell and hit his/her head. The resident reported pain to the right eyebrow. The resident was transferred from the floor to the wheelchair with assistance of two staff. Guardian, DON, administrator, and physician on call notified. Vital signs within normal limits. The resident was transferred to the hospital by Emergency Medical Service (EMS); -On 3/2/24 at 6:00 A.M., the resident was sleeping in the wheelchair in the dining room and fell out of the chair, bumping his/her forehead. No swelling, redness or bruising noted. Vital signs within normal limits. Guardian, physician, and administration notified. The resident was sent to the hospital by ambulance; -On 3/5/24 at 1:29 A.M., the resident fell from the wheelchair to the floor and bumped the side of his/her forehead. The resident complained of pain. Tylenol administered. Vital signs within normal limits. The resident was assessed and sent to the hospital for further evaluation. Physician, DON and guardian notified; -On 3/6/24 at 3:14 P.M., physical therapy (PT) and occupational therapy (OT) ordered for the resident after multiple falls without effectiveness from other interventions. Would like to place seatbelt on resident to keep him/her from falling out of the wheelchair, as well as placing the resident on a toileting schedule so he/she would not fall with toilet transfers. Therapy notified of new orders; -On 3/13/24 at 8:24 P.M., the resident was found on the floor by staff. Resident assisted back up. The resident denied any pain or discomfort. The resident refused a neurological assessment. Guardian, physician and administration notified; -On 3/15/24 at 7:19 P.M., (late entry) the resident was up in the wheelchair and allegedly slipped out of the wheelchair onto his/her bottom. The fall was unwitnessed. No visible injuries. Vital signs within normal limits. Policy of facility is to send out for further assessment. Guardian and administration notified. The resident was sent to the hospital; -On 3/17/24 at 6:30 A.M., the resident was up in a chair by the nurses station. Allegedly the resident went to the dining room and slipped out of the wheelchair onto his/her bottom. The fall was unwitnessed. The resident was assessed and no injuries identified. The resident said he/she was trying to sit in another chair at the table. The resident denied pain. Vital signs within normal limits. Administration and family notified. Sending resident out for further evaluation; -On 3/19/24 at 2:38 A.M., the resident was found on the floor under the sink. The resident was assessed with a skin tear to the left elbow. Sent to the hospital; -On 3/22/24 at 10:44 A.M., the resident reported a fall during night shift and was able to get himself/herself up and back into bed and did not report the fall to night shift. Resident made complaints of pain in middle back, head, and right elbow. Skin assessment showed two skin tears on left elbow with purple bruising, superficial scratch on top of his/her head on the right side, scratch on top of left thigh, redness on right upper back, purple bruising on left knuckles, and redness on the left shoulder. Vital signs within normal limits. Physician, guardian, DON notified. The resident was transported to the hospital by EMS. Review of the resident's care plan, revised 1/17/24, showed no updates or interventions added after the resident fell on [DATE], 2/25/24, 3/2/24, 3/5/24, 3/13/24, 3/15/24, 3/17/24, 3/19/24, or 3/22/24. Review of the resident's FRAPSS score for falls, dated 3/22/24, showed the resident was at high risk for falls, Level 4. Observation of the resident's room on 3/27/24 at 12:35 P.M., showed the resident was not in the room. There was a motion sensor pad alarm (device that contains sensors that trigger an alarm or warning light wh

Based on interview and record review, the facility failed to ensure one resident (Resident #5), of 14 sampled residents, received necessary care and services in accordance with professional standards of practice. Resident #5 had a left breast needle biopsy (a diagnostic procedure used to investigate masses or lumps) completed on 6/8/23 after a mass was found. The facility failed to follow up and report the biopsy results to the physician until 2/5/24, approximately eight months after the needle biopsy was completed. The biopsy results indicated infiltering duct adenocarcinoma (the most common form of breast cancer and if caught and treated early the survival rate is high). The facility also failed to ensure the resident attended a scheduled follow up appointment with the resident's oncologist to discuss his/her treatment plan.The facility census was 175. Review of the facility's policy, Transcription of Orders/Following Physician Orders, last revised 9/20/23, showed the following: -The purpose of the procedure is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians orders are followed. That a process is in place to monitor nurses in accurately transcribing and following physician orders; -After laboratory testing, diagnostic testing or other services are ordered, the nurse will document orders in residents electronic medical record and fill out the corresponding requisition for the specific services to be obtained (or follow up protocol set forth by individual lab company). The facility policy did not address who was responsible to report laboratory testing or diagnostic testing to the physician. 1. Review of Resident #5's care plan, last updated 5/8/23, showed the following: -The resident had impaired thought process related to schizophrenia, it was difficult to follow his/ her train of thought at times, he/she does have a guardian to assist him/her in major decision making; -The resident is independent with activities of daily living (ADL) but requires assist with personal hygiene, provide protective oversight and assist where needed. Review of the resident's ultrasound of the left breast, dated 5/18/23, showed the following: -Diagnostic mammogram (x-ray picture) left breast. Ultrasound (a procedure that uses high-energy sound waves to look at tissues and organs inside the body) left breast; -Impression: Suspicious finding for malignancy (cancer). Biopsy should be considered. Review of the resident's Physician's Order Sheet (POS), dated 5/23/23, showed left breast diagnostic, unspecified lump in left breast. Review of the resident's report of consultation (a report that is filled out by the consulting physician following an appointment indicating what was done at the appointment and a copy of the report returns to the facility with the resident), dated 6/8/23, showed the following: -Appointment: breast biopsy; -Diagnosis: breast lump. Review of the resident's physician encounter, progress note, dated 10/2/23 and untimed, showed the following: -The resident had a biopsy of the left breast some time ago and the facility does not have the results; -Mass of the left breast; -Obtain biopsy results. Review of the resident's POS, dated 10/2/23, showed an order to obtain left biopsy results. Review of the resident's left breast pathology report, dated 6/8/23 at 7:29 P.M., reported to the physician on 2/9/24 after the second request, showed the left breast mass, core needle biopsy showed infiltrating duct adenocarcinoma, well differentiated (the tumor cells look more like normal tissue), nuclear grade one out of three (usually means the cancer is slower to grow). Review of the resident's physician encounter progress note, dated 2/9/24, untimed, showed the following: -Type of visit was an add on problem/facility request; -Chief complaint, nature of presenting problem was review of biopsy results; -The resident was seen after requesting left breast biopsy results, I again asked if the facility had results, as no results had been previously noted in the electronic health records. A staff member from the facility in medical records brought the results and it showed infiltrating duct adenocarcinoma of the left breast; -Overall plan, oncology referral regarding left breast adenocarcinoma. Review of the resident's POS, dated 2/9/24, showed oncology referral regarding left breast adenocarcinoma. Review of the resident's surgical oncology clinic note dated, 3/4/24 at 5:16 P.M., showed the following: -This resident, who resides in a long-term care facility, underwent a needle biopsy of a 7-millimeter (mm) lesion in the upper quadrant of his/her left breast on 6/8/23. This biopsy showed a well-differentiated ductal cancer; -Unfortunately, for some reason the final pathology report did not make it back to the resident's primary physician and so the positive results were just discovered recently. This morning the radiologist noted an abnormal left axillary node (lymph node located in the armpit). The resident presents to clinic this morning to determine the next steps in his/her management; -The resident will need an ultrasound guided core needle biopsy of his/her left axillary nodes as well as a recommended breast magnetic resonance imaging (a non-invasive medical imaging technique the produces three dimensional images of body's internal structures, also called an MRI) of both breasts to determine actual extent of the disease; -Will contact the Director of Nursing (DON) and the resident's physician once the final reports are back. Both are scheduled for 3/8/24. During an interview on 3/14/23 at 3:00 P.M., the resident said he/she had a biopsy of the left breast in June of 2023. He/She did not receive the results of the biopsy from last year. He/She didn't think it was cancer or the facility staff would have told him/her. He/She had a biopsy of the left breast again, last Friday (3/8/24) and the biopsy showed cancer. He/She didn't know what was going to be done to treat the cancer. During an interview on 3/18/24 at 9:15 A.M. the resident's guardian said the following: -She was aware in May of 2023 the resident had some type of mass; -The resident was scheduled to have a biopsy;-She did not hear anything about the biopsy results from last year until last month; -It must have got missed by the facility. The outcome could have been much worse. During an interview on 3/14/24 at 4:14 P.M. the Assistant Director of Nursing (ADON) said the following: -The nursing staff are to follow-up on any biopsy results and to assure those results are sent to the physician in a timely manner; -She found out a couple days ago the resident had cancer in his/her left breast. She was not aware there was a biopsy obtained in June of 2023 of the left breast. During an interview on 3/19/24 at 9:15 A.M. and on 4/2/24 at 10:05 A.M. the DON said the following: -The facility did not have a current procedure in place for who was responsible for following up on biopsy results and other pathology reports; -Breast cancer could potentially metastasize if left untreated for almost eight months; -She has been working the floor on night shift because the facility is short-staffed, it was hard for her to follow-up on things like this; -The resident was scheduled for a follow-up appointment with oncology for 3/25/24, she notified the appointment scheduler of the appointment and set up transportation. She found out later that the appointment was missed, she was not sure why the appointment was missed; -The appointment was rescheduled; -She had concerns with the system that was in place for scheduling appointments, as there was no reason for the resident's appointment to have been missed. During an interview on 3/14/24 at 3:20 P.M. the Administrator said the following: -He would expect the nursing staff to follow-up on any resident biopsy results and assure those results were sent to the physician in a timely manner; -There was a potential for disease progression or of cancer spreading if biopsy results are not obtained and reported to the physician in a timely manner. During an interview on 3/28/24 at 2:40 P.M. the resident's oncologist said the following: -The resident had a biopsy of a mass on 6/8/23 but the results did not make it back it to the resident's primary physician; -The resident was seen on 3/8/24 in her office for a biopsy and to look at a abnormal lymph node; -Breast cancer left untreated for over eight months could possibly metastasize; -The resident has stage I breast cancer define (considered early-stage, localized cancer and is highly treatable and survivable) and there was no metastasis; -She recommends all her patients who have been diagnosed with breast cancer be scheduled for treatment/surgery within less than two months after cancer is diagnosed ; -The resident was scheduled for a follow-up appointment on 3/25/24 to discuss the lymph node findings and to discuss options for treatment, but the resident did not show up to the appointment scheduled for 3/25/24; -She made multiple phone calls to the facility to inquire why the resident missed the appointment, (there was either no answer or the call went to voicemail) she was finally able to reach facility staff and it was determined the appointment was missed, the appointment was rescheduled; -The plan will be for the resident to have have a lumpectomy; -It was possible that delays in having surgery could affect breast cancer outcomes. MO233076

Based on record review, interviews, and facility policy review, the facility failed to develop and implement behavioral health interventions to ensure the physical and psychosocial well-being of four of 42 sample residents (Resident (R)120, R136, R70, and R31). The facility failed to assess R120's mental health status after the resident was found with a cord wrapped around his/her neck and later the same day was found appearing non-responsive requiring an emergency code to be called. The facility failed to update the resident's care plan interventions to ensure adequate monitoring, ensure pharmacological and non-pharmacological interventions were implemented and failed to ensure staff working with the resident were aware of the resident's current behavioral support needs. The facility failed to ensure behavioral health interventions were care planned and implemented for three residents resulting in injury and excessive physical force for three residents (Residents (R)136, R70, and R31) and forced use of antipsychotic medications provided by injection. The census was 178. Immediate Jeopardy related to this failure was identified on 11/14/23 and was determined to first exist since 11/7/23. On 11/14/23 at 9:21 PM, the facility's Administrator was notified of the Immediate Jeopardy. The facility Administrator was notified that the Immediate Jeopardy was removed on 11/20/23. After the immediacy removal, the noncompliance remained at a D scope and severity level. The facility census was 179. Findings include: Review of the facility's policy titled Resident [Name] Safety Assessment, revised 11/06/23, revealed The Licensed/Registered Nurse will assess the resident for signs & symptoms of suicidal, homicidal or elopement ideations. This may include talking with the resident regarding changes in behavior; thoughts or feeling of suicidal, homicidal or elopement ideations or any verbalizations of wanting to harm self or others. The licensed/Registered Nurse will educate the residents on interventions and way to verbalize thoughts of suicide, homicide or elopement. Any resident that states that they are experiencing any suicidal, homicidal or elopement ideations will be placed on 1:1 immediately and interventions will take place to ensure protective oversight of the resident. This may include more intensive monitoring such as 2:1 or hospitalization . lf the Licensed/Registered Nurse assesses the resident to be a suicidal, homicidal or an elopement risk, the Administrator and Director of Nursing will be notified immediately and further policies and procedures will be followed. The Physician will be notified, and doctor's orders will be followed when the system indicates that the resident has answered yes to any of the assessed ideations. Review of the facility policy titled Behavioral Emergency Policy, revised 01/05/23, revealed lf the Resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or Resident to Resident altercations the following steps will occur: - The licensed nursing staff/Team Leader/RCC [Resident Care Coordinator]/nursing administration will assess the Resident who is exhibiting such behaviors, ensuring that safety of Resident and others is the first priority. A one-to-one monitoring of Resident will be initiated immediately; -The Director of Nurses or Designee and the Administrator or Designee and Regional Director will be notified regarding assessment findings. The Director of operations or chief operating officer will review the Resident's plan of care with the Regional Director and Administrator/ Designee and will determine if the Resident's needs can continue to be met safely or whether the Resident continues to be appropriate for placement at the facility; -The licensed nurse/Team Leader/RCC will follow direction from the Management Team Member on call, Resident Care Coordinator and the Administrator or Designee; -The ADMIN [Administrator]/DON [Director of Nursing]/Designee will complete an administrative investigation within 24 hours of the behavioral emergency. This may include a PRN [as needed] intervention Form and notification of state agencies in the event that criteria are met. 9. The Licensed Nurse will document the behavioral emergency in the medical record. Review of the facility's policy titled, Behavioral Emergency Policy, dated 01/05/23, indicated there were only two reasons that staff will utilize approved CALM [Crisis Alleviation Lessons and Methods] hold techniques. These included when a resident is in imminent danger of harming themselves or when a resident is in imminent danger of harming others. Approved CALM hold techniques are never utilized for punitive reasons, discipline or for staff convenience. Residents should never be threatened by the use of CALM as a scare tactic or threat by staff. Review of the undated facility's policy titled, CALM Program Manual indicated CALM is a method utilized to provide a mechanism to manage clients in crisis. Before restraints or holds are used can the team feel comfortable with the following concepts (parts of the process) including not using holds or restraints as punishment and staff emotions are kept in check, and staff have taken into consideration all the needs and request of the person in crisis, and the person in crisis is going to hurt themselves or someone else if we do not intervene. A hold is defined as not allowing a person to move freely about space using human force and a restraint is defined as restricting movement using human force, mechanical devices, or chemicals. Review of the facility's policy titled, Restraints Policy dated 01/05/23, indicated it is the policy of the Facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. 1. Review of R120's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/20/23, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R120 had Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R120's cognition was intact. R120 had no behaviors exhibited, and had diagnoses of schizoaffective disorder, bipolar type, anxiety, depression, and post-traumatic stress disorder. Review of R120's level two PASRR [Preadmission Screening and Resident Review] assessment located in the EMR under the Miscellaneous tab, dated 01/28/20, revealed a documented history of suicide. R120 relates feeling suicidal often with two attempts of overdosing 12/19 and 12/18. Review of R120's PASRR care plan located in the EMR under the Care Plan tab, dated 09/22/21, revealed a history of suicidal ideations with two attempts by OD [overdose]. Interventions included the resident will participate in the [name] program with the goal to achieve a lesser restrictive environment. No other interventions were in place. Review of R120's care plan located in the EMR under the Care Plan tab dated 05/08/23, revealed R120 had a history of post-traumatic stress disorder (PTSD - A condition that develops when a person has been exposed to a serious situation such as a natural disaster, serious accident, death of a loved one or life-threatening event. This condition may cause debilitating symptoms that, depending on the severity, can negatively affect relationships, communication and daily activities. PTSD affects resident symptoms and may flare up without any known trigger.) Avoidance of distressing trauma-related stressors after the event in at least one way his/her PTSD came from sexual abuse by multiple partners. An intervention included for staff to assess the resident for suicidal or homicidal ideations to ensure safety of the resident and others. Review of R120's Behavior Note located in the EMR under the Progress Note tab, dated 11/07/23 at 12:04 AM, revealed the [Hall monitor] went to administer IM [intramuscular] Thorazine 50 mg [milligrams] and upon arriving to resident's room, found the resident with a cord wrapped around his/her neck. Resident vital signs continued to be WNL [within normal limits]. Resident then sat up on the bed angrily. Notified Administrator and DON. Resident then placed on line of sight, IM injection given. Review of 120's Behavior Note located in the EMR under the Progress Note tab, dated 11/07/23 at 10:00 AM, revealed Code Blue called for resident. Resident was laying on the floor appearing non-responsive. Vital signs within normal limits. No distress noted. Resident not actively responding to verbal. Resident then sits up and begins saying no one cares and being verbally aggressive to another resident [initials] who was sitting on the sofa on her phone not engaged with the resident. Hall monitor notified the DON. No additional PRN (as needed) medication administered at this time. Review of R120's behavior notes located in the EMR under the Progress Note tab, dated 11/07/23 at 8:11 PM, revealed hall monitor was notified the resident was sitting on the floor crying with complaint of increased anxiety. Hall monitor arrived to the unit and the resident requested a PRN to help calm him/her down. Hall monitor contacted the DON to get a PRN order. While waiting for the PRN order the hall monitor sat with the resident and the resident expressed concerns in a clear and concise manner. Review of R120's behavior notes located in the EMR under the Progress Note tab, dated 11/07/23 at 8:42 PM, revealed staff administered PRN PO [oral] Thorazine (antipsychotic medication) 25mg at 2036 (8:36 P.M.) per nurse practitioner via DON. Review of R120's order notes located in the EMR under the Orders tab, dated 11/07/23 at 9:54 PM, revealed chlorpromazine HCL (antipsychotic medication -Thorazine) injection solution 25 mg/ml [milliliter], inject 1 milliliter intramuscularly every 8 hours as needed for agitation and anxiety; Delusions for 14 days. Review of the resident's care plan showed the plan was not updated to include any needed support or interventions necessary to ensure resident safety based on resident history of suicide attempts and after a suicide attempt by R120 on 11/07/23. Review of R120's order notes located in the EMR under the Orders tab, dated 11/08/23 at 12:16 AM, revealed chlorpromazine HCL injection solution 25 mg/ml, inject 2 milligrams intramuscularly one time only for agitation, and anxiety; Delusions for 1 day. Review of R120's progress note located in the EMR under the Progress Note tab, dated 11/08/23 at 7:34 PM, revealed the resident said he/she felt a lot better. The resident was cooperative and pleasant. Taken off line of sight monitoring. Review of R120's November 2023 Medication Administration Record (MAR) located in the EMR under the Orders tab, revealed an order for gabapentin (an anticonvulsant) oral capsule 300 MG with a start date 07/22/23 and was discontinued on 11/07/23. A new order for gabapentin oral capsule, give 800 mg TID a day, was ordered on 11/07/23. No gabapentin was administered on 11/07/23. Review of R120's Mental Status Exam revealed located in the EMR under the Miscellaneous tab, dated 11/14/23, revealed the resident was seen today for follow up visit of sleep, mood, anxiety, delusions and medication reconciliation. The section titled Suicidal/Homicidal Ideation & Psychosis revealed None Reported. No mention was made concerning R120's 11/07/23 suicide attempt. Review of R120's EMR revealed no additional assessments or interventions were added or implemented after the attempted suicide including the use of antipsychotics and/or alternate interventions such as line of sight. Review of R120's investigation report provided by the ADM, dated 11/15/23, revealed a document titled 1 on 1 documentation form. The document did not include a date for the monitoring from 12:00 AM through 8:00 AM. During an interview on 11/14/23 at 10:55 AM, R120 was asked about his/her state of mind last week when he/she had a cord around his/her neck and if he/she wanted to harm his/herself. R120 stated no, he/she was in a manic state because his/her insurance wouldn't pay for his/her medication, so he/she missed a dose and also had to be locked up at the facility for four years. R120 stated she did put a cord around his/her neck, but he/she was only trying to pass out and not kill him/herself. R120 stated I'm good now. R120 stated he/she asked for his/her medication to be injected, but could have received it orally if he/she wanted. During an interview on 11/14/23 at 11:21 AM, hall monitor (HM)1 was asked if he/she was aware of R120 having a manic episode or was he/she suicidal. HM1 stated no as R120 was very low key. HM1 stated R120 did not require any monitoring and he/she had not heard of the resident being suicidal. During an interview on 11/14/23 at 11:24 AM, HM2 was asked if he/she was aware of R120 having a manic episode last week and being suicidal. HM3 stated he/she was aware of R120 falling to his/her knees crying once in the lobby, but no suicidal attempts. HM3 stated he/she had not heard of the resident needing to be watched for precautions and had not heard of him/her having a cord around his/her neck. During an interview on 11/14/23 at 11:30 AM, the Medication Technician (MT)1 was asked if he/she was aware of R120 being suicidal. MT1 stated he/she was aware of R120 having a cord around his/her neck because he/she worked the next morning. MT1 stated R120 was placed on line of sight monitoring in the common area until a nurse deemed it was safe to stop. MT1 stated he/she thought the nurse documented the observations for the line of sight in the progress notes or that maybe the hall monitor did. MT1 stated R120 missed a dose of her gabapentin because the physician had changed the order to a higher dose and R120's insurance wouldn't pay for it. During an interview on 11/14/23 at 12:31 PM, the DON was asked if she was aware of R120 being suicidal last week when he/she put a cord around his/her neck on 11/07/23 at 4:00 AM and then at 10:00 AM R120 was found non-responsive. The DON stated she was not aware. The DON stated she was aware of R120's behavior, but did not know about this incident. The DON was asked what line of sight was. The DON stated a resident would stay in a common area and not be left alone. The DON was asked how long a resident would be monitored during a line-of-sight observation. The DON stated it depended, but until management felt the resident was safe. The DON was asked if these observations were documented. The DON stated they should be in the progress notes. The DON was asked if this incident was concerning. The DON stated Yes, it is concerning. The DON was asked if this incident was investigated and the DON said it was not because she did not know about it. The DON stated R120 didn't miss a dose of her medication. The DON was asked if the staff should be aware of R120 having a possible suicidal attempt and she said yes, staff should be aware of R120's situation. Her plan going forward was more education and a more accessible place, such as a book, for all staff to locate that included residents' triggers and coping skills. During a follow up interview on 11/14/23 at 2:57 PM, DON was asked for a policy for line of sight. The DON stated there wasn't one. Once a resident was determined to be safe, the resident came off. The line of sight would be documented in the progress notes. The DON was asked when and why was R120 taken off line of sight observations. The DON stated when staff asked R120 and R120 stated she felt better. The DON was asked if a cord was observed with R120 when she was found unresponsive on 11/07/23 at 10:00 AM, the DON stated she didn't know because she wasn't even aware of this incident. She was in the process of trying to get a hold of the night staff from 11/07/23. The DON was asked again for an investigation regarding this incident with R120 and she reiterated she wasn't aware of this incident. During an interview on 11/16/23 at 1:45 PM, the Administrator presented a two-page document titled 1 on 1 documentation form for R120. The Administrator stated, It was there all along. However, the documentation was not dated and the times for monitoring did not correspond with the times R120 was found with the cord around his/ her neck and when R120 was found unresponsive on the floor. The Administrator was asked again what type of cord was used by R120. The Administrator stated it was a phone cord and they would be replacing it with either a short cord or nail down the long cord. 2. Review of R136's annual MDS with an Assessment Reference Date (ARD) date of 04/24/23, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R136 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R136's cognition was intact. R136 had behaviors exhibited and had diagnoses of Asperger's Syndrome (a developmental disability that is a form of Autism Spectrum Disorder. Persons with Asperger's Syndrome often have a difficult time relating to others socially and their behavior and thinking patterns can be rigid and repetitive) and attention-deficit hyperactivity disorder, other type. Physical restraints were marked as Not used. Review of R136's care plan, dated 08/17/23, located in the EMR under the Care Plan tab revealed per PASRR, the resident has a history of behavioral challenges that require protective oversight in a secure setting. Current Behaviors included yelling, screaming, attention seeking, SI [suicide ideation], impulsiveness, visual hallucination, and auditory hallucinations. Interventions included if the resident is having behaviors and preferred coping skills are found to NOT be effective, refer to CALM de-escalation protocols. CALM technique if needed. Coping Skills noted as music, TV, and talking with peers. None [sic] Pharmaceutical interventions: 1:1 intervention as needed. There was no care plan related to physical restraints. Review of R136's Behavior Note located in the EMR under the Progress Notes tab, dated 07/11/23, revealed This nurse was on hall addressing incident involving two peers when this resident attempted to enter area where the other incident was occurring, this writer redirected resident and requested for resident to return down the hall and explained that there was an incident happening in common area and resident was unable to enter requested area. Resident became physically aggressive with this nurse by grabbing nurse and shoving. Both this nurse and onlooking staff redirected resident to release this nurse, but resident refused to release nurse. Resident placed in a 2-man hold, but resident continued to be physically aggressive, attempting to kick nurse while holding onto handrail and using body to attempt to shove nurse backwards causing this nurse, nurse assisting in 2-man hold, and resident all to fall to the ground. This nurse landed on floor and resident landed partially on this nurse. D/t [due to] resident continuing to be a danger to staff resident was placed in a 5-man hold. After a few minutes in hold, resident made verbal c/o [complaint of] pain to left arm. This nurse looked down to ensure placement was correct, to ensure that no adjustments were required and no needed adjustments to CALM hold were noted by this nurse. Resident received IM [Intramuscular] PRN [as needed] for continued aggression and then resident was released from the CALM hold. Resident was assisted into a sitting position on his/her bottom, resident stated that her arm hurt. This nurse did an immediate assessment and saw that the resident's left arm appeared to be out of place. Resident provided pillow for support of arm. EMS [emergency medical service] contacted, GDN [guardian] contacted, MD [Medical Doctor] contacted, ADMIN[Administrator]/DON [Director of Nursing] contacted. Resident was transported to [name] ER [emergency room ] for evaluation. Review of R136's hospital report located in the EMR under the Miscellaneous tab, dated 07/11/23, revealed diagnosis of recurrent dislocation, left elbow and an order for hydrocodone-acetaminophen (narcotic pain reliever) 5-325 mg [milligrams] oral tablet, take 1 tablet by oral route every 6 hours as needed. Review of R136's hospital follow-up report located in the EMR under the Miscellaneous tab, dated 07/13/23, revealed Diagnosis or Problem(s) addressed at this visit: Left elbow pain; Swelling of left elbow. Medications administered this visit included oxycodone (oxycodone 5 mg oral tablet) 5 mg oral. Review of R136's July 2023 Medication Administration Record (MAR) revealed an order for Norco oral tablet 5-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 6 hours as needed for L [Left] elbow dislocation pain related to pain, unspecified) -start date 07/11/2023 2300 -D/C [discharge] date 10/12/2023. There were no orders or consents related to physical restraints. Review of R136's orders located in the EMR under the Orders tab, dated 11/13/23, revealed acetaminophen tablet 325 MG, give 2 tablets by mouth every 6 hours as needed for pain/temp to equal 650mg. *Max 3gms APAP [acetaminophen]/24 hrs. There were no orders or consents related to physical restraints. During an interview on 11/13/23 at 11:03 AM, R136 stated facility staff fractured his/her elbow during a code. R136 stated another code was being cleared when she tried to walk through to get Kool-Aid. A code was then called on her and staff took her down and she was injured. R136 stated she was sent to the hospital. R136 stated her elbow still hurt and she had pain medication for the pain. During an interview on 11/14/23 at 12:31 PM, the DON was asked about R136 and his/her injured elbow. The DON stated R136 sustained a dislocated elbow during a code green (staff called for behavioral emergency). The DON stated R136 was walking through another active code green and would not respond to the staff's requests to stay away as they were trying to keep everyone out of the area for safety reasons. The DON stated R136 ignored the staff. The DON stated R136 started to kick and hit staff. She stated staff then physically held the resident, and their legs entangled and R136 fell to the ground. The DON stated R136 sat up on the ground and kept kicking staff, so the nurse put her in a calm hold, which is a 5-man hold. The DON stated R136 fell to the floor when staff noticed R136's elbow was dislocated. She stated R136 complained of pain and R136 was sent to the hospital. The DON was asked what de-escalation techniques were used. The DON stated they redirected the resident to leave the immediate area. During a follow up interview on 11/15/23 at 2:36 PM, R136 stated she was following the other residents passing through the crowd when staff told her to leave. R136 stated she tried to tell staff what she wanted, but no one listened. R136 stated she continued through the crowd and staff then took her down. R136 stated if staff had offered to get what she needed, things wouldn't have escalated. R136 admitted to kicking staff because the nurse was holding my wrist and it hurt and this triggered me. 3. Review of R70's undated Diagnosis tab in the EMR revealed R70 was admitted on [DATE]. R70 had diagnoses which included schizophrenia, major depression, generalized anxiety disorder, and idiopathic orofacial dystonia (neurological movement disorder). The resident's most recent quarterly MDS with an ARD of 07/12/23 and 10/12/23 from the MDS tab indicated the resident was independent in all activities of daily living. R70 had a BIMS of 15 out of 15 which indicated R70 was cognitively intact. Review of R70's care plan for management of behavior, dated 06/07/23, revealed no reference to using a five man hold down or psychotropic medication. Review of the the resident's Progress Note tab in the EMR on 05/23/23 at 3:34 PM revealed R70 approached the nurse on his unit while at the cart about the X-Ray of his right hand. The nurse stated the hand was ok and the results were negative. She suggested the resident use an ice pack on the swollen hand to reduce the pain. R70 complained the hand was still swollen and painful and how could the test results be negative. R70 escalated and went to his room tearing his cubicle curtain down and slamming the door to his room. The nurse called a Code Green. The nurse went to get the injection and the staff arrived at the unit. The resident told staff that he was not taking the injection. The assistant administrator educated R70 to calm down. The assistant administrator asked R70 where he wanted the injection and R70 began to yell racial slurs and became aggressive with staff in the area. A five-man CALM hold followed until the injection was given. Review of the resident's Progress Note tab in the EMR on 09/13/23 at 12:15 PM revealed R70 became involved in a peer-to-peer altercation in the corridor near the Hangout room (common area for resident activities and socialization) in the facility. A CODE GREEN was called. Staff tried to intervene. R70 pushed the door open on the way back to his unit causing the staff intervening to fall. Later, support staff arrived and placed the resident in a five man hold. The nurse administered the injection for the resident's behavior. 4. Review of R31's Admission Record, dated 11/19/23 and found in the EMR under the Profile tab, revealed R31 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, borderline intellectual functioning, major depression, bipolar disorder, and anxiety disorder. Review of R31's most recent BIMS assessment, dated 07/24/23 and found in the EMR under the Assessment tab, indicated a score of two out of 15 which indicated R31 had severe cognitive impairment. There was nothing coded for physical or chemical restraints. Review of R31's care plan, dated 10/31/23 and found in the EMR under the Care Plan tab, indicated [R31] displayed manifestations of behaviors r/t (related to) his/her mental illnesses that may create disturbances that affect others. These behaviors include being easily irritated/annoyed by others and verbal/physical aggression. [R31] very agitated and anxious. Interventions included staff to administer and monitor medications as ordered, administer prn medications as needed/ordered when nonpharmacological interventions are not effective, and assist in addressing root cause of change in behavior or mood as needed. Resident's coping skills included talking about (specified) family member, and soda. If the resident is having behaviors and preferred coping skills are found to NOT to be effective, refer to CALM de-escalation protocols. Current behaviors noted as verbal outburst and screaming towards staff and physical aggression. Resident will place self on the floor when he/she feels like his/her request are not met. If you see resident(s) having any behaviors listed in the current behaviors section, refer to preferred coping skills immediately, give positive feedback for good behavior. If [R31] is disturbing others, encourage him/her to go to more private areas to voice concerns/feelings to assist in decreasing episodes of disturbing others. [R31] will put him/herself on the floor at times when upset and when demands are not immediately met, non-pharmacological interventions include meet with administration/staff member that he/she was comfortable with, encourage resident to watch TV, listen to music, 1:1 visits, talk to a trusted person/staff, notify guardian/physician as needed, pharmacy consultant review of medications monthly and prn, psych consult for medication adjustments as needed/ordered, redirect resident and give individualized care when [R31] is showing behavior triggers include shower days, impatient, doesn't like things on his/her clothes. If staff observes a trigger happening to the resident, immediately refer to the resident's preferred coping skills and redirect behavior. Review of R31's Progress Notes, dated 10/17/23 at 4:59 PM and found in the EMR under the Progress Note tab, read Behavior Note: Resident started yelling down the hallway about taking a shower, started to get physically aggressive with staff, when staff tried to talk to him/her Resident tried to get out of wheelchair going towards staff, had to place resident in 2-man CALM hold. Resident was still being physically and verbally aggressive trying to get out of his/her wheelchair, and resident was placed in 5-man CALM hold on the ground with a pillow for the head. Provider was called and ordered chlorpromazine (antipsychotic medication/Thorazine) 50 injection and it was administrated in right buttock. After the injection resident was helped with rolling over on his/her back and sat in sitting position, then gait belt was used to get the resident off the floor into bed. Resident VS [vital signs] within normal limits, skin is intact, no reports of pain. Educated resident on when shower time was and placed on shower list every day in the morning to help with anxiety. Guardian notified of incident and all administration notified. Review of R31's Progress Notes, dated 10/25/23 at 7:13 AM and found in the EMR under the Progress Note tab, read Incident Note - Resident heard yelling in the hallway. Upon intervening, resident stated that he/she was hit by another resident [R23] on the face and he/she was asking for a phone to call the police. He/She continued to yell while wheeling him/herself to that resident's room. The aide tried to get the resident back to his/her room, but the resident hit him/her on her face and stomach. The resident started screaming and trying to jump out of his/her wheelchair. A code was called, and Thorazine (an antipsychotic medication) shot administered. Review of R31's Progress Notes, dated 11/02/23 at 6:12 PM and found in the EMR under the Progress Note tab, read resident in room yelling. Went to room and tried to console resident. Asked the resident if he/she wanted a PO [oral] PRN medication. The resident refused and kept yelling. Code green called. Resident stood up from wc [wheelchair] and punched [name] in the chest. CALM hold in wheelchair applied. Injection given in left deltoid. Resident calmed down and apologized to staff. Guardian, physician, and administration notified. Review of R31's Order Summary Report, dated 11/02/23 and found in the EMR under the Orders tab, indicated to administer chlorpromazine (an antipsychotic) injection solution 50 MG/2ML inject 50 mg intramuscularly every 12 hours as needed for agitation for 14 Days. The resident did not have any current orders for oral as needed psychotropic medication. There was nothing in the orders to indicate alternative nonpharmacological methods of de-escalation for R31. There were no orders or consents related to physical restraints. Review of R31's medical record revealed there was nothing documented related to R31's assessed, and care planned de-escalation interventions/coping skills, such as talking to him/her about his/her named family member, meeting with a staff member the resident is comfortable with, talking to a trusted person, offering him soda, assisting him/her with writing a letter to his/her brother, or listening to music, were attempted prior to physically restraining the resident. During an observation on 11/13/23 beginning at 10:49 AM, R31 was having an altercation with R23 in the facility's dining room/day room area. R31 became agitated, stating R23, who was seated at a separate table approximately 10 feet away from R31, had been calling him a homosexual, and indicating this was extremely upsetting to him since he had been raped by a male family member as a boy. R23 and R31 began arguing. Two staff members (Certified Nurse Aide (CNA) 2 and Health Monitor (HM) 1) were in the dining room assisting other residents, but neither staff member appeared to be monitoring R23 and R31, and neither of the staff members attempted to intervene/stop the arguing between the residents. R23 and R31 argued for five minutes with no observed attempts by staff to intervene, and then the verbal altercation between the two residents escalated and R31 became extrem [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary physical restraint for three of 42 sampled residents (Residents (R)136, R70, and R31) along with implementing behavioral health interventions to prevent injury and excessive force and failed to investigate emergency events that led to an injury for R136. The census was 178. Immediate Jeopardy related to this failure was identified on 11/15/23 and was determined to first exist since 07/11/23 when the facility failed to ensure R136 wasn't physically restrained while sustaining an injury. On 11/15/23 at 5:31 PM, the facility's Administrator was notified of the Immediate Jeopardy. The facility Administrator was notified the Immediate Jeopardy was removed on 11/20/23. After the immediacy removal, the noncompliance remained at a D scope and severity level. The facility census was 179. Findings include: Review of the facility's policy titled, Restraints Policy dated 01/05/23, indicated it is the policy of the Facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Review of the facility's policy titled, Behavioral Emergency Policy, dated 01/05/23, indicated there were only two reasons that staff will utilize approved CALM [Crisis Alleviation Lessons and Methods] hold techniques. These included when a resident is in imminent danger of harming themselves or when a resident is in imminent danger of harming others. Approved CALM hold techniques are never utilized for punitive reasons, discipline or for staff convenience. Residents should never be threatened by the use of CALM as a scare tactic or threat by staff. Review of the undated facility's policy titled, CALM Program Manual indicated CALM is a method utilized to provide a mechanism to manage clients in crisis. Before restraints or holds are used can the team feel comfortable with the following concepts (parts of the process) including not using holds or restraints as punishment and staff emotions are kept in check, and staff have taken into consideration all the needs and request of the person in crisis, and the person in crisis is going to hurt themselves or someone else if we do not intervene. A hold is defined as not allowing a person to move freely about space using human force and a restraint is defined as restricting movement using human force, mechanical devices, or chemicals. 1. Review of R136's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 04/24/23, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R136 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R136's cognition was intact. R136 had behaviors exhibited and had diagnoses of Asperger's Syndrome (a developmental disability that is a form of Autism Spectrum Disorder. Persons with Asperger's Syndrome often have a difficult time relating to others socially and their behavior and thinking patterns can be rigid and repetitive) and attention-deficit hyperactivity disorder, other type. Physical restraints were marked as Not used. Review of R136's care plan, dated 08/17/23, located in the EMR under the Care Plan tab revealed per PASRR [preadmission screening and Resident Review], the resident has a history of behavioral challenges that require protective oversight in a secure setting. Current Behaviors included yelling, screaming, attention seeking, SI [suicide ideation], impulsiveness, visual hallucination, and auditory hallucinations. Interventions included if the resident is having behaviors and preferred coping skills are found to NOT be effective, refer to CALM de-escalation protocols. CALM technique if needed. Coping Skills noted as music, TV, and talking with peers. None [sic] Pharmaceutical interventions: 1:1 intervention as needed. There was no care plan related to physical restraints. Review of R136's Behavior Note located in the EMR under the Progress Notes tab, dated 07/11/23, revealed This nurse was on hall addressing incident involving two peers when this resident attempted to enter area where the other incident was occurring, this writer redirected resident and requested for resident to return down the hall and explained that there was an incident happening in common area and resident was unable to enter requested area. Resident became physically aggressive with this nurse by grabbing nurse and shoving. Both this nurse and onlooking staff redirected resident to release this nurse, but resident refused to release nurse. Resident placed in a 2-man hold, but resident continued to be physically aggressive, attempting to kick nurse while holding onto handrail and using body to attempt to shove nurse backwards causing this nurse, nurse assisting in 2-man hold, and resident all to fall to the ground. This nurse landed on floor and resident landed partially on this nurse. D/t [due to] resident continuing to be a danger to staff resident was placed in a 5-man hold. After a few minutes in hold, resident made verbal c/o [complaint of] pain to left arm. This nurse looked down to ensure placement was correct, to ensure that no adjustments were required and no needed adjustments to CALM hold were noted by this nurse. Resident received IM [Intramuscular] PRN [as needed] for continued aggression and then resident was released from the CALM hold. Resident was assisted into a sitting position on his/her bottom, resident stated that her arm hurt. This nurse did an immediate assessment and saw that the resident's left arm appeared to be out of place. Resident provided pillow for support of arm. EMS [emergency medical service] contacted, GDN [guardian] contacted, MD [Medical Doctor] contacted, ADMIN[Administrator]/DON [Director of Nursing] contacted. Resident was transported to [name] ER [emergency room ] for evaluation. Review of R136's hospital report located in the EMR under the Miscellaneous tab, dated 07/11/23, revealed diagnosis of recurrent dislocation, left elbow and an order for hydrocodone-acetaminophen (narcotic pain reliever) 5-325 mg [milligrams] oral tablet, take 1 tablet by oral route every 6 hours as needed. Review of R136's hospital follow-up report located in the EMR under the Miscellaneous tab, dated 07/13/23, revealed Diagnosis or Problem(s) addressed at this visit: Left elbow pain; Swelling of left elbow. Medications administered this visit included oxycodone (oxycodone 5 mg oral tablet) 5 mg oral. Review of R136's July 2023 Medication Administration Record (MAR) revealed an order for Norco oral tablet 5-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 6 hours as needed for L [Left] elbow dislocation pain related to pain, unspecified) -start date 07/11/2023 2300 -D/C [discharge] date 10/12/2023. There were no orders or consents related to physical restraints. Review of R136's orders located in the EMR under the Orders tab, dated 11/13/23, revealed acetaminophen tablet 325 MG, give 2 tablets by mouth every 6 hours as needed for pain/temp to equal 650mg. *Max 3gms APAP [acetaminophen]/24 hrs. There were no orders or consents related to physical restraints. During an interview on 11/13/23 at 11:03 AM, R136 stated facility staff fractured his/her elbow during a code. R136 stated another code was being cleared when she tried to walk through to get Kool-Aid. A code was then called on her and staff took her down and she was injured. R136 stated she was sent to the hospital. R136 stated her elbow still hurt and she had pain medication for the pain. During an interview on 11/14/23 at 12:31 PM, the Director of Nurses (DON) was asked about R136 and his/her injured elbow. The DON stated R136 sustained a dislocated elbow during a code green (staff called for behavioral emergency). The DON stated R136 was walking through another active code green and would not respond to the staff's requests to stay away as they were trying to keep everyone out of the area for safety reasons. The DON stated R136 ignored the staff. The DON stated R136 started to kick and hit staff. She stated staff then physically held the resident, and their legs entangled and R136 fell to the ground. The DON stated R136 sat up on the ground and kept kicking staff, so the nurse put her in a calm hold, which is a 5-man hold. The DON stated R136 fell to the floor when staff noticed R136's elbow was dislocated. She stated R136 complained of pain and R136 was sent to the hospital. The DON was asked what de-escalation techniques were used. The DON stated they redirected the resident to leave the immediate area. The DON was asked if they had an investigation into this incident. DON stated she did not know. During a follow up interview on 11/15/23 at 2:36 PM, R136 stated she was following the other residents passing through the crowd when staff told her to leave. R136 stated she tried to tell staff what she wanted, but no one listened. R136 stated she continued through the crowd and staff then took her down. R136 stated if staff had offered to get what she needed, things wouldn't have escalated. R136 admitted to kicking staff because the nurse was holding my wrist and it hurt and this triggered me. 2. Review of R70's undated Diagnosis tab in the EMR revealed R70 was admitted on [DATE]. R70 had diagnoses which included schizophrenia, major depression, generalized anxiety disorder, and idiopathic orofacial dystonia (neurological movement disorder). The resident's most recent quarterly MDS with an ARD of 07/12/23 and 10/12/23 from the MDS tab indicated the resident was independent in all activities of daily living. R70 had a BIMS of 15 out of 15 which indicated R70 was cognitively intact. Review of R70's care plan for management of behavior, dated 06/07/23, revealed no reference to using a five man hold down or psychotropic medication. Review of the the resident's Progress Note tab in the EMR on 05/23/23 at 3:34 PM revealed R70 approached the nurse on his unit while at the cart about the X-Ray of his right hand. The nurse stated the hand was ok and the results were negative. She suggested the resident use an ice pack on the swollen hand to reduce the pain. R70 complained the hand was still swollen and painful and how could the test results be negative. R70 escalated and went to his room tearing his cubicle curtain down and slamming the door to his room. The nurse called a Code Green. The nurse went to get the injection and the staff arrived at the unit. The resident told staff that he was not taking the injection. The assistant administrator educated R70 to calm down. The assistant administrator asked R70 where he wanted the injection and R70 began to yell racial slurs and became aggressive with staff in the area. A five-man CALM hold followed until the injection was given. Review of the resident's Progress Note tab in the EMR on 09/13/23 at 12:15 PM revealed R70 became involved in a peer-to-peer altercation in the corridor near the Hangout room (common area for resident activities and socialization) in the facility. A CODE GREEN was called. Staff tried to intervene. R70 pushed the door open on the way back to his unit causing the staff intervening to fall. Later, support staff arrived and placed the resident in a five man hold. The nurse administered the injection for the resident's behavior. 3. Review of R31's Admission Record, dated 11/19/23 and found in the EMR under the Profile tab, revealed R31 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, borderline intellectual functioning, major depression, bipolar disorder, and anxiety disorder. Review of R31's most recent BIMS assessment, dated 07/24/23 and found in the EMR under the Assessment tab, indicated a score of two out of 15 which indicated R31 had severe cognitive impairment. There was nothing coded for physical restraints. Review of R31's care plan, dated 10/31/23 and found in the EMR under the Care Plan tab, indicated [R31] displayed manifestations of behaviors r/t (related to) his/her mental illnesses that may create disturbances that affect others. These behaviors include being easily irritated/annoyed by others and verbal/physical aggression. [R31] very agitated and anxious. Interventions included staff to administer and monitor medications as ordered, administer prn medications as needed/ordered when non pharmacological interventions are not effective, and assist in addressing root cause of change in behavior or mood as needed. Resident's coping skills included talking about (specified) family member, and soda. If the resident is having behaviors and preferred coping skills are found to NOT to be effective, refer to CALM de-escalation protocols. Current behaviors noted as verbal outburst and screaming towards staff and physical aggression. Resident will place self on the floor when he/she feels like his/her request are not met. If you see resident(s) having any behaviors listed in the current behaviors section, refer to preferred coping skills immediately, give positive feedback for good behavior. If [R31] is disturbing others, encourage him/her to go to more private areas to voice concerns/feelings to assist in decreasing episodes of disturbing others. [R31] will put him/herself on the floor at times when upset and when demands are not immediately met, non-pharmacological interventions include meet with administration/staff member that he/she was comfortable with, encourage resident to watch TV, listen to music, 1:1 visits, talk to a trusted person/staff, notify guardian/physician as needed, pharmacy consultant review of medications monthly and prn, psych consult for medication adjustments as needed/ordered, redirect resident and give individualized care when [R31] is showing behavior triggers include shower days, impatient, doesn't like things on his/her clothes. If staff observes a trigger happening to the resident, immediately refer to the resident's preferred coping skills and redirect behavior. Review of R31's Progress Notes, dated 10/17/23 at 4:59 PM and found in the EMR under the Progress Note tab, read Behavior Note: Resident started yelling down the hallway about taking a shower, started to get physically aggressive with staff, when staff tried to talk to him/her Resident tried to get out of wheelchair going towards staff, had to place resident in 2-man CALM hold. Resident was still being physically and verbally aggressive trying to get out of his/her wheelchair, and resident was placed in 5-man CALM hold on the ground with a pillow for the head. Provider was called and ordered chlorpromazine (antipsychotic medication/Thorazine) 50 injection and it was administrated in right buttock. After the injection resident was helped with rolling over on his/her back and sat in sitting position, then gait belt was used to get the resident off the floor into bed. Resident VS [vital signs] within normal limits, skin is intact, no reports of pain. Educated resident on when shower time was and placed on shower list everyday in the morning to help with anxiety. Guardian notified of incident and all administration notified. Review of R31's Progress Notes, dated 10/25/23 at 7:13 AM and found in the EMR under the Progress Note tab, read Incident Note - Resident heard yelling in the hallway. Upon intervening, resident stated that he/she was hit by another resident [R23] on the face and he/she was asking for a phone to call the police. He/She continued to yell while wheeling him/herself to that resident's room. The aide tried to get the resident back to his/her room but the resident hit him/her on her face and stomach. The resident started screaming and trying to jump out of his/her wheelchair. A code was called, and Thorazine (an antipsychotic medication) shot administered. Review of R31's Progress Notes, dated 11/02/23 at 6:12 PM and found in the EMR under the Progress Note tab, read resident in room yelling. Went to room and tried to console resident. Asked the resident if he/she wanted a PO [oral] PRN medication. The resident refused and kept yelling. Code green called. Resident stood up from wc [wheelchair] and punched [name] in the chest. CALM hold in wheelchair applied. Injection given in left deltoid. Resident calmed down and apologized to staff. Guardian, physician, and administration notified. Review of R31's Order Summary Report, dated 11/02/23 and found in the EMR under the Orders tab, indicated to administer chlorpromazine (an antipsychotic) injection solution 50 MG/2ML inject 50 mg intramuscularly every 12 hours as needed for agitation for 14 Days. The resident did not have any current orders for oral as needed psychotropic medication. There was nothing in the orders to indicate alternative nonpharmacological methods of de-escalation for R31. There were no orders or consents related to physical restraints. Review of R31's medical record revealed there was nothing documented related to R31's assessed, and care planned de-escalation interventions/coping skills, such as talking to him/her about his/her named family member, meeting with a staff member the resident is comfortable with, talking to a trusted person, offering him soda, assisting him/her with writing a letter to his/her brother, or listening to music, were attempted prior to physically restraining the resident. During an observation on 11/13/23 beginning at 10:49 AM, R31 was having an altercation with R23 in the facility's dining room/day room area. R31 became agitated, stating R23, who was seated at a separate table approximately 10 feet away from R31, had been calling him a homosexual, and indicating this was extremely upsetting to him since he had been raped by a male family member as a boy. R23 and R31 began arguing. Two staff members (Certified Nurse Aide (CNA) 2 and Health Monitor (HM) 1) were in the dining room assisting other residents, but neither staff member appeared to be monitoring R23 and R31, and neither of the staff members attempted to intervene/stop the arguing between the residents. R23 and R31 argued for five minutes with no observed attempts by staff to intervene, and then the verbal altercation between the two residents escalated and R31 became extremely agitated, screaming R23 was a liar and had been calling him a homosexual, and threatening to kick R23's ass. R23 was yelling at R31 that he was a liar and indicating R31 had recently hit him twice with a closed fist (date unknown). R23 was removed from the dining room by a staff member and Administrator in Training (AIT)1 approached R31 to attempt to calm him down. AIT1 spoke with R31 for approximately two minutes, attempting to calm the resident down but was not able to deescalate the resident, who continued to scream, but was able to get R31 to transfer from a regular dining room chair to his wheelchair to wheel him out of the dining room and into the hallway. Documented coping skills for R31, according to his plan of care (such as offering a soda, offering to play music, asking the resident if there was a trusted staff member he would like to talk to, offering to take the resident to watch television, offering to take the resident to his room to talk about his brother or write his brother a letter) were not observed to be attempted at any point during the observed incident. As R31 was escorted out of the dining room, he further threatened to kick a separate resident's ass (R48). In the hallway, four staff members (AIT1, Corporate AIT2 CNA 2, and Registered Nurse (RN)1) were observed to be verbally asking the resident to calm down and the resident was placed in a 2-person CALM hold by two of the staff members via standing on opposite side of the resident and restraining the resident around his trunk so that he was unable to move in his wheelchair. The resident continued to escalate, kicking, and screaming No! and He called me a homosexual! Again, none of the resident's documented coping skills were observed to be attempted/offered to the resident. R31 continued to yell at staff and so the Director of Nursing (DON) was consulted and directed the team to administer an as needed Intramuscular injection of chlorpromazine (Thorazine a psychotropic medication used to calm residents down) to the resident. R31 continued to yell at the staff, stating he did not want the injection. On 11/13/23 at 11:08 AM, R31 was wheeled to his room in his wheelchair. Four staff members (including RN1, Corporate AIT2, the Administrator, and an unidentified staff member later identified as AIT2) entered the room with the resident and closed the door. The surveyor continued to hear R31 screaming/yelling loudly, stating, Please don't and No! and I don't want a shot! repeatedly. On 11/13/23 11:11 AM, all staff (including RN1, Corporate AIT, AIT2 and the Administrator) exited R31's room. R31 remained in his room and continued to scream No! and He is a liar! and He called me a homosexual! Documented coping skills for R31, according to the resident's plan including offering a soda, offering to play music, asking the resident if there was a trusted staff member he would like to talk to, offering to take the resident to watch television, offering to take the resident to his/her room to talk about his/her specified family member or write the family member a letter, were not observed to be attempted at any point during the observed incident. RN1 was interviewed on 11/13/23 at 11:20 AM after he/she exited R31's room. RN1 confirmed he/she was the staff member who administered R31's IM injection and stated he/she was new to the facility (11/13/23 was his/her first day working in the facility), he/she was an agency nurse and was the nurse in charge when the incident between R31 and R23 occurred. RN1 stated he/she was not familiar with any of the residents in the facility or their non-pharmacological interventions for behaviors, but stated he/she gave R31 an injection of chlorpromazine due to his/her behaviors. RN1 stated, I was called over (to the dining room) because apparently there was a verbal altercation between (R31) and (R23) and (R31) thought (R23) was calling him a (a same sexual orientation term). RN1 indicated (unknown) staff had reported to him/her R23 had not been calling R31 this name, but the DON told him/her the residents had a past and had been in an altercation before. RN1 stated, He/She has a prn (as needed injectable psychotropic medication) for when (R31) gets like that and so (R31) got the prn Thorazine. RN1 indicated R31 initially stated he/she did not want the injection, saying No! to the staff members in the room who were trying to calm the resident down. RN1 stated (R31) can get violent and hit other residents. That is why they (staff) called the code (Code Green). RN1 stated R31 had been physically restrained by staff members while in his/her room because the resident was kicking while RN1 was attempting to give him/her the injection, but stated later R31 calmed down and allowed him/her to give the injection, and stated, I want it (the injection) on my left side. Review of R31's Progress Notes dated 11/13/2023 at 17:51 [5:51 PM] and found in the EMR under the Progress Note tab, read Note Text: Code green called for this resident on this shift: PMHx [past medical history]: 1. schizoaffective DO [disorder] 2. Persistent mood DO 3. Bipolar DO 4. Anxiety DO 5. OCD [obsessive compulsive disorder] 6. MDD [major depressive disorder] Res. got into a verbal altercation w/ [with] another resident because he/she alleged [sic] that the other resident called him/her a (term describing same gender sexual relationship) which according to staff witnesses is not true. Res. [resident] became irate and started swinging (but missed) at staff and resident in DR [dining room]. Res. was screaming at the top of his/her lungs and almost unable to reason with. Res. had to be taken into his/her room where he/she continued to swing at staff and kicked placing him/herself and others in danger, Res, taken to his/her room and did agree to receive his/her PRN IM medication. Res. continued to scream and became and got agitated for about another 15 minutes and then calmed down. All medicals ruled out, no acute sign of infection and or abnormal medical workup, no other more issues noted throughout rest of shift. Cont. to monitor. CNA2 was interviewed on 11/13/23 at 4:13 PM and indicated he/she was familiar with R31. He/She indicated when R31 was upset he/she responded well by talking to him/her, playing music, and writing letters to his/her brother. CNA2 indicated he/she was present during R31 and R23's incident in the dining room and hallway, but was not in R31's room when the injection was given. He/She assisted with using a 2-person CALM hold on R31 while in the hallway via the facility's CALM hold technique. He/She did not know why none of the above interventions were attempted when R31 and R23 initially began to argue or when the resident was being physically held in the hallway. The Administrator and DON were interviewed together on 11/14/23 at 11:11 AM and the DON stated, We try to get them (Residents) to use their coping skills (prior to restraining a resident). The DON was not able to indicate what R31's coping skills were. The Administrator confirmed he was in the room with R31 when the resident was physically restrained and then given the as needed psychotropic medication injection and stated he attempted to talk to R31 to calm him/her down prior to the resident being physically restrained, but was also unable to state what R31's specific coping skills were or that any of those coping skills were attempted prior to physically restraining R31. The Administrator stated, R31 was having an issue with a peer making a statement about him/her being a (term used to describe same gender sexual relationship). I talked to him/her and told him/her I needed him/her to calm down. I told him/her I would talk to staff members and residents to address his/her concerns. Even through all of that he/she still wouldn't calm down. The Administrator stated R31 had a tendency to throw him/herself out of his/her wheelchair when he/she was upset and so for his/her own safety the resident was physically restrained, and an injection administered. The Administrator stated his expectation was if the residents were escalating in the dining room in front of staff, the residents should have been redirected and removed from the situation before they got riled up. He stated if there were any staff members in the dining room when the incident began, they should have intervened to prevent escalation in the first place. The Administrator, DON, Regional Administrator, and Regional Nurse were interviewed together on 11/14/23 at 11:56 AM and the DON stated again stated she was not sure what R31's individual coping skills were, but stated the team tried to verbally deescalate R31 and the resident was placed in a two person CALM hold (Physically restrained by two staff members) with further verbal attempts to deescalate the resident in the hallway and then again in his room, and then an as needed psychotropic injection was administered. The DON stated, During a behavioral emergency we don't attempt all of their (Resident's) coping skills. The DON stated she was not aware of any other recent incidents between R23 and R31 that would have indicated staff should be monitoring R23 and R31 closely or that the residents should have been redirected away from one another earlier in the incident (even though RN1 indicated the DON told him R31 and R23 had past issues with one another). The Regional Administrator stated his expectation was that if R23 and R31 were arguing and staff were present, staff should have intervened before the arguing escalated. The Administrator stated per the CALM method for de-escalation utilized by the facility, the goal was to never have to touch a resident, and every available measure appropriate for a resident would be used to deescalate a resident prior to having to use physical or chemical restraints (including two person holds or the administration of injectable psychotropic medication). The Administrator confirmed he was present in the room during the 11/13/23 incident and the resident had been physically restrained by staff while in his/her room. 18947 07342

