Every finding on record at Parkview Healthcare

Based on observation, interview and record review, the facility failed to protect two sampled residents (Resident #5 and Resident #6) from physical abuse. On 3/14/26 at approximately 1:30 A.M. Resident #6 hit Resident #5 an unknown number of times. Resident #5 then threw his/her walker at Resident #6, which caused Resident #6 to fall to the ground. Resident #5 was transported to the hospital and treated for a chest bruise, abrasions, pain and Resident #6 had pain in his/her right hip out of 11 sampled residents. The facility census was 99 residents.On 3/23/26, the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 3/18/26. All staff received education prior to working their next shift. The deficiency was corrected on 3/18/26. Review of the facility Abuse, Neglect, and Exploitation Policy revised 1/21/26, showed:-It was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.-Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain 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 included, but was not limited to hitting, slapping, punching, biting, and kicking. 1.Review of Resident #5's admission record showed he/she was admitted on [DATE] with the following diagnoses:-Chronic Pulmonary Edema (a long-term, progressive condition characterized by the slow, abnormal accumulation of fluid in the air sacs (alveoli) of the lungs).-End Stage Renal Disease (the final stage of kidney failure where kidneys function at less than 15% of normal capacity).-Congestive Heart Failure (a chronic, progressive condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs for oxygen and nutrients).-Chronic Kidney Disease (a condition where kidneys are damaged and cannot filter blood properly, causing waste and fluid to build up in the body). Review of Resident #5's Care Plan, dated 3/17/26, showed: the resident had an Activities of Daily living (ADL-basic routine tasks that most healthy individuals can perform without assistance). These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another) self-care performance deficits and limitations in physical mobility. Review of Resident #5's admission Minimum data set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 3/18/26, showed he/she was moderately cognitively impaired. Review of Resident #6's admission record showed he/she was admitted on [DATE] with the following diagnoses:-Hemiplegia (a form of permanent or temporary paralysis causing severe loss of strength, movement, and sometimes sensation on one vertical side of the body, often resulting from brain or spinal cord injuries) and Hemiparesis (a neurological condition characterized by weakness, numbness, or reduced movement on one side of the body).-Idiopathic Peripheral Autonomic Neuropathy (damage to the nerves regulating involuntary body functions (heart rate, digestion, blood pressure) where the cause remains unknown after testing).-Congestive Heart Failure (a chronic, progressive condition where the heart muscle cannot pump blood efficiently enough to meet the body's needs for oxygen and nutrients).-Muscle Wasting (the loss of muscle mass, strength, and function, causing muscles to become smaller and weaker) and Atrophy (the loss, wasting, or thinning of muscle tissue, resulting in reduced muscle size, strength, and function).-Major Depressive Disorder (a serious mental health condition characterized by persistent, severe sadness, low energy, and a lack of interest in life lasting at least two weeks). Review of Resident #6's Care Plan, dated 8/22/25, showed:-The resident had self-care deficits related to chronic conditions, history of Cerebrovascular Accident (CVA- the medical term for a stroke) with left hemiplegia impacting function and stability.-The resident had potential for being verbally and physically aggressive at times. Review of Resident #6's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of the Resident #5's progress note, dated 3/14/26 at 4:17 A.M., showed:-Resident #5 reported that Resident #6 kicked his/her dialysis port and scratched his/her face.-Resident #5 requested to go to the hospital for pain. -Resident #5 was sent out to the hospital at 3:30 A.M. -The incident between Resident #5 and Resident #6 was unwitnessed. Review of Resident #5's hospital after visit summary, dated 3/14/26 at 7:52 A.M., showed:-The resident was seen and treated for a bruise on his/her chest wall and abrasion on his/her face after being assaulted.-The resident received a chest Xray.-The resident received Oxycodone (a potent, semi-synthetic narcotic opioid analgesic used to treat moderate-to-severe pain) 5 milligrams (mg) at 5:05 A.M. -The resident was discharged back to the facility with the following diagnoses:--Contusion (an injury to the soft tissue often produced by a blunt force such as a kick, fall, or blow) of right chest wall.--Abrasion (a scrape on one's skin) of face--Injuries were due to a physical assault. Review of Resident #5's skin assessment note, dated 3/16/26 at 9:52 A.M., showed the resident had a small scratch with scab near the right nostril. Review of Resident #5's Medication Administration Record (MAR), dated 3/1/26-3/31/26 showed:-During the night shift on 3/14/26, the resident reported a pain level at a 9 on a 0-10 scale. -During the day shift on 3/15/26, the resident reported a pain level at an 8 on a 0-10 scale.-During the night shift on 3/15/26, the resident reported a pain level at a 9 on a 0-10 scale. Review of Resident #5's undated written statement showed:-Resident #6 went to his/her room through the bathroom and was trying to fight him/her.-Resident #6 hit him/her and then he/she hit Resident #6 back.-Resident #6 fell to the ground after he/she hit Resident #6. Observation and interview on 3/19/26 at 11:00 A.M., Resident #5 said:-He/She went to Resident #6's room to borrow a lighter in the middle of the night when Resident #6 got out of bed and followed him/her back to his/her room.-Resident #6 hit him/her an unknown number of times.-During the fight, Resident #6 fell on the ground and that was when staff came to the room and broke up the fight. -He/She had a scratch on the face where resident #6 hit him/her.-He/She had a bruise on the chest where resident #6 hit him/her.-He/She was in pain after Resident #6 hit him/her.-He/She went to the hospital after the incident because of pain. Review of Resident #6's undated written statement showed:-Resident #5 entered his/her room through the bathroom and took a pack of his/her cigarettes. -He/She stood up and chased Resident #5 back to Resident #5's room.-When he/she entered Resident #5's room, Resident #5 threw a walker at him/her and he/she fell to the ground. -He/She did not make any physical contact with Resident #5. Observation and interview on 3/23/26 at 4:15 P.M., Resident #6 said:-He/She punched Resident #5 three times, because Resident #5 stole cigarettes from him/her.-While he/she punched Resident #6, he/she lost his/her balance and fell on the floor.-When he/she first entered Resident #5's room to confront him/her, Resident #5 tried to throw a walker at him/her. -When he/she fell on the ground, he/she hurt his/her right hip.-He/She had hip pain for a day or so, but the pain had resolved.-There were no witnesses to the incident. During an interview on 3/20/26 at 11:34 A.M., Licensed Practical Nurse (LPN) A said:-Resident #5 and Resident #6 were separated immediately after their resident-to-resident incident and Resident #5 was moved to a different hall away from Resident #6. -There were no witnesses to the incident, and the incident was over before staff entered Resident #5's room.-Resident #5 was sent out to the hospital for evaluation a couple hours after the incident because the resident was worried about his/her dialysis port being damaged from the incident. -Both residents were back in the facility and felt safe.-This was an unexpected incident and the resident's had no continual problems after the incident.-Both residents were given pain medication after the incident.-He/She considered the resident-to-resident incident to be abuse. During an interview on 3/23/26 at 4:45 P.M. Administrator and Director of Nursing (DON) said:-The incident between Resident #5 and Resident #6 was abuse.-All residents had the right to be free from abuse. -Resident #5 went to the hospital for pain management of his/her dialysis port site after the incident.-Resident #6 refused any treatment after the incident. 2804302

Based on observation, interview and record review, the facility failed to ensure the call light system operated as designed, failed to ensure call lights were within reach, and failed to ensure call lights were answered timely for six sampled residents (Resident #4, #10, #2, #8, #9, and #11) to maintain their activities of daily living (ADL) out of 11 sampled residents. The facility census was 99 residents. Review of the facility Call Lights; Accessibility and Timely Response Policy revised 1/1/26, showed:-It was the purpose of the policy to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. -Call lights would directly relay to a staff member or centralized location to ensure appropriate response.-Staff would ensure the call light was within reach of resident's and secured, as needed.-The calling system would be accessible to residents while in their bed or other sleeping accommodations within the residents' room. -Staff would report problems with the call light or the call system immediately to the supervisor and or maintenance director and would provide immediate or alternative solutions until the problem could be remedied. -It would be ensured that the call system alerted staff members directly or went to a centralized staff work area.-All staff members who saw or heard an activated call light were responsible for responding.Review of the facility's Device Activity Report for the resident's who lived on the hall dated 3/1/26-3/19/26 showed:-The average call light response time was 69 minutes and 46 seconds.-Out of the 18 total resident's call lights times reviewed, 16 of the 18 residents had extended call light times. -The extended call light times of the non-sampled residents ranged from the lowest being 23 minutes and 51 seconds to the highest being 1194 minutes and 6 seconds. 1. Review of Resident #4's admission record showed he/she was admitted on [DATE] and had the following diagnoses:- Hemiplegia (partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and Hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing).-Polyneuropathy (a condition characterized by damage to multiple peripheral nerves simultaneously, usually resulting in weakness, numbness, and pain, often starting in the hands and feet).-Foot Drop, left foot (a term that describes a difficulty in lifting the front part of the foot).-Generalized Muscle Weakness (a decrease in muscle strength that requires extra effort to move your arms, legs, or other parts of the body).-Pain in right knee. -Unsteadiness on Feet (a term used to describe when someone is having trouble with their balance or the way they walk).-Difficulty in walking. Review of the resident's Care Plan, dated 11/14/24 showed:-The resident had an Activities of Daily Living (ADL- the tasks of everyday life. These activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) deficit related to a stoke with left side weakness, history of falls, morbid obesity, and cardiac disease. -The goal was to have oversight and support from staff to ensure daily care needs were met.-Staff was to provide the following interventions:--Provide supervision with bed mobility and provide assistance as requested.--Provide supervision with personal grooming.--Provide supervision and assistance with toileting as requested with any incontinence.-The resident was a moderate risk for falls related to history of falls, unsteady gait and balance, and high risk medications.-The goal was to provide oversight and preventive measures to maintain personal safety with reduced risk for serious injury.-Staff was to provide the following interventions:-- Anticipate and meet the resident's needs.--Ensure that the resident's call light was within reach and encourage the resident to use itfor assistance as needed. --Provide the resident a prompt response to all requests for assistance. Review of the resident's Quarterly Minimum data set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/7/26, showed he/she was cognitively intact. During an interview on 3/6/26 at 4:14 P.M. the resident said:-He/she was waiting up to 5 hours for the facility to answer his/her call light.-He/she has had to call 911 on his/her cell phone to receive help because the staff was not answering his/her call light. Review of the facility Device Activity Report dated 3/1/26-3/19/26 showed:-The resident had a call light response time of 83 minutes (1 hour and 23 minutes) and 50 seconds on 3/6/26 at 9:12 P.M.-The resident had a call light response time of 76 minutes (1 hour and 16 minutes) and 55 seconds on 3/7/26 at 7:31 P.M.-The resident had a call light response time of 155 minutes (2 hours and 35 minutes) and 37 seconds on 3/9/26 at 1:09 P.M.-The resident had a call light response time of 23 minutes and 51 seconds on 3/16/26 at 2:24 P.M.-The resident had a call light response time of 350 minutes (5 hours and 50 minutes) and 7 seconds on 3/16/26 at 5:50 P.M. Observation and interview on 3/19/26 at 4:15 P.M., the resident said:-He/She had difficulty standing and walking.-He/She had difficulty transferring to and from his/her bed and wheelchair.-He/She had difficulty transferring to and from the toilet.-He/She needed help with transfers.-He/She had a history of falls.-He/She had occasional urinary incontinent (the inability to control the flow of urine from the bladder). -His/her call light was sometimes not answered for hours.-He/She has had to wait over 5 hours for help when his/her call light was on. -The facility staff was neglecting his/her needs.-The facility staff ignored him/her even when he/she had their call light on and needed help. -Staff was always on their cell phones at the nurse's station. -Staff would many times walk right by his/her room when the call light was on for hours and would not help him.-He/She has had to call 911 to get help because staff was not answering the call light, and he/she needed help. -He/She had to wait long periods of time to get help day and night shifts. -The staff have neglected his/her call light for a long time.-He/She had to wait for help daily for several hours.-His/Her call light was rarely answered in a timely manner. 2. Review of Resident #10's admission record showed he/she was admitted on [DATE] and had the following diagnoses:-Chronic Obstructive Pulmonary Disease (COPD-a long-term lung disease that makes it hard to breathe). -Anxiety Disorder (a mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life). -Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's Care Plan, dated 12/5/23 showed:-The resident had chronic COPD, reduced function and impaired mobility with poor tolerance for physical activity. -The goal was to care tasks to best of his/her ability while having support from staff to ensure daily needs were met.-Staff were to provide the following interventions:--Supervision/touching assistance by 1 staff for bed mobility and positioning.-- Supervision with toileting, providing additional supports as requested.--Supervision with transfers as needed.--Encourage the resident to use call bell for assistance. -The resident had potential for experiencing falls related to chronic health conditions, debility and weakness, medications, and oxygen use.-Staff were to provide the following interventions:--Ensure the resident's call light was within reach and encouraged the resident to use itfor assistance as needed. --Ensure that the resident received prompt response to all requests for assistance.--Keep personal items in easy reach in room.--Maintain a reachable call light for the resident. -The resident had occasional incontinence and required supervision and assistance withelimination needs as necessary.-The goal was to provide support and oversight from staff to ensure elimination needs were met and he/she remained clean, dry and odor free. -Staff were to provide the following interventions:--Encourage routine toileting to decrease episodes of incontinence.--Encourage to report need for elimination and allow staff assistance as needed withincontinence care.--Routine checks during night offering assistance while allowing for periods ofundisturbed rest. Review of the resident's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of the facility's Device Activity Report dated 3/1/26-3/19/26 showed:-The resident had a call light response time of 29 minutes and 0 seconds on 3/13/26 at 3:16 P.M.-The resident had a call light response time of 27 minutes and 57 seconds on 3/16/26 at 11:12 P.M.-The resident had a call light response time of 50 minutes and 16 seconds on 3/17/26 at 2:41 A.M.-The resident had a call light response time of 24 minutes and 42 seconds on 3/18/26 at 12:30 P.M. Observation and interview on 3/19/26 at 4:15 P.M., the resident said:-He/She was on continues oxygen.-He/She had difficulty breathing.-It scared him/her when he/she was short of breath and had to wait so long to get more oxygen.-He/She has run out of oxygen and had to wait several minutes and even hours to get more oxygen because it took so long for someone to answer the call light. -He/She was weak and required help with transfers.-Staff were never good about answering call lights but the wait times have gotten worse in the past few months.-The long call light waits times happened during the day and night.-He/She has waited up to 3 hours before the call light was answered.-There had been times when he/she placed the call light on for help in the evening or nighttime and did not get help until the day shift arrived. -He/She worried that if something bad happened to him/her and needed help, staff would not come to help in time. 3. Review of Resident #2's admission record showed he/she was admitted on [DATE] and had the following diagnoses:-Hemiplegia and Hemiparesis.-Chronic Obstructive Pulmonary Disease (COPD).-Acute Respiratory Failure with Hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function).-History of falls. Review of the resident's Care Plan, dated 12/5/23 showed:-The resident had an ADL self-care performance deficit related to decreased strengthand endurance, unsteady gait and balance, non-ambulatory, COPD, low backpain, left side hemiparesis-The goal was to have oversight and support from staff. -Staff were to provide to following interventions:--Assistance with lower body dressing.--Assistance with personal hygiene.--Assistance with toilet hygiene.--Supervision with toilet use. -The resident was a moderate risk for falls.-The goal was to anticipate and meet the resident's needs.-Staff were to provide the following interventions:--Ensure that the call light was within reach and encourage the resident to use itfor assistance as needed. --Provide prompt response to all requests for assistance.--Educate resident to use call light and wait for assistance prior to attempting transfers Independently. Review of the resident's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of the facility's Device Activity Report dated 3/1/26-3/19/26 showed:-The resident had a call light response time of 147 minutes and 11 seconds on 3/1/26 at 4:57 P.M.-The resident had a call light response time of 66 minutes and 37 seconds on 3/2/26 at 6:27 A.M.-The resident had a call light response time of 49 minutes and 57 seconds on 3/2/26 at 9:36 P.M.-The resident had a call light response time of 80 minutes and 4 seconds on 3/4/26 at 5:43 A.M.-The resident had a call light response time of 20 minutes and 48 seconds on 3/9/26 at 3:22 P.M.-The resident had a call light response time of 28 minutes and 33 seconds on 3/9/26 at 6:47 A.M.-The resident had a call light response time of 29 minutes and 22 seconds on 3/11/26 at 3:28 A.M.-The resident had a call light response time of 25 minutes and 1 second on 3/16/26 at 4:48 A.M.-The resident had a call light response time of 76 minutes and 39 seconds on 3/17/26 at 4:20 P.M. Observation and interview on 3/19/26 at 11:05 A.M., the resident's said:-Staff took hours to answer his/her call light.-He/She has had to call his dad to get him help with shortness of air because staff did not help him.-He/She has had to have a friend track down staff and request assistance for shortness of air because no one ever answered the call light to help. -There have been many times when he/she put on the call light and needed help, and no staff ever came to help at all.-He/She has needed help and placed on the call light and no one came to help until hours later when the next shift arrived to work. -He/She has needed oxygen therapy and could not breath for hours because no one answered his/her call light.-He/She was scared that they would die of respiratory failure in the facility before he/she received help from staff when help was needed. -He/She required assistance with transfers and toileting at times.-He/She was wheelchair bound and could not walk.-He/She has had accidents in their pants when unable to make it to the bathroom because staff never came to answer the call light. -Staff neglect the residents and do not help any of them when they need help.-Staff are always on their phones at the nurse's station and never answered the residents call lights.-He/She has had the call light on for hours and would look down the hall and witness staff sitting at the nurse's station playing on their phones. -He/She felt ignored and worried for his/her safety with his/her respiratory disease. 4. Review of Resident #8's admission record showed he/she was admitted on [DATE] and had the following diagnoses:-Hemiplegia and Hemiparesis.-Difficulty walking.-Muscle weakness.-Need for assistance with personal care. -Repeated falls. Review of the resident's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of the facility's Device Activity Report dated 3/1/26-3/19/26 showed:-The resident had a call light response time of 76 minutes (1 hour and 16 minutes) and 23 seconds on 3/5/26 at 1:53 P.M.-The resident had a call light response time of 282 minutes (4 hours and 42 minutes) and 29 seconds on 3/5/26 at 6:40 P.M.-The resident had a call light response time of 56 minutes and 43 seconds on 3/6/26 at 8:11 A.M.-The resident had a call light response time of 389 minutes (6 hours and 29 minutes) and 46 seconds on 3/6/26 at 4:16 P.M.-The resident had a call light response time of 52 minutes and 49 seconds on 3/16/26 at 5:35 P.M.-The resident had a call light response time of 127 minutes (2 hours and 7 minutes) and 37 seconds on 3/16/26 at 6:36 P.M. Observation and interview on 3/20/26 at 11:00 A.M., the resident said:-He/She waited a long time for the call light to be answered.-He/she waited hours to get help when the call light was pushed.-Sometimes he/she can't reach their call light.-Staff does not make sure he/she had their call light within reach.-He/She could not transfer himself/herself and needed total assistance from staff.-He/She was incontinent.-He/She has laid or sat in urine and/or bowel for hours before the call light got answered and he/she was changes.-He/She was attempting to get into bed from the wheelchair when this surveyor entered the room.-He/She could not reach the call light to ask for assistance with getting into bed. 5. Review of Resident #9's admission record showed he/she was admitted on [DATE] and had the following diagnoses:-Hemiplegia and Hemiparesis.-COPD-Dysphagia (medical term for difficulty swallowing, indicating an impairment in moving liquids or solids from the mouth to the stomach. It is characterized by symptoms like coughing, choking, or food feeling stuck in the throat). Review of the resident's Annual MDS dated [DATE], showed He/she had severe cognitive impairment. Review of the resident's Care Plan dated 1/9/20 showed:-The resident had alteration in elimination with poor awareness of toileting needs and experienced frequent incontinence episodes with need for assistance.-The goal was to have oversight and support from staff to ensure elimination needs were met and remain clean, dry and odor free. -Staff were to complete the following interventions:--Extensive assistance with toileting needs to include transfer, mobility, hygiene, donning absorbent products and clothes management.--Routine checks during night and checking for incontinence while allowing for periods of undisturbed rest.-The resident had potential for respiratory declines related to COPD.-The goal was to have oversight and support from staff to promote oxygen sats remaining greater than 90%.-Staff were to complete the following interventions:--Assist with care tasks as needed to prevent shortness of air (SOA) and fatigue.-The resident was at risk for falls related to reduced function, impaired mobility, medications, impulsiveness.-Staff were to provide the following interventions:--Resident educated on the importance of using call light and waiting for staff toassist with transfers. Review of the facility's Device Activity Report dated 3/1/26-3/19/26 showed:-The resident had a call light response time of 137 minutes and 52 seconds on 3/2/26 at 11:47 P.M.-The resident had a call light response time of 44 minutes and 31 seconds on 3/4/26 at 12:28 A.M.-The resident had a call light response time of 245 minutes and 51 seconds on 3/4/26 at 1:13 A.M.-The resident had a call light response time of 71 minutes and 18 seconds on 3/4/26 at 8:32 A.M.-The resident had a call light response time of 33 minutes and 30 seconds on 3/8/26 at 8:18 A.M.-The resident had a call light response time of 137 minutes and 58 seconds on 3/8/26 at 2:11 P.M.-The resident had a call light response time of 238 minutes and 14 seconds on 3/8/26 at 11:31 P.M.-The resident had a call light response time of 137 minutes and 29 seconds on 3/11/26 at 5:50 A.M.-The resident had a call light response time of 42 minutes and 59 seconds on 3/11/26 at 1:09 P.M.-The resident had a call light response time of 157 minutes and 3 seconds on 3/11/26 at 7:08 P.M.- The resident had a call light response time of 26 minutes and 58 seconds on 3/11/26 at 11:08 P.M.-The resident had a call light response time of 31 minutes and 32 seconds on 3/12/26 at 2:39 A.M.-The resident had a call light response time of 18 minutes and 53 seconds on 3/12/26 at 4:31 A.M.- The resident had a call light response time of 34 minutes and 8 seconds on 3/13/26 at 5:58 P.M.-The resident had a call light response time of 53 minutes and 37 seconds on 3/13/26 at 6:42 P.M.-The resident had a call light response time of 53 minutes and 47 seconds on 3/13/26 at 10:10 P.M.-The resident had a call light response time of 24 minutes and 1 seconds on 3/14/26 at 12:28 A.M.-The resident had a call light response time of 23 minutes and 14 seconds on 3/14/26 at 2:38 A.M.-The resident had a call light response time of 213 minutes and 45 seconds on 3/14/26 at 6:01 A.M.-The resident had a call light response time of 58 minutes and 48 seconds on 3/14/26 at 9:44 P.M.-The resident had a call light response time of 79 minutes and 35 seconds on 3/14/26 at 11:47 P.M.- The resident had a call light response time of 308 minutes and 49 seconds on 3/15/26 at 2:31 A.M.-The resident had a call light response time of 62 minutes and 59 seconds on 3/15/26 at 8:58 A.M.-The resident had a call light response time of 44 minutes and 14 seconds on 3/15/26 at 10:21 A.M.-The resident had a call light response time of 26 minutes and 53 seconds on 3/15/26 at 11:33 A.M. -The resident had a call light response time of 194 minutes and 4 seconds on 3/15/26 at 12:14 P.M.-The resident had a call light response time of 19 minutes and 10 seconds on 3/15/26 at 3:31P.M.-The resident had a call light response time of 167 minutes and 7 seconds on 3/15/26 at 4:07 P.M.- The resident had a call light response time of 53 minutes and 35 seconds on 3/15/26 at 7:22 P.M.-The resident had a call light response time of 93 minutes and 4 seconds on 3/15/26 at 9:27 P.M.-The resident had a call light response time of 169 minutes and 24 seconds on 3/15/26 at 11:13 P.M.-The resident had a call light response time of 149 minutes and 8 seconds on 3/16/26 at 2:59 A.M.- The resident had a call light response time of 117 minutes and 18 seconds on 3/16/26 at 11:48 P.M.-The resident had a call light response time of 119 minutes and 40 seconds on 3/17/26 at 3:24 A.M. Observation and interview on 3/20/26 at 11:15 A.M., the resident's said:-He/She was laying in bed with the door closed. -He/She could not reach the call light which was observed out of the resident's reach.-He/She had on continuous oxygen and was coughing and choking on saliva.-He/She was having shortness of breath. -He/She was on 3 liters of continues oxygen. -He/She waited hours to get help when the call light was pushed and needed help.-He/She often has a hard time breathing.-He/She often got chocked up.-He/She often could not reach the call light.-He/She was scared to choke to death because she never received the help that she needed. -He/She was incontinent of urine and bowel.-He/She laid in urine and bowel for hours when staff did not answer the call light. -He/She did not feel safe and cared for in the facility. 6. Review of Resident #11's admission record showed he/she was admitted on [DATE] and had the following diagnoses:-Multiple Sclerosis (an autoimmune condition that affects your brain and spinal cord).-Muscle weakness.-Reduced mobility.-Need for assistance with personal care. -Lack of coordination. -Hemiplegia and Hemiparesis. Review of the resident's Quarterly MDS dated [DATE], showed he/she had mild cognitive impairment. Review of the facility's Device Activity Report dated 3/1/26-3/19/26 showed:-The resident had a call light response time of 43 minutes and 43 seconds on 3/1/26 at 3:29 A.M.-The resident had a call light response time of 214 minutes and 26 seconds on 3/1/26 at 9:14 A.M.-The resident had a call light response time of 22 minutes and 21 seconds on 3/1/26 at 8:10 P.M.-The resident had a call light response time of 176 minutes and 50 seconds on 3/2/26 at 1:24 A.M.-The resident had a call light response time of 18 minutes and 10 seconds on 3/2/26 at 8:33 A.M.- The resident had a call light response time of 33 minutes and 48 seconds on 3/2/26 at 4:02 P.M.- The resident had a call light response time of 31 minutes and 10 seconds on 3/2/26 at 9:57 P.M.- The resident had a call light response time of 16 minutes and 46 seconds on 3/3/26 at 7:28 P.M.- The resident had a call light response time of 61 minutes and 31 seconds on 3/3/26 at 8:09 P.M.- The resident had a call light response time of 46 minutes and 22 seconds on 3/4/26 at 12:41 P.M.- The resident had a call light response time of 51 minutes and 29 seconds on 3/4/26 at 1:37 P.M.- The resident had a call light response time of 76 minutes and 41 seconds on 3/4/26 at 6:38 P.M.- The resident had a call light response time of 52 minutes and 17 seconds on 3/4/26 at 8:38 P.M.- The resident had a call light response time of 32 minutes and 59 seconds on 3/5/26 at 1:57 P.M.- The resident had a call light response time of 73 minutes and 13 seconds on 3/5/26 at 5:09 P.M.- The resident had a call light response time of 180 minutes and 10 seconds on 3/5/26 at 8:09 P.M.- The resident had a call light response time of 154 minutes and 59 seconds on 3/6/26 at 9:39 A.M.-The resident had a call light response time of 286 minutes and 12 seconds on 3/6/26 at 1:52 P.M.- The resident had a call light response time of 536 minutes and 45 seconds on 3/6/26 at 7:17 P.M.- The resident had a call light response time of 104 minutes and 43 seconds on 3/7/26 at 4:11 P.M.- The resident had a call light response time of 77 minutes and 39 seconds on 3/7/26 at 6:52 P.M.- The resident had a call light response time of 27 minutes and 48 seconds on 3/8/26 at 12:44 A.M.- The resident had a call light response time of 18 minutes and 0 seconds on 3/8/26 at 4:02 A.M- The resident had a call light response time of 21 minutes and 46 seconds on 3/8/26 at 10:50 A.M.- The resident had a call light response time of 21 minutes and 10 seconds on 3/8/26 at 11:17 A.M.- The resident had a call light response time of 23 minutes and 27 seconds on 3/8/26 at 2:25 P.M.- The resident had a call light response time of 89 minutes and 15 seconds on 3/8/26 at 3:01 P.M.- The resident had a call light response time of 84 minutes and 28 seconds on 3/8/26 at 4:49 P.M.- The resident had a call light response time of 158 minutes and 21 seconds on 3/8/26 at 9:10 P.M.- The resident had a call light response time of 58 minutes and 22 seconds on 3/9/26 at 12:39 A.M.- The resident had a call light response time of 143 minutes and 58 seconds on 3/9/26 at 1:21 P.M.- The resident had a call light response time of 56 minutes and 18 seconds on 3/9/26 at 5:54 P.M.- The resident had a call light response time of 70 minutes and 22 seconds on 3/9/26 at 8:32 P.M.- The resident had a call light response time of 80 minutes and 30 seconds on 3/9/26 at 9:56 P.M.- The resident had a call light response time of 29 minutes and 49 seconds on 3/10/26 at 9:20 A.M.- The resident had a call light response time of 51 minutes and 14 seconds on 3/10/26 at 11:33 A.M.- The resident had a call light response time of 20 minutes and 51 seconds on 3/10/26 at 1:21 P.M.- The resident had a call light response time of 58 minutes and 10 seconds on 3/10/26 at 6:00 P.M.- The resident had a call light response time of 47 minutes and 47 seconds on 3/11/26 at 10:38 A.M.- The resident had a call light response time of 24 minutes and 37 seconds on 3/11/26 at 2:28 P.M.- The resident had a call light response time of 21 minutes and 5 seconds on 3/11/26 at 6:13 P.M.- The resident had a call light response time of 18 minutes and 3 seconds on 3/12/26 at 12:51 P.M.- The resident had a call light response time of 258 minutes and 36 seconds on 3/12/26 at 6:55 P.M.- The resident had a call light response time of 25 minutes and 49 seconds on 3/13/26 at 12:41 A.M.- The resident had a call light response time of 392 minutes and 16 seconds on 3/14/26 at 11:36 A.M.-The resident had a call light response time of 176 minutes and 33 seconds on 3/14/26 at 6:23 P.M.- The resident had a call light response time of 25 minutes and 59 seconds on 3/15/26 at 12:15 A.M.- The resident had a call light response time of 100 minutes and 38 seconds on 3/15/26 at 6:00 A.M.- The resident had a call light response time of 87 minutes and 59 seconds on 3/15/26 at 12:25 P.M.- The resident had a call light response time of 65 minutes and 18 seconds on 3/15/26 at 5:50 P.M.- The resident had a call light response time of 129 minutes and 36 seconds on 3/16/26 at 12:36 A.M.- The resident had a call light response time of 65 minutes and 2 seconds on 3/17/26 at 12:58 P.M.- The resident had a call light response time of 17 minutes and 29 seconds on 3/17/26 at 4:35 P.M.-The resident had a call light response time of 75 minutes and 57 seconds on 3/18/26 at 9:11 A.M.- The resident had a call light response time of 35 minutes and 7 seconds on 3/18/26 at 1:40 P.M.- The resident had a call light response time of 44 minutes and 8 seconds on 3/18/26 at 4:29 P.M.- The resident had a call light response time of 36 minutes and 32 seconds on 3/18/26 at 5:36 P.M.- The resident had a call light response time of 59 minutes and 9 seconds on 3/18/26 at 7:08 P.M.- The resident had a call light response time of 58 minutes and 52 seconds on 3/19/26 at 1:08 A.M.- The resident had a call light response time of 92 minutes and 15 seconds on 3/19/26 at 4:02 A.M.- The resident had a call light response time of 54 minutes and 41 seconds on 3/19/26 at 9:27 A.M.-The resident had a call light response time of 48 minutes and 16 seconds on 3/19/26 at 11:48 A.M. Observation and interview on 3/20/26 at 11:26 A.M., the resident's said he/she had her call light on for over 30 minutes currently. Observation of the resident' s room on 3/20/26 at 11:28 A.M., showed:-There was no light on above the resident's door in the hallway.-There was no sound heard in the hallway outside of the resident's door.-There was no sound heard at the nurse's station.-Certified Nurse's Aide (CNA) A was sitting at the nurse's station and scrolling on her cell phone. -CNA C approached the nursing station and pointed to the computer screen and said to the CNA A that was sitting at the nurse's station on his/her phone, You need to go answer that light right now, they are watching the call light times. Observation and interview on 3/20/26 at 11:35 A.M., the resident said:-His/Her call light was on for well over an hour total prior to just being answered by the CNA.-He/She always had long call light times.-He/She didn't think staff liked to answer the call light because he/she was a lot of work to care for. -He/She could not care for herself and required total assistance.-He/She could not get out of bed without a hoyer lift.-He/She could not walk.-He/She was incontinent and laid in urine often for up to 6 hours with no one answering the call light.-He/She pushed the call light the other night at 1:00 A.M., and the light was not answered by staff until almost 8:00 A.M. -He/She was laying in urine and uncomfortable for the entire 7 hours that the call light was on. -There have been several times when his/her call light was not answered for multiple hours, and she was uncomfortable and forced to lay in urine. -The long call light wait times happened on all shifts and happened almost daily.-The long call light times made her feel unsafe. 7. During an interview on 3/23/26 at 2:30 P.M., CNA A said:-The resident call light system was broken. -Staff only knew if a resident's call light was going off if they were sitting right at the nurse's station and saw it on the computer screen. -The process of not having anything to hear or visualize was hard for her as a CNA because he/she was a visual person. -Most of the time, the screen does not make noises when a resident had a call light on but was supposed to light up. -There are no lights above the resident's rooms that go on when a resident placed their call light on.-There is no sound in the hallways when a resident placed their call light on.-Staff are supposed to answer a resident's call light within 5 minutes of being turned on. During an interview on 3/23/26 at 3:20 P.M., Registered Nurse (RN) A said:-CNAs were expected to answer the residents call lights within 10 minutes. -Staff only know when a resident had a call light on by looking at the screen at the nurses' stations.-There are no lights that come on when a resident pushed their call light to alert staff.-There were no sounds that came on when a resident pushed their call light to alert staff.-Staff did not use their cell phones to monitor call lights.-Staff did not use walkie talkies to monitor call lights.-He/She knew there were extended call light times and tried to help answer them when he/she was sitting at the nurses' station. -Staff was not answering the call lights because the call lights can't be seen or heard by staff.-If a call light needed a battery or maintenance, he/she notified maintenance staff, and the problem was fixed immediately.-The extended call light wait times were not causes by battery or maintenance issues.-The call light s system at the facility was not a good system and needed to be fixed. During an interview on 3/23/26 at 4:00 P.M., Licensed Practical Nurse (LPN) C said:-The facility policy stated that call lights must be answered within 10 minutes. -The computers at the nurse's station are what alerts staff when a resident turns on a call light and needed help.-The computers are supposed to have sound to them when a call light is pushed but they don't because somehow the sound gets turned down all of the time.-There are no lights that alert the staff above the resident's rooms when a call light is pushed.-There are no sounds that alert staff when a call light is pushed.-He/She has often had to tell the CNAs to answer call lights because they were not being answered.-Many residents have reported to him/her that they have very long call light wait times.-She assumed the administration already kn

Based on observation, interview and record review, the facility failed to administer oxygen as ordered and to assess and monitor the oxygen saturation levels and respiratory status for one sampled resident (Resident #2) out of 11 sampled residents. The facility census was 99 residents. Review of the facility's Resident Rights Policy revised 1/1/26, showed:-The residents had the right to be informed of, and participate in, his or her treatment, including the right to receive the services and or items included in the plan of care.-The residents had the right to reside and receive services in the facility with the reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.-The residents had the right to, and the facility must promote and facilitate residents' self-determination.-The residents had the right to make choices about aspects of his or her life in the facility that were significant to the resident.-The residents had the right to a safe, clean, comfortable and home like environment, including but not limited to receiving treatment and support for daily living safely. Review of the facility's Vital Signs Policy revised 1/1/26 showed:-The purpose of the policy was to provide guidelines for the measurement and reporting of vital signs.-Vital signs were indicators of health status, and included, temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain.-Oxygen saturation and pain levels were to be obtained and interpreted by licensed nurses.-Vital signs would be obtained at least in the following circumstances: upon admission or readmission, when the residents general condition changed, or when a resident reported. nonspecific symptoms of physical distress.-An acceptable range for an oxygen saturation level was above 90%.-Vital signs would be obtained by the nurse or therapist as indicated, when administering certain medications, or monitoring for effectiveness of medication or therapies.-Oxygen saturation would be assessed for residents requiring oxygen at intervals specified by the physician.-Respiration and pulse rates were assessed for monitoring response to bronchodilators or aerosol treatments.-Respirations, blood pressure, pulse, or oxygen saturation levels would be checked during or after therapy treatment to monitor response to the therapy. Review of the facility's Oxygen Administration policy revised 1/1/26, showed:-Oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. -Oxygen therapy was the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. (decreased perfusion of oxygen to the tissues. -Oxygen was administered under orders of a physician, except in the case of an emergency. In such case, oxygen was administered and orders for oxygen were obtained as soon as practicable when the situation was under control.-Staff would document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 1. Review of Resident #2's admission record showed he/she was re admitted on [DATE] and had the following diagnoses:-Chronic Obstructive Pulmonary Disease (COPD).-Acute Respiratory Failure with Hypoxia (the inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function).-Pneumonia. Review of the resident's Care Plan, dated 7/10/25 showed:-The resident had potential for declines in respiratory status related to recent exacerbation of COPD.-On 10/29/25, the resident was placed on antibiotics for COPD exacerbation.-On 12/11/25, the resident was placed on antibiotics and steroids for respiratory symptoms.-The goal was to have no documented respiratory distress while maintaining oxygensaturation > 90%.-Staff were to provide to following interventions:--Administer medication/puffers as ordered. Monitor for effectiveness and side effects.--Monitor /document changes in orientation, increased restlessness, anxiety, and airhunger.--Monitor for signs and symptoms of respiratory distress and report to physician. Review of the resident's Quarterly Minimum Data Set (MDS-a federal required assessment tool to be completed by facility staff) dated 2/4/26, showed he/she was cognitively intact. Review of the resident's Medication Administration Record (MAR) dated 3/1/26-3/31/26 showed:-An active physician's order for OXYGEN: May have supplemental oxygen at 2Liters/minute via nasal cannula as needed for O2 saturation less than 90% and/or wheezing and Shortness of Air (SOA) as needed with a start date of 10/10/25.-Staff did not document the administered of any oxygen for the month of March.-The resident had no O2 saturation assessments documents for the month of March.-All opportunities for oxygen administration and oxygen saturation assessments were blank. Review of the resident's Physicians Progress Note dated 3/1/26, showed: -Staff was to monitor for recurrent respiratory symptoms including dyspnea, cough, wheezing, or increased sputum production.-Staff was to monitor oxygen saturation and respiratory rate; assess need for supplemental oxygen if clinically indicated.-Staff was to monitor for signs of acute exacerbation or infection. During an interview on 3/17/26 at 8:37 A.M. the resident said:-He/She suffered from pneumonia three times since being admitted to the facility. -He/She had oxygen ordered by the physician. -He/She has experienced SOA during the night and staff do not check his/her oxygen saturations levels. Review of the resident's Oxygen Saturation Summary on 3/19/26, showed the resident's oxygen saturation level was assessed on 9/3/25 and not assessed again until 3/5/26. Observation and interview on 3/19/26 at 11:05 A.M., the resident said:-He/She was not being administered oxygen at the time of the interview by the facility.-There was no oxygen concentrator in his/her room.-There was no portable oxygen tank on his/her room. -He/She has SOA at night. During an interview on 3/19/26 at 11:30 P.M., Registered Nurse (RN) A said:-It was standard practice and facility policy to obtain all the resident's vitals once per month.-The residents vitals included temperature, respirations, blood pressure, pulse, oxygen saturation level, and pain-The residents vitals were charted in the resident's electronical medical record when obtained.-The residents vitals could be viewed in the vital section in Electronic Medical Record (EMR) if they were documented. -He/She did not always document the resident's vitals in the EMR. -He/She was aware that all vitals should be documented in the EMR. -He/She was unsure who obtained the residents monthly vitals.-If a resident complained of SOA, he/she would delegate that the Certified Medication Technician (CMT) to obtain the resident's oxygen saturation level or obtain it himself/herself. -If needed, he/she would obtain an order for oxygen administration. -He/She had not assessed the resident's oxygen saturation level.-He/She was unsure when the resident last had an oxygen saturation assessment completed. -He/She did not know if the resident had an oxygen concentrator in his/her room.-He/She did not know the resident had orders for respiratory assessments and monitoring. -He/She was aware that the resident had COPD and recent pneumonia. During an interview on 3/19/26 at 5:00 P.M., CMT A said:-The resident reported to him/her that he/she was having SOA at times. -He/She did not assess the resident's oxygen saturation levels.-He/She reported the resident's complaint of SOA to RN A. -The resident had an oxygen tank in his/her room.-The resident plays games with the staff and smokes cigarettes.-CMT's do not have a place to document in the resident's EMR when they check the oxygen saturation levels. -He/She was not aware what the resident's respiratory and oxygen orders were because those orders only appeared on the nurse's side of the EMR. During an interview on 3/23/26 at 2:30 P.M., Certified Nurse Assistant (CNA) A said:-It was responsibility of nurses to take vitals for the residents. -Some vitals were taken every day. -Some vitals were taken weekly.-CNA's take the vitals if asked to do so by the nurses. -Vitals were charted in the residents EMR. -Vitals included: Blood pressure, respirations, temperate, heart rate, and oxygen saturation levels. -Oxygen saturation monitors and blood pressure cuffs were on the CMT's med carts. -Each hall had their won vital sign equipment. -CNA's will manage oxygen tanks if oxygen is empty and needed to be replaced for a resident. -If a resident reported SOA, he/she would reported it to the charge nurse. -He/She was not sure if the resident was on oxygen therapy.-CNAs did not know how to look at care plans and did not know how to access them for interventions. -CNAs were not made aware of the resident's oxygen or monitoring orders. During an interview on 3/23/26 at 3:41 P.M., CNA B said:-CMT's were responsible for getting the vitals in the facility.-Vitals ere documented in the resident's EMR. -CNA's report to their nurse if a resident reported SOA.-The nurses were responsible for administering the oxygen to the residents. -He/She did not monitor resident's oxygen saturation levels. During an interview on 3/23/26 at 4:00 P.M., Licensed Practical Nurse (LPN) C said:-It was the responsibility of the nurses and the CMT's to take residents vitals. -Vitals were charted in the resident's EMR. -Residents had standard orders for vitals. -He/She believed the residents vitals were taken once per month at minimum. -Vitals included blood pressure, pulse, respiration, temperatures, 02 saturations, and pain. -If a resident complained of SOA, he/she would check the resident's oxygen saturation level and document the oxygen saturation level in the resident's EMR. -If the oxygen saturation level was below 90%, he/she administered oxygen at 2 liters and would call the doctor. During an interview on 3/23/26 at 5:15 P.M., Administrator and Director of Nursing (DON) said:-It was expected that vitals be obtained once monthly and documented in the resident's EMR.-It was expected that all physician orders were followed.-If a resident reported SOA, it was expected that the staff would complete a respiratory assessment that included vitals.-If a resident had a history of COPD, it was expected that their vitals and oxygen saturation levels be monitored as needed when having SOA. -The nurses were responsible and expected to implement the resident's respiratory orders.-It was expected that residents have their vitals taken upon readmission to the facility from the hospital-It was expected that residents who required oxygen for COPD, be administered oxygen as ordered by the physician. -It was expected that residents receive quality assessment and care regardless of if they chose to smoke or not. 2806110

Based on interview and record review, the facility failed to provide appropriate treatment and behavioral health services per policy for three sampled residents (Residents #1, #2, and #3) who had a known history of substance abuse. The facility staff failed develop a plan of care related to behavioral health services for the use of illicit drug use needs based on the residents' Preadmission Screening and Resident Review (PASRR- DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source) and failed to assess and ensure the interventions for the resident were in place and implemented by facility staff after each behavior of illicit drug use. As a result of the facility failure on [DATE] about 6:30 P.M., Resident #3 shared fentanyl (a potential synthetic opioid) smoked off a piece of foil with Resident# 1 (who had a legal guardian) and Resident #2, whom also had a history of substance abuse, and both Resident #1 and Resident #2 became unconscious, had to be administered Narcan and were hospitalized . Six residents were selected for sample. The facility census was 101 residents. The Administrator was notified on [DATE] at 4:18 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. The undated facility Illicit Drug and Alcohol policy showed: -All illicit drugs, alcohol, and marijuana will be banned from the facility for the safety of all residents. Residents in possession of any of these items could result in the issuance of a 30-day notice, police contact when necessary due to severity, and a call to the physician to advise on administration of orders for medications for residents' safety. -No resident is to bring any form of these substances into the facility at any time. All of these are strictly banned from the premises of the facility. -Any resident who signs out and returns to the facility appearing to be under the influence, physician will be notified and asked how to proceed with orders while resident is under the influence. -If continued use of drugs in the community endanger resident a physician could revoke the standing order for leave of absence for his or her own safety. -Any residents in possession of illicit substances or paraphernalia or caught providing them to another resident could receive a 30-day notice to discharge or police intervention. -Residents who have unsafe behaviors or put other residents at risk secondary to allegedly or knowingly being under the influence will have emergency intervention or police intervention. -Facility offers in house psychological services from a licensed psychiatrist. -Care plans will be created to address specific behaviors such as current illicit drug, marijuana, or alcohol use. -Resident suspected to be under the influence will receive increased monitoring for safety. -Residents' physician will be notified if they appear to be under the influence of a prohibited substance for their safety. -Residents with symptoms of overdose or requiring acute care from a hospital will be sent out to receive services. -Residents with possession of illegal drugs or discovered to be providing to others could receive police intervention or a 30-day notice to discharge. -Residents who appear under the influence will be monitored for their safety and the safety of other residents. -Residents who behaviors put themselves or others at risk could receive police intervention or emergency medical services for the safety. -Residents who habitually violate policy or endanger other residents could receive a 30-day notice. -Monitoring and Visitation Controls: --To protect the health and safety of residents, the facility may implement additional monitoring and supervision measures, which may include: ---Increased observation and safety checks and care plan updates addressing safety risks.---Denial of access to the facility or implementation of supervised visitation for individuals with a known history of bringing illegal substances into the facility. Review of the facility Behavioral Health Services Policy, dated February 2023, showed: -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. -Behavior 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. -The facility will consider the acuity of the resident population; this includes residents with substance use disorders (SUDs). -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. -The facility uses 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 complete PASRR screening. -Obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health. -Monitor the residents closely for expressions or indications 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 trigger in the resident's record. -Ensure appropriate follow-up assessment, if needed. -Discuss potential modifications to the care plan. -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, culturally competent, trauma-informed, and in accordance with professional standards of practice. -Provide for meaningful activities which promote engagement and positive, meaningful relationships. -Resident living with mental disorders and SUDs may require different activities than other nursing home residents. -The facility will ensure that activities are provided to meet the needs of these residents. -Address any other individualized needs the resident may have related to the mental disorder or the SUD. -Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. -If a behavioral contract is used, it will only be used with residents who have the capacity to understand it. -A contract will only be used as method of encouraging the resident to follow their plan of care, and not as a system of reward and punishment. -The contract will not conflict with resident rights or other requirements of participation. -Resident refusal to accept, or non-adherence to the terms of a behavioral contract, will not be the sole basis for a denial of admission, transfer, or discharge. -If a contract is used, it may also address: --The resident's right to have a leave of absence and the health and safety risks of leaving without facility knowledge or leaving against medical advice (AMA). --Facility efforts to help resident with mental disorder and/or SUD, such as individual counseling services, access to group counseling, or access to a medication Assisted Treatment program, if applicable. --Steps the facility may take if substance use is suspected, which may include: ---Increased monitoring and supervision in the facility to maintain the health and safety of the resident suspected of substance use, as well as all residents. ---Restricted or supervised visitation, if the resident's visitors are deemed to be a danger to the resident, other residents, and/or staff. ---Voluntary drug testing if there are concerns that suspected drug use could adversely affect the resident's condition. ---Voluntary inspections, if there is reasonable suspicion of possession of illegal drugs, weapons or other authorized items which could endanger the resident or others. ---Referral to local law enforcement for suspicion of a crime in accordance with state laws, such as possession of illegal substances, paraphernalia or weapons. -All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. -Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological intervention. -The Social Services Director (SSD) shall serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists. 1. Review of Resident #3's PASRR, dated [DATE], showed: -The individual had impairment due to serious mental illness. -The individual had serious difficulty interacting appropriately and communicating effectively with other persons. -This individual had serious difficulty in adapting to typical changes in circumstances associated with work, school, family or social interactions. -The individual had serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings. -The individual had a substance related disorder with most recent abuse within 30 days of the assessment. -Positive for methamphetamine (a lab made stimulant) result on 8/2025. -Psychiatric Assessment History included alcohol abuse, polysubstance dependence (the intentional or unintentional use of three or more different classes of psychoactive substances within a short period), and Methamphetamine abuse. -Per hospital note, [DATE] urine drug screen was positive for opiates and benzodiazepines (a class of central nervous system depressant drugs) with diagnosis of polysubstance abuse. -A skilled care facility was recommended to ensure sobriety, 24-hour supervision, and appropriate medical and psychiatric treatment. -Client would benefit from cessation program (the voluntary or involuntary stopping, discontinuing, or ending of a process, habit, or physical function). -Client would benefit from substance abuse program, including: substance abuse services community-based substance use treatment, 12 step substance use program, and residential/intensive substance use treatment/rehabilitation services. Review of the resident's undated admission Record showed the resident admitted on [DATE] with diagnoses including opioid abuse (a chronic, treatable medical condition characterized by a problematic pattern of using opioids-such as prescription pain relievers (oxycodone, hydrocodone, fentanyl) or illegal drugs like heroin-that leads to significant impairment or distress) and other psychoactive substance abuse. -The resident did not have a legal guardian. Review of the resident's Order Summary Report, dated [DATE], showed an order, dated [DATE], for Buprenorphine (Suboxone - a Schedule III medication used to treat opioid use disorder (addiction) by reducing cravings and withdrawal symptoms) sublingual tablet 8 milligram (mg) give one tablet sublingually two times a day for chronic pain. Review of the resident's medical record showed:-No risk assessments related to substance use/abuse. -No documentation of Narcotics Anonymous (NA) or Alcoholics Anonymous (AA) resources, education or attendance. -No substance abuse programming, no substance abuse services community-based substance use treatment, no 12-step substance use program, and no residential/intensive substance use treatment/rehabilitation services as recommended by the resident's PASRR. Review of the resident's undated Care Plan showed:-The resident received opioid medication for chronic pain.-No identified problem, goal, or interventions for illicit substance use/abuse.-No identified problem, goal, or interventions from the PASRR recommendations. Review of the facility sign in and out sheets for [DATE] showed the facility had no record at all for a visitor log or a resident sign in or out. Review of the resident's progress note, dated [DATE], showed: -He/She brought illicit drug paraphernalia into the building. -He/She was placed on a 30-day restriction. -There was no documentation to describe what the 30-day restriction was supposed to be for the resident. -There was no documentation of facility staff education related to the resident restriction. Review of the resident's care plan, updated [DATE], showed:-He/she had a behavior problem with possession of illegal substances and paraphernalia. -He/she was placed on restriction. -The resident re-educated that not following facility policy would not be tolerated and consequences of continued noncompliance. -There was no documentation on what staff interventions should look like with the LOA (leave of absence) restriction. Review of the facility sign in and out sheet for [DATE] showed the facility had no record at all for a visitor log or a resident sign in or out. Review of the resident's progress note, dated [DATE] at 5:32 A.M., showed: -He/She was found again with drug paraphernalia. -It was documented the resident was given education, but there was no documentation of what the education to the resident was. -He/She was placed on supervised visitation and LOA restriction. -There was no documentation of supervised visitation and LOA restriction or documentation of staff training as to what the resident's LOA restriction was to be. -There was no assessment of the resident's substance use and or resources the resident needed completed. Review of the resident's progress note, dated [DATE] at 8:54 A.M., showed: -He/she was given a 60-day restriction and 30-day discharge notice. -There was no documentation of staff education as to what the facility staff were supposed to do for the resident's 30 day or 60-day restriction. Review of the resident's care plan, updated [DATE], showed:-LOA had been restricted for 60 days for not following facility policy. -Additional items confiscated from the resident. -30 day discharge given for noncompliance. Review of the facility sign in and out sheets for [DATE] showed the facility had no record at all for a visitor log or a resident sign in or out. During an interview on [DATE] at 10:40 A.M., the Administrator said:-The resident had been caught with drug paraphernalia on [DATE] and [DATE] which resulted in a 30 day discharge notice.-The resident was placed on restriction and was required to have someone sign him/her out due to the paraphernalia. -The resident was placed on restriction per the medical director in accordance with the facility Illicit Drug and Alcohol policy.-The facility offered AA and NA programs led by the Administrator. During an interview on [DATE] at 10:50 A.M., the Director of Nursing (DON) said: -The resident was caught on [DATE] with drugs on his/her person and was given a 30 day discharge notice for violating the facility drug policy. -The resident was caught with contraband at one point and was restricted for 30 days. -The resident restriction included having someone sign him/her out when out of the building. During an interview on [DATE] at 3:42 P.M., Licensed Practical Nurse (LPN) A said: -Resident #3 was on restriction after being caught with pipes and meth and had to have someone sign him/her out and they had to show their ID for him/her to leave with them. They were not told to document who the resident left with. -If residents were caught with alcohol or drugs they get restriction. -If anybody has bags, they check the bags, but they do not search the resident themselves. -No special procedures were expected outside of the sign out by another person for a resident on restriction. Review of the facility sign in and out sheets for [DATE] showed the facility had no record at all for a visitor log or a resident sign in or out. Review of the resident's progress note, dated [DATE] at 1:39 P.M., showed: -The SSD left the resident a voicemail checking to see if the resident plans on returning to the acility. -The SSD will follow up again tomorrow. -No documentation that anyone signed the resident out. Review of the resident's progress note, dated [DATE], showed staff documented the resident continued to leave facility on LOA without wheelchair. Further review showed no documentation the resident was signed out of the facility by anyone. Review of the resident's progress note, dated [DATE], showed he/she was signed out of the facility by a family member. Further review showed there was no return date or time documented. Review of the resident progress note, dated [DATE], showed he/she returned to the facility between 1:00 A.M. and 2:00 A.M. 2. Review of Resident #1's PASARR, dated [DATE], showed: -Psychiatric Assessment History including alcohol dependence. -No recent use. -Required 24-hour supervision for his/her safety and the safety of others. -Required medication administration, was a high fall risk, and cannot manage his/her own medications or medical diagnoses. -Remains safe in a skilled care facility. -Due to his/her chronic medical and psychiatric conditions as well as his/her inability to care for him/herself, he/she required around-the-clock nursing care. Review of the resident's admission Record showed Resident #1 was admitted on [DATE] with a court appointed guardian and diagnoses including paranoid schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others), bipolar disorder (a chronic mental health condition causing extreme, often debilitating, shifts in mood, energy, and activity levels, alternating between manic highs and depressive lows), and personal history of traumatic brain injury. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE], showed the resident was cognitively intact. Review of the resident's medical record showed:-No risk assessments related to substance use/abuse. -No documentation of NA or AA resources, education, or attendance. Review of the resident's undated Care Plan showed:-No focus, goals, or interventions for alcohol dependence. -Resident was assessed to have increased depression due to overall decline followed up by relocation to a less restrictive environment. -Limited insight and judgement and the need to for a safe place to live with 24 hour supervision. 3. Review of Resident #2's admission Record showed the resident was admitted [DATE] with diagnoses including schizophrenia and weakness. Review of the resident's PASRR, dated [DATE], showed: -Substance related disorder with most recent use within 30 days of assessment. -Diagnoses relevant to functional and/or skilled nursing needs include history of substance abuse. -Psychiatric Assessment History diagnoses included cocaine dependence, alcohol dependence, other psychoactive substance abuse, and unspecified, alcohol-induced disorder. -[DATE] emergency department records indicate depression with complaint of drug use and someone stole his/her medications.-admitted to cocaine use on [DATE]. -Required 24-hour protective oversight, cannot be without supervision at any time. -Psychiatric history complicated by a history of polysubstance abuse. -His/Her history of psychosis, suicide attempt, and polysubstance use indicated significant risk for decompensation in the absence of structured oversight. -Nursing facility placement offers the level of care necessary to support his/her continued safety, prevent relapse, and promote overall well-being. Review of the resident's MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's undated Care Plan showed no focus, goal, or interventions for diagnoses of cocaine dependence, alcohol dependence, other psychoactive substance abuse, and unspecified, alcohol-induced disorder. Review of the resident's medical record showed:-No risk assessments related to substance use/abuse.-No documentation of NA or AA resources, education or attendance. 4. Review of the facility Suspected Abuse Investigation, dated [DATE], showed: -On the night of [DATE] Resident #3 was actively using a substance in his/her room when Residents #1 and #2 came into the room. -Resident #3 told Residents #1 and #2 to go ahead and take a hit of the illicit substance. -Resident #3 told Resident #1 to take a hit. -Resident #2 held the foil as Resident #3 used the illicit substance. -Resident #2 then used the illicit substance and both Resident #2 and #1 passed out. -Resident #1 used first with the help of Resident #2. -Resident #2 then used the illicit substance and both residents became unconscious. -Two residents overdosed in the facility and required Narcan on [DATE] at approximately 6:40 P.M. -Resident #3 came out of the room at approximately 6:54 P.M. yelling to the nurses the residents in his/her room needed Narcan. -Licensed Practical Nurse (LPN) A and B rushed to the residents. -LPN B assessed for a pulse on Resident #1 and Resident #2 while LPN A obtained the Narcan. -Residents #1 and #2 had Narcan administered and emergency medical services (EMS) was called. -Resident #1 became alert and oriented with the Narcan administration, Resident #2 was going in and out of orientation. -EMS transported Resident #1 and #2 to the hospital. Review of Resident #1's Nurses Note, dated [DATE] at 6:58 P.M., showed:-LPN B had just given report to the oncoming shift and Resident #3 came up to the nursing station at about 7:00 P.M. and said, I need Narcan.- LPN B asked Resident #3 what they needed Narcan for. Resident #3 stated that two residents were in his/her room unconscious. - Resident #3 stated, I woke up and found them that way, I tried to splash water on them, but they aren't waking up.- LPN B ran down the hall to Resident #3's room and noticed Resident #1 unconscious in a wheelchair. - LPN B called to Resident #1 and he/she did not respond. - LPN B advised oncoming nurse to call EMS. - LPN B checked Resident #1 for pulse and noted strong carotid pulse. - LPN B retrieved Narcan from the nurse cart and Resident #1 was given 1 dose of Narcan. - Resident #1 didn't respond to 1st dose, so another was administered shortly after. - LPN B proceeded to do a sternal rub on Resident #1. -Resident #1 responded to the second dose of Narcan. Resident #1 came to and stated he/she was okay.- LPN B informed Resident #1 of unconsciousness and asked the resident what he/she took and the resident stated, I smoked meth. -EMS arrived and Resident #1 was transferred via stretcher to hospital for additional treatment and care. -Director of Nursing (DON) and Administrator notified, guardian notified. Managers and Nurse Practitioner (NP) notified as well. Review of Resident #1's Administration Note, dated [DATE] at 6:48 P.M. through 6:53 P.M., showed:-Narcan nasal liquid 4 MG/0.1ML 1 inhalation in nostril every 2 minutes as needed (PRN) for overdose up to three doses.-Took a breath opened eyes and continued not to respond. -6:53 P.M. administered another dose of Narcan. Resident took a deep breath opened eyes and said, I want Taco Bell.-Second dose PRN Administration at 6:53 P.M. was effective. Review of Resident #2's Nurses Note, date [DATE] at 6:58 P.M., showed:-LPN B had just given report to the oncoming shift and Resident #3 came up to the nursing station at about 1900 (7:00 P.M.) and said, I need Narcan.-LPN B asked Resident #3 what they needed Narcan for. Resident #3 stated that two residents were in his/her room unconscious. -Resident #3 stated, I woke up and found them that way, I tried to splash water on them, but they aren't waking up.-LPN B noticed Resident #2 unconscious on the floor. -LPN B called to Resident #2 and no response. -LPN B advised oncoming nurse to call EMS. -LPN B checked for pulses and noted carotid pulse. -LPN B got Narcan from the nurse cart and Resident #2 was given 1 dose of Narcan. -Resident #2 didn't respond to 1st dose so another was administered. -LPN B and co-nurse continued with sternal rub on Resident #2. -Resident #2 responded to second dose of Narcan but still in and out of consciousness. -EMS arrived and Resident #2 was transferred via stretcher to hospital for additional treatment. -DON, NP, and Administrator notified. Review of Resident #1's hospital records, dated [DATE], showed: -Admit reason was overdose. -Presented to the emergency department by EMS. -He/She lived in a nursing facility. -That night he/she was smoking fentanyl with another resident. They both accidentally overdosed and were found unresponsive. -EMS arrived at the scene and administered 8 mg of Narcan and he/she woke up appropriately. -He/She did not intend to hurt him/herself and was very inexperienced with smoking fentanyl. -He/She had never done fentanyl before and wanted to see what the high was like. During an interview on [DATE] at 4:21 P.M., Resident #1 said:-He/She was aware of the drug being fentanyl, however, he/she had never consumed it before. -He/She only had one hit and it caused him/her to go unconscious. -The last thing he/she remembered was looking at the foil and saw the smoke coming out of the straw, then looked at Resident #2 and blacked out. -The next thing he/she remembered was seeing LPN A. -He/She had never had Narcan before. -He/She thought Resident #3 was on restriction and was not sure where Resident #3 got the fentanyl. -18 years ago his/her drug of choice was meth and he/she broke sobriety to experience the high again. Review of Resident #2's hospital records, dated [DATE], showed: -Admit reason was pulmonary edema and drug overdose on [DATE]. -History of present illness was a past medical history of polysubstance abuse who presents with reported fentanyl overdose at his/her nursing home. -Recent hospitalization last month for alcohol-induced pancreatitis. -That evening he/she planned to smoke methamphetamines with a friend but instead was given fentanyl which he/she accidentally overdosed on. -He/She received several doses of Narcan with some response. -He/She was still very lethargic and nodded yes when confirming fentanyl overdose. -Current use of liquor, cocaine, methamphetamines, and fentanyl. During an interview on [DATE] at 2:51 P.M., Resident #2 said: -He/She recalled having to go to the hospital. -He/She said it was a sad story, he/she didn't know what it was that he/she smoked. -When they passed it to him/her, Resident #3 almost dropped the foil. -Resident #3 kept passing out and waking up. -He/She said man can I get some, because he/she thought it was meth. -When he/she hit it, he/she felt something in his/her brain, thinking it was from the high, he/she hit it again, then started fading away and blacked out. -He/She was out, he/she was dead. -When the staff found him/her dead they found Resident #1. -He/She was really weak when he/she woke up and the ambulance man said he/she was dead. -He/She knew Resident #3 was on restriction, so he/she didn't know Resident #3 could still go out. -Residents #3 and #2 were smoking in front of him/her and then he/she asked for it. -He/She never had hard drugs like that. -If he/she would have known what it was, he/she would not have smoked it. -He/She was told it was fentanyl after he/she overdosed. -He/She had never used fentanyl and had no desire to do fentanyl. -If he/she would have known or had done fentanyl before he/she would have been more careful. -He/She blacked out and fell on the floor by the sink. -Resident #3 had asked to use his/her phone and when he/she went to get his/her phone and came back he/she saw Resident #3 and #1 smoking and passing the foil back and forth.-For Resident #2 when on restriction, he/she cannot leave and was not allowed to go into other's rooms. Resident #2 was placed on restriction after the overdose. During an interview [DATE] at 2:25 P.M., Resident #3 said: -He/She did say they found a pipe in his/her trashcan, which he/she alleged was his/her roommates. -He/She was sleeping and woke up to two residents (Resident #1 and #2) passed out in his/her room. -Two people don't overdose at the same time. -He/She got the nurses who revived the residents and sent them to the hospital. -He/She denied having anything to do with it. -He/She denied history drug use. -Initially he/she had no idea why he/she was on restriction, the reason he/she had a notice was due to an assault. -He/She admitted to being at Denny's on [DATE] and then took an Uber back late at night on Saturday. -He/She denied substance use, but admitted to being on fentanyl forever. -He/She had psychiatric support at [AGE] years old. -The staff said he/she gave Resident #1 and #2 the fentanyl, because the staff don't want to make the Administrator mad. -He/She wouldn't let two people overdose; it wouldn't serve any purpose for him/her to let them get high. -He/She alleged the only reason any of this happened was because nobody wants to make the Administrator mad. -He/She did throw water on Resident #1 and Resident #2, and the cup had chocolate milk in it. He/she also tried to give Resident #1 and Resident #2 mouth to mouth and then he/she went to get help. -He/She told staff help was needed and to bring Narcan. He/She knew they needed Narcan because he/she had seen other people who needed Narcan before. During an interview on [DATE] at 9:03 P.M., CNA C said: -He/She let Resident #3 in the facility on [DATE] at around 2:00 A.M.-He/She did not notice anything different about Resident #3 other than the resident was complaining about money. -Resident #3 was already at the door when he/she saw the resident at the door, so he/she had no idea how the resident arrived at the facility. -The resident said he/she took an Uber to the facility. -Resident #3 did not have any bags with him/her and was in his/her wheelchair. -He/she did not search the resident. During an interview on [DATE] at 3:42 P.M., LPN A said: -He/She was working on [DATE] doing treatments. -Resident #3 came down the hall in his/her wheelchair saying Resident #1 and #2 were on the floor and needed Narcan. -The nurses got the Narcan first, LPN B had already seen Resident #1 and #2 in the room. -Resident #1 was in the chair and Resident #2 was on the floor, covered in chocolate milk. -Resident #3 said he/she was asleep, woke up to the two residents in his/her room, and tried to wake them with water. -LPN A talked to Residnet #2 at his/her doorway about 20-30 minutes before they found the resident and had to give them Narcan.-Resident #2 asked for LPN A to get coffee and orange juice for him/her at the store. -The other nurse was getting something out of the supply at the time of the incident. During an interview on [DATE] at 12:26 P.M., LPN B said: -On [DATE] at about 7:00 P.M. he/she was finishing report to the oncoming nurse when Resident #3 came to him/her at the desk saying he/she needed Narcan. -He/She asked for who and Resident #3 alleged he/she just woke up and found Resident #1 and #2 in his/her room not moving. -Resident #3 reported splashing water on Resident #1 and #2 and they would not wake up. -He/She ran down the hall to Resident #3's room and observed Resident #2 on the floor on his/her back and Resident #1 in his/her wheelchair, both unresponsive.-Resident #3 was freaking out. There was water in the sink and on the floor. -He/She checked Resident #1 and #2's pulses to make sure they were ok, and LPN B got the Narcan. -Resident #3 denied knowing what happened to them. -LPN A gave two doses to each of the unresponsive residents. -Resident #1 responded to the second dose. He/she advised Resident #1 of the administration of Narcan and Resident #1 admitted [TRUNCATED]

