Every finding on record at Riverbend Heights Health & Rehabilitation

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines; failed to follow appropriate infection control practices to ensure facility wide infection control surveillance logs were maintained for twelve months to monitor, track, and identify trends of infections in the facility; and failed to ensure Enhanced Barrier Precautions (EBP- precautions for use during high contact resident care activities for residents with a Multidrug-resistant organism (MDRO- microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who had a chronic wound and/or indwelling medical device) were followed for one sampled resident (Resident #29) out of 18 sampled residents. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 80 residents with a licensed capacity for 154 residents at the time of the survey. Review of the facility's policy titled Infection Prevention and Control Program dated August 2016 showed:-The infection prevention and control program was a facility-wide effort involving all disciplines.-The elements of the infection prevention and control program consisted of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.-The infection prevention and control program was coordinated and overseen by an infection prevention specialist. Review of the facility's policy titled Surveillance for Infections dated September 2017 showed:-The Infection Preventionist (IP) would conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.-The infection Preventionist or designated infection control personnel was responsible for gathering and interpreting surveillance data.-For residents with infections that met the criteria for definition of infection for surveillance, the following data was to be collected:--Identifying information.--Diagnoses.--admission date and date of onset of the infection.--Infection site.--Pathogens.--Invasive procedures.--Pertinent remarks.--Treatment measures and precautions.-For targeted surveillance using facility-created tools, the IP was the use the following guidelines:--Daily, the IP was to record detailed information about the resident and infection on an individual report form.--Monthly, the IP was to collect information from individual resident infection reports and enter line listing of infections by residents for the entire month.--Monthly, the IP was to summarize monthly data for each nursing unit by site and by pathogen.--Monthly or quarterly, the IP would identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends.--Monthly or quarterly, the IP was to compare incidence of current infections to previous data to identify trends and patterns. 1. Review of the facility's floorplan map dated 8/4/2020 showed the building was basically laid out in a horizontal H configuration, with the upper right leg extended farther than the others, creating three separate sections for varying levels of care and populations. Review of the facility's water-borne pathogen prevention program binder titled Legionella, last updated in July of 2025 and provided by the Director of Maintenance (DOM), showed:-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.-A Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens had eight unanswered questions on page 2.-No CDC Legionella Environmental Assessment Form had been done.-Their Water Flow Chart of Riverbend section showed three separate water mains in different locations served the whole facility.-There was an ACCREDITATION STATEMENT from the American Nurses Credentialing Center as the front page for their Water Management Program (WMP) booklet:--The WMP Workbook Components page had 6 Rows for different staff titles such as administrator, maintenance, IC (Infection Control) nurse, etc. with no one's names filled in.--The next WMP: Facility Information page had all 9 rows of facility name, building description, address, etc., not completed,--A Water Safety Program page had all 8 questions unanswered.--The Narrative Description – Detailed, had all 6 rows not completed.--For Water Management Program Control Measures, all 9 rows were blank.--Water Management Program Validation Techniques were not completed. Observation on 3/23/26 between 11:07 A.M. and 11:57 A.M. during the dietary Life Safety Code (LSC) walk-through inspection showed the following:-In the Dishwashing Room there was a chemical washing machine and a 3-sink sanitizing unit.-The kitchen had a steam table (also referred to as a hot food table, specifically, steam tables are designed to hold food at steady, safe serving temperatures, but not designed to cook or warm foods from a raw state), a hand-washing sink, and an ice machine. Observation on 3/25/26 between 10:07 A.M. and 2:27 P.M. during the facility LSC walk-through inspection with the DOM showed the following:-The building was equipped with a complete fire sprinkler system with sidewall and ceiling mounted sprinkler heads located throughout the facility.-The Serenity Hall fire sprinkler riser room (a dedicated space for fire protection equipment) was accessed through an outside door by the south drive.-Two public restrooms were next to the north nurse's station.-A medication room with sink was located behind each of the two separate main nurse's desks.-There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water) and hot/cold water piping throughout the facility.-There were three commercial clothes washers in the laundry area.-There were bathhouses with showers and/or baths in the facility. -There was a beauty shop with a sink.-The Graystone Hall Electrical Room had a holding tank for two tankless heaters.-There were two very large water heaters in the Water Heater Room on the Service Hall to the west parking lot. During an interview on 3/25/26 between 10:21 A.M. and 2:03 P.M. the DOM said:-He/She and the Administrator coordinated the Legionella program.-He/She took water temperatures and spot-checked sinks and showers through the halls on a rotating schedule; the whole cycle took about 5 to 6 weeks.-The Serenity Court was the original building and Santa Fe Lane and Graystone Hall were added later, with the Page Lane east and west halls completed last.-There were three separate water shutoffs throughout the facility, one in each of those respective areas. During an interview on 3/26/26 at 3:11 P.M. the Administrator said:-He/She was educated on the water pathogen prevention management program by using a corporate compliance program online, having safety meetings, and reviewing the plan annually.-There was a team with housekeeping, maintenance, the Director of Nursing, Human Resources, and her/him at the least, that was in charge of its implementation. 2. Review of the facility's Infection Control Log dated April 2025 to March 2026 showed:-The following months had inaccurate information:--April 2025.--May 2025.--July 2025.--September 2025.--November 2025.--December 2025.-The following months had missing/incomplete information:--June 2025.--August 2025.--October 2025.--January 2026.--February 2026. During an interview on 3/26/26 at 11:58 A.M. Corporate Nurse A said:-The facility had recently terminated their IP.-The facility terminated the prior IP due to not fulfilling all his/her job duties.-The current IP had been in place for about three weeks.-The facility's prior IP lost the 2025 infection tracking log/book.-The current IP redid the 2025 infection tracking log/book.-The current IP was also completing the 2026 infection tracking log/book. During an interview on 3/27/26 at 8:44 A.M. the IP said:-He/She had been the designated IP for about three weeks.-He/She had to rebuild the facility's 2025 infection tracking log/book.-He/She had not been given the time to fix anything or ensure accuracy in the 2025 infection tracking log/book and the 2026 infection tracking log/book.-He/She was unsure if the prior IP was tracking infections within the facility correctly. During an interview on 3/27/26 at 12:50 P.M. Certified Medication Technician (CMT) A said:-The nurses were responsible for all infection tracking.-Monitoring infections was important because it reduced the spread of infections throughout the facility. During an interview on 3/27/26 at 12:58 P.M. Licensed Practical Nurse (LPN) B said:-The IP was responsible for tracking all facility infections.-Infection tracking was important because it monitored for trends and could prevent the spread of infection. During an interview on 3/27/26 at 1:35 P.M. the Director of Nursing (DON) said:-The Assistant Director of Nursing (ADON) was the facility's current IP.-He/She would expect the IP to follow all rules and regulations related to infection tracking.-Infection tracking was important because it determined clusters of infections and would aide in determining the root cause of infections. 3. Review of Resident #29's admission Record showed he/she admitted to the facility with a diagnosis of Other Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks). Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff for care planning) dated 2/10/26 showed the resident had moderately impaired cognition. Review of the resident's care plan dated 3/5/26 showed:-The resident was on EBP due to wound care to the resident's toe with the following interventions:--Personal Protective Equipment (PPE) was to be kept in an organizer/cabinet and readily available upon entry to the resident's room.--Staff were to wear a gown and gloves during wound care.--Staff were to wear a gown and gloves for high-contact resident care including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting.-The resident had a trauma wound to his/her right dorsal (back) second toe and a trauma wound to his/her right back leg with an intervention of EBP per facility protocol. Review of the resident's Wound Evaluation and Management Summary dated 3/19/26 showed:-The resident's wound to his/her right dorsal second toe had a duration of greater than or equal to 62 days.-The resident's wound to his/her right leg had a duration of over 49 days. Observation on 3/23/26 at 10:10 A.M. of the resident's door and room showed:-No sign indicating that the resident was on EBP.-No PPE readily available in an organizer or cabinet. Observation on 3/24/26 at 9:52 A.M. of the resident's door and room showed:-No sign indicating that the resident was on EBP.-No PPE readily available in an organizer or cabinet. Observation on 3/25/26 at 10:09 A.M. of the resident's door and room showed:-No sign indicating that the resident was on EBP.-No PPE readily available in an organizer or cabinet. During an interview on 3/26/26 at 10:25 A.M. Certified Nursing Assistant (CNA) A said:-A nurse had put the EBP sign on the resident's door that morning.-A nurse had also hung a PPE organizer behind the resident's door that morning.-The resident received some assistance with care which included incontinence care and assistance in dressing.-He/She had not been following EBP when caring for the resident.-He/She did not know where to find the PPE to follow EBP without the door organizer.-The resident had a wound, so the resident was supposed to have EBP in place. During an interview on 3/26/26 at 10:29 A.M. Bath Aide A said:-He/She was unsure of all that EBP entailed.-He/She knew a resident had EBP in place when there was a sign on the resident's door or if the nurse told him/her.-There was not a sign on the resident's door that indicated the resident was on EBP until that morning.-There was not a door organizer of PPE until that morning. During an interview on 3/26/26 at 10:32 A.M. LPN A said:-He/She thought EBP was standard PPE protocol.-A resident was placed on EBP if the resident had an infection that could be spread to others.-There was not a sign on the resident's door that indicated the resident was on EBP until that morning.-There was not a door organizer of PPE until that morning.-He/She had not used EBP when performing the resident's wound care on 3/25/26. During an interview on 3/26/26 at 12:16 P.M. LPN B said:-He/She placed an EBP sign on the resident's door that morning.-There was not an EBP sign on the resident's door prior to that morning.-He/She hung a PPE organizer on the back of the resident's door that morning.-There was not a PPE organizer on the back of the resident's door prior to that morning. During an interview on 3/27/26 at 8:44 A.M. the IP said:-He/She was responsible for ensuring residents had appropriate EBP signage and PPE when needed.-He/She had not realized that the resident's wounds had turned chronic, and the resident had needed EBP in place.-A resident qualified for EBP if they had a wound that required more than a band-aid as a dressing.-When a resident was placed on EBP the staff needed to wear a gown and gloves during invasive care.-All staff had been recently educated on EBP. During an interview on 3/27/26 at 1:35 P.M. the DON said:-The IP was responsible for placing EBP signs on resident doors when indicated.-The IP was responsible for placing PPE organizers on resident doors when indicated.-The resident needed to be on EBP due to the wounds.-He/She was unaware that an EBP sign had not been placed on the resident's door until 3/26/26.-He/She was unaware that a PPE organizer had not been placed on the back of the resident's door until 3/26/26.-The resident should have had an EBP sign and PPE available for use prior to 3/26/26.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) was in place which had the potential to affect all residents in the facility. The facility census was 80 residents. Review of the facility's policy titled Antibiotic Stewardship dated December 2016 showed the purpose of the Antibiotic Stewardship Program was to monitor the use of antibiotics taken by the residents.Review of the facility's policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes dated December 2016 showed:-Antibiotic usage and outcome data will be collected and documented using facility-approved antibiotic surveillance tracking form.-The data would be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.-As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics would undergo review by the Infection Preventionist (IP), or designee.-The IP, or designee, would review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that were not consistent with the appropriate use of antibiotics.-All resident antibiotic regimens would be documented on the facility-approved antibiotic surveillance tracking form and would include the following information:--Resident name and medical record number.--Unit and room number.--Date symptoms appeared.--Name of antibiotic.--Start date of antibiotic.--Pathogen identified.--Site of infection.--Date of culture.--Stop date.--Total days of therapy.--Outcome.--Adverse events.1. Review of the facility's Infection Control Log dated April 2025 to March 2026 showed the following months had missing or incomplete antibiotic stewardship surveillance data:-April 2025.-May 2025.-June 2025.-July 2025.-August 2025.-September 2025.-November 2025.-December 2025.-January 2026.-February 2026.During an interview on 3/26/26 at 11:58 A.M. Corporate Nurse A said:-The facility had recently terminated their IP.-The facility terminated the prior IP due to not fulfilling all his/her job duties.-The current IP had been in place for about three weeks.-The facility's prior IP lost the 2025 infection tracking log/book, which included the antibiotic surveillance.-The current IP redid the 2025 infection tracking log/book, which included the antibiotic surveillance.-The current IP was also completing the 2026 infection tracking log/book, which included the antibiotic surveillance.During an interview on 3/27/26 at 8:44 A.M. the IP said:-He/She had been the designated IP for about three weeks.-He/She had to rebuild the facility's 2025 infection tracking log/book, which included the antibiotic surveillance.-He/She had not been given the time to fix anything or ensure accuracy in the 2025 infection tracking log/book and the 2026 infection tracking log/book, which included antibiotic surveillance.-He/She was unsure if the prior IP was completing the antibiotic surveillance within the facility correctly.During an interview on 3/27/26 at 12:52 P.M. Certified Medication Technician (CMT) A said:-He/She was unsure if the facility had an Antibiotic Stewardship Program.-He/She was unsure of what antibiotic stewardship meant, or why it was important.During an interview on 3/27/26 at 1:04 P.M. Licensed Practical Nurse (LPN) C said:-He/She thought antibiotic stewardship meant educating residents about their antibiotics.-The nurses were responsible for creating antibiotic progress notes when a resident was on an antibiotic.-The progress note included:--Signs and symptoms.--The reason for taking the antibiotic.--Any adverse reactions.-If he/she suspected a resident had an infection, he/she would call the doctor and get any lab work that was ordered completed.During an interview on 3/27/26 at 1:35 P.M. the Director of Nursing said:-All staff were educated on antibiotic stewardship.-The IP was responsible for the antibiotic surveillance.-He/She was unable to explain what the facility's Antibiotic Stewardship Program entailed.

Based on observation, interview and record review, the facility failed to ensure appropriate psychotropic (relating to drugs that affect a person's mental state) medication side effect monitoring was in place for five sampled residents (Resident #1, #2, #4, #8, and #69) out of 18 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Antipsychotic Medication Use dated December 2016 showed:-Residents would only receive antipsychotic medication when necessary to treat specific conditions for which they were indicated and effective.-The nursing staff should monitor for and report side effects and adverse consequences of antipsychotic medications to the attending physician. Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring dated March 2019 showed:-The facility would comply with regulatory requirements related to the use of medications to manage behavioral changes.-The interdisciplinary team (IDT) would monitor for side effects and complications related to psychoactive medications. Review of the facility's policy titled Depression-Clinical Protocol dated November 2018 showed the staff and physician would monitor the resident carefully for side effects of any medications used to treat a mood disorder as well as interactions between antidepressants and other classes of medications. 1. Review of Resident #1's progress notes dated 1/2/26 to 3/26/26 showed:-No monitoring for target behaviors.-No monitoring for potential side effects related to the resident's psychoactive medications. Review of the resident's order summary report (OSR) dated March 2026 showed he/she had the following diagnoses:-Major depressive disorder (persistent feeling of sadness and loss of interest that can interfere with daily functioning) recurrent, severe with psychotic symptoms (abnormal thinking and perceptions).-Schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).-Bipolar disorder (chronic mental health condition characterized by intense, fluctuating mood shifts between high energy and low energy). Review of the resident's Medication Administration Record (MAR) dated March 2026 showed:-Alprazolam (antianxiety medication) 0.25 milligrams (mg) three times a day for anxiety.--There were no orders for monitoring target symptoms treated by the medication and for monitoring for potential side effects of the medication.-Alprazolam 0.5 mg every 8 hours for anxiety for 14 days.--There were no orders for monitoring target symptoms treated by the medication and for monitoring for potential side effects of the medication.-Buspirone (antianxiety medication) 15 mg two times a day for anxiety.--There were no orders for monitoring target symptoms treated by the medication and for monitoring for potential side effects of the medication.-Mirtazapine (antidepressant medication) 15 mg at bedtime for depression.--There were no orders for monitoring target symptoms treated by the medication and for monitoring for potential side effects of the medication.-Quetiapine (antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) 300 mg at bedtime for schizoaffective affective disorder, depressive type.--There were no orders for monitoring target symptoms treated by the medication and for monitoring for potential side effects of the medication.-Sertraline (antidepressant medication) 25 mg one time daily for depression.--There were no orders for monitoring target symptoms treated by the medication and for monitoring for potential side effects of the medication. Observation on 3/24/26 at 12:29 PM. showed:-The resident was seated in his/her room.-He/she was alert and answered questions. During an interview on 3/24/26 at 12:29 P.M. the resident said:-He/She was bipolar and had depression and anxiety.-Staff did not ask him/her any questions about his/her mood.-Staff did not ask about any side effects he/she may be having from medications he/she received for his/her bipolar, depression and anxiety. 2. Review of Resident #2's admission Record showed the resident admitted to the facility with the following diagnoses:-Delusional Disorders (a type of serious psychotic disorder characterized by the presence of one or more fixed, false beliefs (delusions) that persist for at least one month).-MDD, Recurrent, Unspecified.-Generalized Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). Review of the resident's OSR dated March 2026 showed:-An order for Buspirone Hydrochloride (HCl) Oral Tablet 10 mg, give 10 mg by mouth three times a day related to Generalized Anxiety Disorder.-An order for Lamotrigine (used to treat mood disorders) 100 mg, give one tablet by mouth one time a day for Psychotic Disorder.-An order for Lamotrigine 25 mg, give two tablets by mouth one time a day for Psychotic Disorder.-An order for Risperidone (Risperdal- an antipsychotic) Oral Tablet one mg, give two tablets by mouth at bedtime for Delusional Disorder.-No order in place related to the monitoring of side effects related to the resident's anti-psychotic and anti-anxiety medication. Review of the resident's MAR and Treatment Administration Record (TAR) dated March 2026 showed no documentation related to the monitoring of psychotropic medication side effects. Review of the resident's care plan dated 3/4/26 showed a focus related to the use of psychotropic medication due to behavioral management, psych diagnoses, anxiety, depression, and delusional disorder with an intervention for staff to monitor/document/report as needed any adverse reactions of psychotropic medications. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 3/20/26 showed:-The resident had severely impaired cognition.-The resident had depression.-The resident had an anxiety disorder.-The resident had a psychotic disorder.-The resident took anti-psychotic medication.-The resident took anti-anxiety medication.-The assessment did not indicate whether or not the resident took an anti-depressant. 3. Review of Resident #4's admission Record showed the resident admitted to the facility with the following diagnoses:-Generalized Anxiety Disorder.-Schizoaffective Disorder (a mental health condition that includes features of both schizophrenia and mood disorder), Depressive Type.-MDD, Recurrent, Unspecified. Review of the resident's comprehensive MDS dated [DATE] showed:-The resident was cognitively intact.-The resident had an anxiety disorder.-The resident had depression.-The resident had schizoaffective disorder.-The resident took anti-psychotic medication.-The resident took anti-depressant medication. Review of the resident's OSR dated March 2026 showed:-An order for Abilify (aripiprazole- an atypical anti-psychotic medication used to treat mental health conditions) Oral Tablet five mg, give one tablet by mouth at bedtime for hallucinations.-An order for Sertraline HCl Tablet 100 mg, give two tablets by mouth one time a day related to MDD, Recurrent, Unspecified.-No order in place related to the monitoring of side effects related to the resident's anti-psychotic medication. Review of the resident's care plan on 3/26/26 showed a focus related to the use of psychotropic medication due to schizoaffective disorder and depression with an intervention for staff to monitor/document/report as needed for any adverse reactions of psychotropic medication. Review of the resident's MAR and TAR dated March 2026 showed no documentation related to the monitoring of anti-psychotic medication side effects. 4. Review of Resident #69 admission Record showed the resident admitted to the facility with the following diagnoses:-Vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen).-Bipolar disorder.-Major depressive disorder. Review of the residents' care plan dated 12/11/25 showed:-He/She used antipsychotic medication for bipolar disorder.-His/Her goals were to remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date.-Staff were to implement the following interventions:--Administer psychotropic medications as ordered by physician. --Monitor for side effects and effectiveness every shift.--Educate the resident about risks, benefits and the side effects and/or toxic symptoms of medications being given.--Monitor/document/report as needed any adverse reactions of psychotropicmedications: unsteady gait, tardive dyskinesia (a medication-induced movement disorder characterized by uncontrollable, repetitive movements, often in the face, tongue, or jaw), Extrapyramidal Symptoms ((EPS) shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Review of the resident's OSR dated 12/12/25 showed the resident was ordered the following mediations:-Abilify Oral Tablet 15 mg (atypical antipsychotic) give 7.5 mg by mouth one time a day related to bipolar disorder 1/2 of a 15 mg tab= 7.5 mg daily.-Citalopram Hydrobromide oral tablet 10 mg (antidepressant) give 5 mg by mouth one time a day for depression.-NOTE: There were no orders for monitoring for side effects of psychotropic medications. Review of the resident's MAR and TAR dated January 2026 showed there was no monitoring of psychotropic medication side effects. Review of the resident's MAR and TAR dated February 2026 showed there was no monitoring of psychotropic medication side effects. Review of the resident's MAR and TAR dated March 2026 showed there was no monitoring of psychotropic medication side effects. Review of the residents Quarterly MDS dated [DATE] showed:-The resident had the following diagnoses during the look back period:--Anxiety Disorder.--Depression.--Bipolar Disorder.-The resident had taken the following medication during the look back period:--Antipsychotic.--Antidepressant. During an interview on 3/25/26 at 10:33 A.M. the resident said:-He/She did not know if staff monitored for side effects of medication.-Staff did not ask him/her about side effects. 5. Review of Resident #8's admission Record showed the resident was admitted to the facility with a diagnosis of bipolar disorder. Review of the resident's care plan dated 8/21/25 showed:-He/She uses antidepressant medication.-The goal was the resident will be free from discomfort or adverse reactionsrelated to antidepressant therapy through the review date.-Staff were to implement the following interventions:--Administer antidepressant medications as ordered by physician.--Monitor and document side effects and effectiveness every shift.--Educate the resident about risks, benefits and the side effects and/or toxic symptoms of antidepressant drugs being given.--Monitor, document, and report adverse reactions to antidepressant therapy (changes in behavior, changes in mood, changes in cognition; hallucinations or delusions; social isolation, suicidal thoughts, withdrawal; decline in continence, no voiding; constipation, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness; fatigue, insomnia; appetite loss, weight loss, dry mouth, dry eyes)-He/She used psychotropic medications related to traumatic brain injury (TBI damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile), bipolar disorder, major depressive disorder, anxiety disorder.--The goal was the resident would be/remain free of psychotropic drug relatedcomplications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation, or cognitive/behavioral impairmentthrough review date.--The interventions for the focus were:--- Administer psychotropic medications as ordered by physician. ---Monitor for side effects and effectiveness every shift.---Educate the resident about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given.---Monitor/document/report any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Review of the OSR report dated 12/12/25 showed:-Escitalopram Oxalate (antidepressant) tablet 20 mg give 1 tablet via Percutaneous Endoscopic Gastrostomy tube (PEG a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) one time a day for Depression.-Seroquel (atypical antipsychotic) oral Tablet 50 mg give 1 tablet via Peg tube two times a day for bipolar related to major depressive disorder. -NOTE: There were no orders for monitoring for side effects of psychotropic medication. Review of the resident's MAR and TAR dated January 2026 showed there was no monitoring of psychotropic medication side effects. Review of the residents Quarterly MDS dated [DATE] showed:-The resident had the following diagnoses during the look back period:--Anxiety disorder.--Depression.--Bipolar disorder.-The resident received the following medication during the look back period:--Antipsychotic.--Antidepressant. Review of the resident's MAR and TAR dated February 2026 showed there was no monitoring of psychotropic medication side effects. Review of the resident's MAR and TAR dated March 2026 showed there was no monitoring of psychotropic medication side effects. During an interview on 3/26/26 at 7:51 A.M. the resident said:-He/She was unsure if the staff monitored for side effects of psychotropic medications.-None of the staff asked him/her about side effects of medication. 6. During an interview on 3/27/26 at 12:48 P.M. Certified Medication Technician (CMT) A said:-There was a place in the Electronic Medical Record (EMR) for staff to document the side effects of medication.-If a pro re nata (PRN- as needed) medication was given, an alert would show for the staff to document the effectiveness at a later time.-He/She was unsure about side effect monitoring for scheduled psychotropic medications. During an interview on 3/27/26 at 12:53 P.M. Licensed Practical Nurse (LPN) B said:-The nurses were responsible for completing side effect monitoring documentation.-The Assistant Director of Nursing (ADON) and Director of Nursing (DON) would ensure completion of the documentation.-It was important for the nurses to monitor psychotropic medication side effects to ensure the medication was working and that residents were not having any bad reactions to the medication.-In order for staff to document side effects of any medication, there needed to be an order in place.-Once there was an order in place, staff would then be able to document the side effects on the resident's MAR or TAR.-Resident #1, Resident #2, Resident #4, Resident #8, and Resident #69 should have psychotropic medication side effect monitoring in place.-He/She was unsure if Resident #1, Resident #2, Resident #4, Resident #8, and Resident #69 had current orders for psychotropic medication side effect monitoring. During an interview on 3/27/26 at 1:35 P.M. the DON said:-All psychotropic medication should have side effect monitoring. -Psychotropic side effect monitoring should be documented every shift.-Nurses were responsible for documenting the psychotropic medication side effect monitoring.-There needed to be a specific order in place for nurses to be able to document psychotropic medication side effect monitoring.-Once an order was in place; the nurses would then be expected to document the side effect monitoring on a resident's TAR.-Resident #1, Resident #2, Resident #4, Resident #8, and Resident #69 should have had anti-psychotic, anti-anxiety, and anti-depressant side effect monitoring in place as appropriate for their medications.

Based on observation, interview and record review, the facility failed to provide individualized activities of the resident's preference that provided a sense of comfort and connection, sensory engagement, and purpose for three sampled residents (Resident #40, Resident #16, and Resident #2) out of 18 sampled residents. The facility census was 80 residents. Review of the facility's Activities Program policy, revised June 2018 showed:-The following records will be maintained by the Activities department: Activities evaluation, attendance records, Activities calendar, progress notes and individualized Activities care plan as a portion of the comprehensive care plan.-Activity programs are designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident.-Activities are based on the comprehensive, resident-centered assessment and preferences of each resident.-Activities are scheduled seven days a week and consist of individual, small group, and large group activities designed to meet the needs and interests of each resident. 1. Review of Resident #40's admission Record showed he/she was admitted to the facility with diagnoses that included:-Schizoaffective disorder (a Mental health condition that includes features of both schizophrenia and a mood disorder).-Extrapyramidal and movement disorder (involuntary, often drug-induced movement disorders, caused by dysfunction of the extrapyramidal system).-Glaucoma (a condition of increased pressure inside the eye which could lead to blindness).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Senile degeneration of the brain (progressive, age-related cognitive decline caused by brain cell death). Review of the resident's Activities care plan, dated 8/3/25 showed:-The resident's goal was to maintain involvement in activities that provided cognitive stimulation and social opportunities as desired.-Interventions included:--Ensure activities were compatible with known interests, preferences, choices, and mental capabilities such as coffee hour, talk time, and snacks. --The resident enjoyed doing things that kept his/her hands busy such as folding washcloths and clothes and thought of it as his/her job.-He/She enjoyed Pepsi, sweets, and snacks.-The resident liked to sit by the nurses' station and sing made-up songs. Review of the resident's most recent Activities Evaluation, dated 1/23/25, showed the resident:-Was severely visually impaired.-Utilized a wheelchair.-Loved music and snacks. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 7/24/25 showed the resident:-Was severely cognitively impaired.-Said it was somewhat important to use the phone and very important to have snacks, be around animals, and listen to music. It was not very important to do group activities. Review of the resident's quarterly Activity Participation progress note, dated 7/24/25, showed:-Due to his/her disease progression, the resident had no interest in group activities nor did he/she care for 1:1 unless it involved food. -The resident spent much of his/her time napping but did sit in the common area when awake. -He/She enjoyed snacks and soda when offered.-NOTE: The Activities progress note didn't show what 1:1 activities were actually offered or if multiple attempts had been made to involve the resident on days when the resident was napping during the original visit to the unit. Review of the resident's quarterly Activity Participation progress note, dated 12/19/25, showed:-The resident participated in food activities but couldn't do nor did he/she have the desire to do any other activity. -He/She usually refused any attempts of 1:1 activities but spent much of his/her time sitting in the common area where he/she could visit with anyone passing by and enjoyed talking to staff. -The resident enjoyed music and often sang to staff.-NOTE: The progress note didn't show what the Activities department offered the resident or how often he/she was engaged in activities of interest during the quarter. Review of the facility's activity calendars dated January 2026 and February 2026 showed:-Most activities listed for the resident's unit, except for food-related activities, were geared for residents with moderate to good eyesight, average or better hand dexterity and body movement control, and higher cognitive abilities than the resident.-A note at the bottom of the calendars for all three units showed the activities were subject to change. Activities staff may be available between 9:00 A.M. and 10:00 A.M. and 1:00 P.M. to 2:00 P.M. for residents 1:1. -Calendars for the three units showed regular group activities started most mornings at 9:30 A.M. and didn't end until the resident's lunch time around 12:00 P.M. and were scheduled most afternoons 1:30 P.M. until approximately 4:15 P.M. or 4:30 P.M. after the resident mail was passed out. Group activities were scheduled back-to-back on each of the three units leaving very little time for 1:1 activities. Review of the resident's Activity Participation documentation dated 2/13/26 to 2/28/26 showed:-The resident participated in the Valentine's Day party on 2/13/26 and ice cream floats on 2/24/26. There were no notes to show if he/she only ate or if there was an actual activity offered as well.-The resident participated in no other activities during the last half of February, including scheduled music and food-related activities such as Mardi Gras pancakes on 2/17/26, a birthday party on 2/19/26, karaoke on 2/20/26, coffee and chat on 2/23/26, cookie decorating on 2/25/26, BINGO/music on 2/26/26, and Karaoke on 2/27/26. The activity documentation did not show why the resident did not participate in the scheduled music and food related activities. -There was no documentation of any 1:1 activity attempted with the resident for the second half of February. Review of the facility's activity calendar dated March 2026 showed:-Most activities listed for the resident's unit, except for food-related activities, were geared for residents with moderate to good eyesight, average or better hand dexterity and body movement control, and higher cognitive abilities than the resident.-A note at the bottom of the calendars for all three units showed the activities were subject to change. Activities staff may be available between 9:00 A.M. and 10:00 A.M. and 1:00 P.M. to 2:00 P.M. for resident 1:1. -Calendars for the three units showed regular group activities started most mornings at 9:30 A.M. and didn't end until the resident's lunch time around noon and were scheduled most afternoons from 1:30 P.M. until 4:15 or 4:30 P.M. after the mail was passed. Group activities were scheduled back-to-back on each of the three units leaving very little time for 1:1 activities. Review of the resident's Activity Participation documentation dated 3/1/26 to 3/26/26 showed:-The resident was not listed as having participated in any activity during March.-Given that the resident's favorite activities were music and snacks, there was no documentation why the resident didn't participate in snack and games on 3/2/26, coffee and chat on 3/2/26, karaoke on 3/6/26, coffee on 3/9/26, karaoke on 3/13/26, coffee and hot chocolate on 3/16/26, St Patty's party on 3/17/26, March birthday party on 3/20/26, coffee and hot chocolate on 3/23/26, Chip and Dip Day on 3/23/26, and coffee and donuts on 3/24/26.-There was no documentation why the resident didn't participate in sensory activities such as salt art scheduled on 3/4/26 and fancy nails scheduled on 3/11/26.-There was no documentation what 1:1 activities or experiences were offered since the resident was unable to participate in most scheduled morning activities, BINGO, and mental and physical games. Review of the resident's quarterly Activity Participation progress note, dated 3/17/26, showed:-Due to his/her blindness, the resident didn't participate in group activities, he/she preferred to spend time in the common area. -He/She enjoyed getting food when given during activities. -He/She liked snacks and would often yell for food. -Sometimes he/she would sit at a table and do his/her job whether it was folding clothes, writing invoices, or talking on the phone. -The resident also liked to sing and listen to music.-NOTE: The quarterly Activity Participation progress note did not show why the listed preferred activities were ever offered to the resident during the last half of February or first half of March. Observation on 3/23/26 from 10:40 A.M. to 11:30 A.M. showed:-The resident was in the common area near the nursing desk hollering loudly. -During this time there was no soothing activity taking place such as music. Observation on 3/24/26 from 2:30 P.M. to 3:15 P.M. showed:-The resident was sitting alone in his/her room screaming loudly. -Some of the other residents on the unit were engaged in a BINGO game. -There was no attempt by any staff to do something that might soothe the resident such as playing music in the resident's room. Observation on 3/25/26 from 1:50 P.M. to 3:20 P.M. showed:-Activities was doing a spring craft in the dining room with some of the unit residents.-The resident was sitting in the common area with his/her eyes closed and head down. During an interview on 3/25/26 at 2:02 P.M. Certified Medication Technician (CMT) C said:-When the resident was calm he/she would sometimes fold clothes or would write when given pen and paper.-The facility used to have a radio in the dining room, but he/she didn't know what happened to it. -The resident used to like to hum to the radio. During an interview on 3/25/26 at 2:42 P.M. CMT D said:-The resident liked music. He/She hadn't seen the resident involved in karaoke for a while, but if the resident didn't understand what it was he/she might refuse to do it.-The resident couldn't see; therefore, smells, touch, and hearing were very important to the resident.-He/She loved getting showers probably because of the touch and the clean feeling he/she has afterward. He/She thought the resident would love a spa day. Activities didn't do that, but he/she thought the resident would like it. -The resident would be a good candidate for sensory activities and would love having his/her nails painted and having someone put make-up on him/her. Even though he/she couldn't see it the resident would know he/she looked good. -The resident loved feeling pampered and would love having someone massage his/her hands with a fragrant lotion. -He/She liked having his/her hair washed and would love a nicely scented, moisturizing shampoo. He/She thought the spa day type activities would remind the resident of his/her former life and be a psychological escape. During an interview on 3/25/26 at 3:00 P.M. CMT B said:-Activities didn't do any 1:1 activities on the unit.-The resident loved touch. He/She liked to have his/her head massaged and would love someone rubbing his/her shoulders. He/She had a stuffed ladybug massager and a blanket he/she liked because of the texture.-The resident would love someone gently applying a nice-smelling lotion on his/her hands and loved music. -Nursing staff will sometimes play it on their phone, but he/she hadn't noticed activities playing music much. Observation on 3/26/26 at 10:21 A.M. showed a Certified Nurses Assistant (CNA) giving the resident Jello and talking to him/her in a very calm and gentle voice. The resident turned his/her body toward the CNA as if enjoying the interaction. During an interview on 3/26/26 at 10:38 A.M. CMT E said:-The resident needed 1:1 activities. He/She had never seen the Activities department do any 1:1 activities on the unit.-The resident liked any music staff put on their phone, especially Christmas music and knew the words to Jingle Bells. If staff put music on, the resident would clap his/her hands, [NAME] his/her head, and might hum. -The resident liked to hold staff's hand and the connection with someone. One day he/she sat and watched the [NAME] show while holding the resident's hand, but he/she didn't have time to do that every day.-The resident liked touch and would like hand or shoulder massages or having someone do his/her nails. He/She wouldn't be able to see them, but he/she would like feeling they were pretty.-He/She liked having his/her hair done and would like to have someone put makeup on him/her. -The resident had a ladybug massager which he/she liked to pet. He/She might like a therapy animal to pet.-He/She hadn't seen Activities work with the resident 1:1 and nursing staff usually didn't have time to do activities with him/her. During an interview on 3/27/26 at 9:34 A.M. the Activities Assistant (AA) said:-He/She did an activity on all three units every morning and every afternoon. Sometimes the Activity Director helped him/her with the group activities. The six activities took all day.-Since the beginning of the year there had only been himself/herself and the Activity Director. Before then there was another Activity Assistant and one of them would finish up an activity like a game or craft while the other Activity Assistant started on the next unit. Now it was sometimes hard to get to the unit on time when an activity took longer than expected.-Four residents in the building were on 1:1 activities. He/She tried to catch them before doing the group activity when he/she could and usually spent about five minutes with them when he/she was able to do so. -The resident was not provided 1:1 activities. He/She would probably like to have his/her nails done because he/she liked to get prettied up and could do other activities by feel if provided 1:1 assistance. If there was a second Activity Assistant they could do 1:1 activities with the resident.-When there was a party on the unit he/she had the resident join. -The resident would eat the food brought to the unit, but didn't like group activities. During an interview on 3/27/26 at 10:30 A.M. Licensed Practical Nurse (LPN) D said:-He/She saw the Activity Assistant offer the resident a snack and sit with him/her the previous week which the resident seemed to enjoy. -There were not any activities adapted for someone with the resident's disabilities. There were a lot of residents at the facility who needed the 1:1 assistance, but there wasn't enough Activities staff to do both the group and the 1:1 activities.-The resident liked to fold towels and sometimes nursing staff gave the resident that to do. During an interview on 3/27/26 at 11:29 A.M. the Activities Director said:-He/She planned the Activities program and completed the Activity evaluations at least annually. -The resident would need activities adapted due to his/her lack of vision. He/She had not been on 1:1 activities but probably should be.-The resident liked music. Once the resident had a radio in his/her room and the resident unplugged it and threw it across the room, but they could probably put a radio on a higher shelf.-One day he/she gave the resident a pen and paper and the resident wrote on the paper. -The resident would also fold laundry. 2. Review of Resident #16's admission Record showed he/she admitted to the facility with the following diagnoses:-Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks).-Cognitive Communication Deficit (difficulty with verbal or non-verbal communication caused by disrupted underlying think processes, such as memory, attention, organization, or executive functioning). Review of the resident's Activities Evaluation dated 3/3/26 showed:-The resident enjoyed family/friend visits, movies/television, music/talk radio, parties/social events, and watching television in his/her room.-The resident preferred small group and 1:1 activities.-The resident preferred afternoon time activities.-The resident was cooperative, withdrawn, and passive.-The resident had cognitive impairment with little desire to do the things he/she used to enjoy. Review of the resident's annual MDS dated [DATE] showed:-The resident was cognitively intact.-The resident found it somewhat important to do his/her favorite activities. Review of the resident's care plan dated 3/10/26 showed:-The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs, had little interest in doing things he/she used to do related to cognitive deficits with the following interventions:--Ensure the activities the resident attended were compatible with physical and mental capabilities.--Invite the resident to scheduled activities.--The resident was to receive 1:1 activities from the staff due to the resident's desire to stay in his/her room and not socialize.--The resident was often asleep when staff visited. During an interview on 3/24/26 at 9:21 A.M. the resident said:-He/She was unaware of when facility activities occurred.-He/She had not been offered the activity on 3/23/26.-He/She would go to the activities if he/she knew what they were ahead of time. Review of the resident's Record of 1:1 Activities on 3/27/26 showed:-The resident had 18 documented activities from 11/11/25 to 3/25/26.-Six out of the 18 recorded activities indicated the resident was asleep when staff went to see the resident.-The resident had no recorded 1:1 activities from 1/15/26 to 2/13/26. 3. Review of Resident #2's admission Record showed the resident was diagnosed with Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), Unspecified Severity, with Mood Disturbance on 6/1/25. Review of the resident's annual MDS dated [DATE] showed:-The resident had moderately impaired cognition.-The resident found it somewhat important to listen to the music he/she liked.-The resident found it somewhat important to do things with groups of people.-The resident found it very important to do his/her favorite activities.-The resident found it very important to participate in religious services or practices. Review of the resident's Activities Evaluation dated 1/12/26 showed:-The resident liked to play bingo.-The resident was unwilling to give the Activities Director information related to his/her preferred activities.-The resident preferred small group activities.-The resident had trouble getting along with other residents. Review of the resident's care plan dated 3/4/26 showed:-The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs, had little interest in doing things he/she used to do related to cognitive deficits, immobility, and little interest in doing things he/she used to enjoy with the following interventions:--Ensure that the activities the resident attended were compatible with physical and mental capabilities.--Invite the resident to scheduled activities.--The resident preferred to stay in bed most days but attended bingo when he/she felt like it. During an interview on 3/24/26 at 9:46 A.M. the resident said he/she wished the facility played more bingo. During an interview on 3/26/26 at 8:00 A.M. the resident said:-He/She would have participated in the axe throwing activity if he/she had been told about it ahead of time.-He/She liked crafts, audiobooks, shopping, and playing games.-He/She was unsure if he/she had a recent activity assessment. 4. During an interview on 3/26/26 at 8:04 A.M. CNA A said:-The daily chronicle (facility newsletter) has not been delivered to the memory care unit in over a month.-The residents in the memory care unit were not invited to any activities outside of the unit.-In general, it seemed like there was only activities on the unit when hospice (end of life care) staff came to the unit to do activities.-Resident #16 did not like group activities.-He/She was unsure if Resident #16 was on 1:1 activities but felt the resident would be better suited for 1:1 activities.-The memory care unit was not always given the monthly activity calendars.-Resident #16 did not participate in the craft activity that occurred on 3/25/26. Observation on 3/26/26 at 8:10 A.M. showed no activity calendar posted by the nurse's station. During an interview on 3/26/26 at 8:40 A.M. Bath Aide A said:-The residents in the memory care unit were not invited to any activities outside of the unit.-He/She was unsure if Resident #16 was on 1:1 activities but felt the resident would be better suited for 1:1 activities.-The memory care unit was not always given the monthly activity calendars.-Resident #2 slept during most activities.-If the unit was told there was going to be an activity, then the staff would assist the residents in going to the activity.-Resident #2 really enjoyed bingo but had not been going to bingo as much as usual. During an interview on 3/27/26 at 9:48 A.M. the Activities Assistant said:-He/She passed out the daily chronicle to all units every day before lunch time.-There was a morning activity and an afternoon activity on all units.-Resident #16 was on 1:1 activities.-Frequently, when he/she went to the memory care unit to do an activity, none of the residents would be up and out of bed to participate in the activity.-He/She was not responsible for completing the monthly activity calendar.-He/She confirmed that Resident #16's log was accurate.-He/She was not responsible for completing the activity assessments.-Resident #16 did sleep a lot and he/she had difficulty in completing the 1:1 activities with the resident.-Resident #2 liked playing bingo, attending parties, and music.-Resident #2 would be better suited for 1:1 activity outside of playing bingo.-The Activity Director had told him/her that residents on the memory care unit were not invited to activities outside of the unit because it confused the residents. During an interview on 3/27/26 at 11:29 A.M. the Activity Director said:-He/She was responsible for planning all activities.-He/She kept a record of all activities and attendance in a log.-There were two activities on each unit Monday through Friday.-Sometimes the activity scheduled on the memory care unit had no interest from the residents and when that occurred he/she would visit with the residents instead.-He/She had offered the monthly activity calendar to the memory care unit staff in the past but had not been good about it in the last few months.-He/She would document on the activity log if residents were not up and dressed for the activity.-He/She expected staff on the memory care unit to invite all of the residents to the activity.-He/She would also invite the residents on the memory care unit to the scheduled activity.-There were a couple of activities that happened outside of the memory care unit that residents of the memory care unit were invited to.-Usually, the residents on the memory care unit would become disoriented or confused when going to activities off the unit which was why they typically were not invited.-He/She was responsible for completing all activity assessments.-He/She had made two or three attempts to get a better activity assessment for Resident #2, but they had all been unsuccessful.-He/She thought Resident #2 may be better suited for 1:1 activities.-The March activity calendar was not accurate for the memory care unit.-He/She had copied and pasted from a different unit's calendar and forgot to edit the activities.-On the weekend, he/she set up craft or coloring stations for the memory care unit.-He/She felt that the resident's on the memory care unit did not like to do activities on the weekends.-Resident #16 had been on 1:1 activities before he/she worked for the facility.-He/She was unsure if other attempts were made for 1:1 activity throughout the day if Resident #16 was asleep for a daily visit.-He/She monitored the 1:1 activity log.-He/She was unaware that Resident #16 had missed a month of 1:1 activities. During an interview on 3/27/26 at 12:42 P.M. CNA C said:-Resident #16 was not on 1:1 activities.-Resident #16 had started to participate more in small group activities.-He/She was unsure if Resident #2 would benefit from 1:1 activities because Resident #2 refused to participate in activities frequently.-Resident #2 liked bingo and eating snacks. 5. During an interview on 3/27/26 at 1:35 P.M. the Director of Nursing said:-The activities department was in charge of all activities on the memory care unit.-The Activity Director planned all facility activities.-There was a logbook of all activities and attendees that the Activity Director was responsible for.-There was a logbook for all the residents who were on 1:1 activities.-The Administrator also monitored the activity logs.-He/She was unsure as to why the staff on the memory care unit were reporting activities were not done on the unit.-The Activity Director was responsible for completing all activity assessments.-If an activity assessment was attempted and unable to be fully completed, he/she expected the Activity Director to continue to try and complete a full assessment.-Resident #2 should have had a full and accurate activity assessment completed.-He/She thought Resident #2 would be a good candidate for 1:1 activities.-He/She expected activity staff to make more attempts throughout the day when Resident #16 was asleep during attempts.-He/She was unaware that Resident #16 had missed a month of 1:1 activities.-Resident #40 would benefit from adapted and 1:1 activities. -Resident #40 was particularly into music. -The Activities department should communicate with the residents' families and nursing staff to get ideas of what the resident liked.-He/She expected the activity calendar to be accurate for each unit.-He/She was unaware that the memory care unit's March activity calendar was inaccurate.-He/She expected all residents and units to have copies of the activity calendar.-He/She was unaware that the memory care unit did not have a posted activity calendar near the nurse's station.

