Every finding on record at Parkway Health Care Center

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #6) was free from abuse when on 5/28/26 Resident #6 was hit by Resident #7 causing a skin tear to Resident #6's right eyebrow area out of 13 sampled residents. The facility census was 60 residents.On 6/29/26, the Administrator was notified of past non-compliance which occurred on 5/28/26. Immediate interventions were put into place for both Resident #6 and Resident #7. All staff received education prior to their next working shift. The deficiency was corrected on 5/29/26. Review of the facility's policy titled Abuse and Neglect Policy dated 6/12/2024 showed:-Abuse was 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.-It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.-Physical abuse was purposefully beating, striking, wounding, or injuring any resident or manner whatsoever mistreating or maltreating a resident in brutal or inhumane manner.-Physical abuse also included, but was not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of Resident #7's admission Record showed he/she admitted to the facility with a diagnosis of epilepsy (a seizure disorder). Review of Resident #7's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 4/14/26 showed:-The resident was cognitively intact.-The resident did not exhibit any behavioral symptoms within the seven-day look back period. Review of Resident #6's admission Record showed he/she admitted to the facility with a diagnosis of bipolar disorder (mood disorder that can cause intense mood swings). Review of Resident #6's quarterly MDS dated [DATE] showed:-The resident was cognitively intact.-The resident did not exhibit any behavioral symptoms within the seven-day look back period. Review of an Admin/Registered Nurse (RN) Investigation dated 5/28/26 showed:-The incident occurred on 5/28/26.-The incident type was physical aggression involving the head.-Resident #6 and Resident #7 were the involved residents.-Resident #12 witnessed the incident.-The investigative narrative was as follows:--Resident #6 was upset during mealtime that he/she did not get a peanut butter and jelly sandwich.--Resident #6 left the dining room and walked to the smoke deck.--Resident #7 had been standing by the smoke deck door.--Resident #6 became more agitated when he/she could not go out the door due to it being locked.--Resident #7 responded to this by stating I cannot help that the door is locked.--Resident #6 then began to mumble stuff under his/her breath and walk back to the dining room.--Resident #7 followed Resident #6 and they exchanged words.--Resident #6 then called Resident #7 a derogatory name which caused Resident #7 to become upset.--Resident #6 then said, what are you going to do about it?--Resident #6 walked closer to Resident #7 and swung at Resident #7.--Resident #6 missed Resident #7 and Resident #7 responded by swinging at Resident #6.--Resident #7 made contact with Resident #6's right eye and nose.--Staff responded to the incident once they heard the noise and separated the residents.--Resident #6 initially refused to be assessed. --Once Resident #6 calmed down, he/she let the nurse look at his/her face.--Two small skin tears were noted to Resident #6's right eyebrow.--The skin tears were cleaned and steri-strips (thin adhesive strips which can be used to close small wounds) were placed over the wounds. Review of Resident #6's Skin Check dated 5/28/26 at 7:14 P.M. showed:-The resident had a new skin issue located to his/her right eye.-The issue type was a skin tear.-The resident was in pain.-The interventions included to medicate after dressing changes. Review of Resident #6's Behavior Note dated 5/28/26 at 9:20 P.M. showed:-At approximately 6:48 P.M. Resident #6 began arguing with another resident.-Resident #6 was agitated from dinner when he/she did not receive a peanut butter and jelly sandwich that he/she thought had been ordered.-Resident #6 walked to the smoke deck and was upset that it was locked.-Resident #6 wanted another resident to help him/her get outside to smoke a cigarette.-The resident told Resident #6 that he/she was unable to help Resident #6 outside.-This caused Resident #6 to have increased agitation.-Resident #6 then began mumbling under his/her breath as he/she was walking back to the dining room.-Both residents started to exchange words.-Resident #6 then swung at the other resident.-Resident #6 missed but the other resident swung back at Resident #6.-The other resident made contact with Resident #6's right eye and nose.-Staff then separated the residents.-Resident #6 refused for the nurse to assess him/her.-Eventually the nurse was able to cleanse the wounds and placed steri-strips on the wounds.-The resident complained of 8/10 aching/throbbing pain on the pain scale (aero as no pain and ten as the worst pain imaginable) where the contact was made to his/her face.-Pro re nata (PRN- as needed) pain medication was given, and a cold compress was applied. Review of Resident #7's Behavior Note dated 5/28/26 at 9:36 P.M. showed:-At approximately 6:48 P.M. Resident #7 began arguing with another resident.-The other resident wanted him/her to help the other resident outside to light a cigarette.-Resident #7 told the other resident that he/she was unable to help the other resident get outside.-This caused increased agitation.-The other resident started mumbling under their breath and was walking back to the dining room.-Both residents started to exchange words.-The other resident swung at Resident #7 and missed.-Resident #7 responded by swinging back at the other resident, making contact with the other resident's right eye and nose. During an interview and observation on 6/29/26 at 1:33 P.M. Resident #6 stated:-He/She and Resident #7 were arguing.-He/She called Resident #7 a bitch, which he/she thought was not derogatory.-Resident #7 then pushed him/her to the ground and punched him/her in the face/forehead area.-The staff then separated him/her from Resident #7.-He/She was injured from getting hit in the face.-The nurse had to apply a cold compress and steri-strips to his/her injury.-He/She had no prior history of issues with Resident #7.-He/she had a pink scar above and below his/her right eyebrow, which was where he/she had been injured in the incident. During an interview on 6/29/26 at 1:55 P.M. Resident #7 said:-He/She was unsure of what incident everyone was asking about.-Once remembered, he/she recalled the incident.-He/She said that Resident #6 had called him/her a racial slur which made him/her angry.-Resident #6 swung first and he/she dodged the hit.-He/She then swung at Resident #6 and hit Resident #6 in the eye area. Review of Resident #12's quarterly MDS dated [DATE] showed the resident had moderately impaired cognition. During an interview on 6/29/26 at 2:02 P.M. Resident #12 said:-Resident #6 and Resident #7 were arguing.-Resident #6 then tried to hit Resident #7.-Resident #7 dodged the swing.-Resident #7 then hit Resident #6 in the face.-Staff then separated the residents.-Resident #6 had blood on his/her face after being hit by Resident #7. During an interview on 6/29/26 at 3:35 P.M. Certified Medication Technician (CMT) A and Licensed Practical Nurse (LPN) A said:-There were no staff witnesses to the altercation.-They were both at the facility at the time of the altercation but had not been involved in the incident.-They had been told that Resident #6 and Resident #7 had been arguing which escalated into a physical altercation.-Resident #6 had been injured during the altercation.-Hitting someone would be considered physical abuse.-They would consider the altercation that occurred on 5/28/26 between Resident #6 and Resident #7 as abuse. During an interview on 6/29/26 at 3:52 P.M. the Director of Nursing (DON) said:-He/She had completed the investigation related to the altercation that occurred on 5/28/26.-He/She was not present at the facility when the altercation occurred.-He/She had been called about an altercation that had occurred and came up to the facility.-To his/her knowledge, the following occurred:--Resident #6 was upset about dinner.--Resident #6 called Resident #7 a derogatory name.--Resident #6 then swung at Resident #7 but missed.--In response, Resident #7 swung at Resident #6 and struck Resident #6 in the face.--Resident #6 had a skin tear to his/her right eyebrow.--Resident #6 refused treatment until he/she came up to the facility.--He/She applied steri-strips to Resident #6's skin tear which was the only intervention that was needed.-The root cause of the altercation was as follows: --Resident #6 was upset about dinner, then when Resident #6 could not go out to smoke this caused increased agitation.--Resident #6 then used derogatory language towards Resident #7 which then caused the physical altercation.-He/She had educated Resident #6 on the use of derogatory language.-He/She did not think that abuse had occurred at first.-He/She thought physical abuse was harming another person knowing that they were causing harm.-He/She did not think that Resident #6 or Resident #7 was in the right state of mind to understand what they were doing.-Once told that Resident #7 intended to hit Resident #6, he/she had changed his/her mind and stated that the incident would be considered as abuse. 3052940

Based on interview and record review, the facility failed to ensure safe and secure storage for narcotics for two sampled residents (Resident #10 and #11), when the nursing staff did not conduct a shift-to-shift count of the narcotics which resulted in missing narcotics out of 11 sampled residents. The facility census was 68 residents. On [DATE] the Administrator and the Director of Nursing (DON) were notified of the failure, and the facility took immediate action and began an investigation, in-services and education for the nurses and Certified Medication Technicians (CMT). The facility purchased a new locking box for narcotics, relocated liquid and as needed (PRN) narcotics to the nurse cart and restricted access. All changes and training were completed on [DATE]. Additional training for count on shift change and documentation was completed on [DATE]. Review of the facility Controlled Substance Administration and Accountability Policy dated [DATE] showed:-It was the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. -The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. -Controlled substances are stored in a separate compartment of a locked storage unit with access limited to approved personnel. -All controlled substances (Schedule II, III, IV, V) are accounted for by all controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.-Written documentation must be clearly legible with all applicable information provided.-All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the controlled drug record supplied with the medication or other designated form as per facility policy. -In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the medication administration record (MAR), controlled drug record, or other facility specified form and placed in the patient's medical record. -The controlled drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. -The controlled drug record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy.-The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances.-Spot checks are performed to verify--Medications removed from the medication cart have a documented physician order.-Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use.-Patient-specific controlled substances are stored under double lock until administered to patient. Review of the facility undated Instructions for Medication Cart Reconciliation Log showed:-To maintain regulatory compliance and ensure medication security, this log must be completed during every shift change. -Both the oncoming and outgoing licensed nurses must physically verify the count together before signing. -Shift change documentation:--Enter the current calendar date.--Record the exact time the count is performed.--The nurse finishing their shift signs here to verify the count they are handing over is accurate. --The nurse starting their shift signs here to accept responsibility for the inventory.--Note: never sign until you have personally verified every item on the cart.-Ensure the cart is locked and the keys are physically handed to the oncoming nurse once signatures are complete. 1.Review of Resident #10's admission Record showed the resident was admitted on [DATE] with diagnoses including neuroleptic-induced parkinsonism (a reversible movement disorder caused by dopamine-blocking drugs (antipsychotics/neuroleptics) that mimics Parkinson's disease) and polyneuropathy (the simultaneous dysfunction of multiple peripheral nerves, often causing numbness, tingling, and muscle weakness, typically starting in the feet and hands). Review of the resident's Medication Administration Record (MAR) dated [DATE] through [DATE] showed the following physician orders:-Hydrocodone 5/325 (mg) oral tablet, give one tablet every six hours as needed for pain.-Administered on [DATE]. Review of the resident's MAR dated [DATE] through [DATE] showed:-Hydrocodone 5/325 milligram (mg) oral tablet, give one tablet every six hours as needed for pain. -No documented use. Review of facility narcotic logs showed no individual patient narcotic log for Resident #10's hydrocodone. 2. Review of Resident #11's admission Record showed the resident was admitted on [DATE] with diagnoses including encephalopathy (a syndrome of overall brain dysfunction, not a single disease, characterized by altered mental state, confusion, personality changes, and cognitive issues) and solitary pulmonary nodule ( a small ( 30 mm), round/oval spot in the lung, usually asymptomatic and found on imaging). Review of the resident's MARs dated [DATE] through [DATE] showed the following physician orders:-Oxycodone 5mg tablet give 0.5 tablet by mouth every four hours as needed for pain. -No documented use. Review of facility narcotic log showed no individual patient narcotic log for Resident #11's hydrocodone. 3. Review of the Facility Investigation Report: Suspected Drug Diversion and Significant Loss dated [DATE] showed:-The associated medication cards and controlled substance sign-out sheets were physically missing from the facility carts for Resident #10 and #11.-No facility nurse or Certified Medication Technician (CMT) could account for the whereabouts of these medications or the legal documentation. -Residents #10 and #11 were assessed and found to have no adverse outcomes as a result of the missing medications. -Root cause breakdown was a shift handoff failure; the nursing staff did not count and record medication at the change of shift. -Staff members were not staying until their relief arrived.-During interviews, multiple nurses admitted that they frequently counted narcotics alone because the off-going nurse had already left the facility before they arrived for their shift. During an interview on [DATE] at 2:05 P.M. the Director of Nursing (DON) said: -It was his/her understanding there was some medication wasted, and no staff wanted to admit to it. -They were not able to prove diversion officially and have done audits, education and ensured medication was available for the residents. During an interview on [DATE] at 3:15 P.M. CMT A said:-He/She passed scheduled narcotics only and as needed (PRN) narcotics were passed by the nurses. -At the time the narcotics came up missing, all narcotics were on the same cart, now the PRN narcotics are on the nurse cart.-The nurses were not waiting for the next nurse to count narcotics. -Since the missing narcotics incident, the nurses are actually waiting and counting before they leave. During an interview on [DATE] at 10:54 A.M. the Administrator said:-He/She was notified on [DATE] by the nursing staff of the alleged missing cards of narcotics.-At the time the narcotics came up missing, all of the narcotics were on the same cart giving the CMTs and the nurses access to all narcotics. -It was not just one nurse; it was all of the nurses that were not counting narcotics at shift change.-The last verified count was on [DATE]. -The CMTs no longer have access to the cart and will get these meds from the nurse. -There was education was done for medication administration, neglect, counting narcotics at shift change and reporting. -They have been doing audits since then to ensure they are counting at shift change. -There was no shift change count documentation for the month of [DATE]. During an interview on [DATE] at 3:00 P.M. the DON said:-Audits for narcotic counts were supposed to be done weekly. -The last documented shift to shift count completed was on [DATE]. During an interview on [DATE] at 1:25 P.M. CMT B said: -When she left on Thursday, [DATE], everything was fine and by the time he/she got back on Saturday the medications were missing.-He/She counted with the off going and oncoming staff on [DATE]. -Residents #10 and #11 had not been using the narcotics, so the cards were full or almost full. -Both the narcotic count sheets and the meds were gone on Saturday. -He/She was usually relieved by Licensed Practical Nurse (LPN) B. -Once the count was done, he/she would hand the keys to LPN B and leave the facility. -If there was a call in or something the other CMT's may count with him/her. -He/She always counts with someone, even if they are late, he/she will stay and wait for them. -He/She has seen times when count was not done at shift change, although he/she could not recall when or who, it does not happen often. -He/She was told they thought someone destroyed the meds. -The residents did not miss any medications as a result of the missing narcotics. -They are expected to count narcotics at shift change. -The nurses and CMTs are not allowed to leave the keys and leave the building. -If caught giving keys to anyone, like housekeeping or a Certified Nurses Aide (CNA) you will be in trouble. -Nurses and CMTs were also educated on count, and key control within the same week. During an interview on [DATE] at 1:38 P.M. LPN A said:-There has always been an issue with other nurses and CMTs not signing the narcotic book. -He/She always tried to sign the book. -One weekend some narcotics came up missing he/she was off work. -Sometimes the DON will take the narcotics and then come back and sign the book later. -Counts has not being done with oncoming/off going nurse when there is a nurse short or if there was a call in. -Count was usually done, however the book was not always signed. -There has been a time when someone else other than the nurse had access to the narcotic box. -He/She locked the keys in the medication room, or sometimes the keys were kept on the side of the cart. -There have been times when the CNA keys on the nurse keyring were needed by the CNA on the locked unit and the nurse keys were handed to CMT or CNA to unlock doors. -On Monday, [DATE], when he/she came in there were medications missing, he/she could not recall which ones. -He/She was informed about the missing narcotics cards on Tuesday, [DATE], when he/she got a call asking if he/she destroyed anything or took anything out. -Some of the missing narcotics were expired and he/she thought the cards of narcotics had been taken and destroyed. -When he/she had noticed missing medications, he/she has reported and was told then DON had taken the medications, therefore when he/she noticed the medications missing this time he/she presumed the DON had taken them as before. -He/She locked keys in the medication room, feels it is best to do that for his/her own safety. -He/She will lock the keys in crash cart if the nurse is running late.-The keys have usually been left out on the side of the medication cart. -He/she does keep the keys on his person most of the time. -There are 3 sets of keys for the facility. -If he/she only has one unit, he/she will keep the keys on him/her, otherwise he/she will leave them in the medication room. -He/She will leave the keys at each unit in the medication room, then when the next shift comes in he/she will access the medication room with a code and count with them. -He/She believes as long as the keys are in the medication room he/she can ensure the count will not change and has done that in several other facilities. -Access to the medication room was limited to CMTs and nurses. -When he/she asked a CMT to count liquids, the CMT said they weren't responsible.-He/She advised the CMT if they had the keys, they were responsible to count. -Now the CMTs do not have access to the narcotics. -If the CMT is on the unit, they will have the keys. During an interview on [DATE] at 2:23 P.M. LPN B said:-It was his/her weekend to work before the narcotics were noticed missing.-When he/she got there on Friday [DATE] nobody was there to count or give report.-The keys were left in narc book on the side of the medication cart, and they just started their shift. -He/She had 3 residents that got meds and that was all he/she paid attention to.-He/She didn't question what was there since he/she had been off for the previous two days. -On Saturday, [DATE], he/she counted with someone when he/she left and was not sure if he/she counted with anyone on Saturday evening.-On Tuesday [DATE], when the narcotics were noticed missing, he/she was contacted. -It was pretty common to not get report and count with the nurse at shift change. -He/She was called in to meet with the administration to not leave the keys and make sure the count was done. -The nurses were told not to accept the keys if the count was not correct. -The nurses did have a meeting with the Administrator and DON to put some stuff in place so it doesn't happen again.-He/She will not accept the keys if nobody is there to count and will not leave the keys if someone is not there to count with. -The training was done onsite with administrator and DON. -If he/she had to have control of all the carts, he/she would keep the keys on his/her person.-Everyone has the code to the medication room. -Before they would keep the keys in the medication room, in a drawer or on the cart, now he/she would keep them on his/her person. 2964249

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #1) out of five sampled residents, with known diagnoses of dementia, impulsive disorder, bi-polar disorder, anxiety disorder, cognitive impairment, and who was a known elopement risk received adequate supervision to prevent accidents. On 02/28/26, the magnetic door locks and alarm failed on the secured unit. Staff assigned to supervise the resident, to ensure safety, left the resident unsupervised. The resident went out the door, located off a busy street and major highway, between 7:15 P.M. and 7:20 P.M. The resident remained unaccounted for until 03/01/26 at 2:00 P.M., when he/she was found on the public transit system in a major metropolitan area. The facility census was 69 residents.The Administrator was notified on 03/05/26 at 1:38 P.M., of Past Non-Compliance Immediate Jeopardy which occurred on 02/28/26. All staff were immediately educated on Intensive Monitoring of Residents, When to Notify Management, Abuse and Neglect, and Elopement. New elopement evaluations were completed on all residents to ensure no other residents were at risk. The magnetic locks were repaired. Licensed Practical Nurse (LPN) A was suspended and terminated. The IJ was corrected on 02/28/26. Review of Resident #1's 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), dated 05/06/20, showed he/she had the following diagnoses:--Schizoaffective disorder bi-polar type (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions, disorganized speech) with manic episodes and sometimes major depression);--Bi-polar disorder (a chronic mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels);--Vascular dementia (a cognitive decline caused by reduced blood flow to the brain, which damages or kills brain cells due to lack of oxygen and nutrients);-The resident showed as being only oriented to self and severe memory issues with retention of only 10 to 15 minutes;-He/she showed very slow verbal responses. During an interview on 03/01/26 at 1:36 P.M., the facility Administrator said the resident was transferred to the facility on [DATE] from a sister facility. Review of the resident's Facility admission Record showed he/she was admitted to the facility on [DATE] with additional diagnoses of:-Anxiety disorder (mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life); and-Impulse disorder (mental health conditions marked by an inability to resist harmful or disruptive urges, leading to actions taken without forethought). 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 01/14/26, showed he/she:-Was minimally cognitively intact.-Had a history of behaviors including wandering in and out of other's rooms and throughout the unit.-Was exit seeking. Review of the resident's Nursing Care Plan, dated 01/29/26, showed:-He/she was at risk for wandering and elopement.-The facility staff were to clearly label the resident's room. -The staff were to engage the resident in purposeful activity.-The staff were to attempt to identify times where wandering/elopement was more prevalent.-The staff were to schedule times for regular walks. Review of the resident's Nurse's Notes, dated 02/28/26 at 12:44 P.M., showed a repeat Brief Interview for Mental Status (BIMS) was completed and the resident was not cognitively intact. Review of the resident's Nurse's Notes, dated 02/28/26 at 6:20 P.M., showed:-The resident verbally expressed a desire to leave the facility.-He/she was easily redirected, but continued to pack his/her clothes and press emergency exit doors as well as wander into other resident's rooms.-Frequent visual checks were initiated by the staff. Review of the Facility Registered Nursing Investigation (RNI), dated 02/28/26 at 7:30 P.M., showed:-At 6:00 P.M. on 02/28/26, the facility Administrator was notified of a malfunction with the magnetic locks on the main floor dementia unit.--It was reported the resident had exited the unit, accessed the stairwell, and reached the sidewalk.--The resident remained on facility property and was returned to the unit by the staff. --The Administrator arrived at 6:30 P.M. and Certified Medication Technician (CMT) A and LPN A were monitoring the doors and the resident who was seated in the unit dining room.-The Administrator attempted to restore the locks without success and contacted the local system repair company. -At 7:20 P.M., LPN A reported the resident was last seen at approximately 7:15 P.M., seated in the unit dining room.-The resident had recently asked about the 7:30 P.M. smoke break and was told it was not yet time.-CMT A had left for the day, while LPN A maintained visual oversight of the doors and residents. -Certified Nurse Assistant (CNA) A was preparing for the next smoke break so he/she not in the vicinity of the resident or the doors.-LPN A stated that he/she went to the restroom for approximately two minutes and upon return, the resident was no longer present on the unit dining room.-911 was called to report a missing person and the facility staff initiated an immediate search of the building and grounds.-The conclusion of the investigation was that there was a failure in the magnetic door locking system and in adherence to established policies and procedures. -The facility was aware of ongoing door lock issues and the resident was exhibiting exit-seeking behaviors, yet the facility failed to provide appropriate protective oversight, which directly contributed to the resident's elopement.-The resident was located on 03/01/26 at 2:00 P.M., returned to the facility, and then transported to the hospital for evaluation, where he/she was found to have no injuries. Review of the resident's Nurse's Notes, dated 02/28/26 at 9:47 P.M., showed:-At around 7:15 P.M., the resident was asking when the next smoke break was going to be.-The staff told the resident the next smoke break was at 7:30 P.M.-The resident was seated in the unit dining room when LPN A went to the bathroom located behind the nurse's station in the unit dining room.-When LPN A returned, the resident was gone.-The staff immediately began looking for the resident. During an interview on 03/01/26 at 1:36 P.M., the facility Administrator said:-The magnetic locks on the unit where the resident resided lost power at some point on 02/28/26.-At around 6:00 P.M., the resident went down the back stairway while the magnetic locks were not functioning and left the facility.-The resident was seen quickly and returned to the unit and the Administrator arrived and started to work on the door locks.-He/she thought the issue was a fuse and he/she called the magnetic lock company emergency repair person.-He/she instructed LPN A to ensure the resident was watched by staff at all times and remain in within the line sight until the magnetic locks were repaired.-When LPN A was seated at the nurse's station, he/she had a clear view of the resident and both doors to prevent the resident from leaving the facility. -While he/she was waiting for the door lock repair person in the facility lobby, LPN A called him/her saying that he/she had to use the restroom, and when LPN A came out, the resident was missing. -Prior to LPN A going to the restroom, the resident had been seated in the lobby.-The Administrator said LPN A should have notified someone before going to the restroom as he/she knew the magnetic door locks were not working, and the other staff member was getting residents ready for the next smoke break. During an interview on 03/04/26 at 10:10 A.M., LPN A said:-The resident had only been a resident in the facility for six hours before he/she eloped for the first time.-He/She was notified of the new admission at 10:36 A.M. The resident arrived at noon and he/she had no time to review the resident's admission packet. -The resident eloped for the first time around 6:00 P.M.-He/She was unaware the resident was exit seeking prior to the resident leaving the first time. -He/She was not aware the magnetic locks were not functioning until after the resident eloped.-Staff who went out on the smoking patio with residents alerted him/her the resident must have gotten out around 6:00 P.M., so he/she was able to go get the resident.-Once the resident got out the first time, the staff began checking on him/her every few minutes to make sure he/she didn't leave again. -He/she was instructed to keep the resident within the line of eyesight by the Administrator until the mag locks on the door were repaired. -The shift ended at 7:00 P.M., but the night shift LPN was running late so he/she stayed over.-CMT A left around 7:05 P.M. and CNA A was setting up for the next smoke break when around 7:15 P.M., the resident came and asked him/her when the next smoke break was.-LPN A told the resident the next smoke break was at 7:30 P.M. and told him/her to sit in the dining area and wait.-The resident sat down at a table with his/her drink and some noodles.-At around 7:20 P.M., LPN A had to use the restroom, so he/she went to the restroom behind the nurse's station, closed the restroom door and used the restroom. -He/She returned in about two minutes and when he/she came out of the bathroom, the resident was missing from the unit.-He/She did not think the resident could get out that quickly and felt there was no one to ask to relieve him/her for a restroom break as it was just him/her and CNA A on the unit and CNA A was busy.-He/She immediately called the Administrator and began to search for the resident. -He/She did not think about getting anyone to watch the resident while he/she went to the restroom as the resident seemed to listen and sit to wait for the smoke break. During an interview on 03/04/26 at 11:44 A.M., CMT A said:-He/she was outside on the smoking patio assisting residents at 6:00 P.M., when he/she saw the resident walking down the sidewalk in the back of the facility.-He/she called LPN A, and the resident was brought back inside.-After the resident came back inside, the staff began checking on him/her every few minutes.-They tried to make sure someone always had eyes on the resident. -The Administrator instructed LPN A what the plan was. -LPN A told him/her they would all just need to keep an eye on the resident until the locks were fixed. -He/she got off at 7:00 P.M., so he/she left around 7:05 P.M., and was not there when the resident eloped the second time. During an interview on 3/4/26 at 4:10 P.M., CNA A said:-He/She was not aware the magnetic door locks were not working.-He/She was out on the smoke deck with residents when the resident eloped the first time. -He/She and CMT A saw the resident walking down the sidewalk around 6:00 P.M. and called LPN A to go get him/her.-He/She had not seen the resident try to get out of the facility prior to 6:00 P.M.-The second time the resident eloped, he/she was on another hall preparing things for the resident's next smoke break.-He/She stayed until about 7:45 P.M., helping to look for the resident.-He/She and LPN A had been making sure the resident was always in eyesight of a staff member until the magnetic locks were repaired.-LPN A did not ask him/her for help to watch the resident when LPN A went to the bathroom, he/she continued his/her tasks. During an interview on 03/01/26 at 3:19 P.M., the Administrator said:-The resident had been found and was at the hospital for evaluation.-There were no known injuries as the assessment found no abrasions, scratches, or redness.-The resident was found on the metro bus transit system.-The corporate Chief Nursing Officer's (CNO) spouse works for the transit system and saw the resident on the bus.-The resident was identified and the facility was contacted.-The resident was found with a hoodie on, but the facility was unable to determine where he/she got it as when he/she left, he/she had on a black jacket.-The Administrator felt the event was preventable as the resident had two elopements within an hour of each other.- Facility staff knew the mag locks were not working properly and LPN A knew the magnetic lock company was to be onsite for repairs and the doors and the resident needed oversight until the doors were verified working. -LPN A knew he/she was assigned to ensure the resident remained in the line of sight until the mag locks were fixed. -LPN A assigned CNA A to take residents out to smoke. -LPN A went to the bathroom and did not ask anyone to take over watching the resident. -The Administrator was in the building and could have taken over watching the resident while LPN A went to the restroom.-The resident had been admitted from a sister facility within the corporation because of the facility's new locked dementia unit.-At the time, the resident was the only known exit seeking resident on the locked dementia unit. During an interview on 03/04/26 at 3:00 P.M., the Nurse Practitioner said:-He/She had been notified of the resident's elopements.-He/She would have expected the staff would have been aware of the resident's exit seeking behaviors and provide intensive monitoring for the resident after the first elopement. -He/She did not explain what intensive monitoring should have been for this resident. -He/she would have expected the staff were aware of the oversight needed, since the resident required a locked environment due to dementia.-The resident was a higher risk for wandering and elopement, therefore the staff should have known that added oversight would have been necessary with the magnetic locks having failed. During an interview on 03/04/26 at 5:45 P.M., the Administrator said:-The nursing staff on duty on 02/28/26 not only knew, but had the previous facility's documentation showing the resident was an elopement risk since 10:30 A.M. on 02/28/26 and the resident did not arrive to the facility until around noon on 02/28/26.-There were only 15 residents on the unit and they were staffed with an LPN, CMT, and a CNA.-LPN A should have had enough time to review the admission information as well as communicate with the previous facility staff for a resident report.-He/she would have expected that after the resident first elopement and it was discovered the magnetic locks were not functioning and he/she instructed LPN A to keep the resident in staff sight at all times, that LPN A follow those instructions and lead the team to ensure the resident was never left unattended. Complaint #'s 2791180 and 2791190