Based on interview and record review, the facility failed to notify the guardian in a timely manner when one resident (Resident #1) overdosed on fentanyl, received two doses of Narcan and was sent to the hospital on [DATE]. Six residents were selected for sample. The facility census was 101 residents. The Administrator was notified on 02/03/26 of the Past Non-Compliance which occurred on 02/01/26. The Director of Nursing (DON) educated floor staff on proper notification, location of emergency numbers, what information to leave on a voicemail, and to notify management when a guardian is contacted. The Social Services Director (SSD) was dedicated for follow up, auditing current contact information, and ongoing confirmation of emergency numbers at each care plan meeting and all admissions. Emergency numbers were moved to the special instructions in the electronic medical record for each resident. The deficiency was corrected on 02/06/26. Review of the facility Notification Policy, dated 2024, showed: -The purpose of this policy was to ensure the facility promptly informs the resident, consults with the resident's representative when there is a change requiring notification. -The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. --Accidents resulting in injury or potential to require physician intervention. --Significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status, including life-threatening conditions or clinical complications. --Circumstances that require a need to alter treatment. --A transfer or discharge of the resident from the facility. -Residents incapable of making decisions: --The representative would make any decisions that have to be made. --The resident should still be told what is happening to him/her. -Contact information of the resident's legal representative or family member must be recorded and periodically updated. 1.Review of Resident #1's facility admission Record showed:-The resident was admitted on [DATE] with the following diagnoses: paranoid schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and personal history of traumatic brain injury. -A court appointed guardian with the guardian's phone number, email, and address was listed. Review of the resident's Progress Notes, dated 02/01/26, showed: -Narcan nasal liquid administered at 6:48 P.M. and at 6:53 P.M. -The resident took a deep breath after the second dose of Narcan. -Guardian notified at 6:58 P.M. Review of facility Suspected Abuse Investigation, dated 02/06/26, showed: -On 02/01/26 at approximately 6:40 P.M. Resident #1 overdosed on an illicit substance. -Narcan was administered twice, and the resident became alert and oriented. -The resident was transported by ambulance to the hospital for further evaluation.-Agencies notified included the Department of Health and Senior Services, the provider, and the resident's guardian. - The resident was put on suboxone and agreed to start meeting with Narcotics Anonymous every week at the facility on Thursdays. Review of communication emails, dated 02/03/26, showed: -On 02/03/26 the SSD sent email notification to the guardian (Public Administrator (PA) to notify about an appointment for the resident. -The PA responded to SSD the resident contacted the PA about being sent to the hospital for a fentanyl overdose. -No one from the facility contacted his/her emergency cell to notify him/her or any other deputy of the resident's overdose or that he/she was being sent out to the hospital. -The PA tried to call the administrator and DON on 02/03/26 and the call was transferred but no one ever picked up. -The PA requested direct phone numbers for DON and Administrator. -The DON and Administrator were added to the email chain. Review of communication emails, dated 02/04/26, showed: -On 02/04/26 the Administrator advised the PA to contact him/her. -The nurse on shift (02/01/26) called a number and left a voicemail and the Administrator was going to verify which number was called. -The Administrator would make sure the emergency number was updated in the chart. -The Administrator requested clarification of the emergency number for the PA. -The PA clarified the nurse called the office line around 9:00 P.M. on 02/01/26 and didn't call the emergency cell or try to reach anyone to notify the office on 02/02/26 or 02/03/26. -The PA requested the protocol for notifications. -The Administrator responded to the PA, usually they are directed to call the emergency number, the nurse was unable to find the emergency number, so he/she called the office number listed and left a voicemail. -The PA responded: In the event that someone cannot reach a deputy on their emergency phone, they can call the main switchboard (number given) to be routed to another deputy or supervisor. -They are all on call 24/7 for their individual caseloads but are deputized to give consent for all wards under the Public Administrator. -No one notified the PA on 02/01/26 of the resident's overdose or the fact that he/she went to the emergency room (ER). During an interview on 02/09/26 at 10:40 A.M., the Administrator said: -The resident's guardian was notified, but it was not the emergency number. -There has since been clarification of the emergency number for the guardian. -The DON did not have the right emergency number prior to the incident, and it has been updated in the chart. -02/01/26, Sunday night the nurse called the guardian. -The guardian was spoken with on 02/03/26 by Administrator and DON, via email chain for clarification of emergency contact number. During an interview on 02/09/26 at 3:42 P.M., Licensed Practical Nurse (LPN) A said: -He/She contacted the guardian via phone (02/01/26). -There was no answer when he/she called, so he/she left a voicemail. During an interview on 02/10/26 at 1:56 P.M., the SSD said: -He/She will make notifications if he/she is asked to help. -Normally it is nursing that makes the contact with PA, guardians, families and others for notification. -He/She talks to the PAs during the care plan meetings. -He/She does at times speak with the families, PAs, and guardians about the overall care for the residents. -In acute situations, such as narcotic overdose, he/she would only be involved if needed after the fact. During an interview on 02/11/26 at 1:36 P.M., the PA said: -His/Her major concern was that he/she was not contacted at all, the facility had multiple ways to contact the PA office and the facility was provided emergency contact phone numbers. -There was a voicemail left on 02/01/26 in the evening at the office that indicated it was the facility calling about the resident. -There was no indication he/she needed to return a call or anything. -He/She spoke with SSD when he/she took over the resident's case around July 2025 and gave the facility his/her contact information at that time. -If the facility had called the previous PA's emergency number, it would have still been a way to make a notification. -There was no follow up contact the following day (02/02/26) either. During an interview on0 2/11/26 at 5:48 P.M., the Staffing Coordinator said: -He/She expected notifications to be done as soon as an emergency is stabilized (i.e. on the ambulance) notify the responsible party as soon as possible. -If staff cannot make contact, he/she expected staff to keep calling and use resources and/or email to ensure contact is made. -Be sure to leave a voicemail to call back. -On the voicemail, leave name, where they are from, and to return a call as soon as possible in reference to a mutual resident. -There is a policy for the notification expectations. During an interview on 02/17/26 at 10:20 A.M., the DON said: -The original PA was the only emergency number listed. -LPN A did leave a voicemail at the number that was called. -The voicemail did say to call the emergency number, but there was no emergency number to call. -Leaving a voicemail was considered a notification. -Information left on voicemail is limited in accordance with HIPPA unless the voicemail specifically indicates it is a secure and confidential voicemail. During an interview on 02/17/26 at 1:57 P.M., the Assistant Director of Nursing (ADON) said: -The nurses have been responsible for following up with guardians and families. -The expectation when leaving a voicemail, should include who is calling from the facility, the resident's name, and to please call back with phone number to be reached at. -He/She felt that would be enough information without giving too much. -Most of the time he/she will just keep calling until he/she gets a hold of someone. 2731567

Based on observation, interview, and record review, the facility failed to ensure recommendations provided by the pest control technician were implemented and aggressive measures were taken to prevent or minimize the rodent infestation, potentially affecting any resident at the facility. Nine sampled resident rooms (Rooms 113, 123, 124, 129, 202, 204, 207, 214, and 230), occupied by 14 residents, out of 11 sampled resident rooms, had evidence of rodent activity. The facility census was 93 residents.Review of the facility Pest Control policy, revised May 2008, showed:-The facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents.-Garbage and trash aren't permitted to accumulate and are removed from the facility daily.-Maintenance Services shall assist, when appropriate and necessary, in providing pest control services. 1.Review of the facility's pest control invoices for August 2025 showed services were performed on 8/12/25, 8/20/25 and 8/28/25 with the following findings: -On 8/12/25 evidence of rodent activity was found on the backside of the building and courtyard. Rodent stations were cleaned and fresh bait was replaced. room [ROOM NUMBER] had holes in the corners and room [ROOM NUMBER] had holes in the left corner, creating a potential entry for rodents. Instructions were to please fix.-On 8/20/25 the interior light had captures.-On 8/28/25 two exterior rodent traps had activity by the exterior kitchen door.-On all three visits the kitchen exterior entryway had a gap under the door sweep. The exterior entryway had concrete that was not level, leaving a 1/2 inch gap under the door sweep. Instructions were to use self-leveling concrete and fill the hole. The kitchen door was left open on all three dates. Instructions were to please address with staff. The smoking door did not close properly on any of the three dates. Instructions were to please fix. Severity for pest entry was high for the exterior kitchen and smoking doors. The client (facility) was responsible for fixing. Review of the facility's pest control invoices for September, 2025 showed services were provided on 9/12/25, 9/15/25, 9/25/25, 9/26/25, and 9/29/25 with the following findings: -On 9/12/25 there was evidence of rodent activity in the courtyard and back of building. Rodent stations were cleaned and replaced with fresh bait. Light traps were inspected, and captures recorded.-On 9/25/25 evidence was found of rodent activity on the south exterior of the building. The exterior stations were cleaned and replaced with fresh bait. room [ROOM NUMBER] had opened food throughout which attracts pests. Instructions were to please address with staff. Glue boards were installed in rooms [ROOM NUMBERS] for mouse sightings. The medication room was inspected due to mouse sightings and evidence was found of mouse activity. Glue boards were installed. Observation showed the medication room was very dirty which attracts pests. Instructions were to please address with staff and clean. There was evidence of activity on interior rodent traps by the kitchen back door.-On 9/26/25 room [ROOM NUMBER] had food left out and open which attracts pests. Instructions were to please address with staff and residents. The interior light trap by the west nurses' station and by the smoking door were unplugged. Instructions were to please address with staff.-On 9/29/25 room [ROOM NUMBER] had food left out uncovered which attracts pests. Instructions were to please address with staff and residents and remove and clean. Exterior rodent traps had evidence of activity on the back of the building. Stations were cleaned and replaced with fresh bait.-On 9/12/25, 9/15/25, 9/25/25, 9/26/25, and 9/29/25 the kitchen exterior entryway had a gap under the door sweep and concrete that was not level, leaving a 1/2 inch gap under the door sweep. Instructions were to use leveling concrete and fill the hole. The kitchen door was left open all five dates. Instructions were to please address with staff. The smoking door did not close properly. Instructions were to please fix. Severity for pest entry was severe at the exterior kitchen and smoking doors. The client was responsible for fixing. Review of the facility's pest control invoices for October, 2025 showed services were provided on 10/10/25, 10/13/25, and 10/14/25 with the following findings:-On 10/10/25 evidence was found of rodent activity on the north side of the building. Six out of 21 exterior traps had rodent activity. The interior light traps had captures. room [ROOM NUMBER] had a hole in the left corner and rooms [ROOM NUMBERS] had a hole in each of the closets larger than 1/4 inch, creating a potential entry for rodents. Instructions were to please fix. room [ROOM NUMBER] had wet clothing and torn trash in the right closet. Instructions were to please address with staff and clean. Glue boards were installed for monitoring.-On 10/13/25 rooms [ROOM NUMBERS] each had a hole in the room wall and rooms [ROOM NUMBERS] each had a hole in the closet. All holes were larger than 1/4 inch, creating a potential entry for rodents. Instructions were to please fix.-On 10/14/25 Rooms 100, 121, 123, 124, and 128 had holes larger than 1/4 inch, creating a potential entry for rodents. Instructions were to please fix.-On 10/10/25, 10/13/25, and 10/14/25 the kitchen entryway had a gap under the door sweep and concrete that was not level, leaving a 1/2 inch gap under the door sweep. Instructions were to use leveling concrete and fill the hole. The kitchen door was left open on all three dates. Instructions were to please address with staff. The smoking door did not close properly on any of the three dates. Instructions were to please fix. Review of the facility's Room Readiness checklists, undated, showed:-The checklist identified possible problems in the resident rooms.-There was no documentation of the wall holes for any resident room. Observation on 10/23/25 during an environmental tour beginning at 9:40 A.M. showed a crack in the floor outside the Maintenance office that traveled in an approximately five-foot line that curved an additional two and a half foot to the left. The crack was approximately one-fourth inch wide and went through the concrete under the vinyl tiles, creating a space where pests could potentially enter. Observation on 10/23/25 at 9:50 A.M. in room [ROOM NUMBER] showed:-There were three holes in the toilet room walls near the floor. One hole was approximately eight inches by four and one-half inches; one was approximately 10 inches by five inches; and the hole nearest the toilet was approximately six inches by six inches, creating areas for pests to crawl in and out. -A glue trap was in front of the nightstand near the first bed in the room. During an interview on 10/23/25 at 9:55 A.M. Resident #3 said:-Mice come into the room and sometimes run around. -Earlier in the morning one went under his/her closet sliding doors. -The pest control company put a glue trap on his/her roommate's side of the room because of the mice. Observation on 10/23/25 at 11:33 A.M. showed an approximately one-half inch space between the exterior kitchen door and the doorframe caused by misalignment. Observation in room [ROOM NUMBER] on 10/23/25 at 11:40 A.M. showed an approximately one-half inch crack between a ceiling tile and the wall behind the sink. During an interview on 10/23/25 at 11:43 A.M. Resident #1 said: -He/She could sometimes hear mice run over the ceiling at night. They ate through his/her food bags that were on the top shelf of his/her closet, so now he/she kept food in sealed containers.-A mouse was caught on a glue trap in his/her room around midnight earlier that morning and was disposed of in a Certified Nurse Assistant's (CNA) trash cart. Observation on 10/23/25 at 11:55 A.M. in room [ROOM NUMBER] showed: -A large piece of cardboard was propped against the wall to the left of the window.-Under the cardboard was an approximately one and one-half foot wide by six inches tall hole near the floor and approximately two and one-half foot above that was another hole that was approximately one ft long by three inches tall. During an interview on 10/23/25 at 11:57 A.M. Resident #8 said: -There were holes in the room wall (referring to room [ROOM NUMBER]).-A mouse came in the room one night and he/she just let it stay there. Observation on 10/23/25 at 12:05 P.M. in room [ROOM NUMBER] showed a hole approximately one ft long by six inches tall to the left of the bathroom door where the wall meets the floor. During an interview on 10/23/25 at 12:08 P.M. Resident #9 said:-He/She hears mice in the air conditioning unit mostly at night, but sometimes during the daytime. -A mouse was in his/her trashcan yesterday and he/she stomped on it and tied the trash bag up. The housekeeper took it out. -Sometimes a mouse will run all over the room (room [ROOM NUMBER]). -The pest control guy brought traps for the room. Observation on 10/23/25 at 12:10 P.M. in room [ROOM NUMBER] showed an area about one and one-half foot by two foot with mouse droppings too numerous to count on the right section of the closet floor. During an interview on 10/23/25 at 12:13 P.M. Resident #4 said:-He/She saw a mouse the other day in the hallway. They run in under the door of his/her room (referring to room [ROOM NUMBER]) and will climb the curtain or get on the beds.-One was in the trashcan about a week or 10 days ago. Observation on 10/23/25 at 12:15 P.M. in one of the hallways showed an open area at the base of the wall approximately four foot long by four inches tall to the right of the smoke patio door, creating a possible entrance and exit for pests. During an interview on 10/23/25 at 2:10 P.M. Resident #2 said he/she saw a mouse coming out of his/her nightstand in room [ROOM NUMBER] earlier that morning. Observation on 10/23/25 at 2:12 P.M. in room [ROOM NUMBER] showed:-The nightstand door was ajar, hanging crooked on its hinges.-Mouse droppings were scattered throughout the bottom shelf of the nightstand.-Further into the room to the left of the sink mouse droppings were scattered between a trash can and a mini fridge. During an interview on 10/23/25 at 2:16 P.M. Resident #7 said he/she saw a mouse in his/her room (room [ROOM NUMBER]) the night before when it came out of the air conditioning unit. During an interview on 10/23/24 at 2:20 P.M. Resident #6 said:-He/She saw a little bitty mouse the day before. It came out from under his/her bed where it usually came from. -A mouse would often be on his/her former roommate's side of the room (room [ROOM NUMBER]). Observation on 10/23/25 at 2:23 P.M. showed the top drawer of the former roommate's nightstand contained part of a used cigarette that was slightly torn up and mouse droppings. Observation on 10/23/25 at 2:40 P.M. in RM [ROOM NUMBER] showed mouse droppings were visible to the right of the window. During an interview on 10/23/25 at 2:42 P.M. Resident #5 said:-He/She heard other residents talking about mice.-Mice had gotten into his/her chips recently, so now he/she kept snacks in sealed containers to protect them. During an interview on 10/23/25 at 2:45 P.M. CNA A said in the past couple of months a few residents told him/her they have a mouse in their rooms. He/She always puts the issue on the pest log and the Maintenance Department calls the pest control company to come out. Observation on 10/23/25 at 2:52 P.M. showed the pest control technician knocking on doors and going from one resident room to another. During an interview on 10/23/25 at 2:55 P.M. the pest control technician said:-A mouse can get inside a building if there is a one-forth inch hole. They wiggle until they get inside. -It helped to close up holes in buildings. -He/She made recommendations, but the facility is responsible for fixing the holes. He/She didn't do that. -What would help the facility the most would be to rip out the kitchen door frame and remount it because the doorframe was misaligned. -All exterior holes needed to be filled. Most of the holes were on the exterior of the building. Mice were coming inside that way. They use the exterior walls to travel and then get in.-Dumpsters should be at least 50 feet from the building. Mice were probably under the facility dumpsters because they are a food source. -The Maintenance Director was told that dumpsters should be at least 50 feet from the building on previous visits. The Maintenance Director said he/she had to try to catch the trash company when they came to tell them where to place the dumpsters.-Inside the building most of the holes were in corners or behind the registers.-He/She had been doing the facility's pest control account for 14 months and communicated on every report his/her recommendations. During an interview on 10/23/25 at 3:02 P.M. Housekeeper A said:-He/She saw mouse droppings in rooms where residents have food. Droppings were mostly in resident closets.-He/She has heard residents complain of the mice. -Staff try to encourage residents to use containers to store food. During an interview on 10/23/25 at 3:09 P.M. Housekeeper B said:-He/She saw mouse droppings just today and cleaned it up. -Usually, droppings were in corners of rooms, mainly in rooms where residents have food. -Housekeepers either tell their supervisor or put the pest issue in the pest control log. During an interview on 10/23/25 at 3:12 P.M. Housekeeper C said:-He/She normally noticed mouse droppings where the floor and wall meet under the room sink, on closet floors, and behind dressers. -He/She last saw them 2 days ago in RM [ROOM NUMBER] and did a deep cleaning. -The resident in that room said the mice ate his/her cookies and noodles. He/She suggested the resident get totes to put his/her food in. The resident said he/she bought some. Observation on 10/23/25 at 3:16 P.M. in room [ROOM NUMBER] showed:-A sticky glue trap in the corner of the room to the left of the heating unit. -A few mouse dropping were near the trap. Observation on 10/23/25 starting at 3:20 P.M. in the smoking courtyard showed:-The courtyard was enclosed by four building walls covered in vinyl siding.-The siding was torn at the bottom along much of the outside of the bldg. -At the smoking patio door there was no cap at the end of the siding to prevent rodents and bugs from entering. -Cracks and holes over one-forth inch in size were found throughout the siding mostly on the lower two feet. Observation on 10/23/25 at 3:25 P.M. outside the kitchen area showed:-The facility's three dumpsters were positioned in a row, the furthest one was within approximately 25 feet of the building. -The dumpster nearest the building was six foot from the outside wall and approximately 12 foot from the exterior kitchen door on the dumpster's closest side. -The dumpster nearest the building was so full of trash bags the lid couldn't close. During an interview on 10/23/25 at 3:32 P.M. the Maintenance Director said:-The Maintenance Department used glue traps and filled holes with spray foam with a steel wool soap pad inside. The mice wouldn't come through that. -The last time a staff member reported a pest problem was a few weeks back. He/She asked them to put the issue in the pest control book. They put a rodent glue board in that resident's room. -The pest control contractor came twice a month and more often if there were problems. -The pest control technician told him/her the facility needed to seal holes and that dumpsters should be moved 50 feet away from the building. -He/She told the trash company to move the dumpsters further from the building, but they didn't move it far enough away. He/She had been trying for the past few months to get the trash company to move the dumpsters further away, but the yard wasn't flat and there wasn't much room to move the dumpsters due to the terrain of the yard. -The building was very old and the exterior kitchen door frame was crooked. A company came out and put new hinges on the door, but the building had settled so much the frame remained crooked from the door. He/She hadn't made a request for the frame to be fixed because there were other more important things that had to be fixed and they were prioritizing the facility's needs. During an interview on 10/23/25 at 4:00 P.M. the Administrator said:-Maintenance just started doing Room Readiness checks the previous week. It was a checklist showing what needed to be fixed in each resident room. The facility hadn't established a protocol on how often they would be done. -The facility maintenance department checked with corporate maintenance to get work approved. Maintenance was responsible for following up with pest control issues.-The pest control guy said if they used weatherstripping that stuck to the exterior kitchen door frame it would help, but the facility hadn't followed up with that yet.-A Life Safety company was out a couple of weeks ago and evaluated the fire doors. They were supposed to also check the exterior kitchen door and didn't. -Currently the facility's priority was to fix the front of the building which was hit by a vehicle and is scheduled for repairs starting on 11/15/25. The pest issue hadn't been their top priority. Complaint 2640075

Based on interview and record review, the facility failed to transcribe physician orders correctly for an opioid pain medication (controlled pain medication for moderate to severe pain) and failed to clarify the physician orders when the medication was not received by the pharmacy for one sampled resident (Resident #500) of out of 12 sampled residents. The facility census of 107 Residents. 1. Review of Resident #500's Face Sheet showed he/she admitted to the facility on [DATE] with a diagnosis of frost bite with necrosis (death of body tissue) to his/her left foot and non-pressure chronic wound (caused by prolonged pressure, arise from other factors like poor circulation, trauma, or infection) to his/her left foot. Review of the resident's hospital discharge instruction and summary dated 3/1/25 at 1:50 P.M. showed: -Had diagnosis to include frost bite to his/her left foot. -Oxycodone (opioid-control substance pain reliever) 5 milligram (mg), give one tab by mouth every six hours as needed for severe pain (for 7-10 days) dated 3/2/25. Review of the resident's physician's History and Physical Assessment Note dated 3/3/25 showed: -He/she had reviewed the resident medication list from the hospital and listed on the physician order sheet. -The resident was to receive Oxycodone-Acetaminophen 2.5 mg-325 mg, to give 2.5 mg tab by mouth every six hours as needed for severe pain dated 3/2/25. Review of the resident's Physician Order Sheet (POS) dated March 2025 showed: -Oxycodone-Acetaminophen 2.5 mg-325 mg, to give one-tab by mouth every six hours as needed for severe pain was ordered 3/2/25. -Note: This was ordered from the pharmacy but not received. The order from the hospital was 5 mg and the facility POS order was for 2.5 mg. Review of the resident's Medication Administration Record (MAR) dated 3/3/25 to 3/10/25 showed: -Oxycodone-acetaminophen 2.5 mg-325 mg gives one-tab by mouth every six hours as needed for severe pain. --This was not received by the pharmacy and not administered to the resident. --Note: The resident had been treated by other non-opioid pan medications and his/her pain was documented as controlled. During an interview on 3/17/25 at 4:20 P.M., the resident said: -During the daytime his/her pain was under-controlled. -He/she had more pain in his/her ankles and feet during nighttime when his/her feet were cold. The coldness in the air would cause his/her feet to hurt. -He/she did not notify the nursing staff or asked for pain medication the during the night shift. -He/she had been receiving other pain medication. During an interview on 3/17/25 at 1:30 P.M. Registered Nurse (RN) A said: -On 3/2/25 he/she contacted the hospital to have them send a written prescription for the resident's prescribed Oxycodone 5 mg, give one tab by mouth every six hours as needed for severe pain. -The resident was getting alterative pain control medication. -The resident pain medication order was as needed medication and the resident had to ask for those medication. -The resident was to be seen by the physician on Monday and Friday. -When a resident was admitted on Saturday, then he/she would be seen on Monday by the resident physician. -Physician A would not write prescription for controlled pain medication until seen by him/her first. -The resident had no complaints pain that was not controlled with alterative medication that was given. During an interview on 3/17/25 at 3:30 P.M., Licensed Practical Nurse (LPN) A said: -The facility cannot access the Pyxis (electronic pharmacy medication dispensing machine help ensure medications and supplies are available when and where they're needed) without pharmacy approval for each residents medication. -The facility no longer has a tool box Emergency medication kit (E-Kit, that store extra common medication to include possible control substance medication) for those residents who were new admissions or a resident with new medication changes. -The hospital did not send a written prescription for the oxycodone and the facility had reached out to the hospital with no response. The facility sent the medication list to pharmacy upon admission. The pharmacy required the physician to contact them to get the oxycodone filled. -The resident had other non-opioid pain medications that were administered. During an interview on 3/17/25 at 3:40 P.M., Registered Nurse (RN) A said: -He/she would expect admitting nurse to follow-up with physician orders and pharmacy related to any medication not received as ordered including as needed opioid pain medication. -He/she should have written a progress note that he/she had attempted to get the resident medication refilled on 3/3/25 and required a written script from the physician to be sent to pharmacy. The pharmacy was needing the physician medication number to be able fill the oxycodone medication. -The resident did not voice concern with pain during the day shift. -The resident's pain had been monitored and managed by other pain medications. During an interview on 3/17/25 at 3:55 P.M., Director of Nursing (DON) said: -He/she was not aware the resident was without as needed prescribed substance-controlled pain medication, which was not delivered to the facility. -When a resident discharge from the hospital, would normally send a prescription or supply of medication with the resident, until the facility was able to obtain and send physician ordered for medication needed from pharmacy. -He/she would expect nursing staff to document in progress notes the attempts to obtain medication and who had contacted to be able to get the medication was ordered upon admission. -He/she had talked with the resident several times that week and never mention not having medication needed until 3/10/25. -A new order was obtained for opioid pain medication on 3/10/25 when this was brought to his/her attention. During an interview on 3/17/25 at 4:39 P.M. with Physician A said: -He/she had approved the oxycodone, but the pharmacy needed an electronic script from him/her before could send the medication. Normally the facility sends the medication prescribed ordered to pharmacy and the pharmacy would have to notify the physician of any additional physician orders needed to include for opioid medication. -He/she not made aware the resident did not receive the prescribed Oxycodone pain medication use as needed until 3/10/25 when he/she saw the resident. -The resident had not voiced any complaints of uncontrolled pain while on site. -He/she had observed the resident up walking with therapy staff that day. -He/she would expect the facility nursing staff to contact him/her if not able to get pain medication. -When reviewing the resident script submitted was noted as the wrong dosage to receive, the pharmacy does not have 2.5. mg tab for that pain medication. -After review he/she noted the actual order was for 5 mg and to give ½ tab, which would be 2.5 mg to be given as needed for pain. -That could have been the possible reason why the prescription did not go through. Complaint # MO 00250736

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) out of five sampled residents, was free from physical abuse. On [DATE], Resident #2 struck Resident #1 multiple times on the top of his/her head with a solid wood and metal cane, which resulted in Resident #1 sustaining a laceration to the left temple with four stitches, bruising to his/her left eye socket, defensive bruising on his/her left pinky, ring finger, and a laceration to his/her second knuckle to his/her right middle finger. Resident #1 was sent to the hospital for treatment and stated he/she was afraid of Resident #2. The facility census was 112 residents. The Administrator was notified on [DATE] at 9:31 A.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility Resident Rights Policy, dated February 2023, showed: -The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. -The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Review of the facility Abuse, Neglect and Exploitation Policy, dated [DATE], showed: -It is policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means 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. -Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. -The facility will develop and implement written polices and procedures that prohibit and prevent abuse, neglect, and exploitation of residents. --The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. --Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of property more likely to occur. -The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation, including by not limited to: --Respond immediately. --Examining alleged victim for any sign of injury. --Increased supervision of the alleged victim and residents. --Room or staffing changes, if necessary, to protect residents from the alleged perpetrator. --Protection from retaliation. --Providing emotional support and counseling to the resident during and after the investigation, as needed. --Revision of the resident's care plan if the resident's medical, physical, mental, psychosocial needs or preferences change as a result of the incident of abuse. 1. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations) and generalized anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety). Review of Resident #1's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE], showed the resident was moderately cognitively impaired. Review of Resident #1's undated Care Plan showed: -Potential for communication problem related to Spanish primary and English secondary. --Resident will be able to make basic needs known on a daily basis. ---Ensure/provide safe environment. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including other psychoactive substance abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine), liver cell carcinoma (also known as hepatocellular carcinoma (HCC), is a type of cancer that occurs when malignant tumors grow in the liver), and adjustment disorder with anxiety (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior which can cause a lot of problems in getting along with others). Review of Resident #2's Quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of Resident #2's undated Care Plan showed: -Resident had a potential mood problem related to adjustment disorder with anxiety. --Monitor, record and report to the doctor as needed risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used a weapons. --Observe for signs and symptoms of mania (a state of abnormally elevated mood, energy, and activity) or hypomania (a state of elevated mood, increased energy, and activity that is less severe than mania), racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, agitation or hyperactivity. Observation of the facility video, dated [DATE], showed: -Resident #1 observed at the juice cart then walking down the hall into the vending machine room. -Resident #2 observed walking fast down the same hall holding a cane in both hands in a batting position. -Resident #1 observed with his/her back towards Resident #2 as Resident #2 entered the vending machine room. -Resident #2 went directly to Resident #1, raised the cane up with both hands and struck Resident #1 twice in the head. -Resident #1 retreated several steps from Resident #2. -Resident #2 advanced towards Resident #1 and struck Resident #1 in head with the cane again. -Resident #1 stepped towards Resident #2 and grabbed the cane. -Both residents continued to move and were no longer visible by the camera at that time. -Staff were seen on camera enroute to the vending machine room. -There was no audio to the footage. Review of the police report, dated [DATE] at 9:34 A.M., showed: -Incident type: Assault (Aggravated) -On [DATE] at 9:34 A.M., law enforcement was dispatched to facility on a reported disturbance. -Involved persons were Resident #1 and Resident #2. -Witnesses were Resident #3 and Resident #4. -Resident #1 reported being in the hallway when Resident #2 approached Resident #1 and began to argue with him/her. -Resident #1 separated him/herself from Resident #2 and went to the break room. -Resident #2 then followed Resident #1 into the break room and continued to argue with him/her. -Resident #2 then hit Resident #1 in the face several times with a cane. -Resident #1 took the cane from Resident #2 and began to hit Resident #2 with the cane. -They were separated by staff. -Resident #2 reported Resident #1's face got bloodied, because Resident #1 must have hit him/herself to make it look like Resident #2 assaulted him/her. -Resident #4 reported Resident #1 was in the break room when Resident #2 entered and had some words with Resident #1. Resident #2 began to hit Resident #1 with the cane. Resident #1 took the cane from Resident #2 and began to hit Resident #2 with the cane. Resident #2 then left the break room and Resident #1 followed him/her, hitting him/her with the cane. He/She went to the break room and observed blood on the floor and trailed into the hallway. -He/She observed a camera in the break room that would have captured the incident on video. -The detective from the Assault Squad advised that city charges were appropriate. -He/She was advised to contact the administrator at a later time to watch any video. -He/She was unable to issue charges at that time due to not being able to determine a primary aggressor. -The report was written prior to viewing or accessing any video recordings of the incident and may not reflect verbatim records of statements/interviews or evidence. Review of the facility Suspected Abuse Investigation, dated [DATE], showed: -Resident on resident incident occurred on [DATE] at 9:05 A.M. -Resident #1 was in the vending machine room, Resident #2 entered the room carrying a wooden cane. - The two began arguing, and the staff then witnessed Resident #1 swinging a broken cane at Resident #2. -There was a laceration to Resident #1's head. -The residents were separated and Resident #1 was placed on 1 on 1 supervision for safety. -Police and physician were notified. -Both residents were sent to the hospital for further evaluation. -Law enforcement arrived on [DATE] at 9:35 A.M. -Resident #1 was walking down the hall to the vending machine room and Resident #2 followed with cane in hand, not being used to walk. -Resident #2 calmly asked where Resident #1 was and staff pointed down the hall. -Upon entering the vending machine room where Resident #1 was already, Resident #2 hit Resident #1 in the head with the cane two times. -Resident #1 held his/her head where he/she was hit. -Resident #2 then hit Resident #1 in the head a third time and the cane broke in half. -Resident #1 took the cane from Resident #2 and hit Resident #2 with the broken cane. -Staff separated the residents and Assistant Director of Nursing (ADON, Director of Nursing (DON), Administrator and Law Enforcement notified. -Resident #3 and #4 were witnesses. -All involved parties were interviewed for statements. -Resident #1 sustained laceration to the left side of head, left eye black, and right pinky finger bruised and jammed. -Resident #2 had a small wound to the middle left side of forehead the size of a pea and a skin tear 1 centimeter (cm) in width in between the crease of thumb and pointer finger. -Resident #1 received three stitches to the forehead. -After hospital evaluations, both residents returned to facility and placed on 1 on 1 observation. - After thorough investigation, it was determined that Resident #2 was the assailant, and Resident #1 was the victim. -Police called and court date scheduled. Review of Resident #1's Behavior Note, dated [DATE] at 8:11 P.M., showed: -Licensed Practical Nurse (LPN) A was made aware that two residents (Resident #1 and #2) were involved in a physical altercation. -LPN A was advised Resident #1 was in his/her room and was in need of assistance, while Resident #2 was on the other side being treated by that nurse. -LPN A immediately went to Resident #1's room to treat and noted resident had a bloody towel on his/her head. -Upon removing the towel advised resident the laceration appeared deep enough to receive stitches. -Resident initially refused to go to the hospital. -Management advised to call Emergency Medical Services (EMS) and to put resident on 1 on 1 observation at that time. -Resident spoke to law enforcement before exiting the facility with EMS. -The resident refused vital signs, was watching TV and was making several phone calls prior to leaving the facility making it difficult to assess and speak with the resident. -The resident changed his/her shirt before leaving the facility with EMS. -Hospital reported resident received three stitches on his/her head and was given discharge instructions. Review of Resident #2's Behavior Note, dated [DATE] at 7:01 P.M., showed: -LPN A was advised there was a physical altercation between Resident #1 and Resident #2 at approximately 9:28 A.M. -LPN A was advised Resident #2 was being assessed and treated by the nurse on the other side of the facility. -When LPN A went to assess Resident #2, he/she had a bandage on his/her forehead and was seated at the nurses station with staff present. -At 9:31 A.M. LPN A began neuro assessments and notified management of the incident. -At 9:46 A.M. law enforcement in facility to speak with the resident. -Law enforcement advised there would be a report, provided a report number to the resident, and the resident verbalized an understanding. -At 10:06 A.M. the resident began to complain of 10 out of 10 pain to his/her head. -Resident had a pea size wound to forehead and approximately 1 cm wound to right hand between thumb and forefinger. -As needed (PRN) pain medication given per resident's choice. -Resident complained of dizziness and continued pain. -Resident had previously refused to be assessed by EMS, at 10:12 A.M. requested to be sent to the hospital. -Resident ambulated independently with no change or concern, and denied ongoing dizziness. -Resident transported by EMS at 10:32 A.M. to the hospital. -Resident returned to the facility at 2:22 P.M. with complaint of pain, but would not quantify pain. -Resident stated he/she was poked in the back by Resident #1. -LPN A observed a pea size mark to the mid-right back, resident denied any other injuries. Review of Resident #1's hospital records, dated [DATE] at 2:40 P.M., showed: -Resident was brought by EMS from nursing home with complaint of head injury. -Resident was hit on the left side of his/her head with another resident's cane. -Resident stated the nursing home made him/her come for evaluation. -Denied headache, vision changes, weakness or numbness, neck pain or other injuries. -Irregular laceration to left forehead. -Dried blood on resident's face and t-shirt. -Presented for head injury with cane, large open laceration. -Met criteria for CT of head and neck. -CT of head and neck showed no acute evidence of bleed or fracture. -Laceration repaired with four sutures. -Alert and oriented to person, place, time and situation. -Social Services consult for assault. -Protective service type, social services, adult/elderly abuse/neglect. -Abuse/Neglect details: Resident was assaulted by another resident. -Resident was anxious to return to the nursing home. -Because resident was assaulted social worker completed adult protective services. -Social worker assisted with transportation back to facility. Review of Resident #1's Emergency Department discharge instructions, dated [DATE], showed: -Reason for visit was head injury. -CT (also known as a computerized axial tomography (CAT) scan, is a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body to diagnose and monitor various conditions, including fractures) of head and cervical spine (commonly known as the neck, is the upper portion of the spinal column that connects the skull to the thoracic spine) due to cane injury. -He/She was seen for laceration (a cut that goes through all layer of the skin). -Instructions for laceration care and follow up for stitches. Review of Resident #2's Discharge Instructions dated [DATE] showed: -Diagnosis from today's visit was assault and head injury. -Rest and ice any areas of pain. -Use your medications as previously prescribed. -Tetanus administered. -General head injury instructions given. Review of the General Ordinance citation dated [DATE] showed: -On [DATE] at 9:05 A.M. the Defendant, Resident #2, did unlawfully assault, in violation of Ordinance 50-169. -Signed by the prosecutor. During an interview on [DATE] at 11:20 A.M., the Administrator said: -Both residents remain on 1 on 1 supervision. -He/She was able to review the video of the assault. -He/She was getting ready for a 30 day discharge notice for Resident #2 once placement is found, because Resident #2 was the aggressor. -Resident #1 received three sutures while at the hospital for his/her injury. -Resident #2 had superficial wounds to his/her hand and head. -They reviewed the video and observed Resident #2 was the aggressor. -The preliminary determination was an assault was made by Resident #2 and Resident #1 was protecting him/herself. -There were no prior indicators between the two residents. -Resident #2 was having a bad day as evidenced by the assault, although he/she was not exhibiting behaviors prior to attacking Resident #1. -Resident #2 alleged he/she was the victim, even after observing the video. During an interview on [DATE] at 1:18 P.M., Resident #1 said: (Communication was facilitated by Certified Medication Technician (CMT) A who was fluent in Spanish with consent from the resident.) -He/She was getting some juice and Resident #2 came out yelling at him/her trying to fight. -He/She did not engage with Resident #2 and just ignored Resident #2. -He/She went to get a soda from the machine. -He/She was bent over counting his/her credits when Resident #2 came to him/her yelling Today Motherfucker! repeatedly while hitting him/her with the cane. -He/She raised his/her arms up in a protective stance to show how he/she was trying to protect his/her face and head while Resident #2 was hitting him/her with the cane. -He/She said there was blood in his/her eyes and he/she could not see hardly at all. -He/She took the cane from Resident #2 and attempted to defend him/herself. -He/She swung the cane at Resident #2, making sure to not make contact with Resident #2's face. -He/She was not sure if he/she struck Resident #2, but he/she was sure he/she struck the door frame breaking the cane in half. -Law enforcement came, took pictures and filed a report. -Law enforcement told him/her not to worry because Resident #2 would be arrested. -He/She does not feel safe. -He/She felt like his/her injury was serious, because he/she was hit was a cane. He/she was caught off guard with his/her back towards Resident #2 and bent down. -He/She said when he/she was hit it hurt really bad. -He/She was off balance and dizzy when he/she was hit with the cane. -He/She felt he/she had to defend him/herself to get back to his/her room. -He/She showed his wound to the left side of head (temple area), bruising to the left eye socket, bruising to the right pinky, right ring finger and small wound to the right middle finger. -He/She complained of pain in all three fingers and was unable to bend the fingers without grimacing in pain. -He/She complained of pain to the left side of head when it was touched or when chewing. -He/She did not understand why this happened. -He/She wanted Resident #2 to be punished and removed from the facility. -He/She did not feel it was safe with Resident #2 in the facility and he/she was afraid of Resident #2. During an interview on [DATE] at 3:06 P.M., the DON said: -There was no arrest, law enforcement came to the facility on [DATE] to see Resident #2. -Charges were filed for assault against Resident #2 and a court date was given to Resident #2. -Both residents were on 1 on 1 observation indefinitely. -Psychiatric appointments are being made for both residents. During an interview on [DATE] at 3:15 P.M., Resident #2 said: -Upon entering the room he/she said he/she was a little sore. -They were in the vending machine room and Resident #2 hit him/her in the stomach. -He/She went to his/her room and got the cane, went back to the vending machine room and hit Resident #2 in the head with the cane. -He/She hopes to get moved and was not really happy in the facility. -He/She then explained they were in the vending machine room and he/she had the cane with him/her. -Resident #1 took the cane from him/her, hit him/her with the cane and broke it and stabbed him/her in the back. -He/She then said he/she set the cane on the table in the vending machine room and Resident #1 grabbed the cane off the table and hit him/her with the cane. -He/She grabbed the cane back and hit Resident #1 with the cane to defend him/herself. -He/She alleged Resident #1 pushed and shoved him/her all of the time, but there are no reports, witnesses, or video evidence to support the allegation. -He/She admitted to viewing the video footage of the incident and admitted he/she hit Resident #1 on purpose because he/she was gonna show him/her. -He/She said he/she was getting out of here and that was what he/she wants. -He/She said This is my ticket out of here and I'm going to take it. -Although he/she hit Resident #1 intentionally, he/she did not mean to hurt Resident #1 as bad as he/she did. Review of Resident #3's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on [DATE] at 4:40 P.M., Resident #3 said: -He/She was in the vending machine room when Resident #2 came in swinging the cane. -He/She immediately left the room to stay out of the way. -He/She denied seeing exactly what happened after Resident #2 entered the room. Review of Resident #4's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on [DATE] at 4:49 P.M., Resident #4 said: -He/She was in the vending machine room watching TV at the time of the incident. -He/She saw Resident #2 come into the vending machine room with a cane in his/her hands. -Resident #2 swung the cane like a bat, striking Resident #1 in the head several times by the soda machine. -Resident #1 took the cane away from Resident #2 and broke the cane on the door. -He/She was not sure if Resident #1 hit Resident #2 with the cane. During observation and interview on [DATE] at 5:18 P.M., the Administrator said: -He/She said the incident does meet the criteria for abuse. -He/She will ensure Resident #2 remains on 1 on 1 observation until discharged . -He/She felt Resident #2 could be a threat again to possibly everyone in the building. -A solid wood brown cane which was broken in half. -There was a metal end with a large ball shape at the end of the handle, gold in color. -There were traces of a red substance which appeared to be blood noted all over the cane. During an interview on [DATE] at 3:51 P.M., LPN A said: -He/She had went to the bathroom and upon returning he/she was informed there was a resident to resident altercation and someone was bleeding. -He/She followed the blood trail and located Resident #1 in his/her room sitting on his/her bed with a bloody shirt, his/her phone in one hand, and holding a towel on his/her head with the other hand. -CMT A was present to facilitate communication. -He/She could tell right away the laceration needed stitches. -Resident #1 was fearful, but spoke to law enforcement and then was transported to the hospital by EMS. -He/She had seen Resident #2 pacing the hallways often, but never with a cane. -He/She was confused as to who's cane Resident #2 used as it was the first time he/she saw the cane. -The cane was heavy duty wood with a metal handle. -Resident #1 comes out rarely, maybe one or two times for ice water, almost always in his/her room. -He/She was shocked about the altercation, much less the use of a weapon. During an interview on [DATE] at 7:53 A.M., CMT A said: -He/She was at his/her medication cart when Resident #1 walked by talking about immigration. -Resident #2 was speed walking following Resident #1 mumbling carrying a cane in both hands in front of him/her. -Another resident came up to speak with him/her when he/she heard the commotion and called for help. -He/She was on the opposite end of the hall. -When he/she saw the residents, Resident #1 had the broken cane and was covered in blood. -Resident #1 was walking towards him/her covered in blood with half of the cane. -Resident #2 was following behind Resident #1 down the hall. -He/She did not feel alarmed when Resident #2 went by with the cane as he/she thought Resident #2 was just doing his/her own thing. During an interview on [DATE] at 11:10 A.M., the Physician said it was consensus the assault between Resident #1 and Resident #2 was abuse. 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 be taken to address Class I violation(s). MO00250034, MO00250039, MO00250065

Based on documentation, interview and policy review, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Journal (PBJ)excessively low weekend staff. This deficient practice had the potential to allow 112 residents not to receive the care and services required. Findings include: Review of the undated facility policy titled, Nursing Services and Sufficient Staff revealed, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 1. The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans . Review of the Staffing Data Report the following: The third quarter (April 1- June 30, 2024) indicated excessively low weekend staffing. The fourth quarter (July 1- September 30, 2024) indicated one star staffing rating, excessively low weekend staffing. During an interview on 02/21/25 at 10:14 AM, the Staffing Coordinator/ Human Resources (SC/HR) was asked about the reports and stated that it has been a battle to meet the staffing needs for the weekends. The SC/HR said they have continuously hired, and staff do not show up. During an interview on 02/21/25 at 6:33 PM, the Director of Nursing (DON) was asked about the PBJ and scheduling. The DON stated it has been a challenge to get staffing to cover the weekends.

Based on document review, interview, and facility policy review, the facility failed to ensure eight hours per day of Registered Nurse (RN) coverage. Specifically, the facility reported to the Centers of Medicare and Medicaid (CMS) through mandatory submission of staffing information in the Payroll- Based Journal (PBJ), the lack of RN coverage for three out of four quarters (first, second and fourth quarter of 2024). This deficient practice had the potential to allow 112 residents not to receive the care and services required. Findings include: Review of the undated facility policy titled, Nursing Services and Sufficient Staff revealed, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines . 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day,1 day a week. Review of the Staffing Data Report the following: The first quarter (October 1- December 31, 2024) indicated No RN hours. The second quarter (January 1- March 31, 2024) indicated No RN hours. The fourth quarter (July 1- September 30, 2024) No RN hours. During an interview on 02/21/25 at 10:14 AM, the Staffing Coordinator/ Human Resources (SC/HR) was asked about the reports. The SC/HR stated it has been difficult to get an RN for night shift. The SC/HR stated they have tried to hire nurses through newspaper, media sites and through the facility website. During an interview on 02/21/25 at 6:33 PM, the Director of Nursing (DON) was asked about the PBJ and scheduling. The DON confirmed that the facility did not have RN coverage at least eight hours per day for the first, second and fourth quarters in 2024.

Based on observation, interview, document review and record review, the facility failed to ensure a Certified Dietary Manager (CDM) or other qualified professional was employed by the facility to manage the dietary department when a Registered Dietitian was not employed full-time. Failure to meet this requirement placed all 112 residents receiving foods served by the facility at risk for dissatisfaction with meals, malnutrition and/or a food-borne illness. Findings include: 1. During an interview on 02/19/25 at 10:00 AM, the Dietary Manager (DM) was asked if they had completed a certification course for dietary managers, he/she stated, No. When asked if he/she had completed any formal training in food and or nutrition services, the DM stated, No and explained he/she had assumed the role after working as a cook in the facility for the past two years. 2. The facility failed to assure food was palatable and served at appetizing temperatures for residents reviewed for food concerns. Additionally, review of the Review of Resident Council Meeting Minutes revealed complaints related to food palatability from five of five months of minutes reviewed. 3. The facility failed to ensure that one resident's preference for a sandwich to be add to the lunch and dinner meals was being honored. 4. The facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions. During an interview on 02/19/25 at 10:10 AM, the Director of Nursing (DON) stated the DM was not a CDM and did not meet the criteria.

Based on observation, interview, Food and Drug Administration (FDA) Food Code and policy review, the facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions. This had the potential to 112 of 112 residents who ate food from the kitchen and placed these residents at risk for a food borne illness. Findings include: Review of the 2022 Food Code, published by the Food and Drug Administration (FDA) Food Code and accessible at https://www.fda.gov, revealed, . Handwashing sink shall be equipped to provide water at a temperature of at least . (85 degrees F [Fahrenheit]) through a mixing valve or combination faucet . Review of the facility's policy titled, Food Preparation and Service, revised 04/2019, revealed, . Food and nutrition services [sic] employees prepare and serve food in a manner that complies with safe food handling practices . Appropriate measures are used to prevent cross contamination. These include . cleaning and sanitizing work surfaces . and food-contact equipment between uses, following food code guidelines . Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness . The 'danger zone' for food temperatures is between 41 [degrees Fahrenheit (F)] and 135 [degrees F]. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness . Proper hot and cold temperatures are maintained during food service . Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays . 1. During the initial tour of the kitchen on 02/17/25 at 9:20 AM, the water at the handwashing sink was noted to be cold after the water ran for 10 minutes. The [NAME] stepped to the sink and washed their hands. When asked if the water got hot, he/she stated yes, and then commented he/she did not have enough time to wait for it to warm up. A food processor, located on a counter in the kitchen, was noted to have water inside the bowl. The blade was removed, and food residue was inside the blender bowl. The base of the food processor was soiled with dried food splatter. The Dietary Manager (DM) stated the equipment should be washed and clean if on the base. The can opener was noted to have black colored food residue adhered to the blade, and the base was observed with dried food spills and splash. The head of the dispenser gun for the juice dispenser was heavily soiled with visible juice pulp and smelled of sour juice. The handle of the device was soiled and sticky to the touch. The DM stated Dietary Aide (DA) 13 was responsible for cleaning the machine. DA13 stated he/she did not remove the cap or soak the head of the dispenser to clean it. The handle on the microwave was observed with dried food and was sticky. The interior had food spills inside. The DM commented it must have been used last night. The walk-in refrigerator had one opened and undated box of health shakes. The DM stated the shakes could be served for up to 14 days after being placed in the refrigerator and should have been dated when placed in the refrigerator. An undated and unlabeled pan with two cooked pork loins was noted in the walk-in refrigerator. The DM stated the pork was cooked the previous day, then refrigerated, and would be served for the noon meal that day. The temperature of the handwashing sink was checked, after running the water for 10 minutes, a check of the temperature found it only reached 72 degrees F. The temperature did not reach the FDA recommendation for handwashing sinks in food service areas of 85 degrees F. On 02/19/25, at 9:30 AM, during an interview with the DM, DA12 was observed rinsing soiled dishes and loading them into rack while wearing gloves. After preparing several racks of soiled dishes, DA12 stepped to the clean side of the dish machine and picked up clean water pitchers with the same gloves. The DM was asked about DA12's actions. The DM directed DA12 to wash their hand in the handwashing sink. DA12 doffed his/her gloves, went to the sink, and rinsed his/her hand under the waterspout. DA12 did not use soap or friction to wash his/her hands. The DM observed this and reapproached DA12 and directed him/her to use soap, friction, and water when washing hands. On 2/19/25 at 11:50 AM, the Assistant Dietary Manager (ADM) was observed testing and documenting temperatures of foods served for the noon meal on a log. After preparing to serve the meal, two additional food items, cheese quesadillas and soup were observed on the steamtable; however, the temperature log did not record temperatures for either item. When asked, ADM tested the temperatures and found the soup was 128 degrees F and the quesadillas were 117 degrees F. ADM stated the items were not hot enough and reheated them. On 02/20/25 at 11:00 AM, burritos and toasted cheese sandwiches were noted on the tray line. The [NAME] measured their holding temperatures, and it was noted the temperature of both items was 128 degrees F. [NAME] then moved the items to the oven to reheat them. 2. During delivery of room meal trays in the [NAME] Hall on 02/17/25 beginning at 1:09 PM, the meal trays were observed on a metal cart. Each tray had a plate covered with an insulated cover and a small dish containing the apple cobbler dessert, which was not covered. The staff brought the meal trays from the cart at one end of the hall to residents' rooms up and down the length of the hall with the dessert uncovered. In an interview on 02/17/25 at 1:15 PM, certified nurse aide (CNA) 8 stated the desserts on the trays were not covered because it did not fit under the cover over the main plate. CNA8 stated the dessert was typically served uncovered in a separate dish. During delivery of room meal trays in the [NAME] Hall on 02/19/25 beginning at 1:36 PM, the meal trays were observed on a metal cart covered with plastic. Each tray had a plate covered with an insulated cover and a small dish containing the muffin dessert, which was not covered. The staff brought the meal trays from the cart at one end of the hall to residents' rooms up and down the length of the hall with the dessert uncovered. The Director of Nursing (DON) served a tray to a resident containing an uncovered dessert. In an interview on 02/19/25 at 2:06 PM, the DON confirmed the dessert was uncovered while on the uncovered cart and while in transit down the hall. In an interview on 02/21/25 at 2:31 PM, the DM stated he/she noticed the desserts were not covered again today when going down the hall in the uncovered cart.

