Every finding on record at Pleasant Valley Manor Care Center

Based on interview and record review, the facility failed to ensure three of 15 sampled residents reviewed for unnecessary medications (Resident #1, #2 and #34), and/or their representative were informed of the risks and benefits of taking psychotropic medications, this included anti-depressant medications, anti-anxiety medications, hypnotic medications (sleep aid), and anti-psychotic medications (for the treatment of mood and behaviors associated with mental health conditions). This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 62. Review of the facility's policy for Psychotropic Medications, revised July 2022, included Psychotropic medications may be considered for residents with dementia only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Residents, families and/or the representative will be informed on the risks and benefits of these medications. 1. Review of Resident #1's care plan, revised 7/14/23, showed: - The resident used antidepressant medication trazodone related to depression. Administer antidepressant medications as ordered by physician. Monitor, document, report as needed any adverse reactions to antidepressant therapy. - The resident used antianxiety medications; alprazolam related to adjustment issues. Administer antianxiety medication as ordered by the physician. Monitor for side effects and effectiveness every shift. Review of the resident's Quarterly MDS (Minimum Data Set), a federally mandated assessment completed by facility staff, dated 5/15/25, showed: - Cognitive skills intact. - No behaviors. - Lower extremities impaired on both sides. - Diagnoses included anemia, congestive heart failure, renal insufficiency, malnutrition, and chronic obstructive pulmonary disease. - No falls. - Had seven antidepressants in the last seven days. - Had seven hypnotics in the last seven days. Review of the resident's POS (physician order sheet), dated September 2025, showed a start date of 6/16/25 for Trazodone (antidepressant) 50 mg two tablets by mouth at bedtime for insomnia. Review of the resident's electronic medical record showed no documentation the resident nor their representative was informed of the risks or benefits of Trazadone prior to the start date of 6/16/25. 2. Review of Resident #34's Quarterly MDS, dated [DATE], showed:- Resident had severe cognitive impairment.- Diagnosis: coronary artery disease, kidney disease, and depression.- Resident was prescribed: psychotropic medication for depression and sleep. Review of the resident's Care Plan, revised 6/18/25, showed: -The resident had depression and risk for changes in behaviors decline. - The resident had impaired cognitive function and impaired thought processes related to dementia. Administer medications as ordered.- The resident was on sedative/hypnotic therapy melatonin. Monitor and document adverse effects of therapy.-The resident was using antidepressant medication and antianxiety medications. Review of Resident's Physician Order Summary Report, dated 9/3/25, showed:- Order date 8/15/25, Clonazepam oral tablet 0.25 MG, one tablet daily for anxiety and insomnia;- Order date 8/22/25, Escitalopram Oxalate (antidepressant) tablet 5 MG, two tablets daily for anxiety. Record review of the resident's Medical Records showed no documentation of informed consent for use of psychotropic medications for resident. 3. Review of Resident #2's care plan, revised on 01/01/2025 showed: -The resident had diagnosis of dementia, moderate with anxiety. -The resident was taking anti-psychotic medications: Olanzapine related to mood management. -The resident used anti-depressant medications: Trazadone related to agitation. Review of the Resident's POS (physician order sheet), dated September 2025, showed: -Start date 05/03/25- Trazadone 25mg three times daily, for increase agitation. -Start date 05//03/25- Olanzapine (antipsychotic) 10mg at bedtime, for mood and behavior management. Review of the resident's medical record showed the facility failed to have a psychotropic consent form signed by DPOA prior to use. 4. During an interview on 9/4/25 at 3:15 P.M., Licensed Practical Nurse (LPN) C said he/she thought the staff obtained consents for psychotropic medications but did not know where they would be located in the resident's chart or who was responsible for completing. During an interview on 9/5/25 at 10:45 A.M., the DON said there should be a consent for residents who are taking psychotropic medications. During an interview on 9/5/25 at 11:59 A.M., The Administrator said:- The consents should be obtained prior to the resident starting on the psychotropic medications.- The risks and benefits should be discussed with the resident and/or the responsible party prior to the resident starting on the medication and it should be documented in the resident's chart.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for three residents (Resident #68, #69, and #70) and failed to notify one resident (Resident #21) when they were within $200.00 of the Supplemental Security Income (SSI) resources limit. This affected four of 15 residents sampled. Facility census was 62. Request for a policy covering resident funds upon discharge was not provided by the facility.1. Review of the facility's accounts receivable aging report, dated [DATE], showed the following residents had money in the facility's operating account: - Resident #68 discharged on [DATE], with a credit balance of $4,422.14 in the Private Pay account;- Resident #69 discharged on [DATE], with a credit balance of $4,981,98 in the Private Pay account;- Resident #70 discharged on [DATE], with a credit balance of $2,923.04 in the Private Pay account.During an interview on [DATE] at 1:35 P.M., the Business Office Manager said:- The facility changed accounting software and lost old data on payments to discharged residents. Currently they could not prove that they had made refund payments to the residents #68, #69, and #70;- She was working on refunds with the corporate office for various residents;- The delays in reconciling the accounts were mostly due to issues with Medicaid responding to their requests, but she didn't have any recent correspondence for any of these accounts available;- The expectation from her office was to reconcile within 30 days of discharge for all resident accounts.During an interview on [DATE] at 12:50 P.M., the Administrator said:- Accounts should be reconciled with residents who have discharged or expired within two to three months due to reconciliation delays with Medicare;- Two or three years would be an unacceptable timeline for reimbursement. 2. Review of the facility's Resident fund account balances, dated [DATE], showed resident #21 had a balance of $8,276.82 in their resident account which exceeded the SSI resources limit of $6,068.80. There was no documentation of a notice sent to the resident when he/she was within $200 of the limit. During an interview on [DATE] at 2:30 P.M., the Social Services Designee said:- She was not aware of the exact SSI resources limit that residents were required to not exceed;- The facility had not informed Resident #21 or his/her immediate family that he/she was within $200.00 of the SSI resources limit so they could spend the account down.

Based on observation, interview, and record review, the facility failed to ensure a medication rate under five percent for two sampled residents (Resident #32 and #44) when there were four missed opportunities out of 25, leaving a medications error rate of 16%. The facility census was 62 residents. Review of the facility Medication Administration policy, updated on 7/15/21, showed all resident shall receive medications on a timely basis and in accordance with established policies. Medication orders are to be followed exactly per the physician. If there is any concern regarding the order the physician should be contacted prior to administering the medication. 1.Review of Resident #32 POS (Physician Order Sheet), dated September 2025, showed an order for Psyllium Husk Powder, give 17gm daily for constipation. Instructions read: Mix in 8oz of liquid.in the A.M. Observation and interview on 9/3/25 at 8:30 A.M., showed:-CMT (Certified Medication Technician) A said, Metamucil was in package and is to be mixed with a cup of water. CMT A did not realize the cup of water was short by 3 ounces of water.-During observation of medication pass, the Metamucil was mixed with less than 5 oz (Ounces) of water. Clear cup on medication cart was marked as 5 oz cup, which was short by 3 oz of water. During an interview on 09/05/25 at 10:45 A.M., the Director of Nursing (DON) said Metamucil should be mixed with 8 oz. of liquid, as the order reads. 2. Review of Resident #44's POS, dated September 2025, showed: - Start date: 3/13/24 - MiraLAX oral packet 17 grams daily for constipation. - Start date: 7/31/25 - Psyllium Husk Powder, give 2 scoops daily for constipation. - Start date 7/31/25: Amantadine HCL 100 mg (milligrams) daily for tremors in the morning. Review of the resident's MAR (Medication Administration Record), dated September 2025, showed: - MiraLAX oral packet 17 grams daily for constipation. - Psyllium Husk Powder, give 2 scoops daily for constipation. - Amantadine HCL 100 mg daily for tremors. Staff indicated on the MAR the medication was not administered on 9/1, 9/2, or 9/3. Observation and interview on 9/3/25 at 8:42 A.M., showed: - Licensed Practical Nurse (LPN) A said the Metamucil; did not come with a scoop, so he/she used a medication cup and filled it to two tablespoons and poured it into a clear plastic five-ounce cup and added 70 ml (milliliters) of water and stirred it with a spoon. The label on the Metamucil said to mix it with 8 ounces of water. - LPN A poured 17 grams of MiraLax into a clear plastic five-ounce cup and added 75 ml. of water and stirred it with a spoon. The label on the MiraLAX said to mix it with 4 - 8 oz. of liquid. - LPN A did not administer the resident's Amantadine and said the resident did not have the Amantadine because they were waiting for prior authorization. During an interview on 9/4/25 at 11:53 A.M., LPN A said- The MiraLAX should be mixed with 60 ml of water. - The Metamucil should be mixed with 60 ml. of water. - Residents should have their medication available when it is ordered. During an interview on 9/5/25 at 10:45 A.M., the DON said:- The MiraLAX should be mixed with a minimum of 120 ml. of water. - The Metamucil should be mixed with at least 120 ml of liquid. - The medication should be available for the staff to pass to the resident when it is time.

Based on observation and interview, the facility failed to discard expired medications and biologicals stored within the medication cart, failed to ensure medication was not wedged behind the drawer of the medication cart, which affected four of 15 sampled residents (Resident #33, #20, #71 and #56), and failed to ensure there were no loose pills in the medication cart. The facility census was 62. Record review of the facility's undated policy for Storage of Medications showed:- The purpose of this procedure is to ensure that medications are stored in a safe, secure and orderly manner.- Medications are bubble packaged when they are received. Over the counter may be in a bottle with the label intact and the date the bottle is opened.- Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged or missing labels should be returned to the pharmacy. - No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are to be destroyed. - Medications are stored in an orderly manner in cabinets, drawers or carts. The compartments are of sufficient size to prevent overcrowding. Record review of the facility's undated policy for discontinued/expired medications showed:- Staff shall destroy discontinued or expired medications or shall return them to the pharmacy.- The medications shall be monitored in the medication carts for any expired medications. 1. Observation and interview on 9/3/25 at 9:08 A.M., of the medication cart for the front hall showed:- Resident #33 had an opened Arnuity Ellipta inhaler which was filled on 10/30/24. The label on the box said to discard six weeks after opening the moisture protective foil tray.- There were two loose pills wedged behind the bottom drawer of the medication cart along with Resident #20's Lisinopril, refill date 4/1/24 that had four pills left in the package and expired. Resident #71 had two doxycycline left in the package and was filled 5/25/25, and the resident is deceased . Licensed Practical Nurse (LPN) A said Resident #71 had passed away some time ago. Resident #56 had Lactase, filled 2/10/25 and had 13 tablets left in it. The medication was discontinued. During an interview on 9/3/25 at 9:08 A.M., LPN A said:-The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) check the medication carts for expired medications.-Staff should not use any expired medications; they should be discarded.-Inhalers should be dated when opened and medication should have a pharmacy label to indicate which resident it belonged to.- Staff should make sure to check the inhalers to see if outdated.-There should not be any loose pills wedged behind the drawer of the medication cart and should not have any packages of medication wedged behind the drawer of the medication cart. During an interview on 9/5/25 at 10:45 A.M. the DON said the nurses are responsible for cleaning the medication carts and medication room and making sure there are not any expired medications. There should not be any expired medications in the medication cart or the medication room, they should be destroyed. There should not be any medication packages or loose pills wedged behind the drawer of the medication cart.

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired food items in the dry storeroom and leftovers in the refrigerator, failed to date and label food items in a refrigerator, and failed to properly date incoming food products stored in the dry storeroom. This had the potential to affect all residents by putting them at risk for a food borne illness. The facility census was 62. Record review of the facility's policy Food Receiving and Storage, revised November 2022, showed;- Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date).- All foods stored in the refrigerator are covered, labeled, and dated (use by date).- Refrigerated foods are labeled, dated, and monitored so they are used by their use by date or discarded. Record review of the facility's policy Dietary Food Storage, dated 10/1/21, showed:Refrigerator Storage- Unopened foods shall be stored in the refrigerator until the manufacture's expiration date.- Opened foods shall be stored in an appropriate, sealable container that is labeled with the name of the item, date opened, date to be removed.- The length of time than an opened food item can be stored may vary depending on the product. Refer to the Food Storage Guide.- Prepared items that are left over from a meal must be stored in a covered container and labeled with the name of the item, date placed in the refrigerator and date to be removed. Food may not be held for more than 72 hours.Record review of the facility's policy Food Storage Guide, undated, showed:- Spoiled foods should be removed immediately from refrigerators so decay cannot pass to other foods;- Refrigerated sour cream should be discarded two weeks after being opened. Observation on 9/2/25 at 8:20 A.M., showed the following in the kitchen:Dry Storeroom: 2 containers of thick and Easy 46 fluid ounces thickened iced tea which expired on 8/1/25.Refrigerator:- Undated leftover pancakes with no label.- Undated leftover yellow liquid mixture, unknown product, with no label. - Undated leftover various cheese, shredded, left open.Observation on 9/4 at 9:00 A.M., in the kitchen dry storeroom showed strawberry fountain syrup opened and resealed with no open date.Observation on 9/4/25 at 10:45 A.M., showed Dietary [NAME] (A) re-opened a container of refrigerated sour cream and placed a date on the container after he/she was finished using the food item.During an interview on 9/4/25 at 10:52 A.M., Dietary [NAME] (A) said he/she put a date on the sour cream container to show when it was last opened, today. The food item had been previously used but it didn't have a date on it so he/she put one on it even though he/she did not know when it was originally used by the kitchen. Dates should be put on the container the first time they are opened and only one date per container is allowed. The original receipt date from the [NAME] was on the container and it showed 8/15/25, with an expiration date of 9/28/25 from the manufacturer. He/she would only throw the product out on the expiration date regardless of when the container was opened and resealed.During an interview on 9/4/25 at 10:45 A.M., the DM (Dietary Manager) said:- Items removed from case boxes should have the receipt date annotated on the packaging.- Items should be discarded as soon as they are expired.- Leftovers should have labels to identify the item and when it was originally prepared along with a use by date.- A product stored as a leftover on 9/1/25 should be discarded by 9/7/25 which is seven days after first being prepared.- There should only be one date on a container that has been opened and resealed.During an interview on 9/5/25 at 12:45 P.M., the Administrator said:- Items which are expired should be discarded immediately.- Leftovers should be labeled with product name, date prepared and a use by date.During an interview on 9/16/25 at 3:15 P.M., the RD (Registered Dietician) said- Items should be discarded as soon as they are expired and leftovers should be labeled and have a use by date written on them.