Based on interview and record review, the facility failed to ensure six sampled residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #7 and Resident #11) received medications as prescribed by the physician out of 13 sampled residents. The facility census was 49 residents. Review of the facility's Medication Administration Policy dated 4/6/17 and revised on 6/26/24 showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. -It was the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines. -Sign Medication Administration Record (MAR) after administering medications. -For those medications requiring vital signs, record the vital signs onto the MAR. -Report and document any adverse side effects or refusals. 1. Record review of Resident #1's admission Record showed the resident was admitted on [DATE] under the supervision of a legal guardian with diagnoses including schizoaffective disorder (a psychotic disorder characterized by loss of contact with environment, by noticeable deterioration in the level of functioning in everyday life), anxiety and depression. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 2/26/25 showed the resident was cognitively intact. Review of the resident's MAR and Treatment Administration Record (TAR) dated March 2025 showed: -Atorvastatin Calcium 40 milligram (mg) Tablet, give 40 mg by mouth at bedtime for hyperlipidemia (high cholesterol). The resident did not receive this medication six out of 31 opportunities. -Clonazepam 1mg, give one tablet by mouth three times daily for anxiety related to 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), schizoaffective disorder, bipolar (mood disorders characterized usually by alternating episodes of depression and mania) type. The resident did not receive this medication 18 out of 93 opportunities. -Trazodone 50 mg, given one tablet by mouth at bedtime for insomnia related to depression. The resident did not receive this medication six out of 31 opportunities. -Risperdal Consta intramuscular (IM) suspension Extended Release (ER) 50 mg, inject one application IM one time a day every 14 days for schizophrenia. The resident did not receive this medication one out of two opportunities. Review of the resident's MAR and TAR dated April 2025 showed: -Abilify 10 mg, give one tablet by mouth daily for schizoaffective disorder. The resident did not receive this medication eight out of 16 opportunities. All eight doses were consecutive doses from 4/1/25 to 4/8/25. -Clonazepam 1 mg, give one tablet by mouth three times daily for anxiety related to schizophrenia, schizoaffective disorder, bipolar type. The resident did not receive this medication six out of 48 opportunities. -Trazodone 50 mg, given one tablet by mouth at bedtime for insomnia related to depression. The resident did not receive this medication four out of 16 opportunities. -Risperdal Consta IM suspension ER 50 mg, inject one application IM one time a day every 14 days for schizophrenia. The resident did not receive this medication one out of one opportunities. During an interview on 4/10/25 at 5:53 P.M., Resident #1 said: -He/She does not get his/her medication consistently due to no staff to give his/her medications. -He/She does not refuse his/her medications. 2. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including spina bifida (is a condition that occurs when the spine and spinal cord did not form properly), mood disorder (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior) due to known psychiatric condition and major depression. Review of the resident's Annual MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's MAR and TAR dated March 2025 showed: -Clonazepam 0.5 mg, give 0.5 mg by mouth two times a day for Anxiety. This resident did not receive this medication seven out of 62 opportunities. -Haloperidol 5 mg, give 5 mg by mouth two times a day related to mood disorder due to known physiological condition with major depressive-like episode. This resident did not receive this medication four out of 62 opportunities. -Hydroxyzine Pamoate 25 mg, give 25 mg by mouth three times a day for Anxiety. This resident did not receive this medication eight out of 93 opportunities. -Trazodone 100 mg, give 100 mg by mouth at bedtime for depression. This resident did not receive this medication eight out of 31 opportunities. During an interview on 4/16/25 at 1:20 P.M. Resident #2 said he/she has missed several doses of medications due to them being on order or no nurse or Certified Medication Technician (CMT) to pass medications. 3. Review of Resident #3's admission Record showed the resident admitted on [DATE] with diagnoses including diffuse traumatic brain injury (TBI - a sudden injury that causes damage to the brain) with loss of consciousness of unspecified duration sequela and paranoid schizophrenia (a type of schizophrenia accompanied by paranoia, delusions and hallucinations). Review of the resident's Quarterly MDS dated [DATE], moderately cognitively impaired. Review of the resident's MAR and TAR dated February 2025 showed Cephalexin 500 mg Capsule (an antibiotic), give 500 mg capsule by mouth three times a day for five days for sepsis (severe infection) start date 2/26/25. This resident did not receive this medication seven out of seven opportunities. 4. Review of Resident #5's admission Record showed the resident was admitted on [DATE], readmitted on [DATE] with the following diagnosis: -Diabetes Mellitus Type II (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Chronic Kidney Disease (is when the kidneys are damaged and lose their ability to filter waste and fluid out of the body). -Schizophrenia. -Depression. -High blood pressure. -Chronic Obstructive Pulmonary Disease (COPD - a progressive lung disease that prevents airflow to the lungs, causing breathing problems). -Anxiety. Review of the resident's Quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's MAR & TAR dated March 2025 showed: -Atorvastatin Calcium 80 mg Tablet, give 80 mg by mouth at bedtime for hyperlipidemia. The resident did not receive this medication five out of 19 opportunities. -Pantoprazole Sodium 40 mg Tablet, give 40 mg by mouth in the morning for gastroesophageal reflux disease (GERD - back-up of stomach acid/heartburn). The resident did not receive this medication nine out of 19 opportunities. -Prazosin HCI 2 mg Capsule, give 1 capsule by mouth at bedtime for high blood pressure. The resident did not receive this medication six out of 19 opportunities. -Tiotropium Bromide Monohydrate Inhalation Aerosol Solution 2.5 mcg/act, give 1 puff inhale by mouth at bedtime for shortness of air. The resident did not receive this medication six out of 19 opportunities. -Trazodone HCI 50 mg Tablet, give 50 mg by mouth at bedtime for insomnia secondary to organic mood disorder. The resident did not receive this medication four out of 19 opportunities. -Hydroxyzine HCI 50 mg Tablet, give 50 mg by mouth three times a day for anxiety. The resident did not receive this medication five out of 57 opportunities. -Lidoderm External Patch 5 %, Apply to low back topically every morning and at bedtime for back pain. The resident did not receive this medication 11 out of 38 opportunities. -Accuchecks (blood sugar monitoring) before meals and at bedtime for diabetes. The resident did not receive accuchecks eight out of 96 opportunities. -Novolog Injection Solution (Insulin Aspart - a fast acting insulin), inject as per sliding scale. If the blood sugar is: 150-200 = 1 unit; 201-250 = 2 units; 251-300 = 3 units; 301-350 = 5 units; 351-400 = 8 units; Greater than 400 call the NP, subcutaneously before meals and at bedtime for diabetes. The resident did not receive this medication 14 out of 76 opportunities. --Six of the missed doses was coded 2 due to resident refusing, blood sugars were within parameters and insulin was due to be given. No note of physician being notified. -Lantus Subcutaneously Solution (a long acting insulin) 100 unit/milliliter (ml), inject 45 units subcutaneously at bedtime for diabetes. Do not hold unless blood sugar is below 70. The resident did not receive this medication four out of 19 opportunities. Review of the resident's MAR & TAR dated April 2025 showed: -Atorvastatin Calcium 80 mg Tablet, give 80 mg by mouth at bedtime for hyperlipidemia. The resident did not receive this medication one out of 16 opportunities. -Pantoprazole Sodium 40 mg Tablet, give 40 mg by mouth in the morning for GERD. The resident did not receive this medication 10 out of 16 opportunities. -Prazosin HCI 2 mg Capsule, give 1 capsule by mouth at bedtime for high blood pressure. The resident did not receive this medication one out of 16 opportunities. -Tiotropium Bromide Monohydrate Inhalation Aerosol Solution 2.5 mcg/act, give 1 puff inhale by mouth at bedtime for shortness of air. The resident did not receive this medication two out of 16 opportunities. -Trazodone HCI 50 mg Tablet, give 50 mg by mouth at bedtime for insomnia secondary to organic mood disorder. The resident did not receive this medication two out of 16 opportunities. -Hydroxyzine HCI 50 mg Tablet, give 50 mg by mouth three times a day for anxiety. The resident did not receive this medication five out of 57 opportunities. -Lidoderm External Patch 5 %, Apply to low back topically every morning and at bedtime for back pain. The resident did not receive this medication four out of 32 opportunities. -Accuchecks before meals and at bedtime for diabetes. The resident did not receive accuchecks eight out of 76 opportunities. -Novolog Injection Solution (Insulin Aspart), inject as per sliding scale. If the blood sugar is: 150-200 = 1 unit; 201-250 = 2 units; 251-300 = 3 units; 301-350 = 5 units; 351-400 = 8 units; Greater than 400 call the NP, subcutaneously before meals and at bedtime for diabetes. The resident did not receive this medication 13 out of 64 opportunities. --Two of the missed doses was coded 2 due to resident refusing, blood sugars were within parameters and insulin was due to be given. No note of physician being notified. --One missed dose was code 4 due to the resident having blood sugar on 484, no progress not stating the physician was notified of the high blood sugar or action taken. -Lantus Subcutaneously Solution 100 unit/ml, inject 45 units subcutaneously at bedtime for diabetes. Do not hold unless blood sugar is below 70. The resident did not receive this medication two out of 16 opportunities. 5. Review of Resident #7's admission Record showed the resident admitted on [DATE] with diagnoses including schizoaffective disorder, dementia (is the loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and stroke. Review of the resident's Quarterly MDS dated [DATE] showed the resident was mildly cognitively impaired. Review of the resident's MAR and TAR dated March 2025 showed: -Atorvastatin 20 mg Tablet, give 20 mg by mouth at bedtime for hyperlipidemia. This resident did not receive this medication 10 out of 31 opportunities. -Buspirone HCI 10 mg Tablet, give 10 mg by mouth three times a day for anxiety disorder. This resident did not receive this medication 12 out of 93 opportunities. -Donepezil HCI10 mg Tablet, give 10 mg by mouth at bedtime for dementia. This resident did not receive this medication 10 out of 31 opportunities. -Invega Sustenna IM Suspension Prefilled Syringe 234 mg/1.5ml, inject 1.5 ml IM in the afternoon every 28 days for schizoaffective disorder, bipolar type. The resident did not receive this medication one out of one opportunities. The administration note dated 3/22/25 showed the medication was on order. -Levoxyl 88 mcg Tablet, give 88 mcg by mouth in the morning on an empty stomach without other medications for hypothyroidism (low thyroid). This resident did not receive this medication 26 out of 31 opportunities. -Melatonin 10 mg Tablet, give 10 mg by mouth at bedtime for insomnia. This resident did not receive this medication eight out of 31 opportunities. -Trazodone HCI 50 mg Tablet, give 50 mg by mouth at bedtime for insomnia secondary to mood disorder. This resident did not receive this medication six out of 26 opportunities. Review of the resident's MAR and TAR dated April 2025 showed: -Buspirone HCI 10 mg Tablet, give 10 mg by mouth three times a day for anxiety disorder. This resident did not receive this medication one out of 48 opportunities. -Levoxyl 88 mcg Tablet, give 88 mcg by mouth in the morning on an empty stomach without other medications for hypothyroidism. This resident did not receive this medication 11 out of 16 opportunities. 6. Review of Resident #11's admission Record showed the resident was admitted on [DATE], readmitted on [DATE] with the following diagnosis: -Diabetes Mellitus Type II (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Coronary Artery Disease (CAD-narrowing of the coronary arteries due to build up of plaque). -Chronic Systolic (Congestive) Heart Failure (CHF-heart failure in which the heart is unable to maintain adequate circulation of blood in the tissue of the body or to pump out the venous blood returned to it by the venous circulation). -Hyperlipidemia (HDL-high levels of lipids (fats) in the blood). -Thrombophilia (is a condition that increases the likelihoodof blood clots forming). -Bipolar Disorder (is a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). -Depression. -High blood pressure. -Anxiety. Review of the resident's Quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's MAR & TAR dated March 2025 showed: -Gabapentin 100 mg Capsule, give 400 mg by mouth three times a day for polyneuropathy. The resident did not receive this medication four out of 57 opportunities. -Loratadine 10 mg Tablet, give 10 mg by mouth at bedtime for Prophylaxis related to CHF. The resident did not receive this medication three out of 19 opportunities. -Melatonin 3 mg Tablet, give 3 mg by mouth at bedtime for insomnia. The resident did not receive this medication three out of 19 opportunities. -Mirtazapine 15 mg Tablet, give 15 mg by mouth at bedtime related to mild cognitive impairment. The resident did not receive this medication three out of 19 opportunities. -Oxycodone 5 mg Tablet, give 5 mg by mouth every 12 hours for pain. The resident did not receive this medication four out of 38 opportunities. -Omeprazole 40 mg Capsule, give 40 mg by mouth in the morning for GERD. The resident did not receive this medication nine out of 19 opportunities. -Seroquel 200 mg Tablet, give 200 mg by mouth at bedtime for bipolar disorder. The resident did not receive this medication three out of 19 opportunities. -Seroquel 50 mg Tablet, give 50 mg by mouth at bedtime for bipolar disorder. The resident did not receive this medication three out of 19 opportunities. -Trazodone HCI 50 mg Tablet, give 50 mg by mouth at bedtime for insomnia secondary to depression. The resident did not receive this medication three out of 19 opportunities. -Accuchecks before meals and at bedtime for diabetes. The resident did not receive accuchecks eight out of 76 opportunities. -Lantus SoloStar Subcutaneously Solution Pen-Injector 100 unit/ml, inject 30 units subcutaneously at bedtime for diabetes. The resident did not receive this medication three out of 19 opportunities. -Lantus SoloStar Subcutaneously Solution Pen-Injector 100 unit/ml, inject 8 units subcutaneously in the afternoon for lunch for diabetes. Do not hold unless blood sugar (BS) is 70 or below. The resident did not receive this medication six out of 19 opportunities. --Four missed doses at 12:00 P.M. were coded 4 (vitals outside of parameters for administration) on 3/23/25 BS was 88, 3/26/25 BS was 110, 3/27/25 BS was 140, and 3/30/25 BS was 158. -Novolog Injection Solution (Insulin Aspart), inject 10 units subcutaneously in the afternoon for diabetes. The resident did not receive this medication five out of 19 opportunities. --Three missed doses at 12:00 P.M. were coded 4 (vitals outside of parameters for administration) on 3/23/25 BS was 88, 3/26/25 BS was 110, and 3/27/25 BS was 134, no parameters for this order. -Novolog Injection Solution (Insulin Aspart), inject 10 units subcutaneously in the evening for diabetes. The resident did not receive this medication four out of 19 opportunities. --Two missed doses at 4:00 P.M. were coded 4 (vitals outside of parameters for administration) on 3/22/25 BS was 102 and 3/23/25 BS was 244, no parameters for this order. Review of the resident's MAR & TAR dated April 2025 showed: -Eliquis 5 mg Tablet, give 5 mg by mouth two times a day for CAD. The resident did not receive this medication five out of 32 opportunities. --All five missed doses were blank and had no administration notes. -Glyburide 5 mg Tablet by mouth two times a day for diabetes. The resident did not receive this medication five out of 32 opportunities. -Gabapentin 100 mg Capsule, give 400 mg by mouth three times a day for polyneuropathy. The resident did not receive this medication seven out of 48 opportunities. -Melatonin 3 mg Tablet, give 3 mg by mouth at bedtime for insomnia. The resident did not receive this medication three out of 16 opportunities. -Mirtazapine 15 mg Tablet, give 15 mg by mouth at bedtime related to mild cognitive impairment. The resident did not receive this medication two out of 16 opportunities. -Oxycodone 5 mg Tablet, give 5 mg by mouth every 12 hours for pain. The resident did not receive this medication six out of 32 opportunities. -Omeprazole 40 mg Capsule, give 40 mg by mouth in the morning for GERD. The resident did not receive this medication eight out of 17 opportunities. -Omeprazole 40 mg Capsule, give 40 mg by mouth in evening for GERD. The resident did not receive this medication four out of 16 opportunities. -Seroquel 200 mg Tablet, give 200 mg by mouth at bedtime for bipolar disorder. The resident did not receive this medication two out of 16 opportunities. -Seroquel 50 mg Tablet, give 50 mg by mouth at bedtime for bipolar disorder. The resident did not receive this medication two out of 16 opportunities. -Trazodone HCI 50 mg Tablet, give 50 mg by mouth at bedtime for insomnia secondary to depression. The resident did not receive this medication two out of 16 opportunities. -Accuchecks before meals and at bedtime for diabetes. The resident did not receive accuchecks 14 out of 64 opportunities. -Lantus SoloStar Subcutaneously Solution Pen-Injector 100 unit/ml, inject 30 units subcutaneously at bedtime for diabetes. The resident did not receive this medication five out of 16 opportunities. -Lantus SoloStar Subcutaneously Solution Pen-Injector 100 unit/ml, inject 8 units subcutaneously in the afternoon for lunch for diabetes. Do not hold unless blood sugar (BS) is 70 or below. The resident did not receive this medication seven out of 16 opportunities. --Three missed doses at 12:00 P.M. were coded 4 (vitals outside of parameters for administration) on 4/1/25 BS was 168, 4/5/25 BS was 169, and 4/8/25 BS was 184. -Novolog Injection Solution (Insulin Aspart), inject 10 units subcutaneously in the afternoon for diabetes. The resident did not receive this medication five out of 16 opportunities. --Two missed doses at 12:00 P.M. were coded 4 (vitals outside of parameters for administration) on 4/1/25 BS was 168 and 4/8/25 BS was 184, no parameter on this order. -Novolog Injection Solution (Insulin Aspart), inject 10 units subcutaneously in the evening for diabetes. The resident did not receive this medication eight out of 16 opportunities. --Two missed doses at 4:00 P.M. were coded 4 (vitals outside of parameters for administration) on 4/6/25 BS was 104 and 4/8/25 BS was 94, and one was code 13 (blood sugar outside parameters) on 4/2/25 BS was 128. none of these doses were outside the parameter of 70 or below. During an interview on 4/15/25 at 4:54 P.M., Resident #11 said sometime he/she does not get his/her bedtime medications. 7. During an interview on 4/15/25 at 1:24 P.M. CMT A said: -Medications are to be administered to the residents as ordered by the physician. -If residents refuse medications he/she notifies the charge nurse. -Document why the medication was not given on the MAR & TAR and in the resident administration notes. During an interview on 4/15/25 at 3:03 P.M., Licensed Practical Nurse (LPN) A said: -If two CMTs are on shift they pass the medications and he/she does the nursing stuff like treatments. -If one or no CMTs, then he/she is in charge of passing medications to the residents. -Staff are to document why the medications was not given and notify the physician. During an interview on 4/17/25 at 4:18 P.M. the Director of Nursing (DON) said: -He/She was not aware there were medications that did not get passed, notified the NP or documented. -He/She expected the nurse and/or CMT to pass medication as ordered by the physician. During an interview on 4/18/25 at 11:45 A.M. Nurse Practitioner B said: -He/She was not aware medications were not being administered for any reason. -He/She expects staff to ensure medications are administered and if not administered to be notified as part of the resident's plan of care for mental health and behavioral disorders is medication management. During an interview on 4/21/25 at 5:58 P.M. the Administrator in Training (AIT) said: -He/she would expect medications to be given as ordered and document the medication was given or not given. -He/she would notify the physician or Nurse Practitioner of the missed medications. MO00252031 MO00252201

Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident. The facility assigned one nurse to be on a locked memory care unit and the Transitional Unit at the same time to pass medications, monitor resident behaviors and document such behaviors, leaving one other staff member on each unit, as a result medications were not given to the residents. The facility census was 49 residents. Review of the facility's Sufficient Staff Policy dated 5/18/24 showed: -It was the policy of the 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. -The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. -Must designate a licensed nurse to serve as a charge nurse on each tour of duty. -Was required to provide licensed nursing staff 24 hours a day, seven days a week. -Must ensure that licensed nurses have the specific competencies and skill set necessary to care for resident's needs as identified through resident assessments and described in the plan of care. -Providing care includes, but was not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. -Must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the care plan. -Except when waived, the facility must use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. -The Director of Nursing (DON) may serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Review of the Facility assessment dated [DATE] showed: -The facility was licensed for 97 residents. -The average number of occupied beds during 1/2024 to 10/2024 was 48 residents. -The facility was a locked facility with two locked Specialty Unit inside the locked facility. -Skilled Acuity: --Four with extensive services. --Twenty-eight residents with high special care. --Thirty-two residents with behavioral symptoms and cognitive performance. -Resident acuity affecting licensed nurses: --Ninety-seven residents with Behavioral/Mental health. --Twenty residents' high risk or Intravenous (IV - in the vein)/intramuscular (IM - in the muscle) medications/infusions. --Two hospice residents. --Four wound care residents. -Resident acuity affecting Nurse Aides: --Twelve residents need assistance with dressing. --Sixteen residents need assistance with baths. --Five residents need assistance with transferring and mobility. --Four residents need assistance with eating. --Thirteen residents need assistance with toileting. --Forty-one residents need assistance with behavioral symptoms. -Staffing needs as per shift (adjust as needed). --Day Shift 7:00 A.M. to 7:00 P.M., one RN for 97 residents, one Licensed Practical Nurse (LPN) per 50 residents, One Certified Nursing Assistant (CNA) per 24 residents, and one Certified Medication Technicians (CMT) per 35 residents. --Night Shift 7:00 P.M. to 7:00 A.M., one RN for 97 residents, one LPN per 50 residents, one CNA per 12 residents and one CMT per 35 residents. 1. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/13/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and two CNAs. -The facility census was not provided as requested. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. medications and 5:00 A.M. medications on 3/14/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 2. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/15/25 from 7:00 P.M. to 7:00 A.M. showed: -One LPN, and two CNAs. -The facility census was not provided as requested. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. and 9:00 P.M. medications and 5:00 A.M. medications on 3/16/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 3. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/17/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and two CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 5:00 A.M. medications on 3/18/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. residents who resided on the Transition Unit. 4. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/22/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and one CNA from 7:00 P.M. to 10:45 P.M A second CNA clocked in at 10:45 P.M. -The facility census was 50 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. medications and 5:00 A.M. medications on 3/23/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 5. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/23/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and two CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. medications and 5:00 A.M. medications on 3/24/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 6. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/26/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN, one LPN (until 11:36 P.M.), and three CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. medications and 5:00 A.M. medications on 3/27/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 7. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/27/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and three CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 5:00 A.M. medications on 3/28/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 8. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/29/25 from 7:00 P.M. to 7:00 A.M. showed: -One LPN and two CNAs. -The facility census was 48 residents. NOTE: 7:00 A.M. to 7:00 P.M. nurse did not administer 7:00 A.M., 8:00 A.M., 9:00 A.M., 2:00 P.M., and 4:00 P.M. medications on 3/29/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 9. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/30/25 from 7:00 P.M. to 7:00 A.M. showed: -One LPN and two CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. medications for the 13 sampled out of 29 residents who resided on the Transition Unit. 10. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 3/31/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and two CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. medications and 5:00 A.M. medications on 4/1/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 11. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/4/25 from 7:00 P.M. to 7:00 A.M. showed: -One LPN and two CNAs. -The facility census was 49 residents. NOTE: 7:00 A.M. to 7:00 P.M. nurse did not administer 12:00 P.M. and 4:00 P.M. medications for the 13 sampled out of 29 residents who resided on the Transition Unit. 12. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/5/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN and three CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 5:00 A.M. medications on 4/6/25 medications for the 13 sampled out of 29 residents who resided on the Transition Unit. 13. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/6/25 from 7:00 P.M. to 7:00 A.M. showed: -7:00 P.M. to 7:00 A.M. -One RN and three CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. and 9:00 P.M. medications and 5:00 A.M. medications on 4 /7/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 14. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/7/25 showed: -One LPN and three CNAs from 7:00 A.M. to 7:00 P.M. NOTE: 7:00 A.M. to 7:00 P.M. nurse did not administer 7:00 A.M., 9:00 A.M., 12:00 P.M., 4:00 P.M., and 5:00 P.M. medications for the 13 sampled out of 29 residents who resided on the Transition Unit. -One LPN, one CMT, and three CNAs 7:00 P.M. to 7:00 A.M. -The facility census was 49 residents. NOTE: The 7:00 P.M. to 7:00 A.M. nurse did not administer 5:00 A.M. medications on 4/8/25 medications for the 13 sampled out of 29 residents who resided on the Transition Unit. 15. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/9/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN, one CMT, and two CNAs. -The facility census was 48 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. 9:00 P.M. medications and 5:00 A.M. medications on 4/10/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 16. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/10/25 showed: -One RN, one CMT, one CNA 7:00 P.M. to 7:00 A.M. and one LPN from 7:00 P.M. to 10:00 P.M. -The facility census was 48 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. 9:00 P.M. medications and 5:00 A.M. medications on 4/11/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 17. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/13/25 from 7:00 P.M. to 7:00 A.M. showed: -One CMT and two CNAs. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 8:00 P.M. 9:00 P.M. medications and 5:00 A.M. medications on 4/14/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 18. Review of the facility's Daily Staffing Sheet and Daily Punch In and Out for 4/14/25 from 7:00 P.M. to 7:00 A.M. showed: -One RN, and three CNAs 7:00 P.M. to 7:00 A.M. -The facility census was 49 residents. NOTE: 7:00 P.M. to 7:00 A.M. nurse did not administer 5:00 A.M. medications on 4/15/25 for the 13 sampled out of 29 residents who resided on the Transition Unit. 19. Review of Resident #13's admission Record showed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, insomnia, and anxiety. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) MDS dated [DATE] showed the resident was mildly cognitively impaired with no mood or behavior concerns documented. During an interview on 4/16/25 at 4:46 P.M. Resident #13 said: -Sometimes he/she and the other residents do not get their medications because there is no nurse. -Although there have been staff in the facility, there were no staff on Transition Unit. 20, During an interview on 4/16/25 at 8:01 A.M. CNA C said: -He/She was not responsible for checking residents on the other hall (Transition Unit). -Residents should be checked every hour. -Everybody should be checked at least every two hours. -There have been times when there was no staff on the other hall (Transition Unit), once or twice per month. -Sometimes there was only one nurse and one CNA for the night shift. -Most of the time it was one CNA on the Transition Unit. During an interview on 4/16/25 at 8:37 A.M. CNA D said: -He/She does not usually work the Transition Unit. -CNA E would come to the memory care side to assist the staff in the early morning hours, leaving the Transition Unit unattended. -His/Her concerns were there was no staff on the Transition Unit. During an interview on 4/17/25 at 4:18 P.M. the DON said: -He/She was out of the facility from 3/12/25 to 3/25/25 on personal leave. -He/She expected there to be six direct care staff during the day shift including one nurse, two CMTs, and three CNAs. -He/She expected there to be four to five direct care staff during the night shift including one nurse, one CMT, and three CNAs. -He/She was aware there were medications that did not get passed, notified the Nurse Practitioner (NP) and not documented. -He/She expected staff to check residents hourly and document in the resident chart the face checks. During an interview on 4/18/25 at 9:41 A.M. CNA E said: -He/She is usually the only staff on the hall during the last smoke time for the residents at 9:00 P.M. -Most of the time he/she is the only staff and cannot allow the residents to use the microwave or vending machines. -There are times when there is a CNA for the Transitional Unit and a nurse on the memory care for the entire shift. -He/She goes to the memory care unit at around 4:00 A.M. to help get residents up and will return to the Transition Unit at 6:00 A.M. to smoke the residents. -There had never been a Code [NAME] (when a resident is having behavioral issues and need more staff support) called, but there would not have been enough staff to call a Code Green. -Residents should be checked every two hours. -There are about seven to eight residents who do not sleep through the night. During an interview on 4/18/25 at 10:53 A.M. CNA F said: -He/She has always worked on the Transition Unit and sometimes the whole facility by him/herself. -Residents should be checked every two hours, every hour and some are every 15 minutes. -Many times he/she was the only staff on the hall as the CMT leaves once they are done passing medications. -He/She sat in the hall where he/she could see everything as there were some residents that were out a lot. -There have been times when residents did not get their medications because there was no CMT or nurse for the Transition Unit. -Sometimes the nurse would not come in at all or come in late. -He/She would always go to the memory care side to help in the mornings until 6:00 A.M. when it was time to take the Transition Unit residents out to smoke. During an interview on 4/18/25 at 11:45 A.M. NP B said: -There are staffing concerns and not enough staff to manage the behaviors of the behavioral and mental health side of the Transition Unit. -He/She was not aware medications were not being administered for any reason. -There was not enough staff to do one on one supervision for residents who may need that kind of supervision. During an interview on 4/21/25 at 3:25 P.M. CNA G said: -He/She changed positions to activities but has not been able to perform that job due to not enough staff to work the floor. -He/She works on the floor as an CNA two to five days per week due to the lack of staff. During an interview on 4/21/25 at 5:58 P.M. the Administrator in Training (AIT) said: -When he/she started working in the facility, he/she was a weekend supervisor. -On or about 3/30/25 he/she became the AIT. -On 4/3/25 he/she came to the facility at 4:00 A.M. to pass the 5:00 A.M. and 6:00 A.M. medications and left the facility before 7:00 A.M. -He/She was the Administrator on 4/15/25. -The DON was off from 3/12/25 to 3/25/25. -The DONs last day in the facility was 4/11/25. -He/She was covering the DON position while he/she was off work. -He/She was the AIT, RN coverage and floor nurse on 4/12/25 and 4/13/25. -Interim DON started on 4/15/25. -Staffing for each shift should be one nurse, one CMT and three CNAs. One nurse and two CNAs for the Memory Care Unit and one CMT and one CNA for the transition Unit. If no CMT then two CNAs for the Transition Unit. -Memory Care CNAs take all residents who smoke out for smoke breaks. -He/She had worked when only three staff to help with coverage. -There should be two staff on the Transition Unit at all times to manage behaviors and ensure safety. MO00252031 MO00252201