Based on observation and interview, the facility failed to ensure refuse and garbage was disposed of properly when the lid to the dumpster was not kept closed. This had the potential to increase the risk of rodents and other pests which could affect all 112 residents who resided at the facility. Findings include: During observations of the dumpsters located behind the kitchen on 02/17/25 at 10:00 AM, 02/18/25 at 10:45 AM, 02/20/25 at 11:45 AM and 2/21/25 at 9:30 AM, the dumpster lid was observed open. During an interview on 02/17/25 at 10:00AM, the Dietary Manager (DM) reported that all the departments in the facility discarded garbage in the area and should close the lid when they finished adding trash to the dumpster.

Based on interview, and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) plan was developed containing the process the facility will follow to guide the care and services provided to residents and measure improvement. This deficient practice had the potential to not capture the efforts made in measuring the care and services for 112 residents. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program- Governance and Leadership revised March 2020 revealed, Policy Statement The quality assurance and performance improvement program are overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. During an entrance conference with the facility's Director of Nursing (DON) on 02/17/25 at 9:31 AM and at 4:45PM, a request was made to get the QAPI plan for review. On 02/18/25 at 2:48 PM and 02/20/25 at 11:00AM, a request was made to the Administrator for the QAPI plan. On 02/20/25 at 09:44 AM, the Administrator stated. We do not know what a QAPI plan is and have never heard of that before. We do not have a QAPI plan. During an interview 02/21/25 at 6:33 PM, the DON stated the Administrator was new as of January 2025. There has been only one meeting with staff and that was the passing out of the clinical pathways, that each department head would take what pertains to their department. The group will come together for the next meeting and present their findings. The DON was asked what improvements programs are being worked on. The DON stated he/she could not find the previous meetings with the previous Administrator.

Based on interview, record review, and policy review, the facility failed to ensure the grievances voiced repeatedly by the resident council were addressed and resolution presented to the council regarding food palatability, staff to resident interactions, pest control, and call light response. These failures had the potential to create feelings of dissatisfaction and helplessness among the eight residents who participated in Resident Council (R96, R2, R48, R88, R87, R109, R106, and R17) out of a census of 112 residents. Findings include: 1. During the group meeting interview on 02/19/25 at 10:00 AM, there was seven participants, R96, R48, R88, R87, R109, R106, and R17. a. Review of R48's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE]. Review of R48's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/10/24 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R48 was cognitively intact. b. Review of R96's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R96's quarterly MDS with an ARD of 12/16/24 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R96 was cognitively intact. c. Review of R88's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R88's admission MDS with an ARD of 12/06/24 and located under the MDS tab of the EMR, revealed a BIMS score of 10 out of 15 which indicated R88 had moderately impaired cognition. d. Review of R87's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R87's quarterly MDS, with an ARD of 11/08/24 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R87 was cognitively intact. e. Review of R109's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R109's admission MDS, with an ARD of 01/06/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R109 was cognitively intact. f. Review of R106's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R106's annual MDS, with an ARD of 12/30/24 and located under the MDS tab of the EMR, revealed a BIMS score of 14 out of 15 which indicated R106 was cognitively intact. g. Review of R17's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R17's quarterly MDS, with an ARD of 01/31/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R17 was cognitively intact. During the meeting, all residents stated the food could be hot if you ate in the dining room, but if you chose to eat in your room the food is cold. R88, R106, R96, and R87 stated they preferred to eat in their rooms and received cold food most of the time. All residents agreed there was a problem with staff being on their phones or talking in the halls while they were supposed to be caring for residents. All residents stated the facility had a mouse problem and all had either seen a live mouse or a dead one. 2. Review of the facility's Resident Council Minutes from September 2024 through February 2025, provided on paper, revealed repeated concerns that were not addressed: a. Food palatability On 02/07/25, the minutes documented a complaint about cold food. On 01/10/25, the minutes documented, Condiments not on trays, food still cold, staff refusing to warm up plates when asked . Burnt food, uncooked food, food presentation not good, late food arrival, need reeducating on cooking, and appeal of foods. On 12/06/24, the minutes documented, Dining room aides/ Certified Nurse Aides (CNAs) on all shifts is [sic] not present in dining room in a timely manner to serve meals food is then cold . Issue with food temperature not resolved. On 11/01/24, the minutes documented, Change the cook, meals are not up to par . Meals is [sic] always cold or lukewarm when being passed out both dining room and hallways. On 10/04/24, the minutes documented, Residents stated that the food is served cold when they receive it from the hallway and in dining room. b. Staff and Resident Interactions On 01/10/25, the minutes documented, Nursing staff listening to music, talking on cell phones on all shifts . staff loud in hallways yelling to one another . Nursing staff with bad attitudes. The minutes also documented a resident reported a staff member was rude. On 11/01/24, the minutes documented, Dietary staff are rude and disrespectful when inquiring or asking for something . Nursing staff do not give acknowledgement of [resident's] presence. On 10/01/24, the minutes documented, . the CNA will tell him that she will be back meanwhile 3 hours have passed and no help. He/She feels ignore [sic] and confrontation from staff when needing help. On 09/06/24, the minutes documented, Resident says [staff member] has a smart mouth when asking him/her a question about fixing things. c. Pest Control On 01/10/25, the minutes documented complaints of mouse sightings in three rooms On 11/01/24, the minutes documented, Residents wants [sic] something to be done about the mice issue. d. Call Lights On 02/07/25, the minutes documented a complaint that it took too long for call lights to be answered on all shifts. On 01/10/25, the minutes documented, Call light not being answered on time. On 12/06/24, the minutes documented, Staff not answering residents in distress yelling for help. CNAs turn off call lights and don't address the resident. CNAs passes the bucket [sic] . Call light issues not resolved. On 11/01/24, the minutes documented, Eastside station does not check on them nor acknowledge the call light- there was a call light issue on 10/31/24. On 10/04/24, the minutes documented, Call light is not being answered in a timely manner. 3. Review of R96's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R96's quarterly MDS with an ARD of 12/16/24, revealed a BIMS score of 15 out of 15 which indicated R96 was cognitively intact. During an interview on 02/17/25 at 3:37 PM, R96 stated he/she was the Resident Council President. He/She stated the Resident Council's suggestions and concerns were not always acted on and no resolution was presented to the council. He/She stated facility staff seemingly just blow us off. Review of R2's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE]. Review of R2's quarterly MDS with an ARD of 12/21/24 and located under the MDS tab of the EMR, revealed a BIMS score of 14 out of 15 which indicated R2 was cognitively intact. During an interview on 02/17/25 at 9:35 AM, R2 stated that when he/she attended Resident Council meetings before, grievances were voiced to administration, however, the group never received any follow-up. He/She stated the staff would tell him/her they were working on it, but there would never be any resolution or explanation of the final result. 4. During an interview on 02/21/25 at 11:58 AM, the Director of Nursing (DON) stated there were no grievance forms or Resident Council forms addressing food palatability, staff to resident interaction, pest control, or call light concerns with any resolution. In a subsequent interview on 02/21/25 at 12:48 PM, the DON stated the facility had not yet taken any actions to address residents' concerns regarding food palatability, residents' concerns regarding staff to resident interactions, pest control (other than the routine pest control visits), or call lights. The DON added that the recommendations from the pest control visits had not yet been implemented, and the facility had conducted audits to ensure call lights were functioning, but no actions had been taken to address residents' concerns about call light wait times. 5. Review of the facility policy titled, Resident Council, dated February 2021, revealed, The purpose of the resident council is to provide a forum for: a. residents, families, and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff; and d. disseminating information and gathering feedback from interested residents . A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of the facility policy titled, Grievances/Complaints, Recording and Investigating, dated April 2017, revealed, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s).

26006 Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from physical or verbal abuse by another resident for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse. Findings include: 1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety. Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 was cognitively intact. He did not exhibit mood or behavioral symptoms. Review of R52's Behavior note dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, [Social Service Director] was notified of altercation between a resident and his/her roommate, both resident and roommate was separated and redirected. Res [resident] was educated on the altercation and to follow the policies of the facility . During an interview on 02/20/25 at 12:22 PM, R52 stated he/she remembered being hit by R26, who was his/her former roommate. He/She stated he/she was not afraid of R26 and had no further issues with him/her. He/She stated he/she remembered the police were called about the incident. Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia. Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR revealed BIMS score of 10 out of 15 which indicated that R26's cognition was moderately impaired. He/She did not exhibit mood or behavioral symptoms. Review of R26's Care Plan, dated 12/31/23, revealed, [R26] is able to be physically aggressive [sic] to staff and other residents r/t dementia, history of harm to others (professional boxer), poor impulse control. The approaches included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; . Assess and address for contributing sensory deficits; . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; . Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; . Give the resident as many choices as possible about care and activities; . Monitor as needed. Document observed behavior and attempted interventions in behavior log; . Monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of resident posing danger to self and others; . Psychiatric/Psychogeriatric consult as indicated; . [and] When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of R26's Nurses Note, dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, Resident was in a physical altercation with his/her roommate. Stated roommate punched him/her in the back of the head so he/she went to his/her bed and started punching him/her. Cops called, doctor and administration notified, no injuries noted. In an interview on 02/20/25 at 12:43 PM, R26 stated he/she did not have any fights with anyone in the facility and stated he/she felt safe in the facility. Review of the facility's Incident Report for Physical Aggression Initiated for R26 dated 06/25/24 and provided on paper revealed, Nursing Description: Resident [R26] stated his/her roommate hit him/her in the back of the head and then went over to his/her roommate who was in his/her own bed and started punching him/her, roommate then came up to nurses station to report incident. Resident Description: He/She punched me in the head, so I went over and fought back .Immediate Action Taken: Residents separated, cops called, education given, administration notified, doctor notified. The incident was not witnessed. Interview on 02/20/25 at 2:48 PM, the Administrator stated resident-to-resident altercations were abusive when there was willful action or an intent to harm someone. The Administrator stated he/she did consider the altercation to be physical abuse. 2. During an interview on 02/18/25 at 8:50 AM, R31 was asked if he/she had any issues or confrontations with any other resident. R31 stated, I had some problems with another resident, but we just stay away from each other. Review of the Physical Aggression Initiated form dated 01/23/25 indicated the Incident Description revealed, This resident [R24] entered the dining room in his/her wheelchair and approached resident 2 [R31], being vocal towards resident 2 [R31]. Staff attempted to separate the two residents and this resident [R24] reached out and grabbed the left arm of resident 2 [R31]. This resident [R24] then struck the arm of the staff member as he/she was being wheeled away from resident 2 [R31]to come to the DON [Director of Nursing ] office. Review of R24's EMR revealed, Admission Record revealed the resident was admitted on [DATE] with diagnoses of mild cognitive impairment, anxiety disorder, and major depressive disorder. Review of R24's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/27/24 with a BIMS score of eight out of 15, indicating moderately impaired cognitive capabilities. The MDS documented, Physical behavioral symptoms directed toward others (e.g., hitting, kicking pushing, scratching, grabbing, abusing others sexually),occurred 1-3 days, Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), occurred 1-3 days. Review of R31's EMR revealed Admission Record revealed an admitted [DATE] with diagnoses of lupus, end stage dialysis, and acquired bilateral amputations of lower extremities. Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 01/19/25, showed a BIMS score of 15 out of 15 indicating intact cognitive ability. During an interview on 02/20/25 at 2:49 PM, the Administrator was asked about the incident. The Administrator stated his/her investigation found no abuse because Neither resident felt threatened, scared, etc. It was determined that they had a disagreement. During a follow up interview on 02/20/25 at 1:40 PM, R31 stated there had been another altercation with R24. R31 stated while in activities earlier, R24 came in and started wheeling around everybody. R31 stated, He/She started to come toward me, I told him/her to stay away. He/She started cussing at me and put his/her arms up like he/she was going to hit me. But the activities stopped him/her. R31 was asked if he/she was okay. He/She said, No, he/she keeps coming after me. I feel it's abuse. During an interview on 02/20/25 at 1:48 PM, the Activities Assistant (AA) was asked what happened between R24 and R31 earlier. The AA stated R31 was in the activities this morning and then R24 came in and started over to R31, who told him/her to stay away. Then both residents' voices got louder, and then he/she stepped in between the residents as R24 was going towards R31. The AA stated the Social Service Director (SSD) heard loud voices and came in and took R24 out of the dining room. During an interview on 02/20/25 at 2:05 PM, the SSD stated that the residents was arguing, and staff intervened. During an interview on 02/21/25 a 10:05 AM, Maintenance Assistant (MA) was asked about the altercation between R24 and R31 on 01/23/25. The MA stated, I walked into the dining room because I could hear yelling. When I got in there, R24 was cussing at R31, and he/she was close to R31. The MA further stated he/she had gone up to them and [R24's name] shoved me, and he/she managed to grab on to [R31's name] and was about to hit him/her, but he/she hit me instead. Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse .by anyone including .b. other residents .

26006 Based on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and reporting of all alleged violations to the state survey agency (SSA) for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse. Findings include: 1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety. Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 was cognitively intact. Review of R52's Behavior note, dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, [Social Service Director ] was notified of altercation between a resident and his/her roommate, both resident and roommate was separated and redirected Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia. Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR revealed a BIMS score of 10 out of 15 which indicated R26 had moderately impaired cognition. Review of R26's Nurses Note, dated 06/25/24 and located under the Progress Notes tab of the EMR revealed, Resident was in a physical altercation with his/her roommate. Stated roommate punched him/her in the back of the head so he/she went to his/her bed and started punching him/her. Cops called, doctor and administration notified. Review of the facility's Incident Report for Physical Aggression Initiated for R26 dated 06/25/24 and provided on paper revealed, Nursing Description: Resident [R26] stated /her roommate hit him/her in the back of the head and then went over to his/her roommate who was in his/her own bed and started punching him/her, roommate then came up to nurses station to report incident. Resident Description: He/She punched me in the head, so I went over and fought back . cops called .administration notified, doctor notified. There was no evidence the allegation was reported to SSA within two hours of occurrence. Interview on 02/20/25 at 2:48 PM, the Administrator stated this incident represented resident-to-resident physical abuse. The Administrator stated he/she was unable to find any evidence the alleged violation was reported to the SSA as required. He/She stated it should have been reported to the SSA as an abuse occurrence. 2. During an interview on 02/18/25 at 8:50 AM, R31 was asked if he/she had any issues or confrontations with any other resident. R31 stated, I had some problems with another resident, but we just stay away from each other. Review of the Physical Aggression Initiated form dated 01/23/25 indicated the Incident Description revealed, This resident [R24] entered the dining room in his/her wheelchair and approached resident 2 [R31], being vocal towards resident 2 [R31]. Staff attempted to separate the two residents and this resident [R24] reached out and grabbed the left arm of resident 2 [R31]. This resident [R24] then struck the arm of the staff member as he/she was being wheeled away from resident 2 [R31]to come to the DON office. During an interview on 02/20/25 at 12:10 PM, the Director of Nursing (DON) stated the Administrator was the Abuse Coordinator, who reports abuse to the state. Review of R24's electronic medical record (EMR) revealed, Admission Record reveled the resident was admitted on [DATE] with diagnoses of mild cognitive impairment, anxiety disorder, and major depressive disorder. Review of R24's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/27/24 with a BIMS score of eight out of 15, indicating moderately impaired cognitive capabilities. Review of R31's EMR revealed, Admission Record revealed an admitted [DATE] with diagnoses of lupus, end stage dialysis, and acquired bilateral amputations of lower extremities. Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 01/19/25, showed a BIMS score of 15 out of 15 indicating intact cognitive ability. During a follow up interview on 02/20/25 at 1:40 PM, R31 stated there had been another altercation with R24 while in activities earlier, R24 came in and started to come toward me. I told him/her to stay away. He/She started cussing at me and put his/her arms up like he/she was going to hit me. But the activities assistant (AA) stopped him/her. R31 stated, he/she keeps coming after me. I feel it's abuse. During an interview on 02/20/25 at 1:48 PM, the AA stated R31 was in the activities this morning and then R24 came in and started over to R31, who told him/her to stay away. Then both residents' voices got louder. The AA said he/she stepped in between the residents as R24 was going towards R31. During an interview on 02/20/25 at 2:49 PM, the Administrator stated his/her investigation found no abuse because Neither resident felt threatened, scared, etc. The Administrator confirmed the incident on 01/23/25 and the incident on 02/20/25 had not been called into the SSA. Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives . Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated April 2021, revealed, The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . 3 Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or g. [sic] within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

26006 Based on interviews, record review, and policy review, the facility failed to ensure allegations of resident-to-resident abuse were investigated for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse. Findings include: 1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety. Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52's cognition was intact. Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia. Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR, revealed the BIMS score of 10 out of 15 which indicated R26 had moderately impaired cognition. Review of the facility's Incident Report for Physical Aggression Initiated for R26 dated 06/25/24 and provided on paper, revealed, Nursing Description: Resident [R26] stated his/her roommate hit him/her in the back of the head and then went over to his/her roommate who was in his/her own bed and started punching him/her, roommate then came up to nurses station to report incident. Resident Description: He/She punched me in the head so I went over and fought back. There was no statement from R52 included, nor was there any evidence an investigation had been completed. Interview on 02/20/25 at 2:48 PM, the Administrator stated this incident represented resident-to-resident physical abuse. The Administrator stated that he/she was unable to find any evidence of an investigation, including a statement from R52 or interviews with other residents and staff. He/She stated it should have been investigated thoroughly. 2. Review of the Physical Aggression Initiated form dated 01/23/25 indicated the Incident Description revealed, This resident [R24] entered the dining room in his/her wheelchair and approached resident 2 [R31], being vocal towards resident 2 [R31]. Staff attempted to separate the two residents and this resident [R24] reached out and grabbed the left arm of resident 2 [R31]. This resident [R24] then struck the arm of the staff member as he/she was being wheeled away from resident 2 [R31]to come to the DON office. The investigation included the form, progress notes, and R24's admission record. During an interview on 02/20/25 at 12:10 PM, the Director of Nursing (DON)was asked if this was a complete investigation. The DON stated, yes. The DON was asked about witness statements, the root cause of the investigation and the result. The DON stated he/she would check with the Administrator and see if he/she had more. The DON brought in three undated forms titled, Resident Interviews for Abuse, Neglect, and Exploitation filled out by random residents. The progress notes and the admission records were all printed out on 02/20/25, the same day that the investigation was requested. There was a typed page with the date of 01/24/25 with a recap of the incident and what followed such as care plan update, and a follow up visit from psychiatric dated 01/28/25. Review of R24's electronic medical record (EMR) revealed, Admission Record dated 02/20/25, provide by the facility, reveled the resident was admitted on [DATE] with diagnoses of mild cognitive impairment, anxiety disorder, and major depressive disorder. Review of R24's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/27/24 showed a BIMS score of eight out of 15, indicating moderately impaired cognitive capabilities. Review of R31's EMR Admission Record revealed an admitted [DATE] with diagnoses of lupus, end stage dialysis, and acquired bilateral amputations of lower extremities. Review of R31's quarterly MDS assessment located in the EMR under the MDS tab with an ARD of 01/19/25 showed a BIMS score of 15 out of 15 indicating intact cognitive ability. During a follow up interview on 02/20/25 at 1:40 PM, R31 stated there had been another altercation with R24. R31 stated while in activities earlier, R24 came in and started wheeling around everybody. R31 stated, He/She started to come toward me, I told him/her to stay away. He/She started cussing at me and put his/her arms up like he/she was going to hit me. During an interview on 02/20/25 at 2:49 PM, the Administrator was asked about the incident and stated his/her investigation found no abuse because Neither resident felt threatened, scared, etc. It was determined that they had a disagreement. The Administrator stated that if it were abuse it would have been investigated. Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives . Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated April 2021, revealed, The individual conducting the investigation as a minimum: a. reviews the documentation and evidence . m. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; n. observes the alleged victim, including his or her interactions with staff and other residents; o. interviews the person(s) reporting the incident; p. interviews any witnesses to the incident; q. interviews the resident (as medically appropriate) or the resident's representative; r. interviews the resident's attending physician as needed to determine the resident's condition; s. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; t. interviews the resident's roommate, family members, and visitors; u. interviews other residents to whom the accused employee provides care or services; v. reviews all events leading up to the alleged incident; and w. documents the investigation completely and thoroughly .

Based on interview, record review, and policy review, the facility failed to ensure the electronic medication administration record (MAR) matched the Controlled Drug Administration Record Tablet for three residents (Resident (R)65, R97, and R86) out of a total sample of 27 residents. The deficient practice increased the risk of staff administering narcotic medication that had already been administered to residents which increased the risk of adverse effects. Findings include: 1. Review of R65's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE], with diagnosis of chronic pain syndrome. During an interview on 02/17/25 at 10:18 AM, R65 stated that his/her narcotic medications ran out consistently included: oxycodone (a narcotic pain medication) and buprenorphine (a narcotic pain medication). Review of R65's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 11/22/24 for Oxycodone 10 milligrams (mg) to be administered every 8 hours as needed for moderate to severe pain. On 02/11/25, the order for oxycodone was revised to be administered for three days and a new order was written for Oxycodone 5 mg to be administered every 8 hours as need for pain. Review of R65's Controlled Drug Administration Record Tablet provided by the facility dated 01/26/2025 and the MAR dated February 2025, located under the Orders tab of the EMR for Oxycodone 10mg revealed: On 02/03/25 two of two doses administered were not documented on the MAR. On 02/04/25 one of three doses administered was not documented on the MAR. On 02/05/25 one of two doses administered was not documented on the MAR. On 02/06/25 two of four doses administered were not documented on the MAR. On 02/07/25 one of two doses administered was not documented on the MAR. On 02/08/25 one of three doses administered was not documented on the MAR. On 02/10/25 one of three doses administered was not documented on the MAR. On 02/11/25 three of three doses administered were not documented on the MAR. On 02/12/25 one of two doses administered was not documented on the MAR. On 02/13/25 to 02/17/25 medication was out of stock On 02/19/25 one of two doses administered was not documented on the MAR. Review of R65's Controlled Drug Administration Record Tablet provided by the facility dated 02/17/25 and the Medication Administration Record, dated February 2025, located under the Orders tab of the EMR for Oxycodone 5 mg revealed: On 02/19/25 one of two doses administered was not documented on the MAR. Review of R65's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 02/11/25, the order for buprenorphine was revised to be administered for three days and a new order was written for Buprenorphine 8 mg sublingual tablet to be administered every 8 hours as need for pain. Review of R65's Controlled Drug Administration Record Tablet sheets provided by the facility dated 01/26/25, 02/01/25, and 02/10/25, and the MAR dated February 2025 located under the Orders tab of the EMR for buprenorphine 2mg tablets revealed: On 02/03/25 two of three doses administered were not documented on the MAR. On 02/04/25 one of one dose administered was not documented on the MAR. On 02/05/25 one of three doses administered was not documented on the MAR. On 02/06/25 three of three doses administered were not documented on the MAR. On 02/08/25 one of three doses administered was not documented on the MAR. On 02/09/25 one of three doses administered was not documented on the MAR. On 02/11/25 one of two doses administered was not documented on the MAR. On 02/12/25 three of three doses administered were not documented on the MAR. On 02/13/25 one of two doses administered was not documented on the MAR. On 02/14/25 two of three doses administered were not documented on the MAR. On 02/15/25 three of three doses administered were not documented on the MAR. On 02/16/25 four of four doses administered were not documented on the MAR. On 02/17/25 one of two doses administered was not documented on the MAR. Review of R65's Controlled Drug Administration Record Tablet sheets provided by the facility dated 02/17/25 and the MAR dated February 2025 located under the Orders tab of the EMR for buprenorphine 8mg tablets revealed: On 02/18/25 one of two doses administered was not documented on the MAR. On 02/19/25 two of two doses administered were not documented on the MAR. 2. Review of R97's Admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE] with diagnosis of chronic pain. Review of R97's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 12/12/24 for Oxycodone 5 mg tablets to be administered every 4 hours as needed pain. Review of R97's Controlled Drug Administration Record Tablet sheets provided by the facility dated 12/30/2024 and 02/08/25 and the MAR dated February 2025 located under the Orders tab of the EMR for Oxycodone 5mg revealed: On 02/03/25 one of one dose administered was not documented on the MAR. On 02/04/25 two of two doses administered were not documented on the MAR. On 02/11/25 one of one dose administered was not documented on the MAR. On 02/15/25 one of two doses administered was not documented on the MAR. On 02/16/25 three of three doses administered were not documented on the MAR. On 02/17/25 one of two doses administered was not documented on the MAR. On 02/19/25 one of two doses administered was not documented on the MAR. 3. Review of R86's Admission Record located under the Profile tab of the EMR revealed the resident was admitted on [DATE], with diagnoses which included abdominal pain and neuropathy. Review of R86's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 12/01/23 for Oxycodone 5 mg tablets to be administered every 6 hours as needed for moderate to severe pain. Review of R86's Controlled Drug Administration Record Tablet sheets provided by the facility dated 01/24/25 and 02/07/25 and the MAR dated February 2025 located under the Orders tab of the EMR for Oxycodone 5mg revealed: On 02/03/25 one of two doses administered was not documented on the MAR. On 02/04/25 one of two doses administered was not documented on the MAR. On 02/05/25 one of two doses administered was not documented on the MAR. On 02/06/25 one of three doses administered was not documented on the MAR. On 02/09/25 one of two doses administered was not documented on the MAR. On 02/10/25 two of three doses administered were not documented on the MAR. On 02/11/25 one of two doses administered was not documented on the MAR. On 02/15/25 one of two doses administered was not documented on the MAR. On 02/16/25 four of four doses administered were not documented on the MAR. On 02/18/25 one of three doses administered was not documented on the MAR. 4. During an interview on 02/20/25 at 10:03 AM, Licensed Practical Nurse (LPN) 3 stated, we are required to document narcotics at the time of removal on the Controlled Substances Administration Record sheet and on the MAR in the computer. If we get busy, we might not sign them out on the computer. They want us to sign narcotics out both on the paper narcotics log and on the computer. During an interview on 02/20/25 at 10:09 AM, Registered Nurse (RN)1 stated, to administer narcotic medications, we document on the paper narcotics log when removed and document in computer. The paper narcotic log is considered an administration record. The only time I would not document in the computer would be if the internet was down. During an interview on 02/20/25 at 1:38 PM, the Director of Nursing (DON) stated, As soon as the medication is popped out, the medication is documented as removed from count on the Controlled Substances Administration Record sheet. Then, when the medication is administered, it is documented in the EMR on the MAR. The controlled substance record can be considered an administration record. The EMR is the required administration record. There should not be any instances where a controlled medication would not be documented in the EMR if documented on the Controlled substance record. I expect all medications to be documented on the EMR when administered. Review of the facility's policy titled, Controlled Substances revised April 2019 indicated, Controlled substances are reconciled upon. administration. Upon administration: The nurse administering the medication is responsible for recording: 1) name of the resident receiving the medication; 2) name, strength, and dose of the medication; 3) time of administration; 4) method of administration; 5) quantity of the medication remaining; and 6) signature of nurse administering medication. Review of the facility's policy titled, Administering Medications revised April 2019 indicated, As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; . e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

Based on observation, interviews, and policy review, the facility failed to properly label insulin pens with resident name and opened date and discard expired insulin pens, keep food, personal items and makeup separate from medications for two of six medication carts. The deficient practice could result in altered effectiveness of the medication, worsening of resident's symptoms, Findings include: 1. Observation on 02/19/25 at 1:27 PM of the nurse's medication cart with Licensed Practical Nurse (LPN)3 on the 100 (East) hall revealed: There were two Humalog insulin pens not labeled with the resident's name. There were five Lantus insulin pens open and not dated. There was one Levemir insulin pen that had an open date of 12/08/24. There was one Lantus vial that had an open date of 12/10/24. LPN3 at the time of the observation the insulin was expired and is to be discarded within 28 days after the date opened. A container of applesauce was found stored in the drawer with nebulizer medications. There was lipstick and makeup found in the top drawer without a name. LPN3 stated at the time of the observation, that the makeup belonged to a resident but was unsure to whom. Interview on 02/19/25 at 1:27PM, LPN3 stated the pens were opened/used. 2. Observation on 02/19/25 at 2:27 PM of the nurse's medication cart with Registered Nurse (RN)1 on the 200 (West) hall revealed: There were three insulin pens that were opened and not dated. RN1 stated one pen had a date marked on it 2/17. The date was not legible and there was not a label to indicate if the date was when it was opened or when it expired. There was a bottle of liquid Gabapentin oral solution that was opened and not dated. There was a purse and cell phone in a drawer on top of patient medications. RN1 stated at the time of the observation that the personal items belonged to her. There were two containers of pudding in a drawer with patient medications. There were two bottles of sterile water that expired on 04/12/24. RN1 stated at the time of the observation that food was not to be stored with medications and that the liquids are required to be dated when opened. During an interview on 02/20/25 at 1:28 PM, the Director of Nursing (DON) stated that more than one resident could not use insulin pens. It is expected to have a resident label on each pen with the date opened. Each insulin pen was expected to be dated immediately when opened. The DON stated he/she thought insulin pens and vials would expire 30 days from date opened but was not sure. The DON stated applesauce, and pudding should not be stored in the medication carts and that personal items should not be stored in medication carts. Review of the facility's undated policy titled, Storage of Medication Requiring Refrigeration, indicated The facility must provide safe and effective storage of all drugs and biologicals in a locked storage area under proper temperature controls. consistent with state and federal requirements and professional standards of practice. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable).Remove any expired medications from active stock and discard medication according to facility policy. Date label of any multi-use vial when the vial is first accessed (needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review of the facility policy titled, Administering Medications revised April 2019 indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for the resident.

Based on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment for 11 sampled residents (Residents #304, #69,#600,#621, #617, #96, #601,#603, #18, #508 and #58) out of 17 sampled residents, when they complained that their rooms were hot or had temperatures above 81 degrees Fahrenheit ( F); failed to have a comprehensive monitoring system including documentation for the air temperatures within the resident rooms to maintain comfort level; to maintain documentation for all ongoing maintenance for cooling units in the facility and to conduct random monitoring, or keep record to ensure the comfort of residents in the building. These failures had the potential to affect all residents in the facility. The facility census was 110 residents. The Administrator was notified on 8/21/23 at 6:09 P.M., of the Immediate Jeopardy (IJ) which began on 8/18/23. The IJ was removed on 8/22/23, as confirmed by surveyor onsite verification. Review of the facility's Failure of Heating, Ventilation, and Air Conditioning (HVAC) System Policy and Procedure dated 4/1/22 showed: In the event of all or part of the HVAC system the following steps will be taken include: -Should a major failure occur to the Central HVAC system (water chiller cooler tower) requiring prolonged shutdown, arrangements have been made for portable emergency air service to provide temporary services until the next system was repaired; Contact contractors listed on the emergency phone list. -For something other than a major failure, follow the steps below: --Air Conditioning (AC): check to ascertain if the chillers are operating. Check the unit for the following: Control panel, electric problem, Mechanical failure, and air restriction in cooling tower, water flow in cooling tower, operation of the chill water circulation pumps, and operation of condenser water pump. --If environmental services department personnel are unable to identify the problem, contact the Director of Environmental services or his/her designee to call in outside contractors. --Notify house supervisor and administration. Review of the facility's Code White-Extreme Weather policy dated 11/15/17 showed: -Provided staff specific guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety of residents and staff in the event of extreme weather, temperatures related conditions. -Know the definition and signs of Heat exhaustion (a disorder resulting from overexposure to heat and sun) and Heat Stroke (a profound disturbance of the body's heat-regulation mechanism, caused by prolonged exposure to excessive heat, particularly when there is little to no circulation of air). -The following measures should be taken during extreme heat and humidity include: --Increase fluid intake by providing and encouraging fluids depending upon the individual resident's physical condition and as determined by the nursing staff. --Encourage resident to wear suitable clothing in the facility, i.e., loose fitting, light weight clothing. Strongly encourage the removal of any additional layers of clothing such as sweater, jackets or hats. --Encourage resident to reduce or eliminate any strenuous physical activity. --Discourage resident from going outside and or longer periods of time when the outside temperatures are in 90 degrees Fahrenheit ( F), or if heat index of 90 F. --Encourage resident to leave their bedroom doors open to ensure adequate air flow. --If air conditioning units fail in an area of the facility and or the temperature becomes uncomfortable, upon direction of administrative personnel, resident affected may be moved to another room and or area in the facility where the temperature is adequate. -Internal building temperatures may be taken in various location of the building, including areas occupied by the residents, at regular intervals particularly between 8:00 A.M. to 10:00 P.M. -Close the windows, blinds or curtains when exposed to direct sunlight and or hot wind. -Immediately report any difficulties in the air conditioning unit to the facility Director of Plant Operations. -Temperatures may be taken by facility director of Plant operations, his/her assistant and or the Nursing supervisor and his/her designee to monitor the temperature and determine the cooler room's area within the facility as necessary. -Use additional fans in various locations throughout the building to circulate airflow as needed. Review of the facility's undated Evacuation Instruction sheet showed: -During a general evacuation of the building, the command post and assembly area will be in the front parking lot in front of the Virgin [NAME] statue. -Gather ambulatory residents together and appoint staff member to lead them to the assembly area. Do not leave ambulatory residents unattended. Special care residents such as wheelchair (will appoint staff to use any and all wheelchairs to move these resident to the assembly area, when possible staff member will take the wheelchair back to assist in the evacuation), bed confined or total care (could roll bed to the assembly area) , bariatric resident ( don't try move these resident by yourself) -Once the Evacuation is ordered, call 911 for assistance. Do not assume help is on the way. --Begin plan designation for staff member and establish command post. You may have to delegate roles to staff members in the absence of front line responders. Follow the producers in the front of the manual for front line responders and make sure if you assign a role to someone, they know what responsibilities they have. Review of the facility proposal bid for repair of multiple room units dated 5/24/23 showed: -Units in the Conference Room, room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] all needed a blower motor, capacitor and wheel repair. -Resident room [ROOM NUMBER] unit required replacement of leaking water valve. -Resident room [ROOM NUMBER] unit required replacement and Resident room [ROOM NUMBER] unit required a work order to investigate why the unit had no water flow. That investigation may require the shutting down of the facility chiller and pumps. -Did not have documentation that repairs were made or parts were ordered as of 8/21/23. Review of the facility proposal bid for replacement of the chiller pump dated 7/10/23 showed: -The contractor proposes to replace the chiller pump with the newly tested and repaired pump. --Shut down the chiller loop. --Disconnect the pump form the piping. --Use gantry (crane) to lower the pump into the basement. --Set the newly tested and repaired pump in place. --Use flex connections to make connections to the existing piping. --Start the pump and check the operation. Review of the facility proposal bid for replacement of the exhaust fan dated 7/13/23 showed: --The contractor proposes to install an exhaust fan for hallway (a six week lead time). --Disconnect and dispose of the existing exhaust fan. --Set the new fan on the new curb. --Connect the new fan to the power and check operations. Record review of the National Weather Service's official local weather for the city and state where the facility was located from 8/18/23 through 8/22/23, showed the daily high temperatures and heat index were: -On 8/19/23; Daily High temp of 102 F and heat index 119 F. -On 8/20/23; Daily High temp of 98 F and heat index 117 F. -On 8/21/23; Daily High temp of 99 F and heat index 122 F. -On 8/22/23; Daily High temp of 99 F and heat index 116 F. Review of the website www.weather.com showed August 19-25, 2023 was a historic heatwave starting on 8/19/23. Well-above normal temperatures impacted the central part of the United States, kicking off a heatwave that has not been experienced in the region in recent history. Kansas City International Airport reached high temperatures not recorded in the area since August of 2012. This stretch of hot weather was accompanied by extremely high dewpoints, with frequently reached the upper 70s to middle 80s across the entire area. The combination of the extreme heat and the excessively high dewpoints led to heat indices from August 19 through August 25 to rise to 120-130 degrees 1. Review of the facility's temperature log sheet dated 8/18/23 showed: -No identified time. -Resident room [ROOM NUMBER] was 82.0 F. -Resident room [ROOM NUMBER] was 82.1 F. -Resident room [ROOM NUMBER] was 81.5 F. -Resident room [ROOM NUMBER] was 82.6 F. -Resident room [ROOM NUMBER] was 86.6 F. -Resident room [ROOM NUMBER] was 82.9 F. -Resident room [ROOM NUMBER] was 81.1 F. -Resident room [ROOM NUMBER] was 81.7 F. During an interview on 8/19/23 at 11:36 A.M., Activities Director said the facility AC units were in need of repair, so the facility had industrial AC units placed in hallways to assist in keeping the facility cool. Review of the facility temperature log sheets showed the facility had not collected documentation for resident room temperature checks on 8/19/23 and 8/20/23. During an interview on 8/21/23 at 9:30 A.M., the Director of Maintenance said: -The facility room units had an on-off switch, but were mostly controlled by the HVAC chiller systems. -He/she had been checking the temperatures in the resident rooms, but not over the weekend. -He/she was off work on the weekend, and he/she had not received any complaints related to excess heat. -He/she would have come in if he/she were called. -Temperatures were checked when there were heat advisories. -There were five Industrial AC cooling units in the hallways to make sure the building was cool. -A company had given the facility bids on repairs that needed to be done to the cooling system and room units. -The facility had one chiller for the building and a part had been ordered for that chiller. -The facility had the chiller pump in, but were waiting on the gantry to lower into the basement. Review of the facility's temperature log sheet dated 8/21/23 showed: -No identified time. -53 resident rooms out of 65 resident rooms temperatures recorded were above 81 F. -Seven out of 65 resident's room had temperatures above 90.0 F and with highest was 99.9 F --Resident room [ROOM NUMBER] was 90.9 F. --Resident room [ROOM NUMBER] was 99.9 F. --Resident room [ROOM NUMBER] was 91.9 F. --Resident room [ROOM NUMBER] was 91.9 F --Resident room [ROOM NUMBER] was 94.9 F. --Resident room [ROOM NUMBER] was 92.9 F. --Resident room [ROOM NUMBER] was 98.9 F. Review of the facility's temperature log sheet dated 8/21/23 at 3:05 P.M. to 3:20 P.M. showed: -No identified time. -63 resident rooms out 65 resident rooms temperatures were above 81.0 F. -Highest temp was in Resident room [ROOM NUMBER] at 95.1 F. -18 out of 65 resident's room had temperatures over 90.0 F include: --Resident room [ROOM NUMBER] was 90.7 F. --Resident room [ROOM NUMBER] was 90.1 F. --Resident room [ROOM NUMBER] was 90.5 F. --Resident room [ROOM NUMBER] was 94.2 F --Resident room [ROOM NUMBER] was 94.5 F. --Resident room [ROOM NUMBER] was 92.9 F. --Resident room [ROOM NUMBER] was 90.9 F. --Resident room [ROOM NUMBER] was 90.7 F. --Resident room [ROOM NUMBER] was 92.2 F. --Resident room [ROOM NUMBER] was 92.2 F. --Resident room [ROOM NUMBER] was 91.5 F. --Resident room [ROOM NUMBER] was 95.1 F. --Resident room [ROOM NUMBER] was 95.0 F. --Resident room [ROOM NUMBER] was 94.3 F. --Resident room [ROOM NUMBER] was 90.0 F. --Resident room [ROOM NUMBER] was 91.2 F. --Resident room [ROOM NUMBER] was 90.4 F. --Resident room [ROOM NUMBER] was 90.0 F. (isolation room) Observation and interview on 8/21/23 at 3:20 P.M., Maintenance Assistant showed: -Checking resident room temperature by pointing the Infrared Thermometer Testers toward the resident room ceiling. The facility infrared thermometer had Resident room [ROOM NUMBER] at 95.5 F. -He/she said this was the hottest room found at that time. Observation on 8/21/23 from 3:25 P.M. to 4:02 P.M., showed: -Resident room [ROOM NUMBER] was 84.3 F. -Resident room [ROOM NUMBER] was 86.3 F. -Resident room [ROOM NUMBER] was 85.6 F. -Resident room [ROOM NUMBER] was 87.4 F. -Resident room [ROOM NUMBER] was 85.7 F. -Resident room [ROOM NUMBER] was 87.4 F. -Resident room [ROOM NUMBER] was 90.5 F. -Resident room [ROOM NUMBER] was 88.4 F. -The hallway outside of Resident room [ROOM NUMBER] was 85.5 F. -The hallway outside of Resident room [ROOM NUMBER] was 85.5 F. -The hallway outside of Resident room [ROOM NUMBER] was 84.0 F. Review of Resident #304 Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 5/24/23, showed he/she: -Had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) of 12. -He/she was able to understand others and make his/her needs known. Observation and interview on 8/21/23 at 3:38 P.M., the resident said: -The room AC unit had slight air blowing from the unit. -The resident's hair was wet from sweating. -He/she said it was too hot to move around too much. -He/she had fans in the room and the fans did not really help with cooling his/her room. -The room AC unit had not been working very well for a long time. -His/her room and the facility had been hot for several days and was worse at night. -The room temperature was 90.5 F. Review of Resident #69's Quarterly MDS dated [DATE], showed he/she: -Was cognitively intact with a BIMS score of 13. -He/she was able to understand others and make his/her needs known. Observation and interview on 8/21/23 at 3:40 P.M., the resident said: -The room AC unit had slight air blowing from the unit. -The resident was sweating while laid in bed. -He/she had two fans in room and he/she felt the fans really did not help with cooling the room down. -His/her room and the facility had been hot for several days. -The room temperature was 89.6 F. During an interview on 8/21/23 at 4:20 P.M., Certified Medication Technician (CMT) B said: -The facility had been hot like this for a little over a week. -Most of the resident rooms were hot. -Residents had not really complained about being hot. -He/she had asthma and the heat bothered him/her. -He/she took her breaks in his/her car so he/she could use the air conditioning. Review of Resident #96's Quarterly MDS dated [DATE], showed he/she: -Was cognitively intact with a BIMS score of 15. -He/she was able to understand others and make his/her needs known. Observation and interview on 8/21/23 at 4:25 P.M., the resident said: -He/she was hot. -His/her room had been hot like this the past few days. -He/she had a tracheostomy (surgical opening in the trachea to assist with breathing), and the humidity was making it harder to breathe, more than the heat. -The room was 89.0 F. Review of Resident #601's Quarterly MDS dated [DATE], showed he/she: -Was cognitively intact with a BIMS score of 15. -He/she was able to understand others and make his/her needs known. Observation and interview on 8/21/23 at 4:30 P.M., the resident said: -The day before, his/her blood pressure had been 180/100 (normal range 120/70). -He/she had high blood pressure, but he/she thought the heat made it worse. -He/she thought the heat made it harder to sleep and to breathe. -He/she had been at the facility over a month and the air conditioning had not been working properly the whole time. -The room was 89.2 F. Review of Resident #603's Quarterly MDS dated [DATE], showed he/she: -Was cognitively intact with a BIMS score of 14. -He/she was able to understand others and make his/her needs known. Observation and interview on 8/21/23 at 4:30 P.M., the resident said: -He/she had asthma and COPD. -He/she was on oxygen. -He/she had trouble breathing because of the heat. -The heat made him/her feel dizzy, light-headed and sick to his/her stomach. -It had been hot in the facility since the end of July. -The room was 89.2 F. Review of Resident #18's Quarterly MDS dated [DATE], showed he/she: -Was moderately cognitively impaired with a BIMS score of 9. -He/she was able to understand others and make his/her needs known. Observation and interview on 8/21/23 at 4:35 P.M., the resident said: -He/she was on oxygen. -The heat made it harder for him/her to breathe. -It had been hot all summer. -It was even hotter when the sun came through his/her window. -It was also hot in the dining room and activity room. -The room was 90.3 F. Observation on 8/21/23 at 4:20 P.M. to 4:50 P.M., showed: -Resident room [ROOM NUMBER] was 87.8 F. -Resident room [ROOM NUMBER] was 84.5 F. -Resident room [ROOM NUMBER] was 84.8 F. -Resident room [ROOM NUMBER] was 89.6 F and the door was shut. -Resident room [ROOM NUMBER] was 89.2 F with two bed bound residents. -The hallway outside of Resident room [ROOM NUMBER] was 83.8 F. -The facility main dining room was 82.0 F with 10 residents in the space. Review of Resident #621's Quarterly MDS, dated [DATE], showed he/she: -Was cognitive intact with BIMS of 13. -He/she was able to understand others and make his/her needs known. -Required the use of wheelchair for mobility. -Impairment of both lower extremities. Observation and interview on 8/21/23 at 4:21 P.M., the resident said: -The AC unit had no air blowing. -He/she said the room AC unit had been broken for a while. -The resident had four fans in use in the room and the resident were sweaty. -He/she said it had been very hot in room for several days and was he/she had difficulty sleeping in the heat. Review of Resident #600's Quarterly MDS dated [DATE], showed he/she: -Was cognitive intact with BIMS of 15. -He/she was able to understand others and make his/her needs known. -Required total assistant of two staff member for transfer and all cares. -Required the use of oxygen. Observation and interview on 8/21/23 at 4:40 P.M., the resident said: -He/she was having a hard time catching his/her breathe with the increased temperature in the facility. -He/she had oxygen in place. -The AC unit had slight air movement from the unit. -The resident had a box fan running in room, the window blinds closed and the light off. -He/she had a sheet covering the lower half his/her body. -The room temperature was 83.5 F. During an interview on 8/21/23 at 4:40 P.M., Certified Nurse Aide (CNA) C said: -Some of the residents had complained of being hot. -He/she had not done anything, as none of the residents had negative outcomes that he/she was aware of. During an interview on 8/21/23 at 5:00 P.M., Receptionist B said: -Ice water was available to the residents at all times. -He/she was on oxygen and the heat made it harder to breathe. During an interview on 8/21/23 at 5:55 P.M., the Director of Maintenance said: -There was one chiller for the facility and it was currently on. -The chiller and pump were working, just not efficiently keeping up with the demand. -A replacement pump had to be installed. -A crane would have to be used to put the pump in place. -An exhaust fan was also needed on the roof. The air conditioner company was trying to get it all done in one day. -The same company was also going to fix room blower/capacitor parts. During an interview on 8/21/23 at 6:09 P.M., the Administrator, Regional Support specialist, and Regional Care Coordinator said: -Four additional industrial AC units and 30 box fans had been added to the facility and the facility was not able to maintain the regulation of 71 F to 81 F for resident comfort and safety. -Their review of the facility's temperature log found the highest temperature of 95.5 F in the building and the lowest temperature found was 81 F. Observation on 8/21/23 at 7:40 P.M., showed the contracted AC Repair Company arrived at the facility to evaluate and repair the facility's HVAC chiller system unit. During an interview on 8/21/23 at 8:28 P.M., the Administrator said: -On Sunday 8/20/23 it had been reported to him/her the facility air temperatures were increasing and not maintained in range of 71 F to 81 F. -The facility had planned on Monday 8/21/23 to increase the number of industrial AC units in the buildings. -The facility had obtained four more industrial AC units in the morning of 8/21/23. -The facility contracted AC repair staff thought they would be able to get the chiller working completed that night or first thing in morning. -The facility was working on an evacuation plan if unable to fix the facility HVAC system or if the facility was unable to maintain temperatures within the range of 71-81 F. Observation on 8/21/23 at 8:30 P.M. to 8:55 P.M., showed: -Resident room [ROOM NUMBER] 86.5 F. -Resident room [ROOM NUMBER] was 86.7 F, the door was shut. -Resident room [ROOM NUMBER] was 84.5 F. -Resident room [ROOM NUMBER] was 86.7 F. -Resident room [ROOM NUMBER] was 85.6 F. -Resident room [ROOM NUMBER] was 84.3 F, the door was shut. -Resident room [ROOM NUMBER] was 82.8 F. -Resident room [ROOM NUMBER] was 87 F. -Resident room [ROOM NUMBER] was 88.9 F. -Resident room [ROOM NUMBER] was 87.9 F, -Resident room [ROOM NUMBER] was 88.9 F. -Resident room [ROOM NUMBER] was 81.9 F. -The hallway outside of room [ROOM NUMBER] and room [ROOM NUMBER] was 83.4 F. Observation and interview on 8/21/23 at 8:42 P.M., Resident #600 said: -He/she was more anxious and still heavy breathing -The room temperature was 81.5 F. During an interview on 8/21/23 at 9:50 P.M., the Administrator said: -The AC contractor was able to fix the loop on the chiller. -The facility HVAC system also had blockage of the water systems that supplies water to the HVAC chiller units. -The AC contractor said it could take a while to cool down the facility, since there was such high temperatures in the building and it could possibly take two days to cool down. -The facility was aware of four room units that were not working and were waiting on parts for those room units. Observation on 8/21/23 at 10:55 P.M. to 11:03 P.M., showed: -Resident room [ROOM NUMBER] was 86.3 F, the door was shut. -Resident room [ROOM NUMBER] was 87.2 F. -Resident room [ROOM NUMBER] was 87.2 F, the door was shut. Observation on 8/22/23 at 12:00 A.M. to 1:00 A.M., with facility Administrator and Director of Nursing (DON) showed there were 46 resident rooms out of 65 resident rooms recorded over 81 F. -Resident room [ROOM NUMBER] had highest temp of 88.5 F, the room AC was not on. Observation and interview on 8/22/23 at 8:44 AM., Resident #621 showed: -He/she said the AC unit in room was broken. -Had not been working for several months. -He/she said the temperature had improved overnight but was still hot in room. -The temperature was 82.9 F. Observation on 8/22/23 at 8:44 A.M. to 8:52 A.M., showed: -Resident room [ROOM NUMBER] was 85.2 F. -Resident room [ROOM NUMBER] was 85.8 F. -Resident room [ROOM NUMBER] was 86.1 F. -Resident room [ROOM NUMBER] was 85.6 F. -Resident room [ROOM NUMBER] was 87 F. -Resident room [ROOM NUMBER] was 95.1 F. -Resident room [ROOM NUMBER] was 95.5 F. -Resident room [ROOM NUMBER] was 94.4 F. -Resident room [ROOM NUMBER] was 93 F. -Resident room [ROOM NUMBER] was 87.8 F. -Resident room [ROOM NUMBER] was 85.3 F. -Resident room [ROOM NUMBER] was 84.2 F. -Resident room [ROOM NUMBER] was 84.2 F. During an interview on 8/22/23 at 9:00 A.M., the Administration said: -The facility HVAC chiller unit had stopped working again and the facility building and resident room temperatures were increasing. -The facility had already sent out seven COVID-19 positive residents to three different hospitals. Review of Resident #617's Quarterly MDS, dated [DATE], showed he/she: -Was severely cognitive impairment. -He/she was able to understand others and make his/her needs known. -Required the use of a wheelchair. -Required limited assistance with all cares of one staff member. -Had a diagnosis of Parkinson disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Observation on 8/22/23 between 3:00 P.M. to 4:30 P.M., of the resident showed: -He/she was sitting in a wheelchair by the front desk, when unknown facility staff noticed the resident was sweaty, and had slow response to commands, the staff person moved the resident toward to the fans. -Nursing staff assessed the resident to include vital signs and applied ice to back of the resident neck. -Fire first responder personal who were onsite to evacuate, reassessed the resident and made the decision to call for an ambulance to transport the resident to the hospital for further evaluation and treatment. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level L. 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. A 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 F 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 administration failed to recognize the need to evacuate the facility after temperatures exceeded regulatory requirements for an extended amount of time and to ensure their emergency plan was developed to include all required components. Additionally, the facility failed to evacuate the residents in an orderly, organized manner, which included finding placement and transportation for residents, sending residents medical records, medications, code status, COVID 19 status, and staff with residents to the receiving facilities. The failures delayed evacuation and jeopardized the health and safety for all residents and staff. The facility census was 110 residents. The Administrator was notified on [DATE] at 10:15 A.M., of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's undated Evacuation Instruction sheet showed: -During a general evacuation of the building, the command post and assembly area will be in the front parking lot in front of the Virgin [NAME] statue. -Gather ambulatory residents together and appoint staff member to lead them to the assembly area. Do not leave ambulatory residents unattended. Special care residents such as wheelchair (will appoint staff to use any and all wheelchairs to move these resident to the assembly area, when possible staff member will take the wheelchair back to assist in the evacuation), bed confined or total care (could roll bed to the assembly area), bariatric resident (don't try move these resident by yourself). -Once the Evacuation is ordered, call 911 for assistance. Do not assume help is on the way. --Begin plan designation for staff member and establish command post. You may have to delegate roles to staff members in the absence of front line responders. Follow the producers in the front of the manual for front line responders and make sure if you assign a role to someone, they know what responsibilities they have. Review of the facility's Code White-Extreme Weather policy, dated [DATE], section of the Facility's Emergency preparedness binder showed: -Provided staff specific guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety of resident and staff in the event of extreme weather, temperatures related conditions. -Know the definition and signs of Heat exhaustion (a disorder resulting from overexposure to heat and sun) and Heat Stroke (a profound disturbance of the body's heat-regulation mechanism, caused by prolonged exposure to excessive heat, particularly when there is little to no circulation of air). -The following measures should be taken during extreme heat and humidity include: --Increase fluid intake by providing and encouraging fluids depending upon the individual resident's physical condition and as determined by the nursing staff. --Encourage resident to wear suitable clothing in the facility, i.e., loose fitting, light weight clothing. Strongly encourage the removal of any additional layers of clothing such as sweater, jackets or hats. --Encourage resident to reduce or eliminate any strenuous physical activity. --Discourage resident from going outside and or longer periods of time when the outside temperatures are in 90 degrees Fahrenheit ( F), or if heat index of 90 F. --Encourage resident to leave their bedroom doors open to ensure adequate air flow. --If air conditioning units fail in an area of the facility and or the temperature becomes uncomfortable, upon direction of administrative personnel, resident affected may be moved to another room and or area in the facility where the temperature is adequate. -Internal building temperatures may be taken in various location of the building, including areas occupied by the residents, at regular intervals particularly between 8:00 A.M. to 10:00 P.M. -Close the windows, blinds or curtains when exposed to direct sunlight and or hot wind. -Immediately report any difficulties in the air conditioning unit to the facility Director of Plant Operations. -Temperatures may be taken by facility Director of Plant operations, his/her assistant and or the Nursing supervisor and his/her designee to monitor the temperature and determine the cooler room's area within the facility as necessary. -Use additional fans in various locations throughout the building to circulate airflow as needed. Review of the facility undated emergency red book contacts showed: -The facility number one place for resident evacuation was not a home in the area. -Had number of roof top air conditioners contractor. -Express Transportation. -A boiler contract company. -A list of area Emergency Coordinator and phone numbers. -Facility Administration staff and numbers. Review of the facility's emergency preparedness plan in a binder entitled Emergency Operations Plan, obtained from the nurse station and last revised on [DATE], showed the following: -On pages #21 and #22 with the headings Extreme Weather - Cold and Extreme Weather - Hot, neither policy mentioned a procedural method to maintain temperatures in resident areas at comfortable and safe levels at all times in the event of a power outage and/or HVAC failure, including what those levels are (71 to 81 degrees Fahrenheit), who would be responsible for monitoring the inside temperatures, where they would be measured, what means would be used to measure them, and how often they would be measured. Review of the National Weather Service Website showed an [DATE]-25 Historic Heatwave. Starting on [DATE] well-above normal temperatures impacted the central part of the United States, kicking off a heatwave that has not been experienced in the region in recent history. Kansas City International Airport reached high temperatures not recorded in the area since August of 2012. This stretch of hot weather was accompanied by extremely high dewpoints, which frequently reached the upper 70s to middle 80s across the entire area. The combination of the extreme heat and the excessively high dewpoints led to heat indices from [DATE] through [DATE] to rise to ,d+[DATE] degrees. Review of Climatological Data for Kansas City Area, MO (ThreadEx), dated [DATE], showed: -On [DATE], the maximum temperature was 102 F, the minimum temperature was 73 F and the average temperature was 83.5 F. Heat index was 119 F. -On [DATE], the maximum temperature was 98 F, the minimum temperature was 77 F and the average temperature was 85.5 F. Heat index was 117 F. -On [DATE], the maximum temperature was 99 F, the minimum temperature was 80 F and the average temperature was 87.5 F. Heat index was 122 F. -On [DATE], the maximum temperature was 99 F, the minimum temperature was 79 F and the average temperature was 86 F. Heat index was 116 F. 1. During interviews on [DATE] at 9:50 A.M. and 8:28 P.M., the Administrator said: -On Sunday [DATE] it had been reported to him/her the facility air temperatures were increasing and not maintained in range of 71 F to 81 F. -The facility plan on Monday [DATE] was to increase the number of industrial AC units in the buildings. -The facility had obtained four more industrial AC units that morning. -The AC contractor had been at the facility and was able to fix the loop on the chiller. -The facility HVAC system also had a blockage of the water systems that supplies water to the HVAC units and would need to be fixed. -AC contractor said the facility building could take a while to cool down since it had such high temperature in the building (Possible one to two days to cool down the building). -The facility was aware four room units were not working, were waiting on parts to fix those units and residents remained in those rooms with AC units not working. Observation on [DATE] from 3:25 P.M. to 4:02 P.M., showed: -Resident room [ROOM NUMBER] was 84.3 F. -Resident room [ROOM NUMBER] was 86.3 F. -Resident room [ROOM NUMBER] was 85.6 F. -Resident room [ROOM NUMBER] was 87.4 F. -Resident room [ROOM NUMBER] was 85.7 F. -Resident room [ROOM NUMBER] was 87.4 F. -Resident room [ROOM NUMBER] was 90.5 F. -Resident room [ROOM NUMBER] was 88.4 F. -The hallway outside of resident room [ROOM NUMBER] was 85.5 F. -The hallway outside of resident room [ROOM NUMBER] was 85.5 F. -The hallway outside of resident room [ROOM NUMBER] was 84.0 F. Observation on [DATE] at 4:20 P.M. to 4:50 P.M., showed: -Resident room [ROOM NUMBER] was 87.8 F. -Resident room [ROOM NUMBER] was 84.5 F. -Resident room [ROOM NUMBER] was 84.8 F. -Resident room [ROOM NUMBER], the A/C unit had no air, there were four fans in use in the room and the resident's hair was wet from sweating. -Resident room [ROOM NUMBER] was 89.6 F and the door was found shut. -Resident room [ROOM NUMBER] was 89.2 F with two bed bound residents. -The hallway outside of room [ROOM NUMBER] was 83.8 F. -The facility main dining room was 82.0 F with 10 residents in the space. During an interview on [DATE] at 6:09 P.M., the Administrator, Regional Support Specialist, and Regional Care Coordinator said: -Four additional industrial AC units and 30 box fans had been added to the facility and the facility was not able to maintain the regulation of 71 F to 81 F for resident comfort and safety. -Their review of the facility's temperature log found the highest temperature of 95.5 F in the building and the lowest temperature found was 81 F. -The plan was to shelter in place as it was resident rights. During an interview on [DATE] at 6:50 P.M., the Administrator said: -The HVAC company would be on-site in the next 30 minutes to assess the whole system. -The facility had 10 large air conditioner units already and another 4 were being delivered the next morning. -They could not get the units that night, because there was nobody to deliver them. -The plan was to do temperature checks every three hours. -The director of maintenance was checking them at that time. -He/she would check the temperatures at 10:00 P.M., and the front door person would check them during the night. -There was an evacuation plan, which was to move as many residents as possible to sister facilities located in Festus, Missouri which is four hours from the facility and Toganoxie, Kansas which is 40 minute trip. -The facility had two buses. -The staff were checking the residents to make sure they had fans and water, and were doing okay. -Ice water would be given to everyone. During an interview on [DATE] at 8:28 P.M., the Administrator said: -The facility contracted AC repair staff thought they would be able to get the chiller to work completed that night or first thing in morning. -The facility was working on an evacuation plan of the building, if the facility was unable to fix the HVAC system or if the facility was unable to maintain temperature within the range of ,d+[DATE] F. Observation on [DATE] at 8:30 P.M. to 8:55 P.M., showed: -Resident room [ROOM NUMBER] 86.5 F. -Resident room [ROOM NUMBER] was 86.7 F, the door was shut. -Resident room [ROOM NUMBER] was 84.5 F. -Resident room [ROOM NUMBER] was 86.7 F. -Resident room [ROOM NUMBER] was 85.6 F. -Resident room [ROOM NUMBER] was 84.3 F, the door was shut. -Resident room [ROOM NUMBER] was 82.8 F. -Resident room [ROOM NUMBER] was 87 F. -Resident room [ROOM NUMBER] was 88.9 F. -Resident room [ROOM NUMBER] was 87.9 F, -Resident room [ROOM NUMBER] was 88.9 F. -Resident room [ROOM NUMBER] was 81.9 F. -The hallway outside of room [ROOM NUMBER] and 215 was 83.4 F. Observation on [DATE] at 8:44 A.M. to 8:52 A.M., showed: -Resident room [ROOM NUMBER] was 85.2 F. -Resident room [ROOM NUMBER] was 85.8 F. -Resident room [ROOM NUMBER] was 86.1 F. -Resident room [ROOM NUMBER] was 85.6 F. -Resident room [ROOM NUMBER] was 87 F. -Resident room [ROOM NUMBER] was 95.1 F. -Resident room [ROOM NUMBER] was 95.5 F. -Resident room [ROOM NUMBER] was 94.4 F. -Resident room [ROOM NUMBER] was 93 F. -Resident room [ROOM NUMBER] was 87.8 F. -Resident room [ROOM NUMBER] was 85.3 F. -Resident room [ROOM NUMBER] was 84.2 F. -Resident room [ROOM NUMBER] was 84.2 F. During an interview on [DATE] at 9:00 A.M., the Administration said: -The facility HVAC chiller unit had stopped working again and the facility room temperatures were increasing. -The facility had already sent out seven COVID-19 positive residents to three different hospitals. During an interview on [DATE] at 9:48 P.M., Regional Care Coordinator, Director of Nurses (DON) and Assistant Director of Nurses (ADON) said: -The facility administration had asked all residents if they wanted to shelter in place at the facility or to leave the facility. -The facility administration said they had a combination of resident for both options. -Those residents requesting to leave the facility would be sent to assigned facilities and other residents would be shelter in place at the facility. -The facility was working on making the main dining area and that hallway the cooling center for the facility. -Plans were to bring in resident beds for those resident who required or wish to stay to dining area. -The facility also ensured one shower room would be setup as cooling place to be able to continue resident personal care needs and located on the 100 hallway. -The AC contracted company would be at the facility as soon as possible, to place the new chiller pump and to flush pump system. -The facility was having more AC industrial units delivered that morning. -Seven residents had already been sent to three different hospital due to COVID-19 positive. -The facility had two additional residents test positive for COVID-19. -The facility felt the temperature were coming down slowly. -It was arranged for a sister facility or an area facility to take 50 residents and another would take 30 residents. -The facility was in process of making a tracking form for where the residents would be assigned to go. Observation on [DATE] at 9:45 A.M., showed: -Staff were informing other staff the evacuation would take place and residents had a choice whether or not to evacuate. -Staff were told they would go with residents to the receiving facilities. During an interview on [DATE] at 10:00 A.M., the Regional Care Coordinator said: -Residents were sheltering in place in the 200 hall. -The temperature was coming down in the dining room. -They were trying to work out how many beds would fit in the dining room. -If they were not able to get that area chilled, all residents would be transferred out. -Elopement residents would be requested to transfer to a facility with a locked unit, who would keep them even after an evacuation. -Seven residents had been transferred to three different hospitals due to being COVID-19 positive. Observation on [DATE] at 10:25 A.M., the main entrance area showed two residents with suit cases out 6 resident that were in the entrance area, and waiting to be transported to another facility. Observation on [DATE] at 10:50 A.M., showed: -Several shirtless residents were observed to be congregating in the 100 hallway and another was only wearing shorts sitting in a wheelchair. -Many residents were still in bed or watching television. -Staff were checking room temperatures from the doorways. Observation on [DATE] at 1:10 P.M., showed the back 200 hallway was blocked off with all facility medication carts as the DON, ADON, and unknown CMT sorted through medication to be sent with the residents who were leaving the facility. Observation on [DATE] at 1:14 P.M., showed the city Emergency Management Team arrived at the facility and was observed coordinating with facility administration staff on the facility plan for evacuation of all residents. Observation on [DATE] at 2:05 P.M., showed the first load of residents left the facility in a large city bus and smaller bus. No medical record paperwork was sent with the residents. Observation on [DATE] at 3:15 P.M., showed the next bus loaded with residents with their facesheets left for a receiving facility. Observation and interview on [DATE] at 7:09 P.M., the Administrator said: -He/she was going to all facilities to follow-up on the residents and deliver residents medication where needed. -The last resident signed out and left the facility with a family member. -The facility had completely evacuated all resident from the facility. During an interview on [DATE] at 3:20 P.M., the Assistant Director of Nursing (ADON) said: -He/She could not say they had evacuation training during orientation. -During the evacuation, the unit nurses would have been in charge of assigning staff where to go and what to do. -He/She had provided oversight, resident medications were being pulled for each resident and sent to the appropriate facility. -The staff worked together to print the residents' paperwork. -He/She thought most facilities could have done their evacuation process very quickly. -He/She wanted the residents to be moving with urgency related to the emergency. -He/She did not know if the certified nurse aides (CNAs) were assigned to tasks. -He/She was providing oversight for the process. -He/She thought the Director of Nursing (DON) had the emergency book that had all residents' face sheets and physician order sheets, so if there was a problem during the process there would be a backup plan. During an interview on [DATE] at 8:55 A.M., Administrator B said: -The facility Administrator had called them to see if they had beds available to take residents as they were evacuating. -22 residents arrived from the facility on [DATE] with no face sheets, no medications, no belongings, and no code status. -He/she had sent his/her staff to the facility in the evening of [DATE] to attempt to get some of the resident medications and belongings. -No facility staff were sent with the facility residents on [DATE] or thereafter to assist. During an interview on [DATE] at 12:10 P.M., CNA G said: -When it was time for the residents to be evacuated he/she was instructed to bring the residents to the lobby by the DON, with two to three days worth clothing. -The DON was instructing the staff where the residents were to be going. -He/She did not ride with any residents during the evacuation. -He/She was told to report to the new facility the next day and he/she did. During an interview on [DATE] at 12:15 P.M., CNA H said: -His/Her role during the evacuation was to pack clothing, pass water, and take residents outside to the transportation. -He/She was supposed to ensure each resident had two to three changes of clothing, a water bottle, and any small personal items the resident wanted. -When he/she took the residents outside there was a checklist of which residents were going to which facility and on what bus the resident was to go. -The checklist was being managed by CNA F and you would check in with him/her and be told where to take the resident. -No one from the facility notified him/her where the residents were going. -When he/she took the residents out the CNA with the clipboard would tell him/her where the residents were going, but the fire department, and the ambulances were also telling him/her where residents were going. -There was no single point of contact to find out where the residents were going. It was very chaotic. -He/She did not ride any of the buses with the residents evacuated. -The DON and administration were telling staff where to go and when to be there. During an interview on [DATE] at 12:40 P.M., CNA J said: -He/She was off the day of the evacuation. -No one from the facility called to have him/her report for the emergency. -He/She called the staffing office when he/she heard of the evacuation from coworkers who had texted and called him/her and advised of the situation to find out where she was to report to. -He/She was given the choice of three facilities and he/she chose the facility where to report to and today was his/her first day to work. During an interview on [DATE] at 12:45 P.M., Registered Nurse (RN) A said: -During the evacuation he/she assisted in getting all the residents property together, and ensured the residents were taken up to the lobby. -The residents were to have two changes of clothing. -Other nurses and Certified Medication Technicians (CMT) were boxing up medications and the mediations were to be sent later. -The DON, ADON, a nurse, and CMT delivered the medications for the residents to the facilities where the residents were at. -The front office was in charge of the medical records to include the do not resuscitate (DNR) forms. -The DNR form should have been a part of the medical record. -He/She was given a piece of paper to where the residents were to go by administration, but which resident was going to which facility kept changing. -He/She did not ride with any resident on the evacuation transportation. -He/She was told by staffing where to respond. During an interview on [DATE] at 12:59 P.M., CNA D said: -His/Her role during the evacuation was to work the front desk answering the phones and monitoring the residents in the lobby. -When it was time, he/she would help the residents to the buses for evacuation. -He/She would take the residents out of the building and proceed to the buses where the firefighters and ambulance crews told him/her which bus to put residents on, and no one from the facility was directing which bus the residents were to get on or which facility the resident was to go. -He/She stayed at the facility to help with the evacuation and did not ride on any of the buses with the residents. -He/She was told to report to the new facility on [DATE]. During an interview on [DATE] at 1:05 P.M., Licensed Practical Nurse (LPN) C said: -He/She was at home and off work during the evacuation. -The facility did not call him/her to come in for the emergency. -He/She went to work at the evacuated facility on [DATE] and was told to which facility he/she needed to respond to. During an interview on [DATE] at 1:19 P.M., Graduate Nurse (GN) A said: -He/She was not part of the evacuation. -Human Resources called him/her at home and told her which facility he/she would need to report to. During an interview on [DATE] at 1:34 P.M., CMT D said: -He/She was helping to get the residents medication together and helping get residents to the lobby for evacuation. -Each resident was to have two to three days worth of clothing along with briefs, and whatever small personal items they wanted to bring. -The resident's medications were put on the transportation bus for the residents on the bus. -Social Services was faxing all the residents' medical records to the receiving facilities. -The signed DNR forms should have been faxed to the receiving facilities along with the medical records. -He/She did not help take the residents from the lobby to the buses. -He/She was getting the medication boxes organized, labeled with receiving facility name and all the residents going to that facility had the medications placed in the box. -The box was then taken to the bus by staff. -He/She could not remember which staff were taking medications to which bus. -Human Resources gave him/her a list of names by receiving facility and which residents were going to that facility, and that was how he/she packaged the medication by facility per resident. -He/She did not ride in any of the buses with the residents he/she stayed at the evacuated facility to help out there until 8:30 P.M. -The staffing coordinator told him/her which facility to report to on [DATE] and he/she was to stay at that facility until told to return to the evacuated facility. During an interview on [DATE] at 10:11 A.M., Fire Department Division Chief for EMS (Emergency Medical Services) said: -On [DATE] the facility had two call outs, he/she was part of the first call out to transport 7 COVID-19 positive residents to the hospital since they were not tolerating the heat well. -When he/she arrived to the facility, one [NAME] and ambulances had begun to arrive. -The facility staff had provided facesheets for the residents and his/her team took the residents to their hospital of choice. During an interview on [DATE] at 10:29 A.M., Fire Department Deputy Chief EMS said: -He/she was part of the facility evacuation on the second round. -Agencies involved included, the fire department, the local police for traffic control, the city buses, Mid America Regional Council, KC Emergency Operation Center. -2 strike teams were designated for the facility evacuation. -His/her staff had followed procedures, went down each hallway checked every room, every closet, bathroom and would shut the door when the space was cleared. -The facility staff would go behind the emergency personnel and reopen the doors, take residents back down the hallways to their rooms after the area had been cleared causing emergency personnel to have to start over. -No staff would acknowledge who was in charge, when asked the staff would scatter. -Staff dressed in business casual were noted in business offices with portable A/C units while the fire department did the heavy lifting and denied being in charge. -The facility staff and facility administration were of no assist. -He/she gave the facility administration over two hours to provide a manifest (list of residents and what locations) to evacuate when he/she took over about 3:00 P.M. -He/she had residents placed on buses, facility staff would take the residents off the buses and ask the residents what facility they wanted to go to. -The Administrator said they needed to give the residents a choice. -He/she told the Administrator it was only getting hotter, it was the hottest day of the year and there was not a choice. -About 1:20 P.M., the fire department had brought misters (spraying water) and placed outside, as well as water bottles and cups. The facility had only one carafe set-up for a hydration station for the residents. -Not a single facility staff person would say they were in charge. -He/she asked more than once who was in charge. -He/she asked more than once for the facility emergency plan and did not receive it. -Most of the residents were lovely, all who could verbalize said they were hot, many had questions as to what was happening. -One resident did become angry, refused to get on a bus, was hostile with the facility staff and emergency personnel, he/she confirmed the resident was his/her own person and the resident took off on foot. No staff jumped in to follow the resident as he/she took off and attempt to redirect. -The facility had one bariatric resident who was in the back of the building and bed bound. No facility staff reported he/she was back there until EMS personnel found them when clearing the halls. -He/she was told the facility had 7 residents who could not just go anywhere, he/she asked the facility staff to gather these residents in one place and transport would be arranged, the staff would not cooperate or coordinate. -No medications or paperwork went on the buses with any residents. -No facility staff went on the buses to assist with the residents, only EMS personnel. -3 city buses were provided for the evacuation. -The Mass Casualty Trailer (MCT) was brought onsite to have emergency supplies available. -The facility was hot, the residents were visibly hot and perspiring, the EMS personnel was soaked in perspiration down to the undergarments. -The Administrator tried to say EMS needed to give them a chance to ask the residents what they wanted, he/she told him it did not work that way. -The last residents were removed form the building by them at 5:59 P.M. During an interview on [DATE] at 11:12 A.M., Administrator C said: -On [DATE]: --The facility Administrator had made contact about 8:00 A.M., and asked if resident beds were available for an evacuation. --At 11:30 A.M., the facility Business Office Manager sent a list of people, including a list of COVID-19 positive residents that were sent to the hospital as possible temporary admissions. --At 2:30 P.M., 2 city buses showed up with 28 residents, none had their medications, some had facesheets, and there were no staff present. --Some of the residents who arrived on the buses were not on the resident list emailed previously. --The facility had called later and asked if staff were needed, the answer was yes and staff arrived about dinner time. --At 6:23 P.M., a medication cart arrived at the facility with some of the residents medication. --At 10:15 P.M., the medications for the remaining residents were sent. -On [DATE] it was observed the residents had needed psychosocial supports, the facility was contacted and requested to send over their social worker, the social worker was out and no staff were sent to support the psychosocial needs of the residents. -The facility did not provide an order or documentation for the residents DNR resulting in one resident on [DATE] who was a DNR status to have life saving measures including cardio pulmonary resuscitation (CPR) during a cardiac event. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level L. 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. A 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 F 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). MO00223378

