Every finding on record at Riverview at the Park Care and Rehabilitation Cent

Based on observation, interview, and record review, the facility nursing staff failed to contact the physician in a timely manner for one resident (Resident #1) of five residents sampled when experiencing a change in condition resulting in a hospitalization. The facility census was 100.Based on observation, interview, and record review, the facility nursing staff failed to contact the physician in a timely manner for one resident (Resident #1) of five residents sampled when experiencing a change in condition resulting in a hospitalization. The facility census was 100.Review of the facility's revised policy titled, Change in Resident's Condition or Status, dated 02/2021, showed: -The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition based on the judgment of the clinical staff. - A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without interventions by staff or by implementing standard disease related interventions (is not self-limiting) and impacts more than one area of the residents' health status;1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/09/25, showed:- Cognitively intact;- Requires partial to moderate assist with activity of daily living, including ambulation, and transfers;- Eating requires meal set up only;- Occasionally incontinent of bowel and bladder;- Diagnoses included coronary artery disease (occurs when plaque buildup (atherosclerosis) narrows the heart's arteries, restricting blood, oxygen, and nutrient flow, leading to symptoms like chest pain (angina), shortness of breath, and fatigue, and can ultimately cause a heart attack or heart failure), Anemia (a common blood disorder where your blood lacks enough healthy red blood cells or hemoglobin, impairing its ability to carry oxygen, leading to fatigue, weakness, pale skin, shortness of breath, and dizziness, often caused by iron deficiency, blood loss, or chronic conditions), Cancer, High blood pressure, Orthostatic hypotension (a sudden drop in blood pressure when standing up from sitting or lying down, causing dizziness, lightheadedness, or fainting due to reduced blood flow to the brain), Peripheral arterial disease ( a circulatory condition where narrowed arteries reduce blood flow to your limbs, most commonly the legs, due to plaque buildup (atherosclerosis), causing pain, cramping, and numbness during activity), Diabetes with polyneuropathy (nerve damage from long-term high blood sugar), Depression, dysphagia (difficulty swallowing food or liquids). Review of the resident's plan of care, dated 12/10/25 showed: - The resident required substantial assist with ambulation and wheeled walker.- The resident required partial assist tray set up, like opening packets or cartons and cutting up food. The resident able to feed self. - The resident required partial assist with toileting and is occasionally incontinent of bowel and bladder. Review of Resident #1's progress notes showed:- On 12/13/25 at 3:40 P.M. Resident continues to be alert to self only and confused in general, unable to comprehend how to feed self or cut own food, will stare blankly at food or other residents who are eating. Not bearing weight, staff having to use Hoyer Lift (a mechanical lift to move position) for transfers for safety. Resident continues to be incontinent of bowel and bladder, urine dark amber and strong in odor, skin color is pale;- On 12/14/2025 at 4:54 P.M., Resident has been lethargic (sluggish, drowsy, and lacking energy or enthusiasm, describing a state of extreme tiredness, inactivity, and apathy, often with reduced mental alertness, that goes beyond normal tiredness and can signal an underlying health issue), remains in bed with eyes closed this shift, responds to painful stimuli only. Able to administer fever reducing medications 4:30 P.M. Resident not eating or drinking this shift. Temperature noted at 4:00 P.M. 99.7;- On 12/14/2025 8:39 Resident was unable to swallow medications this evening, Held all per nurse; - On 12/15/2025 at 11:40 A.M., resident noted to be unresponsive this morning, new order received to send to emergency room for evaluation. - No documentation of notifying the resident's physician or physician on call 12/13/25 or 12/14/25. During an interview on 12/30/25 at 12:30 P.M., Licensed Practical Nurse (LPN) A said he/she was the one that documented Resident #1 was unresponsive on 12/15/25. That information had been reported to him/her. LPN A said he/she did not work 12/13/25 or 12/14/25. LPN A said he/she would have expected a nurse to contact a resident's physician if a resident suddenly can no longer feed themselves or bear weight as they had before. During an interview on 12/30/25 at 12:40 P.M., LPN B said on the morning of 12/15/25, he/she visited the resident with the wound nurse practitioner. LPN B said the resident felt warm like a fever and was not responding to verbal commands or painful stimulation. LPN B said he/she reported the information to the nurse. That nurse is no longer employed at the facility. During a phone interview on 12/30/25 at 12:50 P.M., Resident #1's Primary Care Physician (PCP) said no one notified him/her of any status changes for Resident #1 until 12/15/25. The PCP said he/she expected staff to notify him/her immediately of any notable changes to one of his/her patients. The PCP said he/she would consider going from being able to feed oneself to not, in addition to a mental status change a reason to notify his/her office immediately. During an interview on 12/30/25 at 1:15 P.M., the Director of Nursing said based on the documentation in Resident #1's medical record, he/she would have expected the nursing staff to notify the physician on the resident change in condition prior to 12/15/25. COMPLAINTS: 2693690 & 2693979