Based on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage (DS) room, walk in refrigerator, and walk in freezer floors clean; failed to ensure food preparation items/equipment were kept in a sanitary condition; failed to safeguard against foreign material possibly getting into food; failed to maintain plastic and/or rubber cutting boards, plate covers, room trays, and utensils in good condition to avoid food safety hazards (cross-contamination); in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 80 residents with a licensed capacity for 154 residents at the time of the survey. Review of facility policy titled Sanitation revised October 2008 showed:-All kitchens, kitchen areas and dining areas would be kept clean, free from liter and rubbish. -All utensils, counters, shelves and equipment would be kept clean, maintained in good repair, and would be free from breaks, corrosion, open seams, cracks and chipped areas that might have affected their use or proper cleaning.1. Observation on 3/23/26 between 11:07 A.M. and 11:57 A.M. during the dietary areas' walk-through showed:-The walk-in refrigerator had four pieces of plastic and one piece of foil under the baker's racks with an approximately (app.) 5-inch ( ) by 12-foot (') piece of cardboard mid-floor.-In the DS was two pieces of plastic and a wad of tape under the middle baker's racks.-In the walk-in freezer five pieces of plastic, a strip of tape, a 2 ' by 1.5' piece of cardboard, and a hair net under the racks.-The conveyor toaster had excessive crumbs under the belt and in the bottom landing area.-The microwave next to it on the food prep table against the west wall across from the stove had yellow splatters on its ceiling and at the bottom around a plate.-The light blue and red cutting boards were overly scored.Observation on 3/24/26 at 10:27 A.M. showed:-The DS, walk in refrigerator, and walk-in freezer had the same miscellaneous trash present.-The conveyor toaster had excessive crumbs under the belt and in the bottom landing area.-The microwave next to it on the food prep table against the [NAME] wall across from the stove had yellow splatters on its ceiling and at the bottom around a plate.-The light blue and red cutting boards were overly scored.Observation on 3/25/26 at 8:27 showed the breakfast test plate was covered by a round, beige plastic cover that had flaking plastic around the inside rim.Observation on 3/25/26 at 1:36 P.M. showed:-The conveyor toaster had excessive crumbs under the belt and in the bottom landing area.-The microwave next to it on the food prep table against the [NAME] wall across from the stove had yellow splatters on its ceiling and at the bottom around a plate.-The light blue and red cutting boards were overly scored.During an interview on 3/27/26 at 8:42 A.M. the Dietary Manager (DM) said:-The floors of the DS area, walk in refrigerator, and walk in freezers were swept twice a week. -The cook was responsible for cleaning the microwave and toaster and it was supposed to be done daily. -Food should be free from foreign substances (plastic) and cutting boards and the plastic food domes should have been replaced when those items were no longer serviceable with flaking plastic or excessive scoring. -He/She was ultimately responsible to ensure the kitchen was clean, floors swept, and plastic items in the kitchen were in serviceable order. During an interview on 3/28/26 at 8:47 A.M. the Administrator said:-The kitchen staff should be following best industry sanitation practices.-He/She expected the DS, walk in refrigerators, and walk-in freezers were swept daily.-He/She expected cutting boards would be replaced when excessively scored. -He/She expected the plastic food covers to be replaced when they became worn and stared flaking.

Based on interview, and record review, the facility failed to refer one sampled resident (Resident #10) diagnosed after his/her admission with a serious mental disorder (SMD)/mental illness to the appropriate State-designated authority for review, out of 18 sampled residents. The facility census was 80 residents. Review of the facility's Pre admission Screening and Record Review (PASRR- a federally-mandated tool for Medicaid-certified nursing facility applicants to be screened for SMI, ID, or related conditions. If positive, a Level II, in-depth evaluation is indicated ensuring appropriate placement and services) policy, dated 11/28/27 showed:-The nursing facility must notify the state mental health (SMH)/intellectual disability (ID) authority of significant changes in residents with mental disorders or ID. -The PASRR, Level II is to function as an independent assessment process for this population with special needs in parallel with the facility's assessment process. Nursing facilities should know their State's PASRR policy on referral to the SMH/ID authority so that these authorities may exercise their expert judgment about when a Level II evaluation is needed.-Referral to the SMH/ID authority should be made as soon as the criteria indicative of a significant change is evident and should not wait until a Significant Change in Status Assessment (SCSA) is complete.1. Review of Resident #10's admission Record showed the resident was admitted to the facility with a diagnosis of Major depressive disorder (MDD - a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living).Review of the resident's Level I PASRR dated 8/23/22 showed:-The resident had no current, suspected, or history of major mental illness and MDD was not identified on the form as a current diagnosis.-The resident had no intensive psychiatric episode or an episode of significant disruption to normal living requiring supportive services to maintain functioning within the last two years.-The resident had minimal aggression and no delusions (a false belief strongly held despite invalidating evidence) or paranoia (persistent preoccupation with illogical beliefs, usually of a persecutory, suspicious, grandiose, or threatening nature).Review of the resident's behavioral care plan, initiated 8/25/22, showed the resident:-Would scratch himself/herself and say staff did it.-Had threatened staff with eating utensils.-Believed his/her guardian murdered people, including children, because he/she saw the guardian [NAME] them.-Asked other residents to buy him/her snacks and accused them of stealing his/her money.Review of the resident's verbal aggression care plan, initiated 10/20/22 showed the resident:-Had cursed at and threatened staff.-Had been verbally aggressive with other residents related to hallucinating (perception that does not result from an external stimulus and that occurs in the waking state) they murdered people.Review of the resident's Psychiatric progress note, dated 3/18/24, showed the following new mental health diagnoses:-Generalized anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Schizoaffective disorder, bipolar type (a mental condition that causes loss of contact with reality and intense mood swings).Review of the resident's medical record showed generalized anxiety disorder and schizoaffective disorder, bipolar type were added diagnoses both with an onset date of 5/13/24.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 7/19/24, showed the resident:-Was cognitively intact.-Felt down and depressed two to six days out of 14.-Was diagnosed with anxiety disorder, depression, and schizoaffective disorder.-Received antidepressant and antianxiety medications. Did not receive an antipsychotic.Review of the resident's psychotropic medication use care plan, initiated 7/15/25, showed the resident used psychotropic drugs (medications that alter brain chemistry affecting behaviors, perception, and mood) related to schizoaffective disorder, depression, and anxiety. Review of the resident's latest quarterly MDS, dated [DATE], showed the resident:-Was cognitively intact.-Felt down and depressed 12 to 14 days out of 14.-Was diagnosed with anxiety disorder, depression, and schizoaffective disorder.-Received antidepressant and antipsychotic medications. Did not receive an antianxiety medication.Review of the resident's electronic medical record on 3/24/26 showed:-There was no PASRR, Level II evaluation after the resident was diagnosed with a serious mental illness and no documentation of referral to the SMH authority for such an evaluation.-There was no care plan that referred to or incorporated PASRR, Level II recommendations.During an interview on 3/23/26 at 9:50 A.M. the resident said:-His/Her mood was currently very stable.-He/She needed Magnetic Resonance Imaging (MRI) to locate all the many bullets located throughout his/her body to have them removed. The bullets were close to his/her heart, in his/her abdomen, in his/her lungs, and in his/her back. He/She knew they were there because he/she could feel them and he/she wanted them out.-NOTE: The resident's voice tone became agitated as if frustrated when saying he/she wanted the bullets out. During an interview on 3/24/26 at 11:09 A.M. the resident said:-His/Her shoulders and back hurt due to bullets located in those locations.-Nobody believed him/her when he/she complained about the bullets.-NOTE: The resident's tone was agitated when saying nobody believed him/her.During an interview on 3/25/26 at 12:30 P.M. the MDS Coordinator said:-He/She tried to check the residents' diagnoses each time he/she did the annual, significant change and quarterly MDS assessments.-He/She hadn't caught that the resident had a new serious mental illness diagnosis since he/she had been admitted .-Schizoaffective disorder, bipolar type was a serious mental disorder that would trigger for a PASRR Level II referral. -Once completed, the facility received the Level II evaluation by e-mail which showed any recommendations to be incorporated into the resident's care plan. The Level II determined if the nursing facility was the appropriate setting for the resident and any needed specialized services.During an interview on 3/26/26 at 11:09 A.M. Certified Nurse Assistant (CNA) D said the resident often complained about bullets in his/her stomach and thought certain staff had murdered people. He/She said his/her family member was beat up and killed, but that family member was alive.During an interview on 3/26/26 at 11:45 A.M. the Social Services Assistant said:-The resident had been delusional since his/her admission and received psychological services to evaluate his/her psychotropic medication needs.-The resident expressed paranoid and delusional thoughts. He/She said people took him/her out at night and shot him/her with a tranquilizer and he/she was part of a Black Ops secret military mission.-The MDS Coordinator was responsible for the PASRR, Level II referrals. When the Level II evaluations were completed, they should show any special needs and recommendations. -Social Services was responsible for the psychological and behavioral care plans which should include all the resident's needs.During an interview on 3/27/26 at 1:35 P.M. the Administrator said:-If a resident was diagnosed with a serious mental disorder a request should be made to the State authority for a PASRR, Level II evaluation.-The Level II evaluation recommendations should be incorporated into the resident's care plan.

Based on observation, interview and record review, the facility failed to incorporate person-centered interventions that had the potential to proactively impact the resident's mood and offer comfort to him/her when the resident was upset into the behavioral care plan of one sampled resident (Resident #40) out of 18 sampled residents. The facility census was 80 residents. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy, revised March, 2019 showed:-Care plan interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs and strives to understand, prevent or relieve the resident's distress or loss of abilities.-Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes as well as the potential situational and environmental reasons for the behavior. The care plan will include targeted and individualized interventions for the behavioral and/or psychosocial symptoms and the rationale for the interventions and approaches.-Non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms.1. Review of Resident #40's admission Record showed he/she was admitted to the facility with diagnoses that included:-Schizoaffective disorder (a Mental health condition that includes features of both schizophrenia and a mood disorder).-Extrapyramidal and movement disorder (involuntary, often drug-induced movement disorders, caused by dysfunction of the extrapyramidal system).-Glaucoma (a condition of increased pressure inside the eye which could lead to blindness).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Senile degeneration of the brain (progressive, age-related cognitive decline caused by brain cell death).Review of the resident's refusal care plan, revised 7/17/23 showed:-When the resident didn't like the food served, he/she would throw his/her plate and refuse to eat.-Interventions included:--Explain importance of prescribed diet.--Monitor circumstances surrounding mealtime refusals to eat.--Praise efforts to cooperate.-NOTE: There were no proactive interventions for preventing the behavior such as asking the resident what he/she wanted for the following meal or offering an alternative if the resident didn't like the meal option. Review of the resident's verbal/physical aggression care plan, revised 10/25/24 showed:-The resident could become agitated easily and may yell or throw things at staff. He/She had thrown dishes on the floor, screamed for soda and chili, had torn blinds from the windows, and disturbed other residents with his/her yelling.-The resident was delusional and believed he/she was rich and should have whatever he/she wanted. He/She would set himself/herself on the floor at times.-Interventions included:--Remove from area of possible resident to resident altercation for safety.--When yelling out disturbed other residents, encourage him/her to rest in his/her room or closely monitor.--Offer fruit punch and remind the resident he/she could get chili at supper.--Talk with resident when passing by.--Educate the resident on possible injury if he/she placed self on the floor.--Monitor behavioral episodes and determine underlying cause.--Privacy curtains to be in place related to the resident tearing blinds from the window.--Provide a program of activities of interest that accommodated the resident's status.-NOTE: The care plan didn't show what specific activities might help prevent some of the behaviors other than talking to the resident in passing or providing punch and chili when the resident was agitated.Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 7/24/25, showed the resident:-Was severely cognitively impaired.-Found it very important to get showers, have snacks, and listen to music. -Was taking antipsychotic (primarily used to treat psychosis-symptoms like hallucinations, delusions, and paranoia-commonly associated with schizophrenia, bipolar disorder, and severe depression) and antidepressant (medications that treat depression, anxiety, and other mood disorders by balancing brain chemicals) medications.Review of the resident's second behavioral care plan, revised 12/9/25 showed:-The resident yelled out loudly for long periods of time, interfering with other residents' TV viewing. He/She refused to leave clothes on, especially when soiled or uncomfortable and sometimes wouldn't let staff dress him/her. If his/her bed was bumped the resident had thought he/she was in a car and jumped out, causing a fall. He/She had also placed himself/herself on the floor.-Interventions included:--Assess triggers for disrobing or yelling and what might de-escalate.--Talk with the resident while passing by.--Explain procedures before starting and allow the resident time to adjust to changes.--Explain why behaviors were inappropriate.--Divert attention and remove from situation to an alternate location.--Determine underlying cause of behavioral episodes.--Place one side of the bed against the wall.--Provide a program of activities of interest that accommodated the resident's status.-NOTE: There were no specific activities identified that might help de-escalate the resident's behaviors or suggestions of what staff could do proactively to minimize the likelihood of the behaviors except to talk to the resident in passing and explain procedures prior to starting.Observation on 3/23/26 between 10:40 A.M. and 11:30 A.M. showed the resident:-Was sitting in his/her wheelchair in the common area near the nurses' station yelling out loudly.-Another resident was sitting within five feet of the resident in his/her wheelchair.-Was kicking out with his/her legs and arms, very possibly involuntarily while looking in the direction of the other resident.-After a few minutes of the constant yelling the other resident wheeled himself/herself out of the area.-Another resident at the nurses' desk yelled out loudly to Resident #40 that's enough!-Another resident was sitting on the couch trying to watch the television while the resident kept hollering.-Turned away from the nurses' desk and kicked off both shoes, one landing approximately four-feet away and one landing approximately two-feet away. Then he/she threw his/her sunglasses approximately 20 feet in front of him/her where they landed in front of a credenza. There were no residents in the vicinity of the direction he/she was throwing the items.-Continued hollering the whole time with no staff intervention.-No calming activity was taking place such as staff taking the resident to another area and playing music.Observation on 3/24/26 between 2:30 P.M. and 3:15 P.M. showed:-Screaming could be heard at the start of the resident hall several rooms from the resident's room.-The resident was sitting alone in his/her room screaming non-stop extremely loudly.-The resident had constant, involuntary movements of his/her arms and legs.-There was no music playing in the resident's room or any staff doing anything at the time to try to soothe the resident.Observation on 3/25/26 between 1:50 P.M. and 3:20 P.M. showed the resident was sitting in his/her wheelchair with his/her head down and eyes closed and no involuntary arm and leg movements.During an interview on 3/25/26 at 2:02 P.M. Certified Medication Technician (CMT) C said:-The resident had a very bad day the day before. He/She had them every once in a while but could also have several good days in a row where he/she was much calmer.-Activities that helped the resident to focus were to give him/her a pen and paper so he/she could write, or to give him/her clothes to fold. He/She would engage in an activity if having a good day but didn't think it would have helped the day before when the resident was so agitated. -The resident would hum to the radio and that seemed to soothe him/her. They used to have a radio in the dining room, but he/she didn't know what happened to it.During an interview on 3/25/26 at 2:42 P.M. CMT D said:-The resident used to be able to see. Since he/she has been blind he/she has started screaming. Sometimes when he/she was screaming he/she wasn't agitated. He/She would yell sing, sing, sing and tell staff he/she was singing. If he/she yelled out chew, chew, chew it normally meant he/she wanted something to eat. Sometimes he/she screamed out non-stop when agitated.-The resident was more lucid and smiled when his/her family visited, so connections with others were very important to the resident.-Yesterday (3/24/26) early morning he/she could tell the resident was having a bad day and he/she tried to intervene by taking the resident to the shower and washing his/her hair. Giving the resident a relaxing, warm shower and fixing the resident's hair would calm him/her. That helped calm the resident temporarily. -The resident liked to be pampered and would love to have someone massage his/her hands with a fragrant lotion or have someone use a nicely scented shampoo and massage his/her head. -He/She had other things to do yesterday and couldn't continue to give the resident 1:1 attention.During an interview on 3/25/26 at 3:00 P.M. CMT C said:-The resident loved his/her showers and having his/her head massaged.-He/She especially liked touch. He/She liked holding and rubbing his/her stuffed ladybug massager and being wrapped in his/her blanket. He/She would like anything with a soft and interesting texture. He/She seemed to find that calming.-He/She thought a shoulder massage might help keep the resident calm and he/she loved music when nursing staff played it on their phones.-The resident found it calming when staff held his/her hand and would like having someone put a nice-smelling lotion on his/her hands.Observation on 3/26/26 at 10:21 P.M. showed:-An unknown Certified Nurse Assistant (CNA) gave the resident some Jello and talked softly to him/her while he/she ate. -Once the resident finished the CNA lightly touched the resident's shoulder while continuing to talk gently to him/her.-The resident responded by turning his/her body toward the CNA and sitting very still with very minimal arm and leg movements. He/She seemed very focused on the CNA's attention and had a content look on his/her face.During an interview on 3/26/26 at 10:38 A.M. CMT E said:-The resident liked getting treats and listening to music. Both activities seemed to stimulate as well as calm the resident.-The resident felt it calming to have someone sit and watch TV with him/her while holding the resident's hand. The resident had wanted him/her to do that before. They watched a show which would be something the resident would have enjoyed as a younger person. He/She thought the resident just wanted connection with someone and the connection was reassuring to the resident. It was comforting to the resident to have a trusted person close by him/her. The resident could sit for hours 1:1 with a staff person, but staff had other residents to take care of. -The other day the resident was hollering so he/she gave the resident his/her hand and it calmed him/her, but he/she had to leave to take care of other residents, and the resident started yelling again. -The resident would find hand or shoulder massages soothing.-The resident could be in pain sometimes or want to tell staff something and not know how to communicate it.-The resident had a massaging stuffed ladybug which he/she liked to pet. It helped him/her focus on something soothing.-The resident benefitted from having his/her attention diverted in a positive way.Observation on 3/26/26 at 11:26 A.M. showed:-The resident had his/her fuzzy blanket over his/her body.-The resident held the top of the blanket close to his/her neck and lower face as if enjoying the sensation of warmth and/or texture.During an interview on 3/27/26 at 10:30 A.M. Licensed Practical Nurse (LPN) D said:-The resident's behaviors were yelling out and taking his/her clothes off. He/She took his/her clothes off on both day and night shifts about four or five times a week.-When the resident was yelling out he/she might be in pain or trying to communicate and couldn't get out what he/she wanted to say.-He/She spoke with the resident's hospice about possible pain and getting liquid pain medications that would be easier to take.-The resident loved folding towels. He/She sometimes gave the resident that to focus on. -The resident would calm down significantly when someone just sat down and talked to him/her and could sit with someone all day long and talk about how he/she grew up and other past experiences.-The resident would also calm down if given a snack. Last week an activities staff member gave the resident a snack and sat with him/her which seemed to relax the resident.-The resident found physical touch to be very comforting. He/She liked to feel the staff's faces to know them better.-Being in the common area could be over stimulating for the resident at times. Offering a quiet area and 1:1 attention could sometimes calm the resident.-When the resident was screaming staff should toilet him/her, talk with him/her, rule out pain, and try something to see if they could calm him/her.-The CNAs and CMTs didn't have access to the residents' behavioral or other care plans. The nurses had to communicate the resident's behavioral needs. There was nothing in writing such as a Kardex or care cards that the CNAs and CMTs had access to. It would benefit especially the newer CNAs learning the routines of the residents if they had written access to that information if they wanted to look it up when the nurses were busy.During an interview on 3/27/26 at 11:29 A.M. the Activities Director said:-The resident liked to holler. During activities they gave the resident snacks which he/she liked.-A lot of times when they were on the resident's unit the staff put the resident alone in his/her room when he/she was screaming.-The resident had a radio in his/her room before, but he/she pulled the cord and threw it across the room. They could probably put a radio up higher on a shelf but hadn't done that.-The resident seemed calm when he/she folded laundry and liked it one day when he/she was given pen and paper. During an interview on 3/27/26 at 1:35 P.M. the Director of Nursing (DON) said:-Care plan interventions should show what activities and interventions a resident would benefit from.-The resident found it soothing to have a blanket over his/her head, have snacks and sodas, sing, and listen to music.-Behavioral interventions should be resident-centered and not generic and reflect the resident's preferences and needs. -Staff were responsible for knowing and implementing the care plan interventions.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #72) had orders and a plan of care in place for a peripherally inserted central catheter (PICC tube/catheter inserted into a vein for medication administration) for one resident out of 18 sampled residents' facility census was 80 residents. A facility policy was requested for PICC lines and was not received prior to exit from the facility.1. Review of Resident #72's admission Record showed he/she was admitted to the facility with a diagnosis of unspecified severe protein-calorie malnutrition (a severe deficiency of protein and calories, causing muscle wasting, weight loss, and fatigue). Review of the resident's Order Summary Report (OSR) dated 1/5/26 showed:-Intravenous (IV) fluid Use 2000 milliliter (ml) intravenously one time a day related to unspecified protein calorie malnutrition at 83 ml/hour (hr.)-IV or Implanted Port (a small medical device placed under the skin usually in the chest connected to a vein, designed for long-term delivery of medication, fluids, or blood draws): if accessed, change transparent dressing weekly and prn one time a day every Friday order dated 12/26/25.-NOTE: Did not indicate that the resident had a PICC line nor the location. -NOTE: There were no orders for care and monitoring of a PICC line site.Review of the residents' Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 1/16/26 did not indicate the resident had a PICC line, nor that the resident received IV medications. Review of the residents' care plan dated 3/4/26 showed:-The resident required Enhanced Barrier Precautions (EBP precautions used during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who had a chronic wound and/or indwelling medical device) related to indwelling medical devices.-Central Line IV/PICC line with the following interventions.--Flush IV per policy.--Inspect site for signs of inflammation (redness or swelling).--Monitor catheter length that remained external with each dressing change to check for movement.--Monitor for signs and symptoms of complications (pain at site, redness at site, fever, poorly running IV, red streak proximal (pointing toward the center of the body) from the site, purulent drainage (containing discharge or causing the production of pus).Observation on 3/23/2026 at 11:38 A.M. showed the resident had a PICC line in his/her left upper arm and had IV fluids infusing at a rate of 83 ml/hr. Observation on 3/24/2026 at 9:46 A.M. showed the resident had a PICC line in his/her left upper arm and had IV fluids infusing at a rate of 83 ml/hr. Observation on 3/25/2026 at 9:04 A.M. showed the resident had a PICC line in his/her left upper arm and had IV fluids infusing at a rate of 83 ml/hr. During an interview on 3/25/2026 at 9:33 AM, Registered Nurse (RN) A said:-The resident had a PICC line access now.-The resident's port had been removed during his/her last hospitalization.-The PICC line was being used for IV fluids. -The orders should have shown the resident had a PICC line and included the measurements for the PICC line. -Orders should have shown how to assess the PICC site and how often.-Orders should have shown how often to do dressing changes. -A PICC line and port were not the same but were both considered a central line. -The Assistant Director of Nursing (ADON) audits all new admissions or readmissions to ensure orders were correct and in place.-If it was discovered the resident had a PICC line with no orders he/she would have called the doctor and received the correct orders for the type of access the resident had. During an interview on 3/27/2026 at 1:35 P.M. the Director of Nursing (DON) said: -He/She expected the resident's IV access type orders should have been accurate as to what type of access the resident had. -He/She expected orders to assess the line every shift. -He/She expected the orders to list the complications that the PICC line might have had and who to notify. -He/She expected the orders to include when to flush the PICC line and change the dressing.-It was the ADON's responsibility to check and verify all the orders were correct for the resident when admitted or readmitted to the facility. -It was ultimately his/her responsibility to ensure all orders were correct for the resident.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #3) received Zerbaxa (a specialty compounded medication) as ordered 12/13/25 and 12/14/25 resulting in the resident returning to the hospital in order to receive the needed medication out of 16 sampled residents. The facility census was 84 residents.Review of the facility's policy, Medication Therapy, dated April 2007 showed:-Each resident's medication regimen should have included only those medications necessary to treat existing conditions and address significant risks.-Medication use should have been consistent with an individual's condition, prognosis, values, wishes, and responses to such treatment. 1.Review of Resident #3's face sheet showed he/she had been readmitted to the facility on [DATE] with the following diagnoses:Ventilator Associated Pneumonia ([NAME] - serious lung infection that developed in critically ill patients who were on a breathing machine for over 48 hours caused by germs).-Chronic Obstructive Pulmonary disease (COPD - a progressive lung condition that makes it hard to breathe due to damaged airways).-Acute Respiratory Failure (a life- threatening condition where the lungs suddenly can't get enough oxygen into the blood).-Pneumonia (a lung infection causing inflammation and fluid triggered by bacteria, viruses or fungi) due to Methicillin Resistant Staphylococcus Aureus (MRSA -a dangerous staph infection resistant to common antibiotics).-Sepsis (a life- threatening medical emergency caused by the body's extreme response to an infection, leading to a chain reaction that could cause tissue damage, organ failure and death) due to MRSA.-Bronchopneumonia (Inflammation in the lungs).-Traumatic Brain Injury (TBI is damage to the brain from a sudden external force like a blow, jolt, or penetrating object leading to disruption in the brain function).-Tracheostomy Status (a surgical procedure that creates an opening in the neck to the windpipe to provide an airway for breathing and to remove secretions from the lungs).-Gastrostomy Status (a surgically created opening from the skin directly into the stomach for a flexible feeding tube to provide nutrition or medication when swallowing was unsafe). Review of the resident's reentry Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 12/18/25 showed the resident was not cognitively intact. Review of the resident's hospital discharge instructions, dated [DATE] showed the following order:-Zerbaxa (a combination of medications used as a powerful intravenous (IV- medication given through a vein) antibiotic (a substance that fights bacterial infection) for serious bacterial infections) Intravenous Solution Reconstituted 1.5 (1-0.5) grams/ (Ceftolozane Sulfate-3000 milligram (mg) via IV to be given every eight hours. Finish (course of medication) through 12/17/25. Review of the resident's care plan dated 12/11/25 showed he/she required a feeding tube and was to take nothing by mouth. Review of the resident's Nurses' Notes dated 12/11/25 showed the resident came back to the facility at 6:00 P.M. Review of the resident's Nurses' Notes dated 12/12/25 at 10:25 A.M. showed:-The nurse had attempted to place an IV line in the resident twice (unsuccessfully).-The resident was sent to a nearby hospital for IV insertion.-The resident returned to the facility later the same day with a Peripherally Inserted Central Catheter (PICC-a long, thin tube inserted into a vein in the upper arm) line in his/her left upper arm (for medication administration). Review of the resident's Hospital Visit dated 12/12/25 showed:-The resident was seen in the Emergency Department for Vascular (IV) access. -A midline (IV placed in the arm) and one dose of the medication (Zerbaxa) was given.-Staff were to continue his/her antibiotic through 12/17/25 as was previously prescribed.-(The resident returned to the facility the same day). Review of the resident's Nurses' Notes dated 12/13/25 at 4:35 P.M. showed the Pharmacy had been backed up and would send the Antibiotic out later that evening. Review of the resident's Nurses' Notes dated 12/14/25 at 8:26 A.M. showed:-The Nurse Practitioner (NP) was notified that the resident's lungs sounded wet and requested he/she be sent to hospital.-At 11:00 A.M. the resident was sent to nearby hospital. Review of the resident's Nurses' Notes dated 12/14/25 at 1:00 P.M. showed:-The Director of Nursing (DON) had contacted the facility's physician to determine if there was any substitute antibiotic for Zerbaxa due to the high cost of the medication. -Zerbaxa had been ordered for the resident due to Pseudomonas MDRO (Multi drug resistant organization).-The physician confirmed that there was no other substitute drug and the Zerbaxa medication must be the medication given. -A Infectious Disease Physician had been consulted and agreed that Zerbaxa was the only option. -Pharmacy was instructed to go ahead and send the medication at this time. Review of the resident's December 2025 Physician's Order Sheet (POS) showed the following order:-Zerbaxa Use 3000 milligrams (mg) intravenously every eight hours for infection for six days until finished, dated 12/12/25.-Medication should have been given until 12/18/25.-NPO (nothing by mouth) diet. Review of the resident's Nuse Administration Record for December 2025 showed there was no order for the Zerbaxa. Review of the resident's Treatment Administration Record (TAR) for December 2025 showed there was no order for Zerbaxa. Review of the resident's Nurse Practitioner/Physician's note dated 12/14/25 showed:-The resident was sent out on 11/28/25 to the hospital. -He/She was diagnosed with pseudomonas pneumonia and readmitted to the facility on [DATE].-He/She was supposed to have been on Zerbaxa antibiotic every eight hours.-The Nurse reported that the owner of the facility was not willing to pay for the medication and his/her Medicaid had denied payment for the medication.-He/She has gotten worse, and the nurse was requesting to send him/her back to the hospital. -OK was given from the NP for transfer. During an interview on 1/12/26 at 10:30 A.M. Nurse Practitioner (NP) A said: -He/She was unaware the resident had returned to the facility without IV access from the hospital and ordered the resident to be sent to the hospital for the IV access placement on 12/12/25. -He/she was unaware the Zerbaxa medication had not been received until the second discharge 12/15/25 to the hospital. During an interview on 1/12/26 at 11:00 A.M. Registered Nurse (RN) A said:-The resident had a feeding tube and was not able to swallow any medication.-Some medications were able to have been crushed and administered through his/her feeding tube.-The resident was on a special combination IV medication that his/her Medicaid did not approve of.-The Physician had spoken to the Infectious Disease Physician and they both agreed that Zerbexa was the only medication that would work for the resident.-The resident was chronically ill and had just returned for the hospital where he/she had started to receive a couple of doses of the medication while in the hospital, on 12/11/25.-For some reason the hospital staff discontinued his/her IV line before sending him/her back to the facility.-The resident was a very hard stick and staff at the facility was not able to place an IV line. -The NP was notified, and the resident was sent out to the hospital where a PICC line was placed, and one dose of the medication was given.-The resident came back the same day.-The pharmacy was notified, and they said they would send it that night as they were backed up.-The medication came the same day staff had sent the resident out to the hospital.-The resident went two days without the medication.-Pharmacy delivers medications twice a day, seven days a week.-The resident should have received the medication by the next day after going to the hospital to have a PICC line placed.-Staff had been in contact with the NPs about the situation.-If they did not have the medication available then staff should have called the physician to have the resident sent back to the hospital by the next day. -The resident did not receive any Zerbaxa while in the facility. -The resident spent a couple of days in the hospital where he/she had received Zerbaxa and was now back in the facility. During an interview on 1/12/26 at 12:10 P.M. Physician A said:-He/She had consulted with the Infectious Disease Physician and they both agreed that Zerbaxa was the only medication for the resident as he/she had many diagnoses and had been hospitalized several times.-He/She ordered the medication, and it should have been given. -He/She was not aware the resident had not received the medication as he/she had ordered.-If the facility did not have the medication by the next day the resident should have been sent out to the hospital to receive the medication there. During an interview on 1/12/26 at 1:00 P.M. the DON said:-On 12/11/25 the resident came back to the facility without IV access.-The resident was NPO and used a feeding tube for nutrition and oral medications which they crushed. The medication (Zerbaxa)was not available in pill form.-Zerbaxa was a special compound IV medication order by the hospital in his/her discharge instructions.-The Pharmacy delivers twice a day to the facility (2:00 A.M. and 2:00 P.M.) every day of the week.-On 12/12/25 the NP was made aware that the staff were not able to place an IV for the medication.-The resident was sent out to a nearby hospital where they inserted a PICC line, and the resident received a dose of the medication.-He/She returned to the facility that day.-The Physician was made aware of the issue of obtaining the specialty medication. -The Physician had confirmed with the Infectious Disease Physician and they both agreed that there was no substitute for Zerbaxa.-The resident had missed three doses on 12/13/25 and 12/14/25 (total of 6).-The NP was notified of the issue on 12/15/25 and the resident was sent out to a nearby hospital where he/she stayed until the course of antibiotic was completed.-The pharmacy sent the medication to the facility as the resident was transported to the hospital. 2692269