Based on interview and record review, the facility failed to develop an individualized service care plan that identified resident triggers and de-escalation needs to maintain the resident's highest physical, mental and psychosocial well being for one sampled resident (Resident #3) out of 13 sampled residents. The facility census was 49 residents. Review of the facility Behavioral Contracts Policy dated 4/30/24 showed: -Residents who exhibit behaviors which could endanger themselves, other residents, or staff may benefit from a behavioral contract to ensure they are receiving appropriate services and interventions to meet their needs. -Mental disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in a psychological, biological, or developmental processes underlying mental functioning. -Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. -Substance use disorder is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. -The interdisciplinary team, including the resident, and as appropriate the resident's family, should develop a behavioral contract with identified behaviors. -Behaviors should be documented clearly and concisely by facility staff. -Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions. -Behaviors should be identified and approaches for modification or redirection should be included in the comprehensive plan of care. -The plan of care and behavioral contract should be reviewed at least quarterly for continued need of behavior management and appropriate interventions. -A contract will only be used as a 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. -The contract should include the recreation schedule, non-pharmacological interventions, and environmental adjustments needed to help the resident meet his/her highest practicable well-being. 1. Review of Resident #3's admission Record showed the resident admitted on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration sequela define and 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). Review of the resident's Pre-admission Screening Resident Review (PASRR) dated 3/12/24 showed the resident: -Had diagnoses including paranoid schizophrenia , personality disorder (mental health condition characterized by persistent, inflexible patterns of thinking, feeling, and behaving that deviate significantly from cultural expectations and cause significant distress or impairment in daily life), borderline intellectual functioning (a categorization of intelligence wherein a person has below average cognitive ability (generally an IQ of 70-85), but the deficit is not as severe as intellectual disability (below 70) and polysubstance dependence (condition where an individual meets the diagnostic criteria for substance use disorder (SUD) on two or more different classes of substances simultaneously, exhibiting significant problems and impairments in their lives due to their use of multiple substances, such as alcohol, stimulants, opioids, or sedatives). -Recent physical altercation with another resident where he/she punched another resident in the face while out smoking on 2/19/24. -Recent multiple falls. -History of having a guardian. -Had chronic medical and psychological condition requires around the clock medical care and oversight. -Had multiple comorbidities requiring skilled care. -Had resided in a skilled facility for many years. -At that time he remained safest in a skilled nursing facility. -Behaviors to be addressed were aggression, mood liability, and impulsivity. -Required medication therapy and monitoring, structured environment for history of aggression towards other and high fall risk, and crisis intervention plan recommended due to aggression towards others. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 12/17/24 showed the resident was moderately cognitively impaired. Review of the resident's Progress Note dated 3/1/25 at 6:32 P.M. showed: -The resident came out of room multiple times disrobed and had to be redirected multiple times. -The resident yelled and screamed at staff and other residents. -The resident was redirected and educated on the importance of being polite and respectful. -The resident attempted multiple times to get off the unit when others were trying to leave the unit. -The resident attempted multiple times to go on the smoke porch partially disrobed. -When asked if he needed any assistance the resident would try to manipulate the situation and had to be redirected. Review of the resident's Progress Note dated 3/2/25 at 3:30 A.M. showed: -The resident's peer came running out of his/her room to CNA hall monitor, that Resident #3 was naked in his/her bed. -The CNA assisted Resident #3 out of his/her peer's bed helped him/her to get dressed and placed back in his/her bed. -Called the DON to give report of resident's demeanor stated to send him/her out to ER for behavioral and undressing issues. Review of the resident's Care plan dated 3/2/25 showed the resident: -Had been disrobing and coming out of his/her room or going into other resident's rooms naked. -Staff were to ensure protective oversight was provided. -Interventions included: --Administering medications as ordered. --Education and re-education on the importance of dressing. --Staff were to intervene as necessary to protect the rights and safety of others. --He/she was sent to the ER for evaluation and treatment. Note: No triggers for the behavior of disrobing were identified. Note: No instruction for staff on how to redirect the resident's behavior of disrobing. Review of the resident's Progress Note dated 3/9/25 showed: -At 7:19 A.M. he/she did not want to put his/her pants on, he/she had defecated in another resident's room, put his/her urinal full of urine at the nursing station, was cursing at staff, and was difficult to redirect. -At 10:41 A.M. he/she was witnessed defecating and urinating on another resident's bed and on the floor of another resident's room. Nurse Practitioner A was notified and ordered the resident to be sent to ER for evaluation and treatment. Review of the resident's Hospital Record dated 3/9/25 showed: -The resident was given a laxative while at the facility and was throwing feces at the facility staff. The nursing facility had said the past four days the resident had been more aggressive, difficult to redirect, up urinating and defecating on the other residents' property in the facility. -He/she presented to the ED for altered mental status and abnormal behaviors and rapid heart rate. -He/she was admitted for medicine management of altered mental status. -He/she had a low lithium blood level, his/her thyroid stimulating hormone (TSH) was high 16.5, it was unclear if he/she was taking the levothyroxine appropriately or an insufficient dose. -He/she needed a sitter (one to one protective oversight) while in the hospital Review of the resident's Comprehensive Discharge MDS dated [DATE] showed the resident was severely cognitively impaired. Review of the resident's Hospital Discharge summary dated [DATE] showed: -On 3/10/25 hospital staff spoke with the facility staff and it was reported one of the Nurse Practitioners (PA) had stopped Haloperidol (medication for agitation related to paranoid schizophrenia and schizoaffective disorder) 5 mg twice daily, risperidone (medication for schizophrenia) 2 mg twice daily, lorazepam (medication for anxiety disorder ) 0.5 mg twice daily and citalopram (medication for major depressive disorder) 30 mg daily, and replaced with olanzapine (medication for paranoid schizophrenia) 5 mg in the morning and 10 mg at bedtime on 3/5/25 and this was when the behavioral disturbances started for the resident. -The hospital placed several calls to the facility to ascertain why the changes were made in the resident's psychiatric care. The staff at the facility mentioned there was concern about polypharmacy (the simultaneous use of multiple medications by a patient, often defined as five or more drugs) the resident was provided. -At that time the decompensation correlated with medication changes made on 3/5/25 could explain the sudden change in his/her presentation. -Hospital psychiatry recommended an increase in Olanzapine 10mg BID (twice a day) and ordered oral haloperidol 2mg every four hours with an IV as needed for acute agitation. -He/she was discharged back to the facility with adjusted medication regimen after he/she was removed from restraints. Review of the resident's medical record dated 3/14/25 showed: -He/she had returned from the hospital. Immediately began behaviors such as throwing self on the floor and was unable to be redirected. -The facility obtained an order for to the resident to go back to the hospital. Note: There was no update to the resident care plan or update from the hospital admission with new interventions. Review of the resident's Hospital Records dated 3/14/25 to 3/20/25 showed: -The resident was discharged earlier today and was brought back from the facility due to combative behavior. -During hospitalization 3/14/2025-3/20/2025, the patient continued to be managed on his/her mental health regimen. -He/She was seen by the inpatient psychiatric team who commented that the patient likely had a acute decompensation of his/her chronic mental illnesses. -There was no infectious or metabolic etiology identified for patient's increasing agitation. -Patient had presented multiple times to hospital for behavior related concerns recently, i.e. throwing feces in the room of his/her nursing facility. -Medical workup up complete and no reversible etiologies identified. -Psychiatry had evaluated the patient, no medication changes. -Patient was at baseline. -Waxing and waning mentation at times. -If nursing home unable to care for him/her, recommend they initiate placement to another facility. -No medications were changed at discharge. -On 3/20/2025 the patient was discharged in stable condition back to his facility. Review of the resident's Progress Note dated 3/20/25 showed the resident returned to the facility. Review of the resident's Progress Note dated 3/21/25 showed: -Clinical team met to review new orders from hospital including how and when to administer as needed (PRN) medications for behaviors to avoid re-hospitalization. -Discussed mild to moderate behaviors resistance to redirect and administer Haldol 2 mg po PRN and where behaviors have the potential for harm to self or others to use the Haldol IM. -Discussed plan with NP B who is in agreement and will be in to see resident. Note:There was no update to the resident care plan or update from the hospital admission with new interventions. Review of the resident's Hospital Records dated 3/22/25 showed: -He/she was brought to the emergency department due to multiple falls in his/her nursing home. -Assessment trauma activation status post fall at his/her nursing facility. -Reportedly, patient fell from his wheelchair, but he/she did not hit his/her head and there was no loss of consciousness. -He/She had a history of a traumatic brain injury and per emergency services has difficulty speaking. -He/She had a superficial abrasion beneath his/her left eye and above his/her left eyebrow but per nursing facility said these were present prior to this fall. -CT scan of the face showed acute fractures involving bilateral distal nasal bones, with moderate fragment displacement. Review of the resident's Care Plan dated 12/20/23 showed: -The resident was a moderate risk for falls related to psychoactive drug use. -Outcomes were the resident: --Would not sustain serious injury. --Would be free of falls. --Would keep his/her bed in low position to maintain accessibility in and out of bed. -Interventions included: --Anticipate and meet resident needs. --Review information on past falls and attempt to determine cause of falls. --Remove any potential causes and educate as to causes. --The resident needs a safe environment including even floors free from spills and/or clutter and glare free light. Review of the resident's Care Plan dated 2/15/25 showed: -The resident noted to be laying on the floor of room. -Resident to resume usual activities without further incident. -Interventions included: --For no apparent acute injury, determine and address causative factors of the fall. --Monitor, document, and report as needed for 72 hours to physician for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture or agitation. Review of the resident's incident report dated 3/27/25 showed: -The Administrator in Training (AIT) noticed a broken window next to an empty bed in Resident #13's room. -Resident #13 denied breaking window. Review of the resident's Hospital Records dated 4/16/25 showed he/she has been rejected from his/her facility for re-admission and psychiatry was consulted due to concern for his/her continued agitation and for assistance with medications. During an interview on 4/10/25 at 3:03 P.M. the DON said: -He/She did not feel the facility would be able to meet the resident's needs. Note: Fall investigations for the resident were requested and not received. -Resident discharged on 3/22/25 and had not returned, there were no updates to the care plan after 3/22/25. Review of the resident's incident report dated 4/10/25 showed: -Physician was notified of the resident's fall on 3/22/25 at 1:00 A.M. -Disciplinary action required for nurse related to physician notification and fall protocol. -Resident was found on the floor by the nurse sitting on the floor in front of his/her wheelchair. -Full range of motion and appeared in no acute distress. -Resident assisted to wheelchair. -Later in the day, the resident was observed while sitting in wheelchair on the patio getting fresh air. -Reported that he/she fell forward to ground from his/her wheelchair and landed on the left side of body, sustaining two abrasions to his/her the left knee and hematoma to left side of his/her forehead. -Staff was within reach and could not get to the resident to stop the fall. -The resident appeared to be drowsy per staff report. -Note changes to mental and physical condition. -Resident was changing both cognitively and medically. -Resident sent to the hospital. During an interview on 4/15/25 at 11:55 A.M. CNA A said: -If a resident was to have behaviors he/she would tell the charge nurse and the nurse will come do his/her part. -His/Her first action would be to stop the residents from fighting, then get the charge nurse and the nurse does the rest. -Training for behavior management was done about a year ago, CPI (Crisis Prevention Institute) training in mental health equips staff with skills to prevent, de-escalate, and respond to crisis situations, prioritizing safety and well-being for both individuals and staff) and how to throw (put them down on the ground) them when having behaviors. -He/She would go to the charge nurse to know how to work with the resident. During an interview on 4/15/25 at 12:43 P.M. CNA B -He/She had not had any behavior management training in the facility. -If a resident was having behaviors, he/she would walk away, report to charge nurse, wait for the resident to calm down to revisit, and if the resident is out of control let the nurse handle it. -He/She was not aware of any place to find information related to the resident's behaviors, triggers or interventions. -If there is anything available for information related to resident specific behaviors, triggers and interventions, he/she had not seen it. -Sometimes when the CNAs have asked about behavior information for the residents, the nurses have said the aides need to stay in their lane. -All training he/she has received has been generalized training. -He/She would go to the charge nurse to know how to work with the resident. During an interview on 4/15/25 at 1:24 P.M. CMT A said: -He/She used to run the behavior unit that was closed for remodel. -He/She has not had any behavior specific training. -There were some dementia training's last year sometime. -The residents from the behavior unit have done okay, but some were out of control. -In order to know what he/she was supposed to do for a resident having behaviors, he/she must discuss with the charge nurse. -He/She can access the care plan for information, but the CNAs do not have that access. -He/She worked with the resident downstairs. -The resident's behavior was different since the move to the Transition Unit. -The change had been gradual. -The resident struggled with communication, which had gotten worse over time. -De-robe was a new behavior over the last three months and he/she was very difficult to redirect. -The resident was getting into other resident's bed's naked, upsetting those residents and putting him/her at risk to be harmed. -The resident started getting weak and really wasn't the same person. During an interview on 4/15/25 at 3:03 P.M. LPN A said: -He/She has not had any behavior management training in the facility since he/she started about two months ago. -He/She was trained on the job and had some behavior training the last time he/she worked in the facility. -Knowing about the residents and observing residents was how he/she knew resident triggers. -The licensed nurses had access to a [NAME] (a system for organizing and accessing information, used in nursing for quick patient-specific information, and by businesses for data storage and retrieval) for resident interventions for behaviors, the direct care staff do not have access. -He/She has been showing the CNAs interventions for resident triggers. During an interview on 4/15/25 at 5:08 P.M. LPN B said: -He/She started working at the facility on 4/10/25. -He/She did CALM and CPI training at orientation, but no other formal training for behavior management. -Interventions for resident behaviors depends on the behavior, then after the behavior is identified he/she will determine the intervention. -Sometimes information about the behavior, triggers and interventions were in the care plan or he/she would ask other staff. -He/She had no training on how to access resident specific behavior information. During an interview on 4/16/25 at 11:53 A.M. the SSD said: -Care plans were behind and he/she had been trying to update the best he/she could. -The regional care plan coordinator had been asked to come in to assist with updating care plans. There was not anyone in the facility to update the care plans. During an interview on 4/16/25 at 2:32 P.M. Nurse Practitioner (NP) A said: -Staff had reported a decline in the resident over the last few months. -Resident needed assistance with decisions. Review of Resident #13's Quarterly MDS dated [DATE] showed the resident was mildly cognitively impaired with no mood or behavior concerns documented. During an interview on 4/16/25 at 4:46 P.M. Resident #13 said: -He/She moved into room [ROOM NUMBER] about three to four weeks ago. -The window was broken after he moved in by his/her roommate, Resident #3, who returned today. -Resident #3 broke the window in the afternoon before he/she was sent to the hospital the last time on 3/22/25. -He/She saw Resident #3 break the window. -The Administrator knew about the broken window and tried to blame him/her. -Although there have been staff in the facility, there were no staff on the Transition Unit. During an interview on 4/17/25 at 9:40 A.M. the AIT said: -Resident #3 broke the window that was just repaired after returning from the hospital yesterday. -Resident was placed on one-on-one supervision and relocated in room away from the window. -He/She advised the resident's care plan was updated at admission. Review of the resident's Care Plan for 4/17/25 showed: -Problems listed on care plan include: --At risk for COVID. --admitted to facility for long term care. --Facility would follow resident's advanced directive for code status. --Had allergies that may put the resident at risk if used or given. --PASRR evaluation Level II. --Resident was on the stop program due to TBI and COPD. ---Approved five person CALM take down will not be used. NOTE: No care plan for behaviors or falls. During an interview on 4/17/25 at 4:18 P.M. the former DON said: -The resident had a very odd and sudden decline and was exhibiting bizarre behaviors. -There was indication of psychosis related to dementia and mental health diagnoses. -Falls were new for the resident as well and they have been added to the resident medical record as a behavior. -All of the residents medical records were in a box in the DON office. -He/She did not know if Resident #3 broke the window, however there were concerns about his/her behaviors. -Resident #3 was sent out initially for delirium and had a long hospital stay. -Resident #3 had several emergency room visits with falls. -There was discussion about medication changes and finding a good medication regimen for the resident. -He/She noticed the resident's decline the first time the resident was sent out at the beginning of March. There was no identified plan for the decline. -There resident was having bizarre behaviors and had several medications stopped and/or reduced. -When the resident returned he/she did well for a couple of days and then continued to decline with motor ability, mobility and task management. -The resident's decline was sudden and very odd. -There was an indication of psychosis related to dementia and mental health diagnosis per the physician. -The falls were new for the resident as well and had started laying on the floor prior to the delirium. -Behavior management training was mandated at the first of the year online. -CNAs were only able to observe and report behaviors. Direct care staff are to ask the nurses how to work with the residents behaviors. -People that have been with the residents for a while would know what to do for behaviors. -The nurse was responsible for relaying information to the staff on what to look for and what to do for each resident. -Interventions were to be guided by the nurse. During an interview on 4/18/25 at 9:41 A.M. CNA E said: -He/She has been working at the facility since January 2024 and has not had any behavior management training. -He/She has never seen anything for resident specific behaviors, triggers or interventions. -All information related to the residents' behaviors was by word of mouth or the nurse would tell the staff. During an interview on 4/18/25 at 10:53 A.M. CNA F said: -He/She has always worked on the Transition Unit, at times worked the whole building by him/herself. -He/She worked on the Transition Unit on 4/17/25 overnight when the resident had kicked the window out at around 10:00 P.M. -There was no CNA from dayshift to give report and he/she realized the resident had returned to the facility after taking the residents out to smoke at 7:30 P.M. so he/she was not notified the resident had returned by a nurse. -On 4/17/5 at 9:30 P.M. Resident #3 was beating the wall and yelling, the resident's roommate reported the resident had kicked out the window. -He/She reported the broken window to the AIT between 5:00 A.M. and 6:00 A.M. -Many times he/she was the only staff on the hall as the CMT leaves once they are done passing medications. -There were some behavior management videos online, but they had been down and unable to access. -Resident specific interventions have to be something that was written up, but he/she had not been trained on how to find that information. During an interview on 4/18/25 at 11:45 A.M. NP B said: -Around the beginning of March the resident was confused, was getting into things, there was not enough staff and he/she agreed to sent the resident out. -He/She felt the facility did not have enough staff to manage the resident. -There are staffing concerns that there was not enough staff to manage the behaviors of the behavioral and mental health side of the facility (Transition Unit). -There was not enough staff to do one on one for residents who may need that kind of supervision. -He/She was concerned there was not enough staff in the building to manage the behaviors for the residents on the Transition side who have histories of mental health and behavioral needs. -There was not enough staff to have one to one supervision for a resident if needed. -He/She was not aware of any behavior management training for the staff. -He/She expected the staff to be able to find behaviors, triggers and interventions for the residents. -He/She did not feel the PASRR was being utilized for all residents with mental health diagnoses. Review of Resident #3's Progress Note dated 4/20/25 showed: -6:06 A.M. --Resident agitated and keeps yelling out nurse. --Tried to change out dressings and resident refused said it could be done it tomorrow. --Residents and roommates keep getting into it with resident. --He/she keeps going down on the floor, acting helpless and difficult to redirect. --He/she keeps asking for water then spills it on the floor, snacks offered. -2:01 P.M. --Resident slid him/herself to the edge of wheelchair then slid to the floor landing on his/her buttock in the dining room. --Staff witnessed, however was not close enough to intervene. -There was no staff training, no additional information to the plan of care for the resident triggers or interventions. During an interview on 4/21/25 at 3:56 P.M. CNA G said: -He/She worked on the locked unit for the same gender before it closed due to flooding. -The resident was moved to the Transition Unit and it had more stimulation, such as loud music. -He/She had CPI training at the beginning of the year online, otherwise there was no other behavior management training. -When residents have behaviors he/she will try to de-escalate and if unable to do so call a code for help. -Resident specific behavior management information was shared by word of mouth. -He/She was not aware of any source of information for resident specific behaviors, triggers and intervention. During an interview on 4/21/25 at 6:30 P.M. the Administrator in Training (AIT) said: -When he/she started working in the facility, he/she was a weekend supervisor. -On or about 3/30/25 he/she became the AIT. -He/She was unable to give an exact date of the prior administrator's last day. -He/She was the administrator on 4/15/25. -He/She was AIT and being trained by the Administrator to conduct an investigation on 3/31/25. -Checks should have been done at 10:00 P.M., midnight and 2:00 A.M. -If the nurse had completed checks like he/she was supposed to for the midnight census, the residents would have been observed no later than midnight. -He/She expected the staff to do their checks and the charge nurse to ensure the checks were being done. -He/She was aware of Resident #3's behavior becoming erratic at the beginning of the year. -The resident was growling, yelling, screaming and putting self on the floor. -The resident had been on the Transition Unit for approximately three months at that time. -He/She noticed a rapid change in the resident from around Christmas to New Year. -There had been some medications changes and psychiatric evaluations. -By the beginning of March nothing was working and they were unable to manage the resident's behaviors no matter what they did. -The resident was sent out on 3/10, 3/14, and again on 3/22. -The resident returned to the facility on 4/16 and kicked out the window again that same day. -When the resident is sent out the staff sends a medication list and the face sheet, the rest of the information related to the resident's transfer is given to the ambulance crew and the hospital verbally. -The facility does not provide written documentation as to the change for which the resident was being transferred. -When residents are transferred or admit/readmit to the facility he/she expects the nurses to document in the progress notes clear and concise information so the staff providing cares were able to identify behaviors, triggers and interventions for the resident. -He/She knew the window in room [ROOM NUMBER] was broken and the Administrator reported the window was fixed on 3/26/25. -He/She did not who would have fixed the window on that date as there was no in house maintenance person. -It was the Administrator's responsibility to ensure the window was repaired, he/she was not the administrator until 4/15/25. -The Regional Director of Operations was supposed to help him/her as he/she transitioned into the position. -He/She was unable to identify the last day he/she worked for the Administrator. -The move to the memory care unit for Resident #3 was a great move as there was not as much chaos as the Transition Unit and more one-on-one engagement. -The one-on-one supervision has been discontinued as there was more staff and extra oversight. -Denied any knowledge of Resident #3 consuming chemicals on 3/14/25 resulting in his/her transfer to the hospital. During an interview on 4/24/25 at 2:17 P.M. LPN C said: -The resident was on the locked unit prior to moving to the Transition Unit. -Over the last couple of months, he/she started noticing changes with the resident. -The resident would not sleep at night, holler through the night, and would get into his/her wheelchair and argue with other residents. -There was a new psych doctor that she thought was working with the resident. -Since the resident was moved to the memory care unit on 4/21/25, the resident has done much better. -He/She tried to get the administration to move the resident to the memory care unit, unfortunately it did not happen right away. During an interview on 4/15/25 at 1:24 P.M. CMT A said: -He/She has not had any behavior specific training. -There were some dementia training's last year sometime. -The residents from the behavior unit have done okay, but some are out of control. -In order to know what he/she is supposed to do for a resident having behaviors, he/she must discuss with the charge nurse. -He/She can access the care plan for information for the resident, but the CNAs do not have that access. MO00252031 MO00252201

Based on interview and record review, the facility failed to thoroughly complete an assessment for capacity to consent per the facility policy for one sampled resident (Resident #2) including coordination and participation with all health professionals out of 13 sampled residents who were known to engage in sexual activity. The facility census was 49 residents. Review of the facility Sexual Activity Abuse and Neglect Policy, dated 5/14/24, showed: -Residents that are wishing to engage in sexual activity will be allowed to participate in these activities as long as both parties consent and have the ability to consent. Nonconsensual acts and acts of impact negatively on the resident community such as public displays shall not be allowed. -If the resident has a guardian or cognitive impairment an assessment should be completed to determine the resident's ability to consent. This assessment will be completed by the interdisciplinary team with the assistance of the resident physician and or psychiatrist as needed. -The assessment shall include the following: 1) awareness of the relationship including the awareness of who is initiating the relationship and comfort level with sexual intimacy; 2) ability to avoid exploitation including resident's values and ability to refuse unwanted advances; 3) awareness of potential risk associated with the relationship. -The resident guardian will be invited to provide their guidance. 1. Review of Resident 1#'s admission Record showed the resident was admitted on [DATE] under the supervision of a legal guardian with diagnoses including Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) and depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of Resident 1#'s Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/26/25 showed the resident was cognitively intact. Review of Resident 1#'s 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; this includes dually certified beds both Medicare and Medicaid) dated 9/20/22 showed the resident: -Diagnoses including: schizophrenia, schizoaffective disorder, psychotic disorder, bipolar I disorder, major depressive disorder, polysubstance dependency, amphetamine abuse and malingering. -Recommended services included: --Behavior support plan. --Structured environment. --Activities of Daily Living (ADL) program. --Crisis intervention services. --Personal support network. -Behaviors to be addressed in nursing facility plan of care: --Verbal aggression. --Hallucinations. --Wandering. --Paranoia. --Abnormal thought process. --Structured environment. Review of Resident #1's undated Care Plan showed: -On 12/13/24 he/she was found to have a peer in his/her bed during the night. --He/she would have no adverse effects with having peers in his/her bed. --He/she was provided education on safe sex practices, guardian updated. -Capacity to consent was not identified. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including spina bifida and mood disorder due to known psychiatric condition and major depression. Review of Resident #2's Annual MDS dated [DATE] showed the resident was cognitively intact. Review of Resident #2's undated Care Plan showed: -On 5/04/23 he/she was sexually active and refused birth control. --His/her goal was to not have unprotected sex. --Staff were educated on safe sex practices, offer birth control options and provide education to the resident. -On 12/13/24 he/she was found in a peer's bed. --His/her goal remained to have no adverse reactions related to sexual incidents with peers. --He/she was provided education on safe sex practices. -Capacity to consent was not identified. Review of the facility investigation dated 12/13/24 showed: -Certified Nurse Aide (CNA) F found Resident #1 and Resident #2 in bed together. -They admitted to having mutually consensual sex. -Resident #1 and Resident #2 completed capacity to consent forms and were found to be competent. *Note: The investigation did not have copies of the capacity to consent forms. Review of Resident #1's Capacity to Consent to Sexual Activity Form dated 12/13/24 showed: -He/she had a legal guardian. -He/she was able to communicate yes or no decisions. -He/she had the ability to understand relevant information. -He/she had the ability to appreciate the situation and its likely consequences. -He/she had the ability to manipulate information rationally. -The resident had the capacity to consent. -Only one signature was listed on the form. It was the Social Services Designee (SSD). -There was no signature for the resident, legal guardian, evaluator or Administrator. Review of the medical record for Resident #2 showed no capacity to consent form completed in December 2024. Review of Resident #2's Progress Note dated 12/16/24 showed: -SSD received an email from the legal guardian. -Resident #2 had been adjudicated as incapacitated and disabled by the courts. -Legally he/she does not have the legal capacity to consent to sex, nor is he/she allowed to sign any type of written consent or contract. -Only his/her legal guardian may sign consents and we (the guardian) cannot consent to sexual activity on behalf of our ward due to the aforementioned lack of capacity after adjudication. -Please ensure he/she is not left alone with opposite sex residents, as these types of situations jeopardize his/her safety, as it puts him/her in the position of possibly being accused of inappropriate behavior. Review of Resident #2's Progress Note dated 12/18/24 showed: -SSD documented the Director of Nursing (DON) and Administrator present, the legal guardian shared the resident had a history of sexual indecencies and felt that because he/she had been declared an incapacitated adult by the courts, he/she does not have the cognition to consent to sexual relations. -Guardian requested the resident be moved to a locked same sex unit to protect him/her. Review of Resident #1's Progress Note dated 3/25/25 said: -The resident verbalized concerns to SSD about his/he romantic relationship with Resident #2. -Therapy services were offered at that time. Review of Resident #2's Progress Note dated 3/31/25 showed: -He/She was visiting with SSD about bladder training due to the desire to be sexually active. -He/She disclosed he/she engaged in sexual activity with Resident #1 on 3/27/25. -He/She said the sexual encounter was mutually consensual. -He/She completed the sexual consent form. Review of Resident #1's Brief Interview for Mental Status (BIMS) dated 3/31/25 showed the resident was cognitively intact with a score of 13 out of 15. Review of Resident #1's Progress Note dated 3/31/25 showed: -He/She clarified that Resident #2 remained in his/her room from after the last smoke break of the night until approximately 2:00 A.M. -They both were unclothed in bed and engaged in penetration before falling asleep. -He/She was unaware Resident #2 planned to visit him/her after their last smoke break. Review of the Resident #1's Capacity to Consent to Sexual Activity Form dated 3/31/25 showed: -The resident had a legal guardian. -He/she was not able to communicate yes or no decision. -He/she did not have the ability to understand relevant information. -He/she did not have the ability to appreciate the situation and its likely consequences. -He/she did not have the ability to manipulate information rationally. -There was doubt about Resident #1's capacity to consent at this time and further evaluation was necessary. -The signature of the resident and the former Administrator. -There was no signature for the guardian, evaluator or SSD. Review of Resident #2's Capacity to Consent to Sexual Activity Form dated 3/31/25 showed: -The resident did not have a guardian. -Was able to communicate yes or no decision. -Had the ability to understand relevant information. -Had the ability to appreciate the situation and its likely consequences. -Had the ability to manipulate information rationally. -It was concluded the resident had the capacity to consent at that time. -Signature of resident and Administrator. -No signature for the evaluator or SSD. Review of Resident #2's Progress Note dated 3/31/25 showed: -Reported he/she engaged in sexual activity with another resident in the other resident's room from approximately 9:58 P.M. to 3:00 A.M. on the night of 3/27/25. -They had intercourse and he/she fell asleep and did not wake up until 3:00 A.M. -He/She was escorted back to his/her room by the other resident when he/she woke up unnoticed by staff. Review of Resident #1's Progress Notes dated 4/1/25 showed: -SSD communicated with the legal guardian. -Resident to be placed on a 30-day restriction as a result of having sex. -The legal guardian informed SSD while the resident has a legal right to sign a consent for sexual activity, the office policy/principal dictates, that due to the resident being under a Public Administrator and deemed incompetent, the office does not permit the reside to participate in or consent to sexual activity. -Resident signed consent to sexual activity with the understanding that he/she does not have the capacity to consent to sexual activity. Review of facility Incident Report dated 4/1/25 showed: -Alleged sexual contact on 3/27/25 between Resident #1 and Resident #2. -Statements received from witnesses and residents involved. -On 3/31/25 Resident #2 disclosed to the SSD that he/she and Resident #1 engaged in consensual sexual intercourse on 3/27/25. -Resident #2 stated the interaction was voluntary and mutual. -SSD and Registered Nurse (RN) approached Resident #1 to assess the resident's well-being and confirm the interactions was consensual. -Both residents were evaluated for cognitive capacity and understanding of consent. The report did not identify when Resident #1 or Resident #2 was evaluated or how they were evaluated. -After the investigation, it was determined the residents were able to consent but after reading the previous incident that took place on 12/13/24, it was determined by Resident #2's guardian that he/she was not able to consent. -There was no notation the interdisciplinary team was consulted about assessment and determination of the capacity to consent as indicated in the facility policy. During an interview on 4/10/25 at 11:30 the Director of Nursing (DON) said: -Resident #2 was transferred out of the facility to ensure no sexual activity would occur again with Resident #1. -The legal guardian was not in favor of consent for Resident #1 to engage in sexual activity mostly due to how the residents went about things, being sneaky. -There was a policy related to sexual activity and this was the second infraction for both residents. -Resident #2 disclosed sexual activity to the SSD. During an interview on 4/10/25 at 5:53 P.M. Resident #1 said: -He/She was trying to get a hold of someone because someone was supposed to follow up with him/her and Resident #2 about them being together from the last time they were sexually active in December 2024. -He/She just found out consensual sex was not allowed in the facility. -Staff said he/she could engage in consensual sexual activities if he/she signed papers. -He/She was told Resident #2 would get an assault charge if he/she did not sign papers, then he/she was given restrictions. -He/She was dating Resident #2. -They were caught before when a staff member walked in on them while they were in his/her bed. -A couple of weeks ago Resident #2 came into his/her room and exposed him/herself to him/her and they began making out. -He/She did not have any sex protection and Resident #2 was ok with engaging in intercourse without protection. -He/She has had a legal guardian after being homeless. -He/She admitted to having sexual relations with other residents in the past, one of which was no longer living in the facility. -He/She was told on 4/1/25 that he/she could not consent to sexual activity but was told to sign a paper saying he/she did not know consequences of sexual activity. -He/She did not understand why he/she was asked to sign if he/she had a legal guardian. During an interview on 4/16/25 at 1:20 P.M. Resident #2 said: -He/She had been having sex with his/her boyfriend and the first time they had sex they got caught and the facility staff had them sign a papers. A consent paper saying they consented to have sex and they also signed an abuse/neglect regarding sexual activity paper. -He/She had to sign a sex consent and then with Resident #1 was put on a 90 day restriction because Resident #1's guardian disapproved of them having sex. -He/She said the form they made Resident #1 sign was the consent to have sex. During an interview on 4/16/25 at 2:32 P.M. Nurse Practitioner (NP) A said: -He/She was aware of Resident #1 and Resident #2 engaging in sexual activity. -Due to his/her limited interaction with the residents, he/she could not confirm if the residents were competent to consent to sexual activity. -He/She was unaware of the sexual activity that occurred 12/13/24 until about a month ago. -Residents have the right to be sexually active. -If the resident is not competent and/or not their own guardian, he/she is not sure if a decision could be made for them to consent to sexual activity. -If the resident is competent to be his/her own guardian, then should be competent to decide to engage in sexual activity. -He/She has not conducted any assessments for competency to consent to sexual activity. During an interview on 4/17/25 at 11:44 A.M. the Physician said: -He/She expects that there are residents that are still young men and women with desires and the facility should sit down with each of them to explain the risks. -He/She does not support or condone sexual activity for residents. -There should be education and appropriate steps taken to prevent the spread of sexually transmitted disease. -Residents should engage in sexual activity at least in a semi-private room. -The most important thing for sexual activity is consent. -Felt like psych should be involved with assessing for competency to consent for sexual activity. During an interview on 4/17/25 at 4:18 P.M. the Former DON said: -He/She conducted a full investigation related to the sexual interaction between Resident #1 and Resident #2 on 12/13/24. -Based off the legal guardian statement Resident #1 was not able to consent to sexual activity as the guardian did not feel the resident had the capacity to consent. -Resident #1 was not assessed specifically for capacity to consent, something about legal ramifications. -Resident #1 said he/she had not been educated on that part of his/her guardianship. -The issue was Resident #2 was his/her own person. During an interview on 4/18/25 at 11:45 A.M. NP B said: -He/She was informed by the current administrator of Resident #1 and Resident #2 engaging in sexual activity. -Resident #1 and Resident #2 were aware of the risks and consequences of sexual activity. -He/she did not perform competency evaluations or was included in assessment. During an interview on 4/21/25 at 5:58 P.M. the Administrator in Training (AIT) said: -He/She was a part of the investigation began on 3/31/25 for Resident #1 and Resident #2 when Resident #2 disclosed the residents were engaging in sexual activity on 3/27/25. -He/She could not explain why Resident #1 had not been transferred to a secured same sex unit after Resident #1's legal guardian made the request in December 2024 to protect the resident. -Resident #1 was not moved as requested by the legal guardian and now the facility is dealing with the incident. -Both residents disclosed they were aware they were not to engage in sexual activity from the December incident during the interviews conducted on 4/1/25. -He/She did not feel the sexual encounter met the criteria of abuse or neglect. Resident #2 was able to spend from 10:00 P.M. until 2:00 A.M. in bed with Resident #1 and return to his/her own room unnoticed because staff were not doing what they were supposed to. -He/She said NP B was performing assessment for competency on a monthly basis, even though NP B state those assessments were done by the mental health team and not by the NP alone. -Assessments per the facility policy had not been completed for any residents who met the criteria for an assessment. -He/She thought NP B was assessing cognition and capacity during monthly mental health visits. -Since NP B was not performing cognition and capacity, then there were no cognition and capacity assessments for the residents that require determination for the ability consent, therefore they were not in compliance with the facility policy. MO00252031