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices for seven residents (Resident #2, #4, #10, #13, #14, #39, and #107) out of 22 sampled residents and three residents (Resident #12, #111, and #120) outside the sample. The facility census was 106. Review of the facility's policy, Transfer or Discharge, Facility Initiated, revised October 2022 showed: - Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; - When residents are sent emergently to an acute care setting, these scenarios are considered facility­ initiated transfers, NOT discharges, because the resident's return is generally expected; - Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility; - Under the following circumstances, the notice is given as soon as it is practicable, but before the transfer or discharge: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident, the resident's health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required by the resident's urgent medical needs; or a resident has not resided in the facility for 30 days; - Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements); - Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer; - Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments; - Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge; - If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care); - The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care (LTC) Ombudsman; - Notice to the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfers to the hospital. 2. Review of Resident #4's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfers to the hospital. 3. Resident #10's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfers to the hospital. 4. Review of Resident #12's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and has not returned at this time; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 5. Review of Resident #13's medical record showed: - admitted on [DATE]; -The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfers to the hospital. 6. Review of Resident #14's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 7. Review of Resident #39's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 8. Review of Resident #107's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that written notification of transfer or the bed hold policy was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 9. Review of Resident #111's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and did not return to the facility; - No documentation that written notification of transfer or the bed hold policy was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. 10. Review of Resident #120's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and did not return to the facility; - No documentation that written notification of transfer was provided to the resident and/or the resident's representative for the resident's transfer to the hospital. During an interview on 09/12/25, at 1:45 P.M., Licensed Practical Nurse (LPN) A said the facility had been using several different forms and is currently using the Emergency Transfer Sheet. Staff fill out the sheet, scan it in the computer, and give it to the emergency personnel when residents are transferred out to the hospital. During an interview on 09/12/25 at 2:30 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect residents and/or their representatives and families to be notified in writing of transfers.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #14) out of 22 sampled residents and one resident (Resident #8) outside the sample. The facility census was 106. Review of the facility's policy, Comprehensive Assessments, revised October 2023, showed: - Comprehensive MDS assessments are conducted to assist in developing person-centered care plans; - The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument (RAI) specified by CMS; - The comprehensive assessment process includes direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members on each shift; - A comprehensive assessment'' includes completion of the MDS, completion of the care area assessment (CAA) process, and development of the comprehensive care plan; - Comprehensive assessments are conducted in accordance with criteria and timeframes established in the RAI User Manual; - A significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and the error has not been corrected via submission of a more recent assessment; - Completed assessments are maintained in the resident's active record for a minimum of 15 months. These assessments are used to develop, review, and revise the resident's comprehensive care plan. Review of the RAI Manual, Version 1.19.1, dated October 2024, showed: - Section P: Restraints: After determining whether or not an item listed in (P0100) is a physical restraint and was used during the seven-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the seven-day look-back period or it was used but did not meet the definition; - N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any time during the seven-day look-back period (or since admission/entry or reentry if less than seven days). 1. Review of Resident #8's medical record showed: - Diagnoses of morbid obesity (a severe form of the disorder that involves having too much body fat, which increases the risk of health problems), need for assistance with personal care, and muscle weakness; - Bed rail consent form, dated 03/16/25; - Side rail assessment, dated 09/04/25. - An order for quarter side rail times two, per resident preference to promote independence and assist with bed mobility/positioning as needed, dated 03/17/25. Review of the resident's annual MDS, dated [DATE], showed: - Section P0100. Physical Restraints, A. Bed rails, coded with a 2 (used daily); - The facility failed to accurately code the MDS assessment. 2. Review of Resident #14's medical record showed: - admission date of 02/07/25; - Diagnoses of heart failure (chronic condition in which the heart doesn't pump blood as well as it should), muscle weakness, and unsteadiness on feet. - An order for furosemide (diuretic – a medication to help the body get rid of extra fluid and salt) 20 milligrams (mg), give one tablet by mouth one time a day for heart failure, dated 07/29/25. Review of the resident's Medication Administration Record, dated August 2025, showed the resident received furosemide daily during the seven-day look back period. Review of the resident's quarterly MDS assessment, dated 08/12/25, showed Section N0415 marked no for diuretic use for the seven-day look back period. During an interview on 09/12/25 at 1:48 P.M., the MDS Coordinator said medications the resident is currently taking should be coded on the MDS assessment and, if bed rails are being used for mobility and positioning, they are not to be coded as restraints. During an interview on 09/12/25 at 2:30 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS assessments to accurately reflect the condition of the resident.