Based on observation and interview, the facility failed to maintain the floor under the deep fat fryer and the six burner stove free of a heavy grease buildup, maintain the wall mounted fan without dust; failed to identify an item in a 3 quart container in the reach-in fridge; failed to maintain the floors under the reach-in fridge and under the steam table free from debris and food particles; failed to refrigerate items which stated refrigerate after opening on the label; failed to maintain light fixtures and sprinkler heads in the kitchen, free of dust and grease; failed to store the utensils in a container free from food debris; failed to label two containers of a powdery substance; failed to maintain the lower spray wand of the dishwasher free from debris in the nozzles; failed to maintain the milk served in the Serenity kitchenette at a temperature close to or at 41 F (degrees Fahrenheit); failed to date the chicken with the date it was taken from the freezer; failed to clean the dishes from the previous night (6/12/24); failed to ensure the trash container in Serenity Court kitchenette was free of grime; failed to have enough dishes (silverware and coffee cups) to serve residents in the Serenity Court kitchenette; failed to ensure there was a thermometer which would be used for monitoring at the Serenity Court kitchenette; and failed to ensure that 7 of 14 cutting boards were in an easily cleanable condition. This practice potentially affected all residents. The facility census was 92 residents. 1. Observation on 6/10/24 from 10:51 A.M. to 11:11 A.M., during the initial kitchen tour, showed: -A buildup of grease and grime under the deep fat fryer. -A buildup of dust on the wall mounted fan. -An unidentified item in the reach-in fridge. -An unidentified item in a 3-quart container in the reach-in fridge. -A buildup of dust under the white reach-in fridge. -One bottle of beef paste, two containers of chicken base and one bottle of lemon juice which were opened, but not refrigerated according to label. -The presence of dust on the ceilings and on the sprinkler heads. -Utensils were stored in a container with food debris in it. -Two containers of a white powdery substance without a label. -The presence of grime, dishes and food debris under the steam table. -The presence of debris in the lower spray wand of the dishwasher. -The presence of grime and debris under the dishwasher. During an interview on 6/11/24 at 10:48 A.M., the facility Maintenance Director said the dietary department had not notified him/her about cleaning the sprinkler heads and the ceilings in the kitchen. 2. Observation on 6/13/24 from 5:52 A.M. to 9:40 A.M. during the breakfast meal preparation, showed: -A buildup of grease and grime under the deep fat fryer. -A buildup of dust on the wall mounted fan. -An unidentified item in the reach-in fridge. -An unidentified item in a 3-quart container in the reach-in fridge. -A buildup of dust under the white reach-in fridge. -One bottle of beef paste, two containers of chicken base and one bottle of lemon juice which were opened, but not refrigerated according to label. -The presence of dust on the ceilings and on the sprinkler heads. -Utensils were stored in a container with food debris in it. -Two containers of a white powdery substance without a label. -The presence of grime, dishes and food debris under the steam table. -The presence of debris in the lower spray wand of the dishwasher. -One box of chicken in the walk-in fridge, which was not dated with the date that box of chicken was taken from the freezer. -The presence of grime and debris under the dishwasher. -Dietary [NAME] (DC) A used a thermometer to check sausage without sanitizing the probe. -A buildup of grime on the floor of the walk-in fridge. -Seven cutting boards which were not easily cleanable because of numerous indentations and stains that could not be removed. During an interview on 6/13/24 at 6:02 A.M., Dietary Aide (DA) A said the substances in the two containers could be sugar and the containers should be labeled. During an interview on 6/13/24 at 8:39 A.M., the DM said: -The Assistant DM was the only one who cleaned the floor of the walk-in fridge. -The chicken should have been dated when it was taken from the freezer. -He/she could not tell how long the grease buildup behind the stove has been there. -The beef base and the lemon juice should have been refrigerated. -The containers of sugar should have been labeled. -The white reach-in refrigerator was the only fridge that was not cleaned. -He/she expected the dietary staff to sweep under the steam tables and behind the bread racks. -He/she had not had a chance to look at the all the cutting boards with numerous indentations, which rendered them not easily cleanable. -It has taken about a month to train all the dietary staff in cleaning the kitchen. -He/she spoke with the Regional Maintenance Director and the facility Maintenance Director about having the ceilings cleaned. -The nozzles of the dishwasher wands have not been cleaned in about 2 months because they do not have a regular dishwasher. 3. Observation on 6/13/24 from 7:10 A.M. to 8:04 A.M., during breakfast service at the Serenity Court kitchenette, showed: -Numerous unwashed dishes that were left from the night before. -One container of an unlabeled white substance. -Certified Nursing Assistant (CNA) C had to wait to deliver a tray to a resident because they were out of coffee cups. -The absence of a thermometer. -The presence of grime on the cover of the trash container. -The milk in the bottle on the counter had a temperature of 53.2 F after a small portion of milk was poured into a cup for measuring the temperature. -CNA A took a room tray from the kitchenette to resident room [ROOM NUMBER] without a plate cover. During an interview on 6/13/24 at 7:17 A.M., Certified Nurse's Assistant (CNA) D said the white powder in the container was thickener (a substance which can increase the viscosity of a liquid which is used to thicken sauces, soups, and puddings without altering their taste) but the label came off. During an interview on 6/13/24 at 7:36 A.M., DA A said the dietary department was out of plate covers. During an interview on 6/13/24 at 8:09 A.M., CNA C said they run out of coffee cups and silverware, and it was a usual occurrence. During an interview on 6/13/24 from 8:29 A.M. to 8:34 A.M., the DM said: -The dietary department was short of plate covers, bowls, coffee cups, silverware, and plates. -There was an extra thermometer and he/she needed to bring that thermometer to the Serenity kitchenette. -He/she forgot about the trash container in the Serenity kitchenette. -The dishes which were left in the Serenity kitchenette, should have been brought to the dishwashing room and washed. During an interview on 6/14/24 at 10:39 A.M., the Administrator said: -One of the reasons there may not be enough dishes, was it depended on the dietary staff and nursing staff picking up dishes in a timely manner after meals. -He/she was not sure what had happened to the plates because he/she had noticed an increase in the use of disposable paper/foam plates.

Based on observation, and interview, the facility failed to ensure the walk-in fridge operated at a temperature of 41 F (degrees Fahrenheit) or below, and failed to maintain the automated dishwasher in good working order. This practice potentially affected all residents. The facility census was 92 residents. 1. Observation on 6/10/24 at 11:13 A.M., during the initial kitchen tour, showed the temperature of the walk-in fridge was 46.5 F (degrees Fahrenheit) after the thermometer was left in the walk-in fridge for about 10 minutes. Observation on 6/11/24 at 12:23 P.M., showed the temperature of the walk-in fridge was 46.4 F after the thermometer was left in the walk-in fridge for over an hour. During an interview on 6/11/24 at 12:24 P.M., the Maintenance Director said he/she had heard the walk-in fridge was not at the required temperature of 41 F, but he/she noticed the knob to control the temperature, was broken. During an interview on 6/13/24 at 8:29 A.M. the Dietary Manager (DM) said: -He/she had only been working for about a month. -The knob to control the temperature for the walk-in fridge was broken so he/she could not adjust the temperature of the walk-in fridge downward. During an interview on 6/14/24 at 9:33 A.M., the Assistant DM said it had been about 3 weeks since the walk-in fridge had not been operating at the correct temperature. During an interview on 6/14/24 at 10:16 A.M., the Maintenance Director said: He/she first found about the walk-in not operating at the proper temperature on Tuesday, 6/11/24, when he/she and the state surveyor looked at the temperature in the walk-in fridge and -There was not a knob on the controls to change the setting. During an interview on 6/14/24 at 10:41 A.M., the Administrator said he/she did not know about the walk-in fridge not having the proper temperature setting. 2. During an interview on 6/14/24 at 9:2 A.M., the DM said the following about the dishwasher: -One of the Dietary Aides (DA) delimed (to remove a buildup of lime from an area or something) the automated dishwasher. -The dish machine worked for 2-3 days. -The dishwasher was delimed again, and then it did not spray on the first cycle. -It was about 3 weeks ago that he/she told corporate maintenance and the facility Maintenance Director. -The facility Maintenance Director tried to fix it during the week of May 27 2024. -The facility Maintenance Director said on the week of 6/10/24 that he/she would have to call a service person. During an interview on 6/14/24 at 10:16 A.M., the Maintenance Director said the following: -Dietary personnel told him/her that the dishwasher was not spraying on the first cycle. -He/she had not had a chance to look at it. -He/she would go and take a look at the automated dishwasher, but the repair may be beyond his/her expertise and he/she may have to call a service person to take a look at it. During a phone interview on 6/21/24 at 4:24 P.M., the Maintenance Director said on 6/20/24, they discovered the motor for the automated dishwasher was not working properly. 3. During a phone interview on 6/24/24, the Corporate Maintenance Director said: There was a calcium buildup in the left side pump of the dishwasher, which caused the dishwasher not to work properly. The walk-in fridge was frozen and he/she turned off the walk-in to defrost it and adjusted the temperature downward when he/she turned the walk-in fridge back on.

Based on observation and interview, the facility failed to maintain the commode riser in resident room [ROOM NUMBER] in an easily cleanable condition; failed to maintain the restroom ceiling vents free of a heavy buildup of dust inside the ceiling vents in resident rooms 17, 60, 61, 71, 83, 81, 80; failed to maintain the ceiling vent in Greystone shower room free from a heavy buildup of dust; failed to maintain the commode seat in the Greystone shower room fee of numerous indentations; failed to maintain a personal fan free of dust in resident room [ROOM NUMBER]; failed to maintain the ceiling fans in the resident smoke room free of a buildup of dust. The facility census was 92 residents. 1. Observation on 6/10/24 at 1:47 P.M., with the Maintenance Director, showed the presence of rust spots on the commode riser (assistive devices to improve the accessibility of toilets to older people or those with disabilities. They can aid in transfer from wheelchairs and may help prevent falls) in resident room [ROOM NUMBER] which caused the commode riser to be not easily cleanable. During an interview on 6/10/24 at 1:48 P.M., the Maintenance Director said he/she did not know the commode riser had rust spots but would have to get that one changed. During a phone interview on 6/21/24 at 12:19 P.M., the Maintenance Director said facility staff was supposed to tell him/her about the commode risers, because he/she was not asked to check those. 2. Observation on 6/10/24 at 2:30 P.M., with the Maintenance Director, showed a heavy buildup of dust in the restroom ceiling vent of resident room [ROOM NUMBER]. 3. Observation on 6/10/24 at 3:08 P.M., showed a personal fan with a heavy buildup of dust in resident room [ROOM NUMBER]. During a phone interview on 6/21/24 at 12:33 P.M., the Housekeeping Director said: -He/she usually had the maintenance department clean the fans because they had the tools to take the fans apart. -The housekeeping department had an extendable duster that they can use to clean the ceiling vents. 4. Observation on 6/11/24 at 9:41 A.M., showed the following; -A heavy buildup of dust in the ceiling vent of the Greystone Shower room. -Numerous indentations on the commode seat which caused the commode seat in the Greystone shower room to not be easily cleanable. During an interview on 6/11/24 at 9:42 A.M., the Maintenance Director said staff should have notified him/her about that commode seat. During a phone interview on 6/21/24 at 12:37 P.M., the Housekeeping Supervisor said the housekeeping employees do check the commode seats for damage. 5. Observations on 6/11/24 with the Maintenance Director showed: -At 12:36 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 12:37 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 12:59 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 1:50 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 1:51 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 1:53 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 2:03 P.M., a heavy buildup of dust inside the restroom ceiling vent in resident room [ROOM NUMBER]. -At 2:06 P.M., a heavy buildup of dust in the ceiling fans in the resident smoke room. During a phone interview on 6/21/24 at 12:17 P.M., the Maintenance Director said the following: -The housekeeping department was supposed to clean the ceiling vents. -All the attachments on ceilings were the responsibility of the housekeeping department. -The housekeepers have handles on their cleaning tools that can extend to reach attachments such as ceiling vents and fans. During a phone interview on 6/21/24 at 12:33 P.M., Housekeeping Director said the housekeeping department had an extendable duster that they could use to clean the ceiling vents.

Based on interview and record review, the facility failed to have parameters listed in the medication orders for medications that contained Acetaminophen (medication used to treat pain and reduce fever) for three sampled residents (Residents #38, #52, and #54) of out of 19 sampled residents. The facility census was 92 residents. A policy was requested on medication parameters and the facility did not provide one. 1. Review of Resident #54's Admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Medication Review Report, dated June 2024, showed the following orders: -Acetaminophen 325 milligram (mg) give two tablets by mouth every six hours as needed for pain, order was dated 2/6/22 -The order failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 2. Review of Resident #38's Admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Medication Review Report, dated June 2024, showed the following orders: -Acetaminophen 325 mg tablet give 650 mg by mouth at bedtime for pain order dated 2/28/22. -Acetaminophen 325 mg give two tablets by mouth every four hours as needed for pain order dated 6/14/21. -Both orders failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 3. Review of Resident #52's Admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Medication Review Report, dated June 2024, showed the following orders: -Acetaminophen Extended Release 650 mg give 650 mg by mouth every six hours as needed for pain-mild order dated 12/29/22. -Hydrocodone-Acetaminophen 10 mg of Hydrocodone with 325 mg of Acetaminophen compounded together. Give one tablet by mouth four times a day for pain and/or fever order dated 1/8/23. -Both orders failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 4. During an interview on 6/13/24 at 8:07 A.M., Certified Medication Technician (CMT) A said: -Medications that contained Acetaminophen should have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. -When the parameters were not on the medication order he/she would inform the charge nurse. -The parameters were needed to be on the order because too much Acetaminophen could be toxic. -There were no parameters in the Acetaminophen orders for Residents #38, #52 and #54. -Resident #38, #52, and #54 should have had parameters in the Acetaminophen orders. During an interview on 6/13/24 at 8:57 A.M., CMT B said: -The parameters of not exceed three grams of Acetaminophen in 24 hours from all sources should be in the medication order of all medications that contained Acetaminophen. -When the parameters were not there, he/she would have told the charge nurse. -To much Acetaminophen can be toxic. During an interview on 6/13/24 at 9:00 A.M., Licensed Practical Nurse (LPN) A said: -The parameter of not to exceed three grams of Acetaminophen from all sources in 24 hours should be a part of the medication order. -When the parameters were not a part of the medication order, he/she would have notified the doctor, and received an order for the parameters to be added to the medications order. -More than three grams of Acetaminophen could be toxic. -There were no parameters in the Acetaminophen orders for Resident #38, #52, and #54. -There should have been parameters in the Acetaminophen orders for Resident #38, #52, and #54. During an interview on 8/23/23 at 8:37 A.M., the Director of Nursing (DON) said: -It was his/her expectation that all orders that contained Acetaminophen would have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources. -It was his/her expectation that all nurses would have ensured that this parameter was added to all orders that contained Acetaminophen. -It was his/her expectation that when the parameter was missing on an order, the nurse that discovered it would have contacted the doctor and received the order to add the parameter. -It was the responsibility of the Assistant Director of Nursing to audit all the new orders added to a resident's medical record. -He/she was unaware of the missing parameters for medications that contained Acetaminophen. -It was ultimately his/her responsibility to ensure that all medications that contained Acetaminophen had the parameter on all the orders.

Based on observation and interview, the facility failed to maintain the sewer pipe, in the area between the dry goods storage room and the walk-in refrigerator, in good repair to prevent drainage from backing up into the storage room and the walk-in refrigerator; failed to maintain the fans in the laundry room free of a heavy buildup of dust; failed to maintain the area under the vending machines in the Serenity dining room free from a heavy buildup of dust; and failed to ensure the restroom ceiling vent was securely attached to the ceiling in resident room [ROOM NUMBER]. This practice potentially affected an unknown number of residents who used the Serenity Unit dining room and other resident use areas in the facility. The facility census was 92 residents. 1. Observation on 6/10/24 at 11:07 A.M., showed a brownish substance with particles, backed up through the drains in the dry goods storage room and the walk-in refrigerator and the presence of a pungent smell of standing water. During an interview on 6/11/24 at 10:27 A.M., the Maintenance Director said the drains in the area between the walk-in fridge and the dry goods storage area are collapsed, which affected the ability of the water to drain properly because the drainage pipes underground broke. During an interview on 6/13/24 at 8:37 A.M., the Dietary Manager (DM) said: -The drainage in that area of the facility had been backing up for at least 4 years when he/she worked at the facility previously. -He/she asked the housekeeping supervisor to obtain a drain enzyme to take away the smell. During an interview on 6/13/24 at 9:48 A.M., the Administrator said: -He/she knew the drain backed up, but did not know why. -He/she thought that it was only that one time, which was a few weeks prior to the survey. 2. Observation on 6/10/24 at 2:01 P.M., with the Maintenance Director showed a heavy buildup of dust under the vending machines in the Serenity Unit dining room. During an interview on 6/10/24 at 2:02 P.M., the Housekeeping Director said he/she had not asked the vending machine company to come to the facility and move the vending machines so that his/her staff could clean under the machines. 3. Observation on 6/10/24 at 2:11 P.M., with the Maintenance Director, showed the fans on the clothes folding side and the washing side in the laundry, had a heavy buildup of dust on the blades. During an interview on 6/10/24 at 2:12 P.M., the Housekeeping Director said he/she cleaned the fans in December 2023 when he/she first started, but has not cleaned the fans since. During a phone interview on 6/21/24 at 12:36 P.M., the Housekeeping Director said he/she usually had the maintenance department clean the fans because they have the tools to take the fans apart. 4. Observation on 6/11/24 at 1:31 P.M., with the Maintenance Director, showed the restroom ceiling vent in resident room [ROOM NUMBER] was loose. During an interview on 6/11/24 at 1:32 P.M., the Maintenance Director said there were a few missing screws on that vent, which would have held it securely to the ceiling.

Based on observation and interview, the facility failed to maintain the area that was close to the window and the two-compartment sink, free of food debris and soiled dishes, which attracted ants to that area of the kitchen. This practice affected the kitchen. The facility census was 92 residents. 1. Observation on 6/13/24 at 6:16 A.M., 7:28 A.M., and 8:03 A.M., showed numerous dishes from the night before that were not washed and the presence of ants around the two compartment sink in the kitchen. During an interview on 6/13/24 at 8:43 A.M., after seeing the ants crawl in that area around the soiled dishes, the Dietary Manager (DM) said the dishes that were left at the window sill area should have been washed the previous night.

Based on observation, interview, and record review, the facility failed to ensure activities identified as being of interest were offered daily on a 1:1 basis or adapted to meet the resident's cognitive and physical limitations and offered at bedside or at a time when the resident was likely to be out of bed for one sampled resident (Resident #72) out of 19 sampled residents. The facility census was 92 residents. Review of the facility's Resident Self-Determination and Participation policy, revised February, 2021 showed: -Each resident is allowed to choose activities consistent with his/her interests. -Staff will: --Gather information about the residents' personal preferences on initial assessment and periodically thereafter and document preferences in the medical record. --Include information about the resident's preferences in the care planning process. --Document medical limitations affecting participation. -Residents are provided assistance as needed to engage in preferred activities on a routine basis. 1. Review of Resident 72's Admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included: -Huntington's disease (an inherited disease in which nerve cells in the brain break down over time resulting in progressive movement, cognitive, and psychiatric symptoms). -Major depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety). -Restlessness and agitation. Review of the resident's Isolation From Friends/Family Care Plan, initiated 6/12/23 showed: -Encourage phone call, Face Time, Skype, and Video phone. -Encourage participation in Activity program. -Offer supportive visits and in-room activities aided by technology as appropriate. Review of the resident's Activities Evaluation, dated 6/15/23, showed the resident liked: -Going to church. -BINGO. -Gardening and being outdoors. -Music and talk radio. -Looking at nature magazines. -Listening to country music, especially [NAME]. -Note: Information for the evaluation was provided by family and/or friend. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 6/18/23, showed the resident: -Was able to be understood and could understand others. -Had adequate hearing without hearing aids. -Could read large print without eyeglasses. -Had problems with memory and recall and was significantly cognitively impaired. -Had no behaviors. -Required supervision, moderate assistance, or maximal assistance with Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting). -Required supervision with transfers and walking. -Enjoyed the following activities: --Listening to music. --Being around animals. --Doing things with groups of people. --Spending time outdoors. Review of the resident's Meeting Emotional, Intellectual, Physical and Social Needs Care Plan, initiated 6/18/23, showed: -The resident was dependent upon staff to meet his/her needs related to his/her neurocognitive disorder and need for ADL assistance. -Activities should be compatible with the resident's physical and mental capabilities and interests and be adapted as needed such as large print, holders if resident lacks hand strength, and task segmentation. -Provide a program of activities that is of interest, allowing choice and self-expression. -Provide escort to activity functions and assistance with games and crafts. -Engage in simple, structured activities such as going outdoors, simple gardening, and being out on the patio. -The resident prefers: --Country music stations and loves [NAME]. --Church or religious TV channels and activities. --Talk shows. --Being in groups of people. --Being outdoors, gardening, and sitting outdoors. Review of the resident's Activity Calendar, dated January 2024, showed: -Church Services on Wednesdays at 10:00 A.M. (unit location was not indicated). -Karaoke on Fridays at 10:00 A.M. -No 1:1, individualized, or bedside activity time was designated for the resident's unit. Review of Activity Participation sheets, dated January 2024, showed the resident attended: -A snowman craft on 1/3/24. -Painting/crafts on 1/8/24. -Coffee/hot chocolate on 1/8/24. -BINGO on 1/9/24. -Crafts on 1/25/24. -Note: The resident did not participate in any music, pet/animal, 1:1, or religious activities. There was no documentation why he/she didn't engage in any of these activities of interest. Review of the resident's Activity Calendar, dated February 2024, showed: -Church services on Wednesdays at 10:00 A.M. (unit location was not specified). -Karaoke on Fridays at 1:00 P.M. -Only two activities besides Karaoke were on the monthly activity calendar for the resident's unit. -No 1:1, individualized, or bedside activity time was designated on the calendar for the resident's unit. Review of the resident's participation sheets, dated February 2024, showed the resident attended: -A Valentines activity on 2/2/24. -Valentine's cupcakes/punch and cards on 2/14/24. -BINGO and ice cream on 2/20/24. -BINGO on 2/27/24. -[NAME] Day party on 2/29/24. -Note: The resident did not participate in any music, pet/animal, 1:1, or religious activities. There was no documentation why he/she didn't engage in these activities. Review of the resident's Activity Calendar, dated March 2024, showed: -Church services on Wednesdays at 10:00 A.M. (unit location was not specified). -Karaoke on 3/22/24 and 3/29/22. The time and specific unit location were not indicated. -No activity except shopping lists was mentioned for the resident's unit for the entire month. Review of the resident's participation sheets, dated March 2024, showed the resident attended: -BINGO on 3/5/24. -Oreo Cookie Day on 3/6/24. -BINGO on 3/12/24. -Salt art on 3/14/24. -BINGO on 3/14/24. -Trivia on 3/27/24. -Easter Bunny activity on 3/29/24. -Note: The resident did not participate in any music, pet/animal, 1:1, or religious activities. There was no documentation why he/she didn't engage in these activities. Review of the resident's significant change MDS, dated [DATE], showed the resident: -Was receiving hospice services (comfort care for a person with a serious illness who is approaching the end of life). -Had inattention and disorganized thinking. -Wandered four to six days a week, but wandering did not significantly intrude on others. -Required moderate assistance with most ADLs. -Was independent with repositioning and walking. -The following activities were very important: --Using the phone. --Listening to music. --Being around animals. --Doing things with groups of people. --Going outside for fresh air. --Participating in religious services. Review of the resident's Activity calendar, dated April 2024, showed: -Church services were scheduled on Wednesdays at 10:00 A.M. (unit location was not specified). -Karaoke was scheduled on the first three Fridays of the month. A time and unit were not indicated on any of the dates. -There were no 1:1 or bedside activity times designated for the resident's unit. Review of the resident's Activity Participation logs, dated April 2024, showed: -BINGO on 4/2/24. -Truths and Lies game on 4/4/24. -BINGO on 4/11/24. -BINGO on 4/16/24. -BINGO on 4/23/24. -Note: The resident did not participate in any outdoor, patio, gardening, music, pet/animal, 1:1, or religious activities. There was no documentation why he/she didn't engage in any of these activities of interest. Review of the resident's Activity Calendar, dated May 2024, showed: -Outdoor games for Units 2 and 3 were scheduled on 5/6/24. -Bird Feeders was scheduled for Units 2 and 3 on 5/21/24. -Karaoke was scheduled on three of the five Fridays in May. No unit or times were specified on any of the dates. -No church services, religious music or other music activities were on the schedule. -No 1:1 or bedside activity times were designated on the calendar. Review of the resident's Activity Participation sheets, dated May 2024, showed the resident participated in the following: -BINGO on 5/10/24. -Hot chocolate on 5/14/24. -Chocolate Chip Day on 5/15/24. -Donuts and Fruit Kabobs on 5/22/24. -Note: The resident did not participate in any outdoor, patio, gardening, music, pet/animal, 1:1, or religious activities. There was no documentation why he/she didn't engage in these activities. Review of the residents' Activity Calendar, dated June 2024, showed: -There was no mention of any activity on the resident's unit. -Social Hour outside was scheduled on 6/3/24 for Units 2 and 3 only. -No church services or religious music activity was on the schedule. -Karaoke was on the schedule for 6/14/24 and 6/28/24 for Units 2 and 3 only. -There were no 1:1 or bedside activity times shown for the resident's unit. Review of the resident's Activity Participation sheets, dated 6/1/24 to 6/13/24, showed the resident participated in: -[NAME] video on 6/5/24. -BINGO on 6/7/24. -Hydration station on 6/12/24. -Note: The resident did not participate in any outdoor, gardening, music, pet/animal, 1:1, or religious activities. There was no documentation why he/she didn't engage in these activities of interest. Observation on 6/10/24 between 10:30 A.M. and 11:35 A.M., showed: -The Activity Director and Activity Assistants A and B were in the dining room and were observed interacting with some of the residents in the area. -At 11:04 A.M., the resident was observed lying quietly in bed covered in a blanket. The resident was not engaged in a group, 1:1 activity, or interaction with staff and no music was being played for the resident. -Residents who smoked had gone outside during the cooler morning hours. -No other residents were given the opportunity to go outside in the morning. Observation on 6/10/24 between 1:00 P.M. and 2:00 P.M., showed: -The resident was not engaged in a group or 1:1 activity or interaction with staff or other residents. -No activity was on the calendar for any of the units for the 1:00 P.M. to 2:00 P.M. time period. Observation on 6/11/24 between 9:30 A.M. and 11:10 A.M., showed: -The resident was not engaged in a group, music, or 1:1 activity or interaction with staff. -At 9:41 A.M. the resident was observed lying in bed with a blanket covering his/her head. -At 9:50 A.M. Activity Aides A and B were observed going throughout the unit and offering beverages to residents while the Dietary Manager offered residents cookies. -Residents who smoked had gone outside during the cooler morning hours. -No other residents were given the opportunity to go outside in the morning. Observation on 6/11/24 between 1:05 P.M. and 2:00 P.M., showed: -The resident was not engaged in a group or 1:1 activity or interaction with staff or other residents. -No activity was shown as scheduled for any of the units for the 1:00 P.M. to 2:00 P.M. time period. -The calendar showed BINGO on 6/11/24 with no time or unit specified and Unit 2 Shopping lists, with no time specified. Observation on 6/12/24 from 9:23 A.M. to 10:35 A.M., showed: -The resident was not engaged in a group or 1:1 activity or in interactions with staff. -At 9:26 A.M., the resident was in bed with eyes closed. -At 10:08 A.M., the resident walked into the common area and sat at a table with another resident. The two residents did not interact, and staff in the common area did not interact with the resident during this time. -No music was being played for residents. -Residents who smoked had gone outside during the cooler morning hours. -No other residents were given the opportunity to go outside in the morning. Observation on 6/13/24 between 8:40 A.M. and 9:30 A.M., showed: -The resident was not engaged in a group or 1:1 activity or in interaction with staff. -At 9:20 A.M., the resident entered the common area. He/She stood near the Nurses' station. Certified Nurse Aide (CNA) A told the resident to sit at a table, but did not otherwise greet or interact with him/her. A few minutes later CNA A gave the resident his/her breakfast without interacting with the resident. Observation on 6/14/24 between 8:50 A.M. and 9:25 A.M. and at 1:30 P.M., showed: -The resident was not engaged in a group or 1:1 activity or in any interaction with others. -No activities were taking place on the unit during the observation times. -Donuts with Dad was scheduled on 6/14/24 for Unit 2 at 10:00 A.M. and for Unit 3 at 10:45 A.M. Karaoke was scheduled on 6/14/24 and 6/28/24 for Unit 2 at 2:00 P.M. and for Unit 3 at 3:00 P.M., but was not shown as scheduled for the the resident's unit. During an interview on 6/14/24 at 8:10 A.M., Activity Assistant B said: -The resident would sit at the table briefly during BINGO, but couldn't stay focused on the activity even with prompting. -The resident mainly liked consuming food during social activities. During an interview on 6/14/24 at 10:11 A.M., Activity Assistant A said: -Whatever activities were planned for Units 2 and 3 were usually done on the Serenity Unit (the resident's unit) as well, although they usually didn't put Serenity on the monthly calendar. Serenity didn't have a separate monthly calendar. -One of the hospice chaplains did the church services. They either did them on the Serenity Unit or on Unit II depending on how many residents were up on the Serenity Unit. If the services were done on Unit II, the residents on the Serenity Unit didn't attend because that would confuse them, and no alternate activity was scheduled on Serenity. -Church services used to be every Wednesday, but for the past couple of months they were every other Wednesday. When church took place on the Serenity Unit the chaplain usually played religious music on his/her phone. Activity staff brought the Serenity Unit residents to the church services when they were held on the unit, so they knew which Serenity residents attended. -Residents who had difficulty focusing on typical activities could sit during Karaoke or eat during a food activity. If they seemed to be focusing at any point, activity staff documented the resident participated. -Residents who had difficulty focusing could participate in 1:1 activities, go outside, or listen to music. -The resident was mainly active in drinking coffee and eating donuts during social activities. -He/She didn't know what kind of music the resident liked but the resident was capable of watching others during karaoke. -The resident didn't have good hand motor skills, but was capable of watching while a staff person did a craft or activity and could understand if staff talked about the activity they were doing. -The resident was capable of patting down soil with assistance if someone planted a plant or flower and could listen to music. -The resident usually wasn't awake at 10:00 A.M. when morning activities took place. -Activity staff had done some 1:1 activities with four residents on the Serenity Unit, but they hadn't done 1:1 activities with the resident. During an interview on 6/14/24 at 12:21 P.M., the Director of Nursing (DON) said: -Activities should be offered daily for all residents who would like them. -Simple group activities and individual activities should be offered to residents who had difficulty focusing. Ideas of simple activities were looking at magazine pictures, making a collage of cut out pictures, and church activities focusing on music. There were pianos on all the units, and someone could play the piano for residents. -The resident liked to watch others in group activities and might like sensory items and activities. -A resident's activity program should reflect the resident's interests.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #80) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition that is triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, severe anxiety, uncontrollable thoughts about the event and feelings of isolation) received trauma based interventions including ensuring the resident received meal service when he/she was in full view of staff during meal service, out of 19 sampled residents. The facility census was 92 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/), copyright 2021, showed: -Trauma-informed care shifts the focus from What's wrong with you? to What happened to you? -A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation. -Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors. -Trauma-informed care seeks to: --Realize the widespread impact of trauma and understand paths for recovery. --Recognize the signs and symptoms of trauma in patients, families, and staff. --Integrate knowledge about trauma into policies, procedures, and practices; and --Actively avoid re-traumatization. Review of the facility Trauma Informed Care policy, dated 2021, showed: -Trauma informed care is culturally sensitive and person-centered. -Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers (anything - a person, place, thing, or situation - that is a reminder of a past traumatic experience). -Strategies included to interact with all residents in a manner that is welcoming and kind without being intrusive. Review of the facility Dining Experience policy, dated 2021, showed: -The dining experience will be person-centered with the purpose of enhancing each resident's quality of life and being supportive of each resident's needs during dining. -Residents will be involved in choosing where to eat and service staff notified of location selected. 1. Review of Resident #80's Face Sheet showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of PTSD. Review of the resident's care plan, dated 3/12/24, showed: -He/she had prior trauma related to homelessness with triggers noted as unknown, had a diagnosis of PTSD, a potential psychosocial well-being problem related to anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) and lack of motivation, he/she experienced loneliness and isolation and had a potential nutritional problem. -Goals included that he/she would have his/her physical and emotional needs met without increased emotional distress, he/she would have no indications of a psychosocial well-being problem and he/she would maintain adequate nutritional status. -Interventions included that staff would serve his/her ordered diet, explain and reinforce to him/her the importance of maintaining his/her diet and encourage him/her to comply. Review of the resident's Pre-Admission Screening and Resident Review (PASRR Level II, a person-centered evaluation that is completed for anyone identified by the Level I Screening as having, or suspected of having, a PASRR condition, including serious mental illness or related condition) Summary of Findings, dated 5/17/24, showed: -He/she did have a PASRR related disability of a serious mental illness. -His/her needs could be met in a nursing facility. -He/she did not have specialized services beyond those typically available in a nursing facility. -He/she had been homeless prior to admission to the facility and did not associate with his/her family. -His/her diagnoses included anxiety and depression. -He/she had a history of trauma - homelessness. and brain tumor surgery at age 14. -He/she did not require mental health specialized services and his/her needs could be met in a nursing facility. -He/she said he/she was not eating what he/she should be eating due to the brilliance of the kitchen not washing a banana that still had a label on it and was placed on top of his/her sausage and egg. -He/she received antidepressant medications (type of medicine used to treat clinical depression or prevent it recurring). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 6/11/24, showed: -He/she was cognitively intact. -He/she had little interest or pleasure in doing things, feeling down, depressed or hopeless, poor appetite or overeating, feeling bad about himself/herself, trouble concentrating, had thoughts he/she would be better off dead or of hurting himself/herself. -He/she had no behavioral symptoms. -He/she had anxiety, depression and PTSD. -He/she received antidepressant medication. Continuous observation on 6/13/24 from 12:05 P.M. to 12:25 P.M., showed: -The resident was seated in an open area just in front of the wide entryway to the dining room in full view of staff passing lunch trays in the dining room. -Staff in the dining room passed trays to all residents in the dining room and then passed hall trays to rooms on both sides of the nursing station directly across from the dining room, and passed by the resident with each hall tray delivery. -Following completion of staff passing hall trays at 12:25 P.M., the kitchen window rolling shade was pulled down. -The resident was not served a lunch tray. During an interview on 6/13/24 at 12:26 P.M., the resident said: -The kitchen had closed, and no one gave him/her lunch. -He/she had been where he/she always was during the lunch meal service. -The staff knew that was where he/she usually sat, everyone could see him/her, and the staff walked by him/her when they passed room trays. -The staff could see he/she did not get his/her lunch, they just did not care. -He/she guessed he/she was invisible, and no one spoke to him/her or got him/her a lunch meal and that happened often, staff just ignored him/her. During an interview on 6/13/24 at 12:31 P.M., Certified Nursing Assistant (CNA) B said: -The resident got a room tray. Observation on 6/13/24 at 12:32 P.M., showed: -There was no lunch tray in the resident's room. -The resident was not in his/her room. During an interview on 6/13/24 at 12:35 P.M., CNA B said: -The resident's meal card must not have been placed back in with the other residents' meal cards. -They used the meal cards in preparing and delivering meals. -The kitchen staff prepared the meals, and the direct care staff delivered the meals to the residents. -He/she did not see that the resident had not been served a meal. -He/she would get a meal for the resident. Observation and interview on 12/13/24 at 12:42 P.M., showed: -CNA B had a lunch meal on a tray and he/she said he/she was taking it to the resident's room. During an interview on 6/13/24 at 12:46 P.M., CNA B said, -He/she took the resident's lunch to him/her. -The resident refused his/her meal, saying he/she did not want his/her meal now. During an interview on 6/14/24 at 8:05 A.M., the resident said: -When staff walked past him/her, did not speak to him/her, and did not get him/her a meal, he/she felt anxious and alone and as if no one cared about him/her. -It reminded him/her of when he/she was a child and was bullied and made fun of and of being homeless and not knowing if he/she would have any food to eat - it made him/her feel alone and like no one cared about him/her. During an interview on 6/14/24 at 10:47 A.M., the Social Services Director said: -The resident did have PTSD. -The resident complained about the food at the facility. -The resident did not have problem behaviors at the facility. -The resident had trauma from being made fun of as a child due to having had a brain tumor and seizures and also he/she had been homeless prior to his/her facility admission. -He/she could see how not getting a meal when he/she was out where staff could see him/her at mealtime could trigger an emotional response, memories of being homeless and not having food, and being made fun of when a child. During an interview on 6/14/24 at 12:20 P.M., the Director of Nursing (DON) said: -The resident ate most of his/her meals in the dining room. -The facility had recently started a new meal service process that involved laminated meal cards. -At the end of the supper meal service, the meal cards were to be gathered to ensure all the cards had been collected. -When passing meals to residents, if the resident was not in the dining room, staff was to take the resident's meal to their room. -Normally if staff saw a resident without a meal, they asked if the resident got a meal tray and if they wanted a meal tray. -He/she would expect that the staff who normally served the meal trays would have noticed that the resident did not get his/her meal and get him/her his/her food. -The resident had a diagnosis of PTSD, and not being served a meal could be a trigger of his/her past trauma. -With the new system, there should not have been any resident tray missing and not served. -The CNA's served the trays and a licensed nurse oversaw the dining room and meal service. -The meal cards were the key to ensuring every resident was served their meal. -The CNA's and the licensed nurses were responsible for documenting each resident's meal intake for each meal.