Based on observation, interview and record review, the facility failed to ensure a broken window on a locked behavioral and mental health unit from 3/22/25 to 4/16/25 was replaced and cleaned up. Broken glass shards were left on the unit and accessible to all residents on the unit. All resident on the unit had the potential for harm with broken glass left unattended. The facility census was 49 residents. Review of the facility Incidents and Accidents Policy dated 5/18/24 showed: -It is the policy of this facility for staff to utilize Point Click Care Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. -Accident refer to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. -Incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. -Purpose of incident reporting can include: --Assuring the appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. --Conducting root cause analysis to ascertain causative and contributing factors to avoid further occurrences. --Alert risk management and or administration of occurrences that could result in claims or further reporting requirements. --Meeting regulatory requirement for analysis and reporting of incidents and accidents. -Incidents that rise to the level of abuse, misappropriation or neglect will be managed and reported according to the facility's abuse prevention policy. -Incidents include but are not limited to falls, observed accident/incidents, and unobserved injuries require an incident report. -In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk for harm. -Any injuries will be assessed by the license nurse or practitioner and the affected individual will not be moved until safe to do so. -First aid will be given for minor injuries such a as cuts or abrasions. -The supervisor or other designee will be notified of the incident/accident. -The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or there findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of injury. -In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks per protocol and document on the neurological flow sheet. -The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. -Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. -If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. 1. Review of Resident #3's admission Record showed the resident admitted on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration sequela and 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). Review of Resident #3's Comprehensive Discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/10/24 showed the resident was severely cognitively impaired. Review of Resident #3's 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; this includes dually certified beds both Medicare and Medicaid) dated 3/12/24 showed the resident: -Had diagnoses including paranoid schizophrenia, personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems) , borderline intellectual functioning (a categorization of intelligence wherein a person has below average cognitive ability (generally an IQ of 70-85), but the deficit is not as severe as intellectual disability (below 70) and polysubstance dependence (condition where an individual meets the diagnostic criteria for substance use disorder (SUD) on two or more different classes of substances simultaneously and exhibit significant problems and impairments in their lives due to their use of multiple substances, such as alcohol, stimulants, opioids, or sedatives). -Recent physical altercation with another resident where he punched another resident in the face while out smoking on 2/19/24. -Recent multiple falls. -History of having a guardian. -Had chronic medical and psychological condition requires around the clock medical care and oversight. -Had multiple comorbidities requiring skilled care. -Had resided in a skilled facility for many years. -At that time he remained safest in a skilled nursing facility. -Behaviors to be addressed were aggression, mood liability, and impulsivity. -Required medication therapy and monitoring, structured environment for history of aggression towards other and high fall risk, and crisis intervention plan recommended due to aggression towards others. During an observation and interview with Administrator in Training (AIT) on 4/16/25 at 12:04 P.M. said: -room [ROOM NUMBER] had a broken window with glass shards on the windowsill. -He/she was not sure how long the window had been broken. -He/she noticed the window was broken about two weeks ago. -The Maintenance Director left last week and there have been Maintenance workers from sister facilities assisting. Review of Resident #13's Quarterly MDS dated [DATE] showed the resident was mildly cognitively impaired with no mood or behavior concerns documented. During an interview on 4/16/25 at 4:46 P.M. Resident #13 said: -He/She moved into room [ROOM NUMBER] about three to four weeks ago. -The window was broken after he/she moved in by his/her roommate, Resident #3. -Resident #3 broke the window in the afternoon before he/she was sent to the hospital the last time on 3/22/25. -He/She saw Resident #3 break the window. -The Administrator knew about the broken window and tried to blame him/her. Review of facility incident report dated 3/27/25 showed: -AIT noticed a broken window next to an empty bed in Resident #13's room. -Resident #13 denied breaking window. -No action required, waiting for window to be repaired. During an interview on 4/16/25 at 5:01 P.M. the AIT said: -He/She was working as a direct care staff nurse about two weeks ago when he/she noticed the window was broken in room [ROOM NUMBER]. -The Administrator advised him/her the window was being repaired. -He/She started on the investigation on 3/27/25 but had not completed it. During an interview on 4/17/25 at 10:56 A.M. the Regional Maintenance Director said: -He/She repaired the window, cleaned up the glass shards off the windowsill, and replaced the window shade in room [ROOM NUMBER] on 4/16/25. -He/She was not informed when the window was broken in room [ROOM NUMBER] until he/she came to the facility on 4/16/25. -There is a maintenance thread for all department heads, however, there was no information related to the broken window in room [ROOM NUMBER] sent in the thread. -He/She does not know how staff are communicating maintenance needs within the facility. -If he/she had been aware of the broken window when the AIT noticed it was broken on 3/27/25, the window would have been repaired immediately due to the broken glass being dangerous. During an interview on 4/17/25 at 4:18 P.M. the former Director of Nurses (DON) said: -He/She recalled the window in room [ROOM NUMBER] being broken about 3/25/25. -Resident #13 said the window was broken, but he/she could not recall when. -The Administrator and AIT had a conversation about the broken window in room [ROOM NUMBER], but he/she was not a part of that conversation. -He/She did not know if Resident #3 broke the window, however there were concerns about his/her behaviors. During an interview on 4/18/25 at 11:45 A.M. Nurse Practitioner (NP) B said: -He/She was not informed of the resident kicking or breaking any windows in the facility. -He/She was concerned about the broken window in room [ROOM NUMBER] left in disrepair for over twenty-one or more days. -The broken window was located in a locked facility with behavioral and mental health residents and any resident could use the broken glass for self-harm, harm to others or attempt to elope from the broken window which could result in serious injury. During an interview on 4/21/25 at 6:30 P.M. the AIT said: -He/She knew the window in room [ROOM NUMBER] was broken and the previous Administrator reported the window was fixed on 3/26/25. -He/she never followed up. -It was the Administrator's responsibility to ensure the window was repaired. MO00252201

Based on interview and record review, the facility failed to notify the resident or the resident's representative of meetings for care plan (a document that specified health care and supported needs and outlined how the facility met resident requirements) development, review, and revision, for seven sampled residents (Resident #47, #41, #17, #46, #33, #10, and #51) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's policy titled Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 3.0 Care Assessment Summary and Individualized Care Plans dated 11/6/23 showed it did not include any instructions related to inviting the resident and/or their responsible party to participate in care plan meetings. Review of the facility's Comprehensive Care Plans policy, dated 6/26/24 showed: -The purpose of the policy was to develop a comprehensive person-centered care plan for each resident. -It addressed measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs. -Person Centered was defined as the resident being in control of the support the resident needed to make their own choices and have control over their daily lives. -The care planning process included an assessment of the resident's strengths and needs and incorporated the resident' s personal and cultural preferences in developing goals of care. -The comprehensive care plan was prepared by multiple staff as well as the resident or the resident's representative. 1. Review of Resident #47's annual MDS dated [DATE], showed: -The resident was cognitively intact. -The resident's diagnoses included anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), depression (a low mood or loss of pleasure or interest in activities for long periods of time), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During an interview on 10/15/24 at 10:03 A.M. the resident said: -He/She had not been to a care plan meeting. -He/She had no recollection of having been invited to a care plan meeting. Review of the resident's Electronic Health Record (EHR) on 10/18/24, showed no information was found showing the resident was invited to or present at a care plan meeting. 2. Review of Resident #41's quarterly MDS dated [DATE], showed the resident was severely cognitively impaired. Review of the resident's EHR progress notes showed no entries for care plan meeting contacts to the guardian. During an interview on 10/15/24 at 11:43 A.M., the guardian for Resident #41 said: -He/She had not been to see the resident for a while. -He/She was unsure when the last care plan meeting was. -The care plan was overdue. 3. During an interview on 10/21/24 at 8:56 A.M., Certified Nursing Assistant (CNA) A said: -Resident's were invited to care plan meetings. -He/She thought they came to the room of the resident. During an interview on 10/21/24 at 9:20 A.M., CNA B said: -He/She looked on the care plan for information regarding the resident. -Resident's were supposed to go their care plan meeting. During an interview on 10/21/24 at 9:32 A.M., Agency Licensed Practical Nurse (LPN) A said: -Resident' s were invited to care plan meetings. -He/She was not sure of the process. During an interview on 10/21/24 at 9:49 A.M., the Human Resource (HR) director said: -He/She was unaware if residents were invited to care plan meetings. -He/She believed they should be. During an interview on 10/21/24 at 10:11 A.M., Certified Medication Technician (CMT) A said: -Residents were invited to care plan meetings -The Social Services Director (SSD) and the Director of Nursing (DON) got together with the resident or the resident's representative to discuss any changes. 37576 4. Review of Resident #17's Admission record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). -Anxiety. -Psychotic Disturbance (also known as Psychosis is a severe mental disorder that causes a person to lose touch with reality and have abnormal perceptions and thoughts). -Schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). Review of the last care plan meeting dated 7/20/23 at 12:18 P.M., showed: -Care plan meeting held with the Interdisciplinary Team (IDT-usually the DON, Nursing, MDS, SSD, Physician and other ancillary disciplines involved with care). -The resident's guardian was present by phone. -Did not indicate that the resident attended. During an interview on 10/15/24 at 11:18 A.M., the resident said: -He/She did not know what a care plan meeting was. -He/She did not remember ever being invited to a care plan meeting. Review of the resident's EHR on 10/21/24, showed: -No other care plan meeting records were found. -No other documentation that the resident, his/her family or representative were notified or invited to a care plan meeting. 5. Review of Resident #46's Admission record showed he/she was admitted on [DATE] with the following diagnoses: -Diabetes Mellitus II [DM-condition that affects the way the body processes blood sugar (glucose)]. -Anxiety. -Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the last care plan meeting dated 3/30/23 at 12:16 P.M., showed: -Care plan meeting was held with the IDT team. -Did not indicate that the resident attended. -Did not indicate that the resident, his/her family or representative were notified or invited to the care plan meeting. During an interview on 10/15/24 at 11:35 A.M., the resident said: -He/She did not know what a care plan meeting was. -He/She could not recall ever being invited to a care plan meeting. Review of the resident's EHR on 10/21/24, showed: -No other care plan meeting records were found. -No other documentation that the resident, his/her family or representative were notified or invited to a care plan meeting. 6. Review of Resident #33's Admission record showed he/she was admitted [DATE] with the following diagnoses: -Spina Bifida (birth defect in which a developing baby's spinal cord fails to develop or close properly while in the womb). -Anxiety. -Diabetes Mellitus II During an interview on 10/15/24 at 1:49 P.M. the resident said: -He/She had not been to a care plan meeting. -He/She did not remember ever having been invited to a care plan meeting. Review of the resident's EHR on 10/21/24, showed no documentation that the resident, his/her family or representative were notified or invited to a care plan meeting. During an interview on 10/23/24 at 10:43 A.M., the SSD said: -He/She was uncertain if the MDS Coordinator set up the care plan meetings. -Residents and family received invites either by phone or email. -He/She believed care plan meetings were held quarterly. 22727 8. Review of Resident #51's care plan showed the resident's care plan was most recently updated on 6/26/24. Review of the resident's MDS showed the resident's most recent MDS was an annual dated 9/18/24. During an interview on 10/16/24 at 11:49 A.M., the resident's responsible party said he/she did not get invited to care plan meetings. 9. Review of Resident #10's care plan showed the resident's care plan was most recently updated on 4/2/24. Review of the resident's MDS showed the resident's most recent MDS was an annual dated 10/2/24. During an interview on 10/16/24 at 9:25 A.M., the resident's responsible party said no one had called or mailed him/her a care plan meeting invitation. 10. During an interview on 10/23/24 at 8:55 A.M., the Social Services Director said: -He/She's worked at the facility for six weeks (which was the week of 9/16/24). -He/She let the MDS Coordinator know when the guardians were available for care plan meetings and then they invited them. -He/She called family members to invite them. -There have not been care plan meetings for Residents #51 or #10 since he/she had been at the facility. During an interview on 10/23/24 at 9:34 A.M., the MDS Coordinator said: -He/She became the MDS Coordinator on 6/6/24. -He/She and the Social Services Director were responsible for inviting family members to care plan meetings. -He/She and the Social Services Director were supposed to communicate with each other to determine who would mail out the invitations. -They hand deliver care plan meeting invitations to residents who were their own responsible party. -If the resident had a responsible party/guardian, they emailed or called with a follow-up email or call. -They usually mailed the care plan invitations a month in advance. -Not sure if Residents #47, #41, #17, #46, #33, #10, and #51 were invited to or had a care plan meeting. During an interview on 10/23/24 at 12:30 P.M., the DON said: -Family members should have been notified by a phone call or email of care plan meetings. -Care plan meetings should be held quarterly. -They have a letter to follow-up on the schedule of the care plan meeting that could be mailed or emailed. -Residents and family or representative should attend.

Based on observation and interview, the facility failed to maintain essential kitchen cooking, cleaning, and/or storage equipment in a proper and safe operating condition to ensure the ability to meet the residents' nutritional needs in an uncontaminated and timely manner. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility census was 50 residents with a licensed capacity for 97 residents at the time of the survey. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed various kitchen appliances and equipment including, but not limited to, a chemical dishwasher, a stove with a flat-top grilling surface, and a convection oven. During an interview on 10/15/24 between 2:04 P.M. and 2:52 P.M. the DM said the following: -The stove did not work very well because they had to turn it on around 5:00 A.M. so it would be warm enough for lunch time use. -The chemical dishwasher's thermometer was broken so he/she could never tell if it got hot enough to clean items well; no steam issued out when opened after its use. -The convection oven hardly operated any better than the stove. During an interview on 10/23/24 at 2:03 P.M. the Administrator said the following: -They had always had trouble with the dishwashing machine in the kitchen. -The kitchen needed to be gutted and completely redone to work well.

Based on observation and interview, the facility failed to hire an adequate number of dietary staff to safely carry out all of the functions of the food and nutrition services, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service and safety. This deficient practice potentially affected all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 50 residents with a licensed capacity for 97 residents at the time of the survey. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. showed the Dietary Manager (DM) was the only staff in the kitchen at that time. During an interview on 10/15/24 between 2:04 P.M. and 2:52 P.M. the DM said the following: -The dietary staff consisted of 1 morning cook and aide and 1 afternoon cook and aide. -There was not enough staff because of their low resident census. -He/She filled in the gaps in staffing as needed. Observation on 10/18/24 between 12:03 P.M. and 12:11 P.M. showed the DM was accompanied by two other staff members in the kitchen at that time. During an interview on 10/18/24 at 12:11 P.M. the DM said they had started to use Styrofoam plates and cups and plastic utensils because though he/she normally had a cook and two aides, one of which was a dishwasher, because of the low census his/her staff was cut down and they were without a dishwasher now.

Based on observation, interview and record review, the facility failed to ensure the residents' personal possessions were maintained and failed to ensure the residents' dignity when having to wear clothes that didn't fit or were not in good repair for five sampled residents (Residents #5, #41, #42, #43, and #10) and three supplemental residents (Residents #16, #21, and #50) out of 13 sampled residents. The facility census was 50 residents. Review of the facility's policy, Dignity and Respect, dated 6/29/23 showed: -Every resident has a right to be treated with dignity and respect. -All the residents' possessions, regardless of their apparent value to others, must be treated with respect. -Residents have the right to retain and use personal possessions to assist each resident in maintaining their independence. 1. Review of Supplemental Resident #16's care plan dated 5/30/23 showed: -The resident: --Had impaired cognitive function. --Instructions to staff to encourage as much participation by the resident as possible during care activities. --Maintain consistency in timing of care activities as much as possible. -There were no details on how much assistance the resident needed for care activities including getting dressed. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/9/24 showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Cognition was not assessed. -The resident's functional abilities (self-care abilities such as dressing, transferring from one surface to another, etc.) were not assessed. -The resident's diagnoses included dementia (a chronic condition that causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). Review of the resident's inventory of personal effects dated 7/16/24 showed: -The resident had three pants and four shirts. -There were no updates to the resident's inventory. Observation on 10/18/24 at 6:23 A.M. showed: -The resident was wearing red sweatpants and a blue sweatshirt. -The sweatpants waist band was about twice the size of the resident's waist. -The resident was standing up in the dining room. -The sweatpants were down below the resident's brief. -The resident kept pulling up his/her sweatpants and trying to roll them up at the waist. Observation on 10/18/24 at 8:04 A.M. showed the resident's closet was completely empty. Observation on 10/21/24 at 2:11 P.M. showed: -The resident was standing in the dining room wearing plaid pajama pants that were too big around his/her waist. -The resident tried to pull his/her pants up to stay in place multiple times. During an interview on 10/23/24 at 10:01 A.M., Licensed Practical Nurse (LPN) B said the resident got into other residents' stuff and would put on layers of clothes that were not his/hers. 2. Review of Resident #43's care plan dated 8/8/24 showed: -The resident: --Had a diagnosis of schizophrenia. --Had cognitive deficits. -There were no details on how much assistance the resident needed for care activities including getting dressed. Review of the resident's quarterly MDS dated [DATE] showed: -The resident's speech was not assessed. -The resident's ability to understand others and to be understood by others was not assessed. -Cognition was not assessed. -The resident's functional abilities (self-care abilities such as dressing, transferring from one surface to another, etc.) were not assessed. Review of the resident's electronic health record showed no inventory of personal effects. The resident's inventory of personal effects was requested but not received. Observation on 10/21/24 at 1:48 P.M., showed: -The resident was in the dining room. -He/She was wearing blue sweatpants and a red sweatshirt. -The sweatshirt was above his/her stomach and his/her sweatpants were down to his/her hips, leaving the resident's stomach hanging out between the bottom of his/her sweatshirt and the top of the sweatpants. 3. Review of Supplemental Resident #21's care plan dated 7/12/21 showed the resident was independent with care activities. Review of the resident's inventory of personal effects dated 4/10/22 showed: -The resident had two comforters, 40 pairs of socks, and four sweat suits. -There were no updates to the resident's inventory. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Was severely cognitively impaired. -Was dependent upon staff for dressing and putting on footwear. -Some of his/her diagnoses included dementia and schizophrenia. Observation on 10/15/24 from 9:00 A.M. to 1:00 P.M. showed: -The resident's pants kept sliding down and staff pulled them up three times while the resident was in the dining room. -The resident's pants did not have a middle belt loop in the back. -When the resident would sit down, his/her pants would slide down. -At 10:30 A.M., the Director of Nursing (DON) came onto the unit. -The DON asked if the resident had a belt and staff said he/she did not. -The DON took a white plastic trash bag tied it to the resident's belt loops on the sides to keep his/her pants up. -The resident had the trash bag on until after lunch. Observation on 10/21/24 showed: -At 9:30 A.M., the resident walked out of the dining room while his/her pants were falling and he/she was trying to pull them up. -At 10:20 A.M., the resident was standing in front of the television in the dining room while his/her pants were falling and he/she was trying to pull them up. Review of the resident's trust fund current account balance dated 10/22/24 showed the resident had $893.71 in his/her account. Observation on 10/23/24 at 8:29 A.M. showed there were two shirts in the resident's closet. During an interview on 10/23/24 at 12:30 P.M., the DON said: -Using a trash bag to tie the resident's pants up was not an appropriate intervention. 4. Review of Resident #42's care plan dated 10/18/21 and 10/31/21 showed: -The resident had dementia. -The resident was independent with care activities except for needing cueing and supervision. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Was severely cognitively impaired. -Required partial assistance from staff for dressing and putting on footwear. -He/She had a diagnosis of dementia. Review of the resident's inventory of personal effects dated 10/16/24 showed the resident had one pullover, three t-shirts, three joggers, three polo shirts, one long-sleeve shirt, two sweatpants, two hoodies, two flannel pants, nine pairs of socks, five boxers, shoes, and one sweater. Observation on 10/18/24 showed: -At 7:14 A.M., a dietary staff member asked the resident, Why don't you tie your pants up? as the resident was walking down the hall wearing light blue pajama pants that were falling off. -At 7:15 A.M., the resident came back down the hall with the draw string tied on the blue pajama pants. -At 7:23 A.M., the resident was in the dining room while holding his/her pants up using his/her left hand on his/her left hip. -At 8:04 A.M., there was one black shirt in the resident's closet, and it had Resident #15's name on the inside tag. Observation on 10/23/24 at 8:33 A.M., the resident had two pants in his/her closet. 5. Review of Resident #10's incident note dated 9/12/24 showed: -The resident saw another resident sitting in the chair with his/her pants on. -The resident approached the other resident saying, You took my pants! -The nurse separated the residents. Review of the resident's care plan dated 9/29/22 and 1/9/23 showed: -The resident had a diagnosis of schizophrenia, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and dementia. -The resident required assistance of one person for getting dressed. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Was severely cognitively impaired. -Required substantial/maximum assistance with dressing. -Did not walk. -Some of his/her diagnoses included dementia, and schizophrenia. Review of the resident's undated inventory of personal effects showed the resident had one coat, seven shirts, one hoodie, two [NAME], one pair of shorts, three pairs of jeans, two pajamas, and one pair of sweatpants. During an interview on 10/16/24 at 9:25 A.M., the resident's responsible party said: -He/She thought the resident had so many clothes he/she couldn't even begin to describe them all. -He/She brought him/her jogging suits. -The resident's name was on his/her clothes. -The resident told him/her on Saturday, 10/12/24 that another resident recently broke his/her television. -The resident's television was brand new. -The staff did not talk to him/her about the resident's television being broken. Observation on 10/16/24 at 10:11 A.M. showed: -The resident had 12 short-sleeve tops, one pair of shorts, two pairs of pants, one jacket, one sweatshirt, one sweat suit, and one coat. -Of the items in the resident's closet, the resident's name was on seven shirts, one pair of shorts and one coat but another resident's name was written in black marker on the front right side of the coat that was clearly visible. Observation on 10/21/24 at 9:42 A.M. showed: -There was a television on the resident's overbed tray. -The screen was cracked and shattered and had multi-color lines going across the television on the top half. Review of the resident's trust fund current account balance dated 10/22/24 showed the resident had $4,951.26 in his/her account. During an interview on 10/23/24 at 8:55 A.M., the Social Service Director said: -He/She worked at the facility for six weeks. -He/She was told yesterday that the resident's television was broken. -A solution for that would be to have the family replace the television because stuff like that happened in the facility. -Another option might be that there might be an extra television in the one in the attic or somewhere else. During an interview on 10/23/24 at 10:29 A.M., LPN B said he/she was not aware of the resident's television being broken. During an interview on 10/23/24 at 10:30 A.M., Certified Nursing Assistant (CNA) C said he/she saw the resident's television was broken but he/she didn't know how or when it got broken. During an interview on 10/23/24 at 12:30 P.M. the DON said: -He/She had not heard about the resident's television being broken. -The resident's television should be replaced and the family should be notified. 6. Review of supplement Resident #50's inventory of personal effects dated 8/23 showed: -The resident had four pairs of pants, four shirts, one pair of shoes and six pairs of socks. -There were no updates to the resident's inventory. Review of the resident's care plan dated 7/3/24 showed: -The resident had cognitive impairment with a communication deficit. -The care plan did not address the level of assistance required for the resident's care activities such as getting dressed. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was understood by others. -Was severely cognitively impaired. -Some of his/her diagnoses included dementia and schizophrenia. Observation on 10/21/24 at 2:07 P.M. showed: -The resident walked through the dining room wearing gray sweatpants that kept falling. -The resident's brief was visible. -The resident was holding his/her pants at the waist, trying to keep them up. Review of the resident's trust fund current account balance dated 10/22/24 showed the resident had $118.73 in his/her account. Observation on 10/23/24 at 8:29 A.M. showed the resident had six shirts in his/her closet. 39469 7. Review of Resident #5's annual MDS dated [DATE] showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes (a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). -Dementia. -Parkinson's (a disorder of the central nervous system that affects movement often including tremors). -Depression. -Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to maniac highs). -Psychotic Disorder (a mental disorder characterized by a disconnection from reality). -Schizophrenia. -It was somewhat important to choose the clothing he/she wore. -It was somewhat important to take care of his/her personal belongings. -The resident resided on a locked Memory Care unit. Observation on 10/18/24 at 7:42 A.M. with CNA C showed: -The resident had one shirt hanging in his/her closet. -There were no belongings in his/her dresser. -The resident was dressed with high top tennis shoes that did not have shoe laces in them. -The resident did not have socks on. Observation on 10/18/24 at 9:28 A.M. with LPN B showed: -The resident was complaining about a sore on his/her foot. -The resident was wearing high top tennis shoes that did not have shoe laces in them. -The resident had a new blister on his/her left great toe. -He/She cleansed the area and applied a Band-Aid to it. During an interview on 10/18/24 at 9:28 A.M. LPN B said: -The high top tennis shoes belonged to the resident. -If the resident had shoe strings in the tennis shoes and wore socks he/she would not have developed a blister. -Most of the residents do not have much clothing. -The CNA's should have ensured the resident had socks and his/her shoes were tied correctly. -Many of the residents on the unit went shopping going into other resident's closets and take their clothes to wear. -Sometimes it would lead to a fight if a resident saw someone else wearing his/her clothing. Review of the resident's Resident Trust Fund account on 10/22/24 showed he/she had a balance of $978.16. 8. Review of Resident #41's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia. -Cognitive communication deficit. -Need for assistance with personal cares. Review of the resident's Care plan dated 10/8/21 showed: -He/She had a history of wondering throughout the unit, could become intrusive into peers personal space. -Staff was to monitor if he/she was looking for something. Review of the resident's undated inventory list showed the following clothing: -One pair of pants. -One sweater. -One coat. -One cut up shirt. -One arm sling. -One pair of shoes. -The inventory list was not signed. Review of the resident's inventory list dated 6/3/22 showed the following clothing: -One pair of blue and gray pajamas. -One pair of green pants. -One blue suit. -One jogging set. -One blue jacket. Observation on 10/16/24 at 9:45 A.M. showed: -The resident had on black boots that were several sizes too big. -There were no shoe laces in the left boot. During an interview on 10/16/24 at 9:45 A.M. LPN A said: -The boots the resident was wearing were not his/hers. -The resident had a communication problem, he/she understood most English but would only answer with a single word. -He/She did not know where the resident was from or which language he/she spoke. -The residents would go shopping in each others room all the time. -He/She did not know if the resident had any shoes of his/her own. During an interview on 10/16/24 at 9:50 A.M. Certified Medication Technician (CMT) C said: -There was one shirt and one pair of pants in the resident's closet. -The resident was wearing black boots that were many sizes too large. -One boot did not have any shoe strings. -The resident would put on other people's clothes and shoes. -Those were not the resident's shoes. -The residents go shopping in each others closet. -They have tried to redirect him/her but there was a language barrier with him/her. -The residents should have their names written in their clothing. -The Social Worker or nurse would have put their name on their clothing. -The residents should have their belongings such as clothing listed on an inventory sheet when they first come into the facility. -All the residents clothes were put in one or two closets. -Staff would look for the resident's clothes but end up using whatever they think would fit him/her. -There was a cardboard box full of clean socks which they pulled out a pair and put on the residents. -There were hospital gowns for the residents to wear to bed but usually they slept in their clothes. -The residents should have had their own clothing and belongings in their own closet but it was too hard to keep up with. -Most of the residents were incontinent of bowel and bladder and they would wear disposable briefs. -He/She did not know about the residents who wore underwear where they got those. Review of the residents Resident Trust Fund account showed he/she had a balance of $1106.04. 9. During an interview on 10/21/24 at 9:10 A.M. the facility's Physician said: -He/She would expect the residents to wear their own clothes and they should fit them. -The facility should have provided clothing if the residents did not have enough. During an interview on 10/22/24 at 10:00 A.M. the Social Service Director said: -The residents should have had an inventory list made of their belongings upon admission. -The inventory list should have been accurate, dated, and signed by the person who had completed it. -Environmental Services brought personal items into his/her office and they put the resident's name on the belonging. -He/She documented the belongings in the computer system. -If the residents did not have enough clothing there were extra clothing in the attic that had been donated. -Some of the residents had money in their resident account that could have been used to purchase needed clothing. -Some of the residents had family that would purchase needed items for the resident. -The residents should have had enough pants or shorts to cover their briefs. -It was not acceptable to use others clothing. -Staff should have taken the resident back to their room and redressed them in their own clothing if they had been observed with someone else's clothing on. -It was the CNA's responsibility to keep the resident's belongings in their own closet or dresser. During an interview on 10/23/24 at 8:55 A.M., The Social Services Director said: -He/She worked at the facility for six weeks. -He/She was aware of only one resident missing clothes and that resident no longer lived at the facility. -The facility and the family were responsible for residents' clothes. -The facility could help shop for clothing. -It should be reported by the unit staff to him/her that when a resident didn't have any clothes that fit. -He/She has seen that residents are wearing clothes that don't fit. During in interview on 10/23/24 at 9:00 A.M. LPN B said: -The CNA's were responsible for the resident's clothing. -The residents should have been wearing their own clothing and the clothing should have been in good repair such as having the shoestrings in them. During an interview on 10/23/24 at 10:01 A.M., LPN B said: -A lot of the residents' clothes didn't fit and their clothes come up missing. -They should report clothes that don't fit to the DON, laundry or Social Services. -They should call laundry to see if they can find something that fits. During an interview on 10/23/24 at 12:30 P.M., the DON said: -Residents should have their own clothing. -It was a dignity issue for the residents to not have their own clothing. -They do a lot of sharing clothes on that unit. -Clothes should be labeled. -Clothes should be in the residents' closets that they belong to. -The have a hard time keeping up with everything on that unit. -Some families have requested lock on closet doors. -Night shift was a good time to organize clothes and have the residents do that with them as an activity. -Inventory should be done when they move in and when new things are added or when removed. -The clothing should have been marked with the residents' whole names. -The housekeeping director was assigned to the initial inventory completion. -If the residents didn't have adequate clothing, they should have contacted the family or responsible party to ask them to bring what was needed for the resident. -They get clothing donations. -Residents could can make a shopping list and the facility could shop for them. -Laundry has a labeler for when new items brought in. -Things were not getting labeled. -Sometimes initials only were put on clothing. -Staff should privately take the resident to get something that fits if their pants are falling down or change out of the clothing if it was not theirs. -The residents on the locked unit seemed to frequently loose belts. -They should try to keep extra belts around. -They could try sweat pants if the resident's clothes don't fit. -The resident's clothing should have fit well and been kept in good repair. -Staff should notify the Social Services Director if the resident had no clothes. -Residents should wear their own clothing. -The resident's shoes should have had shoe laces.