18947 Based on observation, interview and record review, the facility failed to ensure chemical restraints were not used unless medically necessary for two of 42 sampled residents (Residents (R)31 and R70). As needed intramuscular injections of psychotropic medication were administered to both residents while physically restraining them and without their willing consent. The residents were exhibiting behaviors, however facility staff did not first attempt to utilize the residents' assessed and care planned de-escalation techniques to calm them down. The facility's failure to ensure all appropriate non-pharmacological interventions were attempted for R31 and R70 prior to the administration of as needed injections of psychotropic medication, increased the likelihood of the residents experiencing serious physical and/or psychosocial harm related to being chemically restrained. The census was 178. Immediate Jeopardy related to this failure was identified on 11/15/23 and was determined to first exist since 11/13/23. On 11/15/23 at 4:39 PM, the facility's Administrator was notified of the Immediate Jeopardy. The facility Administrator was notified that the Immediate Jeopardy was removed on 11/20/23. After the immediacy removal, the noncompliance remained at a D scope and severity level. The facility census was 179. Findings include: Review of the facility's policy titled, Restraints Policy, dated 01/05/23, indicated it was the policy of the Facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. 1. Review of R31's Admission Record, dated 11/19/23 and found in the electronic medical record (EMR) under the Profile tab, revealed R31 was admitted to the facility on [DATE] with diagnoses, including schizoaffective disorder, borderline intellectual functioning, major depression, bipolar disorder, and anxiety disorder. Review of R31's most recent Brief Interview for Mental Status (BIMS) assessment, dated 07/24/23 and found in the EMR under the Assessment tab, indicated at score of two out of 15 which indicated R31 had severe cognitive impairment. R31 was not marked for chemical restraint use. Review of R31's care plan, dated 10/31/23 and found in the EMR under the Care Plan tab, indicated [R31] displays manifestations of behaviors r/t [related to] his mental illnesses that may create disturbances that affect others. These behaviors include being easily irritated/annoyed by others, verbal/physical aggression. [R31] very agitated and anxious. Interventions included: administer and monitor medications as ordered, administer prn [as needed] medications as needed/ordered when non pharmacological interventions are not effective, assist in addressing root cause of change in behavior or mood as needed, Coping skills talking about brother, soda, If resident is having behaviors and preferred coping skills are found to be NOT effective, refer to CALM [Crisis Alleviation Lessons and Methods] de-escalation protocols, Current behaviors verbal outburst and screaming towards staff physically aggressive Resident will place self on the floor when he feels like his request are not met. If you see resident(s) having any behaviors listed in the current behaviors section, refer to preferred coping skills immediately, give positive feedback for good behavior, if [R31] is disturbing others, encourage him to go to more private areas to voice concerns/feelings to assist in decreasing episodes of disturbing others, [R31] will put himself on the floor at times when he is upset and when demands are not immediately met, non-pharmacological interventions include: meet with administration/staff member that he is comfortable with, encourage him to watch tv, listen to music, 1:1 visits, talk to a trusted person/staff, notify guardian/physician as needed, pharmacy consultant review of medications monthly and prn, psych consult for medication adjustments as needed/ordered, redirect resident and give individualized care when [R31] is showing behavior, and triggers: shower days, inpatient, doesn't like things on his clothes. If staff observes a trigger happening to the resident, immediately refer to the resident's preferred coping skills and redirect behavior. Review of R31's Progress Notes, dated 10/17/23 at 4:59 PM and found in the EMR under the Progress Note tab, read Behavior Note: Note Text: Resident started yelling down the hallway about taking a shower, started to get physically aggressive with staff, when staff tried to talk to him. Resident tried to get out of wheelchair going towards staff, had to place resident in 2-man calm hold. Resident was still being physically and verbally aggressive trying to get out of his wheelchair, and resident was placed in 5-man calm hold on the ground with pillow for the head. Provider was called and ordered chlorpromazine 50 injection and it was administrated in right buttock. After the injection resident was helped with rolling over on his back and sat in sitting position, then gait belt was used to get him off the floor into his bed. Resident VS [vital signs] within normal limits, skin is intact, no reports of pain. Educated resident on when shower time was and placed on shower list everyday in the morning to help with anxiety. Guardian notified of incident and all administration notified. Review of R31's Progress Notes, dated 10/25/23 at 7:13 AM and found in the EMR under the Progress Note tab, read Incident Note: Note Text: Resident heard yelling in the hallway. upon intervening, he stated that he was hit by another resident [R23] on the face and he was asking for a phone to call the police. he continued to yell while wheeling himself to that resident's room. The aide tried to get him back to his room but he hit her on her face and stomach. He started screaming and trying to jump out of his wheelchair. A code was called and Thorazine shot was administered. Review of R31's Progress Notes, dated 11/02/23 at 6:12 PM and found in the EMR under the Progress Note tab, read Note Text: Resident in room yelling. I went to room and tried to console resident. I asked him if he wanted a PO [oral] PRN medication. He refused and kept yelling. Code green called. Resident stood up from wc [wheelchair] and punched [staff] in the chest. Calm hold in wheelchair applied. Injection given in left deltoid. Resident calmed down and apologized to staff. Guardian, physician, and administration notified. Review of R31's Order Summary Report, dated 11/02/23 and found in the EMR under the Orders tab, indicated Administer chlorpromazine Injection Solution 50 MG/2ML inject 50 mg intramuscularly every 12 hours as needed for Agitation for 14 Days. The resident did not have any current orders for oral as needed psychotropic medication. There was nothing in the orders to indicate alternative nonpharmacological methods of de-escalation for R31. There was consent for chemical restraints. Review of R31's medical record revealed there was nothing documented related to R31's assessed and care planned de-escalation interventions/coping skills, such as talking to him about his brother, meeting with a staff member the resident is comfortable with, talking to a trusted person, offering him soda, assisting him with writing a letter to his brother, or listening to music, were attempted prior to the administration of the as needed injection of psychotropic medication (chemically restraining) the resident. During an observation on 11/13/23 beginning at 10:49 AM R31 was having an altercation with R23 in the facility's dining room/day room area. R31 became agitated, stating R23, who was seated at a separate table approximately 10 feet away from R31, had been calling him a homosexual, and indicating this was extremely upsetting to him since he had been raped by a male family member as a boy. R23 and R31 began arguing. Two staff members (Certified Nurse Aide (CNA) 2 and Health Monitor (HM) 1) were in the dining room assisting other residents, but neither staff member appeared to be monitoring R23 and R31, and neither of the staff members attempted to intervene/stop the arguing between the residents. R23 and R31 argued for five minutes with no observed attempts by staff to intervene, and then the verbal altercation between the two residents escalated and R31 became extremely agitated, screaming R23 was a liar and had been calling him a homosexual, and threatening to kick R23's ass. R23 was yelling at R31 that he was a liar and indicating R31 had recently hit him twice with a closed fist (date unknown). R23 was removed from the dining room by a staff member and Administrator in Training (AIT)1 approached R31 to attempt to calm him down. AIT1 spoke with R31 for approximately two minutes, attempting to calm the resident down but was not able to deescalate the resident, who continued to scream, but was able to get R31 to transfer from a regular dining room chair to his wheelchair to wheel him out of the dining room and into the hallway. Documented coping skills for R31, according to his plan of care (such as offering a soda, offering to play music, asking the resident if there was a trusted staff member he would like to talk to, offering to take the resident to watch television, offering to take the resident to his room to talk about his brother or write his brother a letter) were not observed to be attempted at any point during the observed incident. As R31 was escorted out of the dining room, he further threatened to kick a separate resident's ass (R48). In the hallway, four staff members (AIT1, Corporate AIT2 CNA 2, and Registered Nurse (RN)1) were observed to be verbally asking the resident to calm down and the resident was placed in a 2-person CALM hold by two of the staff members via standing on opposite side of the resident and restraining the resident around his trunk so that he was unable to move in his wheelchair. The resident continued to escalate, kicking, and screaming No! and He called me a homosexual! Again, none of the resident's documented coping skills were observed to be attempted/offered to the resident. R31 continued to yell at staff and so the Director of Nursing (DON) was consulted and directed the team to administer an as needed Intramuscular injection of chlorpromazine (Thorazine a psychotropic medication used to calm residents down) to the resident. R31 continued to yell at the staff, stating he did not want the injection. On 11/13/23 at 11:08 AM, R31 was wheeled to his room in his wheelchair. Four staff members (including RN1, Corporate AIT2, the Administrator, and an unidentified staff member later identified as AIT2) entered the room with the resident and closed the door. The surveyor continued to hear R31 screaming/yelling loudly, stating, Please don't and No! and I don't want a shot! repeatedly. On 11/13/23 11:11 AM, all staff (including RN1, Corporate AIT, AIT2 and the Administrator) exited R31's room. R31 remained in his room and continued to scream No! and He is a liar! and He called me a homosexual! The facility's DON was interviewed on 11/13/23 at 11:08 AM while R31 was in his room with staff. The DON stated RN1 was giving the resident an injection to calm him down. RN1 was interviewed on 11/13/23 at 11:20 AM after he exited R31's room. RN1 confirmed he was the staff member who administered R31's IM injection and stated he was new to the facility (11/13/23 was his first day working in the facility), he was an agency nurse, and he was the nurse in charge when the incident between R31 and R23 occurred. RN1 stated he was not familiar with any of the residents in the facility or their non-pharmacological interventions for behaviors, but stated he gave R31 an injection of chlorpromazine due to his behaviors. RN1 stated, I was called over (to the dining room) because apparently there was a verbal altercation between (R31) and (R23) and (R31) thought (R23) was calling him a homosexual. RN1 indicated (unknown) staff had reported to him R23 had not been calling R31 a homosexual, but the DON told him the residents had a past and had been in an altercation before. RN1 stated, He has a prn (as needed injectable psychotropic medication) for when he (R31) gets like that and so he (R31) got his prn Thorazine. RN1 indicated R31 initially stated he did not want the injection, saying No! to the staff members in his room who were trying to calm him down. RN1 stated, (R31) can get violent and hit other residents. That is why they (staff) called the code (Code Green). RN1 stated R31 had been physically restrained by staff members while in his room because he was kicking while RN1 was attempting to give him the injection, but stated later R31 calmed down and allowed him to give him the injection, and stated, I want it (the injection) on my left side. During an observation on 11/13/23 at 1:35 PM, R31 was in his room sitting on bed with his back against wall. The resident was quiet and appeared to be sleepy. During an observation on 11/13/23 at 1:36 PM, R 31 was being wheeled into his room and assisted to bed by staff after he had eaten his lunch in the dining room. R31 was calm and appeared to be sleepy. During an observation on 11/13/23 at 4:34 PM, R31 was sleeping in his bed. R31's Progress Notes. dated 11/13/2023 at 17:51 [5:51 PM] and found in the EMR under the Progress Note tab, read Note Text: Code green called for this resident on this shift: PMHx [past medical history]: 1. schizoaffective DO [disorder] 2. Persistent mood DO 3. Bipolar DO 4. Anxiety DO 5. OCD [obsessive compulsive disorder] 6. MDD [major depressive disorder] Res. got into a verbal altercation w/ [with] another resident because he alleged [sic] that the other resident called him a homosexual which according to staff witnesses is not true. Res. [resident] became irate and started swinging (but missed) at staff and resident in DR [dining room]. Res. was screaming at the top of his lungs and almost unable to reason with. Res. had to be taken into his room where he continued to swing at staff and kicked placing himself and others in danger, res. taken to his room and did agree to receive his PRN IM medication. Res. continued to scream and became and got agitated for about another 15 minutes and then he calmed down. All medicals ruled out, no acute sign of infection and or abnormal medical workup, no other more issues noted throughout rest of shift. Cont. to monitor. CNA2 was interviewed on 11/13/23 at 4:13 PM and indicated she was familiar with R31. She indicated when R31 was upset he responded well by talking to him, playing music, and writing letters to his brother. CNA2 indicated she was present during R31 and R23's incident in the dining room and hallway but was not in R31's room when the injection was given. She stated she assisted with using a two-person CALM hold on R31 while in the hallway via the facility's CALM hold technique. She stated she did not know why none of the above interventions were attempted when R31 and R23 initially began to argue or when the resident was being physically held in the hallway. The Administrator and DON were interviewed together on 11/14/23 at 11:11 AM and the DON stated, We try to get them (Residents) to use their coping skills (prior to restraining a resident). The DON was not able to indicate what R31's coping skills were. The Administrator confirmed he was in the room with R31 when the resident was physically restrained and then given the as needed psychotropic medication injection and stated he attempted to talk to R31 to calm him down prior to the resident being physically restrained but was also unable to state what R31's specific coping skills were or that any of those coping skills were attempted prior to physically restraining R31. The Administrator stated, He [R31] was having an issue with a peer making a statement about him being a homosexual. I talked to him and told him I needed him to calm down. I told him I would talk to staff members and residents to address his concerns. Even through all of that he still wouldn't calm down. The Administrator stated R31 had a tendency to throw himself out of his wheelchair when he was upset and so for his own safety the resident was physically restrained, and an injection administered. The Administrator stated his expectation was if the residents were escalating in the dining room in front of staff, the residents should have been redirected and removed from the situation before they got riled up. He stated if there were any staff members in the dining room when the incident began, they should have intervened to prevent escalation in the first place. The Administrator, DON, Regional Administrator and Regional Nurse were interviewed together on 11/14/23 at 11:56 AM and the DON stated again stated she was not sure what R31's individual coping skills were, but stated the team tried to verbally deescalate R31 and the resident was placed in a two person CALM hold (Physically restrained by two staff members) with further verbal attempts to deescalate him in the hallway and then again in his room and then an as needed psychotropic injection was administered. The DON stated, During a behavioral emergency we don't attempt all of their (Resident's) coping skills. The DON stated she was not aware of any other recent incidents between R23 and R31 that would have indicated staff should be monitoring R23 and R31 closely or that the residents should have been redirected away from one another earlier in the incident (even though RN1 indicated the DON told him R31 and R23 had past issues with one another). The Regional Administrator stated his expectation was that if R23 and R31 were arguing and staff were present, staff should have intervened before the arguing escalated. The Administrator stated per the CALM method for de-escalation utilized by the facility, the goal was to never have to touch a resident, and every available measure appropriate for a resident would be used to deescalate a resident prior to having to use physical or chemical restraints (including two-person holds or the administration of injectable psychotropic medication). 2. Review of R70's Diagnosis tab in the EMR revealed R70 as admitted on [DATE]. R70 had diagnoses which included schizophrenia, major depression, generalized anxiety disorder, and idiopathic orofacial dystonia (neurological movement disorder). The most recent quarterly MDS with an ARD of 07/12/23 and 10/12/23 from the MDS tab indicated the resident was independent in all activities of daily living. R70 had a BIMS of 15 out of 15 which indicated R70 was cognitively intact. Review of R70's care plan for management of behavior found in the EMR under the Care Plan tab, dated 06/07/23, revealed no reference to using a five man hold down and psychotropic medication. Review of the resident's Progress Notes tab in the EMR on 05/23/23 at 3:34 PM revealed R70 approached the nurse on his unit while at her cart about the X-Ray of his/her right hand. The nurse stated the hand was ok and the results were negative. She suggested he/she use an ice pack on the swollen hand to reduce the pain. R70 complained that this hand was still swollen and painful and how could the test results be negative. R70 escalated and went to his/her room tearing his cubicle curtain down and slamming the door to the room. The nurse called a Code Green (behavioral emergency). The nurse went to get the injection and the staff arrived at the unit. The resident told staff that he/she was not taking the injection. The assistant administrator educated R70 to calm down. The assistant administrator asked R70 where he/she wanted the injection and R70 began to yell racial slurs and became aggressive with staff in the area. A five-man calm hold followed until the injection was given. Review of the resident's Progress Note tab in the EMR on 09/13/23 at 12:15 PM revealed R70 became involved in a peer-to-peer altercation in the corridor near the Hangout room (area for resident activities and socialization) in the facility. A CODE GREEN was called. Staff tried to intervene. R70 pushed the door open on the way back to his/her unit causing the staff intervening to fall. Later, support staff arrived and placed the resident a five man hold down. The nurse administered an injection for behavior. Review of the resident's physician order in the EMR under the Orders tab revealed 50mg Thorazine intramuscularly every eight hours as needed dated, 05/23/23. The order was effective until 06/08/23. Review of the resident's physician order in the EMR under the Order tab revealed 50mg Thorazine intramuscularly every eight hours as needed on 09/13/23. The order range was from 09/01/23 to 09/15/23.

Based on interview and record review, the facility failed to ensure two residents (Resident #1 and Resident #2), in a review of nine sampled residents, remained free from abuse. On 8/15/23, Resident #1 and Resident #3 were in a verbal dispute. Resident #1 expressed being fearful of Resident #3. Resident #1 was placed on one on one monitoring with staff for his/her safety. On 8/16/23, Resident #3 continued to make threats (wanting to beat Resident #1 up or kick his/her ass) towards Resident #1. Resident #3 ran into Resident #1's room, shoved and struck the staff member providing the one on one monitoring, and struck Resident #1 multiples times in the head and body. Resident #1 sustained a concussion (a brain injury from a hard, direct hit (trauma) to your head or body, healing from this injury can take time) and hand contusion (deep bruise to the hand, as a result to a blunt injury to tissues and muscle fibers under the skin). On 8/17/23, Resident #2 and Resident #4 got in to a disagreement over beads while in the outside common area. Resident #4 hit Resident #2 in the face. Resident #2 sustained acute fractures (immediate break in the bone) involving the lateral wall and floor of the left orbit (bones around the eyeball, often caused by a hard blow to the face) and acute fractures involving the lateral wall and anterior wall of left maxillary sinus (broken bones around the nasal cavity and below the eyeball). The facility census was 175. Review of the facility's Abuse and Neglect policy, revised on 1/5/23 showed the following: -Physical Abuse - Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Review of the facility's Behavioral Emergency Policy, revised 1/5/23, showed the following: -The purpose is to provide safe treatment and humane care to the residents in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -The licensed nursing staff/Team Leader/Resident Care Coordinator (RCC) will assess the resident who is exhibiting such behaviors, ensuring that safety of the resident and others is the first priority. A one-to-one monitoring of the resident will be initiated at this time under the direction of the licensed nurse; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Documentation of the behavior emergency in the Administrative Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible; -Behavior emergency= a code green. A code green can be called to be proactive in ensuring that enough qualified staff are present and to warrant the potential need of utilizing approved CALM hold techniques; -The nurse (unless the administrator, director of nursing (DON) or assistant director of nursing (ADON) are present) is ultimately in charge of the code green and all staff responding will follow the direction of the Team leader. The team leader can be the first one to the scene of the code green, the employee with the most experience or the employee that had the best rapport with the resident; -When a code green is called staff will respond promptly and professionally. A code green does not denote that approved calm hold techniques are automatically utilized. The central purpose of calling a code green is recognizing that the resident has become or has the potential to become a danger to themselves or someone else. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/23, showed the following: -Cognition intact; -No behavioral symptoms exhibited; -Independent with walking and locomotion on and off the unit. Review of the resident's progress note dated 8/15/23 at 6:54 P.M., showed a verbal altercation began between the resident and a peer (Resident #3), on the 800 unit dining room, staff intervened. The resident refused to separate himself/herself from his/her peer. A code green was called, peer (Resident #3) attempted to run around the table and the staff member to attack Resident #1. Staff intervened and no contact was made. The resident (Resident #1), was willing and went to the social service office until safe to return to the unit. The resident was currently in his/her room resting. One on one in place. Review of the resident's progress note dated 8/16/23 at 8:00 P.M. showed the following: -A code green was called, with the direction of the Director of Nursing (DON), when Resident #1 was in the smoke room with peer (Resident #3), who was verbally aggressive, said to him/her (Resident #1) he/she still wanted to beat him/her up; -Staff separated both of the residents in the smoke room. Resident #3 went to the common area. Resident #1 smoked, staff escorted him/her back to his/her room, and Resident #1 returned to one on one; -A few minutes later Resident #3 went into Resident #1's room and shoved and punched the staff member. Resident #3 attacked Resident #1, punched his/her body and head, and pulled his/her hair; -Resident #1 said he/she just covered his/her head and face trying to protect himself/herself; -A code green was called again. Staff separated both of the residents. Resident #1 had minor bruises on the right hand and arm and palpable bumps at the back of his/her head. The resident was transferred to the hospital for a medical evaluation. Review of Resident #1's hospital discharge instructions, dated 8/16/23, showed a concussion without loss of consciousness and contusion to hand. During an interview on 8/23/23 at 1:00 P.M., Resident #1 said he/she had a concussion, and was in a lot of pain. Resident #1 had told staff that he/she was scared of Resident #3 so they put him/her on one on one. Resident #3 had threatened to beat him/her up. Review of Resident #3's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 7/26/22, showed the following: -Diagnoses included schizoaffective (a combination of symptoms of schizophrenia, a serious mental illness that affects how a person thinks, feels, and behaves) , bipolar type ( they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania), Bipolar 1 disorder ( manic episode which can include increased energy, excitement, impulsive behavior and agitation, may or may not experience a depressive episode) and Bipolar 2 disorder ( a chronic mental illness defined by episodes of depression and periods of elevated or irritable mood), major depressive disorder and reactive attachment disorder (a condition where a child doesn't form healthy emotional bonds with their caretakers (parental figures) often because of emotional neglect or abuse at an early age; -The resident had historical symptoms of disorganized thinking, impulsive behaviors, suspicious, paranoid abnormal thought process, verbal and physical aggression both suicidal ideation/homicidal ideation; -The resident displayed consistent unsafe/poor decision making, due to mental functioning; -The resident had poor insight and judgement; -Safety plan to address interventions when the resident poses a risk to himself/herself or others. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 4/21/23 showed the resident was cognitively intact. Review of the resident's annual MDS, dated ,d+[DATE], showed the following: -Makes self-understood and understands others; -No physical behavioral symptoms exhibited over the last week; -Verbal behaviors occurred one to three days out of seven; -Required staff supervision/oversight with walking and locomotion on and off the unit. Review of the resident's care plan dated 8/18/23 showed the following: -The resident had a history of behavioral challenges that require protective oversight in a secure setting, needs behavioral support plan, medication therapy, structured environment, crisis intervention, CALM technique if needed, coping skills were drawing and painting, one on one interventions as needed and pharmaceutical interventions as needed; -History of behaviors and current behaviors, impulsive behaviors, psychosis ( a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), suspicious/paranoid, wanders depression/depressed mania; -The resident had a mood problem related to bipolar disorder, educate the resident/family/caregivers to identify strengths, positive coping skills and reinforce these; -The resident had a history of post-traumatic stress disorder (PTSD). PTSD symptoms may flare up without any known trigger. Alterations in reactivity from the traumatic event, including aggressiveness and self-destructive behavior; -Assess anxiety level, determine severity of condition and course of treatment. Coping skills were drawing, painting, listening to music, and talking with staff/peers. Review of the resident's progress note dated 8/16/23 at 10:56 P.M. (late entry) showed the following: -Resident #3 was in the smoke room with peer (Resident #1) when he/she (Resident #3), started becoming verbally inappropriate with peer. Staff separated the residents and implemented different smoke times to prevent further issues. Resident #3 continued to be in the common area and made statements/threats about the peer (Resident #1); -The peer (Resident #1) was placed one on one for protective oversight. Resident #3 was able to be redirected and staff continued to monitor him/her. Resident #3 walked down the hall towards his/her room, but instead he/she ran into the peer's (Resident #1's) room; -The one on one staff attempted to redirect the resident. The resident allegedly shoved/struck staff member. He/She then struck the peer multiple times in the head/body areas. The resident was immediately placed one on one and order was given to send out the resident to be evaluated. During an interview on 8/23/23 at 12:30 P.M. Hall Monitor C said the following: -He/She worked on the hall when the altercation took place between the two residents; -On 8/15/23 Resident #1 was one on one because Resident #3 had charged at Resident #1. On 8/16/23 around 12:00 P.M., Resident #1 was removed from one on one because he/she felt safe; -Hall monitor C thought Resident #3 should have been one on one, because Resident #3 made threats against Resident #1, but he/she didn't know the protocol on that; -On 8/16/23 (later that day) in the smoke room, Resident #3 told Resident #1 he/she was going to beat his/her ass. Resident #1 left the smoke area until Resident #3 was done smoking; -Resident #1 went back to the smoke room and finished smoking. Resident #3 sat outside the smoke area and said he/she was going to beat his/her (Resident #1) ass. A code green was called because of the comments Resident #3 made; -He/She tried to calm Resident #3 down. Staff were instructed to keep Resident #1 in the smoke room until Resident #3 was sent out for evaluation; -Registered Nurse (RN) A responded to the code. Code green staff escorted Resident #1 to his/her room and he/she was placed one on one; -He/She explained to the code green team, that Resident #3 had threatened to beat Resident #1's ass, but the staff that responded to the code green left the hall. He/She knew something was going to happen as he/she worked routinely with the residents; -Resident #3 headed down the hall to his/her room, and suddenly sprinted across the hall to Resident #1's room. When hall monitor C made it to Resident #1's room, Resident #3 was on top of Resident #1 hitting him/her; -He/She should have spoken up when all the staff left the hall, but felt the code green staff that responded were above him/her in their position. During an interview on 8/28/23 at 8:45 A.M. Registered Nurse (RN) B said the following: -He/She worked the evening of the altercation; -Resident #1 was one on one for his/her safety because Resident #3 had threatened Resident #1 on 8/15/23; -On 8/16/23 around 4:00 P.M., Resident #1 felt safe so the resident was removed from one on one; -Later in the shift, hall monitor C called and said Resident #3 started making threatening comments again towards Resident #1. The residents were in the smoke area and hall monitor C had separated the residents; -Resident #3 was typically aggressive and based on his/her history, the instigator. Resident #3 was unpredictable and many of the CNAs were afraid of him/her; -The Director of Nurses (DON) instructed staff (over the phone), to not allow Resident #1 to leave the smoke area until Resident #3 was sent out. Resident #3 (who sat outside of the smoke room), made threatening comments about wanting to beat up or hurt Resident #1 when he/she came out of the smoke room; -A code green was called and RN B left the hall to set up transportation to send Resident #3 out for evaluation due to aggressive behaviors; -Typically, the aggressor was placed one on one. RN B thought staff was sitting with Resident #3 when he/she left the hall to set up transportation. RN B felt the altercation could have been prevented if staff that responded to the code green would not have left the floor. During an interview on 8/28/23 at 9:26 A.M., RN A said the following: -On 8/16/23 he/she arrived to the facility and was only at the facility for just a few seconds before a code green was called; -He/She responded to the code green, but had no knowledge of what occurred between the two residents prior to the code green; -When he/she arrived to the hall, everything was calm. Resident #3 was visiting with his/her peers. An unidentified staff member said we need help getting Resident #1 to his/her room; -RN A did not know Resident #3 had been aggressive. If he/she would have known what had occurred before he/she arrived to the facility, he/she would have done things differently; -Resident #3 should have been placed one on one if he/she was the aggressor and was being sent out for evaluation due to behaviors; -The facility staff should have either called RN A before he/she arrived to the facility to explain what had happened between the two residents, or explained concerns during the code green; -RN A told the staff that responded to the code green he/she didn't see an issue, and the code green staff returned to their halls; -RN A was unaware the DON had instructed Resident #1 to remain in the smoke room until Resident #3 was transferred out. During an interview on 8/23/23 at 1:50 P.M. Staffing Coordinator D said the following: -On 8/16/23 hall monitor C called him/her and said Resident #3 was outside the smoke room and had made threats that he/she was going to fight Resident #1 when he/she came out of the smoke room; -Staffing Coordinator D gave strict orders to staff to not allow Resident #1 to leave the smoke area because once Resident #3 was mad and had something in his/her head, it was going to happen; -Resident #3 was to be sent out for a psychiatric evaluation. He/She had communicated back and forth with the DON about the issue prior to the altercation; -When RN A responded to the code green staff should have spoke up and explained what had been going on before all of the staff that responded to the code green left the hall. During an interview on 8/23/23 at 11:34 A.M. the DON said the following: -On 8/16/23, facility staff called Staffing Coordinator D and said Resident #3 was outside the smoke room waiting to hit Resident #1; -She communicated with Staffing Doordinator C and called RN B and instructed him/her to not allow Resident #1 to leave the smoke room because the smoke room had a lock on the door; -She instructed RN B to call a code green and get Resident #3 sent out for a psychiatric evaluation; -If a code green was called it would be five staff to one resident; -She would never turn his/her back on Resident #3. Resident #3 could be very calm, but was very manipulative. During an interview on 8/22/23 at 9:00 A.M. and 12:06 P.M., and 8/23/23 at 2:25 P.M., and at 4:00 P.M., the administrator said the following: -On 8/15/23, Resident #1 and Resident #3 were arguing over a chair, Resident #1 left the hall and came back and was upset that his/her chair had been taken by another resident. Resident #3 said we don't save seats; -Resident #3 said you want to go, lets go, and staff intervened; -Resident #1 was actually the instigator; -Resident #1 was Resident #3's focus, so staff put Resident #1 one on one monitoring for his/her safety; -Resident #3 was not placed one on one as he/she didn't have any issues with other residents at the facility; -Many of the residents at the facility make aggressive comments towards other residents, that doesn't mean the facility automatically puts the resident who made threatening comments one on one. If they always put residents one on one for aggressive comments made, they would not have any staff to work because staff would be tied up with one on one residents all of the time; -Staff called a code green on Resident #3 after he/she made threatening comments; -On 8/16/23 Resident #1 said he/she felt safe so he/she was removed from one on one. Later in the smoke room there were verbal comments made by Resident #3 towards Resident #1 and staff put Resident #1 back on one on one for his/her safety. One of the residents needed to be secured to assure nothing else happened; -On 8/16/23 RN A responded to the code green when he/she arrived to work. RN A thought everything was calm and didn't find an issue; -Later, Resident #3 walked down the hall and staff took off after him/her at a fast pace. Resident #3 went in his/her room, then took off into Resident #1's room, punched the one on one staff and pulled Resident #1's hair; -Resident #1 said he/she had a headache and was sent out to see if he/she had a concussion; -Resident #3 was fixated with Resident #1. This was not normal for Resident #3, so that was the reason Resident #3 was being sent out for an evaluation. 2. Review of Resident #2's quarterly MDS dated [DATE] showed the following: -Cognition intact; -No behaviors exhibited; -Ambulation and locomotion on and off the unit occurred only once or twice during the last week no setup or physical help from a staff member needed. Review of the resident's progress note, dated 8/17/23 at 9:50 P.M., showed the following: -Resident to resident altercation in which the residents fought over beads that the resident (Resident #4) wanted back. Resident #2 allegedly threw the beads at Resident #4, at which point Resident #4 began hitting Resident #2 in the face; -A code green was called. All available staff went to the Hang Out (common area) to find Resident #2 bleeding from his/her nose, forehead, and above his/her left eye; -A while ago, Resident #4 made Resident #2 a necklace with some of his/her beads. Resident #2 placed some of the beads in his/her hair. Resident #4 asked for six beads back and wanted to pick the beads out. Resident #2 brought the beads to the Hang Out out after he/she took a shower; -Resident #4 said he/she wanted them all, but Resident #2 paid for them. Resident #2 got mad so he/she threw the beads at Resident #4. Resident #4 started hitting Resident #2; -Resident #2 had a large laceration above his/her eye which was swollen, black and blue, and his/her eye was red and irritated. Staff called EMS (emergency medical services) for transportation to the emergency department for evaluation and treatment. Review of Resident #2's hospital radiology report, dated 8/17/23 at 9:14 P.M., showed the following: -Assault, resident punched in the face multiple times; -Acute fractures (immediate break on the bone) involving the lateral wall and floor of the left orbit (bones around the eyeball, often caused by a hard blow to the face). There was also acute fractures involving the lateral wall and anterior wall of left maxillary sinus (broken bones around the nasal cavity and below the eyeball). During interview on 8/22/23 at 11:38 A.M., Resident #2 said the following: -Resident #4 said he/she wanted six beads back from a necklace he/she had given to him/her previously, Resident #2 had put the beads in his/her hair because the necklace turned his/her neck green; -On shower day Resident #2 took the beads out of his/her hair and went to the Hang Out; -Resident #4 said he/she wanted all the beads, so Resident #2 just threw the beads and Resident #4 started hitting him/her in the head; -He/she fell down and didn't remember much about what happened after that. Review of Resident #4's PASRR, dated 8/5/16, showed the following: -Diagnoses included schizo-affective (a mental health problem where you experience psychosis as well as mood symptoms), Bipolar I disorder, rule out intermittent explosive disorder (repeated, sudden episodes of impulsive aggressive, violent behavior or angry outbursts in which you react grossly out of proportion to the situation) verses impulsive control disorder (chronic problems in which people lack the ability to maintain self-control); -Problematic behaviors include impatient/demanding, strikes others provoked; -Specific symptoms included delusional, anxious, labile, restless, pacing, poor concentration. History of angry outbursts, physical aggression, easily agitated, depression, and mood swings. He/She was also guarded; -Functional limitations in interpersonal functioning, concentration, persistence, pace or adoption to change in the last six months included difficulty interacting, appropriately/communicating effectively with others, a history of altercations, evictions, firing, fear of strangers, difficulty concentrating, difficulty in adapting to typical changes associated with work, family or social interaction, and manifests agitation, and exacerbated signs and symptoms associated with the illness. Review of the resident's annual MDS dated [DATE] showed the following: -Cognition intact; -No behavioral symptoms exhibited; -Supervision with walking in room and corridor; -Independent with locomotion on and off the unit; Review of the resident's care plan last revised on 8/19/23 showed the following: -The resident has a history of behavioral challenges that require protective oversight in a secure setting, current behaviors poor judgement, poor decision making, verbally aggressive, physically aggressive, poor insight, impatient and demanding; -Coping skills were crafting (making bracelets), painting, drawing, watching television, coloring, and making bookmarks; -One on one interventions as need and pharmaceutical interventions as needed. Review of Resident #4's progress note dated 8/17/23 at 10:04 P.M., showed the resident and peer (Resident #2) were in a verbal altercation over beads from a necklace. The resident struck the peer in face three times. Immediately placed one on one and resident sent out for psychiatric evaluation. Review of the facility RNI dated 8/18/23 (completion of investigation untimed), showed the following: -Date of incident: 8/17/23; -Type of incident: physical aggression involving head; -Criteria for reporting was abuse; -Code green called to the hang out after Resident #4 allegedly struck Resident # 2 in the face after they had a disagreement over beads. Resident #4 reported he/she made a necklace made of beads for Resident #2 and he/she bought it from him/her some time ago; -Resident #2 agreed to give the beads back, but when it was time to give them back he/she didn't. Resident #4 tried to snatch the beads out of his/her hand; -Resident #4 said Resident #2 shoved his/her shoulder so Resident #4 punched the bitch. Resident #4 claimed it was self-defense for Resident #2 shoving him/her; -Conclusion of the investigation: Facility can confirm that Resident #4 struck Resident #2 when they had a disagreement over beads. There was no build up to the incident and the residents had not had any previous incidents with each other; -Resident #2 noted with redness and swelling to left eye area and a laceration above the left eye. Resident #2 found to have left orbital floor fracture/lateral wall fracture, left maxillary sinus lateral wall and anterior wall fractures. During an interview on 8/23/23 at 11:35 A.M. the DON said the following: -Resident #4 had no recent change in behaviors prior to the altercation with Resident #2; -Resident #4 was sent out for a psychiatric evaluation and later arrested. During an interview on 8/23/23 at 8:50 A.M. the administrator said the following: -Resident #4 sold a necklace to Resident #2 and Resident #4 wanted the beads back. Resident #2 threw the beads and the altercation occurred; -There had been no previous incidents between the two residents; -Resident #4 was arrested and Resident #2's guardian will be pressing charges. MO00223131 MO00223077

Based on interview and record review, the facility failed to ensure one resident, (Resident #1) in a review of six sampled residents, was free from abuse when Certified Med Tech (CMT) E cussed and yelled at Resident #1 causing him/her to be afraid of the staff member. The facility census was 178. Review of the facility Abuse and Neglect Policy, dated 1/5/23, showed the following: -Verbal abuse - using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples include harassing a resident, mocking, insulting, ridiculing, yelling at a resident, with the intent to intimidate or threatening residents; -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. This includes hovering over a resident with the intent to intimidate or threatening residents; -Mistreatment, neglect or abuse of residents is prohibited by the facility. This includes physical abuse, sexual abuse, verbal abuse, mental abuse and involuntary seclusion; -The facility does not condone resident abuse by anyone, including employees. 1. Review of Resident #1's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 9/2/2015, showed the following: -The resident had diagnoses that included serious mental illness; schizoaffective disorder (a combination of symptoms of schizophrenia, a serious mental illness that affects how a person thinks, feels, and behaves) and mood disorder, such as depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Attention Deficit Disorder (trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active), conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others), Post Traumatic Stress Disorder, traumatic brain injury and intermittent explosive disorder (IED - a mental health condition marked by frequent impulsive anger outbursts or aggression); -The resident functioned at a lower social level than his/her age and had poor impulse control and poor judgment; -The resident was not a threat to self or others; -The resident had difficulty interacting appropriately/communicating effectively with others and adapting to typical changes associated with work, family or social interaction. Review of the resident's care plan, dated 4/4/23, showed the following: -The resident had a behavior problem of verbal and physical aggression related to depression and schizophrenia; -Ensure protective oversight is provided; -Anticipate and meet the resident's needs. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/11/23, showed the following: -The resident's cognition was intact; -The resident did not have verbal, physical or other behaviors towards others. Review of the facility's registered nurse investigation (RNI), completed 6/16/23, showed the following: -On 6/7/23 the charge nurse, Licensed Practical Nurse (LPN) D and Psych Aide C reported to the administrator that CMT E took off his/her top shirt and approached Resident #1 aggressively while using profanity; -Staff took Resident #1 to his/her room and CMT E was escorted off the unit and suspended pending the investigation; -Resident #1 reported that he/she and CMT E were joking and talking trash and making fun of one another. CMT E then flinched at Resident #1 as if CMT E were going to hit Resident #1. Resident #1 jumped and accidentally struck CMT E in the face. CMT E took off his/her shirt and said, You better run. I am fucking pissed. Resident #3 stepped between Resident #1 and CMT E and walked Resident #1 to his/her room; -CMT E reported he/she was passing medications when Resident #1 tried to push a soda off the medication cart. When CMT E asked Resident #1 to stop, Resident #1 tried to close the computer on the medication cart. When CMT E asked him/her to stop, Resident #1 balled up his/her fist and hit CMT E in the nose. CMT E got really upset and told Resident #1 to keep his/her fucking hands to himself/herself; -Both LPN D and Psych Aide C, as well as four resident witnesses (Residents #2, #3, #5, and #6) all reported hearing CMT E using profanity; -Conclusion: The facility finds that CMT E used profanity towards Resident #1. CMT was terminated from employment on 6/8/23. Review of a written statement by the resident, provided by the facility, dated 6/7/23, showed the following: -Resident #1 and Certified Medication Technician (CMT) E were joking around and talking trash; -CMT E got mad and flinched at Resident #1 like he/she was going to hit Resident #1 in the face; -CMT E took off his/her shirt and said, You better run, I'm fucking pissed; -CMT E had played with Resident #1 like that before and acted like he/she was going to hit the resident (but never did), but this time CMT E was really close. Review of a written statement by Psych Aide C , provided by the facility, dated 6/7/23, showed the following: -Psych Aide C came onto the hall and saw CMT E screaming at Resident #1; -CMT E told Resident #1, Hit me in the face again mother fucker, I'm mad and you should run; -Psych Aide C got to Resident #1 and took the resident to his/her room, CMT E was escorted off the unit by the Director of Nursing (DON). Review of a written statement by Licensed Practical Nurse (LPN) D, provided by the facility, dated 6/7/23, showed the following: -LPN D was in the nurse's station when he/she heard CMT E yell, Are you going to hit me again, fucking do it; -LPN D saw Psych Aide C come around the corner and take the resident to his/her room; -LPN D contacted administration and the DON came and escorted CMT E off the unit. Review of a written statement by Resident #3, provided by the facility, dated 6/8/23, showed Resident #3 saw CMT E in Resident #1's face. Review of a written statement by Resident #5, provided by the facility, dated 6/8/23, showed the following: -Resident #5 was getting medications from CMT E when Resident #1 knocked the CMT's soda over and closed the computer; -CMT E and Resident #1 started slap boxing and Resident #1 accidentally hit CMT E in the face; -CMT E took off his/her shirt and told Resident #1, Do it again mother fucker, I'll fuck you up; -Resident #3 got inbetween CMT E and Resident #1, then Psych Aide C came and took Resident #1 to his/her room. Review of a written statement by Resident #2, provided by the facility, dated 6/8/23, showed the following: -CMT E got in Resident #1's face aggressively; -Resident #2 heard CMT E say Keep your hands to your fucking self. During an interview on 6/21/23 at 2:56 P.M., Resident #6 said the following: -CMT E popped off and mouthed to Resident #1 then Resident #1 punched CMT E; -CMT E told Resident #1, I'm going to fuck you up; -CMT E cussed at the residents and told them they were pieces of shit. During an interview on 6/20/23 at 10:10 A.M., Resident #1 said the following: -He/She and CMT E were horse playing, they were joking around and making fun of each other and then CMT E got mad; -CMT smacked the resident's hand (the resident held up his/her hand with the palm facing towards CMT E). The resident told CMT E he/she did not mean to make him/her mad. CMT E jumped at the resident; -CMT E took off his/her glasses and shirt and said, You might want to run. The resident asked why and CMT E said Because I'm pissed; -The resident was really, really scared of CMT E at that point. The resident did not know what CMT E would do next; -Psych Aide C came and walked the resident to his/her room. During an interview on 6/20/23 at 10:25 A.M., Psych Aide C said the following: -The psych aide came in the building from outside and heard yelling; -The psych aide got to the end of the 200 hall on [NAME] unit and saw Resident #1 at the opposite end of the hallway in the corner. CMT E was yelling and cussing at the resident; -The psych aide got in between CMT E and the resident and assisted the resident to his/her room. During an interview on 6/20/23 at 4:31 P.M., CMT E said the following: -Resident #1 kept messing with stuff on the medication cart; -CMT E was behind on passing medications and Resident #1 kept messing with stuff on the cart. CMT E asked Resident #1 five or six times to stop; -Resident #1 acted like he/she was going to punch CMT E and then he/she did hit CMT E in the nose with a closed fist; -CMT E told Resident #1 Keep your fucking hands off and then CMT E took off his/her shirt. CMT E was mad, but not that mad. During an interview on 6/20/23 at 5:05 P.M., the administrator said the following: -She expected all staff not to cuss at the residents; -Staff should not be horse playing with the residents. Some residents cannot tell the difference between horse play and someone being upset with a resident; -She would consider CMT E's actions to be abuse. MO219670

Based on interview and record review, the facility failed to follow their policy to report, promptly begin an investigation for an allegation of staff to resident abuse and put measures in place to protect residents. Registered Nurse (RN) G told the administrator an altercation had occurred between Licensed Practical Nurse (LPN) C, Certified Nurse Aide (CNA) D and Resident #1 at approximately 12:00 A.M. on 5/21/23. The administrator said RN G did not tell her it was an altercation between staff and Resident #1, so she allowed LPN C and CNA D to finish out their shifts on another unit. The facility did not begin an investigation or report to the state agency until the afternoon of 5/21/22 after the administrator heard rumors at the facility that Resident #1 was involved in an incident with LPN C and CNA D and that CNA D hit the resident. No other staff reported staff abuse to administration. The facility census was 177. The Administrator was notified on 5/22/23 at 5:05 P.M of the Immediate Jeopardy (IJ), which began on 5/21/23. The IJ was removed on 5/22/23 as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy, revised on 1/5/23, showed the following: -The purpose is to ensure immediate reporting of all abuse allegations to the administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -The facility will take steps to prevent mistreatment while the investigation is underway. Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by the administrator; -Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home; -Employees are required immediately to report any occurrences of potential mistreatment including alleged violations, mistreatment, neglect, abuse and injuries of unknown source and misappropriation of resident property they observe, hear about or suspect to a supervisor or the administrator; -If the incident occurs after hours the administrator/designee and Director of Nursing (DON)/designee will be notified at home or by cell phone and informed of any such incident; -Upon learning of the report of abuse or neglect, the administrator shall initiate an incident investigation. 1. Review of Resident #1's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 02/02/2022, showed the following: -The resident had serious mental illnesses; -The resident was easily frustrated and had limited emotional control. He/She needed clear, concise explanations at his/her level of understanding; -The resident's communication and interaction with others was generally pleasant and cooperative, soft spoke, but easily frustrated. The resident lost his/her temper easily. -The resident had intact immediate, short term and long term memory; -The resident's limitations were his/her impulsiveness, lack of self-control, poor coping skills and quick to anger; -The resident needed support and services that provided a structured environment that included, an environment with low stimulation, instructions at the individual's level of understanding and assess and plan for the level of supervision required to prevent harm to self or others. Review of the resident's care plan, dated 8/19/22, showed the following: -The resident had a history of trauma. Maintain a calm, non-threatening manner while working with the resident; -The resident had a history of behavioral challenges (physical aggression, verbal aggression, suicidal ideation and homicidal ideation) that required protective oversight in a secure setting. One-on-one interventions as needed and pharmaceutical interventions as needed. Review of Resident #1's care plan, dated 8/22/22, showed the resident had triggers; being yelled at, not being in control and condescending tones. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/18/23, showed: -The resident was cognitively intact; -The resident had diagnoses that included serious mental illness, anxiety, depression, autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication) and Attention Deficit Hyperactivity Disorder (ADHD - trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active). Review of a facility provided Resident Statement, dated 5/20/23, showed the following: -The statement was transcribed for the resident by an unknown staff member; -The resident said CNA D came to the 100 hall about 11:30 P.M. on 5/20/23 and yelled at Hall Monitor E; -The resident was not sure why CNA D yelled at the hall monitor, but the resident told the CNA he/she was unprofessional; -CNA D said something (unsure what) smart and Resident #1 said he/she did not walk away like he/she should have; -CNA D and LPN C grabbed Resident #1 by the shirt so he/she grabbed their hair just to keep them from doing anything to him/her; -Hall Monitor F held Resident #1 back and CNA D said, Who is going to hold me back from (the resident)?. During an interview on 5/22/23 at 2:26 P.M., Resident #1 said the following: -LPN C came to the resident's room to give his/her roommate medication and it woke him/her up. This made the resident mad and he/she went to the dining room to have a snack; -Everything really started when CNA D came to the 100 hall dining room yelling, cussing and threatening Hall Monitor E; -Resident #1 told CNA D he/she needed to take the conversations somewhere else. Resident #1 got up from the table and headed to his/her room; -CNA D said something (unsure what), and Resident #1 turned around and yelled a curse word at CNA D; -CNA D kept egging it on and mouthed off again to Resident #1 and they started to scream at one another at the nurse's station; -At that point LPN C came and yelled at Resident #1; -Resident #5, Resident #1's roommate, came and said, Let's go to our room. Resident #1 and #5 were headed to their room when CNA D yelled at Resident #1 again; -Hall Monitor F told LPN C and CNA D to leave the hall because they were upsetting the residents; -Hall Monitor F held Resident #1 back while Resident #1 yelled at LPN C and called her a racial slur; -CNA D yelled, Who is going to hold me back from him/her! and lunged at Resident #1 with both fists up; -CNA D grabbed Resident #1's shirt and Resident #1 grabbed LPN C's and CNA D's hair. Finally everyone let go and Hall Monitor F let go of Resident #1; -CNA D went at Resident #1 again and that is when Resident #2 stepped between them; -Resident #1 accidentally hit Resident #2 and CNA D hit Resident #1 on top if his/her head; During an interview on 5/22/23 at 12:07 P.M. and 2:05 P.M., Resident #5 said the following: -He/She was in his/her room at the end of the hall when he/she heard yelling; -He/She walked up the hall towards the nurse's station and Hall Monitor E and LPN C were arguing; -Resident #5 saw Resident #1 (his/her roommate), about half way between their room and the nurse's station and tried to get Resident #1 back to their room; -Resident #5 got Resident #1 almost to their room and there was a lot of yelling and chaos going on; -LPN C, Hall Monitors E and F were at the nurse's station arguing; -Resident #1 walked past the staff at the nurse's station and went to the dining room. Resident #5 got Resident #1 headed back to their room again when someone made a comment and Resident #1 went back towards the staff; -CNA D lunged towards someone and Resident #2 was trying to keep CNA D and LPN C separated and that is when Resident #1 hit Resident #2; -Everyone yelled and cussed. Hall Monitor F said, You are upsetting my residents to CNA D and LPN C; -Resident #5 had never seen staff cuss, hit and act that way to residents. During an interview on 5/22/23 at 11:22 A.M. and 5/24/23 at 3:49 P.M., Resident #2 said the following: -Resident #2 and #3 heard someone yelling and they walked out of their room towards the nurse's station and saw Resident #1. He/She was upset and they tried to calm Resident #1 down; -LPN C mouthed off to Resident #1 and then CNA D jumped in and it escalated super quick; -Residents #2, #3 and #4 and Hall Monitor F got CNA D and LPN C away from Resident #1; -CNA D and LPN C walked towards the 300 hall then turned around and came back around the corner to the nurse's station; -CNA D started running his/her mouth again to Resident #1 and the next thing Resident #2 knew there was a pile up. LPN C and CNA D kept running their mouths and that kept Resident #1 riled up; -CNA D was swinging his/her fists and Resident #1 had a hold of CNA D and LPN C by the hair. CNA D and LPN C hit Resident #1 on top of the head; -CNA D and LPN C walked towards the 300 hall again and came back to the nurse's station. Hall Monitor F grabbed Resident #1 and CNA D went at Resident #1. Resident #2 bumped CNA D out of the way and that is when Resident #2 got hit in the right eye by Resident #1. During an interview on 5/22/23 at 12:19 P.M., Resident #14 said he/she saw CNA D hit Resident #1. During an interview on 5/22/23 at 1:39 P.M., Resident #3 said the following: -On Saturday night (5/20/23), Residents #2 and #4 were in his/her room and they heard loud yelling; -CNA D followed Hall Monitor E down the hallway and cussed him/her out; -Hall Monitor E tried to get out of the situation; -Then the fight started between Resident #1, CNA D and LPN C. Resident #3 saw CNA D with his/her fist up and swinging towards Resident #1 like he/she was trying to hit Resident #1; -Hall Monitor F separated the two staff and Resident #1 but the two staff just kept egging it on; -Hall Monitor F told the two staff to get off the hall but they wouldn't leave. Hall Monitor F told them again to leave and they left, but came back on the hall two to three more times. Resident #3 told the two staff to leave because they made things worse; -CNA D and LPN C cussed at Resident #1 using the F word and every cuss word they could. During an interview on 5/23/23 at 1:20 P.M., Hall Monitor E said the following: -He/She was working with LPN C on the 100 and 200 halls; -LPN C and Hall Monitor E got into a personal argument; -Hall Monitor E walked away from LPN C and stood at the locked double doors between the 300 hall and 200 hall; -CNA D came to the unit and screamed, cussed and threatened Hall Monitor E then left; -About five minutes later CNA D came back to the unit. Hall Monitor E sat in the dining room with Residents #1 and #7 when CNA D came up and yelled and cussed at him/her again. Hall Monitor E told the residents to just ignore CNA D. CNA D told the residents, Don't you fucking ignore me, I am a CNA; -Resident #1 jumped up and mouthed off to CNA D. Hall Monitor E stood up, put his/her hands up and walked off; -As Hall Monitor E walked to the 300 hall he/she saw CNA D go at Resident #1 and LPN C go toward them. During an interview on 6/2/23 at 1:00 P.M., Hall Monitor E said the following: -If there is an incident that would require management be notified, he/she would tell the nurse and they would report to management; -Registered Nurse (RN) G did tell management on the phone about the physical and verbal argument between LPN C, CNA D and Resident #1; -RN G told Hall Monitor E that management was on their way, but they never showed up; -Hall Monitor E reported the incident to the day shift nurse the next morning. During an interview on 5/23/23 at 11:38 A.M., Registered Nurse (RN) G said the following; -On 5/20/23 LPN C called him/her on the Meadowbrook unit and said he/she had a verbal argument with CNA D. RN G told LPN C to call the on call supervisor, Assistant Administrator A. LPN C said an attempt was made and there was no answer; -At 11:38 P.M. a code green was called and RN G went to the [NAME] unit; -Hall Monitor F was telling LPN C and CNA D you shouldn't be doing that to a resident; -RN G was told staff and residents were cussing each other and Resident #1 was trying to attack LPN C and CNA D; -At 11:52 P.M., RN G spoke with the Administrator on the phone and told her there was an altercation between a resident and staff. RN G asked if he/she should collect statements from residents and was told by the administrator to do so; -RN G asked Hall Monitors E and F to gather statements from residents and told LPN C to call and tell Assistant Administrator A what took place. LPN C did not want to call and report the incident, he/she wanted to write a statement. Review of a facility Staff/Witness Statement, dated 5/21/23, for Assistant Administrator A, showed the following: -He/She was on call and received a phone call from the staffing coordinator about a staff to staff verbal altercation; -He/She called RN G and asked him/her to get statements regarding the claims that a staff member was verbally aggressive to another staff member; -RN G called the assistant administrator about 4:30 A.M. to ask if the police should be called because staff had threatened staff; -Assistant Administrator A told the RN they would investigate, get statements and he/she could call the police if he/she wanted; -No one reported alleged abuse to Assistant Administrator A. During an interview on 6/2/23 at 1:12 P.M., Assistant Administrator A said the following: -He would expect staff to report anytime there was an abuse situation; -He thought the situation was a miscommunication between RN G, the administrator and himself/herself and that is why the investigation did not start right away. During interviews on 5/22/23 at 10:05 A.M., 2:38 P.M. and 4:00 P.M., the Administrator said the following: -She got no phone calls about the incident at the time it occurred. The staffing coordinator (who was not working at the time), called her and said he/she got a text from a staff at the facility that two staff members got into an argument at the facility; -She called and spoke with RN G who said staff exchanged words, but never told her that a resident was involved. RN G asked if statements were needed. She told him/her they only have to get statements if residents were involved. Staff started getting statements but did not notify administration; -She also spoke with LPN C right after speaking with RN G and LPN C never said anything about a resident being hit. LPN C told her Resident #1 attacked him/her; -She told LPN C to go work on the Meadowbrook/Parkwood units and CNA D to go back to the Meadowbrook unit; -On 5/21/23 in the afternoon there was a rumor that a nurse hit Resident #1 and that is when she started the investigation and got statements from Resident #1 and other residents. During an interview on 6/1/23 at 2:40 P.M., the administrator said the following: -She would expect staff to notify administration immediately of a staff to resident altercation; -She would have expected staff involved or that witnessed abuse to report to administration immediately; -She would not expect staff to have an argument that involved yelling, cussing and screaming or anything that would have upset the residents; -She would have suspended LPN C and CNA D immediately if she had known they were involved in an altercation with a resident. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO218773 MO218771 MO218757 MO218758