Based on interview and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase their ROM and/or prevent a further decrease in their ROM. The facility staff failed to perform restorative services as ordered for three residents (Resident #13, #50, and #82) out of 22 sampled residents and one resident (Resident #35) outside the sample. The facility census was 106.The facility did not provide a policy for restorative services. 1. Review of Resident #13's medical record showed: - admitted on [DATE]; - Diagnoses of muscle weakness, pain in right hip, pain in left hip, reduced mobility, need for assistance with personal care, and repeated falls; - An order for Restorative Nursing Program one to seven days a week as tolerated by resident to aid in maintaining current level of function. Provide: Active Range of Motion (AROM) to Left Upper Extremity (LUE), AROM to Right Upper Extremity (RUE) training and skill practice in communication, dated 05/21/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 08/28/25, showed: - No cognitive impairment; - Used a wheelchair; - Dependent with toileting, bathing, upper and lower body dressing, and personal hygiene. Review of the resident's care plan, revised 09/04/25, showed Activities of Daily Living (ADL) self-care performance deficit. Review of the resident's restorative nursing documentation showed restorative therapy occurred on 08/13/25, 08/22/25, 08/29/25, 09/05/25, 09/07/25, and 09/08/25. During an interview on 09/09/25 at 12:00 P.M., Resident #13 said the restorative aide is often pulled to help with transport, so he/she sometimes does not receive restorative services. 2. Review of Resident #35's medical record showed: - admitted on [DATE]; - Diagnoses of Amyotrophic Lateral Sclerosis (ALS - a progressive and fatal neurological disease that affects nerve cells controlling voluntary muscle movement), muscle weakness, and reduced mobility; - An order for Restorative Nursing Program one to seven days a week as tolerated by resident to aid in maintaining current level of function. Bilateral Upper Extremity (BUE) and Bilateral Lower Extremity (BLE) AROM/Active Assisted Range of Motion (AAROM), dated 03/12/25. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Lower extremity impairment on both sides; - Used a wheelchair; - Partial/moderate assistance for upper body dressing and personal hygiene; - Substantial/maximal assistance for toileting, bathing, and lower body dressing. Review of the resident's care plan, revised 07/03/25, showed the resident may have restorative therapies as ordered and directed by his/her primary care provider (PCP) and as the resident tolerates the therapy. Review of the resident's restorative nursing documentation showed restorative therapy occurred on 7/29/25 and 9/10/25. During an interview on 09/11/25 at 11:00 A.M., Resident #35 said he/she isn't getting restorative therapy with the Certified Nurse Aide (CNA). 3. Review of Resident #50's medical record showed: - admitted on [DATE]; - Diagnoses of morbid severe obesity (very high body weight from overeating), reduced mobility, pain in right knee, need for assistance with personal care, adult failure to thrive (overall decline in health and functioning), muscle weakness (weak muscles), difficulty in walking, and unsteadiness on feet; - An order for Restorative Nursing Program one to seven days a week as tolerated by resident to aid in maintaining current level of function. Provide: AROM to LUE, AROM to RUE, AROM to Left Lower Extremity (LLE), AROM to Right Lower Extremity (RLE) training and skill practice in: walking 20-50 feet with walker and minimum assist and close wheelchair follow, bed mobility, communication, dressing & grooming, transfer times one assist, red TheraBand (resistance band) for BLE range of motion, dated 06/19/25. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Used a wheelchair and walker; - Partial/moderate assistance with toileting, bathing, upper and lower body dressing, and personal hygiene. Review of the resident's care plan, dated 09/04/25, showed requires partial to moderate assistance with ADLs. Review of the resident's restorative nursing documentation showed no documentation of restorative therapy having been provided. During an interview on 09/12/25 at 1:30 P.M., Resident #50 said he/she goes to occupational therapy three days a week and doesn't receive any other therapy at this time. 3. Review of Resident #82's medical record showed: - admitted on [DATE]; - Diagnoses of morbid severe obesity, restless leg syndrome (uncomfortable urge to move legs, usually at night), depression (persistent sadness or low mood), muscle spasms (sudden involuntary muscle tightening), difficulty in walking, and edema (swelling from fluid buildup); - An order for Restorative Nursing Program one to seven days a week as tolerated by resident to aid in maintaining current level of function. BUE/BLE AROM/scifit (a piece of exercise equipment)/omni-cycle (exercise equipment) and transfers, dated 01/08/25. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Used a walker and wheelchair; - Partial/moderate assistance for toileting and bathing; - Supervision or touching for upper body dressing; - Substantial/max assistance with lower body dressing; - Supervision or touching assistance with personal hygiene. Review of the resident's care plan, revised 07/09/25, showed requires partial assistance with daily care. Review of the resident's restorative nursing documentation showed restorative therapy occurred on 08/12/25, 08/13/25, 08/14/25, 08/21/25, 08/22/25, 08/25/25, 08/29/25, 09/03/25, and 09/08/25. During an interview on 09/09/25 at 1:54 P.M., Resident #82 said he/she doesn't receive restorative services the way he/she should because the restorative aide is always getting pulled to transport and doesn't have time to provide the restorative services to the residents. He/she would like to receive the services that he/she is supposed to. During an interview on 09/12/25 at 2:00 P.M., Restorative Aide B said he/she has been doing restorative services for about a year. He/she is given an order list each day of which residents he/she needs to work with. He/she does half the building and the other aide does the other half. He/she and the other aide both do transports as well, so he/she will try to alternate days when he/she has to miss working with the residents. Transports can sometimes take all day and will sometimes interfere with restorative care, causing them to not be able to complete the services for the week. They complete a log each day they work with the residents and will copy it into the electronic records at the end of each day. During an interview on 09/12/25 at 2:45 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect restorative services to be completed as ordered and appropriate documentation to be completed regarding the services.