Based on interview and record review, the facility failed to designate one or more individuals, qualified by completing specialized training in infection prevention and control, as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The facility had a census of 50 residents. A policy for Infection Preventionist was requested but not received at the time of exit. 1. Review of the facility Infection Control Surveillance log book showed the Director of Nursing (DON) completed the infection control training modules 1 - 15 on 10/19/24. The final test showed he/she did not pass the IP test. During an interview on 10/21/24 at 2:07 P.M., the DON said: -He/She was the IP for the facility. -He/She was not IP certified. -He/She had been in classes for the IP program since 10/1/24 and finished the last module on 10/17/24. -The previous DON was the previous IP. -He/She did not spend a minimum of 20 hours per week on the Infection Control Program due to also performing DON duties.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. Additionally the facility failed to ensure an Infection Control Surveillance program was completed for the previous 12 months to include all infections in the facility, including those not treated with an antibiotic, failed to ensure residents were tested upon admission and annually with a two step tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) skin test for five sampled residents (Resident #5, #43, #46, #41, and #33) out of 13 sampled residents and for four sampled employees (Employee A, B, C, and G) out of seven sampled employees, failed to ensure staff wore gloves when cleaning up a bodily fluid spill, failed to ensure supplies were available for staff and residents to perform hand hygiene (soap and towels), failed to ensure Enhanced Barrier Precautions were utilized while staff provided wound care, and failed to ensure EBP signage and an isolation cart with Personal Protective Equipment (PPE) supplies were readily available outside of the resident rooms for one sampled resident (Resident #43), and failed to ensure soap, towels, and toilet paper were readily available for staff and residents to perform hand hygiene on the locked unit. The facility census was 50 residents with a licensed capacity for 91 residents at the time of the survey. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a three-sink area, an ice machine, a chemical dish-washing machine, a hand-washing sink, and an ice machine out in the hallway. Review of the facility's policy, dated 2017 and provided by the Administrator, showed a 2-page (pg.) document entitled Emergency Water Protocol, that consisted of guidelines and procedures on how much drinkable water they should have on-hand in an emergency or disaster, and included nothing about water-borne pathogen prevention. During an interview on 10/21/24 at 2:07 P.M. the Administrator said that 2-pg. document was their Legionella paperwork. Observation on 10/23/24 between 12:56 P.M. and 1:45 P.M. during the facility LSC walk-through inspection showed the following: -The building was equipped with a full fire sprinkler system and had its incoming water supplied by the local water company. -There were two commercial clothes washers in the laundry area. -On the 100 Unit there was a steam table and a sink in the dining room along with a Utility closet with a mop hopper and six multi-bed resident rooms with restrooms. -On the East 200-300 Unit there was a Bathhouse along with 14 single and multi-bed resident rooms with restrooms. -There was a steam table and a sink in the Main Dining Room that led to the 400 Unit. -On the [NAME] 400 Unit that was being renovated behind plastic curtains there was a Bathhouse along with 12 unoccupied single and multi-bed resident rooms with restrooms. -On the Lower Level 30 Unit that was also being renovated there was a sink in the dining room, a Bathhouse, and 11 unoccupied resident rooms with restrooms. Review on 10/23/24 of the facility's undated binder entitled Legionella Water Management, provided by the Maintenance Supervisor (MS), showed the following: -There were eight sections of various information, guidelines, policies and procedures, most of which were educational. -The pages with the Building Water Flow Diagram also had a written explanation of the water flow throughout the facility, but nowhere indicated specific areas of risk, like dead ends or unused plumbing/pipes, with their rated potential of likelihood and risk level for each. -The last section was a 36-pg. CDC toolkit with the assessment questions left blank. -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no documentation of any site logbook being maintained with any cleanings, sanitizings, descalings, and/or inspections mentioned. During an interview on 10/23/24 at 2:03 P.M. the Administrator said the following: -He/She read their Legionella policies in order to apply things to this facility. -His/Her Regional Plant Operations person also showed them how to find certain things. During an interview on 10/23/24 at 2:11 P.M. the MS said the following: -He/She went by the binder to implement the program's basic requirements. -They had started the program after a resident was admitted with Legionella a few years ago. -He/She was educated on the requirements by the previous Administrator. -The two units being renovated was due to a resident having pulled down a fire sprinkler pipe which burst and flooded the [NAME] 400 Unit and the Lower Level 30 Unit below it. 32720 2. Review of the facility's Infection Prevention and Control Program policy dated 6/26/24 showed: -A system of surveillance was utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. -The Infection Preventionist (IP) served as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility. Review of the facility's Infection Control Surveillance log book for the previous 12 months showed: -No documentation of infection tracking for October 2023, November 2023. -December 2023 showed one resident had a Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -January 2024 and February 2024 showed no documentation of any infections. -March 2024 showed three residents with a UTI and one resident with an unknown infection. -April 2024 showed one resident with an unknown infection. -May 2024 showed one resident with an unknown infection and one resident with a UTI. -June 2024 showed one resident with an unknown infection. -July 2024 showed one resident with an unknown infection and three residents with a UTI. --A map included in the tracking folder showed two residents with UTI, five residents with a skin infection, and one resident with COVID (a new disease caused by a novel (new) coronavirus). -August 2024 showed one resident with a UTI. -September 2024 showed no documentation of any infections. During an interview on 10/21/24 at 2:07 P.M., the Director of Nursing (DON) said: -The Infection Control Surveillance log book should have included all infections in the building. -He/She had a system in the electronic medical records he/she could use to help track infections in the building. It did not match the infections listed in the log book. -It appeared the book only contained infections that were treated with antibiotics. -The July 2024 map included all infections, not just those that were treated with antibiotics. -The log book was incomplete. 3. Review of the facility's Tuberculosis Testing policy dated 6/29/23 showed: -The purpose was to ensure each resident and employee of the facility was tested for TB after entering the facility to prevent the spread of infection. -Upon hire, a new employee would receive a two step TB skin test. -Upon admission and readmission each resident would receive a two step TB skin test. -Each resident would also have an annual one step TB skin test. Review of the facility's Infection Prevention and Control Program policy dated 6/26/24 showed direct care staff should be tested for TB upon hire. 3a. Review of Employee A's employment file showed: -His/Her hire date was 7/30/24. -He/She had a TB skin test completed on 8/1/24. A second step TB skin test was not completed. 3b. Review of Employee B's employment file showed: -His/Her hire date was 9/24/24. -No documentation a TB skin test was completed. 3c. Review of Employee C's employment file showed: -His/Her hire date was 4/23/24. -No documentation a TB skin test was completed. 3d. Review of Employee G's employment file showed: -His/Her hire date was 6/11/24. -No documentation a TB skin test was completed. 4a. Review of Resident #5's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's annual TB skin test showed a TB skin test was documented as administered on 1/11/24 with a result of 0 millimeters (mm) induration. The result did not include the date the TB test was read. 4b. Review of Resident #43's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's admission TB skin test showed: -He/She had a TB skin test from a previous facility. The test was documented as completed on 4/23/24 with a result of 0 mm induration. The result did not include the date the TB test was read. -No documentation a second TB skin test was completed upon admission to the facility. 4c. Review of Resident #46's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's annual TB skin test showed no documentation of a TB skin test since 6/29/22. 4d. Review of Resident #41's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's annual TB skin test showed he/she had a TB skin test on 1/11/24 with a result of 0 mm induration. The result did not include the date the TB skin test was read. 4e. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE], Review of the resident's annual TB skin test showed: -He/She had a TB skin test on 1/11/24 with a result of 0 mm induration. The result did not include the date the TB skin test was read. -He/She had a TB skin test on 1/23/24 with a result of 0 mm induration. The result did not include the date the TB skin test was read. During an interview on 10/21/24 at 2:07 P.M., the DON said: -All residents should have a two step TB skin test upon admission to the facility. -If the resident had a recent TB skin test from another facility, they would use that as the first step, but the resident would still need a second step TB skin test upon admission. -All staff should have a two step TB test. The first step upon hire, the second step a couple weeks later. -TB skin tests should have a read date within 48-72 hours from the test being administered. -It appeared as though the resident TB skin tests were not entered in the electronic medical records correctly which was why it did not give staff the option of entering the TB skin test read dates. -Any staff nurse could administer and read the TB skin tests. -Normally the Human Resource person would track staff TB to ensure they were completed and completed timely. 39469 5. Review of the CDC Implementation of PPE Use in Nursing Homes to Prevent Spread of Multi Drug-Resistant Organisms (MDROs), dated 4/2/2024, showed the following: -Enhanced Barrier Precautions (EBP) may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO. -When implementing enhanced barrier precautions, it was critical to ensure that staff had awareness of the facility's expectations about hand hygiene and gown/glove use. -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE. -For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility Enhanced Barrier Precautions policy dated 5/18/24 showed: -EBP expanded the use of PPE beyond situations which exposure to blood and body fluids was anticipated. -EBP used gown and gloves during high contact resident care activities. -EBP (gown and gloves) must be used for high contact resident care activities for residents with wounds and/or indwelling medical devices. -High contact resident care activities included but were not limited to: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care. 6. Observation on 10/15/24 at 10:23 A.M. showed Licensed Practical Nurse (LPN) B was wiping up a resident's saliva (spit) with paper towels and ungloved bare hands. He/She did not wash his/her hands after cleaning up the saliva. Observation on 10/15/24 at 11:25 A.M. showed: -No paper towels were readily available for staff or residents to dry their hands at the sink in the dining room. -An unidentified resident washed his/her hands in the dining room sink and wiped his/her hands dry on his/her dirty pants due to not having paper towels available. Observation on 10/15/24 at 1:15 P.M. showed: -The outside door leading to the smoking area had a red colored stain on it. -The warming table in the resident's dining room had not been cleaned off after lunch service. Observation on 10/16/24 at 9:00 A.M. showed: -The warming table in the resident's dining room had not been cleaned off after breakfast service. -One resident was eating crumbs off of the warming table. -The outside door leading to the smoking area had a red colored stain on it. Observation on 10/16/24 at 1:00 P.M. of resident room [ROOM NUMBER] showed: -The bathroom did not have any soap or paper towels for hand hygiene and did not have any toilet paper for the residents. -The bathroom was shared by four residents who resided in room [ROOM NUMBER]. Observation on 10/18/24 at 9:00 A.M. of resident rooms [ROOM NUMBER] showed: -room [ROOM NUMBER] was shared by four residents. The bathroom did not have any soap or paper towels for hand hygiene and did not have any toilet paper for the residents. -room [ROOM NUMBER] was shared by four residents. The bathroom did not have any soap or paper towels for hand hygiene and did not have any toilet paper for the residents. -room [ROOM NUMBER] was shared by four residents. The bathroom did not have any soap or paper towels for hand hygiene and did not have any toilet paper for the residents. During an interview on 10/18/24 at 9:28 A.M., LPN B said he/she did not know how the residents would have cleansed their hands after they used the restroom without soap or paper towels. During an interview on 10/18/24 at 10:10 A.M., Certified Medication Technician (CMT) B said: -He/She knew they did not put paper towels or soap in the residents' bathrooms because the residents would eat the soap or flush the paper towels down the toilet. -There should be toilet paper in the rooms. During an interview on 10/21/24 at 9:50 A.M. , CMT C said: -They did not put paper towels in the resident's restrooms as they would flush them down the toilet and it would stop up the toilets. -The rooms should have toilet paper, but they usually did not. -They did not stock hand soap in the rooms as the residents would eat it. -He/She did not know how or when the residents cleaned their hands. -The stain on the outside door had been that way for several months. -Housekeeping should have cleaned it. -Housekeeping or the kitchen staff should have cleaned the warming table after each meal. Observation on 10/21/24 at 10:20 A.M. showed the following resident rooms did not have toilet paper, paper towels, or hand soap in their rooms: -101, 102, and 105. During an interview on 10/21/24 at 10:30 A.M., Agency LPN A said: -The residents would get into everything so they could not put soap, paper towels, or toilet paper in the rooms as they flushed it down the toilet or ate the soap. -He/She did not know if the residents' cleaned their hands. -Most of the residents wore disposable briefs. -Staff should help residents cleanse their hands before meals. -If the bathrooms were out of order there was one public bathroom which they could use but it was kept locked so a staff member would have to unlock it for them to use. -The stain on the outside door might have been rust. -Maintenance or Housekeeping should have cleaned it. -He/She had not reported it to them. -The residents would eat anything and he/she was not surprised they had picked crumbs off of the warming tray. -Housekeeping or the kitchen staff should have cleaned it after each use. 7. Review of Resident #43's Face Sheet showed he/she was readmitted to the facility with a diabetic foot ulcer (an sore or open wound on the foot that can occur in people with diabetes). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/23/24 showed he/she was moderately cognitively impaired. Observation on 10/16/24 at 9:30 A.M. of the resident showed no isolation cart or signage on his/her bedroom door indicating the resident was on Enhanced Barrier Precautions. During an interview on 10/16/24 at 9:30 A.M., Agency LPN A said: -He/She did the resident's wound care daily. -The resident did not require any precautions when providing care. During an interview on 10/16/24 at 9:30 A.M., the resident said: -The nurse usually did his/her cares. -The staff did not wear a gown when providing cares, but they did wear gloves. During an interview on 10/18/24 at 6:15 A.M., Registered Nurse (RN) A said: -The locked unit had one resident who required Enhanced Barrier Precautions. -There was one isolation cart for the unit that was kept near the nurse's station. -The nurse's station was on the far side of the locked unit and not near the resident's room who was on EBP. -The DON had provided an inservice last week on EBP. The education included staff were to wear a gown and gloves when providing catheter care or wound care for a resident. -Resident #43 had a diabetic foot wound and another (unsampled) resident had a scalp laceration (cut) which required a bandage dressing. -Staff should wear gown and gloves when treating those two wounds. -He/She thought there should have been a sign on the residents' doors showing they were on EBP, but they did not have any of the signs on the residents' doors on the locked unit. Observation on 10/18/24 at 6:30 A.M. showed: -The isolation cart was stored at the nurse's station which was not near the hall the resident resided on. -RN A went into multiple rooms to help the residents get dressed wearing the same gown. -He/She did not change gowns between resident rooms. Observation of Resident #43's wound care and interview with LPN B on 10/18/24 at 9:28 A.M. showed: -No EBP signage outside the resident's room. -No isolation cart outside the resident's room or near the resident's room. -LPN B provided wound care to the resident's left foot diabetic ulcer. He/She wore gloves but did not wear a gown. During an interview on 10/18/24 at 9:28 A.M. LPN B said: -He/She had education last week from the DON regarding EBP. -He/She should have worn a gown and gloves since the resident had an open wound. During an interview on 10/18/24 at 10:10 A.M., Certified Medication Technician (CMT) B said: -He/She did not know when he/she should wear gown and gloves. -He/She was not sure if he/she had any education on using PPE with EBP. During an interview on 10/21/24 at 9:50 A.M. , CMT C said he/she did not know anything about EBP. During an interview on 10/23/24 at 12:30 P.M. the DON said: -They had just started to use EBP at the facility maybe two weeks ago. -The DON and Administrator were in charge of educating the staff about EBP. -He/She had educated the staff about EBP on 10/3/24. -The education included when EBP should have been used and what PPE staff was expected to wear. -If a resident had a tube such as a catheter, central line, or any wound which required more than a band aide staff was to have used EBP. -There should have been an EBP sign on the resident's door. -There should have been an isolation cart nearby the resident's door. -The residents who should have had EBP should have been passed on in report. -EBP should have been in the resident's care plan. -He/She would have expected the residents to have hand soap, paper towels, and toilet paper in their rooms. Staff should have over seen hand hygiene after the residents used the restroom. -The rooms including bathrooms should have been in good repair or maintenance should have been notified. -Maintenance should have been notified about the stain on the door. -Housekeeping or a CNA should have cleaned the warming table after each use.

Based on observation, interview, and record review, the facility failed to maintain a well-known, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors, to ensure the food's safe and sanitary handling, storage, and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 50 residents with a licensed capacity of 97 residents. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed there was a reach-in refrigerator in a hallway outside the kitchen and a reach-in freezer in the Dry Storage room. Review of the Dietary Resident Rights Policy, last reviewed 11/6/23 and provided by the Administrator, under Section XIII. Accommodation of Needs, read, Food purchased from vending machines, brought in by family or friends of the patient, or ordered by the resident will be considered personal property of the patient. Staff will assist resident in storage of food in a safe, sanitary manner. During an interview on 10/23/24 at 12:44 P.M., in the kitchen the DM said the following: -He/She did not know if the facility had any policy about outside food brought in for residents. -He/She did know they would need to eat it in the lobby and not take it back to their room.

Based on observation and interview, the facility failed to keep the kitchen and Dry Storage (DS) room floors clean; failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to maintain plastic and/or rubber cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; and failed to store foodstuffs within recommended temperature parameters, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 50 residents with a licensed capacity for 97 residents at the time of the survey. 1. Observation on 10/15/24 between 2:04 P.M. and 2:52 P.M. during the initial kitchen inspection with the Dietary Manager (DM) showed the following: -There was a 6 pound (lb.) 10 ounce (oz.) can of fruit cocktail on a dispenser rack that was heavily dented at its bottom side and two 7 lb. 5 oz. cans of jellied cranberry sauce with rusted top rims on the top shelf of a bakers rack next to the dispenser rack in the DS room. -Blood was puddling in the bottom of Unit #4 reach-in refrigerator labeled Meat Freezer and a temperature log on the outside with only [DATE] & 2 marked at 0 degrees Fahrenheit (F.), but an inside thermometer read 20 F. -An open 1 gallon (gal.) jug of teriyaki sauce approximately (app.) 1/7 full on a rack next to the can dispenser read Refrigerate After Opening on its label. -There was cardboard, an artificial sweetener packet, an onion peel, a 32 oz. bag of powdered sugar, and puddling water under the food racks in the DS. -An open 1 gal. jug of soy sauce on a rack behind the door to the DS read Refrigerate After Opening for Quality on its label. -There was paper residue on a manual can opener in the kitchen. -2 white spatulas with chipped edged blades were in a utensil drawer of a food preparation table. -A green cutting board by the dishwashing machine was excessively scored to the point of plastic bits flaking off. Observation on 10/18/24 between 12:03 PM and 12:11 P. M showed the following: -There was a 6 lb. 10 oz. can of fruit cocktail on a dispenser rack that was heavily dented at its bottom side and two 7 lb. 5 oz. cans of jellied cranberry sauce with rusted top rims on the top shelf of a bakers rack next to the dispenser rack in the DS room. -Blood was puddling in the bottom of Unit #4 reach-in refrigerator labeled Meat Freezer and no temperature log on the outside, but an inside thermometer read 22 F. -An open 1 gal. jug of teriyaki sauce approximately 1/7 full on a rack next to the can dispenser read Refrigerate After Opening on its label. -There was a small packet of iodized salt, an artificial sweetener packet, an onion peel, a 32 oz. bag of powdered sugar, and puddling water under the food racks in the DS. -An open 1 gal. jug of soy sauce on a rack behind the door to the DS read Refrigerate After Opening for Quality on its label. -There was paper residue on a manual can opener in the kitchen. -2 white spatulas with chipped edged blades were in a utensil drawer of a food preparation table. -A green cutting board by the dishwashing machine was excessively scored to the point of plastic bits flaking off. During an interview on 10/23/24 at 1:44 P.M. the new DM said the following: -All dietary staff were responsible for cleaning the kitchen and DS floors twice weekly. -He/She would expect if a foodstuff read store at a certain temperature on its label that it would be. -Damaged foodstuff cans were set aside, their Regional Dietary Manager (RDM) notified, and they would contact the food vendor for a credit. -Damaged food preparation items were reported to the RDM, tossed and replaced. -He/She would expect food to be free of foreign substances.

Based on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional adequacy needs of residents; failed to have basic food items in stock that were called for in their main menus; and failed to have a comparable always available or alternate foods menu posted that was nutritionally equal to the main dishes, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service. This deficient practice potentially affected all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 50 residents with a licensed capacity for 97 residents at the time of the survey. Review of the 7-page Dietary Resident Rights Policy, last reviewed 11/6/23 and provided by the Administrator, showed under Section XIII. Accommodation of Needs, that Substitutes of like calorie value will be offered to the resident if the planned menu is refused. 1. Review of the pre-prepared 4-week rotation of menus for the current month provided by the Dietary Manager (DM) showed the meal items that were listed were taken from a website called DiningRD.com. During an interview on 10/15/24 at 2:04 P.M. the DM said the following: -Their menus did not come from their food vendor who was U.S. Foods. -If a resident did not like the pork being served, they had soup on hand. Observation on 10/18/24 between 9:33 A.M. and 11:07 A.M. showed there were no alternate foods or always available foods menus posted in either of the dining rooms currently in use. Review of the pre-prepared 4-week rotation of menus for the current month provided by the DM showed the meal items that were listed for lunch on 10/23/24 were roast beef, mashed potatoes and gravy, mixed vegetables, and cake with a beverage. Observation on 10/23/24 at 12:19 P.M. showed a test plate delivered from the kitchen consisted of a Sloppy [NAME] on a hamburger bun and tater tots. During an interview on 10/23/24 between 12:11 P.M. and 12:44 P.M. the DM said the following: -He/She did not order their foodstuffs, their Regional Dietary Manager (RDM) did. -Sometimes the RDM did not check the menus for what was actually needed. -One time they received hot dogs instead of the scheduled pulled pork so they had to make a substitution. -That day they apparently did not order the roast beef for lunch so he/she had to substitute Sloppy [NAME]'s instead. -If a resident did not like what was scheduled for a particular meal he/she would try to give them something in similar calories and nutritional value.

Based on observation, interview and record review, the facility failed to accurately complete the residents' Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for six sampled residents (Residents #10, #43, #45, #51, #9, and #41) and one supplemental resident (Resident #16) out of 13 sampled residents. The facility census was 50 residents. Review of the facility policy titled MDS 3.0 Care Assessment Summary and Individualized Care Plans, revised 11/6/23, showed: -The purpose of the MDS policy was to ensure that the MDS 3.0 sections were completed accurately and in a timely manner by the responsible parties. -Section F was to be completed by the activity director. -Section F allowed the resident to determine his/her own preferences for daily activities. -Section L was to be completed by the nursing staff. -Section L was used to document any dental problems. -The MDS defined the dental health of the resident and included an assessment of mouth and facial pain. -The focus of section L was the relationship between poor oral health, the quality of life, and the nutritional status of the resident. -MDS's must be kept current and up to date. 1. Review of Resident #10's annual MDS dated [DATE] showed the activities section (section F) was left blank for resident and facility staff assessment. Review of the resident's care plan dated 1/19/24 showed: -The resident had a diagnosis of dementia (a decline in mental ability that affects a person's daily life). -The resident had little activity participation due to dementia. Review of the resident's annual MDS dated [DATE] showed the cognitive assessment interview was marked to be completed with the resident, but it was not assessed, and the facility staff assessment of the resident's cognition was not completed. During an interview on 10/15/24 at 10:06 A.M. the resident was able to engage in conversation. Observation on 10/22/24 at 10:43 A.M. showed the resident was singing along to music being played in the dining room. During an interview on 10/23/24 at 9:34 A.M., the MDS Coordinator said: -He/She took over the position of MDS Coordinator on 6/6/24. -The Activity Director should complete the activity section with the MDS Coordinator as back-up. -The MDS Coordinator was responsible for the cognition assessment. -When residents couldn't answer questions about their preferences or to complete the cognition assessment, the staff should complete the staff questions/assessments of those sections. 2. Review of Resident #16's care plan dated 2/3/23 showed: -The resident had impaired cognition due to diagnosis of dementia. -The care plan did not include what assistance the resident required for care activities. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Cognition was not assessed. -The resident's functional abilities (self-care abilities such as dressing, transferring from one surface to another, etc.) were not assessed. Observation on 10/18/24 at 6:23 A.M. showed the resident was standing in the dining room. During an interview on 10/23/24 at 9:34 A.M., the MDS Coordinator said: -He/She took over the position of MDS Coordinator on 6/6/24. -The MDS Coordinator was responsible for the cogitation assessment. -All sections should have been completed on the MDS. 3. Review of Resident #43's quarterly MDS dated [DATE] showed: -The resident's speech was not assessed. -The resident's ability to understand others and to be understood by others was not assessed. -Cognition was not assessed. -The resident's functional abilities were not assessed. During an interview on 10/23/24 at 9:34 A.M., the MDS Coordinator said: -When residents couldn't answer questions to complete the cognition assessment, the staff should complete the staff questions/assessments of those sections. -All sections should have been completed on the MDS and should have been accurate. 4. Review of Resident #45's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had clear speech. -Understood others and was usually understood by others. -Could not participate in the cognitive assessment because he/she was rarely understood. During an interview on 10/23/24 at 9:34 A.M., the MDS Coordinator said all sections should have been completed on the MDS and should have been accurate. 5. Review of Resident #51's care plan showed: -On 3/18/24 the resident was independent with bed mobility, eating, locomotion, personal hygiene, toilet use, transferring, and walking. -On 4/2/24 the resident received anti-depressant medication for depression. -On 4/30/24 the resident had impaired cognitive impairment due to dementia. -On 9/18/24 instructions to staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. -On 9/18/24 instructions to staff were to provide structured activities such as walking inside and outside, reorientation strategies included signs, pictures, and memory boxes. 6. During an interview on 10/23/24 at 8:55 A.M., the Social Services Director said: -He/She's worked at the facility for six weeks. -He/She did section C and one or two other sections, he/she would have to look to see what they were. -He/She didn't know if it was his/her responsibility to answer the employee section of section C if the resident couldn't answer the questions. -He/She thought the Director of Nursing (DON) did the employee answers section of section C if the resident couldn't answer the questions. During an interview on 10/23/24 at 12:30 P.M., the DON said: -They currently do not have an Activity Director to complete the activities section of the MDS. -The Social Services Director was responsible for completing the mood and behavior sections. -In the absence of a Social Services Director or an Activity Director, the MDS Coordinator was responsible for completing those sections of the MDS. -The MDS should be accurate. 51150 7. Review of Resident #9's admission MDS, dated [DATE] showed: -The resident was cognitively intact. -Section F was blank and not completed at the time of admission. -In section L, the resident did not have any dental problems upon admission to the facility. -In section L, the resident did not have any missing/broken teeth upon admission to the facility. Observation on 10/16/24 at 10:30 A.M., showed the resident had a broken tooth. During an interview on 10/22/24 at 1:00 P.M. the resident said: -He/she had a broken tooth upon admission to the facility. -He/she informed the facility staff of the broken tooth upon admission to the facility. 8. During an interview on 10/23/24 at 9:06 A.M., the MDS Coordinator said: -He/she was currently the one responsible for creating a resident's MDS assessment and care plan. -He/she was temporarily covering as the MDS Coordinator at this facility as they do not have a full time MDS Coordinator. -A MDS assessment should be completed upon a resident's admission to the facility and should have included a dental assessment. -He/she would expect a broken tooth to be reflected on a resident's MDS. -He/she would expect activity preferences to be assessed on a resident's initial MDS assessment. During an interview on 10/23/24 at 9:40 A.M., the Social Services Director said: -He/she worked as the Social Services director at this facility part time. -He/she worked on average 2-3 days per week at the facility. -He/she was not aware of the resident's broken tooth. -The admission nurse and the MDS Coordinator should have told the previous social worker about the resident having a broken tooth upon admission to the facility. -The broken tooth should have been documented in the resident's MDS assessment. -He/she was unaware that the resident's activities preferences on his/her initial MDS assessment were not completed. -He/she would expect that activity preferences be completed on a resident's initial MDS assessment. During an interview on 10/23/24 at 12:34 P.M., the DON said: -A resident who had a broken tooth on their initial assessment should have been addressed on the MDS and care plan. -A resident with a broken tooth on their initial assessment should have been communicated to the Social Services Director. -He/she was not aware of the resident having a broken tooth. -He/she was not aware of the resident's activity preferences not being completed on his/her initial MDS assessment. -The activity preferences on the initial MDS assessment were supposed to be completed by the Social Service Director. -He/she would expect the activity preference section to be completed when a resident was admitted into the facility. 39469 9. Review of Resident #41's face sheet showed he/she was admitted to the facility with the following diagnoses: -Dementia. -Cognitive communication deficit. -Need for assistance with personal cares. -The resident had a guardian. Review of the resident's Quarterly MDS dated [DATE] showed: -The resident resided on a locked Memory Care Unit. -Section C: Cognitive Patterns was not completed. During an interview on 10/22/24 at 11:00 A.M. the Social Service Director said: -The MDS should have been completed upon admission. -Section C: Cognitive Patterns should have been completed upon admission and updated quarterly. -Resident #41 was missed. During an interview on 10/23/24 at 12:30 P.M. the DON said: -Every resident should have been evaluated in Section C: Cognitive Patterns upon admission and quarterly. -Resident #41 was missed. -The Social Service Director was responsible for ensuring Section C was completed.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment for residents in the resident rooms and shared bathrooms. Specifically, resident rooms on the locked dementia unit #104, #105, #102, #106, #103, #101 and #207 had no toilet paper, paper towels, or soap for the residents to utilize after toileting, resident rooms on the locked dementia unit #104, #102, #106, and #105 had broken toilet paper holders, broken or missing baseboards, broken drywall, broken or dirty door vents, missing molding, and resident rooms #104 and #207 were dirty with feces and a dark brown/blackish mold-like substance on the floors and walls. The facility census was 50 residents. Review of the facility's Safe and Homelike Environment policy dated 6/5/24 showed: -Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment. -The facility will maintain bed and bath linens that are clean and in good condition. -Report any furniture disrepair to Maintenance promptly. 1. Observation on 10/15/24 at 12:50 P.M. of resident room [ROOM NUMBER] showed: -The room was equipped for three residents. -There were two residents that shared the room. -The mattress on bed 3 was ripped up and not in an easily cleanable condition, the privacy curtain was ripped, and the blinds were broken. -The toilet was missing a toilet bowl lid. -The bathroom did not have paper towels, toilet paper/toilet paper holder, or soap in the soap dispenser. -There was a large hole in the floor underneath the sink. -The walls were covered in a dark brown/black mold-like substance. -The floor vent was covered in a dark brown/black mold-like substance. -The bathroom had feces on the floor and wall, 2. Observation on 10/16/24 at 1:00 P.M. showed the resident's bathroom in room [ROOM NUMBER] there was no paper towels, soap, or toilet paper. There were four residents that shared the room. -There was feces on the floor and dirty underwear. -Feces was smeared on the stool. During an interview on 10/16/24 at 1:05 P.M., Housekeeper A said he/she had just finished cleaning the resident's room. 3. Observation on 10/18/24 at 9:00 A.M. showed resident rooms on the locked dementia unit: -Resident room [ROOM NUMBER] which housed four residents did not have paper towels, toilet paper/toilet paper holder, or soap in the soap dispenser. -Resident room [ROOM NUMBER] which housed four residents did not have paper towels, toilet paper/toilet paper holder, or soap in the soap dispenser. -Resident room [ROOM NUMBER] which housed four residents did not have paper towels, toilet paper/toilet paper holder, or soap in the soap dispenser. Observation on 10/18/24 between 12:59 P.M. and 1:41 P.M. on the locked dementia unit showed the following: -In resident room [ROOM NUMBER] the wall-mounted toilet paper holder holder only had one side present and there was no toilet paper present in the bathroom. -The resident room [ROOM NUMBER] bathroom had baseboard on the left wall left of the toilet coming off which revealed the broken drywall underneath and there were two pieces of dried shriveled food in the under-sink cabinet with one broken door hinge. -There was a dirty toilet paper roll on the back of the toilet in resident room [ROOM NUMBER] and inside the double closets most of the baseboards were missing. -In resident room [ROOM NUMBER] the outside bathroom door vent on its lower quarter was askew and the inside door vent of the other door to an adjoining room was the same way; the wall-mounted toilet paper holder bar was missing. Observation on 10/21/24 at 10:20 A.M. on the locked dementia unit showed resident rooms #101, #102, and #105 did not have toilet paper, paper towels, or hand soap in their rooms. Observation on 10/21/24 between 10:29 A.M. and 10:41 A.M. on the locked dementia showed the following: -In resident room [ROOM NUMBER] the south door jamb to a double closet had its left side molding missing approximately (app.) 18 inches (in.) from the floor up and the right side was completely gone. -The southeast upper wall vent in resident room [ROOM NUMBER] had excessive lint on its louvers (a set of angled slats or flat strips fixed at regular intervals in a vent, shutter, or screen to allow air to pass through). -The northeast upper wall vent in resident room [ROOM NUMBER] had excessive lint on its louvers. 4. During an interview on 10/18/24 at 10:10 A.M., Certified Medication Technician (CMT) B said: -Staff did not put paper towels or soap in the resident bathrooms on the locked dementia unit because the residents would eat the soap or flush the paper towels down the toilet. -There should be toilet paper in the rooms. During an interview on 10/21/24 at 9:50 A.M., CMT C said: -Staff did not put paper towels in the resident's restrooms on the locked dementia unit as they would flush them down the toilet and it would stop it up. -The rooms on the locked dementia unit should have toilet paper but they usually did not. -They did not stock hand soap in the resident rooms on the locked dementia unit as the residents would eat it. -He/She did not know how or when the residents cleaned their hands. During an interview on 10/21/24 at 10:30 A.M., Agency Licensed Practical Nurse (LPN) A said: -The residents on the locked dementia unit would get into everything so they could not put soap, paper towels, or toilet paper in the rooms as they flush it down the toilet or eat the soap. -He/She did not know if the residents cleaned their hands. -Most of the residents wore disposable briefs. -Staff should help them cleanse their hands before meals. During an interview on 10/23/24 at 12:30 P.M., the Director of Nursing (DON) said: -There should be toilet paper, paper towels and soap in each resident's bathroom. -He/She had not seen bathrooms with no paper towels. -If an item, such as a chemical, had not have around children, then he/she had told staff to use that same decision-making process and not let those items around residents. -The rooms should have trash cans. -Staff should do constant rounds and should assist residents with hand hygiene, including before the residents eat. -He/She would expect the resident beds to at least have a bedspread. The Certified Nursing Assistants (CNA) were responsible to ensure beds were made. -All walls should be cleaned, they should not have rust or red stuff on it. During an interview on 10/23/24 at 2:03 P.M. the Administrator said the following: -There were plans to fix any broken baseboards, doors, and jambs. -He/She had sent requests to their corporate office to finish renovations on occupied rooms. -He/She would expect bathroom fixtures and any vents to be complete, intact, and clean. MO00243433