Based on interview and record review, the facility failed to protect one resident (Resident #1), with diagnoses that included serious mental illness, autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication), and attention deficit hyperactivity disorder (ADHD - trouble paying attention, controlling impulsive behaviors, may act without thinking about what the result will be), in a sample of 17 residents, from verbal and physical abuse by staff. On 5/20/23 at approximately 11:30 P.M., Licensed Practical Nurse (LPN) C woke Resident #1 up when he/she administered medication to the resident's roommate. The resident became agitated and went to the dining room. LPN C and Hall Monitor E got into a verbal argument at the nurse's station and then the hall monitor went to the dining room and sat by the resident. Certified Nurse Aide (CNA) D arrived to the unit and also engaged in a verbal argument with Hall Monitor E in front of the resident. The resident became upset and began yelling and cussing. LPN C and CNA D continued to yell and cuss at the resident and follow the resident as he/she walked back towards his/her room, escalating the situation further. CNA D physically abused the resident when he/she struck Resident #1 on top of the head with a closed fist. The facility census was 177. The Administrator was notified on 5/22/23 at 5:05 P.M of the Immediate Jeopardy (IJ), which began on 5/21/23. The IJ was removed on 5/22/23 as confirmed by surveyor onsite verification. Review of the facility Abuse and Neglect Policy, last revised 1/5/23, showed the following: -Mistreatment, neglect, or abuse of residents is prohibited by this facility. This includes physical abuse, sexual abuse, verbal abuse, mental abuse and involuntary seclusion; -Abuse includes physical abuse: purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting and kicking; -Verbal abuse includes using profanity or speaking in a demeaning, non therapeutic, undignified, threatening, or derogatory manner in a resident's presence. Examples include harassing a resident, insulting, ridiculing, yelling at a resident with the intent to intimidate and threatening residents; -The facility does not condone resident abuse by anyone, including employees. 1. Review of Resident #1's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 02/02/2022, showed the following: -The resident had serious mental illnesses; -The resident was easily frustrated and had limited emotional control. He/She needed clear, concise explanations at his/her level of understanding; -The resident's communication and interaction with others was generally pleasant and cooperative, soft spoken, but easily frustrated. The resident lost his/her temper easily; -The resident had intact immediate, short term and long term memory; -The resident's limitations were his/her impulsiveness, lack of self-control, poor coping skills and quick to anger; -The resident needed support and services that provided a structured environment that included an environment with low stimulation, instructions at the individual's level of understanding and assess and plan for the level of supervision required to prevent harm to self or others. Review of the resident's care plan, dated 8/19/22 and 8/22/22, showed the following: -The resident had a history of trauma. Maintain a calm, non-threatening manner while working with the resident; -The resident had a history of behavioral challenges (physical aggression, verbal aggression, suicidal ideation and homicidal ideation) that required protective oversight in a secure setting. One-on-one interventions as needed and pharmaceutical interventions as needed; -The resident had triggers that included being yelled at, not being in control, and condescending tones. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/18/23, showed: -The resident was cognitively intact; -The resident had diagnoses including serious mental illness, anxiety, depression, autistic disorder and attention deficit hyperactivity disorder (ADHD). Review of the resident's progress notes, dated 5/20/23 at 10:04 P.M., charted by Licensed Practical Nurse (LPN) C, showed the following: -The resident sat in the dining room with a hall monitor. The resident got mad and started yelling at staff members that were talking; -The resident yelled at LPN C for waking him/her up and got in the LPN's face and yelled a racial slur and offensive name; -Staff got between the resident and LPN C and the resident began to swing; -LPN C called for help and the resident walked off; -The resident got upset again and yelled a racial slur and threats to kill LPN C; -Another nurse stepped in and and administered as needed medication. Review of a facility provided Resident Statement, dated 5/20/23, showed the following: -The statement was transcribed for the resident by an unknown staff member; -The resident said CNA D came to the 100 hall about 11:30 P.M. on 5/20/23 and yelled at Hall Monitor E; -The resident was not sure why CNA D yelled at the hall monitor, but the resident told the CNA he/she was unprofessional; -CNA D said something (unsure what) smart and Resident #1 said he/she did not walk away like he/she should have; -CNA D and LPN C grabbed Resident #1 by the shirt so he/she grabbed their hair just to keep them from doing anything to him/her; -Hall Monitor F held Resident #1 back and CNA D said, Who is going to hold me back from (the resident)?. During an interview on 5/22/23 at 2:26 P.M., Resident #1 said the following: -LPN C came to the resident's room to give his/her roommate medication and it woke him/her up. This made the resident mad and he/she went to the dining room to have a snack; -Everything really started when CNA D came to the 100 hall dining room yelling, cussing and threatening Hall Monitor E; -Resident #1 told CNA D he/she needed to take the conversation somewhere else. Resident #1 got up from the table and headed to his/her room; -CNA D said something (unsure what), and Resident #1 turned around and yelled a curse word at CNA D; -CNA D kept egging it on and mouthed off again to Resident #1 and they started to scream at one another at the nurse's station; -At that point LPN C came and yelled at Resident #1; -Resident #5, Resident #1's roommate, came and said, Let's go to our room. Resident #1 and #5 were headed to their room when CNA D yelled at Resident #1 again; -Hall Monitor F told LPN C and CNA D to leave the hall because they were upsetting the residents; -Hall Monitor F held Resident #1 back while Resident #1 yelled at LPN C and called him/her a racial slur; -CNA D yelled, Who is going to hold me back from him/her! and lunged at Resident #1 with both fists up; -CNA D grabbed Resident #1's shirt and Resident #1 grabbed LPN C's and CNA D's hair. Finally everyone let go and Hall Monitor F let go of Resident #1; -CNA D went at Resident #1 again and that is when Resident #2 stepped between them; -Resident #1 accidentally hit Resident #2 and CNA D hit Resident #1 on top of his/her head; -Resident #1 said he/she was very tired. The resident had not slept well because all of this was in his/her head. The resident had been very worried about the whole situation. During an interview on 5/22/23 at 12:07 P.M. and 2:05 P.M., Resident #5 said the following: -He/She was in his/her room at the end of the hall when he/she heard yelling; -He/She walked up the hall towards the nurse's station and Hall Monitor E and LPN C were arguing; -Resident #5 saw Resident #1 (his/her roommate), about half way between their room and the nurse's station and tried to get Resident #1 back to their room; -Resident #5 got Resident #1 almost to their room and there was a lot of yelling and chaos going on; -LPN C, Hall Monitors E and F were at the nurse's station arguing; -Resident #1 walked past the staff at the nurse's station and went to the dining room. Resident #5 got Resident #1 headed back to their room again when someone made a comment and Resident #1 went back towards the staff; -CNA D lunged towards someone and Resident #2 was trying to keep CNA D and LPN C separated and that is when Resident #1 hit Resident #2; -Everyone yelled and cussed. Hall Monitor F said, You are upsetting my residents to CNA D and LPN C; -Resident #5 tried to protect Resident #1 from getting in trouble; -Resident #1 never hit a staff member; -All the chaos upset him/her and a lot of residents; -Resident #5 had never seen staff cuss, hit and act that way to residents. During an interview on 5/22/23 at 11:22 A.M. and 5/24/23 at 3:49 P.M., Resident #2 said the following: -Resident #2 and #3 heard someone yelling and they walked out of their room towards the nurse's station and saw Resident #1. He/She was upset and they tried to calm Resident #1 down; -LPN C mouthed off to Resident #1 and then CNA D jumped in and it escalated super quick; -Residents #2, #3 and #4 and Hall Monitor F got CNA D and LPN C away from Resident #1; -CNA D and LPN C walked towards the 300 hall then turned around and came back around the corner to the nurse's station; -CNA D started running his/her mouth again to Resident #1 and the next thing Resident #2 knew there was a pile up. LPN C and CNA D kept running their mouths and that kept Resident #1 riled up; -CNA D was swinging his/her fists and Resident #1 had a hold of CNA D and LPN C by the hair. CNA D and LPN C hit Resident #1 on top of the head; -CNA D and LPN C walked towards the 300 hall again and came back to the nurse's station. Hall Monitor F grabbed Resident #1 and CNA D went at Resident #1. Resident #2 bumped CNA D out of the way and that is when Resident #2 got hit in the right eye by Resident #1; -Resident #1 went to his/her room and CNA D and LPN C left the hall. During an interview on 5/22/23 at 12:19 P.M., Resident #14 said the following: -Resident #14 saw CNA D hit Resident #1. During an interview on 5/22/23 at 1:39 P.M., Resident #3 said the following: -On Saturday night (5/20/23), Residents #2 and #4 were in his/her room and they heard loud yelling; -CNA D followed Hall Monitor E down the hallway and cussed him/her out; -Hall Monitor E tried to get out of the situation; -Then the fight started between Resident #1, CNA D and LPN C. Resident #3 saw CNA D with his/her fist up and swinging towards Resident #1 like he/she was trying to hit Resident #1; -Hall Monitor F separated the two staff and Resident #1, but the two staff just kept egging it on; -Hall Monitor F told the two staff to get off the hall, but they wouldn't leave. Hall Monitor F told them again to leave and they left, but came back on the hall two to three more times. Resident #3 told the two staff to leave because they made things worse; -CNA D and LPN C cussed at Resident #1 using the F word and every cuss word they could. During an interview on 5/22/23 at 3:15 P.M., Resident #4 said the following: -It all started when LPN C woke up Resident #1 when he/she gave medication to Resident #5 (they are roommates); -Resident #4 got hit in the cheek when he/she tried to help separate CNA D, LPN C and Resident #1; -Hall Monitors E and F told CNA D and LPN C to leave the hall more than once. During an interview on 5/23/23 at 1:20 P.M., Hall Monitor E said the following: -He/She was working with LPN C on the 100 and 200 halls; -LPN C and Hall Monitor E got into a personal argument where LPN C called Hall Monitor E names and said get off my clock (meaning to leave/clock out); -Hall Monitor E walked away from LPN C and stood at the locked double doors between the 300 hall and 200 hall; -CNA D came to the unit and screamed, cussed and threatened Hall Monitor E then left; -About five minutes later CNA D came back to the unit. Hall Monitor E sat in the dining room with Residents #1 and #7 when CNA D came up and yelled and cussed at him/her again. Hall Monitor E told the residents to just ignore CNA D. CNA D told the residents, Don't you fucking ignore me, I am a CNA; -Resident #1 jumped up and mouthed off to CNA D. Hall Monitor E stood up, put his/her hands up and walked off; -As Hall Monitor E walked to the 300 hall he/she saw CNA D go at Resident #1 and LPN C go toward them; -Hall Monitor E went to the 300 hall and told Hall Monitor F he/she was done and couldn't do this; -Hall Monitor F left the 300 hall and walked down to the end of the 200 hall. Hall Monitor E watched through the crack in the double doors. Hall Monitor E heard Hall Monitor F ask, What are you doing? -Hall Monitor E heard Resident #2 yell call a code green and Hall Monitor E called the code; -Hall Monitor E heard Hall Monitor F yell, Get off my hall to CNA D and LPN C and they left the unit. During an interview on 5/23/23 at 11:38 A.M., Registered Nurse (RN) G said the following; -On 5/20/23 at 11:38 P.M. a code green was called and RN G went to the [NAME] unit; -Hall Monitor F was telling LPN C and CNA D you shouldn't be doing that to a resident; -RN G was told staff and residents were cussing each other and Resident #1 tried to attack LPN C and CNA D. During an interview on 6/1/23 at 10:07 A.M., CNA H said the following: -CNA D told him/her that Hall Monitor E talked rude to LPN C and asked if he/she would go to the [NAME] unit to see what was going on; -When they got to the unit they went to the dining room where Hall Monitor E and Resident #1 were sitting. CNA D immediately asked Hall Monitor E what is your problem?; -Resident #1 jumped up and started yelling at CNA D. CNA H got between CNA D and Resident #1. CNA D told the resident he/she was not talking to him/her; -Resident #1 got up and left the dining room and headed towards his/her room. CNA D stayed around the nurse's station; -CNA H stayed on the unit for a few more minutes to make sure the resident was ok and then left. During an interview on 6/2/23 at 1:12 P.M. and 6/6/23 at 2:39 P.M. Assistant Administrator A said he/she did not think LPN C and CNA D abused Resident #1. During an interview on 6/1/23 at 2:40 P.M., the administrator said: -She would not expect staff to have an argument that involved yelling, cussing and screaming or anything that would have upset the residents; -She would expect the staff to have a discussion behind closed doors if they do not agree on something, not in front of the residents and definitely no yelling or cussing at one another. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO218773 MO218771 MO218757 MO218758

Based on observation, interview, and record review, the facility failed to ensure four residents (Resident #1, #2, #3 and #5), in a review of 17 sampled residents, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being when three staff members, (Licensed Practical Nurse (LPN) C, Certified Nurse Aide (CNA) D and Hall Monitory E, had a verbal argument with yelling and cussing that escalated and upset Resident #1 to the point it became a physical altercation between LPN C, CNA D and Resident #1. Residents #2, #3 and #5 became involved when they tried to break up the physical altercation. Resident #1 required an as needed medication for agitation. Resident # 2 was upset got caught in the middle of the physical altercation and got hit in the face which resulted in a swollen black eye with pain. Resident #3 said it triggered his/her Post Traumatic Stress Disorder (PTSD - a mental health condition that's triggered by a terrifying event) and Resident #5 was upset about Resident #1 being in the physical altercation and tried to get him/her back to their room. The facility census was 177. Review of the facility's Behavioral Emergency Policy, revised 1/5/23, showed the following: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure the resident is not being coerced, punished, or disciplined for staff convenience; -It is the policy of the facility to provide a safe environment and provide humane care to all residents; -The licensed nursing staff/Team Leader/Resident Care Coordinator (RCC)/nursing administration will assess the resident who is exhibiting behaviors, ensuring the safety of the resident and others is the first priority. A one to one monitoring of the resident will be initiated immediately; -Documentation of the Behavior Emergency in the Administrative Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the situation to permit underlying case identification to the extent possible; -Other supportive methods to control behaviors will be outlined in the plan of care individually for those residents in a behavior emergency crisis; -In the event the resident is unable to be redirected or is requesting an as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a PO (by mouth) or IM (intramuscular, injection given in the muscle) PRN for mood stabilizing medication, the licensed nurse must completed the PRN Intervention Form; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Behavioral Emergency = Code Green. A Code Green can be called to be proactive in ensuring that enough qualified staff are present. The main purpose of calling the Code Green is recognizing the resident has become or has the potential to become a danger to themselves or someone else. Calling a Code Green also ensures that all staff is readily available to utilize approved Crisis Alleviation Lessons and Methods (CALM, techniques to deescalate and manage behaviors safely) hold techniques if necessary. 1. Review of Resident #1's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 02/02/2022, showed the following: -The resident had serious mental illnesses; -The resident was easily frustrated and had limited emotional control. He/She needed clear, concise explanations at his/her level of understanding; -The resident's communication and interaction with others was generally pleasant and cooperative, soft spoken, but easily frustrated. The resident lost his/her temper easily. -The resident had intact immediate, short term and long term memory; -The resident's limitations were his/her impulsiveness, lack of self-control, poor coping skills and quick to anger; -The resident needed support and services that provided a structured environment that included, an environment with low stimulation, instructions at the individual's level of understanding and assess and plan for the level of supervision required to prevent harm to self or others. Review of the resident's care plan, dated 8/19/22, showed the following: -The resident had a history of trauma. Maintain a calm, non-threatening manner while working with the resident; -The resident had a history of behavioral challenges (physical aggression, verbal aggression, suicidal ideation and homicidal ideation) that required protective oversight in a secure setting. One-on-one interventions as needed and pharmaceutical interventions as needed. Review of the resident's care plan, dated 8/22/22, showed the following: -The resident had triggers; being yelled at, not being in control and condescending tones; -No interventions were documented on the care plan for the resident's triggers. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/18/23, showed: -The resident was cognitively intact; -The resident had diagnoses that included serious mental illness, anxiety, depression, autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication), Attention Deficit Hyperactivity Disorder (ADHD - trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active). Review of the resident's medication administration record, dated May 2023, showed the following: -The resident was monitored for behaviors every shift; -The resident had no behaviors in May 2023. Review of the resident's progress notes, dated 5/20/23 at 10:04 P.M., charted by LPN C, showed the following: -The resident sat in the dining room with a hall monitor. The resident got mad and started yelling at staff members talking; -The resident yelled at LPN C for waking him/her up and got in the LPN's face and yelled; -Staff got between the resident and LPN C and the resident began to swing; -LPN C called for help and the resident walked off; -The resident got upset again and yelled a racial slur and threats to kill LPN C; -Another nurse stepped in and an as needed medication was administered. Review of a statement by Resident #1, obtained by the facility, dated 5/20/23, showed the following: -The statement was transcribed for Resident #1 by an unknown staff member; -Resident #1 said CNA D came to the 100 hall about 11:30 P.M. on 5/20/23 and yelled at Hall Monitor E; -Resident #1 was not sure why CNA D yelled at the hall monitor but the resident told the CNA he/she was being unprofessional; -CNA D said something (unsure what) smart and Resident #1 did not walk away like he/she should have; -CNA D and LPN C grabbed Resident #1 by the shirt so he/she grabbed their hair just to keep them from doing anything to him/her; -Hall Monitor F held Resident #1 back and CNA D said who is going to hold me back from him/her?; -Resident #1 called LPN C a racial slur; -Resident #1 said he/she blacked out but remembered bits and pieces. Review of the resident's medication administration record, dated May 2023, showed the resident received an as needed psychotropic medication on 5/21/23 at 7:35 A.M., (day following the incident). Review of the resident's progress notes, dated 5/22/23 at 9:19 A.M., charted by the MDS Coordinator, showed the following: -The MDS Coordinator assessed the resident for periods of blacking out; -The resident said Sometimes I feel myself blacking out, it depended on how aggressive the person is with me. The more aggressive they get with me, I feel the anger rise and I black out. I don't remember anything when I black out but over the next few days I remember things. It comes back to me in bits and pieces; -The MDS Coordinator asked the resident if he/she passed out or if staff was still there when the resident blacked out. The resident said, I don't remember anything. I feel like a separate personality inside me. I have no memory of anything. I don't know what happens, it just happens. During an interview on 5/22/23 at 2:26 P.M., the resident said the following: -LPN C came to the resident's room to give his/her roommate medication and it woke Resident #1 up. This made the resident mad and he/she went to the dining room to have a snack; -Everything really started when CNA D came to the 100 hall dining room. CNA D yelled, cussed and threatened Hall Monitor E; -Resident #1 told CNA D he/she needed to take the conversations somewhere else. Resident #1 got up from the table and headed to his/her room; -CNA D said something (unsure what), and Resident #1 turned around and yelled at CNA D; -CNA D kept egging it on and mouthed off again to Resident #1 and they started to scream at one another at the nurse's station; -At that point LPN C came and yelled at Resident #1; -Resident #5, (Resident #1's roommate), came and said, let's go to our room. Resident #1 and #5 were headed to their room and CNA D yelled at Resident #1 again; -Hall Monitor F told LPN C and CNA D to leave the hall because they were upsetting the residents; -Hall Monitor F held Resident #1 back while Resident #1 yelled at LPN C and called him/her a racial slur; -CNA D yelled, Who is going to hold me back from him/her? and lunged at Resident #1 with both fists up; -CNA D grabbed Resident #1's shirt and Resident #1 grabbed LPN C's and CNA D's hair. Finally everyone let go and Hall Monitor F let go of Resident #1; -CNA D went at Resident #1 again and that is when Resident #2 stepped between them. -Resident #1 accidentally hit Resident #2 and CNA D hit Resident #1 on top if his/her head; -Resident #1 said he/she was very tired. He/She had not slept well because all of this was in his/her head. He/She had been very worried about the whole situation. 2. Review of Resident #2's undated face sheet showed the resident had diagnoses that included; major depressive disorder, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder and nightmare disorder (a pattern of repeated frightening and vivid dreams that affects quality of life). Review of the resident's PASRR, dated 9/2/15, showed the following: -The resident had serious mental illnesses; -The resident had diagnoses that included schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression, bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others), paranoid personality disorder (PPD - a mental health condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious) and a traumatic brain injury at age five; -The resident functioned at a lower social level than his/her age, had poor judgment, insight and impulse control. He/She had poor endurance when presented with stressful situations; -The resident was not a threat to self or others. Review of the resident's care plan, dated 4/4/23, showed the following: -The resident had a behavior problem, verbal and physical, related to depression and schizophrenia; -Ensure protective oversight is provided; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident did not have verbal, physical or other behaviors towards others. Review of the resident's progress notes, dated 5/21/23, showed the following: -At 2:43 A.M., the resident reported to Registered Nurse (RN) G he/she was hit in the right eye and complained of pain. The RN administered as needed pain medication to the resident; -At 7:37 A.M., RN G administered as needed pain medication; -At 9:43 A.M., the resident complained of anxiety to nursing staff; -At 11:56 A.M. nursing staff administered as needed anxiety medication. Review of the resident's progress notes, dated 5/21/23 at 2:43 A.M., showed the following: -The resident reported to RN G he/she was hit in the right eye; -The resident complained of pain; -Vital signs were within normal limits; -No skin tear noted; -As needed pain medications; -Will continue to monitor. Review of the resident's progress notes, dated 5/22/23, showed the following: -At 6:00 A.M.,the resident's right eye was extremely swollen and skin around the eye was red. The resident was unable to open his/her right eye. The resident said it was painful; -At 11:52 A.M. the resident was seen by the nurse practitioner (NP) with encouragement to utilize as needed pain medication and ice packs. The NP ordered x-rays of the resident's right eye. During an interview on 5/22/23 at 11:22 A.M. and 5/24/23 at 3:49 P.M., Resident #2 said the following: -On 5/20/23 Resident #2 and #3 were in their room and heard someone yelling. They walked out of their room towards the nurse's station and saw Resident #1. He/She was upset and they tried to calm Resident #1 down; -LPN C mouthed off to Resident #1 and then CNA D jumped in and it escalated super quick; -Residents #2, #3 and #4 and Hall Monitor F got CNA D and LPN C away from Resident #1; -CNA D and LPN C walked towards the 300 hall then turned around and came back around the corner to the nurse's station; -CNA D started running his/her mouth again to Resident #1 and the next thing Resident #2 knew there was a pile up. LPN C and CNA D kept running their mouths and that kept Resident #1 riled up; -CNA D was swinging his/her fists and Resident #1 had a hold of CNA D and LPN C by the hair. CNA D and LPN C hit Resident #1 on top of the head; -CNA D and LPN C walked towards the 300 hall again and came back to the nurse's station. Hall Monitor F grabbed Resident #1 and CNA D went at Resident #1. Resident #2 bumped CNA D out of the way and that is when Resident #2 got hit in the right eye by Resident #1; -Resident #1 went to his/her room and CNA D and LPN C left the hall. Review of the resident's progress notes, dated 5/23/23, showed the following: -The resident went to the nurse and asked about x-ray results. The nurse informed the resident the x-ray came back good and to continue to utilize over the counter pain medications and ice packs; -The resident was not happy about the results and said more was wrong. He/She went and slammed his/her room door and ripped the privacy curtain. A code green was called and the resident was placed in a five man calm hold; -The resident received an as needed psychotropic (medication that affect a person's mental state) intramuscular injection for threatening behavior, combative aggressive imminent danger to self or others; -The resident was placed on 72 hour observation. 3. Review of Resident #3's PASRR, dated 1/16/23, showed the following: -The resident had diagnoses that included borderline intellectual functioning (a categorization of intelligence wherein a person has below average cognitive ability), anxiety disorder, schizoaffective disorder (is combination of symptoms of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and mood disorder, such as depression; mood disorder and Post Traumatic Stress Disorder; -The resident had a history of anxiety and was suspicious and paranoid. He/She had anxiety a lot of the time; -The resident had hallucinations including command delusions, impaired insight and judgment, and abnormal thought process; -The resident needed a structured environment that included individual personal space, environment with a minimum of visual/auditory distractions, consistent routines and instructions at the individual's understanding; -Crisis intervention: Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance and how staff should work together with the individual during the crisis. Review of the resident's care plan, dated, 2/6/23, showed the resident had impaired coping. Encourage the resident to verbalize feelings regarding fear and/or anxiety. Review of the resident's care plan, dated 4/10/23, showed the resident had a behavior problem with verbal and physical aggression related to schizophrenia, anxiety, mood disorder and PTSD. Ensure protective oversight is provided. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -The resident had mildly impaired cognition; -The resident had no verbal, physical or other behaviors towards others; -The resident had diagnoses that included schizoaffective disorder, medically complex conditions, anxiety disorder and mood disorder (symptoms that are characteristic of a depressive disorder and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning). Review of the resident's care plan, dated 4/20/23, showed the following: -The resident had a history of PTSD and it affects the resident's symptoms and may flare up without any known trigger. Encourage the resident to verbally identify current ineffective coping techniques. Help the resident understand their current behaviors that may be preventing effective healing or treatment; -Administer medications appropriately and monitor for side effects or dependence; -Assess anxiety level, determine severity of condition and course of treatment or therapy needs; -Asses the resident for suicidal or homicidal ideations to ensure safety of the resident and others. During an interview on 5/22/23 at 1:39 P.M., Resident #3 said the following: -On Saturday night (5/20/23), Residents #2 and #4 were in his/her room and we heard loud yelling; -CNA D was following Hall Monitor E down the hallway and cussing him/her out; Hall Monitor E was trying to get out of the situation; -Then a fight started between Resident #1, CNA D and LPN C. Resident #3 saw CNA D with his/her fist up and swinging it towards Resident #1 like he/she was trying to hit Resident #1; -Hall Monitor F separated the two staff and Resident #1 but the two staff just kept egging it on; -Hall Monitor F told the two staff to get off the hall but they wouldn't leave. Hall Monitor F told them again to leave and they left but came back on the hall two to three more times. Resident #3 told the two staff to leave because they were just making things worse; -CNA D and LPN C were cussing at Resident #1 using the F word and every cuss word they could. 4. Review of Resident #5's undated face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included borderline personality disorder (a mental illness that severely impacts a person's ability to manage their emotions), adjustment disorder with depressed mood (feeling hopeless and sadder than would be expected after a stressful event), mood disorder, panic disorder (an overreaction of fear and anxiety to daily life stressors), anxiety disorder and PTSD. Review of the resident's PASRR, dated 4/30/14, showed the following: -The resident had serious mental illnesses; -The resident had poor judgement and did not make good decisions; -The resident appropriately responds to others; -The resident appropriately initiates contact with others; -The resident was withdrawn with little to no interaction with others; Review of the resident's care plan, dated 6/13/22, showed the resident had impaired thought process related to mental illness of personality disorder and depression; Review of the resident's care plan, dated 8/19/22, showed the following: -The resident had a history of behavioral challenges that required protective oversight in a secure setting. -The resident had a history of trauma related to family suicides. The resident had triggers that included physical aggression and agitation. Assist the resident when feeling overwhelmed by providing positive support and talk the resident through his/her feelings. Review of the resident's care plan, dated 10/19/22, showed the resident had impaired coping skills. Encourage resident to verbalize feelings regarding fear and/or anxiety and provide one-on-one visits as needed/requested for ventilation of feelings/concerns and attempt to resolve as able. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident's cognition was in tact; -The resident had no verbal, physical or other behaviors towards others. Review of the resident's care plan, dated 5/8/23, showed the resident had a history of PTSD and it affected the resident's symptoms and may flare up without any known trigger. During an interview on 5/22/23 at 2:05 P.M., the resident said the following: -He/She was in his/her room at the end of the hall when he/she heard yelling; -He/She walked up the hall towards the nurse's station and Hall Monitor E and LPN C were arguing; -Resident #5 saw Resident #1 (also his/her roommate), about half way between their room and the nurse's station and tried to get Resident #1 back to their room; -Resident #5 got Resident #1 almost to their room and there was a lot of yelling and chaos going on; -LPN C, Hall Monitor E and Hall Monitor F were at the nurse's station arguing; -Resident #1 walked past the staff at the nurse's station and went to the dining room. Resident #5 got Resident #1 headed back to their room again when someone made a comment and Resident #1 went back towards the staff; -Everyone was yelling and cussing. Hall Monitor F said you are upsetting my residents to CNA D and LPN C; -Resident #5 was trying to protect Resident #1 from getting in trouble; -All the chaos upset a lot of residents. 5. During an interview on 5/23/23 at 11:38 A.M., Registered Nurse (RN) G said the following; -On 5/20/23 at 11:38 P.M. a code green was called and RN G went to the [NAME] unit; -RN G was told staff and residents were cussing each other and Resident #1 was trying to attack LPN C and CNA D; -Resident #1 was upset and required an as needed medication to calm him/her. Resident #2 said he/she had right eye pain from being hit and Resident #3 said it triggered his/her PTSD. During an interview on 5/23/23 at 1:20 P.M., Hall Monitor E said the following: -He/She was working with LPN C on the 100 and 200 halls; -LPN C and Hall Monitor E got into a personal argument where LPN C called Hall Monitor E names and said get off my fucking clock (meaning to leave/clock out); -Hall Monitor E walked away from LPN C and stood at the locked double doors between the 300 hall and 100 hall; -CNA D came to the unit and started screaming, cussing and threatening Hall Monitor E and then CNA D left; -About five minutes later CNA D came back to the unit. Hall Monitor E was sitting in the dining room with Residents #1 and #7 when CNA D came up and started yelling and cussing at him/her again. Hall Monitor E told the residents to just ignore CNA D. CNA D told the residents don't you fucking ignore me, I am a CNA; -Resident #1 jumped up and mouthed off to CNA D. Hall Monitor E stood up, put his/her hands up and walked off; -LPN C said where the fuck are you going, you need to deal with this; -As Hall Monitor E walked to the 300 hall he/she saw CNA D go at Resident #1 and LPN C go toward them; -Hall Monitor E went to the 300 hall and told Hall Monitor F he/she was done and couldn't do this; -Hall Monitor F left the 300 hall and walked down to the end of the 200 hall; -All of the residents were upset. RN G, Hall Monitor E and Hall Monitor F had to get the residents calmed down and back to their rooms. During an interview on 6/1/23 at 2:40 P.M., the administrator said the following: -She would not expect staff to have an argument that involved yelling, cussing and screaming or anything that would have upset the residents; -She would expect the staff to have a discussion behind closed doors if they do not agree on something, not in front of the residents and definitely no yelling or cussing at one another. -She would expect them to act professionally at all times with the residents. During an interview on 6/7/23 at 2:59 P.M., the DON said the following: -Nurses have access to all resident care plans in full. Hall monitors and CNAs have access to care plans that are specific to the scope of practice such as; behaviors, triggers, coping skills, and limitations; -She would expect staff to refer to the care plans and use them to direct their cares for each resident; -She would expect the staff to keep the overall environment to be as calm as possible; -She would expect staff to put aside any differences they may have and deal with them on their own time. If that isn't possible then they should ask for coverage and go somewhere private to have a discussion; -Staff are provided behavioral training upon on hire and annually; -Staff also have access to phone numbers for the Administrator, Assistant Administrators and DON if they had any questions. During an interview on 6/7/23 at 3:05 P.M., Assistant Administrator B said the following: -Crisis Alleviation Lessons and Methods (CALM) classes are provided to all staff upon hire. The class is a six to eight hour class that expands on the Behavioral Emergency Policy; -The staff are given a CALM book on how to handle any type of behavioral emergency; -Upon hire staff have to sign off on the facility abuse and neglect and behavioral emergency policies; -Assistant Administrator B taught the CALM class to both LPN C and CNA D. MO218773 MO218771 MO218757 MO218758

Based on interview and record review, the facility failed to ensure one resident (Resident #116), in a review of 30 sampled residents, was free from abuse when Resident #103 hit the resident with a closed fist in the head, causing the resident to fall to the floor and sustain injuries including a laceration requiring staples to the back of his/her head. The facility census was 176. Review of the facility policy , Resident Rights, revised 4/29/21, showed the resident has the right to be free from verbal, sexual, mental and physical abuse, corporal punishment and involuntary seclusion. See Abuse and Neglect Policy. Review of the facility's undated Abuse and Neglect policy showed the following: -Physical Abuse - Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. 1. Review of Resident #116's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/7/22, showed the following: -Cognitively intact; -Makes self understood; -Usually understands others; -Independent with walking and required supervision (oversight, encouragement or cueing) with locomotion on and off the unit. Review of the resident's progress notes on 6/28/22 at 11:23 A.M., showed the following: -The resident stood in the hall when peer (Resident #103) approached him/her and struck him/her in his/her mouth with a closed fist. The resident fell to the ground hitting the back of his/her head on the floor; -The resident sustained a cut to the inside of his/her bottom lip and small abrasion approximately one inch long, with unknown depth, to the back of his/her head. Review of the resident's progress notes on 6/28/22 at 11:37 A.M., showed the resident was transported to the hospital via facility transport. Review of the resident's progress notes on 6/28/22 at 2:56 P.M., showed the resident returned to the facility from the hospital around 1:00 P.M., with three staples to the back of the resident's head. 2. Review of Resident #103's care plan, initiated on 11/19/19, showed the following: -PASARR evaluation (a federal assessment utilized to ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) notes: resident had a history of psychiatric symptoms, agitation, delusions, verbally/physically aggressive, threatening behaviors, and impaired insight/judgment. The resident was easily angered -He/She resided on a secured unit and would be provided with intensive monitoring per facility protocol to ensure protective oversight; -He/She had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors included poor impulse control and aggressive at times. Review of the resident's quarterly MDS, dated [DATE], showed the following: -He/She made himself/herself understood and he/she usually understood verbal content (missed some part/intent of messages but comprehended most conversation); -His/Her cognition was intact; -He/She required supervision (oversight, encouragement or cueing) for locomotion on the unit. Review of the resident's progress notes, dated 6/28/22 at 11:16 A.M., showed the resident approached a peer (Resident #116) and struck him/her in the mouth with a closed fist. Review of the resident's progress notes, dated 6/28/22 at 11:53 A.M., showed the following: -The resident said his/her roommate (Resident #116) had been stealing his/her sodas and popcorn, and he/she just realized it; -The resident went to staff and told staff what was going on. Staff assisted the resident with marking his/her initials on the rest of his/her snacks; -The resident was still upset and went to Resident #116 and punched him/her; -Resident #116 fell to the ground. Review of the facility's investigation, dated 6/29/22, showed the following: -On 6/28/22, Resident #103 reported his/her suspicions of Resident #116 stealing items to Psych Aide A; -Psych Aide A went with Resident #103 to his/her room and assisted him/her in writing his/her name/initials on personal snack items; -Psych Aide A reported the incident to Quality of Life Advocate (QLA) F, who then reported the incident to the charge nurse and social services director; -Before any interventions could be put in place, and while Psych Aide A was getting trash bags for another resident on the unit, Resident #103 approached Resident #116 in the hallway and struck him/her in the face, causing Resident #116 to fall backwards and hit his/her head on the floor; -There was some bleeding noted on the inside of Resident #116's mouth and an abrasion on the back of his/her head. The resident was sent to the hospital for assessment; -Resident #103 reported Resident #116 was stealing his/her sodas and popcorn, and he/she became aware of it so he/she struck Resident #116. During interview on 9/6/22 at 12:49 P.M., Psych Aide A said he/she labeled Resident #103's items and then Resident #103 went and hit Resident #115. He/She was in the snack room getting trash bags for another resident, when he/she heard Resident #103 say, I'm tired of people taking my stuff. When Psych Aide A came out of the snack room, he/she saw blood on the floor, and Resident #115 was on the floor. During an interview on 9/6/22 at 7:27 P.M., the administrator said if a resident is upset about an issue involving another resident, she expected staff to try to separate the residents and for staff to utilize one-to-one monitoring as needed. MO203348

Refer to Event ID YST412. Based on observation, interview and record review, the facility failed to ensure four residents (Resident #23, #24, #3, and #18), in a review of 38 sampled residents with mental disorders who lived on secured behavioral units received individualized treatment and services to meet their needs. The residents displayed verbal and physical behaviors directed toward other residents on multiple occasions. Facility staff identified Resident #23 had anger issues and bullied other residents, including Resident #24, and failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being before verbal and physically aggressive behaviors occurred. Resident #24 expressed he/she had enough of Resident #23's bullying behavior and decided to stand up for himself/herself (which resulted in additional physical and verbal altercations between the residents). Residents #3 and #18 were involved in two verbal and physical altercations while Resident #3 was on one-on-one direct monitoring. Staff were pulled from all departments, including dietary and housekeeping to sit with residents who experienced behaviors. These staff were not familiar with the residents' history or behavior in order to deescalate behaviors. The facility census was 176. Review of the facility's [NAME] of Focus Program: An Accountability and Responsibility System. A Comprehensive Care Plan for the Mentally Ill, Second Edition 2019, showed the following: -The vision of the program is focused on the individual resident and what accountability and responsibility he/she can achieve in the least restrictive environment; -The direction of the program is focused on helping the individual resident cope with their illness on a day to day basis. The program and its integrity is uniquely designed to assist the resident and their responsible party in achieving individualized goals with an objective measuring tool that is realistic and easy to comprehend; -The program includes physical, mental, medical, spiritual, social, and activities that are individualized to specifically address the resident's holistic being; -The program focuses on the individual resident achieving their maximum level of functioning by utilizing an individual plan of care designed for the resident to be successful in a therapeutic milieu which offers safety and security; -The program allows the resident and staff to be innovative in developing creative individual plans of care that focus on goals and positive outcomes; -The basic philosophy of the [NAME] of Focus is to empower the resident to maintain or make positive life changes while working towards their interdisciplinary individualized plan of care and encourage the resident to work on their GAP (Goals Action Plan) goals; -Each phase of the program encourages the resident to focus on short and long-term goals. These goals become part of the individualized care plan with the resident, legal guardian, and interdisciplinary staff input. As the transition takes on success, the resident begins to feel encouraged to reach for the next phase; -Each resident will have an individual assessment and plan of care that is tailored to intermingle with the resident's assessment tool and will outline limitations and privileges set forth by the legal guardian; -Each week, the legal guardian will receive a weekly star report which will update them on the resident's progress and goals. This allows the legal guardian to be notified with any plan of care changes and provides the legal guardian with the opportunity to provide input or further direction in the resident's voyage; -In the [NAME] of Focus Program the resident will be known as the Captain. Members of the Interdisciplinary Care Plan Team/designated department heads will be known as Co-Captains and assigned to certain residents. For the first 30 days after admission, the resident's Co-Captain will be the Director of Nursing or the Administrator; -The Co-Captain will meet with their assigned Captains daily to discuss their progress, concerns, and positive/negative behaviors; -The Captain's progress will be documented on the daily Star Report; -The Star Program has five key components that will be monitored daily by the resident's Co-Captain: personal hygiene, homelike environment, social skills, covenant guidelines, and plan of care; -Each day the Co-Captain will utilize the five key components to evaluate the resident's progress for the previous day. The resident can be awarded up to seven stars per week. The stars awarded Friday, Saturday, and Sunday, will be evaluated and rewarded on Mondays; -The Co-Captain will demonstrate and indicate whether the resident was successful in the five key areas by placing a star on the resident's MAP (My Action Plan); -The resident will be disqualified from being awarded a star from the previous day if they demonstrate negative behaviors (this does not include decompensation from psychosis); -If a Captain earns a star, two days will be subtracted from their current phase; -If a Captain does not receive a star due to negative behavior, no days will be subtracted from the current phase; -If the Captain does not receive a star due to not meeting the appropriate number of goals, one day will be subtracted from the current phase; -The Interdisciplinary Team (IDT) and Co-Captains will attend a weekly [NAME] of Focus meeting to review the behavior, care concerns, and resident requests. It is mandatory for all IDT members to attend. The Co-Captain will bring the Daily Star Report to the weekly [NAME] of Focus meetings to discuss changes in the resident's behavior and progress; -The administrator and the Director of Nursing (DON) will be the driver for the weekly [NAME] of Focus meetings. Ultimately, the administrator and DON are responsible for administrating this process. Review of the facility's Behavioral Emergency Policy, dated 2021, showed the following: -The purpose is to provide safe treatment and humane care to the residents in a behavioral crisis, to outline steps to follow to correctly care for the residents in a behavioral crisis and to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -The DON/Assistant Director of Nursing (ADON)/Registered Nurse (RN)/Designee will complete an RN investigation within 24 hours of the behavioral emergency. This may include a PRN (as needed) Intervention Form and notification of state agencies in the event that criteria are met; -In the event the resident is unable to be redirected or is requesting an as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a PO (by mouth) PRN mood stabilizing medication, the licensed nurse must complete the PRN Intervention Form. If the resident receives an IM (intramuscular, injection given in the muscle) PRN for mood stabilization a RN Investigation will be completed including the PRN Intervention Form; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Documentation of the behavior emergency in the RN Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, not identifying or attempting to identify the root causes of the behaviors and not revising the plan of care with measurable goals and interventions to address the care and treatment for a resident with behavioral and/or mental/psychosocial -All Behavioral Emergency Code Green Reviews filled out by the responding staff will become part of the RN investigation to ensure that the behavioral crisis was handled professionally, that it could not have been avoided, and was handled by CALM certified staff using appropriate techniques, following policies of the facility. -Following the Behavioral Emergency Policy is vital and all areas that the Behavioral Emergency Policy addresses must be clearly understood and documented. Review of the facility's undated one-on-one (1:1) staff reminders showed the following: -You must stay with your 1:1 resident; -Your responsibility when assigned a 1:1 is to provide protective oversight for that individual; -Before taking responsibility for a 1:1, understand the purpose behind the 1:1 oversight so that you were fully aware what you should be monitoring for; -Keep in mind that a resident was placed on 1:1 monitoring due to emergent reasons (falls, altercations, self-harm, etc.). 1. Review of Resident #30's Pre-Admission Screening and Resident Review (PASRR) evaluation (a federal assessment utilized to ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care), dated [DATE], showed the following: -He/She had history of abuse and neglect by parents and unstable childhood; -His/Her diagnoses included bipolar affective disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), borderline personality disorder (illness marked by an ongoing pattern of varying moods, self-image, and behaviors often result in impulsive actions and problems in relationships), oppositional defiant disorder (mental disorder characterized by a pattern of angry antagonistic, hostile, negative, irritable, and/or vindictive behaviors), and post-traumatic stress disorder (PTSD, mental disorder that developed after experiencing and or witnessing terrifying or life-threatening event); -The resident presented to the emergency room at 36 weeks pregnant on [DATE]. C-section (surgical removal of baby) was performed, he/she was cleared medically, and admitted to psychiatric unit. The child was taken into protective custody. -He/She had a history of numerous hospitalization s, both inpatient and outpatient; -Recommended the resident received mental health services from a therapist who would work with him/her consistently; -The resident should be evaluated regularly to determine ability to transition to less restrictive place. It was recommended that transition to less restrictive placement be incremental and slow. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed the following: -He/She was admitted to facility on [DATE]; -His/Her cognition was intact; -He/She had no documented psychosis including delusions and/or hallucinations in the previous seven days; -He/She had no behaviors that affected others in the previous seven days. Review of the resident's care plan, initiated on [DATE], showed no interventions to address the resident's mental health, including mental health services from a therapist, and no documentation of interventions to address the resident's mental status and mood following the recent birth of a son/daughter and then loss of the child to protective custody. Review showed no interventions to address the resident evaluation to transition to a less restrictive environment. During an interview on [DATE] at 6:00 P.M., the resident said the following: -Resident #23 bullied him/her and Resident #24; -Resident #23 called him/her a meth head junky who was not going to get his/her kid back, told him/her he/she was ugly because he/she had no teeth, and he/she was going to beat the fuck out of us; -He/She told staff, including administration and his/her guardian about Resident' #23's comments; -Resident #23 would throw a fist and had chest bumped him/her; -He/She was scared of Resident #23, but he/she could not respond because he/she wanted to get out of the facility and be with his/her child. During an interview on [DATE] at 11:30 A.M., the resident's guardian said the resident had called him/her to report Resident #23 was bullying him/her. The resident was trying to be good and not have any behaviors because he/she wanted to get back to his/her child. During an interview on [DATE] at 9:26 A.M., the administrator said the following: -The facility was working with a state agency, the resident's guardian, and court system for the resident to be able to have visitation with his/her child; -The resident had not voiced concerns to staff about being depressed. The resident wanted to be good so he/she could get out to be with his/her child; -Staff encouraged the resident to attend groups, medications were administered as ordered, and counseling had been requested. She was unsure if the resident had started counseling sessions or if it was in process. Counseling service required written consents and paper work to be completed prior to initiation of services. She was unsure if that had been completed yet, but a request had been made; -The resident had to become acclimated with his/her new environment and being in a secured unit. The resident learned how to navigate with new surroundings. 2. Review of Resident #24's PASRR, dated [DATE], showed the following: -The resident was raised by his/her grandparents and lived with them most of his/her life. His/Her grandparent, to whom he/she was very close, died in late [DATE]. He/She still had contact with his/her parent; -His/Her diagnoses included paranoid schizophrenia (presence of one or more prominent delusions or auditory hallucinations in a person who have otherwise relatively normal thinking ability and emotions), schizoaffective disorder, social phobia (fear of social situations), dysthymic disorder (mental and behavioral disorder specifically a disorder primarily of mood consisting of same cognitive and physical problems as depression, but with longer lasting symptoms), borderline personality disorder, adjustment disorder (type of mental disorder resulting from maladaptive or unhealthy responses to stressful of psychologically distressing life events), PTSD, anxiety disorder, delirium (a disturbed state of mind), depressive disorder, and substance-induced mood disorder; -His/Her symptoms included mood instability, severely depressed mood, sad demeanor, suicidal ideations by history, feelings of guilt/hopelessness, very high anxiety level, crying spells, frequent worries and fears, self-isolation, low energy level, impulsivity, impaired insight/judgement, marked physiological reactions to internal/external cues that resemble aspects of traumatic events, efforts to avoid memories of events, negative alterations in mood/cognition, persistent negative emotional state including fear, anxiety, guilt, and reckless/self-destructive behaviors; -He/She required 24 hour/daily supervision and oversight to assure he/she was safe and to assure he/she had consistent access to psychotropic medications and psychiatric follow up; -He/She would benefit from a daily structured routine and behavioral program to improve ability to function, care for self, and cope with stressors related to his/her traumatic history and patterns of self-destructive behaviors; -He/She required ongoing medical and psychiatric follow up to promote maximum stability; -He/She would benefit from staff support during periods of severely depressed mood or anxiety to assist him/her to calm self, choose options for managing his/her emotions that were not harmful in nature; -He/She would benefit from opportunities to engage in structured social and recreational activities with peers near his/her age to decrease social isolation, to promote a sense of acceptance/belonging, and to decrease stress; -He/She would benefit from completing the World of Focus Program to increase understanding of his/her mental health issues, to learn new coping skills, and to develop increased independence in managing his/her emotions and behaviors; -Provisions of a structured environment included provide individual personal space, maintain an environment with a minimum of visual/auditory distractions, assess and plan for level of supervision required to prevent harm to self or others; -He/She required ongoing assessment of mood, thought process, and behaviors to identify signs that may indicate increased risk for self-harm or impulsive behaviors; -He/She would benefit with staff assistance to maintain contact with his/her parent if authorized by his/her legal guardian; -He/She would benefit from nursing facility's assistance to engage in social and recreational activities to decrease sense of isolation and loneliness. Review of resident's care plan, initiated on [DATE], showed the following: -He/She displayed impaired social interaction; -He/She would participate in social situations; -Staff were to encourage the resident to participate in social situations; -Staff were to monitor him/her for presence of negative thoughts and feelings; -He/She displayed impaired coping skills; -He/She would demonstrate effective coping mechanisms and would be free from fear and/or anxiety; -Consult social worker as needed; -Staff were to determine his/her coping methods. (Review showed no documentation of the resident's specific coping methods.); -Monitor effectiveness of resident's immediate support system; -He/She was at risk for injury related to behaviors of aggression towards self, staff, and peers; -He/She would not harm self or others; -Administer medications as prescribed; -Notify provider if he/she posed a potential threat to injure self and or others. Review of the resident's care plan showed no documentation of interventions to address the resident's identified needs on his/her PASRR completed on [DATE]. The care plan did not address providing the resident with a structured routine and behavioral program to improve ability to function, care for self, and cope with stressors related to his/her traumatic history and patterns of self-destructive behaviors; did not address staff providing support during periods of severely depressed mood or anxiety to assist him/her to calm self, and to choose options for managing his/her emotions that were not harmful in nature; did not address the World of Focus Program (as identified as a benefit to the resident on the PASRR) to increase understanding of his/her mental health issues, to learn new coping skills, and to develop increased independence in managing his/her emotions and behaviors; did not address providing the resident with a structured environment including provision of individual personal space, maintaining an environment with a minimum of visual/auditory distractions, assessing and planning for level of supervision required to prevent harm to self or others; did not address staff providing assistance to ensure the resident maintained contact with his/her mother if authorized by his/her legal guardian; and did not address staff providing assistance to the resident to engage in social and recreational activities to decrease sense of isolation and loneliness. Review of the resident's annual MDS, dated [DATE], showed the following: -His/Her cognition was intact; -He/She had no evidence of psychosis (hallucinations or delusions) in the previous seven days; -He/She had not had any behaviors in the previous seven days. During an interview on [DATE] at 9:40 A.M., the resident said the following: -He/She was fearful of Resident #23 because he/she bullied him/her; -Resident #23 would say things like, go have a panic attack and die, and cry baby, cry baby, go suck your thumb; -He/She was afraid of Resident #23 and had not been sticking up for himself/herself, but approximately four months ago, he/she had enough and ran down the hall and hit Resident #23; -He/She was not normally a violent person, but he/she couldn't take it anymore; -Staff just tell him/her that he/she just needs to walk away and do nothing else to stop the bullying; -He/She took PRN medication because it was stressful here, there were a lot of fights, yelling, and drama; -Staff attempt to control it, but could not; -There were no activities for residents. During an interview on [DATE] at 5:50 P.M., Certified Medication Technician (CMT) K said the following: -The resident would cycle and be depressed and think everyone was against him/her; -When Resident #24 was depressed he/she would call the nurse and administer PRN medication for agitation/depression. 3. Review of Resident #23's PASRR, dated [DATE], showed the following: -Diagnoses included bipolar disorder, intermittent explosive disorder (disorder characterized by recurrent episodes of serious assaultive acts or destruction of property due to failure to resist aggressive impulsiveness), oppositional defiant disorder, attention disorder with hyperactivity (neurodevelopmental disorder characterized by inattention or excessive activity and impulsivity which are otherwise not appropriate for a person's age), schizoaffective disorder, mild intellectual disorder and severe intellectual disorder, obstructive hydrocephalus (accumulation of cerebral spinal fluid within the ventricle of the brain that causes obstruction in any area of the brain) history of a total brain injury, and Rett's syndrome (genetic neurological disorder that affects the way the brain develops); -The resident had history of behaviors, impulsivity, emotional/anger outbursts. He/She had poor boundaries, mood swings, manic episodes, periods of agitation, history of property, and aggression; -He/She had recent admission to psych for homicidal ideation toward his/her guardian and made threats to kill him/her out of anger over the phone. He/She had poor insight and judgement. He/She had a progressive decline over the past six months. He/She had ongoing behaviors and problems since childhood; -He/She required 24-hour supervision due to aggressive behaviors, impulsiveness, emotional outbursts, and poor insight and judgement. Review of the resident's admission MDS, dated [DATE], showed the following: -He/She was admitted to the facility on [DATE]; -His/Her cognition was intact; -He/She had verbal behavioral symptoms toward others one to three days of the previous seven-day look back period; -He/She had other behavioral symptoms not directed toward others such as hitting, scratching self, pacing, and verbal/vocal symptoms like screaming or disruptive sounds; -Overall behavioral symptoms interfered with resident's participation in activities and/or social interaction; -He/She significantly intruded on privacy and activities of others; -He/She significantly disrupted care/living environment. Review of the resident's behavioral progress note, dated [DATE] at 8:34 P.M., showed the resident remained two-on-one (two staff to one resident) monitoring for protective oversight. He/She continued to show increased agitation and displayed difficult-to-redirect behaviors and a threatening manner. Charge nurse conferred with facility administration as well as physician and responsible party. Orders received to send the resident to the hospital for psychiatric evaluation. Facility believed the resident required acute physician and medication evaluation Review of the resident's medical record showed no documentation a care plan was developed at this time to address the resident's behaviors. Review of the resident's behavioral progress note, dated [DATE] at 11:05 A.M., showed staff met with the resident concerning behavior earlier while he/she was in the Hangout (a common area in the facility for residents to socialize and participate in activities). The resident reported that a peer called him/her a bitch, and he/she became upset and swung the door open hard. The door hit a peer, but it was not his/her intention to hit the peer. He/She was just upset and angrily swung it open. The resident was educated on appropriate behaviors and Hangout expectations. The resident verbalized understanding. The resident may return to the Hangout on [DATE]. Review of the resident's behavioral progress note, dated [DATE] at 12:21 P.M., showed the resident was yelling in the hall and was destroying peers' art hanging on the doors. He/She was taken to the administrator's office to discuss positive coping skills and goals. He/She was aggressive and threatening to attack peers when he/she had the chance due to his/her feeling that some peers were favored. The physician ordered as needed (PRN) Ativan (antianxiety medication) injection. Once the resident was able to remain calm, he/she requested to FaceTime (video call via an electronic device) his/her family member once or twice a week to help him/her cope. Staff ensured he/she would be able to do so. He/She was sent back to the hall with zero concerns. Review of the resident's care plan, initiated on [DATE], showed the following: -He/She may attend the Hangout; -On [DATE], the resident was suspended from the Hangout. The resident swung the door and struck peer on the knee. The resident verbalized the action was not on purpose, but peer reported the resident intentionally struck him/her. Review showed no documentation interventions were developed to address the resident's behaviors on [DATE]. Further review showed no documentation of the resident's behaviors on [DATE] and interventions to prevent further incidents, including FaceTime with his/her family member to help him/her cope. Review showed no documentation of a plan to ensure the resident would be able to FaceTime his/her family member twice a week as staff told him/her would be done (per the resident's request). Review of the facility's Registered Nurse Investigation (RNI), dated [DATE], showed Resident #24 and Resident #23 purchased a vape (electronic cigarette) by splitting the cost with the agreement that Resident #23 could hit the vape (inhale the electronic cigarette) anytime he/she wanted to. When Resident #24 became irritated with Resident #23 for coming into his/her room and hitting the vape, he/she asked Resident #23 to back off and give him/her a minute. Resident #23 went in the hallway and words were exchanged between the two residents. Staff began to redirect both residents and told them the situation would be handled and administration would be notified. The residents continued exchanging words and a code green (behavioral emergency) was called to the unit. Resident #24 ran down the hall charging at Resident #23. Staff stepped in front of Resident #23 and stopped Resident #24 from striking Resident #23. While staff focused on keeping Resident #24 from striking Resident #23, Resident #23 went behind the staff and swung and struck Resident #24. Resident #24 fell backwards and hit his/her head on the floor. As additional staff arrived, the residents were separated. Resident #24 was sent to the hospital emergency room for evaluation and treatment related to hitting his/her head. Conclusion of the investigation showed Resident #23 became loud and upset when Resident #24 asked him/her to wait to use their mutual vape. Resident #24 gave Resident #23 the vape, but Resident #23 continued to talk loudly about the situation. Due to Resident #24 initiating the altercation, he/she was placed on one-on-one observation until he/she was sent for a psychiatric evaluation per physician's orders. Review of Resident #23's care plan, updated [DATE], showed the resident could not return to the Hangout until he/she met with the administrator due to borrowing/selling/trading, and a physical altercation with his/her peer (Resident #24). Review showed no interventions, other than suspending the resident from the Hangout (revoking a privilege), were implemented to address the resident's behaviors on [DATE]. Review of Resident #24's care plan showed on [DATE], he/she charged after peer and attempted to attack the peer. While staff were attempting to keep the resident from making contact with peer, peer struck resident which caused resident to lose his/her balance, fall backwards, and strike his/her head on the floor. A code green was called and residents were separated. The resident was sent to hospital for medical evaluation and later sent to another facility for psychiatric evaluation. (Review showed no interventions were added to the care plan to address the resident's behavior). Review of Resident #23's progress notes, dated [DATE] at 8:02 P.M., showed the resident provoked peers on his/her hall throughout the day, causing staff to intervene and redirect multiple times. The charge nurse was on the hall and heard the resident cussing at peers and threatening to drag [NAME] and telling peers to get the fuck down the hall. Charge nurse intervened, situation was deescalated, peers were separated, and the administrator was notified of the resident's behaviors. Review of resident's record showed no documentation staff attempted to identify the root cause of the resident's behavior and implement interventions to address the resident's behavior. Review of the resident's care plan, initiated on [DATE], showed the following: -He/She had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. Behaviors included talking loudly, being rude to both staff and peers, and exhibiting verbal and physical aggression toward peers; -Desired outcome was to minimize episodes of inappropriate behaviors that could affect others; -On [DATE], a peer became upset when he/she was talking loudly and rude towards staff and peers. While staff were redirecting and educating the resident on appropriate behaviors and unit rules, peer walked in room behind staff and struck resident (date initiated [DATE]); -On [DATE], the resident broke unit rules by purchasing a vape with a peer (Resident #24) to share. He/She became upset when peer didn't honor their agreement. Peer charged at resident while staff were focused on keeping peer from hitting resident. The resident took the opportunity to strike peer. The residents were separated. (date initiated [DATE]); -Interventions added on [DATE] included to administer and monitor medications as ordered, give positive feedback for good behaviors, and pharmacy consultant would review medications monthly and as needed (PRN). Review showed no further interventions documented to address the resident's verbal and physical aggression toward other residents. -The care plan did not direct staff to suspend or revoke use of the Hangout to modify behaviors. Review of the resident's behavioral progress note, dated [DATE] at 6:05 P.M., showed the resident was yelling and threatening peers. Staff attempted to redirect. The resident went in his/her room for a short amount of time, but opened the door and yelled at the charge nurse, why don't you stop worrying about who I'm threatening and get me some fucking juice! The charge nurse educated the resident on appropriate communication with staff without use of curse words and yelling. The resident threatened to slap the charge nurse and a code green was called. Staff were not able to redirect the resident, and staff administered PRN medication to address. Review of the resident's record showed no documentation staff attempted to identify the root cause of the resident's behavior and implement interventions to address the resident's verbal aggression and threats of physical aggression tow [TRUNCATED]