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus SARS-CoV-2) and other infections when staff failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate six sampled residents (Resident #604, #605, #606, #607, #608 and #88) who tested positive for COVID-19 from six sampled residents (Resident #609, #610, #611, #612, #613 and #504), who had tested negative for COVID-19. One sampled resident (Resident #609) turned COVID-19 positive on 8/22/23 after sharing a room with a COVID-19 positive resident (Resident #604) who was diagnosed with COVID-19 on 8/18/23, out of sample of 37 sampled residents. The facility census was 110 residents. The Administrator was notified on 8/24/23 at 10:15 A.M., of the Immediate Jeopardy (IJ) which began on 8/18/23. The IJ was removed on 8/22/23, as confirmed by surveyor onsite verification. Review of reference from the Center for Disease Control and Prevention (CDC), updated 5/8/23, showed: -The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. -Section two: recommended Infection Prevention and Control Practices when caring for resident with suspected or confirmed SARS-CoV-2 infection showed: These residents should not be cohorted with residents who were confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. -Placement of the resident with suspected or confirmed SARS-CoV-2 infection in a single person room. The door should be kept closed and ideally the resident should have a dedicated bathroom. -Section under nursing homes showed: ideally the resident should be placed in a single-person room. -If limited single rooms are available, or if numerous resident are simultaneously identified to have SARS-CoV-2 exposure or symptoms concerning for COVID-19, resident should remain in their locations. Review of the facility Infection Control Interim Policy related to Human Corona Virus, revision on 3/16/21, showed: -Cohorting resident on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected resident. If cohorting symptomatic residents, care should be taken to ensure infection prevention and control intervention are in place to decrease the risk of cross-transmission. -Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if all possible should not share rooms with other residents unless they remain asymptomatic and/or have tested negative. 1. Review of Resident #604's Face Sheet showed he/she was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Review of the resident's Nursing Note, dated 8/18/23 at 3:08 P.M., showed: -Resident tested positive for COVID-19, vital signs taken and oxygen saturation levels (the amount of oxygen carried by red blood cells) was at 92% (The normal oxygen saturation level is from 97% to 100%). -Had complaints of cough, congestion, runny nose and body aches pains. -The resident was dependent with cares and will remain on isolation precaution for COVID-19. Resident's physician was notified of positive COVID test and symptoms. Observation on 8/21/23 at 3:09 P.M. to 3:26 P.M., of the resident showed: -The resident was in his/her room and shared a room with COVID negative Resident #609. 2. Review of Resident #605's Face Sheet showed he/she was admitted to the facility with a diagnosis of stroke affecting left side. Review of the resident's Nursing Note, dated 8/20/23 at 10:26 A.M., showed: -Resident tested positive for COVID-19. -The resident was informed to stay in his/her room. -The resident's physician was notified of positive COVID test and management notified. -Nursing staff will continue to monitor the resident for any change of condition. Observation on 8/21/23 at 3:09 P.M. to 3:26 P.M., of the resident showed: -The resident was in his/her room and shared a room with Resident #610 who was covid negative. 3. Review of Resident #606's Face Sheet showed he/she was admitted to the facility with a diagnosis of moderate intellectual disabilities. Review of the resident's Nursing Note, dated 8/20/23 at 10:20 A.M., showed: -Resident tested positive for COVID-19. -The resident was informed to stay in his/her room. Observation on 8/21/23 at 3:09 P.M. of the resident showed: -The resident was in his/her shared room with his/her COVID negative roommate Resident #611. -He/She shared a private bathroom with COVID negative roommate, Resident #611. 4. Review of Resident #607's Face Sheet showed he/she was admitted to the facility with a diagnosis of dementia. Review of the resident's Nursing Note, dated 8/20/23 at 4:00 P.M., showed: -Resident tested positive for COVID-19. -The resident was informed to stay in his/her room. -Nursing staff will continue to monitor the resident for any change of condition. Review of the resident's Nursing Note dated 8/21/23 at 3:49 P.M., showed: -The resident refuses to wear a mask or stay in his/her room. -The resident was COVID positive and wanted to use the telephone and for staff to give to him/her. The resident has nasal congestion. No cough noted. -The resident went out to smoke with others and said he/she was not sick. -The resident educated on importance of not spreading the disease, but not effective. Observation on 8/21/23 at 3:12 P.M., the resident showed: -The isolation (ISO) room door was open and the resident had just exited out of the shared bathroom. -The resident privacy curtain was not pulled and did not have a mask on at that time. -Roommate Resident #612 (who COVID-19 negative) was also in room and did not have mask on. 5. Review of Resident #608's Face Sheet showed he/she was admitted to the facility with the following diagnoses of: -Cancer of the bladder. -admitted to hospice (end of life) services. Review of the resident's Nursing Note, dated 8/20/23 at 10:17 A.M., showed: -Resident tested positive for COVID-19. Observation on 8/21/23 at 3:09 P.M., of the resident showed: -The resident was in his/her room with his/her Covid negative roommate, Resident #613. Review of the resident's Nursing Note, dated 8/22/23 at 12:42 A.M., showed: -The resident being monitored due to having COVID-19. -Vital signs taken and had a temperature of 99.1 degrees Fahrenheit ( F) (The average normal temperature is 98.6 F). -The resident had no complaints at that time. 6. Review of Resident #88's Face Sheet showed he/she was admitted to the facility with the following diagnoses of Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). Review of the resident's COVID-19 testing verification dated 8/21/23, no time when tested showed the resident tested positive for COVID. Review of the resident's Nursing Note, dated 8/21/23 at 5:34 P.M., showed: -The resident was not feeling well and went to nurse with complaints of dizziness and not feeling well in general with a low grade temperature of 99 F and oxygen saturation levels at 93%. -The resident tested positive for COVID-19. During an interview on 8/22/23 at 10:32 A.M., Director of Nursing (DON) said: -Resident #88 tested positive for COVID-19 on 8/21/23. -Resident #88 did have a roommate, Resident #511 who tested negative for COVID on 8/21/23. 7. Review of Resident #609's Face Sheet showed he/she was admitted to the facility with the following diagnoses: -Dementia. -Type 2 Diabetes Mellitus with hyperglycemia (happens when the body has too little insulin or when the body can't use insulin properly, with high blood sugars). Review of the resident's COVID-19 testing verification dated 8/18/23, no time when tested , showed the resident tested negative for COVID. Review of the resident's roommate, Resident #604 showed he/she had tested positive on 8/18/23. Observation on 8/21/23 at 9:35 A.M., of the resident's room showed: -The resident was in his/her room in isolation with COVID positive roommate, Resident #604. -Did not have face mask on and privacy curtain (to be used as barrier) was not pulled. Review of the resident's Nursing Note, dated 8/21/23 at 1:40 P.M., showed: The resident refused to stay in his/her room. -The staff educated the resident on importance of not spreading disease, his/her roommate had COVID-19. -The resident kept getting out of his/her room and propelling himself/herself wherever he/she wanted to go in the facility. -The resident said he/she does not care and he/she was not sick. Review of the resident's COVID-19 testing verification, dated 8/22/23, no time when tested , showed the resident tested positive for COVID. During an interview on 8/22/23 at 10:32 A.M., DON said: -The facility had two additional residents test COVID-19 positive. -Resident #609 tested positive for COVID-19 on 8/22/23. -He/she was roommate to Resident #604 who tested positive on 8/18/23 and had been cohorting with negative resident. 8. Review of Resident #610's Face Sheet showed he/she was admitted to the facility with the following diagnoses of: -Multiple Sclerosis (MS, is a potentially disabling disease of the brain and spinal cord (central nervous system). -History of COVID-19. -Dementia. Review of the resident's COVID-19 testing verification, dated 8/20/23, no time when tested , showed the resident tested negative for COVID. Review of the resident's Nursing Notes for 8/1/23 to 8/22/23 showed the resident had no documentation that he/she was placed in isolation due to his/her roommate Resident #605, had tested positive for COVID-19 on 8/20/23. Review of the resident's Physician Order Sheet (POS) and TAR from 8/1/23 to 8/31/23 showed no physician order documented for monitoring for signs and symptoms or for testing the resident for COVID-19. Observation on 8/21/23 at 9:35 A.M., of the resident's room showed: -The resident was in isolation with covid positive roommate, Resident #605. 9. Review of Resident #611's Face Sheet showed he/she was admitted to the facility with the following diagnoses of: -Past history of COVID-19 on 8/11/22. -Cancer of the breast. -Dementia. Review of the resident's roommate Resident #606, showed he/she had tested positive on 8/20/23. Review of the resident's COVID-19 testing verification dated 8/20/23, no time when tested showed the resident tested negative for COVID. Review of the resident's Nursing Notes, dated 8/1/23 to 8/22/23, showed the resident had no documentation that Resident #611 was placed in isolation due to his/her roommate Resident #606, had tested positive for COVID-19 on 8/20/23. Review of the resident's POS and TAR, dated 8/1/23 to 8/31/23, showed no physician order documented for monitoring for signs and symptoms COVID-19 or for testing the resident for COVID-19. Observation on 8/21/23 at 9:37 A.M., of the resident's room showed: -The resident was in his/her room with his/her positive roommate, Resident #611. -The resident did not have face mask on while in room. 10. Review of Resident #612's Face Sheet showed he/she was admitted to the facility with a diagnosis of Diabetes Mellitus. Review of the resident's COVID-19 testing verification dated 8/20/23, no time when tested showed the resident tested negative for COVID. Review of the resident's roommate, Resident #607 showed he/she had tested positive on 8/20/23. Review of the resident's Nursing Notes , dated 8/1/23 to 8/22/23, showed the resident had no documentation that Resident #612 was placed in isolation due to roommate, Resident #607 had tested positive for COVID-19 on 8/20/23. Review of the resident's POS and TAR from 8/1/23 to 8/31/23 showed no physician order documented for monitoring for signs and symptoms COVID-19 or for testing the resident for COVID-19. Observation on 8/21/23 at 9:37 A.M., of the resident's room showed: -The resident was in his/her room with positive roommate, Resident #607. -Privacy curtain not pulled. -The resident did not have mask on while in room. -The resident positive roommate, Resident #607 was up ambulating in their room. 11. Review of Resident #613's Face Sheet showed he/she was admitted to the facility with the following diagnoses of: -Dementia. -Chronic kidney disease. Review of the resident's COVID-19 testing verification, dated 8/20/23, no time when tested showed the resident tested negative for COVID. Review of the resident's roommate Resident #608 showed he/she had tested positive for COVID on 8/20/23. Review of the resident's Nursing Notes for 8/1/23 to 8/22/23 showed the resident had no documentation that Resident #613 was placed in isolation due to roommate, Resident #608, tested positive for COVID-19 on 8/20/23. Review of the resident's TAR dated 8/1/23 to 8/31/23 showed: -May perform COVID-19 testing as needed for development of COVID-19 symptoms, routine screening or facility outbreak ordered on 1/17/23. -Had no documentation of the resident COVID-19 testing for that month. Observation on 8/21/23 at 9:37 A.M., of the resident's room showed: -The resident was in his/her room with positive roommate,Resident #608. -Privacy curtain not pulled. -The resident did not have mask on while in room. 12. Review of Resident #504's Face Sheet showed he/she was admitted to the facility with a diagnosis of Chronic Kidney Disease. Review of the resident's COVID-19 testing verification dated 8/15/23, no time when tested showed the resident tested negative for COVID. Review of the resident's Nursing Notes, dated 8/1/23 to 8/22/23, showed the resident had no documentation that Resident #504 was placed in isolation due to roommate, Resident #88 tested positive for COVID-19 on 8/21/23. Review of the resident's TAR dated 8/1/23 to 8/31/23 showed: -May perform COVID-19 testing as needed for development of COVID-19 symptoms, routine screening or facility outbreak ordered on 3/20/23. -Had no documentation of the resident COVID-19 testing for that month. Observation on 8/22/23 at 10:55 A.M., of the resident showed: -He/she was at doorway of room and did not have a mask on. -Certified Nursing Assistant (CNA) communicated with the resident and a COVID negative resident, Resident #511 who resided in the room next door to Resident #504. During an interview on 8/22/23 at 10:55 A.M., RN B said he/she was prepping to COVID test all residents in the building. 13. Review of facility email sent on 8/16/23 to City Health Department showed: -The facility had four positive residents with COVID, who had tested positive on 8/15/23. All residents have been tested , the total census was 108 residents. -The facility had 3.7% of their residents test positive for COVID. -In a 10-day time frame, six facility employees have tested positive for COVID out of 105 employees, which would be 5.7% of employees who have tested positive for COVID. -The facility plan put in place for ongoing COVID testing of the building and staff on Friday 8/18/23 and again on Sunday 8/20/23 per the CDC guidelines. During an interview on 8/21/23 at 9:30 A.M., the Administrator, DON, and Assistant Director of Nursing (ADON) said: -The facility currently had five residents who were COVID positive. -The facility did not have an ISO unit and did not dedicate any rooms for those COVID positive residents. -The facility did not have the extra room to be able to isolate negative residents from positive residents. -The facility was following the Centers for Medicare and Medicaid Services (CMS) Reference QSO-23-13-ALL dated 5/1/23 showed Guidance for expiration of the COVID-19 Public Health Emergency related to cohorting already exposed residents. Observation on 8/21/23 at 9:35 A.M., of the facility isolation residents rooms showed: -Residents that were in isolation room in their rooms due to testing positive for COIVD were Resident #607, Resident #608, Resident #606, Resident #605, and Resident #604. -A few of the residents' doors were open. -The facility had positive resident and negative roommate cohorting in same room. Isolation in place. -The COVID isolation room did not have privacy curtains pulled as a infection control barrier and neither resident wore mask while in room together. During an interview on 8/21/23 at 10:30 A.M., Registered Nurse (RN) A and Certified Medication Technician (CMT) A said: -Resident #604, Resident #605, Resident #606, Resident #607 and Resident #608 were all COVID-19 positive. -Those residents' roommates (Resident #609, Resident #610, Resident #611, Resident #612 and Resident #613) tested negative at that time. -The facility had just tested all residents and staff for COVID-19 on 8/20/23. -RN A said they were to monitor the COVID-19 positive resident and their roommates for signs and symptoms for COVID-19. -The COVID positive residents and COVID negative roommates were to isolate in their room with the door closed, privacy curtain pulled, and encourage use of masks when in contact with roommate. During an interview on 8/21/23 at 10:40 A.M., DON said: -The first COVID-19 positive resident was on 8/15/23. That resident was sent to the hospital on 8/18/23. -The facility completed COVID-19 testing for all residents on 8/20/23. -The CDC guidance reference showed the residents were to be on ISO for three days if already exposed and to maintain those resident in one location. -The positive resident and the negative roommate could isolate together in the same room since they were already exposed to COVID-19 by the roommate. -The Infection Control Preventionist (ICP) had sent an email to notify the city health department of positive COVID-19 residents During an interview on 8/21/23 at 11:55 A.M., Physician A said: -The expectation would be that the facility would follow the current CDC guidance on room placement for residents who were positive for COVID-19. -The COVID-19 positive residents should be in isolation for a period of at least 5 days. -Most of the COVID positive residents were asymptomatic. -For a roommate who tested negative, the guidelines were the wild, wild west (unclear). -The facility tried to isolate the COVID-19 positive residents the best they could. -He/she spoke with Physician B, who was an infectious disease specialist at a hospital out of the area, who said the best thing would be to cohort the COVID-19 positive residents together, but if facility could not find separate isolation rooms, they should do the best they could with isolation in place. -Non-symptomatic residents were probably not contagious at that time. During an interview on 8/21/23 at 12:00 P.M., DON said: -He/she had just talked with County Health Department related to cohorting positive roommates with negative residents. -Was informed that since the roommate had already been exposed, the facility did not need to separate positive and negative roommates. -Recommended isolate in room for five days and to wear a mask for 10 days after isolation. Review of the documentation of conversation with DON and a local County Health Department representative, dated 8/21/23 and untimed, showed: -Related to positive COVID residents in long term care facility with shared semi-private rooms. -The recommendation for semi-private rooms when one resident tested positive and one does not, but is exposed: the residents can stay in the same room together. -Isolation in room for five days and the resident who tested positive should be encourage to wear mask for 5 more days once off isolation. -While in a semi-private room, the resident privacy curtain can be used as a barrier and plastic placed on entrance into the resident room. -Isolation carts should be located at each room that has a COVID-19 positive resident. -Signed by the DON on 8/21/23. During an interview on 8/21/23 at 12:40 P.M., County Health Department said: -The facility did call the county and did inform the facility need to contact the city health department for additional guidance and for reporting of any COVID-19 infections. -He/she did inform the facility, that County Health department was made aware of an other long term care facility who had limtied space, was approved to cohorted roommates together after one resident had tested positive for COVID-19 and the roommate was COVID negative. -Since roommate already exposed would isolate in place for 5 days and the facility uses barriers in room to separate the resident, such as privacy curtain, and encourage the resident to wear masks when in room together. -The facility should be testing the negative roommate two days after exposure of COVID-19 and then follow the recommendation for testing for COVID-19 every 48 hours. During an interview on 8/21/23 at 1:35 P.M., Infection Control Preventionist (ICP) said: -He/she had reported the first positive cases to City Health Department on 8/16/23 after they completed facility COVID testing for resident and staff on 8/15/23. -He/she was not aware of any resident who were immunocompromised. -He/she was responsible for tracking and trending of all infections in the facility. -The facility reference provided was what the facility were following related to care for resident with COVID-19 per CDC and CMS guidance. -It was the facility understanding that residents could cohort together due to the positive resident had already exposed the negative roommate to the virus. -They were to ISO in rooms together. During an interview on 8/22/23 at 9:48 A.M., Regional Care Coordinator, DON and ADON said: -The facility had two additional residents (Resident #88 and Resident #609) test positive for COVID-19 after 8/20/23 testing. During an interview on 8/22/23 at 9:55 A.M., City Health Department staff said: -He/she was not aware if the facility had notified the City Health Department of any positive COVID-19 infection in the facility. -COVID-19 positive residents were not to cohort with negative roommates. -He/she would send the latest information related to care of COVID-19 positive resident. -He/she would have to follow-up with supervisor related to the facility reporting COVID-19 infection from the facility. Review of email the DON had received, that was sent to Physician A from Physician B, dated 8/23/23 at 6:42 A.M., showed: -On 8/22/23 at 8:49 A.M. the Physician A had spoken to Physician B about isolation. It was difficult to isolate in a full building. -The ideal would be to have an empty room, also cohorting residents. -But if these options are not available, you would try your best on isolating in the resident room by leaving the curtains closed between resident. With any resident who are asymptomatic, the likelihood of transmission of COVID-19 would be lower. --Response from Physician B was: he/she agreed, during the quarantine period, the resident should not intermingle with other residents during meals, activities and etc . NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00223251

Based on interview and record review, the facility failed to provide supervision for one sampled resident (Resident #614) who was identified at risk on the facility's elopement risk assessment and was actively exit-seeking prior to the elopement . On 8/17/23 the resident broke out a facility window and walked to a busy street. Licensed Practical Nurse (LPN) A saw the resident on the street, returned to the facility without the resident and reported where he/she last saw the resident. The Administrator was notified and the resident was found three blocks away from the facility out of 37 sampled residents. The census was 110 residents. On 8/24/23 at 10:15 A.M., the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 8/17/23. On 8/17/23 the facility administration was notified of the incident and the investigation was started. No employees were allowed to work prior to reeducation. The IJ was corrected on 8/19/23. Review of the facility's undated Wandering and Elopement policy showed: -If identified as at risk for wandering, elopement or other safety issues, the resident's care plan should include strategies and interventions to maintain the resident's safety. -If an employee observed a resident trying to leave the premises, he/she should attempt to prevent the resident from leaving, in a courteous manner; he/she should get help from other staff members in the immediate vicinity, if necessary; and should instruct another staff member to inform the charge nurse or director of nursing services (DON) that a resident was attempting or had left the premises. -If a resident was missing, the elopement emergency procedure should be initiated, which was to determine if the resident was out on an authorized leave or pass; notifying the administrator and DON, the resident's legal representative, the attending physician, and law enforcement officials, if necessary. -When the resident returned to the facility, the DON or the charge nurse should examine the resident for injuries; contact the attending physician and report findings and condition of the resident; the resident's legal representative should be notified; an incident report should be completed and filed; and relevant information documented in the resident's medical record. 1. Review of Resident #614's facesheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified psychosis not due to a substance or known physiological condition (a mental disorder characterized by disconnection from reality). -Dementia in other diseases classified elsewhere, unspecified severity, (a group of conditions characterized by impairment of at least two brain functions), with psychotic disturbance, (a collection of symptoms that affected the mind, where there was loss of contact with reality). -Unspecified dementia, with agitation, (a state of inner tension and restlessness). -Major depressive disorder, (a mood disorder that produced a persistent feeling of sadness and loss of interest). -Family Member A was the resident responsible party. Review of the resident's hospital medical record, dated 5/31/23, showed he/she needed memory care placement and was an elopement risk. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/14/23, showed: -The resident exhibited behaviors and wandering that had worsened from prior assessment. -He/she had a Brief Interview for Mental Status (BIMS) score of 6 indicating he/she was cognitively impaired. Review of the resident's facility Wandering Risk Scale, dated 7/20/23, showed he/she had a score of 10, which placed him/her in the category of at risk to wander. Review of the resident's progress note, dated 8/17/23 at 4:48 P.M., showed: -He/she broke the window in his/her room, and crawled out the window and began walking down the street towards a busy street. -He/she was observed by staff who was arriving to the facility. -The facility Administrator and the DON were immediately notified. -He/she was located by the facility Administrator. -He/she was returned to the facility by the police. -He/she was initially unwilling to enter the facility. -He/she was accompanied willingly into facility with staff. -He/she was assessed and negative for injury, cuts, or bruising. -Physician A was notified by phone with no new orders received. -Family member was notified via phone. Review of the resident's progress note, dated 8/18/23 at 11:04 A.M., showed: -It was reported by another resident that he/she attempted to exit the facility front door three times by pushing on it to open. -The attempts were unsuccessful. -He/she remained with close protective oversight by staff. Review of the facility's Suspected Abuse Investigation, dated 8/18/23 at 2:00 P.M., showed: -The resident attempted to exit the facility out the front door on the morning of 8/17/23. -After being redirected, he/she went to his/her room and relaxed. -Shortly after lunch, the resident returned to his/her room and physically broke the security lock in order to open the window beyond six inches. -He/she opened the window and removed the screen. -He/she stepped out the window and began to walk around the facility. -He/she was first acknowledge by staff a block away from the facility, but failed to get the resident to return. -The resident began to have behaviors, so the Licensed Practical Nurse (LPN) returned to the facility for his/her safety. -The LPN notified the Administrator who immediately began to search for the resident in his/her car. -The Administrator called the DON and notified him/her that he/she had begun to search for the resident. -The resident was located three blocks from the facility. -The administrator tried to convince the resident to return, due to the temperature outside, but the resident stated he/she was ok. -The Administrator followed the resident and continued trying to convince him/her to return, but also called the police for assistance. -The resident became agitated and started striking the Administrator. -The resident said he/she was going to run into the traffic and darted toward the street. -The Administrator wrapped his/her arms around the resident's waist, holding him/her in order to prevent serious injury. -The police arrived and the resident calmed down. -The resident agreed to return to the facility with the police officers. -The resident was physically assessed by the DON and found to have no injuries or physical distress. -The facility initiated finding placement for the resident at a facility with a locked unit. -The staff member who initially discovered the resident should not have let him/her leave his/her sight and called for assistance instead. During an interview on 8/21/23 at 9:15 A.M., Maintenance Director A said: -The security locks were put on the windows with a special tool that snapped them on. -The resident did not say how he/she got the lock off. -All of the other resident windows were fitted with the same locks, which would prevent the windows from sliding open more than approximately six inches. -There had not been any previous issues with residents removing locks. -He/she walked the building three times a week to check the security locks. -He/she did not really know this resident well, because he/she usually kept to him/herself or walked around the facility. During an interview on 8/21/23 at 10:30 A.M., the resident's family member A said: -He/she was the resident's power of attorney. -He/she was aware of the resident eloping. -The resident had tried to leave two previous facilities. -The whole reason the resident was transferred to this facility was because the facility administration had assured the resident could be properly cared for. -He/she had reported to the front desk receptionist the resident could not be let out and the resident would try and escape. -He/she told the social worker the resident tried to leave two previous facilities when paperwork was completed for the resident. During an interview on 8/21/23 at 10:40 A.M., the resident said: -He/she wanted to walk around the neighborhood and see his/her godfather's old house and look at the churches. -He/she did not remember leaving the facility. During an interview on 8/21/23 at 10:57 A.M., LPN A said: -He/she had only worked at the facility a few weeks, and did not know all the residents' names to their faces. -He/she had been on his/her lunch break, around 1:00 P.M., on 8/17/23 and was coming back from a restaurant. -He/she saw the resident at the four-way stop on a street near the facility Avenue. -The resident was wearing a plaid shirt, pants, and shoes. -The resident was walking along, and he/she did not know if the resident was was on the list of people who should not leave the facility without permission. -He/she stayed in his/her car and lowered the window and asked the resident where he/she was going. -He/she could not make out the resident's answer. -He/she had heard this resident could be combative, so he/she was not sure if he/she should approach him/her any further. -Since he/she did not know if the resident was supposed to be out of the facility, he/she felt it would be faster to go to the facility and tell someone, rather than call the facility from his/her car. -When he/she got to the facility, Registered Nurse (RN) A, with whom he/she had been training, was also eating lunch in the parking lot, and he/she asked him/her if the resident should be out. -RN A said the resident should not be out. -He/she walked in the building and told the Administrator about it. -He/she did not fill out an incident report. -In retrospect, he/she thought he/she should have called the facility by cellphone and stayed with the resident. -He/she had not had any training at the facility about resident elopement until after this happened. During an interview on 8/21/23 at 11:20 A.M., RN A said: -He/she had been training LPN A and was the nurse for the resident. -LPN A was driving back to the facility and saw the resident on the street. -He/she was eating lunch in his/her truck and LPN A told him/her that the resident was walking down the street. -He/she told LPN A to go tell the Administrator, because the resident was not supposed to go out alone. -He/she did not see the resident go out and continued his/her lunch. -The Administrator went and got the resident, which only took a short time. -The resident had been refusing his/her medications and the physician was aware. -Prior to this incident, the resident had been acting normally. -The staff had no idea the resident would try to exit, as he/she had never tried it before. -Residents were supposed to be checked every two hours, but he/she had not had any more frequent monitoring previously. During an interview on 8/21/23 at 11:30 A.M., LPN B said: -He/she was working on the east side nursing station at the facility the morning of the elopement. -The resident lived on the west side of the facility. -On the morning of 8/17/23, the receptionist told him/her that the resident was trying to get out the front door. -He/she went to redirect the resident. -The resident said he/she had to go to his/her house in Independence, which he/she thought was in walking distance, to get some paperwork. -He/she took the resident to the facility's courtyard to redirect him/her. -The resident told him/her, This is a joke and you know it! and waved his/her hand dismissively. -When the resident realized he/she could not exit the courtyard, he/she wanted to go back in the facility. -He/she reported the resident's behavior to RN A. -RN A said the resident had not been taking his/her medications. -After he/she talked to RN A, he/she went back to work on his/her side of the facility. -He/she did not fill out an incident report. During an interview on 8/21/23 at 11:55 A.M., Physician A said: -He/she was aware of the resident's elopement, but did not know the story behind it. -The resident was typically pretty complacent and happy where he/she was, but in the last week had been wound up. -Usually when he/she saw the resident, he/she was just hanging out. -He/she was aware the resident had been refusing his/her medications. -He/she was not sure whether the medications the resident refused would have made a difference or prevented the elopement. -Common sense would say that LPN A should have stayed with the resident. -He/she had been unaware of the resident making any elopement attempts at other facilities, however in reviewing resident paperwork, the resident had an elopement at a previous facility, which he/she had not been aware of. -It was obvious the resident was going to need a locked unit. During an interview on 8/21/23 at 12:25 P.M., the Administrator said: -LPN A came in the facility and found him/her, approximately around 1:00 P.M. -LPN A said he/she thought he/she saw the resident out on the street. -LPN A tried to talk to the resident and he/she refused to respond. -He/she immediately got in his/her car, called the DON, and went to find the resident. -He/she tried to talk the resident into coming back to the facility with him/her, and the resident started screaming that he/she was going to store. -He/she told the resident that it was warm out and the resident said he/she was fine. -The resident tried to hit him/her and run out into the street, so he/she put his/her arms around the resident's waist to keep him/her from doing that. He/she only did this to keep the resident from running in to traffic. -As soon as he/she found out the resident had gotten out, he/she also notified the police. -The police arrived and the resident calmed down and was willing to go with him/her back to the facility. -The police tried to get the resident to go with him/her first. They just dropped him/her off at the facility and did not create a report. -There was a list of residents who were not allowed to leave the facility and were elopement risks, and copies of it were at the nurses' stations and at the receptionist's desk. -The person at the front desk monitored who went in and out. -The residents' room windows were set with a lock so they could only open about six inches. -The resident broke the lock off on his/her window and pushed the screen out to leave. -It was his/her expectation that staff should know who was on the list of people who were elopement risks. -It was not a good idea for LPN A to leave the resident on the street. -He/she should have called the facility to notify of the elopement. -For the resident's safety, he/she should have stayed with him/her. -The resident was back at the facility around 1:30 P.M. -The police talked to the resident for about ten minutes and then he/she came back to the facility. -The DON assessed the resident upon his/her return, and he/she had no harm. -He/She was aware the resident had behaviors at other facilities, but did not know if he/she had elopements. -The resident was usually pretty calm, sometimes he/she was very clear and other times confused. During an interview on 8/21/23 at 12:45 P.M., the DON said: -He/She was in the facility when the resident eloped. -Before the resident eloped, the receptionist told LPN B he/she was trying to get out the front door, and he/she tried to redirect him/her. -Around 1:00 P.M., LPN A saw the resident on the street. -He/she did not stay with the resident, and the resident refused to come with him/her. -LPN A told RN A, who was also at lunch, about the resident being out, and RN A told him/her to go tell the Administrator. -The Administrator got in his/her car and went to get the resident, who refused to come with him/her. -The Administrator called him/her at 1:58 P.M. on 8/17/23 to see if the resident was in the building, and at 2:07 P.M., the Administrator was already with the resident. -The Administrator then called the police, and the resident did go with the police back to the facility. -He/she did his physical assessment when he/she returned to the facility. -The resident was placed on 1:1 observation after that. -He/she thought the resident might have been out an hour, though nobody knew when he/she went out. -The resident was very smart and strong enough to break a window lock. -It was his/her expectation that all staff should know who was on the elopement list. -He/she thought the resident's elopement risk was low, because although he/she had made comments about leaving, he/she had never previously attempted it. -LPN A should have called and not left the resident alone. LPN A should have kept the resident in the line of eyesight. -He/she expected all staff once aware the resident had eloped to respond and ensure the safety of the resident. During an interview on 8/21/23 at 3:05 P.M., Receptionist A said: -He/she did not see the resident try to get out the door, but he/she was very adamant all morning that he/she wanted to leave. -He/she told LPN B, because he/she was the closest to the reception desk. -The receptionist knew he/she was not to go out the door. -He/she notified LPN B that the resident was adamant about leaving. -The resident told him/her he/she did not live far away and wanted to go to his/her house. -He/she had never seen the resident behave like this before, and tried to redirect him/her. -LPN B told the resident if he/she wanted to leave, he/she had to call his/her sister. He/she redirected him/her back to his/her room. During an interview on 8/21/23 at 3:21 P.M., RN A said: -The resident said he/she wanted to leave all the time. -He/she was orienting LPN A, but was unaware if he/she knew about the elopement list. -When LPN B brought the resident in, he/she went back to his/her room. -The resident would often wander around the hallways. -He/she had not given LPN B any training about what to do in an elopement situation. -When LPN A told him/her about the resident being on the street, he/she was eating lunch and stayed in his/her truck and did not leave the parking lot. -He/she saw LPN A run in the facility and get the Administrator and saw the Administrator run out to his/her car. During an interview on 8/21/23 at 3:25 P.M., the Admissions Coordinator said: -He/she did not review resident referrals. -He/she did not know if the resident was an elopement risk. During an interview on 8/24/23 at 11:40 A.M., the Admissions Coordinator said: -He/she would get a referral for a resident, then it would be sent to the clinical coordinator for review and to the business office to verify benefits. -They would make the decision whether or not to admit a resident. During an interview on 8/24/23 at 11:45 A.M., the MDS Coordinator said: -The nurses on the floor did the admission assessments. -He/she would read through everything and make the care plans. -He/she reviewed the facility's doctor's notes to create a care plan, rather than discharge notes, because with a dementia resident, the change of environment could change the resident's care plan needs. -The facility did not get information from previous facilities about residents. During an interview on 8/24/23 at 3:25 P.M., CNA D said: -The resident often would wander around the unit. -The staff would have to follow him/her around. During an interview on 8/24/23 at 7:15 P.M., the Security Director said: -The resident walked around the facility a lot. -He/she had never seen the resident actively exit-seek. -The resident could be aggressive. -If a resident tried to exit through the front door, he/she could be stopped. -Any resident who left through the front door had to sign out in a book. -Staff should know who was on the elopement list. During an interview on 8/30/23 at 1:52 P.M., the DON said: -In an elopement attempt, staff should not lose eyesight of the resident. -He/she and the Administrator should be contacted by phone. -There was an elopement book at each nurses' desk and at the front desk. -The resident should remain in constant line of eyesight until help arrived. During an interview on 8/30/23 at 2:11 P.M., the Administrator said: -If a staff person found a resident who had eloped, he/she should keep the the resident within eye sight. -If the resident were aggressive, he/she should keep a distance for safety, but the resident still kept in eye sight. -The staff person should have stayed with the resident and called for assistance. -Staff were shown the elopement books at the time of hire. MO00223154

Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #25 and #30) were free from abuse, out of 10 sampled residents. On 2/10/23 Resident #26 struck Resident #25 multiple times on the top of his/her head with a metal object resulting in Resident #25 sustaining a laceration to the top of his/her head in the scalp area, laceration to his/her left ear and abrasion to his/her right elbow. On 2/5/23 Resident #30 was shoved five times by Certified Nurses Aide (CNA) C. The facility census was 113 residents. The Administrator was notified on 2/14/23 at 1:00 P.M., of the Immediate Jeopardy (IJ) which began on 2/10/23. The IJ was removed on 2/15/23, as confirmed by surveyor onsite verification. Record review of the facility's policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed: -All residents had the right to be free from abuse, neglect, exploitation, and misappropriation. -All residents were to have been protected from abuse by facility staff, other residents, consultants, volunteers, agency staff, family members, legal representatives, friends, visitors, and any other individual. -The facility was obligated to ensure there was adequate staffing and oversight/supervision to prevent burnout, stressful working situations and high turnover rates. -All facility staff were to have been trained on abuse prevention, identification, reporting, stress management, and handling verbally and physically aggressive resident behavior. -The facility was to establish and maintain a culture of compassion and caring for all residents and in particular, those with behavioral, cognitive or emotional problems. 1. Record review of Resident #25's facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Alcohol abuse. -Depression. Record review of the resident's nursing care plan, dated 5/24/21, showed: -He/she had a behavior problem related to refusing to abide by the facility policies in regards to smoking times, refusing medications, refusing skin checks and threatening to get facility staff fired. -He/she was to have fewer episodes of behaviors through the next review period. -The facility staff were to anticipate and meet his/her needs. -The facility staff were to document all refusals and behaviors. -The facility staff were to reinforce and redirect him/her regarding the facility policies. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility staff and used for care planning), dated 1/21/23, showed: -Was cognitively intact. -Had issues with being depressed, sleeping too much, changes in eating habits, little interest in doing things, feelings of being better off dead, feeling bad about himself/herself, being tired with little energy and feeling as though he/she let his/her family down, from several days to nearly every day of the past 14 days. -Had no behaviors. -Was independent with all cares except for dressing and toileting where he/she needed supervision of one staff member. Record review of Resident #26's admission MDS, dated [DATE], showed he/she: -Was cognitively intact. -Had no issues with mood. -Had no issues with negative behaviors. -Was independent with daily personal cares. Record review of the resident's nursing care plan, dated 11/16/22, showed: -He/she had the potential for mood problems related to bi-polar disorder. -He/she would show happier, calmer appearance with no signs of depression, anxiety or sadness. -The facility staff were to assist him/her in developing a program of activities that was meaningful and of interest. -The facility staff were to reinforce his/her strengths, encourage/reinforce positive coping skills. -The facility staff were to obtain a behavioral health consult as needed. An observation of video surveillance, dated 2/10/23, showed: -At 7:37.06 P.M., Resident #26 was seen wheeling out of his/her room in his/her wheelchair holding what appears to be a reacher (an assistive device utilized for reaching items placed overhead or on the floor by individuals with arthritis, post-surgical total joint replacement, spinal injuries and more) in his/her left hand. -The resident wheeled up the hall and around in circles waving the reacher in his/her left hand. -At 7:37.09 P.M., Resident #26 went back into his/her room. -At 7:37.38 P.M., Resident #25 came out of his/her room wheeling in a wheelchair, covered in blood all the way down his/her chest, and holding a reacher in his/her right hand. -Resident #26 was then seen with a staff member at 7:38-7:48 P.M., holding what appeared to be a metal club in his/her left hand. Record review of the facility Suspected Abuse Investigation, dated 2/10/23 at 8:30 P.M. through 2/15/23 at 3:00 P.M., showed: -On 2/10/23 at approximately 7:15 P.M., Resident #26 entered Resident #25's room that they shared as roommates. -Resident #26 began to scream at Resident #25, who was sleeping at the time. -Resident #26 picked up a long handled reacher and began to strike Resident #25. -Resident #26 then picked up another object and attempted to continue striking Resident #25. -Resident #25 was able to get into the hallway and staff immediately separated the two residents. -Resident #26 was taken outside while Resident #25 was attended to by facility nursing staff inside the facility. -Police arrived and wrote Resident #26 a summons. -Emergency Medical Services (EMS) took Resident #25 to the hospital for evaluation and treatment and returned later on that same night. -Resident #26 was taken to the hospital on a psychiatric hold. -The hospital was planning on looking for more appropriate long term placement for Resident #26. -Resident #25 had mild to moderate pain, a few small lacerations and a few small bruises, but was not fearful of any of the residents other than Resident #26. -All appropriate entities and persons were notified of the incident. -Record review of Resident #26's Statement/Administrator Interview, dated 2/10/23, showed: --When the Administrator approached Resident #26, he/she was outside. --When asked what happened, Resident #26 stated, I hit the mother fucker because he/she stole my cell phone charger. --Resident #26 had a beer with him/her which was confiscated and emptied. --The Administrator educated the resident that any type of abuse to another resident would not be tolerated, but Resident #26 remained belligerent. --The resident did agree to go to the hospital on a psychiatric hold upon the Administrator's request for the safety of the facility residents. -Record review of Resident #9's Statement/Administrator Interview, dated 2/10/23, showed: --He/she smoked a cigarette with Resident #26 just prior to the incident. --Resident #26 appeared calm and visited with the group outside. --The group came in and was hanging out outside of Resident #26's room to continue to visit. --Resident #26 then went inside of his/her room and began to scream at his/her roommate (Resident #25). --Resident #26 picked up a long handled reacher and began to strike Resident #25 who was in his/her bed sleeping. --Resident #25 was able to get up and out into the hallway while Resident #26 continued to scream. --Staff intervened and the police were called. -Record review of Resident #29's Statement/Administrator Interview, dated 2/10/23, showed: --Resident #26 was outside with a group of residents smoking cigarettes and visiting. --The group came inside and was sitting in the hallway outside of Resident #26's room. --Resident #26 entered his/her room and began to scream at Resident #25 who was sleeping in his/her bed. --Resident #26 picked up a long handled reacher and began to strike Resident #25 with it. --Resident #25 managed to get into his/her wheelchair and exit the room where the facility staff separated the two residents. --The police were called and Certified Nurses Aide (CNA) A took Resident #26 outside to separate the two residents until the police arrived. -Record review of Resident #25's Statement/Administrator Interview, dated 2/11/23, showed: --He/she was interviewed after returning back to the facility from the hospital. --He/she and Resident #26 had no prior confrontations and he/she was not expecting anything like the incident to happen. --He/she was asleep in his/her room that he/he shared with Resident #26. --He/she was awakened by Resident #26 screaming at him/her. --Resident #26 then grabbed a long handled reacher and began to strike him/her. --Resident #26 then grabbed another object and hit him/her with that as well. --Resident #25 was able to get into his/her wheelchair and into the hallway where the facility staff intervened. --Resident #26 was taken outside and separated from him/her by his/her CNA A. --Resident #25 was bleeding so he/she was sent to the hospital. -Record review of Resident #25's Licensed Nurse Skin Observation, dated 2/11/23 at 6:35 P.M., showed: --He/she had a laceration on his/her scalp measuring 3.0 centimeters (cm) by 2.0 cm. -He/she also had a laceration to his/her left ear which was 2.5 cm in length. During an interview on 2/11/23 at 3:50 P.M., Licensed Practical Nurse (LPN) C said: -Resident #25 had returned from the hospital with diagnosis of head injury, the facility was waiting on the computerized tomography (CT) scan (combines a series of X-ray images taken from different angles around your body). -Resident #26 remained in the hospital on a psychiatric hold. Observation on 2/11/23 at 4:04 P.M., showed: -Resident #25 had an abrasion to the bridge of his/her nose. -Dark bruising in the inside corners of both eyes. -His/her right elbow had a small abrasion. -His/her left ear had a laceration across the top with bruising behind the ear and moving down his/her neck. -His/her scalp area on the front lobe had a laceration, caked in a dried reddish substance. During an interview on 2/11/23 at 4:05 P.M., Resident #25 said: -He/she had awakened from sleep in his/her bed to Resident #26 hitting him/her with a reacher. -Resident #26 used to carry the reacher for protection when he/she was homeless. -He/she had no idea why Resident #26 had attacked him/her. -Resident #26 had went berserk and tried to kill him/her. -Resident #26 had even thrown his/her wheelchair upside down. -Resident #26 was not going to stop. -He/she yelled for help. -He/she told the police he/she wanted to press charges. -He/she was hurting so bad. During an observation and interview on 2/11/23 at 4:29 P.M., the Director of Nursing (DON) assessment of Resident #25 showed: -He/she had a laceration on the front left forehead on his/her scalp area. -The DON indicated the laceration on his/her forehead was open about 1 1/2 cm by 4 cm long. -He/she had bruising to both inner corners of each of his/her eyes and the bridge of his/her nose. -The back of the resident's left ear had bruising and a laceration on top of his/her ear with bruising down the back of his/her ear. -The DON indicated the laceration on the resident's ear was about 6 cm long by 1 cm wide. -He/she also had an abrasion to his/her right elbow. -The DON indicated the resident's elbow was tender and soft to the touch. Record review of the Resident #29's quarterly MDS, dated [DATE] showed he/she: -Was moderately cognitively intact. During an interview on 2/11/23 at 4:12 P.M., Resident #29 said: -He/she, Resident #9, and Resident #26 were out on the smoke deck and had just come in. -Resident #26 returned to his/her room directly in front of the smoke door where they had been visiting while inside. -He/she heard yelling out of Resident #25 and Resident #26's room. -He/she opened the door. -He/she saw Resident #26 hitting Resident #25 while Resident #25 was in bed. -Resident #26 was using an object that looked like a pole. -He/she described it as boom, boom, boom. -He/she and Resident #9 yelled for help. Record review of Resident #9's quarterly MDS, dated [DATE], showed he/she: -Was cognitively intact. During an interview on 2/14/23 at 10:00 A.M., Resident #9 said: -He/she saw Resident #26 beating up Resident #25 with what looked like a [NAME] club. -He/she went out into the hallway to yell for help. -It didn't take long at all for the staff to come running to separate the residents. -He/she didn't know Resident #26 very well as he/she was new. -He/she was just coming down the hall, heard yelling and saw the beating occurring. -He/she had no idea why. -There was a lot of blood so he/she was glad the staff was quick. During an interview on 2/14/23 at 9:25 A.M., LPN B said: -He/she was completing medication pass on the other end of the [NAME] Hall near the nursing station, when he/she heard yelling and recognized it as Resident #9's voice. -He/she heard Resident #9 and Resident #29 yelling help, hurry up. -He/she and CNA A hurried down the hallway. -Resident #26 was in the hallway yelling, screaming and swinging a metal pole that extended over his/her head in the hallway directly in front of Resident #25 and Resident #26's room. -Upon arrival, Resident #25 rolled out of his/her room covered in blood from the top of his/her head to his/her navel area. -Resident #26 was yelling he/she would do it again. -CNA A took Resident #26 outside. -He/she attended to Resident #25. -Resident #9 and Resident #29 said they had both heard voices in Resident #25 and Resident #26's room. -Resident #9 and Resident #29 said they opened the door and began to scream for help. -Resident #25 was in bed asleep. -Both Resident #25 and Resident #26 were transported to the hospital. During an interview on 2/14/23 at 9:25 A.M., the Medical Director said: -He/she had never had any issues with Resident #26. -He/she never knew the resident to be violent with anyone. During an interview on 2/14/23 at 10:20 A.M., CNA A said: -He/she was in the hallway and overheard yelling for help. -He/she ran down the hall and found Resident #26 yelling at and hitting Resident #25 with some sort of weapon. -He/she helped the nurse intervene and took Resident #26 outside, while the nurse attended to Resident #25's injuries. -Resident #26 said that Resident #25 stole from him/her so that was why he/she beat him/her up. During an interview on 2/14/23 at 12:00 P.M., the DON said: -He/she never knew Resident #26 to be violent. -He/she was not aware of any behavior issues with him/her prior to this incident. -He/she had a reacher from the room that he/she used to hit Resident #25 and also had some sort of a metal rod which he/she also used to hit the resident. During an interview on 2/14/23 at 12:20 P.M., the facility Administrator said: -He/she was not aware that either resident had any behavior issues, but Resident #26 had not been in the facility for very long. -He/she was not aware of Resident #25 stealing anything from Resident #26. -He/she thought that Resident #26 not only used a reacher to strike Resident #25, but also used some sort of metal pole that the resident stated he/she used to defend himself/herself when he/she was homeless on the street. -He/she heard Resident #25 state that he/she thought that if staff had not come when they did, Resident #26 would have killed him/her. During an interview on 2/15/23 at 10:00 A.M., Resident #26 said: -Resident #25 stole from him/her. -If I see the mother fucker again, I will kill him/her! -I don't want to go back to that place again and if I do go back there, I will kill the mother fucker! -He/she used a reacher that was in his/her room. -He/she never had a metal looking rod that he/she used on Resident #25. 2. Record review of Resident #30's facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile). -Seizures. Record review of the resident's quarterly MDS, dated [DATE], showed he/she: -Was cognitively intact. -Had issues with feeling depressed, trouble falling asleep, staying asleep or sleeping too much, and showed little interest or pleasure in doing things several days per week. -Had no negative behaviors. Record review of the resident's Concern/Compliment Form, dated 2/6/23, showed: -CNA C came into the resident's room on 2/5/23 at at 6:15 A.M., and started going through the resident's closet for no reason. -When the resident asked CNA C to leave, the CNA said he/she was the cops and did not have to leave. -CNA C then began pushing the resident. -The facility Administrator was able to substantiate the concern via facility camera showing the incident did occur. -CNA C was immediately terminated and the appropriate entities were notified. Record review of the written statement for CNA C, dated 2/6/23, showed: -On 2/5/23 at approximately 6:30 A.M., as he/she walked into the resident's room, the resident pushed him/her saying he/she did not want anyone in his/her room. -The resident then followed him/her out into the hallway and was trying to hit him/her. -He/she then notified the charge nurse. -He/she had never seen the resident act that way. Record review of the facility Staff Interview conducted by the facility Administrator, dated 2/6/23, showed: -The Administrator called CNA C for a phone interview, but CNA C stated he/she had left a written statement in the DON's mailbox. -It had been established that CNA C did not notify the charge nurse of the incident. -When the facility Administrator began to explain to CNA C that he/she was terminated for pushing the resident and it was captured on camera, CNA C immediately hung up the phone. -When CNA C was called back, he/she stated he/she did not tell anyone because he/she did not want to get in trouble, as he/she did not start the confrontation. -The facility Administrator then explained to CNA C at no time were staff to retaliate or put their hands on residents in a bad way, to which CNA C hung up the phone. Record review of the Resident Interview conducted by the facility Administrator, dated 2/6/23 at 8:50 A.M., showed: -On the morning of 2/5/23, CNA C came into Resident #30's room around 6:15 A.M., and began going through the resident's items in his/her closet. -The resident asked CNA C to get out of his/her room immediately. -CNA C refused to leave so the resident got up to chase him/her out of the room. -Both parties began pushing at each other and the incident finished in the hallway. -After shoving at each other a few times, the two separated, exchanged words and the resident went back into his/her room. -No other parties were present to witness the incident. -The resident stated he/she was fearful of CNA C. -The facility Administrator reassured the resident that CNA C would not be returning to the facility. Record review of the facility Suspected Abuse Investigation, dated 2/6/23 at 8:30 A.M. through 2/11/23 at 9:30 A.M., showed: -CNA C entered Resident #30's room at approximately 6:10 A.M. -The resident stated CNA C was looking in his/her and his/her roommate's closet and the resident asked CNA C to exit the room. -When CNA C refused to exit, Resident #30 charged at CNA C and gave him/her a slight push to get him/her out of the room. -CNA C then turned and could be seen on camera in the doorway shoving Resident #30. -The video continued to show Resident #30 walking towards CNA C while CNA C continued to shove him/her. -Resident #30 did not report the incident at the time but instead, slid a paper under the Social Services Director's door with his/her statement. -CNA C also did not report the incident, but instead placed a statement into the DON's mailbox. -The incident was reported to the appropriate entities and CNA C was terminated. -The resident was not injured. Observation of the video surveillance located in the hallway outside of Resident #30's room on 2/10/23, showed: -CNA C was seen walking into Resident #30's room on 2/5/23 at 6:11.22 A.M. -CNA C exited the resident's room at 6:11.43 A.M. -Resident #30 came into view of the camera, exiting into the hallway at 6:11.47 A.M. -Resident #30 was pushed by CNA C at 6:11.48 A.M. -The resident was then seen walking towards CNA C and was pushed a second time at 6:11.54 A.M. -The resident continued to walk towards CNA C while he/s he was walking backwards, shoving the resident a third time at 6:11.57 A.M. -The resident was pushed by CNA C a fourth time at 6:12.02 A.M. -The resident continued to walk towards CNA C who in turn, pushed the resident a fifth time at 6:12.13 A.M., before he/she then exited down the hallway. During an interview on 2/10/23 at 12:05 P.M., Resident #30 said: -He/she had never had any issues with this particular CNA in the past. -Around 6:15 A.M. on 2/5/23, CNA C came into the resident's room and proceeded to nose through the resident and his/her roommate, who was in the hospital at the time, belongings. -He/she told CNA C to get out of his/her room to which the CNA replied, he/she was the cops. -The resident knew he/she was not the police, so he/she jumped out of bed, as CNA C began opening up the resident's closet doors. -He/she once again told the CNA to leave and as he/she exited the room, the resident gave the CNA a little shove and followed him/her out of the room. -As he/she was walking toward the CNA down the hallway, the CNA began pushing him/her. -The whole time he/she was walking down the hallway towards CNA C, CNA C was walking backwards saying, bring it on, like he/she wanted to fight. -He/she then returned to his/her room and put a chair up against the door so no one could get in his/her room. -He/she was afraid the CNA was going to hit him/her. -He/she was only afraid of that one CNA so now that he/she knows the CNA was gone, he/she was no longer fearful. During a phone interview on 2/10/23 at 1:30 P.M., CNA C said he/she would not answer any questions and hung up the phone. During an interview on 2/10/23 at 3:00 P.M., the Administrator said: -He/she was not made aware that anything had occurred with CNA C and Resident #30 until the DON and Social Worker told him/her they each had a note in their offices regarding the incident. -He/she definitely thought it was an abusive incident. -He/she had not known this staff member to be abusive or have any disciplinary problems in the past. 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. A 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). MO00213645 and MO00213890