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of a transfer to a hospital, including the reasons for the transfer in writing for three sampled residents (Residents #14, #60, and #10) out of 13 sampled residents. The facility census was 50 residents. Review of the Facility's Notification of Changes Policy dated 5/14/2024 showed: -The purpose of the policy was to ensure that the facility promptly informed the resident, consulted the resident's physician; and notified, consistent with his/her authority, the resident's representative when there was a change requiring notifications. -The facility must have informed the resident, consulted with the resident's physician, and/or notified the resident's family member or legal representative when there was a change that required such notification. -Circumstances that required notification were a significant change in the resident's physical, mental, or psychosocial condition, such as deterioration in health, mental, or psychosocial status. -Circumstances that required notification were a transfer or discharge of the resident from the facility. 1. Review of Resident #14's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/12/24, showed: -The resident was discharged to a hospital with his/her return anticipated. Review of the resident's discharge MDS dated [DATE], showed: -The resident was discharged to a hospital with his/her return anticipated. Review of the resident's quarterly MDS dated [DATE], showed: -The resident was moderately cognitively impaired. Review of the resident's admission record dated 10/18/24, showed: -The resident was his/her own responsible party. -The resident's original admitted was 9/8/16. -The resident's re-admitted was 6/12/24. Review of the resident's medical record on 10/21/24 at 11:30 A.M., showed: -No discharge notice dated 3/12/24. -No discharge notice dated 6/12/24. 2. Review of Resident #60's discharge MDS dated [DATE], showed the resident was discharged to a hospital with his/her return anticipated. Review of the resident's quarterly MDS dated [DATE], showed the resident was cognitively impaired. Review of resident's discharge MDS dated [DATE], showed the resident was discharged to a hospital with his/her return not anticipated. Review of the resident's medical record on 10/18/24 at 6:40 A.M., showed: -No discharge notice dated 6/30/24. -No discharge notice dated 8/13/24. 3. During an interview on 10/21/24 at 11:56 A.M., the Director of Nursing (DON) said: -A notice of transfer should have been given to a resident in writing when the resident was sent out to the hospital. -A notice of transfer was not given to Resident #14 at either time of the resident's hospital transfers. -He/she had no information on Resident #60's transfer notice and was not sure if it was done. -He/she was working on a plan to prevent this from happening in the future. During an interview on 10/23/24 at 11:38 A.M., Licensed Practical Nurse (LPN) B said: -The nurses were responsible for sending the transfer notices when a resident was transferred to the hospital. -The DON had been stepping in and helping with the transfer notices. -He/she was unsure why the transfer notices were not given to Resident's #14 and #60 and/or the resident's guardian's. 22727 4. Review of Resident #10's discharge assessment with return-anticipated dated 1/2/24 showed the resident discharged to an acute hospital. Review of the resident's entry tracking forms showed the resident returned to the facility on [DATE]. Review of the resident's discharge assessment with return-anticipated dated 1/16/24 showed the resident discharged to an acute hospital. Review of the resident's entry tracking forms showed the resident returned to the facility on [DATE]. Review of the resident's medical record showed no transfer/discharge notice for 1/2/24 or 1/16/24. The transfer/discharge notices for 1/2/24 and 1/16/24 were requested on 10/21/24 but were not received. During an interview on 10/21/24 at 10:07 A.M., LPN A said the nurses were supposed to send the transfer/discharge notice when a resident was being discharged to the hospital. During an interview on 10/23/24 at 12:30 P.M., the DON said the nurses were responsible for sending the transfer/discharge notice when a resident was being discharged to the hospital.

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when a staff member threw a plastic meal tray at the resident, hitting the resident on his/her upper lip and causing the resident to go to the hospital and receiving eight stiches to the space between his/her lip and nose. Facility staff failed to protect three residents (Resident #2, #3, and #10) out of 10 sampled residents, from abuse by another resident. On 5/22/24, Resident #2 self-propelled him/herself towards Resident #10 unprovoked and struck him/her in the face causing his/her nose to bleed. On 5/28/24, Resident #2 called Resident #3 a racial slur and struck the resident. In response, Resident #3 struck Resident #2 multiple times, causing two skin tears and a knot on the resident's head. The facility census was 92. The Administrator was notified on 6/4/24 at 9:44 A.M. of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 5/29/24. On 5/30/24, the facility Interim Director of Nurses (DON) reported to the Administrator. The facility in-serviced staff before the start of their next shift. CNA A was terminated. The IJ was corrected on 5/30/24. Review of the facility's policy titled Abuse and Neglect Policy, dated 5/29/24, showed: -The definition of abuse was 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. -It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. -Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. -Physical abuse included but was not limited to hitting, slapping, punching, biting, and kicking. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Vascular Dementia (a common form of 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, judgement, and impulses) caused by impaired supply of blood to the brain). -Primary Insomnia (a decreased ability to fall asleep and/or stay asleep). -Need for Assistance with Personal Care. Review of Resident #1's Annual Minimum Data Set (a federally mandated assessment instrument completed by facility staff for care planning), dated 3/21/24, showed: -The resident was severely cognitively impaired. -The resident had not exhibited any behaviors within the seven days look back period in which the assessment was completed. -The resident had clear speech. -The resident was usually able to make himself/herself understood (difficulty communicating some words or finishing thought, but able if prompted or given time). -The resident was able to understand others. Review of the resident's care plan, showed no care plan prior to 5/31/24 related to any resident behaviors. Review of the late entry nurse skin note, dated 5/29/24, showed: -Incident occurred, resident threw glass of water on staff member. -Staff member threw tray and accidentally hit resident above the lip and below nose causing a laceration which would need stiches. Review of an Admin/(Registered Nurse) RN Investigation, dated 5/30/24, showed: -The date the incident occurred was 5/29/24. -The incident involved Resident #1 and Certified Nurse Aide (CNA) A. -Resident #1 had been wandering on the unit with a drinking cup in his/her hand. -Resident #1 had been mumbling to himself/herself. -Resident #1 was observed walking towards CNA A pointing at the cup in his/her hand, nodding, and smiling. -Resident #1 approached CNA A and gestured like he/she was raising his/her arms up, but threw the contents of the cup onto CNA A's face. -CNA A was startled and unsure of what had been thrown on his/her face and responded by holding up a food tray that was in his/her hands. -CNA A stated, It must have come out of my hand and struck him/her, I didn't even know. -CNA A was then sent home. -Resident #1 had fallen backwards after being struck with the tray and fell on his/her buttocks. -Upon assessment. Resident #1 had a laceration to his/her upper lip with active bleeding. -Resident #1 had an irregular shaped linear laceration approximately four centimeters in length to his/her upper lip. -When first aid was administered the bleeding was controlled with a cloth and pressure. -After notifying the physician, an order was given to send Resident #1 to the emergency room for evaluation and treatment. -The resident was sent to the emergency room and returned to the facility at 2:10 A.M. on 5/30/24. -Resident #1 had eight nylon sutures placed to his/her upper lip with an order for an antibiotic ointment and oral antibiotic. -The surrounding skin of the sutures was edematous (swollen) and discolored after arriving back to the facility. -Resident #1 nodded yes when asked if he/she had pain and pain medication was given to the resident. -Resident #1 was unable to verbalize what had happened. -In conclusion to the investigation it was found CNA A showed poor judgement in response to the action of Resident #1 which caused bodily harm and needed to be terminated. -This altercation was determined as abuse. Review of the resident's hospital After Visit Summary, dated 5/30/24 at 1:45 A.M., showed: -Resident #1 had been seen due to a facial laceration. -Resident #1 had received eight sutures. Review of the resident's Psychosocial Post-Incident Impact Questionnaire, dated 5/30/24, showed the only response the resident gave was that he/she had not felt safe. Review of the resident's Skin and Wound Evaluation, dated 5/30/24, showed: -The resident had a wound to his/her upper lip. -The wound measured 2.9 centimeters (cm) x 1 cm x 4 cm. Review of a witness Statement, dated 5/30/24 completed by CNA A, showed: -He/She first interacted with Resident #1 while completing resident rounds. -He/She had seen Resident #1 during these rounds. -He/She had gone behind the steam table to get a table for a different resident on the unit. -The steam table had trays on top of it. -While setting up the table he/she overheard Resident #1 speaking with CNA C. -He/She then turned around and saw Resident #1 approaching him/her. -Resident #1 yelled something. -Resident #1 had a cup in his/her hands and threw it in CNA A's face. -He/She closed his/her eyes not knowing what liquid had been thrown on his/her face. -Resident #1 yelled something again and thought the resident still had the cup in his/her hands. -He/She could not recall if he/she already had the tray in his/her hand or not but ended up throwing a tray in Resident #1's direction. -He/She walked away from Resident #1 wiping the liquid from his/her face. -He/She walked out onto the smoke patio as CNA C retrieved a towel for Resident #1. -He/She walked back into the unit and apologized to Resident #1. -He/She spoke to the charge nurse and was instructed to leave. During an interview on 5/30/24 at 1:46 P.M., CNA A said: -The altercation occurred on 5/29/24 at approximately 10:00 P.M. -He/She had seen Resident #1 at approximately 9:50 P.M. when performing face checks. -At that time, Resident #1 was lying in bed, and he/she had placed a cover over Resident #1. -He/She had been standing behind a steam table preparing a table for a different resident on the unit. -He/She had seen Resident #1 speaking with CNA C, but could not determine what they were saying. -Resident #1 then started to approach him/her and threw a cup with an unknown liquid towards him/her. -In response to this, he/she threw a meal tray towards Resident #1. -He/She had not known the tray hit Resident #1 at first, because he/she was wiping the liquid from his/her eyes. -He/She had thrown the tray towards Resident #1 out of defense, but had not intended to hurt the resident. -He/She apologized to Resident #1 and left the unit. -He/She was told to go home after the altercation occurred and left the building around 10:59 P.M. -He/She had not participated in any resident care after the altercation occurred. -Resident #1 was known to be aggressive and had thrown things at other staff and residents before. -He/She was very remorseful of his/her actions and kept repeating that he/she had worked with this population frequently and he/she was appalled by his/her actions. -He/She had not responded to the situation appropriately. -He/She should have tried to re-direct Resident #1 and called for help. Review of a Witness Statement, dated 5/30/24 completed by CNA B, showed: -He/She had seen CNA A turning away from the resident and wipe away something from his/her eyes. -CNA A had not been able to see, because Resident #1 had thrown water in CNA A's face. -CNA A had been trying to put a tray down on the steam table and it slid off the steam table and hit Resident #1. -CNA A had not known the tray hit Resident #1. -The incident occurred around 10:00 P.M. -CNA A had been trying to place the tray on to the steam table and ended up hitting Resident #1 in the face. -Resident #1 fell back onto the floor and he/she noticed the resident was bleeding from his/her mouth. -He/She grabbed towels and a different shirt for Resident #1. -CNA A apologized to Resident #1 and walked out of the unit. During interviews on 5/31/24 at 11:43 A.M. and 12:36 P.M., CNA B said: -Resident #1 walked up to CNA A and threw water in his/her face. -CNA A had been standing behind the steam table when the water was thrown into his/her face. -From his/her point-of-view the incident had not seemed purposeful. -The incident happened really fast, within a minute, and the tray had barely tapped Resident #1. -CNA A hadn't hit the resident with the tray while the tray was still in CNA A's hands, the tray had left CNA A's hands when it hit the resident. -After the altercation occurred, he/she grabbed towels to put on Resident #1's face and a new shirt for Resident #1 to wear. -He/She also had to mop the floor due to the amount of blood that came from Resident #1's injury. -Resident #1 returned to the facility during the same shift and seemed to be acting at baseline. -Resident #1 had aggressive behaviors before this altercation, including hitting staff. -CNA A had not responded to Resident #1's actions appropriately. -CNA A should have tried to re-direct Resident #1 and determine what might have been the trigger to Resident #1's actions. Review of a Witness Statement, dated 5/30/24 completed by CNA C, showed: -He/She had been standing in the dining area when Resident #1 had turned the corner and was heading in his/her direction. -The resident had been upset about something and had asked Resident #1 what was wrong. -He/She could not understand what Resident #1 was saying. -Resident #1 had been pointing to the cup that he/she was holding. -He/She told Resident #1 that the cup in his/her hands had not belonged to CNA C. -Resident #1 then went around him/her and walked towards CNA A. -Resident #1 started to complain to CNA A and CNA A had asked him/her what was wrong. -Resident #1 pretended like he/she was going to throw the cup at CNA A and CNA A leaned back. -As CNA A moved upright then Resident #1 threw the water on him/her. -CNA A had been shocked at what Resident #1 had done and grabbed a food tray and hit the resident with it, but the resident had blocked the hit. -CNA A then lost control of the tray, when CNA A grabbed the tray again, he/she hit Resident #1 with the tray under his/her nose. -The nurse on the unit asked him/her what had been going on. -He/She told the nurse CNA A had hit Resident #1 with a tray and the resident was bleeding due to being hit. -The nurse returned to the office. -He/She walked towards Resident #1 and used a towel that CNA B had given him/her to help stop the bleeding. During an interview on 5/31/24 at 6:32 P.M., CNA C said: -The incident occurred around 10:00 P.M. on 5/29/24. -He/She had seen Resident #1 storm out of his/her room and had been mumbling something under his/her breath. -Resident #1 had a cup in his/her hands and Resident #1 was pointing at it. -He/She joked with Resident #1 stating that the cup had not belonged to CNA C. -Then Resident #1 pointed at CNA A and started to approach CNA A. -Resident #1 gestured like he/she was going to throw the cup at CNA A, but then had actually threw the cup at CNA A. -CNA A tried to block the cup with a tray that CNA A had in his/her hands, but ended up throwing it towards Resident #1. -CNA A had thrown the tray like a Frisbee. -He/She had not been able to determine whether or not CNA A had purposefully thrown the tray at Resident #1. -He/She went to Resident #1 after the tray had hit him/her and Resident #1 was bleeding a lot. -He/She tried to stop the bleeding and left the unit. Once back on the unit, Resident #1's wound had stopped bleeding. -CNA A had not responded appropriately to Resident #1's action. -There would be no reason for any item to be thrown at a resident in response to a resident's behaviors. -CNA A should have removed himself/herself from the situation and tried to determine what Resident #1 might have needed. During an interview on 6/5/24 at 9:45 A.M. Registered Nurse (RN) A said: -He/She had been getting medications ready on the unit when the incident occurred between Resident #1 and CNA A. -He/She had not seen the altercation, but had been informed immediately afterwards. -He/She had seen CNA C throw his/her hands up in the air, so he/she exited the booth and tried to figure what happened. -He/She had seen the resident on the floor with a towel covering his/her face. -He/She had been told Resident #1 had been joking around and threw water at CNA A. -CNA A had told him/her that he/she had not intended to hit Resident #1 with a tray. -CNA A stated that he/she was irritated and had attempted to put the tray up on the steam table but ended up throwing it towards the resident. -He/She thought CNA A's actions were unlike him/her and had not thought CNA A meant to hurt Resident #1. -CNA C had told him/her that CNA A had meant to throw the tray at Resident #1. -He/She had instructed staff to write statements related to what happened. -He/She told CNA A to exit the unit. -He/She sent Resident #1 to the hospital and the resident's came back at 2:10 A.M. on 5/30/24. -He/She thought the resident felt bad about joking around with CNA A. -Resident #1 had been fine for the remainder of the shift. -Resident #1 tended to wander through the night but exhibited more behaviors during the day shift. -CNA A's response to the resident's action was not appropriate. -He/She would have tried to prevent the resident's action from happening. Observation and interview on 5/31/24 at 9:45 A.M., the resident said: -He/She could not remember how he/she had been injured. -He/She had eight sutures under his/her nose above his/her lip. The area was reddened and slightly swollen with dried blood around the site. During an interview on 6/4/24 at 11:08 A.M., Guardian A said: -He/She was told that Resident #1 had thrown water on a staff member and that staff member threw a tray back at the resident. -The staff member should not have thrown the tray at the resident. -The staff member should have known his/her limits when working with this type of resident population and controlled his/her own behavior. During an interview on 6/4/24 at 11:18 A.M., Nurse Practitioner (NP) A said: -He/She had been made aware of the incident between the resident and CNA A on the night of the incident. -He/She was told a CNA had been aggressive towards the resident, but was unsure of what had happened. -He/She knew that physical contact had been made and the resident needed to be sent to the emergency room for treatment. -The staff person should not have thrown a tray at the resident. During an interview on 6/4/24 at 2:42 P.M. the Director of Nursing (DON) said: -CNA A had worked with the resident prior to the incident. -When he/she was first notified of the incident, the staff had made it seem like it had just been horseplay and the resident had been injured through that with a tray. -He/She had been told CNA A had been specifically involved, so he/she had sent CNA A home. -The injury Resident #1 received was not consistent with horseplay. -CNA A's first statement had been too vague, so they needed CNA A to complete a new statement. -CNA A was brought in and told the following: --There were three trays on a beside table near the steam table. --CNA A had been behind the steam table and was getting something for a different resident. --CNA A had made it sound like the tray had slid off and hit Resident #1, but as CNA A continued to explain, it was determined that it had been thrown more like a Frisbee. --CNA A had not been able to remember if a tray had been in his/her hands when Resident #1 threw the water at him/her. -CNA A's decision to throw the tray at Resident #1 had not been rational. -He/She would have expected CNA A to have ducked and to determine the reasoning behind Resident #1's action. -CNA A could have walked away if he/she felt like his/her response would not have been appropriate. -CNA A should have also asked for help from the other staff on the unit. -Nothing should ever be thrown at a resident regardless of a resident's action or behavior. During an interview on 5/31/24 at 11:06 A.M., the Administrator said that the employee-to-resident altercation was determined to be abuse. 2. Review of Resident #2's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Early Onset Alzheimer's Disease (a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain). -Insomnia. -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Delusional Disorders (a type of psychotic disorder with the main symptom of the presence of one or more delusions) -Dementia. -Cognitive Communication Deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). -Personal History of Traumatic Brain Injury (TBI- brain dysfunction caused by an outside force). -Unspecified Psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality). Review of Resident #2's Quarterly MDS, dated [DATE], showed the resident was severely cognitively impaired. Review of Resident #10's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Dementia. -Insomnia. -Anxiety Disorder. Review of Resident #10's Quarterly MDS, dated [DATE], showed the resident was severely cognitively impaired. Review of an Admin/RN Investigation, dated 5/22/24, showed: -Resident #10 and Resident #2 had been involved in physical aggression involving the head. -Resident #2 had been the aggressor and Resident #10 the victim. -On 5/22/24 staff observed Resident #2 self-propel towards the table where Resident #10 had been sitting. -Resident #2 struck Resident #10 suddenly in the nose. -Resident #10 sustained an injury to his/her nose. -Resident #10 had been sent to the emergency room for evaluation due to taking a blood thinner. -Resident #10 was typically non-verbal, but could respond to yes/no questions and would follow directions. -Staff that observed the altercation had not seen any triggers that would have caused Resident #2 to strike Resident #10. -Upon interview of Resident #2, the resident remembered hitting someone after being called a bitch. -Resident #2 had a history of aggression towards others. During an interview on 6/4/24 at 2:18 P.M. Resident #10 said he/she felt safe at the facility. 3. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Diffuse traumatic brain injury -Paranoid Schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly, delusions and hallucinations are two symptoms that can involve paranoia). Review of Resident #3's Quarterly MDS dated [DATE] showed: -Resident #3 had moderately impaired cognition. During an interview on 5/31/24 at 10:12 A.M. Resident #3 said: -The altercation started when Resident #2 was cursing at others and then directed the cursing towards Resident #3. -He/She had told Resident #2 that he/she could not talk to people like that. -Resident #2 then got up and punched Resident #3 in the face. -In response Resident #3 punched Resident #2 back underneath his/her right eye, bridge of his/her nose, and lower left jaw. -Staff intervened after that. -He/She had punched Resident #2 in self-defense. -There were no other issues after that altercation. -He/She had received no injuries during the altercation, but had taken some pain medication. -He/She had been in a previous physical altercation with Resident #2. -He/She was not sure what interventions were put in place after the first altercation. -He/She was not afraid of Resident #2. -Resident #2 had been in other physical altercations with other residents. During an interview on 5/31/24 at 10:32 A.M., CNA D said: -He/She had been asked to go relieve the staff person that was monitoring Resident #2. -Resident #3 approached the table where he/she had been sitting with Resident #2 and introduced himself/herself. -Resident #2 turned to Resident #3 and called him/her a racial slur. -Resident #3 responded to Resident #2 and said, You can't call people that. -Resident #2 then repeated himself/herself and CNA D realized that something was about to go down. -He/She attempted to pull Resident #2 away from the table, but was unsuccessful. -Resident #2 was able to get to Resident #3 and punched Resident #3. -Resident #3 responded to Resident #2 by punching Resident #2 back. -Resident #3 continued to punch Resident #2 and in doing so hit him/her and took both Resident #2 and him/her to the ground. -He/She then called out a Code [NAME] (a behavioral emergency). -There had been another staff person on the unit and had not intervened. -The other residents on the unit started to come towards the altercation. -He/She tried to get Resident #3 off Resident #2, but was unsuccessful. -He/She got elbowed to the back of his/her head, so he/she then tried to remove Resident #2 from the altercation, which again was unsuccessful. -The other staff person then called a Code Green. -Less than a minute later Resident #2 and Resident #3 were separated. -He/She took Resident #2 over to the nurse's station to be assessed as Resident #2 had blood coming from his/her nose and mouth. -It was determined Resident #2 needed to go to the hospital, so he/she stayed with Resident #2 until emergency services arrived. -He/She then gave a statement related to the incident and went home. -He/She had never worked on the unit before. During an interview on 5/31/24 at 11:48 A.M., CMT A said: -He/She had been the staff person assigned to the locked unit when the altercation between Resident #2 and Resident #3 occurred. -He/She had not seen the beginning of the altercation. -He/She had been passing out cigarettes at the start of the altercation. -By the time he/she had looked over to Resident #2 and Resident #3, the residents were already in a fist fight. -He/She had called a Code [NAME] before going over to the altercation. -He/She saw Resident #2 laying on the ground while Resident #3 was punching Resident #2. -He/She then leaned over Resident #3 and tried to pull Resident #3 off of Resident #2 and told Resident #3 to stop hitting Resident #2. -That was when the Code [NAME] team arrived, and Resident #2 and Resident #3 were separated. -He/She had been told that Resident #2 called Resident #3 a racial slur. -Resident #2 and Resident #3 had been in a physical altercation before. -Resident #3 had been moved to the locked unit when the first altercation occurred. -Resident #2 had moved down to the unit within the last month due to getting into altercations on other units. -Resident #2 had been in a previous altercation on the locked unit. -Resident #2 had been put on 1:1 monitoring, due to an altercation prior to the one on 5/28/24. -Resident #3 had not had any altercations with other residents. -He/She only remembered seeing blood on Resident #2's forehead after the altercation. -He/She had not heard an argument or seen any triggers that would have initiated the altercation. -Resident #2 was known for using derogatory language. -Resident #2 would say the derogatory words under his/her breath, but just loud enough for others to hear. Review of Resident #4's Quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 5/31/24 Resident #4 said: -He/She had heard a Code [NAME] called. -Resident #2 called Resident #3 a racial slur then punched Resident #3. -Resident #3 responded by hitting Resident #2 back. -CMT A pulled Resident #3 off of Resident #2. -Resident #2 had never called him/her any names. -Resident #2 was known to call other staff and resident names. -He/She was unsure if Resident #2 had been involved in any other altercation. -He/She felt a lot safer since Resident #2 was no longer on the unit. During an interview on 5/31/24 at 3:25 P.M. Resident #2 said: -He/She had fallen off the bed and that was how he/she had sustained the skin tears and injury to his/her head. -Resident #3 had started the fight with him/her. -He/She hit Resident #3 in the jaw and nose. -He/She had not been in any altercation before the altercation on 5/28/24 with Resident #3. -He/She had not been in any physical altercations with other residents. -He/She had not remembered if any words were exchanged between Resident #3 and him/her during the altercation. -He/She felt safe at his/her new facility. Observation on 5/31/24 at 3:25 P.M., showed Resident #2: -with a small, penny sized, pink/red bump to his/her forehead just above his/her right eye; -a skin tear to his/her right proximal elbow that was pink and beginning to scab over; and -a skin tear to his/her left posterior hand that had been scabbed over but was red and swollen surrounding the wound site. During an interview on 6/4/24 at 11:18 A.M., NP A said: -He/She had been made aware of the altercation between Resident #2 and Resident #3. -All he/she had been informed of was the altercation was physical. -When he/she was informed of the altercation, the staff also requested a PRN medication for Resident #2. -He/She was unsure about Resident #2's altercation history. -Resident #2 was known to be verbally aggressive towards staff and other residents. -Resident #3 had been aggressive towards staff before. During interviews on 6/4/24 at 2:42 P.M. and 6/7/24 at 9:37 A.M. the DON said: -He/She had de-briefed with staff after each altercation that Resident #2 had with the other residents. -Resident #2 had a TBI and needed increased monitoring overtime. -All the resident-to-resident altercations that Resident #2 had been involved in were behavioral incidents and not abuse. -Resident #10 and Resident #2 had not had any issues prior to their altercation and a root cause was not able to be determined outside of Resident #2 being impulsive. During an interview on 6/7/24 at 10:12 A.M. the Administrator said: -All of the resident-to-resident altercations that Resident #2 had been involved in were behavioral incidents and not abuse. -The root cause of all the resident-to-resident altercations stemmed from the derogatory language that Resident #2 used. MO00236823 and MO00236892