Based on observation, interview and record review, the facility failed to ensure that dietary staff followed the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs, which resulted in the eggs being unpalatable. This practice potentially affected two residents with pureed diets. The facility census was 92 residents. 1. Observation on 6/13/24 from 6:08 A.M. to 6:24 A.M., during the breakfast meal preparation, showed: -A disorganized recipe book on one of the tables with numerous amount of the pages which were not in order. -Dietary [NAME] (DC) A made pureed eggs with no recipe book open. -DC A added cold milk to the eggs and an unmeasured amount of thickener. -The state surveyor tasted the pureed eggs, and the eggs had a bland taste. -DC A did not taste the eggs himself/herself. -DC A placed the pureed eggs in the steam table. Review of the undated recipe for 100 servings of eggs showed: -Twelve 0.5 pounds (lbs.) portions of pasteurized liquid egg product. -Two tablespoons (Tbsp) of ground black pepper. -Two Tbsp. salt. -One 0.25 cup of melted margarine. -For pureed steps: Remove the desired number of servings and add nutritive liquid, milk, broth etc. Blend until desired consistency add approved thickener to achieve desired consistency if needed. During an interview on 6/13/24 at 6:42 A.M., DC A said: -He/she did not add salt or pepper to the eggs before cooking them. -He/she did not add margarine either. -The recipe book was disorganized which made it hard to find recipes. During an interview on 6/13/24 at 9:00 A.M., DC A said he/she was not trained in making the pureed foods correctly, because he/she was told not to add any salt by a previous Dietary Manager (DM). During an interview on 6/14/24 at 9:18 A.M., DC B said: -He/she tasted all pureed foods except eggs and onions. -If he/she was not able to taste something with eggs and onions in it, he/she would ask one of the Dietary Aides to taste that food item. During an interview on 6/14/24 at 9:35 A.M., the Dietary Manager (DM) said: -He/she expected the cooks to taste everything they cook. -DC A confirmed to him/her that a previous DM said not to add salt to the foods.

Based on observation, interview and record review, the facility failed to provide adequate protective oversight for one sampled resident (Resident #1) when the resident obtained access to a sharps container on the medication cart, found the tip/needle portion of an insulin pen and poked his/her finger out of ten sampled residents. The facility census was 94 residents. Review of the facility policy for Sharps Disposal revised January 2021 showed: -The facility staff was to discard contaminated sharps into designated containers immediately or as soon as feasible, into designated containers. -All containers used for discarding contaminated sharps were to be closable, puncture resistant, leakproof on sides and bottom, labeled or color-coded in accordance with the established labeling system and impermeable and capable of maintaining impermeability through final waste disposal. -During use, containers for contaminated sharps were to be handled by: --Designated individuals will ensure that the containers were easily accessible to employees and located as close as feasible to the immediate area where sharps were used. --Nursing staff were to ensure that the containers were maintained in an upright position throughout use,. --Designated individual were to be responsible for sealing and replacing containers with they were 75% to 80% full to protect employees from punctures and/or needle sticks where attempting to push sharps into the container. --When moving containers of contaminated sharps from the area of use, employees were to close the container immediately prior to removal, or replacement to prevent contents from spilling or protruding during handling, storage, transport or shipping, place the container in a secondary container if leakage was possible ensuring the second container used was closeable, constructed to contain all contents and prevent leakage during handling, storage, transport or shipping and label or color-coed according to established policies governing the labeling or containers and seal and replace containers when they were 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. 1. Review of Resident #1's Facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Unspecified intellectual disabilities (a developmental disorder characterized by less than average intelligence and significant limitations in adaptive behavior with onset before the age of [AGE] years old). -Adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life). -History of behavioral and mental disorders (mental/behavioral health disorders affect the way a person thinks and behaves, changing mood and making it difficult to function in society). Review of the resident's Nursing Care Plan dated 11/25/23 showed: -He/she had impaired cognitive function or an impaired thought process related to intellectual disabilities. -The facility staff was to cue, reorient and supervise him/her as needed. -The facility staff was to reduce any extra outside stimulation and ensure he/she understood the communication. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 11/28/23 showed he/she: -Was not cognitively intact. -Had severe mood issues including but not limited to little interest in doing things, feeling down, sleeping too much or not enough, poor appetite or over eating, feeling bad about himself/herself, trouble concentrating, moving slowly or too fast, and feeling better off dead. -Had behaviors such as delusions, hallucinations, verbal behaviors directed toward others and physical behaviors not directed at others. -The resident's behaviors put the resident at potential risk as well as interfered in his/her participation in activities and social interactions. -His/her behaviors also placed the resident and other residents at risk for injury, interfered in their privacy and disrupted their living environment. Review of the resident's Nurse's Notes dated 1/12/24 at 4:30 P.M., showed: -Licensed Practical Nurse (LPN) A left the nurse's station to use the restroom. -When LPN A returned to the nurse's station, Resident #1 had an insulin pen needle with a cap in his/her hand and said he/she had poked himself/herself with it. -The end of the insulin pen needle that would go into a resident had a plastic cover on it so the end exposed would have been the end that plugged into the insulin pen therefore, the resident would not have been exposed to any blood or body fluids. -LPN A asked the resident where he/she got the insulin pen needle and the resident showed him/her the sharps box on the side of the nurse's medication cart. -No blood was visible to LPN A as the resident said he/she poked his/her right index finger. -The sharps box was not open and the lid was completely closed where the resident would have had to use force to get into the box to obtain the insulin pen needle. -The Administrator was contacted as well as the physician and Public Administrator (PA). -The resident was to have been monitored for signs and symptoms of infection. Review of the facility's undated Follow-up Investigation Report showed: -The resident was monitored throughout the weekend per physician's order to ensure the resident had no adverse reaction related to a self-inflicted needle stick. The note did not indicate when it was written, the dates the resident was monitored, or the date of the incident. -There were no changes in the health status of the resident. -The Administrator assessed and interviewed the resident after the needle stick site was thoroughly cleaned. -The resident initially reported the needle stick to the wrong hand/finger with an assessment of the other hand, located a small puncture wound. -The resident reported no pain and stated, I'm sorry. I am a good. Please don't send me out to a pysch ward. -The resident was reassured that he/she was okay and would remain in the facility and that he/she would be taken care of. -It was discovered there was no concern for cross contamination as the side of the needle exposed was attached to the insulin, not the resident. -The resident was not cognitively intact with intellectual disabilities which could result in impulsivity. Review of LPN A's written statement dated 1/12/24 showed: -At approximately 5:00 P.M., on 1/12/24 he/she was notified that the resident had reached into the sharps container located on the medication cart and had poked himself/herself with an insulin pen needle. -He/she went to investigate and found the resident sitting at the dining room table with two staff members. -The Administrator asked the resident where he/she was poked as the resident had initially said the wrong hand/finger. -The resident had a small puncture wound on the tip of his/her right hand index finger. -LPN A cleaned the site immediately with hydrogen peroxide. -Upon further investigation, the sharps container was filled just above the fill line. -The resident, lifting the protective lid on the container and placing his/her hand into the container, grabbed the insulin pen needle. -The resident poked his/her finger with the side of the insulin pen needle that would have gone into the insulin, not a resident's finger, as the other side of the needle was retracted and protected. -He/she notified the physician who requested the resident be monitored for any changes. Observation and interview on 1/23/24 at 11:30 A.M., showed: -The resident was laying in bed in his/her room. -He/she did not recall taking the insulin pen needle from the sharps box. -He/she wanted to eat lunch. During an interview on 1/29/24 at 3:01 P.M., LPN A said: -On the day of the incident, 1/12/24 the resident had been doing very well with no signs of impulsivity or behaviors. -He/she needed to use the restroom and the resident was seated in his/her wheelchair next to the nurse's station. -He/she left for a few short minutes to use the restroom and upon returning, the resident showed him/her that he/she had an insulin pen needle in his/her hand and had poked himself/herself with it. -He/she assessed the resident and saw no blood. -The resident asked him/her not to take him/her to the hospital. -He/she told the resident that he/she need to call the doctor but did not think he/she needed to go to the hospital. -The resident had been doing very well for the past few weeks after some medication changes and extra attention. -He/she was surprised that the resident would put his/her hands in the sharps box in the first place. -He/she should have gotten another staff member to watch the resident knowing the resident's impulsivity and curious personality. During an interview on 1/29/24 at 3:30 P.M., the Administrator and Assistant Director of Nursing (ADON) said: -He/she would have expected the facility staff to have emptied the sharps box once the box got half full. -He/she would have expected the sharps box lid to have been completely closed after placing the insulin pen needle in the box. -He/she would have expected staff to have notified another staff member to watch the resident while he/she went to the restroom. MO00230209

Based on observation, interview and record review, the facility failed to ensure two sampled residents (Resident #3 and #4) remained free from abuse. On 9/29/23, Resident #3 hit Resident #4 resulting in Resident #3 sustained a fractured right leg and cut to his/her right arm and Resident #4 sustained a cut to his/her nose, a cut on the foot and bruising to his/her face out of nine sampled residents. The facility census was 102 residents. Review of the Abuse Prevention Program Policy dated 12/16 showed: -Policy Statement: --The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. --This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident symptoms. -Policy Interpretation and Implementation: --As part of the resident abuse prevention, the administration will: ---Protect the residents from abuse by anyone including, but not limited to other residents. Review of the undated Identification of Abuse document showed: -Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. -Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, choking, pulling hair, and burning. 1. Review of Resident #3's Admission Record showed the resident was admitted on [DATE], readmitted on [DATE] with the diagnoses: -Antisocial personality disorder (a condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society). -Dementia (a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging). -Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems). -Bipolar disorder, major depressive disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Anxiety disorder. -Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile). Review of Resident #3's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/14/23 showed he/she was cognitively intact. Review of Resident #3's undated Care Plan showed the resident: -Can become verbally abusive and threatening to others. -Can be easily agitated. -History of physical altercation with peer. --Monitor for behavioral outburst. --Redirect the resident to his/her room. --Allow period of time to calm down. --Counsel the resident on behaviors. --Educate the resident on need to keep hands to him/herself, and if someone was bothering him/her to get up and move to different are, notify staff of the problem. --Intervene as necessary to protect the rights and safety of others. --Monitor behavior episodes and attempt to determine underlying cause. -The resident was physically aggressive toward other resident's wanted to protect staff members from abuse or troubles caused by other residents towards staff related to history of TBI. --The resident will not harm self or others through the review date. --The resident's triggers for physical aggression were when other residents are verbally or physically abusive towards staff members. --When the resident becomes agitated, intervene before agitation escalates. Review of Resident #4's Preadmission Screening and Resident Review (PASARR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid) dated 5/20/19 showed: -Was oriented to person, alert and poor memory. -Moderately confused and withdrawn. -Minimally wanders and combative. -Moderately suspicious and supervised for safety. -Minimally controlled with medications. Review of Resident #4's Admission Record showed the resident was 1/21/22 with the diagnoses: -Schizophrenia. -Major depressive disorder. -Anxiety. -Dementia. Review of Resident #4's undated Care Plan showed the resident: -Had a behavior problem related to impulsiveness, refusing cares, showers, and medication, yelling/cursing at peers, refuses to wear regular shoes. -Resides on a secured unit. --No harm to self or others through next review. --Staff to intervene as necessary to protect the rights and safety of others. --Divert attention. --Remove from situation and take to alternate location as needed. -Was verbally aggressive to staff and other residents at times, verbally abusive to staff and other resident related to dementia and head injury. --When being verbally abusive or aggressive to other resident's encourage resident to move from that area to a more quiet area to let conflict resolve. Review of Resident #4's Annual MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had delusional behaviors. Review of Resident #3's Progress Note dated 9/29/23 at 7:01 P.M. showed: -Resident #3 was in the dining hall when Resident #4 was yelling at other residents and staff. -Resident #3 approached and pulled Resident #4 out of his/her wheelchair. -Resident #3 lost his/her balance and came down on Resident #4. -Resident #3 obtained a skin tear to his/her right forearm and was unable to bear weight on his/her right knee/leg. -Primary Care Physician (PCP) was contacted and Resident #3 was sent to the emergency room (ER) for evaluation as there was a bump on the outer aspect of the resident's right leg at the area of the knee. Review of the facility Follow-Up Investigation Report dated 9/29/23 showed: -Resident #3 had a fracture of his/her right tibial plateau and skin tear on his/her right forearm. -Resident #4 had discoloration to the side of his/her face. -Resident #4 was calling other residents names and went near Resident #3. -Resident #3 hit Resident #4 they both ended up on the ground. -Resident #3 said Resident #4 was cussing at the female staff and other residents, including Resident #3. -Resident #3 reported Resident #4 cussed at him/her, he/she went [NAME], then we fell to the floor, he/she hit Resident #4 again, then it stopped. -Certified Nursing Assistant (CNA) C observed Resident #4 calling other residents names. -CNA C asked Resident #4 to stop and when he/she did not, Resident #3 swatted Resident #4. -Resident #4 grabbed Resident #3 and they fell to the ground. -CNA C left to get the Director of Nursing (DON) and when he/she returned the residents were separated. -CNA D observed Resident #4 calling other residents names. -CNA D tried to de-escalate the situation but was unsuccessful. -The DON talked to Resident #4 and he/she stopped for awhile. -When Resident #4 started calling other resident's names again, Resident #3 swatted Resident #4. -The residents fell to the floor and the altercation was stopped. -It was determined the incident did occur and was behavior based. Review of Resident #3's hospital discharge documents dated 9/29/23 showed he/she was diagnosed with abrasions and a right leg fracture. Review of the Resident #3's Progress Note dated 9/30/23 at 1:20 P.M. showed the resident returned to facility with a leg brace on his/her right leg and was non-weight bearing. Review of the Resident #3's Weekly Skin Check dated 9/30/23 showed the resident: -Had a 2 centimeter (cm) x 2 cm skin tear to his/her right elbow. -Had bruising to his/her left elbow and right knee. -Had a knot to his/her right lower leg, suspected knee/lower right leg fracture. Review of Resident #4's Progress Note dated 9/29/23 showed the resident: -Was being verbally aggressive towards other residents and staff, yelling at them and calling them names. -Was approached by Resident #3 and pulled him/her out of his/her wheelchair and onto the floor, hitting him/her in the face several times. -Obtained a skin tear to his/her nose, right foot and a bruise to the corner of the left eye. Review of Resident #4's Nursing Weekly Skin Check dated 9/29/23 showed: -Bruising to his/her left elbow and right elbow. -Skin tear to his/her right toes. -Skin tear, swelling and bruising noted to his/her left face and eye. -Would not allow nurse to assess or treat wounds. -Refused x-rays to left eye/face and refused treatment at the emergency room . -Scattered bruising noted to his/her bilateral arms. Review of Resident #4's Radiology Results dated 9/30/23 showed bruising and pain post altercation. Review of Resident #4's Psych Progress Noted dated 10/2/23 showed he/she had a physical altercation with a co-resident during which he/she sustained peri-orbital (tissues surrounding the eye) bruises. Review of Resident #3's Psych Progress Note dated 10/2/23 showed: -Chief complaint: I broke my leg accidentally. -He/she had a physical altercation with co-resident leading to him/her having a fractured leg. -Reported falling on his/her wheelchair while fighting with a co-resident and fractured his/her leg. During an interview and observation on 10/16/23 at 2:56 P.M. Resident #3 said: -He/She was in a wrestling match when asked about the altercation. -He/She was getting along fine now with Resident #4. -When asked about his/her injury he/she referred to it as a chipped bone. -Resident #4 was cussing the ladies and I shut him/her up. -Resident #4 got a black eye out of the deal. -He/She had to do something, them girls are working. -Observation showed the resident in his/her wheelchair and right knee brace in place. During an interview on 10/16/23 at 3:04 P.M. the Staffing Coordinator said: -He/She does not feel there would have been any way to stop Resident #3. -Resident #3 was protecting the female staff from Resident #4. -He/She has had no real behavioral management training in the facility. During an interview on 10/16/23 at 12:58 P.M. the DON said: -He/She was aware of the resident to resident altercation for Residents #3 and #4. -Resident #3 sustained a broken tibia and skin tear to the right elbow. -Resident #4 sustained a left black eye, skin tear to right foot stub, and skin tear to bridge of nose. -Resident #3 was sent to the hospital for evaluation and returned. -He/She was not sure what exactly happened between Resident #3 and Resident #4. During an interview on 10/16/23 at 4:16 P.M. the DON said: -Abuse was a willful act that could potentially cause harm to a person. -Expects staff to intervene immediately and de-escalate, and prevent or help prevent resident to resident altercations. -He/She was the nurse working at the time of the altercation with Resident #3 and Resident #4. -When Resident #4 was observed to be verbally aggressive in the dining room the staff came to get him/her. -He/She sat Resident #4 down at the table and educated him/her that it was not okay to talk to the staff the way he/she was. -The staff came to get him/her a second time due to the resident to resident altercation. -Resident #3 grabbed Resident #4 because he/she was defending the females, both staff and residents, from Resident #4. -He/She said the incident happened too quick and could not have been prevented. -Resident #4 refused to be redirected out of the dining room. -He/She was not aware of any triggers for Resident #4, just that the resident had verbal behaviors. -Resident #3 told staff he/she was protective of females and that is a trigger for him/her. During an interview on 10/30/23 at 2:04 P.M. Certified Medication Technician (CMT) A said: -He/She started working in the facility on the behavior unit. -He/She had not had any training specific to working with behaviorally challenged residents. -He/She was present for the altercation between Resident #3 and #4. -He/She got the charge nurse and tried to intervene to get them away from each other so they could calm down. -His/Her opinion was that a lot of time it is the approach you take with the residents. During an interview on 10/30/23 at 2:30 P.M. CMT B said: -He/She was working the when Resident #3 and #4 had an altercation. -He/She noticed Resident #4 was in an odd mood and was being vulgar to another resident. -Resident #3 told Resident #4 not to be doing that. -They began to argue. -Resident #4 went towards and began swing at Resident #3. -The residents began fighting and they both fell to the floor. -The staff separated the residents. -Resident #3 was having leg pain and was sent to the hospital. -Resident #4 had cuts and bruises (a black eye). -Staff tried to prevent the altercation by talking to both of the residents. -Resident #3 had not gotten involved until one of the women became teary eyed. -Neither resident would listen to staff. -Although staff tried to separate the residents, but it was not possible. During an interview on 10/30/23 at 4:002 P.M. CNA D said: -Prior to the altercation between Resident #3 and #4, he/she was in the dining room and observed Resident #4 talking a bunch. -Resident #4 had went to two different residents calling them names when he/she went to get the DON. -The DON came and spoke with Resident #4 about his/her behavior. -When he/she hear Resident #4 yelling at one of the residents, he/she turned to see Resident #3 walking fast towards Resident #4. -There was immediate contact between the residents. -He/She left the other CNA with the residents and ran to get the DON. -There was no way the altercation was going to be stopped. -When he/she returned to the dining room the altercation was stopped. During an interview on 10/30/23 at 4:14 P.M. CNA E said: -Prior to the altercation between Resident #3 and #4, Resident #3 was in the dining room when Resident #4 came to the dining room calling other resident's names. -He/She was trying to redirect Resident #4. -The other CNA went to get the DON to talk to Resident #4. -After the DON left, Resident #4 started calling other resident names again. -Staff attempted to redirect Resident #4 without success. -Resident #3 came over and punched Resident #4. -He/She did not know what to do and stood by just watching the altercation. -He/She was told not to break up a fight because it was out of his/her scope. -CNA D left during the altercation to get the DON. -The residents had fallen to the floor and eventually stopped fighting. -The DON and other staff came and helped get both residents up. -Resident #4 had a history of yelling, cussing and calling both staff and residents names. -Resident #3 becomes overprotective of female staff and residents. -He/She tried to stop Resident #3, but he/she was on a mission. During an interview on 10/30/23 at 4:47 P.M. the Administrator said: -He/She defined abuse as intentional infliction of harm. -Reviewed the definition of abuse per facility policy. -He/She stated the altercation between Resident #3 and #4 was abuse. -He/She did not believe residents have the right to be physically aggressive with one another. -Behavioral, mental health and psychiatric disorder training was done during orientation, there are slides dealing with behavior, and some top ten tips on de-escalation. -Expects staff to try to de-escalate situations before they become physical. -When asked about techniques, he/she said depends on the person. -Resident specific training is done by working with the resident and learning the resident. During an interview on 10/31/23 at 1:21 P.M. the Physician said: -Resident #3 was at high risk for aggressive behaviors and is protective of others. -Resident #3 was at best the maturation of a teenager. -Expected staff to ensure the safety of the staff and residents. -Expected the staff to call law enforcement if necessary. -Expected a plan to be in place for any and all possible behaviors including physical aggression. During an interview on 11/1/23 at 10:07 A.M. the Public Administrator (PA) said: -He/she was the PA for both Resident #3 and Resident #4. -Once he/she was made aware of the details of the altercation, he/she felt the incident was abuse. -He/She does not feel the training for the staff was adequate for the staff to manage the behaviors of the residents on the behavior unit. -He/She was concerned about the extent of injuries the residents sustained. -He/She was concerned about his/her residents in the facility where the staff was unable to manage their behaviors and ensure their safety. MO00225181