Based on observation, interview, and record review, the facility failed to provide an alternative appealing option of similar nutritive value to one resident (Resident #35) who refused food being served. This affected one resident of 15 residents sampled. The facility's census was 62.Record review of facility policy Resident Food Preferences, revised July 2017, showed the food services department will offer a variety of foods at each scheduled meal and substitutions with the same nutritive value Record review of meal substitutes for lunch, dated 9/2/25, showed: Hot dogs, chicken noodle soup, cheese puffs, ice cream, side salad, diced pears, yogurt or chips.1. Record review of Resident #35's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/8/25, showed:- The resident was severely cognitively impaired;- The resident had moderate difficulty hearing;- The resident had clear speech and he/she was usually understood and usually understands communications;- The resident was independent in eating;- Diagnosis: coronary artery disease, hypertension, diabetes, dementia, and depression. During an observation of the resident in the dining room on 9/2/25 at 12:20 P.M., showed: - The resident ate only cherry cheesecake and did not eat any of the cheeseburger macaroni casserole, vegetables, or dinner bread roll provided for the lunchtime meal; - Certified Medical Technician (CMT) A while giving resident his/her medications at the table, encouraged resident to eat their meal and noted the food had not been touched;- The resident told CMT A he/she did not like the meal and did not want to eat it; - CMT A offered to bring the resident a substitute from the kitchen and did not ask them what they wanted or provide a list of substitute items the resident could choose from for that meal;- CMT A returned with a peanut butter and jelly sandwich on white bread and gave it to the resident:- The resident took two bites out of the sandwich and spit it out on his/her plate and discontinued eating, while staff were in the dining room; - The resident left the dining room without eating anymore food, while staff observed. During an interview on 9/2/25 at 12:40 P.M., CMT A said:- He/she did not know what the menu substitutes were for today's meal;- He/she went into the kitchen and asked for a meal substitute for the resident and he/she was handed a peanut butter and jelly sandwich and not given any options for the resident to consider.During an interview on 9/3/25 at 8:45 A.M., the resident said:- At yesterday's lunch he/she was not offered any specific substitute for the meal he/she did not eat;- The resident accepted the peanut butter and jelly sandwich, because he/she normally likes eating them; - The resident was not offered a hot dog, chicken noodle soup, cheese puffs, ice cream, side salad, diced pears, yogurt or chips which were all on the lunch time list of suitable substitutes for the meal; - The resident would have chosen one of the available substitutes for the lunch time meal if he/she had been informed of that option.During an interview on 9/5/25 at 9:45 A.M., the DM said a peanut butter and jelly sandwich was not a suitable nutritional substitute for a lunch time meal. Dining room staff will normally go to the kitchen ask for a substitute and we will tell them their options and provide what the resident wants to eat. During an interview on 9/5/25 at 12:45 P.M., the Administrator said:- The facility has a list of rotating substitute items for meals if the resident does not like what is being served;- A peanut butter and jelly sandwich is not a suitable nutritional substitute for a lunch time meal.

Based on observation, interview, and record review, the facility failed to ensure staff prepared foods per the prescribed therapeutic diet needs of individual residents when they did not ensure the main entree for a resident was mechanically altered with accompanying gravy or broth for one resident (Resident #1) out of 15 sampled. The facility census was 62.The facility did not provide the requested policies on therapeutic diets and pureed food preparation. Record review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/1/25, showed:- Resident was cognitively intact;- Resident dependent on staff for set up assistance for eating;- Diagnosis: heart failure, kidney disease, diabetes, and anxiety disorder, dysphagia, oropharyngeal phase (difficulty or inability to move food from the mouth through the throat into the esophagus);- Mechanically altered diet.Record review of the resident's Care Plan, dated 7/7/25, showed the resident required a mechanical soft diet per resident request.Record review of the resident Physicians Orders Sheet, dated 9/2/25, showed an order, dated 6/17/25, for Regular diet consisting of mechanical soft texture, regular/thin consistency, mechanical soft meat with binder, regular sides, upright for all food intake.During an interview on 9/2/25 at 11:35 A.M., the resident said his/her meal main courses are supposed to be ground up, but normally they are not done that way and it makes it hard to eat.Record review of Meal Card on 9/4/25 at 10:30 A.M., showed the resident required all meats to be ground up and with gravy or broth added.Observation on 9/4/25 at 12:02 P.M., showed the lunch meal brought to the resident on a hall tray. The main course item of salmon patty was unaltered from original form out of oven and there was no gravy present in the bowl or on the plate for the resident.During an interview on 9/4/25 at 12:04 P.M., the resident said this happens all the time and I cannot eat the salmon the way it is because it might make me choke. I would have told the staff member, but they delivered the tray and left immediately. During an interview on 9/5/25 at 11:15 A.M., Dietary [NAME] (A) said today's main course is a salmon patty, which is salmon fish ground up and made into a patty with other fillers. It is cooked into a firm patty that is removed from the oven and served to the residents. It is already mechanically separated and does not have to be ground up for the resident. As long as there is gravy on the side that's all that is required. He/she thought there was gravy on the tray but was not sure why it was not included today. During an interview on 9/5/25 at 12:45 P.M., the Administrator said a salmon patty needs to be separated and served with a gravy or broth if a mechanically soft diet is ordered for a resident.During an interview on 9/16/25 at 3:15 P.M., the RD (registered dietitian) said a salmon patty cooked and removed from the oven should have gravy or broth on the side or on the main entree so that it is served properly for a mechanically soft diet.

Based on observations, interviews, and facility policy review, the facility failed to ensure food stored in the main kitchen was labeled, dated, disposed of upon expiration, and the thermometer was properly sanitized in-between taking temperatures of the food. These failures had the potential to increase the prevalence and spread of foodborne illnesses and infection for all 60 facility residents. Findings include: Review of the facility's undated policy titled, Handling Leftover Foods, indicated that leftover foods will be properly handled, cooled, and stored to ensure food safety. Review of the facility's undated policy titled, Monitoring Food Temperatures, indicated that the probe should be washed, rinsed, and sanitized with an alcohol wipe and re-sanitized after each use. During an observation of the kitchen on 09/02/24 at 8:48 AM, the following items were observed in reach-in refrigerator one and verified by Dietary Aide (DA) 1 during the initial kitchen tour: -One carton of Almond Milk opened, with no open date with manufacturer's instructions (written on the carton) to use within seven days of opening. -One carton of thickened lemon water opened, with no open date with manufacturer's instructions to use within seven days. -One carton of thickened Orange Juice with an open date of 8/13 (08/13/24) with manufacturer's instructions to use within seven days. -One carton of thickened Iced Tea with an open date of 8/13 (08/13/24) with manufacturer's instructions to use within 10 days. During an observation of the kitchen on 09/02/24 at 8:48 AM, the following items were observed in reach-in refrigerator two and verified by DA1 during the initial kitchen tour: -An opened package of deli ham with a use by date of 8/28 (08/28/24). During an observation of the tray line on 09/04/24 at 11:29 AM, DA1 was observed to take the temperature of the food which included pot roast, asparagus tips, beef gravy, mashed potatoes, ground pot roast, pureed asparagus, and pureed pot roast; without sanitizing the thermometer before use and in between each food item tested . During an interview on 09/04/24 11:38 AM, DA1 stated that she usually sanitized the thermometer when taking temperatures but had run out of alcohols swabs and was in a hurry. During an interview on 09/05/24 9:12 AM, the Dietary Manager (DM) stated that she did not know to look at the manufacturer's instructions for expiration dates.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the sit to stand mechanical lift was functioning properly before use for one of three residents (Resident (R) 5) who utilized the sit to stand lift; ensure the air conditioning unit for two of two residents (R51 and R17) was sealed to prevent pests from entering the rooms; ensure the laundry room floor was a cleanable surface; and ensure the northeast shower room was clean and safe for the residents utilizing the room of 28 sample residents. This failure had the potential to affect the 60 residents' right to reside in a safe, clean, and comfortable environment. Findings include: Review of the facility's policy titled MECHANICAL LIFT _ MANUAL OR BATTERY OPERATED, dated 06/24/24 and revealed the procedure as: 1. Assemble the equipment and supplies to perform the procedure. 2. Identify yourself and tell the resident what you are going to be doing. 3. Wash hands before beginning. 1. Review of R5's Face Sheet located under the Resident tab in the electronic medical record (EMR) revealed R5 was admitted [DATE] with diagnoses that included neuralgia and neuritis, lack of coordination, type two diabetes mellitus, anxiety disorder, and repeated falls. Review of R5's quarterly Minimum Data Set (MDS) located under the Resident Assessment Instrument (RAI) tab of the EMR, with an Assessment Reference Date (ARD) of 08/09/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact. The MDS revealed R5 was dependent on staff for transfers. Review of R5's Care Plan located under the RAI tab of the EMR, updated 08/27/24, revealed [R5] has an ADL [activity of daily living] self-care performance deficit r/t [related to] dementia .The resident is totally dependent on x2 staff for transferring with a HOYER [mechanical] lift. During an interview on 09/04/24 at 12:03 PM, R5 stated, The equipment here doesn't work. It's always broken. I asked to go back to bed after the meeting (Resident Group) yesterday and the sit to stand didn't work. I was in it. I don't feel safe. R5 said the failures had been occurring for the past two months and I tell them all the time. R5 stated, I use the lift twice a day. R5 denied falling out of or from the lift during a transfer when the battery failed. During an interview on 09/04/24 at 12:05 PM, the Certified Nursing Assistant (CNA) 5, delivering R5's lunch tray to her room, stated Yes, the sit to stand batteries don't last. One of us (staff) has to run to get another battery. The batteries have to be put on the charger. During an interview on 09/05/24 at 12:10 PM, the Maintenance Director (MD) denied knowledge of the sit to stand lifts not working. The MD stated, staff can tell me or write it in the maintenance book at the nurses' stations so I can check. If it's something I cannot fix, there's a phone number on the machine to call for maintenance. The MD confirmed that the batteries did need to be charged. During an interview on 09/05/24 at 2:30 PM, the Director of Nursing (DON) provided a list of residents who utilized the Hoyer lift and those who utilized the sit to stand lift. R5 was one of three residents identified to use the sit to stand lift. During an interview on 09/05/24 at 1:24 PM, CNA2 stated, Yes, the batteries do run down. That happens. During an interview on 09/05/24 at 2:10 PM, CNA 1 stated, Yes, I'm the one who put [R5] to bed after the council meeting. I use the sit to stand with her. She was in it and the batteries ran out, we always have two people, I ran to get the other charged battery. She said her arms hurt. She always complains about that. During an interview on 09/05/24 at 2:05 PM, CNA3 stated, [R5] always complains about the lift not working, the batteries run out. During an interview on 09/05/24 at 2:15 PM, CNA7 stated, It doesn't happen to me because I always check for the green light on the battery before I use the lift. During an interview on 09/05/24, the DON denied knowledge of the sit to stand lifts not being charged or running out of battery charge with a resident in the lift. The DON stated, I guess I need to educate the staff about charging the batteries. I don't know why they all don't do that. 2. An environmental tour of the facility was conducted on 09/05/24 at 12:10 PM with the MD and the Housekeeping Supervisor (HSK). The following observations were made: a. R51's air conditioning unit, located in the wall under the window, was observed to have an approximate 1/2 inch unsealed gap which allowed one to see through the unit to the outside which allowed pests to enter the room. Both the MD and HSK confirmed the gap and the flies in the room. The casing around the window was broken with jagged edges and exposed nails. The head of R51's bed was located at the base of the window casing. The headboard had been gouged by the exposed nail. One of two window screens was located propped against the wall. The screen was severely damaged. The MD stated he was unaware of the condition of the window casing and screen. The MD said he was going to have someone seal the air conditioning unit, but it had not yet been done. R51 was unable to be interviewed about the air conditioner, window, screen, or flies in the room. b. R17's air conditioning unit, located in the wall under the window, was observed to have an approximate 1/2 inch unsealed gap which allowed one to see through the unit to the outside which allowed pests to enter the room. Both the MD and HSK confirmed the gap and the flies in the room. The window screen was off the window, propped against the wall. The screen was severely damaged. Flies were observed in the room along with a live black spider in the corner of the window, just above R17's headboard. R17 was unable to be interviewed about the air conditioner, window, screen, flies, or spider in the room. During an interview on 09/03/24 at 12:33 PM, Family Member (FM) 1 for R17 moved the curtain back and there was a bent window screen. The window also had exposed wood where a piece was missing and had rough edges. There was also a nail head sticking out. Also, the air conditioner had a gap at the top where the outside light could be seen. c. Observation of the Northeast shower room on 09/05/24 at 12:20 PM with the MD and the HSK revealed a soiled privacy curtain in front of the toilet stall. The HSK stated, Oh, I'll take care of that, it should be clean. An electrical outlet, located inside the toilet stall, was falling out of the wall. d. Observation of the laundry room floor, on 09/05/24 at 12:40 PM, revealed an exposed, unsealed, concrete floor with minimal floor tiles in place. The HSK confirmed the condition of the floor and stated, It's supposed to be retiled in two weeks, we have 30 boxes of tile. During an interview on 09/05/24 at 7:00 PM, the Administrator stated, I was not aware of the air conditioners, that's not acceptable. 18750

Based on record review and interview, the facility failed to coordinate resident care with other health care providers who provide care for one of three residents (Resident (R) 32) with care provided by an outside health care agency of 28 sample residents. The facility's failure to provide ongoing communication with the outside health care provider places the resident at risk for inadequate or inappropriate care. Findings include: Review of the undated Face Sheet located in the electronic medical record (EMR) under the Census tab for R32 revealed an admitted [DATE] with diagnosis including end-stage renal disease. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24 revealed R32 was dependent on one to two staff for activities of daily living (ADL) and a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R32 was severely cognitively impaired. Review of R32's Care Plan located under the Care Plan tab of the EMR and updated upon the resident's return from the hospital on 06/18/24, informed staff the resident was on dialysis, was served a liberalized diet and the nurse was to assess the thrill and bruit (the access used by dialysis) each shift. During an interview on 08/04/24 at 8:59 AM, the Certified Medication Technician (CMT) confirmed the facility did not prepare and send information regarding R32 for the dialysis treatment, nor did the dialysis center return documents with R32's information to the facility following the treatment. During an interview on 09/04/23 at 11:32 AM, the Director of Nursing (DON) confirmed the facility lacked policies and procedures for the ongoing care of R32 by the dialysis center including the sharing of pertinent clinical information, physician orders, and R32's response to the treatment. The DON stated that no documentation (including vital signs, weights, medications ordered/ administered, and other pertinent resident information) was prepared by the facility and sent to the dialysis provider for the continuing care of R34.