Refer to Event ID YST412. This deficiency is uncorrected. For previous examples, see Statement of Deficiencies dated 12/22/22. Based on interview and record review, the facility failed to ensure one resident (Resident #55), who had a diagnosis of chronic pain, in a review of 38 sampled residents, was free from neglect when Licensed Practical Nurse (LPN) E fell asleep during his/her shift and failed to administer the resident his/her as needed pain medication. As a result, the resident reported his/her pain was a nine (on a scale of one to ten, with ten being the worst pain possible). The facility also failed to ensure residents were free from abuse when Certified Nurse Assistant (CNA) V yelled, cursed and belittled the residents. The facility census was 176. Review of the facility's policy, Abuse, Neglect, Grievance Procedures, dated 11/28/16, showed the following: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. It is also the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; -Mistreatment, neglect, or abuse of residents is prohibited by this facility; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -The facility abuse prohibition program included screening, training, prevention, identification, reporting/investigating, and protection of the resident. -Class I neglect is defined as failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any resident when that failure presents either imminent danger to the health, safety, or welfare of a resident, or a substantial probability that death or physical injury would result. -Class II neglect is defined as failure of an employee to provide reasonable or necessary services to a resident according to the individualized/habilitation plan, if feasible, or according to acceptable standards of care. This includes action or behavior, which may cause psychological harm to a resident due to intimidating, causing fear or otherwise causing undue anxiety. -Verbal abuse is defined as using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples include harassing a resident, mocking, insulting, ridiculing, yelling at a resident with the intent to intimidate, and threatening residents. 1. Review of Resident #29's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -His/Her diagnoses included paranoid schizophrenia (mental condition characterized by presence of one or more delusions or auditory hallucinations in a person who seemed to have otherwise relatively normal thinking ability and emotions). Review of the resident's admission Minimum Data Set (MDS), federally mandated assessment to be completed by the facility, dated 1/13/22, showed his/her cognition was intact and that he/she had no hallucinations, delusions, and/or behaviors that affected others in the previous seven-day look back period. Review of the resident's care plan, dated 1/19/22, showed the following: -He/She had impaired thought process related to paranoid schizophrenia; -He/She would participate in decision making for daily tasks of life; -He/She would accept judgement from staff as appropriate; -Staff would approach him/her in a warm, positive, and calm manner; -Staff would calmly talk with him/her and always explain what they would be doing before they did it. Review of the facility's Registered Nurse Investigation (RNI), dated 2/4/22, showed on 2/4/22, the resident reported to the charge nurse that CNA V said he/she was not getting him/her (Resident #29) a fucking thing after the resident asked for a snack. The resident reported that CNA V twisted his/her (Resident #29's) words around, and said I didn't ask if you're fucking yourself. Resident #56 witnessed the event and reported that CNA V said, fuck you, no when Resident #29 asked for a snack. Review of the resident's written statement, dated 2/4/22, showed he/she kept asking CNA V for a snack. CNA V told the resident, I'm not getting you a fucking thing. During an interview on 3/8/22 at 2:47 P.M., Resident #56 said he/she witnessed CNA V say fuck you, no when Resident #29 asked for a snack. CNA V treated him/her and other residents horrible. CNA V cursed and called him/her and other residents names like, bitch, whore, and sluts. CNA V used profanity including the F word. CNA V made him/her feel like a little child. During an interview on 3/15/22 at 11:07 A.M., Resident #29 said the following: -He/She didn't like that CNA V was nasty and made the ugly part of him/her come out; -CNA V was very abrupt, hateful, and had a bad attitude. During an interview on 3/8/22 at 10:00 A.M., Resident #18 said CNA V cursed at residents. During an interview on 3/8/22 at 2:40 P.M., Resident #33 said CNA V yelled at him/her. CNA V made him/her feel lousy and incompetent. During an interview on 3/8/22 at 2:47 P.M., Resident #31 said CNA V didn't talk nicely to residents. CNA V made him/her feel like shit when he/she spoke to him/her in this way. During an interview on 3/8/22 at 2:47 P.M., Resident #27 said CNA V would get mad at him/her when he/she asked to get a soda. CNA V used curse words when he/she spoke to him/her (the resident). CNA V made him/her feel like shit when he/she spoke to him/her in this way. During an interview on 3/9/22 at 12:00 P.M., Resident #35 said CNA V was hateful, harsh, very rude, and sarcastic to the level of disrespectful of other's integrity. CNA V made him/her feel like shit for even asking for help. CNA V provoked him/her until the point of anger, then he/she (Resident #35) would be in trouble. Administration did not listen to his/her and others' reports of CNA V's provoking behaviors. During an interview on 3/15/22 at 11:25 A.M., Resident #26 said CNA V was rude and mouthy. He/She was so sick of CNA V's mouth. CNA V would say, I'm sick of this and sigh when residents asked for something. CNA V made residents feel like a piece of crumb off of a shoe. During an interview on 3/8/22 at 10:16 A.M., CNA Y said CNA V was rude to everyone. CNA V yelled and cursed at residents. All staff had complained to management about CNA V cursing, screaming, and belittling residents. He/She witnessed CNA V treat Resident #38 like an animal by telling Resident #38 to sit down and shut up. During an interview on 3/8/22 at 2:54 P.M., Nursing Assistant (NA) X said CNA V was rude and did not care about the residents. He/She witnessed CNA V be rude and treat residents like they didn't amount to anything and curse at residents. During an interview on 3/15/22 at 4:40 P.M., Certified Medication Technician (CMT) P said he/she witnessed CNA V yell, curse, call residents names and belittle residents; During an interview on 3/15/22 at 2:40 P.M., the administrator said the following: -On 3/15/22, he/she received an email from Resident #26's guardian stating Resident #26 reported to his/her guardian that CNA V said, what the fuck do you want, bitch to Resident #26 when Resident #26 knocked on the 900 hall door to obtain the phone; -She considered it abusive if staff called residents names with use of both profanity and non-profanity; -She expected staff to talk to residents with dignity and respect and without the use of profanity. 2. Review of Resident #55's care plan, dated 7/7/21, showed the following: -Chronic back pain, and fourth and fifth contracted finger pain; -Resident will report new onset of pain to staff promptly; -Ongoing assessment of pain status. Monitor for worsening of pain status; -Administer medications as ordered. Monitor effectiveness and side effects. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Presence of constant pain (rated eight); -Pain affected sleep and day to day activities; -Received scheduled and as needed (PRN) pain medications. Review of the resident's physician's orders, dated February 2022, showed the following: -Diagnoses included pain; -MS Contin (morphine sulfate; narcotic pain medication to treat moderate to severe pain) Extended Release (ER) 15 milligrams (mg) every 12 hours for pain; -Morphine sulfate immediate release (IR) 15 mg every six hours PRN for breakthrough pain. During an interview on 3/22/22 at 5:22 A.M., the resident said the following: -He/She had chronic pain and took scheduled and PRN pain medications; -Last week, he/she had to wait four hours for his/her PRN pain medication after he/she had requested it; -He/She requested the pain medication at 3:30 A.M., and did not receive the medication until around 6:45 A.M.; -His/Her pain worsened (as he/she waited for the pain medication) getting up to a hard nine; -Staff told him/her they could not find the charge nurse. During an interview on 3/22/22 at 5:03 A.M., CNA F said the following: -Resident #55 had requested a pain pill around 2:30 A.M.- 3:00 A.M., and staff could not locate LPN E (on 3/17/22); -He/She went to the other unit to find LPN E, and found him/her behind the nurse's desk (asleep); -He/She attempted to wake LPN E, but could not; -He/She went a second time to find LPN E and he/she was in the nursing office (behind the desk) asleep and still would not respond. During an interview on 3/22/22 at 5:03 A.M., CNA G said the following: -He/She sent LPN E a message on 3/17/22 around 3:41 A.M. because the resident needed pain medication; -CNA F went over to the other unit and found LPN E asleep; -He/She went to the other unit after CNA F returned, and observed LPN E sleeping in the office (behind the nurses' station); -He/She attempted to wake LPN E as the resident needed pain medication. He/She tried shaking LPN E and placed cold water rags on him/her but was not able to wake him/her. During an interview on 3/22/22 at 11:36 A.M., LPN E said the following: -He/She worked night shift on 3/16/22 as the charge nurse and was responsible for two units (Meadowbrook and Homestead); -He/She was responsible for Resident #55's care; -He/She was responsible for administering PRN medications after 11:00 P.M.; -He/She was not aware the resident was needing pain medication that night; -He/She was not aware staff had searched for him/her due to the resident needing pain medication; -He/She fell asleep (during his/her shift) but did not know what time; -He/She should not sleep while on duty; -Once a resident requested pain medication, the resident should be assessed and the medication administered immediately. Review of the resident's Medication Administration Record (MAR), dated March 2022, showed the resident received Morphine IR 15 mg on 3/17/22 at 7:27 A.M. During an interview on 3/22/22 at 1:30 P.M., the administrator said the following: -She did not learn that LPN E had fallen asleep (during his/her shift) until around 6:00 A.M. (on 3/17/22) when LPN H sent her a text message. She then learned LPN E had slept from midnight to around 6:00 A.M.; -She would not expect staff to sleep while on duty; -Staff should administer pain medications timely within 10 to 15 minutes. If a resident's pain is greater then five, the nurse would assess the resident; -Although LPN E sleeping and not administering pain medication could be considered neglect, it was not intentional, willful neglect. MO 197906 MO 198598

Based on interview and record review the facility failed to ensure nine residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, and #9), who resided on locked behavioral units, were free from abuse when Hall Monitor A and Floor Maintenance Staff B sold the residents [MEDICATION(S)] (a powerful, highly addictive stimulant that affected the central nervous system. Crystal meth resembled glass fragments and was an illegally altered version of the prescription version.). All nine residents tested positive for [MEDICATION(S)]. Hall Monitor A admitted he/she brought [MEDICATION(S)] into the facility, sold [MEDICATION(S)] to the residents who had history of drug abuse, psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator was notified on 12/10/21 at 3:10 P.M., of the Immediate Jeopardy (IJ) which began on 12/9/21. The IJ was removed on 12/10/21, as confirmed by the surveyor onsite verification. Record review of the facility's policy, Abuse, Neglect, Grievance Procedures, dated 11/28/16, showed the following: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. It is also the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; -Mistreatment, neglect, or abuse of residents is prohibited by this facility; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -The facility abuse prohibition program included screening, training, prevention, identification, reporting/investigating, and protection of the resident. During an interview on 12/10/21 at 8:45 A.M., the administrator said an anonymous resident informed her on 12/9/21 he/she saw Hall Monitor A handing out [MEDICATION(S)] to residents in the hang out (a supervised enclosed open aired area where residents smoked and socialized) ) court yard and saw Resident #3 shoot up a drug in his/her room. Staff immediately started assessing and interviewing residents who lived on the locked men's and women's behavioral units. Residents' guardians and physicians were notified. Permission was obtained for room searches and drug testing. Multiple residents were tested and nine residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, and #9), tested positive for [MEDICATION(S)]. Drug paraphernalia was found, but no drugs of any kind were found. On 12/9/21, a drug dog came to the facility and no additional drugs were located. All nine residents who tested positive for [MEDICATION(S)] were sent to the emergency room for evaluation and had returned to the facility. Multiple residents identified Hall Monitor A as the person who had sold them [MEDICATION(S)] on multiple occasions and delivered the drug to the facility over the previous weeks. Residents showed the administrator multiple text messages between residents and Hall Monitor A. She interviewed Hall Monitor A on 12/9/21 when he/she came to work at 3:30 P.M. Hall Monitor A said he/she brought the [MEDICATION(S)] into the facility in his/her pocket. Hall Monitor A said he/she went out to his/her car on break during the evening shift, obtained the packets of [MEDICATION(S)] from his/her car, and passed the packets of the illegal drug out to the residents in the hang out court yard while the residents were on smoke break. The residents had paid him/her between $10.00 and $50.00 for each delivery. Hall Monitor A said he/she was aware he/she was not supposed to provide any drugs to the residents including methamphetamines. During the investigation the administrator learned Floor Maintenance Staff B also sold residents methamphetamines and delivered the illegal drug to the facility. Both Hall Monitor A and Floor Maintenance Staff B were suspended and would be terminated. Review of the text messages from Resident #2's telephone, acquired, verified, and provided by the facility on 12/10/21 showed the following conversations in part: -At unknown date or time: Hey (first name of Hall Monitor A) this is Resident #1 and Resident #2 told me to text you as he/she made me aware that you are willing to make the same deal with us that you made last night, but you would first have to go pick it up and then drop it back off here. All I need you to do before you do the drop off here is you should stop by a fast food restaurant and buy a cheap meal that doesn't have to be nothing major and that will be your excuse and your way to enter back into the building. If asked any questions or stopped by anyone your excuse will be that you're dropping off a meal to a resident who asked you right before you clocked off; -11/20/21 at 12:12 A.M. response from Hall Monitor A (the response included Hall Monitor A's identification picture and full first name): I get what your are saying and that's quite smart. I don't think I will be able to get back out tonight. Are you gonna be up later I was kinda wanting to talk to you about an idea I was thinking about or you could add me on Facebook yourself and we can talk there; -11/20/21 at 1:46 A.M. response from Resident #1: I truly understand. I'm about to send you a friend request right now; -11/20/21 at 2:40 P.M. from Hall Monitor A: I have been waiting all day to get more; the person was asleep till 11 this morning and then they didn't have enough so they had to go to the city to re-up. But he/she should be back in town before I take my break; -11/20/21 at 7:29 P.M. from Hall Monitor A: I won't be able to make up for anything till tomorrow, the guy sold me some [OBSCENITY] ing rock salt; -11/21/21 at 2:37 P.M. from Resident #2's telephone: Are you coming? At 8:05 P.M.: did you get it?; -11/21/21 at 8:18 P.M. from hall Monitor A: Yeah I got it, but was thinking about how much I owe you it wasn't as much as I said yesterday, but I got you a nice chunk; -Response from Resident #2's telephone was 67; -11/24/21 at 10:25 P.M. from Hall Monitor A: I don't know if I'll be able to bring it in after I get it cause it takes forever for someone to answer the front door to let anyone in. And I have to be home shortly. I can bring it tomorrow when I come in for sure; -11/24/21 at 11:11 P.M.: This is (part of Resident #1's first name). I have a little plan we can try to make it work out, but if it don't then it don't. I am either going to have someone meet you at the front but put it in a cigarette box with 2 cigs left with tissue in it too to take up the rest of the space; -Response from Hall Monitor A: My [NAME] is not any good he/she got arrested. If you want you can send the 20 back; -Response from Resident #2's telephone: No hold on to it; -11/25/21 at 2:01 P.M. from Resident #2's telephone: Could you send that 20 to (part of Resident #1's name) cash app; -12/1/21 at 2:14 A.M. Hall Monitor A's first name missed your video chat. Can you get me a bowl tomorrow before you come to work. Part of (Resident #1's first name) broke his/hers; -12/1/21 at 2:34 A.M. from Hall Monitor A: I don't have the money for it or I would; -Response from Resident #2's telephone: Could you get one on break please; -Response from Hall Monitor A: Yeah as long as you got the $5.00 for it; -Response from Resident #2's telephone: That's nothing; -Response from hall Monitor A: Okay, but can I be honest with you, I'm really not wanting to do this anymore. Review of the text messages from Resident #1's telephone, acquired and verified by the facility, and provided by the facility on 12/10/21 showed the following conversation in part: -11/26/21 at 12:14 P.M. from Resident #1's telephone: I was wondering if you work the next shift from 3:00 P.M. to 4:00 P.M. till 11:00 P.M. and if so I was wondering if you can front me a 20$ play until I get paid on the 3rd of December. I will keep my promised word and pay you back with interest around that time frame. I just want to chill by myself tonight while enjoying the pleasure of relaxing and giving. I promise I will have you money returned to yo no later than the 3rd; -11/26/21 at 1:37 P.M. and at 1:41 P.M. Hall Monitor A's first name missed your call; -11/26/21 at 3:01 P.M. from Hall Monitor A: My bad just woke up like 30 minutes ago. I would if I had it or if I had the money to buy some but I'm broke and spent my last bit of money I could last night to get you all right from last night; -11/26/21 at 3:29 P.M. from Resident #1's telephone: I have a way we could both come out on top. I understand you don't have the money to even spend on yourself to scratch your itch, but I do have a way that I can pay for your fun and my fun as we split the product in 2 ways. I'm still putting moves into play to hustle up enough cash that will make it possible to help me and you out. Do you work today; -Response from Hall Monitor: Yeah I'm at work today; -Response from Resident #1's telephone: Are you already here in the hang out?; -Response from Hall Monitor A: Yes, but I would wait until later to come when no higher ups are here; -11/26/21 at 4:21 P.M. from Resident #1's telephone: Okay sounds like a plan. Just hit me up when they leave. We ain't gotta rush anything. I'm just still trying to make your ends and my ends match and worth the money; -Response from Hall Monitor A: I hear you and will do; -11/26/21 at 4:54 P.M. from Resident #1's telephone; Do you already have it or anything with you cause if so I got 10 in cash for you right now plus my older brother is sending me a 20 later and I'm bringing that to you when he does right before you clock off. I promise to send an extra 15 on the 3rd for interest; -Response from Hall Monitor A: I don't have anything, because I have to pay for it before I get some. I can't keep on doing it after work. But I do get to take a break today after dinner; -Response from Resident #1's telephone: Okay. I understand and I don't wanna add pressure placed upon you by making you feel rushed but what time do you think you will have the dining room cleaned and everybody fed. Because if you have your duties done before or around 5:30 or close to 6:00, I was going to bring the 10 in cash I got for you and send the 20 my brother is sending me to you so I know how late it will be by the time you drop it off; -11/26/21 at 5:59 P.M. from Hall Monitor A: We are all done serving and about done cleaning. But someone is here so it's not a good idea to bring it yourself. Have someone you trust bring it to me; -11/29/21 at 9:57 P.M. from Resident #1's telephone: I just wanna know if there's a possibility of you putting together a 20 for me. Resident #2 and first name of Resident #6 and I will have your money handed back to you Friday on the 3rd when my check hits; -12/3/21 at 11:29 P.M. from Hall Monitor A: I'm here; -12/4/21 at 12:27 A.M. from Resident #1's telephone: [NAME] (first name of Hall Monitor A) I truly appreciate you if I never told you that before but I'm just being honest; -12/4/21 at 4:19 A.M. from Resident #1's telephone: I'm just really looking out for you cause I care and one last thing the leads are talking about doing an environmental through the while facility by next week so be smart; -Response from Hall Monitor A: Thanks for the heads up, But could you possibly explain what all is searched in an environmental? I wouldn't ask but I've never watched them do one; -12/4/21 at 6:04 A.M. from Resident #1's telephone: Me, and (two residents listed by first name) are all talking about how we should prepare for this environmental. They will be probably even search you too at a high rate, but NO they cannot physically search you by patting your body down cause they are not police. But still, keep all your[OBSCENITY]put up in our car if you do bring anything. Just know the environmental will happen at an unexpected time; -Response from Hall Monitor A: Oh you are good. Oh okay, I don't know if you know or not, but in the paperwork during orientation it states that they can search vehicles as well as long as they are on the premises; -12/4/21 at 5:12 P.M. from Resident #1's telephone: To be honest I truly don't even think that's even legal for more than one reason. First off say they search your car without police on the scene which now they have easy access to plant drugs on you, or even steal some of you belongings but point blank period no they can't search your car that's illegal action. They must call police to make that move and even after that the police can't search your car without probable cause; -12/4/21 at 5:46 P.M. from Hall Monitor A: True true I get what your' re saying and see where you're coming from. Yes they would have to have probable cause, but not if they get a warrant; -Sunday at 7:09 P.M. (no date) from Resident #1's telephone: I'll just wait to see if you can get the ten or 50 fronted and by the time you get back I'll have your money waiting right here but it may even be sent to you before you even make it back; -Sunday at 9:07 P.M. (no date) from Resident #1's telephone: I'm sitting here in a friend's room trying to let my phone charge and use his hotspot at the same time. I'm also sitting here thinking about you. I came up with a plan on how to save you and me to end this whole thing for us. Just do me this last favor. (Resident #2's first name) had $10.00 sent to my cash app and I got 50 about to hit my account. When you go to your plug, have him/her put the 10 and the 15 in separate bags that way Resident #2 won't know how much I got and will have his/hers to him/herself so if he/she smokes all his/her[OBSCENITY]up that's on him/her, but he/she can't come to ask me for none. After that as far as you this will be your escape route, because you made me feel your pain which made me feel that this is my last rodeo and this will be your last trip; -Sunday at 11:20 P.M. (no date) from Hall Monitor A: Hey I just got off the phone with my [NAME] and he/she said that he/she is on his/her way to get good and probably won't be back till tomorrow; -Sunday at 11:32 P.M. (no date) from Resident #1's telephone: Just send the 60 back and we will try to make it happen some other day and once again thank you anyways; -Sunday at 11:44 P.M. (no date) from Hall Monitor A: Alright I will send it back once I get home cause my phone is almost dead. Thanks for being one of the only people who understood. And much respect for the help with handling that situation; -Tuesday at 3:36 P.M. (no date) from Hall Monitor A: Hey I know you want me to send your money back but I already got cash so I will have to bring you the cash. My original [NAME] is on his/her way back from out of town; -Tuesday at 3:52 P.M. (no date) from Resident #1's telephone: So basically the money I sent you pulled it off the ATM; -Response form Hall Monitor A: Yes I pulled it out the ATM. I still got the cash it ain't going anywhere unless it's in your hands; -Response from Resident #1's telephone:You work tomorrow?; -Response from Hall Monitor A: Yes I do work tomorrow; -Response from Resident #1's telephone: Well if you don't get it by tonight just let me know weather to expect it to be tomorrow; -Response from Hall Monitor A: Okay I most definitely will; -Wednesday at 2:13 A.M. (no date) from Hall Monitor A: Hey almost forgot to let you know but my [NAME] came through and I will be bringing that to work with me; -Wednesday at 1:07 P.M. (no date) from Resident #1's telephone: Okay thank you, I will see you when you get here; -Wednesday at 2:35 P.M. (no date) from Resident #1's telephone: I got (unknown first name) coming to get that from you. I don't want nobody as far as (Resident #2's first name) in our business; -Wednesday at 2:47 P.M. (no date) from Hall Monitor A: I'm not there yet, I'm running late. But I got you; -Wednesday at 3:19 P.M. (no date) from Resident #1's telephone: Okay just know (unknown first name) will be waiting for you to hand it to him/her; -Wednesday at 10:45 P.M. (no date) from Hall Monitor A: Hey tell (Resident #6's first name) to do what I asked you to do; -Thursday at 12:16 A.M. (no date) from Resident #1's telephone: I meant it when I said I care for you and I'm honestly not wanting to see you get caught up with what's going on in here I don't want to even see you lose your job; -Response from Hall Monitor A: I don't want that either cause I love this job; -Response from Resident #1's telephone: After I smoke all my fumes up I'm placing my glass piece out on the hangout only where I know where it is and nobody else will find. I'm going to keep it there until these environmental and rumors die off; -Response from Hall Monitor A: [NAME] that's a good idea; -Thursday at 3:26 A.M. (no date) from Resident #1's telephone: Unless I settle my second choice of putting it in my window sill which will be in between my window and the screen leading to the outside and that is a place I know the staff nor Feds or the K9's will find out; -Thursday at 8:14 A.M. (no date) from Resident #1's telephone: Just make sure you fall back after tonight and please don't fall back into it. If you even consider it just trust me when I say let a week maybe even a week and a half go by first before you even decide weather you want continue to start doing business with anyone again. But if you do choose to start back up on making fast and easy money keep a smaller circle because truthfully I'm hearing but also already knowing that residents are moving too fast and sloppy as well letting other residents into their business. One resident brought more drama into the game and is truly the reason behind how (Resident #3's first name) found out you are the one supplying. 1. Record review of Resident #1's Preadmission Screening and Resident Review (PASRR) (a screening tool used to ensure appropriate placement of persons known or suspected of having a mental impairment, serious mental illness and/or intellectual disability/developmental disability. The screening assured appropriate placement of persons known or suspected of having a mental impairment and also that the individual needs of mentally impaired persons could be and were being met in the appropriate environment) dated 2/19/21 showed the following: -Psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Intellectual disability with severe [MEDICATION(S)] use and cannabis (marijuana, a psychoactive drug that can be smoked, eaten or vaped and could affect mental health) abuse; -Positive for use of heroin (an illegal drug made from [MEDICATION(S)] poppy plants used by injecting, snorting or smoking), cannabis abuse and [MEDICATION(S)] use; -Became more difficult to manage by family at home. Mental health included substance abuse. Defiant with family, oppositional, aggressive and confrontational; -Based on the resident's drug use, services for rehabilitation/support might be indicated and suggested; -The resident was appointed a legal guardian. Record review of the resident's face sheet showed admitted [DATE] and the resident was under guardianship. Record review of the resident's care plan dated 3/3/21 showed the following: -The resident was at risk for altered mental status and mood swings related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -At risk for harming self or others; -Had impaired social interaction and previously was determined to have consumed alcohol while residing at the facility; -Staff should report any new behaviors to the physician, administer medications as ordered, encourage the resident to discuss any negative thoughts with staff, encourage to participate in social activities and perform Activities of Daily Living (ADLs) daily with help as needed; -Staff should encourage the resident to verbalize cause for aggression, allow personal space, provide clear, simple instructions, reorient to situation and provide verbal feedback to resident regarding behaviors; -Staff should monitor for presence of negative thoughts and feelings, monitor interactions with others, monitor level of eye contact and speech and provide positive enforcement when the resident participated in activities. Record review showed no documentation the resident's care plan included the resident's history of severe [MEDICATION(S)] use and cannabis abuse or include his/her positive for use of heroin and did not provide interventions regarding use of these drugs. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in Activities of Daily Living (ADLs). Record review of the resident's progress note dated 12/9/21 at 8:56 P.M. showed staff documented following an allegation of the resident possibly using illegal drugs in the facility, the resident was brought to the office and interviewed. The resident's drug test came back positive for methamphetamines. Record review of the resident's urine drug screening results obtained and verified by the facility and provided on 12/10/21 showed positive for methamphetamines. During an interview on 12/10/21 at 10:27 P.M., the resident said he/she used [MEDICATION(S)] at 9:00 P.M. on 12/9/21 just before the drug testing started. He/She used [MEDICATION(S)] before coming to the facility in his/her earlier life. [MEDICATION(S)] was hard to get off of. The [MEDICATION(S)] came to the facility in busted up rock form and was provided by a staff member. He/She did not know who brought the drug to the facility. During interview on 12/10/21 at 8:45 P.M. the administrator said a bowl used to smoke [MEDICATION(S)] was found in the resident's room during the room search on 12/9/21. 2. Record review of Resident #2's PASRR dated 1/19/15 showed the following: -Psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -History of hearing voices, preoccupation with demons and visual hallucinations. Had used PCP (a hallucinogenic illegal drug with street names of angel dust, super grass and rocket fuel), cannabis, alcohol and cocaine (an illegal street drug); -The resident was appointed a legal guardian. Record review of the resident's face sheet showed the following: -admitted [DATE]; -Additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident was under guardianship. Record review of the resident's care plan updated 11/24/21 showed the following: -The resident had pain; -Staff should observe and report changes in usual routine sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. Staff should report change in usual activity attendance patterns or refusal to attend activities related to pain or discomfort. Record review showed no documentation the resident's care plan included the resident's history of used PCP, cannabis, alcohol and cocaine and did not provide interventions regarding use of these drugs. Record review of the resident's admission MDS dated [DATE] showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in ADLs except required supervision with eating. Record review of the resident's progress note dated 12/9/21 at 2:10 P.M. showed staff documented following an allegation of the resident possibly using illegal drugs in the facility, the resident was brought to the office and interviewed. At 2:19 P.M. staff documented the resident's drug test was positive for [MEDICATION(S)]. Record review of the resident's urine drug screening results obtained and verified by the facility and provided on 12/10/21 showed positive for methamphetamines. Record review of the resident's facility acquired written statement, dated 12/9/21 showed the resident had not gotten any illegal drugs since living at the facility. He/She allowed a few different residents to use his/her phone and they contacted different people. His/Her drug of choice was cocaine and not [MEDICATION(S)]. He/She tried a bowl (term for a device used to inhale the vapors from [MEDICATION(S)] or other illegal drugs such as marijuana) the previous night. He/She did not know what it was. During an interview on 12/10/21 at 11:10 A.M., the resident said he/she saw transactions between Floor Maintenance Staff B and a resident (unwilling to disclose the resident's name) over the last few days. Floor Maintenance Staff B brought [MEDICATION(S)] to the facility in a cigarette wrapper. Residents put the [MEDICATION(S)] in a bowl and smoked it. He/She smoked whatever was in the bowl. 3. Record review of Resident #5's PASRR dated 2/22/18 showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -By the age of 18 was in a residential care facility three different times. diagnosed with extensive substance abuse to include alcohol, cannabis, amphetamines and opioids; -History of hallucinations, agitation, disorganization, paranoid and delusional, aggressive when unsupervised; -Assigned a public administrator as guardian. Record review of the resident's face sheet showed the following: -Readmitted [DATE]; -The resident was under guardianship; -Additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in ADLs. Record review of the resident's care plan dated 9/28/21 showed the following: -The resident had behaviors related to mental illness and could create disturbances that affected other. The behaviors included verbal/physical aggression with provocation and suspiciousness. At risk for alteration in mood related to diagnosis; The resident had several hospitalization s beginning in his/her early teens; -The resident was involved in many fights, extensive substance abuse, hallucinations, delusional, aggressive when unsupervised, and depression. -Staff should assist resident in addressing root cause of change in behavior or mood, give positive feedback for good behavior, encourage the resident to go to a more private area to voice concerns and feelings to assist in decreasing episodes of disturbing others; -Staff should anticipate and meet the resident's needs, assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately. Provide opportunity for positive interaction, attention, and praise any indication of progress and improvement in behavior; -If reasonable discuss the resident's behavior. Explain/reinforce why behavior was inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors by offering tasks which diverted attention. Provide a program of activities that was of interest and accommodated the residents status. Record review of the resident's progress note dated 12/9/21 at 8:09 P.M. showed staff documented following an allegation of the resident possibly using illegal drugs in the facility, the resident was brought to the office and interviewed. At 8:43 P.M. staff documented the resident's drug test was positive for [MEDICATION(S)]. Review of the resident's urine drug screening results obtained and verified by the facility and provided on 12/10/21 showed positive for methamphetamines. During an interview on 12/10/21 at 10:10 A.M. the resident said his/her urine test was positive for [MEDICATION(S)] last night. He/She smoked or sniffed the drug and the last time he/she used the drug was months ago. He/She did not know why his/her urine tested positive for [MEDICATION(S)] after more than a month. 4. Record review of Resident #3's PASRR dated 7/19/14 showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -History of impulsiveness and easily frustrated, had confusion and agitation, altered mental status; -History of drug abuse but resident denied use, history of prescription drug abuse, he/she took more than prescribed; -The resident was appointed a legal guardian. Record review of the resident's face sheet showed the following: -admitted [DATE]; -The resident was under guardianship; -Additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in ADLs except required supervision with personal hygiene. Record review of the resident's care plan updated 9/24/21 showed the following: -The resident had manifestations of behaviors related to mental illness and could create disturbances that affected others. The behaviors included verbal/physical aggression; -Staff should assist resident in addressing root cause of change in behavior or mood, give positive feedback for good behavior, encourage the resident to go to a more private area to voice concerns and feelings and to assist in decreasing episodes of disturbing others. Record review showed no documentation the resident's care plan included the resident's history of drug abuse, history of prescription drug abuse, he/she took more than prescribed and did not provide interventions regarding use of these drugs. Record review of the resident's progress note dated 12/9/21 at 5:52 P.M. showed staff documented the resident possible using illegal drugs in the facility. The resident was brought to the office and interviewed. At 6:53 P.M. staff documented the resident's drug test was positive for [MEDICATION(S)]. Record review of the resident's urine drug screening results obtained and verified by the facility and provided on 12/10/21 showed positive for methamphetamines. Review of the facility acquired resident written statement dated 12/19/21 showed Hall Monitor A and Floor Maintenance Staff B were both bringing drugs to several residents for a couple of months. The last time he/she used was yesterday (12/9/21). During an interview on 12/10/21 at 12:00 P.M., the resident said he/she took [MEDICATION(S)] yesterday (12/9/21). He/She smoked and snorted the drug. He/She did not shoot up the drug. Hall Monitor A offered him/her [MEDICATION(S)] while in the hang out and he/she took the drug from Hall Monitor A. The resident had a lighter and during the room search, drug paraphernalia was found in his/her room. He/She had been on [MEDICATION(S)] prior to living at the facility. 5. Record review of Resident #6's PASRR dated 4/30/14 showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Long history of alcohol abuse, auditory hallucinations (hearing voices) and paranoia; -The resident was appointed a legal guardian. Record review of the resident's face showed the following: -admitted [DATE];

Based on observation, interview and record review, the facility failed to ensure four residents (Resident #23, #24, #3, and #18), in a review of 38 sampled residents with mental disorders who lived on secured behavioral units received individualized treatment and services to meet their needs. The residents displayed verbal and physical behaviors directed toward other residents on multiple occasions. Facility staff identified Resident #23 had anger issues and bullied other residents, including Resident #24, and failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being before verbal and physically aggressive behaviors occurred. Resident #24 expressed he/she had enough of Resident #23's bullying behavior and decided to stand up for himself/herself (which resulted in additional physical and verbal altercations between the residents). Residents #3 and #18 were involved in two verbal and physical altercations while Resident #3 was on one-on-one direct monitoring. Staff were pulled from all departments, including dietary and housekeeping to sit with residents who experienced behaviors. These staff were not familiar with the residents' history or behavior in order to deescalate behaviors. The facility census was 176. Review of the facility's [NAME] of Focus Program: An Accountability and Responsibility System. A Comprehensive Care Plan for the Mentally Ill, Second Edition 2019, showed the following: -The vision of the program is focused on the individual resident and what accountability and responsibility he/she can achieve in the least restrictive environment; -The direction of the program is focused on helping the individual resident cope with their illness on a day to day basis. The program and its integrity is uniquely designed to assist the resident and their responsible party in achieving individualized goals with an objective measuring tool that is realistic and easy to comprehend; -The program includes physical, mental, medical, spiritual, social, and activities that are individualized to specifically address the resident's holistic being; -The program focuses on the individual resident achieving their maximum level of functioning by utilizing an individual plan of care designed for the resident to be successful in a therapeutic milieu which offers safety and security; -The program allows the resident and staff to be innovative in developing creative individual plans of care that focus on goals and positive outcomes; -The basic philosophy of the [NAME] of Focus is to empower the resident to maintain or make positive life changes while working towards their interdisciplinary individualized plan of care and encourage the resident to work on their GAP (Goals Action Plan) goals; -Each phase of the program encourages the resident to focus on short and long-term goals. These goals become part of the individualized care plan with the resident, legal guardian, and interdisciplinary staff input. As the transition takes on success, the resident begins to feel encouraged to reach for the next phase; -Each resident will have an individual assessment and plan of care that is tailored to intermingle with the resident's assessment tool and will outline limitations and privileges set forth by the legal guardian; -Each week, the legal guardian will receive a weekly star report which will update them on the resident's progress and goals. This allows the legal guardian to be notified with any plan of care changes and provides the legal guardian with the opportunity to provide input or further direction in the resident's voyage; -In the [NAME] of Focus Program the resident will be known as the Captain. Members of the Interdisciplinary Care Plan Team/designated department heads will be known as Co-Captains and assigned to certain residents. For the first 30 days after admission, the resident's Co-Captain will be the Director of Nursing or the Administrator; -The Co-Captain will meet with their assigned Captains daily to discuss their progress, concerns, and positive/negative behaviors; -The Captain's progress will be documented on the daily Star Report; -The Star Program has five key components that will be monitored daily by the resident's Co-Captain: personal hygiene, homelike environment, social skills, covenant guidelines, and plan of care; -Each day the Co-Captain will utilize the five key components to evaluate the resident's progress for the previous day. The resident can be awarded up to seven stars per week. The stars awarded Friday, Saturday, and Sunday, will be evaluated and rewarded on Mondays; -The Co-Captain will demonstrate and indicate whether the resident was successful in the five key areas by placing a star on the resident's MAP (My Action Plan); -The resident will be disqualified from being awarded a star from the previous day if they demonstrate negative behaviors (this does not include decompensation from [CONDITION(S)]); -If a Captain earns a star, two days will be subtracted from their current phase; -If a Captain does not receive a star due to negative behavior, no days will be subtracted from the current phase; -If the Captain does not receive a star due to not meeting the appropriate number of goals, one day will be subtracted from the current phase; -The Interdisciplinary Team (IDT) and Co-Captains will attend a weekly [NAME] of Focus meeting to review the behavior, care concerns, and resident requests. It is mandatory for all IDT members to attend. The Co-Captain will bring the Daily Star Report to the weekly [NAME] of Focus meetings to discuss changes in the resident's behavior and progress; -The administrator and the Director of Nursing (DON) will be the driver for the weekly [NAME] of Focus meetings. Ultimately, the administrator and DON are responsible for administrating this process. Review of the facility's Behavioral Emergency Policy, dated 2021, showed the following: -The purpose is to provide safe treatment and humane care to the residents in a behavioral crisis, to outline steps to follow to correctly care for the residents in a behavioral crisis and to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -The DON/Assistant Director of Nursing (ADON)/Registered Nurse (RN)/Designee will complete an RN investigation within 24 hours of the behavioral emergency. This may include a PRN (as needed) Intervention Form and notification of state agencies in the event that criteria are met; -In the event the resident is unable to be redirected or is requesting an as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident receives an IM (intramuscular, injection given in the muscle) PRN for mood stabilization a RN Investigation will be completed including the PRN Intervention Form; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Documentation of the behavior emergency in the RN Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, not identifying or attempting to identify the root causes of the behaviors and not revising the plan of care with measurable goals and interventions to address the care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -All Behavioral Emergency Code Green Reviews filled out by the responding staff will become part of the RN investigation to ensure that the behavioral crisis was handled professionally, that it could not have been avoided, and was handled by CALM certified staff using appropriate techniques, following policies of the facility. -Following the Behavioral Emergency Policy is vital and all areas that the Behavioral Emergency Policy addresses must be clearly understood and documented. Review of the facility's undated one-on-one (1:1) staff reminders showed the following: -You must stay with your 1:1 resident; -Your responsibility when assigned a 1:1 is to provide protective oversight for that individual; -Before taking responsibility for a 1:1, understand the purpose behind the 1:1 oversight so that you were fully aware what you should be monitoring for; -Keep in mind that a resident was placed on 1:1 monitoring due to emergent reasons (falls, altercations, self-harm, etc.). 1. Review of Resident #30's Pre-Admission Screening and Resident Review (PASRR) evaluation (a federal assessment utilized to ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care), dated [DATE], showed the following: -He/She had history of abuse and neglect by parents and unstable childhood; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident presented to the emergency room at 36 weeks pregnant on [DATE]. C-section (surgical removal of baby) was performed, he/she was cleared medically, and admitted to psychiatric unit. The child was taken into protective custody. -He/She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -Recommended the resident received mental health services from a therapist who would work with him/her consistently; -The resident should be evaluated regularly to determine ability to transition to less restrictive place. It was recommended that transition to less restrictive placement be incremental and slow. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed the following: -He/She was admitted to facility on [DATE]; -His/Her cognition was intact; -He/She had no documented [CONDITION(S)] including delusions and/or hallucinations in the previous seven days; -He/She had no behaviors that affected others in the previous seven days. Review of the resident's care plan, initiated on [DATE], showed no interventions to address the resident's mental health, including mental health services from a therapist, and no documentation of interventions to address the resident's mental status and mood following the recent birth of a son/daughter and then loss of the child to protective custody. Review showed no interventions to address the resident evaluation to transition to a less restrictive environment. During an interview on [DATE] at 6:00 P.M., the resident said the following: -Resident #23 bullied him/her and Resident #24; -Resident #23 called him/her a meth head junky who was not going to get his/her kid back, told him/her he/she was ugly because he/she had no teeth, and he/she was going to beat the [OBSCENITY] out of us; -He/She told staff, including administration and his/her guardian about Resident' #23's comments; -Resident #23 would throw a fist and had chest bumped him/her; -He/She was scared of Resident #23, but he/she could not respond because he/she wanted to get out of the facility and be with his/her child. During an interview on [DATE] at 11:30 A.M., the resident's guardian said the resident had called him/her to report Resident #23 was bullying him/her. The resident was trying to be good and not have any behaviors because he/she wanted to get back to his/her child. During an interview on [DATE] at 9:26 A.M., the administrator said the following: -The facility was working with a state agency, the resident's guardian, and court system for the resident to be able to have visitation with his/her child; -The resident had not voiced concerns to staff about being depressed. The resident wanted to be good so he/she could get out to be with his/her child; -Staff encouraged the resident to attend groups, medications were administered as ordered, and counseling had been requested. She was unsure if the resident had started counseling sessions or if it was in process. Counseling service required written consents and paper work to be completed prior to initiation of services. She was unsure if that had been completed yet, but a request had been made; -The resident had to become acclimated with his/her new environment and being in a secured unit. The resident learned how to navigate with new surroundings. 2. Review of Resident #24's PASRR, dated [DATE], showed the following: -The resident was raised by his/her grandparents and lived with them most of his/her life. His/Her grandparent, to whom he/she was very close, died in late [DATE]. He/She still had contact with his/her parent; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -His/Her symptoms included mood instability, severely depressed mood, sad demeanor, [CONDITION(S)] by history, feelings of guilt/hopelessness, very high anxiety level, crying spells, frequent worries and fears, self-isolation, low energy level, impulsivity, impaired insight/judgement, marked physiological reactions to internal/external cues that resemble aspects of traumatic events, efforts to avoid memories of events, negative alterations in mood/cognition, persistent negative emotional state including fear, anxiety, guilt, and reckless/self-destructive behaviors; -He/She required 24 hour/daily supervision and oversight to assure he/she was safe and to assure he/she had consistent access to [CONDITION(S)] medications and psychiatric follow up; -He/She would benefit from a daily structured routine and behavioral program to improve ability to function, care for self, and cope with stressors related to his/her traumatic history and patterns of self-destructive behaviors; -He/She required ongoing medical and psychiatric follow up to promote maximum stability; -He/She would benefit from staff support during periods of severely depressed mood or anxiety to assist him/her to calm self, choose options for managing his/her emotions that were not harmful in nature; -He/She would benefit from opportunities to engage in structured social and recreational activities with peers near his/her age to decrease social isolation, to promote a sense of acceptance/belonging, and to decrease stress; -He/She would benefit from completing the World of Focus Program to increase understanding of his/her mental health issues, to learn new coping skills, and to develop increased independence in managing his/her emotions and behaviors; -Provisions of a structured environment included provide individual personal space, maintain an environment with a minimum of visual/auditory distractions, assess and plan for level of supervision required to prevent harm to self or others; -He/She required ongoing assessment of mood, thought process, and behaviors to identify signs that may indicate increased risk for self-harm or impulsive behaviors; -He/She would benefit with staff assistance to maintain contact with his/her parent if authorized by his/her legal guardian; -He/She would benefit from nursing facility's assistance to engage in social and recreational activities to decrease sense of isolation and loneliness. Review of resident's care plan, initiated on [DATE], showed the following: -He/She displayed impaired social interaction; -He/She would participate in social situations; -Staff were to encourage the resident to participate in social situations; -Staff were to monitor him/her for presence of negative thoughts and feelings; -He/She displayed impaired coping skills; -He/She would demonstrate effective coping mechanisms and would be free from fear and/or anxiety; -Consult social worker as needed; -Staff were to determine his/her coping methods. (Review showed no documentation of the resident's specific coping methods.); -Monitor effectiveness of resident's immediate support system; -He/She was at risk for injury related to behaviors of aggression towards self, staff, and peers; -He/She would not harm self or others; -Administer medications as prescribed; -Notify provider if he/she posed a potential threat to injure self and or others. Review of the resident's care plan showed no documentation of interventions to address the resident's identified needs on his/her PASRR completed on [DATE]. The care plan did not address providing the resident with a structured routine and behavioral program to improve ability to function, care for self, and cope with stressors related to his/her traumatic history and patterns of self-destructive behaviors; did not address staff providing support during periods of severely depressed mood or anxiety to assist him/her to calm self, and to choose options for managing his/her emotions that were not harmful in nature; did not address the World of Focus Program (as identified as a benefit to the resident on the PASRR) to increase understanding of his/her mental health issues, to learn new coping skills, and to develop increased independence in managing his/her emotions and behaviors; did not address providing the resident with a structured environment including provision of individual personal space, maintaining an environment with a minimum of visual/auditory distractions, assessing and planning for level of supervision required to prevent harm to self or others; did not address staff providing assistance to ensure the resident maintained contact with his/her mother if authorized by his/her legal guardian; and did not address staff providing assistance to the resident to engage in social and recreational activities to decrease sense of isolation and loneliness. Review of the resident's annual MDS, dated [DATE], showed the following: -His/Her cognition was intact; -He/She had no evidence of [CONDITION(S)] (hallucinations or delusions) in the previous seven days; -He/She had not had any behaviors in the previous seven days. During an interview on [DATE] at 9:40 A.M., the resident said the following: -He/She was fearful of Resident #23 because he/she bullied him/her; -Resident #23 would say things like, go have a panic attack and die, and cry baby, cry baby, go suck your thumb; -He/She was afraid of Resident #23 and had not been sticking up for himself/herself, but approximately four months ago, he/she had enough and ran down the hall and hit Resident #23; -He/She was not normally a violent person, but he/she couldn't take it anymore; -Staff just tell him/her that he/she just needs to walk away and do nothing else to stop the bullying; -He/She took PRN medication because it was stressful here, there were a lot of fights, yelling, and drama; -Staff attempt to control it, but could not; -There were no activities for residents. During an interview on [DATE] at 5:50 P.M., Certified Medication Technician (CMT) K said the following: -The resident would cycle and be depressed and think everyone was against him/her; -When Resident #24 was depressed he/she would call the nurse and administer PRN medication for agitation/depression. 3. Review of Resident #23's PASRR, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident had history of behaviors, impulsivity, emotional/anger outbursts. He/She had poor boundaries, mood swings, manic episodes, periods of agitation, history of property, and aggression; -He/She had recent admission to psych for homicidal ideation toward his/her guardian and made threats to kill him/her out of anger over the phone. He/She had poor insight and judgement. He/She had a progressive decline over the past six months. He/She had ongoing behaviors and problems since childhood; -He/She required 24-hour supervision due to aggressive behaviors, impulsiveness, emotional outbursts, and poor insight and judgement. Review of the resident's admission MDS, dated [DATE], showed the following: -He/She was admitted to the facility on [DATE]; -His/Her cognition was intact; -He/She had verbal behavioral symptoms toward others one to three days of the previous seven-day look back period; -He/She had other behavioral symptoms not directed toward others such as hitting, scratching self, pacing, and verbal/vocal symptoms like screaming or disruptive sounds; -Overall behavioral symptoms interfered with resident's participation in activities and/or social interaction; -He/She significantly intruded on privacy and activities of others; -He/She significantly disrupted care/living environment. Review of the resident's behavioral progress note, dated [DATE] at 8:34 P.M., showed the resident remained two-on-one (two staff to one resident) monitoring for protective oversight. He/She continued to show increased agitation and displayed difficult-to-redirect behaviors and a threatening manner. Charge nurse conferred with facility administration as well as physician and responsible party. Orders received to send the resident to the hospital for psychiatric evaluation. Facility believed the resident required acute physician and medication evaluation Review of the resident's medical record showed no documentation a care plan was developed at this time to address the resident's behaviors. Review of the resident's behavioral progress note, dated [DATE] at 11:05 A.M., showed staff met with the resident concerning behavior earlier while he/she was in the Hangout (a common area in the facility for residents to socialize and participate in activities). The resident reported that a peer called him/her a [OBSCENITY] , and he/she became upset and swung the door open hard. The door hit a peer, but it was not his/her intention to hit the peer. He/She was just upset and angrily swung it open. The resident was educated on appropriate behaviors and Hangout expectations. The resident verbalized understanding. The resident may return to the Hangout on [DATE]. Review of the resident's behavioral progress note, dated [DATE] at 12:21 P.M., showed the resident was yelling in the hall and was destroying peers' art hanging on the doors. He/She was taken to the administrator's office to discuss positive coping skills and goals. He/She was aggressive and threatening to attack peers when he/she had the chance due to his/her feeling that some peers were favored. The physician ordered as needed (PRN) [MEDICATION(S)] (antianxiety medication) injection. Once the resident was able to remain calm, he/she requested to FaceTime (video call via an electronic device) his/her family member once or twice a week to help him/her cope. Staff ensured he/she would be able to do so. He/She was sent back to the hall with zero concerns. Review of the resident's care plan, initiated on [DATE], showed the following: -He/She may attend the Hangout; -On [DATE], the resident was suspended from the Hangout. The resident swung the door and struck peer on the knee. The resident verbalized the action was not on purpose, but peer reported the resident intentionally struck him/her. Review showed no documentation interventions were developed to address the resident's behaviors on [DATE]. Further review showed no documentation of the resident's behaviors on [DATE] and interventions to prevent further incidents, including FaceTime with his/her family member to help him/her cope. Review showed no documentation of a plan to ensure the resident would be able to FaceTime his/her family member twice a week as staff told him/her would be done (per the resident's request). Review of the facility's Registered Nurse Investigation (RNI), dated [DATE], showed Resident #24 and Resident #23 purchased a vape (electronic cigarette) by splitting the cost with the agreement that Resident #23 could hit the vape (inhale the electronic cigarette) anytime he/she wanted to. When Resident #24 became irritated with Resident #23 for coming into his/her room and hitting the vape, he/she asked Resident #23 to back off and give him/her a minute. Resident #23 went in the hallway and words were exchanged between the two residents. Staff began to redirect both residents and told them the situation would be handled and administration would be notified. The residents continued exchanging words and a code green (behavioral emergency) was called to the unit. Resident #24 ran down the hall charging at Resident #23. Staff stepped in front of Resident #23 and stopped Resident #24 from striking Resident #23. While staff focused on keeping Resident #24 from striking Resident #23, Resident #23 went behind the staff and swung and struck Resident #24. Resident #24 fell backwards and hit his/her head on the floor. As additional staff arrived, the residents were separated. Resident #24 was sent to the hospital emergency room for evaluation and treatment related to hitting his/her head. Conclusion of the investigation showed Resident #23 became loud and upset when Resident #24 asked him/her to wait to use their mutual vape. Resident #24 gave Resident #23 the vape, but Resident #23 continued to talk loudly about the situation. Due to Resident #24 initiating the altercation, he/she was placed on one-on-one observation until he/she was sent for a psychiatric evaluation per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #23's care plan, updated [DATE], showed the resident could not return to the Hangout until he/she met with the administrator due to borrowing/selling/trading, and a physical altercation with his/her peer (Resident #24). Review showed no interventions, other than suspending the resident from the Hangout (revoking a privilege), were implemented to address the resident's behaviors on [DATE]. Review of Resident #24's care plan showed on [DATE], he/she charged after peer and attempted to attack the peer. While staff were attempting to keep the resident from making contact with peer, peer struck resident which caused resident to lose his/her balance, fall backwards, and strike his/her head on the floor. A code green was called and residents were separated. The resident was sent to hospital for medical evaluation and later sent to another facility for psychiatric evaluation. (Review showed no interventions were added to the care plan to address the resident's behavior). Review of Resident #23's progress notes, dated [DATE] at 8:02 P.M., showed the resident provoked peers on his/her hall throughout the day, causing staff to intervene and redirect multiple times. The charge nurse was on the hall and heard the resident cussing at peers and threatening to drag [NAME] and telling peers to get the [OBSCENITY] down the hall. Charge nurse intervened, situation was deescalated, peers were separated, and the administrator was notified of the resident's behaviors. Review of resident's record showed no documentation staff attempted to identify the root cause of the resident's behavior and implement interventions to address the resident's behavior. Review of the resident's care plan, initiated on [DATE], showed the following: -He/She had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. Behaviors included talking loudly, being rude to both staff and peers, and exhibiting verbal and physical aggression toward peers; -Desired outcome was to minimize episodes of inappropriate behaviors that could affect others; -On [DATE], a peer became upset when he/she was talking loudly and rude towards staff and peers. While staff were redirecting and educating the resident on appropriate behaviors and unit rules, peer walked in room behind staff and struck resident (date initiated [DATE]); -On [DATE], the resident broke unit rules by purchasing a vape with a peer (Resident #24) to share. He/She became upset when peer didn't honor their agreement. Peer charged at resident while staff were focused on keeping peer from hitting resident. The resident took the opportunity to strike peer. The residents were separated. (date initiated [DATE]); -Interventions added on [DATE] included to administer and monitor medications as ordered, give positive feedback for good behaviors, and pharmacy consultant would review medications monthly and as needed (PRN). Review showed no further interventions documented to address the resident's verbal and physical aggression toward other residents. -The care plan did not direct staff to suspend or revoke use of the Hangout to modify behaviors. Review of the resident's behavioral progress note, dated [DATE] at 6:05 P.M., showed the resident was yelling and threatening peers. Staff attempted to redirect. The resident went in his/her room for a short amount of time, but opened the door and yelled at the charge nurse, why don't you stop worrying about who I'm threatening and get me some [OBSCENITY] ing juice! The charge nurse educated the resident on appropriate communication with staff without use of curse words and yelling. The resident threatened to slap the charge nurse and a code green was called. Staff were not able to redirect the resident, and staff administered PRN medication to address. Review of the resident's record showed no documentation staff attempted to identify the root cause of the resident's behavior and implement interventions to address the resident's verbal aggression and threats of physical aggression towards oth