Based on observation, interview, and record review, the facility failed to provide supervision for one sampled resident (Resident #13) with a known history of self-harming behavior. The facility failed to ensure the resident did not have access to razors, resulting in he/she using a razor to cut his/her left leg in approximately four areas on his/her upper, left thigh. One of the thigh wounds was so deep that fatty tissue was exposed and required sutures. The facility census was 109 residents. The Administrator was notified on 12/17/21 at 3:34 P.M. of an Immediate Jeopardy (IJ) which began 12/16/21. The IJ was removed on 12/20/21 as confirmed by surveyor onsite verification. The facility did not have a policy regarding procedures for staff to follow when a resident has a history of self-injurious behavior to ensure resident safety. 1. Record review of Resident #13's Initial Assessment - Social and Medical (DA 124 A/B form-used to initiate the process for admission to a Nursing Facility and to determine the need for nursing facility services through level of care criteria), dated 5/8/21, showed: -The resident was impulsive and needed constant supervision to monitor for safety. -Some of the resident's diagnoses included [CONDITION(S)] (a disorder characterized by extreme mood swings from depression to [CONDITION(S)]), borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships), post-traumatic stress disorder ([CONDITION(S)]-an anxiety disorder that is triggered by a traumatic or terrifying event), [CONDITION(S)]/dependence, stimulant use disorder, adjustment disorder (experiencing more stress than would be expected) with disturbance of conduct (symptoms include behavioral issues such as acting rebellious, destructive, reckless or impulsive). -Hospital records showed the resident had self-inflicted [CONDITION(S)] to his/her lower, right leg. -The resident had chronic anxiety (nervousness, fear, apprehension, and worrying) and hallucinations. Record review of the resident's Preadmission Screening and Resident Review (PASRR-A screening used to identify a resident who has a mental illness or is suspected of having a mental illness, an intellectual/developmental disability, or a related condition to determine if specialized services are needed during their stay in a long-term care facility) Level II (confirms whether the applicant has a mental illness or intellectual/developmental disability, assesses the individual's need for nursing facility services and assesses whether the individual requires specialized services or specialized rehabilitative services) Evaluation, dated 5/12/21, showed: -The resident had a long history of self-injury behaviors beginning at age [AGE] years old due to panic attacks and anxiety. -The resident may pocket any available items with which to use to harm himself/herself. -The resident continued self-cutting behaviors which he/she said were not suicidal, but either made other people respond or provided him/her with stress relief. -Current psychiatric support/services needed included safety, suicide, and assault precautions. Record review of the resident's Admission Record, dated 12/17/21, showed: -The resident admitted to the facility on [DATE]. -Diagnoses included [CONDITION(S)] and anxiety disorder. Record review of the resident's history and physical, dated 11/11/21, showed his/her primary care physician documented: -The resident was transferred from another facility, because he/she needed a lock down unit due to some significant problems. -Some of the resident's diagnoses included [CONDITION(S)], borderline personality disorder, and suicide ideation (thinking about suicide or wanting to take your own life). Record review of the resident's Admission Assessment, dated 11/12/21, showed: -The resident was independent with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting). -The skin condition section indicated the resident had no skin issues. Record review of the resident's nurse's note, dated 11/14/21 at 4:50 A.M., showed: -Another resident reported to the nurse that on 11/13/21 after lunch, the resident asked him/her for a CD (a small plastic device on which sound is recorded) to break in half so he/she could cut his/her legs with it. -The other resident refused to give the resident a CD. -The resident said it was ok because he/she had razor blades that he/she could use to cut his/her wrists. Record review of the resident's nurse's note, dated 11/14/21 at 5:42 A.M., showed the resident's room was searched for sharp items and items found included a razor, set of hair clippers, tape dispenser, wire brush cleaner, sewing needles, and a pedicure buffer and they were removed. Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 11/16/21, showed the following staff assessment of the resident: -Cognitively intact. -No physical behaviors, verbal behaviors, or other behaviors that were directed toward others since admission. -Refused cares four to six days since admission. -Displayed mood signs and/or symptoms that indicated moderate depression (symptoms may include intense sadness and a loss of interest or loss of pleasure in activities and/or life). -Independent with ADLs. -Walked independently. -Diagnoses including anxiety disorder, [CONDITION(S)], [CONDITION(S)], and borderline personality disorder. -Received antipsychotic medication (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat [CONDITION(S)]) six days and antianxiety medication four days since admission. -No skin problems or wounds. Record review of the resident's care plan, dated 11/19/21, showed: -The resident had a diagnosis of [CONDITION(S)] and the interdisciplinary team was responsible for developing a crisis intervention/safety plan as indicated to address any crisis or safety concerns the resident might experience. -The resident resided on a secure unit. -The resident had a significant history of suicidal ideation's and non-suicidal self-harm. -The resident had a history of self-harm by burning and/or cutting himself/herself related to [CONDITION(S)]. -The resident had impaired cognitive function and/or impaired thought processes related to diagnoses of [CONDITION(S)] (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others), borderline personality disorder and history of [CONDITION(S)]. -The resident frequently hid from staff. -Instructions for staff to: --Check clothing, personal belongings, and his/her room for items that could harm him/her and remove them. --Search the resident's room for items that could harm him/her such as sharp objects, ropes, string, cords, etc. any time the resident made a statement about having thoughts of harming himself/herself. --Assess what the resident's triggers were and what may de-escalate behaviors. --If the resident talked about doing harm to himself/herself, monitor the resident's whereabouts and increase monitoring to every 15 minute checks or to one-on-one observation. --Provide counseling, psychologist and psychiatrist care. Record review of the resident's care plan showed an update on 12/7/21 that the resident was not to have sharp objects in his/her room related to his/her history of cutting himself/herself. Record review of the resident's nurses' notes showed: -On 12/15/21 at 1:17 A.M., --The resident was upset because he/she was having issues with his/her roommate. The resident reported it was causing him/her a great deal of stress and making him/her want to cut himself/herself. --The resident asked if he/she could be moved to a different room. --The request for a room change was reported to the Assistant Director of Nursing (ADON). -On 12/16/21 at 7:42 A.M., --Another resident reported around 7:15 A.M. that yesterday (12/15/21) he/she witnessed the resident putting his/her cigarette out on his/her abdomen and that the resident had cut himself/herself with a disposable razor blade. --The nurse looked for the resident for about 15 minutes. --The resident was found lying in another resident's room on the bed. --The resident refused three times to allow the nurse to see his/her wounds. --The nurse gave the resident [MEDICATION(S)] (an antianxiety medication), because the resident complained of having anxiety. --15 minutes later, the nurse had difficulty finding the resident. --The resident was found on the floor in the closet of the same resident room he/she was in previously. --The staff continued 15 minute checks. -On 12/16/21 at 9:14 A.M.: --The resident allowed staff to look at his/her wounds. --The resident had cut himself/herself on his/her upper right arm in multiple places with scabbed areas present as well. --The resident had cut himself/herself on his/her right upper thigh in multiple areas with scabbed areas present as well. --The resident had cut himself/herself in approximately four areas on his/her upper, left thigh. --One of the thigh wounds was very deep and required sutures. --The resident was being sent to the hospital for treatment of a wound and for a psychiatric evaluation. -On 12/16/21 at 9:15 A.M., the Director of Nursing (DON) documented: --The charge nurse reported to him/her that the resident had harmed himself/herself and was hiding. --The resident was found lying on the floor in a resident room closet and was in the fetal position. --The resident was encouraged to come out of the closet and he/she did. --The resident refused to allow the DON to assess his/her thigh wound, but showed the DON a picture of a multi tissue laceration on the resident's phone. -On 12/16/21 at 9:40 A.M., the resident was transported to the hospital. Record review of the resident's care plan showed an update on 12/15/21 that the resident cut himself/herself causing injury to his/her legs. During an interview on 12/17/21 at 8:45 A.M., the Activity Assistant/Certified Nursing Assistant (CNA) said: -He/She knew the resident had a history of cutting himself/herself prior to coming to the facility. -He/She was not aware of the resident having any self-harm behaviors since admission to this facility. - He/She was told by other staff members on the morning of 12/16/21 that the resident was going to be placed on 15 minute checks, but he/she did not know why. - He/She went to check on the resident to see what was going on. -The resident was not in his/her room. -The resident was found in another resident's room. -He/She asked the resident if they could talk and the resident agreed to talk. -They went into an empty resident room. -The resident said he/she felt sick. -The resident said he/she was hearing things, was paranoid, anxious, and stressed out because of issues with his/her roommate. -The resident showed him/her the cut on the resident's thigh and he/she told the resident that a nurse needed to assess it because it was pretty bad and nasty looking. -The cut was about 2 long by 1.5 wide and it was so deep that fatty tissue was exposed. -The resident had several other cuts on both thighs, his/her stomach, and one on his/her arm. -The ADON came down and the resident let him/her assess his/her wounds. -The ADON asked the resident what he/she used and he/she said it was a razor blade and that it was in the closet. -The ADON said the DON was going to come to decide whether to place steri-strips on the wound at the facility or whether to send the resident to the hospital for stitches. -The residents were not supposed to have razors. -The CNAs were supposed to watch the residents while they shaved and then put the razor in a sharps container. -The shower rooms were supposed to be locked. -Somehow the resident got a hold of a razor and hid it. -The resident did not tell him/her how he/she got a hold of a razor. -The resident said he/she did not want to die, but that he/she used cutting as a coping mechanism. During observation and interview on 12/17/21 at 11:18 P.M., -Resident #12 said: --Residents can get the razors anywhere on the unit. --Resident #13 previously told him/her that he/she cut his/her legs. --Resident #13 previously told him/her that Resident #13 takes razor blades from the shower room and takes the plastic off and hides them in his/her room in his/her jewelry box and showed them to him/her. --On 12/15/21, Resident #13 showed him/her cuts on his/her legs. --On 12/15/21, Resident #13 told him/her he/she burned himself/herself with a cigarette. --On 12/15/21, Resident #13's arms and legs looked like a butcher block. -- On 12/16/21, he/she told Licensed Practical Nurse (LPN) A that Resident #13 cut himself/herself and burned himself/herself. --LPN A told him/her to tell Resident #13's charge nurse. --He/She told Agency LPN D that Resident #13 cut himself/herself and burned himself/herself. --Resident #13 came in his/her room on 12/16/21, asking him/her to hide him/her. --Resident #13 hid under his/her bed. --The DON was looking for Resident #13. --Resident #13 hid in another resident's closet. --Resident #13 was sent out with the paramedics. Observation showed Resident #12 had three disposable razors in his/her bathroom. They were not secured so that others could not access them. Record review of Resident #12's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 12/17/21 at 12:29 P.M., Agency Registered Nurse (RN) C said: -The resident had multiple lacerations on his/her legs and cigarette [CONDITION(S)] on his/her stomach that were all at different stages of healing upon admission. -Nothing sharp was supposed to be in the resident's room. -The resident was supposed to be observed while shaving, the razor returned to staff, and staff are supposed to put it in a sharps container. During an interview on 12/17/21 at 12:41 P.M., the Shower Aide said: - He/She was aware the resident had a history of self-harm. -The shower room had a key pad that required a code to get into it. - He/She doesn't think the resident had the code to the shower room. -The door to the shower room was propped open and left open at times by staff or residents. -He/She had told staff not to prop open the shower room door. -The resident was independent with showering and shaving. -He/She kept the shower curtain open just a little so he/she can monitor the resident when he/she was shaving. He/She takes the razor from the resident when the resident was done and puts it in the sharps container. -On 12/15/21 around 2:15 P.M., he/she saw the shower room door propped open and found a broken part of a razor with the plastic missing inside the open shower room. -He/She reported this to LPN C and told LPN C that he/she thought it was Resident #13 that did that to the razor. -LPN C said there was nothing they could do about it and said to put the razor in a sharps container. -He/She was giving showers on 12/16/21 and the nurse told him/her the resident was hiding and was anxious. -The resident was having problems with his/her roommate which were making him/her scared, bothered, and anxious. During an interview on 12/17/21 at 1:59 P.M., LPN C said: -He/She was informed of the resident's history of self-harm upon the resident's admission. -They searched the resident's room within the first few days of him/her being at the facility and removed items that were potentially harmful. -The resident had multiple scabs upon admission and the resident picked at them. -He/She was not aware of any other wounds since admission and prior to this incident. -When the resident wanted to shave, the resident would request a razor from staff at the nurses' station, and staff would supervise him/her while he/she was using the razor. -None of the residents on the unit should have a razor. -All residents should have to get razors from a staff member. -None of the razor was missing when a razor was found in the open shower room by the shower aide the day before (12/15/21) this incident (12/16/21). -He/She could tell someone tried to take the plastic off of the razor. -The razor was disposed of in the sharps container. -He/She did not know who tried to break apart the razor or if it was just run over by a wheelchair or something like that. -Another resident reported to him/her that the resident put a cigarette out on his/her stomach and that he/she cut himself/herself the night before (12/15/21). -He/She referred the other resident to the charge nurse at the time, Agency LPN D. -He/She saw the ADON come down on 12/16/21 and go into the resident's room. During an interview on 12/20/21 at 9:54 A.M., Agency LPN D said: -He/She usually worked two or three days a week. -He/She worked on the resident's unit about three times. -He/She was aware of the resident's history of self-harm. -They were supposed to monitor the resident, especially when he/she was stressed. -Everything dangerous should be locked up. -He/She did not know if any residents on the unit were allowed to have razors. -The razors were locked up on the treatment cart. -Early in the morning on 12/16/21, Resident #12 came up to him/her and said: --He/She saw the resident put a cigarette out on his/her abdomen. --The resident showed him/her places he/she had cut himself/herself and it looked bad. -The resident was hiding and they had to search for him/her. -The resident was found and he/she went to see the resident. -The resident would not let him/her assess his/her skin. -He/She stayed in the room and talked with the resident. -The resident talked about having problems with his/her roommate. -He/She put the resident on 15 minute checks. -He/She called the Administrator, but he/she did not answer so he/she called the DON. -The DON said to keep the resident on 15 minute checks. -He/She told the DON he/she did not think that was enough because the resident had been hiding, found lying in a closet on the floor, and holding a towel to his/her thigh. -Everyone was trying to keep track of the resident. -The resident was going back and forth from hall to hall. -The ADON and the Activity Aide were able to get the resident to show staff his/her wounds. -The ADON gave him/her the bloody towel and razor. -He/She cleaned the resident up and put a dressing on the resident's thigh wound. -He/She called 911 to send the resident to the ER. -Staff stayed with the resident one-on-one until he/she went out to the ER. During an interview on 12/17/21 at 3:00 P.M., the DON and ADON both said: --They were aware of the resident's history of suicidal ideation and self-harm. --They were not aware of the resident saying he/she wanted to harm himself/herself since his/her admission. --They were not aware of the report of the resident asking another resident for a CD or razor to cut himself/herself on 11/13/21. -The DON said: --Some interventions included the resident's preference for exercising to stop the urges to self-harm and the resident knew he/she could talk to any of the staff about how he/she was feeling. --If a resident wanted to shave, the shower aide would be present in the shower room with them and put the razor in the sharps container when the resident was done. --Extra razors were locked in the supply cabinet. --The razors should all be kept locked up. --The ADON told him/her the resident had problems with his/her roommate. --They wanted to introduce the resident to any potential roommate prior to moving the resident. --They were not able to determine where the resident obtained the razor he/she used to cut himself/herself. -The ADON said: --LPN C told him/her on 12/15/21 that the resident said he/she wanted to cut himself/herself because of the issues with his/her roommate. --No new interventions were put in place after LPN C reported this information to him/her. --He/She told LPN C to tell the resident that they would talk about a room move. --They discuss roommate issues and/or room moves in their morning meetings and he/she planned to discuss the possibility of moving the resident to another room the morning of 12/16/21. --When he/she arrived at the facility on 12/16/21: ---The Activity Aide told him/her the Activity Aide needed him/her. ---Agency LPN D was the charge nurse on 12/16/21. ---LPN C was passing medications on 12/16/21. ---He/She went to the resident's room with the Activity Aide. ---The Activity Aide told the resident that the ADON was there to see his/her wounds. ---The resident had mostly superficial wounds on his/her left, upper arm and abdomen. ---The resident had one new burn on his/her stomach. ---There was a deep wound on the resident's left thigh. ---When asked about what the resident used to cut himself/herself, the resident said he/she used a piece of broken razor and pointed to the closet door. ---The ADON found a piece of a razor blade with a towel in the closet. ---The resident told him/her that he/she dropped his/her cigarette on his/her stomach. ---When he/she asked the resident why he/she was so upset, the resident said it was due to the issues with his/her roommate. ---He/She went to Agency LPN D and asked him/her to report it to the physician and send the resident to the hospital. During an interview on 12/17/21 at 5:01 P.M., Certified Medication Technician (CMT) A said: -He/She was aware of the resident's history of self-harm. -He/She was not told any specific interventions that should have been in place based on the resident's history of self-harm. -Razors were to be kept at the nurses' station. -The residents go to the nurses' station and ask for a razor and the staff give them to the residents. -On 12/15/21 the shower aide asked him/her and some other staff if any of them left the shower room open and they said they had not. -The shower aide said when he/she saw the shower room propped open, he/she found a razor in the shower room that was taken apart. -He/She had not noticed the shower room propped open that day. -CMT E saw bloody towels in a trash can in an employee bathroom on the unit on 12/15/21 and showed CMT A. -CMT E said he/she would report it to LPN C. -He/She believed the resident was the only resident that would do something like that. -On 12/16/21, the resident said he/she was upset because he/she was on 15 minute checks. -The shower aide told him/her that the resident had hurt himself/herself. During an interview on 12/20/21 at 2:00 P.M., the DON said they did not have a policy on keeping unsafe items secured such as razors on the locked unit. During an interview on 12/22/21 at 12:51 P.M., Agency CMT E said: -Razors were supposed to be kept locked in the supply closet or in the locked cabinet in the shower room. -If a resident wanted to shave themselves, the staff watched them while shaving. -On 12/15/21, the shower aide said he/she found a razor with missing parts and told him/her and other staff to make sure the shower door was kept closed and locked. -Later on 12/15/21, he/she went to the employee bathroom and found a bunch of bloody paper towels in the trash can. -He/She reported the bloody paper towels to LPN C and Agency LPN D, because of the shower aide finding the razor and because the resident sometimes hid in the area of the employee bathroom. -He/She was not sure what was done regarding the bloody paper towels. -He/She was serving breakfast on 12/16/21 when the resident pulled on his/her call light. -When he/she responded to the resident's call light, the resident said he/she needed a bandage and an [MEDICATION(S)]. -He/She reported the request to the nurse and the nurse went to the resident's room but the resident would not show the nurse what he/she needed a bandage for. During an interview on 12/23/21 at 8:23 A.M., the resident said: -He/She had been having trouble with his/her roommate. -His/Her roommate was paranoid and blaming him/her for stuff. -His/Her roommate left him/her notes telling him/her to stop doing certain things. -The facility knew this for about four or five days. -He/she slept on the floor and in the lobby because he/she was not comfortable being in his/her room with his/her roommate. -The conflict was starting to wear on him/her. -He/She got depressed, anxious and upset so he/she cut himself/herself on the leg with a razor he/she got out of the bathroom. -He/She saw the shower room door was open so he/she went in. -He/She took a razor from off the shelf in the shower room. -He/She cut himself/herself to release tension, not to kill himself/herself. During an interview on 12/17/21 at 12:12 P.M., Physician A said: -The facility should have made sure there was nothing the resident could reach that could harm him/her. -The facility staff should be suspicious that the resident might try to harm himself/herself based on his/her history of self-harm. -The facility staff should notify the DON when a resident expresses the desire to self-harm. -The resident usually caused self-harm, but usually did not try to kill himself/herself. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 697

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to ensure all staff were either vaccinated for COVID-19 (a disease caused by a virus names [CONDITION(S)]-CoV-2), or had an approved or pending exemption. This failure included the tracking and secure documentation of information provided by staff who have requested exemption and ongoing monitoring for compliance of facility staff vaccination/exemption status. The facility census was 99 residents. Record review of facility staff COVID-19 Vaccination policy, revised 10/13/21, showed: -The policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complication form COVID-19 ([CONDITION(S)]-CoV-2) by education and offering staff the COVID-19 vaccine. The following guidance from Centers for Disease Control and Prevention (CDC), and any additional state and local guidelines. -Staff may accept, or change their decision about COVID-19 vaccination unless COVID-19 vaccination mandated. -All Staff were to become and remain fully vaccinated for COVID-19 virus or complete and submit a validated exemption for the COVID-19 vaccination and provide verification. -Employees must provide written evidence of vaccination or the validated exemption to the Director of Human Resource with approval and to be maintained in the employees file. -Exemption and /or reasonable accommodation are not guaranteed. Personal and philosophical reason for not getting vaccinated are insufficient, and request of this nature will be denied. -Options for the employee: --Become fully vaccinated for COVID-19 and provide verification of vaccination. --Complete and have approved a medical exemption/accommodation. --Completed and have an approved a sincerely held religious belief exemption/accommodation. --The medical exemption/accommodation or religious exemption/accommodation forms completed and must be maintained in the employees file. -Requirements for non-vaccinated employees (those approved exemption) include, but not limited to, weekly testing, N95 mask (N95 respirator Mask (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), wearing appropriate eye protection, and maintain six feet social distancing at all times. -Staff documentation related to COVID-19 to include the Staff education regarding the risk, benefits and potential side of effects of COVID -19 vaccine. COVID-19 vaccine status of staff and related information as indicated by NHSN. -Included as part of facility policy was the CMS FAQ for religious belief accommodation and proof needed: A religious exemption requires that you provide details of the sincerely held religious and personal belief and how obtaining COVID-19 vaccine would infringe upon those beliefs. This form must be completed before an exemption will be granted. 1. Record review of the facility staff COVID-19 Vaccination policy, dated 10/13/21, showed the facility policy: -Did not have a documentation of a detail approval process in place for the facility staff member's religious exemption and medical exemption. -Did not have an updated policy to include, but not limited to, the recent change in CMS COVID-19 Vaccine Mandate Ruling as of 1/14/22, which may include and not limited to: --Policy Process for ensuring all staff are fully vaccinated, have a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, prior to providing care. -Process for tracking staff vaccination status to include: --Type of vaccine, date received, and if applicable next scheduled dose --Staff who received booster's vaccines. --Staff granted exemptions with type of exemption and supporting documentation if required. --Staff who are temporarily delayed. --Ongoing process by which staff may request an exemption and the facility process for tracking/documenting exemptions. --Process for ensuring clinical contraindications are signed and dated by a licensed practitioner, identify which COVID-19 vaccines are contraindicated and statement that staff member must be exempted. --Contingency plan for those staff members that not vaccinated to include deadline of compliance. The plans should also indicate the actions the facility will take if the deadline are not met. During interview on 2/23/22 at 5:20 P.M., the Administrator said: -The policy provided was the facility's most updated COVID-19 Vaccination Policy. -He/she was not aware of written Contingency Plans. -Non-vaccinated staff members were to wear mask (either N95 or KN95) at all-times while in the facility and social distance when onsite. During interview on 2/28/22 at 8:30 A.M., the Administrator said: -The facility corporate office staff were responsible for revising the facility's policy. -Facility staff were to complete required paper work for vaccine verification and/or have requested exemption forms by 2/1/22. -He/she would expect new staff member hired, were to either be fully vaccinated, in process of getting vaccinated or have completed an approved exemption form at the time of hire. 2. Review of the facility's COVID-19 staff vaccination documentation showed, the facility had 97 employees. Documentation showed 76.3% of employees received either one or both doses of vaccination, or had a pending or approved exemption. Review of the facility's COVID-19 resident outbreak documentation showed 3 residents tested positive for COVID-19 in the four weeks prior to the onsite review. Record review of the facility staffing vaccine record or exemption record received on 2/25/22 showed: -The facility had 97 active staff members. -The facility had 23 staff members with incomplete vaccine documentation forms for either proof of vaccine or staff requested medical and religious exemption forms. -The documentation on the exemptions forms were incomplete and/or were dated with completion during the time of survey. Record review on 2/23/22 of eight sampled staff members for COVID-19 vaccination record or vaccine exemption request showed 3 out 4 sampled staff who had declined vaccine and had requested an exemption, did not have a completed facility religious or medical exemption form documented on file. Observation and interview on 2/23/22 at 12:00 P.M., Hospitality Aide (HA) A said: -He/she had declined the COVID-19 vaccine. -Had completed the paperwork for declining and exemption upon hire. -He/she was not informed of any special precaution needed to take, since he/she did not have COVID-19 vaccination. -He/she was required to wear a face mask while at the facility, unsure if he/she was required to wear an N95. -He/she was observed wearing a N95 at time of survey. During an interview on 2/23/22 at 2:40 P.M., with the Infection Control Preventionist (ICP) said he/she was not responsible for tracking or trending of the facility staff COVID-19 vaccination status. The Administrator and Human Resource (HR) personnel were responsible for staff documentation and tracking of staff vaccine and vaccine exemption. During interview on 2/23/22 at 5:20 P.M., the Administrator and Director of Nursing (DON) said: -The facility staff COVID-19 vaccine status had been maintained by Human Resources (HR) personnel. -HR staff were responsible for the documentation, tracking, and record keeping of the facility staff COVID-19 vaccine and exemption forms. -HR staff were responsible for obtaining the exemption forms from non-vaccinated staff and placing the exemption form into the employee file. -The facility administration was having a hard time locating staff vaccine records and exemption forms after the HR staff member left employment. -The facility currently did not have a HR staff member, he/she may have not obtained completed exemption forms or he/she may had destroyed part of the facility staff vaccine records. -The Administrator was responsible for entering vaccine status into CDC's National Healthcare Safety Network (NHSN, is the nation's most widely used healthcare-associated infection tracking system) weekly upon receipt from the HR staff member. During interview on 2/28/22 at 8:30 A.M., the Administrator said: -The facility's staff vaccine status report received on 2/23/22 and dated 2/17/22 showed: --It was not a current record for the facility staff vaccine status. --The record had 11 inactive employee information and the previous HR staff member had not accurately documented vaccine or vaccine exemption and probably had resulted in the facility's missing staff vaccine status information. -The facility Office Manager was assigned the responsibility for maintaining the employee vaccination status and would be obtaining required staff vaccine verification records or any vaccine exemption forms. -The Corporate office had let go their corporate HR Manager. -He/he would have assisted the facility pervious HR staff member with monitoring of the facility staff vaccine status for accuracy and compliance.

Based on observation, interview and record review, the facility failed to provide supervision to prevent elopement for one sampled resident (Resident #40) out of 20 sampled residents, who were identified at risk on the facility elopement risk assessment and whom presented as exit seeking by wandering. On 5/6/21 at 9:00 P.M., the resident eloped from the the secured unit and went out the North door. The secured unit staff did not hear the alarm and did not know the resident was outside. The resident on return was placed on 15 minute checks. The resident room location was outside of the nursing station view behind plastic sheeting. On 5/6/21 at 11:00 P.M., the East door alarm sounded. Licensed Practical Nurse (LPN) C was the only staff on the unit, the certified nursing assistants (CNAs) had left the unit at approximately 10:00 P.M. and a CNA did not return until after 2:00 A.M. The nurse went to the East door, shut off the alarm, first checked the resident's room, the nurse had to pass the resident's room to get to the East door and found he/she was not in his/her room, and then walked outside to the North side of the building. He/she did not see the resident. The resident was not found. A code pink was called. A facility staff person found the resident about 3/10th of a mile away in a nearby neighborhood. The resident was returned to the building at 11:15 P.M. There was only one facility staff person on the unit at the time of the second elopement. The facility census was 112 residents. The Administrator was notified on 5/10/21 at 3:15 P.M. of an Immediate Jeopardy (IJ) which began on 5/6/21. The IJ was removed on 5/12/21 as confirmed by surveyor onsite verification. Record review of the facility Emergency Procedure Missing Resident Policy dated August 2018 showed: -Residents elopement resulting in a missing resident is considered a facility emergency. -Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. -Announce CODE PINK with the resident's room/unit number. -Note the time that the resident was discovered missing. -Report to the nursing station to see if the resident was signed out. -Notify the Administrator, Director of Maintenance and Director of Nursing if not on the premises. -Report to the resident's unit for a briefing and instructions. -Initiate a thorough search by staff members to locate the resident. -If the resident is not located, proceed with the following: --Instruct staff members to search the entire facility, grounds and neighboring streets. --Assign each staff member a section to search in order to minimize overlapping of or overlooking an area. --When conducting a search, it is important to look under the beds and furniture, in the walk-in refrigerators/freezers, in closets, under desks, behind doors, as well as in storage rooms, behind boxes, in boxes, and on shelves. A resident who has eloped may be frightened and may be hiding. Being thorough is extremely important. --Instruct staff to report to the Administrator/Incident Commander when finished searching a section. -If the search is unsuccessful after a period of ten minutes, call the police to report the resident missing. -Notify the family/responsible party and attending physician if the resident is not found in the facility or the grounds. -Examine the resident for injuries. -Update care plan. -Evaluate implementing additional measures, such as the addition of a wander bracelet if not in current use and 15 minute safety checks, and document in the resident record. -Complete an incident report and follow the facility's incident reporting process. --Emergency Management Color Codes: ---Missing Resident (Code Pink) 1. Record review of Resident #40's Admission Record showed the resident was admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE] with the following diagnosis: -Dementia (loss of memory, language, problem-solving and thinking abilities that are severe enough to interfere with daily living) with Behaviors (include agitation, verbal and physical aggression and wandering) -Restlessness and Agitation -Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the resident's Wandering Risk Scale dated 8/25/20 showed he/she: -Was a high risk to wander. -Had a history of wandering. -Medical diagnosis of dementia/cognitive impairment. -Had wandered within the home without leaving grounds. -Had wandered in the past month. Record review of the resident's Baseline Care Plan dated 5/6/21 at 12:09 P.M. showed the resident: -Was cognitively impaired. -Could communicate and understand staff. -Walked independently without assistive devices. Record review of the Facility Daily Staffing Sheet for the Serenity Court (the facility secured unit) dated 5/6/21 showed: -Licensed Practical Nurse (LPN) C came in at 6:00 P.M. -CNA H was scheduled and did not come to work, as evidenced by his/her timecard. -The unit was comprised of two halls, East and West with 25 residents. Record review of the facility timecard dated 5/6/21 showed: -LPN C punched in at 5:55 P.M. on 5/6/21. -CNA H had no record of timing in or out on 5/6/21. Record review of the resident's Nurse's Note dated 5/6/21 at 9:29 P.M. showed: -Unit 2 nurse LPN D had brought resident back stating the resident was outside. -Maintenance notified that alarm on north exit door is too quiet for staff to hear while staff are in resident's rooms. -Responsible party notified. -Resident placed on 15 minute checks. -There was no Incident Report filled out for the elopement on 5/6/21 at 9:29 P.M.; and the DON, Administrator, and Physician were not notified. -The nurses note did not show assessment upon resident return. Record review of the resident's Wandering Risk Scale dated 5/6/21 at 10:15 P.M. showed the resident: -Was a high risk to wander. -Had a history of wandering. -Medical diagnosis of dementia/cognitive impairment. -Had wandered aimlessly within the home or off the grounds. -Had wandered in the past month. Record review of the resident's Elopement Incident Report dated 5/6/21 at 11:00 P.M. showed: -Alarm to east door sounded. -Upon checking resident's room, resident not present. -Resident previously placed on 15 minute checks and located at 10:45 P.M. -LPN C went out the east door and walked around to the north door and entered into the facility via the north door and did not see the resident -DON notified of possible elopement 11:01 P.M. -CODE PINK announced over Intercom and staff dispersed to check rooms and outside building/street/highway. -Two staff members designated to circle around the building to search premises for missing resident. -Notified Responsible party at 11:37 P.M., DON at 11:33 P.M. and physician at 11:35 P.M. -Department of Health and Senior Service (DHSS) report submitted. -Resident was recovered at 11:12 P.M. on 5/6/21. -Resident was brought inside and assessed for injury. -No injuries were observed at time of incident. -Resident placed on 1:1 monitoring (one staff member to stay with the resident at all times) for safety at this time. -Awaiting further evaluation. -Code PINK called and resolved. -Wandering assessment updated and care plan to be updated. -Staff assisted the resident into a vehicle and was returned to the facility. -Upon arrival, DON assessed resident's situation and evaluated East door to ensure the door was secure and armed to sound upon use. -Resident remains exit seeking at that time, but is pleasant and re-directable. -No apparent injuries at that time. -Facility immediately educated staff on notification of DON, administrator, physician and responsible party. -Education reinforced on elopement (Code PINK) Policy and Procedures. -Resident oriented to person and place. -Active exit seeker. -Resident appears uncomfortably anxious and does not understand why he/she is in the facility. -Reorientation techniques and distraction the resident is minimally responsive to. -No witnesses found. Record review of LPN D's facility statement dated 5/6/21 showed: -At 9:15 P.M., the resident was noted walking west on the sidewalk, directly in front of the building. -The resident asked LPN D for a ride home. -LPN D redirected the resident back into the building, back to his/her locked unit on Serenity, in the care of the unit charge nurse. -A voice mail was left on the DON's phone and LPN D returned to her unit. -At approximately 11:06 P.M., he/she had timed out and was on his/her way home. -He/she was notified by LPN C the resident had exited the facility. -He/she was driving and noted a gentleman standing in the motel parking lot (before you reach the liquor store). -The gentleman stated he/she did see the elderly man walking and he/she went in the direction of the subdivision across the street (business route Highway 13). -The resident was noted in the neighborhood and returned to the facility by Hospitality Aide (HA) A via his/her pickup truck without further incident. -LPN D contacted the DON who gave instructions for the resident to be placed on 1:1. Record review of the resident's facility 15 Minute Check Sheet dated 5/6/21 showed: -The resident was on 15 minute checks and was at the Nurse's desk at 9:30 P.M. and 9:45 P.M. checks. -The resident was in the common area at 10:00 P.M. and 10:15 P.M. -At 10:30 P.M. and 10:45 P.M., the resident was standing by the North door which leads outside. -At 11:00 P.M., no notation regarding where the resident was, left blank. -11:15 P.M. and 11:30 P.M., resident sitting at a table drinking coffee. -11:45 P.M., resident tried to get out of the facility. -There was no documentation of the resident being on 15 minute checks or 1:1 monitoring on 5/7/21 from 2:30 A.M. to 10:00 P.M. Record review of the resident's Nurse's Note dated 5/6/21 at 11:01 P.M. charted by LPN C showed: -The alarm to the east door sounded. -Upon checking resident room, resident not present. -He/she exited same door for inspection and no resident was seen. -DON notified of possible elopement. -Code Pink announced over intercom and staff dispersed to check rooms and outside the building/street/highway. -Awaiting resident return. -At 11:00 P.M., resident located by staff east of business route Highway 13 on a dead end road. -Staff member pulled vehicle alongside the resident and asked if he/she needed a ride. -The resident entered the staff members vehicle of own accord and without assistance. -Staff then returned to the facility with the resident and was able to convince the resident to enter the building by promising him/her a cup of coffee. Record review of the resident's Nurse's Note dated 5/7/21 at 12:23 A.M. showed: -Resident returned to room and got into bed. -1:1 initiated with resident's return to the facility and continues. -The nurses note did not show assessment upon resident return. During an interview on 5/7/21 at 1:40 P.M., LPN B said: -The resident was admitted to the facility on his/her shift. -At first the resident's daughter told the resident that he/she was at the facility to see someone. -The resident ate lunch and the staff took the resident back to his/her room. -The daughter wanted him/her here so when the spouse would be admitted he/she could help him/her adjust. -The spouse was in the hospital. -He/she took a nap for a while in the P.M. before 3:00 P.M. -He/she came to the dining room before supper and was just hanging out. -He/she made comments about why he/she was at the facility, he/she could stay at his/her house and visit his/her spouse. -He/she kept pacing between his/her room and the dining room with no attempts to get out of the exit doors. -That is why he/she scored high on the Wandering Assessment. -LPN B expected the staff to maintain eye contact with the resident. -LPN B peeked in the resident's room. -The resident's room was down the far hall behind plastic doors. -The resident was placed in the middle zone for observation. During an interview on 5/7/21 at 2:36 P.M., CNA C said: -He/she was on the secured unit to place some clothes in the soiled utility room, between 9:30 P.M. and 10:00 P.M. on 5/6/21. -The resident said he/she wanted to go home. -He/she saw the resident roaming around the nurse's desk off the resident's secured unit between 9:30 P.M. and 9:45 P.M. -He/she did not think the secured unit realized the resident was missing. -He/she returned the resident back to the secured unit. During a phone interview on 5/7/21 at 3:00 P.M. LPN C said: -He/she was the charge nurse on evening shift last night (5/6/21). -There were two CNAs and him/herself. -There was enough people to supervise the unit. -He/she was administering medications and the CNAs were assisting residents in getting to bed. -There was not any staff members watching the nursing station main area. -He/she was behind the quarantine area. -The two aides were transferring another resident with the Hoyer lift, the first time the resident got out from the North door on the secured unit. -He/she said the North door alarm was too quiet to be heard in the rooms. -He/she did not hear the alarm after the door was opened. -Even if the staff heard the alarm, the two aides would not have left the other resident until the transfer was complete. -The second time the resident had been at the nurse's station,he/she then walked towards the North door turned around and walked away and walked towards his/her room which is behind the plastic partition. -Some amount of minutes after that, LPN C heard the East door alarm. -He/she deactivated the alarm and walked outside to see if the resident was just outside. -He/she walked around the building on the north side and came back in the facility. -He/she did not see the resident during his/her walk around the building. -That was at 11:01 P.M. on 5/6/21, -He/she came back onto the secured unit through the north door. -He/she checked the rooms while on the phone with the supervisor. -Then he/she returned to the desk and called a Code Pink. -This took place right after the East door alarm went off. -One of the staff members found the resident across Highway 13, close to a red building by the HA A. -He/she did not leave the building with HA A to see where the resident was found. During a follow up phone interview on 5/8/21 at 1:40 P.M., LPN C said: -He/she was by him/herself for about 15 minutes or more, but the true amount of time is unknown. -He/she was by him/herself during the time of the second elopement. -He/she did implement the 15 minute checks. -The resident was near the nurse's station, so he/she was able to watch the resident. -The resident left the area for two to three minutes prior to the time the alarm was activated. -He/she did not initiate a Code Pink during the first elopement because he/she was not aware of an elopement because both CNAs were in a room assisting another resident and he/she was passing medications. -It is difficult to see the rooms beyond the plastic sheeting. -He/she said that is where the new admits rooms are. -He/she could CNA on the evening shift because of wanderers and sundowners syndrome (a state of confusion occurring in thenot realistically keep an eye on the residents who are behind the plastic sheeting. -The secured unit is typically understaffed with one CNA and one LPN on the evening and night shift. -He/she believes the secured unit needs an extra late afternoon and spanning into the night, which can contribute to behaviors, such as confusion, anxiety, aggression or ignoring directions). During observation of the path the resident took during the second elopement on 5/10/21 at 9:46 A.M. showed: -The resident exited the east door. The view of the hallway is blocked from view by a plastic partition. -The resident's room was also behind the plastic partition. -He/she walked to business route Highway 13, walked down business route Highway 13 and crossed the highway at some point in time and was found about a half of a mile north of the facility walking down a dead end street by four lane Highway 24. -There were no street lights or sidewalks on business route Highway 13 and it was dark outside at the time of the elopement. During an interview on 5/7/21 at 2:45 P.M., the Admissions Coordinator said: -He/she spoke with the resident's family member before admission. -The resident's family member told him/her the resident needed more care and supervision. -The resident needed reminders about eating, showering and medications. During an interview on 5/7/21 at 2:05 P.M., the resident's family member said: -He/she brought the resident to the facility around 11:30 A.M. on 5/6/21. -The resident wandered from his/her house to a caretaker's house across the street. -The facility was notified about the resident's wandering behaviors. -He/she spoke to the Admission's Coordinator about the resident's wandering. -He/she had provided the resident was upset and did not want to be at the facility. -The resident was strong willed and wanted to leave the facility. -The attempted elopement did not surprise him/her. -He/She thought he/she eloped twice but only received one call from the facility. -He/she asked if the resident was okay and that he/she was back in the facility. During an interview on 5/10/21 at 12:41 P.M., the physician said: -The staff should have put the resident on 1:1 monitoring the first time the resident got out of the facility earlier that night. -He/she was not notified of the first elopement. -The resident's dementia has gotten worse. -The resident was told he/she was going to visit his wife when admitted to the facility. -The resident should have been placed closer to the nurse's desk unless a staff member was going to sit in the COVID area (where new resident come to the facility without COVID test or shots to quarantine for 10 days) for 10 days. -The resident was here before and was a high elopement risk then. -The staff should have kept a better eye on the resident since he/she was exit seeking. During observation on 5/10/21 at 6:00 P.M. showed: -The north alarm sound was very low in volume. -Maintenance had put an additional alarm on the door until the door company could come and turn the alarm up in volume. -The additional alarm was a bed/chair alarm set up to go off when the door was opened. -No alarms were on the plastic partition doors. -The facility could not put an alarm on the first plastic door because the facility still had residents staying in the rooms behind the plastic partition with no set staff behind it. -The facility could put an alarm on the second plastic door to give the staff a head start before the residents made it to the east door and possibly outside. -The resident was observed behind the plastic partition trying to go out the east door. -The plastic partition is cloudy and cannot be seen through. -The alarm sounded and LPN C went to check the east door. -When LPN C opened the plastic door the resident was standing on the other side. -The resident was on 15 minute checks at that time. -The DON placed the resident on 1:1 supervision for safety until further notice. -The facility had put a louder alarm on the north door so it could be heard in the resident's rooms on the Serenity Unit with the doors closed. During an interview on 5/10/21 at 10:03 A.M., the Administrator said: -He/she was not notified of the first elopement. -He/she would have put the resident on 1:1 monitoring for resident safety. During an interview on 5/10/21 at 10:13 A.M., the DON said: -He/she was not notified of the first elopement or he/she would have come to the facility and had LPN C put the resident on 1:1 supervision. -He/she was called about an hour after the second elopement. -He/she got to the facility around 12:30 A.M., and started educating the employees that were on shift. During an interview on 5/12/21 at 12:50 P.M., LPN G said: -He/she was educated on Friday night 5/7/21 on the Elopement Policy, door alarms and when and who to notify if an elopement. -He/she was on the secured unit two days and there was not enough help to keep up with the residents. During an interview on 5/12/21 at 4:03 P.M., the DON said: -He/she did not know the facility was short staffed until LPN C called about the elopement. -He/she cannot fix the staffing if he/she is not notified that a staff member did not show up for work. -He/she would have came to the facility earlier if he/she had known of the staffing shortage. -LPN C told the DON that he/she could handle the secured unit all by him/herself, but the DON said, no, there needs to be at least a CNA on the unit also. -The daily schedule was in real time on the tablet to show who is working where. -That way the schedule sheet is not all scratched out and a mess. -If the staff member does not come to work, the staff member filling that spot just puts his/her name in the spot he/she is covering. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 004 & MO 005