Based on record review, interview, and facility policy review, the facility failed to ensure two of three Certified Nursing Assistants (CNA) 1 and CNA2 reviewed had received annual performance reviews along with 12 hours of in-service training for the last year. This deficient practice had the potential to allow CNAs to not receive the in-service training based on the outcome of the performance review. Findings include: Review of the facility's policy titled, In-Service Training Program, Nurse Aide, revised date May 2019, revealed Policy Statement: All nurse aide personnel participate in regularly scheduled in-service training classes. Policy Interpretation .1. All personnel are required to attend regularly scheduled in -service training classes. 2. The facility completes a performance review of nurse aides at least every 12 months .8. All training classes attended by employee are entered in the respective employe's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor . Review of CNA1's employee file revealed a hire date of 08/06/23. There was no performance review over 13 months ago. Review of CNA1's in-service training revealed the hours were not being tracked. Review of CNA2's employee file revealed a hire date of 07/21/17. The last performance review was dated 07/13/23, over 13 months ago. Review of CNA2's in-service training revealed the hours were not being tracked. During an interview on 09/05/24 at 5:07 PM, the Director of Nursing (DON) was asked about the training hours. The DON stated, We make the calendar from the state requirements. We put out January through December what training they will be. We are not tracking the training hours. The DON was asked about the performance reviews. I get a folder monthly with the performance reviews that are due. I am behind in getting them completed.

Based on interview and record review, the facility failed to report to law enforcement (LE) and the Department of Health and Senior Services (DHSS) when the facility Director of Nursing (DON) became aware on 9/9/23 that there was an allegation of abuse by Certified Nurse Aide (CNA) A towards Resident #1. This affected one of five sampled residents (Resident #1). The facility census was 69. Review of the facility Abuse Prevention Policy, dated 11/2017, showed: -All allegations of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury occurred, will be reported immediately in compliance with state law and regulation. -Any and all identified types of allegations will be investigated. The DON/designee will be responsible for conducting an investigating and reporting the results to the proper authorities. -In the event an allegation that meets or has the potential to meet one of the definitions stated in the policy on abuse/neglect, the Administrator will contact Missouri Department of Health and Senior Services hotline immediately or within no more than two hours. The investigation will proceed after reporting to the state agency. All reports will be forwarded to Missouri Department of Health and Senior Services within five working days of the allegation. Review of the facility Compliance and Ethic Investigation/Reporting policy, undated, showed: -The facility will follow the regulations for investigating and reporting suspected abuse neglect or other potential crimes against a resident. -If the incident results in serious bodily injury the report must be made within 2 hours. If there is no serious injury the report is to be made within 24 hours. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff, dated 9/5/23, showed: -Extensive assistance with two person physical assist with bed mobility and transfers. -Brief Interview Mental Status (BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) of 12, resident has mild cognitive impairment; -Highly impaired hearing, used hearing aid -Severely impaired vision -Diagnoses included: heart disease and peripheral vascular disease (the reduced circulation of blood to a body part other than brain or heart), and chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). During an observation and interview on 9/25/23 at 9:01 A.M., Resident #1 said: -When CNA A was getting him/her up in the morning on September 9, 2023 CNA A pushed his/her lips shut. -Resident #1 demonstrated actions of CNA A using index and middle finger pushing together lips in a duck like pose. -CNA A was rough with the rest of his/her care while wiping his/her bottom and putting him in his/her recliner. Review of facility investigation report showed DON documented the time of the abuse allegation reported to him/her as 9/9/2023 at 2:47 P.M. Review of electronic medical record showed entry made by Registered Nurse (RN) A on 9/9/23 at 2:47 P.M. said Resident #1 verbalized concern regarding care from morning shift being rough. Skin assessment was completed and showed his/her skin was intact, and no bruises noted. His/her family member was notified. DON was made aware as well. Review of DHSS intake report showed report was received on 9/11/23 at 2:33 P.M. During an interview on 9/25/23 at 11:00 A.M., the Administrator said: -He/She started an investigation on 9/11/23 at approximately 11:00 A.M.; -DON reported the allegation investigation to him/her; -He/She would consider the allegation abuse if everything the resident stated had happened; - He/She did not contact law enforcement. During an interview on 9/25/23 at 11:24 A.M., the DON said: -He/She became aware of the abuse allegation when RN A contacted her on 9/10/23; -He/She did not contact Administrator because administrator was gone; -The facility started interviews immediately on Monday morning with the Assistant DON questioning staff and Social Services Director interviewing residents about CNA A; -When he/she interviewed Resident #1 he/she vocalized abuse from CNA A; -The resident took fingers and put on his/her lips showing what CNA A had done to him/her; -The resident said he/she never wanted CNA A in his/her room again -CNA A was agency staff; -CNA A had already left shift for the day, agency was notified of facility investigation and that CNA A was not to return to facility. During an interview on 9/25/23 at 12:15 P.M., RN A said: -He/She was receiving report on 9/9/23 at shift change when CNA B came to report allegation against CNA A; -CNA A was no longer on site as it was shift change; -He/She went to talk to the resident about the incident; -The resident said CNA A told him/her to shhh and put fingers on his/her lips; -He/She contacted the resident's family member; -He/She contacted the DON immediately on 9/9/23; -DON advised him/her to contact staffing agency and notify staffing agency not to allow CNA A to return to facility. During an interview on 9/25/23 at 12:40 P.M., Administrator said: -He/She did not report within two hours as he/she did not consider the abuse allegation serious harm; -He/She did not report to law enforcement as there was no serious injury that would result in criminal offense. MO224273

Based on interview and record review, the facility Administrator and Director of Nursing (DON) failed to investigate allegations of abuse from Resident #1 when the DON was made aware on 9/9/23 that CNA A held Resident #1's mouth closed with his/her fingers. This affected one of one sampled residents. The facility census was 69. Review of the facility Abuse Prevention Policy, dated 11/2017, showed: -All allegations of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury occurred, will be reported immediately in compliance with state law and regulation. -Any and all identified types of allegations will be investigated. The DON/designee will be responsible for conducting, investigating and reporting the results to the proper authorities. -In the event an allegation that meets or has the potential to meet one of the definitions stated in the policy on abuse/neglect, the Administrator will contact Missouri Department of Health and Senior Services hotline immediately or within no more than two hours. The investigation will proceed after reporting to the state agency. Review of the facility Compliance and Ethic Investigation/Reporting policy, undated, showed: -The facility will follow the regulations for investigating and reporting suspected abuse neglect or other potential crimes against a resident. -If the incident results in serious bodily injury the report must be made within 2 hours. If there is no serious injury the report is to be made within 24 hours. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated instrument completed by facility staff, dated 9/5/23, showed: -Extensive assistance with two person physical assist with bed mobility and transfers. -Brief Interview Mental Status (BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) of 12, resident has mild cognitive impairment; -Highly impaired hearing, used hearing aid -Severely impaired vision -Diagnoses included: heart disease and peripheral vascular disease (the reduced circulation of blood to a body part other than brain or heart), and chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). During an observation and interview on 9/25/23 at 9:01 A.M., the resident said: -When Certified Nurses Aide (CNA) A was getting him/her up in the morning, CNA A pushed his/her lips shut. -The resident demonstrated the actions of CNA A using his/her index and middle finger pushing together his/her lips in a duck like pose. -CNA A was physicially rough with the rest of his/her care while wiping his/her bottom and putting him in his/her recliner. Review of facility investigation showed the investigation was started by DON and Assistant DON on 9/11/23. The resident and other residents were not interviewed by the DON until 9/11/23. Staff interviews were conducted on 9/11/23. Record review showed CNA B notified RN A following starting his/her shift at 2:00 P.M. on 9/9/23 after Resident #1 told him/her about the abuse allegation. The DON was notified by RN A on 9/9/23 at 2:47 P.M. During an interview on 9/25/23 at 11:00 A.M., the Administrator said: -He/She started investigation on 9/11/23 at approximately 11:00 A.M.; -DON reported the allegation to him/her on 9/11/23; During an interview on 9/25/23 at 11:24 A.M., the DON said: -The facility abuse investigator was the Administrator -He/She became aware of allegation when RN A contacted her on Sunday 9/10/23; -He/She did not contact the Administrator because the administrator was gone; -The facility started interviews immediately on Monday morning with the Assistant DON questioning staff and Social Services Director interviewing residents about CNA A; -When he/she interviewed the resident he/she vocalized the abuse allegation from CNA A; -The resident used his/her fingers and put on his/her lips showing what CNA A had done to him/her; During an interview on 9/25/23 at 11:30 A.M., the Assistant DON said: -He/She interviewed staff as a part of the investigation on 9/11/23. During an interview on 9/25/23 at 12:15 P.M., RN A said: -He/She was receiving report on 9/9/23 at shift change when CNA B came to report allegation against CNA A; -He/She went to talk to the resident about the incident; -The resident said CNA A told him/her to shhh and put fingers on his/her lips; -He/She contacted DON immediately about the abuse allegation on 9/9/23; MO224273