Based on observation and interview, the facility failed to maintain an effective pest control program. This practice affected five residents (Resident #13, #26, #51, #71, and #201) out of 20 sampled residents and seven residents (Resident #17, #28, #41, #54, #61, #85 and #86) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 99. Review of the facility's policy, Pest Control, revised May 2018, showed: - Our facility shall maintain an effective pest control program; - This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents; - Pest control services are provided by Van Pest; - Only approved Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) insecticides (a substance used for killing insects) and rodenticides (a substance used for killing rodents) are permitted in the facility and all such supplies are stored in areas away from food storage areas. Windows are screened at all times; - Garbage and trash are not permitted to accumulate and are removed from the facility daily; - Maintenance services assist, when appropriate and necessary, in providing pest control services. 1. Observations of Resident #85 showed: - On 07/21/24 at 2:50 P.M., the resident with a fly buzzing around his/her face and two flies on a stain on the roommate's sheet; - On 07/24/24 at 10:48 A.M., the resident lay in bed with a fly crawling on his/her head. During an interview on 07/21/24 at 2:50 P.M., Resident #85 said there is a fly problem. 2. Observation on 07/21/24 at 3:08 P.M. showed Resident #13 in bed with his/her eyes closed. Five ants were observed climbing on top of the bedside table/dresser which contained a package of peanut butter crackers, a canister of cereal, a 20 ounce bottle of soda pop, and a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs). One fly was on the divider curtain. 3. Observation on 07/21/24 at 3:13 P.M. showed three flies buzzing around Resident #17. During an interview on 07/21/24 at 3:13 P.M., Resident #17 said the flies are bad. 4. Observation on 07/21/24 at 3:29 P.M. showed a fly buzzing around Resident #71. 5. Observation on 07/21/24 at 3:41 P.M. showed Resident #51 lay in bed with eyes closed with a fly buzzing around the room. During an interview on 07/21/24 at 3:41 P.M., Resident #51's roommate, Resident #54, said he/she keeps the door closed to keep the flies out. He/She has to look out for Resident #51 because Resident #51 is bedbound. 6. Observation on 07/21/24 at 5:36 P.M. showed Resident #41 sat in a wheelchair with two flies on his/her hand and shirt. 7. Observation on 07/21/24 at 4:00 P.M. showed one fly continued to buzz and land on Resident #28's face. During an interview on 07/21/24 at 5:36 P.M., Resident #28 said the flies are bad. He/She is a quadriplegic (loss of movement and sensation in all four limbs and, sometimes, parts of the chest, abdomen, and back), so he/she is unable to shoo flies off of himself/herself. 8. Observation on 07/22/24 at 8:49 A.M. showed Resident #201 lay in bed with eyes closed with a fly on a used napkin on the bedside table, a fly on the resident's sheet, and a fly buzzing around the room. 9. Observation on 07/22/24 at 9:55 A.M. showed an ant crawled up Resident #86's wall while the resident received morning medications. 10. Observation on 07/24/24 at 9:50 A.M. showed four dead gnats on the top left of Resident #61's sink. During an interview on 07/22/24 at 9:10 A.M., Resident #61 said he/she has ants in his/her room and kills a few every day. They come in from the outside and around the air conditioner unit beside the bay window. He/she has gnats in his/her room and said, they are real bad. 11. Observation on 07/24/24 at 8:50 A.M. showed an ant crawling in Resident #26's window seat in his/her room. During an interview on 07/24/24 at 2:43 P.M., Certified Nurse Aide (CNA) M said if he/she would see something in the building that needs fixed or noticed an issue with pests, he/she would notify the nurse or maintenance. During an interview on 07/24/24 at 2:50 P.M., Licensed Practical Nurse (LPN) N said he/she will call the maintenance director if he/she sees something in the building that needs fixed or sees pests somewhere. Maintenance will typically come right away to fix something. If it's something they can't get to right away, then he/she will complete a maintenance slip. During an interview on 07/24/24 at 3:00 P.M., the Maintenance Supervisor said they have a contract with a pest control company, and they come once a month to treat the facility. If they need them to come more often, they can. There is a folder in their office that staff can list the date and location they saw pests for the pest control company to treat. During an interview on 07/24/24 6:30 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect the facility to be free from pests. Complaint #MO00238791

Based on interview and record review, the facility failed to ensure that Nurse Aide (NA) Registry checks were completed prior to the employment start date of four employees out of a sample of ten employees and failed to ensure their policy addressed checking the NA Registry for all employees prior to employment. The facility also failed to follow their policy to ensure the Criminal Background Check (CBC), Employee Disqualification List (EDL) or Family Care Safety Registry (FCSR) were completed prior to the employment date of one employee out of a sample of ten employees. The facility's census was 99. Review of the facility's policy, Background Screening Investigations, revised March 2019, showed: - The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors; - Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment; - For any individual applying for a position as a certified nursing assistant (CNA), the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and /or theft of property have been entered into the applicant's file; - For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license; - The policy did not address checking the nurse aide registry for employees other than CNAs. Review of the facility's Nurse Aide Registry Verification Policy, revised August 2022, showed: - Certified nurse aide licenses shall be verified through the state registry of nurse aides before individuals may serve as nurse aides or nursing assistants. 1. Review of Licensed Practical Nurse (LPN) C's personnel file showed: - Hire date of 08/08/23; - The facility failed to check the NA Registry for LPN C. 2. Review of Registered Nurse (RN) D's personnel file showed: - Hire date of 12/21/23; - Family Care Safety Registry (FCSR) letter for RN D dated 05/03/24. 