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #6) was free from a significant medication error by giving a medication without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's Adverse Consequences and Medication Errors dated 4/2014 showed: -Residents receiving any medication that has a potential for an adverse consequence (an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status) will be monitored to ensure that any such consequences are promptly identified and reported. -A medication error is the preparation or administration of drugs or biological which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Unauthorized drug, a drug that is administered without a physician' order. -In the event of a significant medication-related error or adverse consequence, immediate action is taken as necessary, to protect the resident's safety and welfare. -The physician is notified promptly of any medication error or adverse consequence. -The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Record review of Resident #6's Admission Record showed the resident was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -[CONDITION(S)] in both eyes. -Abnormalities of gait and mobility (a walking abnormality, person cannot walk in the usual way). -Repeated falls. Record review of the resident's Discharge Assessment Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 6/16/20 showed: -The resident was cognitively intact. -The received antianxiety medication once in the last seven days. Record review of the resident's Baseline Care Plan dated 6/12/20 showed: -The resident was not taking any anxiety medications. -The resident did not have visual impairment but the resident did wear glasses. Record review of the resident's Order Summary Review dated 6/19/20 showed: -[MEDICATION(S)] (Lorazepam) Tablet 1 milligram (mg), give every eight hours as needed for agitation for 14 days, start on 6/17/20. --No order for Lorazepam 0.5 mg. -The order for Lorazepam 1 mg was received after Lorazepam 0.5 mg tablet was administered to the resident on 6/16/20. Record review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Lorazepam 0.5 mg administered to the resident on 6/16/20. --No valid physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Nurses Note on 6/16/20 showed: -RN C borrowed Lorazepam 1 mg from Resident #24 on 6/16/20. -He/She broke the Lorazepam 1 mg tablet in half and administered the half tablet to Resident #6. -No documentation what RN C did with the other half of the Lorazepam 1 mg tablet. Record review of the resident's Individual Narcotic Records showed: -No documentation Lorazepam 0.5 mg was ordered, received, or was available for administration for the resident. -No documentation Lorazepam 1 mg was received or available for administration for the resident. Record review of an undated note left for the resident's physician written by RN C showed: -Doctor, Resident #6 was very agitated and hard to control. -RN C called the resident's family member to talk to him/her. -The family member suggested that RN C give the resident [MEDICATION(S)] 0.5 mg, which RN C did. -Could he/she please get an as needed (PRN) order for [MEDICATION(S)] 0.5 mg in case the resident becomes unruly. -The resident's gait was very unsteady and he/she was a fall risk. Record review of Resident #6's Nurse's Note dated 6/17/20 at 3:18 A.M. showed: -The resident was convinced he/she was going home this hour of sleep and his/her family member was coming to pick him/her up. -RN C called the resident's family member to convince the resident otherwise. -The family member talked to the resident on the phone and he/she became irate. -The family member suggested to give the resident 0.5 mg of [MEDICATION(S)] to calm the resident down. -RN C gave the resident a one half of another resident's (Resident #24) [MEDICATION(S)]. -Soon the resident was much more [NAME] and agreed to go to bed. 2. Record review of Resident #24's Admission Record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Stroke. -Memory Deficit (general cognitive decline and failure of the memory process). -Cognitive Communication Deficit (difficulty with thinking and how someone uses language). -Depressive Episodes (periods of feeling sadness and loss of interest and can interfere with daily function). Record review of the resident's Quarterly MDS dated [DATE] showed: -The resident was moderately cognitively impaired. -The resident receives antianxiety medications seven days a week. Record review of the resident's Care Plan date 12/11/19 showed: -The resident had potential to be physically or verbally aggressive towards others. -Administer medications as ordered. 3. Record review of the facility's Medication Error Report dated 6/17/20 showed: -On 6/16/20, Resident #6 was walking down the hall as Registered Nurse (RN) C was getting ready to assist another resident. -Resident #6 was telling RN C that his/her family member was coming to pick him/her up and he/she was going home that night. -RN C sat Resident #6 down in one of the easy chairs. -He/she stood back up and was staggering and unsteady on his/her feet. -RN C was worried the resident was going to fall. -RN C tried to convince the resident that he/she was not going home tonight. -The resident became agitated and would not sit down. -RN C told the resident to use his/her walker if he/she was going to get up. -The resident would not use the walker. -After so many minutes of the resident's agitation and poor safety awareness, refusing to sit down or use the walker, RN C called the resident's first family member and left a message to call back. -The second family member talked to the resident for a while but the resident was getting agitated at his/her family member because he/she would not come and get him/her from the facility. -The first family member called back and was quite concerned because he/she did not feel the resident was ready to come home yet. -At that point the resident was very agitated and stated things would be different when he/she goes home. -The first family member asked to speak to RN C and stated that when the resident was like that at home he/she would give the resident 0.5 mg of [MEDICATION(S)] (Lorazepam) and the resident would calm down. -RN C assumed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -RN C removed an [MEDICATION(S)] 1 mg tablet from Resident #24's medication supply and broke it in half and gave the [MEDICATION(S)] to Resident #6. -Resident #6 calmed down and was escorted back to his/her room and went to bed. -RN C called the resident's physician at 6:30 A.M. on 6/17/20 and asked for an as needed order for [MEDICATION(S)] and the physician said Resident #6 probably needs 1 mg of [MEDICATION(S)] three times a day as needed for 14 days. Immediate Action Takes: --The Director of Nursing (DON) notified the physician, resident, regional nurse consultant of the medication error. --DON and Assistant Director of Nursing (ADON) had a conference with RN C. --The DON received report from the physician that he/she did not give the order for [MEDICATION(S)] 0.5 mg during the incident. --He/she did give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Record review of the facility's Suspension Pending Investigation dated 6/18/20 showed: -Reason for suspension was RN C operated outside of the scope of practice. -RN C was suspected of administering a benzodiazepine (antianxiety medication)/Narcotics to Resident #6 without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 3/11/21 at 9:43 A.M., RN A said: -He/she would call the physician and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she would never share a resident's medication with another resident. -If a resident ran out of a medication, staff should check the Emergency kit (E-Kit - hold medications in case of an emergency) to see if the medication was there, if not then staff should call the physician and get an order to hold the medication or get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -He/she would chart on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -He/she would write a progress note on what took place. During an interview on 3/11/21 at 10:25 A.M., DON said: -Nurses should never give a medication without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Nurses should never remove medications from one resident's medication supply and give that medication to another resident. -Borrowing medications was not acceptable and should be reported to the proper agencies as misappropriation of property. -An investigation should be done on the incident. -If the medication had not arrived from the pharmacy, staff should call the resident's physician and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -Nurses should check the E-kit to see if the needed medication was in the E-kit and pull the medication from there and administer the medication to the resident as ordered by the physician. -RN C was suspended for another incident and terminated on 6/25/20. During an interview on 3/11/21 at 11:56 A.M., the acting administrator said borrowing medications should be reported and investigated. During an interview on 3/16/21 at 11:58 A.M., the physician said: -He/she would expect the facility nurse to call and get an order before administering any medications. -Resident #6 did not have any bad outcome from taking the medication. During an interview on 3/17/21 at 2:20 P.M., RN C said: -He/she was afraid that Resident #6 was going to fall and was refusing to use his/her walker. -Resident #6 was very agitated and would not stay sitting in a chair. -He/she called the resident's family member and he/she said at home he/she would give the resident [MEDICATION(S)] 0.5 mg and the resident would calm down. -He/she borrowed an [MEDICATION(S)] 1 mg from Resident #24 and broke it in half and gave half of the tablet to Resident #6. -He/she then called the resident's physician and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #6 [MEDICATION(S)] without an order. -Resident #6 calmed down and went to bed and slept the rest of the night. MO 722

Based on observation, interview and record review, the facility failed to ensure preventative measures were in place for development of pressure ulcers resulting in an avoidable unstageable pressure ulcer on the right heel for one sampled resident (Resident #35); failed to ensure preventative measures were in place, failed to assess, monitor, track and stage the resident's pressure ulcers, failed to obtain physician's treatment orders for treatment of [REDACTED].#25) who had avoidable pressure ulcers including a right thigh blister, a blister on the back of his/her left leg, a right planter foot unstageable pressure ulcer, and an unstageable pressure ulcer on his/her left great toe; failed to correctly assess and document the stage for one resident's (Resident #50) unstageable pressure ulcer on his/her left gluteal fold (crease between the lower buttocks and upper thigh); and failed to assess for support surface needs (mattress) and prevention needed for one sampled resident (Resident #19) who was at risk for pressure ulcers out of 32 sampled residents. The facility census was 65 residents. Record review of the facility's Wound Care Policies and Procedures Reference revised 6/1/15 showed: -Stage2 pressure ulcers: (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue). It may also present as an intact or open/ruptured blister); --Goals: Prevention of progress through relief of pressure, absorption of drainage; moist wound healing; protection from injury; --If a resident was on a standard mattress, replace with a pressure redistributing mattress; --If friction was the suspected injury as to the feet and heels, wear loose white cotton socks while in bed; --Apply a [MEDICATION NAME] dressing (an adhesive dressing which had combined absorbent materials with an adhesive substance to manage and contain light to moderate drainage) extending beyond the wound bed by 1 ½ to two inches; -Stage 3 pressure ulcers: (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining (is caused by erosion under the wound edges resulting in a large wound with a small opening) in or tunneling (is a channel or tunnels that extend into the subcutaneous tissue under the skin). --Goals: Prevention of progress through relief of pressure, absorption of drainage; moist wound healing; protection from injury; insulation of wound bed; --Relieve pressure to the area though a turning schedule or elevate the area. --If the resident was on a standard mattress, replace with either a pressure redistributing mattress or a specialty surface; --If friction was the suspected injury as to the feet and heels, wear loose white cotton socks while in bed; --Clean with normal saline and evaluate the wound bed; apply a skin sealant around the wound bed and pack with gel impregnated gauze (packing dressing for wounds with depth); -Stage 4 pressure ulcers: (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (tan, brown or black dead tissue)may be present on some parts of the wound bed. Often includes undermining and tunnelling); --Moderate amount of drainage and less than 50% slough in the wound bed; --Goals: Prevention of progress through relief of pressure, absorption of drainage; moist wound healing; protection from injury; insulation of wound bed; --Relieve pressure to the area though a turning schedule or elevate the area. --If the resident was on a standard mattress, replace with either a pressure redistributing mattress or a specialty surface; --Clean with normal saline and evaluate the wound bed; apply a skin sealant around the wound bed and pack with gel impregnated gauze; -Unstageable pressure ulcers: (Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar); --Relieve pressure to the area though a turning schedule or elevate the area. --If the resident was on a standard mattress, replace with either a pressure redistributing mattress or a specialty surface; --If friction was the suspected injury as to the feet and heels, wear loose white cotton socks while in bed; and --Clean with normal saline and evaluate the wound bed. 1. Record review of Resident #35's Face Sheet showed the resident was admitted to the facility on [DATE] and with the following Diagnoses: [REDACTED]. -Muscle Weakness; -[MEDICAL CONDITIONS] disease of the arteries and veins of the extremities); and -Cognitive communication deficits. Record review of the resident's significant change Minimum Data Set (a federally mandated assessment tool required to be completed by facility staff for care planning) dated 7/7/18 showed: -The resident was severely cognitively impaired; -Did not reject cares; -Needed extensive assistance with bed mobility, transfers, and dressing; -Was incontinent of bladder and occasionally incontinent of bowels; -Used a wheelchair; -Was at risk for the development of pressure ulcers; and -Did not have prevention in place to prevent pressure ulcers including no turning or repositioning schedule or a pressure reducing mattress. Record review of the resident's pressure ulcer Care Plan dated 7/10/18 showed: -The resident had the potential for pressure ulcer development related to immobility, incontinence, and his/her Braden score risk (a tool completed by staff to show if the resident was at risk of developing pressure ulcers). Record review of the resident's Braden Scale for Predicting Pressure Sore Risk dated 7/22/18 showed the resident was at moderate risk for developing pressure ulcers. Record review of the resident's Pressure Ulcer Risk Evaluation Prevention Intervention Protocol dated 7/22/18 showed the resident was at moderate risk for developing pressure ulcers. Record review of the resident's Weekly Skin assessment dated [DATE] showed: -The resident's skin condition was dry and had redness; and -The buttock area was circled on the body site area. Record review of the resident's Weekly Skin assessment dated [DATE] by Licensed Practical Nurse (LPN) D showed: -The resident's skin condition was dry and had redness; and -The back of the legs were circled on the body site area. Record review of the resident's Weekly Skin assessment dated [DATE] completed by LPN A showed: -The resident's skin condition was dry and the resident had blisters; -The areas affected were the hip area and ankle area; and -The right hip area was circled on the body site area. Record review of the resident's Nurse's Notes dated 9/22/18 at 3:45 A.M., completed by Licensed LPN D showed: -The resident had a blister on the back of the right heel that has lost fluid, the skin was loose and intact; -The nurse would continue to monitor; and -There were no physician's order for treatment of [REDACTED]. Record review of the resident's Nurses Notes dated 9/23/18 at 2:00 A.M. showed: -The resident had a raised area to his/her right heel; -The resident's right heel was cleaned and gauze was applied; and -There were no physician's order for treatment of [REDACTED]. Observation on 9/24/18 at 12:21 P.M., showed: -The resident was in his/her wheelchair in the dining room; -Had on pink low ankle socks and his/her feet were resting on the foot pedals of his/her wheelchair; and -His/her ankles and legs appeared severely swollen. Record review of the resident's Nurses Notes dated 9/24/18 completed by LPN D showed new physician's orders were received for Skin Prep (a topical barrier for use between skin and adhesives) to the back of the right heel daily until healed for open area. Record review of the resident's Physician's Orders Sheet (POS) showed: -On 9/24/18: Skin Prep to the back of the right heel daily until healed; and --This physician's order was received two days after the right heel pressure ulcer was identified by the staff. Observation on 9/26/18 at 10:00 A.M., showed the resident: -Was sitting in his/her wheelchair at the dining room table with her head resting on the table; -Was wearing white anklets socks and his/her feet were resting on the dining room floor; -The residents feet and ankles were swollen; -LPN B wheeled the resident to his/her room; -LPN B removed the resident's right sock and the sock was wet; -The resident had a blister to his/her right lateral (outside) heel that had popped; the skin from the blister was laying over the wound bed and you could not assess the wound bed; -The wound was the size of a golf ball and the popped blister was draining clear drainage; -LPN B washed his/her hands and put on gloves and applied skin prep to the resident's popped blister; -LPN B and Certified Medication Technician (CMT) A transferred the resident to his/her bed and laid the resident on his/her left side facing the wall; and -The resident's mattress was a regular foam mattress, the staff did not float the resident's heels with a pillow or apply bunny boots or another pressure reducing boot to prevent further skin breakdown to his/her heels. Record review of the resident's Nurses Notes dated 9/26/18 showed: -The resident's right heel blister had erupted; -The resident's physician was notified and gave new orders to apply Triple Antibiotic Ointment (TAO) and cover with a border dressing (a self-adherent, bordered foam dressing) daily and as needed; and -The staff were to contact the outside wound company to evaluate and treat the resident's blister. Observation on 9/25/18 at 12:30 P.M. showed: -The resident was in his/her wheelchair in the dining room; -Had on pink low ankle socks and his/her feet were resting on the foot pedals of his/her wheelchair; -The ankle socks appeared very tight around his/her ankles; and -His/her ankles and legs appeared severely swollen. Record review of the resident's (MONTH) (YEAR) Physician's Orders Sheet (POS) showed: -On 9/26/18: The skin prep order to the back of the right heel was discontinued; and -On 9/26/18: Clean the right heel with normal saline the apply TAO and cover with a border dressing; contact the outside wound company to evaluate and treat. Observation on 9/27/18 at 8:37 A.M. showed: -The resident was lying in bed on his/her right side; -The resident's heels were lying flat on a regular mattress; and -There were no pillows floating the resident's heels or in between the resident's knees. During an interview on 9/27/18 at 8:40 A.M., CMT A said: -He/she would turn the resident side to side but the resident was combative; -The resident would sometimes let him/her turn him/her in the bed but not often; -The resident had a spot on his/her heel; -The resident has heelbo (Heel/Elbow Protectors protect the elbow or heel from abrasion and promotes healing of pressure ulcers) socks at night; --Observation showed the heelbo cushion sock in the resident's night stand drawer and not on the resident; -The resident wore non-skid socks during the day; -The resident did not wear bunny boots (soft padded boots) or (Pressure Relief Ankle Foot Orthosis-Prafo, a device that is worn on the calf and foot similar to a boot and is often used for patients that spend the majority of their time in bed to prevent pressure ulcers from developing on the back of the heel or for patients who are ambulatory ) boots; -The nurse would assess the residents' wounds; and -CMTs were not to assess the residents' wounds. During an interview on 9/27/18 at 8:51 A.M.; CMT B said: -In bed, the resident rubbed his/her leg a little bit and got a wound on his/her heel; -He/she was not sure who found the resident's wound; -He/she saw a little redness on his/her heel a couple weeks ago and he/she reported it to LPN A; -He/she thought skin prep was being applied to the heel; -He/she had completed the skin prep treatment to the heel when it was red; -He/she did not treat pressure ulcers but could put skin prep on a red area; -He/she would also treat open wounds like skin tears; -He/she used pillows to float the resident's heels because he/she could not find the resident's bunny boots; -He/she would put pillows in between the resident's knees; -He/she would put a pillow between his/her feet so the heel did not touch the bed when he/she put him/her to sleep; and -The resident would occasionally be combative. Observation and interview on 9/27/18 9:02 A.M., the Assistant Director of Nursing (ADON) showed/said: -He/she had looked at the resident's heel and the wound was not draining at that time so the physician's orders for treatment might not be appropriate; -The Resident was in bed and the resident's right heel was lying flat on a regular mattress with no pressure prevention; -Since there was no drainage today he/she needed to call and get a more appropriate treatment; -The resident's left foot had a discolored area to the right ankle which was small and dry; -The ADON had a wound measuring device; -He/she had not been told of the resident's ankle blisters; -The area was non-blanchable (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue); -He/she could not see the wound bed on the dark area which could be unstageable; -He/she was responsible for completing all the wound measurements when a resident developed a wound at the facility and would also would assess the wounds; -The resident had a blister that was being skin prepped and the blister broke was a possibility; -No one reported the blister to him/her; -The resident should have heel protectors on his/her feet; -The resident was not combative during treatment; -The resident's right heel blister had 60% epithial tissue (line the outer surfaces of organs and blood vessels throughout the body), 40%-red/purple which would make the wound an unstageable pressure ulcer; -The pressure ulcer to the resident's right heel measured 6.0 centimeters (cm) in length by 5 cm in width; -The darkened area was by 4.2 cm in length and 3.7 cm in width for the unstageable part of the pressure ulcers pressure ulcer; -There was redness to the right lateral ankle that was blanchable that needed to be watched closely; -The resident's pressure ulcer on his/her heel was caused by pressure; -The blister was fluid filled and then it opened; -The resident needed an alternating low air loss pressure mattress and heel protectors; -The staff should not be placing socks and shoes on the resident during the day; -The ADON cleaned the heel with wound cleanser; -The ADON put TAO on the right heel and with covered the heel with border gauze; -This was the physician's order but he/she would call the physician for a more appropriate treatment order; and -The resident was on a solid foam mattress. During an interview on 9/27/18 at 9:40 A.M., LPN A said: -For pressure ulcer prevention, the resident had moisture barrier cream to his/her buttocks; -The resident's right heel area was getting skin prep to it when LPN A returned to work on 9/24/18; -The area had been wrapped with kerlix (woven gauze that is non-adhesive used to wrap wounds and burns); -When the kerlix was taken off it tore the resident's right heel pressure ulcer open; -He/she was not sure if the ADON was informed; -The right heel was breaking down; -He/she was the charge nurse for the unit but was in the office this week completing MDSs so he/she has not been on the unit; -He/she had worked on the unit over the weekend and had gone to assess the resident's right heel pressure ulcer this past weekend; -He/she wrote it down on the Weekly Skin Assessment sheet (dated 9/22/18); -The resident had a blister with skin prep being applied; -He/she did not assess or measure the resident's right heel; -He/she did not document much about the resident's right heel; -Usually the ADON looked at skin assessment sheets and they would go look at the wound together; -The resident liked to lay on his/her right side but did not want to re-position; -He/she did not put preventative measures in place at the time; -The staff should not put socks and shoes on the resident; -He/she would not have been able to get a low air-loss mattress on the weekend; -The staff knew of the pressure ulcer and the staff should be floating the resident's heels; -The resident's right heel should not be touching the floor or any surface; and -The resident should be positioned by pillows to float the heel. Observation on 9/27/18 at 10:00 A.M. showed: -The resident was lying in bed on a regular mattress with yellow ankle socks on; and -The resident's heels were resting on a pillow and were not floated. During an interview on 9/27/18 at 1:17 P.M., LPN B said: -He/she had only worked on this unit two times; -This was the first he/she has saw the resident's blister (on 9/26/18); -He/she did not get any information in report from the nurse that the resident had a heel blister; -The resident did not have any prevention in place for the prevention or treatment of [REDACTED].>-The resident was only on a foam mattress; -He/she had not seen any prafo boots or prevention on his/her feet; -The resident should have his/her heels floated and a low air loss mattress; and -The resident should have had prafo boots and not have tight socks or shoes on. Observation on 9/27/18 at 1:24 P.M., showed the resident: -Was in his/her wheelchair in the dining room; and -Had bunny boots on and his/her right heel pressure ulcer was resting directly on the foot pedal of the wheelchair. During an interview on 9/27/18 at 1:33 P.M., Registered Nurse (RN) Supervisor A and LPN C said: -If a resident has skin break down; -The nurse needed to reinforce education with staff including repositioning; -The nurse should notify the resident's family and physician; -If a resident had a heel wound, the resident should be reposition every two hour; -The resident should have heel protectors on and the staff should be floating the resident's heels; -The staff should have a prafo boot versus a bunny boot if resident has an unstageable wound to the heel so the heel would be floated; -The staff may put a low air loss pressure mattress in place; -The staff should put interventions in to meet the individualized needs of the resident; and -The ADON would be the first one to assess a resident's wound and determine what services were needed. During an interview on 9/27/18 at 2:44 P.M., LPN D said: -At night the resident was up on 9/22/18; -A Certified Nursing Assistant (CNA) had changed the resident and noticed the resident had a blister on his/her heel; -The CNA report it to him/her; -He/she assessed the resident's blister and it looked like the blister had lost the fluid; -The blister was a flesh color at that time; -He/she looked at it and did not see any drainage; -He/she had cleaned it and put his/her socks back on him/her; -The blister was not open; -He/she did not call and get orders from the resident's physician or notify the resident's family in the morning; -He/she had covered the resident's right heel blister with gauze for drainage and cushioned it; -He/she did not put a low air loss mattress in place or prafo boots; -He/she had propped his/her foot back up in the wheelchair because the resident wanted to be up; -On 9/24/18 the resident's right heel blister was still a skin color and he/she called the resident's physician to get an order for [REDACTED].>-The wound was not open at that time; -He/she passed the blister information on in report to the on-coming nurse; -He/she did not notify the ADON, DON or call the family; -He/she would normally pass the information of a new wound to the ADON; and -The ADON would assess for whatever actions and interventions were needed for the wound. During an interview on 9/27/18 at 4:21 P.M., LPN A said: -When he/she completed the resident's skin assessment on 9/22/18, the resident had a red hip area and a right heel blister; -He/she had documented ankle area instead of heel area on the skin assessment; -He/she did not notify the resident's physician or the resident's family member; -He/she did not write a nurses note about the blister; -He/she was told about it and did not add any prevention or interventions; and -He/she should have called the resident's physician at that time. During an interview on 9/27/18 at 4:29 P.M., the Director of Nursing (DON) said: -Whoever identified the pressure ulcer and the charge nurse would need to contact the resident's physician and family; -He/she expected the nurse to call the resident's physician for treatment orders before doing a treatment; -The pressure ulcer needed to be reported to the on-coming nurse, the ADON and to himself/herself; -He/she had not been notified of the resident's right heel blister; -If need be the outside wound company would be called to assess the wound; -He/she expected the nurse to put interventions in place at the time the wound was found; -The Braden and the pressure ulcer prevention guide was used so a care plan could be developed; -The resident, according to the assessments, should have a pressure relieving mattress; -At this time, he/she ordered a low air loss mattress for the resident due to active pressure ulcer; -On 9/22/18, physician's orders and prevention/treatment should have been put in place immediately by the charge nurse; -The physician and family should have been notified; -He/she expected better documentation about the resident's pressure ulcer and where it was located; -The resident's physician order was for TAO but he/she thought skin prep was needed to toughen the area of the heel; -The resident's heels should be floated at all times and not resting on the floor or hard surface; and -The ADON would generally assess the pressure ulcer along with the nurses to make determinations. Observation on 9/27/18 at 5:01 P.M., showed: -The resident was in his/her wheelchair eating dinner; and -The resident had bunny boots on both feet which were resting directly on the foot rest of the wheelchair. 2. Record review of Resident #25's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -High blood pressure; -Heart failure; -Dysphagia (inability or difficulty swallowing) -[MEDICAL CONDITION] ([MEDICAL CONDITION] - a disease process that decreases the ability of the lungs to perform ventilation); -Cognitive communication deficit; and -[MEDICAL CONDITION]. Record review of the resident's Pressure Ulcer care plan dated 1/3/18 showed: -The resident had a left heel wound; -The staff were to administer the resident's medications as ordered; -The staff were to avoid shearing during positioning, transferring, and turning; -The staff were to conduct a weekly skin assessment by a licensed nurse and daily with cares by the nursing staff; -Consult with the outside wound company as needed; -Complete treatment orders to the wound area; and --Staff documented on the care plan discontinued-healed with no date. Record review of the resident's POS showed: -On 1/3/18, a physician's order (for a left heel wound) to cleanse the left heel with normal saline and apply skin prep to the left heel daily. Record review of the resident's Treatment Administration Record (TAR) dated (MONTH) (YEAR) showed: -A physician's order on 1/3/18 to cleanse the left heel with normal saline and apply skin prep to the left heel daily; and -The treatments were completed by CMTs and licensed nursing staff. Record review of the resident's Braden Scale for Predicting Pressure Sore Risk dated 7/25/18 showed: -The resident was at risk for the development of pressure ulcers; -Friction and shearing: --The resident required moderate to maximum assistance with moving; and ---Complete lifting without sliding against sheets was possible. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired with inattention and disorganized thinking; -Needed supervision and the assistance of one staff member for bed mobility; -Needed the limited assistance of one staff member for transfers; -Needed the extensive assistance with mobility in his/her wheelchair and personal hygiene; -Did not have contractures (an abnormal usually permanent condition of a joint, characterized by flexion and fixation); -Was at risk of pressure ulcers; -Did not have pressure ulcers; -Needed a pressure relieving device in his/her wheelchair; and -Did not need a pressure relieving mattress or a turning and repositioning program. Record review of the resident's TAR dated (MONTH) (YEAR) showed: -A physician's order on 1/3/18 to cleanse the left heel with normal saline and apply skin prep to the resident's left heel daily; and -The treatments were documented as completed by CMTs and licensed nursing staff. Record review of the resident's Weekly Skin Integrity Review dated 8/24/18 completed by showed: -The resident's skin was dry and intact; -The resident had an old, healed area; and -The resident's left elbow area was circled on the body site area. Record review of the resident's Nurse Notes dated 8/28/18 showed: -The resident had a large reddened area on the right bottom of his/her foot with a small blister; -The hospice nurse was here and notified the family and new physician's orders were obtained; and --There was no documentation that showed pressure ulcer prevention or healing interventions were put in place. Record Review of the POS [REDACTED]. Record review of the resident's TAR 8/28/18 through 8/31/18 showed: -A physician's order to apply skin prep to the resident's reddened areas and blister on the resident's right foot each shift and PRN; and -This was documented as being administered by CMTs and licensed nursing staff. Record review of the resident's Weekly Skin Integrity Review dated 9/7/18 showed the resident's skin was dry and intact. Record review of the resident's Nurses Notes dated 9/8/18 at 10:28 A.M. showed: -The resident had two fluid filled blisters; -One blister was 1 ¾ inch long on his/her right upper/outer thigh and one blister ¼ inch on the left back of his/her thigh; and --There were no physician's treatment orders or wound tracking completed for this wound. Record review of the resident's Nurses Notes dated 9/10/18 showed the resident continued to have the noted areas. Record review of the resident's Nurses Notes dated 9/11/18 showed: -The resident had a black area to the end of his/her left great toe; and -The resident's physician was notified and treatment orders were obtained for the left great toe. Record review of the resident's POS dated (MONTH) (YEAR) showed the following physicians: -Not dated: Skin Prep to the left great toe every shift and as needed until healed; and -There were no physician's orders for the resident's blisters to his/her right upper/outer thigh area or the resident's left back of the thigh until 9/14/18. Record review of the Resident's TAR dated (MONTH) (YEAR) showed: -On 1/2/18: Cleanse left heel area with normal saline and apply Skin Prep once daily; --This was completed by nursing staff and CMTs. -On 9/11/18: Skin Prep to the left great toe every shift and as needed until healed; --This was completed 43 times out of 49 times and signed as completed by nursing staff and CMTs; and -There was no documentation that showed the resident's blisters to his/her right upper/outer thigh area or the resident's left back of the thigh were treated in this month. Record review of the resident's Nurses Notes dated 9/14/18 at 9:00 A.M. showed: -The resident's physician was here to see the resident; -The physician assessed the area of the resident's toe and the left thigh area; -The physician stated the left thigh area was due to shearing during movement and gave orders; -The physician ordered TAO and cover the areas; and --These physician's orders were not on the (MONTH) (YEAR) POS or TAR. Record review of the resident's Weekly Skin Integrity Review dated 9/21/18 showed: -The resident's skin was intact with bruises; and -The coccyx area was circled on the body site area. Record review of the resident's Medical Record on 9/27/18 showed: -The POS dated (MONTH) (YEAR) had no treatment orders for the right thigh blister or left thigh blister. Record review of the resident's TAR dated (MONTH) (YEAR) showed: -On 9/27/18, a new physician's order to apply skin prep to the resident's left heel each shift and as needed. Record review of the resident's Weekly Skin Integrity Review dated 9/27/18 by LPN B showed: -The resident's skin was dry; -The resident had a left heel dark area; -The resident's left thigh was scabbed; and -The buttocks area, the back of the right leg, and the left heel were circled on the body site area. Record review of the resident's Nurses Notes dated 9/27/18 at 2:00 P.M., showed: -The resident had a dark discolored area to the left heel; -Skin Prep was applied per the resident's physician; and -Hospice (end of life care) would provide heel protectors and a low air loss mattress. Observation on 9/27/18 at 5:04 P.M. showed: -The resident was in the dining room in a geri-chair (a reclining chair used for positioning and comfort); -Both hands were contracted and closed; -The resident had white socks pulled tightly on his/her feet and toes; and -His/her feet were hanging over the cushioned foot rest. Observation on 9/27/18 at 5:12 P.M. showed: -A regular foam mattress was on the resident's bed. Observation on 9/28/18 at 8:46 A.M. showed: -The resident was in a geri-chair in the common area; -Both hands were contracted and closed; -The resident had white socks on that fitted tightly and his/her heels were floated off the end of the foot rest; and -The resident had a hoyer sling (Hoyer lifts are used for transfers when a person requires 90-100% assistance to get into and out of bed. A sling fits under the person's body in the bed and connects with chains to the hoyer lift frame. A hydraulic pump is used to lift the person off the bed surface) underneath him/her. Observation on 9/28/18 at 9:34 A.M. showed: -The resident's white socks were fitted closely to both feet; -The resident had a hoyer sling underneath him/her; and -Both of the resident's arms were fitted closely to the inner area of his/her geri-chair. Observation on 9/28/18 at 10:08 A.M. showed: -The resident was alert, seated in his/her geri chair and had a heel protector on his/her right foot; -The Chief Operating Officer (COO)/RN and LPN B transferred the resident to his/her bed with a hoyer lift then roll