Based on observation, interview, and record review, the facility failed to maintain an infection control program during a Coronavirus disease 2019 pandemic, to provide a safe environment for residents, when the facility failed to prevent the cohorting of residents who had tested positive for COVID (a new disease caused by a novel (new) coronavirus) (Residents #13, #14, #15, #17, #18 and #19) with residents who had tested negative for COVID (Residents #15 and #17) to prevent the spread of COVID-19, resulting in two residents testing positive for COVID (Resident #15 and #17); failed to have appropriate staff in the COVID unit to provide cares to the residents; failed to contain trash from the COVID unit in a trash can with a lid prior to transporting the trash through the facility to dispose of it; failed to follow infection control and prevention procedures by propping a door open and preparing drinks for resident's meals; failed to follow infection control and prevention procedures by allowing staff to go back and forth between residents in transmission based precautions and residents not in transmission based precautions without removing the Personal Protective Equipment (PPE) worn in rooms on transmission based precautions and/or not wearing appropriate PPE when entering a room in transmission based precautions; The facility census was 71 residents. is 17 positive or negative? they are listed both places #17 started as negative, residing in a room with a positive resident and then #17 tested positive as a result of cohorting in a room with a positive resident. i don't see resident 17 in the same room as a positive? where is that in the write up? This was my error. #17 started out as negative as a new admission post op abdominal surgery. She was NOT in the same room with a positve resident but was surrounded by positive residents. She tested negative up until 8/27. She was one of many negative residents that staff had gone into a positive residents room and then into her room without changing out PPE as stated lower in the tag. So my error The Administrator was notified on 8/27/21 at 4:51 P.M. of an Immediate Jeopardy (IJ) which began on 8/19/21. The IJ was removed on 9/3/21 as confirmed by surveyor onsite verification. Record review of the facility policy for Infection Control, dated 3/5/20, showed: -The policy was intended to be used as guidelines to address the health care concern of COVID-19. -The facility was to have completed the CMS COVID-19 Focused Survey Self-Assessment Tool to ensure the facility had implemented proper infection prevention and control practice to prevent the development and transmission of COVID-19 and other communicable diseases and infections. -During a COVID-19 outbreak, residents were to have been encouraged to remain in their room as much as possible, to wear a mask when leaving their room, practice social distancing and hand hygiene. -Every effort was to have been made to designate staff to be assigned to the COVID unit (red zone). -A COVID-19 positive resident was not to have been housed in the same room as a patient with an undiagnosed respiratory infection, -Where possible the facility was to have designated a hallway for known or suspected COVID-19 positive residents. -It was preferred to have a physical barrier separating the COVID-19 positive (red zone) from the non-COVID-19 positive (green zone) and the observation area or (yellow zone). -Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected resident (e.g., residents who have a fever, for example, due to a non-COVID-19 illness could be put at risk if move in a COVID-19 unit). -If cohorting symptomatic residents, care should have been taken to ensure infection prevention and control interventions were in place to decrease the risk of cross-contamination. -A floor to ceiling type barrier to separate and seal off the COVID-19 unit rooms from other rooms such as closed fire doors, zip wall, etc. -The facility should have designated consistent caregivers to reduce the number of staff and potential exposures. -Staff should have changed all Personal Protective Equipment (PPE - is equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, face masks, or face shields, respirators, foot and eye protection, and gowns) including their N95 masks (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and sanitize their face shields or goggles when moving in between the Red Zone and Yellow zone. -A resident with COVID-19 should not have been placed in the same room as a resident without COVID-19. -The Red zone should have been used for COVID positive residents only. -Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected resident and if resident who are positive were cohorted with residents who were negative, care should have been taken to ensure infection prevention and control interventions were in place to decrease the risk of cross-transmission. (Isn't this a duplicate of info above?) -A floor to ceiling type physical barrier to separate and seal off the Red Zone rooms from other rooms was preferred, but if not possible, the resident's status should be clearly identified by signage, tape on the floor, table, empty room or rope across the entry point. -Roommates of residents who had tested positive for COVID-19 should have been considered exposed and not share a room with other residents unless they remain asymptomatic and have tested negative for a total of 14 days after the latest exposure. -It was preferred that exposed residents remain in a room alone, but if that was not possible, they could have shared a room with another exposed resident. -The Yellow Zone was to have been used to monitor new admissions and re-admissions for the 14 day quarantine period. -Single rooms were preferred, but if not available, those residents could have cohorted with another recent asymptomatic admission or readmission as long as there were no conflicting infections. -Facility staff should have performed hand hygiene (either by washing hands for 20 seconds, or by using antiseptic hand sanitizer with 60-95% alcohol) before and after all resident contact, contact with potentially infectious material, and before putting on and after removing PPE including gloves. -Facility staff should have been able to select the appropriate PPE and demonstrate knowledge of when to use it, which was necessary under which circumstances, how to properly don (apply), use, and doff (remove) PPE to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, including properly cleaning reusable PPE in between uses. -For all residents on Contact and Droplet Precautions, facility staff were to have applied an N95 mask, gown, gloves, and eye protection before entering the room for any reason. -When a resident was identified with COVID-19, facility staff should have worn N95 mask, gloves, gown, eye protection regardless of symptoms. -The facility staff should have performed hand hygiene and put on clean gloves upon entry into the resident's room. -Gloves should have been changed in between each resident during care. -Gloves should have been discarded upon leaving the resident's room and hand hygiene immediately performed. -Isolation gowns should have been put on upon entry into the resident's room and removed upon leaving the resident's room, and discard the gown into a dedicated container inside the resident's room. 1. Record review of Resident #15's facility Admission Record showed the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Stroke. -History of [CONDITION(S)]. Record review of his/her COVID-19 testing sheets showed the resident tested negative on 8/24/21. 2. Record review of Resident #18's facility Admission Record showed the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Pulmonary fibrosis (a lung disease that occurs when a lung tissue becomes damaged and scarred making it more difficult for the lungs to work properly). -Shortness of air. Record review of the resident's COVID 19 test sheet, dated 8/24/21, showed his/her COVID-19 test was positive. Record review of the resident's Physician Order Sheet (POS), dated 8/25/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's medical record showed he/she had no Nursing Care Plan for COVID-19. Observation on 8/24/21 at 11:30 A.M., showed Resident #15, who was COVID negative, in the same room as Resident #18 who tested positive for COVID 19 on 8/24/21. Record review of the facility Midnight Census Report dated 8/24/21 showed Resident #15, who tested negative for COVID was residing on the COVID positive unit in the same room as Resident #18 who tested positive for COVID-19 on 8/24/21. Record review of the Resident #15's Nursing Care Plan, dated 8/25/21, showed: -He/she was at risk for COVID-19. -The facility staff were to have been educated regarding signs, symptoms and precautions. -The facility staff were to have followed the Facility Protocol for COVID-19 screening/precautions. Record review of the facility resident roster, dated 8/25/21, showed Resident #15, who tested negative for COVID-19 on 8/24/21, continued to reside in the same room as Resident #18, who tested positive for COVID-19 on 8/24/21. Record review of the facility Midnight Census Report, dated 8/26/21, showed Resident #15, who tested negative for COVID-19 on 8/24/21, continued to reside in the same room as Resident #18, who tested positive for COVID-19 on 8/24/21. Record review of the facility resident roster, dated 8/26/21, showed Resident #18 was COVID positive and resided in a room with Resident #15 who was COVID negative. Observation on 8/26/21 at 12:10 P.M., showed Resident #15 continued to reside in the same room as Resident #18. Record review of the facility Daily Census sheet, dated 8/30/21, showed: -Resident #15 continued to test negative for COVID 19 remained in the same room as Resident #18 who had tested positive for COVID-19 on 8/24/21. (Why was this resident not moved as part of the immediate/imminent danger Class I removal plan on 8/27/21?) Record review of Resident #15's COVID-19 testing sheet, dated 8/30/21, showed he/she tested positive for COVID-19. after having resided in the same room with Resident #18 who was COVID positive on 8/24/21. 2. Record review of Resident #18's facility Admission Record showed the resident was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Pulmonary fibrosis (a lung disease that occurs when a lung tissue becomes damaged and scarred making it more difficult for the lungs to work properly). -Shortness of air. Record review of the resident's COVID 19 test sheet, dated 8/24/21, showed his/her COVID-19 test was positive. Record review of his/her Physician Order Sheet (POS), dated 8/25/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's medical record showed he/she had no Nursing Care Plan for COVID-19. Record review of the facility resident roster, dated 8/26/21, showed Resident #18 was COVID positive and resided in a room with resident #15 who was COVID negative. 3. Record review of Resident #13's facility Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] (CHF-a disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). -[CONDITION(S)] C (an infection caused by a virus that attacks for liver and leads to inflammation). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 5/15/21, showed he/she: -Was cognitively intact. -Had no behaviors. -Required supervision/oversight of one facility staff member for bed mobility. -Was independent with personal hygiene, dressing, eating, toileting and transferring. -Was not ambulatory. Record review of the resident's COVID-19 test, dated 8/19/21, showed he/she tested positive for COVID-19. Record review of the resident's Nursing Care Plan, dated 8/20/21, showed: -He/she was COVID-19 positive and at risk for spreading the infection to others. -He/she was to remain in his/her room. -Education was to have been provided regarding hygiene and isolation precautions. Record review of the resident's POS, dated 8/25/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . what is the failure for this resident? The failure on many of these residents was that the staff were not following their policy for COVID. They were not changing out their PPE when going from COVID positive rooms into COVID negative rooms. They were not removing gloves and disinfecting their hands. IF they were even wearing shields, they were not disinfecting them. As you will see below, they were not even aware of which residents were positive and which were negative as they moved in and out of the rooms providing care with the same PPE on. This caused residents who were testing negative, to test positive. i do not see any specific observation of staff infection control failure with resident #13 ie going in their room without changing PPE or going from this residents room to a Covid negative residents room without change PPE, Handwashing failures, etc? 4. Record review of Resident #14's facility Admission Record showed the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed he/she: -Was cognitively intact. -Had no behaviors. -Required supervision/oversight of one facility staff member for bed mobility personal hygiene, dressing, eating, toileting and transferring. -Was not ambulatory. Record review of the resident's COVID-19 test results, dated 8/24/21, showed he/she tested positive for COVID-19. Record review of the resident's POS, dated 8/25/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the resident's Nursing Care Plan, dated 8/25/21, showed: -He/she had COVID-19 and was at risk of transmitting it to others. -He/she was to remain in his/her room. what is the failure for this resident? This is one of the residents who had been out in the hallway when the COVID unit was open with no barrier, conversing with a COVID positive resident #19. This resident became positive after interacting with positive residents as his room was near the open COVID unit. He was near #19 who was positive, in the hall, not masked and blowing his nose leaving the used kleenexes on the floor. i don't see an observation of resident #14 talking to resident 19? was it after the facility knew that resident 19 was positive, because the test results and the observation are on the same day. Not sure we can say that talking to resident 19 caused resident to test positive especially since they both tested positive on 8/24/21 It was resident #14 who turned positive later after having conversed with #19. 5. Record review of Resident #17's facility Admission Record showed he/she was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/26/21 at 12:15 P.M., the resident said: -He/she was currently negative for COVID-19. -This was the third room he/she had been in since his/her admission to the facility. -He/she had just had major surgery and was sent to the facility to recover, get intravenous (IV) antibiotics and therapy so he/she could go home. -When he/she was placed on this hall, he/she was told that there were residents with COVID-19 who were residents near him/her. -He/she did not want to be on that hallway as, All I need is to get COVID-19 on top of everything else! Record review of the resident's POS, dated 8/27/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the resident's Nursing Care Plan, dated 8/27/21, showed: -He/she was at risk for COVID-19. -He/she was to remain in his/her room. -The facility staff were to have been educated regarding signs, symptoms and precautions. During an interview on 8/27/21 at 9:53 A.M., the resident said: -He/she was not feeling well. -He/she had told the facility staff and they were going to re-test him/her for COVID-19. -He/she had been testing negative for COVID-19, but was not feeling well when he/she woke up. -He/she had been scheduled to be taken out of quarantine that day, but would not move if he/she tested positive for COVID-19. During an interview on 8/27/21 at 1:30 P.M., the MDS Coordinator said: -The COVID test for Resident #17 came back positive for COVID 19. -He/she would remain on the COVID unit where he/she had been residing on observation/isolation as a new admission. -NOTE: The facility was unable to provide documentation of the resident's positive COVID test results. do we have a negative test result for this resident too? We have negative test results from her prior to the 27th was the resident in the same room as a positive resident? what is the failure for the resident? This resident was not with a positive resident but resided on the COVID unit and was one of many where the staff went into COVID positive rooms, did not change out PPE and then went into COVID negative rooms such as this resident. As you will see in her interview below, she voiced concerns over being so sick and being surrounded by COVID positive people. She was very vulnerable as she had major abdominal surgery, had a PICC line for antibiotics and had very little resistence. i do not see any observation of staff going in a Covid positive resident room and then going into resident #17's room while they were negative - do we have an observation of staff going into a Covid positive residents room and providing care and then going into resident #17's room? There are observations below that show the CNA going in and out of all the rooms both positive and then into negative rooms See below 6. Record review of Resident #19's facility Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions and relate to others). -Diabetes (a complex disorder of carbohydrate, fat and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of his/her quarterly MDS, dated [DATE], showed the resident: -Was cognitively intact. -Had verbal behaviors towards others such as screaming, cursing or threatening others one to three days per week. -Was independent with bed mobility, transferring, toileting, personal hygiene, dressing and eating. -Required set up of one staff member for bathing. -Did not ambulate. Record review of the resident's COVID-19 testing, dated 8/24/21, showed he/she tested positive for COVID-19. Observation on 8/24/21 at 11:30 A.M., showed: -Resident #19 (who was COVID positive) was sitting out in the hallway between his/her room and room [ROOM NUMBER]-131 which were located directly across from Resident #19's room of 233. is room [ROOM NUMBER]-131 rooms occupied? have negative residents positive residents? doors open or closed? The room had been occupied with Residents #13 and #14. residents 13 and 14 are Covid positive correct? The COVID unit was completely open at the time allowing the positive residents to be out of their rooms unmasked, conversing with residents who had not yet tested positive. So, since there was no actual closed COVID unit at the time, residents who were positive ended up causing negative residents to turn positive. #14 for example. we can't say that resident 19 caused resident 14 to test positive when they tested positive on the same day. also i don't see a observation of positive residents in the hallway talking to negative residents in the hallway. There is an observation where the CNA is going in and out of all the rooms going into positive rooms and then into negative rooms. See below -He/she did not have a mask on. -He/she was conversing with other residents while not masked. -He/she had a tissue in his/her hands and placed the used tissues on the floor. -He/she appeared to have a runny nose with the sniffles. is this normal for this resident? No. how do we know that - do we have an interview with the resident saying this was not normal for them? Yes there was an interview with #19 to show that he had hayfever, but it was not severe until he became positive. please add -Other residents were observed walking in the hallway conversing with the resident, not wearing masks. were they positive or negative? One was positive on 8/17 and was moved to the COVID unit, but the unit was open to other units until 8/25. The other resident showed as positive on 8/24. so the residents that were observed in the hallway were positive? do we have an observation showing exactly what residents were in the hallway talking to this resident? or an observation of negative residents walking the hallway by this resident? we only observation we have is on 8/24 when #19 was in the hallway speaking with #13 and #14. #13 and #19 positive both tested positive on 8/24 in the aftertoon sometime. #13 was later moved to the covid unit and #14 tested positive 8/26 I believe and was moved to the covid unit then. Record review of the resident's POS, dated 8/25/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the resident's Nursing Care Plan, dated 8/25/21, showed: -He/she was at risk for COVID-19. -He/she was to reduce the risk of transmission by remaining in his/her room. -Education was to have been provided regarding hygiene and isolation precautions. Observation on 8/26/21 at 2:25 P.M., showed Resident #19 who was COVID positive and sitting outside of his/her room without a mask on, coughing into his/her hand. did we ask this resident if this was normal for them? or when did it start? other residents around? He had hay fever but the symptoms were more severe. They became more severe once he tested positive. See above as #13 and #14 were near the positive residents with no barrier, doors open and the positive resident out in the hallway. residents 13 and 14 were both positive, correct? resident tested positive on 8/19 prior to resident 19 and resident 14 and 19 both tested positive on the 24th. were there negative residents in the hallway near resident 19 at this time? did we get the information about the hay fever from the resident in an interview or how did we get that info? Resident #14 did not test positive until 8/25 I believe. 7. Record review of the facility staffing sheets for 8/26/21 showed: -One Certified Nursing Assistant (CNA) assigned to the COVID unit where 16 residents currently resided. -No Licensed Practical Nurse (LPN) was designated for the COVID hall. what is the infection control failure The failures were as stated above, staff not adhering to the policy, not following IC precautions, changing PPE, etc. I will include in the based on statement. in the policy it just says every effort will be made to have designated staff for the Covid unit not that they have to have designated staff for the Covid unit. Do we have specific interviews regarding staff - if so please put them here with the record review. do we have observation of staff going Covid negative hall to the Covid positive hall? We do have observations below as stated above. 8. Observation on 8/25/21 at 11:00 A.M., showed: -Two trash barrels labeled Isolation Trash were sitting outside the double doors of the COVID unit and had one to two full red and yellow isolation bags of trash piled on top of the barrel lids. -A resident was sitting in the hallway in a wheelchair without a mask right next to the bags of isolation trash. was the resident messing with the trash? The trash barrels were outside of the COVID unit near negative residents. There was COVID positive trash bags on top of the barrel lids. The resident was not messing with them but was within less than a foot of them. The housekeeping staff would then have to take the trash barrels with the contaminated bags on top, through the negative halls to dispose of them. do we have observations of housekeeping staff taking the trash barrels with contaminated bags on top of them through the halls to dispose of them? Added Observation on 8/25/21 at 11:45 A.M., showed: -CNA C had the double doors to the COVID unit propped open with a cart holding resident beverages. -CNA C was pouring drinks into cups and transferring the cups onto a different cart which was inside the double doors to the COVID unit. -CNA C had on full PPE while pouring the drinks. -After pouring the drinks and placing them all on the cart inside the COVID unit, he/she began to pass the drinks out to the residents on the COVID unit, going in and out of rooms without changing out PPE, removing his/her gloves or washing his/her hands. did the cna do any care for the residents, touch the residents? etc? She went into multiple COVID positive rooms, did not change PPE, remove gloves, disinfect hands, disinfect shield (if they were even worn at all), and then went into COVID negative rooms. do we have any specific observations of the cna going into a Covid positive resident room and then going to a Covid negative room and not changing their PPE/washing hands? i don't see anything about disinfecting face shields between residents just between units in the policy -NOTE: The facility's COVID unit housed both COVID positive and negative residents. CNA C entered and exited a COVID positive resident room and with the same PPE, without changing PPE and gloves and without washing or sanitizing his/her hands, entered a COVID negative resident's room. do we have an specific observation of this Observation on 8/25/21 at 12:20 P.M., showed: -CNA A walked through the double doors onto the COVID unit with only an N-95 mask on. -CNA A did not don a gown, gloves or face shield prior to going onto the COVID unit. did they go in any rooms/provide care? She went in and out of the rooms looking for a resident who had moved rooms. do we have an observation of that? Yes, as above, she only had on an N-95 mask with no donning of gown, gloves, or shield -CNA A walked up and back down the hall, exiting back out of the COVID unit and onto a unit with COVID negative residents, to assume his/her duties of caring for the COVID negative residents. -CNA A did not change his/her mask or wash/sanitize hands after leaving the unit and before entering a COVID negative resident room. did they go in any rooms/provide any care? what says they have to change their masks after leaving the unit? CDC CMS and QSO all say to wear appropriate PPE and remove/change PPE inbetween COVID positive and negative residents. do we have specific observations of this staff member going in a positive residents room without the correct ppe/ or gloving and then go in to a Covid negative residents room. Are we trying to say we expect them to change a n-95 masks between each resident? Yes. Those are below. We are not expecting them to change masks but instead to change all other PPE and disinfect their shields which was not observed. Observation on 8/25/21 at 1:45 P.M., showed: -The facility Transportation Director was putting up a plastic barrier at the end of the COVID hall after room [ROOM NUMBER]. -Residents who were COVID positive, new admissions, and COVID negative on isolation remained on the same hall behind the newly placed barrier. anything that says they have to be closed? QSO 20-38 NH had the link listed for prevention Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes: QSO 20-38 NH https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html link to specific CDC guidance Patient Placement specific information in the CDC guidance Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. Observation on 8/25/21 at 2:30 P.M., showed: -A housekeeper took the two isolation trash barrels with the isolation trash piled on top, down the west, COVID negative hall and out the west hall door for disposition. Observation on 8/26/21 at 12:10 P.M., showed: -Two large black bins labeled Isolation Trash were sitting outside of the double doors leading to the COVID unit, outside of COVID negative room [ROOM NUMBER], with one to two red and yellow trash bags piled on top of the bins. residents around it? was the trash open and falling out? See above where the contaminated trash bags were sitting on top of the barrels in the non COVID hallway. -Doors on the COVID unit were open. was the plastic barrier up? There was a barrier up at the end of the hallway, however the residents were still intermingled. Observation on 8/26/21 at 12:30 P.M., showed: -CNA C was observed passing residents' lunch plates in and out of both COVID positive resident rooms and COVID negative rooms without changing his/her PPE, removing his/her gloves, washing his/her hands, or sanitizing his/her face shield. were they doing any direct care? They were providing lunch plates, setting up lunch for both COVID positive and COVID negative residents without changing PPE. can we be more specific on which residents rooms they went in and out of without changing ppe? I watched her go down the hallway into and out of every single room on the hall without changing out ANY PPE. So she went from positive to negative rooms on several different occasions. I watched her pass all the lunches to the rooms for all 13 residents that were on that hall. So she would have gone from positive rooms into #17's room as well as others. Observation on 8/26/21 at 2:25 P.M., showed: -No bins were present in any of the COVID-19 rooms for the staff to dispose of their used PPE. -Facility staff had to leave a COVID positive resident's room and discard their PPE into bins down the hallway in the COVID unit. -White drawer carts were observed inside the COVID hallway, however many of the carts had little PPE inside the drawers. -The cart had gloves on top and one gown in one drawer with no other supplies. -One cart was observed to only have one gown in a drawer. Observation on 8/30/21 at 9:05 A.M., showed: -A plastic barrier had been placed at the end of the COVID hall after room [ROOM NUMBER]. -The barrier that was placed did not separate the COVID positive residents from the COVID negative residents. -Residents who were on the unit as new residents in an observation/isolation period, remained on the same unit as those residents who tested positive for COVID-19. what says they have to be on different units? Their policy as stated above showed they were to have three separate units Red for Covid positive, Yellow for new admits/observation/isolation residents, and Green for non COVID positive residents. 9. During an interview on 8/25/21 at 10:52 A.M., CNA B said: -The hallway which was behind a set of closed double doors was where the facility placed new admissions and COVID positive residents. -He/she thought thought that was how COVID wa

Based on observation, interview and record review, the facility failed to ensure that one sampled resident (Resident #5) out of six sampled residents was free from abuse, when another facility resident (Resident #6) was witnessed naked from the waist down on top of Resident #5 who was also found to have had his/her brief removed; failed to notify local law enforcement and emergency services immediately upon findings and failed to ensure that the ongoing investigation wasn't impeded when peri-care continued for Resident #5 prior to sending him/her to hospital. The facility census was 69 residents. The Administrator was notified on 4/9/21 at 6:44 P.M. of an Immediate Jeopardy (IJ) which began on 4/8/21. The IJ was removed on 4/9/21, as confirmed by surveyor onsite verification. Record review of facility policy titled Abuse Prevention and Reporting, dated 11/28/16, showed: -Residents have the right to be free from all forms of abuse. -Facility will establish a resident sensitive and resident secure environment. 1. Record review of Resident #5's undated Face Sheet showed: -The resident was admitted to the facility on [DATE]. -English was not his/her primary language. -The resident was admitted with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission Minimum Data Set Assessment (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 6/24/19, showed: -Was not cognitively intact. -Had a brief mental status (BIMS-brief interview for mental status) score of two out of 15 possible points (indicating severe cognitive impairment). -Required staff assistance in all areas of his/her activities of daily living. -Required two staff to move around in bed and for other activities that required mobility. Record review of the resident's Care Plan, dated 7/1/19, showed: -He/She had impaired communication due to a language barrier. -Had health conditions that contributed to impaired communication. Record review of the resident's quarterly MDS dated [DATE] showed: -Was sometimes able to make himself/herself understood. -Was sometimes able to understand others. -Had short term and long term memory problems. -Was not able to recall the current season, location of his/her room, staff's names or faces, that he/she was in a nursing home. -His/Her decision making was moderately impaired, poor decisions would be made, and required cues/supervision. -Showed signs of disorganized thinking and inattention. -Was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, and toileting. -Required extensive assistance with dressing. -Had lower extremity impairment on both sides. -Used a wheelchair for mobility. -Was dependent on staff to roll him/her left and right, move from a sit to lying position, lying to seated position, sit to stand position, chair to bed transfer, and toileting transfers. -Was unable to wheel himself/herself 150 feet. -Was unable to participate in the assessment. 2. Record review of Resident #6's undated Face Sheet showed: -He/She was admitted to the facility on [DATE]. -Had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's discharge MDS, dated [DATE], showed: -Was cognitively intact. -Did not display any disorganized thinking. -Had a BIMS score of 14 out of 15 possible points (indicating cognitively intact). 3. Record review of the law enforcement Incident Report, dated 4/8/21 at 3:24 A.M. showed: -The incident type was rape, reported on 4/8/21 at 3:24 A.M. located at the facility. -Resident #5 was identified as the victim, Resident #6 was identified as the suspect. -Resident #6 said he/she had consensual sex with Resident #5, because Resident #5 had nodded at him/her and Resident #5 had his/her pants down. -Certified Nurses Aide (CNA) A said he/she had observed Resident #6 standing over Resident #5 and appeared to have his/her pants off. He/she was unable to see if there was any contact between the two residents genitalia or if there was penetration due to a blanket covering the two. -Resident #5 spoke only Swahili. -Evidence recovered included: the resident's white and blue blanket atop the bed, white sheet atop the bed, purple blanket on the chair; the suspect's [MEDICATION(S)] swab, swab of the right hand, left hand, genitalia, scrotum and pubic hair combing; the suspect's black long sleeved shirt, gray sweatpants, and red plaid boxers; the hinge lift (assistive device that allows residents in the nursing home to be transferred from a bed, chair or other similar resting place) had apparent hair on the absorbent pad and was collected. Record review of the Facility Investigation, dated 4/16/21 showed: -The facility administration had determined resident to resident abuse occurred on 4/8/21 when Resident #6 was found on top of Resident #5 by a facility staff person. -At 1:40 A.M., the Director of Nurses (DON) was notified of the incident. -At 1:48 A.M., the Administrator was notified of the incident and then notified the DON and facility staff to place Resident #6 on one to one facility staff person observation. -At 3:00 A.M., local law enforcement were contacted and ordered police dispatch. -At 3:10 A.M., law enforcement and the ambulance arrived. --Written undated statement from CNA A showed: -He/she was doing rounds when he/she went to Resident #5's room and saw his/her legs on the floor. -He/she went to reposition the resident on the bed when he/she said I didn't believe my eyes, Resident #6 was having sex with Resident #5. -He/she called for Licensed Practical Nurse (LPN) B. --Written statement from LPN B dated 4/8/21 showed: -CNA A called him/her to Resident #5's room. -CNA A had pushed Resident #6 out of Resident #5's room. -CNA A said Resident #6 was having sex with Resident #5. -He/she called the DON to report, completed assessment and found no injury. Record review of the electronic case report State versus Resident #6 showed: -On 4/9/21 he/she was charged with sexual abuse, first degree. -The incident took place on 4/8/21. -He/She was being held with no bond. During an interview on 4/8/21 at 8:38 P.M., Hospital emergency room Social Worker said: -Resident #5 was in the hospital emergency room and would be admitted in-patient. He/She needed a translator. He/She presented confused with cognitive impairment due to brain cancer and was not ambulatory. -Through report on 4/8/21 a facility staff person had found another resident on top of the resident, with pants around his/her ankles; but denied penetration. The perpetrator/resident was in police custody. During an interview on 4/8/21 at 9:00 P.M., Hospital Sexual Assault Nurse Examiners (SANE) Nurse said: -The resident would not cooperate with a rape kit, he/she kept pulling the blanket up over his/her face and swatted at the nurse where only limited evidence was able to be gathered. -He/She attempted to interview the resident with his/her spouse present, but the resident refused to speak. -An interpreter was called after the resident's spouse left, but the translator stated the resident wasn't making any sense. -He/She contributes the resident's uncooperative behavior to the resident's brain injury, language barriers, and his/her family being there. During an interview on 4/9/21 at 9:00 A.M., the Hospital Social Worker said: -Hospital staff were unable to perform the rape kit due to resident showing signs of agitation During an interview and observation with the assistance of a translator on 4/9/21 at 9:15 A.M., showed Resident #5: -Identified that there was someone in his/her room, the day prior, that he/she did not want to be there. -He/She did not want to talk about the events of the previous day. -He/She said many things happened. -He/She looked away periodically when directly asked about events of the previous day. -He/She became tearful when he/she was asked questions about what he/she remembered. During an interview on 4/9/21 at 10:15 A.M., Detective A said: -His/her coworker was in charge of the investigation, but he/she was familiar with the case. -Resident #6 was being held in the county jail. -The judge had signed the paperwork to continue with the conviction of sexual assault against Resident #5. During observation and interview on 4/9/21 at 12:00 P.M., Resident #6 said: -The resident was brought into the county jails visitation area in a wheelchair. -He/She did not know why he/she was being held in jail. -He/She was able to describe and recall the event clearly and without hesitation. -He/She entered Resident #5's room at around 1:10 A.M. -Resident #5's door was left open, he/she went in to talk to him/her, and he/she didn't invite me in the room. -He/She denied the ability to speak Swahili and Resident #5 did not speak English -He/She pulled the covers back and Resident #5 understood. -He/She had sweat pants pulled down and was laying on top of him/her (Resident #5). -He/She was in the room on top of Resident #5 for around 20 minutes. -CNA A came into the room and pulled me away. -He/She went back to his/her room and went to sleep. -He/She said,I was just humping Resident #5. -He/She said They have nothing on me and I don't know why they can keep me here. During an interview on 4/9/21 at 1:15 P.M., CNA A said: -He/She was doing rounds around 1:10 A.M. -He/She checked residents every two hours. -He/She remembered seeing legs, and thought that Resident #5 was falling out of bed. -He/She walked into Resident #5's room and saw Resident's #5 and #6 having sex. -He/She immediately pulled Resident #6 who was on top of Resident #5, away from Resident #5. -He/She observed Resident #5 seeming very confused. -He/She called the charge nurse by yelling down the hall. -He/She reported that Resident #5 told police that Resident #6, placed his/her hands over my mouth, but would not say anything else. -Resident #5 is often confused and does not understand what's going on even when his/her spouse and family come for visits. -CNA A was sent to the nurses station to calm down after event and another staff performed pericare on Resident #5. He/She noticed when he/she went to check on the resident later that the resident was wearing a small brief that was not normally placed on him/her. During an interview on 4/14/21 at 1:59 P.M., Registered Nurse (RN) C said: -He/She was working on the other side of the building during the incident. -Staff came to him/her to relay the event. -He/She immediately went to assist on the other side. -He/She did not directly witness the event. -He/She was told that the curtain was pulled in Resident #5's room and this was not normally closed. -He/She was told by CNA A that Resident #6 was naked from the waist down and found on top of Resident #5. -He/She was told that Resident #5's brief was pulled to the side and he/she was partially exposed from the waist down. -He/She said that Resident #6 is normally very talkative and spends most of the night awake. -On the night of the event Resident #6 came to him/her asking for an unscheduled dressing change to his/her wound prior to event and he/she felt that he/she was trying to figure out where all the staff were. During an interview on 4/16/21 at 11:59 A.M., LPN B said: -CNA A called to him/her at around 1:30 A.M.- 2:00 A.M. on 4/8/21. -CNA A explained what he/she had witnessed. -He/She was working another hall, but came over to assist. -He/She entered Resident #5's room, and CNA A had already separated Resident's #5 and #6. -He/She was unsure if Resident #5 was exposed. -Another staff member proceeded to make sure that Resident #6 was taken back to their room, and stayed with him/her. -The former DON was called and the DON said that it was not a big deal. -He/She did not agree with this and called the Administrator and spoke with the Registered Nurse on duty. -He/She came back to do a skin assessment on Resident #5, who already had pericare performed on them. -During skin assessment it was hard to separate what was naturally occurring bodily fluid and what may have been a product of the incident. -Resident #5 appeared to be confused, but was not acting strangely. -Police arrived in the building at around 2:30 A.M.- 3:00 A.M. -He/She felt that the former DON was downplaying, the situation. -CNA A came to him/her and told them that they were going to quit because the former DON was trying to have them say things that did not happen. -CNA A told LPN B that they thought Resident #5 was penetrated during the rape and the former DON did not want him/her telling the police that information. -The police initially left without making an arrest. Resident #5 was not taken to the hospital at this time. Record review of sampled Resident #7's undated Face Sheet showed: -The resident was admitted on [DATE]. -Was admitted with [CONDITION(S)] and [CONDITION(S)] following cerebral infarction (total or [CONDITION(S)] of one side of the body that results from disease of or injury to the motor centers of the brain). Record review of the resident's admission MDS dated [DATE] showed: -Was cognitively intact. -Had a BIMS score of 15 out of a possible 15 points. During an interview on 4/9/21 at 2:20 P.M., the Resident #7 said: -Resident #6 would come into his/her doorway in a wheelchair and masturbate. -This had happened at least four different times. -The last time this occurred was three to four days ago. -He/She did not tell staff about what Resident #6 had done, because he/she did not think the facility staff would do anything about it. During an interview on 4/9/21 at 2:11 P.M., CNA B said: -Typically Resident #6 was very talkative and stays up most of the night. -Resident #6 was very quiet after the event and went straight to sleep after. -He/she was not aware of Resident #6 going into other resident rooms at nights. During an interview on 4/9/21 at 2:30 P.M., CNA C said: -Resident #5 was confused most of the day. -Resident #5's family comes in and he/she seemed to recognize them. -Resident #5 says yes to everything. -Resident #6 went all over the facility in and out of other residents rooms. -He/she had not seen Resident #6 inappropriate with other residents, but he/she is sexually explicit with facility staff. -Resident #6 will often describe what he/she would like to do to staff sexually and then how it would make them feel. During an interview on 4/9/21 at 2:40 P.M., CNA D said: -Resident #5 was often confused and does not feel that he/she could make choices independently. -Resident #6 is often sexually inappropriate with staff. During an interview on 4/9/21 at 3:11 P.M., the facility Physician said: -Resident #5 would have to have someone make important decisions for him/her. -Resident #6 is aware of choices and can make choices for him/herself. During an interview on 4/9/21 at 3:33 P.M., Social Service Staff said: -He/She knew about the sexually inappropriate comments Resident #6 made to staff. -Resident #6 has made comments to him/her. -He/She had never been aware of sexually inappropriate behavior with residents. -Resident #6 was previously homeless. -The resident's history prior to homelessness, is unknown. During interview on 4/9/21 at 3:50 P.M., the Assistant Director of Nursing (ADON) said: -Resident #5 was very submissive to his/her spouse. -He/She did not feel that Resident #5 could make decisions, or, consent without help. -He/She denied any knowledge that Resident #6 was sexually inappropriate with any staff members or residents. During an interview on 4/9/21 at 3:50 P.M., the Administrator said he/she was not aware of any sexually inappropriate comments made by Resident #6 to staff or residents. 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). MO 829 and MO 798

Based on interview and record review, the facility staff failed to ensure that 12 medications out of 30 ordered medications were accurately transcribed from a hospital discharge transfer order to the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to ensure the medications were administered according to the resident's discharge medication orders to one sampled resident (Resident #1) out of a sample of six residents. The facility failed to ensure Resident #1 was free from significant medication errors. The resident went 14 days without the medications resulting in elevated blood sugars. The resident was sent to the emergency room and hospitalized for elevated blood sugars. The facility census was 69 residents. Record review of the facility's undated admission of resident policy showed facility staff were to: -Contact the physician (attending), ensuring that admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Inform physician of allergies and diet requests or needs. -Explain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the facility's physician orders, entering and processing policy dated 8/22/17, and revised 1/31/18 showed facility staff were to: -Enter order into the resident's electronic chart under order tab according to the instructions for the type of order that was received. -Be sure to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -A medication order should include: the route, the dose, the time(s), the frequency and if a treatment the directions and specific area(s) to be treated. -Notify the resident's physician if not the prescribing physician for verification if applicable. -Notify the resident's family/responsible party and the resident (if alert) of new orders. 1. Record review of Resident #1's Admission Record showed he/she was admitted to the facility on [DATE] from an acute care hospital with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] ([CONDITION(S)] -a disease process that decreases the ability of the lungs to perform ventilation). -Metabolic [CONDITION(S)] (disease in which functioning of the brain is affected by some agent or condition [such as [CONDITION(S)] infection or toxins in blood]). -Type 2 Diabetes Mellitus (DM) without complications. -Alcoholic Liver Disease. -Alcohol-induced Chronic Pancreatitis (long [MEDICATION(S)] inflammation of the pancreas caused by chronic alcohol use). -Chronic [CONDITION(S)] [CONDITION(S)] (infection caused by a virus that attacks the liver and leads to inflammation). -Alcohol abuse. -Essential Hypertension ([CONDITION(S)] - high blood pressure). Record review of the resident's hospital discharge record on 3/16/21 showed the resident was admitted on [DATE] at 5:41 P.M., and discharged on [DATE] at 4:08 P.M. with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Pancreatitis (inflammation of the pancreas- a gland behind stomach secretes digestive enzymes and the hormones insulin and [MEDICATION(S)]) since 5/24/12. -[CONDITION(S)] (low blood sugar) since 8/18/15. -Alcohol intoxication since 8/18/15. -Alcohol dependence since 8/18/15. -[CONDITION(S)] since 8/18/15. -Type 2 DM since 11/8/16. Record review of the resident's hospital discharge record medication list on 3/16/21 showed the following 12 medications out of 30 ordered medications were not transcribed to the resident's POS or the MAR: -Insulin (regulates the amount of glucose [sugar] in the blood) [MEDICATION(S)] U-100 (Novolog) 100 Units/milliliter (ml) - 3 ml subcutaneous (SQ). -Insulin Gargline ([MEDICATION(S)]) 100 Unit/ml -3 ml SQ. -[MEDICATION(S)] ([MEDICATION(S)]) (a medication to help lower high blood pressure) 10 milligrams (mg). -[MEDICATION(S)] ([MEDICATION(S)]) (a medication used to treat [CONDITION(S)] and nerve pain) 600 mg tab. -[MEDICATION(S)] ([MEDICATION(S)]) (a medication used to treat high blood pressure) 6.25 mg tab. -Fluticasine ([MEDICATION(S)]) (oral inhalant to treat allergies and chronic [CONDITION(S)]) 50 micrograms (mcg)/actuation nasal spray. -[MEDICATION(S)] ([MEDICATION(S)]) (a medication used to treat [CONDITION(S)] ([CONDITION(S)]-enlargement of the prostate gland) 5 mg tab. -[MEDICATION(S)] (Folvite) (a medication used to treat [CONDITION(S)]). -[MEDICATION(S)] ([MEDICATION(S)]) (a pain medication) 5% patch. -Acetaminophen (Tylenol) 325 mg tab. -Aspirin 81 mg chewable tab. -Guaifenisin LA ([MEDICATION(S)]) (a medication used to treat colds and cough) 600 mg tab. Record review of the resident's Nurses Notes dated 3/16/21 at 5:22 P.M., and entered by Registered Nurse (RN) A showed the resident: -Was alert and oriented. -Was continent of bowel and bladder. -Was an assist of one staff with transfers and to stand and pivot. -Used two liters (L) oxygen per nasal cannula (NC-a narrow, flexible plastic tubing used to deliver oxygen through the nostrils of the recipient in a sanitary manner). -Had [CONDITION(S)]. -Had no skin issues. -Used a wheelchair to ambulate and propelled self. -Was a smoker. -Vital Signs were within normal limits. -Denied pain at that time. -Was resting in his/her bed with his/her eyes open. Record review of the resident's Advanced Practice Registered Nurse - Board Certified (APRN-BC) assessment and progress notes dated 3/17/21 showed: -Resident reports his/her HgBA1C (a hemoglobin test used to monitor diabetes) in October of 2020 was 10.8. -Hospital hemoglobin (a protein in red blood cells that carries oxygen) of 8.0. -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] --[CONDITION(S)] with acute exacerbation. --Type 2 DM without complications. --Long term (current) use of insulin. --Liver failure. --Pancreatic insufficiency. --Essential [CONDITION(S)]. --[CONDITION(S)]. --Chronic [CONDITION(S)]. --Portal (major vein leads to the liver) [CONDITION(S)] (increased hepatic [liver] resistance). -Plan: --Monitor respiration status for [CONDITION(S)]. --Monitor Accu-checks for DM. --Monitor Blood pressure for [CONDITION(S)]. --Monitor lab. -POS reviewed with staff. --Continue current medications unchanged with exceptions of those on the POS. --Follow-Up by physician for admission history and physical. Record review of the resident's 72 hour Nurse Note dated 3/19/21 at 10:31 A.M., showed the resident was alert with no evidence of acute changes in mental status from baseline. Record review of the resident's Physician Visit History and Physical report dated 3/23/21 showed: -Active problems: --Metabolic [CONDITION(S)]. --Weakness. --[CONDITION(S)]. --Type 2 DB. --Alcoholic liver disease. --Alcoholic-induced chronic pancreatitis. --[CONDITION(S)]. --[CONDITION(S)]. -History of present illness: --admitted to hospital with decompensation of his/her liver disease due to alcohol history. --Had underlying diabetes, chronic alcoholic pancreatitis. --Patient stated: just does not feel right and really can not put a point in it. --History of type 2 diabetes and did not report any [CONDITION(S)]. --No seizures reported with a [CONDITION(S)]. --No elevation in BP with [CONDITION(S)]. --Denied shortness of breath with [CONDITION(S)]. -Review of systems and physical exam showed no issues/problems. -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] --Metabolic [CONDITION(S)] improved. --Weakness stable no change in medication or plan. --[CONDITION(S)] with exacerbation stable no medication or plan. --Type 2 diabetes mellitus without complications stable no change in medication or plan. --Liver failure without hepatic coma stable no change in medication or plan. --Pancreatic insufficiency stable no change in medication or plan. --Essential hypertension stable no change in medication or plan. --[CONDITION(S)] stable no change in medication or plan. --Chronic [CONDITION(S)] stable no change in medication or plan. --Portal hypertension (term used for increased pressure of portal venous system [major vein leads to liver]). -Plan: --Continue to monitor liver symptoms. --On [MEDICATION(S)] (a medication) for hepatic [CONDITION(S)] (loss of brain function when a damaged liver does not remove toxins from the blood). --Currently not on any glucose (sugar) lowering agents for type 2 diabetes. --Will get CMP,CBC, and INR (labs to monitor hepatic function). --Medication reconciliation. --Continue current medications unchanged. -Follow-up next monthly medical review or sooner if needed. Record review of the resident's Skilled Charting dated 3/23/21 at 3:25 P.M., and dated 3/28/21 at 7:45 P.M., showed the resident was alert and oriented times three with no evidence of acute changes in mental status from baseline. Record review of the resident's lab results received date 3/30/21 at 4:22 P.M. showed: -NA (sodium) 129 low - reference range in units 134-145 millimoles per liter (mmol/L - mmol is one-thousandth of a mole a liter measures fluid volume). -CO2 ([MEDICATION(S)]) 8 low - reference range in units 21-31 mmol/L. -Glu (glucose) 704 high - reference range in units 70-105 milligrams per deciliter (mg/dl indicates amount of a particular substance in a specific amount of blood). -TP (total protein) 9.3 high - reference range in units 6.4-8.9 grams per deciliter (g/dL). -ALKP (Alkaline phospatase - an enzyme in blood helps break down proteins made primarily by the liver) 189 high reference range in units 34-104 units per Liter (U/L). Record review of the resident's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -History of present illness: --Resident lying in bed. --Easily arousable. --No new complaints. --Was admitted with metabolic [CONDITION(S)], alcohol liver disease, and chronic pancreatitis. --No elevation in BP reported with [CONDITION(S)]. --No shortness of breath reported with [CONDITION(S)]. -Plan: --Going to get CMP, CBC,and [MEDICATION(S)] level to follow up on liver function as well as [MEDICATION(S)] (lab). --CMP was obtained today and noted glucose of 704. --Called the Director of Nursing (DON) and we are going to send the resident to the emergency room (ER) with 704 glucose. --POS reviewed. --Medication reconciliation. --Continue current medications unchanged. --Follow-up on readmission. Record review of the resident's Skilled Charting dated 3/30/21 at 4:46 P.M., showed the following: -Tympanic (by ear) temperature 97.6. -Pulse 86 and regular. -Respirations 18. -Blood Pressure 139/67 taken in right arm and sitting. -Oxygen saturation 97% on room air. -No pain. -Alert and oriented times three with no evidence of acute changes in mental status from baseline. Record review of the resident's Nurses Notes dated 3/30/21 at 5:43 P.M., showed the resident: -Was sent to the emergency room per physician request due to [CONDITION(S)] (high blood sugar). -Was drowsy and lethargic upon departure. -Left via stretcher on ambulance and the physician and the DON verified. During an interview on 4/2/21 at 12:45 P.M., the DON said: -The admitting Charge Nurse gets the admit packet from the Emergency Medical Technician (EMT) who brings the resident from the hospital to the facility. -RN A was the admitting Nurse for the resident on 3/16/21. -RN A only works as needed (PRN). During a phone interview on 4/2/21 at 1:13 P.M., RN A said: -Orders for a new resident come from the hospital or another facility. -Sometimes orders come with the resident or are faxed/emailed to the DON. -When he/she gets orders he/she goes into the patient profile on the computer under the order tab. -Clicks on new orders. -Puts in who ordered the medication and the type of drug. -The drug name pops up automatically on the computer. -Clicks on the one that matches from the admit paper orders. -Enters all the information for each step in the computer for the MAR or the TAR including a stop date if any. -The entered medications go automatically to the pharmacy. -The pharmacy may need a hard (paper) script if the medication is a narcotic. -If a script came in the admit packet it is faxed to the pharmacy. -If there was not a script the pharmacy contacts the physician to get the script. -He/She double checks all the orders with the paperwork and what was put in the computer. -If he/she is not sure what a drug is he/she will ask the DON or the ADON for help in putting that drug in the computer. -Sometimes the hospital will call the facility to verify the medications. -Sometimes he/she calls the nurse who gave the report if he/she does not understand an order. -He/She admitted the resident on 3/16/21 -He/She put all of the orders in except the Insulin and accu-check orders. -The Insulin and the accu-check orders would not go into the computer right. -He/She called the ADON and the ADON was supposed to put the Insulin and accu-check orders in the computer. -He/She put all the other medications in the computer and did the resident's physical assessment. During an interview on 4/2/21 at 1:40 P.M., the DON said: -The ADON worked the night shift on 3/15/21 and split the night shift with another staff on 3/16/21 working the last half of the 12 hour shift. -The ADON was not in the building on 3/16/21 when the resident was admitted during the late afternoon, early evening to be able to put in the resident's insulin orders. -He/She remembers when the resident admitted . -RN A was written up on 4/1/21 for the incident of not entering the resident's medications on admission on 3/16/21. -RN A was notified of the investigation regarding the incident and removed from the building on 4/1/21. -He/She started re-educating all nursing staff on entering medication orders by an in-service on 3/31/21. During an interview on 4/2/21 at 1:50 P.M., LPN F said: -Generally the hospital nurse calls to give a report to the facility admitting nurse and informs the nurse if the orders were faxed and/or sent with the resident. -He/She starts putting the faxed orders into the computer when they are received. -When the resident arrives with the paper copy orders he/she checks it with the faxed order copy to be sure everything is in the computer right. -The computer system automatically sends the orders to the pharmacy. -He/She also sends the faxed and/or paper copy of orders to the pharmacy. -The computer system does not automatically send narcotic orders. -He/She calls the resident's physician on a narcotic order to verify it. -The narcotic script is in the packet and he/she faxes it to the pharmacy if there were no changes to it from the physician. -The pharmacy calls the physician for a signature on a narcotic. -He/She has not had any orders he/she has put into the computer not be there afterwards. -He/She has heard of instances where orders were put into the computer and not there later. -He/She has worked at the facility for about three years. During an interview on 4/2/21 at 2:05 P.M., RN B said: -The admitting coordinator gets new orders faxed from the hospital for a new resident. -A paper packet also arrives with the new resident. -He/She goes through all the orders before putting anything into the computer. -He/She looks for the medications, diet, appointment orders and other orders. -He/She puts the medication orders into the computer and checks them off on the paper work from the hospital so he/she knows the order was entered. -He/She then double checks what he/she put in the computer with the paper orders to be sure it is correct. -He/She notifies the physician of the resident's arrival and confirms the hospital orders. -The computer system sends the medication orders to the pharmacy. -The pharmacy contacts the physician for a signature. -The faxed copy of a narcotic script or the hard copy of a narcotic script are faxed to the pharmacy. -He/She has had to pass off a new admit resident to the next on coming nurse at the end of his/her shift. -His/Her check off system works to let the on coming nurse know what has or has not been completed. -He/She has never passed off to an on coming nurse medication orders that he/she has started and not finished putting into the computer. -He/She finishes putting all of a resident's medication orders into the computer before leaving his/her shift. During an interview on 4/5/21 at 9:20 A.M., the resident's Physician said: -The last he/she heard the resident was OK but still in the hospital. -He/She expected new admission medication orders to be entered into the facility's computer system and the system to be working properly. -He/She expected the facility admitting nurse to notify his/her office when a new admit arrives. -His/Her nurse is able to approve a resident's medication orders or notify him/her if there is a question with an order. -He/She saw the resident about seven to eight days after his/her admission. -He/She reviews the resident's MAR and missed that there were no insulin or accu-check orders. -The resident said he/she was fine and his/her blood sugars were good at this time. -He/She has seen in the past that on a resident discharge orders from a hospital that blood sugar check orders may not be on the order. -Sometimes a line may be skipped when entering a resident's discharge hospital orders at facilities. -The Admissions Coordinator and the DON receive a new resident's discharge orders from the discharging hospital. -He/She is now on this facility's email thread from the Admissions Coordinator and the DON for new admissions and new medication orders. During an interview on 4/5/21 at 9:48 A.M., the DON said: -Routine labs are drawn on Tuesday's and Friday's in the mornings. -The resident's labs were ordered on Tuesday 3/23/21 in the afternoon and were not stat (immediate) orders. -Lab came on 3/26/21 in the morning to draw the resident's ordered labs. -The resident refused and RN B tried to convince him/her to have the labs drawn. -Lab came back on Tuesday 3/30/21 in the morning for the ordered labs and stuck the resident twice and missed both times. -Another lab technician came back on 3/30/21 at 12:00 P.M. and was able to get enough blood sample to run the CMP lab. -The Physician came in the late afternoon on 3/30/21 to see the resident and saw the lab results with the high blood sugar of 704 and gave the DON the order to send the resident to the hospital. -He/She had left the facility when he/she received the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -On 3/16/21 he/she relieved the off going nurse RN A and split the 12 hour night shift with the ADON around 11:30 P.M., or midnight. -RN A did not relay any information to him/her about not getting all of the resident's medications into the computer or having any issues with entering any medications. -He/She was told by RN A that all of the resident's medications were in the computer and did not double check them. -The facility at the time did not have a policy to double check new medications by a second nurse. -When medications are put into the computer system they are automatically sent to the pharmacy. -The facility has been working with their corporate office, since 3/30/21 to come up with a policy to double check or a system to be sure that new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/5/21 at 11:31 A.M., RN A said: -He/She worked the next day, 3/17/21, and had the resident again. -He/She forgot that the resident was a diabetic. -It never crossed his/her mind that there were no insulin orders on the MAR to give the resident. -He/She thought he/she had put all of the resident's medications into the computer when admitting the resident. During a follow up interview on 4/5/21 at 9:43 A.M., the resident's Physician said: -During his facility visit on 3/30/21 the resident's blood pressures were in a normal range. -The resident has chronic pancreatitis and a history of metabolic [CONDITION(S)]. -The resident does run high blood sugars at times. -His/Her Nurse Practitioner (NP) saw the resident on 3/17/21. -The NP had access to the resident's hospital discharge record and listed insulin on his/her progress notes. -He/She is not sure if the NP had access to the facility's POS or MAR to see if insulin was ordered. -He/She does not believe the resident's missed [MEDICATION(S)] would have made a harmful difference. -He/She does not think the missing insulin caused a definite harm to the resident. -It did cause the resident to go to the hospital. -He/She heard that the resident's blood sugars were reversed and corrected with insulin at the hospital. -He/She cannot excuse the fact that the resident was not getting insulin or that he/she missed it not being ordered on his/her earlier visit to the facility. -He/She does not feel it caused the resident long [MEDICATION(S)] harm without seeing the hospital report. -A pancreatic patient can get better and not require insulin or can get hypoglycemic on insulin. -The resident's pancreas must have been handling it OK for the 14 days without insulin. During an interview on 4/5/21 at 1:00 P.M., the ADON said: -He/She did not talk with RN A, who admitted the resident on 3/16/21. -RN A had never contacted him/her for help in putting in insulin or accu-check orders or any other medications that he/she can recall. -He/She was not in the facility. -He/She was home sleeping due to the nurse scheduled to come on at 6:00 P.M., had called off. -He/She and the DON were splitting the shift. -The DON worked the first half of the shift 6:00 P.M. to about 11:30 P.M., or midnight. -He/She did not recheck the resident's medication orders when taking over the shift. -The facility did not have a policy or practice in place to double check new admit orders before this incident. -The facility has completed a full audit of all resident charts against admitting orders. -The facility is re-educating the nursing staff to double check new resident orders when taking over a shift. -The facility now has an admission checklist for new residents. -The admitting nurse fills out the checklist as to what admission areas have been covered. -The admitting nurse will turn the checklist in when completed to the DON or ADON. -The admitting nurse must put in a resident's full physical and skin assessment, all medication orders, the diet order, and the resident's code status before turning the new resident over to the oncoming nurse. During an interview on 4/5/21 at 1:40 P.M., the Administrator said: -The ADON was not in the facility on 3/16/21 for RN A to have asked for his/her help as RN A had said. -An audit was completed on all resident's medication orders since this incident. MO 527