Based on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified way that a reasonable person would expect when they failed to respond to residents yelling out, provide privacy during catheter peri-cares, provide clothing assistance to resident with belly exposed, notify a visually impaired person they were leaving, did not cover a catheter bag, and did not provide residents access to call buttons. This affected four of 16 sampled residents (Residents #10, #48 , #57, and #179). The facility census was 76. The facility policy, dignity, dated February 2021, showed: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 3. Individual needs and preferences of the resident are identified through the assessment process. 4. Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person or entity associated with this facility. 5. When assisting with care, residents are supported in exercising their rights. a. groomed as they wish to be groomed b. encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities; c. encouraged to dress in clothing they prefer d. allowed to choose when to sleep, eat, and conduct activities of daily living; and e. provided with a dignified dining experience. 6. Residents' private space and property are respected at all times. Staff do not handle or move a resident's personal belongings without the resident's permission. 7. Staff are expected to knock and request permission before entering residents' rooms. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice ad not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. 9. Staff inform and orient residents to their environment. Procedures are explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. 10. Staff protect confidential clinical information. Examples include the following: a. Verbal staff-to-staff communication are conducted outside the hearing range of residents and the public. b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible. c. In the interest of public health, posting the resident's isolation status or transmission-based precautions is permissible as long as the type of infection remains confidential. d. The display of the resident's name on the door or the presence of memorabilia among the resident's belongings is not considered a violation of the resident's privacy or dignity. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered; b. promptly responding to a resident's request for toileting assistance; and c. allowing residents unrestricted access to common areas open to the public, unless this poses a safety risk for the resident. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. addressing the underlying motives or root causes for behavior; and b. not challenging or contradicting the resident's beliefs and statements. 1. Review of Resident #10's admission Minimum Data Set (MDS), a federally mandated instrument completed by facility staff, dated 6/7/23, showed: -Extensive assistance with two person physical assist with bed mobility and transfers. -Brief Interview Mental Status (BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) of 13, resident is cognitively intact; -Highly impaired hearing, used hearing aid -Severely impaired vision -Diagnoses included: heart disease and peripheral vascular disease (the reduced circulation of blood to a body part other than brain or heart). Review of care plan dated 6/19/23 showed: -Resident has an Activity of Daily Living (ADL) self-care performance deficit due to blindness and he/she was hard of hearing, (speak to left ear); -He/She is able to feed him/herself when the staff tell him/her where items are on his/her plate. During an observation on 6/19/23 at 12:08 P.M., - The facility staff placed his/her lunch in front of him/her, but the staff member did not tell resident what was on his/her plate. - Certified Nurse Aide (CNA) F told the resident someone would be over to help him/her eat. Observation showed on 6/19/23 at 12:24 P.M.: - A staff member placed the resident's plate in front of him/her at 12:08 P.M., uncovered it and walked away. Observation on 6/19/23 at 12:37 P.M. showed: - CNA G sat next to the resident and began assisting resident to eat, twenty-nine minutes after meal had been served to resident. During an interview on 6/19/23 at 1:53 P.M., resident said: -Staff will leave and not tell him/her they have left and he/she will still be talking. - He/She wishes staff would say something to him/her before they leave. 44395 2. Review of resident #55 Quarterly MDS dated [DATE] showed: - BIMS of 0 which indicated severe cognitive defect. - Dependence of 2 staff for ADL's - Incontinence of bowel and bladder. Review of the resident's comprehensive care plan dated 1/29/2023 showed: -He/She had an ADL self-care performance deficit due to a diagnosis of Alzheimer's. (a disorder of the brain that causes problems with memory, thinking and behavior) -He/She was dependent on staff for meeting emotional,intellectual, physical and social needs due to his/her cognitive deficits. -Staff are to anticipate his/her needs and wants. Observation on 6/19/23 at 11:33 A.M. the resident was in a broda chair (a large reclining wheeled chair) in the dining room. He/She was slouched down in the chair with his/her bottom on the foot rest. His/her shirt hem was above his/her belly button. He/She was scratching at his/her bottom/pants. Observation on 6/21/23 at 10:47 A,AM., the resident was sitting in the dining room in his/her broda chair. lying flat on back. His/her right hand was down the front of his/her pants, inside his/her adult brief, scratching at him/her self. Resident then removed his/her hand, rubbed along his/her forehead, eyes and nose picked his/her nose, rubbed his/ her legs and exposed his/her abdomen above the belly button and under his/her breasts. He/She then put his/her hand inside the adult brief again , took it out and began rubbing face. Other residents sitting at dining room table with resident. At 12:27 P.M. the residents meal tray was served. He/She remained in reclined position . Other residents are sitting at the table, and in the dining area. During an interview on 6/22/23 at 12:01 P.M. CNA H said the resident should be covered up. He/she had not had time to assist this resident today. The resident constantly moves, scratches and rubs. 46706 3. Review of Resident #57's quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Extensive assistance of two staff for bed mobility and transfers; -Extensive assistance of one staff for dressing, personal hygiene; -Indwelling catheter; -On hospice services; -Diagnosis included cancer, coronary artery disease (a disease in there hearts major blood vessels) and heart failure. Review of the resident's are plan dated 4/25/23 showed: -Resident was dependent on staff for meeting emotional, intellectual, physical, and social needs; - Ensure the resident's call light is within reach; -Resident will maintain or develop clean and intact skin; -Residents dignity and autonomy will be maintained at highest level; -Has indwelling catheter; -Ensure that a catheter leg strap/anchor is in place; -Resident is receiving Hospice services. Observation of CNA on 6/22/23 at 2:39 P.M., showed: -CNA A doing perineal care on the resident; -The resident was exposed from the waist down; -The window curtains were open; -CNA A opened the privacy curtain and opened the door then went down the hall; -The door to the resident's room was left open; -The resident was exposed from the waist down; -The resident can be seen from the hall; -The resident's room mate walked into the room. During an interview on, 6/22/23, at 5:12 P.M., CNA A said: -The door to a residents room should be shut during cares; -The curtains on the window should be closed when providing care; -The privacy curtain should be pulled closed between residents if the resident has a room mate. 4. A review of Resident #179's quarterly MDS dated [DATE], showed: -No cogitative impairment; -Total dependence with bed mobility, transfers, -Assist of one for dressing and ADL's; -The resident had an indwelling catheter -Diagnosis included Multiple Sclerosis (a disease in which the immune systems eats away at the protective covering of the nerves) stroke, and heart failure. A review of the resident's care plan dated, 4/25/23 showed: -The resident has an ADL self-care performance deficit related to Multiple Sclerosis; -The resident was totally dependent on staff to provide showers; -The resident was totally dependent on staff for dressing; -The resident had an indwelling suprapubic catheter (a tube inserted in the bladder through the abdomen to drain urine); -The resident will be/remain free from catheter-related trauma. Observation of CNA on 6/19/23 at 9:53 A.M., showed: -The resident was propelling himself/herself down the hall in a wheel chair; -The resident's shirt was raised up above his/her naval and his/her chest was showing; -The resident's catheter drainage bag was on dragging on the floor behind the wheel chair; -CNA H walked by the resident and did not pull the resident's shirt down or pick the catheter drainage bag up off the floor. Observation of CNA J on 6/19/23 at 2:20 P.M., showed: -CNA J pushing the resident down the hall a wheel chair; -The resident's shirt was pulled up above the resident's navel; -The resident's pants had a yellow substance on the left leg. During an interview on, 6/22/23, at 5:20 P.M., CNA J said: -He/She should ensure the resident's catheter is not on the floor and secured to the wheel chair; -He/she ensure the resident is wearing clean clothes and that that the resident is dressed appropriately; -He/she should have pulled down the resident's shirt before leaving the resident's room. 5. During an interview on, 6/22/23, at 6:22 P.M., the Director of Nursing (DON) said: -The door should be closed when providing resident care; -The staff should knock, pull the window curtains and privacy curtain and shut the door; -The staff should ensure the residents' clothes are fitting appropriately; -Staff should address residents in the dining room that are yelling to see if they need assistance; -Residents should be in an upright position at meals. 6. During an interview on, 6/22/23, at 6:25 P.M., the administrator said: -The door should be closed when providing resident care; -The staff should knock, pull the window curtains and privacy curtain and shut the door; -The staff should ensure the residents' clothes are fitting appropriately; -Staff should address residents in the dining room that are yelling to see if they need assistance; -Residents should be in an upright position at meals.

Based on observation, record review, and interviews, the facility failed to maintain the building in a homelike environment. The facility failed to provide an environment with comfortable sound levels when a door alarm went off multiple times throughout the day. The facility also failed to monitor and maintain air temperatures in the 71 degrees Fahrenheit and 120 degrees Fahrenheit. The facility failed to replace broken blinds, mount mirror to wall, and replace light bulb in a resident room. The facility census was 76. The facility did not provide a policy on homelike environment. 1. Review of resident #66's annual Minimum Data Set (MDS), a federally mandated instrument completed by facility staff, dated 4/11/23 showed: -Brief Interview Mental Status (BIMS) a mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) of 14, resident is cognitively intact; -Minimal difficulty with hearing -Diagnoses included insufficient intake of food and water and hypertension Observation and interview on 6/21/23 at 4:01 P.M. showed Resident holding hands over his/her ears after someone entered facility setting off the door alarm. 2. Review of Resident #43's quarterly MDS, dated [DATE], showed: -BIMS of 15, resident is cognitively intact -No difficulty in hearing in normal conversations -Diagnoses included: stroke and depression Observation on 6/19/23 at 11:42 A.M. showed alarm went off as facility guest entered building. Resident sitting in dining room advised person entering building the code, then that they were entering code on the wrong key pad. Guest responded 'they shouldn't have two buttons at the door, that makes it difficult'. 3. Review of Resident #59's quarterly MDS, dated [DATE], showed: -BIMS of 12, showed moderately impaired -Diagnoses included: anxiety, depression, unsteadiness on feet, and need for assistance with personal care. -Hearing showed no difficulty in normal conversation. During an interview on 6/22/23 at 4:44 P.M., The resident said: -Alarm bothers him/her sometimes as he/she can hear it in the middle of the night in his/her room; -The alarm has awakened him/her when he/she was sleeping; -The front door alarm should not have to be that loud. 4. Review of Resident #51's quarterly MDS, showed -BIMS of 13, moderately impaired cognition. -Diagnoses included: anxiety and depression. -Hearing showed no difficulty in normal conversation. During an interview on 6/22/23 at 4:44 P.M., Resident, said: -He/she did not like alarm and did not understand the reason for it because it is so loud. During an observation and interview on on 6/22/23 at 4:03 P.M., Social Services stated when front entry alarm was sounding off and heard from inside social services office with the door closed 'I wish we didn't have to have that alarm on, it is so loud.' During an interview on 6/22/23 at 4:48 P.M., Medication Technician A stated: -He/she frequently has had to go shut off alarm or tell guests to enter code; -Residents often tell people entering how to turn off alarm. During an interview on 6/22/23 at 4:57 P.M., LPN A said: -Staff complain about the noise of the front entry alarm; -Alarm is irritating for staff and residents. A lot of the residents do not like the loud noise the alarm makes; -The alarm does not promote a home like environment; -He/she would not have the alarm in his/her home; -Alarm went off more frequently during the day shift due to more visitors to the facility; -During the night shift the alarm does not alert often. During an interview on 6/22/23 at 4:57 P.M., RN B said: -Residents tell people the code to the door frequently. -Alarm is not set off as frequently after 6:00 P.M. as it calms down during evening hours and will likely only go off two to three more times during his/her shift; -There are two key code boxes, one on the door and one next to the door and guests get confused where to enter the code; -Alarm is set off more frequently when new residents families come in to visit or new vendors enter due to them not knowing about the door alarm; During an interview on 6/22/23 at 6:19 P.M., the Director of Nursing (DON) said: -Front entry alarm is for security so facility staff know if a resident exits the facility. -Residents shout the door code out to everyone who sets off the alarm -The alarm did not promote a home like environment when resident's were in the dining room. During an interview on 6/22/23 at 7:06 P.M., the Administrator said: -Front entry alarm notified staff when someone exited facility; -Front entry alarm had one sound, all other door alarms in facility make a different sound; -Alarm did not promote home like environment; -Front entry alarm had two boxes, the other box was for delayed egress system; -He/she would have to hire electrician to take old box out; -Most people knew how to use door code but forget setting alarm off. 44395 Observation on 06/19/23 at 3:22 P.M. the back west hall temperature was 81.5 degrees Fahrenheit. Observation on 6/19/23 at 3:36 P.M. on the back east hallway temperature was 84.3 degrees Fahrenheit. The outside temperature was 92 degrees Fahrenheit. Observations on 6/22/23 at 2:43 P.M. showed the back west hallway temperature was 81.5 degrees Fahrenheit . Observations on 6/22/23 at 3:26 P.M. the center hall temperature was 81.5 degrees Fahrenheit. The outside temperature was 91 degrees Fahrenheit. During an interview on 6/19/23 at 3:36 P.M. Resident # 5 said it was very hot and stuffy in the facility halls. It was uncomfortable at times. During an interview on 6/19/23 at 3:45 P.M the Administrator said the hallways do not have air conditioning. The hallways are cooled only by resident rooms and dining room air conditioners. It will get warm in the halls when the residents have their doors shut. Sometimes staff have had to tell the residents to open their doors up.