Based on observation, interview and record review, the facility failed to assess, monitor and maintain proper alignment of a lower extremity hinged brace; to document when staff notified the resident's physician of the blood blister area that developed into an open area on the resident's left ankle when it was first identified and obtain physician's orders [REDACTED].#6); to document the effectiveness of medication administered as needed (PRN) for two sampled residents (Residents #2 and Resident #11); and to ensure the narcotic PRN medication was accurately documented on the resident's Medication Administration Record (MAR) and Controlled Substance Record for one sampled resident (Resident #11), out of 15 sampled residents. The facility census was 73 residents. Record review of the facility's wound care policy revised on 6/1/15, showed the following: -The components of the wound documentation included the location of the wound, size of the wound by length, width and depth, the onset date, color, odor, necrotic tissue when present, sinus tracts (is an abnormal channel that originates or ends in one opening), infection, healing when present, surrounding skin, and pain; -Any significant abnormal findings are reported to the resident's physician and the resident's contact person. (it does not instruct the staff on how soon to notify the resident's physician and responsible when the wound is first identified) and -Documentation of the primary care provider notification, orders received, family notification and resident response to any treatment. 1. Record review of Resident #6's nursing data collection tool dated 8/28/17 showed he/she: -Had an active [DIAGNOSES REDACTED]. -Had Dementia (memory issues), hearing difficulty, and wore glasses; -Was non ambulatory and had impairment to both lower extremities; -Had a Braden scale (tool for predicting pressure sore risk) score of 18 which means the resident is at high risk for developing pressure sores; -Had a surgical wound to his/her left knee and -Skin assessment portion of the form was left blank by the licensed nursing staff. Record review of the resident's nurse's notes dated 8/28/17 showed he/she: -Was readmitted to the facility at 630 P.M; -Was alert and oriented and -Had an ace wrap under a long hinged knee immobilizer to his/her left leg. Record review of the resident's Interim Plan of Care dated 8/28/17 showed the following interventions: -Provide a pressure relieving device; -Turn and reposition the resident; -Inspect skin according to skin protocol; -Provide incontinent care; -Manage pain and use the pain scale 1-10 (1 being the least amount of pain possible and 10 being the worst pain possible); -Monitor duration and frequency of pain to the resident's left leg and -Maintain alignment of the resident's left leg. Record review of the resident's MAR dated 8/28/17 showed the weekly skin assessment during the evening shift was left blank on 8/28/17. Record review of the facility's 24 Hour Nurses Report sheet dated 8/28/17 for all three shifts showed the staff did not document from the off going charge nurse to the ongoing charge nurse anything regarding a blood blister found just above the resident's left ankle during change of shift report. Record review of the resident's nurse's notes dated 8/29/17 showed: -At 12:15 A.M., the resident: --Was requesting to have his/her left leg be repositioned and complained of left leg pain; --Had an ace wrap and a hinged brace in place to his/her left leg and --Had a three centimeter (cm) blood blister to his/her left ankle; -There was no documentation by the licensed nursing staff if they notified the resident's physician of the blood blister and if the staff obtained physician's orders [REDACTED]. -At 2:00 P.M: --The resident was able to make his/her needs and wants known; --The hinge knee immobilizer remains on and intact and -- The staff did not document anything regarding the blood blister to the resident's left ankle area. -At 8:00 P.M: -- The resident complains of pain in his/her left leg, pain medication given as ordered; -- The staff did not document anything regarding the blood blister to the resident's left ankle area. -At 8:30 P.M: --The staff did not document anything regarding the blood blister to the resident's left ankle area. -At 11:45 P.M: --Brace to the resident's left leg in place and -- The staff did not document anything regarding the blood blister to the resident's left ankle area. Record review of the facility's 24 Hour Nurses Report sheet dated 8/29/17 for all three shifts showed the staff did not document from the off going charge nurse to the ongoing charge nurse anything regarding the blood blister found just above the resident's left ankle during change of shift report. Record review of the resident's nurse's notes dated 8/30/17 showed: -At 1:00 P.M. the resident: --Was able to make his/her needs and wants known; --Skin was warm and intact; --His/her left knee was supported with pillows; -- The staff did not document anything regarding the blood blister to the resident's left ankle area. -At 5:40 P.M: -Staff did not document anything regarding the blood blister to the resident's left ankle area. Record review of resident's surgical wound care plan created on 8/30/17 showed: -The resident had a surgical repair to the fracture to the resident's distal femur (leg bone) and underwent surgery for [REDACTED]. -There was no problem, goal or interventions listed for the knee hinge immobilizer ordered on [DATE] and -There was no problem, goal or interventions listed for the blood blister that was identified on 8/29/17. Record review of the facility's 24 Hour Nurses Report sheet dated 8/30/17 for all three shifts showed the staff did not document from the off going charge nurse to the ongoing charge nurse anything regarding the blood blister found just above the resident's left ankle during change of shift report. Record review of the resident's nurse's notes dated 8/31/17: -At 1:40 A.M. the resident: --Denied any pain; --The staff did not document anything regarding the blood blister to the resident's left ankle area. -At 9:30 A.M., the resident: --Complained of left knee pain which was at a 10 on a pain scale of 1-10; --Had an ace wrap to his/her left leg; --The staff did not document anything regarding the blood blister to the resident's left ankle area. -At 9:00 P.M: -The staff did not document anything regarding the blood blister to the resident's left ankle area. Record review of resident's nurses notes dated 9/1/17 showed the following: -At 8:00 A.M.: --The resident noted an open wound to his/her left outer ankle area that was draining a scant amount of red blood; --The wound measurements were 3.5 centimeters (cm) in length by 2.5 cm in width and there were no depth measurements documented; --A message was left for the resident's physician; --The wound care company was scheduled to be at the facility that day and will have the wound care company look at the resident's left ankle area wound; -At 10:00 A.M., the resident's physician's office called and gave physician's orders [REDACTED].>--The wound care company to assess the wound to the resident's left outer ankle; --To clean the wound to the resident's left ankle, then apply [MEDICATION NAME] (antibiotic ointment), then cover with a dry dressing. Change the dressing daily and prn (when needed) till healed; --The area appears to have occurred from the hinged knee immobilizer rubbing or pinching the area. Record review of resident's Physician order [REDACTED]. -Daily wound care to left outer ankle; --Wash to cleanse wound; --Apply [MEDICATION NAME] (a topical antibiotic); --Cover with dry dressing and -The wound care company to evaluate and treat the resident's left outer ankle. Record review of the resident's POS dated 9/1/17 thru 9/30/17 showed the following: -Hoyer-lift (used for patients whose mobility is limited), needs assist with transfers; -Wheelchair; -Non-weight bearing to left lower extremity; -Change dressing to left knee as needed; -No showers until cleared by the resident's Physician; -The wound care order dated 9/1/17 for [MEDICATION NAME] was not transcribed to the MAR; -[DIAGNOSES REDACTED].>--Open Reduction Internal Fixation (ORIF) left distal femur fracture (a commonly used treatment for [REDACTED]. --Dementia (a chronic memory disorder of the mental processes caused by brain disease or injury) and --Chronic pain. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff) dated 9/3/17 showed he/she: -Had a BIMS (Brief Interview for Mental Status used to determine cognitive function) score of 15 which sowed the resident was alert and oriented and cognitively intact; -Had depression; -Total dependent upon staff for transfers, and bathing; -Did not walk; -Was at risk for Pressure Ulcers; -Had an open [MEDICAL CONDITION] and a surgical wound; -Was always incontinent of bowel and bladder and -Had chronic pain. Record review of the resident's nurses notes dated 9/3/17-9/8/17 showed the licensed staff did not document any characteristics about the resident's left outer ankle wound. Record review of resident's wound care company's initial documentation dated 9/8/17 showed the resident: -Recently had returned from the hospital after a repair to the resident's left fracture foot caused from a traumatic injury; -Currently had a suspected traumatic wound from his/her hinged knee immobilizer; -The wound to the resident's left lateral lower leg was numbered as wound #5, and labeled a trauma wound and was acquired outside the facility per the Assistant Director Of Nursing (ADON); -This is a new wound and the predebridement measurements were 2.90 cm in length, 2.30 cm in width, and 0.10 cm deep. The area was 6.67 cm; -The description of the wound was it had a moderate amount of serosanguineous (blood tinge) drainage, the peri wound (surrounding area) was not intact, was friable (dry crumbling) skin, had tenderness, and the wound was a 100% blister that previous was expressed with bloody drainage and -New wound care orders were to clean the wound and skin with the facility's cleanser of choice, apply skin prep (sticky skin protector) to the skin and apply Vaseline gauze over the wound and cover with dry dressing and change the dressing daily and prn. Record review of the resident's wound team notes showed: -On 9/8/17 the wound measured 2.90 cm length, 2.30 cm width, 0.10 cm depth; --Clean the wound, apply skin prep and Vaseline gauze and cover with dry gauze dressing. - On 9/12/17 the wound measured 1.90 cm length, 1.20 cm width, 0.10 cm depth; --Quality of tissue deteriorated, debrided slough tissue; --New order for Hydrogel (autolytic debridement fiber) and cover with dry gauze; - On 9/22/17 the wound measured 1.50 cm length, 1.20 cm width, 0.10 cm depth; --Wound status improved, continue Hydrogel treatment and - On 9/29/17 no wound report available at time of exit. Record review of the resident's Physician Consultation dated 9/14/17 showed a new order to keep the brace on except for hygiene (showers). During an observation and interview on 9/25/17 at 12:50 P.M., showed the resident: - Had his/her left leg was elevated on the wheelchair leg rest with pillows and strapped with Velcro to hold in place; -The brace has shifted down on his/her leg and the hinges are no longer in alignment with the knee bend; -Complained of pain in the left leg rating it on a five out of ten and -Said, I'll call the nurse for a pain pill. During observation on 9/26/17 at 10:00 A.M., showed the resident: -Did not have the ace wrap bandage under the hinged brace immobilizer on the left lower extremity; -The hinged knee immobilizer was out of alignment with the knee bend and had slid down over the ankle and -The resident said, The brace is hurting my ankle. During an observation and interview on 9/26/17 at 1:45 P.M., showed Licensed Practical Nurse (LPN) B: -Changed the dressing to the resident's left ankle wound; -Cleansed the area with a wound cleanser; -Applied a dime size Hydrogel (debridement fiber) to the wound bed; -Covered the wound with a dry gauze dressing; -He/she was not sure if the brace was in proper alignment and called the Certified Occupational Therapy Assistant (COTA) to check it and -Said he/she has not had any training on how to assess the hinge knee immobilizer to ensure it was properly placed at the bend of the knee and did not know what the hinge knee immobilizer settings were on how much the knee should be bent. During observation and interview on 9/27/2017 at 8:00 A.M., the resident: -Was sitting in the dining room doing a word search puzzle; -Was in his/her wheelchair with his/her left leg elevated on the wheelchair leg; -Was complaining his/her left ankle and left heel had pain that was rated at a 6 level of pain; -Said, the brace is rubbing on my sore ankle -Said he/she told the Certified Nurses Aide (CNA) and -Removed his/her lap blanket and the ace wrap was not under the brace and the hinge dials were not lined up with the bend of the knee to ensure the correct bend of the resident's knee. During an interview on 9/28/17 at 07:50 A.M., the COTA said: -The purpose of the hinged brace is to keep the leg and knee immobilized; -The hinges are locked at 30 degrees by the orthopedic surgeon, to allow for some bend in the knee; -The little circles at the hinges should line up with the knee condyle (a rounded protuberance at the end of some bones, forming an articulation with another bone); -The brace should allow for one finger width at top and bottom; -The brace should be checked at least daily for positioning and friction; -The staff needed help applying the brace so I went to the shower room and showed them how to put it on the resident; -Occupational Therapy is providing therapy for wheelchair leg-rest positioning by using pillows, for bed mobility, and for transfers with the Hoyer lift (a mechanical lift that uses a sling to lift and transfer the resident from one surface to another surface; -He/she had in-serviced the CNA's and some of the charge nurses on the correct way to position the resident's leg while in the wheelchair, in bed and when transferring the resident and he/she had inserviced a couple of the charge nurses on how to apply the hinge knee brace properly to ensure the resident's knee is at the correct degree of bend; -He/she would expect the charge nurse to pass on this information to the rest of the staff, but most of the staff are familiar with the hinge knee immobilizer and -He/she was not aware that some of the charge nurses still do not know how to ensure the hinge knee brace was on correctly. Record review of the resident's September 2017 MAR, Treatment Administration Record (TAR) and medical record showed the staff did not documented if they assessed and or monitored the resident for the proper placement of the hinge knee immobilizer to ensure the resident's knee is at the degree of bend and that they checked the resident's skin under the hinge knee immobilizer. During an interview on 9/28/17 at 8:15 A.M., the resident said My ankle hurts, I think the brace is too tight. Observation of resident's left leg while up in the wheelchair on 9/28/17 at 8:17 A.M. showed the following: -The hinge knee immobilizer was twisted to the resident's right side of the resident's left lower leg with the pillows hanging off to one side; -The lock out hinges of the knee immobilizer were not aligned with the bend of the resident's left knee and -The resident could not get one finger under the brace at the top of the resident's thigh. During an interview on 9/28/17 at 10:00 A.M., the CNA E said: -The resident can have a shower now. They take him/her to the shower room and take the brace off on Tuesdays and Fridays and -The Occupational Therapist showed us how to put the brace back on the resident. During an interview on 9/28/17 at 2:30 P.M., the Director of Nursing (DON) said: -Yes, he/she recalls one of the nurses talking about a skin issue on the resident's ankle and -He/she should have followed up on it and it was not noted on the 24 hour report sheet. During an interview on 9/29/17 at 5:47 A.M., LPN C said: -Thought he/she passed the information about the blood blister on to the on coming charge nurse LPN A on 8/29/17 and - He/she charted it in the nurse's notes, but did not call the resident's physician on 8/28/17 when the blood blister was first identified on the resident's left outer lower leg. During an interview with LPN G on 9/29/17 at 10:10 A.M., he/she said: -Expected the night nurse to pass on to the day nurse any findings so they can call the doctor; - He/she would also let the DON know what was passed on especially if it is of unknown origin and -Was unsure of what needs to be monitored when checking a hinge knee immobilizer. During an interview on 9/29/17 at 1:00 P.M., LPN A said he/she did not recall the off going charge nurse reporting to him/her during shift change report anything about a blood blister for that resident. During an interview on 9/29/17 at 1:45 P.M., the MDS Coordinator said: -It is ultimately his/her responsibility to write and update the care plans; -Nurses can update the care plans, but they don't do it and - He/she update care plans after looking at a copy of the physician orders [REDACTED]. During an interview on 9/29/17 at 2:00P.M., the DON said: -The MDS Coordinator and any nurse can update the care plans; -Yes, the hinge knee immobilizer and weight bearing status should be care planned and carried over from the POS to the MAR/TAR; - He/she would expect the wound to be identified on the care plan; -Once the skin is compromised he/she would expect the nurse to call the doctor, get an order, consult wound care company, put a dressing over it, write an incident report, call the family, get a dietary consult, and pass it on in report; -Blister wound protocol is skin prep and notify the resident's physician and -He/she would expect the night nurse to pass the skin issues on to the day shift charge nurse so they can follow-up. During a telephone interview with the wound care company nurse on 10/2/17 at 2:05 P.M. said the definition of a trauma wound would be from a pinching of the skin, that would leave a blood blister versus a pressure wound would be from prolonged friction, sheering or pressure. A message for the resident's physician was made from 9/29/17-10/3/17 and the resident's physician did not return the call. 2. Record review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE], and most recently readmitted on [DATE]. His/her [DIAGNOSES REDACTED].>-Anxiety Disorder (feeling of worry, nervousness or unease); -Constipation (bowel movements that are infrequent or hard to pass); -[MEDICAL CONDITION] (a disease that reduces the density and quality of the bones) and -Probable [MEDICAL CONDITION] changes of knees and ankles (joint and bone deterioration causing pain). Record review of the resident's September 2017 POS showed PRN medication orders that included the following: -An order dated 8/4/17 for [MEDICATION NAME] Oral Concentrate, 2 milliliters (ml): Take 0.25 - 1 ml by mouth or sublingually every hour as needed for anxiety and -An order dated 6/13/17 for Milk of Magnesia, (laxative) 30 ml: After 8 hours [MEDICATION NAME] suppository (laxative), after 8 hours fleet enema, if no results in 8 hours calls the physician. Record review of the resident's comprehensive MDS dated [DATE], showed he/she: -Was severely cognitively impaired; -Had no behavior or mood disorders; -Needed extensive to total assistance with transfers, bathing, dressing, hygiene, toileting and bathing and -Had no antianxiety medication within the seven day look back period. Record review of the resident's Care Plan, updated 8/10/17 showed the resident: -Was receiving Hospice Care (end of life care); -Had [DIAGNOSES REDACTED]. -Was to receive medication as ordered for depression and -There was no mention of medication for anti-anxiety. Record review of the resident's September 2017 MAR showed: -The resident received [MEDICATION NAME] Oral Concentrate on 9/20/17 at 10:00 A.M. documentation on the back of the MAR showed the following: --The route was sublingual; --The reason was he/she was anxious and --The results showed effective, but did not describe the state of the resident or the effectiveness of the medication; - The resident received Milk of Magnesia, 30 ml, on 9/21/17 at 12:00 Noon. Documentation on the back of the MAR showed the following: -The reason was he/she had not had a bowel movement in 3 days and -There was no documentation showing the results or effectiveness of the medication. 3a. Record review of Resident #11's face sheet showed he/she was admitted to the facility on [DATE], and most recently readmitted on [DATE]. His/her [DIAGNOSES REDACTED].>-Ileus (a painful obstruction of the ileum or other part of the intestine); -Right Lobe [MEDICAL CONDITION] Embolism (a sudden blockage in a lung artery); -Abdominal Hernia (a bulge in an opening in the abdominal wall); -[MEDICAL CONDITION] (Stroke - impaired blood supply to the brain); -[MEDICAL CONDITION] (weakness of one entire side of the body); -Anxiety Disorder; -Hypertension (high blood pressure); -[MEDICAL CONDITION] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain); -Gout (Gout is a type of arthritis that causes inflammation); -Nicotine Dependence (an addiction to tobacco products caused by the drug nicotine) and -[MEDICAL CONDITION] (the habitual misuse of alcohol). Record review of the resident's comprehensive MDS dated [DATE], showed he/she: -Was cognitively intact; -Needed extensive assistance of two people with bed mobility, dressing, hygiene, and bathing; -Needed total assistance of two people with transfers; -Was frequently incontinent of bowel and bladder; -Had frequent pain and -Received antipsychotic, antidepressant, anticoagulant, and diuretic medication during all seven days of the look back period. Record review of the resident's Care Plan, updated 9/20/17, showed he/she: -Was at risk for problems related to medications and -Medications should be administered as ordered by the physician. Record review of the resident's POS for September 2017 showed his/her PRN medication orders included the following: -An order dated 8/10/17 for [MEDICATION NAME] Immediate Release (IR) 10 mg: Take one tablet by mouth every six hours as needed for pain. The order was discontinued on 9/6/17 and -An order dated 9/6/17 for [MEDICATION NAME] IR 10 mg by mouth BID (twice daily) as needed for pain. Record review of the resident's MAR showed the following PRN orders for [MEDICATION NAME] IR 10 mg: -An order dated 8/10/17: Take one tablet by mouth every six hours as needed for pain; and the resident received the [MEDICATION NAME] IR 10 mg: --On 9/1 at 6:15 A.M. for general pain. The result was not documented; --On 9/2 at 7:00 A.M. There was no documentation on the back of the MAR showing why the medication was administered or the result. --On 9/3 at 11:00 P.M. There was no documentation on the back of the MAR showing why the medication was administered or the result. --On 9/4 at 4:30 A.M. with no documentation on the back of the MAR; at 1:00 P.M. with eff noted under result; and at 6:45 P.M. for general pain, with eff noted under result. --On 9/5 at 7:00 A.M. for general body pain, with eff noted under result. --On 9/6 at 7:00 A.M. and at 7:45 P.M. for general body pain, with eff noted under result. -- (Note: The order was discontinued on 9/6/17.) - An order dated 9/6/17: Take one tablet by mouth BID as needed for pain; and the resident received the [MEDICATION NAME] IR 10 mg: --On 9/6 at 7:30 A.M. and at 7:25 P.M. for general pain, with no documentation showing the reason or result at 7:25 P.M. --On 9/9 at 7:00 A.M. and at 7:15 P.M., with no documentation showing the reason or result. --On 9/10 at 7:30 A.M. and at 7:30 P.M., with only eff noted under result. --On 9/11 at 4:15 A.M. with only eff noted under result. --On 9/13 at 7:30 A.M. with only eff noted under result. --On 9/20 at 7:00 P.M., with no documentation showing the reason or result. --On 9/21 at 7:25 A.M. with only eff noted under result. --On 9/22 at 7:25 P.M. with only eff noted under result. 3b. Review of Resident #11's Controlled Substances Proof of Use Record for [MEDICATION NAME] IR 10 mg, for September 2017, showed staff documented he/she receieved the medication: -Two times daily on 9/1, 9/2, 9/3, 9/5; -Three times on 9/4; -Two times on 9/5; -Three times on 9/6; and -Two times daily on 9/7 through 9/29. (Note: The resident's MAR did not match all of the above documentation.) Record review of the resident's MAR for September 2017 showed the resident received [MEDICATION NAME] IR 10 mg: -One time daily on 9/1 and 9/2; -Two times daily on 9/3 and 9/4; -One time daily on 9/5 and 9/6; -Two times on 9/7; -None on 9/8; -Two times on 9/10; -One time daily on 9/11, 9/12, and 9/13; -None on 9/14; -Two times on 9/15; -One time on 9/16; -None on 9/17; -Two times daily on 9/18 and 9/19; -One time on 9/20; -Two times daily on 9/21, 9/22, and 9/23; -One time on 9/24; -Two times daily on 9/25 and 9/26; -One time daily on 9/27 and 9/28. During an interview on 9/29/17 at 9:38 A.M., Licensed Practical Nurse (LPN) D said when PRN medications of any type are administered documentation should occur: -Documentation should be on the back of the MAR showing why the medication was administered; -For PRN laxatives there should be documentation showing whether the result was a bowel movement; -For PRN pain medication there should be documentation showing where the pain was, with pain scale number from 1-10, and any non-pharmacological interventions attempted and -After one or two hours the effectiveness of the medication should be documented. During an interview on 9/29/17 at 10:40 A.M., LPN E said: -The MAR and Controlled Substance Record should match and -When resident is given PRN controlled pain medication there should be documentation on the front of the MAR showing it was administered, on the back of the MAR showing the reason the medication was administered an the effectiveness of the medication. During an interview on 9/27/17 at 1:35 P.M., the DON said: -When any PRN medication is administered, the reason for administering the medication must be documented; -If a PRN pain medication is administered, the pain should be assessed and the pain scale number documented before administering, and the effectiveness of the medication documented about an hour after giving the medication and -It is not okay to just put the word effectiveness, there should be a pain scale number or description for non-verbal signs of effectiveness that show how well the medication was working.

Based on interview and record review, facility staff failed to ensure the Registered Dietitian (RD) recommendations were implemented to increase water intake for two sampled residents (Residents #1 and #4) who relied on a gastrostomy (an opening into the stomach through the skin for nourishment and fluids) tube for nutrition and hydration. Additionally, facility staff failed to ensure one sampled resident (Resident #1) received treatment for [REDACTED]. Facility staff failed to follow the facility's wound policy for assessment, documentation, and treatment of [REDACTED]. Nine residents were sampled and the facility census was 84 residents. Record review of the facility's Wound Care Policies and Procedures, revised 6/1/2015, showed: -Wound evaluation will be performed on admission, weekly, and on discovery to include: location, measurements, appearance, drainage, odor, stage, and date of onset of a pressure ulcer; -Wound documentation is performed on admission and/or discovery; -The Braden Risk Assessment will be used for all residents upon admission, weekly for the first three weeks after admission, quarterly, and then as needed; -Skin care options for treatment of [REDACTED]. -All residents are to have a thorough weekly skin evaluation performed by a licensed nurse. 1. Record review of Resident #1's hospital laboratory blood work, dated 7/21/15, showed his/her: -Hemoglobin was 11.7 Low; range 14.0-18.0 (measures the amount of hemoglobin protein in the blood, Hemoglobin carries the oxygen in the red blood cell. Low hemoglobin with low Hematocrit and low red blood cells may indicate [MEDICAL CONDITION]); - Hematocrit (measures the percentage of red blood cells in the total blood volume, Low can indicate [MEDICAL CONDITION]) was 40.0; Low (range 42.0-52.0). - Red blood cells (measures the number of red blood cells in the blood) was 5.13 (range 4.5-6.0). - Sodium (measures the amount of sodium in the blood, helps to maintain water and electrolyte balance in the body) was 140 (range 136-145). - Potassium (measures the amount of potassium in the blood, potassium is used when muscles contract) was 3.7 (range 3.5-5.1). - Chloride (measures the amount of chloride in the blood, the kidneys control the levels of chloride) was 103 (range 98-107). - BUN (Blood Urea Nitrogen, measures the amount of urea nitrogen in the blood and indicates how the liver and kidneys are functioning) was 9 (range 7-18). - [MEDICATION NAME] (measures the amount of [MEDICATION NAME] protein in the blood to determine kidney or liver function or nutritional status) was 2.7 Low (range 3.4-5.0). Record review of the resident's Physician Transfer Orders from the hospital to the facility, dated 7/21/15, showed he/she was to receive water flushes of 350 milliliters (ml) every six hours. Record review of the resident's Physician order [REDACTED]. - The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. - A order, dated 7/20/15, for staff to flush the resident's gastrostomy tube ([DEVICE]) with 120 ml of water every 8 hours. Staff did not clarify the discrepency between the Physician's Transfer order dated 7/21/15 and the POS dated 7/20/15 to ensure staff provided the resident water flushes as directed by the physician. Review of the resident's 7/2015 Treatment Administration Record showed staff recorded: -give 120 cc water flush via [DEVICE] every eight hours Record review of the resident's Nursing Data Collection Tool, dated 7/21/15, showed staff documented: -The resident did not have any open wounds; -The resident was incontinent of bowel, had a catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine), a [MEDICAL CONDITION] (a surgical opening into the wind pipe into which a tube is inserted to allow passage of air and removal of secretions), and a [DEVICE] in place. Record review of the resident's Braden Scale, dated 7/21/15, showed staff assessed the resident was at risk for the development of pressure ulcers and were directed to put interventions in place to prevent pressure ulcers. Record review of the resident's Hydration Risk Evaluation, dated 7/21/15, showed staff assessed the resident was at risk for dehydration. Record review of the resident's Data Collection/Evaluation-Nutritional Form showed: -On 7/24/15, the facility RD reviewed the resident's 7/21/15 lab report and determined the resident's caloric, protein, and fluid needs; -The RD documented the resident was a new admission who took nothing by mouth; -The RD recommended to increase the resident's fluids to meet the resident's needs; -The RD recommended to increase the water flushes to 200 ml every 6 hours. Record review of the resident's POS and telephone physician's orders [REDACTED]. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrumented, dated 7/28/15, showed staff assessed the resident as totally dependent on two staff for bed mobility and transfers. Record review of the resident's Weekly Skin Documentation for July 2015, showed staff documented the resident's skin was intact on 7/22/15 and 7/29/15. Record review of the resident's Weekly Skin Documentation for August 2015, showed staff did not document they completed any weekly skin assessments for the month. Record review of the resident's care plan, dated 8/14/15, showed staff were instructed to: -Complete skin treatments; -Consult with wound care company as needed; -Complete daily skin assessments by Certified Nursing Assistants (CNA's); -Complete hydration assessments quarterly; -Dietary consult as needed; -Licensed Practical Nurses (LPN's) to complete weekly skin assessments; -Flush the [DEVICE] as ordered; -RD to evaluate per routine and as needed. Further review of the care plan showed staff did not update the care plan with any skin findings, wound assessment findings, or wound treatment orders. Record review of the resident's CNA Daily Skin Inspection Record for August 2015 showed: -On 8/15/15, CNA staff showed the resident had an open area across both buttocks. Record review of the resident's Nurse's Notes, dated 8/15/15, showed: -At 1:00 P.M., staff documented the resident had excoriation to his/her buttocks, discolorations to both outer ears, right arm [MEDICAL CONDITION] without redness or increase in temperature. -Staff contacted the resident's physician and an order was received for the resident to be seen by the Outside Wound Physician's Group and for a Doppler for the right arm. -Staff did not document if the area on the buttocks was measured or assessed for drainage, if the resident's physician ordered any treatments for the excoriation, or if staff administered any treatments. Record review of the resident's POS, dated 8/15/15, for Contracted Wound Physician to evaluate and treat as indicated. Record review of the resident's CNA Daily Skin Inspection Record for August 2015, showed: -On 8/16/15 and 8/17/15, CNA staff documented the resident had an open area across both buttocks. Record review of the resident's Contracted Wound Physician Evaluation and Treatment report, dated 8/17/15, showed the wound physician documented: -The resident had an unstageable pressure ulcer (full thickness tissue loss in which the base of the wound is covered by slough and or eschar in the wound bed) on his/her left and right buttocks, that measured 8.5 x 13.30 x 0.10 centimeters (cm), wound base was 10% red, 10% yellow, and 80% black, no odor, and scant serous drainage (watery, clear, or slightly yellow/tan/pink drainage); -Treatment: clean wound with saline, apply moisture barrier in a thin layer, apply Santyl (a medicated ointment used for debridement or the removal of dead tissue and foreign matter), change every shift and as needed. Record review of the resident's CNA Daily Skin Inspection Record for August 2015, showed: - On 8/18/15 and 8/19/15, CNA staff documented the resident had an open area across both buttocks. Record review of the resident's POS showed the following orders: - 8/19/15 (two days after the wound physician ordered the treatment), clean buttocks with normal saline, apply Santyl and moisture barrier every shift; - 8/20/15, increase the [DEVICE] water flushes to 200 ml every 6 hours (the first recommendation was dated 7/24/15); -8/20/15, discontinue current treatment to buttocks; -8/20/15, clean buttocks with normal saline, apply [MEDICATION NAME] (a spray medication used on wounds to debride and promote healing) every shift and as needed. Record review of the resident's Nurse's Notes from 8/16/15 through 8/20/15, showed staff did not document any further assessments of the excoriation or wound on the resident's buttocks. Record review of the resident's Nurse's Notes showed staff documented: -On 8/20/15 at 10:05 A.M., the resident had two red, unopened areas to the right elbow, and an open area with blisters to the right outer lower extremity. New physician orders [REDACTED]. Clean right outer lower extremity with normal saline, apply triple antibiotic ointment (TAO), cover with a dry dressing, and wrap two times a day. -On 8/20/15 at 12:20 P.M., New physician's orders [REDACTED]. -On 8/20/15 at 1:00 P.M., new physician orders [REDACTED]. Clean discolored areas on back with normal saline, apply skin prep daily to open areas with normal saline, apply [MEDICATION NAME] every shift and as needed. Cleanse left ear with normal saline, apply TAO and cover with dry dressing daily and as needed. Record review of the resident's Wound Treatment and Progress Record, dated 8/20/15, showed: - Staff initialed wound care was done with the physician's orders [REDACTED]. Record review of the resident's Social Service Progress Notes showed: -On 8/20/15 (not timed), the Administrator, DON, Nursing Supervisor and Social Services Designee met with the family. The family had concerns they wanted to talk about. Staff documented the family's expectations were not realistic. The nursing staff with the Administrator tried to explain the resident was declining and that his/her body was shutting down. Record review of the resident's Nurse's Notes, dated 8/20/15 at 5:55 P.M., showed staff documented the resident was transferred to the hospital by ambulance. Record review of the resident's Discharge Summary showed staff documented the resident was discharged to the hospital on [DATE] at 5:35 P.M. due to his/her wounds. Record review of the resident's hospital emergency room notes, dated 8/20/15, showed he/she was admitted to the hospital for treatment of [REDACTED]. Record review of the resident's hospital History and Physical report, dated 8/20/15, showed he/she: -Had a sacrum pressure ulcer which was foul smelling with necrotic black tissue in the shape of a dressing patch and on his/her left buttock, which measured approximately 7 x 4 cm in a heart-shaped pattern; -Was assessed as having [MEDICAL CONDITION] (high concentration of sodium) secondary to moderate-to-severe volume depletion as well as inadequate intake of free water and moderate-to-severe dehydration with an elevated BUN/creatinine ratio. Record review of the resident's hospital Consultation report, dated 8/21/15, showed he/she had extensive Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure depth of tissue loss, may include undermining and tunneling) to Stage IV ulcerations (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often includes undermining and tunneling) to his/her sacrum which measured 20 x 15 cm with significant eschar (dry, dead tissue). Record review of the resident's hospital Operative Report, dated 8/21/15, showed his/her sacral pressure ulcer measured at 20 x 15 x 0.2 cm and was debrided down through the muscle. During an interview on 8/22/15 at 5:35 P.M., the Administrator said he/she expected the nurse to notify the physicians as soon as possible about recommendations. During an interview on 9/2/15 at 2:30 P.M., Physician A said he/she: - Was in the facility usually one and a half days a month; - Would expect nursing to observe a compromised skin area on a resident if the area was dry; - Would expect wound treatment to start the day the Contracted Wound Physician saw the resident and recommended treatment; - Thought staff usually called him/her to notify him/her of the Wound physician's orders [REDACTED]. During an interview on 9/2/15 at 3:15 P.M., ADON A said: - He/she looked at the CNA Daily Skin Inspection Record form on his/her side of the facility and ADON B probably did too; - He/she expected the charge nurses to look at the form and to investigate and see what CNA's marked on the form; - He/she expected the charge nurse who evaluated a wound to obtain treatment orders from the resident's primary physician; - The facility did not have standing wound treatment orders; - The facility did not have a wound nurse and no facility staff accompanied the Contracted Wound Physician or their staff when they saw residents at the facility; - The Contracted Wound Physician made recommendations, staff printed the recommendations from the computer, called the resident's primary physician, and obtained physician orders [REDACTED].>- He/she usually printed the recommendations (which include the wound assessment, measurements, and treatments) and gave those to each nurses station. During an interview on 9/2/15 at 5:00 P.M., Licensed Practical Nurse (LPN) A said: - He/she did not think he/she obtained a treatment order for Resident #1's excoriation area on the buttocks; - Sometimes staff did get treatment orders for wounds while a resident waited to see the Contracted Wound Physician; - Staff did not get a copy of the Contracted Wound Physician treatment recommendations or orders; - The Contracted Wound Physician faxed the orders the next day, staff contacted the resident's physician and clarified the orders and then the wound treatments were put in place; - It might have been two or three days before the treatment orders were started after the Contracted Wound Physician saw the resident; - The facility did not have standing wound treatment orders. During an interview on 9/2/15 at 5:25 P.M., the DON said: - He/she would have expected staff to obtain treatment orders for Resident #1's excoriation area on the buttocks on 8/15/15; - He/she would expect staff to obtain treatment orders for both avoidable and unavoidable wounds. During an interview on 9/10/15 at 10:00 A.M., the Contracted Wound Physician said: - Resident #1's wound covered both buttocks and was spread across the midline; - He/she would expect the wound treatment to begin when the facility obtained the medications for the treatment; - He/she felt for a wound to go from excoriation to having eschar in two days would be a rapid transition but he/she had not seen the wound with excoriation and could not speak to what the staff saw or documented; - He/she did not change the treatment order from Santyl and did not use the product [MEDICATION NAME]; - Staff did not consistently go with him/her when he/she was assessing the residents wounds before 9/10/15; - He/she always told the staff when any treatments were changed before he/she left the facility. During an interview on 9/10/15 at 11:20 A.M., LPN C said: - The Braden Risk Assessment form is completed upon admission and quarterly for residents; - The Weekly Skin Documentation form is in the Treatment Administration Record (TAR) and when it is completed (form has areas for multiple days to be documented), it is placed in the resident's medical record. If staff identified any skin issues, they would report them; - He/she was not aware of any staff monitoring the form. During an interview on 9/10/15 at 11:45 A.M., LPN D said: - The Braden Risk Assessment form is completed upon admission and quarterly for residents; - He/she did not know if anyone looked at the completed Weekly Skin Documentation forms. During an interview on 9/10/15 at 12:00 P.M., the Medical Records Director said: - He/she checked the hospital transfer forms, physician order [REDACTED].>- He/she audits all admission and readmission orders [REDACTED] - Upon examination of Resident #1's medical record to include hospital transfer orders and facility written physician orders, he/she said he/she would have asked a nurse regarding the difference between the orders for water flushes; - Did not remember if he/she asked a nurse about the difference in the water flush orders; - Did not have any documentation of questioning the difference in the water flush orders in the audit record he/she kept. During an interview on 9/10/15 at 2:05 P.M., Registered Nurse (RN) A said: - The Braden Risk Assessment form is completed upon admission, weekly for the first three weeks following admission, and then quarterly; - ADON A monitored the Weekly Skin Documentation form; - He/she was the one who wrote Resident #1's admission orders [REDACTED] - He/she did not know where the physician's orders [REDACTED]. - The hospital notified them two or three times of the intent to transfer the resident, and each time the transfer was postponed which was why there were some dates of 7/20/15 on paperwork; - He/she spoke to a hospital nurse at one time during this period and the nurse said the resident could not tolerate a lot of fluids at once; - He/she did not document this in the resident's medical record. During an interview on 9/10/15 at 2:40 P.M., the DON said: - He/she did not think the Braden Risk Assessment forms were being completed for the first three weeks following admission; - The Weekly Skin Documentation form was being checked for completion randomly; - The Medical Records Director did the chart audits but he/she expected nursing staff to assist each other and check physician orders; - Upon examination of Resident #1's medical record to include hospital transfer orders and facility physician orders, he/she did not know where RN A obtained the physician orders [REDACTED]. - He/she would have expected a nursing note regarding the change of water flush or why it was different than the 350 ml every six hours; - The nurse on duty would not have questioned the difference in the water flushes as RN A had written the telephone order sheets on 7/20/15. 2. Record review of Resident #4's admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Severely impaired cognitively; -Totally dependent on staff for all needs; -Had [DIAGNOSES REDACTED]. -Had a feeding tube and received over 51% of nutrition through the feeding tube. Record review of the resident's admission orders [REDACTED] -[MEDICATION NAME] 65 ml/hour per pump; -Flush the feeding tube with 100 ml water every six hours. Record review of the resident's Data Collection/Evaluation- Nutritional, dated 7/24/15, showed the RD documented: -The resident's admission weight was 157 pounds; -Evaluation of nutritional needs: Calorie needs 2130 kilocalorie (kcal), protein needs 71 gm/day, and fluid needs 2130 ml/day; -New admission tube feeding as ordered provides 1560 ml (2340 kcal, 100 gram of protein, 1586 ml water). Regimen exceeds established kcal/protein needs, falls short of fluid needs (history of high sodium noted); -The RD recommended to increase water flushes to 200 ml every six hours and monitor monthly weight and labs. Record review of the resident's POS from 7/24/15 through 8/13/15, showed no new orders to increase his/her water flushes. Record review of the resident's care plan for tube feeding nutritional needs, dated 8/6/15, showed: -Flush feeding tube as ordered; -Observe for signs and symptoms of dehydration (low blood pressure, dry mucus membranes, and dizziness) and notify physician. Record review of the resident's physician's orders [REDACTED]. 3. During an interview on 8/22/15 at 3:12 P.M., RD A said: - Three facility staff, the Director of Nursing (DON), the Administrator, and the Dietary Manager, received a copy of his/her report, Request for Diet Changes; - The DON was to obtain any physician's orders [REDACTED]. During an interview on 8/22/15 at 3:50 P.M., Assistant Director of Nursing (ADON) A said: - The RD made recommendations and gave staff a form, Request for Diet Changes, at the end of each visit; - He/she distributed the forms to the nurses stations for the nurses to notify the physicians; - Some physicians wanted to address the recommendations after seeing the residents. During an interview on 8/22/15 at 5:35 P.M., the Administrator said he/she expected the nurse to notify the physicians as soon as possible about recommendations. During an interview on 9/2/15 at 2:30 P.M., Physician A said he/she: - Was in the facility usually one and a half days a month; - Was usually notified of the RD's recommendations by the Dietary Manager and he/she would be given a list of RD recommendations to initial once a month; - Should have been called that day for the RD's recommendation to increase Resident #1's and Resident #4's water flushes. During an interview on 9/2/15 at 3:15 P.M., ADON A said: - The recommendations from the RD were handled through the same process as wound treatment recommendations; - The RD did not usually leave the facility until after managerial staff were gone; - He/she copied the Request for Diet Changes form and gave them to the charge nurses; - The charge nurse should contact the physicians and have the RD recommendations approved or declined; - Any changes to increase Resident #1's water flushes should have been done the day it was handed out. During an interview on 9/2/15 at 5:00 P.M., Licensed Practical Nurse (LPN) A said: - Staff usually faxed the physician the Request for Diet Changes depending on how close it was to the date the physician was to be at the facility. During an interview on 9/2/15 at 5:25 P.M., the DON said: - After the physicians are contacted regarding the RD recommendations, he/she looks at the Request for Diet Changes form to make sure they are done; - He/she did not have a set time frame when he/she looked at the form; - The ADON's had been looking at the form; - Nurses write notes on the Request for Diet Changes form, they are placed in the medical records box, and then placed in the DON in box; - Staff needed three to four days in order to process the recommendations through the channels; - He/she would like the charge nurse to call the physicians the day or the day after they receive the Request for Diet Changes forms from the ADON's. During an interview on 9/10/15 at 1:50 P.M., the Dietary Manager said: - He/she received a copy of the RD recommendations after the RD left the building; - He/she gave a copy of the recommendations to the ADON; - Denied giving Physician A a list of the RD recommendations. MO 634, MO 749, MO 753, MO 774