3. Review of Dietary Staff E's personnel file showed: - Hire date of 03/20/24; - NA Registry check for Dietary Staff E dated 04/11/24. 4. Review of LPN F's personnel file showed: - Hire date of 04/02/24; - The facility failed to check the NA Registry for LPN F. 5. Review of LPN G's personnel file showed: - Hire date of 10/27/23; - The facility failed to check the NA Registry for LPN G. During an interview on 07/24/24 at 6:00 P.M., the Administrator and Director of Nursing said they would expect the NA Registry to be run on new hires and background checks to be completed.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice affected four residents (Residents #3, #13, #66, and #201) out of 20 sampled residents and four residents (Residents #23, #27, #87, and #251) outside the sample, and had the potential to affect all residents in the facility. The facility's census was 99. Review of the facility's policy titled, Work Orders, Maintenance, revised April 2010, showed: - Maintenance work orders shall be completed in order to establish a priority of maintenance service; - In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director; - It shall be the responsibility of the department directors to fill out and forward such work orders to the maintenance director; - A supply of work orders is maintained at each nurses' station; - Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily; - Emergency requests will be given priority in making necessary repairs. 1. Observation of Resident #201's bed showed: - On 07/21/24 at 2:50 P.M., the fitted sheet with approximately 3 inch by 4 inch gray-colored stain in right lower quadrant and approximately five inch round hole on bottom right corner; - On 07/22/24 at 8:49 A.M., the resident lay in bed with the same fitted sheet with approximately 3 inch by 4 inch gray-colored stain in right lower quadrant and approximately five inch round hole on bottom right corner; - On 07/22/24 at 10:29 A.M., the resident lay in bed with the same fitted sheet with approximately 3 inch by 4 inch gray-colored stain in right lower quadrant and approximately five inch round hole on bottom right corner; - On 07/23/24 at 9:57 A.M., the resident lay in bed with the same fitted sheet with approximately 3 inch by 4 inch gray-colored stain and approximately five inch round hole on bottom right corner; - On 07/23/24 at 11:22 A.M., the resident lay in bed with the same fitted sheet with approximately 3 inch by 4 inch gray-colored stain and approximately five inch round hole on bottom right corner; - On 07/24/24 at 8:15 A.M., the resident lay in bed with the same fitted sheet with approximately 3 inch by 4 inch gray-colored stain and approximately five inch round hole on bottom right corner. 2. Observation on 07/21/24 at 3:14 P.M. showed Resident #13's bedsheets with multiple tiny holes. 3. Observation on 07/21/24 at 3:40 P.M. showed Resident #66's wheelchair arms cracked and missing pieces of the vinyl covering. 4. Observation on 07/21/24 at 4:20 P.M. showed Resident #27's bedsheets with multiple tiny holes. 5. Observation on 07/21/24 at 4:42 P.M. showed Resident #23's bed sheets with multiple tiny holes. 6. Observation on 07/22/24 at 8:48 A.M. of room [ROOM NUMBER] showed: - The door would not latch and stayed closed all the way unless the door handle was lifted up; - Four holes located next to the closet mid way up the wall; - Black scuffs along the left wall of the room next to bed A; - Black scuff along the right wall at the room's entrance. During an interview on 07/22/24 at 8:50 A.M., Residents #3 and #87 said they were not happy with the condition of room [ROOM NUMBER]. They said they had reported the door not latching three weeks prior and it still had not been fixed. They said they did not like the scuff marks and holes in the wall and would like the issues corrected. 7. Observation of room [ROOM NUMBER] on 07/24/24 at 8:50 A.M. showed thin, tattered sheets on the bed, two screw-sized holes in the wall behind the T.V., and the vinyl peeling and cracking off the recliner's headrest. 8. Observation of room [ROOM NUMBER] on 07/24/24 at 9:06 A.M. showed the toilet paper holder broken off of the wall on the left side with the toilet paper sitting on top of the grab bar and an approximately one square foot area of a clear-colored liquid on the floor in front of the toilet. 9. Observation on 07/24/24 at 10:45 A.M. showed: - Thresholds missing from flooring transitions at the start of each hallway throughout the facility; - Thresholds missing to the entrance of Rooms 111, 112, 114, 115, 117, 201, 202, 203, 204, 205, 206, 207, 209, 212, 214, 215, 216, 217, 218, 308, 409, 411, 412, 415, 414, and 418. 10. Observation on 07/24/24 at 10:50 A.M. showed: - The front vents of the air conditioner units missing from the units in Rooms 109, 110, 112, 201, 203, 205, 207, 208 209, 212, 214, 215, 216, and 218. 11. Observation on 07/24/24 at 12:18 P.M. showed Resident #251's wheelchair arms cracked and missing pieces of the vinyl covering. During an interview on 07/24/24 at 11:01 A.M., Laundry Aide L said the sheets are thin and have holes in them because they are very old. He/She does not know if management is aware of how bad some of the sheets are. He/She reports things like this to his/her supervisor, but does not know what happens once things are reported. During an interview on 07/24/24 at 2:43 P.M., Certified Nurse Aide (CNA) M said if he/she sees something in the building that needs fixed or notices an issue with pests, he/she will notify the nurse or maintenance. During an interview on 07/24/24 at 2:50 P.M., Licensed Practical Nurse (LPN) N said he/she will call the maintenance director if he/she sees something in the building that needs fixed or sees pests somewhere. Maintenance will typically come right away to fix something, and if it's something they can't get to right then, he/she will complete a maintenance slip. During an interview on 07/24/24 at 3:00 P.M., the Maintenance Director said staff typically call, text or page him overhead if they have something that needs attention and he will fix whatever needs fixed right then. Otherwise he does things by priority, such as a water leak would take priority. Most requests are a quick turnaround time. There are also slips staff can complete to request something to be fixed. During an interview on 07/24/24 at 6:30 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect thresholds to be in place between rooms, walls to be free from holes, scratches and marks, and wheelchair arms to be free of rips, cracks, sheets to be in good condition and for resident room doors to close/latch properly. Complaint #MO00238791 46555