Based on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected four of ten sampled staff (Dietary Aide A, Housekeeper A, Dietary Aide B, and Laundry Aide A). The facility census was 76. Review of the facility policy, Abuse Prevention Policy, dated 11/2017., showed: -To ensure screening and training of potential employees, have procedures in place for prevention, to identify alleged abuse/neglect/exploitation, procedures in which to investigate and protect residents, and immediate resorting of any alleged, suspected or witnessed abuse/neglect/exploitation to any resident. -Screening: No later than two working days of the date an applicant for a position to have contact with residents is hired, a request for a criminal background check will be completed, as well as a check of the employee disqualification list. This facility will not employ individuals who have been [NAME] guilty of abusing, neglecting, or mistreating elders by a court of law. All claims of professional licensure listed on employment application or resume will be verified with the appropriate professional agency or board. Any person whose name appears on the employee disqualification list will be terminated upon notification. Testing for the presence of drugs may be conducted prior to employment and at the request of the department director and or administrator. Attempts will be made to check personal/professional references to verify information. 1. Review of Dietary Aide A's employee file showed: -Hired on 5/16/23; -No CNA Registry check found. 2. Review of Housekeeper A's employee file showed: -Hired on 1/5/23; -No CNA Registry check found. 3. Review of Dietary Aide B's employee file showed: -Hired on 8/9/22; -No CNA Registry check found. 4. Review of Laundry Aide A's employee file showed: -Hired on 8/15/22; -No CNA Registry check found. During an interview on 6/21/23 at 2:20 P.M., the Staffing Coordinator, said: -He/she has been in the position for two weeks. -The nurse aide registry checks are only completed on Certified Nurse's Aides (CNA's); -He/she did not complete registry checks on dietary, housekeeping, laundry, and nursing staff. During an interview on 6/21/23 at 2:27 P.M., the Administrator said: -The nurse aide registry checks are completed upon hire for nurse aides only. - The facility does not check nurse aide registry for employees hired who are not certified nurse aides, a dietary person is not going to be on CNA registry.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's for five sampled residents (Resident #12, #57, #48, #10 and #18). The facility census was 76. Review of the facility's Comprehensive, Person-Centered Care Plan Policy, revised December 2016, showed: - The comprehensive, person-centered care plan will: o Include measurable objectives and timeframe's; o Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; o Included the resident's stated goals upon admission and desired outcomes; o Incorporate identified problem areas; o Reflect treatment goals, timetables and objectives in measurable outcomes; o Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/23, showed: - Severe cognitive impairment; - Extensive assist of two with bed mobility, transferring, dressing, toileting and personal hygiene; - Incontinent of bowel and bladder; - Bed rails not used; - Diagnoses included dementia (a condition that causes impairment to brain function, such as memory loss and impaired judgement), high blood pressure seizure disorder. Review of the resident's care plan dated 4/25/23, showed: - The resident was dependent on staff for meeting physical needs due to cognitive deficits; - The resident had a seizure disorder; -The care plan did not address the use of side rails. A review of the resident's medical record showed no side rail assessment or entrapment assessment. Observation on 6/19/23 at 11:11 A.M., showed: -The resident in his/her room sitting in a Broda Chair (an adjustable wheelchair that is used for the prevention of skin breakdown and positioning needs) two feet away from the foot of the bed facing toward the door; - A cane rail at the head of the bed on the left side; - The resident's call light was wrapped around the left cane rail at the head of the bed. Observation on 6/19/23 at 3:11 P.M., showed: -The resident lying in bed and yelling for the staff; -The resident's call light was sitting on the air-conditioning unit at the foot of the bed; -A cane rail at the head of the bed on the left side. Observation on 6/21/23 at 8:48 A.M., showed: -The resident lying in bed; -The resident's call light was sitting on the air-conditioning unit at the foot of the bed; -A cane rail at the head of the bed on the left side. 2. Review of Resident #57's quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Extensive assistance of two staff for bed mobility and transfers; -Extensive assistance of one staff for dressing, personal hygiene; -Indwelling catheter (a tube inserted into the bladder to drain urine); -On Hospice Services; -Diagnoses included: Cancer, coronary artery disease (CAD), and heart failure. Review of the resident's are plan dated 4/25/23 showed: -Resident was dependent on staff for meeting emotional, intellectual, physical, and social needs; - Ensure the resident's call light is within reach; - Resident will maintain or develop clean and intact skin; - Residents and autonomy will be maintained at highest level; - Has indwelling catheter; - Ensure that a catheter leg strap/anchor is in place; - The care plan did not address specific person-centered objectives and timeframe's. Observation on 6/19/23, at 12:50 P.M., showed; -The resident's catheter drainage bag was laying on the floor on the left side of the bed; -The call light was on the bedside table that was three feet away next to the privacy curtain. During an interview on 6/22/23, 5:12 P.M., CNA A said: -The call light should be within reach; -Catheter bags should not be on the floor. 44395 3. Review of Resident #48 Admission MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 10 which indicates some cognitive deficit. -Extensive assistance of one staff for dressing, toilet use, and hygiene. -Occasional incontinence of bowel and bladder. Review of the residents medical record showed: -Fall risk assessment (FRA) score of 6 on 4/13/23, 8 on 5/5/23 and 10 on 6/16/23. A score of 10 or higher indicated the resident was at high risk. -The resident was found on the floor of his/her room with skin tears to his/her elbow. -Physician orders for oxygen at 4 liters per minute (LPM) via nasal cannula (tube that delivers oxygen and fits into the nose) -The resident was admitted to Hospice services on 6/16/23 Review of the resident's comprehensive care plan showed: -No care plan for fall risk. -No care plan for use of oxygen -No care plan for Hospice services. Observation on 6/19/23 03:14 PM showed the resident was lying in bed, O2 on at 4 LPM per nasal cannula. Observation on 6/20/23 at 9:34 AM showed the resident lying in bed with O2 on at 4 LPM per nasal cannula. Wedge cushion lying on floor beside bed. During an interview on 06/22/23 09:29 AM Licensed Practical Nurse (LPN) C said the resident uses oxygen at all times; he/she is a fall risk During an interview on 6/22/23 at 12:01 PM CNA H said the resident has fallen before; he/she wears oxygen all the time. He/she does not know if oxygen and falls are care planned for this resident. During an interview on 6/22/23 at 5:29 P.M. RN A said: -Charge nurse do not change care plan, that would come from the MDS Coordinator. 47195 4. Review of Resident #10's admission MDS, a federally mandated instrument completed by facility staff, dated 6/7/23, showed: -Extensive assistance with two person physical assist with bed mobility and transfers -BIMS of 13, indicating the resident was cognitively intact; -Restraints showed bed rail not used; -Highly impaired hearing, used hearing aid -Severely impaired vision -Diagnoses included: heart disease, peripheral vascular disease (the reduced circulation of blood to a body part other than brain or heart), and hyperlipidemia During an interview on 06/19/23 at 1:55 PM resident stated he/she smokes twice a day. Staff have to wheel him/her outside and light his cigars for him/her. Observation on 6/19/23 at 2:03 PM showed resident had side half side rail on left side of bed, and partial side rail on right side of bed closest to the wall. During an interview on 06/22/23 at 11:30 AM, resident said his/her side rails help him/her to turn over. Review of care plan dated 6/19/23 showed side rails and smoking not care planned. Review of electronic medical record showed: -Smoking assessment completed 5/31/23, he/she follows facility policy on location and time of smoking, smokes cigars, and staff lights cigar for him/her. Resident is able to hold his/her own cigar without difficulty and staff will extinguish if needed. -Side rail assessment completed on 5/26/23 showed side rails not indicated at that time. -No entrapment assessment. During an interview on 6/22/23 at 11:17 A.M., Maintenance director said: -He/she did not assess resident's bed, it is a hospice bed. During an interview on 6/22/23 at 11:30 A.M., Physical Therapist said: -Resident's family requested the side rails on the bed. 5. Review of Resident #18's quarterly MDS, dated [DATE], showed: -BIMS of 13, cognitively intact; -Independent with bed mobility, transfers, and walking; -One fall with no injury since prior assessment; -Diagnoses included: Lung cancer, heart failure, anxiety, depression and respiratory failure. Review of care plan, dated 1/25/23, showed: -He/she is a moderate risk for falls, will have no injuries due to falling. -No interventions added since recent falls have occurred. During an interview on 6/19/23 at 2:58 P.M. resident stated he/she had a fall on May 11 th and broke his/her arm. Review of electronic medical record showed: -Fall risk evaluation completed 2/2/23 with score of 10.0 showed balance problem with walking and required use of assistive devices. -Progress notes showed fall occurred 5/18/23, a x-ray was completed on 5/19/23 which showed an acute and non-displaced humeral neck fracture -Progress notes resident had a fall on 6/16/23 -Post fall assessment completed 6/15/23-6/20/23 when resident he/she went to roll over and rolled out of bed. -No interdisciplinary meeting notes to address falls found. During an interview on 6/22/23 at 4:57 P.M. the MDS Coordinator said: -The Interdisciplinary Team met every Wednesday to discuss any changes in the residents. -He/she updates care plan from that meeting. - The charge nurses can activate the baseline care plan. -The nurses can update the care plan with falls, side rails/assist bar, and specific interventions for the resident During an interview on 6/22/23 at 6:19 P.M., Director of Nursing (DON) said: -The nurses can updated resident's care plans; -He/she would expect care plan to be updated with change of condition, new medications, falls, psychiatric med changes, significant change, hospice, side rails; -Everything about specific to resident should be care planned. During an interview on 6/22/23 at 7:06 P.M., the Administrator said: -Care plans should be updated quarterly and as changes occur with the resident. -He/she would expect hospice to be care planned. -Care plans should be specific to each resident. -Nurses can access and update care plans.

Based on observations, interviews, and record review the facility failed to provide appropriate positioning for four of 16 sampled residents (Resident #72, #38, #55, and #4) while eating. The facility census was 76. Facility did not provide a policy on positioning during meals. Facility policy titled activities of daily living (ADL), supporting, dated March 2018, showed: -Residents will be provided care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, dining. -Interventions to improve or minimize a resident's functional ability's will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. 1. Review of Resident #72's quarterly Minimum Data Set ((MDS) a federally mandated assessment instrument completed by facility staff), dated 4/14/23, showed: -Total dependence on one staff for eating. -Dependent on staff to reposition from sitting to lying. -Dependent on wheelchair for locomotion. -Diagnoses included: Alzheimer disease (a type of dementia that affects memory, thinking, and behavior), diabetes (a disease that result in too much sugar in the blood), muscle weakness, cognitive communication deficit, need for assistance with personal care, During an observation on 6/19/23 at 11:56 A.M., aide was feeding resident while they were reclined in geri-chair. 2. Review of Resident #38's quarterly MDS, dated [DATE], showed: -BIMS of 9, showed moderately impaired cognition -Supervision oversight for eating with setup or clean-up assistance; -Dependent on staff to change position from sitting to lying; -Use of wheelchair for mobility; -Diagnoses included: stroke, type 2 diabetes, fatigue, generalized muscle weakness, unsteadiness on feet, and cognitive communication deficit. During an observation on 6/19/23 at 12:14 P.M., resident's wheelchair reclined and wheels not locked. Resident attempted to pull self up to the table and his/her wheelchair kept sliding back from the table. During an observation on 6/19/23 at 12:18 P.M. Resident continued using hand to grip onto table to hold self up to the table. 3. Review of Resident #55's quarterly MDS, dated [DATE], showed: -Dependent on staff for eating and repositioning. -Diagnoses included dementia (condition of regressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), anxiety disorder, gastro-esophageal reflux disease with esophagitis (condition in which stomach contents move up into the esophagus), and abnormal weight loss During an observation on 6/22/23 at 5:41 P.M. showed resident laying down in geri chair eating food. Certified Nurse Aide (CNA D) gave him/her drinks with a straw and bites of food as the resident laid at a 160 degree angle. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Dependent on extensive assistance by one person for eating; -Required supervision or touching assistance while eating; -Extensive assistance needed for bed mobility by one person assist; -Substantial or maximum assistance needed for moving from sitting to lying; -BIMS of 5, severely cognitively impaired; -Diagnoses included: bipolar disorder (a mental health condition that causes extreme mood swings), gastro esophageal reflux disease (digestive disease when stomach acid or bile irritates the food pipe lining), functional quadriplegia (complete inability to move due to severe disability), lack of coordination, abnormal posture, and abnormal weight loss. Review of care plan, dated 1/17/23, showed resident is at risk of weight loss due to impaired mobility. -Ensure he/she is in proper position, with dentures for meals. During an observation on 6/22/23 at 5:41 P.M. showed resident was eating in a reclined position in his/her wheelchair. 5. During an interview on 6/22/23 at 6:19 P.M., the Director of Nursing (DON) said: -He/she expected residents head's to be up when residents were eating in rooms or in their beds. -He/she expected the chairs to be in an upright position when the resident was eating or drinking.

Based on observation, interview and record review, the facility failed to ensure facility staff provided three of 16 sampled residents (Resident #28, #48 and #55), that were unable to do their own activities of daily living (ADLs tasks done in a day to care for oneself such as bathing, toileting, personal hygiene, etc), the necessary care and services to maintain good personal hygiene. The facility census was 76. Review of the facility provided policy Activities of Daily Living dated March 2018 showed in part: -Residents will be provided with care, treatment and services as appropriate to mainitain or improve their ability to carry out activities of daily living. -Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintian good nutrition, grooming and personal and oral hygiene. 1. Review of Resident #28 Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 4/3/23 showed: -Brief Interview of Mental Status (BIMS) of 14; indicating no cognitivie defecits. -Extensive assistance to total dependence for ADL's. -Incontinent of bowel and bladder -Diagnoses included: Muscle weakness, Restless Leg Syndrome, need for assistance with personal care, and shortness of breath. -Review of the resident's comprehensive care plan showed: -The resident needs assistance with ADL's related to decreased mobility. -Check nail length, trim and clean on bath days and as necessary. -The resident is completely dependent on staff for repositioning and turning. -The resident is completely dependent on staff for personal hygiene. Observations on 6/19/23 at 11:23 A.M. showed the resident's toe nails were very long, thick, and adhered to the tip of the toe. His/her toes were discolored with brown scaling on pads of toes and tips of toes. His/her hair was greasy and long. During an interview on 6/19/23 at 11:23 A.M the resident said he/she has not had a bed bath in 3 weeks, has gone a long time without getting his/her pants changed because there was not enough staff and they just do not get to him/her. He/she has not gotten a haircut for over a year. Continuous observation on 6/22/23 showed: -9:32 AM the resident was lying flat in bed; hair greasy and long, -10:44 AM the resident remained in bed on his/her back, toes exposed. -11:44 AM The resident remained in bed, on his/her back -12:00 PM no change in the resident's position. No staff had entered room. No meal tray brought to the resident. -2:08 PM staff provided incontinent care for the resident. He/She was wet, throught the incontinent pads and onto the bed sheets, buttocks and thighs were red with no open areas. During an interview on 6/22/23 at 12:01 PM Certified Nurse Aide (CNA) H said:, -Residents who are incontinent should be changed every 2 hours. -There was only 1 CNA for each side of the hall. -Staff do not always have time to get to every resident in the 2 hour window. -The resident should have been changed but it was busy and he/she was just not able to do it with only 1 CNA on each side. -Most days there was only one CNA on each side. 2. Review of Resident # 48 Admission MDS dated [DATE] showed: -BIMS of 10; indicating some cognitive defecit. -Extensive assistance with dressing, toilet use and personal hygiene. -Occasional incontinence of bowel and bladder -Diagnosis of sepsis (the body's extreme response to an infection and can be life threatening) , Diabetes, Congestive Heart Failure (CHF a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply) kidney disease and falls Review of the resident's comprehensive care plan dated 5/1/23 showed: -The resident was at risk for ADL deficit related to decreased mobility. -Check the resident's nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. -The resident requires assistance by getting pulled up in the bed by 2 staff to turn and reposition in bed as necessary. -The resident requires transfer assistance and at times, clean up assistance by staff for toileting. Observation on 6/19/23 at 3:14 PM showed -The resident was in bed lying sideways with legs out, yelling out help, hey help. -No call light in reach. -The resident was calling hello? hello? Please please help me! please help me. -3:36 PM the resident was yelling out please please help. He/she was trying to get out of bed. His/her brief was exposed, and saturated. His/her fingernails were long, chipped with thick brown debris underneath. His/her hair was disheveled and greasy. -4:21 PM staff entered room, put the residents legs back into the bed, covered the resident up and left the room.