Based on observation, interview and record review, the facility failed to prevent one sampled resident (Resident #5) from experiencing physical and verbal abuse of being struck, threatened and cursed at by one employee (Smoke Monitor A) and to ensure the employee was trained in accordance with the facility Abuse Prevention and Reporting policy, out of 11 sampled residents. The facility census was 64 residents. Record review of the facility Abuse Prevention and Reporting policy dated 11/28/16 showed that during orientation of new employees the facility would cover at least the following: -Sensitivity to resident rights and resident needs. -What constitutes abuse, neglect, exploitation, mistreatment and misappropriation of resident property. -Staff obligations to prevent and report abuse, neglect, exploitation, mistreatment and misappropriation of resident property. -Dementia management and resident abuse prevention. -How to assess, prevent, and manage aggressive, violent and/or a catastrophic reactions of residents in a way that protects both residents and staff. --How to recognize and deal with burnout, frustration, and stress that may lead to inappropriate responses or abusive reactions to residents. Record review of the facility Resident's Rights policy Appendix A dated November, 2019 showed: -Residents had the right to be free from mental, physical and verbal abuse. -All employees would receive a complete statement of the residents' guaranteed rights and were expected to promote and protect those rights throughout their employment. -All employees had an ethical and professional responsibility to support and promote the highest standards of conduct. -The facility had a zero tolerance for abuse and neglect. 1. Record review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] end of right humerus (the long bone in the arm that extends from the shoulder to the elbow). -[MEDICAL CONDITION] disorder (a mental health disorder characterized by a combination of symptoms of [MEDICAL CONDITION], including hallucinations or delusions, and symptoms of a mood disorder, such as elevated energy, mod and behavior and depression). -History of [MEDICAL CONDITION]. -Anxiety disorder. -Major [MEDICAL CONDITION]. -Mild cognitive impairment (a condition in which a person experiences a slight - but noticeable - decline in memory and thinking skills serious enough to be noticed by the person affected and family members/friends, but do not affect the individual's ability to carry out everyday activities. Record review of the resident's Order Recap Report dated 4/29/20 showed the following physician's orders [REDACTED]. -[MEDICATION NAME] (antianxiety medication) 0.5 milligrams (mg), give one tablet three times a day for anxiety. -[MEDICATION NAME] (antidepressant medication) capsule delayed release 60 mg, give two capsules one time a day for mental disorder. -Ziprasidone [MEDICATION NAME] (HCl) (antipsychotic medication) 80 mg, give one capsule at bedtime for [MEDICAL CONDITION] disorder. Record review of the resident's Care Plan Meeting Note dated 4/28/20 timed at 12:10 P.M. showed: -The resident attended the meeting. -Staff educated him/her about mutual respect. -He/she said he/she liked to have the last word to feel good. -Social Services discussed other options as coping skills with him/her. Record review of the resident's Behavior Progress Note dated 4/28/20 timed at 10:39 P.M. showed: -Licensed Practical Nurse (LPN) C was down the hall from the lobby area and heard someone asking where the nurse for Resident #5 was. -Smoke Monitor A told LPN C that the resident had pushed everything off the desk, was cursing, calling him/her nigger and swung at him/her. -LPN C observed the resident stand up from his/her wheelchair and accuse Smoke Monitor A of lying, calling him/her a [***] and grabbed Smoke Monitor A by his/her arms. -Smoke Monitor A was calm and called the police at that time, LPN C called the Administrator and the Director of Nursing (DON). -LPN C was able to calm the resident and asked him/her if he/she wanted him/her to get his/her antianxiety medications and the resident agreed. -LPN C retrieved the resident's antianxiety medication. -On his/her way back to the resident, LPN C heard commotion, walked up and saw the resident sitting back in his/her wheelchair. -Resident #6 told him/her that Smoke Monitor A had hit the resident after the resident again hit staff. -The police arrived and talked to the staff and the resident. -The police determined that the resident was the aggressor after also talking to other residents. -LPN C informed Smoke Monitor A that he/she had to leave and that he/she needed to write a statement, Smoke Monitor A just clocked out and left without giving a written statement. -The police report was a non-aggravated assault and no charges were brought against the resident. -The police left information about the case which LPN C put under the Administrator's door. -The resident calmed down and said he/she was going to go to bed. -LPN C completed a head to toe assessment (physically assessed the resident for from head to toe); the resident denied any pain or discomfort and the assessment was within normal limits (WNL-normal findings). -LPN C notified the resident's physician. -The resident was on 15 minute checks. -The resident's responsible party was unable to be reached. Record review of the resident's 15 minute monitoring sheets, dated 4/28/20 showed he/she was monitored every 15 minutes continuing through 4/29/20 at 1:15 P.M. when the copy of the 15 minute check sheets were made available. Record review of the resident's Social Service Progress Note dated 4/29/20 at 11:51 A.M. showed: -Social Services spoke with the resident that morning per the resident's request. -The resident wanted to call his/her guardian listed on file; the guardian was unavailable and Social Services left a voice mail message. -The resident also wanted to talk about the incident that occurred the previous evening. -The resident said he/she wanted Social Services to know that he/she would never say the N word and asked to speak with the Administrator. -Social Services told the resident that he/she could help with his/her grievances but he/she was welcome to knock on the Administrator's door if he/she needed. During an interview on 4/29/20 at 12:03 P.M. the Administrator said: -The resident had been admitted about two weeks ago. -On the evening of 4/28/20, the resident was at the Smoke Monitor desk and physically attacked Smoke Monitor A two times. -Smoke Monitor A Put hands on the resident the second time the resident attacked him/her. -He/she needed to find some witnesses. -The police were called; a police report was made. -The incident happened at about 7:45 P.M. -The charge nurse, LPN C, called the DON, and the DON then called him/her. During an interview on 4/29/20 at 12:05 P.M., the DON said: -He/she received a call from LPN C at 7:56 P.M. on 4/29/20 stating that Smoke Monitor A had struck the resident with his/her closed fist. -LPN C told him/her that the resident was agitated Smoke Monitor A had struck the resident with his/her closed fist. -The incident happened at about 7:45 P.M., the second interaction of the resident and Smoke Monitor A, when Smoke Monitor A struck the resident with his/her fist. Observation on 4/29/20 at 12:27 P.M. showed the resident: -Was seated in a chair in his/her room. -Was alert, dressed, and answered questions. -Had no visible signs of injury on his/her face and sides of his/her head. -Had a cast on his/her lower right arm. During an interview on 4/29/20 at 12:27 P.M. the resident said: -Sometime after supper Smoke Monitor A hit him/her in his/her head two times. -Smoke Monitor A had said he/she had called him/her a nigger. -Smoke Monitor A was a pathological liar. -Smoke Monitor A should have given him/her his/her stuff that had been brought to the facility for him/her. -Two Certified Nursing Assistants (CNAs) were there when Smoke Monitor A hit him/her, he/she did not know their names. -He/she got in trouble for chasing Smoke Monitor A around the desk; that was the reason Smoke Monitor A hit him/her. -He/she had not hit Smoke Monitor A. -It was on the left side of his/her head, near his/her ear that Smoke Monitor A had hit him/her; it did not hurt him/her at all, Smoke Monitor A had not hit him/her that hard. -It made him/her mad that Smoke Monitor A hit him/her. -Smoke Monitor A should not have hit him/her. -The nurse looked him/her all over to see if he/she was hurt. During an interview on 4/30/20 at 2:22 P.M. Smoke Monitor A said: -He/she was working the evening shift on 4/28/20 and arrived at work at 2:00 P.M. -The resident got upset with Smoke Monitor A during the day shift on 4/28/20. -The resident asked him/her for a package and started arguing with him/her. -The resident knocked his/her cell phone and charger off the desk. -At about 8:00 P.M. the resident hit him/her A good few times and hit me one good time. -He/she punched the resident. -He/she used his/her open hand when he/she punched the resident. -He/she believed he/she hit the resident once, he/she was not sure how many times he/she hit the resident. -There were a couple of residents in the area, he/she was not sure who the residents were. -The resident had come around the desk after him/her. -He/she was running away from the resident. -He/she was yelling at the resident. -He/she hit the resident on the side of the resident's head one or two or three times. -The resident kept coming toward him/her. -Two staff were there the third or fourth time the resident came after him/her. -The resident came after him/her five or six times. -The staff who were there told him/her to just go but the resident came after him/her one more time. -His/her mother had taught him/her to not put up with anything and to fight for himself/herself. -He/she should not have hit the resident, he/she was just so upset with the resident coming after him/her and he/she was not going to take that, and the racial slurs were just too much to take. -He/she called the police, the police came and talked to him/her. -A facility staff person told him/her to leave the facility and to write a statement before he/she left. -He/she did not write a statement before he/she left; he/she was just too upset. -The facility had not trained him/her on abuse or neglect of residents, or if a resident was having a reaction to something or having behaviors. -For training and orientation the facility only told him/her how to answer the facility telephone, how to transfer phone calls, how to do screening for persons who entered the facility for COVID-19 (a contagious disease for which the facility screened persons who entered by taking the persons temperature and filling out a questionnaire related to risk factors). 2. Record review of Resident #6's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required for care planning) 1/28/20 showed he/she: -Was admitted to the facility on [DATE]. -Was cognitively intact. During an interview on 4/29/20 at 12:44 P.M., the resident said: -He/she was in the lobby in the evening on 4/28/20 when Resident #5 yelled at and chased Smoke Monitor A around the desk. -He/she did not see Smoke Monitor A hit or touch Resident #5. 3. Record review of Resident #7's annual MDS dated [DATE] showed he/she: -Was admitted to the facility on [DATE]. -Was cognitively intact. During an interview on 4/29/20 at 12:58 P.M. the resident said: -He/she was in the lobby in the evening on 4/28/20 when Resident #5 attacked Smoke Monitor A. -He/she had not seen what had caused the resident to attack Smoke Monitor A. -During the attack, Resident #5 hit Smoke Monitor A four times. -Smoke Monitor A said: I'm not going to take this, do that again and I'll hit you back. -He/she did not see Smoke Monitor A hit Resident #5, a CNA he could not identify was standing between him/her and Smoke Monitor A. -The resident was violent toward Smoke Monitor A. -The police were called. -It started at the Smoke Monitor desk in the lobby and moved to just inside the dining room entry door. 4. During an interview on 4/29/20 at 1:45 P.M. The Human Resources Director said: -On 4/28/20 he/she received a telephone call from Smoke Monitor A at 6:49 P.M. which was a missed call and a text message from Smoke Monitor A at 7:51 P.M. requesting that he/she call him/her. -He/she called and spoke with Smoke Monitor A at 7:56 P.M. on 4/28/20. -Smoke Monitor A was really upset and said the resident had scratched him/her on his/her arms and hit him her with his/her cast. -Smoke Monitor A said the resident had said that he/she wanted his/he stuff and knocked everything off the desk; the resident said that his/her stuff had been dropped off at the desk and that Smoke Monitor A had stolen his/her stuff. -Smoke Monitor A said there were two CNAs present; he/she did not know the names of the CNAs. -Smoke Monitor A said the CNAs could not hold the resident back and the resident got up out of his/her wheelchair and attacked him/her; he/she went to the dining room and the resident followed him/her saying he/she needed to give him/her his/her stuff; the resident knocked everything off the desk and he/she called the police and the resident was crying. -He/she asked Smoke Monitor A if he/she had hit the resident and he/she said yes, he/she had hit the resident. -He/she then included the DON in a three way conversation with Smoke Monitor A and Smoke Monitor A again said he/she had hit the resident. -He/she was told he/she needed to write a statement and leave the facility. During an interview on 4/29/20 at 8:53 P.M. LPN C said: -He/she went to the lobby area when staff asked him/her what nurse was assigned to the resident and on the way to the lobby he/she heard loud noise. -When he/she got to the lobby, the resident, Smoke Monitor A and a couple of other staff were in the lobby; he/she could not remember who the other staff were, just that they were CNAs. -The resident got up from his/her wheelchair and grabbed Smoke Monitor A by his/her arms. -He/she was able to get the resident to let go of Smoke Monitor A, sit down in his/her wheel chair and calm down. -He/she asked the resident if he/she wanted his/her antianxiety medication and he/she left the area to get the resident's medication. -Upon return to the lobby, CNA A told him/her that Smoke Monitor A had hit the resident on the side of his/her head with his/her closed fist. -He/she was told Smoke Monitor A had called the police and the police arrived about 10 minutes after he/she got to the lobby. -He/she called the DON and reported that he/she had been told Smoke Monitor A had hit the resident. -He/she was told to have Smoke Monitor A write a statement and leave the facility. -He/she told Smoke Monitor A he/she would need to write a statement and then leave. -Smoke Monitor A left the facility without giving a written statement. During an interview on 5/1/20 at 1:09 P.M. CNA A said: -He/she was working the evening shift on 4/28/20. -He/she was not in the area with the resident and Smoke Monitor A when the incident started. -He/she went to the lobby in the middle of the incident. -He/she was in the employee break room and heard a noise. -He/she went to the lobby where the noise was coming from. -The resident and Smoke Monitor A were cursing at each other, -The resident said the B word and both were cursing at each other. -Smoke Monitor A said the B word too and said, [***] , stand up and fight if you want to fight. I'm going to beat you up to the resident. -The resident stood up. -He/she tried to calm the resident down; the resident and Smoke Monitor A kept fighting. -He/she had to call for more employees to come. -He/she tried to hold the resident's left arm. -The resident and Smoke Monitor A were both trying to push each other. -The resident sat down. -Smoke Monitor A said [***] you. I'm going to beat you up to the resident. -Smoke Monitor A stood up and punched the resident twice with his/her closed fist; hitting the resident close to his/her ear on the left side of his/her face. -He/she grabbed Smoke Monitor A and held onto him/her by holding his/her arms and the side of his/her body close to him/her. -Smoke Monitor A kept saying, Let go of me!, he/she told Smoke Monitor A to calm down. -The resident went outside to smoke. -The police arrived about that time. -CNA B was in the lobby but did not help. During an interview on 5/1/20 at 2:42 P.M. CNA B said: -He/she was working the evening shift on 4/28/20 and while on his/her break walked into the lobby when the incident was half way over with the resident and Smoke Monitor A was close to the end. -The resident went after Smoke Monitor A more than five times, charging at him/her. -Smoke Monitor A hit the resident three times with his/her hand on the left side of the resident's face. -Smoke Monitor A also picked up a wet floor sign and started to swing it at the resident. -CNA A held Smoke Monitor A until he/she calmed down. -The resident went outside; then he/she went outside on his/her break. MO 588

Based on interview and record review, the facility failed to maintain continuous one to one monitoring of one sampled resident in order to prevent the resident from ingesting narcotic and benzodiazepine medications that were not prescribed to the resident, resulting in the resident's hospitalization for one sampled resident (Resident #8) out of four sampled residents who were prescribed narcotic medications and 11 residents in the sample. The facility census was 64 residents. 1. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's Comprehensive Care Plan showed the following: -4/14/2020 the resident had significant cognitive conditions and had a need to adjust to situation and life change. The intervention showed the resident needed one to one bedside/in room visits and activities if he/she is unable to attend out of room events. -4/23/2020-The resident had [MEDICAL CONDITION] or an acute confusion episode related to his/her disease process. The intervention showed staff should use the resident's first name and identify themselves at each interaction, Face the resident and make eye contact when speaking, reduce distractions and provide necessary cues; monitor the resident's and other residents safety when the resident is ambulating out of his/her room. The resident's risks which increase safety risks was confusion; monitor record and report new onset of [MEDICAL CONDITION] signs and symptoms; provide medications to alleviate agitation, and monitor/document side effects and effectiveness. The Care Plan also showed the resident had impaired communication. Interventions showed the resident should be encouraged to continue stating thoughts even when having difficulty, monitor the resident for physical and non-verbal indicators of discomfort or distress. It also showed the resident was independent with bed mobility, dressing, transfers, bathed with supervision, was incontinent and was at risk for falls, confusion, poor communication and comprehension. The care plan did not show whether the resident ambulated or used an assistive device. -There was no update to the resident's care plan that showed the resident's behaviors related to wandering or one to one monitoring until 5/12/2020. Record review of the resident's physician's orders [REDACTED].>-Descovy Tablet 200-25 milligrams (mg), give one tablet by mouth once daily related [MEDICAL CONDITION](this was ordered 4/9/2020). -Dolutegravir Sodium 50 mg, give one tablet by mouth daily related [MEDICAL CONDITION](this was ordered 4/9/2020). -[MEDICATION NAME] 50 mg, give one tablet twice daily related to hallucinations (this was ordered 4/29/2020). -[MEDICATION NAME] HCI 100 mg, give one tablet once daily related [MEDICAL CONDITION](this was ordered 4/20/2020). -[MEDICATION NAME] 5 mg give one tablet twice daily for hallucinations (this was ordered 4/27/2020). -The resident did not have any physician's orders [REDACTED]. Record review of the resident's Medication Administration Record [REDACTED] -The resident did not have any physician's orders [REDACTED]. -The resident had an additional physician's orders [REDACTED]. Reassess after two weeks (this order was dated 4/26/2020). -All of the resident's prescribed medication listed on the MAR indicated [REDACTED]. Record review of the resident's Nursing Notes showed: -5/5/2020 at 11:59 A.M. - Resident remained on one to one observation and had not had any unwanted behaviors or outbursts during this shift. Staff will continue to monitor and follow up as needed. -5/6/2020 at 1:02 A.M. - Resident was having hallucinations with paranoid thoughts that someone was going to shoot someone. Resident needed constant redirection and was receiving one on one monitoring. -5/7/2020 at 11:28 P.M. - Resident continued on one to one monitoring, was redirected frequently and given food and drinks. Was toileted-continue to monitor. -5/8/2020 at 1:10 A.M. Resident was in his/her bed resting with eyes closed. Breathing was even and unlabored, one to one monitoring maintained. -Late Entry 5/8/2020 at 5:00 A.M. - (note: the electronic record showed this entry was documented on 5/11/2020 at 12:54 P.M.) - Resident was up and stating he/she was hungry. Cookies and juice was provided. Resident requested a sandwich but was informed breakfast would be in an hour. Resident was assisted to toilet and then was sitting on the side of his/her bed eating cookies. The resident was alert, confused and continues to talk non-stop to people that were not there, yelling out for his/her girlfriend and family. -Late Entry 5/8/2020 at 6:15 A.M. - (note: the electronic record showed this entry was documented on 5/11/2020 at 12:58 P.M.) - Resident was sitting on the side of his/her bed quietly eating cookies. The day supervisor was in the building and report was given. Monitoring taken over by the nurse. -5/8/2020 at 12:45 P.M. - Resident was seen by the Nurse Practitioner and there were new orders to send the resident to the hospital for low blood pressure, heart rate and change of mental status. -5/8/2020 at 1:03 P.M. - Resident was sent to the hospital for change in condition. The resident presented with hypothermia (low body temperature), [MEDICAL CONDITION] (low heart rate) and his/her vital signs were: temperature was 90.8 degrees Fahrenheit (F)(normal temperature is 98.6 degrees F), blood pressure was 93/67 (normal is 110/70), heart rate was 45 beats per minute (normal range is between 60-80 beats per minute), and oxygen was 97 percent (%)(normal is greater than 95%). The resident was unable to be aroused from sleep completely. The resident responded to verbal and physical stimulus with groans. The resident was last seen after breakfast with one to one monitoring in his/her room. The resident was transported by ambulance to the hospital. Record review of the facility's Pro Re Nata (PRN-as needed) Medication Audit Report dated 5/11/2020, showed all of the PRN narcotic medications that were administered from 4/12/2020 to 5/11/2020, who administered the mediation, the time the medication was administered and to whom. The record showed: -On 5/7/2020 the Assistant Director of Nursing (ADON) administered the following narcotic pain medications: [REDACTED]. -There was no documentation showing any narcotics were administered to Resident #8 and Resident #8's name was not represented on the Narcotic medication report. Record review of the facility's PRN Medication Audit Report dated 5/11/2020, showed PRN medications administered between 5/2/2020 to 5/11/2020. Documentation showed: -On 5/7/2020 at 8:02 PM, the ADON administered [MEDICATION NAME] (a benzodiazapine) to a resident that was not Resident #8. -On 5/8/2020 at 5:23 AM, the ADON administered [MEDICATION NAME] to a resident that was not Resident #8. -Resident #8 did not have any PRN medications administered on 5/7/2020 or 5/8/2020. Record review of the resident's Hospital Record dated 5/8/2020 at 1:20 P.M., showed: -The resident arrived from the facility (on 5/8/2020) with an altered mental status and the report from the facility showed the resident was at baseline yesterday, but this morning the resident more lethargic than normal and hard to wake up. Upon arrival, the resident was sitting up and aware of the situation. He/she presented with altered mental status and hypothermia. -The resident's body temperature was 88 degrees F and his/her heart rate was in the 40's and the resident was on room air. -The resident was able to nod to answer questions and was able to follow commands. -The resident's lab results showed positive for benzodiazepines and opioids. -The resident showed no intracranial bleeding, no cardiac, lung, or musculosketal abnormalities. -The resident was negative for any acute findings. -The resident was cool to the touch and his/her temperature was 89.6 degrees F. Record review of the resident's hospital records dated 5/11/2020, showed: -The resident's [MEDICAL CONDITION] was due to hypothermia, but the cause of hypothermia was unclear. The resident was started on [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic) for [MEDICAL CONDITION] (a condition caused by the body's response to an infection). -The resident's temperature had normalized. -Noted the resident was positive for benzodiazepines and [MEDICATION NAME], which were not prescribed and could have contributed to the resident's presentation with hypothermia and [MEDICAL CONDITION]. Documentation of the resident's one to one monitoring records was requested from the facility Administrator on 5/12/2020 and again 5/13/2020 (Administrator and Director of Nursing (DON)). Record review of the resident's Care Plan showed an update on 5/12/2020, which showed the resident was on one to one monitoring and/or safety checks related to risk for wandering into other resident rooms, and upsetting other residents, related to poor communication skills and inability to follow directions due [MEDICAL CONDITION] process. Interventions showed staff was to: -Complete a face to face safety check per assignment and notify the nurse if unseen. -Assess exit seeking behavior by walking with the resident and redirect him/her from inappropriate behavior/engage in diversional activity. -Administer medications and observe for adverse side effects, if noted, and report them to the physician. -Anticipate the resident's care needs and provide them before the resident becomes overly stressed. -Attempt any or all of the following to assist in redirection: toileting, providing snacks, beverages, move to a quiet area, walking, validate feelings, provide reassurance, provide music, encourage resting/naps, call family, provide an alternate caregiver, use humor, redirect with activity, provide one to one monitoring as needed. -Provide psychological/psychiatric services as physician ordered. During an interview on 5/12/2020, at 10:43 A.M. the hospital Social Worker said: -The resident was admitted to the hospital on [DATE]. -They called the facility to confirm whether the resident had physician's orders [REDACTED]. -The resident's lab tests confirmed that the resident had both benzodiazepine and narcotic medications in his/her system. -The resident was currently in the hospital progressive care unit (PCU-a hospital unit that specializes in treating medical and surgical patients whose needs are not serious enough for the Intensive Care Unit (ICU) but too complex for the regular hospital floor). -An attempted visit to the resident 5/12/2020 at 11:23 A.M. at the hospital was unsuccessful. During an interview on 5/12/2020 at 1:00 P.M. with the Administrator and DON, the DON said: -On the afternoon of 5/8/2020, nursing staff noticed the resident was lethargic and hard to arouse. They took his/her vital signs and they were not normal (low pulse and respirations) and they received a physician's orders [REDACTED]. -Later that afternoon Registered Nurse (RN) B (also a Unit Manager) followed up with the hospital staff and the hospital staff informed him/her that the resident was in the PCU unit and was found to have benzodiazepines and narcotics in his/her system. When RN B checked the resident's physician's orders [REDACTED]. -RN B notified the Administrator and him/her, and they could not determine how the resident obtained the medications. -He/She checked the residents' (who were administered narcotics on 5/7/2020) individual narcotic records and there were no discrepancies noted and no medication mismanagement noted. -There was no documentation showing the ADON gave Resident #8 any narcotics or benzodiazepines on 5/7/2020 or 5/8/2020. -The resident was ambulatory but was very confused and did not self-administer medications. -The Administrator said they began the investigation and he/she contacted the Department of Health and Senior Services (DHSS) to make a report. He/She began interviewing staff and were not able to find out how the resident obtained the narcotics and benzodiazepines. -The Administrator and DON said this morning, the agency they work with to assist with staffing called and said that some of the staff that had worked at the facility on 5/7/2020, reported that the ADON gave the resident liquid [MEDICATION NAME] (a narcotic) that belonged to another resident while working during the night shift. The Administrator said the agency liaison said they would have the nursing staff call and give their statements, but he/she had not yet heard from the nursing staff. The Administrator said they pulled the staffing sheets and saw that the ADON was working on the floor from 10:00 P.M. to 6:00 A.M. on 5/7/2020. He/She said RN B had obtained statements from some staff who worked the night shift but was out on sick leave currently. -The Administrator said that once he/she received information regarding the allegations, he/she spoke with the ADON, who was at work on 5/11/2020, explained to him/her the allegations and placed him/her on suspension pending investigation. During a telephone interview on 5/12/2020 at 2:11 P.M., agency Certified Nursing Assistant (CNA) C said: -He/she was working the night shift (10:00 P.M. to 6:00 A.M.) on 5/7/2020 and was assigned to the East Unit. -The ADON was working on the floor for that shift and was working on the West Unit. -Resident #8, who normally received one to one monitoring was not on a one to one monitoring during this shift and the ADON had taken the resident off of the one to one monitoring. -He/she saw the ADON passing medications around 11:00 P.M., but he/she did not see what medications the ADON was passing. -Regarding Resident #8, he/she said the resident had been up ambulating in the hallway (without a monitor). During an interview on 5/12/2020 at 2:50 PM, agency CNA D said: -He/she worked on the day shift on 5/7/2020 (from 6:00 A.M. to 2:00 P.M.). While he/she was at work, Resident #8 was ambulatory without an assistive device and was confused. He/she was on one to one monitoring at all times because he/she wandered and was very active. On that date, the resident was behaving normally. -He/she worked the day shift on 5/8/2020, and when he/she saw the resident the resident was not acting himself/herself (he/she did not remember what time he/she saw the resident). He/She said the Charge Nurse, Licensed Practical Nurse (LPN) D, took the resident's vital signs (blood pressure, pulse temperature and respirations) and they were not normal, so he/she called to have the resident sent to the hospital and the resident was sent out. -Later that afternoon, the hospital called to say that the resident had medications in his/her system that the resident did not have a physician's orders [REDACTED]. one to one monitoring because he/she was going to give the resident something that would knock (him/her) on (his/her) butt. He/she said the nursing staff said the ADON told them to check on the resident frequently to make sure he/she was still breathing, (during the shift). He/she said that the nursing staff told him/her (after nursing staff found out that the resident had medications in his/her system that he/she should not have ingested), staff was trying to contact the ADON and the ADON called the nursing staff to tell him/her not to say anything. During an interview on 5/12/2020 at 3:15 P.M., LPN E said: -He/she was not working on 5/7/2020, when the resident was sent to the hospital, but LPN D told him/her that the ADON had given another resident's narcotic medication to Resident #8 in order to sedate him/her. -Resident #8's normal behavior was that he/she was ambulatory and very active, was confused, hallucinated and roamed the halls at night. -On 5/8/2020, the nursing staff noticed the resident was not easily aroused and when they took his/her vital signs they were low (he/she looked at the resident's vitals). The resident's blood pressure was 93/67, temperature was 90.8 degrees F and heart rate was 45 beats per minute. -LPN D told him/her that he/she had approached the Unit Manager to have the resident sent to the hospital and was initially told they did not need to send him/her out, but he/she called to have the resident sent out to the hospital and the resident was sent out to the hospital. During a telephone interview on 5/13/2020 at 9:49 AM, RN D said: -He/She was the RN who worked on the morning of Friday, 5/8/2020, and he/she came to work at 6:00 A.M. that morning. -When he/she came into the facility, he/she saw the resident standing in the doorway to his/her room and he/she was talking to staff that was providing one to one monitoring. -The resident at baseline, was alert and oriented to person and sometimes was more lucid but he/she had significant confusion. He/She said the resident could answer yes/no questions but had hallucinations. -The resident was ambulatory without assistance and wandered throughout the day and needed constant redirection and this was why he/she was receiving one to one monitoring (to keep the resident from going into other resident's rooms). -He/She did not see the resident go to breakfast and did not see any of the medication pass that morning, but the staff who were responsible for passing the medications on that unit (West Unit) on the morning shift was Certified Medication Technician (CMT) B, who passed all of the non-narcotic medications and LPN D, who passed all of the narcotic medications. -Around 10:00 or 10:30 A.M., he/she was completing rounds via teleconference with the Nurse Practitioner, and went to the resident's room. He/She said the resident looked to be asleep at that time and he/she did not notice anything to be alarmed about. -He/She continued with rounds, saw CMT B in the hallway and overheard him/her say that the resident's heart rate was 48. He/She asked the Nurse Practitioner if he/she wanted to go back to the resident's room. He/she went back to the resident's room. At this time the resident still appeared to be sleeping and CMT B said that the resident's heart rate was 48 and they were having difficulty arousing the resident. The Nurse Practitioner gave the order to send the resident out to the hospital. CMT B went to tell LPN D, the Charge Nurse, of the order to send the resident to the hospital and both LPN D and RN B, the Nurse Unit Manager, went to the resident's room and prepared to send the resident out to the hospital. -He/she continued to round with the Nurse Practitioner via teleconference. -The resident was sent out to the hospital before lunch at 12:00 P.M. and he/she dictated a note in the resident's nursing notes after the resident was sent out. -At the time that the resident was sent to the hospital, he/she was not aware that the resident had been given any narcotic medications or benzodiazepines that he/she was not supposed to receive, and was not aware of any narcotic medication mismanagement by any of the nursing staff. During a telephone interview on 5/13/2020 at 10:41 A.M., CMT B said: -He/She worked the 6:00 A.M. to 6:00 P.M. shift at the facility, was familiar with the resident and passed his/her medications. -The resident received [MEDICATION NAME], Dolutegravir Sodium and Descovy. -He/She did not give the resident [MEDICATION NAME] because the resident was only supposed to receive that medication at bedtime. -The resident typically was alert but confused, ambulated independently without assistance and usually wandered around the facility. -The resident was on a one to one continuous monitoring due to wandering. -When he/she worked on 5/7/2020, the resident was behaving the way he/she always does and there were no issues that he/she saw that were alarming. -When he/she came to work on 5/8/2020, at 6:00 A.M., he/she saw the resident was dressed in his/her bed gown, but he/she was in his/her room and was behaving normally. He/She said the resident was not lethargic or asleep at that time and the resident's one to one monitor was sitting with the resident. -The resident received breakfast in his/her room and he/she saw the staff take the resident' meal tray, but he/she did not see how much the resident ate. -Between 8:00 A.M. and 8:30 A.M., he/she went into the resident's room to give him/her his/her medication and the resident was sitting on the side of his/her bed drinking milk. He/She gave the resident his/her medication and the resident ingested the medication without any problem. He/She said he/she did not notice any problems with the resident. He/She said he/she administered the resident [MEDICATION NAME], Dolutegravir Sodium and Descovy. -At around 11:00 A.M., before lunch, he/she went to the resident's room to take his/her vital signs. The one to one monitor was in the resident's room and the resident was fully dressed, but was laying down on his/her bed and appeared to be sleeping. When he/she took the resident's temperature, it was around 90.7 which was too low, so he/she went to tell the Charge Nurse, LPN D. Around the same time, RN D was completing rounds with the Nurse Practitioner and he/she came to the resident's room as did LPN D. -He/She did not speak directly with the Nurse Practitioner and the nurses took over from there, attending to the resident. -He/She was unaware of the conversation that was had between them, but the resident was sent out to the hospital. -He/She found out later that the resident was found to have narcotics in his/her system and he/she did not know how that could have happened. -He/She has never given the resident any narcotic or benzodiazepine medication and only gave him/her the prescribed medications that were on his/her medication cards. -All narcotic medications were given by the nurse. -He/She had not seen LPN D give the resident any medications that day. -He/She was familiar with the ADON and had worked with him/her but had not had any problems with the ADON and had not seen him/her give the resident any narcotic medication and was not aware of anyone diverting any medications. During a telephone interview on 5/13/2020 at 11:40 A.M., the ADON said: -He/She was the ADON at the facility and was working on 5/7/2020. He/She said he/she worked his/her normal shift during the day, primarily completing administrative tasks and was not providing any resident care. -He/She left after his/her shift was over, but was called at around 6:00 P.M. and informed that one of the Charge Nurses that was scheduled to work the night shift had called in and he/she would have to come back to work to cover the night shift (to provide patient care). -He/She arrived back at the facility at around 7:00 PM., and was working on the West Unit. He/She said the staff assigned to the unit to work the night shift (10:00 P.M. to 6:00 A.M.) were CNA F and agency CNA G. -When he/she arrived at the facility, Resident #8 was wandering on the unit, which was normal for the resident. -The resident was ambulatory without assistive devices and was confused, had hallucinations and behaviors (going into other resident rooms) and was difficult to manage at times. He/She usually was up at night and slept very little, so someone had to watch him/her at all times. -They had placed the resident on one to one monitoring and they had also been looking for alternative placement for the resident (a facility with a secured dementia unit) due to the resident's behaviors and because other residents were complaining that they were afraid of him/her and some were tired of him/her going into their rooms and were beginning to talk about getting at the resident. -When he/she came to work at 7:00 P.M., he/she asked CNA H to provide one to one monitoring to the resident because the nursing aide that was assigned did not come to work. He/She said CNA H provided continual one to one monitoring to the resident from 7:00 P.M. to 10:00 P.M. and then he/she told CNA F and CNA G that they would all take turns monitoring the resident that night (because CNA H could not continue continual one to one monitoring throughout the shift). -He/She began completing accuchecks (taking and documenting blood sugars) and administering insulin at around 9:00 P.M., so he/she had a late start passing medications and did not start the rest of the medication pass until around 10:00 P.M. -He/She administered [MEDICATION NAME] and Trazadone to Resident #8 at around 11:00 P.M., and at that time the resident was alert and kept saying he/she was hungry so he/she provided the resident with cookies and a beverage and he ate/drank. -The resident stayed up wandering and hallucinating and at 1:00 A.M., he/she took the resident to the bathroom and provided him/her with more snacks and a beverage. The resident was in his/her room at this time eating/drinking and eventually fell asleep sitting up on his/her bed. She said she thought the medication was working, so he/she went to the nursing station to complete some of his/her charting, but he/she could see the resident's room from the nursing station. -Between 2:30 A.M. and 2:45 A.M., the resident was up and standing at his/her doorway yelling. He/She said he/she went to the resident's room, took him/her for a walk in the hallway and gave the resident a snack and beverage. The resident stayed up the rest of his/her shift, walking up and down the hallway. -At around 5:50 A.M., RN C (also a Unit Manager) came to work and he/she told RN C the resident had only slept between one to two hours at best, and he/she would have to monitor the resident until the day shift nursing staff came on duty. He/She said he/she gave report to the day Charge Nurse, LPN D, and completed the narcotic medication count with him/her. He/She said he/she did not pass the resident any morning medications. -There were no problems with the narcotic count. -He/She left the facility around 7:15 A.M. on 5/8/2020. -When he/she came back to work on Saturday 5/9/2020, he/she was informed that the resident was sent to the hospital on [DATE], because nursing staff found the resident unresponsive around 11:00 A.M. that day. He/She said he/she worked again on 5/11/2020 and part of 5/12/2020. On 5/12/2020 at around 12:30 P.M., the Administrator called him/her in to tell him/her that there were allegations about him/her misappropriating medication and over medicating the resident. -He/She denied the allegations and wrote a statement and was placed on immediate suspension pending investigation. -He/She did not know how the resident obtained narcotics but it would not be hard to believe that one of the other residents in the facility may have given the resident the medication due to some of their resident population. He/She said he/she did not believe the resident had received any narcotics or barbiturates during his/her shift on 5/7/2020 and he/she did not understand that if the resident was alert and at baseline when staff saw him/her on the morning of 5/8/2020, how the resident became unresponsive four hours after he/she had already left the building and after he/she had received his/her morning medications. -He/She last charted on the resident at 1:00 A.M. and had not completed any additional charting because he/she was with the resident and did not get back to charting on him/her. He/She said when management told him/her that she had not completed/ her charting, he/she went into the resident's medical record and charted late entries. During a telephone interview on 5/13/2020 at 1:53 P.M., CNA G said: -He/she worked on the West Unit on 5/7/2020 and 5/8/2020 from 2:00 P.M. to 10:00 P.M. and from 10:00 P.M. to 6:00 A.M. both days. -When he/she was working on 5/7/2020, he/she was not assigned to the resident, but he/she saw the resident and had interaction with him/her. -The resident was normally on one to one continual monitoring because he/she wandered a lot and had confusion, he/she was also unsteady on his/her feet but did not use any device and this was normal for the resident. -On 5/7/2020 on the night shift, he/she was scheduled to work on the West Unit with CNA F and the ADON, who was filling in for a Charge Nurse who did not show up to work. The ADON came onto the unit at 6:00 P.M. -The resident was on continuous one to one monitoring until 7:00 P.M., and the CNA that was supposed to come in at 7:00 P.M. to continue monitoring the resident did not show up to work, so the ADON told CNA H (who was scheduled to work night shift on the East Unit) to fill in to provide one to one monitoring to the resident until his/her shift started. -When CNA H left to go over to the East Unit to work, the ADON told him/her and CNA F that they would have to take turns watching the resident, and it was okay for the resident to walk up and down the hallway as long as he/she did not go into any resident rooms. -They were not providing continuous one to one monitoring to the resident. -The ADON was passing medications that night, but he/she did not observe the ADON pass any medications to the resident. -He/She only observed the ADON pass one liquid medication to one resident. -The ADON told him/her to go into the resident's room to check on him/her and he/she checked on the resident at around 9:00 P.M. and the resident was at the vending machine with CNA H, and he/she was alert and mobile. -He/She checked on the resident at around 1:00 A.M., and the resident was wearing his/her gown, was sitting up on the side of his/her bed and the resident was awake and alert behaving normally without any signs or symptoms of distress or change in condition. -He/She looked in at the resident again at 2:00 A.M., and the resident was on his bed and looked to be asleep. He/She said the resident did not seem to have any difficulty breathing and did not seem that anything was wrong with him/her. -He/She last saw the resident around 6:00 A.M., when he/she was preparing to leave the facility. The resident was up, alert and standing in his/her doorway with the ADON, who was asking the resident to sit down. He/She said he/she left the facility when his/her shift ended. -He/She came back to work on 5/8/2020 at 2:00 P.M., and found out that the resident had been sent to the hospital due to the staff not being able to arouse the resident. He/She said nursing staff and the Unit Manager were trying to contact the ADON, but were unsuccessful, so he/she tried to call and text the ADON. He/She said he/she spoke with the ADON at 4:43 P.M. and informed him/her of what had occurred and the ADON asked if the resident had passed away, then told him/her that he/she had not heard or seen anything. -He/She immediately informed the Charge Nurse, LPN D, CNA D and another CNA of his/her conversation with the ADON. -He/She had never worked with the ADON on the floor before and had not had any issues with the ADON. -He/she did not witness the ADON yelling at any of the residents or being abusive, and did not witness him/her misappropriate any medications. During an

Based on observation, interview and record review, the facility staff failed to complete a thorough fall investigations to include the cause of a resident's falls; identify, implement, and reassess interventions based on root cause of the fall; document notifications to the responsible party and/or physician of a resident's multiple falls, resulting in a resident experiencing ten falls in three months with four of those falls resulting in injuries that requiring hospital visits for one sampled resident (Resident #1). The facility failed to complete a thorough fall investigation and documentation for two sampled residents (Resident #5 and #6) out of twelve sampled residents. The facility census was 73 residents. Record review of the facility's undated Falls policy showed no process for completing the fall investigation or expectation for documentation of the fall investigation. 1. Record review of Resident #1's Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION]-(a progressive mental deterioration causing progressively worse confusion). -Anxiety disorder-(a constant feeling of uneasiness). Record review of the resident's Nursing Care Plan dated 9/27/19 showed: -The resident was at high risk for falls related to poor safety awareness and confusion. -The facility staff was to work to anticipate the resident's needs. -The facility staff was to review the information on past falls and attempt to determine the cause. -The facility staff was to identify the root cause of the fall. -The facility staff was to remove any potential causes of the fall and educate the resident, family and staff as to the cause of the fall. -The facility staff was to provide activities for the resident that provide diversions and distractions for the resident. -The resident had issues with anxiety and restlessness and the facility staff was to take him/her out to the nurse's station for closer observation when he/she demonstrated increased anxiety. Record review of the resident's Progress Notes dated 9/27/19 at 8:00 P.M., showed: -The resident had a witnessed fall in his/her room. -The resident was attempting to transfer himself/herself into the bed from his/her wheelchair. -The resident fell just as a caregiver was entering the resident's room. -The caregiver was unable to reach the resident in time to prevent him/her from falling. -The resident hit his/her left cheek on the footboard of the bed during the fall. -The resident denied any pain from the fall. -No neurological checks were completed for the resident. -The facility did not have a comprehensive fall investigation. Record review of the resident's Progress Notes dated 9/27/19 at 9:25 P.M., showed: -The resident fell from his/her wheelchair near the nurse's station, attempting to stand up from the wheelchair with the wheels unlocked. -The fall was witnessed and the resident was not injured. Record review of the resident's Progress Notes dated 9/30/19 7:05 P.M., showed: -The resident was found sitting on the floor by the sink in his/her room. -The resident had been unsteady with his/her gait and transfers. -The resident had tried to go to the bathroom, had a bowel movement and was attempting to change his/her clothes when found by facility staff. -The resident was not injured. -The facility did not have a comprehensive fall investigation. Record review of the resident's Progress Notes dated 10/6/19 at 3:48 P.M., showed: -The resident was observed in the dining room. -The resident stood up to walk away and collapsed to the floor. -The resident was not injured in the witnessed fall. Record review of the facility fall investigation dated 10/6/19 showed: -The resident attempted to stand up in the dining room and collapsed to the floor. -The fall was witnessed by staff in the dining room. -The physician was notified. -The resident was not injured. -The resident was not oriented, had a gait imbalance, and attempted to ambulate without assistance. -The resident's vital signs were taken and the staff were continuing to monitor the resident. -The staff attempted to notify the guardian, but the voicemail was full. -The facility staff did not attempt to re-notify the guardian. -The facility continued the interventions that had been in place prior to this fall. -No new interventions were identified. -There were no additional interventions mentioned or noted as being attempted to prevent the resident from falling again. -There was no determination of why the resident had fallen. Record review of the resident's Progress Notes dated 10/18/19 at 3:18 P.M., showed: -The staff member placed him/her in bed. -The resident then immediately rolled off the bed, onto the mattress which had been placed on the floor, then onto the floor. -The resident hit the back of his/her head on an unknown object causing a three centimeter (cm) slit to the back of his/her head with a hematoma (a solid swelling of clotted blood within the tissues). -The physician was notified and ordered for the resident to go to the hospital for evaluation. -The resident left for the hospital at 3:00 P.M. -When the resident returned, the hospital physician recommended one to one staff observation. -The hospital physician recommended the facility obtain a helmet to keep the resident's head protected from further falls. Record review of the facility fall investigation dated 10/18/19 showed: -The resident had been placed in bed. -The resident immediately rolled off the bed onto the floor mat and then onto the floor. -Vital signs and neurological checks were completed. -The resident was disoriented. -The resident was confused. -He/she was restless. -No thorough investigation was completed as to why the resident fell . -The facility continued the same interventions that had been in place prior to this fall. -There was no mention of the resident wearing a helmet. -There was no documentation of the resident being monitored one to one by facility staff. -No additional interventions were mentioned. Record review of the resident's Progress Notes dated 11/1/19 at 1:34 A.M., showed: -The resident had been placed on one to one staff observation for the day shift, by a nurse or certified nursing assistant (CNA) related to a fall which occurred on 10/31/19 at 1:30 P.M -The resident had been placed in bed and was observed asleep at 1:15 P.M. -At 1:30 P.M., the resident was observed on the floor mat next to his/her bed. -The resident had been agitated, vocal and attempting to get out of his/her chair all day. -The nurse placed the resident on one to one staff observations for the remainder of the 6:00 P.M. to 6:00 A.M., shift. -The charge nurse documented, patient needs eyes on him/her at all times. Record review of the facility fall investigation dated 11/1/19 showed: -The resident had been agitated, vocal and trying to get out of his/her chair all day. -The resident was found on the floor mat next to his/her bed. -There was no documentation of vital signs or neurological checks being completed. -The resident was disoriented. -The resident was confused. -He/she was restless. -There was no documentation of the resident having been wearing a helmet. -There was no documentation of the resident being monitored by facility staff one to one. -No additional interventions were mentioned. Record review of the resident's updated Nursing Care Plan dated 11/11/19 showed: -The resident had an injury fall on 11/11/19 and was sent to the Emergency Department (ED) and returned to the facility on [DATE] with a significant cognitive change. -The resident had an injury fall on 11/23/19 and was sent to the ED. -The resident had a non-injury fall on 12/3/19. -The resident slid out of his/her chair on 12/3/19 and did not sustain any injuries. -The resident had an injury fall on 12/22/19 and was sent to the hospital. -The facility staff was to monitor for signs of increased agitation or restlessness during cares and on rounds, and notify the charge nurse of any changes in behaviors. -The facility staff was to notify the physician of any changes as needed. -The facility staff was to observe for weakness and tiredness and encourage the resident to rest. -The resident was to use a Broda chair (a specific type of padded reclining chair which helps with positioning and posture) when up. -The resident was to have Spanish music playing to assist in keeping him/her calm. -Therapy was to evaluate the resident for a new chair as needed. -The resident's door was to be kept open at all times when the resident was in bed. -The resident was to have a fall mat next to the bed. -If the resident became restless in bed, the staff was to get the resident up in the Broda chair for closer observation. -There was no mention of adding a helmet as an intervention to protect the resident's head -There was no mention of adding that the resident needed one to one facility staff monitoring or even intense staff monitoring. Record review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff and used for care planning) dated 11/11/19 showed the resident: -Was not cognitively intact. -Had daily issues with inattention, being unable to focus and being easily distracted. -Had disorganized, incoherent thoughts. -Required extensive assistance for bed mobility, dressing, personal hygiene, toileting and eating. -Was totally dependent on facility staff for transferring and ambulation. Record review of the resident's hospital progress note dated 11/14/19 showed: -The resident had been admitted to the hospital after multiple falls in the facility. -The resident had fallen out of the chair to the ground with head trauma but no loss of consciousness. -He/she required a dose of [MEDICATION NAME] (a medication used to treat anxiety) in the ED for severe agitation. -Computed tomography-(CT-an x-ray image where the computer controls the motion of the x-ray and in turn processes very specific data) showed no new bleeding. -The CT scan showed an area of old blood from the original fall at home which had required surgery prior to admission. -He/she remained agitated throughout the hospitalization and required additional medications to treat the agitation. -The resident was discharged from the hospital with a recommendation that he/she have a helmet on to prevent further head injuries, and one to one facility staff observation. Record review of the resident's Progress Notes dated 11/14/19 at 2:49 P.M., showed: -The resident arrived back at the facility via stretcher at 2:30 P.M., on 11/14/19. -The resident denied pain. -The hospital discharge orders stated the resident was to have a helmet and one to one staff observation. -The nurse discussed the helmet with the Administrator and he/she was going to check into getting the helmet for the resident. -The Administrator was concerned about the facility being able to provide round the clock one to one staff observation. -There was no previous mention in the Progress Notes of the resident having a fall, however, the resident's Nursing Care Plan noted the resident had an injury fall on 11/11/19. -There was no documentation as to how the resident fell . -There was no fall investigation completed by the facility staff. Record review of the resident's Progress Notes dated 11/17/19 at 1:59 P.M., showed: -The facility had a meeting with the resident's family. -The resident's Power of Attorney (POA-a person designate by law who has the authority to speak on behalf of the person who is unable to make their own decisions) stated that he/she was supportive of the floor mattress next to the resident's bed. -The POA was informed by the facility staff that they had not been able to get a helmet for the resident. -The POA was okay with the resident not having one to one staff observation. -The POA was supportive of the resident not wearing a helmet. Record review of the resident's Progress Notes dated 11/19/19 at 12:55 P.M., showed: -The Assistant Director of Nursing (ADON) spoke with the resident's physician expressing concerns over being able to provide one to one staff observation. -The ADON stated that the facility had not been able to locate a helmet for the resident. -The physician was supportive of the resident not having a helmet or one to one staff observation. -The physician wanted the resident to be monitored closely when he/she was up in his/her chair. Record review of the resident's Progress Notes dated 11/23/19 at 11:27 P.M., showed: -The resident was observed by the charge nurse being wheeled down the hallway with a large, fluid-filled area in the center of the resident's forehead. -The resident had been with facility staff all day. -An un-named staff member observed the resident's door closed at 10:00 P.M -The staff member opened the door and found the resident on the floor. -The staff had stated the resident had just been placed in bed. -Staff had been instructed to place the resident in his/her wheelchair, so the staff went to get the resident up in his/her wheelchair for closer observation and found the resident on the floor. -The physician was notified and ordered for the resident to be sent to the hospital. -The family was notified. -The resident left the facility by ambulance at 11:30 P.M. Record review of the facility fall investigation dated 11/23/19 showed: -The resident was found on the floor in his/her bedroom with a large fluid filled area in the middle of his/her forehead. -The resident's door was found to be closed at 10:00 P.M., and when the door was opened the resident was found on the floor. -The resident was disoriented. -The resident was confused. -He/she was restless. -There was no documentation of the facility having completed a thorough investigation as to why the resident fell . -There was no documentation of the facility providing any new interventions other than the interventions previously completed. -No additional interventions were mentioned. Record review of the resident's Progress Notes dated 12/4/19 at 4:55 P.M., showed: -The resident was up in his/her chair and trying to get out of the chair. -The resident was witnessed falling out of his/her chair. -No further information was documented. The facility did not have a comprehensive fall investigation. Record review of the resident's Progress Notes dated 12/22/19 showed: -Licensed Practical Nurse (LPN) was answering an emergency call light while the resident was at the nurse's station. -The resident was found sitting on his/her buttocks with both hands on the floor. -The resident had a golf ball sized knot above his/her brow. -The physician was notified and instructed to apply ice, do neurological checks and monitor. -The resident's vital signs were observed along with neurological checks and his/her blood pressure rose. -The resident's pupils were equal but became sluggish after a few neurological checks were completed, so the physician was notified of the changes. -The physician ordered for the resident to be sent to the hospital. Record review of the facility fall investigation dated 12/22/19 showed: -The resident was at the nurse's station being monitored when LPN had an emergency light he/she had to attend to. -The resident was found on the floor behind the nurse's station on his/her buttocks. -The resident had a golf ball sized knot above his/her right eye brow. -The resident was disoriented. -The resident was confused. -He/she was restless. -The physician was notified after the resident's vital signs and neurological checks changed. -The resident was sent to the hospital for evaluation. -There was no documentation of a thorough investigation being completed as to why the resident fell . -There was no documentation of any new interventions having been attempted prior to this fall. -No additional interventions were mentioned. During an interview on 12/27/19 at 10:29 A.M., the Director of Nursing (DON) said: -The resident sits in his/her Broda chair at the nurse's station while awake so he/she can be observed by a staff member. -The resident is not on one to one staff observation, but staff is with him/her all the time. During an interview on 12/27/19 at 10:29 A.M., Certified Medication Technician (CMT) A said if the resident was in bed, a staff member sits by the resident's door. During an interview on 12/27/10 at 10:35 A.M., LPN C said: -The resident was not on one to one staff observation but was attended to all the time. -The day that the resident fell at the nurse's station and sustained the golf ball sized knot on his/her forehead, LPN A had left to attend to an emergency call light. -Before he/she left, he/she noted a staff member coming down the hall and had the resident in his/her sight. -Before the staff member could get there, the resident fell out of his/her Broda chair. -There was no staff member within arms length of the resident preventing him/her from falling During an interview on 12/27/19 at 10:40 A.M., CNA A said someone sits with the resident all the time. During an interview on 12/27/19 at 4:55 P.M., Physician A said: -He/she was aware the resident had frequent falls. -The facility staff notify him/her when the resident falls. -He/she was not familiar with adults using helmets for frequent falls. -The facility had tried to obtain a helmet but could not locate one that was adult size. -The facility staff was staying with the resident all the time. -This particular resident was very complicated. During an interview on 12/30/19 at 10:23 A.M., CMT B said the resident was on a one to one observation all the time. Observation on 12/30/19 at 10:30 A.M., showed: -The resident was sitting in a Broda chair behind the nurse's station with two staff members present. -The resident had a large, golf ball sized knot above his/her right eye with greenish/yellowish bruising present around his/her eye and down his/her right cheek. -The resident was sleeping. During an interview on 12/30/19 at 4:35 P.M., CNA B said the resident had been on one to one staff observation. During an interview on 12/20/19 at 4:35 P.M., the ADON said: -The resident has a low bed and a mattress on the floor. -The resident had been on one to one staff observation. During an interview on 12/31/19 at 2:55 P.M., the Administrator and DON said: -The resident had torn up his/her wheelchair from thrashing so hard trying to get up. -The facility ordered him/her a Broda chair and the day the chair arrived, the back fell off the wheelchair. -He/she expected that the facility staff would notify the appropriate individuals after a fall including the physician, family contact, someone from Administration, and the DON. -He/she expected the licensed staff to write a thorough note and begin the fall investigation after putting the fall protocol in place. -He/she would have expected the facility staff would have done a thorough fall investigation, including a Registered Nurse investigation which would have a root cause and possible new interventions to prevent further falls. During an interview on 1/14/20 at 11:10 A.M., Physician A said: -He/she had a brain storming session with the facility staff two to three weeks ago, attempting to come up with new ideas to prevent falls. -Prior to the DON coming to the facility a month ago, there was no one at the facility to coordinate the residents' care. -He/she thought the facility had tried a low bed and mattress early on in the resident's stay. -He/she did not want to sedate the resident but had recently ordered [MEDICATION NAME] (a drug used to treat [MEDICAL CONDITION] disorders which was also known to assist with the symptoms of other mental health disorders) and [MEDICATION NAME] (a medication used to treat depression) to the resident's medications in an effort to assist with impulsivity. -He/she felt that a helmet might not have protected the resident's head well enough. -He/she felt that at this point in the resident's care, shy of maintaining the one to one staff observations, he/she was not sure what else to recommend. During an interview on 1/15/19 at 8:35 A.M., the resident's POA said: -He/she was not being consistently notified of the resident's falls by the facility. -He/she felt the facility was not watching the resident closely enough or he/she would not have fallen at the nurse's station or in his/her room. -He/she spoke with the DON and did not feel that the residen't care was improving; -He/she was going to the facility to have a meeting with the facility social worker to see if the resident could be moved to a facility closer to the POA's home. -He/she was going to provide information and contact numbers for facilities near the POA so that he/she could better observe the resident's care. -He/she recognized the efforts to improve the care but did not feel it was in the best interest of the resident to allow him/her to remain in the facility any longer. 2. Record review of Resident #5's Admission Record showed he/she was admitted on [DATE] with the following Diagnosis: [REDACTED]. -Dementia-(a progressive mental disease which causes confusion). Record review of the resident's fall investigation dated 12/4/19 showed: -The resident's roommate came and reported that the resident was on the floor in their room. -The resident was found to be on his/her back on the floor. -The resident stated that he/she did not fall but slipped from his/her wheelchair. -The resident was not injured. -The resident was incontinent and had a gait imbalance. -The resident had a history of [REDACTED]. -The resident was also restless. -The nurse assessed the resident, and the resident did not complaint of any pain. -The resident was educated regarding using the call light. -The physician and family were notified. -There was no documentation of determination to why the resident fell . -No new interventions were documented. Record review of the resident's Nursing Care Plan dated 2/14/19 showed: -The resident was at risk for falls related to increased weakness and decreased mobility. -The facility staff was to anticipate the resident's needs and encourage him/her to use his/her call light. -The facility staff was to supervise the resident while in his/her wheel chair in order to promote safe positioning. -The facility staff was to ensure the resident had a safe environment with even flooring, no spills, reduced clutter and no clutter. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was not cognitively intact. -Had no issues with mood or behaviors. -Needed limited assistance of one facility staff member for bed mobility, transferring, personal hygiene, bathing and dressing. -Needed supervision for toileting and was independent with eating. 3. Record review of Resident #6's Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -Above the knee amputation. Record review of the resident's Nursing Care Plan dated 12/5/19 showed: -The resident was at risk for falls due to instability related to his/her above the knee amputation. -The facility staff was to ensure the resident's call light was within reach and encourage him/her to use it. -Physical therapy was to evaluate the resident and treat as indicated. -The facility staff was to review previous falls and attempt to determine the root cause of the fall. -The facility staff was to remove any potential causes of the falls if possible and provide fall prevention education for the resident and family. Record review of the resident's fall investigation dated 12/7/19 showed: -The resident's fall was not witnessed. -The resident had an amputated limb. -The resident stated that he/she did not lock the wheelchair wheels before he/she attempted to transfer into bed. -The physician and family were not documented as being notified. -There was no documentation as to why the resident fell . -There was no mention of new interventions. Record review of the resident's admission MDS dated [DATE] showed he/she: -Was cognitively intact. -Had trouble falling asleep and concentrating more than half the days. -Had no behaviors. -Required supervision of one facility staff member for bed mobility, transferring, locomotion, bathing, dressing. -Required limited assistance for personal hygiene, bathing and toileting. MO 661