Based on observation, interview, and record review, the facility failed to provide adequate monitoring and protective oversight for residents who required supervision to smoke, to prevent residents from obtaining smoking materials and smoking in unauthorized areas, including occupied resident rooms and bathrooms, for nine residents (Resident #83, #130, #152, #17, #162, #22, #109, #158 and #106 ) of 65 sampled residents. The facility failed to consistently provide adaptive and safety smoking equipment for residents who required them to smoke safely for three additional residents (Resident #48, #98, and #145). The facility also failed to provide protective oversight to prevent residents with mental illness from obtaining and ingesting cleaning chemicals and toiletries for two residents (Resident #130 and #113). Further review showed the facility failed to provide protective oversight for one sampled resident (Resident #144) and one additional resident (Resident #60), who had a history of suicidal ideation when staff failed to put effective interventions in place after attempts or expressed feelings of self-harm. The facility failed to employ appropriate methods for repositioning one sampled resident (Resident #45), when staff lifted and repositioned the resident by the waist of the resident's pants and under his/her arms and failed to provide the resident with foot rests on his/her wheelchair causing the resident's feet to drag the ground. The facility failed to ensure staff implemented interventions identified to prevent falls for another sampled resident (Resident #165) and for one additional resident (Resident #482). The facility failed to assist or provide assistive equipment to one resident (Resident #175), who voiced concerns about knee pain and fear of falling that resulted in a fall, and failed to ensure staff implemented interventions identified to prevent falls, investigate a fall, and re-evaluate current interventions for one additionally sampled resident's (Resident #48's), care plan to prevent future falls. The facility staff failed to propel an additionally sampled resident (Resident #145) to a safe area in the designated smoking area, which resulted in him/her rolling down the hill with a lit cigarette and coming to an abrupt stop when he/she hit the fence. The facility failed to provide foot pedals for wheelchairs and ensure staff used foot pedals for two sampled residents (Resident #32, #62) and three additional residents (Resident #48, #145 and #24), to prevent injuries from entanglement, or residents feet dragging the floor. The facility census was 170. The administrator was notified on 4/7/21 at 2:50 P.M. of an Immediate Jeopardy (IJ) which began on 3/30/21. The IJ was removed on 4/7/21, as confirmed by surveyor onsite verification. Review of the facility's policy titled Smoking Safety Regulations, dated April 2017, showed the following: -The purpose of the policy was to ensure all staff and residents are following the safety regulations for smoking as outlined by the Life Safety Code of the National Fire Protection Association and State and Federal Regulations; -The facility will follow all smoking regulations; -The facility will ensure that all designated smoking areas will utilize a non-combustible, self-closing, container for the residents smoking to ensure cigarette and ashes are disposed of properly; -The facility will provide direct supervision for smoking by patients classified as not responsible; -Immediately after the resident's smoking session is completed the Certified Nurse Aide (CNA)/designee is to dispose of the cigarette and residue in the metal container located in the designated area; -Smoking is allowed ONLY in designated smoking areas and at times set forth by the administration of the facility. 1. Review of Resident #130's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/21/20, showed the following: -Diagnoses included anxiety, [CONDITION(S)], and psychotic disorder; -Cognition was intact; -Independent with activities of daily living. Review of the resident's nurse's note, dated 1/2/21 at 11:46 P.M., showed the resident came to the nurse's station at 11:45 P.M. asking for an antacid. The resident asked if he/she could smoke. The charge nurse said no. The resident then grabbed a hand full of cigarettes out of the box (at the nurse's stations). The nurse made the resident empty his/her pockets and took the cigarettes and a lighter. Review of the resident's smoking safety evaluation, dated 2/21/21, showed the following: -Resident utilized tobacco; -Supervision will be required for all residents during designated smoking times; -This evaluation will be utilized to the resident's smoking care plan on admission and as indicated. Review of the resident's nurse's note, dated 2/22/21 at 4:00 P.M., showed the Interdisciplinary Team (IDT) met with the resident today in regards to contraband being found in his/her locked drawer and smoking in unauthorized areas. The resident reports it was other people's things in his/her drawer. Staff encouraged the resident to not hold contraband for other residents. The resident reports other residents come into his/her room while he/she is sleeping and smoke in his/her bathroom and hide things in his/her room. Staff encouraged the resident to alert staff when others are smoking in his/her room. The resident was suspended from Hangout (activities area) until the next care plan. Review of the resident's care plan, revised 2/26/21, showed the following: -The resident has a diagnosis of [CONDITION(S)] with a history of paranoia and audio and visual hallucinations, hearing voices, seeing demons and anger issues; -The resident has a history of alcohol and drug abuse; -The resident has disorganized thinking related to mental illness and lives on a secured unit; -Intensive monitoring per unit/facility protocol to ensure protective oversight; -The resident is a smoker. All lighters and smoking materials will be kept and dispersed by staff; -The resident will smoke only in designated smoking areas. During an interview on 3/29/21 at 12:45 P.M., the [NAME] of Focus (WoF, a goal directed program for residents with mental illness) Coordinator said there had been an issue with residents smoking inside the building in unauthorized areas. Resident #130 had been found smoking inside his/her room and bathroom a few weeks ago, but the WoF Coordinator was not aware of any issues since then. A few weeks ago, a new policy went into effect that staff could not bring their lighters on to the unit. The facility supplies the lighters and they are kept with the resident's cigarettes and counted at the end of each shift. Observation on 3/30/31 at 11:05 A.M. showed the following: -Hall Monitor D took residents outside the 100 hall to the courtyard to smoke. There were 11 residents who ended up outside smoking and Hall Monitor D was the only staff present; -Hall Monitor D handed residents cigarettes from a plastic container and lit the cigarettes with a lighter he/she removed from his/her pants pocket as he/she sat on a bucket outside the exit door; -Hall Monitor D lit his/her own cigarette and smoked while seated on the bucket by the door; -Several residents, including Resident #130, walked around the side of a brick wall in the courtyard, out of Hall Monitor D's line of sight with their lit cigarettes and continued to smoke out of the view of any staff; -Several residents threw their lit cigarettes on the ground in the courtyard, out of view of staff; -Hall Monitor D allowed residents, including Resident #130, to return inside the facility through the 100 hall exit door without showing him/her they had extinguished their cigarettes. Observation on 3/31/21 at 1:40 P.M. showed the resident's bathroom, shared with Resident #18, #7, and #83, had ashes that appeared to be from a cigarette on the floor beside and in front of the toilet as well as the toilet seat. There were dark areas that appeared to be [CONDITION(S)] on the plastic toilet seat in several places. During an interview on 3/31/21 at 3:10 P.M., Housekeeper L said he/she noticed the ashes on the residents' bathroom floor and the black marks on the toilet seat. Housekeeper L said it was common to find ashes in most of the bathrooms on the unit and finding ashes on the bathroom floors was a daily occurrence. Housekeeper L said he/she usually would let the charge nurse know when he/she found ashes or [CONDITION(S)] on the unit. Housekeeper L had not mentioned the ashes in the resident's bathroom to anyone yet that day. During an interview on 3/31/21 at 2:00 P.M., Hall Monitor G said he/she carried a personal lighter on his/her person while on the unit. Hall Monitor G said he/she was not aware staff were not to carry lighters onto the unit and was not aware the lighters had to be counted at the end of the shift. During an interview on 3/31/21 at 3:25 P.M., the WoF Coordinator said he/she conducted daily environmental rounds on the unit where he/she looked for signs of smoking, other contraband, cleanliness, and broken items. Monday was the one day a week where the environmental rounds were really thorough when he/she would go through residents' drawers and really looked for things that may be hidden. Residents tended to go to Resident #130's bathroom to smoke. Daily rounds were completed by 10:30 A.M. He/She did not observe ashes in the resident's bathroom during rounds that morning. The WoF Coordinator said it was a struggle to keep the residents from smoking in unauthorized areas, especially with only two aides on the hall. There was typically one certified nurse assistant (CNA) and one hall monitor on the unit. There was also a charge nurse that covered the 100, 200, 300 halls and the 800 and 900 halls and a Certified Medication Technician (CMT) that passed medications on the 100, 200, and 300 halls. Staff provided the residents with ten cigarettes a day, which should be enough to keep the residents from wanting to smoke in unauthorized areas, but they still did this. One staff monitored the residents who smoked on the 100/200 halls. Activity staff were responsible for monitoring residents who smoked in the Hangout (common area with and outdoor courtyard where residents from the different units could go to smoke or do an activity at scheduled times). Staff should monitor to ensure the residents extinguish the cigarette butts and do not bring the cigarettes back into the facility or outside the designated smoke room. During an interview on 4/1/21 at 10:42 A.M., Resident #130 said the day before, staff found cigarettes on Resident #18's (his/her roommate's) side of the room and now Resident #130 had a 24-hour restriction of no smoking. Resident #130 said he/she did not think it was fair since the cigarettes belonged to his/her roommate. Resident #130 spoke to the WoF Coordinator who told the resident he/she needed to take responsibility and keep other residents who are smoking out of his/her room. Observation on 4/6/21 at 10:55 A.M. showed a strong odor of cigarette smoke in Resident #130's room. During an interview on 4/6/21 at 10:56 A.M., Resident #130 denied smoking in his/her room. The resident said staff searched his/her room a few days ago, but nothing was found so he/she didn't get into trouble. During an interview on 4/7/21 at 8:30 A.M., the administrator said the last time staff reported contraband found in a resident's room was sometime last week when two packs of cigarettes were found in Resident #130's room. The cigarettes were not the kind purchased by the facility. Staff were still trying to determine where the cigarettes came from. Review of the resident's smoking safety evaluation, dated 4/7/21 showed the following: -Resident utilized tobacco; -Supervision will be required for all residents during designated smoking times; -This evaluation will be utilized to the resident's smoking care plan on admission and as indicated. Review of the resident's nurse's note, dated 4/10/21 at 6:55 P.M. showed the WoF Coordinator caught the resident smoking in his/her room with his/her roommate and another resident. The resident lost his/her smoking privileges for 24 hours after the incident. 2. Review of Resident #83's care plan, dated 10/28/19, showed the following: -The resident was at risk for alteration in mood due to diagnoses of depression and [CONDITION(S)]; -The resident had a history of paranoid ideation, delusions, physical and verbal aggression, self-harm, impaired judgement and insight, and polysubstance abuse; -Attempt to ascertain what the resident will accept to calm down and provide as able. It was usually smoking; -The resident is a smoker. All smoking materials/lighters will be kept and dispersed by staff; -The resident will smoke in designated smoking areas only. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included depression and [CONDITION(S)]; -Cognition was intact; -Independent with activities of daily living. Review of the resident's smoking safety evaluation, dated 1/24/21, showed the following: -The resident utilized tobacco; -Supervision will be required for all residents during designated smoking times; -Follow the facility's policy on location and time of smoking. Review of the resident's nurse's note, dated 2/2/21 at 5:11 P.M., showed the IDT met with the resident following altercation with another resident due to smoking in the bathroom. The resident gave up a lighter that someone had given him/her. Staff discussed the dangers of smoking in unauthorized areas and potential consequences of smoking. Staff encouraged the resident not to engage in this behavior anymore so he/she can proceed in [NAME] of Focus program and go to the Hangout when it opened again. Resident expressed understanding. Observation on 3/29/21 at 11:10 A.M. showed the resident was outside the 100 hall smoking with ten other residents and one staff member. The staff member stood by the exit door and did not keep all residents in line of sight while they smoked. Several residents threw their cigarettes on the ground and returned inside without staff ensuring the residents had extinguished and disposed of their cigarette. During an interview on 3/29/21 at 11:15 A.M. in the smoking courtyard outside the 100 hall, the resident said staff found him/her smoking in the bathroom inside the facility a few weeks ago. The resident said he/she kept a half smoked cigarette from smoke break and brought it back to his/her room and got a lighter from another resident. The resident said other residents have lighters in the facility and he/she can find a light from someone. The resident would not disclose which residents had lighters in the facility or how they obtained them. Observation on 3/31/21 at 1:40 P.M. of the resident's bathroom showed ashes on the floor beside and in front of the toilet as well as a black mark on the front of the toilet seat. There was a faint smell of cigarette smoke present in the bathroom. Housekeeper L came in and began cleaning the room and the bathroom. During an interview on 3/31/21 at 3:11 P.M. Housekeeper L said he/she noticed a burn mark on the resident's toilet and saw the ashes on the bathroom floor. Housekeeper L said he/she usually would let the charge nurse know when he/she found ashes or [CONDITION(S)] on the unit. Housekeeper L had not mentioned the ashes in the resident's bathroom that day yet to anyone. 3. Review of Resident #152's care plan, dated 6/8/20, showed the following: -Intensive monitoring per unit and facility policy to ensure protective oversight; -The resident was at risk for alteration in mood related to [CONDITION(S)] disease and [CONDITION(S)]; -One-on-one intensive monitoring as needed/warranted for protective oversight and verbalization and ventilation of concerns/feelings. (The resident's care plan did not address the resident's smoking.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included manic depression, [CONDITION(S)], and post-traumatic stress disorder; -Cognition was intact; -Independent with activities of daily living. Review of the resident's smoking safety evaluation, dated 1/19/21, showed the following: -The resident utilized tobacco; -Supervision will be required for all residents during designated smoking times; -Follow the facility's policy on location and time of smoking. Review of the resident's nurse's note, dated 2/19/21 at 5:53 P.M., showed the IDT met with the resident. Staff witnessed the resident smoking in an unauthorized area. The resident reported feeling agitated about another resident, but would not say who or why. A limitation was initiated for no smoking for 24 hours because of smoking in an unauthorized area and the resident would be suspended from the Hangout until 2/22/21. The Hangout is supervised by activities department staff, WoF Coordinator and other various staff during smoking breaks. Observation on 3/29/21 at 11:10 A.M. showed the resident outside the 100 hall smoking with ten other residents and one staff member. The staff member stood by the exit door and did not keep all residents in line of sight while they smoked. Several residents threw their cigarettes on the ground and returned inside without staff ensuring they had extinguished and disposed of their cigarette. Review of the resident's nurse's note, dated 4/10/21 at 6:58 P.M., showed the WoF Coordinator caught the resident in his/her room smoking with another resident. The resident lost his/her smoking privileges for 24 hours after the incident. 4. Observation on 4/7/21 at 12:15 P.M. showed the bathroom between occupied resident rooms 105 and 107 had multiple burn marks on the toilet seat and in the laminate flooring in front of and beside the toilet. During an interview on 3/31/21 at 3:40 P.M., Certified Nurse Aide (CNA) Y said he/she caught residents smoking in unauthorized areas several times. It was usually found in the bathroom between rooms 110 and 112 (the bathroom shared by Resident #83, #7, #18, and #130). The main two residents who had been caught smoking in their rooms multiple times were Resident #83 and Resident #130. Staff tried to keep an eye out for smoking in unauthorized areas, but they could only see so much and one staff could not watch every single resident while they smoked to ensure they had finished smoking and extinguished their cigarette. CNA Y said he/she thought some residents were not finishing their cigarettes on smoke break and then brought them back in the building. CNA Y did not know how residents were getting a lighter. CNA Y tried to do environmental rounds daily, but it depended on what was going on as to whether he/she got them completed. CNA Y looked for signs of smoking during rounds by looking in the bathrooms, and looking under and inside of mattresses. The residents were really good at hiding things and were very creative. Residents would sometimes stash items up in the ceiling tiles. If a resident was found smoking in an unauthorized area, they were typically suspended from going to the Hangout. Observation on 3/31/21 at 4:14 P.M. showed CNA Y outside the 100 hall with three residents smoking. One resident threw his/her cigarette on the ground, unobserved by CNA Y, and then returned inside the facility. CNA Y did not observe the residents extinguish their cigarettes before coming back inside the facility. Observation on 4/6/21 at 10:56 A.M. in the Hangout showed 37 residents lined up at a table where two activity staff members passed out cigarettes and lighted cigarettes for the residents. There were three, red, metal cans lined up by the door to the courtyard. Some residents threw their cigarettes on the ground and others placed their cigarette in the red metal containers before returning inside the facility. Staff did not monitor residents to ensure their cigarettes were properly extinguished and disposed of prior to coming back inside the building. During an interview on 4/7/21 at 12:00 P.M., Laundry Aide AA said he/she saw burn holes in sheets, clothes, and socks, mostly on the 100, 200, 300, 400, and 500 halls. He/She found cigarette burn holes in residents' clothing in the past. The last time he/she saw any burn holes in any laundry items was several weeks ago. Whenever he/she observed this, he/she reported to his/her supervisor. Laundry Aide AA smelled cigarette smoke on the 100, 200 and 300 halls several times in the past; the last time being a couple of weeks ago. Laundry Aide AA reported this to the Certified Medication Technician (CMT) who was supposed to let the charge nurse know. Laundry Aide AA did not remember the name of the person he/she reported this to. Laundry Aide AA said residents wouldn't say where they were getting the lighters, but his/her guess was staff had to be the ones providing the residents with lighters. During an interview on 4/6/21 at 2:25 P.M., the administrator said staff monitoring the residents' smoking should be handing the resident the cigarette and lighting it for them. Staff should encourage residents to extinguish the cigarette in the red metal cans before returning inside or before lighting another cigarette. If staff smell smoke or see ashes in a room or bathroom, they should immediately tell the charge nurse and complete environmental checks. Staff did not document environmental checks. If something was found, then staff usually documented a note for that resident. The repercussions for a resident who was caught smoking in an unauthorized area was individualized. Some residents have limitations in place not to smoke for 24 hours afterward. Usually staff will just talk with the resident if it was their first offense. If it is the resident's second or third offense, staff contact the guardian and get limitations in place as a last resort. Residents who were found smoking in unauthorized areas were suspended from the Hangout area. The administrator had not pinpointed how residents were getting cigarettes or lighters, but it could be coming in through packages or they could be getting them from staff. Staff should not be bringing their own lighters onto the unit and should be utilizing the lighter that is kept with the residents' cigarettes which was on a leash and staff should have control of the lighter at all times when in use. 5. Record review of Resident #162's face sheet showed the following: -The resident's diagnoses included [CONDITION(S)] disorder, intellectual disabilities and major depressive disorder; -The resident was admitted to the facility on [DATE]; -The resident had a guardian. Record review of the resident's PASRR, dated 5/21/20, showed the following: -The resident had a history of angry, verbal outbursts directed toward staff over his/her smoking and tobacco availability; -The resident is uncooperative with smoking rules; -The resident goes outside to look for partially used cigarette butts; -The resident has stolen cigarettes from staff; -The resident does not make good decisions; -The resident needed a structured environment and monitoring of his/her behavioral symptoms. Review of the resident's Smoking Safety Evaluation, dated 3/10/21, showed the following: -The resident utilizes tobacco; -Supervision required for the resident during designated smoking times; -The evaluation would be utilized for the resident's smoking care plan on admission and as indicated; -The resident does not follow the facility's policy on location and time of smoking; -The resident could safely light, hold and use an ashtray to extinguish a cigarette. Record review of the resident's MDS, dated [DATE], showed the resident's cognition was intact. Record review of the resident's care plan, revised on 3/15/21, showed the following: -The resident will remain safe; -The resident will not cause significant harm to self or others; -The resident will have daily opportunities for socialization; -No documentation to address the resident's current tobacco use. Observation on 3/31/21 at 11:35 A.M., showed a Styrofoam cup containing a brown liquid and four to five cigarette butts sat on the counter by the sink in the resident's room. There was also a cigarette butt on the floor beside the resident's bed. The room smelled of cigarette smoke. During an interview on 3/31/21 at 11:35 A.M., the resident said he/she and other residents pocket cigarettes during smoking breaks and take them inside to smoke in their rooms. The resident shrugged his/her shoulders when asked if the cigarettes in the cup were his/hers. 6. Review of Resident #17's face sheet showed the resident had a guardian. Record review of the resident's care plan, dated 10/27/19, showed the following: -The resident is a smoker; -The resident will follow facility protocol for smoking; -Staff will keep and disperse all smoking materials; -The resident will smoke in designated smoking areas only. Review of the resident's Smoking Safety Evaluation, dated 2/26/21, showed the following: -The resident utilized tobacco; -Supervision required for the resident during designated smoking times; -The evaluation would be utilized for the resident's smoking care plan on admission and as indicated; -The resident did not follow the facility's policy on location and time of smoking; -The resident could safely light, hold and use an ashtray to extinguish a cigarette. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident's cognition is intact; -The resident had diagnoses of depression, [CONDITION(S)], stroke, [CONDITION(S)] and traumatic [CONDITION(S)]. During an interview on 3/31/21 at 11:35 A.M., the resident said he/she and other residents used matches to light cigarettes in their rooms. Observation on 4/6/21 at 5:07 P.M., showed the resident exited Resident #22's room with half a cigarette in his/her right hand. During an interview on 4/6/21 at 5:07 P.M., the resident said the cigarette he/she had was brought in after a smoke break. The resident said he/she lights the cigarettes inside the facility with matches. When asked where he/she got the matches, the resident turned his/her head. When asked if he/she got the matches from staff, the resident smiled. 7. Review of Resident #22's face sheet showed the following: -The resident had a guardian; -The resident's diagnoses included [CONDITION(S)] disorders, anxiety disorder, [CONDITION(S)] disorder and hallucinations. Review of the resident's Smoking Safety Evaluation, dated 12/10/20, showed the following: -The resident utilizes tobacco; -Supervision required for the resident during designated smoking times; -The evaluation would be utilized for the resident's smoking care plan on admission and as indicated; -The resident follows the facility's policy on location and time of smoking; -The resident could safely light, hold and use an ashtray to extinguish a cigarette. Review of the resident's care plan, revised on 1/20/21, showed the following: -The resident is a smoker; -The resident will adhere to the tobacco/smoking policies of the facility; -Conduct smoking safety evaluation on admission and as needed. Review of the resident's quarterly MDS, dated [DATE], showed the resident's cognition was intact. During an interview on 3/31/21 at 4:15 P.M., the resident said the staff don't check rooms for drugs or cigarettes very often. The resident said he/she does not smoke in his/her room, but other people come in his/her room sometimes and smoke. The resident will ask the other residents to leave his/her room. Observation on 3/31/21 at 4:38 P.M., showed Resident #106 left Resident #22's room. Resident #22's room had a strong odor of cigarette smoke. During an interview on 3/31/21 at 4:40 P.M., Resident #22 said Resident #106 came in his/her room and smoked a few minutes ago and that was why his/her room smelled of cigarette smoke. He/She asked Resident #106 to leave and not smoke in his/her room. The resident said the residents hold the cigarettes behind their back after smoke breaks and walk in the building with them. Once they are inside they use a lighter to light the cigarettes. He/She was not sure where the residents got the lighters. Record review of the resident's progress note, dated 4/8/21 at 9:31 A.M., showed the resident attempted to take a half smoked cigarette to his/her room after returning from a smoke break. The resident will lose Hangout privileges until he/she has met with the team to determine appropriateness for Hangout. Record review of the resident's progress note, dated 4/8/21, showed Social Services contacted the resident's guardian. The guardian consented to no smoking for the resident for 24 hours and suspension from the Hangout. During an interview on 4/14/21 at 8:53 A.M., the resident's guardian said the facility emailed him/her and asked for a limitation for the resident to lose smoking privileges for 24 hours. The facility stated the resident would lose Hangout privileges and the resident's mattress had recently been found with burn holes in it. 8. Record review of Resident #109's Face Sheet showed the resident had a guardian. Review of the resident's care plan, dated 2/6/20, showed the following: -The resident was a supervised smoker; -The resident will adhere to the tobacco/smoking policies of the facility; -The staff will educate the resident/responsible party on the facility's tobacco/smoking policy; -The resident will smoke in designated smoking areas only; -Staff will keep and disperse all smoking materials. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident's cognition was intact; -The resident used tobacco; -The resident had a diagnosis of [CONDITION(S)]. Review of the resident's Smoking Safety Evaluation, dated 2/14/21, showed the following: -The resident utilizes tobacco; -Supervision required for the resident during designated smoking times; -The evaluation would be utilized for the resident's smoking care plan on admission and as indicated; -The resident did not follow the facility's policy on location and time of smoking; -The resident could safely light, hold and use an ashtray to extinguish a cigarette. During interview on 03/29/21 at 12:38 P.M., Resident #109 looked down and shook his/her head yes when asked if he/she had been smoking in the bathroom in room 309. Observation on 3/30/21 at 12:46 P.M., showed cigarette ashes on the resident's bathroom floor by the toilet and a cigarette burn on the toilet seat lid. 9. Review of the Resident #158's face sheet showed the resident had a guardian. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident's diagnoses included [CONDITION(S)], depression, anxiety, and hepatitis; -The resident's cognition was intact. Review of the resident's Smoking Safety Evaluation, dated 3/10/21, showed the following: -The resident utilizes tobacco; -Supervision required for the resident during designated smoking times; -The evaluation would be utilized for the resident's smoking care plan on admission and as indicated; -The resident did not follow the facility's policy on location and time of smoking; -The resident could safely light, hold and use an ashtray to extinguish a cigarette. Review of the resident's care plan, revised on 3/15/21, showed the following: -The resident is a smoker; -The resident will follow facility policy for smoking; -Staff will keep and disperse all lighters and smoking materials; -The resident will smoke in designated smoking areas; -The resident had a history of smoking in inappropriate areas. Observation on 4/8/21 at 5:35 P.M., showed the resident sat in his/her recliner in his/her room. Half a smoked cigarette lay on the resident's night stand. Review of the resident's progress note, dated 4/10/21 at 7:00 P.M., [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide ordered pain medication for four residents (Residents #157, #175, #134 and #176), in a review of 65 sampled residents, which resulted in unrelieved pain. One sampled resident (Resident #157), experienced symptoms of withdrawal following failure to provide ordered narcotic pain medication. Additionally, the facility failed to administer a sampled resident's (Resident #157) pain medication according to FDA (federal drug administration) recommendations every 4-6 hours to ensure the resident received adequate pain relief, at times doubling the prescribed dosages, which resulted in the resident being unable to sleep and caused a disruption in the resident's daily routine while he/she was in pain. The facility census was 170. Review of the facility policy Pain Monitoring policy, revised 4/6/2017, showed the following: The purpose of this policy is to ensure that all residents that have pain are identified by assessment and provided interventions to decrease their pain intensity to the resident's acceptable level: Procedure: 1. All residents in the facility will have a pain assessment upon admission and quarterly and as needed to address and determine the following: a. Presence of pain; b. Origin of pain; c. If the pain is acute/chronic; d. Frequency of pain; e. Changes in baseline behavior due to pain; f. Acceptable pain level g. Identify the resident's current pain management plan of care; h. Effectiveness of current pain management plan of care; i. Changes required in the plan of care to help lower the resident's pain intensity to no pain or their acceptable pain level; 2. All residents that are cognitively impaired or unable to answer questions regarding pain will have an assessment to determine if pain signs/symptoms are present that might indicate that the resident is experiencing pain; 3. The Resident Care Coordinator (RCC) will develop a pain management list and update it weekly of all residents receiving pain medications routinely and as needed (PRN) pain medications three or more times a week; 4. The care plan will reflect the plan of care changes based on the pain management list and interventions; 5. The pain management list will be reviewed weekly by a Registered Nurse (RN) to determine cause of pain, pain medication effectiveness and further interventions if needed in the weekly Nursing Quality Assurance (QA) Meeting; 6. The primary care physician will be updated as needed on the effectiveness of the pain management and provide further interventions as deemed necessary; 7. All residents receiving routine pain medication will be documented on shiftly. If the resident received pain medications three or more times a week, they will be documented on daily and as needed when a pain medication is given; 8. When the resident's pain medication reaches eight doses remaining, the medication will be reordered by the Certified/Licensed/Registered Nursing staff that gave the 9th remaining dose; 9. In the rare event that a pain medication is unavailable, the primary care physician will be notified to offer an alternative to manage the resident's pain. Review of the facility policy Ordering and Ensuring Scripts are Provided to Pharmacy, revised 7/11/14, showed the following: Purpose: The purpose of this policy is to implement a system to ensure that residents are receiving narcotics as prescribed by physician without delay due to unavailability of the signed original script. The purpose of this policy is also to implement a system that effectively addresses pain management of the individual resident in the event that the prescribed narcotic medication is unavailable; Procedure: 1. The Director of Nursing (DON) will assign a Licensed or Registered Nurse (RN), to be responsible during business hours, of monitoring all narcotics in the facility for the need to obtain a written prescription to ensure availability of the narcotic medication; 2. The Licensed/Registered Nurse will review all routine and as needed (PRN) narcotic medication orders with the available medication in the facility daily to ensure at least three days worth of the medication is available in the facility; 3. In the event that the narcotic medication has been exhausted to three days remaining, the Licensed/Registered Nurse will reorder the medication from the pharmacy; a. If the medication requires a written, signed script from the prescribing physician, the Licensed/Registered Nurse will contact the physician during office hours; b. The Licensed/Registered Nurse will ensure that the script has been received by the pharmacy within 24 hours to prevent the unavailability of the prescribed narcotic; 4. All routine and PRN narcotic pain medications that are ordered by the Licensed/Registered Nurse will be checked within 24 hours to ensure that they were delivered to the facility; 5. If the narcotic medication was not delivered to the facility, the Licensed/Registered Nurse will re-order the medication and contact the pharmacy directly to verbally confirm its arrival to the facility; 6. The Licensed/Registered Nurse will ensure that all residents who are taking routine or PRN medication for pain have an emergency PRN pain medication in the event that the primary/routine pain medication is not available; a. The Licensed/Registered Nurse will notify the primary care physician/prescribing physician of the request for an emergency pain medication until the primary pain medication arrives; b. All emergency pain medication orders will be ordered from the pharmacy to ensure availability as needed; 7. At any time a medication is not available in the facility, the charge nurse/Certified Medication Technician (CMT) will notify the Resident Care Coordinator (RCC)/designee, DON/Assistant Director of Nursing (ADON)/RN/designee, administrator/designee, legal guardian and primary care physician/prescribing physician. Any further orders will be following; 8. Upon delivery to the facility, all medications will be checked with the delivery receipt to verify that all medications, including narcotics, are present at the time of delivery; 9. All prescription narcotic medications will be reconciled on a shiftly basis with two staff members, one of which will be licensed. This will include change of responsibility for the narcotic medication administration; 10. All PRN, scheduled and back up narcotics will be counted during the medication reconciliation; 11. Both staff members will sign off on the medication reconciliation form, verifying that all narcotic medication has been accounted for. 1. Review of email communication from the administrator, dated 4/14/21 at 11:11 P.M., showed there was no facility policy for block medication times. 2. Review of www.accessdata.fda.gov/drugs, showed the following: -[MEDICATION(S)] tablets are an opioid agonist indicated for the management of acute and chronic pain severe enough to require an opioid [MEDICATION(S)] and for which alternative treatments are inadequate; -Recommended dose for [MEDICATION(S)] tablets: 15 to 30 mg every 4 hours as needed; -Risks of addiction, abuse, and misuse with opioids, even at recommended doses; -Do not abruptly discontinue [MEDICATION(S)] tablets in a physically dependent patient because rapid discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide; -When discontinuing [MEDICATION(S)] tablets in a physically dependent patient, gradually taper the dosage; -Rapid tapering of [MEDICATION(S)] in a patient physically dependent on opioids may lead to a withdrawal syndrome and return of pain; -Physical dependence is a physiological state in which the body adapts to the drug after a period of regular exposure, resulting in withdrawal symptoms after abrupt discontinuation or a significant dosage reduction of a drug; -For patients on [MEDICATION(S)] tablets who are physically opioid-dependent, initiate the taper by a small enough increment (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms; -Common withdrawal symptoms include restlessness, lacrimation (tearing), rhinorrhea (nasal discharge), yawning, perspiration, chills, myalgia (aches), and mydriasis (dilated pupils). Other signs and symptoms also may develop, including irritability, anxiety, backache, joint pain, weakness, abdominal cramps, [CONDITION(S)], nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. 3. Review of Resident #157's Face Sheet showed the resident admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care, Level II (screening refers to clients with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Takes [MEDICATION(S)] (pain medication) every 4 hours as well as [MEDICATION(S)] (medication for pain); -Back pain and right hand pain chronic in nature; -Followed by the pain clinic. Review of the resident's care plan, updated 11/18/19, showed the following: -Chronic pain in his/her right hand due to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the 4th and 5th fingers; -Takes routine pain medications; -Goal: Resident will be able to verbalize adequate relief of pain or the ability to cope with incompletely relieved pain, resident will report new onset of pain to staff promptly; -Administer [MEDICATION(S)] (pain medications) medications as ordered; -Give pain medications 30 minutes before treatments or care; -Monitor for worsening pain status; -Physical therapy evaluation and treatment as needed; -Pain management consult. Review of the resident's Physician's Orders, dated 11/2019, showed the following: -[MEDICATION(S)] (opioid pain medication) sulfate IR (immediate release) 15 milligrams four times a day; -[MEDICATION(S)] (medication used for nerve pain) 150 mg two times a day. Review of the resident's care plan, dated 1/28/20, showed the following: -Pain management consult for low back pain, leg pain, joint pain; -Refer to physical therapy as instructed; -No medication adjustments. Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment completed by facility staff, dated 12/6/20, showed the following: -Cognitively intact; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Routine pain medication; -Pain interview not conducted; -No staff pain interview conducted; -Opioids received everyday. Review of the resident's MAR, dated 2/15/21, showed the resident received his/her 6:00 P.M. dose of [MEDICATION(S)] at 9:00 P.M. Review of the resident's Nurses Notes, dated 2/16/21, at 6:22 A.M., showed the following: -[MEDICATION(S)] immediate release 15 mg tablet; -None available for resident; -Director of Nursing (DON) notified. Review of the resident's Nurses Notes, dated 2/16/21 at 6:37 A.M., showed the following: -Last dose of [MEDICATION(S)] given at bedtime on 2/15/21; -Charge nurse notified, nurse looked in Omnicell (machine that dispenses medications in the facility for new orders, or needed doses), and there was none in stock; -Medication is ordered; -Will let next shift follow up with pharmacy. Review of the resident's Nurses Notes, dated 2/16/21, at 12:20 P.M., showed the following: -[MEDICATION(S)] immediate release 15 mg tablet; -None available for resident; -None in the Omnicell either; -Pharmacy has it back ordered. Review of the resident's Nurses Notes, dated 2/16/21, at 5:59 P.M., showed the resident's [MEDICATION(S)] arrived from another pharmacy. Review of the MAR, dated 2/16/21, showed the following: -[MEDICATION(S)] not given for the 7:00 A.M. or 11:00 A.M. doses; -[MEDICATION(S)] 3:00 P.M. dose administered at 6:00 P.M. -The resident did not have [MEDICATION(S)] from 9:00 P.M., on 2/15/21, until 6:00 P.M. on 2/16/21 for a total of 21 hours. Review the resident's Nurses Notes, dated 3/1/21, showed the resident returned from the hospital at 4:00 P.M. Review of the resident's MAR, dated 3/1/21, showed the resident did not receive his/her 6:00 P.M. medications after return from the hospital. 3/1/21. No medications documented as administered. Review of the resident's Medication Administration Audit Report, dated 3/1/21-3/6/21, showed the following: -On 3/2/21 7:00 A.M. [MEDICATION(S)] administered at 6:09 A.M. (prior to scheduled time), the 11:00 A.M. and 3:00 P.M. [MEDICATION(S)] doses administered at 2:51 P.M. (two scheduled doses administered at the same time), and the 6:00 P.M. [MEDICATION(S)] administered at 9:23 P.M.; -On 3/3/21 7:00 A.M. [MEDICATION(S)] administered at 9:44 A.M. (12 hours and 21 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:25 P.M. (2 hours and 41 minutes from the last dose), 3:00 P.M. [MEDICATION(S)] administered at 3:15 P.M.(2 hours and 50 minutes from the last dose), and the 6:00 P.M. [MEDICATION(S)] administered at 7:25 P.M.; -On 3/6/21 7:00 A.M. [MEDICATION(S)] administered at 10:06 A.M. (13 hours and 9 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:05 P.M. (2 hours and 1 minute from the last dose), 3:00 P.M. [MEDICATION(S)] administered at 4:25 P.M., and the 6:00 P.M. [MEDICATION(S)] administered at 6:50 P.M.(2 hours and 25 minutes from the last dose); Review of the resident's MAR, dated 3/7/21-3/8/21, showed the following: -On 3/7/21 the resident did not receive his/her 7:00 A.M., 11:00 A.M., 3:00 P.M., or 6:00 P.M. doses of [MEDICATION(S)]; -On 3/8/21 the resident did not receive his/her 7:00 A.M. dose of [MEDICATION(S)]. Review of the resident's Nurses Notes, dated 3/8/21, showed the following: -[MEDICATION(S)] immediate release 15 mg tablet; -None available for the resident; -Waiting on the medication from the pharmacy. Review of the resident's Medication Administration Audit Report, date 3/8/21-3/31/21, showed all the following: -On 3/8/21 administered 11:00 A.M. [MEDICATION(S)] at 1:37 P.M. (42 hours and 27 minutes from last dose on 3/6/21); 3:00 P.M. [MEDICATION(S)] at 3:23 P.M. (1 hour 46 minutes from last dose), 6:00 P.M. [MEDICATION(S)] at 6:47 P.M. (3 hours and 24 minutes from last dose); -On 3/9/21 administered 7:00 A.M. [MEDICATION(S)] at 9:51 A.M. (15 hours and 3 minutes from last dose, 11:00 A.M. [MEDICATION(S)] at 11:48 A.M. (1 hour and 57 minutes from the last dose), 3:00 P.M. and 6:00 P.M. dose at 7:47 P.M.; -On 3/10/21 administered 7:00 A.M. [MEDICATION(S)] at 9:08 A.M. (13 hours and 21 minutes since the last dose), 11:00 A.M. [MEDICATION(S)] at 10:50 A.M. (1 hour and 42 minutes from last dose), and 6:00 P.M. dose at 8:05 P.M.; -On 3/11/21 administered 7:00 A.M. [MEDICATION(S)] at 7:53 A.M. (11 hours and 48 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 11:17 A.M. (3 hours and 20 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 4:52 P.M., and the 6:00 P.M. [MEDICATION(S)] at 7:10 P.M. (2 hours and 18 minutes from the last dose); -On 3/12/21 administered 7:00 A.M. [MEDICATION(S)] at 6:09 A.M. (11 hours and 59 minutes from last dose on 3/6/21); 11:00 A.M. and 3:00 P.M. [MEDICATION(S)] at 3:17 P.M. (two doses at the same time), 6:00 P.M. [MEDICATION(S)] at 7:23 P.M.; -On 3/13/21 administered 7:00 A.M. [MEDICATION(S)] at 8:38 A.M. (13 hours and 16 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 11:58 A.M. (3 hours and 20 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 3:10 P.M. (3 hours and 12 minutes from the last dose), and the 6:00 P.M. [MEDICATION(S)] at 7:10 P.M.; -On 3/14/21 administered 7:00 A.M. [MEDICATION(S)] at 9:16 A.M. (14 hours and 6 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 2:42 P.M., 3:00 P.M. [MEDICATION(S)] at 4:15 P.M. (1 hour and 33 minutes from the last dose), and the 6:00 P.M. [MEDICATION(S)] at 6:26 P.M. (2 hours and 11 minutes from the last dose); -On 3/15/21 administered 7:00 A.M. [MEDICATION(S)] at 8:07 A.M. (13 hours and 41 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 11:19 A.M. (3 hours and 12 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 3:20 P.M., and the 6:00 P.M. [MEDICATION(S)] at 6:40 P.M. (3 hours and 20 minutes from the last dose); -On 3/16/21 administered 7:00 A.M. [MEDICATION(S)] at 8:28 A.M. (13 hours and 48 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 10:59 A.M. (2 hours and 31 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 2:54 P.M., and the 6:00 P.M. [MEDICATION(S)] at 6:31 P.M. (3 hours and 37 minutes from the last dose); -On 3/17/21 administered 7:00 A.M. [MEDICATION(S)] at 7:02 A.M. (12 hours and 31 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 1:37 P.M., 3:00 P.M. [MEDICATION(S)] at 5:09 P.M., and the 6:00 P.M. [MEDICATION(S)] at 7:21 P.M. (2 hours and 12 minutes from the last dose); -On 3/18/21 administered 7:00 A.M. [MEDICATION(S)] at 9:32 A.M. (14 hours and 11 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:23 A.M. (2 hours and 51 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 3:11 P.M.(2 hours and 48 minutes from the last dose), and the 6:00 P.M. [MEDICATION(S)] at 7:10 P.M.; -On 3/19/21 administered 7:00 A.M. [MEDICATION(S)] at 10:02 A.M. (14 hours and 52 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 11:55 A.M. (1 hour and 53 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 3:31 P.M.(3 hours and 36 minutes), and the 6:00 P.M. [MEDICATION(S)] at 8:58 P.M.; -On 3/20/21 administered 7:00 A.M. [MEDICATION(S)] at 9:27 A.M. (12 hours and 29 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 1:33 P.M., 3:00 P.M. [MEDICATION(S)] at 6:19 P.M., and the 6:00 P.M. [MEDICATION(S)] at 6:19 P.M. (2 dose administered at the same time); -On 3/21/21 administered 7:00 A.M. [MEDICATION(S)] at 9:02 A.M. (14 hours and 41 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 10:33 A.M. (1 hour and 31 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 14:28 P.M. (3 hours and 55 minutes), and the 6:00 P.M. [MEDICATION(S)] at 5:58 P.M. (3 hours and 30 minutes from the last dose); -On 3/22/21 administered 7:00 A.M. [MEDICATION(S)] at 8:39 A.M. (14 hours and 41 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 1:46 P.M., 3:00 P.M. [MEDICATION(S)] at 4:59 P.M. (3 hours 13 minutes from the last dose), and the 6:00 P.M. [MEDICATION(S)] at 6:24 P.M. (1 hours and 24 minutes from the last dose); -On 3/23/21 administered 7:00 A.M. [MEDICATION(S)] at 8:18 A.M. (13 hours and 54 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:15 A.M., 3:00 P.M. [MEDICATION(S)] at 3:21 P.M. (3 hours and 6 minutes from last dose), and the 6:00 P.M. [MEDICATION(S)] at 6:12 P.M. (2 hours and 51 minutes from the last dose); -On 3/24/21 administered 7:00 A.M. [MEDICATION(S)] at 9:56 A.M. (15 hours and 44 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 10:38 A.M. (42 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 3:40 P.M., and the 6:00 P.M. [MEDICATION(S)] at 6:14 P.M. (2 hours and 34 minutes from the last dose); -On 3/25/21 administered 7:00 A.M. [MEDICATION(S)] at 1:23 P.M. (19 hours and 9 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 1:23 P.M. (two doses at the same time), 3:00 P.M. [MEDICATION(S)] at 5:23 P.M., and the 6:00 P.M. [MEDICATION(S)] at 5:23 P.M. (2 doses at the same time); -On 3/26/21 administered 7:00 A.M. [MEDICATION(S)] at 9:00 A.M. (15 hours and 37 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 11:31 A.M. (2 hours and 31 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 4:13 P.M., and the 6:00 P.M. [MEDICATION(S)] at 7:06 P.M. (2 hours and 53 minutes from the last dose); -On 3/27/21 administered 7:00 A.M. [MEDICATION(S)] at 8:09 A.M. (13 hours and 3 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:01 A.M., 3:00 P.M. [MEDICATION(S)] at 4:56 P.M., and the 6:00 P.M. [MEDICATION(S)] at 6:06 P.M. (1 hour and 10 minutes from the last dose); -On 3/28/21 administered 7:00 A.M. [MEDICATION(S)] at 8:22 A.M. (14 hours and 16 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:27 A.M., 3:00 P.M. [MEDICATION(S)] at 4:52 P.M., and the 6:00 P.M. [MEDICATION(S)] at 7:10 P.M. (2 hours and 18 minutes from the last dose); -On 3/29/21 administered 7:00 A.M. [MEDICATION(S)] at 9:46 A.M. (14 hours and 36 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 11:01 A.M. (1 hour and 17 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 7:11 P.M., and the 6:00 P.M. [MEDICATION(S)] at 7:11 P.M. (two doses administered at the same time); -On 3/30/21 administered 7:00 A.M. [MEDICATION(S)] at 8:01 A.M. (11 hours and 50 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:03 P.M., 3:00 P.M. [MEDICATION(S)] at 3:27 P.M.(3 hours and 24 minutes from the last dose), and the 6:00 P.M. [MEDICATION(S)] at 7:59 P.M.; -On 3/31/21 administered 7:00 A.M. [MEDICATION(S)] at 9:44 A.M. (12 hours and 45 minutes from the last dose), 11:00 A.M. [MEDICATION(S)] at 12:25 P.M. (2 hours and 41 minutes from last dose), 3:00 P.M. [MEDICATION(S)] at 4:18 P.M., and the 6:00 P.M. [MEDICATION(S)] at 7:13 P.M. During an interview on 3/31/21, at 7:25 P.M., the resident said the following: -He/She has chronic back pain; -The staff do not give his/her [MEDICATION(S)] like they are supposed to; -Before he/she came to this facility, the previous facility spaced out the doses; -The previous facility gave him/her one [MEDICATION(S)] in the morning, one before bed and spaced out the other doses to give him/her pain relief for the entire day; -Yesterday he/she got his/her 7:00 A.M. dose at 9:45 A.M., then a dose at 12:30 P.M., the third dose at 3:00 P.M., and then his/her last does at 6:30 P.M.; -This puts all his/her [MEDICATION(S)] doses within eight or nine hours of each other and he/she does not have any pain medications for the other 15 to 16 hours of the day; -Sometimes the staff give him/her two doses at the same time like the 7:00 A.M. dose and the 11:00 A.M. doses both at 11:00 A.M.; what was the point of having it scheduled four times a day?; -If his/her pain medications were closer to every six hours he/she would have better pain relief; -His/Her pain medications wear off in the middle of the night and he/she can not sleep. In the morning he/she has an 8 or a 9 pain level and feels awful; -When his/her pain is over a 5, which is daily, he/she spends his/her time trying to be comfortable. I can't sit too long, lay too long, or walk too long, and am constantly repositioning. Because of this he/she cannot watch a movie when his/her pain is elevated, or do anything that requires being in one position for any length of time. During an interview on 3/31/21, at 7:50 P.M., certified medication technician (CMT) YY said the following: -The resident had run out of [MEDICATION(S)] several times; -Usually the pharmacy was waiting on a prescription from the physician; -Earlier this month the facility had to get an emergency prescription filled from a pharmacy in town; -The DON has to handle the prescriptions so sometimes the residents just have to wait until their medication gets here; -The facility does block time medication pass so he/she can give the resident's [MEDICATION(S)] that is four times a day, anytime within the block time; -The medication pass times are 7:00 A.M.-11:00 A.M., 11:00 A.M.-3:00 P.M., 3:00 P.M.-6:00 P.M. and 6:00 P.M.-10:00 P.M.; -He/She tried to space the medications that are several times a day out, but as long as they are within the time frame it was not a problem; -The facility cut the budget about a month ago and now there was no one to pass medications after 7:00 P.M. on the resident's side of the building (referring to the 500, 600, and 700 halls); -All the 500 hall medications are done by 7:00 P.M., 7:30 P.M. at the latest. Review of the resident's Nurses Notes, dated 4/5/21 at 9:30 P.M., showed the following: -[MEDICATION(S)] immediate release 15 mg tablet; -None available for resident; -The [MEDICATION(S)] was reordered, but pharmacy awaiting a new signed prescription from the physician's office; -Pharmacy said they would be sending a partial card of eight pills tonight until the prescription was refilled; -ADON and DON notified; -Attempted to reach the physician's office via Emergency Line to receive a supplement order but it went to voicemail; -Nurse left a voicemail; -Nurse attempted to call three more times and left messages, no response yet. Review of the resident's Nurses Notes dated 4/5/21 at 9:54 P.M., showed staff received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's MAR, dated 4/5/21, showed the resident missed his/her [MEDICATION(S)] dose at 3:00 P.M. and 7:00 P.M. because the medication was not available. Review of the resident's Nurses Notes, dated 4/6/21 at 2:33 A.M., showed the following: -Resident upset about pain medicine not being available earlier in this shift and wanted to wait until pain medication was available to take night medications; -When pain medication became available, administered with night medications per orders; -Resident cooperative; -States he/she has lower back pain and nothing else seems to help. During an interview on 4/6/21, at 3:45 P.M., CMT YY said the following: -Staff order the resident's medication when the resident gets down to four pills for the daily medications, and ten pills for medications that are administered more often; -The resident ran out of [MEDICATION(S)] on 4/5/21; -He/She does not know why the resident ran out this time; -He/She does not routinely ask for resident's pain score, the resident will tell him/her if he/she is in pain. During an interview on 4/6/21, at 3:50 P.M., the resident said the following: -He/She missed his/her 3:00 P.M. dose of [MEDICATION(S)] yesterday because staff said they ran out; -The night nurse gave him/her one at 12:30 A.M. when they came in from the pharmacy because the nurse knew he/she was pain; -His/Her pain was an 8 or 9 by then; -He/She was hurting so bad and felt so bad he/she could not go to sleep; -Staff said the pharmacy only sent four pills; -He/She asked for Tylenol (pain medication) and CMT YY said he/she was out of Tylenol, he/she was not able to get Tylenol today; -He/She requested Tylenol for breakthrough pain, especially if he/she was having more pain. During an interview on 4/6/21, at 4:07 P.M., CMT YY said the following: -He/She was out of the stock Tylenol; -He/She was waiting on the stock medications to be delivered; -If he/she had the Tylenol he/she would give it, otherwise the resident would have to wait; -He/She didn't call the other units to see if they had Tylenol. During an interview on 4/6/21, at 4:10 P.M., the resident said the following: -He/She requested Tylenol at 2:00 P.M.; -His/Her back was aggravated more than normal; -His/Her pain was a 6 on a scale of 1-10; -He/She thinks he/she twisted wrong in therapy and his/her back was already a little fired up from running out of [MEDICATION(S)] yesterday; -His/Her lower spine has one vertebra that presses against his/her spine, and a disc that is not in the right place; -His/Her pain goes from his/her lower back, then down the left side of his/her body from his/her lower back, through the buttock, down the back of his/her left leg to his/her heel; -Surgery was not an option for him/her because the physician said it could paralyze him/her; -Before his/her admission to this facility he/she went to the pain clinic every month; -At the pain clinic he/she received steroid injections in his/her back; -His/Her pain at the lowest is a 3, which is tolerable, his/her normal, the pain is always there; -When his/her pain is at a 5, it interferes with what he/she wants to do because he/she will have to change positions frequently, he/she can't sit too long, lay too long, or walk too long because of the pain; -Four hours after he/she takes his/her [MEDICATION(S)] his/her pain gets up to a 5 and he/she is uncomfortable, after 6 hours his/her pain gets up to the 6 or 7 pain level which is when he/she can't sleep, can't get comfortable, he/she feels himself/herself get grumpy and anxious; -After several hours he/she starts to have withdrawal symptoms; -He/She will feel anxious, sweaty, his/her eyes water, and he/she has body aches like he/she has the flu, and the longer it goes the worse his/her withdrawal symptoms get; -He/She feels that way every morning now that the staff are giving him/her his/her last dose by 7:00 P.M.; -By 9:00 A.M. or 10:00 A.M. the next day he/she already feels terrible. During an interview on 4/7/21, at 5:30 P.M. CMT AAA said the following: -The facility uses a 1-10 pain scale, one the least pain and ten is the worst pain, or the faces for the residents that can't tell staff their pain level; -The resident was sometimes over a 5 on his/her pain scale, it depended on how his/her back was that day; -He/She used the resident's last dose of [MEDICATION(S)] at 3:00 P.M.; -The resident had a lot of anxiety when he/she was out of [MEDICATION(S)]. The resident worries about when it will come; -He/She let nursing administration know the pharmacy did not send the resident's [MEDICATION(S)]; -There was no night CMT, the position was cut on 3/1/21, and now the CMT on days works a 12 hour shift; -The day shift CMT tries to give all the bedtime medications before they leave at 7:00 P.M. or 7:30 P.M. During an interview on 4/7/21, at 5:30 P.M., ADON B said the following: -He/She called the pharmacy on 4/5/21 about the resident's [MEDICATION(S)]; -He/She thought it was a prescription issue and between the physician and the pharmacy; -The resident would have to take [MEDICATION(S)] if his/her [MEDICATION(S)] does not come; -[MEDICATION(S)] was not as strong as [MEDICATION(S)] and would not stop withdrawal symptoms. During an interview on 4/7/21, 9:17 A.M., pharmacy control technician ZZZ, said the following: -Pharmacy received a refill request for the resident's [MEDICATION(S)] on 2/10/21, and eight tablets were sent on 2/11/21; -Pharmacy received a refill request for the resident's [MEDICATION(S)] on 2/13/21, and the request had a message that a new script was needed; -Pharmacy received a refill request for the resident's [MEDICATION(S)] on 2/15/21, at 9:00 P.M., the request for the refill prescription was sent to the physician on 2/16/21, and it takes 24-48 hours to get a response; -Pharmacy received the prescription on 2/17/21 and sent 56 tablets on the 8:05 P.M. delivery; -Record showed the resident went to the hospital on 2/26/21; -Pharmacy received the refill request for the resident's [MEDICATION(S)] on 3/7/21 at 6:45 A.M. and sent out 56 tablets on 3/8/21 night delivery; -Pharmacy received a refill request for the resident's [MEDICATION(S)] on 3/30/21, and the system had a message ordered too soon, there was an error on the pharmacy side and it did not order the medication to be sent in the pharmacy system when it was able to refill; -On 4/5/21 the pharmacy sent eight tablets and requested a new prescription and had not received it at this time; -To get an emergency delivery the DON has to request a medication to be sent STAT (immediately), there was no STAT request on any of the resident's [MEDICATION(S)] refills. During an interview on 4/8/21, at 2:45 P.M., the resident's physician said the following: -The resident has [MEDICATION(S)] IR ordered four times a day routinely for chronic pain; -The facility is expected to order t