Based on observation, interview and record review, the facility failed to provide a safe environment for three sampled residents when staff did not ensure call lights were accessible to Resident #12, #13 and #57. The facility failed to ensure Resident #31 did not have access to medication that he/she did not have an order for. The facility census was 76. Review of the facility's Answering the Call Light Policy, revised March 2021, showed: - Staff are to be sure the call light is plugged in and fuctioning; -When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident; - Staff are to check on residents that may not be able to use their call light frequently. 1. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/23, showed: - BIMS (a mandatory tool used by facility staff to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 3 (severe cognitive impairment); - Extensive assist of two nursing staff with bed mobility, transferring, dressing, toileting and personal hygiene; - Incontinent of bowel and bladder; -Bed rails not used; - Diagnoses included dementia (a condition that causes impairment to brain function, such as memory loss and impaired judgement), high blood pressure and seizure disorder. Review of the resident's care plan, dated 4/25/23, showed: - The resident is dependent on staff for meeting physical needs due to cognitive deficits; - The resident has a seizure disorder; -The care plan did not address the use of side rails. A review of the resident's medical record showed no side rail assessment or entrapment assessment was completed. Observation on 6/19/23, at 11:11 A.M., showed: -The resident in his/her room, sitting in a Broda Chair (an adjustable wheelchair that is used for the prevention of skin breakdown and positioning needs) two feet away from the foot of the bed, facing towards the door; - A cane rail at the head of the bed, on the left side, in the upward position; - The resident's call light is wrapped around the left cane rail at the head of the bed. Observation on 6/19/23, at 3:11 P.M., showed: -The resident lying in bed and yelling for the staff; -The resident's call light was setting on the air-conditioning unit at the foot of the bed and not within reach. -A cane rail at the head of the bed on the left side in the upward position. Observation on 6/21/23, at 8:48 A.M., showed: -The resident lying in bed; -The resident's call light was setting on the air-conditioning unit at the foot of the bed and not in reach. -A cane rail at the head of the bed on the left side in the upward position. 2. Review of the Resident #13's annual MDS, dated [DATE], showed: - BIMS of 2 (severe cognitive impairment); - Extensive assist of one with with bed mobility, transferring, dressing, toileting and personal hygiene; - Incontinent of bowel and bladder; - Bed rails not used; - Diagnoses included diabetes (diseases that results in too much sugar in the blood), coronary artery disease (damage to heart's major blood vessels), and high blood pressure. A review of the resident's care plan, dated 6/20/23, showed: -Total dependent on one nursing staff for toilet use; - Staff are to encourage the resident to use call light to call for assistance; -The care plan did not address the use of side rails. A review of the resident's medical record showed no side rail assessment or entrapment assessment was completed. Observation on 6/19/23, at 11:15 P.M., showed: -The resident in bed with cane rails on the left and right side and in the upward position at the top of the bed. - A fall matt on the floor on the left side of the bed; - The call light was hanging down beside of the foot of the bed and out of reach for the resident. Observation on 6/21/23, at 9:22 A.M., showed: -The resident in bed with cane rails on the left and right side in the upward position at the top of the bed. - A fall matt on the floor on the left side of the bed; - The call light was hanging down beside of the foot of the bed and out of reach of the resident. During an interview on 6/22/23, at 4:20, P.M., Certified Nurses Aide (CNA) C said: -The resident uses the bed rails for positioning; -The resident requires assist of one staff member for transferring to the wheel chair and toileting; -The resident uses the call light when he/she remembers to. During an interview on 6/22/23, at 5:17, P.;M., Licensed Practical Nurse (LPN) A said: -Residents use their side rails for positioning; -The call light should be within the resident's reach; -The side rails are ordered by therapy; - He/she was not sure who did the side rail assessments. During an interview on 6/22/23, at 6:54, P.M., the Director of Nursing (DON) said: -The residents use the bars for mobility; -He/she did not consider the bars the resident used for mobility as bed rails; -No bed rail assessments or entrapment assessments have been done. During an interview on 6/22/23, at 7:06, P.M., the administrator said: -The residents use the bars for mobility; -He/she did not realize bed rail assessments had to be done for all bed rails; -He/she did not know that bed rail assessments or entrapment assessments haven't been done. 3. A review of Resident #31's quarterly MDS dated [DATE] showed: -BIMS of 3 (severe cognitive impairment); -Extensive assistance of two staff for bed mobility and transfers; -Assist of one staff for ADL's; -Incontinent of bowel and bladder; -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental function ), high blood pressure and anemia a condition that can lead to reduced oxygen flow to the body's organs). Observation on 6/20/23, at 8:26 A.M., showed: -The resident laying in bed with access to the night stand. -A 10 ounce bottle of wound cleanser was setting on the the night stand next to the bed; -A bottle of 2% fungal powder was setting on the night stand next to the bed; -The bottle of fungal powder was open with powder on top of the bottle and on the surface of the night stand. Observation on 6/21/23, at 11:04 A.M., showed: -The resident propelling himself/herself around the facilty; -The resident propelled himself/herself back to his/her room and sat in his/her wheel chair; -The bottle of wound cleanser and fungal powder were on the night stand by the bed; -The bottle of fungal powder was open. 4. Review of Resident #57's quarterly MDS, dated [DATE], showed: -BIMS of 2 (severe cognitive impairment); -Extensive assistance of two staff for bed mobility and transfers; -Extensive assistance of one staff for dressing, personal hygiene; -Indwelling catheter; -On hospice Services; -Diagnoses included cancer, coronary artery disease, and heart failure. Review of the resident's are plan, dated 4/25/23 showed: -Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs; - Ensure the resident's call light is within reach; -Resident will maintain or develop clean and intact skin; -Residents and autonomy will be maintained at highest level; -Has indwelling catheter; -Ensure that a catheter leg strap/anchor is in place; -Resident is receiving Hospice services. Observation on 6/19/23, at 12:50 P.M., showed; -The resident's catheter drainage bag was laying on the floor on the left side of the bed; -The call light was on the bedside table that was three feet away next to the privacy curtain. Observation on 6/19/23, at 2:20 P.M., showed: -The resident's catheter drainage bag was laying on the floor on the left side of the bed; -The call light was on the bedside table that was three feet away next to the privacy curtain. Observation on 6/21/23, at 9:01 A.M., showed the call light was on the bedside table that was two feet away next to the wall. During an interview on 6/22/23, at 4:20, P.M., Certified Nurses Aide (CNA) C said: -No chemicals, cleaning supplies or anything that could be hazardous to the residents should be kept where the residents could have access to them; -He/she thought the housekeeper was in charge of making sure the MSDS (Material and Safety Data Sheets) were kept up to date; -He/she was not sure who is responsible. -He/she was not sure were the MSDS sheets were kept. During an interview on 6/22/23, at 5:17, P.M., Licensed Practical Nurse (LPN) A said: -No hazardous chemicals should be in the resident rooms, because too many residents wander; - Chemicals and cleaning supplies are to be kept wear the residents don't have access to them. During an interview on 6/22/23, at 6:54, P.M., the Director of Nursing (DON) said: -Chemicals/hazardous chemicals should be locked up and secured away from residents; - Residents should not have hazardous chemicals in their room; - He/she was not aware that a resident had medications at bedside. During an interview on 6/22/23, at 7:06, P.M., the Administrator said: -Residents should not have access to hazardous materials; -Any cleaning chemicals in the shower rooms should be locked in a cabinet; -Medications should not be kept at the bedside unless there is a specific order for this. 44395 47195

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards when staff did not properly maintained a Liko Viking mechanical lift according to the manufacturer's directions. Staff did not perform daily and routine maintenance checks on the lift, causing the lift to malfunction during a transfer resulting in an injury to one resident (Resident #1). The facility census was 70. Review of the Liko Viking mobile lift instruction guide showed for trouble-free use, certain details should be checked each day the lift is used: move this to the top - Inspect the lift and make sure that there is no external damage. - Check the sling bar attachment. - Check the functionality of the latches. - Check the integrity of the lifting motion and the base-width adjustment. - Check to make sure the emergency lowering (both electrical and mechanical) works. - Charge the batteries each day the lift is used and then check that the charger works. - Service: A periodic inspection of the lift should be carried out at least once per year. Review of the facility's policy for mechanical lift - manual or battery operated, reviewed and updated on 3/8/18, showed in part, staff should do the following prior to a transfer: - Do not use any kind of plastic backed incontinent pad or cushion between the resident or sling that may cause the resident to slide out of sling. - Prior to transfer be sure to check for wear, tears and loose stitching, torn, cut, frayed or broken slings. - Check the sling attachments each time the sling is removed and replaced to ensure that it is property attached before the resident is removed. - If transferring to a wheelchair, make sure that the wheelchair brakes are locked to keep the wheelchair from moving. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/17/21, showed the resident did have problems with short- or long-term memory. He/she required total assistance of two or more staff for transfers, did not walk, used a wheelchair for locomotion. He/she was 63 inches tall and weighed 215 pounds. Diagnoses: Multiple sclerosis(MS), Type 2 diabetics mellitus without complications, Acute Kidney failure, Chronic obstructive pulmonary disease(COPD). Review of the resident's current care plan, dated 7/13/20, showed: - Staff will keep call light in reach. - Place personal items such as phone, remote, Kleenex in reach. - Staff will make sure the resident has proper footwear on. - While in bed the bed will be kept in the low and locked position. - Position the resident in the middle of the bed to decrease the potential for rolling. - Parameter mattress will be placed to help define the edges of the bed. - Staff will lock the wheelchair prior to transferring the resident. - Currently, the resident is a two-person mechanical lift transfer. Review of the facility's Accident and Injury Record Form dated 12/27/21, completed by the Director of Nursing, showed: this should be moved up above the MDS - CNA A and LPN A where transferring Resident #1 from his/her bed via mechanical lift to his/her wheelchair. The straps were secured. - CNA A was controlling the lift and LPN A was positioning the resident's wheelchair. - CNA A and LPN A heard a loud snapping sound and the resident immediately fell from the back left of the sling, directly onto his/her shoulders then hit his/her posterior (the back) head on the floor. - LPN A immobilized the resident. - CNA A yelled for help. - LPN A assessed the resident's mental status, vital signs (VS), neurological status, pain, and kept the resident immobilized while other staff immediately called 911. - The resident remained responsive. - The resident remained immobilized until he/she was rolled off the sling and transferred to gurney by EMS with staff assist. - The resident was taken to the hospital. - Notified the resident's family, primary care physician (PCP), and DON. During an interview on 12/27/21, at 2:51 P.M., Certified Nurse Aide (CNA) A said the following: - They were transferring the resident before supper from the bed to a wheelchair. - They had hooked the resident up with a sling to the lift. - He/she moved the resident back away from the bed as License Practical Nurse (LPN) A guided the resident. - They heard a loud snap from within the bar, not really sure where at. - The resident kind of slid back head first,kind of like a slide. - He/she yelled for assistance. - He/she stayed with the resident until assistance came and emergency medical services (EMS) came. - The mechanical lift and sling have not been used since that night. During an interview on 12/27/21 at 3:00 P.M., LPN A said: - He/she was in the room assisting CNA A with the transfer; - He/she knew all the straps where attached properly. - He/she knew the straps where attached correctly; because if not the straps on the sling would have come lose when they lifted the resident about one inch off of the bed. - When they lifted the resident #1 up, he/she was guiding the resident they heard a loud snap and that is when the resident slid down and fell . - CNA A immediately yelled for help. - LPN A started checking the resident's vitals. - He/she did not fill out an incident report because he/she has only been working at the facility six weeks and did not know how to do one. Review of the resident's medical records from the hospital showed: - The resident was transported to the hospital after a fall during a transfer at the nursing home. - After a computed tomography scan (CT, combination of a series of x-ray images taken from different angles of your body) was done, it was found that the resident suffered from a subarachnoid hemorrhage (brain bleed) in the high left parietal area (top center). During an interview on 12/28/21 at 2:30 P,M,, the DON said: - She does not know who is inspecting the lifts. - When she called to request service on the lift to the company, she had to provide all of the contact information for the facility as no one had called before. - An investigation report was not completed prior to the surveyor's onsite because the nurse who was working had not completed an incident report about the resident's fall. - Staff should have completed an incident report as soon as it happened. - The sling looks brand new. - The mechanical lift that was used during the transfer was not rented but owned by the facility. - Normally, the facility's maintenance department does the maintenance on the machines. During an interview on 12/28/21 at 2:34 P.M., the maintenance supervisor said: - If the staff say something is not working on one of the lifts, he will look at it, or the batteries, and he fixes it. - He does not keep a log or inspect the lifts. - He does not think that outside service comes to do that either. During an interview on 12/29/21, at 11:14 A.M., the Administrator said: - She does not have anyone who does inspections of the lifts. - She talked to maintenance today. - He looks at them monthly but does not keep a log so she cannot provide anything in writing. MO#195073