Based on interview and record review, the facility failed to ensure three nurse aides (NAs) completed a nurse aide training program within four months of his/her employment at the facility. The facility's census was 99. Review of the facility's policy, Nurse Aide Qualification and Training Requirements, revised August 2022, showed: -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise unless: that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in ss483.150 9 (a) and (b) of the requirements of participation; -Nursing Assistants failing to successfully compete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. 1. Review of NA I's personnel file showed: - A hire date of 01/06/24; - NA I had completed the nurse aide program, but had not taken the test; - The facility failed to ensure the completion of the program within four months of hire date. 2. Review of NA K's personnel file showed: - A hire date of 04/01/24; - NA K had been attending the nurse aide program; - The facility failed to ensure the completion of the program within four months of hire date. 3. Review of NA P's personnel file showed: - A hire date of 04/01/24; - NA P had been attending the nurse aide program; - The facility failed to ensure the completion of the program within four months of hire date. During an interview on 07/24/24 at 1:45 P.M., the Administrator said their Certified Nursing Assistant (CNA) instructor resigned on 06/26/24 to take another position. The corporate office is actively interviewing and has made an offer for employment, and they are awaiting a response from the candidate for the instructor position. During an interview on 07/24/24 at 6:30 P.M., the Administrator and Director of Nursing said they would expect NAs to be certified within four months of hire. During an interview on 07/31/24 at 12:24 P.M., the Administrator said two NAs are currently enrolled in CNA classes; NA K and NA P. NA K had not completed classes due to being in and out related to medical issues and NA P had not completed classes due to the facility not currently having an instructor. During an interview on 07/31/24 at 3:11 P.M., the Administrator said anyone who is in the nurse aide program and had not completed the nurse aide program within four months would be offered another position in a non-nursing department, such as laundry, housekeeping, or dietary.

Based on interview and record review, the facility failed to inform the resident and/or resident's representative, in writing, of the facility's bed hold policy at the time of transfer to the hospital for three residents (Resident #7, #66, and #201) out of 20 sampled residents. The facility's census was 99. Review of the facility's policy, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet) and at the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. Review of Resident #7's medical record showed: - Transferred to the hospital on 12/29/23, and readmitted to the facility on [DATE]; - Transferred to the hospital on 01/18/24, and readmitted to the facility on [DATE]; - Transferred to the hospital on 02/08/24, and readmitted to the facility on [DATE]; - No documentation the Resident or Resident's Representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #66's medical record showed: - Transferred to the hospital on 05/13/24, and readmitted to the facility on [DATE]; - Transferred to the hospital on 06/04/24 and readmitted to the facility on [DATE]; - No documentation the Resident or Resident's Representative was informed in writing of the facility's bed hold policy at the time of transfer. 3. Review of Resident #201's medical record showed: - Transferred to the hospital on 07/13/24 and readmitted to the facility on [DATE]; - No documentation the Resident or Resident's Representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 07/24/24 at 6:30 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect residents discharging to the hospital to be notified of the bed hold policy in writing per the regulation.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to hospital, including the reason for transfer, and failed to notify the Office of the State Long-Term Care Ombudsman for four residents (Resident #7, #66, #71, and #201) out of 20 sampled residents and two residents (Resident #41 and #43) outside the sample. The facility's census was 99. Review of the facility's policy, Discharging the Resident, revised December 2016, showed: - The resident should be consulted about the discharge; - If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed and telephone report is called to the receiving facility; - The policy does not address notifying the resident and/or representative in writing or notifying the ombudsman. 1. Review of Resident #7's medical record showed: - Transferred to the hospital on 12/29/23, and readmitted to the facility on [DATE]; - Transferred to the hospital on 01/18/24, and readmitted to the facility on [DATE]; - Transferred to the hospital on 02/08/24, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. 2. Review of Resident #41's medical record showed: - Transferred to the hospital on 11/20/23, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. 3. Review of Resident #43's medical record showed: - Transferred to the hospital on 06/25/24, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. 4. Review of Resident #66's medical record showed: - Transferred to the hospital on 05/13/24, and readmitted to the facility on [DATE]; - Transferred to the hospital on 06/04/24 and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. 5. Review of Resident #71's medical record showed: - Transferred to the hospital on 02/02/24, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. 6. Review of Resident #201's medical record showed: - Transferred to the hospital on 07/13/24, and readmitted to the facility on [DATE]; - No documentation that the resident or resident's responsible party had been notified in writing; - No documentation of transfer/discharge notice given to the Ombudsman. During an interview on 07/24/24 at 1:30 P.M., the Administrator said they have not been sending the transfer/discharge logs to the ombudsman at all this year. The last month they were sent was December 2023, but she was unable to provide email proof to show they were sent. During an interview on 07/24/24 at 6:28 P.M., the Director of Nursing said they cannot produce transfer notices for the residents in question. During an interview on 07/24/24 at 6:30 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect residents or their representatives to be notified in writing when residents are transferred or discharged and would expect the ombudsman to be notified as well. 46460 46555