Based on interview and record review, the facility failed to ensure additional resident (Resident #48), was free from abuse, including mental anguish, when staff refused to allow the resident to smoke if he/she did not feed him/herself meals. The resident had tremors in his/her hands and arms and required assistance to eat. The smoking restriction had no basis and caused the resident to feel awful and to go hungry. Additionally, the facility failed to ensure sampled resident, Resident #141, was free from abuse when Resident #2 hit him/her on the head with a porcelain toilet tank lid. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to keep residents free from abuse when one resident (Residents #43) of 65 sampled residents and an additional resident (Resident #379), who resided on locked behavioral units, obtained alcohol and marijuana from staff. Resident #379 tested positive for marijuana on 12/8/20 and resident #43 tested positive for alcohol. Floor technician PP admitted to the administrator he/she brought marijuana into the facility for Resident #379. The facility failed to protect the residents from staff verbal and mental abuse when Licensed Practical Nurse (LPN) LLL yelled, cussed and accused additional Resident #304 of being at fault when another resident self harmed. The facility census was 170. Review of the facility's policy, Abuse, Neglect, Grievance Procedures, dated 11/28/16, showed the following: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. It is also the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; -Mistreatment, neglect, or abuse of residents is prohibited by this facility; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -The facility abuse prohibition program included screening, training, prevention, identification, reporting/investigating, and protection of the resident. 1. Review of Resident #48's significant change Minimum Data Set (MDS), a federally required assessment, dated 1/9/20, showed the following -Severe cognitive impairment; -Required extensive physical assistance from one staff member with eating; -Required limited physical assistance from one staff member for bed mobility, transfers, dressing, toilet use, and hygiene. Review of the resident's smoking care plan, last revised 1/12/20, showed the resident at times had increased tremors. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Regular diet; -Mechanical soft; -Two handled cups to increase fluid intake during meals; -Two health shakes three times a day with meals; -No order to restrict smoking if the resident did not eat. Review of the resident's care plan, revised 8/27/20, showed the following: -Mechanical soft, regular diet, two health shakes three times a day with meals and a divided plate; -Edentulous (no natural teeth) and has dentures but refuses to wear them; -Requires supervision and assist of one staff member at times for meals and eats in assist to dine dining room; -Uses two handled cups to increase fluid intake with a straw; -History of significant weight change and recent significant weight change; -Attempts to feed him/herself but will ask for staff assistance when he/she has increased tremors, assist the resident as needed; -Will let food run out of his/her mouth at times and will usually consume 100% of meals; -Allow extra time to eat as needed; -Aspiration risk-follow aspiration protocol; -Refuses meals at times, he/she will eat if rewarded with a candy bar at times; -No direction to prohibit resident from smoking if the resident did not feed him/herself. Review of the resident's annual MDS, dated [DATE], showed the following -Moderate cognitive impairment; -Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Weighs 112, significant weight gain not on a physician prescribe weight-gain regimen (resident had lost weight, not gained); -Supervision and set up with eating. Review of the resident's Weight Record, dated 1/19/21, showed the resident weighed 106 lbs. Review of the resident's care plan, revised 1/26/21, showed staff revised the resident's goal to have no significant decline in nutritional status. Review of the resident's Weight Record, dated 2/22/21, showed the resident weighed 102 lbs. Review of the Dietitian's Recommendations to Nursing Services, dated March 2021, showed the following recommendations regarding the resident: -Concern/Recommendation: Recommend Med Pass 2.0-90 cc (nutritional supplement), TID (three times daily) with med pass due to continued weight loss (significant in three and six months) and due to underweight weight status per BMI. Review of the resident's Weight Record, showed on 03/16/21, the resident weighed 98 pounds, a 22.10% loss in six months. Observation on 3/30/21, at 12:23 P.M.-1:30 P.M., showed the following: -Staff served the resident spaghetti, green beans, roll with butter on a divided plate and two glasses of tea in two handled cups with straws; -The resident appeared emaciated and his/her eyes were sunken; -The resident had spastic involuntary movements of both arms and hands at the elbow, wrist and fingers; -The resident asked the MDS Coordinator (MDSC) for help to eat; -The MDSC responded to the resident, You have to choose, I can help you eat, but then you can't smoke; -The resident responded, I want to smoke; -The MDSC walked away from the resident; -The resident picked up his/her fork and his/her spastic movements worsened; -After several attempts the resident had loaded his/her fork with spaghetti; -When the resident attempted to bring the spaghetti to his/her mouth the food flew off his/her fork onto the table, the resident's clothing, and the floor; -The resident sat his/her fork down; -The resident attempted to eat his/her spaghetti with his/her hands. When the resident picked up the spaghetti it flew out of his/her hands, and the resident put his/her hands in his/her lap; -At 12:44 P.M. the resident said, Will you please, please help me, I am hungry to the MDSC; -The MDSC responded, You know the rules, it is a restriction in your care plan and the physician ordered it, if I help you eat you cannot smoke, the MDSC walked away from the resident; -The resident picked up a handled cup of tea, his/her spastic movements worsened; -The resident's straw hit his/her forehead, cheeks and nose several times when the resident attempted to drink; -The resident sat in front of his/her food and did not attempt to eat; -At 1:05 P.M. the resident said, I want to eat and I want to smoke, will you help me? to the MDSC; -The MDSC responded, You can do it, get your belly full, and the MDSC walked away from the resident; -The resident attempted to load his/her fork with green beans, his/her spastic movements worsened, the green beans flew off the resident's fork and onto the table and the floor; -The resident attempted to load his/her fork with spaghetti, the spastic movements worsened, -When the resident attempted to bring the spaghetti to his/her mouth the food flew of his/her fork onto the table, the resident's clothing and the floor. During an interview on 3/30/21, at 2:52 P.M., CNA RR said the following: -The resident always needed help to eat; -Some of the staff make him/her choose to have assistance to eat or smoke; -He/She does not know why he/she has to feed himself/herself to smoke, they say it is a limitation; -The resident was not able to physically feed himself/herself; -The resident has had that limitation for several months; -The resident will choose smoking over eating. During an interview on 3/30/21, at 2:55 P.M., CNA II said the following: -A nurse on Homestead told staff if the resident did not feed himself/herself the resident could not smoke; -Today he/she could not let the resident smoke because the MDSC saw him/her feed the resident. During an interview on 3/31/21, at 7:45 P.M., Licensed Practical Nurse (LPN) BBB said the following: -Previous staff trained current staff that the resident has a limitation that if he/she does not feed himself/herself he/she cannot smoke, he/she does not know where the limitation came from; -He/She did not know what was on the resident's care plan. During an interview on 4/6/21, at 11:23 A.M., the resident said the following: -Staff never ask him/her what he/she wanted for lunch; -For a long time, like months, the staff would not let him/her smoke unless he/she fed him/herself. This made him/her feel awful; he/she wants to eat and wants to smoke. -Sometimes he/she couldn't feed himself/herself so he/she, Would just be hungry, he/she could not help that his/her arms shake. During an interview on 3/30/21, at 3:15 P.M., the Director of Nursing (DON) said the resident does not have limitations on when he/she can smoke. Staff are expected to help the resident if he/she needs assistance, sometimes his/her tremors are worse than other times. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/27/20, showed the following: -Staff did not assess the resident's memory; -Resident is understood by others and understands others; -Had no behaviors. Review of the resident's PASRR (Preadmission Screening and Resident Review), dated 7/11/19, showed he/she had been physically aggressive with a female staff member while living at his/her previous placement. Further review showed no history of physical aggression towards peers. Review of the resident's care plan, dated 10/22/19 and last reviewed on 8/3/20, showed the resident had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. He/She was at risk for alteration in mood/behavior related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He/She has a history of physical aggression. Review of the resident's nurses' notes, dated 12/26/20, showed at 12:30 A.M., a Code Blue was called due to the resident getting into a physical altercation with another resident. The resident was sitting by the nurses' station appearing calm and quiet. The other resident was injured with several lacerations to the face. When asked what happened, the resident said he/she felt as if the other resident was out to get him/her. The two residents had previously been arguing about the temperature of their room. Staff had went in and talked with the residents, redirected them and came up with a compromise. Resident #2 came out of his/her room to ask staff if he/she could shut his/her door, and the resident returned to his/her room with the door shut. Moments later Resident #2 came out of the room and told staff to call 911, I attacked him/her. Staff found Resident #141 sitting on the side of his/her bed injured and distraught. Other staff attended to Resident #141. Resident #2 was sent for a psychiatric evaluation. Review of the facility's investigation, dated 12/29/20, showed the following: -On 12/26/20, the resident came out of his/her room holding the back of the toilet (porcelain lid that covers the tank), and reported to staff he/she attacked his/her roommate (Resident #141) and staff should call 911. When staff entered the room, Resident #141 was sitting on the side of his/her bed with a laceration (cut) over his/her right eye, a laceration on his/her scalp and a scratch on his/her nose. Code Blue was immediately called and staff ensured the residents remained separated. Staff called 911 and provided first aid to Resident #141, then sent the resident to the hospital for treatment; -Upon interview with Resident #2, he/she refused to talk about the incident and claimed he/she did not know what happened to Resident #141; -Resident #141 reported he/she and Resident #2 could not agree over the room temperature, and then Resident #2 came over and knocked him/her in the head; -Staff reported Resident #141 had told staff he/she was unhappy with the temperature in the room and felt it was cold. The temperature in the room was set to 80 degrees. Resident #141 was observed wearing a coat, scarf and hoodie. Resident #2 was observed wearing a t-shirt and jeans and voiced he/she was hot. Staff were able to get the roommates to agree to a compromise of 75 degrees. Approximately ten minutes later, Resident #2 came out of his/her room with the lid to the toilet tank and told staff to call 911 because Resident #141 needed to be sent to the hospital; -Summary of findings: After reviewing statements, it was understood that after agreeing to compromise about the room temperature, Resident #2 went to get the lid from the toilet tank and hit Resident #141 on his/her head and face. Resident #2 does not have any history of physical aggression towards peers and it is not listed in his/her PASRR. During his/her stay at the facility, Resident #2 had not had any physical altercations or even verbal altercations. When leaving the room, staff reported that Resident #2 was calm and did not show any signs of agitation or anger. Resident #2's care plan showed he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #141's face sheet showed he/she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Did not have any behaviors or [CONDITION(S)]. Review of the resident's hospital discharge notes, dated 12/26/20, showed the resident had two lacerations (cuts) which required sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) and a left orbital lateral wall fracture (a break in the bone around the eye), inferior wall blowout fracture (a break in one or more bones around the eye) and nasal (nose) bone fractures. Review of the resident's care plan, dated 11/18/19 and last revised on 3/2/21, showed no documentation of a resident to resident altercation with Resident #2 resulting in lacerations to Resident #141's head and fractured orbital bone (bone around the eye). During interview on 3/29/21 at 10:49 A.M., Resident #141 said Resident #2 hit him/her in the head with the toilet lid because they were fighting over the temperature in the room. During interview on 4/7/21 at 8:13 P.M., Certified Nurse Aide (CNA) TT said the following: -He/She was working when Resident #2 hit Resident #141 with the toilet tank lid; -The residents had their call light on and staff said they were arguing about the temperature in the room. Staff set the room temperature at 72 degrees; -Resident #2 came walking up the hall with the toilet tank lid and told staff to call 911; -Resident #141 had blood on his/her head and the nurse assessed him/her. During interview on 3/31/21 at 8:30 P.M., Licensed Practical Nurse (LPN) DD said the following: -Resident #2 came out of his/her room and told staff he/she hit Resident #141 with the toilet tank lid and to call 911; -Staff called a Code Blue and found Resident #141 sitting on his/her bed with blood on his/her head; -Resident #141 was sent to the hospital and came back to the facility with stitches and a fractured orbital bone; -Resident #2 told him/her he/she didn't know why he/she hit Resident #141; he/she was just tired of Resident #141 making comments, but was non-specific as to what the comments were. 3. Review of Resident #379's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognition was intact; -Received antipsychotic and anti-anxiety medication daily. Review of the resident's care plan, dated 9/23/20, showed the following: -At risk for alteration in mood related to [CONDITION(S)], history of minimal confusion, being withdrawn, and causing management problems; -Intensive monitoring per unit and facility protocol to ensure protective oversight; -One on one visits as needed for venting of concerns/feelings; -Re-direct as able to encourage positive behavior choices. Review of the resident's nurse's notes showed the following: -On 12/8/20 at 4:40 P.M., the administrator interviewed the resident about being in possession of and smoking marijuana the day before. The resident admitted to having smoked marijuana the day before and said there was nothing the facility could do about it. The resident refused to say who provided the marijuana. The resident tested positive for marijuana on urinalysis. The medical director, police and guardian were notified. -On 12/11/20 at 9:15 A.M., the physician was made aware of the resident's continued physical and verbal behaviors. An order was received for the resident to be transported to the acute psychiatric hospital for evaluation and treatment. The guardian was notified. Review of the facility's Investigative Narrative Note, undated, showed the following: -It was reported by another resident that Staff PP brought drugs into Resident #379; -Floor technician PP was suspended pending the investigation; -Floor technician PP came into the facility the following day for an interview and was asked if he/she had brought any drugs or contraband into the facility. Floor technician PP admitted to the administrator he/she had brought in roaches for Resident #379. When asked what are roaches, Floor technician PP responded marijuana; -The administrator asked Floor technician PP if he/she understood it was against the rules of the facility and the law to bring marijuana in to residents, Floor technician responded, My bad; -Floor technician PP was terminated and asked to leave the facility; -A police report was filed; -Staff questioned Resident #379. The resident admitted to smoking marijuana, but would not tell administration who brought it in to him/her. The resident became agitated when questioned; -Resident #379 tested positive for marijuana on a drug test; -Summary: It was found Floor technician PP brought illegal drugs into the facility and he/she was terminated. Residents were educated on the danger of mixing illegal drugs with their medication regimens. During an interview on 3/30/21 at 2:50 P.M., the administrator said Floor technician PP admitted to her that he/she brought marijuana into the facility for Resident #379. During an interview on 4/6/21 at 5:50 P.M., the resident's guardian said the facility made him/her aware the resident tested positive for marijuana and they suspected a staff member brought it into the facility. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Review of Resident #43's PASRR, dated 12/15/12, showed the following: -He/She had a lengthy/significant history of polysubstance use/abuse; -He/She denied any significant history of alcohol problems, but did report using from age 13 until 18; -He/She sought treatments for abuse multiple times; -He/She was coherent, alert and oriented to person, place and time; -He/She had poor judgement and did not make good decisions; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's care plan, initiated on 11/6/19, showed the following: -He/She had mood swings, ups and downs, [CONDITION(S)], racing thoughts, difficulty completing activities of daily living (ADLs); -He/She began hallucinating at age 18- tactile/auditory/visual and required multiple psychiatric inpatient admissions and medication adjustments; -He/She was impulsive, impatient, disorganized, nervous and anxious; -He/She had a lengthy drug history with use of cannabis (marijuana), meth, and pills, but meth was drug of choice; -He/She was at risk for alteration in mood related to [CONDITION(S)] disorder, anxiety, [CONDITION(S)] disorder, and insomnia; -He/She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -Staff were to offer one-on-one time to allow him/her to voice his/her feelings/concerns, offer support/encouragement as needed/requested; -Staff were to assist him/her to use coping skills and provide examples as needed; -Staff were to redirect as able/needed to encourage positive behavior choices; -Social service was to consult as needed/requested. Review of the resident's progress note, dated 3/21/21 at 5:24 P.M., showed earlier that morning, LPN W was called over to the unit for another resident issue, and the resident's roommate said the resident had alcohol and was drunk. Upon investigation, the nurse found alcohol and pills in the resident's room. The resident's physician was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was negative for any drugs, but tested positive for alcohol. Review of the facility's RN (Registered Nurse) Investigation report showed the following: -Date of incident: 3/21/21; -Resident #139 reported to staff that Resident #43 had alcohol that Hall Monitor W had provided him/her; -Upon environmental rounds, alcohol was recovered along with several empty containers of alcohol; -Drug and alcohol screenings were conducted which were negative for drugs, but the resident's alcohol level was noted to be 0.08% (legal limit for drivers over age 21); -Resident #43 admitted to paying a staff member to get him/her alcohol and cigarettes, but denied receiving them from Hall Monitor W; -Review of camera footage showed Hall Monitor W never entered the resident's unit and stayed on his/her assigned unit; -After further questioning, the resident continued to deny that it was Hall Monitor W; -During investigation, several staff members were mentioned, however upon review of camera footage, Hall Monitor EE was noted to have been the only staff member on the hall out of all the accused staff members; -Hall Monitor EE was suspended due to the allegations. Review of Resident #139's written statement, provided by the facility, dated 3/21/21, showed Resident #43 told him/her he/she had been receiving alcohol from a person (and provided the person's first name), and he/she had been going to the end of the hall to meet him/her. During an interview on 3/29/21 at 10:51 A.M., the resident said staff personally brought him/her alcohol. He/She was given a small bottle of Crown Royal and Honey Turkey. He/She refused to disclose the staff's name, but mentioned the staff had been terminated. He/She said the employee approached him/her about bringing him/her the alcohol. He/She did not ask for the alcohol. During interview on 3/30/21 at 11:55 A.M., the administrator said the resident mentioned another staff's name who he/she said provided the contraband, but that particular staff member was never on the resident's unit. Empty bottles were found in resident's room and his/her blood alcohol (BAC) level was 0.08% (legal intoxication limit). During interview on 3/31/21 at 4:35 P.M., the resident said Hall Monitor EE had provided him/her with the alcohol. During an interview on 3/31/21 at 5:08 P.M., LPN FF said the resident had pseudo seizures (triggered by anxiety). He/She contacted the resident's physician, but the physician did not feel comfortable with ordering any medications for increased anxiety because the resident was getting medications and alcohol from other people and he/she did not know what else he/she could have access to. During an interview on 3/31/21 at 6:20 P.M., Certified Medication Technician (CMT) V said Hall Monitor EE had been known to bring drugs, alcohol, and cigarettes in for other residents, but residents would not tell on him/her. CMT V did not say how he/she knew this was occurring. During an interview on 4/8/21 at 4:00 P.M., CMT GG said the following: -He/She worked with Hall Monitor EE the night he/she allegedly brought alcohol to the resident (3/21/21); -He/She was the staff member who reported Hall Monitor EE's suspicious activity that night; -Hall Monitor EE kept going in and out of the facility and had a big bulge in his/her jacket pocket when he/she went into the resident's room, but was not bulging when he/she came out of resident's room; -Before that, Hall Monitor EE said he/she was going to go to the gas station; -Residents (no names provided) said Hall Monitor EE provided alcohol for residents and he/she told the charge nurse. During an interview on 5/3/21 at 12:00 P.M., LPN I said he/she worked the morning after resident allegedly consumed alcohol. It was brought to his/her attention that resident was not acting right. He/She assessed the resident who showed him/her the empty alcohol bottles, but would not tell him/her who supplied him/her with alcohol. Daily environmental rounds had been done the day prior with nothing found. The resident's roommate (#139) told staff the resident had alcoholic beverages and he/she was concerned. During interview on 3/31/21 at 4:30 P.M., the Assistant Director of Nurses (ADON) A said he/she reviewed six hours of camera footage from 3/20/21-3/21/21 and tracked each individual working. Video footage showed Hall Monitor EE took off his/her shoes and left them on the floor under a table in the common area and went to the shower room. He/She had a towel wrapped up, holding it like a baby and just had weird behavior. First thing the next morning (3/22/21), Hall Monitor EE alerted staff he/she had spent a lot of time with the resident because he/she had a bad night. The resident's roommate, Resident #139, reported to the environmental service director (EVS) Director and LPN I to check the resident's room. The resident had hidden something under his/her undergarments because there was an obvious disfigurement. He/She pulled down the undergarment and several small sized bottles of various alcoholic beverages (12 total), two packages of cigarettes, a lighter, CBD (cannabidiol - found in marijuana) oil, and three pills that appeared to look like [MEDICATION(S)] (anti anxiety prescription medication), fell out. Resident #139 informed staff that resident received pills and CBD oil in the mail. The resident's alcohol level was 0.08 several hours after ingestion. Hall Monitor EE was suspended. The resident told him/her Hall Monitor EE provided him/her with the alcohol. He/She saw a Snap Chat (social media application), conversation on the resident's phone. The resident asked Hall Monitor EE, How are you doing? I didn't tell anyone anything. During an interview on 4/7/21 at 8:30 A.M., the resident's guardian said he/she received a call from the facility who reported the resident was receiving alcohol. The resident should not be provided alcohol. During interview on 4/30/21 at 12:50 P.M., the resident's physician said the resident would not decline any type of drug or alcohol. The resident would seek it out. Staff informed her of the situation and she would expect that staff not provide residents street drugs or alcohol. Staff should protect residents from harm. 5. Review of Resident #304's undated Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -admitted d 12/23/19; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's significant change MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's nurses' notes, dated 3/31/20, showed the following: -Up in the hall socializing appropriately with staff and peers. Dressed appropriately and denied complaints or concerns; -No feelings of agitation or negative thoughts. -No staff documentation of altercations or behaviors occurred on 3/31/20. Review of the facility undated RN Investigation Report, Investigative Narrative Note, showed the following: -CMT MMM reported to facility administration on the night of 3/31/20 that LPN LLL yelled at Resident #304. Another resident self-harmed and LPN LLL said it was Resident #304's fault. Certified Nurse Aide (CNA) MMM reported the incident to the Director of Nursing (DON) at the end of his/her shift. CMT MMM provided four written statements from staff who witnessed the incident; -Staff documented during interview Resident #304 said a resident (unknown name) told him/her a resident (friend) cut his/her wrists. He/She was very upset and requested a cigarette from the charge nurse. The charge nurse, LPN LLL, yelled at him/her and said, It's all your fault the resident did what he/she did. Resident #304 became very upset and yelled back, It was not! LPN LLL came out of the nurses' station and yelled back, Yes it was! Resident #304 said he/she walked to his/her room and LPN LLL followed. He/She yelled at LPN LLL to get out of his/her room. LPN LLL told the resident no that he/she did not have to listen to the resident, but the resident had to listen to him/her because he/she was the nurse. LPN LLL then left the room; -Staff documented during interview Resident #82 recalled the incident the same as Resident #304. Resident #82 was in the hallway when he/she heard LPN LLL yell at Resident #304 that it was all Resident #304's fault that a resident had self-harmed. Resident #82 approached Resident #304's room. LPN LLL was in the resident's room, but he/she could not hear what was said. Staff documented during interview, CNA GGG said he/she observed Resident #304 yelling and cussing at LPN LLL that it was not his/her fault. LPN LLL came out of the nurses' station and loudly said he/she did not care and he/she was not going to sugar coat anything. They needed to stop and think about their actions and how it affected others. CNA GGG attempted to take Resident #304 to his/her room, LPN LLL followed the resident into the room and was still talking to him/her about the situation. Resident #304 left his/her room and entered Resident #82's room. Resident #82 told staff to stay out and LPN LLL replied, Don't tell me what to do. LPN LLL left and said, I'll remember that; -Staff documented during interview, CNA NNN said he/she was present when the incident occurred. Resident #304 was upset due to another resident self-harming and asked CNA NNN for a cigarette. CNA NNN directed the resident to ask the charge nurse. Resident #304 asked LPN LLL and LPN LLL said it was not his/her problem. Resident #304 became more upset and LPN LLL replied, I don't care. Then LPN LLL told the resident it was his/her fault and he/s

Based on observation, interview and record review, the facility failed to follow the facility's weight loss policy for weekly weights, re-evaluation of the care plan and interventions with continued weight loss, notification of the physician for continued weight loss, and failed to provide assistance with eating for one sampled resident (Resident #32) of 65 sampled residents, who had a 10% weight loss in one month and one additional resident (Resident #48) who had a 22% weight loss in six months. The facility staff also failed to re-evaluate the resident's care plan for weight loss, provide adaptive equipment, provide assistance, and provide desserts and all items on the menu for a diabetic resident (Resident #62), who had significant weight loss in the previous six months. The facility also failed to ensure two sampled residents (Residents #172 and #136) and four additional residents (Residents #122, #126, #8 and #25) received supplements as indicated on their meal tickets. The facility census was 170. Review of the facility policy, Unintentional Weight Loss, dated 2017, showed the following: -Discussion: Unintentional weight loss can have serious implications for older adults. Studies indicate unintentional weight loss can lead to malnutrition, poor wound healing, risk of pressure ulcers, decline in function and inability to fight infection. Unintentional weight loss can be rapid or sometimes slow and insidious. It is important that systems are in place to detect, assess and develop an individualized plan of care for persons with unintentional weight loss; -Causes/Risk Factor of Unintentional Weight Loss: Frequent causes of unintentional weight loss include inadequate oral food and beverage intake to match activity, inadequate absorption and metabolism of foods consumed, a wasting disease that increases metabolic rate such as in cancer, AIDs, [CONDITION(S)], or excess energy during psychological or emotional stress; -Consideration of Environmental Factors Affecting Intake: It is important to consider the environmental factors contributing to decreased appetite. Factors to evaluate include food and meal time preference, the need for assisted devices for self-feeding, the temperature of the food served, the appearance of the meal, the atmosphere of the dining room and the need for coaching or cueing at the meal and proper body positioning; -Screening to Identify Individuals with Unintentional Weight Loss: Weight can be a useful indicator of nutritional status, when evaluated in context with the individual's personal history and overall condition. Recent changes in weight or insidious weight loss may indicate a nutritional problem. Therefore, it is important that a health care community maintain a screening program to identify individuals at risk for unintentional weight loss. In a health care community the Center for Medicare and Medicaid Services (CMS) roster/matrix report generated from the Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) identifies individuals that have experienced weight loss. Weight tracking tools, often available in meal card programs of care plan software, can all be helpful tools to identify and monitor for unintentional weight loss. Observation of individuals at mealtime is often the best way to identify people that have a change in normal eating patterns or are eating poorly and at risk for weight loss. Current standards for weighing individuals in health care communities recommend weighing the individual for the first four weeks after admission at least monthly thereafter to help identify and document trends such as insidious weight loss. More frequent weighing is often suggested for individuals at risk or with unintentional weight loss. In some cases, weight monitoring is not indicated such as the terminally ill that requests comfort care. When evaluating weight it is important to take into consideration current medical conditions such as the following: Fluid loss and retention, Altered nutrient intake, absorption and utilization, Chewing abnormalities, Swallowing abnormalities, Functional Ability, Medications, Goals and prognosis, Lab analysis/diagnostic evaluation; -Individual Preferences Honored and Choices Provided at Meals: Offering choices of food at meals and giving people foods they enjoy eating has been shown to decrease the need for fortified food or supplements. The New Dining Practice Standards of the Pioneer Network report that individuals offered a choice among a variety of foods and fluids twice a day may be a more effective intervention than oral supplementation. Therefore it is recommended to attempt food favorites before initiating a nutritional supplement or nutritional supplementation between versus with meals to encourage food intake at meals; -Consideration of Environmental Factors Affecting Intake: It is important to consider the environmental factors contributing to decreased appetite. Factors to evaluate include food and meal time preference, the need for assisted devices for self-feeding, the temperature of the food served, the appearance of the meal, the atmosphere of the dining room and the need for coaching or cueing at the meal and proper body positioning. Breakfast is often the meal consumed the best in the day and offers excellent opportunities to increase caloric and protein intake; -Registered Dietitian/Dining Services Manager Role: If it is determined that the individual requires additional calories and /or protein, the Registered Dietitian or Dining Services Manager assesses the individual with unintentional weight loss to determine the goal for calories and/or protein. Improving intake via wholesome foods is generally preferable to adding nutritional supplements. The Registered Dietitian or Dining Services Manager will work with the individual to determine the food or foods that the person might enjoy and be willing to consume. It is very important that an individualized plan of care be developed, based on the individual's physical condition and preferences. The plan should be documented in the individual's medical record and care plan. Breakfast is often the meal consumed best in the day and offers excellent opportunities in increase caloric and protein intake; -Ongoing Monitoring and Adjusting: For individuals with unintentional weight loss, monitoring is vital after plan of care implementation to assess progress on nutritional related goals. Goals may need to be modified and new interventions implemented based on the individuals's responses to current interventions, their weight and other factors related to their medical condition. Review of the undated facility policy, Nourishments, showed the following: -Nourishments will be provided to offer therapeutic nutritional support. A physician's order will be required; -Procedure: Residents receiving nourishments may include those who are underweight, who are on therapeutic diets, and those with poor intake, weight loss, skin problems, low [MEDICATION(S)] and other problems addressed on care plans; -A Nourishment and Supplement List is maintained for residents receiving physician-ordered supplements, renal diets and calorie-controlled diets; -This list is posted in Dietary Department; -These nourishments are delivered by Dietary in individual portions that are labeled with the resident's name, date and time; -Percentage of consumption of these nourishments is recorded on the consumption log sheets by the nursing department. Review of the undated policy, House Supplements, showed the following: -When an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . At least 6 grams of protein and 180 calories will be provided in all products used as house supplements; -Procedure: House supplements will be dated when taken out of the freezer; -Cartons will not be sent out of the kitchen without being individually dated; -A physician's order must be received for a house supplement to be given; -Frequency and amounts must be specific in the physician's order; -House supplements will be delivered at routine meal times in this facility unless otherwise specified in the physician's order; -The preferred house supplement is a shake supplement. 1. Review of Resident #48's significant change Minimum Data Set (MDS), a federally required assessment, dated 1/9/20, showed the following -Severe cognitive impairment; -Required extensive physical assistance from one staff member with eating; -Required limited physical assistance from one staff member for bed mobility, transfers, dressing, toilet use, and hygiene. Review of the resident's smoking care plan, last revised 1/12/20, showed the resident at times had increased tremors. Review of the resident's Physician's Orders, dated 3/21/20, showed the following: -Regular diet; -Mechanical soft; -Two handled cups to increase fluid intake during meals; -Two health shakes three times a day with meals. Review of the resident's care plan, revised 8/27/20, showed the following: -Mechanical soft, regular diet, two health shakes three times a day with meals and a divided plate; -Edentulous (no natural teeth) and has dentures but refuses to wear them; -Requires supervision and assist of one staff member at times for meals and eats in assist to dine dining room; -Uses two handled cups to increase fluid intake with a straw; -History of significant weight change and recent significant weight change; -Attempts to feed him/herself but will ask for staff assistance when he/she has increased tremors, assist the resident as needed; -Will let food run out of his/her mouth at times and will usually consume 100% of meals; -Allow extra time to eat as needed; -Aspiration risk-follow aspiration protocol; -Assess for any change in nutritional intake as needed; -Dietary consult as needed/ordered; -Refuses meals at times, he/she will eat if rewarded with a candy bar at times; -Obtain labs as ordered-report results to physician when available; -Obtain weights as ordered/needed-report significant gain/loss to physician promptly; -Offer diet as ordered; -Therapy to evaluate and treat as ordered/needed; -No direction to prohibit resident from smoking if the resident did not feed him/herself. Review of the resident's Weight Record, dated 9/8/20, showed the resident weighed 125.8 pounds (lbs.). Review of the resident's quarterly MDS, dated [DATE], showed the following -Moderate cognitive impairment; -Supervision and set up with eating; -Weight 126 lbs Review of the resident's Weight Record, showed the following: -10/15/2020 121. lbs.; -11/1/2020 113.0 lbs.; -12/14/2020 112.0 lbs. Review of the resident's annual MDS, dated [DATE], showed the following -Moderate cognitive impairment; -Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Weighs 112, significant weight gain not on a physician prescribe weight-gain regimen (resident had lost weight, not gained); -Supervision and set up with eating. Review of the resident's Weight Record, dated 1/19/21, showed the resident weighed 106 lbs. Review of the resident's care plan, revised 1/26/21, showed staff revised the resident's goal to have no significant decline in nutritional status. There was no evidence any new interventions were added or current interventions were revised. Review of the resident's Dietitian Note, dated 1/26/21, showed the following: -Resident remains on a mechanical soft diet with two health shakes three times a day and two handled cups; -Resident having variable intake by mouth recently, often refusing meals; -Height is 63 (inches); -January 21 weight: 106 lbs., -Down 6 lbs. in one month (5.4% loss), -Down 15 lbs. in three months (12.4% loss), down 10 lbs. in six months. -BMI (Body Max Index) = 18.8 - low-end of normal weight range; -No further recommendations at this time; -Will continue to follow and be available as needed. Review of the resident's Weight Record, dated 2/22/21, showed the resident weighed 102 lbs. Review of the resident's Dietitian Note, dated 2/27/21, showed the following: -Resident remains on a mechanical soft diet with two health shakes three times a day and two handled cups; -Continues to eat fairly well, with 76-100% of most meals consumed; -Does occasionally skip meals; -Height is 63; -February 21 weight: 102 lbs; -Down 4 lbs. in one month; -Down 11 lbs. in 3 and 6 months (9.7% loss); -BMI = 18.8 - low-end of normal weight range; -No further recommendations at this time; -Will continue to follow and be available as needed. Review of the Dietitian's Recommendations to Nursing Services, dated March 2021, showed the following recommendations regarding the resident: -Concern/Recommendation: Recommend Med Pass 2.0-90 cc (nutritional supplement), TID (three times daily) with med pass due to continued weight loss (significant in three and six months) and due to underweight weight status per BMI. Review of the resident's Weight Record, showed on 03/16/2021, the resident weighed 98 pounds, a 22.10% loss in six months. Review of the spreadsheet menu for lunch on 3/30/21, showed residents were to receive spaghetti with meat sauce, Italian tossed salad (green beans were substituted for all residents), fruit cobbler (item not prepared by staff and residents received cake instead) and garlic bread (residents received a dinner roll). Observation on 3/30/21, at 12:23 P.M.-1:30 P.M., showed the following: -Staff served the resident spaghetti, green beans, roll with butter on a divided plate and two glasses of tea in two handled cups with straws; -The resident appeared emaciated and his/her eyes were sunken; -The resident had spastic involuntary movements of both arms and hands at the elbow, wrist and fingers; -The resident asked the MDS Coordinator (MDSC) for help to eat; -The MDSC responded to the resident, You have to choose, I can help you eat, but then you can't smoke; -The resident responded, I want to smoke; -The MDSC walked away from the resident; -The resident picked up his/her fork and his/her spastic movements worsened; -After several attempts the resident had loaded his/her fork with spaghetti; -When the resident attempted to bring the spaghetti to his/her mouth the food flew off his/her fork onto the table, the resident's clothing, and the floor; -The resident sat his/her fork down; -The resident attempted to eat his/her spaghetti with his/her hands. When the resident picked up the spaghetti it flew out of his/her hands, and the resident put his/her hands in his/her lap; -At 12:44 P.M. the resident said, Will you please, please help me, I am hungry to the MDSC; -The MDSC responded, You know the rules, it is a restriction in your care plan and the physician ordered it, if I help you eat you cannot smoke, the MDSC walked away from the resident; -The resident picked up a handled cup of tea, his/her spastic movements worsened; -The resident's straw hit his/her forehead, cheeks and nose several times when the resident attempted to drink; -The resident sat in front of his/her food and did not attempt to eat; -At 1:05 P.M. the resident said, I want to eat and I want to smoke, will you help me? to the MDSC; -The MDSC responded, You can do it, get your belly full, and the MDSC walked away from the resident; -The resident attempted to load his/her fork with green beans, his/her spastic movements worsened, the green beans flew off the resident's fork and onto the table and the floor; -The resident attempted to load his/her fork with spaghetti, the spastic movements worsened, -When the resident attempted to bring the spaghetti to his/her mouth the food flew of his/her fork onto the table, the resident's clothing and the floor; -At 1:16 P.M., the resident asked certified nurse assistant (CNA) II for assistance; -CNA II did not offer to reheat the resident's food; -CNA II fed the resident and he/she consumed 75% of his/her meal; -The resident was not served cake or his/her nutritional shakes. Review of the resident's meal ticket showed the following: -Regular diet; -Mechanical Soft; -Divided plate; -Two handled cups with a straw; -Ground meats with gravy. -The meal ticket did not include the resident's two health shakes. During an interview on 3/30/21, at 2:52 P.M., CNA RR said the following: -The resident always needs help to eat; -Some of the staff make him/her choose to have assistance to eat or smoke; -He/She does not know why he/she has to feed himself/herself to smoke, they say it is a limitation; -The resident was not able to physically feed himself/herself; -The resident has had that limitation for several months; -The resident will choose smoking over eating. During an interview on 3/30/21, at 2:55 P.M., CNA II said the following: -A nurse on Homestead told staff if the resident did not feed himself/herself the resident could not smoke; -Today he/she could not let the resident smoke because the MDSC saw him/her feed the resident. During an interview on 3/30/21, at 3:15 P.M., the Director of Nursing (DON) said the resident does not have limitations on when he/she can smoke. Staff are expected to help the resident if he/she needs assistance, sometimes his/her tremors are worse than other times. Review of the resident's Dietitian Note, dated 3/31/21, showed the following: -Resident remains on a mechanical soft diet with two health shakes three times a day and two handled cups; -Continues to eat fairly well, with 76-100% of most meals consumed; -Does occasionally skip meals; -Height is 63; -March 21 weight: 102 lbs. -Down 4 lbs. in one month; -Down 14 lbs. in three months, a 12.5% wt. loss; down 28 lbs. in six months, a 22.2% wt. loss. BMI = 17.4 - underweight weight range; -Recommend adding Med Pass (nutrition supplement) 2.0 - 90 cubic centimeter (cc) three times at this time due to weight loss (significant in three and six months), and due to underweight weight status per BMI; -Will continue to follow and be available as needed. During an interview on 3/31/21, at 7:45 P.M., Licensed Practical Nurse (LPN) BBB said the following: -Previous staff trained current staff that the resident has a limitation that if he/she does not feed himself/herself he/she cannot smoke, he/she does not know where the limitation came from; -He/She did not know what was on the resident's care plan. Observation on 4/6/21, at 10:58 A.M., showed the following: -CNA RR assisted the resident from bed to a standing position; -When the resident stood, his/her pants slid down and fell to the floor. During an interview on 4/6/21 at 10:58 A.M., CNA RR said a lot of the resident's pants were too big now. During an interview on 4/6/21, at 11:23 A.M., the resident said the following: -Staff never ask him/her what he/she wanted for lunch; -For a long time, like months, the staff will not let him/her smoke unless he/she feeds him/herself. This made him/her feel awful; he/she wants to eat and wants to smoke. -Sometimes he/she couldn't feed himself/herself so he/she, Would just be hungry, he/she could not help that his/her arms shake.; -He/She liked shakes, and gets them once in a while; -He/She does not get two shakes every meal. Observation on 4/6/21, at 12:25 P.M., showed the following: -Staff served the resident his/her meal; -The resident had two handled glasses one with tea and one with milk; -The staff did not serve the resident his/her two health shakes. Review of the Physician's Orders on 4/12/21, showed no documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Care Plan, on 4/12/21, did not show Med Pass 2.0 90 cc three times a day. Review of the resident's medical record did not show documentation of weekly weights. During an interview on 4/12/21, at 4:42 P.M., the DON said the resident's health shakes should be on the resident's dietary ticket. 2. Review of Resident #32's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Physician's Orders, dated 11/13/19, showed the following: -No Added Salt diet; -Regular texture; -Thin/Regular consistency; -Large portions at all meals. Review of the resident's Physician's Orders, dated 12/10/19, showed the physician ordered [MEDICATION(S)] Packet (nutritional supplement) give 1 packet by mouth two times a day. Review of the resident's Physician's Orders, dated 1/3/20, showed the physician ordered health shakes three times a day with meals. Review of the resident's weight record, dated 9/16/20, showed the resident weighed 124 lbs. Review of the resident's Care Plan, revised on 9/22/20, showed the following: -Regular no added salt diet with large portions; -History of dysphagia (difficulty swallowing); -Wears dentures; -Eats in the assisted dining room on Meadowbrook related to aspiration risk with the assistance of restorative nursing staff; -Health shakes three times a day with meals; -Risk factors include mouth pain, difficulty chewing, aspiration, weight instability and abnormal lab values; -Needs encouragement to finish his/her meals; -Has had significant weight loss; -Goal will not have decline in current nutritional status through next review; -Dietician consult as needed; -Provide supervision during meals; -Tray set up as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Supervision and set up with eating; -Range of motion limited to one upper extremity; -Weight 126 lbs.; -Mechanically altered diet. Review of the resident's weight record showed the following: -On 10/14/20 126 lbs.; -On 11/1/20 126 lbs. Review of the resident's Progress Notes, dated 12/9/20, showed the Nurse Practitioner documented no reported concerns with the resident's appetite. Review of the resident's weight record, dated 12/14/20, showed the resident weighed 112 lbs. (11% weight loss in one month). Review of the resident's medical record showed no evidence facility staff notified the resident's physician of his/her weight loss. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Supervision and set up with eating; -Loss of liquids/solids from mouth when eating or drinking, pocketing and choking; -Weight 112 lbs. (10% wt loss in one months); -Significant weight loss, not on a physician prescribed plan; -Mechanically altered and therapeutic diet. Review of the resident's medical record did not show re-evaluation of the resident's current interventions for weight loss. Review of the resident's Progress Notes, dated 1/13/21, showed the Nurse Practitioner documented no concerns with appetite reported. Review of the resident's Progress Notes, dated 2/10/21, showed the Nurse Practitioner documented all diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's weight record showed the following -On 2/22/21 112 lbs.; -On 3/16/21 111 lbs. (a 10.48% weight loss in six months.) Review of the resident's medical record showed no evidence facility staff notified the physician regarding the resident's initial significant weight loss in December, or continued weight loss in February or March. Review of the Dietitian's Recommendations to Nursing Services, dated March 2021, showed the following: -Concerns/Recommendations: Recommend Med Pass 2.0-90 cc TID (three times daily) due to continued weight loss (significant in six months) and due to decreased PO (by mouth) intake; -Can discontinue the [MEDICATION(S)] BID (twice daily) if desired, he/she no longer has any skin issues; -The med pass will provide more calories and protein than the [MEDICATION(S)]. Review of the facility's Diet Roster-By Diet, dated 3/29/21, showed the following for the resident: -Diet: Regular; -Diet Other: NAS (no added salt), Health Shakes TID (three times daily), large portions; -Texture: Regular; -Dislikes: Spinach. Review of the Dietitian Note, dated 3/31/21, showed the following: -Resident remains on a regular, no added salt diet with large portions; -[MEDICATION(S)] two times a day; -Health shakes three times a day with meals; -Resident has not been eating as well, having a variable intake; -Eating 0-100% of meals per documentation; -Height: 64; -March 2021 weight: 111 lbs., down 1 lb. in one and three months, down 13 lbs. in six months, a 10.5% weight loss; -BMI = 19.1 - lower end of normal weight range; -Recommend adding Med Pass 2.0 (nutritional supplement) - 90 cc three times a day at this time due to continued weight loss (significant in six months) and decreased intake of meals; -Will continue to follow and be available as needed. Review of the resident's medical record on 4/13/21, showed no evidence the Med Pass 2.0 was implemented as recommended on 3/31/21, or weekly weights since the resident's initial significant weight loss on 12/14/20. Observation on 3/30/21, at 12:43 P.M., showed the following: -Resident sat in his/her wheel chair at the dining room table in the assist to dine dining room on Meadowbrook; -Staff served the resident spaghetti, green beans, a roll (no butter) on a regular plate, and cake in a Styrofoam bowl; -The resident with paralysis of his/her left arm, attempted to eat with his/her right arm; -Each time the resident tried to load his/her fork with spaghetti, the plate slid away from him/her or the food fell off the edge of the resident's plate; -The resident pushed his/her plate away; -Staff did not assist or cue the resident; -He/She consumed 10% of his/her spaghetti, ¾ of his/her cake, and his/her mighty shake (supplement). Review of the resident's Progress Note, dated 4/8/21, showed the Nurse Practitioner documented the following: -Weight: 111 pounds; -Height: 64 inches; -BMI: 19.1; -Chief Complaint / Nature of Presenting Problem: Interval medical round and medication reconciliation; -Nursing reports a poor appetite and mostly just drinks his/her health shakes; -His/Her weight in October 2020 was 126 lb.; -Weight for March 2021 is 111 lb. -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/12/21, at 2:24 P.M., CNA LL said the following: -He/She does not know which residents have weight loss; -The resident does not always want to get up for breakfast. During an interview on 4/12/21, at 3:40 P.M., LPN BBB said the following: -He/She did not know if the resident had a weight loss; -The resident does not always get up for breakfast; -He/She eats in the assisted dining room and staff should help the resident if he/she needs it; -He/She was not sure if the resident has supplements or interventions for weight loss. 3. Review of Resident #62's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] \mellitus, arthritis, [CONDITION(S)] disease (disease which may affect movement), anxiety, dysphagia (difficulty swallowing); -Requires supervision and set up with and eating; -Weight 228 lbs.; -Therapeutic diet. Review of the resident's Weight Record, showed the following: -On 8/14/20 206 lbs.;(9.6% weight loss in one month) -On 9/16/20 210 lbs. Review of the resident's annual MDS, dated [DATE], showed the following: -Weight 217 lbs.; -Weight gain, not on physician prescribed program; -Therapeutic diet. Review of the resident's Weight Record, showed the resident's weight on 11/1/20, at 208 lbs. Review of the resident's Care Plan, last revised on 11/19/20, showed the following: -Regular low concentrated sweets diet; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Wears dentures; -Eats all meals in the assisted dining room (on Meadowbrook); -Aspiration risk; -Goal will maintain current nutritional intake; -Administer insulin and medication as ordered; -Dietitian consult as needed; -Weighted mug, weighted utensils, and divided plate for meals to increase food and drink intake and decrease spillage; -Report significant weight changes to the physician; -Offer substitutes if the resident refuses what is being offered; -Provide supervision during meals and tray set up assistance. Review of the resident's Weight Record, dated 12/6/20, showed the resident weighed 186 lbs. (a 9.45% weight loss in one month). Review of the resident's care plan showed no evidence staff re-evaluated goals and interventions after the resident lost more weight. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight gain, not on physician prescribed program; -Mechanically altered and therapeutic diet. Review of the resident's Weight Record, dated 1/19/21, showed the resident's weight at 188 lbs. Observation on 3/29/21, at 12:35 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table on Homestead; -CNA LL served the resident ground meat, shredded cheese, black beans on a flat Styrofoam plate, tomatoes in a Styrofoam bowl, plastic utensils, and a glass of tea; -The resident said, My food is cold; -The resident said he/she did not know why his/her food was on a Styrofoam plate; -The resident attempted to load his/her utensils and the plate moved across the table; -The resident had tremors in his/her hands; -The resident dropped his/her fork; -The resident attempted to load beans on his/her spoon; -The beans fell off the edge of the resident's plate; -The resident pushed his/her plate away and left the table; -The resident consumed less than 25% of his/her meal; -Staff did not give the resident a weighted mug, a divided plate or weighted utensils. Review of the resident's meal ticket showed the following: -CCHO (consistent carbohydrate diet) low concentrated sweets; -Mechanical soft; -Divided plate; -Adaptive equipment per therapy. Observation on 3/30/21, at 12:52 P.M., showed the following: -The resident sat in his/her wheel chair at the dining room table in the assist dining room on Meadowbrook; -Staff served the resident spaghetti, green beans and a roll on a divided plate, cake, a glass of tea, regular utensils, and two chocolate milk cartons; -The resident fed himself/herself; -The resident's plate moved across the table as he/she ate; -The resident dropped his/her fork two times during the meal; -Staff did not give the resident a weighted mug or weighted utensils; -A licensed nurse did not supervise the meal. Observation on 3/31/21, at 12:31 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table in the assist dining room on Meadowbrook; -Staff served the resident ground turkey, mashed potatoes and gravy, spinach on a divided plate and a glass of tea; -Staff did not serve the resident dessert (other residents were served cake); -The resident did not have a weighted cup or weighted utensils. Observation on 3/31/21, at 5:50 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table in the assist dining room on Meadowbrook; -Staff served the resident a chicken salad sandwich and cheese curls on a divided plate, regular si