Based on interview and record review, the facility failed to prevent resident to resident abuse for one sampled resident (Resident #1) out of six sampled residents, when on [DATE] Resident #2 punched Resident #1 several times in his/her face resulting in a bloody nose, a black eye and red marks on his/her head. The facility census was 91 residents. On [DATE] the Administrator was notified of the past noncompliance, which occurred on [DATE]. On [DATE], the facility administration was notified of the incident and the investigation was started. Facility staff were educated on abuse and neglect policy, resident intervention and behaviors on their next shifts. The deficiency was corrected on [DATE]. Record review of the facility's Abuse and Neglect Policy dated [DATE] and revised [DATE] showed: -Physical abuse was purposefully beating, striking, wounding or injuring any resident and included hitting and punching. -Abuse of residents was prohibited by the facility, including physical abuse. -The facility was committed to protecting the residents from abuse by anyone, including other residents. 1. Record review of Resident #1's face sheet showed he/she was admitted on [DATE] with major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Record review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) showed the resident had a BIMs (brief interview for mental status) of 15, indicating the resident was cognitively intact. Record review of Resident #1's care plan dated [DATE] and closed [DATE] due to discharge showed: -Problem dated [DATE]: --Resident was/had potential to be physically aggressive related to anger and poor impulse control. -Desired outcomes dated [DATE]: --Resident would demonstrate effective coping skills. --Resident would not harm self or others. --Resident would seek out staff/caregiver when agitation occurred. -Interventions dated [DATE]: --Allowed resident to vent and verbalize feelings and concerns to staff. No PRNs (pro re nata-as needed) were needed. --Analyzed times of day, places, circumstances, triggers and what de-escalated behavior and document. --Assessed and addressed for contributing sensory deficits. --Assessed and anticipated resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. --Provided physical and verbal cues to alleviate anxiety; gave positive feedback, assisted verbalization of source of agitation, assisted to set goals for more pleasant behavior and encouraged seeking out of staff member when agitated. --Gave resident as many choices as possible about care and activities. --Monitored/documented/reported PRN any signs and symptoms of resident posing danger to self or others. --Moved resident to another unit. --Psychiatric/psychogeriatric consult as indicated. --Sent resident to emergency room for evaluation and treatment. --When resident became agitated: Intervened before agitation escalated; Guided away from source of distress; Engaged calmly in conversation; If response was aggressive, staff walked calmly away and approached later. Record review of Resident #2's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -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). -End stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). - Major depressive disorder. -Generalized anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety [anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus]). -Metabolic encephalopathy (any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or degenerative conditions). -Pain. Record review of Resident #2's Physician Order Sheet (POS) dated [DATE] showed an order to monitor him/her for behaviors every shift related to paranoid schizophrenia. Record review of Resident #2's Quarterly MDS dated [DATE] showed the resident had a BIMs of 15, indicating the resident was cognitively intact. Record review of Resident #2's undated care plan showed: -Problem dated [DATE]: --Resident was/had potential to be verbally aggressive related to ineffective coping skills, poor impulse control. -Desired outcome dated [DATE]: --Resident would demonstrate effective coping skills. --Resident would verbalize understanding of need to control verbally abusive behavior. -Interventions dated [DATE]: --Administered medications as ordered and monitored/documented for side effects and effectiveness. --Analyzed key times, places, circumstances, triggers and what de-escalated behavior and document. --Assessed and anticipated resident's needs: food, thirst, toileting needs, comfort level, body positioning, paint, etc. --Assessed resident's coping skills and support system. --Assessed resident's understanding of the situation and allowed time for resident to express self and feelings towards the situation. --Provided positive feedback for good behavior and emphasized the positive aspects of compliance. --Psychiatric/Psychogeriatric consult as indicated. -Problem dated [DATE]: --Resident was/had potential to be physically aggressive related to anger, poor impulse control and hallucinations. -Desired outcome dated [DATE]: --Resident would demonstrate effective coping skills. --Resident would not harm self or others. --Resident would seek out staff/caregiver when agitation occurred. -Interventions dated [DATE]: --Administered medications as ordered and monitored/documented for side effects and effectiveness. --Analyzed times of day, places, circumstances, triggers and what de-escalated behavior and document. --Assessed and addressed for contributing sensory deficits. --Assessed and anticipated resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. --Education on triggers of anger, irritation and disappointment including peers, staff and when his delusions or hallucinations were talking to him and where to go for support. --Gave resident as many choices as possible about care and activities. --Monitored/documented/reported PRN any signs and symptoms of resident posing danger to self and others. --Psychiatric/Psychogeriatric consult as indicated. Record review of the facility's investigation dated [DATE] showed: -Investigative narrative note showed on [DATE], Resident #2 made physical contact with Resident #1 at approximately 5:35 P.M. -Certified Medication Technician (CMT) A's statement dated [DATE] showed: -Around 5:30 P.M., Resident #1 and Resident #2 got into an altercation over Resident #1's remote control. -Resident #2 was cussing at Resident #1 and told the resident to turn the fucking television to the news. -Resident #1 told Resident #2 that he/she could not use the remote to the television in the dining area anymore. -Resident #2 ran up to Resident #1 and started hitting him/her in the face, making his/her nose bleed. -Hospitality Aide A's statement dated [DATE] showed: -The fight started over the television. -He/she broke it up. Record review of the police report taken [DATE] showed: -CMT A said Resident #2 was yelling and cussing at Resident #1 to turn the television to the news. -CMT A said Resident #1 said he/she was unable to do that and Resident #2 ran up to Resident #1 and struck him/her about five times in the face with a closed fist. -Resident #1 said Resident #2 yelled at him/her to change the television to the news and he/she told Resident #2 that he/she was not able to do so. -Resident #1 said Resident #2 walked up to him/her and struck him/her in the face about four to five times with closed fists. -The police officer observed bruising around Resident #1's eyes and a bloodied nose. Record review of Resident #1's incident report dated [DATE] showed: -Nursing description showed the resident was assaulted by another resident. -Resident description showed: --Resident #2 asked him/her to turn the television and he/she told him/her that he/she couldn't turn the television. --Resident #2 said turn the fucking television. --He/she told Resident #2 that he/she was told he/she was not supposed to turn the television with his/her remote. --Resident #2 started hitting him/her in the head and nose. --His/her nose was bleeding. -The resident was taken to the hospital. -The resident had a pain level of 8 out of 10 and was alert and ambulatory without assistance. -The resident was oriented to person, situation, place and time. -No injuries were observed post incident. -There were no predisposing environmental factors. -There were no predisposing physiological factors. -There were no predisposing situation factors. Record review of Resident #2's incident report dated [DATE] showed: -Nursing description showed a call was received from CMT A that the resident hit another resident several times in his/her face. -The resident description showed as another resident was returning from his/her room to get a television remote, the resident thought the other resident was approaching him/her to punch him/her so he/she hit the other resident first. -The resident was taken to the hospital. -No injuries were observed at time of incident. -No injuries were observed post incident. -There were no predisposing environmental factors. -There were no predisposing physiological factors. -There were no predisposing situation factors. Record review of Resident #1's progress notes dated [DATE] showed: -At 7:24 P.M., Licensed Practical Nurse (LPN) A wrote: -The resident was involved in a physical altercation with another resident. The resident was asked to turn the television and when the resident told the other resident that he/she could not turn the television, he/she was hit in the head and face several times. -The resident sustained a nosebleed that he/she cleaned up. -The resident had a red swollen left eye and a red right eye. -At 7:42 P.M., the Administrator wrote: -The resident said he/she did not provoke the other resident or hit back. - The resident said the other resident asked him/her to get his/her remote for the TV and he/she told the other resident that he/she could not get it. -The other resident started hitting him/her. -During investigation, it was found that the resident had gone to his/her room to get the remote. -Upon return to the dining room, the other resident approached him/her asking him/her to get the remote. -The resident told the other resident he/she already had it and showed it to the other resident. -The other resident hit him/her. Record review of Resident #2's progress notes dated [DATE] showed: -At 7:31 P.M., LPN A wrote: -The resident was involved in a physical altercation with another resident and resident was the aggressor. -The resident asked another resident to turn the television. -The other resident said he/she could not turn the television, the resident started hitting the other resident in the head and face several times. -The Police and Emergency Medical Services (EMS) were called. -The resident went to the hospital for evaluation. -At 7:33 P.M., the Administrator wrote: -When asked why the resident hit the other resident, the resident said he/she thought the other resident was coming at him/her and was going to hit him/her so he/she hit the other resident first. Record review of Resident #1's skin assessment dated [DATE] showed: -He/she has ecchymosis (bruise) to his/left eye. -He/she had red, non-raised unopened areas to his/her forehead. Record review of Resident #2's progress note dated [DATE] showed: -The Director of Nursing (DON) wrote: -Call received from CMT A that the resident had a physical altercation with another resident. -CMT A said the resident had hit another resident several times in the face with his/her fist. During an interview on [DATE] at 12:54 P.M., Hospitality Aide A said: -He/she thought it was about dinner time and he/she had his/her head down putting out drinking cups. -He/she heard Resident #1 and Resident #2 fighting. -He/she rushed over and separated them. -He/she did not know what they were fighting about. -One resident was bloody but he/she cleaned him/herself up. -He/she wasn't sure of the resident's injury. During an interview on [DATE] at 1:01 P.M., CMT A said: -He/she did not see Resident #2 hit Resident #1. -He/she saw Resident #1 standing in the doorway with his/her hand balled up in a fist. -He/she heard Resident #2 arguing with Resident #1. -He/she saw Hospitality Aide A separate Resident #1 and Resident #2. During an interview on [DATE] at 1:16 P.M., Certified Nurses aide (CNA) A said: -He/she was on break and didn't see the altercation. -He/she did see Resident #1's face and it looked like he/she had a red ring around his/her eye. -Resident #1 told him/her that Resident #2 had hit him/her. During an interview on [DATE] at 1:23 P.M., LPN A said: -He/she was told there was an altercation between Resident #1 and Resident #2. -When he/she got onto the unit, it was all over. -Resident #1 had an injury to his/her face and eye. During an interview on [DATE] at 3:11 P.M., the DON said: -Resident #1 had bruising under his/her left eye and a small amount of swelling on top of his/her eye. -Resident #1 had a bloody nose but once it was cleaned up, there was no further bleeding or injury seen. During an interview on [DATE] at 11:44 A.M., Psychiatric Nurse Practitioner said: -Resident #2 had a serious mental illness with very serious medical illnesses. -When residents were on dialysis, this frequently caused electrolyte imbalances, which can cause altered mental status. -Chronic medical issues could impact mental illnesses. -End stage renal failure can be unpredictable. -These could have all contributed to his/her behavior. During an interview on [DATE] at 12:41 P.M., the Administrator said: -He/she watched a recording of the incident. -He/she saw Resident #1 come out of his/her room. -Resident #2 was in the hallway and asked Resident #1 something. -Resident #1 held a remote up and Resident #2 hit him/her. -Resident #2 said he/she thought Resident #1 was coming after him/her so he/she hit Resident #1 first. -He/she did not believe the incident was abuse. During an interview on [DATE] at 11:57 A.M., Physician A said he/she thought it sounded like Resident #2's mental illness might be what caused the behavior. Record review of Resident #6's face sheet showed he/she was admitted on [DATE] with a diagnosis of anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety [anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus]). Record review of the resident's Annual MDS dated [DATE] showed the resident had a BIMS of 15, indicating the resident was cognitively intact. During an interview on [DATE] at 11:55 A.M., the resident said: -Resident #1 and Resident #2 were arguing. -Resident #1 called Resident #2 a racial slur. -Resident #2 punched Resident #1. -Resident #1 had a black eye. Record review of Resident #4's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Paranoid schizophrenia. -Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). -Cannabis (marijuana) abuse with psychotic disorder (a mental disorder in which there is a severe loss of contact with reality). Record review of the resident's Quarterly MDS dated [DATE] showed the resident had a BIMS of 15, indicating the resident was cognitively intact. During an interview on [DATE] at 12:11 P.M., the resident said: -They don't have a direct remote to the television in the dining area. -Sometimes the television went back to the home screen. -Resident #2 asked Resident #1 to use Resident #1's remote. -Resident #1 felt like he/she was being used for the remote. -He/she thought Resident #1 said why don't you get your own remote to Resident #2. -Resident #2 got aggressive with Resident #1 for no reason. -Resident #1 said a racial slur and Resident #1 and Resident #2 argued briefly for maybe two to three seconds. -Resident #2 hit Resident #1 in the face. MO00213628 and MO00213611

Based on observation, interview, and record review, the facility failed to provide supervision to prevent an elopement for one sampled resident (Resident #7) who was identified at risk on the facility elopement risk assessment and his/her care plan. Staff failed to check on the resident between the night shift and the day shift, and staff were not aware the resident had left the building. At 7:52 A.M. the resident was found a mile and a half away from the facility at a busy intersection. The resident resided on a locked behavioral dementia unit. Eight sampled residents were reviewed. The facility census was 93 residents. The Administrator was notified on 6/10/22 at 5:05 P.M., of the Immediate Jeopardy (IJ) which began on 6/10/22. The IJ was removed on 6/12/22, as confirmed by surveyor onsite verification. Record review of the facility policy for Intensive Monitoring/Visual Checks, revised 3/5/22, showed: -The purpose of the policy was to ensure that a system was in place to ensure the increased monitoring of those resident with behavioral/psychiatric and medical issues who required intensive, frequent monitoring. -Intensive monitoring was defined as periodic, (hourly, every two hours, or shift checks) completed by a licensed nurse or designated employee which included visual face to face observations of the resident. -Each resident on every unit was to have been monitored by visual face to face checks at least every two hours or more frequently depending on the resident population. -All documentation was to have been completed using the computer generated monitoring sheets. Record review of the facility Elopement Protocol, revised on 1/19/22, showed: -An elopement was defined as any time a resident was missing from the facility or there was a possibility a resident had left the facility without appropriate supervision and their whereabouts were unknown. 1. Record review of Resident #7's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Dementia (a group of thinking and social symptoms that interferes with daily functions). Record review of the resident's care plan, dated 10/18/21, showed: -The resident was at risk of elopement due to dementia and had a history of elopement from a prior secure facility. -Expressed a desire to elope from the facility. -Had the physical capability to do so. -The staff were to complete the Elopement assessment upon admission, readmission, and quarterly. -The staff were to check before leaving the unit that the resident was not following them off the unit. -Face checks, intensive monitoring would be completed per facility protocol. -The resident had impaired cognitive function or impaired thought processes related to dementia. -The resident was at risk for falls related to confusion. -The resident had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others which included wanders and steals other resident's belongings. -The resident frequently refused his/her medications. Record review of the resident's Elopement Evaluation, dated 1/16/22, showed he/she had a history of elopement from home and the resident was currently at risk for elopement from the facility. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/20/22, showed: -His/her Brief Interview for Mental Status (BIMS - a tool to determine cognitive status) should be conducted. -The residents BIMS score was 6 (severely cognitively impaired) -Wandering not identified. -He/she was independent with bed mobility, transfers, walking, personal hygiene, eating, toileting, dressing and bathing. Record review of the resident's Elopement Evaluation, dated 4/22/22, showed: -The resident had a history of an elopement while at home. -The resident had a history of attempted leaving the facility without having informed staff. -The resident wandered. Record review of the facility Investigation, dated 6/10/22, showed: -The incident occurred on 6/10/22. -The type of incident was an elopement. -The resident was his/her own responsible party. -There were no witnesses. -At approximately 9:45 A.M., on 6/10/22, the Administrator got a call from the hospital stating the resident was in the emergency room at the hospital. -The Administrator immediately went to the unit to question staff who stated the resident was in his/her room. -The Administrator and staff went to the resident's room and the resident was not there. -The Administrator immediately questioned the staff about the last time they had seen the resident. -All staff denied having seen the resident that morning and had not done face checks at the beginning of their shift at 6:30 A.M. -The Administrator then notified the staff that the resident was in the hospital and had been picked up by the police in the early morning hours and taken to the hospital. -The Administrator then notified the charge nurse that the resident would be returning shortly and would need a full assessment and one to one staff intensive monitoring. -The investigation determined the magnet on the door leading out of the locked unit and into the hallway leading towards the offices an exit door malfunctioned. -Face checks had not been completed by the staff. -After interviews with the night shift staff, it was determined the resident was last seen between four and five A.M. -The resident was assessed by the DON and showed no injuries. -The resident was unable to answer any questions due to dementia. Record review of the resident's medical record on 6/10/22 showed the facility did not document hourly checks until after the resident returned from the hospital on 6/10/22. During an interview on 6/10/22 at 11:00 A.M., the Paramedic said: -The patient was fully dressed in brown slacks, brown and tan striped shirt, and shoes. -The patient was taken to the nearby hospital on 6/10/22 at 8:49 A.M. During an interview on 6/10/22 at 11:30 A.M., Hospital Registered Nurse (RN) said: -The Paramedics called in a report of a person sitting in a car off of a busy intersection. -The car did not belong to the resident. -The resident did not know how he/she got to be sitting in a car. -The resident was able to tell him/her his/her name and date of birth only. -The resident's significant other listed on the hospital past record was contacted. -The significant other told the nurse the patient was a resident in a nearby nursing home. -The nurse made several attempts to contact the nursing facility. During an interview on 6/10/22 at 12:15 P.M., the Administrator said. -He/she was notified by the hospital staff that the resident was at the hospital on 6/10/22 about 9:30 - 9:45 A.M. -The hospital staff said the police were notified the resident was in a car. -The hospital staff did not say where the police had found the resident. -The police had brought the resident to a nearby hospital about 8:30 A.M. -The hospital had a hard time figuring out where the resident was from, as he/she could not tell them anything other than his/her name and date of birth. -The resident was returned to the facility between 11:00 to 11:30 A.M. today. -When he/she had received the phone call from the nurse at the hospital, he/she had thought the resident was downstairs in the locked unit. -He/she had not realized the resident was not in the facility. -The resident resided in the locked dementia behavioral unit. -The facility had started an investigation, it appeared an alarm had gone off and that a door had a magnetic lock that had failed. -Maintenance was responsible for a monthly check of the doors in the facility. -The door leaving the unit should be secured with a magnetized lock (maglock) on it with a keypad the staff would have to punch in a code to enter or leave the unit and an alarm sounded whenever it was opened. -Staff should respond to any sound that might be an alarm: -Staff were expected to do face checks on all residents, count and ensure each resident was accounted for when they get to work and after an alarm had sounded. -The unit nurse was responsible to have documented every hour at the time the count was completed in the resident charts for all residents on the unit. -There were two staff members working last night; one CNA and one Hall monitor, which was usual for the night shift. -There was a nurse upstairs if the staff on the unit needed someone to come downstairs to give medications. During an interview via telephone on 6/10/22 at 1:10 P.M., CNA A said: -He/she worked the night before, which was the night the resident eloped. -He/she last saw the resident between 4:30 - 5:00 A.M. during the last face check he/she did. -After that, he/she started to get people up for the day. -It was always busy and he/she does not have enough help. -The other staff member was helping other residents get up on another floor. -Then the day shift staff had come in. -He/she had heard an alarm go off, but did not think it was on the unit, he/she thought it was in the hallway by the Human Resources' offices just off the unit, but he/she did not check to see what door was alarming. -The door going out of the locked unit usually alarms, but it did not go off when the resident left. During an interview on 6/10/22 at 2:10 P.M., Hall Monitor (HM) A said: -The resident did not get out when he/she had come back from helping the unit upstairs. -When he/she arrived back on his/her unit both he/she and CNA A noticed the alarm in the stairwell had went off. -The alarm went off sometime between 9:30 P.M. to 11:00 P.M. on 6/9/22 and again at about 4:30 A.M. on 6/10/22 and nobody checked the alarms. During an interview on 6/10/22 at 1:55 P.M., CNA B said: -He/she took report from the night CNA A on 6/10/22 at 6:15 A.M. -CNA A and HM A had worked the previous night shift. -CNA A had said the residents were good and the shift had been quiet. -He/she was responsible first thing was to do a room check to ensure everyone was accounted for. -He/she had not done this, because one of the residents had soiled his/herself and he/she went to clean up the resident and the resident's room. -HM A/housekeeper was cleaning up the dining room after breakfast. -The resident sometimes slept through breakfast. Breakfast was around 7:20 A.M.-8:00 A.M. and the HM/HK did not do a face check that morning. -Until the hospital called he/she was not aware the resident was missing. -The Administrator came down to ask where the resident was about 9:15 A.M. -He/she and the other staff checked the resident room and the resident was not there. -They checked all of the rooms and the resident was not there. -They then checked the doors to see if they were locked which they were. -They tried to push the doors open without putting the code in the keypad and were not able to push open the doors. -They could not find a malfunction in the maglock doors. -They asked the resident's roommate if he/she knew where the resident was and the roommate said the resident was still asleep where he/she had been all night. -They do not use a resident roster to check off the residents as they were observed, because the staff know the residents by sight. -CNA B was not sure what the protocol was for a missing resident. -The resident came back down to the unit at about 11:15 A.M. -The resident had on gray pants, sports pullover, shoes and socks. -The resident did not appear upset. -CNA B had been employed at the facility about a month and had behavior training during orientation, but did not have training for elopements. During an interview on 6/10/22 at 2:20 P.M., Housekeeper B said: -There were two CNAs here when he/she came to work at 6:00 A.M. -He/she went upstairs to talk to his/her supervisor and was off the unit for about an hour. -When he/she came back he/she went to help a resident. -He/she had started to clean the floors. -He/she left the unit for about 45 minutes to go upstairs to get cleaning supplies. -When he/she came back he/she continued his/her cleaning. -When he/she cleaned the residents' rooms he/she had done a visual check to ensure all residents were there. -He/she did not do that this day, because he/she forgot. -The Administrator had came down and asked the staff to check the rooms to see if they could find the resident and no one could find him/her. -He/she did not know what time, only sometime after breakfast. -He/she has had education on what to do during an elopement. -He/she did not have any idea how the resident got out of the facility. -The night shift was leaving today as he/she arrived on the unit. During an interview on 6/10/22 at 2:50 P.M., RN A said: -He/she arrived to work at 7:30 A.M. -He/she had went upstairs to get the keys. -When he/she came back downstairs he/she started to check a resident's blood sugar. -There was one Nurse, one CNA, and one Housekeeping on the shift. -All of the staff, CNAs and HMs, on the unit should have checked to ensure all the residents were here, but they did not do that because he/she was late getting started on his/her shift. -About 9:30 A.M. the DON called to see if the resident was there. -The resident was missing. -The staff looked everywhere. -The resident would keep trying to get out of the doors. -He/she did not think the door going out of the locked unit to the hallway was latched appropriately. -Other residents have tried to get out of the doors. -The Maintenance person was responsible to have checked the doors, but he/she did not know how often. -You can hear the door alarm at the far end of the hall and out on the smoking patio every time someone enters or leaves the unit. -The Nurse was responsible for doing a face count every hour and it should have been documented on the residents' chart every hour when they were done. -He/she had not done the face counts today as he/she had been busy. -He/she had not charted anything until after 11:00 A.M. when the resident came back. During an interview and observation on 6/10/22 at 1:50 P.M., the Medical Records Director said: -The door that goes in or out of the locked unit needed a code to enter into the keypad to enter or leave the unit. -The door would alarm for about 15 seconds after it was opened. -He/she was not able to push the door open without the code unlocking it. -The facility had a video camera above the door on the inside of the unit. -It was on a live feed and did not record who was entering or exiting the unit. -He/she verified he/she could hear the door alarm at the end of the hallway farthest from the door about 120 feet. -He/she verified that he/she could hear the door alarm at the farthest point on the smoking porch away from the door about 90 feet. -The staff should have been able to hear the alarm whenever the door opened at any place on the unit. -He/she verified that if the staff were in the dining room or at the nurse's station he/she could hear the alarm from the second door outside of the unit if it was opened. During an interview on 6/10/22 at 3:15 P.M., the Maintenance Director said: -Previous to this date sometimes the mag lock on the door to the unit does not engage. -If the door closes before the maglocks it was not locked because it had not engaged. -The alarm does not stop alarming until the code was put into the keypad. -He/she thought the resident came through the door off of the locked unit then down the hallway where the therapy department was and other offices. -The door at the end of hallway (straight down the hall) was not locked. -Door #11 (the last door the resident went out of that leads outside the facility) did not have a lock or alarm and it leads outside of the building. -He/she ordered locks for the doors that did not have locks on them today. -Door #13 on the left goes to the old smoking area was always locked so the resident could not have left that way. -The resident most likely snuck off the unit after someone went through the unit door. -The facility did not have any records of when the doors were opened only if there had been a fire. -The facility had a live feed from the video, but does not have a recording of the video. -He/she checks the doors quarterly for good repair, door frame, maglock, the door latching, and for gaps under the door per fire safety code. During an interview on 6/14/22 at 11:00 A.M., Nurse Practitioner (NP) A said: -He/she thought the facility staff had been doing face to face observations of every resident every hour, and he/she would have expected the facility staff to do so. -He/he would have expected the facility staff to have notated where each resident was located at the time they were observed. -He/she was just notified by the administrator the facility staff was either documenting their face to face observations either before they were completed or at the very end of their shift. -He/she would have expected the facility staff to have documented the face to face observation at the time each resident was observed. -He/she was just made aware the facility staff had not notified the DON and Administrator at the time of the incident and the Administrator did not find out about the incident until the hospital called him/her. -He/she would have expected the facility staff to have notified the charge nurse, DON and Administrator of the missing resident immediately. -He/she was seeing the resident while on site. -He/she was aware the resident had a long history of eloping from home, past facilities and this facility, which was why the resident was transferred to the locked unit from upstairs. During an interview on 6/14/22 at 2:00 P.M., HM B said: -He/she was to have done face checks every two hours where he/she observed where the resident was and at what time they were there. -He/she was to have documented that at the time that he/she actually observed the resident. During an interview on 6/14/22 at 2:10 P.M., CMT B said: -He/she was to observe every resident, noting where they were every hour. -He/she was to document the face to face observation at the time he/she actually observed the resident. During an interview on 6/14/22 at 2:20 P.M., the DON said: -He/she would have expected the facility staff to have been doing face to face observations of every resident every hour. -He/he would have expected the facility staff to have notated on the monitoring sheets where each resident was located at the time they were observed. -He/she would have expected the facility staff to have documented the face to face observation at the time each resident was observed. 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). MO00202360

Based on interview and record review, the facility failed to prevent employee to resident abuse for one sampled resident (Resident #1) when on 12/22/21 Hall Monitor A was observed by the Corporate Human Resources (HR) Manager dragging the resident across the cement floor by his/her shirt and arms from the smoke deck patio back inside to the memory care unit. The facility census was 92 residents. The Administrator was notified on 12/23/21 at 3:07 P.M. of an Immediate Jeopardy (IJ) which began 12/22/21. The IJ was removed on 12/27/21 as confirmed by surveyor onsite verification. Record review of the facility's abuse and neglect policy dated 9/17/21, showed: -The facility was committed to protecting residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. -Physical abuse was purposeful beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse included handling a resident with any more force than was reasonable for a resident's proper control, treatment or management. Physical abuse included, but was not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse included corporal punishment, which was physical punishment used as a means to correct or control behavior 1. Record review of Resident #1's admission face sheet showed he/she was admitted [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] disorder (a combination of symptoms of [CONDITION(S)] and mood disorder, such as depression or [CONDITION(S)] disorder). -[CONDITION(S)] disorder (a mental health condition that causes extreme mood swings that include emotional highs). -Post-traumatic stress disorder ([CONDITION(S)]- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). 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 9/23/21 showed: -His/her cognitive status was undefined. -He/she was independent in transfer, walking in his/her room and corridor. Record review of the resident's care plan dated 9/17/21 showed: -The resident had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include yelling, cursing, talking to female staff inappropriately. -The resident would minimize episodes of inappropriate behaviors that can affect others. -He/she was administered and monitored medications as ordered. -The resident has manifestations of behaviors related to his/her mental illness that may create disturbances that can affect others. These behaviors include being verbally aggressive with staff and peers. -The resident would minimize episodes of inappropriate behaviors that could affect others. Record review of the resident's progress note dated 12/23/21 at 5:46 P.M., by the Director of Nursing (DON) showed: -On 12/22/21 the resident was involved in an incident with a staff member. -The Psychologist Nurse Practitioner (NP), Psychologist, Physician's office, the Administrator, DON and (Corporate) Regional Staff was notified. -Skin assessment was completed by the facility nurse with no abrasions or injuries noted. Record review of a written statement dated 12/22/21 by the Regional Human Resource (HR) Manager, showed: -On 12/22/21 about 1:30 P.M., he/she heard a person yelling. -He/she looked out of the window from the HR office to the designated resident smoking area and witnessed a facility staff person dragging Resident #1 across the cement floor through the doorway to the memory care unit. -He/she reported it to the Social Service Director. Record review of a written statement dated 12/23/21 by Hall Monitor A, showed: -He/she had asked the resident to go inside after a smoke break when the resident said he/she wanted another smoke (cigarette). -He/she had told the resident he/she could not have another cigarette. -The resident had started yelling at him/her and refused to go inside. -He/she asked the resident three more times to go inside and the resident continued to refuse. -He/she had written I should have did things better and said I was about to call a code green (a Crisis Alleviation Lessons and Methods (C.A.L.M.) hold technique which an Registered Nurse (RN) or Licensed Practical Nurse (LPN) must be present when a resident is in imminent danger of harming themselves or in imminent danger of harming others and must never be used as a punishment for discipline or staff convenience). -The resident said [OBSCENITY] them people and your momma too. -He/she responded and reached under the resident's arms and proceeded to bring the resident inside. -The resident fought him/her and ended up on the floor when he/she pulled the resident inside. Record review of the facility investigation dated 12/30/21 showed: -Facility staff to resident incident on 12/22/21. -The Regional HR Manager was in the HR office and heard the resident yelling, when he/she looked out of the window to the resident smoking area he/she observed Hall Monitor A dragging the resident across the cement floor and through the doorway to the memory care unit. The Regional HR Manager reported to the Social Worker. -Activities Assistant A observed Hall Monitor A pulling the resident through the door. Hall Monitor A had his/her hands under the resident's arm pits pulling the resident backwards with his/her buttocks on the floor. The resident was yelling. -The Activities Assistant held the door for Hall Monitor A so the door would not shut on the resident's legs. -Hall Monitor A left the resident inside the door in the dining room and walked off the unit. During an interview on 12/23/21 at 9:13 A.M., the Administrator said: -He/she was doing rounds in the building. -He/she had walked onto the memory care unit and saw the resident crying. -The resident was unable to report why he/she was upset. -He/she later found out from the Social Worker that Hall Monitor A had dragged the resident from the smoke patio inside the memory care unit. During an interview on 12/23/21 at 9:19 A.M., the Regional HR Manager said: -He/she heard yelling and looked out the HR window onto the men's smoking area off of the memory care unit. -He/she observed a facility staff person dragging the resident across the cement floor by his/her shirt and his/her arm through the door to the memory care unit. -He/she was unable to identify the facility staff person by name. During an interview on 12/23/21 at 9:37 A.M. the Social Worker said: -He/she was not an eye-witness, he/she was in the room with HR and had heard arguing outside. -The Regional HR Manager reported to him/her what he/she observed. -He/she then went over to the hall to determine who the staff person was but before he/she had went to the hall, Hall Monitor A had stopped by HR and said he/she was leaving the building. -He/she spoke to Certified Medication Technician (CMT) A and found it was Hall Monitor A who was outside with the resident. During an interview on 12/23/21 at 11:50 A.M., the Regional HR Manager said: -He/she and the Social Worker were sitting in the HR office. -He/she heard someone screaming. -A facility staff person was bent over the resident and drug the resident across the cement floor of the smoking area and through the doorway into the memory care unit. -The resident was screaming to let him/her go and to stop. -The facility staff person did not stop dragging the resident until he/she was through the door into memory care unit. -Once the door was closed to the memory care unit, he/she did not see anything else. -He/she did not remove or go and stop Hall Monitor A, he/she reported to the Social Worker what was observed. During an interview on 12/23/21 at 11:57 A.M., the Social Worker said: -He/she did not see the abuse on 12/22/21, he/she was on the phone in the same office as the Regional HR Manager. -He/she reported the incident to the Administrator. -He/she had not removed Hall Monitor A from the floor, Hall Monitor A had said he/she was leaving the building before the Regional HR Manager had reported the observation. During an interview on 12/23/21 at 12:08 P.M., the MDS Coordinator said: -When he/she arrived to the memory care unit, he/she saw the resident sitting on the floor. -The resident did not say anything to him/her. -The resident cried at the time. -He/she did not see the incident. -He/she did a skin assessment after the incident. -The resident did not mention to him/her about anyone being mean to him/her or mistreating him/her. -He/she did not see any bruising any marks or any lacerations on the resident's skin. -The resident's clothes were not torn from being dragged on the concrete. During an interview on 12/23/21 at 12:16 P.M., the resident said: -Hall Monitor A dragged him/her across the floor because he/she asked to smoke another cigarette. -He/she felt worthless after being dragged across the floor. During an interview on 12/23/21 at 1:07 P.M., CMT A said: -He/she did not know what had taken place between Hall Monitor A and the resident on the smoke patio because he/she was at the nursing station. -He/she witnessed the resident dragged on the floor through the door to the entrance to the memory care unit from the smoke patio by Hall Monitor A. -Hall Monitor A did not help the resident to his/her feet. -He/she and another nurse on the memory care unit, helped the resident to his/her feet. During an interview on 12/23/21 at 1:44 P.M., Hall Monitor A said: -He/she asked the resident to come in to the memory care unit about five times. -The resident cursed at him/her. -He/she grabbed the resident from the backside, then held the resident under his/her arm pits and dragged him/her inside to the memory care unit. -Only the lower part of the resident's body from the lower back down was on the floor. -He/she thought the resident may have felt scared and frightened. -The resident wanted to smoke extra. -After the incident, he/she left the unit, told the Social Worker he/she was going home, then went upstairs and told the Administrator he/she needed to go home, he/she did not tell the Administrator about the incident and the Administrator did not yet know what had happened. -He/she did not realize the distance that he/she dragged the resident from the smoking patio to the door of the memory care unit. -He/she did not help the resident to his/her feet. -If he/she had to do this again, he/she would have just came back inside to the memory care unit and called a code green. During an interview on 12/23/21 at 2:01 P.M., Housekeeper A said: -He/she was on the smoke patio with the resident. -Hall Monitor A asked the resident to come back onto the memory care unit at least four times. -The resident started to curse at Hall Monitor A and called him/her names. -Hall Monitor A grabbed the resident out of his/her chair. -He/she left the smoke patio and went inside and did not know what happened after that. During an interview on 1/5/21 at 10:05 A.M., Activities Assistant said: -He/she witnessed the Hall Monitor A dragging the resident with the resident's legs on the ground and the door was about to shut on the resident's legs. -He/she grabbed the door to keep from injuring the resident -The resident was yelling and calling names at Hall Monitor A. -The resident stood up once inside and continued to call Hall Monitor A names, Hall Monitor A said nothing and walked off. -He/she did not know what had happened. During an interview on 12/23/21 at 3:56 P.M., the MDS Coordinator said: -He/she had walked onto the memory care unit and saw the resident on the floor by the smoke patio door. -CMT A was near the resident and the Hall Monitor A was walking away. -The resident stood himself/herself up independently. -The resident was visibly crying. -The resident was unable to say what had happened. -The resident was punching the walls and doors. During an interview on 12/23/21 at 4:44 P.M., the Administrator said: -He/she would have expected Hall Monitor A to have given the resident space, because the resident was not harming himself or harming others. -Hall Monitor A should not have drug the resident inside. During an interview on 12/23/21 at 4:45 P.M., the DON said: -He/she would have expected Hall Monitor A to let the resident stay on the smoke patio for a while, and let the resident calm down. -The resident could have been offered a snack. -Hall Monitor A should not have forced the resident inside. During an interview on 12/27/21 at 2:52 P.M., the NP said: -He/she was notified on the morning of 12/23/21 about the abuse towards the resident. -He/she would have expected the employee to follow the policies the facility had in place to prevent abuse. -Getting physical with the resident was not the best way to handle the situation. -He/she expected facility staff to speak calmly to the resident. During an interview on 12/29/21 at 12:11 P.M., Hall Monitor A said: -He/she had been trained enough to know better. -He/she did not feel that dragging the resident was abuse. -He/she did not feel what he/she did was mistreating the resident. During an interview on 1/5/21 at 11:38 P.M. the Administrator said: -Hall Monitor A on 11/26/19 signed the harassment and violence facility policy, the customer service facility policy and and completed the RELIAS online leaning on preventing, recognizing and reporting abuse. -Hall Monitor A was most recently trained on Abuse and Neglect during payday in-services on 10/7/21, 10/16/21, 10/21/21, 11/4/21, and 11/18/21. -Hall Monitor A abused the resident. -Hall Monitor A was terminated. 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). Complaint MO 956