Based on observation, interview, and record review, the facility failed to implement an infection control program and a risk management process specific to Legionella disease (a serious type of pneumonia caused by Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility's census was 94. 1. Review of the facility's policy titled, Legionella Water Management Program, revised September 2022, showed: - Our facility has a water management program, which is overseen by the water management team; - Water management team consists of infection preventionist, administrator, medical director or designee, director of maintenance and director of environmental services; - Water management program consists of the water management team, a detailed description and diagram of the water system in the facility, identification of areas that could encourage the growth and spread of Legionella or other waterborne bacteria, identifications of situations that can lead to Legionella growth, specific measures to control the introduction and/or spread of Legionella; - Water management program is reviewed at least once a year or sooner if needed. During an interview on 07/26/23 at 2:10 A.M., the Maintenance Supervisor (MS) said he/she did not know of any documentation related to waterborne pathogens or Legionella disease nor were routine checks being performed. He/she said the facility flushes the lines sometimes with really hot water to kill any bacteria. During an interview on 07/27/23 at 12:05 P.M., the Administrator said the facility was in the process of getting a company to come in and set up the Legionella program. He/she said checks were not being performed currently. During an interview on 07/27/23 at 12:06 P.M., the Director of Operations said the facility is currently contacting a company to come in as soon as possible and set up the checks for the Legionella Program.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for ten residents with side rails (Residents #6, #11, #13, #22, #24, #30, #35, #52, #73, and #248) out of 19 sampled residents. The facility's census was 94. Review of the facility's policy titled, Bed Safety and Bed Rails, revised [DATE], showed: - Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; - Maintenance provides a copy of inspections to the administrator and reports results to the quality assurance committee; - Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety dated February 2013, showed seven different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. 1. Review of Resident #6's medical record showed: - admitted on [DATE]; - No maintenance assessment for side rails. Observations of the resident showed: - On [DATE] at 11:53 A.M., Resident #6 laid in bed with quarter side rails up on both sides; - On [DATE] at 9:56 A.M., Resident #6 laid in bed with quarter side rails up on both sides; - On [DATE] at 08:24 A.M., Resident #6 laid in bed with quarter side rails up on both sides. 2. Review of Resident #11's medical record showed: - admitted on [DATE]; -No maintenance inspection for side rails. Observations of the resident showed: - On [DATE] at 11:00 A.M., Resident #11 laid in bed with U-shaped grab bar used for positioning on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved to the upright position; - On [DATE] at 8:49 A.M., Resident #11 laid in bed with grab bar on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved to the upright position; - On [DATE] at 2:26 P.M., Resident #11 sat on the left side of the bed with grab bar on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved it to the upright position; - On [DATE] at 9:47 A.M., Resident #11 laid in bed with grab bar on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved to the upright position. During an interview on [DATE] at 11:04 A.M., Resident #11 said he/she used the grab bar to help reposition in bed. The resident said he/she is unsure how long the grab bar on the left side of the bed had been hanging and unable to stay upright, but nursing was aware. The resident said if he/she has an issue with a maintenance problem, he/she notifies nursing staff. The resident said he/she would use the grab bar if it was functioning appropriately and it may have even kept him/her from falling out of bed about a week ago. 3. Review of Resident #13's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rail. Observations of the resident showed: - On [DATE] at 11:27 A.M., resident laid in bed with one side rail on his/her right side in the up position; - On [DATE] at 02:45 P.M., resident utilized side rail on right side to reposition self. 4. Review of Resident #22's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rails. Observations of the resident showed: - On [DATE] at 11:55 A.M., resident laid in bed with half rails up on both sides; - On [DATE] at 01:56 P.M., resident laid in bed with half rails up on both sides; - On [DATE] at 10:25 A.M., resident laid in bed with half rails up on both sides. 5. Review of Resident #24's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rails. Observations of the resident showed: - On [DATE] at 1:55 P.M., resident laid in bed with half rails up on both sides; - On [DATE] at 10:56 P.M., resident sat in wheelchair beside his/her bed with half rails up on both sides; - On [DATE] at 4:25 P.M., resident laid in bed with half rails up on both sides. 6. Review of Resident #30's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rails. Observations of the resident showed: - On [DATE] at 10:55 A.M., resident sat on the edge of the bed with half rails up on both sides; - On [DATE] at 3:20 P.M., resident sat on the edge of the bed with half rails up on both sides; - On [DATE] at 10:36 A.M., resident sat on the edge of the bed with half rails up on both sides. 7. Review of Resident #35's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rails. Observations of the resident showed: - On [DATE] at 11:46 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 10:00 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 8:20 A.M., resident laid in bed with quarter rails up on both sides. 8. Review of Resident #52's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rails. Observations of the resident showed: -On [DATE] at 11:45 A.M., resident laid in bed with quarter rails up on both sides; -On [DATE] at 10:09 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 8:26 A.M., resident laid in bed with quarter rails up on both sides. 