Based on observation, interview, and record review, the facility failed to provide two residents (Residents #1 and #2), with mental illness and a history of drug abuse, who resided on one of the facility's locked units, with protective oversight when both residents exited the facility through a window, without staff knowledge. Resident #2 had eloped from previous facilities, and the facility had identified the resident as being at risk for elopement. Staff reported last seeing the residents on 6/8/20 at approximately 1:30 P.M. Staff discovered the residents were not in the facility on 6/8/20 at approximately 4:45 P.M. Per facility administration, staff were to visually monitor the residents at least hourly. A sample of seven residents was selected for review. The facility census was 175. The administrator was notified on 6/10/20 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 6/8/20. The IJ was removed on 6/10/20, as confirmed by surveyor onsite verification. Record review of the facility's Intensive Monitoring/Visual Check Policy and Procedure, dated 4/6/17, showed the following: -A licensed nurse will monitor residents who require intensive monitoring due to medical behavior/psychiatric symptoms and will be monitored with visual face checks; -Intensive monitoring is defined as hourly checks by a licensed nurse or one-on-one monitoring by a designated employee assigned by the licensed nurse; -Face-to-face check is defined by the employee visually seeing the face of the resident; -Residents who show poor impulse control including verbal/physical aggression, elopement ideation, suicide/homicide ideation, decompensation mentally or medically may also be placed on one to one or two to one (within eye sight of the resident at all times) monitoring at the discretion of the administrative staff; -All residents on each unit will be monitored by visual face checks at least every two hours by a licensed nurse or more intensive monitoring by the licensed nurse every hour; -Special units will not be left unattended at any time; -Certified nurse assistants (CNAs) will continue to monitor residents at the discretion of administration. This provides direction only to the CNAs, and the licensed nurse will be the only designated employee to guarantee face checks are provided unless the resident required one on one monitoring by the designated employee assigned by the licensed nurse; -CNAs can be provided direction to monitor the resident in a timely manner at the discretion of administration or a medical or behavior decompensation; -The facility recognizes that the licensed nurse is the only truly dedicated employee to provide face checks every two hours, or if required more intensively every one hour. The facility will not depend on the CNAs to guarantee intensive monitoring checks. However, the administration will continue to assign time checks with the understanding that the CNA's time may be based upon the needs of the resident and assigned duties in the facility. 1. Review of Resident #1's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -His/Her [DIAGNOSES REDACTED]. -He/She had a legal guardian. Review of the resident's elopement risk assessment, dated 4/3/20, showed the resident was not at risk for elopement. Review of the resident's Preadmission Screening and Resident Review (PASRR; a federal assessment utilized to ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) Level II, dated 4/9/20, showed the following: -The resident had a history of [REDACTED]. -The resident was hospitalized in an inpatient psychiatric treatment unit from 1/30/20 until placement in the facility on 4/3/20; -The psychiatric hospital felt the resident needed a guardian to assist with decisions and support. A legal guardian was recently appointed; -The resident had [MEDICAL CONDITIONS] disorder, neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness), [MEDICATION NAME] dependence, cannabis dependence, and [MEDICATION NAME] induced [MEDICAL CONDITION]; -The resident had labile mood, poor decision making, low average intelligence, and impulsivity problems; -The resident had past legal problems related to drug use; -The resident had auditory and visual hallucinations with some question as to whether this was substance related; -Current psychiatric support services included a secured/behavioral unit; -Due to a [MEDICAL CONDITION], the resident required assistance with decision making from guardian and staff intervention to help; -The resident had previously lived with a boyfriend/girlfriend and his/her family member. The resident reported the boyfriend/girlfriend used drugs with him/her; -The resident required ongoing structure and support to support and manage residual effects of a [MEDICAL CONDITION]. The resident's memory was poor, and he/she could be impulsive and make poor decisions. Review of the resident's care plan, dated 4/9/20, showed the following: -The resident had a history of [REDACTED]. -Allow the resident time to voice his/her feelings and frustrations; -Provide the resident with one-on-one monitoring as needed to ensure protective oversight. (The resident's care plan did not specify how often staff should monitor the resident.) Review of the resident's physician order [REDACTED]. -[MEDICATION NAME] (medication used to treat some mental disorders) 15 milligrams (mg) daily for [MEDICAL CONDITION]; -[MEDICATION NAME] (anti-manic medication) 15 mg three times a day for [MEDICAL CONDITION] disorder; -[MEDICATION NAME] (medication to regulate blood sugar) 1500 mg every evening for diabetes; -Toperimate (medication used in the treatment of [REDACTED]. Review of the resident's face check documentation, dated 6/8/20, showed the following: -At 2:25 P.M., Certified Medication Technician (CMT) C electronically signed a face check was completed; -At 3:34 P.M., CMT C electronically signed a face check was completed; -At 4:00 P.M., CMT C electronically signed a face check was completed; -At 4:37 P.M., CNA E electronically signed a face check was completed. 2. Review of Resident #2's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -His/Her [DIAGNOSES REDACTED]. -He/She had a legal guardian. Review of the resident's elopement risk assessment, dated 4/16/20, showed the following: -The resident had a history of [REDACTED].>-Monitor the resident's location frequently; -Notify staff of elopement risk. Review of the resident's PASRR/Level II Evaluation, dated 4/23/20, showed the following: -The resident had a history of [REDACTED]. -The resident had been in and out of drug treatment facilities frequently; -The resident's [DIAGNOSES REDACTED]. -The resident had a history of [REDACTED]. -The resident had problems with insight and judgement; -The resident had auditory and visual hallucinations and delusions; -Current psychiatric support services required were a secured/behavioral unit and guardianship; -A secured nursing facility with 24 hour protective oversight for medication administration and monitoring was recommended due to risk of elopement. The resident was recently missing for several weeks and off of medications leading to exacerbation of psychiatric symptoms and substance use. Review of the resident's physician order [REDACTED]. -[MEDICATION NAME] 10 mg daily for [MEDICAL CONDITION]; -[MEDICATION NAME] (medication used to treat nightmares caused by [MEDICAL CONDITION]) 2 mg at bedtime for nightmares; -[MEDICATION NAME] (antidepressant) 50 mg daily for depression; -[MEDICATION NAME] (antidepressant) 150 mg daily for depression. During an interview on 6/9/10 at 4:15 P.M., the Director of Nursing (DON) said the resident did not have a care plan. The care plan coordinator quit and the resident's care plan was missed. Review of the resident's face check documentation, dated 6/8/20, showed the following: -At 2:25 P.M., CMT C electronically signed a face check was completed; -At 3:34 P.M., CMT C electronically signed a face check was completed; -At 4:00 P.M., CMT C electronically signed a face check was completed; -At 4:37 P.M., CNA E electronically signed a face check was completed. Review of the facility's summary of events, dated 6/8/20, showed the following: -A code white (missing resident) was called on 6/8/20 at approximately 4:45 P.M. because staff were unable to locate Resident #1 and Resident #2; -All unit staff completed head counts for every unit and department heads immediately started searching for the residents in surrounding areas and businesses; -Employees at two nearby businesses reported seeing the residents and overheard conversations between the two residents that they were going to a town 30 miles away to meet up with Resident #2's boyfriend/girlfriend; -Law enforcement was notified. Review of Resident #1's and Resident #2's face check documentation, dated 6/8/20, showed CNA A electronically signed he/she competed a face check on both residents at 4:54 P.M. (nine minutes after the residents were found missing). During an interview on 6/9/20 at 1:25 P.M., CMT C said he/she worked on the residents' hall on 6/8/20 from 7:30 A.M. to 7:30 P.M. When CMT C went to pass the evening medications, he/she noticed Resident #1 was not in his/her room. When CMT C entered Resident #1's room to check the bathroom, he/she noticed Resident #1's window had been removed. CMT C yelled code white (missing resident). Staff began a search and found Resident #2 was also missing. CMT C thought he/she found Resident #1 was not in the facility around 3:25 P.M., but CMT C said he/she was not sure of this. CMT C had not seen either resident on 6/8/20 since around 1:30 P.M. CMT C did not hear either resident mention wanting to leave or having plans to leave the facility. Resident #2 had make-up on and had fixed his/her hair on 6/8/20 which was not something Resident #2 did on a daily basis. CMT C did not complete or document any face checks on any resident on 6/8/20 as this was not his/her responsibility on that day. (Documentation showed CMT C electronically signed he/she completed face checks for both residents on 6/8/20 between 2:25 P.M. and 4:00 P.M.) During a follow up interview on 6/9/20 at 2:30 P.M., CMT C said he/she did not document the face checks as they were documented on the face check form (on 6/8/20). CMT C said he/she was not sure why the documentation showed his/her electronic signature. He/She said it was possible someone else logged in and documented the face checks under his/her name. The DON (who was present during the interview) also had no explanation for the discrepancy. Review CNA A's statement, obtained by the facility on 6/8/20 (no time), showed at approximately 4:45 P.M., CNA A overhead paged a code white (missing resident) because CMT C said to do so. Staff searched all the rooms on the unit. The screen on Resident #1's room window had been removed and was under the bed. The glass was not broken and was outside of the building. CNA A did not hear any commotion from the room and neither resident voiced or threatened wanting to leave. The last time CNA A saw Resident #1 or Resident #2 was right before 1:30 P.M. During an interview on 6/9/20 at 12:40 P.M., CNA A said he/she worked on the residents' unit on 6/8/20 from 7:00 A.M. to 7:00 P.M. The last time CNA A saw Resident #1 and Resident #2 was just before 1:30 P.M. They were both in Resident #1's room and then went to the courtyard to smoke with activity staff. CNA A did not recall seeing the residents come back inside after smoking and did not recall seeing the residents after 1:30 P.M. CNA A saw Resident #1's room door was closed and he/she assumed both residents were in the room, but did not open the door to visually check. Resident #2 used the phone before lunch time and ordered pizza. CNAs complete face checks every hour. CNA A did not complete or document the face checks at 2:30 P.M. or 3:30 P.M., because he/she busy with other tasks. CMT C noticed the residents were missing sometime after 4:00 P.M. when he/she went to administer medications. CNA A called the code white on the overhead pager. Staff searched inside and outside of the building. The screen had been removed from Resident #1's room window and was laid up against the wall. The window pane had been removed and was laid against the outside of the building. The maintenance staff put the window back in. It was very easy to push out with just a little force. During a follow up interview on 6/9/20 at 2:30 P.M., CNA A said he/she was not sure what time he/she last documented a face check on either resident on 6/8/20, but was certain the last time he/she saw either resident was prior to 1:30 P.M. and CNA A did not document any face checks after that time. (Documentation showed CNA A electronically signed he/she completed a face check for both residents on 6/8/20 at 4:54 P.M., nine minutes after staff identified the residents were missing from the facility.) During an interview on 6/9/20 at 1:52 P.M., Licensed Practical Nurse (LPN) D said he/she was the charge nurse on the residents' unit on 6/8/20 from 7:00 A.M. until 7:00 P.M. LPN D said Resident #1 walked the hallway like he/she normally did. Resident #2 stayed in his/her room most of the time. LPN D was not on the unit as much as usual on 6/8/20 as he/she rounded with a physician and was taking off new orders. LPN D took medications to the unit between 2:30 P.M. and 3:00 P.M., but could not be certain if he/she saw either resident at that time. The CNAs and the nurses were responsible for completing and documenting the face checks for residents. CMT C told LPN D he/she was keeping up with the face checks on 6/8/20. LPN D did not complete or document any face checks for Resident #1 or Resident #2 on 6/8/20, as he/she was under the impression CMT C was doing so. LPN D heard staff call a code white at approximately 4:45 P.M. on 6/8/20. LPN D went to the unit and saw the window missing from Resident #1's room. Staff said both Resident #1 and Resident #2 were missing. During an interview on 6/9/20 at 1:20 P.M., Activity Staff B said he/she was the staff person who went to the courtyard to monitor residents smoking on 6/8/20 at 1:30 P.M. Resident #2 went outside and smoked at that time, but Resident #1 did not. Resident #2 came back inside the facility after smoking at 1:30 P.M. without any incident. Resident #2 was not as talkative as he/she usually was on 6/8/20, but Activity Staff B did not think anything about it at the time. During an interview on 6/9/20 at 5:05 P.M., Maintenance Staff F said he/she did not recall seeing Resident #1 on 6/8/20, but remembered seeing Resident #2 because he/she had his/her hair done and make-up on and was smiling very big. Maintenance Staff F asked CNA A if he/she had noticed anything unusual, but CNA A said Resident #2 was not doing anything out of the ordinary, so he/she didn't think any more about it. During an interview on 6/9/20 at 11:40 A.M., the Administrator said staff reported seeing the residents around 2:00 P.M. (on 6/8/20). A code white was called at 4:45 P.M. The administrator expected staff to complete and document face checks every hour on both residents. Staff originally said they completed the face checks, but did not document them. When she reviewed the report, the face checks had been documented as completed on both residents. During an interview on 6/9/20 at 4:42 P.M., CNA E said he/she did not work on the resident's unit on 6/8/20, he/she worked on another hall that day. CNA E would not have documented any face checks for Resident #1 or Resident #2 on 6/8/20, as he/she was not working on their hall. CNA E said Resident #2 was originally on another unit, but was moved a couple of weeks ago due to not getting along with other residents. CNA E said the computer used for documenting face checks was shared between two units and someone may have logged in under his/her name without CNA E knowing. (Documentation showed CNA E electronically signed he/she completed a face check for both residents on 6/8/20 at 4:37 P.M.) During an interview on 6/9/20 at 12:00 P.M., Resident #3 said she overheard Resident #1 and Resident #2 talking on the phone to someone the day before about getting picked up at the gas station. Resident #3 said he/she did not think the residents were serious and did not report this to any staff member. The last time Resident #3 saw Resident #1 and Resident #2 was around 1:30 P.M. on 6/8/20. During an interview on 6/9/20 at 12:25 P.M., Resident #4 said about two weeks after Resident #1 was admitted , he/she told Resident #4 he/she was going to bust out of here, but Resident #4 did not take him/her seriously or report the comment to staff. Resident #1 and Resident #2 had been in Resident #1's room with the door closed the day before. The last time Resident #4 saw either resident on 6/8/20 was around 10:00 A.M. Observation of Resident #1's room on 6/9/20 at 11:45 A.M. showed a plexiglas window secured in the frame with screws. The window led directly to the front parking lot of the facility. During an interview on 6/9/20 at 2:25 P.M., the DON said Resident #1 had just called facility staff and requested someone pick him/her up and return him/her to the facility. The resident was in a town 30 miles from the facility. Staff were enroute to pick up the resident. The plan was to get the resident to an inpatient psychiatric hospital. Resident #2 had not been found. Observation on 6/9/20 at 4:22 P.M. showed Resident #1 sat in a facility van in the facility parking lot. The resident appeared disheveled and was visibly upset and tearful. During an interview on 6/9/20 at 4:22 P.M., Resident #1 said Resident #2 talked him/her into kicking out his/her room window the day before. At approximately 2:00 P.M. on 6/8/20, Resident #1 kicked the window twice and it came out. Resident #1 and Resident #2 walked to a nearby gas station and asked people for money and a ride to a town 30 miles away. Someone gave them 20 dollars, cigarettes, and two beers. Resident #1 and Resident #2 then walked to a nearby restaurant (approximately one mile from the facility). Resident #1 asked to use the phone and called a friend who came and picked them up and drove them to the town 30 miles away. Resident #1 said when the friend arrived, he/she remembered it was 3:46 P.M., because Resident #1 saw it on the clock in the car. Resident #1 and Resident #2 met up with friends and smoked [MEDICATION NAME]. Resident #1 said he/she did not have any plans to leave the facility, it was a spur of the moment idea. Resident #1 did not take any belongings with his/her, but Resident #2 took some of his/her clothes. Observation on 6/9/20 at 5:20 P.M. of the gas station where the residents were observed on 6/8/20, showed it was across a busy four lane highway and approximately a quarter mile away from the facility. During an interview on 6/9/20 at 5:20 P.M., gas station staff G said he/she worked on 6/8/20 and saw two individuals walking around outside the gas station a little after 2:00 P.M. About an hour later, around 3:00 P.M., one of the individuals came inside the gas station and said he/she had $10.00 and wanted a cab ride to a town 30 miles away. The individual bought a pack of cigarettes and two lighters. The individual then asked for the phone number to a restaurant down the road and asked to use the phone. During an interview on 6/10/20 at 7:45 A.M., gas station manager H said gas station staff called him/her on 6/8/20 around 5:00 P.M. to report facility staff had just been in the gas station asking about two residents who were missing. He/She reviewed the camera footage from 6/8/20 which showed the first resident entering the gas station at 2:20 P.M. During a telephone interview on 6/10/20 at 10:42 A.M., Resident #1's guardian said Resident #1 was easily manipulated and talked into things. Resident #1 has a history of drug use and criminal charges related to drug use. The resident suffered from mental illness, [MEDICAL CONDITION], and cognitive deficit. Resident #1's guardian did not think he/she would elope from the facility. The facility and the resident's unit are locked. The resident would frequently ask when he/she would be getting out the facility. Resident #1's guardian was not certain how frequently staff checked on the resident. During a telephone interview on 6/10/20 at 10:50 A.M., Resident #2's guardian said the resident had eloped from previous facilities in the past. Resident #2 had a history of [REDACTED]. Resident #2's drug addiction was a big motivator for him/her. The last time Resident #2 eloped from a facility, prior to this time, he/she had hitch hiked a significant distance to be with his/her boyfriend/girlfriend. It was the guardian's understanding the facility placed Resident #2 on a locked unit and he/she would not be able to leave the facility. Resident #2's guardian was not certain how often staff completed face checks on the resident, but it was his/her understanding facility staff would monitor the resident's whereabouts given his/her history of previous elopement. The police have followed up on some leads, but Resident #2 had not yet been found. During a telephone interview on 6/10/20 at 11:37 A.M., Resident #1's and Resident #2's physician said he/she understood both residents lived on a locked unit. The physician was not sure of the facility's policy, but staff should be monitoring the whereabouts of residents. Both residents had mental illness and were on medications for this. Going for an extended period without taking physician ordered medications could be detrimental and obviously smoking [MEDICATION NAME] would not be beneficial for anyone. MO 3 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure residents with mental health disorders received appropriate person-centered and individualized treatment to meet their needs for three residents (Resident #1, #2 and #12), in a review of 21 sampled residents. Resident #1 had a history of [REDACTED]. On [DATE], Resident #1 and Resident #2 were involved in an altercation. Resident #2 sustained a severe head injury which required surgical intervention including a craniectomy (a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand) and a [MEDICAL CONDITION] (a tube placed through a surgical procedure in the neck to provide an airway), mechanical ventilation and feeding tube placement. Resident #12 had a history of [REDACTED]. The resident reported he/she ingested foreign objects, which resulted in hospitalization to remove the objects (parts of a CD, paper clips, and staples). The facility failed to adequately assess the residents' specific needs and develop resident specific interventions as appropriate to address these needs. The facility census was 174. Review of the facility Abuse, Neglect, Grievance procedures, revised [DATE], showed the following: -It is the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; -Mistreatment, neglect, or abuse of residents is prohibited by this facility; -This facility is committed to protecting our residents from abuse by anyone including other residents; -Definition of physical abuse-Purposefully beating, striking, wounding, or injuring or in any manner whatsoever mistreating or maltreating in a brutal or inhumane manner; -Physical abuse includes handling a consumer with any more force than is reasonable for a consumer's proper control, treatment or management or physical abuse; -Prevention and Identification: Prevention will also include assessment care planning and monitoring of residents with needs or behaviors which may lead to conflict or neglect; -The facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the administrator and the proper authorities; -The facility desires to prevent abuse, neglect, and theft by establishing a resident sensitive and resident secure environment. This will be accomplished by comprehensive quality management approach involving concern identification and follow-up. 1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR; a federal assessment utilized to ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) Level II, dated [DATE], showed the following: -Historical symptoms: Delusional: communicates with other/sister through a chip/radio in his/her ears (does not have a hearing aid), aggressive, poor insight, non-compliant with medications and treatment, isolates, poor insight and judgement; -Current symptoms or behaviors indicating a psychiatric disorder: states he/she hears voices through a radio/electricity in each ear. Isolates, does not attend to orientation factors in his/her environment, belief that others steal from him/her; -Problematic behavior: refuses some activities, refuses to eat breakfast, seclusive, and suspicious of others; -Medical history: head trauma/subdural hematoma in 1992, history of gunshot to abdomen, alcohol/drug abuse; -Neurological problems: [MEDICAL CONDITION] and tremors. Tremor comes and goes in a nervous manner. Review of the resident's care plan, dated [DATE], showed the following: -Independently ambulatory as desires and able to transfer self; -Communication: The resident is hard of hearing at times in situations and doesn't always understand what is said related to confusion due to delusions, hallucinations and paranoia; -The resident reports the voices in his/her ears were electrocuting his/her ears, but denied suicidal ideation/homicidal ideation at this time; -At risk for alteration in mood related to [MEDICAL CONDITION]. The resident was often resistive to cares/treatments and attempts to refuse medications at times related to delusions, paranoia, and hallucinations. The resident socially isolates himself/herself at times; -Staff to attempt to redirect when attempting to refuse care, ensure physician and guardian aware of refusals, analyze behavior for possible cause/effect relationship. Re-approach at another time when actively hallucinating/delusional, when refusing medications. Always speak to him/her in a positive voice and re-approach at a different time with a different approach is unsuccessful; psych consult as needed/ordered; assess resident for changes in mood/behavior PRN (as needed); allow resident one-on-one time for ventilation of feelings/frustrations as able; -Prefers to isolate himself/herself by staying in his/her room, but will talk to staff during one-on-one visits; -Intensive monitoring per unit and facility protocol to ensure protective oversight. The resident will remain safe. (Review of the resident's PASRR showed he/she believes others steal from him/her. The resident's care plan does not address these symptoms/behaviors or provide interventions to address them.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Intact cognition; -[DIAGNOSES REDACTED].>-Independent for transfers and walking; -Set up assistance with activities of daily living (ADLs) and eating; -No verbal or physical behaviors; -No delusions or hallucinations. Review of the resident's social services note, dated [DATE], showed the resident continued to reside on the Homestead unit (a secured unit for residents with behaviors). The resident was able to communicate wants and needs effectively and prefers to spend most of his/her time in his/her room, watching television or resting. The current plan is for continued placement at the facility and for social services to monitor for any mental health changes and be available to meet with the resident as needed or requested. 3. Review of Resident #1's PASRR Level II evaluation, dated [DATE], showed the following: -Reason for referral to nursing facility: The client has a history of being a brittle diabetic and needs frequent checks and monitoring of glucose. Staff feels he/she has limited insight to his/her diabetes. Needs encouragement and supervision for diet compliance; -If admitted to a nursing facility, the individual needs or continues to need services of a lesser intensity including occupational therapy for daily living skills; individual, group and family psychotherapy; drug therapy and monitoring of drug therapy; training in drug therapy management; structured socialization activities to diminish tendencies toward isolation and withdrawal; development and maintenance of necessary daily living skills including grooming, personal hygiene, nutrition, health and mental health education, money management, and maintenance of the living environment; -Resident was released on parole on [DATE] to a group home. He/she violated parole on [DATE] by leaving the group home and going to buy beer. Staff and guardian feel initial discharge to a nursing facility with possibility of going to a residential care facility (RCF) at a later date would give the resident a better chance of success. This, in conjunction with poorly controlled diabetes and connected behaviors, require close monitoring by staff. He/she does have a history of major [MEDICAL CONDITION] that is well controlled with medication, and does not appear to be an issue. Intellectual disability does impact his/her daily living skills and insight into diabetes. -Major [MEDICAL CONDITION], intellectual disability, and diabetes mellitus; -Incarcerated since arrested on [DATE] for murder in the second degree. Documentation of periodic episodes of angry outbursts; -Documentation of refusal of medications at times; -Referral notes uncooperative with diet at times and limited insight; -Current symptoms or behaviors indicating a psychiatric disorder: Staff report the resident is cooperative and pleasant, with the exception of occasional angry outbursts. Review of the resident's facility initial psychosocial history, dated [DATE], showed the following: -Admission on [DATE]; -Prior living arrangements: prison; -Ambulatory; -Services Needed/Suggested: Physical therapy, occupational therapy, speech therapy, restorative therapy, dental, audiology, ophthalmology, podiatry, and psychiatric; -Advance Directives: Legal guardian; -Parents deceased and no contact with siblings; -Recollection of family relationships: They all died ; -Current psychiatric Diagnosis: [REDACTED].>-Highest level of education completed: ninth grade; -Exceptional skills, talents or gifts: Cleaning; -Never married and no children; -Prefers activities alone, watching television, playing games, smoking; -Past history: homicidal ideations/attempts; -Legal history: Thirty year prison sentence for second degree murder; -Discharge planning: anticipated length of stay: Until desired level of independence is achieved; -Goals and future desired outcomes: I don't know, Stay alive; -Current Diagnosis: [REDACTED]. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition was moderately impaired; -[DIAGNOSES REDACTED]. -Independent transferring and walking; -Set-up assistance with activities of daily living (ADLs) and eating; -No verbal or physical behaviors; -No delusions or hallucinations. Review of the resident's care plan, dated [DATE], showed the following: -At risk for alteration in mood related to mild intellectual disabilities, major [MEDICAL CONDITION], and [MEDICAL CONDITION]; -Incarcerated for second degree murder; -History of angry outbursts verbal aggression/physical aggression; -History of noncompliance with medications and diet; -One-on-one visits as needed/requested for verbalization and ventilation of concerns/feelings; -One-on-one intensive monitoring as needed/warranted for protective oversight; -Redirect as able/needed to encourage positive behavior choices; -Assist resident in using coping skills as needed; -Attempt to ascertain what resident would accept/need to calm down and provide as able; -Notify guardian, administrator, director of nursing (DON), physician, and resident care coordinator (RCC) if behavior emergencies occur; -Psychiatric/physician consult as needed/ordered; -Has impaired thought processes related to mild intellect disability and major [MEDICAL CONDITION]; -Monitor and document behaviors as needed. Report significant changes in cognitive functioning to physician promptly; -Ongoing assessment for changes in mental status, behavior emergencies, and impaired cognitive functioning; -At risk for adverse side effects related to [MEDICAL CONDITION] medication use for treatment of [REDACTED]. -Ongoing assessment of behavior status. Review of the resident's facility investigation for an incident that occurred [DATE], showed the following: -Staff reported Resident #1 hit Resident #8. Resident #8 said Resident #1 walked up to him/her and hit him/her for no reason. Resident #8 threw up his/her hands to block Resident #1's punch but got hit in the jaw area; -Resident #1 said Resident #8 threatened him/her saying, You wanna fight? He/she was forced to defend himself/herself and swung at Resident #8. Resident #1 was not positive he/she hit Resident #8, but Resident #8 said he/she did hit him/her; -Staff actively tried to de-escalate the situation and did not see Resident #1 hit Resident #8; -The nurse assessed both residents. Resident #8 had complaint of slight pain to face, but no other discomfort upon assessment; -The interdisciplinary team (IDT) met with Resident #1 and discussed alternatives to his/her actions. This was the first time Resident #1 had shown any kind of aggression/striking out. They educated him/her on appropriate interaction with peers, even when he/she felt challenged by them. Resident #1 signed a behavior agreement that he/she would handle situations like that differently, and would not strike anyone else. Review of the resident's nurse's notes showed no documentation of an incident that occurred between the resident and Resident #8 on [DATE]. During an interview on [DATE] at 10:35 A.M. and [DATE] at 10:45 A.M., the administrator said staff reported on [DATE], Resident #1 hit Resident #8. Resident #8's story changed and said Resident #1 did not hit him/her. There were no marks and no injuries. Staff said they never saw Resident #1 hit Resident #8. Resident #1 said he/she did not hit Resident #8. Review of the resident's care plan, dated [DATE], showed a handwritten note, dated [DATE], for staff to educate the resident on appropriate interactions with peers as needed; behavior contract that the resident would not strike anyone else. (The care plan did not address the specific incident and did not include modified individualized interventions to prevent similar situations and physical aggression towards peers.) Review of the resident's nurse's notes, dated [DATE], showed the resident had increased agitation and refused accuchecks (test used to monitor and check blood glucose levels) and medications. Staff attempted to educate and encourage the resident multiple times. One-on-one time spent with resident to verbalize feelings/concerns. The resident continued to be agitated. Staff notified the resident's physician. The physician gave new orders for PRN medication to help calm the resident. The resident on one-on-one for protective oversight. Staff notified the administrator, physician, and the resident's guardian. Staff continued with intensive monitoring for protective oversight. At 4:35 P.M., the resident's blood sugar was 226. At 6:30 P.M., the resident's blood sugar was 233. At 7:15 P.M., staff called a code green (behavioral emergency or incident involving physical force). Staff reported the resident had been displaying verbal aggression, physical aggression, and homicidal ideation to staff. The resident allegedly broke the television in his/her room and verbalized homicidal ideation and was unable to be re-directed. The resident also displayed physical aggression to staff. The resident was placed on the floor in a Crisis Alleviation Lessons and Methods (CALM) hold (restraining technique requiring staff to hold a resident's arms, legs, and supporting his/her head). Staff notified the administrator and DON and received physician orders [REDACTED]. During an interview on [DATE] at 9:40 A.M., Licensed Practical Nurse (LPN) F said he/she did not know what caused Resident #1 to be off on [DATE]. When the resident's blood sugar was off, the resident would get upset and walk the halls. His/her blood sugar would sky rocket and bottom out in minutes. The medication technicians check the resident's blood sugar levels and he/she hadn't been notified of high or low blood sugar levels with the resident that day until the accuchecks completed around 4:00 P.M. It all started that evening and the resident refused to have the accucheck done. The resident had been on the ,[DATE] hall and moved to the 300 hall. The resident was in a room by himself/herself and had been on this hall for two weeks when this incident happened. The resident wanted to go back to live on the ,[DATE] hall. He/she got upset, ripped the paper towel dispenser off the wall in his/her room, ripped the television and its mount off the wall, and destroyed the television. LPN F tried to talk to the resident, he/she didn't want to talk, he/she wanted to destroy his/her room. His/Her behaviors were not directed toward residents and staff. The resident was not reporting self-harm, but talked about breaking out the window and the nurse was worried about the resident hurting himself/herself. The resident would pace the halls when he/she became upset and this calmed him/her down. He/She walked all the time and his/her agitation was very minimal. Usually his/her blood sugar caused him/her to get upset and this time it wasn't his/her blood sugar. On [DATE], the resident was off the normal. Staff tried to get the resident to watch television, listen to music, and he/she sat with him/her on this particular evening. The resident would calm down, sit down on the bed and then get upset. The resident was very persistent about not being on the 300 hall. They sent the resident to the hospital for medication evaluation. He/She notified the administrator who said he/she would look into it. During an interview on [DATE] at 11:33 A.M., Certified Nurse Aide (CNA) D said he/she responded to a Code Green on the 300 hall when the resident refused his/her accuchecks and insulin. CNA D was able to talk to the resident to have his/her blood sugar checked and get the insulin to help him/her feel better and calm down. The resident said he/she didn't want to die, but would not give a reason for feeling this way. CNA D said he/she could always talk to the resident, but the resident never really gave a reason why he/she refused accuchecks and medications, but would say, he/she didn't want to die. During interviews on [DATE] at 10:35 A.M. and [DATE] at 10:45 A.M., the administrator said Resident #1 went out to the hospital, because he/she seemed off baseline. He/she was hospitalized , and came back to a room with Resident #2 (on the 400 hall). Review of the resident's psychiatric hospital discharge summary showed the following: -admitted [DATE] and discharged [DATE] back to the facility for major [MEDICAL CONDITION]; -New medication started [DATE] were [MEDICATION NAME] (an antipsychotic) 5 mg at bedtime; -On [DATE], listed medications included [MEDICATION NAME] (for depression)150 mg daily, [MEDICATION NAME] (a hormone)10 mg once daily at bedtime and trazadone (anti-depressant) 25 mg every day at bedtime. Review of the resident's hospital Medication Administration Record [REDACTED] -Start date [DATE], [MEDICATION NAME] (antipsychotic) 5 mg every six hours as needed (last administered [DATE] at 9:30 P.M.); -Start date [DATE] [MEDICATION NAME] (anti-anxiety) 1 mg oral tablet every six hours as needed (last administered [DATE] at 9:30 P.M.); (There were no other hospital notes provided to show how they addressed the resident's behaviors and no recommendations for treatment.) Review of the resident's care plan with handwritten note dated [DATE], showed the resident was readmitted from the hospital to the facility. The resident resided on the Homestead (400 hall) unit. No concerns or questions voiced. The resident was calm and cooperative and compatible with current room and roommate. The resident was able to voice needs and desires. Staff educated on current orders and importance of compliance with current orders and cares. The resident voiced understanding. Review of the nurse's notes, dated [DATE] at 7:40 A.M., showed at approximately 8:30 P.M. staff called a code green on the 400 hall. The nurse arrived to see the resident surrounded by other nurses and staff. The nurse witnessed staff and nurse trying to redirect the resident. The resident said he/she was upset, because he/she felt like he/she was being rushed out of the shower. The team leader said staff found a lighter in the resident's clothing. The resident should not have the lighter and staff took it. The resident was also upset over staff taking the lighter. The team leader explained that once the resident left the shower room, he/she went into the dining room, picked up a chair and threw it through two windows. The charge nurse notified the administrator and staff administered PRN [MEDICATION NAME] 5 mg and [MEDICATION NAME] 2 mg intramuscular (IM). The resident was calm and sat in a chair by the nurse's desk. The nurse allowed the resident to smoke and asked if he/she would go to bed afterward. The resident agreed and no further incidents. During an interview on [DATE] at 10:45 A.M., the administrator said the incident with Resident #1 (on [DATE]) occurred because the resident was mad when he/she was caught with a lighter and threw chairs at the window. The resident was not mad at anyone, but his/her blood sugar was low at the time. The resident was a brittle diabetic and was easily redirected. The resident sat in a chair by the nurse's station. This was a first and only outburst. The resident saw the psychiatrist on [DATE]. Review of the care plan showed no evidence of the incident that occurred on [DATE] that involved the resident throwing a chair through two windows, and no evidence staff evaluated, modified, or implemented new interventions following the incident to address the resident's psychosocial/emotional needs. Review of the resident's psychiatric consult note, dated [DATE], showed the following: -Staff reports periods of verbal and physical aggression. The resident's attention was drawn to complaint of periods of verbal and physical aggression as well as refusing blood sugar check. The resident responded he/she will dedicate himself/herself to being good from henceforth; -Plan: Psycho-education and support provided. Continue with current medications. Diet and exercise discussed, smoking cessation discussed. Relaxation techniques discussed. Cognitive distortions discussed. Return to clinic in four weeks or sooner on an as needed basis. Call if problems, concern or deterioration in condition, call 911 or emergency room if unsafe. Will follow up in the facility and will be available to staff between visits; -Medications attached to this encounter: [MEDICATION NAME] HCl 150 mg every morning (start date [DATE]), [MEDICATION NAME] 10 mg at bedtime (start date [DATE]), [MEDICATION NAME] HCl 25 mg at bedtime (start date [DATE]), [MEDICATION NAME] (an antipsychotic) 10 mg twice a day (start date [DATE]). Review of the resident's care plan showed no evidence to show staff was educated on the plan as discussed with the resident during his/her psychiatric visit on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was intact; -[DIAGNOSES REDACTED]. -No verbal or physical behaviors. Review of the resident's social services notes, dated [DATE], showed the resident continues to reside on the 400 hall. The resident was able to communicate wants and needs effectively and socializes with peers on the unit. The current plan was for continued placement at the facility and social services will meet with him/her as needed or requested. Transportation will be available for outside appointments as needed. (The facility did not provide any other social service notes for the resident except an immediate discharge letter emailed to the ombudsman on [DATE].) Review of Resident #1's nurse's notes, dated [DATE], showed the following: -Resident #1 was involved in an altercation with Resident #2; -Resident #1 said Resident #2 accused him/her of taking his/her clothing and came towards him/her; -Resident #1 felt like he/she was in a corner and could not relocate reality and began hitting Resident #2, because of feeling threatened; -Resident #1 denied any previous concern or issue with roommate, Resident #2; -Resident #1 was cooperative and calm during one-on-one observation; -Staff got an order to send Resident #1 to the hospital; -The resident was immediately discharged from the facility. Review of Resident #2's nurse's notes, dated [DATE], showed staff found the resident in his/her room on the floor directly inside the door in between the closet door laying in a downward position. Staff noted the resident had an injury to his/her left ear and cheek. Staff noted the resident was in a position in which noted possible head and/or neck trauma. Not knowing the origin or extent of the injury at that time, the resident was encouraged to maintain his/her current position until emergency medical services arrived. Staff noted multiple areas of concern. The resident had a hematoma to his/her left ear with a large amount of swelling to his/her cheek bone, as well with blood coming from the middle of his/her left cheek hematoma and directly from his/her posterior left ear. The resident had obvious lacerations. The resident was unable to answer questions appropriately when attempting to obtain cognitive abilities. The resident was alert to self only. Staff noted the resident displayed episodes of quiet mumbling words when attempting to speak words out loud. Review of the facility's investigation/conclusion of the incident that occurred [DATE], showed the following: -Staff responded to a commotion in Resident #1 and Resident #2's room; -Resident #1 said Resident #2 came into the room, got in his/her face, and accused Resident #1 of taking something out of his/her closet; -Resident #1 said he/she felt trapped in the room by Resident #2; -Resident #1 said Resident #2 put up his/her hands as to fight with him/her and Resident #1 hit Resident #2; -While fighting together, Resident #2 fell to the ground. Resident #1 hit Resident #2 a couple of times while Resident #2 was on the ground and then staff showed up; -Staff reported they heard a banging sound and went to see what it was. When they got to Resident #1 and Resident #2's room, Resident #2 lay on the ground trying to cover up his/her head, and Resident #1 stood over Resident #2. Resident #1 walked out of the room; -Staff placed Resident #1 on one-on-one immediately. The nurse assessed Resident #2, notified the physician, and received orders to send to the resident to the hospital for an evaluation; -Resident #2 had discoloration and swelling on the left side of the face and ear. The resident verbally responded when attempts to assess were made; -Resident #1 was sent to the hospital for psychiatric evaluation and will not be returning. Resident #1 and Resident #2 were roommates for almost two months and had not had any previous issues; -Resident #1 was admitted to the facility in ,[DATE], and had only one minor physical aggressive altercation towards any residents during this time. Staff educated the resident and had a behavioral contract in place not to strike other and to get staff if he/she felt threatened. There was no warning or signs of problems leading up to the incident. For this reason, Resident #1 was given a discharge. During an interview on [DATE] at 1:00 P.M., Resident #1 said he/she had the door open and clothes on his/her bed. Resident #2 came into the room and got into a fight with him/her. Resident #2 would not let Resident #1 out of the room. Resident #2 got in his/her face and said Resident #1 stole something. Resident #2 made Resident #1 mad, but Resident #1 was not sure why he/she was mad. I was mad and pissed off at him/her. Resident #1 said he/she balled up both his/her hands into fists and hit Resident #2's face. Resident #1 said he/she swung first at Resident #2 and Resident #2 fell by the closet door. When Resident #1 knocked Resident #2 down to the floor, Resident #1 hit Resident #2 while he/she was on the floor. Resident #2 did not get up. During an interview on [DATE] at 1:15 P.M., CNA A said the following: -He/She heard a banging noise like thonk, thonk down the hall; -He/She and CNA B checked the residents' rooms; -Resident #1 stood over Resident #2 in their room and then tried to hide behind a closet door; -Resident #2 was face down on the ground with his/her hands balled up beneath him/her; -Resident #1 kept saying loudly and raised his/her voice, I'm going to kill him/her over and over as he/she took Resident #1 down the hall to the nurse's desk; -Resident #1 said, He/she's always asking about his/her jeans; -Resident #1 said his/her anger got the best of him/her; -This was unusual behavior for Resident #1 and Resident #2; -He/She had never seen conflict between Resident #1 and Resident #2; -He/She did one-on-one with Resident #1 until the resident left to the hospital. During an interview on [DATE] at 2:03 P.M., CNA B said the following: -He/She heard an odd noise and ran down the hall; -He/She saw Resident #2 on the floor and Resident #1 walked around him/her and out the room door; -The closet door in the room was wide open; -Resident #2 lay face down on the floor in front of the closet; -The resident did not move or say anything, but the nurse talked to the resident; -He/She never saw any other fights involving Resident #1 or Resident #2. During an interview on [DATE] at 12:45 P.M., LPN C said the following: -He/She was called to the same unit for another altercation between two residents; -He/She heard a noise like a door slam and CNA B ran down the hall toward the noise; -When he/she got to the room, Resident #2 lay face down on the floor with his/her arms up around his/her head and a pair of jeans underneath him/her; -He/She saw swelling on his/her head and he/she kept him/her in the same position; -Resident #2 said, I'm not a snitch; -CNA B told him/her Resident #1 had been in the room with Resident #2. When he/she came into the room, Resident #1 turned around and walked out of the room; -Resident #2 has paranoid audible hallucinations which was normal for him/her and had been fine earlier that day; -He/She did not know the extent of the injury, but saw swelling of Resident #2's left ear and side of head and a little blood on the resident's left cheek but there was no laceration, just weeping fluid; -They called the physician to send Resident #2 to the hospital; -When Resident #2 left for the hospital, he/she talked to Resident #1; -Resident #1 said Resident #2 accused him/her of taking his/her jeans. When Resident #1 went into the room, Resident #2 stood behind the closet door and Resident #1 thought Resident #2 was in his/her closet; -Resident #1 said he/she thought Resident #2 was in his/her closet or tried to barricade him/her from coming into the room; -Resident #1 said he/she hit Resident #2; -The administrator and DON came in and sent Resident #1 to the hospital. During an interview on [DATE] at 11:00 A.M., the DON said the following: -Resident #1 was going through his/her own clothes and seeing if the clothes were labeled and thought Resident #2 took something of his/hers; -Resident #2 never says much; -Resident #1 hit Resident #2 a couple of times; -They placed Resident #1 one one-on-one and sent him/her to the hospital. During an interview on [DATE] at 10:35 A.M., the administrator said the following: -There was a commotion between Resident #1 and Resident #2 on [DATE]; -Resident #1 accused Resident #2 of taking something out of his/her closet; -Words were said, and Resident #1 felt trapped and hit Resident #2 on the left side of his/her head; -Resident #2 was being treated for [REDACTED]. -They discharged Resident #1 from the facility. During an interview on [DATE] at 2:27 P.M., LPN C said Resident #1 had low and high blood glucose levels. He/She could tell the way the resident was blinking his/her eyes that blood sugar levels were not right with him/her. He/She would get agitated and pace the halls. He/She also got agitated when he/she lost his/her own watch. He/She was pacing and looking in residents' rooms. The nurse helped him/her look for the watch for 45 minutes and could not find it. The resident was agitated and threatened to pick up a chair and throw it out the window. He/She never picked up a chair to do this, but just yelled at him/her across the dining room. He/She never seemed mad, just a

Based on observation, interview, and record review, the facility failed to ensure residents located on the secured behavior unit were free from abuse from six residents (Resident #2, #6, #7, #10, #13 and #16) who had verbal and physical behaviors and had a history of [REDACTED].#1, #4, #8 and #9), in a review of 17 sampled residents. The facility failed to evaluate the effectiveness of interventions and identify new interventions to ensure the safety of residents and to prevent resident to resident abuse. Resident #2 punched Resident #1 in the face causing a bloody nose; Resident #7 punched Resident #8 and Resident #9 in the face; Resident #10 punched Resident #8 in the nose until it bled; Resident #6 hit Resident #4 in the left lower jaw and forehead which caused a bruise; Resident #13 hit Resident #4 causing his/her nose to bleed and Resident #16 reportedly almost bit off the tip of an unidentified resident's toe. The facility census was 175. 1. Record review of the facility's Abuse, Neglect, Grievance Policy and Procedure, dated (MONTH) 28, (YEAR) showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse and neglect, To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -It is the policy of the Facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse; -It is the policy of this Facility that each resident has the right to personal privacy of not only his/her own physical body but also of his/her personal space, including accommodations and personal care; -Mistreatment, neglect, or abuse of residents is prohibited by this Facility; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to other residents; -Physical Abuse-Purposefully beating, striking, wounding, or injuring any consumer or any manner whatsoever mistreating or maltreating a consumer in a brutal or inhumane manner; -Sexual Abuse-Any touching, directly or through clothing, of a consumer for sexual purpose, or in a sexual manner, this includes but is not limited to kissing. This also includes failure to intervene or attempt to stop or prevent inappropriate sexual activity or performance between consumers; -Staff obligations to prevent and report abuse and neglect; -Prevention and Identification: The facility will provide residents, facility and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution and proved feedback on the concerns that they have expressed. The facility will identify and correct by providing interventions in which abuse and neglect is more likely to occur; -This will include; assessment of the physical environment, which may make abuse or neglect more likely to occur, such as more secluded areas in the facility, the deployment of staff on each shift in sufficient numbers to meet the resident's needs and the staff are knowledgeable of resident care needs; -Prevention will also include assessment care planning and monitoring of resident with needs or behaviors which may lead to conflict or neglect; -The facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the administrator and the proper authorities; -Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for [REDACTED].>-Reporting and Investigating allegations: Employees are required immediately to report any occurrences of potential mistreatment including; alleged violations, mistreatment, neglect and abuse they observe, hear about or suspect to a supervisor or the administrator; -All residents are encouraged to report their concerns or suspected incidents of potential mistreatment to a supervisor or the administrator or to the Compliance Hotline, such reports may be made without fear of retaliations and anonymous reports well also be thoroughly investigated; -The facility does not condone resident abuse by anyone, including other residents; it is the responsibility of our employees to promptly report any incident or suspected incident of abuse/neglect to Facility management immediately. If such incidents occur after hours the administrator or designee and Director of Nursing (DON) or designee will be notified at home or by cell phones and informed of any such incident; -The facility must ensure that all alleged violations involving abuse or neglect are reported immediately, but no later than two hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency) in accordance with state law through established procedures; -Additionally, the following should be notified: The local/state Ombudsman, the resident or their guardian/legal representative; Adult Protective Services, resident's physician and facility medical director; -Upon learning of the report of abuse or neglect, the Administrator shall initiate an incident investigation, upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator of designee; -The following process will be used in investigations: Appointing an investigator, once the administrator or designee determines that there is a reasonable possibility that mistreatment occurred, the administrator or designee will appoint a person to take charge of the investigation; -The person in charge of the investigation will include assessment of all residents involved and interventions to ensure protective oversight of all residents and involved residents in the facility/interventions could include; nursing staff separating alleged perpetrator and alleged victim including moving the residents to separate halls, physician involvement, 1:1 face checks of alleged perpetrator and alleged victim; psychiatric or medical needs of the resident, legal guardian notification, possible hospitalization or immediate discharge; -More intensive monitoring will be determined by the administrative staff after an assessment of the resident is completed; -Updates to the administrator, the person in charge of the investigation will update the administrator or designee during the process of the investigation, the Administrator or designee will keep the resident or resident representative informed of the progress of the investigation; -Final Report, a final report of the investigation will be sent to the Department of Public Health/Department of Health and Senior Services no later than five days following the initial complaint or incident, all investigation results will be made available as requested; -Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway; -Resident who allegedly mistreats another resident will be removed from contact with the resident during the course of the investigation; the accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. 2. Review of Resident #2's care plan, dated [DATE] showed: -Mood/Behavior: Risk for alteration in mood related to paranoid [MEDICAL CONDITION] and has a history of verbal and physical aggression, delusions and hallucinations; -Will not cause significant harm to self or others; -Notify guardian, Administrator, DON, physician and RCC if behavior emergencies occur; -Encourage/educate resident on the importance of coming to staff with any concerns before becoming verbally and physically aggressive as needed; -Discuss options for appropriate channeling of anger as needed; -Ongoing assessment for changes in mental status, behavior emergencies, and impaired cognitive functioning; -Several psych hospitalization s and he/she does have a history of verbal and physical aggression, delusions and hallucination. Review of the resident's Long Term Psych Management note, dated [DATE], showed: -Staff reported the resident had increased confusion with verbal and physical aggression; -The staff reported he/she has been a behavioral issue and fighting with other residents; -He/she was started on as needed [MEDICATION NAME] (antipsychotic) for aggressive/violent/dangerous behavior; -Past history: Major events unprovoked physical attacks; -His/her thought process was goal directed; judgment was fair to good; and insight fair to good; -His/her memory was grossly intact and alert and oriented times three; -He/she had increased confusion with verbal and physical aggression. Record review of the resident's Minimum Data set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Short term memory problems; -Moderately impaired cognitive skills for daily decision making; -Physical, verbal and other behaviors; -Supervision of staff while walking in the corridor and with locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of the resident's nurse's note, dated [DATE] untimed, showed the resident became physically and verbally aggressive toward a peer. The residents were immediately separated and redirected. The resident continued displaying physical aggression to the nurse and CALM (Crisis Alleviation Lessons and Methods) technique was utilized. The resident's physician was notified with orders to discharge to the hospital. The DON and guardian were notified of the incident. Review of the resident's care plan, dated [DATE], showed the resident was immediately discharged to the hospital due to physical aggression and undirectable behaviors. Review of the resident's transfer sheet, dated [DATE] untimed, showed the resident was transferred for physical aggression. Review of the resident Immediate Notice of Discharge, dated [DATE], showed specifically on [DATE], without provocation, the resident attacked another resident. There was no further information available in the resident's medical record regarding this incident. During interview on [DATE] at 10:30 A.M., the resident's family member said the DON called him/her [DATE] and told him/her the resident was receiving an emergency discharge because the resident was in an altercation with another resident and fractured his/her face. During interview on [DATE] at 3:52 P.M., Licensed Practical Nurse (LPN) D said Resident #2 was discharged from the facility because he/she punched Resident #1 in the face and Resident #1's face and his/her nose was bleeding. Whenever Resident #2 hit other residents in the face it wasn't always investigated or documented in the resident's medical record. Staff had to keep an eye on the resident because you never knew when he/she was going to hit another resident. Resident #1 and Resident #2 had two code greens (a behavioral emergency and/or an incident needing physical support and presence when an individual poses a threat to himself/herself or others) within two weeks. 3. Record review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Understood and understands; -Severely impaired cognition; -Physical behaviors; -Supervision of staff while walking in the corridor and with locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated [DATE] showed: -Mood/Behavior: Will not cause significant harm to self or others; -Notify guardian, administrator, DON, physician and RCC (Resident Care Coordinator) if behavior emergencies occur; -Assist with using coping skills as needed, give examples of appropriate coping skills as needed; -Immediately remove the resident from negative situation as needed; -Educate/encourage to keep hands to him/herself as needed; -Cognition: Impaired thought processes related to major [MEDICAL CONDITIONS], ADHD (Attention Deficit [MEDICAL CONDITION] Disorder), [MEDICAL CONDITION], mild intellect disability; -History of verbal and physical aggression, [MEDICAL CONDITIONS], reactive attachment disorder, mood disorder, personality disorder and he/she has a legal guardian who assists him/her in major decision making at this time. Review of the resident's psychiatric mental health nurse progress note, dated [DATE], showed: -Chief complaint: Has a behavior when he/she doesn't get what he/she wants and bullies others; -Past psychiatric history: History of social paranoia; -Subjective: The resident said, I have a bit of an anger issue sometimes, but that's about it; -Mood swings reported, I feel angry today and easily agitated; -Endorses auditory hallucinations; -Objective: Judgement fair to good, insight fair to good, memory grossly intact and alert and oriented times three; -Review of symptoms: verbal and physical aggression (overt, often harmful, social interaction with the intention of inflicting damage or other unpleasantness upon another individual); -Assessment: In our clinical opinion the resident is not at baseline given ongoing verbal aggression towards others. Record review showed no treatment recommendations documented. Review of the resident's nurse's note, dated [DATE] at 1:24 A.M., showed the resident was involved in a verbal and physical aggression with a peer. The resident was immediately removed from area and given 1:1 time to vent/verbalize feelings. There was a small amount of active bleeding noted to the nares (nose). He/she complained of nasal pain. The physician was notified and new orders were received for facial x-ray. The administrator and DON were notified. Continue with intensive monitoring and protective oversight and continue with plan of care. There was no further information in the resident's medical record. The care plan was not updated; there was no documentation showing staff assessed the effectiveness of interventions or identified new interventions to address the resident's aggression. Review of the resident's nurse's note, dated [DATE] at 1:18 P.M., showed at 7:10 A.M., the resident was allegedly involved in verbal and physical aggression with a peer. A code green was called. The residents were immediately separated and given time to vent and verbalize feelings and frustrations to staff, the resident was easily re-directed He/she said he/she may have been hit in the head. Review showed the resident's care plan was not updated; there was no documentation showing staff assessed the effectiveness of interventions or identified new interventions to address the resident's behavior. Review of the resident's nurse's note, dated [DATE] at 12:13 P.M., showed the resident was allegedly involved in physical aggression with a peer. The resident had red marks on his/her neck. The residents were separated. The administrator, DON and physician were aware. Continue with the resident's plan of care. There was no further information in the resident's medical record. The care plan was not updated; there was no documentation showing staff assessed effectiveness of interventions or identified new interventions. Review of the resident's nurse's note, dated [DATE] at 12:20 P.M., showed the resident was allegedly involved in physical aggression with a peer. The resident's neck was red but no swelling. The residents were immediately separated. Staff spent 1:1 time with the resident allowing him/her to vent feelings/frustrations and the resident was able to be redirected. The residents were placed on intensive monitoring. Review showed the resident's care plan was not updated, there was no documentation showing staff assessed the effectiveness of interventions or identified new interventions. During interview on [DATE] at 10:22 A.M., Resident #1 said Resident #2 hit him/her once or twice in the nose and it bled. Staff pulled him/her off of Resident #2. He/she didn't feel safe; staff didn't monitor them more frequently or keep them separated. During interview on [DATE] at 12:51 P.M., the resident's guardian's deputy said the following: -On [DATE], he/she received notification the resident was involved in an altercation and he/she didn't start this one, -On [DATE], he/she was notified the resident was involved in an altercation and he/she didn't start this one; -On [DATE], the resident was in an altercation with a resident, he/she was struck in the nose and an x-ray was ordered. During interview on [DATE] at 1:26 P.M., the administrator said intensive monitoring meant staff are to provide residents with protective oversight with face checks and the staff continue to monitor the residents. 4. Record review of Resident #7's annual MDS dated [DATE], showed the following: -Understood and understands; -Cognition intact; -No behaviors; -Supervision of staff while walking in the corridor and with locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated [DATE], showed: -At risk for alteration in mood related to [MEDICAL CONDITION] disorder (a chronic mental health condition characterized primarily by symptoms of [MEDICAL CONDITION], such as hallucinations or delusions, and symptoms of a mood disorder, such [MEDICAL CONDITION] depression), anxiety, [MEDICAL CONDITION], mood disorder, [MEDICAL CONDITIONS], attention deficit hyperactive disorder and he/she does have a history of verbal aggression and physical aggression; -History of mental illness can be paranoid and voice delusions; -Notify guardian, administrator, DON, physician, and RCC if behavior emergencies occur; -On-going assessment for changes in mental status, behavior emergencies and impaired cognitive functioning -On [DATE], the resident received [MEDICATION NAME] (antianxiety) 2 mg (milligrams) and [MEDICATION NAME] (antipsychotic) 5 mg IM (intramuscular) now for increased agitation/aggression. Review of the resident's nurse's progress note, dated [DATE] at 4:24 A.M., showed on [DATE] at 11:00 P.M., a code green was called; the resident allegedly displayed verbal aggression and physical aggression to peer. The residents were immediately separated. Staff spent 1:1 with the resident to allow time to vent feelings/frustrations, but the resident was not receptive to this and displayed increased agitation. The administrator, DON and physician were notified. Orders were received for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM now. The medication was given and the resident continued displaying verbal aggression to a resident and was placed 1:1 intensive monitoring for protective oversight per the DON. A detailed message was left with the guardian. There was no further information available in the resident's medical record about this incident. Review of the resident's care plan showed the following: -On [DATE], the resident received [MEDICATION NAME] 5 mg by mouth every six hours as needed for 14 days for increased [MEDICAL CONDITION]; -On [DATE], the resident received [MEDICATION NAME] 2 Mg and [MEDICATION NAME] 5 mg IM now for increased agitation/aggression. There was no documentation showing staff assessed effectiveness of interventions or identified new interventions to address the resident's agitation/aggression. Review of the resident's nurse's progress note, dated [DATE] at 3:38 A.M., showed the resident displayed increased agitation and verbal/physical altercation. The resident was given 1:1 time to vent/verbalize feeling and frustrations. The physician was notified and a new order was received for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM now. The resident had a small scratch to his/her right fourth finger; faint bruising to bilateral knuckle area. The administrator and DON aware and a detailed message left for guardian to return call if further questions and concerns. Intensive monitoring for protective oversight was continued. Continue with plan of care. There was no further documentation in the resident's medical record regarding this incident. The resident's care plan was not updated and there was no documentation showing staff assessed the effectiveness of interventions or identified new interventions to address the resident's aggression. During interview on [DATE] at 10:40 A.M., the resident said three or four days ago Resident #8 started making his/her way into the resident's room without knocking; he/she snapped and hit Resident #8 in the face twenty times and caused swelling. The first time he/she had hit someone was his/her last roommate (Resident #9) who went after staff so he/she snapped and hit Resident #9 a few times in his/her face. He/she didn't receive an injection and Resident #9 was immediately discharged . He/she could be protective over authority figures. The residents did not hit him/her back. He/she had several assault charges in the past. The staff tried to intervene but this made him/her even angrier. He/she didn't feel safe with his/herself; he/she worried he/she would hurt someone else due to his/her bad temper which causes him/her to lash out. During interview on [DATE] at 11:08 A.M., Hall Monitor E said he/she was 1:1 with Resident #7 at one time because Resident #9 went after Resident #7 and Resident #7 hit Resident #9 in the back of the head. The charge nurse talked to the hall monitor or resident about the altercation. During interview on [DATE] at 3:39 P.M., Nursing Staff D said the following: -At 3:39 P.M., He/she said he/she received information that Resident #7 hit Resident #8; -At 3:52 P.M., He/she said Resident #7 said Resident #8 tried to come in his/her room so he/she got up and hit him/her. Resident #7 had another code green that same night but he/she didn't know what it was about. He/she was not aware of all resident to resident altercations but should be. During interview on [DATE] at 12:5 P.M., the resident's guardian's deputy said the following: -On [DATE], he/she was notified the resident was in an altercation and received a scratch on his/her ring finger and his/her knuckles were bruised; -On [DATE], the resident called and said he/she apologized for hitting the other resident but he/she deserved it and he/she wanted the hell out of here. 5. Record review of Resident #8's admission MDS, dated [DATE], showed the following: -Severe mental illness and [MEDICAL CONDITION]; -Understood and understands; -Cognition intact; -Physical and verbal behaviors; -Overall presence of behavioral symptoms; -The identified symptoms put the resident as risk for physical illness or injury; -Significantly interfered with resident care; -Significantly interfered with the resident's participation in activities or social interactions; -Put others for significant risk for physical injury; -Significantly intruded on the privacy or activity of others or activity of others; -Significantly disrupted care or living environment; -Supervision of staff while walking in the corridor and with locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of the resident's nurse's note, dated [DATE] at 1:44 A.M., showed on [DATE] at 8:30 P.M. a code green was called due to the resident displaying verbal and physical aggression to a peer. The DON was notified and the resident was placed 1:1 monitoring for protective oversight. The administrator and the physician were aware. A detailed message was left with the resident's guardian with instructions to call back for further questions or concerns. Review of the resident's care plan, dated [DATE], showed: -Psych: History of emotional and physical abuse and has a history of physical and verbal aggression, being intrusive and impulsive; -At risk for alteration in mood related to mild intellectual disabilities post-traumatic stress disorder ([MEDICAL CONDITION]), mood disorder, schizotype personality, borderline personality, ADHD he/she does have a history of verbal aggression and physical aggression, being intrusive and impulsive. He/she has difficulty setting boundaries; -Will not cause significant harm to self or others; -Notify guardian, administrator, DON, physician, and RCC if behavior emergencies occur. Review of the resident's nurse's note, dated [DATE] at 9:18 P.M., showed the resident displays verbal and physical aggression toward peer; immediately separated and 1:1 attention provided allowing the resident time to vent and verbalize feelings and concerns. The resident's physician was notified and renewed order for [MEDICATION NAME] 1 mg and [MEDICATION NAME] 5 mg as needed. This was administered. A detailed message was left for the administrator and resident's guardian. Review of the resident's care plan, dated [DATE], showed [MEDICATION NAME] 5 mg and [MEDICATION NAME] 1 mg every six hours as needed for 14 days for anxiety and agitation. The care plan was not updated; there was no documentation showing staff assessed the effectiveness of interventions or identified new interventions to address the resident's aggression. Review of the resident's nurse's note, dated [DATE] at 8:31 P.M., showed the resident was allegedly struck by a peer. The resident's physician was notified. The resident continues on intensive monitoring for protective oversight, administrator/DON aware and detailed message left on guardian's phone and will continue with plan of care. There was no further documentation in the resident's medical record about this incident. Review of the resident's care plan, dated [DATE], showed [MEDICATION NAME] 5 mg and [MEDICATION NAME] 2 mg IM now for agitation and aggression. There was no further documentation in the resident's medical record. The care plan was not updated; there was no documentation showing staff assessed effectiveness of interventions or identified new interventions to address the resident's agitation and aggression. Review of the resident's nurse's note, dated [DATE] at 3:16 A.M., showed: -At 10:00 P.M., the resident was displaying increased agitation and verbal aggression/physical aggression; -A code green was called; -The resident was given 1:1 time to vent/verbalize feelings and frustrations and is calm at this time; -The administrator and DON were aware; -At 10:20 P.M., the resident displaying verbal aggression; -A code green was called and the resident continued to be agitated and physically aggressive; -CALM was utilized and a new order was received for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM now; -The resident was given further 1:1 time to vent/verbalize feelings and frustrations; -The administrator/DON and physician were aware a detailed message was left for the guardian to return call if further questions/concerns; -Intensive monitoring was continued for protective oversight. The plan of care was continued. There was no further information available in the resident's medical record. The care plan was not updated; there was no documentation showing staff assessed effectiveness of interventions or identified new interventions to address the resident's continued agitation and aggression. Review of the resident's nurse's note dated [DATE] showed: -At 1:51 A.M., the resident complained of his/her right hand swelling and discomfort; At 8:49 P.M., the resident complained of right hand pain and order was received for 2 view right hand x-ray due to pain and swelling. Review of the right hand 2 view x-ray results, dated [DATE], showed no fracture. During interview on [DATE] at 10:58 A.M., the resident said the following: -On [DATE], he/she was hit by Resident #7 because he/she punched Resident #7's door and Resident #7 punched him/her in the side and back of the head ten times; -Hall Monitor A couldn't help because he/she was 1:1 with another resident so he/she got staff to call a code green; -Resident #8 sustained a scratch to his/her forehead which still hurt; -A few days prior to the altercation on [DATE] Resident #8 was hit by Resident #10 and he/she got a bloodied nose and kicked; -Resident #10 was going after staff and he/she tried to intervene; -He/she did not feel safe with Resident #10; -Staff did not make any changes or monitor the residents more frequently; -Resident #10 has hit other residents before. During interview, on [DATE] at 2:04 P.M., the resident's guardian said on [DATE] at approximately 1:30 A.M., the facility notified him/her the resident had a code green because the resident attacked another resident; then the resident got up and went after staff. During interview on [DATE], Employee D said the following: -At 3:39 P.M., He/she said he/she received information that Resident #8 had two code greens. -He/she was not aware of all resident to resident altercations but should be. 6. Record review of Resident #10's annual MDS, dated [DATE], showed the following: -Understood and understands; -Cognition intact; -No behaviors; -Supervision of staff while walking in the corridor and with locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated [DATE], showed: -Mood/behavior: The resident may have an altercation in mood related to [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], mood disorder, anxiety and mild mental [MEDICAL CONDITION]. He/she can be verbally and physically abusive. He/she had a history of [REDACTED]. The resident can become easily agitated and have verbal outbursts; -Notify physician, administrator, DON, RCC and guardian of need for code green and results. Review of the resident's physician note, dated [DATE], showed: -Staff report the resident was utilizing as needed [MEDICATION NAME] several times daily for aggressive behavior and complaint of anxiety; -The resident was very hostile and agitated during today's encounter; -The nursing staff reported the resident does get easily agitated and violent; -Assessment: Clinical opinion the resident was at baseline; -Plan-Relaxation techniques discussed; -Cognitive distortions discussed; -Individualized therapy discussed and recommended; -Call 911/emergency room if unsafe. Review of the resident's physician history and physical, dated [DATE], showed: -At request of staff the resident was seen today for hospital follow up; -The resident was sent to the hospital for increased behaviors; -He/she hit another resident; -He/she was verbally and physically assaultive against others; -Goals-control of psychiatric symptoms and aggressive behaviors. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Understood and understands; -Cognition intact; -Physical and verbal behaviors and other behaviors; -Rejected evaluation or care that is necessary to achieve the resident's goals for health and well-being, including behavior that have already been addressed and/or determined to be consistent with resident's values, preferences or goals; -Supervision of staff while walking in the corridor and with locomotion on and off the unit; -[DIAGNOSES REDACTED]. Review of resident's the nurse's note, dated [DATE] untimed, show (TRUNCATED)