Based on observation, interview, and record review, the facility failed to ensure a resident's wound was accurately assessed and documented on weekly; to ensure the resident's physician was notified of changes in the resident's wound to include changes in size, painful to touch and slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy); to complete wound treatments as prescribed by the resident's physician resulting in the resident's developing a new open wound on his/her foot; and to ensure appropriate wound care when facility staff manually [MEDICATION NAME] a wound with slough for one sampled resident (Resident #14); to ensure weekly skin and wound assessments, including accurate documentation of skin irregularities; and to complete wound care treatments as prescribed by the resident's physician for one sampled resident (Resident #8) and to ensure accurate weekly skin and wound assessments for two sampled residents (Resident #9 and #13) out of 27 sampled residents. The facility census was 74 residents. 1. Record review of Resident #14's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Care Plan dated 8/28/19 showed: -The resident had the following Diagnoses: [REDACTED]. --[MEDICAL CONDITION] (a bacterial skin infection). --Pain. --[MEDICAL CONDITION] (nerve pain). -He/She had a care plan for an Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) deficit and required skin inspection by the Certified Nursing Assistant (CNA). The CNA was directed to observe the resident for redness, open areas, scratches, cuts, and bruises and to report changes to the nurse. --The care plan was not individualized for the resident. The related to area was left blank and the frequency of skin inspection was left blank. -He/She had a care plan for a skin tear. The skin tear location was left blank and the related to area was left blank. -Did not have a care plan for a wound on his/her foot. Record review of the resident's medical record on 11/8/19 showed: -An Entry Tracking Record Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) was dated 8/27/19. -No admission MDS was completed or submitted for this resident. Record review of the resident's September 2019 physician's orders [REDACTED]. -Apply Skin Prep (a topical barrier between skin and adhesives)to his/her right heel scabbed area daily with dressing dated 8/29/19. -Weekly skin assessment every Wednesday for skin integrity dated 8/27/19. Record review of the resident's September 2019 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed: -No documentation of the resident's physician's orders [REDACTED]. -No documentation staff completed the resident's physician's orders [REDACTED]. -A physician's orders [REDACTED]. -Staff did not document the resident refused to have his/her skin assessment completed. Record review of the resident's Weekly Skin Observations dated 9/6/19 showed: -The resident had an open area to his/her foot. -The open area was not new. -The resident had a callous (hardened or thickened skin) area under his/her left right heel measuring 1 centimeter (cm) in length by 2.5 cm in width. -Skin prep and dressing was applied to his/her right heel. --Staff did not document a description of the open area to the resident's right heel to include the color of the wound bed, if there was drainage, and/or if the open area had an odor. Record review of the resident's History and Physical dated 9/11/19 showed: -The resident had a [DIAGNOSES REDACTED]. -The resident's skin was intact. -Staff were to contact the resident's physician if there were any changes in his/her medical condition. -Staff were to continue all current medications and treatments. Record review of the resident's Weekly Skin Observations dated 9/12/19 showed: -The resident had an open area to his/her foot. -He/she had a scabbed area on his/her right heel. -Skin prep was applied. -The open area was not new. --Staff did not document measurements of the open area to the resident's right heel, a description of the open area to the resident's right heel to include the color of the wound bed, if there was drainage, and/or if the open area had an odor. Record review of the resident's Weekly Skin Observations dated 9/19/19 showed: -The resident's skin was intact. -The resident had no foot concerns. --Staff did not document physician notification of the resident's healed right heel open area. Record review of the resident's Weekly Skin Observations dated 9/26/19 showed: -The resident had an open area to his/her foot. -He/She had a scabbed area under his/her right heel. -Skin prep was applied. -The open area was not new. --Staff did not document measurements of the open area to the resident's right heel, a description of the open area to the resident's right heel to include the color of the wound bed, if there was drainage, and/or if the open area had an odor. --Staff documented the resident did not have any open areas to his/her right heel the previous week. --Staff did not document physician notification of a change in the resident's right heel wound. Record review of the resident's October 2019 POS showed: -Apply skin prep to right heel scabbed area daily with dressing dated 8/29/19. -Weekly skin assessment every Wednesday for skin integrity dated 8/27/19. Record review of the resident's October 2019 MAR and TAR showed: -No documentation of the resident's physician's orders [REDACTED]. -No documentation staff completed the resident's physician's orders [REDACTED]. -A physician's orders [REDACTED]. -Staff did not document the resident refused to have his/her skin assessment completed. Record review of the resident's Weekly Skin Observation dated 10/3/19 showed: -The resident had skin concerns that were not new. -He/She had no foot concerns. --Staff did not document what the skin concerns were. --Staff did not document measurements of the open area to the resident's right heel, a description of the open area to the resident's right heel to include the color of the wound bed, if there was drainage, and/or if the open area had an odor. Record review of the resident's physician's notes dated 10/9/19 completed by Nurse Practitioner (NP) A showed: -The resident's skin was intact with no rashes or ulcers. -The resident had a [DIAGNOSES REDACTED]. -Staff were to continue the resident's current medications and treatments. -Staff were to report any changes in condition to the resident's physician. Record review of the resident's Weekly Skin Observations dated 10/10/19 showed: -The resident had skin concerns. -The resident's skin concerns were not new. --Staff did not document what the skin concerns were. -The resident did not have any foot concerns. --Staff did not document physician notification of a change in the resident's right heel wound. Record review of the resident's Weekly Skin Observations dated 10/18/19 showed: -The resident's skin was intact with no concerns. -The resident did not have any foot concerns. Record review of the resident's Weekly Skin Observations dated 10/25/19 showed: -The resident's skin was intact with no concerns. -The resident did not have any foot concerns. Record review of the resident's November 2019 POS showed: -Apply skin prep to right heel scabbed area daily with dressing dated 8/29/19. -Weekly skin assessment every Wednesday for skin integrity dated 8/27/19. Record review of the resident's November 2019 MAR and TAR showed: -No record of the resident's physician's orders [REDACTED]. -No documentation staff completed the resident's physician's orders [REDACTED]. -A physician's orders [REDACTED]. -Staff did not document the resident refused to have his/her skin assessment completed. Record review of the resident's Weekly Skin Observations dated 11/1/19 showed: -The resident had an open area to his/her foot. -The open area was not new. -The resident had a callous area under his/her right heel measuring 2 cm in length by 2 cm in width. -The wound was tender to the touch. -Skin prep and dressing was applied to his/her right heel. --Staff did not document if the physician was notified of the change in condition of the resident's right heel wound. --Staff did not document a description of the open area to the resident's right heel to include the color of the wound bed, if there was drainage, and/or if the open area had an odor. During an observation and interview of the resident's right foot in the presence of the Corporate Human Resources person on 11/7/19 at 1:00 P.M. showed: -Black discoloration to the resident's right big toe under the area of the toenail. -An open area 2.5 cm in length by 2 cm in width by 0.1 cm in depth under the resident's right heel with 30% pink wound bed and 70% white slough in the wound bed. -An opened blister on the outside of the right foot under the ankle bone. -The resident said he/she had pain in his/her right foot and that it was tender to the touch. During an observation and interview with the Interim Director of Nursing (DON) on 11/8/19 at 1:30 P.M. showed : -The Interim DON said the resident had a callous under his/her right heel. -He/she had not been notified of a change in the resident's skin noted the previous day with the Corporate Human Resources person. -The resident had an open area under his/her right heel approximately 2.5 cm in length by 2 cm in width by 0.1 cm in depth with 30% pink wound bed and 70% white slough. -The resident had a black discoloration under his/her right big toe under the area of the toenail. -The resident had an opened blister on the side of his/her right foot under the ankle bone. -The Interim DON, with gloved hands, manually debrided (the removal of dead tissue) the resident's open wound under his/her right heel by picking the slough, pulling it away from his/her foot multiple times. -He/she acknowledged he/she was manually [MEDICATION NAME] the resident's open foot wound. During an interview on 11/8/19 at 1:50 P.M., the Interim DON said: -Staff should perform an accurate skin assessment weekly. -On the weeks the resident had no foot concerns noted, he/she asked the resident if he/she had any foot concerns, and he/she said no. -The resident was alert and oriented, so if he/she said he/she did not have any problems with his/her feet, then that was what was documented. -He/she did not actually observe the resident's skin weekly. -The resident had skin prep orders for his/her foot wound. -The order for skin prep had not been discontinued by the resident's physician. -He/she was not sure why the order for skin prep was not on the resident's MAR/TAR. -He/she could not see documentation the staff were applying the skin prep to the resident's right heel per the resident's physician's orders [REDACTED]. During an interview on 11/15/19 at 11:35 A.M., the Nurse Practitioner said: -He/she was notified on 11/8/19 of the resident's open callous on his/her right foot and blister on his/her right ankle. -Wound care orders were given at that time. -He/she would prefer staff not manually debride a wound. -Staff should accurately document a resident's skin. -He/she would expect staff to follow physician orders. -He/she was not aware staff had not been performing the prescribed wound treatment. -He/she was not aware staff were not actually visualizing the resident's foot when they had documented the skin assessments. -He/she would expect staff to notify him/her of any change in the resident's condition. -The resident would need ongoing monitioring and treatments to his/her foot. 2. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's October 2019 POS showed: -He/she had a [DIAGNOSES REDACTED]. -Wound care to the resident's right foot with wound cleanser, pat dry, fill wound with Kerlix moistened with Dakin's solution (a wound care solution made from diluted bleach used to cleanse wounds and to prevent infection) 1/4 strength and cover with an Abdominal (ABD) pad (a large dressing) and wrap twice daily dated 10/17/19. -Wound care to the resident's right first and second toes, clean with wound cleanser, pat dry, apply silver alginate (an absorbent dressing to promote wound healing) between toes and cover every day shift dated 10/17/19. Record review of the resident's October 2019 MAR and TAR showed: -Wound care to the resident's right foot with wound cleanser, pat dry, fill wound with Kerlix moistened with Dakin's solution 1/4 strength and cover with an ABD and wrap twice daily dated 10/17/19. -Staff documented the wound care was completed 23 out of 29 opportunities, refused two times, not documented as completed one time, and was documented as other/see progress notes three times without a progress note. -Wound care to the resident's right first and second toes, clean with wound cleanser, pat dry, apply silver alginate between toes and cover every day shift dated 10/17/19. -Staff documented the wound care was completed 10 out of 14 opportunities, not documented as completed or refused one time, documented as refused two times, and was documented as other/see progress notes without a progress note one time. Record review of the resident's medical record on 11/8/19 showed: -An Entry MDS dated [DATE] showed In Progress and not submitted. -An Admission MDS dated [DATE] showed In Progress and not submitted. Record review of the resident's Admission Note dated 10/17/19 showed: -The resident was admitted to the facility from a hospital for wound care to his/her right foot related to a traumatic injury. -The resident's wound documentation did not include the number of wounds, the location of the wounds, the description of the wounds, or measurements of the resident's wound. Record review of the resident's Admission Follow-up note dated 10/18/19 showed: -The resident had wound/skin conditions present upon admission to the facility. -He/she had treatable wounds. -He/she had dressing changes per treatment orders. -He/she received surgical wound care to the top of his/her right foot. --The note did not address the wounds to the resident's first and second toes. Record review of the resident's Weekly Skin Observations dated 10/18/19 showed: -The resident's skin was intact. -Foot observations/care included: Open lesion to the resident's foot. He/she was admitted with a wound on his/her foot. He/she had dressing changes daily. The skin concern to the resident's foot was not new and he/she received wound care to his/her foot/feet. Dressings were applied to his/her foot/feet and were present and intact. --The note did not describe the number or location of wounds on his/her foot, what foot or feet were effected, a description of the wound or wounds, or measurements of the wound or wounds. Record review of the resident's Care Plan dated 10/23/19 showed: -He/She had a care plan for an Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) deficit, had contractures required skin care to keep skin clean and to prevent skin breakdown. --The care plan was not individualized for the resident. The related to area was left blank, the area to specify the location of contracture was left blank, and the frequency of skin care was left blank. -He/She had a care plan for the potential for skin impairment, staff were directed to administer and monitor the effectiveness of medications as ordered, to assess and record changes in skin status, and to report pertinent changes in skin status to his/her physician. -Did not have a care plan for the actual wound on his/her right foot. Record review of the resident's Weekly Skin Observations dated 10/25/19 showed: -The resident's skin was intact. -Foot observation/care included: No foot concerns were noted. -Notifications was left blank. --NOTE: Staff were documenting wound care was being completed per the resident's physician to the resident's right foot and to the resident's first and second toes on his/her right foot daily per the resident's physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated 10/28/19 showed: -The resident had a red wound bed with granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) tissue surrounding the open area which was decreasing in size. -The note did not include where the open area was, the current size of the open area, and if this was a new wound. --The resident's Weekly Skin Observation dated 10/25/19 showed the resident's skin was intact with no foot wounds. Record review of the resident's Nurse's Notes dated 10/30/19 at 9:19 A.M. showed: -The resident's treatment to his/her right foot was completed per the resident's physician's orders [REDACTED]. -The wound had serosanguinous (containing blood and watery drainage) drainage with a red wound bed and pink granulation tissue around the open area. -The wounds on the resident's right instep (top of the foot) had healed. --The description of the wound did not indicate where the wound was located. --Staff documented continuing to complete wounds care to the resident's right foot and first and second toes on his/her right foot. Record review of the resident's Nurse's Notes dated 10/30/19 at 11:17 P.M. showed: -The resident's dressing change to his/her right foot was completed. -The wound measured 3 cm in length by 2 cm in width by 0.5 cm in depth with moderate serosanguinous drainage on the old dressing. -The resident's wound was healing slowly and the open area underneath had healed. --The measurements did not specify if this was for the wound previously documented as being located on top of the resident's right foot. If the open area had healed, then there could not be a measurement of with depth and drainage from the wound. --The note did not address the wounds on the resident's first and second toes on his/her right foot. Record review of the resident's Weekly Skin Observation dated 11/1/19 showed: -His/her skin was intact. -Foot observations/care included: Open lesion to the resident's foot. He/she had an open area on his/her right instep measuring 2 cm in length by 3 cm in width by 0.3 cm in depth with serosanguinous drainage on the old drainage. The resident's wound bed had pink red tissue with some granulation along the edges. He/She had dry skin around his/her sole and toes on both feet. --The note did not address the wounds to the resident's first and second toes on his/her right foot which staff had continued to document completing wound care treatments. -The Notification section was left blank. Record review of the resident's November 2019 POS showed: -He/she had a [DIAGNOSES REDACTED]. -Wound care to the resident's right foot with wound cleanser, pat dry, fill wound with Kerlix moistened with Dakin's solution 1/4 strength and cover with an ABD and wrap twice daily dated 10/17/19. -Wound care to the resident's right first and second toes, clean with wound cleanser, pat dry, apply silver alginate between toes and cover every day shift dated 10/17/19. Record review of the resident's November 2019 MAR and TAR showed: -Wound care to the resident's right foot with wound cleanser, pat dry, fill wound with Kerlix moistened with Dakin's solution 1/4 strength and cover with an ABD and wrap twice daily dated 10/17/19. -Staff documented the wound care was completed 15 out of 15 opportunities. -Wound care to the resident's right first and second toes, clean with wound cleanser, pat dry, apply silver alginate between toes and cover every day shift dated 10/17/19. -Staff documented the wound care was completed eight out of eight opportunities. During an interview and observation on 11/8/19 at 10:30 A.M. with the resident showed: -An undated dressing with tape on top of the resident's right foot. -No dressing between the resident's first and second toes on his/her right foot. -A small open area under the resident's right big toe. -A black discoloration under the resident's toenail to the tip of the toe of the resident's third toe on his/her right foot. -He/she said staff change the dressing on his/her foot. During an interview and observation of the resident's skin on 11/8/19 at 11:31 A.M. with the Interim DON and LPN A showed: -An open area approximately 0.5 cm in length by 0.5 cm in width on top of the resident's right foot. --A black discoloration under the resident's toenail to the tip of the toe of the resident's third toe on his/her right foot. -The resident said his/her third toe was sore. -A small open area under the resident's big toe on his/her right foot. -The Interim DON said he/she did not see an open area under the resident's big toe on his/her right foot and that the black discoloration on the resident's third toe on his/her right foot was under the toenail and that the area that was discolored at the tip of the toe was due to the discoloration under the resident's toenail. 3. Record review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's 72 hour Admission/Readmission Charting note dated 10/22/19 showed: -He/she had wound/skin concerns present with no change in skin integrity. -Had treatable wounds with dressing change not required. --Staff did not document where the resident's wound/skin concern was located, a description of the treatable wounds, if the wound had any drainage or odor. Record review of the resident's Care Plan dated 10/22/19 showed: -He/she had a surgical incision. -The site of the incision was left blank. -Staff were directed to keep the incision site clean and dry. -Staff were directed to monitor the site for signs and symptoms of infection, including increased drainage, foul odor, redness, and warmth. Record review of the resident's Weekly Skin Observations dated 10/25/19 showed: -His/her skin was intact. --Staff documented on 10/22/19 the resident had treatable wounds and did not document if those wounds were now healed. --Staff did not document notification of the resident's physician of the change in wound/skin status. Record review of the resident's Weekly Skin Observation dated 11/1/19 showed: -The resident had skin concerns. -The skin concerns were not new. -Staff were directed to complete section 3 to list the skin concern. -Staff did not document what the skin concern was, where it was located, or a description of the skin concern. Observation on 11/8/19 at 11:36 A.M. with the Interim DON and LPN A showed: -An undated dressing on the resident's lower left abdomen. -Eight staples on the resident's lower left abdomen under the dressing. -A pinpoint scabbed area on top of the resident's right foot with a pink thread adhered to the skin. -The Interim DON picked at the area until he/she was able to remove the pink thread adhered to the resident's skin. -The Interim DON said the area on top of the resident's right foot was not open and the pink thread was attached to the resident's intact skin. --No documentation by the facility staff regarding the incision to the resident's lower left abdomen, the condition of the incision, or the number of staple to the incision site upon admission to the facility. 4. Record review of Resident #13's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 14 out of 15. -Required staff supervision for dressing, personal hygiene, and bathing. -Did not have any skin issues. Record review of the resident's Weekly Skin Observations dated 9/26/19, 10/4/19, 10/10/19, 10/17/19, 10/25/19, and 11/1/19 showed the resident's skin was intact with no concerns. Observation of the resident's skin and interview on 11/8/19 at 11:49 A.M. with the Interim DON and LPN A showed: -Two small scabbed areas on the resident's forehead. -One small scabbed area on top of the resident's head. -Multiple small scabbed areas scattered along the top of the resident's left hip. -A scabbed abrasion on the top, back of the resident's lower right leg and calf area. -The Interim DON said he/she wound not document the scabbed areas because they were not considered wounds or skin irregularities, just scabbed areas. 5. During an interview on 11/8/19 at 11:20 A.M., the Interim DON said: -He/she does the weekly skin assessments for all the residents. -If a resident is alert and oriented, he/she will ask the resident if they have any sores or open areas. If the resident reports no sores or open areas, that is what he/she will document, even though he/she may not have actually visualized the resident's skin. -He/she only documents wounds or open areas that require a dressing. -He/she does not document any other skin issues such as scabs, blisters, or abrasions. -He/she did not believe resident's with blackened areas on their toes near or under the toenail needed to be documented. -He/she was not wound care certified. -He/She did not have a facility-wide wound tracking program because he/she knew all of the resident's by heart and would know who had an infection, was on an antibiotic, was on narcotics for pain, and had wounds. During an interview on 11/8/19 at 12:50 P.M., the Administrator said: -The Interim DON was the Assistant Director of Nursing (ADON) prior to the DON abruptly quitting the end of October 2019. -Wound and skin monitoring were among the duties assigned to the ADON. -The Interim DON continued to perform wound and skin assessments since moving to his/her new role. -He/she expected resident's skin and wounds to be accurately documented each week, including scabbed areas and abrasions. MO 785

Based on observation, interview and record review, the facility failed to assess a resident when the Certified Nurse Assistant (CNA) notified the charge nurse that the resident had a fever and was having frequent diarrhea stools for nine days which resulted in the resident having loss of appetite of eating less than 25% of his/her meals and losing nine pounds which is a significant loss of body weight of 5.9% in one month; to notify the resident's physician of the resident's fever, frequent diarrhea stools and significant weight loss during the week of 4/4/18-4/12/18; to obtain a physician's orders [REDACTED].# 36), and to ensure to have a physician's orders [REDACTED]. checks, for one sampled resident (Resident #38) out of 23 sampled residents. The facility census was 72 residents. Review of the Missouri CMT Manual ,Revised (MONTH) 2008 (with new regulations) showed: -No medication can be given to a resident without a physician's orders [REDACTED]. -As Needed orders (PRN) - medications are administered only as needed according to a designated time frame identified in the order. All prn orders must contain a specific reason for giving the medication such as pain, fever, etc. The licensed nurse assesses the resident and makes the decision when to administer a prn medication. 1. Record review of Resident #36's Face Sheet showed, he/she was admitted to the facility on [DATE]. Had a diagnoses of [MEDICAL CONDITIONS] (is a blood-[MEDICAL CONDITION], infection that affect the liver), long term blood thinner use, protein and vitamin deficiency and [MEDICAL CONDITION] (is a low red blood cell count). Record review of the resident's Care Plan with a review date of 12/26/17 showed: -The nutrition plan for the resident showed he/she was on a regular diet and his/her weight was stable and -Due to the resident [DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 3/11/18 showed: -The resident's Brief Interview of Mental Status (BIMS, evaluates cognitive impairment) scored was an 15, which indicates the resident was cognitively intact; -Required supervision and encouragement from staff for personal hygiene and setup for meals and -Weight documented at time of MDS assessment was 156 pounds. Record review on of the resident's Physician order [REDACTED]. Record review of the resident's MAR indicated [REDACTED] -Had an physician order [REDACTED].>-- 4/4/18 at 3:38 P.M. for a headache and was helpful; -- 4/8/18 at 3:30 P.M. for headache and was effective; --4/10/18 at 12:50 P.M. for aches and pain and no results were listed. -Had a physician's orders [REDACTED]. --4/4/18 at 3:38 P.M. for a cough and was helpful; --4/8/18 at 7:30 A.M. for a cough and was better and --4/8/18 at 3:30 P.M. for a cough and was effective. Record review of the resident's electric Meal Intake Record from 4/3/18 to 4/12/18 showed: -On 4/3/18, the resident had refused breakfast and lunch and there was no documentation for dinner; -On 4/4/18, the resident had refused breakfast and lunch and there was no documentation for dinner; -On 4/5/18, the resident ate 0-25% his/her breakfast, had refused lunch and ate 76-100% of his/her dinner; -On 4/6/18, the resident refused breakfast and there was no documentation for lunch or dinner; -On 4/7/18, 4/8/18 and 4/9/18, there was no documentation of the resident's meals intake; -On 4/10/18, the resident ate 76-100% of his/her breakfast and lunch and there was no documentation for dinner; -On 4/11/18, the resident had refused breakfast and there was no documentation of the resident's meals during lunch or dinner and -On 4/12/18, there was no documentation of the resident's meals intake. Record review of the facility's Licensed Nurses 24 hour nurses report (uses to share new information or concerns related to the resident) dated 4/3/18 to 4/11/18 showed: -On 4/3/18, the resident had complained of a cough; -On 4/8/18, the resident had cold symptoms; -On 4/12/18, the resident had diarrhea one time, a physician's orders [REDACTED]. -There was no documentation of the resident having complaints of diarrhea during the week of 4/3/18 to 4/10/18 or that the nursing staff had completed a nursing assessment on the resident for his/her complaints. During an observation and interview on 04/10/18 at 9:20 A.M. the resident said: -Had concerns with getting his/her medication for cold symptoms and diarrhea, and he/she had not been receiving meals when he/she was sick; -Had informed the staff of his/her complaints of headache, cough, and diarrhea for over a week and staff had not provided ongoing medication as he/she thought they should have; -Also had concerns of with the lack of licensed nursing follow-up during his/her recent illness; -Had that he/she had lost some weight this last week due to his/her illness and missed meals; -He/she was able to care for himself/herself, but when was sick was needing a little more assistance and -Was having a difficult time making it to the bathroom and had soiled himself/herself, which had caused him/her to run out of underwear, and had to go without underwear for several days. Record review of the resident Nurse Progress Notes showed the resident fid not have any nursing documentation in his/her nursing progress notes for the month of April, (YEAR). Record review of the resident's electric medical record and hard chart medical record showed the resident did not have any nursing documentation related to the resident's complaints of illness during the week of 4/3/18 to 4/10/18, which would had included a nursing assessment or monitoring and an assessment for fever, abdominal pain, vital signs or treatment for [REDACTED]. Record review of the resident's medical record on 4/12/18 showed the only temperature that had been record was on 4/11/18 at 2:49 P.M. and was 98.3 °F Tympanic (is a type of Ear thermometers by placing an electronic probe in the ear canal). During an observation and interview on 04/12/18 at 7:50 A.M., the resident said he/she: -Had been weighed on 4/12/18 and his/her weight was now 147 pounds; -Was unable to leave his/her room due to many episodes of loose stools and stomach pain and it seem to be more frequent stools when he/she was moving around; - Had light brown in color stools; -Had not been going to the main dining room to eat due to his/her illness; -Had went without meals for a few days, he/she had to finally ask the staff members for a meal room tray; -Staff members had not been following-up with him/her about his/her missed meals; -The licensed nursing staff had not asked him/her how he/she was feeling during the time of his/her illness; -He/she was not aware if his/her physician had been notified; -Had reported to the CNA the diarrhea, and had received anti-diarrhea medication one time from the CMT; -He/she was not aware that he/she had to ask for medication when he/she was sick and -Shouldn't have to stand and wait at the nurse's desk for the nurse to come and for the nurse to give you medication or to be checked on when he/she was not feeling well. During an interview on 4/12/18 at 9:25 A.M., CNA D, said that resident; -Had a fever on 4/10/18 and he/she had reported the resident's fever to the charge nurse; -Unsure if had received medication that week and -He/she did not work with the resident the week of 4/3/18. During an interview on 4/12/18 at 9:40 A.M., Licensed Practical Nurse (LPN) B said: -He/she was not aware the resident had been sick; -If resident had diarrhea, he/she would have assessed the resident, and documented in the nurses notes and -Any anti-diarrhea medication would had been given by the CMT. During an interview on 4/12/18 at 10:00 A.M., CNA C said that resident: -Had been reporting of being sick and had requested a room tray last week; -Had complaints of a cold symptoms and diarrhea; -The CNA had reported the resident's conditions to the charge nurse and to CMT A; -He/she did not notice an foul odors in the resident's room and -It was not normal for the resident to stay in his/her room. During an interview on 4/12/18 at 10:05 A.M., CMT A said: -The resident had been sick with diarrhea, and did not have a physician's orders [REDACTED]. -The licensed nurse would have to call to get a physician order [REDACTED].>-He/she also inform the resident that the CMT would have to see the next bowel movement; -On around Thursday 4/5/18 or 4/6/18 the CMT had seen the resident bowel movement and the stool was loose and watery; -He/she did not have a physician's orders [REDACTED]. -The CMT did not find an physician's orders [REDACTED]. -The CMT went ahead and gave the resident the anti-diarrhea medication; -He/she had described the medication as a green liquid diarrhea medication, He/she did not have the bottle of the medication on his/her medication cart at that time; -The CMT had given the resident about 5 ml of the anti-diarrhea medication, since he/she did not have a physician's orders [REDACTED].>-The CMT said, he/she had followed-up with the resident and the resident said the medication did help with the diarrhea; -The CMT had reported again to the LPN that the resident was needing a physician's orders [REDACTED]. -He/she had not documented in the resident's MAR indicated [REDACTED] -Was aware he/she should have had a physician order [REDACTED].>-Should have gone to another charge nurse, the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) to ask for assistance in obtaining a physician's orders [REDACTED].>During an interview on 4/12/18 at 10:05 A.M., the ADON was present for part of the CMT interview and said the CMT should have not given any medication without a physician's orders [REDACTED].>Record review of the CMT MAR indicated [REDACTED].M., showed CMT A had documented a note after the interview that stated on 4/5/18, had documented back of the CMT MAR medication sheet, that he/she had been given 1 teaspoon of anti-diarrhea medication for the resident's loose stools, had notified the LPN prior to giving the medication, Record review of the resident's nurse notes dated 4/12/18 at 3:23 P.M. showed; -Around 10:00 A.M. the resident had diarrhea stool. He/she was given liquid over the counter anti diarrhea medication. The resident Physician's office was called and a physician's orders [REDACTED]. The physician's orders [REDACTED].>-No documentation was found that the resident's physician had been notified about the resident weight loss or fever. Record review of the facility's Licensed Nurses 24 hour nurses report showed on 4/12/18, the resident had diarrhea one time, a physician's orders [REDACTED]. Record review of the resident's nurse notes dated 4/12/18 at 3:31 P.M. showed; -The resident was out on pass for about 30 minutes. He/she had said that he/she felt better and needed to get some fresh air. His/her weight today was 147.6 pounds. He/she said, he/she has been eating better since he/she been getting over a cold and -No documentation was found that the resident's physician had been notified about the resident weight loss. Record review of resident medical record on 4/12/18 showed: -The resident had a weight loss 8.4 pounds in one month which equals to 5.9 % loss; --On 3/13/18, the resident weight was 156 pounds and --On 4/12/18, his/her weight was 147.6 pounds. During an interview on 4/13/18 at 10:00 A.M., LPN A said: -If CNA had reported that a resident was ill, he/she would have completed a head to toe assessment on the resident to include vital signs; -He/she would check the resident MAR for any PRN medication to help treat any of the symptoms , after treatment would call the resident physician and reassess the resident before leaving; -Should document in the resident's nurses notes, on the resident's MAR indicated [REDACTED]. When documenting would include who was notified that the resident was sick, the complaints, the assessments, and any treatment or action taken; -Licensed nursing staff are responsible for notifying the resident's physician for any new orders or reporting any change of condition and -CMT should never have given the anti-diarrhea medication without a physician's orders [REDACTED].>During an interview on 4/13/18 at 10:40 A.M., CNA C said that resident: -When a resident has weight lost he/she would talk with the resident's to see if they had any new changes, if they have been sick , have not been eating well and this would help to find the reason for the resident's weight loss; -He/she had reported the resident's weight lost to the charge nurse and to the weight management team; -The resident had been sick this last week and had frequent diarrhea stools, had another episode of diarrhea stool on 4/12/18; -The resident has been know to drop weight fast and especially when he/she had been sick; -Staff does monitor the resident's meal intake and fluid intake, should have documented this in the resident's medical record and -The resident was able to perform his/her on personal cares. During an interview on 4/13/18 at 11:35 A.M., LPN B said he/she does not remember being asked to obtain an physician orders [REDACTED]. During an interview on 4/13/18 at 3:00 P.M., the DON said: -He/she expected for the CMT to have a physician's orders [REDACTED]. -Licensed nursing staff are responsible for obtaining the resident's physician orders [REDACTED]. -If the resident's was ill, the nurse should be notified and should assess the resident for further physician ordered treatments; -Would have expected the licensed nursing staff to follow-up and check on the resident when notified of a resident not feeling well, and to document the findings in the resident's nurses progress notes, and to call the resident's physician's for orders as needed; -At this time the facility does not require for licensed nursing staff to make daily or shift round to check in on the resident's or to ensure if resident is in the facility and -The facility discusses any resident weight loss during morning meetings and at weight meetings. During an interview on 4/20/18 at 4:45 PM, Physician A said he/she: -Had been monitoring the resident blood thinner medication by monthly blood levels; -The resident was able to care for himself/herself, but does continue to use alcohol while residing at the facility; -He/she was not aware that the resident had a recent change of condition, or that he/she had been having frequent diarrhea stools or he/she had recent weight loss; -Was not contacted by the staff to obtain a physician's orders [REDACTED]. -He/she would expect the facility licensed nursing staff to follow-up and assess the resident that has complaints of diarrhea more than one time; -He/she would expect the facility licensed nursing staff to check on the residents who are not feeling well and -Would expect licensed nursing staff to contact the him/her when the residents are having frequent loose diarrhea stools more than one time and to obtain physician's orders [REDACTED]. 2. Record review of Resident #38's Face Sheet showed, he/she was admitted to the facility on [DATE] and was admitted to hospices (end of life care) services on 2/9/18. He/she had a [DIAGNOSES REDACTED]. Record review of the resident's significant change MDS dated [DATE], showed the resident: -Was placed on hospices services, [DIAGNOSES REDACTED]. -BIMS score was an 3, which indicated the resident had cognitive impairment, and had difficulty with memory; -Required total assistant and supervision and encouragement from staff for transfer, personal hygiene and setup for meals and -No diagnosis listed to support his/her pacemaker. Record review of the resident's Care Plan with a review date of 3/14/18 showed: -The resident had a pacemaker of unknown type or date of placement related to [MEDICAL CONDITION]; --The resident's goal was to remain free from signs and symptoms of pacemaker malfunction or failure; --Intervention included for nursing staff to arrange for cardiology follow-up as indicated by the physician for pacemaker monitoring and management and -- Nursing staff were to monitor, document and report any signs or symptoms of altered cardiac output or pacemaker malfunction: dizziness, [MEDICAL CONDITION], difficulty breathing(dyspnea, pulse rate lower than programmed rate lower than baseline blood pressure,. update the resident's physician with any changes or concerns. Record review on of the resident's POS date 3/1/18 to 3/31/18 showed the resident did not have a physician's orders [REDACTED]. Record review of the resident's Physician's Progress note dated 3/21/18 showed: -The resident was on Hospice services. had a history of [REDACTED]. Had no complaints that day. Staff denies any acute issues; -The resident's heart beat was normal and regular and -No documentation was found related to the follow-up or the monitoring of the resident's pacemaker or pending cardiologist visit. Record review on of the resident's POS date 4/1/18 to 4/31/18 showed the resident did not have a physician's orders [REDACTED]. Record review of the resident's nurses progress notes for February, (MONTH) and (MONTH) (YEAR) showed there was no documentation found related to the resident's pacemaker for any follow-up or monitoring or the resident had or scheduled cardiologist visit. During an interview on 4/12/18 at 9:30 A.M., hospice home aide A had called talked with the hospice Registered Nurse (RN) and said, that at this time the hospice did not have a physician's orders [REDACTED]. During an interview on 4/13/18 at 10:00 A.M., LPN A said: -Licensed nursing staff are responsible for notifying the resident's physician's for any new physician's orders [REDACTED]. -Upon admission of a resident with a pacemaker there should have had a physician's orders [REDACTED]. -Licensed Nursing staff would ensure to obtain a physician's orders [REDACTED]. -The night shift nursing staff were assigned the task of chart check that include ensure physician's orders [REDACTED]. -The resident on hospice services the resident physician's orders [REDACTED]. During an interview on 4/13/18 12:50 P.M., RN B said: -He/she would check the old MAR/TAR with the new MAR/TAR; -Check and compare the POS during the monthly changeover; -Send physician's telephone orders to the pharmacy on the 19 th or 20 th of each month so that any new orders were on the next months printed POS and -He/she would then review them to ensure the order had been transcribed to the new POS. During an interview on 4/13/18 at 3:00 P.M., the DON said: - Licensed nursing staff were responsible for obtaining the resident's physician's orders [REDACTED]. -Would expect licensed nursing staff to ensure the resident's had physicians orders for pacemaker monitoring and follow-up; -The POS and and the telephone orders were the night shift nursing staff and weekend supervisor responsibility for ensuring physician's orders [REDACTED]. -During the POS monthly change over, the weekend supervisor was responsible for ensuring any new physician's orders [REDACTED]. During an interview on 4/20/18 at 4:45 PM, Physician A said he/she: -The resident does have a Pacemaker, is on hospice services at this time; -He/she would expect for the licensed nursing staff to obtain physician's orders [REDACTED]. -Was not aware that the resident's does not have documentation in his/her medical records, for his/her pacemaker checks or monitoring; -He/she would expect the facility licensed nursing staff to follow-up with the resident's Cardiologist to obtain clinic appointment medical records of the resident monitoring and to ensure the resident's pacemaker had been checked and -He/she would expect the facility licensed nursing staff to notify him/her if unable to make appointment or unable obtain documentation from any medical appointment or referral for the resident's and to document it in the resident's medical records of his/her outcomes from the visit.

Based on observation, interview and record review, the facility failed to provide protective oversight for one confused resident (Resident #11) who was assessed by facility staff as an elopement risk, had a history of [REDACTED]. On 2/19/15, the resident left the facility without staff knowledge and was found 60 feet from the building kneeling in the snow, on a night when the temperature was well below freezing. The facility failed to promptly notify the resident's physician and family of the elopement. Further, the facility failed to provide protective oversight for one confused resident (Resident #13) who left the building on two separate occasions, to initiate appropriate interventions after the elopements, to notify the resident's physician and/or family members after the elopements, to complete elopement risk assessments, and to fully investigate the elopement occurrences. The facility failed to complete a detailed fall investigation report of one resident's fall; to complete an occurrence report and detailed fall report for a reported fall of a resident, to identify the root cause of a resident's fall, to implement appropriate interventions in order to prevent future falls from occurring, and to update the resident's fall risk care plan with interventions to ensure the resident's safety for one sampled resident (Resident #16); failed to assess and update residents' care plans with individualized interventions, to evaluate interventions used and to conduct a root cause analysis of falls for three sampled residents (Residents #3, #4, #9) after each fall, and to maintain a system of identifying and communicating to staff which residents had falls and the interventions in place; and failed to ensure a licensed staff member was present for the lunch meal to monitor residents in both the assisted and main dining rooms affecting three sampled residents (Residents #1, #2, and #3), when Resident #1 coughed while eating and potentially choked in the assisted dining room, and Resident #2 fell into Resident #3 in the dining room while unattended by staff. The total of 16 residents were sampled for review. The facility census was 88 residents. Record Review of the facility's Elopement Policy with a revision date of March 2001, showed: -The policy was from the old corporation, and not from the facility's new corporation. -Nursing personnel must report and investigate all reports of a missing resident. -Elopement is defined as the ability of a nursing home resident who is unable to care for himself or herself to leave the premises unsupervised and undetected. -The premises of this facility is defined as the facility and/or enclosed grounds. -It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing to the charge nurse immediately. -Notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Risk Manager if the resident was not found after searching the building. -Should an employee observe a resident leaving the premises, he/she should: --Attempt to prevent the departure; --Obtain assistance from other staff member in the immediate vicinity, if necessary; --Instruct another staff member to inform the charge nurse or DON that a resident has left the premises; --Be courteous in preventing the departure and in returning the resident to the facility. -Upon return of the resident to the facility, the DON or charge nurse should: --Examine the resident for injuries; --Contact the physician and report what happened; --The DON, ADON, or Risk Manager will contact the resident's legal representative (sponsor) and inform him/her of the incident; --Complete an incident report. -Should an employee discover that a resident is missing from the facility, he/she should determine if the resident is out on an authorized leave or pass. If not, make a thorough search of the building(s) and premises. If not located: --Notify the DON immediately; --Notify the attending physician; --The DON, ADON, Risk Manager will come in to help with the search; --If necessary, notify volunteer agencies (i.e. Emergency Management, Rescue Squads, etc); --Provide search teams with resident identification information; and --Make an extensive search of the surrounding area. -Upon return of the resident to the facility, the DON or charge nurse should: --Examine the resident for injuries; --Contact the attending physician and report findings and condition of the resident and follow orders; --The resident's legal representative (sponsor) will be notified by DON, ADON, or Risk Manager; --Notify search teams that the resident has been located; and --Complete and file an incident report. 1. Review of Resident #11's Admission Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses); -Cerebral degeneration (a steady decline over time of the part of the brain responsible for thoughts, memories, actions, and personality); -Hypertension (HTN - high blood pressure); -Reflux (a condition in which acid in the stomach rises up into the esophagus); -Depressive disorder (mental illnesses characterized by a profound and persistent feeling of sadness or despair); -Symbolic dysfunction (a disorder that affects somebody's ability to communicate); -Muscle weakness; and -History of falls. Record review of the resident's admission Nursing Evaluation dated 2/7/15, showed he/she: -Had a [DIAGNOSES REDACTED]. -Was confused with mild sundowners (when people with dementia get confused and agitated as the sun goes down and sometimes through the night); and -had a history of [REDACTED]. Record review of the resident's Activity assessment dated [DATE], showed he/she: -Was up at night; -Had short-term memory deficits; and -Had a short attention span of less than 30 minutes. Record review of the resident's Nursing Health Status Note dated 2/11/15 at 12:27 A.M., showed he/she was: -Fixated on his/her money and going to the bank and not easily redirected; -Up after resting a few hours in bed ambulating in the hall; and -Easily redirected to bed. Record review of the resident's Nursing Health Status Note dated 2/14/15 at 4:23 A.M., showed he/she: -Had dementia and confusion; -Wanted to leave the facility; -Was redirected back to his/her room after some coaching. Record review of the resident's 14 day admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/14/15, showed he/she: -Had impaired cognition and a [DIAGNOSES REDACTED]. -Required limited standby assistance for transfers; -Required physical assistance of one staff member for ambulation, dressing, bathing, and hygiene; -Had unsteady ambulation and was and only able to stabilize with one staff assistance. Record review of the resident's Nursing Health Status Note dated 2/15/15 at 10:35 P.M., showed he/she: -Was alert and oriented to self with confusion; and -Attempted to go out the door twice before being redirected. Record review of the resident's Nursing Health Status Note dated 2/16/15 at 7:00 A.M. showed the resident was confused and wanted to drive his/her truck home. Record review of the resident's Nursing Health Status Noted dated 2/16/15 at 10:08 A.M., showed he/she: -Was ambulating in the hallway and trying to go out the doors to the outside; -Was looking for his/her friends so he/she could get his/her truck to drive himself/herself home; -Had a WanderGuard (bracelets are monitoring devices that are attached to patients and electronically notify nurses when the patient leaves the ward or unit to which the patient is assigned) placed on his/her lower extremity; -Had daily confusion; -Would not stay in the dining room for breakfast; -Was easily agitated when he/she did not understand what was being said to him/her. Record review of the resident's undated Elopement Investigation Worksheet showed: -No date was documented as to when he/she eloped from the facility; -An elopement assessment was completed on 2/7/15 and updated on 2/16/15; -The resident was at risk for elopement; -The facility became aware of the elopement by the main door alarm sounding; -The police were not notified; -Not all staff had been interviewed as to the events; -The resident was not on behavior tracking before the incident; -The State agency was not notified; -Interventions initiated included: --Reassessed the resident for elopement potential; --Updated the resident's care plan; --Initiated additional monitoring; --The resident's medications were adjusted; --Discussed the incident with the resident and his/her family; --All door alarms were reviewed; and --Reviewed the resident's continued placement in the facility. Record review of the resident's Physician's Telephone Order dated 2/16/15 at 11:00 A.M., showed the following physician's orders [REDACTED]. -Place a WanderGuard on the resident due to elopement; -Check for placement of the WanderGuard every shift; and -Check the function of the WanderGuard every night on the 10:00 P.M. to 6:00 A.M. shift. Record review of the resident's Elopement Risk assessment dated [DATE], showed he/she: -Was cognitively impaired with poor decision-making skills; -Had a dementia diagnosis; -Would ambulate independently at times without assistance; -Verbally expressed the desire to go home to family; -Had a picture placed on the wander list; -Was known to staff as a wander risk; -Had a severe decrease in cognitive thinking skills in the afternoon and evening; and -Had a WanderGuard bracelet placed on his/her left ankle. Record review of the resident's Nursing Health Status Note dated 2/17/15 at 4:24 A.M., showed he/she: -Was confused; and -Was wandering after dinner. Record review of the resident's Nursing Health Status Note dated 2/18/15 at 5:46 A.M., showed he/she: -Was confused; and -Wanted to get in his/her truck and go home some nights. Record review of the resident's care plan dated 2/7/15 with an update on 2/18/15, showed: -The resident was an elopement risk/wanderer related to impaired cognitive ability and confusion; -The resident exhibited exit seeking behaviors; -Staff was to redirect the resident if he/she attempted to exit exterior doors; -Staff was to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books; -The resident wore a WanderGuard bracelet on his/her right ankle; -The resident had a history of [REDACTED]. -No new interventions were documented as put in place after the 2/19/15 elopement. Record review of the resident's Nursing Health Status Note dated 2/19/15 at 2:35 A.M., showed he/she: -Was observed wandering the unit and inquiring about employment for himself/herself at 1:00 A.M.; -Was encouraged to sit in a chair at the nurse's station to have a snack and rest until ready for bed; -Was assisted to bed at 1:15 A.M. by Licensed Practical Nurse (LPN) B; -A WanderGuard was heard alarming at 1:45 A.M. and LPN B went and checked the front entrance door; -Was observed approximately 60 feet from the building kneeling in the snow by LPN B; -Was assisted back into the building by two staff members; -Vital signs were obtained from the resident and included a body temperature of 86.5 ("normal" body temperature can range from 97 degrees Fahrenheit (° F) to 99° F) due to extreme cold (the recorded temperature for Kansas City at 1:54 A.M. on 2/19/15, via Weather Underground, was 10° F with a wind chill of 1.8° F); -Had several small bleeding scratches to his/her left hand; -Stated he/she was out looking for a job; -Had a body temperature of 97° F at 2:35 A.M.; -LPN B faxed a concern sheet to the resident's physician with a recommendation for a sleep aid; and on the sheet, LPN B did not identify the incident to the physician as an elopement but as a fall, and did not state the resident had been found outside kneeling in the snow, how long he/she had been outside, and what his/her body temperature was. Record review of the facility's Communication Form dated 2/19/15, showed the resident: -Had a fall resulting in left hand abrasions; -Was ambulating and very confused at night; -Was an elopement risk; -Had no documentation of the resident's elopement from the building and being found approximately 60 feet from the building kneeling in the snow; -Had no documentation of what clothing the resident had been wearing; -Had no documentation of the resident having a temperature of 86.5° F; and -The physician was to have been called, not faxed for emergency issues. -LPN B requested an order for [REDACTED]. Record review of the resident's Time-Out Huddle form dated 2/19/15 at 4:00 A.M., showed: -The resident had a fall resulting in left hand abrasions; -An intervention of every 15 minute checks at night was to have been initiated; -The DON had been notified; -The physician had been notified via fax; -The family had not been notified (one attempt had been made); -No documentation the resident had eloped, had a body temperature of 86.5° F, had been found approximately 60 feet from the building kneeling in the snow, and what clothing he/she was wearing. The facility was unable to provide documentation of the every fifteen minute checks being done. Record review of the resident's Fall Detail Report dated 2/19/15, showed he/she: -Had a WanderGuard alarm that was sounding; -Was wearing well fitting shoes; -Was found on the ground outside, kneeling in the snow; and -Wheelchair was not in use. Record review of the resident's Occurrence Report dated 2/19/15, showed he/she: -Had a fall; -Was oriented to person only before and after the occurrence; -Had a temperature of 86.5° F; -Was kept under continuous supervision; -Had neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) were initiated; -Had abrasions to the back of his/her left hand; -The document: --Did not show if the physician had been notified; --Did not show the resident had an elopement; --Did not show the resident had been found approximately 60 feet from the building kneeling in the snow; without a coat, wearing only a tee shirt, khaki pants and shoes. --The facility was unable to provide documentation of the neurochecks. Record review of the resident's Situation, Background, Assessment, Request (SBAR) Communication Form dated 2/19/15, showed he/she: -Had a body temperature of 86.5° F; -Had increased confusion at night; -Had a fall resulting in abrasions to the left hand; -The document did not show he/she had eloped, had a temperature of 86.5°F, and had been found approximately 60 feet from the building kneeling in the snow, wearing only a tee shirt, khaki pants and shoes. Record review of the resident's February 2015 physician's orders [REDACTED]. Record review of the resident's Social Services Note dated 2/19/15 at 3:28 P.M., showed: -The resident's spouse stated he/she had not been notified of the elopement/fall; -The resident's brother/sister was upset about not being notified; -The ADON had informed both the spouse and family members that the facility was not required to notify the spouse due to the resident being his/her own responsible party; -The resident had stated he/she did want his/her spouse and family member to be notified of medical changes and emergency concerns; -A letter was placed in the resident's chart for staff to notify the spouse and family member of all changes; -The resident had already given verbal consent for his/her spouse to make all decisions for him/her; -The family was aware of the need for a secure unit and referrals had been faxed for placement that had a secure unit. Record review of the resident's Nursing Health Status Note dated 2/21/15 at 1:52 P.M., showed: -He/she made three attempts to walk out of both back and front doors during the 7:00 A.M. to 7:00 P.M. shift. Record review of the resident's Nursing Health Status Note dated 2/22/15 at 10:19 P.M., showed: -He/she made several attempts to walk out of both back and front doors on the 7:00 A.M. to 7:00 P.M. shift. Observation on 2/23/15 at 8:30 A.M., showed the resident: -Was sitting in his/her wheelchair at the breakfast table in the main dining room with his/her spouse; -Had a cup of coffee and a bowl of hot cereal in front of him/her; -Was feeding himself/herself with verbal encouragement from his/her spouse. During an interview on 2/23/15 at 9:25 A.M., the resident's spouse said: -He/she was concerned that cares were not where they should be and was worried about the resident when he/she would leave the facility; -The resident had wandered outside at night and fell hurting his/her left hand; -He/she was very upset that the facility had not notified him/her of the incident; -The resident would be moving to a locked unit that day or the next per the family request; -He/she was not aware that the resident would not have been secure at this facility; -He/she does not believe there is enough staff to care for the residents properly; -He/she felt concerned that the resident's left side of his/her face and left eye were swollen since the elopement/fall and "does not look right;" -He/she requested to speak with the charge nurse about sending the resident to the hospital for evaluation prior to transferring him/her to the new nursing home; -The resident had not been sent to hospital after the elopement/fall. Observation on 2/23/15 at 1:15 P.M., showed: -The resident was sitting in his/her wheelchair in his/her room talking with the Physical Therapist (PT); -The resident had a WanderGuard bracelet in place on his/her left ankle; -The resident had an unlit cigarette hanging from his/her mouth; During an interview on 2/23/15 at 2:22 P.M., the Social Services Designee (SSD) said: -The resident began wandering the facility after 4:00 P.M. on a daily basis; -The resident was an elopement risk; -He/she spoke with the resident's family in regards to transferring the resident to a facility with a locked unit; -The resident was to transfer to the new facility at 2:30 P.M. that day. Observation on 2/23/15 at 2:25 P.M., showed: -The resident was sitting in the hallway in his/her wheelchair; -The resident stated he/she was "lost and don't know where to go"; -The resident was assisted back to his/her room by a Certified Nursing Assistant (CNA). Observation on on 2/23/15 at 2:48 P.M., showed a staff member from a different facility was in the resident's room to transfer him/her to the new facility. Observation on on 2/23/15 at 2:37 P.M., showed: -The resident was sitting in his/her wheelchair in the hallway beside the East nurse's station medication cart; -Registered Nurse (RN) B removed the resident's WanderGuard bracelet by cutting the band with scissors. The WanderGuard was placed in the top middle drawer of the medication cart; -The resident, who was sitting in a wheelchair, was moved by the side door while awaiting the wheelchair van for transfer to another facility. The resident was accompanied by a staff member from the new facility. Record review of a Social Services Note dated 2/23/15 at 3:10 P.M., showed: -The resident was discharged to another nursing facility with a locked unit. Record review of the resident's Telephone Orders Sheet (TOS) and POS did not show the resident had been sent to the hospital after the elopement on 2/19/15, for evaluation prior to discharge on 2/23/15 to another facility. During an interview on 2/25/15 at 4:26 P.M., LPN A said: -He/she had not been working the day the resident eloped, and did not have any interactions with him/her; -If a resident was found outside the building, the nurse should have: --Performed a head to toe assessment on the resident and started neurochecks; --Called the physician; --Placed a WanderGuard on the resident; --Called the resident's family even if the resident was his/her own responsible party; --Called the DON; --Taken a picture of the resident and placed it in the elopement book at each nurses station; -The WanderGuard system alarm would have sounded at the East nurse's station and the front door; -The WanderGuard system did not prevent the doors from opening; -The WanderGuard system did not alarm in the dining room; -All exterior exit doors, when opened, had an alarm that sounded and lights that lit up on a panel at the nurse's station. During an observation on 2/25/15 at 4:35 P.M., LPN A attempted to use a WanderGuard bracelet taken from the top middle drawer of the East nurse's station medication cart to set off the alarm on the front door. The alarm did not sound. LPN A left, then returned with two new WanderGuard bracelets and was able to set off the WanderGuard alarm on the front exit doors. During an interview on 2/26/15 at 5:03 P.M., LPN B said: -He/she saw the resident approximately 30 minutes prior to his/her elopement (Elopement incident occurred on 2/19/15 at 1:45 A.M.); -He/she noted the resident wandering the halls and sat the resident in a chair at the nurse's station for a snack, and then escorted the resident to bed; -He/she did not put precautions in place related to the resident wanting to leave and find a job after he/she placed the resident in bed; -He/she left the resident in his/her clothes and shoes because he was so disoriented wanting to go find a job, and he/she was not sure he/she would not leave the building to "look for a job"; -He/she was at the far end of the hall attending to other residents for approximately 30 minutes and was unable to hear the WanderGuard alarm until he/she was next to the East nurse's station; -He/she went to check the front door and saw the resident outside kneeling in the snow; -The resident was dressed in khaki pants, a tee shirt and shoes; -The resident was taken to his/her room and his/her clothes were changed; -The resident was placed in bed with extra covers; -The resident's vital signs were taken every 15 minutes until his/her temporal (the sides of the skull behind the eyes) temperature was back to normal; this was after the third or fourth set was taken; -When the resident was found outside, he/she seemed worn out and stated, "Thank you Jesus, you are here,"; -A huddle was performed with the CNAs; -Fifteen minute checks were set in place to check on the resident, but had not been documented; -He/she now realized the fifteen minute checks should have been written down; -He/she did not think to place the resident on continuous monitoring; -Staff did not monitor the front door; -He/she attempted to contact the resident's spouse one time and was not able to contact him/her or leave a voicemail; -The physician was notified of the fall via fax, but was not notified of the resident's elopement; -He/she did not feel it was an emergency and did not call the physician; -An emergency would be if the resident was in pain or needed to be sent to the emergency room (ER); -A fall occurrence report was filled out in place of an elopement occurrence report because the resident was just outside and he/she did not think that was an elopement; -If a resident was an elopement risk, they should have been placed in a room away from the doors, had a WanderGuard placed on the resident, and had a medication evaluation to see if a new medication would have helped with wandering; -Elopement documentation should have included: --Physician, DON and family notification; --Elopement report; --Care plan adjustments; --Resident assessments; and --Documentation of the fifteen minute checks. -Occurrence reports should be placed in the medical record when completed; and -He/she had never had to report an elopement to the State Agency because he/she never had anyone elope; they just went outside the building. During an interview on 12/27/15 at 2:30 P.M., the ADON said: -He/she expected staff to notify the physician, DON/Risk Manager and the resident's family if the resident was not his/her own responsible party for all elopements; -The DON was the Risk Manager; -He/she expected staff to call the physician and not fax for an elopement; an elopement meant call; -He/she expected staff to continue to call the physician until he/she was reached. -The resident's physician or his/her Nurse Practitioner were always available for contact through his call service; -Staff had repeatedly been told to place a WanderGuard on any residents that were an elopement risk at night using anything available to keep it on until the morning if no WanderGuard bands are available; -His/her definition of an elopement was twofold: --Leaving the facility; and --Leaving the grounds without signing out; -He/she had not been contacted when Resident #11 eloped; -He/she expected the incident to be written up as a fall and an elopement; -He/she would have expected the nurse to not leave the resident alone when he was confused or angry to care for other residents at the other end of the hall; -The nursing should have documented 15 minute checks on the resident prior to the elopement and after the elopement; -Forms for 15 minute checks were available to staff; -His/her expected interventions for the elopement were: --Fifteen minute checks at the least if not continuous monitoring; --Checking vital signs, range of motion (ROM) and Neurochecks; --Monitoring for pain and comfort; --Make sure the resident was safe; -He/she had not been notified that the WanderGuard alarm was not loud enough to be heard away from the nurse's station; -If neurochecks were not a part of the documentation provided, they are not in the medical record; -He/she did not know if the elopement was reported to the State Agency, because it is the responsibility of the DON or the Administrator. During an interview on 3/2/15 at 1:40 P.M., the DON stated: -He/she expected to have been notified immediately of any resident elopement; -He/she expected the physician to have been notified by phone immediately; -He/she expected a total body assessment to have been performed and reported to the physician; -He/she expected the resident to have been placed on 15 minute checks or continuous monitoring; -He/she expected the resident's picture to have been placed in the elopement book located at each nurse's station and reception office; -He/she expected the nurse to have alerted all staff of the residents risk for elopement; -He/she expected an Occurrence Report and SBAR to have been completed; -He/she did not expect a nurse's note to be written if the information had been written on the last page of the SBAR, He/she expected it to be in one place or the other but not both; -He/she expected the nurse or assigned staff to have stayed with the resident for continuous one-on-one monitoring if the resident had been at risk for elopement and his/her shoes had been left on; -Elopement education had been provided in the form of Code Green drills, which included searches by all staff for a staged eloped resident using the facility's Search Zone Map; -Elopement training had not been previously provided to staff upon hire; -The facility would not have contacted the family if the resident is their own responsible party, even if the resident had cognitive impairment; -The resident wanted his/her family member notified, not his/her spouse; -The family member was notified; -If the spouse/responsible party was unable to be reached, he/she expected the staff to have continued to attempt to contact family by trying the next person on the resident emergency contact list until someone had been reached; -He/she had not been notified that the WanderGuard alarm was not loud enough to be heard away from the nurse's station. During a telephone interview on 3/12/15 at 5:35 P.M., the facility Medical Director said he/she had not been notified of an elopement for this resident. He/she expected to be notified immediately by phone when the resident eloped from the facility and was found outside in the snow and had a decreased body temperature. When the resident was stating he/she wanted to leave and find a job, the nurse should have increased the monitoring of the resident. The nurse should not have left the resident unattended after being placed in bed. The nurse should have notified the DON of the elopement. He/she had been told by the staff the resident was being transferred due to the facility not being able to meet the resident's needs. 2. Record Review of Resident #13's Admission Record face sheet showed he/she was admitted to the facility on [DATE], was listed as his/her own responsible party, and had a family member listed as the first emergency contact. His/her [DIAGNOSES REDACTED]. -Chronic airway obstruction (COPD - a disease process that decreases the ability of the lungs to perform ventilation); -Muscle weakness; -Congestive heart failure (CHF-a disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body); -Hypertension (high blood pressure); -Gout (a hereditary disease which may cause painful arthritic changes in the joints such as the knee); -[DIAGNOSES REDACTED](abnormal heart rhythm); and -Edema (swelling). Record review of resident's Fall Risk Evaluation and Plan of Care initiated 2/4/14, showed the staff needed to: -Provide safety education to the resident; -Supervise the resident with ambulation; -Ensure the resident had appropriate glasses on to minimize falls. Record review of resident's Health Status Note dated 2/4/14 at 9:19 P.M., showed he/she: -Was forgetful of where his/her room was and had to be reminded by staff several times where his/her room was. Record review of resident's Health Status Note dated 2/15/14 at 3:05 P.M., showed he/she was alert and oriented to himself/herself only. Record review of resident's Activity Care Plan updated 2/17/14, showed the staff were to encourage him/her to sit on the porch/courtyard/patio weather permitting. Record review of resident's General Durable Power of Attorney (DPOA - a person previously identified to make decisions for an individual in the event of inability to make wishes known) dated 3/10/14, showed the resident's family member was his/her DPOA. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Had moderately impaired cognition. -Had an acute mental status change. -Exhibited no wandering behavior. -Required limited assist for performance and one person assist for support for transfers, bed mobility, toileting, personal hygiene and dressing; -Walked in his/her room and corridor with supervision and required no support. -Did not wear glasses or have corrective lenses. Record review of the resident's Activities of Daily Living (ADL-how a person self-performs dressing, grooming, bathing, eating, and toileting) care plan initiated 2/12/14 with an update of 2/17/15, showed he/she: -Required minimal assist/supervision with ADL's related to confusion, edema and generalized weakness. -Required staff members to assist with set up for eating, dressing and personal hygiene; -Required supervision/cues to reposition him/her in bed, -Required supervision with transfers. Record review of the resident's Wound Care Progress Notes dated 11/19/14, showed he/she had a [DIAGNOSES REDACTED]. Record review of resident's Behavior Note dated 11/27/14 at 7:45 P.M., showed he/she: -Was found outside the building at the far back end of the facility building at 7:00 P.M. -Was brought back into the facility by staff. -Could not remember why he/she went outside the facility or how to get back in to the facility. -Was very pleasantly confused. -Was easily redirected. -Needed continued monitoring by staff. Record review of Resident's Behavior Note dated 11/27/14 at 8:00 P.M., showe