Based on observation, interview and record review, facility staff failed to provide protective oversight and supervision for one resident (Resident #5) of nine sampled residents. Resident #5 has a history of self-harming behaviors/suicide attempts, and reported to the charge nurse that he/she heard voices telling him/her to swallow a screw. The charge nurse failed to notify the physician, administrative staff, or intervene to ensure the resident did not have access to other screws or other devices of self-harm, which resulted in endoscopic removal of a screw. The facility census was 84 residents. Record review of the facility's Suicidal Precaution Management Policy, email revision [DATE], showed in part: -Policy: --The facility will provide and/or arrange for transfer to the safest, practicable living environment for all patients/residents who voice suicidal thoughts, attempt suicide, or cause self-injury. The highest level of emotional and physical well-being of the patients/residents will be promoted using all available resources including but not limited to Physicians, Psychologists, Social Service Directors, Counselors, Psychiatrists, inpatient psychiatric therapy, and family meetings; --If the assessment identifies that the patient/resident requires constant supervision, the facility will arrange for transfer to a more appropriate setting; -Procedures: If a patient/resident, who is voicing suicidal thoughts or attempts suicide, is a danger to self or others, additional interventions will be initiated including: --Physician/psychiatrist/Counselor/Psychologist and family are notified immediately. If the patient/resident does not have a psychiatrist then a referral is made at this time; --Suicide precautions are implemented immediately if a resident is deemed to be a threat to themselves or others to preserve the well-being of the patient/resident. The Physician should be notified immediately of suicide ideations and for further orders; --If it is determined that the facility cannot provide a safe environment due to the suicidal ideation of the resident/patient, the resident/patient will be transported to an acute care setting for evaluation and treatment; -Suicide precautions will be implemented immediately for any resident/patient that presents with a significant level of depression or suicidal preoccupation and will be used to address the risk factors presented by the resident/patient; -Suicide precautions include the following: --The resident/patient will eat in the unit without sharp utensils; Until evaluation transfer can occur, certain items such as belts, drawstring pants, shoes with laces, sheets, etc. may be prohibited if they present a potential danger for the resident/patient; Call light cord is removed from patient/resident room; -For residents requiring one-to-one supervision: --The resident/patient will be assigned a one-to-one staff member who will remain within six (6) feet of the resident/patient and maintain constant visual contact with the resident/patient at all times. 1. Record review of Resident #5's face sheet showed he/she: -Was admitted on [DATE]; -Had [DIAGNOSES REDACTED]. Record review of the resident's nurse's notes, dated [DATE] at 7:30 P.M., showed staff documented: -The resident had expressed he/she was feeling very depressed and suicidal and wanted to go to the psychiatric hospital for a medication adjustment. The resident was placed on 15 minute checks at that time. At approximately 6:00 P.M., the Certified Medication Technician (CMT) brought the resident to the nurse's station and reported that the resident attempted to hang himself/herself with a bed sheet tied around his/her neck, standing on a wheelchair with the sheet over the closet door, getting ready to step off of the wheelchair. No red marks to resident's neck. Staff notified the appropriate administrative personnel, and the physician of the incident. The resident was sent to the hospital for evaluation and treatment at that time. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as: -Cognitively intact with fluctuating inattention and disorganized thinking; -Mildly depressed; -Had hallucinations (perceptual experiences in absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Had physical and other behavior symptoms directed toward others; -Was independent with activities of daily living (ADL), except required supervision and setup with eating. Record review of the resident's care plan regarding impaired cognitive function, updated [DATE], showed interventions included: -Provide supervision/assistance with decision making. Record review of the resident's care plan regarding attempted suicide in the past, updated [DATE], showed in part: -If the resident threatens suicide or to hurt someone else, place on one-on-one monitoring, contact the physician, and transfer to an appropriate hospital; -Offer as needed injectable if he/she hears voices. Record review of the resident's nurse's notes, dated [DATE] at 11:00 A.M., showed staff documented: -The resident came to this writer with a long screw, stated his/her mother was telling him/her to swallow the screw. Discussed with the resident about his/her mother having passed away and the voices. Explained to the resident the complications of swallowing a screw. The resident handed the screw to this writer. The resident verbalized understanding and requested Zyprexa IM due to the hallucinations and possible self-harm statements. The medication was given at this time in the left deltoid. The resident tolerated well. Record review of the resident's nurse's notes, dated [DATE], showed the ADON documented: -At 12:20 P.M. the resident came to the writer and reported he/she had been hearing voices this morning, his/her mothers voice. The resident's mother is deceased . The resident reports he/she swallowed a screw because his/her mother told him/her to. When questioned the resident reports it was three inches long and came from towel holder on the wall. The resident reports he/she was not sure what time he/she swallowed the screw but it was just a little while ago. When asked if he/she was in pain the resident reported a little pain in his/her chest in the middle. The resident denies any shortness of air (SOA), his/her skin was warm and dry, current temperature was 99.1, pulse 89, oxygen saturation 93, and blood pressure ,[DATE] (all within normal limits); -At 12:25 P.M., the physician was notified and a new order was received to send the resident to the hospital for evaluation and treatment. The ambulance was called and hospital notified of transfer; -At 12:30 P.M., ambulance here at this time. The resident requested his/her sibling not be notified. The resident reports he/she did not try to kill himself/herself, reports he/she deserved it because he/she was fat. Resident exited facility with ambulance personnel at this time; -At 12:35 P.M., the DON and Administrator were notified. The resident remained on one to one care and did not eat or drink anything since the reporting incident; -At 1:45 P.M., a member of the ER crew called and reported the resident swallowed a screw and was being transferred to another hospital for removal. Record review of the resident's esophagogastroduodenscopy (EGD - a diagnostic procedure that allows the physician to diagnose and treat problems in the upper gastrointestinal tract by using a long, flexible, lighted tube called an endoscope), dated [DATE], showed: -One 4 centimeter (cm) screw removed from the upper gastrointestinal tract; -The patient with schizoaffective disorder and bipolar disorder who was transferred from another hospital for emergent endoscopy after swallowing a screw earlier today. He/she heard his/her mother's voice, who is deceased , tell him/her that he/she might as well eat a screw, he/she ate everything else. For this reason, he/she ate the screw and is here now for evaluation. The resident had some problems with mild left upper quadrant pain but it has not been severe. He/she presents now for emergent endoscopy. He/she has never done this in the past; -The procedure was completed with removal of a 4 cm screw without injury to the esophagus, and no apparent damage related to the screw. Record review of the resident's nurse's notes showed he/she returned to the facility on [DATE] at 1:45 P.M. Record review of the resident's medical record showed staff placed the resident on 15 minute checks on [DATE]. Review of the resident's 15 minute check sheets showed staff did not document they completed the checks on: -[DATE]: 2:45 A.M., 3:00 A.M., 3:00 P.M., 3:15 P.M., 3:30 P.M., and 3:45 P.M.; -[DATE]: 7:30 A.M. through 2:15 P.M.; -[DATE]: 12:00 A.M. through 6:15 A.M., 2:45 P.M. through 11:45 P.M.; -[DATE]: 12:00 A.M. through 2:30 P.M. Record review of the resident's care plan regarding hearing voices, dated [DATE], showed: -Goal: no self harm over the next review. -Interventions included: Administer as needed injectable medications when he/she starts to hear voices. Encourage him/her not to eat non-food items. Resident to inform staff immediately when he/she starts hearing voices. During an interview on [DATE] at 9:55 A.M., the resident said: -He/she hears voices and the voice said to swallow the screw; -He/she got the screw from the towel rack, there were two screws exposed and he/she took one out and swallowed it; -They pulled the screw out through his/her mouth. He/she did not have surgery; -He/she would not do it again. -He/she said he/she will not do what the voices say now because he/she knows his/her mother's voice and knows he/she would not ask him/her to do that; -He/she shot himself/herself in the stomach in the past; -He/she really is trying to get better. He/she is in therapy to deal with the voices. Observation on [DATE] at 10:00 A.M., showed a 10 foot long black karate belt hanging on a hook on the resident's side of the room, an approximately 3 inch used ammunition shell, antiperspirant. and a three-quarters full bottle of hydrogen peroxide in his/her room. During an interview on [DATE] at 2:30 P.M., the Medical Director said: -He/she expected the facility to increase monitoring and check the resident's room after he/she told staff he/she heard voices telling him/her to swallow a screw. He/she also expected to be called immediately and he/she could have given an order to send the resident out to the hospital for evaluation; -He/she believes the resident may benefit from a lock-down behavioral placement. During an interview on [DATE] at 2:50 P.M., the ADON said: -The resident reported to him/her he/she swallowed a screw. The resident was very calm. He/she came to his/her office to tell him/her; -He/she first asked the resident if he/she was suffering from any pain. He/she said a little in his/her upper stomach, lower chest; -He/she took his/her vital signs, he/she was in no immediate distress. He/she called the physician, the ambulance, and had the resident stay with him/her until the ambulance came; -The resident did not want his/her sibling notified and the ADON did not notify him/her; -He/she did notify the DON and the Administrator; -A little over a year ago, the resident tied the bed sheets around his/her neck, the other end of the sheet was draped over the closet door and the closet door was shut. The resident had the sheet tied around his/her neck and was standing on the wheelchair when staff found him/her; -The resident said this most recent incident was not an attempt to harm himself/herself; -The charge nurse did not tell the ADON about the resident coming to him/her earlier that day saying he/she was hearing voices telling him/her to swallow a screw; -He/she expected the charge nurse to notify him/her but he/she did not. If the resident would have brought him/her a screw and said he/she heard voices telling him/her to swallow a screw, he/she would have checked the room, placed the resident on one-to-one monitoring, called the physician to get further orders, and requested a psychiatric evaluation; -After the ambulance arrived, the ADON checked the resident's room and found the towel rack off the wall and two screws were missing; -He/she asked where the resident obtained the screws and he/she told him/her that he/she pulled the towel rack from the wall; -Since the resident returned from the hospital, the Social Worker searched the room and removed sharp items. Maintenance placed screws for a towel rack into studs so they could not be easily pulled from the wall; -The resident has been on 15 minute checks since he/she returned on [DATE]; -With as much as the resident moves around and his/her tendency of taking things, it would require very frequent checking of the resident's room to ensure he/she had not gotten anything dangerous and placed it in his/her room. During an interview on [DATE] at 3:35 P.M., the Social Service Director said: -He/she has worked at the facility since [DATE]; -Staff reported the resident swallowed the screw to him/her after the fact; -The day before or the morning the resident returned from the hospital, the SSD went through the resident's room to ensure nothing sharp was in the room, no loose screws, removed thumb tacks, scissors, and other sharp objects; -He/she was told about an incident in which the resident had bed sheets tied around his/her neck; -When the resident gets depressed he/she talks to him/her at length to help things run smoother; -The resident saw the psychiatrist on [DATE]; -In the management team meeting, staff discussed how to make things safer for the resident; -He/she focused on removing sharp objects, objects he/she could swallow. He/she did not feel the resident would try anything with his/her black belt because resident sees that as an accomplishment; -He/she did not see any hydrogen peroxide when he/she searched the room; -The resident has been on 15 minute checks since the incident; -The resident usually tells someone when he/she hears voices. During an interview on [DATE] at 4:50 P.M., Licensed Practical Nurse (LPN) A said: -The resident came to his/her medication cart around 11:00 A.M. and told him/her he/she was told by his/her mother to swallow a screw. He/she talked to the resident about the dangers of swallowing a screw, that his/her mother was deceased , The resident gave him/her the screw. The resident then asked for the screw back, they talked some more about the dangers of doing something like, that he/she could really hurt himself/herself and the resident then was ok with not getting the screw back. The resident then asked for a Zyprexa injection, and he/she gave him/her the shot in his/her deltoid and the resident went out to smoke; -He/she then finished giving residents insulin and medications; -He/she thinks it was right after smoke break that the resident talked to the ADON and told him/her he/she swallowed the screw; -He/she did not tell anybody that the resident heard voices telling him/her to swallow a screw. He/she does not believe it was more that 10 to 15 minutes between when the resident talked to him/her and when he/she went to the ADON; -Smoke breaks usually last 15 to 20 minutes; -He/she was side tracked with giving insulin and medications and did not check the resident's room for other items he/she could swallow; -It seemed like such a short time, and it seemed that people, other residents were all around him/her. He/she does not believe the resident went back to his/her room; -He/she should have told the ADON that the resident heard voices telling him/her to swallow a screw before administering insulin's again; -Usually after the Zyprexa shots, the resident feels better. It did not cross his/her mind that the resident would really swallow a screw; -He/she knew the resident tried to harm himself/herself in the past. During an interview on [DATE] at 5:25 P.M., the ADON confirmed that the resident came to him/her at about 12:20 P.M. It was during lunch and after insulins had been given. He/she said there was sometime that had gone by between when the resident told the charge nurse and when the resident came to him/her and told him/her he/she had swallowed the screw. During an interview on [DATE] at 5:25 P.M., the DON said: -He/she was not informed by the LPN when the resident first came to him/her regarding hearing voices telling him/her to swallow a screw; -He/she learned of this after the resident informed the ADON he/she swallowed the screw; -He/she insisted the hospital keep the resident for a psychiatric evaluation after they removed the screw. The hospital tried to send the resident right back after removing the screw. He/she told the hospital they needed to be assured the resident would not try this again; -He/she expected the nurse to immediately inform him/her or the ADON. They would have wanted to contact the physician and place him/her on one to one monitoring; -The Administrator and Social Worker searched the resident's room and removed some questionable items prior to the resident's return. Record review of the facility summary of two incidents occurring on [DATE] and [DATE], showed staff documented: -On [DATE], the facility started one-to-one monitoring of the resident for protective oversight. On the evening of [DATE] at approximately 8:15 P.M., during one-on-one monitoring he/she informed his/her Certified Nurse Aide (CNA) A that he/she hid thumb tack he/she wanted to swallow. CNA A notified the charge nurse; -On [DATE], the physician gave an order to send the resident for an inpatient psychiatric evaluation. The facility social services found a placement that requested the resident be sent to the hospital emergency room for medical clearance prior to going to the psychiatric hospital. -On [DATE] at 3:30 P.M., the ADON and social worker spoke with the resident about being transferred for inpatient psychiatric care, the resident agreed to do so. -On [DATE] at 3:45 P.M., the Administrator and social worker gave the resident an immediate discharge notice. -On [DATE] at 4:25 P.M., CNA B and the resident went to the resident's room where the resident went through his/her drawers of belongings. The resident pulled out some money and went to another drawer. CNA B assumed he/she was looking for more money. CNA B heard the resident smash something that sounded like glass. CNA B attempted to try to get the resident not to put the object in his/her mouth but could not. CNA B called for the charge nurse stat, the charge nurse arrived. CNA B informed the charge nurse of what happened. LPN B took the resident from the room was going up the hall and saw the emergency medical personnel arrived. LPN B informed the emergency medical personnel of what happened. At approximately 4:30 P.M., the emergency medical personnel took over the scene and got the resident on the gurney. One of the emergency medical personnel pried open the resident's mouth and LPN C removed the base and jagged glass edge of a small light bulb from the resident's mouth. LPN C saw a small amount of blood in the resident's mouth prior to the emergency medical personnel taking the resident to the hospital. MO 857 and #MO 277

Based on interview and record review, facility staff failed to provide and implement interventions for one of 12 sampled residents (Resident #1) to prevent a fall that resulted in a cervical spine fracture, contusion (bruise) of the face, laceration (deep cut or tear) of the nose, and nasal bone fracture; failed to assess the resident in a timely manner on the morning of the resident's fall and apply interventions for the resident's positioning; and assess the resident prior to placement of the resident from a reclining wheelchair to a regular wheelchair. The facility census was 68 residents. Record review of the facility's Policy and Procedure for Fall Management dated October 2010, showed the staff were: -Trained to ensure the timeliness of completion of the resident's fall assessment; -Held accountable for implementing appropriate interventions based on the results of the resident's fall risk assessment; -Trained to keep the resident's physician informed about their balance, gait, mobility, and physical limitations; -To apply anti-tip devices for resident's who lean forward excessively; -To reassess the appropriateness of the device on a routine basis; and -To ensure the resident had an initial evaluation by the physical therapist and re-evaluation as needed. 1. Record review of Resident #1's Physician order [REDACTED]. -Advanced dementia (a decline in mental abilities such a thinking, reasoning and memory) with agitation/aggression; -Abnormal posture; -Macular degeneration (a medical condition that usually affects older adults and results in a loss of vision in the center of the visual field (the Macula) because of damage to the retina); and -Muscle weakness. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument required to be completed by facility staff) dated 1/2/14, showed he/she: -Had long-term and short-term memory problems; -Was totally dependent on one person with bed mobility, locomotion of his/her wheelchair, dressing, and hygiene; -Was totally dependent on two plus staff physical assistance for transfers and toileting; -Used a wheelchair for mobility that required staff to push or propel; -Was not able to move from surface to surface without staff assistance; -Received restorative therapy for range-of-motion exercises five days during the look back period; and -Had no falls within the look back period or since the prior assessment. Record review of the resident's Fall Risk Evaluation dated 12/26/13, showed he/she: -Had one to two falls in last 90 days, with the most recent fall being on 12/21/13; -Had behaviors that showed a cognitive deficient with no change in cognition over the past 90 days; -Had moderately impaired or limited vision; -Was continent of bowel and bladder with assistance; -Was confined to his/her wheelchair; -Was not able to balance without physical assistance; -Had predisposing diseases and took medications that could contribute to falling; and -Had a total score of 20 (a total score of 10 or above represented high risk for falls), he/she should be considered at high risk for potential falls, and interventions should promptly be put in place. Record review of the resident's Care Plan dated 1/14/14, showed: -He/she was at risk for falls related to poor communication and comprehension; -He/she may be up in a Tilt-N-Space wheelchair (a type of wheelchair that tilts backwards into a reclining position) as tolerated, related to sliding down in his/her chair secondary to abnormal posture and muscle weakness; -Staff was directed to anticipate and meet the resident's needs; -The resident was on the fall prevention program; -He/she had an activities of daily living self-care performance deficit related to weakness and advanced dementia; -Staff were directed to check and reposition every two hours and as needed; and -He/she required total assistance from staff for transfers. Record review of the resident's Occupational Therapy Discharge Summary dated 2/7/14, showed: -It provided interventions for wheelchair management, analysis of the resident's body alignment and functional skills in a new or existing wheelchair, and assessment of current seating system for appropriate modifications; -Instructed administration in use of assistive devices in order to increase safety and reduce the risk of further medical complications [REDACTED]. -He/she had not received his/her new wheelchair, waiting on arrival for proper positioning techniques and staff education; -His/her prognosis was good with consistent staff follow-through; -Discharge recommendations upon arrival of the new wheelchair included staff being educated on the proper positioning of the resident. Record review of the resident's POS dated February 2014, showed physician's orders [REDACTED]. Record review of the resident's order for a new Tilt-N-Space wheelchair with medical justification dated 2/10/14, showed: -The resident had a severe orthopedic abnormality of his/her pelvis; -The resident had a posterior pelvic tilt along with a right pelvis rotation which caused him/her to present with abnormal posture while seated in his/her current wheelchair; and -The resident was unable to reposition himself/herself; Record review of the resident's nurse's note dated 3/16/14 at 8:30 A.M., showed: -At approximately 7:30 A.M., he/she was found in the lobby area after breakfast with his/her alarm going off on his/her wheelchair; -He/she was lying in front of his/her wheelchair in a prone (when the body lies flat with the chest on the floor) position; -His/her nose was bleeding with purple discoloration and a laceration across the bridge of his/her nose; -His/her Designated Power of Attorney was notified, and staff received orders from the resident's physician to send him/her to the hospital for evaluation and treatment; -His/her vital signs were taken, he/she was treated for [REDACTED]. Record review of the resident's hospital admission records dated 3/16/14 at 8:31 A.M., showed: -He/she fell out of his/her wheelchair today and his his/her face was on the floor (not observed by caregivers); -According to the nursing facility he/she was usually in a wheelchair that leans back, and today they thought they would place him/her in an upright wheelchair; -He/she had severe Alzheimer's according to the facility, this was his/her baseline, and he/she was always nonverbal; -He/she had a bilateral nose bleed (both sides of the nose) and a laceration across the bridge of his/her nose; -His/her vitals signs were taken; -The patient' resident's x-ray showed he/she had a cervical spine C1 ring fracture and C2 odontoid (a part of the spine) fracture; contusion of his/her face; laceration of his/her nose requiring five sutures (stitches); and a nasal bone open fracture; -The patient was admitted to the hospital with [REDACTED]. -The treating physician noted "it is quite possible that the patient will not fully recover from these injuries and eventually palliative care hospice (end of life care) care may have to be considered down the road." During an interview on 3/27/14 at 1:45 P.M., the Director of Nursing (DON) said the resident's incident report and the facility investigation showed: -Staff had come to the DON late December due to the resident's tilt wheelchair not rolling and tilting properly, and Therapy and the facility ordered a new chair for the resident on 2/10/14 (the chair did not arrive prior to the resident's fall on 3/16/14); -The facility had ordered two (first order for new wheelchairs) new regular wheelchairs in order to start gradually replacing some of the wheelchairs (order date 1/28/14, ship date 2/4/14), and when the new regular wheelchairs arrived on an unspecified date, the Medical Records staff gave the new wheelchair to the Certified Nurse Assistant (CNA), who placed Resident #1 in the regular wheelchair on an unspecified date, and nursing staff left the resident in a regular wheelchair; -On 3/16/14: -The resident kept leaning forward, and CNA A who fed the resident said the resident's eyes were open, but the resident almost put his/her nose in oatmeal at one point during breakfast, though he/she ate 100 percent; -CNA B said the resident in a regular wheelchair was sitting up straight in his/her wheelchair, and he/she left the resident in front of the television in the lobby area while he/she went to lay down other residents; -The resident's wheelchair alarm was sounding, and the resident was found by nursing staff on the floor in front of his/her wheelchair in the lobby area -The resident was alert, with blood coming from his/her nose area. Range of motion was normal to all extremities, and nursing treated the laceration across the bridge of his/her nose, while the other nurse called "911," the resident's responsible party, the resident's physician, and the resident was sent to the hospital by ambulance. -All staff were inserviced about preventing injury of the residents (notifying the charge nurse if they noticed a resident leaning or having poor positioning, giving immediate attention to resident's at risk, not leaving resident's unattended if in danger of falling, and ensuring fall prevention program interventions were followed); and three staff received written reprimands for providing a regular wheelchair to Resident #1, allowing the resident to remain in a regular wheelchair for several weeks, and leaving the resident unattended after the resident was leaning in his/her wheelchair at breakfast. During an interview on 3/27/14 at 2:50 P.M., the Director of Rehabilitation Services said: -He/she was out on medical leave from 12/28/13, Resident #1 at that time was in a reclining type wheelchair, and when he/she return in March 2014, the resident was no longer on his/her case load; -When the DON called 3/17/14, and asked the Physical Therapist why Resident #1 was in a regular wheelchair and when he/she was evaluated for a regular wheelchair, the Rehabilitation Services Regional Manager handled the investigation, since the Director had been on medical leave during the time 12/28/13 through March 2014; and -He/she said the paperwork showed the resident received medical approval and a new Tilt-N-Space wheelchair was ordered on [DATE], but was not received prior to the resident's fall and discharge to the hospital on [DATE]. During an interview on 3/27/14 at 4:00 P.M., the Medical Records and Central Supply Coordinator said: -He/she was directed to order regular wheelchairs two per month in order to get the resident's wheelchairs replaced; -Two regular wheelchairs came-in on an unspecified date, and the maintenance director was busy, so three to four days later he/she put the wheelchairs together and took them to the staff and asked who needed a new wheelchair, and staff told him/her Resident #1 and #5; and -He/she saw Resident #1 last on 3/14/14, he/she was in the new regular wheelchair with foot rests in front, he/she was not leaning, but staff were repositioning him/her as he/she did slide down in his/her wheelchair. During an interview on 3/28/14 at 9:10 A.M., Licensed Practical Nurse (LPN) B and the unit manager said: -Resident #1 was in a regular wheelchair (two new ones came in February 2014 and Resident #1 got one, and Resident #5 got the other new wheelchair, but Resident #5 switched shortly after to a reclining high back because he/she was sliding and the pommel cushion (like a saddle with center piece between legs) was uncomfortable) without foot platforms (liked to cross feet in front) and had previously had a high back wheelchair on approximately September 2013 when he/she took over as manager of the unit; -There were a couple of times staff had to pull Resident #1 back in his/her wheelchair, but he/she never saw him/her lean forward, more sliding down in his/her wheelchair; -Last time he/she saw the resident was Friday 3/14/14, and there was no report he/she had a change or was not sleeping well; and -After Resident #1 fell , he/she was directed to do an audit to determine that all residents were in appropriate wheelchairs and using correct assistive devices. No residents required changes, and the facility's Registered Nurse and Assistant Director of Nursing conducted an inservice on what to do if a resident had a change in condition or was unsafe. During an interview on 3/28/14 at 8:50 A.M., the Activity Director said the following regarding Resident #1: -Normally he/she conducted one-to-one activities in his/her room (reading newspaper to him/her, music and singing to him/her, soothing sounds, and talking books); -The last time he/she saw the resident on 3/13/14, the resident was seated in a regular wheelchair, and he/she assisted the resident to place his/her feet on the foot rests; and -He/she never saw the resident propel his/her own wheelchair, sliding down or leaning forward in his/her wheelchair, he/she would sleep in his/her wheelchair in the lobby area, and he/she never saw a decline in the resident, but the resident would have days when he/she was "more sleepy." During an interview on 3/28/14 at 9:30 A.M., CNA B said: -Resident #1 had a higher back wheelchair that had a front wheel that did not turn well, and someone came through with a new wheelchair; -He/she did not recall his/her positioning being any different in the new wheelchair (the regular wheelchair with foot rests in front); -Resident #1 was alert, awake, and seldom did he/she get to point of leaning, and he/she never saw the resident leaning forward, but at times he/she would set-up towards the front of his/her wheelchair and staff would scoot him/her back in the wheelchair; -Normally when he/she arrived at work, the resident would be in the front lobby in his/her wheelchair with his/her feet on the foot rests, and after breakfast we would change him/her and return to the lobby where he/she could be watched by staff at the nurse's desk; -On 3/16/14, staff pushed him/her to the dining table as normal. They had to pull him/her up in his/her wheelchair, but he/she did not seem drowsy. He/she was unsure who fed the resident. After breakfast, he/she placed the resident in his/her wheelchair in the front lobby, and he/she did not know anything until heard someone holler, and he/she arrived in the front lobby to see the resident on the floor and being cared for by nurse; and -In looking back there was nothing out of the ordinary with the resident, but maybe we should have laid him/her down first. During an interview on 3/28/14 at 10:00 A.M., LPN A said the following regarding Resident #1: -On 3/16/14, nothing was reported from night shift out of the ordinary, the resident was already up in the lobby and in a regular wheelchair with foot rests, staff assisted the resident at breakfast and he/she received no reports from staff; -The next time he/she saw the resident was after breakfast when the Certified Medication Technician (CMT) B came to get him/her and said someone had fallen, and he/she came into the lobby where another nurse was with Resident #1; -The resident was lying on his/her left side with no grimacing, a cut across the bridge of his/her nose, and bleeding from his/her nose. He/she was alert, and the other nurse stayed with the resident while he/she called "911," the responsible party, the doctor, and they received consent to send him/her out to the hospital; and -During the seven to eight times he/she worked with the resident during February and March, he/she did not recall the resident needing a new chair or positioning devices due to his/her leaning or posture. During an interview on 3/28/14 at 10:20 A.M., CMT B said the following regarding Resident #1: -He/she was assisted by staff at meals, he/she sleeps and dozes a lot of the time, and he/she required two staff for repositioning in his/her wheelchair; -At one time the resident had a tilt wheelchair but it was worn out, the wheel did not work, and one of the back handles did not work to recline one side; -On 3/16/14, when he/she arrived at 6:30 A.M., the resident was setting in a regular wheelchair in the dining room, which was nothing out of the ordinary, dozing off and on; CMT A and Registered Nurse (RN) A were in the dining room, he/she did not recall the resident leaning into his/her food, and the resident was not acting tired when he/she was in the dining room; -He/she gave the resident his/her medications with no problem, the resident was slumped in his/her wheelchair and had to be repositioned, but he/she was alert; -He/she was giving medications and the next thing he/she heard was an alarm, and RN A said the resident fell , so he/she went to get LPN A and to get cold cloths for the resident's bleeding, and the nurses took care of the resident; and -Staff received training on watching resident alarms to ensure they were working, not to leave any resident when they were leaning or an accident risk, and to make sure they were alert to what was occurring with the resident's, and to notify the nurse for suggestions in what to do to take care of the residents. During an interview on 3/28/14 at 10:55 A.M., the Restorative Assistant (RA) said the following regarding Resident #1: -He/she worked with him/her Monday through Friday for upper and lower extremity exercises (more passive); -He/she would take him/her to gym in a high back recliner type wheelchair, and sometime in January 2014 that wheelchair broke where both sides would not recline together, and sometime in February 2014 central supply got him/her a new wheelchair, a regular wheelchair with front foot rests; -Had to have him/her sit-up, never placed his/her feet on the foot rests, but he/she liked to cross his/her legs in front, and no matter what time they did restorative he/she would be sleeping, but could get to wake-up and would doze off during exercise; -The last time he/she saw the resident on Friday, 3/14/14, the resident was in the lobby when he/she arrived. He/she saw staff assisting the resident at breakfast, and he/she was always a good eater, and that day did not notice any changes in the resident; and -There was never a time when he/she felt the resident was unsafe in his/her wheelchair. During an interview on 3/28/14 at 11:55 A.M., RN A/RN Weekend Nurse Supervisor said the following regarding Resident #1: -He/she required total assistance from staff, and tried to feed himself/herself, but would get more food on himself/herself, and staff would assist; -Prior to 3/16/14, the resident was in a wheelchair that reclined with foot rests; -On 3/16/14, he/she was assisting residents at another table across from where the resident was assisted by CNA A/CMT, the resident was leaning forward in his/her wheelchair but not falling into his/her food, and he/she said to CNA A after breakfast they needed to try and find another wheelchair, and the CNA A agreed; -He/she was staying with another resident who was not doing well, and CNA A/CMT had gone to assist with medication pass; and the next thing he/she heard was an alarm and a "thud," and he/she found Resident #1 on the floor in the lobby by the piano and close to the television; -The resident was face down, and blood going into his/her eye from a cut on the bridge of his/her nose and coming out of his/her nose. He/she applied pressure on the wound and the other nurse called "911," and he/she recalled saying I think his/her nose was broken, they applied medical attention; and the resident was alert and was sent to the hospital; and -Prior to 3/16/14, he/she recalled the resident in a reclining chair; and on 3/16/14, he/she was with another resident and did not see the staff take the resident out of the dining room. During an interview on 3/28/14 at 12:20 P.M., CNA A/CMT said the following regarding Resident #1: -He/she assisted in the dining room, worked at times as a CNA, and other times worked as a CMT; -When he/she arrived normally the resident was up and seated in the lobby by the radio or television, or already in the dining room; -Prior to 3/16/14, he/she worked three weeks prior, and the resident had a reclining wheelchair that the front wheel did not want to turn properly, and one side did not lean back properly; -The resident would lean forward and put his/her elbows on his/her knees and staff would have to scoot back in his/her chair (approximately two times throughout the shift); -On 3/16/14, he/she was working as a CNA and assisted the resident in the dining room, the resident was in a regular wheelchair with foot rests, staff had to reposition him/her so his/her face would not go into his/her food, and the resident was not feeding himself/herself so he/she assisted the resident to eat; -RN A and he/she had talked about the resident had not leaned that bad prior, and said they needed to get him/her another wheelchair; -He/she finished feeding the resident, and the resident ate well never dozing-off, and the resident was upright in his/her wheelchair; -He/she and another CNA finished moving resident's out of the dining room, and he/she never saw who moved Resident #1; and -Later in the day after the resident had fallen and gone to the hospital, he/she was in the shower room, and noticed a reclining wheelchair stored in the shower room, but was not certain who it belonged to, and he/she did not know if anyone had ever gone to find Resident #1 another wheelchair. During an interview on 3/28/14 at 3:15 P.M., Resident #1's guardian said: -Usually the facility very was good about calling him/her with any changes with Resident #1; -When he/she saw the resident last (unsure of the date), the resident was in a tilt back type wheelchair, and his/her understanding why the resident was in that type of chair was due to the resident's history of falling; -He/she had no knowledge or any information from staff regarding the resident being changed to a different type of wheelchair until the resident fell on [DATE]; and -What occurred to Resident #1 was not "something common." During a telephone interview on 4/8/14 at 10:05 A.M., the Rehabilitation Services Regional Manager said regarding Resident #1: -The last time the Occupational Therapist saw the resident on 2/7/14, the resident was in the same reclining wheelchair he/she had been using since he/she was picked-up on their therapy case load to evaluate for wheelchair positioning and to find an appropriate wheelchair; -The last time he/she observed the resident on 1/28/14, the resident was in a reclining wheelchair in the dining room reclined at a 40 degree angle; -While the Rehabilitation Director was out on leave he/she received all rehabilitation orders, and had daily conversations with the therapist who attended daily meetings with the facility staff, and there were no new orders for evaluation of the resident for positioning for any new wheelchair other than the one ordered on [DATE]; -After the resident fell on [DATE], he/she received a call from the Rehabilitation Director on 3/17/14, that the DON had asked the therapist why the resident was in a regular wheelchair, and if Rehabilitation Services had evaluated the resident for that wheelchair; -He/she conducted an investigation and saw the facility's Corporate Nurse on 3/18/14, at which time they went to look at the wheelchair the resident had fallen out of on 3/16/14 (located in the resident's room); -He/she and the Corporate Nurse saw a new regular standard wheelchair, maroon in color, with no seat cushion; and -The Corporate Nurse and he/she both had concerns with the resident's current regular wheelchair ("don't know how the resident could sit-up straight," since he/she leaned to the right side in a reclining wheelchair, there was no cushion and given the resident not having "a lot of hip flexion," the resident could have "easily slid out of the wheelchair," and the last evaluation by the OT on 1/7/14, showed the resident falls sideways and the resident's hip, knees, and ankles were at 90 degrees in his/her current reclining wheelchair). During a telephone interview on 4/8/14 at 11:40 A.M., the resident's physician said: -When asked what he/she expected staff to do when changing the resident from the physician ordered Tilt-N-Space wheelchair, he/she could not say since the resident's chart was in another facility; -He/she recalled the facility had concerns with the resident's current wheelchair, and since the resident required a wheelchair staff would have had to use a temporary wheelchair until the resident's new Tilt-N-Space wheelchair arrived; and -When asked what he/she expected staff to do for the resident's safety when on 3/16/14, the Nurse and CMT saw the resident leaning more at breakfast, he/she said without looking at the resident's chart, he/she would expect staff to monitor (no set parameters or time given) the resident, make sure the resident leaned back in his/her wheelchair, and the Nurse could monitor from the nurses' desk. Complaint #MO 503