Based on observation, interview and record review, facility staff failed to provide 24 hour protective oversight for one resident (Resident #107) with a history of elopements at a previous facility, assessed at risk of elopement, and diagnosed with [REDACTED]. Staff did not complete 15 minute face checks as scheduled and the resident left the facility without staff knowledge, exiting through two unalarmed, locked doors in sub-zero temperatures. Staff last saw the resident at approximately 12:00 A.M. on 1/1/18 and did not know the resident was missing until 1:40 A.M. on 1/1/18. The resident walked the highway and woods through the night and into the next day. The second night, the resident arrived at a home in a town located approximately 20 miles from the facility where he/she slept in an open shed for the night. At approximately 9:00 A.M. on 1/2/18, the resident approached a home owner, in distress and shaking uncontrollably from cold exposure. The home owner drove the resident to an area hospital (approximately 36 hours after leaving the facility) for treatment. The facility census was 171. 1. Record review of the facility's Elopement Policy and Procedure, dated 4/6/17, showed the following: -An elopement is defined as any time a resident is missing from the facility or there is a possibility that a resident left the facility without appropriate supervision and their whereabouts are unknown; -The first person aware of an elopement is to call a Code White; -If the resident is possibly still in the facility, the first person aware of the missing resident is to page all units to search room to room for the resident; -Staff to notify the Administrator; -If the resident in fact left the facility, staff are to notify the resident's family or legal guardian; -The charge nurse is to initiate a ground search, call the police and provide the police with the resident's name, sex, time discovered missing, where last seen, physical description and picture if available, physical and mental impairments, language spoken, color and type of clothing, if harmful to self or others, and home address of family or friends; -The Administrator is to initiate the call list and coordinate the search; -Staff are to use the call list to notify the next staff member; -After the resident is located and returned to the facility, staff are to notify the family or guardian, notify persons involved in the search, perform a full body assessment, obtain vital signs, document all findings, notify the physician, complete an elopement investigation form and initiate intensive monitoring protocol upon return for attempted or actual elopement; -Notification of state agencies will be at the discretion of the Administrator/designee. Record review of the facility's Intensive Monitoring/Visual Check Policy and Procedure, dated 4/6/17, showed the following: -A licensed nurse will monitor residents who require intensive monitoring due to medical behavior/psychiatric symptoms and will be monitored with visual face checks; -Intensive monitoring is defined as hourly checks by a licensed nurse or one on one monitoring by a designated employee assigned by the licensed nurse; -Face to face check is defined by the employee visually seeing the face of the resident; -Residents who show poor impulse control including verbal/physical aggression, elopement ideation, suicide/homicide ideation, decompensation mentally or medically may also be placed on one to one or two to one (within eye site of the resident at all times) monitoring at the discretion of the administrative staff; -All residents on each unit will be monitored by visual face checks at least every two hours by a licensed nurse or more intensive monitoring by the licensed nurse every hour; -Special units will not be left unattended at any time; -CNAs (certified nurse assistants) will continue to monitor residents at the discretion of administration. This provides direction only to the CNAs, and the licensed nurse will be the only designated employee to guarantee face checks are provided unless the resident required one on one monitoring by the designated employee assigned by the licensed nurse; -CNAs can be provided direction to monitor the resident in a timely manner at the discretion of Administration or a medical or behavior decompensation; -The facility recognizes that the licensed nurse is the only truly dedicated employee to provide face checks every two hours, or if required more intensively every one hour. The facility will not depend on the CNAs to guarantee intensive monitoring checks. However, the Administration will continue to assign time checks with the understanding that the CNA's time may be based upon the needs of the resident and assigned duties in the facility. Record review of Resident #107's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/31/17, showed the resident's [DIAGNOSES REDACTED]. Record review of the resident's care plan, dated 6/6/17, showed the following: -The resident resided on a secured unit; -Face checks per unit and the facility protocol to ensure protective oversight; -The resident is on elopement precautions; -He/she required a secured environment to limit exposure to substances and protective oversight to manage impulsive behaviors and meet his/her basic needs. Record review of the resident's elopement risk assessment, dated 11/1/17, showed the following: -The resident had a history of [REDACTED]. -The resident scored a 14 on the elopement risk assessment (0 to 15 is considered low risk). Record review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Understood others; -Others understood the resident; -Ambulated without an assistive device; -Adequate vision, hearing and speech; -Rejected care. Record review of the facility's elopement book (kept in the front office) showed an elopement risk identification sheet for the resident (not dated) that included the resident's name, date of birth, room number, height, weight, hair color, eye color and a photo of the resident. Record review of the facility's 15 minute face checks dated 12/31/17-1/1/18 showed: -Five residents on the 100 hall including Resident #107 were on 15 minute face checks; -Resident #58 was being monitored every 15 minutes for protective oversight; -Staff did not document the residents' whereabouts after 12:00 A.M. on 1/1/18; -Staff resumed documenting 15 minutes face checks for the remaining four residents at 3:45 A.M. on 1/1/18. Review of the resident's Licensed Nurse Intensive Monitoring check (completed by Licensed Practical Nurse (LPN) A), dated 1/1/18 at 12:00 A.M., showed the resident was in the common area. Record review of the resident's nurse's notes, dated 1/1/18, showed staff documented: -At approximately 1:40 A.M., the resident was not observed in his/her room; -Staff called a code white (elopement); -Staff looked for the resident inside and outside the facility; -Staff was unable to find the resident; -Staff contacted the local police department. Record review of the local Police Department event, dated 1/1/18, showed: -The police responded on 1/1/18 at approximately 2:02 A.M. to a missing person report at the facility; -LPN B said LPN A discovered the resident missing from his/her room; -LPN B said the last time staff saw the resident was approximately 12:30 A.M.; -LPN A said the last time he/she saw the resident was between 10:30 P.M. and 11:00 P.M., -Hall monitor (HM) C said he/she left work approximately 12:30 A.M. due to not feeling well; -HM C said he/she could not find the nurse for over one and a half hours, he/she had worked at the facility for a couple of weeks and did not know the policy for leaving the facility; -He/she said he/she left a note at the front desk for the charge nurse and exited through the back door; -The resident was not located following a search of the residence. Record review of the facility's undated investigation summary (not dated) showed: -On 1/1/18 at approximately 12:20 A.M., HM C left the hall assigned to him/her without notification to other staff members; -HM C was responsible for assisting 18 residents on the 100 hall; -Staff were directed to monitor each resident on their hall; -The resident was on 15 minute monitoring checks for physical aggression; -HM C monitored the resident at 12:00 A.M.; -HM C left the facility at approximately 12:30 A.M. through the back service door area; -This took place around the time the resident left the building; -The courtyard door opened to the same area HM C left though; -At 1:40 A.M., staff notified the unit nurse the back court yard door was opened; -At the same time the nurse was made aware of a note left by HM C in the front office that he/she left the facility; -The resident was not found after staff accounted for all other residents; -Staff called a code white (elopement); -Staff did not monitor the 100 hall between 12:00 A.M. and 1:40 A.M.; -Staff completed monitoring after the code white was called; -The courtyard has a 12 foot fence with a door secured by two magnetic locks; -The resident scored low on an elopement risk assessment; -Staff immediately looked for the resident up until mid-day. During an interview on 1/1/18 at 1:17 P.M., the administrator said: -HM C left a note at the front desk that showed he/she left because he/she was sick; -Security video showed he/she left the facility around 12:20 A.M. through the back service exit; -There was no video of the resident leaving the facility; -After a staff member reported the exterior courtyard door open, staff found the resident was gone; -Staff actively looked for the resident from 1/1/18 at 1:50 A.M. until approximately 1:00 P.M. Observation on 1/1/18 at 2:05 P.M. showed the following: -Interior doors separating one unit from another were locked and required the use of a code at the keypad to unlock the doors; -The exit doors from the 100 and 300 halls were locked and required the use of a code at the keypad to unlock the doors; -The facility back service door opened to a small enclosed hallway that led to a rear parking lot set at the end of a driveway; -The exterior courtyard door for the 100, 200, and 300 halls opened at the driveway; -The exterior door on the fence of the court yard surrounding the 100, 200, and 300 court yard was locked and required the use of code at the adjacent keypad to unlock the door; -The top magnetic lock of the exterior door did not engage. -A large foot print was on the center of the door. During an interview on 1/1/18 at 6:00 P.M., the administrator said maintenance fixed the upper magnetic lock on the exterior courtyard door that lead to the parking lot on 1/1/18 after observation showed the upper magnetic lock not engaged. Record review of Weather Underground weather history of surrounding townships for 1/1/18 showed the following: -At 1:55 A.M., the temperature was minus 2.9 degrees F (Fahrenheit) with a wind chill factor of minus 15.4 degrees F; -At 5:55 A.M., the temperature was minus 7.1 degrees F with a wind chill factor of minus 21.4 degrees F; -At 10:55 A.M., the temperature was minus 0.4 degrees F with a wind chill factor of minus 12.0 degrees F; -At 2:55 P.M., the temperature 9.9 degrees F with a wind chill factor of minus 1.1 degrees F; -At 6:55 P.M., the temperature 5.0 degrees F; -At 11:55 P.M., the temperature 0.3 degrees F with wind chill factor of minus 7.5 degrees F. During an interview on 1/1/18 at 4:30 P.M., LPN D said: -He/she last saw the resident around 11:45 P.M. on 12/31/17 to 12:00 A.M. on 1/1/18 at the nurse's station when she/he left the unit; -He/she went to the front office and returned to the unit around 12:30 P.M.; -He/she did not see HM C at the front of the facility or in the office; -He/she assigned HM C to the 100 hall, HM D to the 200 hall and HM E to the 300 hall to complete face checks; -At approximately 12:30 A.M., he/she noticed HM C was not around; -LPN E said he/she found the note left by HM C at 12:30 P.M. -He/she realized HM C was not around after he/she received notice of the note left in the front office; -He/she assigned face checks for the 100 hall to HM D at approximately 12:30 A.M.; -The hall monitor is to complete face checks as assigned; -He/she did face checks at 1:40 A.M. with HM D after staff notified him/her the courtyard door was open; -Staff attempted to account for all residents, but the resident was not found; -Staff called a code white, searched for the resident, but were unable to locate the resident. Record review of a written statement, dated 1/1/18, showed LPN D said: -The resident was seen at the nurse's station between 11:45 P.M. on 12/31/17 and 12:00 A.M. on 1/1/18; -He/she assigned face checks to HM D when he/she was notified HM C left the facility; -At 1:40 A.M., staff notified him/her the courtyard exterior door was open; -Staff completed a head count of all the residents; -Staff could not find the resident. Record review of Weather Underground weather history 1/2/18 of surrounding townships for 1/2/18 showed the following: -At 1:55 A.M., the temperature was minus 3.3 degrees F; -At 5:55 A.M., the temperature was minus 5.8 degrees F; -At 9:55 A.M., the temperature was 4.5 degrees F. During an interview on 1/2/18 at 9:00 A.M., the resident's legal guardian said: -The facility reported the resident eloped; -The administrator said he thought a staff member assisted the resident with eloping; -The administrator said staff found the outside courtyard door (to the gate) open; -The administrator said the resident kicked the outside courtyard door open and it had a foot print on it. Record review of the resident's emergency room report from an area hospital, dated 1/2/17 at 9:50 A.M., showed the following: -The resident said he/she ran away from a group home (the facility); -He/she said he/she had been outside for two days living in a shed; -He/she wanted an evaluation due to uncontrolled shivering and being cold; -The resident's temporal (forehead) temperature reading was 35.6 degrees Celsius (96.8 degrees F) (normal temporal temperature 97.6). During an interview on 1/2/18 at 10:50 A.M., the resident's legal guardian said: -The resident went to the ER, he/she was very cold, needed food, and to warm up; -The resident said he/she stayed inside a shed; -The resident did not have frost bite or injuries; -The resident had a history of [REDACTED]. -The resident was admitted to the current facility following a psychiatric hospital stay due to a second elopement. During an interview on 1/2/18 at 11:48 A.M., HM D said the following: -He/she was assigned to complete face checks on the 200 hall; -LPN D then assigned the 100 hall to him/her around 1:00 A.M.; -He/she was not sure when he checked the resident's room, but he was not in his/her room; -He/she was not sure if LPN D told him/her to complete face checks at 12:00 A.M. on the 100 hall; -He/she did not do face checks on the 100 hall between 12:00 A.M. and 1:40 A.M.; -The last time he/she saw the resident was around 9:30 P.M.; -The last time he/she saw HM C was around 11:00 P.M. Record review of a written statement, dated 1/2/18, showed HM D said he/she did not do face checks on the 100 hall between 12:00 A.M. to 1:40 A.M. During an interview on 1/2/17 at 1:17 P.M., HM F said he/she: -Took a break from the 900 hall at 1:30 A.M. on 1/1/18; -Went outside to his/her vehicle; -Saw the courtyard exterior door open; -Notified staff the door was open. During an interview on 1/2/18 at 1:40 P.M., the Maintenance Director said: -He/she was called to the facility between 1:45 A.M. and 2:00 A.M. on 1/1/18 because of a Code White; -He/she first checked the video surveillance following the Code White; -He/she found the exterior courtyard door open and checked the exterior door to ensure it locked; -He/she verified both magnetic locks engaged on the exterior courtyard door; -He/she kicked the exterior courtyard door and it opened; -He/she did not know why the upper lock on the door did not engage during observation on 1/1/18; -He/she put a new magnetic lock on the upper portion of the exterior door yesterday after the top magnetic lock did not engage; -He/she did not know if the foot print on the door was there before he/she kicked the door; -He/she kicked the 100 hall door, but it did not open; -The interior and exterior exit doors were locked by keypad, but were not alarmed; -These doors only open with the security code. Record review of a written statement, dated 1/2/18, showed the Maintenance Director said: -He/she checked the exterior courtyard door between 2:45 A.M. to 3:00 A.M. and found it open; -He/she verified both magnetic locks on the courtyard exterior door engaged; -He/she kicked the exterior courtyard door and it opened; -He/she replaced the upper magnet yesterday afternoon; -After he/she replaced the upper magnet, he/she did not kick the door, because residents watched him/her; -He/she checked the 100 hall interior exit door by kicking it, it did not open. During an interview on 1/2/18 at 2:42 P.M., LPN D said the following: -Face checks are completed every five minutes, every 15 minutes or every hour based on the resident's elopement risk; -Resident #107 was on 15 minute face checks; -The charge nurse is to complete one hour face checks; -Management decides on the frequency of face checks, not the charge nurse; -Hall monitors receive the scheduled times of the resident face checks at the beginning of their shift. During an interview on 1/2/18 at 3:00 P.M., the Director of Nursing (DON) said: -The charge nurse completes face checks at least every two hours; -She expects staff to complete face checks as scheduled; -Blank face checks are not acceptable; -HM D said he/she started face checks when the charge nurse assigned them to him/her; -HM C left the facility without informing anyone; -LPN D thought HM C was on his/her break; -At the beginning of (MONTH) (YEAR), the resident was on 30 minute face checks; -On 12/28/17, the resident had physical and verbal aggression and was placed on 15 minute face checks. During interview on 1/2/18 at 3:15 P.M. and 1/3/18 at 1:45 P.M., Citizen A said his/her spouse, Citizen B, live in a community 20 plus miles from the facility. Citizen A said his/her spouse contacted him/her at work and relayed the following: -At 9:00 A.M. on 1/2/18, the resident appeared at the door to their home; -The resident was shaking violently, his/her face was pale white and was having trouble speaking; -The resident was freezing to death; -Citizen B took the resident in to the house to warm him/her, Citizen B felt the resident was close to death; -The resident wanted a drink and it was provided; -Citizen B allowed the resident to remain in the house to warm up for about 30 minutes before transporting the resident in a warm car to a regional hospital about a 30 minute drive from Citizen B's home; -The resident continued to shake in the warm car; -The resident said he/she hoped Citizen B did not mind that he/she slept in his/her shed last night, that he/she was freezing; -The outbuilding the resident stayed in was an old chicken house without doors and there was an old lawn chair and an old sheet in the building the resident may have wrapped up in; -The shed was not heated, was open to air and very cold; -The resident wore a flannel insulated shirt, pants and a hat; -The resident told Citizen B he/she had stopped at a shelter, had gotten food and gotten warm; -The resident was headed to Pilot Grove, he/she was trying to hitch hike from the town where the facility was located, but no one would pick him/her up; -Citizen B asked the resident why he/she did not come to his/her house last night and the resident said it was dark and he/she could not see the house; -The resident wanted to go to a regional hospital; -Citizen A said they did not use or visit the shed during winter months. During an interview on 1/2/18 at 3:25 P.M., the administrator said: -Exit doors and the exterior courtyard door are keypad locked without alarms; -The Maintenance Director said he kicked the inside 100 exit door, but was unable to kick it open; -The upper magnetic lock to the courtyard exterior door engaged the morning of 1/1/18; -He did not know why the upper magnetic lock did not engage during observation the afternoon of 1/1/18; -He expected staff to complete face checks as scheduled per policy; -Licensed nurses were to complete face checks at least every two hours; -Scheduled face check times are at the discretion of management, the facility policy included more intensive monitoring for some residents; -HM C left without telling other staff after 12:00 A.M.; -Face checks were completed after 1:40 A.M. and forward although they were not documented; -He felt the facility met regulations per their policy, because staff checked on the resident every two hours; -The last time LPN A saw HM C was at 12:00 A.M.; -The facility investigation showed LPN D thought HM C was on break and did not realize HM C left the facility; -If staff was on break/lunch, he expected the charge nurse to delegate responsibilities/face checks to another staff member; -LPN D said he/she told HM D to do face checks on the 100 hall; -The facility has no specific time for intensive monitoring, only every two hours by a licensed nurse per the facility's policy. During an interview on 1/2/18 at 6:11 P.M., the resident said: -He/she opened the 100 interior exit door by shouldering it open between 11:30 P.M. to 12:00 A.M. (12/31/17); -He/she said he/she also shouldered the exterior court yard door (to the gate) and it opened; -He/she had no plan to elope, but when he/she decided to leave, he/she made sure no staff were around; -He/she saw one staff member go into the break room when he/she left, no other staff were around; -He/she walked to the business highway to the railroad tracks, left town, and got back on the highway; -He/she then went into the woods for most of the day; -He/she came across an old shed and stayed there all night; -In the morning, he/she saw a guy outside the nearest house; -He/she went to the house and knocked; -The man invited him/her inside; -The man gave him/her some water and said he/she thought the resident needed to go to the emergency room ; -He/she said when at the ER, his/her body temperature was low and had increased blood pressure, but did not have any injuries; -He/she did not know how cold it was outside when he/she decided to leave the facility. During an interview on 1/3/18 at 11:48 A.M., HM C said: -He/she was a new employee; -He/she worked as a hall monitor the night shift on 12/31/17 on the 100 hall (where the resident resided); -He/she did face checks on the 100 hall; -The resident asked for a snack around 11:00 P.M.; -The resident had on jeans, a long sleeved t-shirt and boots; -At 11:30 P.M., he/she saw the resident in his/her room; -The resident was in his/her bed and under the covers with his/her eyes closed; -The resident wore the same white t-shirt he/she was wearing when he/she was at the nurse's station getting a snack; -He/she did not check on the resident after 11:45 P.M.; -He/she did not check on the resident again because another resident (Resident #58) from the 100 hall busted through the interior doors (got off the unit); -Licensed Practical Nurse (LPN) D charge nurse and HM D left the 100 and 200 halls to assist in finding the Resident #58; -HM C could not find the charge nurse or the hall monitor assigned to the adjoining 200 hall; -He/she left a note at the unlocked empty front desk that he/she was going home sick; -He/she exited the facility through the back service door, but did not know what time; -When he/she left the facility, he/she noticed the exterior courtyard door (to the gate) was open, but did not think anything about it; -He/she did not see the resident or anyone else outside; -His/her driver said he/she noticed the door was open when he/she arrived around 12:20 A.M. During an interview on 1/3/18 at 6:45 P.M., LPN E said the following: -He/she worked the 600 and 700 halls on the 7:00 P.M. to 7:00 A.M. shift on 12/31/17; -A code gray (transfer to a hospital) was called and a resident was sent to the hospital; -He/she was unsure of the time; -He/she saw HM C at the 600/700 nurse's station, but did not know what time; -He/she thought HM C was on break; -A code white was called around 12:15 A.M. when another resident (Resident #58) from the 100 hall was found at the main dining room located at the front of the facility; -He/she did not know how Resident #58 got from the 100 hall up to the front of the facility, but the resident was in an area he/she should not have been; -The interior doors separating one unit to another are keypad locked, but do not alarm; -He/she thought LPN D was busy filling out paper work for the hospital transfer; -He/she said he/she found the note left by HM C after the code white was called on the resident (between 1:30 A.M. and 1:40 A.M.), while getting the facility's elopement book for Resident #107's personal information and picture; -He/she told LPN D about the note (left by HM C) after the code white was called on the resident when LPN D came to the front office to speak to the police. During an interview on 1/4/18 at 1:55 P.M., the DON said: -He/she was not aware the resident was an elopement risk; -The facility elopement risk identification sheets are completed for resident's at risk for elopement. During an interview on 1/26/18 at 11:55 A.M., the DON said the following: -Elopement precautions means a resident is at risk for elopement; -The resident will be placed on a secured unit; -The resident will be reassessed for elopement risk; -Elopement precautions are individualized for each resident; -As of 12/31/17, Medical Records and Social Services were responsible for completing the Elopement Risk Identification sheet kept in the Elopement Book; -Once an Elopement Risk identification is placed in the elopement book it is communicated to other staff through the resident's care plan and chart. MO 255 NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began inservicing staff on the facility's intensive monitoring policy and how to properly perform intensive monitoring and not leaving the floor or building without notifying the charge nurse. The charge nurse would then be responsible for setting direction for staff in the absence of a staff. The departments heads will be responsible for the inservicing that will continue at the beginning of every shift until all staff have been inserviced. The department heads are responsible for randomly checking the intensive monitoring checks on every shift. The administrator/designee will monitor this is completed. All external exit doors off of the specialized behavior units will be alarmed. A department head would be responsible for inservicing staff once the alarms are installed. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for two residents with mental illnesses (Residents #17 and #20) in a review of 23 sampled residents, to help them maintain or improve their highest practicable mental, physical, and psychosocial well-being. Resident #20 had a known history of agitation, aggression, impulsivity, and suicide attempt. The facility failed show evidence the resident's behaviors were evaluated, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, not identifying or attempting to identify the root causes of the behaviors and not revising the plan of care with measurable goals and interventions to address the care and treatment for [REDACTED]. The resident had 20 episodes of verbal and/or physical aggression between 3/4/14 and 6/18/14, in which 12 Code Greens (behavioral emergencies) were called and of those 12 Code Greens, 8 required the CALM (Crisis Alleviation Lessons and Methods used) intervention. During this period the resident was seen once by psychiatrist on 4/2/14 resulting in the time change of one medication and the dosage decreased of another medication. On 6/18/14 the resident was discharged after having explosive behavior, destroying the dining room, hitting staff in the face with his/her fist, and attempting to hit staff with a broken table leg to an outlying psychiatric hospital with return anticipated. On 7/7/14 he/she returned to the facility, the resident again had two more episodes of verbal and physical aggression, injuring one resident causing bruising and swelling to that resident's face. Resident #17 had [DIAGNOSES REDACTED]. The facility failed to provide the resident with a Co-Captain as described in the facility's World of Focus Program, failed to provide meaningful groups, failed to provide the resources (programs to increase independence and self-determination, development of personal support networks, individual counseling, family support/education, substance abuse programs) to prepare the resident for discharge, and failed to develop a plan of care with measurable goals and interventions to address the care and treatment for [REDACTED]. The facility census was 170. 1. Review of the facility's Behavioral Emergency Policy, dated 11/30/12, showed the following: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the Policy of the Corporation to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations the following steps will occur: 1) The licensed nursing staff/Team Leader/Resident Care Coordinator (RCC) will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one to one monitoring of resident will be initiated at this time under the direction of the licensed nurse. 4) The guardian will be notified at this time and imposed limitations may be placed on the resident, including hospitalization or other specific directives. 5) The physician will be notified of the licensed nurse/Team Leader/RCC assessment and orders will be followed. 6) The licensed nurse/Team Leader/RCC will follow all physician orders [REDACTED]. 7) If the Management Team Member on call and Administrator or Designee decide that a resident ' s needs cannot continue to be safely met, or that the resident is not appropriate for placement at the facility, the Physician (Primary Psychiatrist, House Psychiatrist, or Medical Director) will be notified by the licensed nurse requesting for a Psychiatric evaluation, at this time an immediate discharge notice may be sent with the resident. The Legal Guardian will be notified of the immediate discharge and the reason for the notice. 8) The DON/ADON/RN/Designee will complete an RN Investigation within 24 hours of the behavioral emergency; -If the resident was not sent with an immediate discharge notice by the facility the following will occur: The assessment team will meet and provide a pre-admission screening prior to the resident returning from the hospital. The readmission nurses notes will include that the Administrator or Designee and Management Team Member on call feel that this resident is appropriate for placement in the facility and that his/her needs can be safely met by the facility. 2. Review of the facility's Behavior Emergency Guidelines, undated, showed the following: -Behavioral Emergency = Code Green- The Licensed Practical Nurse (LPN) or Registered Nurse (RN) must be present during the entire use of approved CALM hold techniques and release of any resident who poses imminent danger to self or others; -There are only two reasons that staff will utilize approved CALM hold techniques. They are as follows: 1) When a resident is in imminent danger of harming themselves. 2) When a resident is in imminent danger of harming others. 3. Review of the facility's Behavior Emergency Crisis Investigation Form, undated, showed if the use of the approved CALM hold technique was required to ensure the resident's safety, ensure that the resident's plan of care is reviewed and updated with new interventions provided as the use of approved CALM hold techniques was a treatment plan failure. 4. Record review of Resident #20's PASRR (Preadmission Screening and Resident Review), dated 7/9/12, showed the following: -The resident had a legal guardian; -Manner: Threatening, aggressive, easily frustrated, agitated/excited, irritable, easily distracted, nervous/restless; -Problematic Behaviors: impatient/demanding, wandering, alcohol/drug use, destroys property, verbally abusive, verbally threatening, physically threatening, pacing, seclusiveness, suspicious of others, lies purposefully, steals deliberately, talks of suicide/ideation, suicide threats, injures self; -The resident expresses frustration and anger by damaging property or threatening to hurt him/her self; -Describe the reason for referral to Nursing Facility: The resident is in need of a structured, safe, and secured environment in which medications can be adjusted and administered on a consistent basis to determine if his/her condition can improve and stabilize. The resident cannot be controlled in the community to allow enough time to assess responses to medications and to address inappropriate and out of control behaviors; -Summary: The resident has a lengthy history of treatment for [REDACTED]. He/she has been physically aggressive with his/her family member, grabbing the family member's arm and holding to try and get what he/she wants. The resident admits to smoking incense and K2 and he/she enjoys this and does not wish to stop. When the resident is at home, he/she is seclusive in his/her room, punches holes in the wall when angry, pulls clothing out of the closet and throws them on the floor. The resident displays many behaviors which the family member believes are related to "really, really, bad obsessive-compulsive". The resident unfortunately has been ostracized (excluded) while in school, and it is reported per records that he/she has been involved in gang activity since age nine. It is unknown the age at which he/she began to abuse substances, but apparently this has been more long-standing than suspected by the family member. The resident requires a structured, secured environment in which aggressive treatment can occur to address behavioral issues and prevent accidental self-harm. Review of history and physical from outlying hospital, dated 2/22/14, showed the following: -Chief complaint: "I got into a fight with somebody."; -History of Presenting Illness: The resident was sent in by ambulance from an outlying facility where staff there reported the resident had become more verbally and physically aggressive to the point that he/she physically assaulted another resident. The facility felt the resident was unsafe to remain in their facility, so transported to an outlying hospital for a psychiatric evaluation and subsequent admission to the hospital; -Past Psychiatric History: The resident has a lengthy psychiatric history dating back to his/her teenage years with multiple inpatient psychiatric admissions, with a [DIAGNOSES REDACTED]. He/she does have a court-appointed legal guardian. He/she does have a history of agitation, aggression, and impulsivity. He/she does admit to a history of a suicide attempt approximately two months ago by cutting his/her arm; -Plan: Admit to acute inpatient psychiatric hospitalization for further evaluation and treatment. Medications will be reviewed and titrated as needed to better stabilize mood and thought disorder. Continue close observation and assault precautions. Review of the resident's discharge summary from outlying hospital, dated 3/4/14, showed the following: -Reason for hospitalization : agitated, aggressive behavior; -Hospital Course: Medically stabilized by physician; -Condition of resident upon discharge: Mood stabilized; -Prognosis: Stable. Review of the resident's nurse's notes, dated 3/4/14 at 5:00 P.M., showed the resident was admitted to the facility. He/she was dropped at the front door. The resident was calm. The resident is med and care compliant. Placed on one to one for protective oversight. Will continue to monitor. Review of the resident's nurse's notes, dated 3/13/14 at 4:30 P.M., showed the following: -The resident called another resident a name. The other resident hit this resident in the head. The resident spent time with staff and was educated about being kind and not calling names. Will continue to monitor. Review of the resident's nurse's notes, dated 3/15/14 at 3:00 P.M., showed the following: -The resident was caught smoking in another resident's room. The resident's guardian was called and message left. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/16/14, showed the following: -Cognitively intact; -Disorganized thinking; -Mood interview score was zero; -Had delusions (misconceptions or beliefs that are firmly held, contrary to reality) in the last seven days; -Had no physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) in the last seven days; -Had no verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) in the last seven days; -Had no other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) in the last seven days; -Had no rejection of care; -Had no wandering; -Current tobacco use; -Had received antipsychotic, antianxiety, and antidepressant medication. Review of the resident's nurse's notes, dated 3/23/14, showed the following: -At 3:35 P.M., received an order for [REDACTED]. -At 9:00 P.M., received x-ray results of right hand. No fracture or dislocation seen. Normal right hand. Review of the resident's care plan, dated 3/21/14 and as reviewed on 3/25/14, showed the following: -Problem: Risk for alteration in mood/behavior, has a history of verbal/physical aggressive behavior. Has a history of cutting self due to hearing voices and delusional thinking, punching walls, and throwing objects. Has a history of alcohol and drug induced [MEDICAL CONDITION]. Has [DIAGNOSES REDACTED]. -Goal and Target Date: The resident will exhibit socially acceptable behavior without harm to self or others (no target date noted); -Approaches: Provide one to one, allowing ventilation of feelings/problems. Attempt to resolve areas of concern promptly; Provide frequent redirection as needed; Attempt to refocus behavior to something positive when exhibiting adverse behaviors as able; One to one intensive monitoring for behavioral emergencies as needed; Administer medication as ordered; Psych consult as needed/ordered; Pharmacy review of current medication regimen as needed/ordered; Always approach him/her calmly and unhurriedly and speak in a calm tone so not to escalate his/her anger as able; -Problem: Supervised smoker history of smoking in unapproved areas; -Goal and Target Date: The resident will follow facility policy for smoking (no target date noted); -Approaches: All lighters/cigarettes will be kept and distributed by staff when needed; The resident will smoke in designated times and in designated areas only. Review of the resident's nurse's notes, dated 3/28/14 at 2:00 P.M., showed the following: -The resident displaying increased verbal and physical aggression. The resident was hard to redirect, Code Green called CALM technique used effectively with no incidence. Program director, administrator, and physician made aware. The resident was given [MEDICATION NAME] (sedative, hypnotic, antianxiety) 2 milligram (mg) given by mouth, no adverse reaction noted. The resident was immediately placed on one to one to ensure protective oversight. The resident assisted to his/her room by staff. The resident was allowed to vent and verbalize all feelings to one to one staff, support provided. The resident was remorseful voicing apologies to staff. The resident continues one to one to ensure protective oversight. The resident's guardian made aware of issues, will continue with current plan of care; -The nurse's notes described verbal and physical aggression without specific description of how the aggression presented, who or what the aggression was/was not directed toward. Review of the resident's care plan, showed the following: -On 3/28/14 at 2:00 P.M., increased verbal and physical aggression noted. Unable to redirect. Code Green called/CALM utilized and [MEDICATION NAME] by mouth given. Continues on one to one for oversight and voices feelings/concerns. Will follow up and contact physician as ordered or needed. Guardian aware of above; -On 3/28/14 at 6:00 P.M., the resident continues to be calm and no negative behaviors noted. Denies pain or discomfort. No adverse reactions to [MEDICATION NAME] noted. Continue face checks as needed/ordered; -No revisions to the plan of care noted to prevent future incidents. Review of the resident's nurse's notes, dated 3/29/14 at 10:05 A.M., showed the resident was caught smoking in his/her room, having negative behaviors due to this. Guardian notified, will continue to monitor and will continue with plan of care; -This was the second documented occurrence of the resident smoking unsupervised in a non-designated smoking area. Review of the resident's long term psych note, dated 4/2/14, showed the following: -Chief complaint: I am okay; -Subjective data: The resident was seen for medication review and management. Per staff the resident has been irritable and hyper. He/she gets more irritable in the late afternoon. He/she was admitted to the facility in 3/14, prior to that he/she was at a sister facility where he/she had a fight and was sent to an outlying hospital. He/she was stabilized there and then sent to this facility. He/she is currently on [MEDICATION NAME] (cerebral stimulant) 20 mg by mouth every morning and at noon. The resident complains of feeling anxious. He/she has a history of getting agitated and getting involved in fights requiring hospitalization s. He/she reports that he/she sleeps fair. The resident complains of anxiety off and on but manageable. Behavior: None currently. Agitation: None now. The resident denies mood swings or racing thoughts. He/she has some baseline [MEDICAL CONDITION] with paranoia; -Objective data: Mood: Okay; Affect: congruent with mood and flat; Thought process: goal directed; Thought content: absent of suicidal or homicidal intent; Judgment: limited; Insight: limited; -Plan: Psycho education and support provided. The resident reassured. Decrease [MEDICATION NAME] to 10 mg twice a day possibly contributing to his/her anxiety, irritability, and impulsive dysregulation (poorly controlled impulse), also plan to discontinue at next visit. Change morning [MEDICATION NAME] to evening as it will help with afternoon anxiety, irritability, and restlessness. Continue other current medications. Monitor mood, behavior, and side effects. Call if problems, concerns, or deterioration. Review of the resident's nurse's notes, dated 4/10/14 at 2:30 P.M., showed the following: -Code Green called today, the resident was being verbally aggressive towards another resident. Staff responded quickly and appropriately. The resident was separated from other residents and was able to be re-directed. Continue with plan of care and continue to monitor; -The note described verbal aggression without specific description of the verbal aggression. Review of the resident's nurse's notes, dated 4/11/14 at 4:30 P.M., showed the resident was being verbally aggressive towards another resident. Resident #20 separated from other resident and was redirected with several attempts. The resident voiced his/her concerns to the nurse. Will continue to monitor and continue with plan of care; -The note described verbal aggression without specific description of the verbal aggression. Review of the resident's nurse's notes, dated 4/12/14 at 1:30 P.M., showed the resident was caught smoking in another resident's room, the resident handed a pack of cigarettes and a lighter to staff. Will continue with plan of care; -This was the third documented occurrence of the resident smoking unsupervised in nondesignated areas. Review of the resident's care plan showed the facility planned no new interventions to address the resident's repeated occurrence of smoking in a non-designated area. Review of the resident's nurse's notes, dated 4/20/14 at 11:10 P.M., showed the following: -Code Green called related to the resident being aggressive, knocking over table and chairs in the dining room. The resident said he/she was hearing voices and was just mad. The resident was easily redirected and just needed to vent feelings. The resident was cooperative with staff. Continue plan of care. Review of the resident's care plan, showed the following notation: -On 4/20/14, increased aggression noted. Code Green called. Complains of increased voices and feeling mad. Was able to be easily redirected/vent feelings. Guardian/physician aware. Continue on face checks for protective oversight. - No documentation the facility addressed the resident hearing voices. Review of the resident's nurse's notes, dated 4/21/14 at 5:00 P.M., showed the following: -The resident complained of hearing voices that were telling him/her to hurt/kill him/herself. The resident told this to the Certified Medication Technician (CMT) and to the nurse. New order for [MEDICATION NAME] (antipsychotic, neuroleptic) 5 mg by mouth one time was obtained to help the resident. The resident is requesting a medication change. The resident care coordinator notified. Continue with plan of care. -No documentation staff provided additional monitoring of the resident, contacted the resident's guardian, or if the resident had a plan to act on the voices telling him/her to harm self. Review of the resident's care plan, showed the following: - On 4/21/14, the resident complains of hearing voices. Physician notified and new order received for [MEDICATION NAME] one time. Will follow up as ordered/needed. No adverse reactions or complaints voiced/noted related to medication. During a telephone interview on 7/17/14 at 1:20 P.M., the Director of Nursing (DON), said the following: -She expected staff to try and find out if the resident has a plan to harm self; -Place the resident on one to one if threatens to harm self; -Document in the nurse's note the resident is on one to one; -Contact the guardian and let the guardian know that the resident has made a comment of harming self. Review of the resident's nurse's notes, dated 4/25/14 at 6:00 A.M., showed the resident had been up all night long. The resident informed the nurse that he/she had slept all day long and was not tired. Review of the resident's nurse's notes, dated 5/3/14 at 7:00 P.M., showed the following: -The resident came in from smoke break and went to the dining room, was throwing a chair and table. The behavior was non redirectable and Code Green was called. The resident was taken down without injury. Staff response was appropriate. Received a onetime order for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg intramuscular (IM) from the resident's psychiatrist. The resident was compliant with the injection. The resident was placed on one to one for protective oversight. On call administration, primary physician, and guardian made aware. Continue with plan of care. Review of the resident's care plan showed no revision or update of interventions/approaches to prevent future incidents. Review of the resident's nurse's notes, dated 5/9/14 at 1:00 P.M., showed the following: -The resident displayed increased verbal and physical aggression, Code Green called, the resident immediately removed from the situation. The resident was able to be redirected and provided support. Physician, guardian, administration, and program director made aware, new order received to administer [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM one time. Injection administered, no adverse reactions noted, the resident tolerated well. Neurochecks completed and initiated. No complaints of pain voiced, is apologetic and easily redirected. The resident moved to every 15 minute face checks to ensure protective oversight. Continue with plan of care; -No documentation as to why neuro checks were initiated and completed (head injury?); -The note described verbal and physical aggression that required a Code Green without specific description of the aggression. Review of the resident's care plan, showed the following: -On 5/9/14, increased verbal and physical aggression noted. Code Green called and the resident was removed from the situation and redirected. The physician aware of increased agitation/anxiety and new order received for [MEDICATION NAME]/[MEDICATION NAME]. Meds given as ordered. No adverse reactions noted. No complaints voiced or noted. Continues on face checks as ordered. Will follow up as ordered/needed. Guardian aware; -No documentation regarding any new interventions/approaches in regards to the resident's behavior. During a telephone interview on 7/17/14 at 1:40 P.M., the DON said the following: -She was not sure why neurochecks were initiated on the resident on 5/9/14; -Neurochecks usually were initiated when a resident has a fall and hits his/her head, has an unwitnessed fall, or is in a physical altercation and gets hit in the head; -She would expect staff to document in the nurse's notes as to why neurochecks were initiated. Review of the resident's Limitation Form, dated 5/14/14 by the facility administrator, showed the following: -Reason for limitation: Provide protective oversight and establish appropriate behavior; -Defining the limitation: The resident will abide by the facility's Covenant guidelines; -Duration of limitation: Three months; -Goals of limitation: To develop a safe and consistent environment for residents of the facility and to provide structure and organization; -Potential Positive Outcomes: The resident learns to adhere to guidelines and function in a structured environment; -Potential Negative Outcomes: The resident will not adhere to guidelines. Review of the resident's nurse's notes, dated 5/15/14 at 3:00 P.M., showed the following: -The resident displaying increase verbal and physical aggression, the resident was hard to redirect. Code Green called and CALM technique used effectively with no incidence. The program director, administration, and primary care physician made aware. The resident redirected after multiple attempts. The resident was given a cigarette to calm down. The resident was placed immediately on one to one to ensure protective oversight. The resident was assisted to the room by staff. The resident was allowed to vent and verbalize all feelings to the one to one staff, support provided. The resident continued one to one to ensure protective oversight. Guardian made aware, will continue with plan of care; -The nurse's notes described verbal and physical aggression without specific description of how the aggression presented, who or what the aggression was/was not directed toward. Review of the resident's 5 Minute Checks, dated 5/15/14, showed the resident was on five minute face checks from 3:00 P.M. until 4:30 P.M. (the nurse's note documented the resident was placed on one on one monitoring after the 3:00 P.M. incident). Review of the resident's nurse's notes, dated 5/15/14 at 4:30 P.M., showed the following: -The resident displayed increased verbal and physical aggression. The resident was hard to redirect and a Code Green was called with CALM technique used effectively with no incidence. The program director, administration, and physician made aware. The resident was given [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM, no adverse reactions noted. The resident immediately placed on one to one to ensure protective oversight. The resident assisted to his/her room by staff. The resident allowed to vent and verbalize all feelings to one to one staff and support provided. The resident was remorseful voicing apologies to staff. The resident continues on one to one to ensure protective oversight. Guardian made aware of incidence. Will continue with current plan of care; -The nurse's notes described verbal and physical aggression without specific description of how the aggression presented, who or what the aggression was/was not directed toward. Review of the resident's care plan, showed the following: -On 5/15/14, increased verbal and physical aggression noted. Code Green called, CALM technique used. Unable to redirect, support and one to one time spent. Apologetic to staff, physician and guardian aware given [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM. No adverse reaction noted. Placed on one to one; -Review showed no new interventions/approaches to address the resident's behavior. Review of the resident's 5 Minute Checks, dated 5/15/14, showed the resident was on five minute checks at the time when the second Code Green was called on him/her. Record review of the resident's nurse's notes, dated 5/16/14 at 8:00 P.M., showed the resident has increased verbal and physical aggression toward another resident. Resident #20 received a split lip, area cleaned and bleeding stopped. The resident refused any as needed (PRN) pain medication. On call administration, primary care physician, and guardian made aware; -The nurse's notes described verbal and physical aggression without specific description of how the aggression presented (a punch, slap, fall etc.), when one resident received a split lip as a result. Review of the resident's care plan, showed on 5/16/14, increased verbal and physical aggression noted, was able to redirect, support and one to one time spent. Physician and guardian aware; -Review showed no new interventions/approaches to address the resident's behavior to prevent future incidents. Review of the resident's nurse's notes, dated 5/17/14 at 4:00 P.M., showed the following: -Code Green called. The resident displaying increased verbal and physical aggression, unable to redirect. CALM, five person take down utilized, staff responded appropriately. The resident de-escalated while resting on the floor. The resident was apologetic. Administration, management, primary care physician, and guardian made aware. New order received from psychiatrist for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM one time now for increased anxiety and agitation. Administered the injection as ordered. The resident was calm and compliant and was released from hold. No signs and symptoms of injury obvious. The resident placed on one to one for protective oversight; -The nurse's notes described verbal and physical aggression requiring a five person take down to the floor and injection of antipsychotic medication without specific description of how the aggression presented, who or what the aggression was/was not directed toward. Review of the resident's care plan, showed the following: -On 5/17/14, increased verbal and physical aggression, unable to redirect. Code Green called, CALM technique used without injury. The resident was able to de-escalate easily. Apologetic, one to one time spent. The physician and guardian aware, new order for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM one time received. The resident tolerated well. No injury noted. Placed on one to one to ensure protective oversight; -Review showed no new interventions /approaches to prevent future incidents. Review of the resident's nurse's notes, dated 5/27/14 at 4:30 P.M., showed Code Green called due to the resident having increased verbal and physical aggression. The resident redirected after several attempts. The resident was apologetic and calm. Primary care physician made aware. No new orders received, will continue with plan of care; -The nurse's notes described verbal and physical aggression without specific description of how the aggression presented, who or what the aggression was/was not directed toward. Review of the resident's nurse's notes, dated 5/27/14 at 4:45 P.M., (fifteen minutes later), showed the following: -Code Green called due to increased verbal and physical aggression, unable to redirect the resident. CALM technique performed. New order received for [MEDICATION NAME] 2 mg and [MEDICATION NAME] 5 mg IM onetime now for increased anxiety and agitation per psychiatrist order. Administered the injection as ordered, the resident compliant. The resident de-escalated and was calm and apologetic. The resident placed on five minute face checks for protective oversight. The resident denies pain or signs and symptoms of obvious injury related to CALM technique. The resident smiling and laughing with staff, will continue to monitor. Guardian, primary care physician, administration, and management made aware. Will continue with the plan of care -The nurse's notes described verbal and physical aggression requiring a CALM hold and injection of antipsychotic medication without specific description of how the aggression presented, who or what the aggression was/was not directed toward. Further review of the resident's care plan, showed no mention of the incidents on 5/27/14 The facility failed to revise the plan of care with new interventions/approaches to prevent future incidents. Review of the resident's nurse's notes, dated 5/29/14 at 10:00 P.M., showed the resident wanting a new roommate. Said he/she was having trouble sleeping due to the roommate snoring. Will continue with the plan of care. Further review of the resident's care plan, showed no mention of the resident having difficulty sleeping and no interventions/approaches to address the resident's reported concerns. During a telephone interview on 7/17/14 at 1:40 P.M., the A

Based on observation, interview and record review, the facility failed to provide protective oversight for one resident (Resident #1), a resident with a history of eloping from numerous prior placements, who presented with borderline intellect and with psychiatric diagnosis, of three sampled residents. The resident had attempted elopement from the facility prior to the current incident. Facility staff documented on face checks the resident was in his/her room when the resident was not present in the facility. The resident was found on 1/2/12 by law enforcement over four miles from the facility, with facility staff unaware the resident had eloped. The resident was found in below freezing temperatures, wearing inadequate clothing for the climate. The resident exited a window on the locked unit which was easily breached. The facility census was 173. 1. Review of a court document titled Letter of Guardianship and Conservatorship dated 3/24/08, showed Resident #1 was under guardianship. Review of the resident's nurses notes showed the following: -On 1/17/11 the resident was admitted to the facility; -On 7/13/11 the resident was seen trying to pry a window open; -On 11/14/11 the resident left the facility without permission with no apparent injuries; -On 11/27/11 the resident with increased ambulation and wandering in the hallways. Review of the resident's physician progress notes [REDACTED]. -[DIAGNOSES REDACTED]. -Psychiatric issues; -Alert to person and place. Review of the resident's psychiatric physician progress notes [REDACTED]. -The resident said he/she does not belong in the facility; -The resident had a [DIAGNOSES REDACTED]. -The resident had attempted to leave the facility; - Resident said he/she cannot "wait to get out of here". Review of the resident's discharge minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff dated 12/22/11, showed the following: -The resident had mood indicators including depression, trouble concentrating and sleep disturbance; -The resident was cognitively intact; -Noted presence of delirium; -The resident ambulated with assist of one. Review of the resident's care plan last updated 12/22/11, showed approaches and interventions as follows: -The resident on 12/21/11 showed increased anxiety, with 1:1 time and medication provided; -The resident had impaired thought processes due to schizophrenia and to administer medications as ordered, redirection, and encouragement; -The resident had alteration in mood and staff should assess the resident's mood, and factors contributing to mood, and notify the physician as needed; -The resident had breathing problems and staff should have oxygen available; -The resident was at risk for falls, staff should assess steadiness, and provide face checks more frequently than one hour for protective oversight; -The resident was at risk for safety, with a goal he/she remain safe and staff will and provide face checks more frequently than one hour for protective oversight; - The resident was at risk for elopement, with the goal the resident will not leave the facility unsupervised, he/she will remain safe and staff will and provide face checks more frequently than one hour for protective oversight, evaluate elopement risk as needed, and make sure staff was with the resident when he/she leaves the unit. Review of the resident's physician history and physical dated 12/22/11 showed the following: -A [DIAGNOSES REDACTED]. -Borderline intellect; -A [DIAGNOSES REDACTED]. -Unable to care for self. Review of the resident's physician orders [REDACTED]. -Depakote 500 milligram (mg) at bedtime for treatment of [REDACTED]. -Seroquel XR 800 mg at bedtime for treatment of [REDACTED]. -Albuterol inhaler every four hours as needed for wheezing and dyspnea (shortness of breath), with the original order date of 12/28/11; -[DIAGNOSES REDACTED]. Review of the resident's elopement risk assessment dated [DATE] showed the resident was a high risk for elopement. Review of the resident's nurses notes for 1/1/12 showed the following: -At 8:00 P.M. the resident was quiet in bed; -The next entry noted at "2400" (midnight), received a phone call from law enforcement the resident was picked up and was being returned to the facility. Review of the facility form labeled Five Minute Face Checks for 1/1/12, showed the following: -The resident was in his/her room 11:00 P.M. through 11:55 P.M. with checks signed every five minutes; -The staff documented "other" for 12:00 A.M. through 12:10 A.M. on 1/2/12. Review of the police report regarding the resident dated 1/2/12, showed the following: -The resident was found at the intersection of county road 2250 and county road 2245 at midnight on 1/2/12; -The resident was found wearing thin shirts and was stumbling; -The "subject was mentally handicapped"; -The resident reports he/she had left the facility and had been walking since 8:00 P.M.; -The resident was observed to be extremely cold, and was warmed up in the police car; -When contacted the facility staff "informed me that the resident had a history of [REDACTED]. Interview on 1/24/12 at 2:27 P.M. with the resident, showed he/she said the following: -He/she eloped from the facility, did not like arguments and noise; -He/she was walking to Kansas to see his/her guardian; -He/she had been away from the facility for approximately two hours when picked up by the police; -When he/she was picked up by the police, he/she was very cold, and had on two shirts and no coat; -He/she had eloped from a window before, but did not get too far before; -He/she eloped out of another resident s room window that was not enclosed by a fence; -Staff did not supervise his/her whereabouts; the only time they looked for him/her was when it was time for medication, and it was common not to see staff for hours at a time; -He/she did not receive a ride after elopement, he/she walked until picked up by law enforcement, he/she could not recall the route he/she took. Interview on 1/24/12 at 2:02 P.M. with the resident's guardian, showed he/she said the following: -He/she had been the resident's guardian since 2008; -The resident had been institutionalized since he/she was [AGE] years old; -The resident had eloped form numerous facilities, approximately 12 different facilities; -The resident has paranoid schizophrenia with "a mind of a [AGE] year old"; -Informed the facility before admission the resident was a high elopement risk. Observation on 1/26/12 at 2:25 P.M. of room 315 on the facility men's locked unit showed a bar limiting the windows from opening fully was bent allowing the window to open to 9.5 inches when slight pressure was applied to the bottom of the wood framed plexi-glass window. Observation on 1/26/12 at 3:45 P.M. showed the following: -Room 903 on the men's locked unit with two small metal 90 degree brackets screwed to the outside of the window limiting the window travel; -The two brackets when bent (beyond 90 degrees), would allow the window to open fully; -The window opened to an unsecured, unfenced area; -Maintenance staff was able to bend the thin metal brackets back to 90 degrees with one hand. Interview on 1/26/12 at 3:45 P.M. with Maintenance Staff C, showed he/she said the following: -The first of January 2012 a male resident eloped from the facility, found the window limiting brackets outside room 903 bent where the window could open; -After the resident eloped the window was permanently secured with screws. Interview with CNA C on 1/27/12 at 2:27 P.M. showed he/she said the following: -He/she had worked on the mens' locked unit, his/her job hall assignment varied; -Residents may ambulate to the 100, 200, 300, 900 halls and the dining room; -The number of five minute, 30 minute, and one hour face checks varied daily on each hall; -Every resident on the locked mens' unit were on a minimum of every hour face check; -One CNA staff worked the 100 hall and had the responsibility for all the face checks on that hall; -The face checks can be done, if the CMT helps; -The CMT usually helped, but could not always help. Interview with CNA D on 1/27/12 at 2:44 P.M. showed he/she said the following: -He/she worked the 200 hall usually, occasionally floated to the 100 hall; -The face checks could be completed on the 200 hall; -The 100 hall was the hardest hall to get the face checks completed. Interview with CNA B on 1/27/12 at 2:49 P.M. showed he/she said the following: - He/She worked on the men's locked unit, his/her job assignment varied and he/she usually worked the 100 hall; -It was "difficult to keep up" with the 100 hall face checks due to other job demands; -The 100 hall residents were mobile, "they walk everywhere"; -The residents on the locked men's unit could walk to the 100, 200, 300 and 900 halls without exiting the unit. Interview with CNA A on 1/27/12 at 2:52 P.M. showed he/she said the following: -He/she worked on the men's locked unit, his/her job assignment varied and usually floated to the 100 and 200 hall; -He/She had no problem getting face checks done on any hall except the 100 hall; -It was "almost impossible" to get all the face checks done when working the 100 hall; -The 100 hall had "a lot" of five minute face checks, and this was difficult to manage with other duties such as showers, dinner meal service, passing ice, passing snacks, and the ability of the residents to leave the 100 hall and be located on any hall of the unit. Interview on 1/23/12 at 2:17 P.M. , 1/26/12 at 2:00 P.M. and 2/2/12 at 12:04 P.M. with the director of nursing (DON) showed she said the following: -The resident was on a minimum of one hour face checks by the unit certified nurse aide (CNA) staff; -More supervision or increased frequency and duration of face checks were at the discretion of the unit charge nurse and were behavior driven; -The resident was a high elopement risk, was located on the locked men's unit at the time of his/her elopement; -Unsure the details of how the resident eloped from the facility; -The staff were alerted the resident was missing by a telephone phone call from law enforcement; -Face checks are performed by CNA staff and supervised by the charge nurses; -Face checks are actual visualization of the resident by staff, if the staff cannot find the resident then a "code white" should be called. Interview with the Administrator on 1/23/12 at 2:36 P.M. and 1/26/12 at 4:00 P.M., showed he said the following: -Cannot recall the last elopement in the facility, happened over three months ago, cannot recall the details or the resident involved; -Resident #1 had a history of [REDACTED]. -He should have reported resident #1's elopement to the state agency. Review of the undated facility policy and procedure titled Elopement Policy and Procedures, showed the following: -A high risk elopement will be placed on intensive monitoring; -No explanation of the meaning of "intensive monitoring"; -Care plan must address warning and intervention of protocol; -Repeated incidents require a meeting including the administrator and DON to determine if the resident's safety needs can be met. Review of the undated facility policy titled Monitoring of Residents on Visual Face Checks, showed the following: -The purpose is "to ensure a system in place for residents who require increased monitoring for behavioral/psychiatric and medical issues, and to monitor staffing on units with residents who require more intensive monitoring"; -Residents who show poor impulse control such as elopement ideations may be placed on one on one monitoring at the discretion of the administrative staff; -All residents on each unit will be monitored by visual checks at least within one hour; -Residents may require, based on behavior or medical symptoms, less intensive monitoring which would require staff to visually check the resident more often than every fifteen minutes; -Residents may be moved off the less intensive monitoring of more than 15 minutes at the discretion of the administration. 2. Review of the nearest reporting weather station history (Columbia, Missouri), from Weather Underground (http://wunderground.com), showed on 1/1/12 at 11:54 P.M. the temperature was 30.0 degrees Fahrenheit. -Review of Map quest website (http://www.mapquest.com), and Garmin GPS comparison, showed the intersection of county road 2250 and county road 2245 to be 4.5 miles from the facility address, taking the shortest distance route. Observation on 1/27/12 at 1:45 P.M. showed the following regarding the intersection of county road 2250 and county road 2245: -Garmin Nuvi 205W with current map update 2012 showed the facility address registered 4.7 miles with the shortest distance option selected from the location; -The county roads were two lane rough blacktop surface; -No visible streetlights; -Moderate traffic, with no posted speed limit signs; -No sidewalks; -The roads were bordered by dirt and grass ditches; -Three residential houses were visible with open fields surrounding the intersection. Complaint #MO NOTE: At the time of the 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 facility began to assess all residents for risk of elopement and to update the plan of care based on the assessments. The facility began in-servicing staff regarding the facility elopement policy and procedure and on the facility face check procedure. Maintenance staff began assessments and repairs of windows on the unit to ensure security. The facility identified the LPN/RN/team leader to monitor staff to ensure face checks were completed and accurate. The facility still has to complete measures initiated to address the immediacy and abatement. The facility proposed to install yard fencing to enclose all windows on the secured unit. A final revisit will be conducted to determine if the facility is in substantial compliance with the participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well being by failure of staff to assess and monitor one resident (Resident #33) out of four sampled residents who had a change of condition and subsequently went to the hospital and had an emergency surgery. The facility census was 166. 1. Review of Resident #33's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 08/23/10, showed the following: -Had some difficulty in making decisions in new situations only; -Had mild pain less than daily; -[DIAGNOSES REDACTED]. Review of the resident's October, 2010, physician orders, showed other [DIAGNOSES REDACTED]. Review of the nurses notes dated 10/23/10, showed the following: -At 7:00 A.M., Resident #33 stated he/she had emesis (vomiting) off and on all night. The resident was afebrile (did not have a fever). The resident complained of stomach cramps at beginning of shift and refused any medication. The resident wanted to stay in bed all day or until feeling better; -At 10:00 A.M., the resident was resting in bed and remained afebrile. The resident complained of pain and had cramps in stomach when asked. The resident took medicine as directed and staff would continue to monitor. No emesis noted. The psychiatrist saw the resident but no new orders received; -Between 7:00 P.M. and 7:00 A.M., the resident was up about the unit per wheelchair. No emesis reported this shift. The resident complained of stomach cramps and staff administered a prn (as needed) medication. The resident's temperature was 98.6 degrees F.; (Review of the resident's October, 2010, MAR (Medication Administration Record) showed there was no prn medication administered. The physician had prescribed [MEDICATION NAME] 325 mg two tablets every 4 hours as needed for pain/temp and [MEDICATION NAME] 200 mg two tablets as needed for pain/temperature); Review of the nurses notes dated 10/24/10, showed the following: -Between 7:00 A.M.and 7:00 P.M., the resident's temperature was 98 degrees. The resident lay in bed resting quietly, did not want to get up for breakfast, and had breakfast in his/her room. There were no complaints of nausea and vomiting this shift. The resident said he/she tasted blood in his/her mouth and staff did not observe any blood. Will continue to monitor; -Between 7:00 P.M.and 7:00 A.M., the resident was in bed resting quietly watching television. No complaints voiced. The resident's temperature was 97.4 degrees, pulse 104, and blood pressure 100/52. There was no emesis this shift and no complaint of tasting blood in the mouth. Staff would continue to monitor; Review of the nurses notes dated 10/25/10 (untimed) showed the nurse was called to the resident's room and assessed the resident was alert, not oriented, unable to answer simple questions, and unable to state where he/she was. The physician was made aware of the resident's status. Staff took vital signs which were within normal limits. (Staff did not document these vital signs). The physician gave new orders to send the resident to the hospital for evaluation and treatment. (There was no documentation of assessment and vital signs). Review of the hospital operative report dated 10/25/10, showed the resident was admited to the emergency room with abdominal distention, tenderness, guarding, and rigidity. An abdomen scan showed evidence of acute appendicitis. The operative procedures were exploratory laparatomy, appendectomy, and peritoneal lavage. The procedure showed that upon opening the peritoneal cavity, a [MEDICAL CONDITION] (serum and pus) fluid was noted. Further exploration showed evidence of dilated loops of small bowel, periappendiceal abscess, and abscess in the pelvis. After completion of appendectomy, thorough peritoneal lavage was done using copious amount of saline (salt solution). The resident was transferred to the intensive care unit. During interview on 11/10/10 at 9:55 A.M., Licensed Practical Nurse (LPN) P said that on Monday, October 25, he/she knew the resident was not feeling good all weekend and after report, he/she went to the resident's room and saw the resident. LPN P took vital signs and all were within normal limits. This was around approximately 7:20-7:30 A.M. The resident was alert but confused and not him/herself because the resident did not know who the nurse was. LPN R had told LPN P that the resident felt better on the night of October 24, 2010, and had gotten up in his/her wheelchair but did not go smoke which the resident usually smoked. The resident had said he/she was nauseated. LPN P said there was a daily vital sign sheet but was put in the shred box and not kept. Staff would write in the nurses notes normally. On the morning of the 25th, LPN P thought about the resident's meds and tried to call the physician. The physician's nurse practitioner answered for the physician and told LPN P to get immediate labs. LPN P got the lab staff but did not get labs and sent the resident to the hospital immediately. The resident had passed out. LPN P said he/she got the first set of vitals on the resident and a nurse aide took vital signs again. LPN P said he/she carries his/her own personal paper and records for personal use. LPN P said he/she usually tried to document in the nurses notes. LPN P said he/she heard Resident #33 felt bad that Friday evening and complained of nausea and not feeling well over the weekend. LPN R had reported this to LPN P on Monday morning, October 25, 2010. During interview on 11/10/10 at 10:00 A.M., LPN P said that if a resident complained of abdominal pain and not feeling well, he/she would have labs checked first. He/she cannot diagnose but the resident would need an x-ray or scan. LPN P said he/she would call the physician first even on the weekend. It takes up to 15 minutes for the physician to call the facility back. The physician has two different number. Because Resident #33 was on [MEDICATION NAME] (a [MEDICAL CONDITION] medication) and had routine labs for this, he/she would check these levels. During interview on 11/10/10 at 1:40 P.M., Resident #35 said that he/she knew Resident #33 had a bad fever and did not get out of bed for 2-3 days. Resident #33 was sick from early in the week on and then it hit the resident hard and he/she had no energy. (This would have been approximately a time period of 6-7 days before sent to the hospital). The resident was sick on a weekend and went to the hospital the next Monday or Tuesday. Resident #35 said Resident #33 had demanded to go see the doctor or go to the hospital. Resident #35 said he/she did not see Resident #33 in the dining room and went to check on the resident. Resident #35 said Resident #33 had a stroke before, was unable to move on one side, and was not able to get out of bed. Resident #35 had asked LPN S about Resident #33 and LPN S said the resident had some kind of flu. Resident #35 said it was strange that it got to the point that the resident's appendix burst inside of Resident #33. Resident #35 said he/she had gone out to visit Resident #33 at the hospital two times. The resident had a lot of infection. During interview on 11/10/10 at 11:30 AM., LPN S said he/she worked on Sunday, October 24, 2010, from 7:00 A.M. to 7:00 P.M. Resident #33 wanted to stay in bed all day and told LPN S that he/she had a cold. LPN S said he/she checked the resident's temperature and lung sounds which were clear. The resident did not complain of nausea or stomach pain. Resident #33 took his/her medications that day but did not eat a whole lot and did eat in his/her room. LPN S said Resident #33 did not ask for pain medication but had smoked in the evening. LPN S said if resident had nausea and vomiting or had a fever of 101 degrees Fahrenheit or greater, he/she would call the physician. The resident's temperature was 97.4 degrees (normal 98.6 degrees). LPN S did not check Resident #33's bowel sounds. LPN S said that on the shift report sheet for Saturday night, staff reported the resident had a fever. LPN S heard the resident had a ruptured appendix and had emergency surgery. LPN S said he/she did not know the resident had surgery until after the resident had surgery. Review of Resident #33's shift report sheet showed the following: -On October 22-23, 2010, between 7:00 P.M. and 7:00 A.M., the resident had emesis on and off. Staff checked on the resident all night, and resident was afebrile; (Staff failed to assess the resident, and did not notify the physician); -On October 23, 2010, between 7:00 A.M. and 7:00 P.M., the resident complained of emesis. Staff checked on the resident and the resident was afebrile; (Staff failed to assess the resident and did not notify the physician); -On October 23-24, 2010, between 7:00 P.M. and 7:00 A.M., the resident's temperature was 98.6 degrees and had no emesis last night. The resident said he/she still doesn't feel well this a.m.; (Staff failed to assess the resident and notify the physician); -On October 24, 2010, between 7:00 A.M. and 7:00 P.M., the resident was in bed all day; (Staff failed to assess the resident and notify the physician); -On October 24-25, 2010, between 7:00 P.M. and 7:00 A.M., the resident was in bed all evening. Vital signs at beginning of shift were 97.4 degrees temperature, pulse was 104 (normal is 60-80 beats per minute), and blood pressure was 100/52 (normal range is 120/80). Vital signs at 1:00 A.M. were 98.6 degrees temperature, pulse was 52, and blood pressure was 123/59.; -October 25, 2010, was Hospital- Ruptured Appendix. During interview on 11/10/10 at 12:15 P.M., the DON (Director of Nursing) said if a resident complained of stomach pain and had nausea and vomiting, he/she would expect staff to assess the resident's vital signs, give any prns (as needed) medications, and do a whole body assessment from head to toe that included lung sounds, bowel sounds, capillary refill, assess PERLA (neurological assessment of pupils equal and reactive to light), and mucous membranes. The staff were to notify the physician if a resident had a temperature over 99 degrees Fahrenheit which was a low grade fever, if a resident said they were not feeling well, and complained of nausea and vomiting. Resident #33 was alert, oriented, and his/her own person. He/she would tell them if needed to go to the hospital. The psychiatrist had seen Resident #33 on October 23, which was Saturday. On Monday, October 25, the DON came in and felt the resident needed to go to the hospital because he/she was confused. They were to do labs on the resident that morning but called and sent the resident to the hospital. The DON had gone to check on the resident but he/she was confused and not acting like him/herself. Review of the psychiatric note, dated October 23, 2010, showed nothing documented on the form or signed by the psychiatrist. During interview on 11/10/10 at 2:04 P.M., CMT (Certified Medication Technician) T said Resident #33 had not been eating right at the beginning of the week and said he/she didn't feel good. CMT T said he/she had told the charge nurse that Resident #33's stomach was hurting. CMT T said that on Thursday and Friday, the resident did not want to eat. The resident tried to eat a health shake but said it hurt his/her stomach. Staff had someone check his/her vital signs but was not aware the resident had any fever. The resident had nausea and maybe vomiting but the vomiting did not occur on his/her shift. The resident came to him/her and said, "I don't feel good. My stomach hurts." The resident uses a motorized wheelchair and had asked him/her to help put on his/her boots. The resident usually doesn't ask for help but the resident seemed down. CMT T said he/she did not work the weekend. Resident #33 has a routine of waking up, going smoke, eating, and going to therapy. The resident was more active in the evenings and napped twice in the day. CMT T said he/she thought he/she turned this information in to LPN S and CMT V. During interview on 11/10/10 at 2:24 P.M., CNA U said about a week before the resident went to the hospital, the resident told CNA U that he/she felt like he/she was going to throw up and maybe had the flu. CNA U said he/she thought he/she reported this to LPN P but not for sure. CNA U said he/she did not take his/her vital signs on that day but the resident did not have a fever that he/she was aware of. CNA U did not see a change in the resident's behavior. The resident got up, smoked, ate breakfast, went to therapy, and back to nap. It was common for the resident to sleep after meals. During interview on 11/10/10 at 2:29 P.M., the DON said staff were to notify the physician when there was a significant change in the resident's condition such as a fall, any incident, skin tear, wounds, and abnormal vital signs. (The DON did not provide a written policy for notifying the physician when requested.) During an interview on 11/10/10 at 4:30 P.M., RN (Registered Nurse) W said he/she worked the 7 A.M.-7 P.M. shift on Saturday, October 23, 2010. Resident #33 said he/she did not feel good and did not want to get out of bed. The resident said his/her stomach hurt and complained of being nauseated and had thrown up twice. RN W offered to send the resident to the hospital and he/she said no that he/she was fine and wanted to rest. The resident is his/her own guardian and RN W said he/she could not make him/her go to the hospital. RN W said he/she assessed the resident's heart, lung and bowel sounds, and palpated his/her stomach. The resident was not really having pain. RN W checked his/her pedal pulses on feet, color was good, and was not hot to touch. Staff offered the resident food and he/she took a couple of bites and a little water. RN W did not check him/her at lunch but the resident was asleep. RN W and the nurse aides checked on him/her but he/she did not eat lunch. The night staff reported the night of the 24th, the resident complained of throwing up twice but they did not see the emesis. There was no nausea. RN W did not take care of the resident on Sunday, October 25, 2010. RN W said no staff told him/her to go check on the resident since he/she was the only RN in the building. LPN S worked on the resident's unit that Sunday. Review of the Dietary Meal Monitoring Sheet for October, 2010 showed the following: -On October 23rd, the resident refused all three meals; -On October 24th, the resident ate 25 % for breakfast and had 240 ml (milliliters) to drink, 10% for noon meal and drank 240 ml, and refused supper; -On October 25th, Hospital. Complaint MO