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) A was provided dementia (a general term used to describe symptoms of impairment in memory, communication, and thinking) training or inservicing prior to providing direct care to residents diagnosed with [REDACTED].#101); and further failed to ensure residents with dementia were treated with dignity and respect when CNA A provided cares for four sampled residents (Residents #101, #102, #103, and #104) out of four sampled residents. Twenty residents resided on the 400 hall. The facility census was 91 residents. Record review of the facility's Customer Service Policy and Procedure, revised 9/20/01 showed: -Employees were required to treat all customers with dignity and respect. Customers included residents. -Courtesy and respect were required at all times. -Difficult situations were to be referred to the immediate supervisor or the administrator. *(The facility did not provide a policy that referenced dignity during personal care or promoting enhanced quality of life.) Record review the Training Section of the facility's Abuse, Neglect, Grievance Procedures Policy, revised 8/28/18, showed employees would be trained through orientation and ongoing training on practices such as: -Dealing with aggressive residents. -Frustrations or stress that may lead to abuse. -Sensitivity to resident rights and resident needs. (A policy related to dementia training was not provided.) 1. Review of Resident #101's Face Sheet dated 1/31/20, showed he/she was admitted to the facility 2/16/12, and most recently readmitted [DATE]. The resident's current [DIAGNOSES REDACTED].>-Cognitive Communication Deficit (attention and concentration difficulties, difficulty communicating because of injury to the brain that controls the ability to think). -Dementia with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function because of abnormal microscopic deposits that damage brain cells over time). -Pressure ulcer of sacral region (skin injury in the area of the lower back near the spine). Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/20 showed he/she: -Was cognitively impaired. -Required extensive staff assistance with bed mobility, dressing, and personal hygiene. -Required total staff assistance with transfers and toilet use. Review of the resident's care plan, dated 4/21/20, showed: - The resident was unable to support his/her trunk and used side rails to assist himself/herself with functional mobility tasks such as bed mobility. -Staff would assist the resident while he/she utilized his/her side rails. -Staff would provide peri-care in a timely manner to maintain skin integrity of his/her peri-area. -The resident had impaired memory with cognitive inability and poor decision making skills related to his/her [DIAGNOSES REDACTED]. -Staff should approach the resident from the front in a calm, unhurried manner and validate the resident's thoughts and feelings when confused or anxious. -The resident could become agitated with care, especially when staff performed peri-care. -The resident was known to punch at staff and become verbally aggressive. -Staff should allow the resident sufficient time to make needs known verbally. -Staff should give clear and simple directions and provide a safe environment for the resident to express himself/herself and his/her needs. Record review of the resident's nurse's notes showed: -Documentation dated 6/23/20 at 12:42 P.M., stating: --The resident complained of pain in his/her left hand. --The nursing assessment established bruising was present on the anterior and posterior portion of the fifth index finger and palm. --The resident was unable to close his/her left hand in a fist completely. --The physician ordered a three view x-ray be completed on the resident's hand and wrist. -Documentation dated 6/23/20 at 12:45 P.M., stating the x-ray findings showed the resident's left hand had an acute [MEDICAL CONDITION] of proximal phalanx (bone found at the bottom of the finger) of the resident's fifth finger. -On 6/23/20 at 2:10 P.M., the resident's physician gave an order to send the resident to the hospital for further evaluation. -Documentation dated 6/24/20 at 12:53 A.M., showed: --The resident returned to the facility at 7:15 P.M. (which would have been 6/23/20) on a gurney escorted by emergency medical services workers. --The resident returned with a splint and splint instructions, and an order for [REDACTED]. Record review of the resident's Radiology Patient Report findings and impressions, dated 6/23/20, showed the resident's left hand had an acute [MEDICAL CONDITION] of proximal phalanx (bone found at the bottom of the finger) of the fifth finger. During an interview on 6/24/20 at 1:35 P.M., the Assistant Director of Nursing (ADON) said: -At around 7:30 A.M. on 6/23/20, the floor nurse told him/her and the Director of Nursing (DON), the resident's finger looked swollen. -He/she and the DON did an assessment and the DON immediately contacted the physician and a stat (urgent) x-ray was ordered. Observation of the resident, with the DON present, on 6/24/20 at 1:58 P.M., showed: -The resident was in his/her room sitting in his/her wheelchair. -He/she was eating his/her lunch. -The resident had a splint on his/her left hand. During an interview with the resident and the DON on 6/24/20 at 2:04 P.M., the resident was shaking at times, had difficulty with recall and appeared anxious, but would calm down with redirecting or subtle reminders. -The DON said one finger, the resident's pinky finger, was the main reason for the wrap. -The DON said the resident spent two or three hours at the hospital yesterday. -The resident said he/she had a fight yesterday. -The resident said he/she did not grab the person, but the person grabbed him/her. -The resident said he/she thought the incident occurred in the morning. During an interview on 6/24/20 at 2:47 P.M., CNA C said: -He/she came in on 6/23/20 around 5:30 A.M. -When he/she approached the resident's room, between 5:30 A.M. and 6:00 A.M., CNA A was coming out of the room and said the resident was being aggressive and wanted to fight. -He/she peaked in the room and told CNA A that he/she would take care of the resident. After CNA A walked away from the room, the resident relaxed. -He/she went into the room and got the resident changed. -He/she told the oncoming charge nurse about the incident. -The night shift nurse knew something was going on between CNA A and the resident. During an interview on 6/24/20 at 10:01 P.M., the Hall Monitor said: -Some residents would become combative, and if a resident became too combative, he/she was asked to come into the resident's room and monitor the residents who liked to lash out. -The residents that became combative were not like that every day. -He/she had to watch Resident #101 a few times. -The resident had been irritated lately. It may have been because of the rash on the resident's buttocks. -On the 6/22/20 during the night shift, the resident was yelling, pulling and punching the air when being changed because it was painful when he/she was getting changed. He/she thought it was because of the resident's skin breakdown, which was terrible. -He/she didn't see anything happen that he/she thought could have caused injury to the resident's left hand. During an interview on 6/24/20 at 10:21 P.M., Licensed Practical Nurse (LPN) B said: -He/she had not witnessed CNA A being rough with the residents. -The resident does a lot of hitting on the wall. -He/she did not recall any staff member reporting a resident injury on 6/22/20 or 6/23/20. During an interview on 6/25/20 at 3:15 P.M., CNA A said: -Anytime you change the resident he/she is going get aggressive. -The resident had skin breakdown on his/her scrotum and buttocks and he/she knew it was painful for the resident. -He/she was putting cream on the resident. -The resident tried to backhand hit him/her and he/she caught the resident's hand in mid-air and told the resident what he/she was doing. -The resident tried to hit him/her a second time with his/her right hand, but he/she was able to get out of the way. -The resident was angry while swinging his/her hand and hit a metal part on the bed, but he/she didn't think the resident hurt his/her hand when he/she hit the metal part on the bed. -The resident was hitting the wall when he/she had him/her rolled over toward the wall. He/she thought that might be how the resident injured his/her hand. During an interview on 7/2/20 at 1:53 P.M., LPN A said: -CNA C reported to him/her about the resident being upset on the morning of 6/23/20, and him/her having to take over care for the resident. -In less than five minutes after CNA C got the resident changed and told him/her about how upset the resident had been, the resident was yelling for assistance. -The resident was stuttering and kept saying he/she broke my hand .He/she broke my hand. -He/she asked who and the resident said that person, referring to CNA A. -When trying to ask the resident about what happened all he/she could get out of the resident was he/she broke my hand. -He/She looked at the resident's hand and it appeared swollen. -He/She reported the incident to the ADON. 2. Record review of Resident #102's Face Sheet dated 7/1/20 showed he/she was admitted to the facility 5/14/13, and most recently readmitted [DATE]. The resident's current [DIAGNOSES REDACTED].>-Dementia with Behavioral Disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning with manifestations of underlying psychological symptoms). -[MEDICAL CONDITION] with late onset (the most common form of the progressive mental deterioration due to generalized degeneration of the brain, characterized by clinical symptoms and signs that become apparent after the age of 60). -Poly-[MEDICAL CONDITION] (related to the process of aging, as water content of body cartilage increases, and the protein makeup of cartilage degenerates, characterized by join pain and stiffness). Record review of the resident's care plan, dated 4/21/20, showed: -The resident was his/her own person, would remain able to make his/her own care decisions until the next review date, and would participate in all decisions regarding his/her care. -The resident had impaired short/long term memory. -One of the goals was to meet the resident's needs and maintain dignity. -The resident needed total care with activities of daily living (ADL)s and transfers, but was able to feed himself/herself at the table in the dining room with nurse supervision, set up and clean up assistance. -Staff should approach the resident warmly and positively and in a calm manner. -Staff should always address the resident by his/her/name; and calmly talk with the resident and offer reassurance prior to initiating cares. Record review of the resident's Annual MDS, dated [DATE], showed he/she: -Required extensive staff assistance with bed mobility, locomotion, dressing, and personal hygiene. -Required total staff assistance with transfers and toilet use. During an interview on 6/24/20 at 3:08 P.M., CNA D said: -Residents complained to him/her about another staff member being rough with them, and he/she saw another CNA being rough with Resident #102. -Resident #102 yelled out and he/she went into the resident's room, and he/she saw CNA A trying to put the resident's shirt on him/her, but being rough while assisting the resident with getting dressed. The incident occurred about three weeks ago. -He/she told CNA A that he/she could not be rough like that. -He/she talked to CNA A about the best way to assist the resident. -He/she reported the incident to LPN B. -The resident had become combative at times, but if you left and came back, the resident would normally say something like What you got there? You got some cookies? When the resident responded in that manner you knew he/she normally was ready to cooperate. -The resident had dementia, but did converse and interact with others. -He/she had learned to pay special attention to residents with dementia and read their signals. -With Resident #102 staff had to relax, relate, release and come back to the resident. During observation and interview on 6/26/20 at 1:56 P.M., the resident was covered with a blanket, sitting in his/her wheelchair, near the door in his/her room. -The resident joked around with his/her greeting of the DON. -The DON introduced the surveyor and left the room. -The resident would not respond to the surveyor when the surveyor tried to talk with him/her. -When the surveyor asked the resident if he/she wanted him/her to leave, the resident responded Yes. 3. Review of Resident #103's Electronic Health Record (EHR) Face Sheet on 7/1/20, showed he/she was admitted to the facility 9/7/16, and most recently readmitted [DATE]. The resident's current [DIAGNOSES REDACTED].>-Dementia with behavioral disturbance. -[MEDICAL CONDITION] (the gradual loss of kidney function). -[MEDICAL CONDITION] (a progressive nervous system disorder that affects movement). -Major [MEDICAL CONDITION] (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning). Record review of the resident's Quarterly MDS, dated [DATE], showed he/she: -Was moderately impaired cognitively. -Required set up assistance only with bed mobility, transfers, walking, locomotion, eating, dressing, and personal hygiene. -Required staff assistance with toilet use. -Was unsteady, but able to stabilize. -Used a walker when ambulating. Review of the resident's care plan, updated 4/17/20, showed: -Staff was to assist the resident with ADL care due to the resident's decline in cognition and mental illness. -Staff should allow extra time for the resident to assist in his/her care. -Staff was to redirect the resident when the resident demonstrated increased agitation, and allow space and time to calm down. -The resident liked to be private and did not respond well to change and redirection. -He/she had side rails to assist with functional mobility such as bed mobility and transfers. During an interview on 6/24/20 at 2:47 P.M., CNA C said: -He/she had heard residents complaining about rough treatment from staff. -Resident #103 was one who expressed concern with rough treatment. -The resident complained about CNA A being impatient and rough. During an interview on 6/24/20 at 3:08 P.M., CNA D said the resident had complained to him/her about another staff member being rough when administering care. During observation and interview on 6/24/20 at 3:38 P.M., the resident was lying in his/her bed watching television. -The resident said he/she did not always receive appropriate care/assistance. -The resident began crying as he/she talked about a CNA that handled him/her very roughly, and how one day the CNA left him/her naked in bed while he/she left the room. -He/she could not accurately recall the name of the CNA, but described the CNA to a point that the DON had an idea who the resident was talking about. During an interview on 6/24/20 at 3:43 P.M., the resident's roommate said: -It took a while for staff to help his/her roommate. -Sometimes his/her roommate was not cooperative with the staff. -His/her roommate told the staff when he/she did not like what they were doing. 4. Review of Resident #104's EHR Face Sheet on 7/1/20, showed he/she was admitted to the facility 3/3/15, and most recently readmitted [DATE]. The resident's current [DIAGNOSES REDACTED].>-Dementia without behavioral disturbance. -Acute Kidney Failure (when kidneys suddenly become unable to filter waste products from your blood). -Dysphasia (difficulty swallowing). Review of the resident's care plan, updated 4/22/20, showed: -The resident was at risk for altered thought processing, and staff should monitor for changes in abilities, and document for the doctor to review. -Staff should calmly talk with the resident and offer assurance prior to initiating cares. -Staff should provide peri-care and brief changes every two hours and as needed. Record review of the resident's Quarterly MDS, dated [DATE], showed he/she: -Was cognitively intact. -Required extensive staff assistance with bed mobility, transfers, locomotion, dressing, and toilet use. -Had impaired range of motion in both lower extremities. During an interview on 6/24/20 at 3:50 P.M., the resident said: -CNA A, was kind of a new person, was rough and he/she wanted someone to do something about it. -The aides had attitudes and he/she had an attitude too, which he/she knew was not right. -One particular aide, CNA A is really rough. -He/she didn't think CNA A meant any harm, but was rough. 5. Record review of CNA A's training record showed: -He/she completed training required during orientation on 2/25/20. -The training completed during orientation did no show dementia training. -Relias Online Learning (an online learning system that allowed completion of facility/state required training at leisure, but within a specified time-period) documentation. -The Relias Online Training acknowledgement showing the employee acknowledged he/she must complete the courses listed within the timeframe's indicated was signed by the CNA A. -The Relias training shown on the required courses list did not show dementia training. Record review of the Daily Staffing Sheet for 6/22/20 showed CNA A worked on the unit where residents with a dementia [DIAGNOSES REDACTED]. Record review of the Daily Staffing Sheet for 6/23/20 showed CNA A worked on the unit where residents with dementia [DIAGNOSES REDACTED]. During an interview on 6/25/20 at 3:48 P.M., CNA A said: -He/she had not had dementia training. -He/she completed required training during orientation. -He/she completed some general training and the CALM training, and the five man take down training. During record review and interview on 7/1/20 at 11:48 A.M., the DON provided a notebook containing in-services. -Training that CNA A attended did not include dementia training. -He/she said the corporate office would have to provide the content of the Relias training's CNA A completed. 6. During an interview on 7/1/20 at 8:50 A.M., the DON said: -An investigation had taken place related to the first allegation regarding Resident #101's injury. -The facility was in the process of completing the investigation related to Resident #102 allegation of not being treated with dignity. -CNA A had not been back to work since the incident was reported. -During the investigation all residents on the 400 hall where CNA A had worked were interviewed and did not express concerns. During an interview on 7/1/20 at 11:48 A.M. with the DON and Administrator, both the DON and Administrator agreed that training and in-services regarding treatment of [REDACTED]. -The Administrator said mistreatment or rough handling of residents was not expected and not tolerated. -The Administrator said the specifics of the training material on Relias would have to come from the corporate office. -The DON said the notebook he/she maintained had a record of the in-services provided with sign-in sheets showing who attended the training's/in-services. -The DON said he/she would expect the residents to be treated with dignity and respect. Record review of the facility investigation dated 7/3/20 showed: -On 6/23/20, the charge nurse reported Resident #101's left hand was bruised, had a hematoma and slight [MEDICAL CONDITION]. -Resident #101 when interviewed by the charge nurse said, he/she hurt me. -CNA A was identified as assigned to provide cares for Resident #101 on the night of 6/22/20 through 6/23/20. -Resident #1 was diagnosed with [REDACTED]. -On 6/25/20, CNA B reported an allegation against CNA A slapping at Resident #102. -CNA A said he/she messed around with Resident #102 since the resident was aggressive with him/her. -Abuse was not found, it was determined Resident #101 had an injury of unknown origin; it was determiend Resident #102 was not treated with dignity and allowed time to get ready. -Facility staff were educated resident rights to refuse care. -CNA A was terminated on 7/3/20. Complaint #MO 779

Based on interview and record review, the facility staff failed to follow the facility policy by not notifying one (Resident #6) of eight sampled residents physician of his/her significant weight loss, and to ensure interventions were implemented to prevent continued weight loss including placing the resident on supplements if ordered, monitoring the resident's meal percentage consumption, monitoring the need for assistance with eating, assessing for the cause of the weight change, and to ensure their Registered Dietician (RD) assessed the resident after a significant weight loss. The facility census was 76 residents. Record review of the facility's undated Weight Policy, showed: -If a resident's weight is above or below five percent (%) in the last 30 days or 10% in the last 180 days, the physician will be notified and the resident will be placed in the AT RISK program; -The resident will be placed on supplements as ordered, monitored for meal percentage consumption, monitored for the need for assistance with eating, and assessed for the cause of weight change; -Nutritional status will be discussed at quarterly care plan meetings as triggered on the Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff ) and at weekly AT RISK meetings. 1. Record review of Resident #6's admitted d 10/15/15 showed he/she: -Was admitted to the facility on [DATE]; -Was moderately cognitively impaired; -Was independent with eating; -Weighted 178 pounds; -Had no signs or symptoms of a possible swallowing disorder; -Had no significant weight loss or gain in the last six months; and -Did not require a mechanically altered or therapeutic diet. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Weight Record showed he/she: -Was weighed weekly; -Weighed 178 pounds on 10/3/15, 182 pounds on 10/12/15, 183 pounds on 10/19/15, and 184 pounds on 10/26/15, -Weighed 183 pounds on 11/2/15, 184 pounds on 11/9/15, 184 pounds on 11/23/15, and 183 pounds on 11/30/15, -Weighed 184 pounds on 12/7/15, 184 pounds on 12/14/15, 181 pounds on 12/21/15, and 185 pounds on 12/28/15, and -Weighed 188 pounds on 1/4/16, 188 pounds on 1/11/16, 185 pounds on 1/18/16, 184 pounds on week four with no date documented. Record review of the resident's significant change MDS dated [DATE], showed he/she: -Was now severely cognitively impaired; -Required set up and supervision for eating; -Weighed 188 pounds which was a 10 pound (5.3%) weight gain since admission; -Was 72 inches (in) tall; -Had no signs or symptoms of a possible swallowing disorder; -Had no significant weight loss or gain in the last six months; -Did not require a mechanically altered or therapeutic diet, although his/her care plan stated he/she received a pureed diet and -Was on a physician prescribed weight gain program. Record review of the resident's care plan dated 1/18/16, showed he/she: -Was on a pureed diet and was able to feed himself/herself; -Required reminding of meal times; -Had a weight gain and was at risk for fluctuation in his/her weight; -Had a goal to maintain his/her current weight without a five pounds loss or gain thru the next 90 days; and -Interventions included to provide diet texture as ordered, remind the resident of meal times, allow him/her a choice of what he/she wanted, and to consult the RD as needed. Record review of the resident's RD note dated 1/27/16, noted the resident's weight was stable. Record review of the resident's Weight Record showed he/she: -Was weighed weekly; -Weighed 179 pounds on 2/1/16, 177 pounds on 2/8/16, 178 pounds on 2/15/16, and week four 178 pounds with no date documented; -Weighed 178 pounds on 3/1/16, 153 pounds on 3/7/16 which was a 25 pound (14%) weight loss, 160 pounds on 3/16/16 which was a 18 pound (10%) weight loss, and 164 pounds on 3/21/16 which was a 14 pound (7.8%) weight loss, and -Weighed 161 pounds in April 2016 with no specific date documented, which was a 17 pound (9.5%) weight loss. Record review of the resident's Physician's Progress Note dated 3/7/16, showed: -The chief complaint was the March medication and care plan review; -He/she had a weight loss of 5% or more in the last 30 days; -He/she had not developed a significant complication, new problem, or major change in status, and a creation of a new medical plan of care was not required; and -Additional details regarding the visit included the addition of an appetite stimulant such as [MEDICATION NAME] (medication used to treat allergies [REDACTED]. Record review of the resident's care plan showed no additional changes or interventions implemented after his/her significant weight loss was identified on 3/7/16. Record review of the resident's POS dated 3/10/16, showed no new physician's orders [REDACTED]. Record review of the resident's Nursing Notes dated 3/7/16 - 4/7/16, showed no documentation that the resident's physician or the RD was notified of the resident's continued significant weight loss, or of any additional interventions that were attempted or added such as supplements, fortified foods to provide additional calories, or snacks between meals. There were no notes showing the resident's significant weight loss was monitored in risk meetings. Record review of the resident's Physician's Progress Note dated 4/7/16, showed: -The chief complaint was an abscess (an accumulation of pus any where on the body that causes swelling) which was being treated; -His/her diet and oral intake was poor; -He/she had not developed a significant complication, new problem, or major change in status, and a creation of a new medical plan of care was not required; and -The progress note did not identify the resident's significant weight loss. Record review of the resident's telephone orders dated 4/7/16, showed a physician's orders [REDACTED]. During an interview on 4/28/16 at 2:35 P.M., the Assistant Director of Nursing (ADON) said meal and fluid intake was not recorded at the facility. The administrative staff did monitor residents who were at risk for weight loss each week in a Patient At Risk (PAR) meeting. The ADON said the information discussed at the PAR meetings was for the facility use only and they did not provide that information to the surveyors. During an interview on 4/28/16 at 3:00 P.M., the Director of Nursing (DON) said the resident had been on the list for the PAR meeting and the weight of 153 pounds on 3/7/16 was noted, but there was no other information in the PAR meeting notes. The resident's meal percentage intake was not monitored or documented. The DON had thought the RD was notified because a list was provided for each of the RD's visit. He/she questioned the accuracy of the 3/7/16 weight of 153 pounds but did acknowledged that the subsequent weekly weights did show a significant weight loss. He/she would have expected the staff to notify the resident's physician of continued significant weight loss. During an interview on 4/28/16 at 3:10 P.M., the RD said he/she was not aware of the resident's significant weight loss. During an interview on 4/28/16 at 3:15 P.M., the resident's physician said he/she had not been aware of the resident's significant weight loss. He/she was surprised because he/she watched the weights. The Nurse Practitioner saw the resident on 3/7/16. The physician thought the reason the [MEDICATION NAME] had not been ordered was because insurance companies usually did not cover [MEDICATION NAME]. He/she would have expected the facility staff to notify him/her of the resident's continued significant weight loss. He/she questioned whether the 3/7/16 weight of 153 pounds may have been inaccurate, but acknowledged that the subsequent weekly weights did show a significant weight loss. During an interview on 4/29/16 at 4:30 P.M., the resident's Nurse Practitioner said he/she thought that was an inaccurate weight on 3/7/16. He/she had thought about adding [MEDICATION NAME] but did not because it was not covered by insurance companies. As far as he/she knew the resident ate well, had been at risk for weight loss since admission, and had been receiving [MEDICATION NAME] since admission. Complaint MO 184

Based on observation, interview and record review, facility staff failed to assess the resident's pain level and administer pain medication prior to performing wound care when the resident told the staff it really hurts when his/her dressing was changed to his/her left foot, and to stop the wound care procedure when the resident showed signs of pain such as grimacing, tensing up, squirming and making faces. The resident kept saying to the staff that it was hurting and staff proceeded to hold the resident's left leg held down during wound care for a worsening Stage III pressure ulcer for one sampled resident (Resident #9) out of 14 sampled residents. The facility census was 83 residents. Record review of the facility's policy titled, Wound and Skin Care Policy and Protocol revised 3/2015, showed the following treatment guidelines: -Factors relevant to the selection of treatment include: ulcer location, size and depth, presence of undermining or tunneling, presence of necrotic tissue, type and amount of drainage, presence of granulation or [MEDICATION NAME], presence of surrounding skin [DIAGNOSES REDACTED], [MEDICAL CONDITION], or induration and presence and severity of ulcer-related pain. -Residents should be assessed for pain, related to pressure ulcer or its treatment per policy. -Manage pain by eliminating or controlling the source when possible (wound coverings, support surfaces, repositioning). -Try to prevent or relieve pain associated with or made worse during dressing changes and debridement. -[MEDICATION NAME] may be given routinely before dressing changes and as needed after dressing changes or debridement. -Assess and care plan management. Record review of the facility's policy titled, Clean Dressing Change revised 2/1/11, showed the following information should be recorded in the resident's medical record: -Adverse tolerance to the procedure, and -Any problems or complaints made by the resident related to the procedure. 1. Record review of Resident #9's face sheet showed he/she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Record review of the resident's Annual Minimum Data Set (MDS- a federally, mandated assessment tool required to be completed by facility staff and used for care planning) dated 6/3/15, showed he/she: -Was cognitively intact for making daily decisions; -Required the total assistance of one person with dressing and hygiene; -Needed limited assistance of one person with bed mobility; -Required total assistance of two or more people for transferring; -Had impaired range of motion of his/her upper and lower extremities on one side; -Was frequently incontinent of bowel and always incontinent of urine; and -Had one worsening Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.) pressure ulcer. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Required the total assistance of one person with dressing and hygiene; -Needed extensive assistance of one person with bed mobility; -Required total assistance of two or more people for transferring; -Had impaired range of motion of his/her upper and lower extremities on one side; -Was frequently incontinent of bowel and always incontinent of urine; and -Had two worsening Stage III pressure ulcers. Record review of the resident's Care Plan dated 8/25/15, showed he/she: -had a history of [REDACTED]. -Was at risk for wound infection; -Was being treated for [REDACTED]. -Should receive a weekly skin assessment; -Should receive weekly wound consultation; -Should be monitored for wound redness, odor and pain; and -Should be assessed for pain every shift. Record review of the resident's Weekly Wound Report dated 10/20/15 showed: -The resident had a chronic pressure ulcer on his/her left lateral heel with a measurement of 3.5 centimeters (cm) X 3.0 cm X 0 cm. -The resident had a chronic pressure ulcer on his/her left posterior heel that measured 4.5 cm X 4 cm X 0 cm. The wound was described as a Stage III wound with a wound bed description of loose, moist eschar. Record review of the resident's physician's orders [REDACTED]. -an order for [REDACTED].>-An order dated 9/16/15 to cleanse the wound on the resident's left heel with wound cleanser, apply powder to the wound bed, cover with silver alginate and foam dressing and wrap with Kling. The order was to change the dressing daily and as needed until healed and -A handwritten order dated 10/20/15 for daily dressing changes on the resident's left heel wound. Record review of the resident's Medication Administration Record [REDACTED]. Observations on 11/3/15 beginning at 12:55 P.M. showed: -The resident was in bed, resting on his/her low air loss mattress; -Registered Nurse (RN) A entered the resident's room to administer wound care/treatment on the resident's left heel; -At 12:57 P.M. the resident said it really hurts when the dressing is changed; -RN A asked the resident about his/her pain and the resident confirmed he/she had pain; -RNA asked Certified Medication Technician (CMT) A if the resident had received any pain medication; -CMT A said that he/she had not given the resident anything for his/her pain because the resident had not told him/her about his/her pain; -RN A brought in his/her wound treatment supplies, washed his/her hands and proceeded with setting up the supplies for the resident's wound treatment and dressing change; -The resident's socks were removed and the wrap was cut and removed; -As RN A began removing the resident's old dressing, the resident grimaced, became tense and said the wound was hurting; -RN A described the resident's wound as a lateral and posterior Stage III heel wound with the wound bed covered with necrotic tissue, slough, and the edges were callused; -The resident continued squirming and making faces while the wound was being cleansed and the treatment applied; -CMT A held the resident's leg in place. The resident was pulling and moving his/her legs and -At 1:15 P.M. CMT A and RN A tried to encourage the resident to keep still so that the treatment could be completed. The resident kept stating it was hurting. During an interview on 11/6/15 at 11:25 A.M., RN A said: -The resident usually complains because he/she does not want the wound treatment done and -He/she should have stopped, assessed and treated the resident's pain before continuing with the wound treatment and dressing change. During an interview on 11/6/15 at 5:15 P.M., the Director of Nursing (DON) said he/she would have expected the treatment to be stopped and pain medication to be administered. During an interview on 11/19/15 at 10:32 A.M. Physician A said: -Usually a pain medication has been ordered that can be administered prior to a treatment if the resident is in pain; -The resident is verbal and can make it known if pain is present and -Pain medication should have been given to the resident when he/she said he/she had pain, prior to the dressing change and treatment being continued.