Based on observation, interview, and record review, facility staff failed to provide quality of life choices which promoted self-determination, sufficiency, and participation related to linguistic (of or relating to language) and cultural barriers including dietary preferences which resulted in the resident's failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments, that can result in weight loss, decreased appetite, poor nutrition, and inactivity) for one randomly sampled resident (Resident #19); and to provide communication and dietary preferences related to linguistic and cultural barriers for one sampled resident (Resident #8) out of 16 sampled residents. The facility census was 88 residents. Record review of the facility's previous corporation policy and procedures for language translation, revised 1/10/08, showed: -Resident's rights and facility policy are translated as necessary into the language understood by the resident to meet the specific communication needs of each resident as much as feasibly possible. -Should a non-English speaking or deaf resident be admitted , the facility will attempt to translate the resident rights and facility policy into the appropriate foreign or sign language that is understood by the resident. -In the case of less commonly encountered foreign languages, a representative of the resident (if available) may sign that he/she has explained the statement of rights to the resident prior to his/her acknowledgement of receipt. -The policy did not address how the facility will communicate with non-English speaking residents for daily cares and meeting the culture needs of the resident while living at the facility. 1. Record review of Resident #19's face sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. -Chronic [MEDICAL CONDITION] with exacerbation (an inflammation of the air passages within the lungs); -Closed [MEDICAL CONDITION] vertebrae (a part of the spinal column); -Backache; -Chronic fatigue syndrome (profound fatigue that is not improved by bed rest and that may be worsened by physical or mental activity); -[MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulated metabolism); -Paralysis Agitans ([MEDICAL CONDITION]-a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait); -Shortness of breath; -Hypertension (HTN-high blood pressure), -General Weakness; -Abnormality of gait (a deviation from normal walking); -Lack of coordination. Record review of the resident's Cognitive Status/Decision Making Evaluation, dated 6/3/13, showed he/she: -Was unable to complete the cognitive test due to his/her language barrier; -Spoke only Vietnamese; -Did not have a third party translator available from the facility for the resident evaluation; -Did not have another updated evaluation completed by the facility at the time of the survey. Record review of the resident's Nutritional Progress Notes, dated 10/3/13, showed: -A recommendation by the Registered Dietician to provide him/her snacks specific to his/her culture to increase his/her food intake. Record review of the resident's Interdisciplinary Care Plan Conference Record, dated 4/10/14, showed: -The resident, his/her family member, and a translator were not present during the care plan meeting. Record review of the resident's Nutritional Evaluation, dated 6/1/14, showed staff documented the resident: -Had a diet order for vegetarian mechanical soft diet; -Had supplements which were fortified and received med pass (a physician ordered dietary medication) 99 milliliters (ml) three times daily; -Had a fair appetite; -Received average portion sizes; -Dined in his/her room or dining room; -Had teeth missing; -Was hearing impaired; -Was alert and verbal, confused at this time, and non-English speaking; -Was independent and staff supervised with his/her feeding. Record review of the resident's Social Service Assessment, dated 6/2/14, showed staff documented: -The resident spoke Vietnamese and understood very little English; -A family member provided the history and physical for the resident; -A family member said the resident was satisfied with his/her life; -He/she used a communication book as a way to communicate with staff; -He/she had no memory problems, had modified decision-making, and was orientated to person and place; -He/she had lived alone prior to admission to the facility. Record review of the resident's Physician's Visit progress note, dated 6/4/14, showed the resident's physician documented: -The resident was Vietnamese; -The resident made no complaints but it was difficult to elicit because of his/her language barrier. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/11/14, showed staff assessed the resident as: -Rarely/never understood; -Rarely/never able to understand others; -Independent in bed mobility, transfer, walk in room/corridor, locomotion on and off the unit, eating, and toileting; -Required supervision from staff, oversight, encouragement or cuing when dressing; -Was continent of bowel and bladder; -Received a mechanically altered diet and a therapeutic diet. Record review of the resident's Communication Care Plan, revised 6/12/14, showed he/she had an alteration in communication related to a language barrier, and spoke only Vietnamese. Staff were instructed to: -Ensure the resident could make basic needs known on a daily basis; -Anticipate and meet needs; -Assess and/or document for physical and/or nonverbal indicators of discomfort or distress and follow up; -Communicate by using a communication board, gestures, and a translator; -Provide a communication book at the nurse's station, which the resident refused to keep in his/her room; -Avoid isolating the resident; -Family to provide translator as necessary to communicate. Record review of the resident's Nutrition Care Plan, revised 6/20/14, showed he/she had a potential for altered nutrition related to a history of weight loss and inadequate intake. Staff were instructed to: -Provide a mechanically altered diet; -Maintain adequate diet intake to achieve a stable weight; -Provide fortified foods; -Complete labs ordered and monitor as directed by the physician; -Monitor weight monthly; -Observe and record for consistently refusing foods; -Provide diet as ordered. Further review of the Nutrition Care Plan, showed staff did not include interventions for cultural preferences with his/her diet. Record review of the resident's weight summaries showed: -On 7/2/14 he/she weighed 97.1 pounds; -On 9/4/14 he/she weighed 93.0 pounds. Record review of the resident's Monthly Summary, dated 9/9/14, showed staff documented the resident: -Was alert and oriented; -Was withdrawn, friendly, quiet, and expressed himself/herself according to the situation; -Had a language barrier; -Was on a regular diet with no added sodium; -Had poor eating habits, with less than 50% of intake at meals; -Received supervision for personal hygiene; -Was continent of bowel and bladder. Record review of the resident's Quarterly Nursing Evaluation, dated 9/18/14, showed he/she: -Was served a regular diet; -had a history of [REDACTED]. -Had rarely eaten a complete meal and generally would eat only about half of the food offered. Record review of the resident's Physician's Visit progress note, dated 9/24/14, showed the resident's physician documented: -The resident was difficult to communicate with because of a language barrier; -Was unable to contribute to history due to the language barrier. Record review of the resident's weight summary, dated 10/5/14 at 3:16 P.M., showed: -He/she weighed 91.8 pounds. Record review of the resident's Facility Concern Sheet, dated 10/6/14, showed staff documented the resident: -Had not been out of bed in four days; -Ate 0% of his/her meals over the weekend; -Took a few sips of a soft drink. Record review of the resident's Interdisciplinary Care Plan Conference Record, dated 10/10/14, showed staff: -Encouraged intake of fluids and food; -Referred the resident to hospice (end of life care) per the resident's physician orders. Further review of the Care Plan Conference Record showed staff documented the resident, the resident's family member, and a translator were not present at the care plan conference. Record review of the resident's Health Status Note Progress Note, dated 10/12/14, showed staff documented: -The resident's family member reported to facility staff that the resident had difficulty swallowing and the resident said he/she wanted to die. Record review of the resident's Facility Concern Sheet, dated 10/13/14, showed staff documented: -The resident would only drink some of his/her supplemental shakes; -The dietician requested staff administer [MEDICATION NAME] (a medication used as an anti-depressant and to increase appetite) for 30 days. Record review of the resident's Speech Therapist (ST) Progress and Discharge Summary, dated 10/31/14, showed staff documented: -The resident had speech therapy services from 10/13/14 through 10/21/14; -The goals were not met upon discharge from speech therapy; -The resident safely consumed thin liquids utilizing small sips at a slow rate with minimal verbal and visual cues; -The resident refused to consume solid foods during the treatment sessions; -The ST provided education to nursing related to the resident's refusal at trials of solid food during the treatment sessions; -Nursing reported the resident consumed the meals the resident's family brought in for him/her to eat; -The resident was discharged from ST skilled services due to the refusal to participate in treatment activities. Record review of the resident's Resident Handling Evaluation (the facility assessment tool used to determine the method of transfer for the resident), dated 10/18/14, showed staff documented: -The resident failed to thrive; -He/she was able to follow simple commands; -He/she had comprehension issues related to his/her language barrier. Record review of the resident's Social Service Progress Note, dated 11/3/14, showed staff documented: -Facility staff contacted a family member related to the resident's decline in health; -A family member communicated to another family member who communicated to the resident; -The resident refused a feeding tube; -He/she was provided verbal and written information for Hospice services in English; -He/she did not speak English; -The facility used a third party person for communication and the communication book. Record review of the resident's weight summary, dated 11/4/14 at 2:00 P.M., showed he/she weighed 96.8 pounds. Record review of the resident's Physician Telephone Orders (TOS), dated 11/5/14, showed: -The resident was admitted to hospice with a [DIAGNOSES REDACTED]. Record review of the resident's Food Consumption Report, dated 12/1/14 through 12/31/14, showed he/she: -Refused the facility meals 26 times out of 93 times for that month; -Ate 0-25% of his/her meals 40 times out of 93 times for that month; -Ate 26-50% of his/her meals three times out of 93 times for that month; -Ate 51-75% of his/her meals 12 times out of 93 times for that month; -Ate 76-100% of his/her meals 13 times out of 93 times for that month; -Staff supervised seven meals during the month; -Was independent with eating. Record review of the resident's weight summary, dated 12/8/14 at 11:15 A.M., showed: -He/she weighed 88.8 pounds. Record review of the resident's Interdisciplinary Care Plan, revised 12/7/14, showed: -Staff discussed advanced directives with the resident's family member; -The resident's family member elected hospice services. Record review of the resident's Interdisciplinary Care Plan Conference Record, dated 12/10/14, showed: -Staff documented the resident preferred Vietnamese food that his/her family would bring in to the resident; -The resident, the resident's family member, and a translator were not present for the meeting. Record review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Rarely/never understood by others; -Rarely/never understood others; -Had no short term and long term memory problems; -Required modified independence in some new situations only related to cognitive skills for decision making; -Required one person physical assist from staff for bed mobility, transfer, locomotion off and on unit, dressing, personal hygiene; and bathing; -Required supervision, oversight, encouragement, and cuing for eating with set-up assist from staff; -Frequently incontinent of bowel and bladder. -Used non-verbal sounds and facial expressions as indicators for pain; -Received hospice services; -Received a mechanically altered diet and a therapeutic diet. Record review of the resident's Social Service Progress Note, dated 12/13/14, showed staff documented the resident: -Received hospice services; -Remained in his/her room most of the time; -Communicated with a translator present. Record review of the resident's Nutrition Progress Note, dated 12/16/14, showed staff documented the resident: -Received a mechanical soft diet; -Ate 25-50% of most meals; -Received 50% of his/her meals fortified; -Had no significant weight changes; -Fed himself/herself in his/her room for most meals; -Had no swallowing problems; -Received hospice services; -Met goals and would continue with same goals. Record review of the resident's Physician Visit progress note, dated 12/17/14, showed the resident's physician documented the impression of the visit as: -[MEDICAL CONDITION]; -Weight loss; -Failure to thrive; -The resident did not like the facility meals very well. Record review of the resident's Food Consumption Report, dated 1/1/15 through 1/31/15, showed staff documented the resident: -Refused the facility meals 23 times out of 93 times for that month; -Ate 0-25% of his/her meals 42 times out of 93 times for that month; -Ate 26-50% of his/her meals 14 times out of 93 times for that month; -Ate 51-75% of his/her meals ten times out of 93 times for that month; -Ate 76-100% of his/her meals six times out of 93 times for that month; -Staff supervised 11 meals during the month. Record review of the resident Physician order [REDACTED]. -Add or discontinue extra calorie orders as needed; -Provide hospice services; -Provide a regular diet, med pass 2.0 (a nutritional supplement) 90 ml by mouth four times daily, and mighty shakes (supplemental drinks) at each meal for supplements. Record review of the resident's Food Consumption Report; dated 2/1/15 through 2/23/15, showed staff documented the resident: -Refused the facility meals 22 times out of 72 times for that month; -Ate 0-25% of his/her meals 22 times out of 72 times for that month; -Ate 26-50% of his/her meals one time out of 72 times for that month; -Ate 51-75% of his/her meals seven times out of 72 times for that month; -Ate 76-100% of his/her meals thirteen times out of 72 times for that month; -Had staff supervision with five meals for that month. Record review of the resident's Nutritional Progress Notes, dated 2/2/15, showed: -The registered dietician recommended staff provide the resident foods as requested for comfort within the diet order. Record review of the resident's undated Diet Preferences form completed by the Dietary Manager showed: -The resident's favorite foods were rice and tea; -He/she did not like meat and was to have all vegetables; -He/she received hot fortified cereal, orange juice, and scrambled eggs for the breakfast meal; -He/she received low-fat milk and hot tea for all meals as the beverage choice; -The resident's bread preference was white or wheat bread. Observation on 2/26/15 at 11:00 A.M., showed: -A Vietnamese calendar and a spiritual picture on the wall above the resident's bed; -An activities calendar in English posted in the resident's room; -A communication book by the television, which contained words in Vietnamese such as "are you happy" and "are you tired." During an interview on 2/26/15 at 11:00 A.M., the Assistant Director of Nursing (ADON) said the resident did not speak English, the resident does not want the communication book in his/her room, and he/she would throw the communication book in the hallway. The ADON said the resident was on hospice but was able to get in and out of his/her bed and change by himself/herself. The ADON said the facility had a nursing student in the building who spoke Vietnamese and could translate for the surveyor, then offered to get the student. During an interview on 2/26/15 at 11:00 A.M., the resident said (through the translation of a nursing student): -He/she only eats once a day; -A family member brought food for the resident to the facility when he/she was not at work; -He/she would not eat when the family member was at work and would only drink ensure; -The facility staff did not provide a translator for him/her; -When asked about not being able to speak in his/her native tongue, he/she said he/she was "sad" and gestured to his/her eyes, and made a crying motion; -He/she said he/she could not remember his/her family member's phone number when asked if facility staff made the phone available to contact his/her family. During an interview on 2/26/15 at 3:40 P.M., the Social Services Designee said: -Non-English speaking residents are encouraged to have their family members involved in resident care planning to assist in translation; -Therapy made communication books for Vietnamese residents; -Translators for the Vietnamese residents are family members and that the facility had a nursing student who spoke Vietnamese; -The resident's hospice agency provided a phone translator service; -The resident pointed to make his/her needs known; -The Dietary Manager prepared foods and menus for the residents; -The facility provided Chinese food to Vietnamese residents at times. Observation on 2/26/15 at 6:20 P.M., showed the resident: -Lay in bed with the lights off; -Gestured to have her curtain pulled half way; -An unopened can of ensure sat on the bedside table with a cup upside down on top of it. During an interview on 2/27/15 at 7:34 A.M., Certified Nursing Aide (CNA) O said: -The Vietnamese residents used hand language and gestures to express needs; -The resident liked to drink mighty shakes but did not eat much; -The facility cooked rice for the Vietnamese residents; -There was no documentation if the resident ate the facility rice; -The resident refused to eat regular foods; -The resident's family brought him/her food; -The resident is a vegetarian. Observation on 2/27/15 at 8:20 A.M., showed the resident sat in his/her wheelchair. Staff delivered breakfast to the resident's room. Observation showed staff circled both tea and milk on the meal ticket. The meal ticket listed a dislike of meat, and diet was mechanical soft. Staff served the resident orange juice, oatmeal, pancakes, syrup, and fortified milk. The resident ate 0% of the meal and drank 75% of the orange juice. During the above observation, the Director of Nursing (DON) walked into the resident's room and said: -The resident cannot understand you; -The resident refused to eat his/her breakfast, he/she waited for his/her family to bring food; -The resident refused to drink the fortified milk, but drank the juice. Observation on 2/27/15 at 8:26 A.M., showed Certified Medication Technician (CMT) D asked the resident if he/she wanted to eat. The resident gestured for CMT D to take his/her food. CMT D removed the resident's tray from his/her room. CMT D did not offer the resident an alternative. During an interview on 2/27/15 at 8:26 A.M., CMT D said: -The resident does not like to use the communication book and does not want it in the room; -The family brings in lunch for the resident most days at noon. During an interview on 2/27/15 at 9:30 A.M., the Dietary Manager said: -Nursing was responsible for the diet slips to get to the dietary department; -He/she talked to the residents two to three days after their admission to the facility to collect the residents' preferences; -He/she did not talk to the resident or to his/her family after admission to the facility; -He/she was aware the resident's family members brought in food for the resident; -"We do what we can, he/she (the resident) refuses so much"; -A nurse told the Dietary Manager the resident's family said he/she did not eat much at home; -He/she had spoke to a night shift nurse who appeared to be the same nationality of the resident and got the night shift nurses' dietary preferences to use as the resident's preferences; -The Dietician gave him/her some spices specific for Vietnamese food but he/she did not know what to do with them; -The Dietician gave the Dietary Manager recipes specific to Vietnamese culture, but the facility's distributors did not have the ingredients, and he/she was only able to buy food from the distributors; -The Dietician recommended serving Vietnamese meals to aid the resident in eating better; -He/she attempted a version of a recipe with beef and stock, but the resident refused to eat it; -He/she had not seen the resident's family. During an interview on 2/27/15 at 3:35 P.M., the Social Services Designee said: -He/she picked a hospice provider for the resident that had a Vietnamese phone translator. Observation on 2/27/15 at 11:57 A.M., showed: -The resident sat in his/her wheelchair with a family member present; -The family member brought Vietnamese food the resident prefers; -The resident ate 80% of the rice, 85% of the soup, and 10% of the oranges; -The family left Vietnamese coffee and tea. During an interview on 2/27/15 at 4:10 P.M., CNA P said: -Staff used gestures as a sign language to communicate with Vietnamese speaking residents; -The resident's family brings food; -The family leaves left over food in the refrigerator at the nurse's desk for the resident; -Staff used gestures and nods to complete cares for the resident. Observation on 3/2/15 at 12:10 P.M., showed: -The resident was up in his/her wheelchair; -The resident's family member brought the resident Vietnamese food; -The resident ate oranges; -The family member brought Vietnamese soup, coffee, and tea. During an interview on 3/2/15 at 1:45 P.M., the DON said: -He/she explained to the resident's family the importance for the resident to get out of bed and eat; -Afterward, the family began to bring in Vietnamese food daily; -The resident had a daily interpreter as family brings food daily. During an interview on 3/2/15 at 5:11 P.M., the resident's family member said: -The resident did not eat much for his/her breakfast or supper meals; -Family members will bring in the noon meal most days for the resident; -The food brought to the resident is Vietnamese food, soups, and broths; -The family will bring fresh fruit, grapes, and oranges for the resident; -The family peels the fruit as the resident's fingers are weak; -The family leaves ensure by the resident's bed in case the resident does not want to get out of bed. 2. Record review of Resident #8's POS, February 2015, showed the resident's physician directed staff to serve him/her a full regular diet. Further review showed the physician diagnosed the resident with: -Acute [MEDICAL CONDITION] (a condition caused by abnormally high levels of potassium in the blood); -[MEDICAL CONDITION] Stage III (CKD Stage III - chronic [MEDICAL CONDITION], a progressive loss in renal function over a period of months or years); -Dementia; -HTN; -[MEDICAL CONDITION] ([MEDICAL CONDITION] - damage to the brain caused by a disruption of the blood supply to a part of the brain); -Depression; -[MEDICAL CONDITION]. Record review of the resident's undated diet preferences completed by the Dietary Manager showed: -The resident required a renal diet; -The resident's favorite food was rice; -The resident did not like coffee or tea; -The resident was to have cream of wheat, apple juice, and scrambled eggs for the breakfast meal; -The resident's spouse brought in a renal supplement as the beverage choice; -The resident's bread preference was white or wheat bread. Record review of the resident's nursing evaluation, dated 1/30/15, showed staff documented the resident: -Spoke Vietnamese and had a language barrier; -Was alert, awake, withdrawn and confused; -Was uncooperative and resistant during care; -Required supervision for transfers; -Required supervision with eating; -Had adequate nutrition. During an interview on 2/27/15 at 9:30 A.M., the Dietary manager said: -The resident was provided rice and his/her family member brought in a renal diet. During an interview on 2/27/15 at 10:30 A.M., CMT A said: -Another Vietnamese resident who speaks English communicated with other Vietnamese non-speaking English residents; -He/she used hand gestures and pointed to communicate with non-English speaking residents. During an interview on 2/27/15 at 7:00 P.M., the resident's family said: -The resident's family member brought the resident Vietnamese tea and food; -The resident prefers the Vietnamese foods; -The facility does not provide Vietnamese foods; -The resident does like cheese and milk; -The resident was to have [MEDICAL TREATMENT] weekly but due to his/her combative behavior and his/her language barrier, staff were unable to calm the resident down, and he/she was not receiving those services at this time. Observation on 3/2/15 at 11:50 A.M., showed: -CNA A gestured to the resident to go eat and move into his/her wheelchair from a lobby chair; -CNA A with another CNA placed the gait belt around the resident; -The resident moved his/her arm out of the belt; -CNA A gestured with his/her hands to the resident to go eat and placed the gait belt back under the resident's arm; -The resident moved to pull his/her arm back out of the gait belt, CNA A held the gait belt in place, and both CNA's transferred the resident to the wheelchair; -The resident waved his/her head back and forth and shook his/her hands in a sideways motion in front of his/her body. 3. During an interview on 2/27/15 at 2:26 P.M., the ADON said: -There were five Spanish speaking residents, four Vietnamese speaking residents, one resident spoke a language from the Philippines, and one resident spoke a form of African. All of these residents had language barriers; -The facility provided communication books and boards; -An outside agency could be contacted for translators; -Vietnamese community members come to the facility on Vietnamese holidays; -The resident's family brought in food for the resident; -Nursing recommended the Dietary Manager speak with the family regarding the resident's diet preferences. 4. During an interview on 2/27/15 at 3:35 P.M., the Social Services Designee said: -Residents speak Vietnamese, Spanish, English and African; -Most residents at the facility speak English; -The facility relies on family for those who speak Vietnamese; -Staff should contact family members on the initial social services assessment; -The facility does not have Vietnamese or African interpreters; -The social service assessment was about the "quality of life" and included activities of daily living, communication, the resident's whole being; -A total assessment was determined over time for non-English speaking residents by observation and learning residents' routines; -The Dietary Manager determined food preferences for all residents; -The Administrator provided the permission for a translator and social services arranged for the interpreter; -The facility did not have a translator in the building; -The residents translated for one another to communicate their needs to facility staff. 5. During an interview on 2/27/15 at 4:18 P.M., Registered Nurse (RN) A said: -Staff communicate with residents who have language barriers by using language books or the families are used as interpreters; -Another resident who speaks some English has translated for the resident, -Student nurses, when available and speak the desired language, are used to communicate with non-English speaking residents; -The resident's family will sometimes bring the resident meals; -Dietary staff have made the resident's food preferences including rice, milk, milkshakes, water, juice, and fish; -The family increased visits and brought food regularly after the resident's illness; -Staff assessed the resident for pain when the resident was observed holding his/her head and with gestures; -Staff used gestures to communicate when they performed cares. 6. During an interview on 3/2/15 at 1:45 P.M., the DON said: -He/she was not familiar with culture change; -He/she thinks residents should have their own homelike environment specific to their wants; -The Dietary Manager completes an interview upon admission of any dietary needs for each resident, then reassesses quarterly; -Resident needs are met for non-English speaking residents by staff, nursing students, family, phone translators, gestures, and communication books, depending upon the needs of the resident. 7. During an interview on 3/2/15 at 3:20 P.M., the Social Services Designee said: -Translators have not been in the building to her knowledge; -When a translator is needed the family is used to communicate to make decisions; -It is the nursing staff's responsibility to communicate to the social services designee when a translator is needed; -Staff should not have other residents translate for residents; -Culture change was making sure the living environment, activities, music, food are meeting the resident's needs of a complete social well being; -Assessments should not be completed until the family or an interpreter is contacted.

Based on observation, interview and record review, the facility staff failed to accurately assess and address a decline after one (Resident #4) out of 16 sampled residents experienced a decline in his/her condition over a period of several days, resulting in the resident becoming totally dependent on facility staff for his/her total care after the decline; to assess and monitor his/her ongoing jaundice (yellowing of the skin) and abdominal distention, and to follow his/her care plan and to notify the physician of the change in his/her condition, resulting in him/her being sent to the hospital three days after staff first noted the changes. The facility census was 88 residents. 1. Record review of Resident #4's Hospital History and Physical dated [DATE] showed: -Patient complained of dizziness, lives in a homeless shelter and was reported to not be acting him/herself. Patient was confused and not making any sense. He/she said he/she was off his/her medications for approximately three weeks, and recently started them back up in the past two days. His/her skin has been more jaundiced (yellowing of the skin and whites of the eyes), and the swelling in his/her bilateral lower extremity was worse. -He/she was admitted to the hospital for treatment of [REDACTED]. -Drained off three liters of fluid from his/her abdomen. Record review of the resident's Hospital Discharge Summary dated [DATE] showed: -The nursing home was to call the previous hospital for re-establishment of care as they have his/her medical records, and if this does not happen then to see this physician in six weeks so he/she will be followed up by physician for his/her liver condition. Record review of the resident's facility medical record showed he/she was admitted to the facility on [DATE] from the hospital with the following Diagnoses: [REDACTED]. -Ascites and -Transient alteration of awareness (an altered mental status which was significantly different than normal waking). Record review of the resident's Physician order [REDACTED]. -A physician's orders [REDACTED]. - He/she was a full code; -A physician order [REDACTED]. Record review of the resident's Resident Care Kardex (a form used by staff in the Get To Know Your Neighbor notebook at the nurses' desk) showed he/she was depressed, forgetful, and his/her mental status varied throughout the day. He/she needed set-up only for meals and fed him/herself meals. Record review of the resident's Progress Notes showed: -On [DATE] at 5:54 P.M., staff documented he/she was alert and orientated to person, place and date with some confusion at times. He/she had some abdominal distention noted related to [MEDICAL CONDITION], and jaundice was noted. He/she was assisted by one staff to bed without difficulty. Documentation did not show if staff measured or assessed his/her abdominal distention. -On [DATE] at 3:42 A.M., staff documented he/she was alert and orientated, needed standby assistance of one staff for activities of daily living (ADL). Record review of the resident's Nursing Evaluation dated [DATE] showed he/she was awake, alert, had mild confusion, needed supervision with eating, was not noted to be jaundiced and his/her abdomen was soft and non-tender. Record review of the resident's Situation Background Assessment or Appearance Request (SBAR) Communication Form dated [DATE] at 07:15 A.M., showed he/she had a non injury fall and the physician was notified by concern sheet fax. Record review of the resident's progress notes showed: on [DATE] at 9:47 A.M., he/she was to received 80 cc/hr-100 milliliters (ml) of NS via Hypodermolclysis. Record review of the resident's SBAR Communication Form dated [DATE] at 07:00 A.M., showed staff evaluate him/her as having a non injury fall, confusion, and a high white blood cell count (WBC). The Nurse Practitioner was notified by fax and orders were received to get a Urinalysis (UA) with culture and sensitivity (C&S) related to the high WBC. At 2200 P.M., the CBC results, high WBC, and note that the resident was more confused was sent to the Nurse Practitioner. Order for UA C&S. Record review of the resident's progress notes showed: -On [DATE] at 16:24 P.M., he/she was to receive 80 cc/hr to total one liter NS per Hypodermolclysis over one hour. -On [DATE] at 06:42 A.M., his/her Hypodermolclysis was dripping at 80 ml/hr. Record review of the facility communication form dated [DATE] faxed to the physician showed the resident was "very confused and somewhat non compliant. Last episode like this his/her ammonia level was very high. Should we order another test?" There was a fax back that asked how long has he/she been there? A Complete Metabolic Panel (CMP), Complete Blood Count (CBC), [MEDICATION NAME] and ammonia level was ordered. Observation on [DATE] at 2:10 P.M., showed the resident in bed with his/her head of bed up, the bed in a low position and mats on both sides of the bed. The resident spoke in a low, soft voice when spoken to. Record review of the resident's SBAR Communication Form dated [DATE] at 8:30 P.M., showed he/she had a injury fall and lost consciousness for approximately two minutes. 911 and the physician was notified. Record review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff for care planning) dated [DATE], showed he/she: -Was severely impaired in cognitive skills for daily decision making. -Had clear speech, was understood and understood others. -Needed supervision and set up help only for eating and -Had no swallowing disorders. Record review of the resident's progress notes showed: -On [DATE] at 12:26 A.M., the resident was back from hospital from a fall. Has a hematoma (blood pooling under the skin) in back of his/her head. Computer Tomography (CT) negative. Was able to roll him/her self off the cot onto his/her bed, partial weight bearing with the assist of one staff. Record review of the resident's SBAR Communication Form dated [DATE] showed the resident had a fall and complained of dizziness. The physician was notified with a note to "See Computer." Record review of the resident's Progress Notes showed: -On [DATE] at 6:55 A.M., staff documented he/she was hallucinating and stated a woman and a child were in his/her room and also spoke of snakes in his/her room. Staff took him/her out of the room and wheeled him/her around the facility until he/she calmed down. -On [DATE] at 3:51 P.M., staff documented he/she was alert and oriented with confusion noted. He/she required the assistance of one staff with transfers and dressing. He/she fed him/herself small amounts of food without difficulty. A new physician order [REDACTED]. Record review of the resident's care plan showed he/she had a care plan for liver disease related to [MEDICAL CONDITION] dated [DATE] with interventions to observe for signs or symptoms of complications to include anorexia (severe weight loss), altered level of consciousness, confusion or disorientation, observe his/her skin and whites of his/her eyes and report to the physician. Record review of the resident's Monthly Summary dated [DATE] showed he/she was alert and oriented, fed him/herself a regular diet with a fair appetite. Record review of the resident's Progress Notes showed: -On [DATE] at 9:03 A.M., staff documented he/she was alert and orientated with periods of disorientation and fed him/herself small amounts of food without difficulty in the main dining room. -On [DATE] at 6:40 A.M., staff documented he/she was slow to comprehend. Record review of the resident's Speech Therapy (ST) plan of care dated [DATE] showed he/she was referred to therapy due to reports from nursing of swallowing difficulties and choking during meals over the weekend ([DATE] - [DATE]). Nursing downgraded his/her diet from regular consistency to mechanical soft due to safety concerns. He/she had no history of dysphasia (difficulty swallowing). Nursing also recently moved him/her from the independent dining room to the assisted dining room as he/she has become more dependent upon staff during meal consumption. His/her swallowing difficulties were caused by impaired oral efficiency and impaired airway protection. He/she also presented to speech therapy with a recent decline in communication abilities due to inconsistent ability to produce his/her voice impacting the resident's ability to express his/her wants and medical needs. He/she had been independent in speech as of [DATE], and now displayed a severe limited ability to produce speech. He/she had been independent in his/her cognition and as of [DATE], needed consistent direction by staff. Record review of the resident's Occupational Therapy (OT) Progress and Discharge Summary from [DATE] through [DATE] showed: -Prior level on [DATE], he/she had been able to put on and remove his/her own clothing without the use of an assistive device and required moderate assistance while sitting. As of [DATE], he/she required 100% assistance by staff to put on and remove his/her clothing while sitting. -Prior level on [DATE], he/she was able to achieve balance on the toilet and utilized grab bars which required minimal assistance at wheelchair level. As of [DATE], he/she required 100% assistance for this task. Record review of the resident's SBAR Communication Form undated said on [DATE] at approximately 8:45 P.M., this writer checked in on resident and found with eyes open and jerking his/her torso with enough force to raise torso off of bed, not responding, physician notified and orders to call 911. Record review of the resident's Progress Notes showed: -On [DATE] at 2:18 A.M., staff documented he/she was alert and oriented times two to three. He/she needed standby assist from one staff member for ADL's. He/she was able to verbalize his/her needs and to propel him/herself in a wheelchair. -On [DATE] at 3:54 P.M., staff documented he/she had some abdominal distention noted related to his/her [MEDICAL CONDITION]. He/she continued to have weakness upon transfers, poor appetite noted with assist of one staff. He/she had a poor appetite, and was not answering questions. Documentation did not show staff if staff measured or assessed his/her abdominal distention. -On [DATE] at 4:21 A.M., staff documented on [DATE] at approximately 8:45 P.M., they had checked on him/her and observed the resident to be lying in bed, eyes open with jerking type movements in torso area with enough force to raise his/her torso up off of the bed. He/she was not responsive, could not hold the writer's gaze and eyes were drifting back and forth very slowly all the way from inner to outer canthus (corner of the eye where the upper and lower eyelids meet) with his/her iris touching the canthus. He/she was moaning softly with his/her mouth slightly open. Vital signs were obtained and were within normal limits. A physician's orders [REDACTED]. Record review of the Emergency Medical Services (EMS) report dated [DATE] at 9:16 P.M., showed: -Facility staff reported the resident had been profoundly jaundiced and obtunded (extremely round) for the last 24 hours. -The resident had dilated pupils with jaundiced sclera (whites of eyes) and skin was profoundly jaundiced. Record review of the resident's hospital ER note dated [DATE] showed: -He/she was seen at theER on [DATE] at 10:38 P.M., with a complaint of decreased mental status, mouth movements and an intermittent gaze wandering from right to left repeatedly. -He/she was nonverbal and did not follow commands. -Per EMS they were not sure how long he/she had been like this but stated "at least 24 hours" his/her body and neck were stiff. -His/her pupils were equal, dilated and had a sluggish response to light. - His/her CT on [DATE] showed no bleeding or mass or diagnostic abnormality. -Lab levels reported on [DATE] at 11:52 P.M., were: ---Ammonia 312 H (high) (normal range ,[DATE]) (a test to measures the amount of ammonia in the blood, which results when protein is broken down and the liver normally converts the ammonia which is eliminated in urine) ---BUN 38 H (normal range ,[DATE]) (a test to measure the amount of nitrogen in the blood which comes from the waste product of urea-a part of urine) ---Creatinine 1.63 H (normal range 0XXX,[DATE].3)(a test to measure kidney function). ---BUN/Creat Ratio 23.3 H (normal range is ,[DATE]) (a test to check for acute kidney failure, shock, or dehydration). ---[MEDICATION NAME] 2.1 L (low, normal range 4XXX,[DATE].0) (a test to measure a type of protein in the blood which contains clotting factors etc., a low can indicate advanced liver disease among other diseases) ---[MEDICATION NAME] 5.2 H (normal range 2XXX,[DATE].5) (a test to measure a type of protein in the blood which helps to fight diseases, a high can indicate an infection) ---[MEDICATION NAME]/[MEDICATION NAME] Ratio 0.4 L (normal range is ,[DATE].1) (a test to measure the two proteins in comparison to each other, low levels can indicate advanced liver disease) ---Bilirubin Total 5.2 H (normal range 0XXX,[DATE].0) (a test to measure a protein made in the liver, high can indicate liver disease) -He/she was admitted to Intensive Care Unit (ICU) for acute mental status change and [MEDICAL CONDITION] ( a whole body inflammation caused by an infection or poor organ function). -A phone call was made to the facility where staff said in the past two days, the resident had became more mute (inability to speak), not responding verbally and responded to yes/no questions with head nodding. - He/she had [DIAGNOSES REDACTED].) -The resident expired at the hospital on [DATE]. During an interview on [DATE] at 12:04 P.M., Licensed Practical Nurse (LPN) E said: -He/she had not been the resident's charge nurse. -He/she would have assessed the abdominal girth or distention of a resident with [MEDICAL CONDITION] and ascites. -Some facilities have physician orders [REDACTED]. During an interview on [DATE] at 1:55 P.M., Occupational Therapist Assistant (OTA) A said he/she noticed a change with the resident's ability to participate during therapy on [DATE] and then on [DATE], he/she was not able to follow directions. During an interview on [DATE] at 2:00 P.M., Speech Therapist A said: -He/she had evaluated the resident and changed the resident's food consistency. The resident had changed over the weekend to a mechanical soft diet due to choking and his/her voice had changed. -The resident had been talking the previous week and had an overall decline by Monday, [DATE] and was not following any verbal commands. -The resident had been moved to the assist dining room by Monday, [DATE] and was not feeding him/herself. -He/she had discussed the change in the resident with nursing staff and had discussed the changes at the morning stand up meeting. -The resident was worse on Tuesday, [DATE], was unable to handle the mechanical soft diet, and was pocketing food. -The resident's diet was changed to puree on [DATE], which he/she accepted. -OTA A and he/she spoke with the charge nurse in charge of the resident's care again on Tues, [DATE] about the resident's change in condition and the nurse said he/she would talk to the resident's physician on Wednesday when he/she was scheduled to be at the facility. -He/she asked about the resident's vital signs which were within normal limits. -He/she had ordered a video swallow test on Monday, [DATE]. During an interview on [DATE] at 2:25 P.M., the Director of Nursing (DON) said: -He/she did not know if anyone had called the resident's physician on Monday, [DATE]. -He/she would have expected the physician to be called if a resident had a change in condition from feeding him/herself to having to be fed. -Facility staff did not measure the resident's abdomen distention but the physician might but they did not. -If they were expecting the resident to die, he/she would not have expected the physician to be called. During an interview on [DATE] at 4:40 P.M., Physician A, the resident's facility physician said: -He/she did not recall being contacted about the resident having a change of condition in not being able to feed him/herself and in not being able to speak. -He/she did not know about facility staff measuring the abdominal distention but staff should have noted it and reported any change in distention and jaundice to him/her. -Physician A asked the Nurse Practitioner if he/she had been notified and the Nurse Practitioner said he/she had been contacted about a change in diet consistency but did not recall any information regarding the resident having a change in condition. -When told the resident's [MEDICATION NAME] 50 mg had been changed on [DATE] from scheduled four times a day to one every six hours as needed, Physician A said the on-call physician may have changed the [MEDICATION NAME] if they thought the resident had a change and it was due to the [MEDICATION NAME] use. He/she was not aware of the call on [DATE]. -He/she felt the resident had a short life expectancy due to his/her [DIAGNOSES REDACTED]. -He/she would have probably ordered lab work and checked the resident's [MEDICATION NAME] levels. -He/she probably would have sent the resident out for evaluation if he/she had been contacted. -He/she should have been contacted by [DATE] of the resident's change of condition. During an interview on [DATE] at 9:10 A.M., Restorative Services Director said: -He/she remembered the resident could not feed him/herself. A resident came to him/her and said the resident was just sitting there and was unable to feed him/herself. -He/she moved the resident to the Assisted Dining room and sat with the resident to monitor his/her eating. -He/she referred the resident to speech therapy. -He/she denied seeing the resident choke and said that was not what he/she was told by the other resident. -He/she had probably did not documented it due to the resident was being observed to figure out what was going on with him/her and he/she was not the resident's nurse that day so he/she did not document on the resident. -He/she told the nurse, the restorative aide and the certified nursing aids (CNAs) he/she had moved the resident to be observed. -He/she did not notify the physician when a resident was unable to feed him/herself; or about moving someone to the RA table. He/she observed the residents and wrote orders; therapy writes orders and does not call the physician. -He/she was not familiar with the resident's cognitive ability and only worked the floor as a charge nurse when staffing needed him/her to. -He/she did not change the resident's diet order from regular to mechanical soft; he/she was assessing the resident for feeding him/herself and he/she did not know if the resident had swallowing issues or not. During an interview on [DATE] at 3:49 P.M., LPN H said: -He/she remembered working with the resident four maybe five times on the weekends. -He/she remembered that day, Sunday, [DATE], the resident was taken back to his/her room because he/she did not want to eat. The resident ate in his/her room the majority of the time. -He/she did not remember the resident choking but did remember the resident was not able to eat lunch that day. -He/she did not change the resident's diet from regular to mechanical soft but remembered Restorative Services Director did. -The resident sometimes seemed more alert than at other times. -The resident's baseline was frail and he/she had a high pitched voice and at times was short of air and had difficulty talking. -He/she did not see any change in the resident on Sunday, [DATE]. Complaint #MO 233

Based on observation, interview, and record review, facility staff failed to provide quality of life choices which promoted self-determination, sufficiency, and participation related to linguistic (of or relating to language) and cultural barriers including dietary preferences which resulted in the resident's failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments, that can result in weight loss, decreased appetite, poor nutrition, and inactivity) for one randomly sampled resident (Resident #19). The facility census was 88. 1. Record review of Resident #19's face sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. -Chronic [MEDICAL CONDITION] with exacerbation (an inflammation of the air passages within the lungs); -Closed [MEDICAL CONDITION] vertebrae (a part of the spinal column); -Backache; -Chronic fatigue syndrome (profound fatigue that is not improved by bed rest and that may be worsened by physical or mental activity); -[MEDICAL CONDITION] (below normal function of the [MEDICAL CONDITION] which regulated metabolism); -Paralysis Agitans ([MEDICAL CONDITION]-a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait); -Shortness of breath; -Hypertension (HTN-high blood pressure), -General Weakness; -Abnormality of gait (a deviation from normal walking); -Lack of coordination. Record review of the resident's Cognitive Status/Decision Making Evaluation, dated 6/3/13, showed he/she: -Was unable to complete the cognitive test due to his/her language barrier; -Spoke only Vietnamese; -Did not have a third party translator available from the facility for the resident evaluation; -Did not have another updated evaluation completed by the facility at the time of the survey. Record review of the resident's Nutritional Progress Notes, dated 10/3/13, showed: -A recommendation by the Registered Dietician to provide him/her snacks specific to his/her culture to increase his/her food intake. Record review of the resident's Interdisciplinary Care Plan Conference Record, dated 4/10/14, showed: -The resident, his/her family member, and a translator were not present during the care plan meeting. Record review of the resident's Nutritional Evaluation, dated 6/1/14, showed staff documented the resident: -Had a diet order for vegetarian mechanical soft diet; -Had supplements which were fortified and received med pass (a physician ordered dietary medication) 99 milliliters (ml) three times daily; -Had a fair appetite; -Received average portion sizes; -Dined in his/her room or dining room; -Had teeth missing; -Was hearing impaired; -Was alert and verbal, confused at this time, and non-English speaking; -Was independent and staff supervised with his/her feeding. Record review of the resident's Social Service Assessment, dated 6/2/14, showed staff documented: -The resident spoke Vietnamese and understood very little English; -A family member provided the history and physical for the resident; -A family member said the resident was satisfied with his/her life; -He/she used a communication book as a way to communicate with staff; -He/she had no memory problems, had modified decision-making, and was orientated to person and place; -He/she had lived alone prior to admission to the facility. Record review of the resident's Physician's Visit progress note, dated 6/4/14, showed the resident's physician documented: -The resident was Vietnamese; -The resident made no complaints but it was difficult to elicit because of his/her language barrier. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/11/14, showed staff assessed the resident as: -Rarely/never understood; -Rarely/never able to understand others; -Independent in bed mobility, transfer, walk in room/corridor, locomotion on and off the unit, eating, and toileting; -Required supervision from staff, oversight, encouragement or cuing when dressing; -Was continent of bowel and bladder; -Received a mechanically altered diet and a therapeutic diet. Record review of the resident's Communication Care Plan, revised 6/12/14, showed he/she had an alteration in communication related to a language barrier, and spoke only Vietnamese. Staff were instructed to: -Ensure the resident could make basic needs known on a daily basis; -Anticipate and meet needs; -Assess and/or document for physical and/or nonverbal indicators of discomfort or distress and follow up; -Communicate by using a communication board, gestures, and a translator; -Provide a communication book at the nurse's station, which the resident refused to keep in his/her room; -Avoid isolating the resident; -Family to provide translator as necessary to communicate. Record review of the resident's Nutrition Care Plan, revised 6/20/14, showed he/she had a potential for altered nutrition related to a history of weight loss and inadequate intake. Staff were instructed to: -Provide a mechanically altered diet; -Maintain adequate diet intake to achieve a stable weight; -Provide fortified foods; -Complete labs ordered and monitor as directed by the physician; -Monitor weight monthly; -Observe and record for consistently refusing foods; -Provide diet as ordered. Further review of the Nutrition Care Plan, showed staff did not include interventions for cultural preferences with his/her diet. Record review of the resident's weight summaries showed: -On 7/2/14 he/she weighed 97.1 pounds; -On 9/4/14 he/she weighed 93.0 pounds. Record review of the resident's Monthly Summary, dated 9/9/14, showed staff documented the resident: -Was alert and oriented; -Was withdrawn, friendly, quiet, and expressed himself/herself according to the situation; -Had a language barrier; -Was on a regular diet with no added sodium; -Had poor eating habits, with less than 50% of intake at meals; -Received supervision for personal hygiene; -Was continent of bowel and bladder. Record review of the resident's Quarterly Nursing Evaluation, dated 9/18/14, showed he/she: -Was served a regular diet; -had a history of [REDACTED]. -Had rarely eaten a complete meal and generally would eat only about half of the food offered. Record review of the resident's Physician's Visit progress note, dated 9/24/14, showed the resident's physician documented: -The resident was difficult to communicate with because of a language barrier; -Was unable to contribute to history due to the language barrier. Record review of the resident's weight summary, dated 10/5/14 at 3:16 P.M., showed: -He/she weighed 91.8 pounds. Record review of the resident's Facility Concern Sheet, dated 10/6/14, showed staff documented the resident: -Had not been out of bed in four days; -Ate 0% of his/her meals over the weekend; -Took a few sips of a soft drink. Record review of the resident's Interdisciplinary Care Plan Conference Record, dated 10/10/14, showed staff: -Encouraged intake of fluids and food; -Referred the resident to hospice (end of life care) per the resident's physician orders. Further review of the Care Plan Conference Record showed staff documented the resident, the resident's family member, and a translator were not present at the care plan conference. Record review of the resident's Health Status Note Progress Note, dated 10/12/14, showed staff documented: -The resident's family member reported to facility staff that the resident had difficulty swallowing and the resident said he/she wanted to die. Record review of the resident's Facility Concern Sheet, dated 10/13/14, showed staff documented: -The resident would only drink some of his/her supplemental shakes; -The dietician requested staff administer [MEDICATION NAME] (a medication used as an anti-depressant and to increase appetite) for 30 days. Record review of the resident's Speech Therapist (ST) Progress and Discharge Summary, dated 10/31/14, showed staff documented: -The resident had speech therapy services from 10/13/14 through 10/21/14; -The goals were not met upon discharge from speech therapy; -The resident safely consumed thin liquids utilizing small sips at a slow rate with minimal verbal and visual cues; -The resident refused to consume solid foods during the treatment sessions; -The ST provided education to nursing related to the resident's refusal at trials of solid food during the treatment sessions; -Nursing reported the resident consumed the meals the resident's family brought in for him/her to eat; -The resident was discharged from ST skilled services due to the refusal to participate in treatment activities. Record review of the resident's Resident Handling Evaluation (the facility assessment tool used to determine the method of transfer for the resident), dated 10/18/14, showed staff documented: -The resident failed to thrive; -He/she was able to follow simple commands; -He/she had comprehension issues related to his/her language barrier. Record review of the resident's Social Service Progress Note, dated 11/3/14, showed staff documented: -Facility staff contacted a family member related to the resident's decline in health; -A family member communicated to another family member who communicated to the resident; -The resident refused a feeding tube; -He/she was provided verbal and written information for Hospice services in English; -He/she did not speak English; -The facility used a third party person for communication and the communication book. Record review of the resident's weight summary, dated 11/4/14 at 2:00 P.M., showed he/she weighed 96.8 pounds. Record review of the resident's Physician Telephone Orders (POS), dated 11/5/14, showed: -The resident was admitted to hospice with a [DIAGNOSES REDACTED]. Record review of the resident's Food Consumption Report, dated 12/1/14 through 12/31/14, showed he/she: -Refused the facility meals 26 times out of 93 times for that month; -Ate 0-25% of his/her meals 40 times out of 93 times for that month; -Ate 26-50% of his/her meals three times out of 93 times for that month; -Ate 51-75% of his/her meals 12 times out of 93 times for that month; -Ate 76-100% of his/her meals 13 times out of 93 times for that month; -Staff supervised seven meals during the month; -Was independent with eating. Record review of the resident's weight summary, dated 12/8/14 at 11:15 A.M., showed: -He/she weighed 88.8 pounds. Record review of the resident's Interdisciplinary Care Plan, revised 12/7/14, showed: -Staff discussed advanced directives with the resident's family member; -The resident's family member elected hospice services. Record review of the resident's Interdisciplinary Care Plan Conference Record, dated 12/10/14, showed: -Staff documented the resident preferred Vietnamese food that his/her family would bring in to the resident; -The resident, the resident's family member, and a translator were not present for the meeting. Record review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Rarely/never understood by others; -Rarely/never understood others; -Had no short term and long term memory problems; -Required modified independence in some new situations only related to cognitive skills for decision making; -Required one person physical assist from staff for bed mobility, transfer, locomotion off and on unit, dressing, personal hygiene; and bathing; -Required supervision, oversight, encouragement, and cuing for eating with set-up assist from staff; -Frequently incontinent of bowel and bladder. -Used non-verbal sounds and facial expressions as indicators for pain; -Received hospice services; -Received a mechanically altered diet and a therapeutic diet. Record review of the resident's Social Service Progress Note, dated 12/13/14, showed staff documented the resident: -Received hospice services; -Remained in his/her room most of the time; -Communicated with a translator present. Record review of the resident's Nutrition Progress Note, dated 12/16/14, showed staff documented the resident: -Received a mechanical soft diet; -Ate 25-50% of most meals; -Received 50% of his/her meals fortified; -Had no significant weight changes; -Fed himself/herself in his/her room for most meals; -Had no swallowing problems; -Received hospice services; -Met goals and would continue with same goals. Record review of the resident's Physician Visit progress note, dated 12/17/14, showed the resident's physician documented the impression of the visit as: -[MEDICAL CONDITION]; -Weight loss; -Failure to thrive; -The resident did not like the facility meals very well. Record review of the resident's Food Consumption Report, dated 1/1/15 through 1/31/15, showed staff documented the resident: -Refused the facility meals 23 times out of 93 times for that month; -Ate 0-25% of his/her meals 42 times out of 93 times for that month; -Ate 26-50% of his/her meals 14 times out of 93 times for that month; -Ate 51-75% of his/her meals ten times out of 93 times for that month; -Ate 76-100% of his/her meals six times out of 93 times for that month; -Staff supervised 11 meals during the month. Record review of the resident Physician order [REDACTED]. -Add or discontinue extra calorie orders as needed; -Provide hospice services; -Provide a regular diet, med pass 2.0 (a nutritional supplement) 90 ml by mouth four times daily, and mighty shakes (supplemental drinks) at each meal for supplements. Record review of the resident's Food Consumption Report; dated 2/1/15 through 2/23/15, showed staff documented the resident: -Refused the facility meals 22 times out of 72 times for that month; -Ate 0-25% of his/her meals 22 times out of 72 times for that month; -Ate 26-50% of his/her meals one time out of 72 times for that month; -Ate 51-75% of his/her meals seven times out of 72 times for that month; -Ate 76-100% of his/her meals thirteen times out of 72 times for that month; -Had staff supervision with five meals for that month. Record review of the resident's Nutritional Progress Notes, dated 2/2/15, showed: -The registered dietician recommended staff provide the resident foods as requested for comfort within the diet order. Record review of the resident's undated Diet Preferences form completed by the Dietary Manager showed: -The resident's favorite foods were rice and tea; -He/she did not like meat and was to have all vegetables; -He/she received hot fortified cereal, orange juice, and scrambled eggs for the breakfast meal; -He/she received low-fat milk and hot tea for all meals as the beverage choice; -The resident's bread preference was white or wheat bread. Observation on 2/26/15 at 11:00 A.M., showed: -A Vietnamese calendar and a spiritual picture on the wall above the resident's bed; -An activities calendar in English posted in the resident's room; -A communication book by the television, which contained words in Vietnamese such as "are you happy" and "are you tired." During an interview on 2/26/15 at 11:00 A.M., the Assistant Director of Nursing (ADON) said the resident did not speak English, the resident does not want the communication book in his/her room, and he/she would throw the communication book in the hallway. The ADON said the resident was on hospice but was able to get in and out of his/her bed and change by himself/herself. The ADON said the facility had a nursing student in the building who spoke Vietnamese and could translate for the surveyor, then offered to get the student. During an interview on 2/26/15 at 11:00 A.M., the resident said (through the translation of a nursing student): -He/she only eats once a day; -A family member brought food for the resident to the facility when he/she was not at work; -He/she would not eat when the family member was at work and would only drink ensure; -The facility staff did not provide a translator for him/her; -When asked about not being able to speak in his/her native tongue, he/she said he/she was "sad" and gestured to his/her eyes, and made a crying motion; -He/she said he/she could not remember his/her family member's phone number when asked if facility staff made the phone available to contact his/her family. During an interview on 2/26/15 at 3:40 P.M., the Social Services Designee said: -Non-English speaking residents are encouraged to have their family members involved in resident care planning to assist in translation; -Therapy made communication books for Vietnamese residents; -Translators for the Vietnamese residents are family members and that the facility had a nursing student who spoke Vietnamese; -The resident's hospice agency provided a phone translator service; -The resident pointed to make his/her needs known; -The Dietary Manager prepared foods and menus for the residents; -The facility provided Chinese food to Vietnamese residents at times. Observation on 2/26/15 at 6:20 P.M., showed the resident: -Lay in bed with the lights off; -Gestured to have her curtain pulled half way; -An unopened can of ensure sat on the bedside table with a cup upside down on top of it. During an interview on 2/27/15 at 7:34 A.M., Certified Nursing Aide (CNA) O said: -The Vietnamese residents used hand language and gestures to express needs; -The resident liked to drink mighty shakes but did not eat much; -The facility cooked rice for the Vietnamese residents; -There was no documentation if the resident ate the facility rice; -The resident refused to eat regular foods; -The resident's family brought him/her food; -The resident is a vegetarian. Observation on 2/27/15 at 8:20 A.M., showed the resident sat in his/her wheelchair. Staff delivered breakfast to the resident's room. Observation showed staff circled both tea and milk on the meal ticket. The meal ticket listed a dislike of meat, and diet was mechanical soft. Staff served the resident orange juice, oatmeal, pancakes, syrup, and fortified milk. The resident ate 0% of the meal and drank 75% of the orange juice. During the above observation, the Director of Nursing (DON) walked into the resident's room and said: -The resident cannot understand you; -The resident refused to eat his/her breakfast, he/she waited for his/her family to bring food; -The resident refused to drink the fortified milk, but drank the juice. Observation on 2/27/15 at 8:26 A.M., showed Certified Medication Technician (CMT) D asked the resident if he/she wanted to eat. The resident gestured for CMT D to take his/her food. CMT D removed the resident's tray from his/her room. CMT D did not offer the resident an alternative. During an interview on 2/27/15 at 8:26 A.M., CMT D said: -The resident does not like to use the communication book and does not want it in the room; -The family brings in lunch for the resident most days at noon. During an interview on 2/27/15 at 9:30 A.M., the Dietary Manager said: -Nursing was responsible for the diet slips to get to the dietary department; -He/she talked to the residents two to three days after their admission to the facility to collect the residents' preferences; -He/she did not talk to the resident or to his/her family after admission to the facility; -He/she was aware the resident's family members brought in food for the resident; -"We do what we can, he/she (the resident) refuses so much"; -A nurse told the Dietary Manager the resident's family said he/she did not eat much at home; -He/she had spoke to a night shift nurse who appeared to be the same nationality of the resident and got the night shift nurses' dietary preferences to use as the resident's preferences; -The Dietician gave him/her some spices specific for Vietnamese food but he/she did not know what to do with them; -The Dietician gave the Dietary Manager recipes specific to Vietnamese culture, but the facility's distributors did not have the ingredients, and he/she was only able to buy food from the distributors; -The Dietician recommended serving Vietnamese meals to aid the resident in eating better; -He/she attempted a version of a recipe with beef and stock, but the resident refused to eat it; -He/she had not seen the resident's family. During an interview on 2/27/15 at 2:26 P.M., the ADON said: -The resident's family brought in food for the resident; -The Vietnamese community will come to the facility on Vietnamese holidays, -Nursing recommended the Dietary Manager speak with the family regarding the resident's diet preferences. During an interview on 2/27/15 at 3:35 P.M., the Social Services Designee said: -He/she picked a hospice provider for the resident that had a Vietnamese phone translator. Observation on 2/27/15 at 11:57 A.M., showed: -The resident sat in his/her wheelchair with a family member present; -The family member brought Vietnamese food the resident prefers; -The resident ate 80% of the rice, 85% of the soup, and 10% of the oranges; -The family left Vietnamese coffee and tea. During an interview on 2/27/15 at 4:10 P.M., CNA P said: -Staff used gestures as a sign language to communicate with Vietnamese speaking residents; -The resident's family brings food; -The family leaves left over food in the refrigerator at the nurse's desk for the resident; -Staff used gestures and nods to complete cares for the resident. During an interview on 2/27/15 at 4:18 P.M., Registered Nurse (RN) A said: -Staff communicate with residents who have language barriers by using language books or the families are used as interpreters; -Another resident who speaks some English has translated for the resident, -Student nurses, when available and speak the desired language, are used to communicate with non-English speaking residents; -The resident's family will sometimes bring the resident meals; -Dietary staff have made the resident's food preferences including rice, milk, milkshakes, water, juice, and fish; -The family increased visits and brought food regularly after the resident's illness; -Staff assessed the resident for pain when the resident was observed holding his/her head and with gestures; -Staff used gestures to communicate when they performed cares. Observation on 3/2/15 at 12:10 P.M., showed: -The resident was up in his/her wheelchair; -The resident's family member brought the resident Vietnamese food; -The resident ate oranges; -The family member brought Vietnamese soup, coffee, and tea. During an interview on 3/2/15 at 1:45 P.M., the DON said: -He/she explained to the resident's family the importance for the resident to get out of bed and eat; -Afterward, the family began to bring in Vietnamese food daily; -The resident had a daily interpreter as family brings food daily. -He/she was not familiar with culture change; -He/she thinks residents should have their own homelike environment specific to their wants; -The Dietary Manager completes an interview upon admission of any dietary needs for each resident, then reassesses quarterly; -Resident needs are met for non-English speaking residents by staff, nursing students, family, phone translators, gestures, and communication books, depending upon the needs of the resident. During an interview on 3/2/15 at 5:11 P.M., the resident's family member said: -The resident did not eat much for his/her breakfast or supper meals; -Family members will bring in the noon meal most days for the resident; -The food brought to the resident is Vietnamese food, soups, and broths; -The family will bring fresh fruit, grapes, and oranges for the resident; -The family peels the fruit as the resident's fingers are weak; -The family leaves ensure by the resident's bed in case the resident does not want to get out of bed.