Based on observation, interview and record review, the facility failed to develop and implement appropriate measures to address behaviors exhibited for one of 15 sampled residents (Resident #11) when the resident isolated him/herself, refused to get out of bed, refused care, and verbally and physically abused staff when they provided care. The facility census was 87. 1. Review of the facility's Gradual Dose Reduction/Behavior Procedure policy, dated 6/12/13, showed the following: - Make every effort to comply with state and federal regulations related to the use of psychopharmacological medications to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. - Staff instructed to document every shift for a period of no less than seven days for changes in behaviors, cognition, and/or health status. - The pharmacist would monitor [MEDICAL CONDITION] drug use to ensure the medications are not used in excessive doses or for excessive duration. Review of the Care Area Assessment Summary (CAAS, an assessment of cares needed for determining a plan of care), dated 2/4/13, showed the following: - Cognitive loss/dementia: Non-Alzheimer's dementia; mood state indicated possible impact on cognition; hospice; pain with scheduled pain medications; alert, oriented to name of facility, did not know staff names, but aware staff were caregivers; able to voice needs; stated he/she was tired, his/her time was getting short and he/she was glad about that and was not worried about it. - Activities of daily living: Mood decline; anti-anxiety medications; mental errors and physical limitations result in need for staff assistance with all cares; depression; urinary incontinence; bowel incontinence; able to ask for assistance; needed assistance for bathing; refused showers and often refused bed baths. - Urinary incontinence: Anxiety disorder; pain; terminal illness; frequently incontinent of bowel and bladder; did not notify staff of the need to void; did not use the bed pan; did not want to get out of bed; preferred to stay in bed. - Psychological well-being: Importance of doing favorite activities not important; preferred to be alone, did not want to come out of his/her room; little interest in doing things; verbally abusive and insulting towards others; uncooperative with cares at times related to desire not to be bothered; psychological evaluations as needed. - [MEDICAL CONDITION] drug use: Anti-anxiety medications; no anti-depressants; currently received [MEDICATION NAME] for anxiety; taken this medication for some time without any adverse reactions. - Pain: Limited day-to-day activities; hospice; disturbed sleep; hurt at times when turned; did not want to get up because he/she fell in 2010; as needed (PRN) medications for pain. Review of the social service assessment and review, dated 2/4/13, showed the following: - Speech clear, able to express needs; - Required assist with activities of daily living; - Incontinent of bowel and bladder; out of bed for bathing only; - Preferred to stay in bed related to fear of falling; verbally abusive and insulting to staff. - No mood decline. Review of social service notes, dated 5/3/13, showed the following: - Abusive physically and verbally to staff. - Frequently uncooperative with cares. Review of the monthly behavior flow sheet for July, 2013, showed the following: - 7/4/13, night shift: Hitting/pinching; one episode; treatment: redirection, changed position, toileted resident; outcome: unchanged, no side effects. - 7/5/13, night shift: Hitting/pinching; one episode; treatment: medication with positive outcome and no side effects. - 7/5/13, night shift: Anxiety; two episodes, treatment: medication with positive outcome. - 7/6/13, night shift: Hitting/pinching; two episodes, treatment: redirection, outcome unchanged, no side effects. - 7/8/13, night shift: Hitting/pinching; one episode treatment: redirection, outcome unchanged. - 7/17/13, day shift: Hitting/pinching; treatment: redirection, refer to nurses' notes changed position, outcome unchanged. - 7/18/13, evening shift: Anxiety; one episode; treatment: see nurses' notes. - 7/18/13, day shift: Hitting/pinching; two episodes; treatment: refer to nurses' notes. - 7/18/13, evening shift: Hitting/pinching; three episodes; treatment: refer to nurses' notes. - 7/18/13, night shift: Hitting/pinching; two episodes; treatment: redirection, outcome unchanged, no side effects. - 7/19/13, night shift: Anxiety; two episodes; no treatment or response recorded. - 7/19/13, day shift: Hitting/pinching; two episodes; no treatment or response recorded. - 7/19/13, night shift: Hitting/pinching; three episodes; treated with medication, no outcome response recorded. Review of the nursing monthly summary sheet, dated 7/2/13, showed the following: - Inattention, memory problems; - Mood: Inattention, little interest in doing things, appeared depressed, trouble falling and staying asleep, felt tired, poor appetite, short tempered, and stated life was not worth living, wished for death. - Behaviors: Physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, rejected care, hallucinations, [MEDICAL CONDITION]. - Functional status: Extensive assist with changing body positions, dressing, toileting; transfers did not occur; supervision needed with eating; total dependence of staff for bathing; no mobility devices used. - Frequent, moderate pain. - Physician made no changes in treatment in last 30 days. Review of nurses' notes showed the resident did and said the following: - 7/6/13, 2:45 A.M.: Combative with care, struck and scratched caregivers, verbally abusive to caregivers; - 7/11/13, 8:00 A.M.: Refused all medications; - 7/16/13, 9:10 A.M.: Pharmacy recommendation for GDR of [MEDICATION NAME]; order received to decrease [MEDICATION NAME] to 0.25 mg every night; - 7/18/13, 2:00 P.M.: Refused medications and threw them across the room; - 7/18/13, 4:00 P.M.: Hit certified nurse's aide (CNA) in the face with fecal material in the resident's hand and called the CNA "bull[***]er;" took pills, spit them out into medication cup and said "here, you can have them back. Now turn around and get the hell out!" - 7/18/13, 9:00 P.M.: Threw shake all over CNAs in the room; smacked a CNA, called Licensed Practical Nurse (LPN) A "[***] " and said he/she did not know what he/she was doing; - 7/24/13, 9:30 P.M.: Refused pills, told LPN A to "get his/her fat ass out of here, you do not know what you are doing;" a certified medication technician (CMT) reported to LPN A that the resident called him/her an idiot. - LPN A did not record he/she informed the physician of the increased aggressive behaviors exhibited by the resident. Review of Physician A's progress notes showed the following: - 7/24/13: Hospice; dementia, [MEDICATION NAME] 10 mg, no reduction of dose; - Interval history today; no additional information added from staff. Did not address behaviors exhibited by resident. - 7/25/13: Hospice; dementia; interval history today; no additional information add from staff; [MEDICATION NAME] 10 mg, [MEDICATION NAME] 5 mg BID (twice a day); no decline per staff. Review of nurses' notes showed LPN A recorded the following: - 7/26/13, 2:30 P.M.: Resident smeared fecal material on lunch tray and filled coffee cup with fecal material; - 7/29/13, 2:30 P.M.: Resident threw shake on a CNA who tried to cut the resident's fingernails; 7/31/13, 8:30 P.M.: Refused medications this shift. - LPN A did not record he/she notified the physician of these behaviors. Review of the monthly behavior flow sheet for August, 2013, showed the following: - 8/3/13, evening shift: Hitting/pinching; one episode; refer to nurses' notes; outcome unchanged with no side effects. -8/21/13, night shift: Anxiety; one episode; treated with medication; with a positive outcome and no side effects. - 8/24/13, night shift: Hitting/pinching; two episodes; not treatment or outcome recorded. Review of nurses' notes showed the following: - 8/3/13, 8:15 P.M.: A CNA reported the resident struck him/her in the face and called him/her a "[***] " when the CNA attempted to perform perineal care. A CMT reported the resident refused all medications. LPN D did not record he/she contacted the physician of the behaviors. Review of the nursing monthly summary sheet, dated 8/6/13, showed the following: - Memory problems; disorganized thinking; modified independence with some difficulty in making decisions. - Mood: Little interest in doing things; felt depressed; short tempered; stated life not worth living and wished for death. - Behavior: Rejected care. - Pain: Rarely complained of moderate pain and shortness of breath. - Physician made no changes in treatment in last 30 days. Review of social service notes, dated 8/5/13, showed the following: - History of being physically and verbally abusive toward staff; - Frequently uncooperative with cares; - Refused medications frequently. - Able to express needs and wants; - Incapacitated for decision making. - Alert with confusion. - Speech clear, hearing and vision adequate. Review of nurses' notes, dated 8/16/13, showed the following: - At 3:50 A.M.: Combative with care, striking out at staff, used abusive language, pulled a CNA's hair during care; redirection not effective, resident became more agitated. Staff did not record he/she notified the physician. - At 10:00 P.M.: Resident resistant to care; combative and verbally aggressive with inappropriate language; called staff names and cursed; claimed a staff member "was killing me" when nails cleaned; hit both staff members who provided care. Staff did not record he/she notified the physician. Review of nurses' notes showed the following: - 8/23/13, 1:10 A.M.: The resident slid out of bed when tried to turn off light; said he/she was tired of asking for help; said there was "nothing good about old age;" complained of right knee and right low back pain; physician and hospice notified of fall. - 8/25/13, 2:00 A.M.: The resident complained of right hip pain; said "it's killing me when you turn me like that;" no bruising noted; called the CNA a "fat [***] ;" - 8/25/13, 8:45 A.M.: Complained of right hip and right foot pain with facial grimacing during positioning; Physician A and hospice notified; order received to x-ray right hip and foot. - 8/25/13, 10:00 A.M.: The resident refused vital signs; hit and pinched LPN E; and said "get out of here blackie! Don't like your kind!" LPN E attempted to explain to the resident that an x-ray would be taken today and left the room. LPN E did not record he/she reported behaviors to the physician. Review of the physician's progress note, dated 8/26/13, showed the following: - Fall on 8/23/13, complained of right hip and right foot pain after fall. X-ray of hip and foot with negative findings. Dementia, [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg BID. Alert but confused with flat affect. - Physician did not address the behaviors staff noted on 8/16/13. Review of nurses' notes showed the following: - 8/30/13, 9:30 P.M.: The resident hit a CNA in the face and knocked the CNA's glasses off his/her face then said "I hope they broke, you [***] y [***] !" The resident refused medications this shift. LPN A did not record he/she notified the physician. Review of the monthly behavior flow sheet for September, 2013, showed the following: - 9/10/13, evening shift: Hitting/pinching; one episode; treatment refer to nurses' notes; - 9/13/13, night shift: Anxiety; three episodes; treated with [MEDICATION NAME] 1 mg with a positive outcome and no side effects. - 9/16/13, night shift: Anxiety; three episodes; treated with [MEDICATION NAME] 1 mg with a positive outcome and no side effects. - 9/18/13, evening shift: Hitting/pinching; one episode; treatment see nurses' notes. - 9/19/13, evening shift: Anxiety; two episodes; no treatment or outcome recorded. Review of the nurses' notes showed the following: - 9/7/13, 5:40 A.M.: The resident smacked a CNA on the neck and used abusive language toward the CNA. No record of staff notifying physician. - 9/10/13, 8:30 P.M.: The resident hit a CNA during a bed bath; called the CNA a "[***] " and told him/her to "go to hell!" No record of staff notifying physician. Review of the nursing monthly summary sheet, dated 9/16/13, showed the following: - Cognitive patterns: Inattention disorganized thinking, short and long term memory okay; some difficulty making decisions; - Mood: Little interest in doing things, depressed, trouble sleeping, felt tired, poor appetite, indicated he/she felt bad about him/herself, trouble concentrating on things, short tempered, and stated life was not worth living, wished for death. - Behaviors: Physical and verbal behavioral symptoms towards others, rejected care, wanders, and [MEDICAL CONDITION]. - Functional status did not change. - Pain: Frequent; - Physician made no changes in treatment in last 30 days. Review of the nurses' notes showed the following: - 9/18/13, 7:00 P.M.: The resident removed fecal material from him/herself and attempted to hit two CNAs with the fecal material; called one CNA "fat ass, shift ass, [***] , told him/her to go to hell," and told him/her "nobody loved her because he/she was a fat ass;" called the second CNA a "nigger with bad breath." No record of staff notifying physician. - 9/22/13, 12:30 A.M.: Resident had fecal material on hands and under his/her fingernails; a CNA cleaned the resident's fingernails, the resident called the CNA ugly, and tried to hit the CNA with fecal material. No record of staff notifying physician. - 9/22/13, 8:00 P.M.: CNAs reported the resident became verbally and physically abusive, hit them and called them names; staff re-approached the resident multiple times and behaviors continued; continued to monitor. No record of staff notifying physician. Review of the monthly behavior flow sheet for October, 2013, showed the following: - 10/4/13, day shift: Anxiety; one episode; treated by redirection with unchanged outcome. - 10/4/13, day shift: Hitting/pinching; one episode; treatment refer to nurses' notes; no outcome recorded. - 10/4/13, evening shift: Hitting/pinching; one episode; treated by redirection with worsened outcome. - 10/6/13, night shift: Anxiety; one episode; treated with medication and an improved outcome with no side effects. - 10/11/13, evening shift: Hitting/pinching; two episodes; treatment recorded in nurses' notes. - 10/24/13, night shift: Hitting/pinching; one episode; treated with redirection and food with an improved outcome. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [MEDICATION NAME] 10 mg one at bedtime; staff documented the resident refused on 10/22/13 and 10/25/13. - [MEDICATION NAME] 0.5 mg tablets, administer 0.25 mg or ? tab at bedtime for anxiety; - [MEDICATION NAME] 5 mg BID for dementia; - [MEDICATION NAME] 5/500 mg one tablet every eight hours for pain; - [MEDICATION NAME] 1 mg, administer on tablet every six hours as needed for agitation/restlessness; staff documented they administered this on 10/20/13, at 7:00 P.M., 10/18/13, at 1:00 A.M., and 10/27/13, at 4:00 P.M. Review of nurses' noted showed the following: - 10/4/13, 3:45 A.M.: The resident removed fecal material from his/her rectum, was combative, verbally abusive, and struck out at staff. - 10/4/13, 10:40 A.M.: Combative, threw coffee and breakfast food at staff; cursed staff during . - 10/11/13, 3:00 P.M.: Combative with care during bed bath; hit and pinched LPN A and a CNA; used foul language and called staff "shitasses and [***] es;" said staff did not care about his/her pain; LPN A offered the resident pain medication, but the resident refused. - 10/11/13, 6:30 P.M.: The resident slapped a CNA in the face. Review of the physician's progress notes, dated 10/18/13, showed the following: - Dementia, [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg BID. No decline per staff assessments. Affect normal, alert, but confused. - Did not address behaviors exhibited by resident. Review of nurses' notes, dated 10/20/13, at 5:30 P.M., showed the following: - A CNA reported the resident punched him/her in the face when he/she served the resident's supper tray. - The CNA approached the resident a short time later and the resident threw a glass full of milk on him/her. - LPN D administered PRN [MEDICATION NAME] to the resident. - No further behaviors; - LPN D did not record if he/she notified the physician. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/13, showed the following: - A Brief Interview for Mental Status (BIMS) score of three, severely cognitively impaired, never/rarely made decisions. - Resident mood interview: Little interest or pleasure in doing things, nearly every day; - Resident mood interview: staff did not assess the resident for feeling down, depressed, or hopeless, trouble staying asleep, feeling tired or having little energy, poor appetite, feeling bad about self, trouble concentrating, moving or speaking slowly, being fidgety or restless, thoughts that he/she would be better off dead; - Resident mood interview: Total severity score of three, minimal depression. - No staff assessment of resident mood which included little interest or pleasure in doing things, poor appetite, stated life is not worth living, wishes for death, being short tempered, easily annoyed. - No behavior symptoms; No indicators of [MEDICAL CONDITION]; - Rejected care one to three days during assessment period. - Extensive assist of one staff for bed mobility, dressing, and hygiene. - Transfers, walking in room or corridor, and locomotion on/off unit did not occur; - Supervision and set-up of meals only; - Total dependence of one staff for toileting and bathing; - Always incontinent of bowel and bladder. - Pain present; frequent and severe; not able to answer numeric rating scale of pain; zero being no pain, 10 as worst pain imaginable; pain limited daily activities; no staff assessment for indicators of pain; - Weight: 88 pounds; - Prognosis: Chronic condition/disease that may result in a life expectancy of less than six months; hospice; - Anti-anxiety medications during last seven days prior to MDS assessment; - Family and resident participated in MDS assessment; - [DIAGNOSES REDACTED]. Review of the monthly behavior flow sheet for November, 2013, showed the following: - 11/3/13, night shift: Anxiety; one episode; refer to nurses' notes for treatment; improved outcome. - 11/12/13, evening shift: Hitting/pinching; one episode; refer to nurses' notes for treatment; no outcome recorded. - 11/28/13, night shift: Anxiety; two episodes; treated with [MEDICATION NAME] 1 mg; improved outcome. - 11/28/13, evening shift: Hitting/pinching; one episode; no treatment or outcome recorded. Review of the MAR for November, 2013, showed the following: - [MEDICATION NAME] 10 mg one tablet at bedtime; staff documented the resident refused on 11/14/13, and 11/24/13; - [MEDICATION NAME] 0.5 mg tablets, administer 0.25 mg or ? tab at bedtime for anxiety; staff documented the resident refused on 11/14/13, and 11/24/13. - [MEDICATION NAME] 5 mg BID for dementia; staff documented the resident refused 11/2/13, and 11/14/13. - [MEDICATION NAME] 5/500 mg one tablet every eight hours for pain. Given as ordered. - [MEDICATION NAME] 1 mg, administer on tablet every six hours as needed for agitation/restlessness. Administered on 11/6/13, 11/25/13, 11/27/13, and two undated times. Review of the social services progress note, dated 11/1/13, showed the following: - Alert with confusion. - Able to express needs. - History of verbal and physical abuse towards staff. - Frequently uncooperative with cares. Review of nurses' notes, dated 11/4/13, at 11:30 P.M., showed the following: - The resident asked for a sleeping pill to relax; no order for sleeping medication. Staff administered PRN [MEDICATION NAME] to calm resident and enable him/her to sleep. Review of the nurses' monthly summary sheet, dated 11/11/13, showed the following: - Cognitive: Disorganized thinking, short and long term memory problems; difficulty making decisions. - Mood: Little interest in doing things; depressed; felt tired; poor appetite; felt bad about self; short tempered; stated life not worth living, wished for death. - Behaviors: Physical and verbal behaviors directed toward others and rejected cares. - Pain: Frequent, 7 on scale of 0-10. - Physician visited and made no changes in treatment in last 30 days. Review of nurses' notes, dated 11/12/13, at 9:30 P.M., showed the following: - Cursed and hit CNAs who assisted him/her. The resident dug at rectum and held fecal material in his/her hand. Review of the physician's progress sheet, dated 11/13/13, showed the following: - Dementia; [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg BID. - Alert but confused; flat affect. - Did not address behaviors exhibited by resident. Review of nurses' notes, dated 11/19/13, at 8:30 P.M., showed the following: - Increased behaviors this shift. Hit, scratched, and cursed CNAs who provided care. Review of the physician's progress note, dated 11/21/13, showed the physician did not address dementia, medications for dementia or behaviors exhibited by resident. Review of nurses' notes, dated 11/24/13, at 8:50 P.M., showed the following: - Refused meds for the evening shift; called the nurse a "[***] " and told him/her to get out of his/her room. Review of the monthly behavior flow sheet, dated 12/1/13, through 12/31/13, showed the following: - 12/20/13, night shift: Anxiety; two episodes; treated with change of position; unchanged outcome. -12/20/13, night shift: Hitting/pinching; two episodes; treated with change of position; unchanged outcome. Review of the MAR, dated 12/1/13, through 12/21/13, showed the following: - [MEDICATION NAME] 10 mg one tablet at bedtime. Staff documented the resident refused the medication on 12/26/13, and 12/27/13; - [MEDICATION NAME] 0.5 mg tablets, administer 0.25 mg or ? tab at bedtime for anxiety. Staff documented the resident refused on 12/15/13, 12/26/13, and 12/27/13. - [MEDICATION NAME] 5 mg BID for dementia. Staff documented the resident refused 12/25/13, 12/26/13, and 12/27/13. - [MEDICATION NAME] 5/500 mg one tablet every eight hours for pain. - [MEDICATION NAME] 1 mg, administer on tablet every six hours as needed for agitation/restlessness. Administered on 12/31/13. Review of the physician's progress sheet, dated 12/3/13, showed the following: - Dementia; [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg BID. - Alert, confused with a flat affect. - Did not address behaviors exhibited by resident. Review of nurses' notes, dated December, 2013, showed the following: - 12/6/13, 7:00 P.M.: Verbally abused staff during bed bath. - 12/11/13, 9:30 P.M.: Verbal behaviors during carr; called CNA "stupid [***] ." - 12/12/13, 9:30 P.M.: Refused medications and spit out medications; verbal behaviors directed towards staff. Review of the nurse's monthly summary sheet, dated 12/13/13, showed the following: - Cognitive: Disorganized thinking, short and long term memory problems, and difficulty making decisions. - Mood: Little interest in things, felt depressed, felt tired, poor appetite, felt bad about self, a failure, short tempered, stated life not worth living, and wished to die. - Behaviors: Physical and verbal behaviors directed towards others; rejected cares. - Physician visited and made no changes in treatment in last 30 days. Review of nurses' notes, dated 12/15/13, at 2:30 A.M., showed the resident exhibited verbal behaviors towards staff. Review of the MAR for January, 2014, showed the following: - [MEDICATION NAME] 10 mg one tablet at bedtime. - [MEDICATION NAME] 0.5 mg tablets, administer 0.25 mg or ? tab at bedtime for anxiety. - [MEDICATION NAME] 5 mg BID for dementia - [MEDICATION NAME] 5/500 mg one tablet every eight hours for pain. - [MEDICATION NAME] 1 mg, administer on tablet every six hours as needed for agitation/restlessness. Administered on 1/8/14. Review of the monthly behavior flow record for 1/1/14, through 1/31/14, showed staff did not record any behaviors for the month on any shift. Review of a nurse's note, dated 1/6/14, at 2:00 P.M., showed a change in pain medication order from [MEDICATION NAME] (a [MEDICATION NAME] and Tylenol pain medication) 5/500 mg to Vicoden 5/325 mg every eight hours. Review of the nurse's monthly summary sheet, dated 1/12/14, showed the following: - Cognitive: Short and long term memory problems; disorganized thinking; moderately impaired decision making. - Mood: Little interest in things; felt depressed; felt tired; poor appetite; felt bad about self; short tempered; stated life was not worth living and wished to die. - Physician visited within last 30 days and made no changes in treatment. Review of a nurses' note, dated 1/18/14, at 4:00 A.M., showed the resident verbally abused staff and called staff names. Review of the physician's progress sheet, dated 1/21/14, showed the following: - Dementia; [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg BID. - Alert with normal affect. - Did not address behaviors exhibited by resident. Review of the social service progress note, dated 1/29/14, showed the following: - Did not attend activities. - No behaviors noted in this assessment period. History of combative behaviors and verbal aggression. - No changes in mood; anxious at times; isolated self in room; refused to get out of bed. Review of the annual MDS, dated [DATE], showed the following: - BIMS score of two which indicated severe cognitive impairment; - Inattention continuously present, out of touch, easily distracted. - No acute change in mental status. - Total severity score of mood: 00; - No staff assessment of mood recorded; - No behaviors recorded; - Behavior symptoms remained the same. - Rejection of care not exhibited. - Extensive assist of one staff for bed mobility, dressing, and hygiene. - Transfers, walking in room or corridor, and locomotion on/off unit did not occur. - Supervision and set-up of meals only. - Total dependence of one staff for toileting and bathing. - Balance during transfers and walking did not occur. - Impairment on one side of the upper and lower extremity. - No mobility devices. - Always incontinent of bowel and bladder. - Pain present; Pain frequently; Pain intensity: Severe; Not able to answer numeric rating scale of pain; zero being no pain, 10 as worst pain imaginable; Pain limited daily activities; No staff assessment for indicators of pain; - Weight: 85 pounds; - Prognosis: Chronic condition/disease that may result in a life expectancy of less than six months; - Hospice; - Anti-anxiety medications during last seven days prior to MDS assessment; - Family and resident participated in MDS assessment; - [DIAGNOSES REDACTED]. Review of the care plan, dated 1/30/14, showed the following: - Problem: Isolated self in room; preferred to stay in room; - Goal: Will make appropriate decisions related to life in the facility. - Approaches: Greet resident before care performed; inform of cares to be given; anticipate needs and remind the resident not to attempt to transfer without assistance; assist with decision making when his/her decisions seemed inappropriate and explain why; provide with time to express his/her feelings; encourage participation in scheduled activities; offer to get him/her up to chair. - Problem: Preferred to stay in room. - Goal: Received social interaction on daily basis; - Approaches: Monitor for comfort measures, assess pain; monitor behaviors and report changes to charge nurse and hospice; staff should identify themselves before provision of care; encourage to come out for meals and activities; assess physical needs; converse with resident during cares. - Problem: Belligerent, rude, combative with caregivers; refused care and medications; - Goal: The resident will accept need for assistance without cursing, rudeness, or combative behaviors; - Approaches: Staff to remind resident they are there to assist him/her; offer to return to assist at a later time if necessary; offer choices and allow independence as much as possible; inform charge nurse of mood and behaviors; document inappropriate behaviors; inform physician of continued or increased frequency of behaviors; psychiatric evaluation PRN; medications as ordered; assess mood before beginning care; document when refused medication and inform physician. - Problem: Refuses to get out of bed; stated staff will not get him/her up; - Goals: Remain free of falls and injury; - Approaches: Encourage to call for assist with transfers; transfers with assist of one staff and a gait belt for standing and pivot transfer; keep pathways free from obstacles; bed in low position at all times; wheelchair brakes locked when up in wheelchair; call light within reach and encourage resident to use call light; check and change PRN to keep clean and dry; proper foot wear. - Problem: Prefers to remain in bed; history of being mean to staff and refused care. - Goal: Continue to interact positively. - Approaches: Engage resident in conversation; provide monthly activity calendar; provide independent activities for resident; monitor any changes in activity participation and socialization; turn on TV; redirect when in a bad mood. - Problem: Potential for side effects of [MEDICAL CONDITION] medications and [DIAGNOSES REDACTED]. - Goals: Will remain free of signs and symptoms of adverse reactions to [MEDICAL CONDITION] medications. - Approaches: Psychiatrist to follow PRN; medication as ordered; notify physician of adverse side effects; labs as ordered; monitor for side effects of medications; pharmacy consultant to monitor drug use monthly. Review of the physician's orders [REDACTED]. - [MEDICATION NAME] 10 mg, one at bedtime for dementia, initially ordered 12/4//12. - [MEDICATION NAME] 5/325 mg, one tablet every eight hours for pain, initially ordered 2/14/12. - [MEDICATION NAME] 0.5 mg, give ? tablet (0.25 mg) at bedtime for anxiety; initially ordered on [DATE]. - [MEDICATION NAME] 5 mg BID, initially ordered 12/9/10. - [MEDICATION NAME] 1 mg, one tablet every six hours as needed for agitation/restlessness; initially ordered on [DATE]. Observation on 2/11/14, at 6:40 A.M., the resident called CNA L a "piece of shift" and "fatso" after he/she provided care to the resident. During an interview on 2/11/14, at 7:05 A.M., CNA L said: - Staff had to handle Resident #11 very carefully; - He/she provided perineal care to the resident, even though the resident called him/her names; - The resident frequently threw wet incontinent pads on the floor. During an interview on 2/11/14, at 7:50 A.M., the resident said the following: - The surveyor attempted to talk with the resident in his/her room. - He/she said he/she had not been out of bed since he/she fell out of a chair in the facility and broke his/her arm in 2009. - He/she wanted to get up, but "they" would not get him/her up. - The resident angrily told the surveyor he/she was "tired of talking" and to "get out of my room!" During an interview on 2/11/14, at 8:05 A.M., LPN C said the following: - The resident did not want to get out of bed and stayed in his/her room since a fall in 2009 when he/she fractured his/her arm. - He/she had the right to refuse and the facility respected his/her rights. - There was no medical reason he/she needed to stay in bed in his/her room. - He/she did have behaviors directed at staff at times. During an interview on 2/11/14, at 9:00 A.M., LPN E said the following: - He/she worked with the resident for a while. - The resident was always mad and wanted to leave, meaning to die. - The resident was hateful to staff a lot. - The resident said hateful things to him/her and called him/her names. - It had been a while since the resident had a psychiatric evaluation. - The resident was hateful with another nurse who did not work on the unit anymore. During an interview on 2/11/14, at 9:05 A.M., CNA B said the following: - The resident was hateful to everyone. - He/she had behaviors. - He/she dug fecal material from his/her rectum and placed it on meal trays, threw it on the floor or on the window. - This happened fast and they had to be on guard for his/her behaviors. During an interview on 2/11/14, at 10:55 A.M., LPN E said the following: - Staff should record behaviors on th