9. Review of Resident #73's medical record showed: - admitted on [DATE]; - No maintenance inspection for rails. Observations of the resident showed: - On [DATE] at 11:40 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 10:10 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 8:28 A.M., resident laid in bed with quarter rails up on both sides. 10. Review of Resident #248's medical record showed: - admitted on [DATE]; - No maintenance inspection for side rails. Observation on [DATE] at 09:53 A.M. showed the resident sat on the edge of the bed with half rails up on both sides. During an interview on [DATE] at 4:40 P.M., the Maintenance Director said he/she never assessed the rails for the risk of entrapment as part of a routine maintenance program. Maintenance Director said the nurses and housekeeping report if there are any loose bed rails. Maintenance requests are reported by word of mouth. There is not a maintenance log. The requests used to be able to be sent to the maintenance computer but the application (app) does not work. During an interview on [DATE] at 12:36 P.M., Registered Nurse (RN) B said he/she was unsure of who is responsible for checking side rails for safety and regular maintenance but assumed it was the Maintenance Director's responsibility. RN B said if there was an observed side rail issue, then nursing would tell maintenance. RN B was not aware of a maintenance log. During an interview on [DATE] at 12:47 P.M., Certified Medication Technician (CMT) C and CMT D said if there was a maintenance issue, the maintenance director was called or paged overhead. CMT C and CMT D were unaware of any maintenance log to report maintenance issues. CMT C and CMT D said maintenance issues were reported by word of mouth. During an interview on [DATE] at 1:20 P.M., Licensed Practical Nurse (LPN) E said he/she was not sure who was responsible for checking side rails for safety and regular maintenance. LPN E said he/she told maintenance if he/she noticed an issue with a side rail. LPN E was not aware of a maintenance log. During an interview on [DATE] at 3:08 P.M., the Administrator said side rails should have been assessed for safety as part of the regular maintenance program. Administrator said there was a maintenance app on the Maintenance Director's computer to report maintenance issues. The Administrator was unaware that the app was not being used. 42699 46460

Based on observation, interview, and record review, the facility failed to obtain physician's orders for bed rails and failed to care plan specific monitoring and supervision provided during the use of the bed rails, including how needs will be met during use of the bed rails, such as for re-positioning, hydration, meals, use of the bathroom and hygiene for ten residents with side rails (Residents #6, #11, #13, #22, #24, #30, #35, #52, #73, and #248) out of 19 sampled residents. The facility's census was 94. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE] showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety dated February 2013, showed seven different potential, zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, showed the potential risks of bed rails may include: - Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; - More serious injuries from falls when patients climb over rails; - Skin bruising, cuts, and scrapes; - Inducing agitated behavior when bed rails are used as a restraint; - Feeling isolated or unnecessarily restricted; - Preventing patients, who are able to get out of bed, from performing routine activities such are going to the bathroom or retrieving something from a closet. 1. Review of Resident #6's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: - Moderately impaired; - Total dependence with bed mobility x 2 staff members; - Physical assist x 2 staff members with transfers; - Diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone or posture caused by abnormal brain development, often before birth), severe obesity due to excess calories and cerebral infarction (stroke). Review of the resident's medical record showed: - No physician order's for side rails; - Side rails not addressed on care plans. Observations of the resident showed: - On [DATE] at 11:53 A.M., Resident #6 laid in bed with quarter side rails up on both sides; - On [DATE] at 9:56 A.M., Resident #6 laid in bed with quarter side rails up on both sides; - On [DATE] at 08:24 A.M., Resident #6 laid in bed with quarter side rails up on both sides. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assistance with bed mobility x 1 staff member; - Supervision with transfers x 1 staff member; - Diagnoses include seizure disorder, anxiety (persistent worry and fear about everyday situations), bipolar disorder (mental disorder that causes unusual shifts in mood), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act) and chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: - On [DATE] at 11:00 A.M., Resident #11 laid in bed with a U-shaped grab bar used for positioning on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved to the upright position; - On [DATE] at 8:49 A.M., Resident #11 laid in bed with grab bar on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved to the upright position; - On [DATE] at 2:26 P.M., Resident #11 sat on the left side of the bed with grab bar on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved it to the upright position; - On [DATE] at 9:47 A.M., Resident laid in bed with grab bar on the right side of the bed. Grab bar on the left side of the bed hung down and did not stay upright when moved to the upright position. During an interview on [DATE] at 11:04 A.M., Resident #11 said he/she used the grab bar to help reposition in bed. Resident said he/she is unsure how long the grab bar on the left side of the bed had been hanging and unable to stay upright, but nursing was aware. Resident said if he/she has an issue with a maintenance problem, he/she notifies nursing staff. Resident said he/she would use the grab bar if it was functioning appropriately and it may have even kept him/her from falling out of bed about a week ago. 3. Review of Resident #13's comprehensive admission MDS assessment, dated [DATE], showed: - Severe cognitive impairment; - Extensive assistance with bed mobility requiring two staff members; - Total dependence with transfers requiring two staff members; - Diagnoses include heart failure (chronic condition in which the heart doesn't pump blood as well as it should), muscle weakness, and reduced mobility. Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: - On [DATE] at 11:27 A.M., resident laid in bed with one side rail on his/her right side in the up position; - On [DATE] at 02:45 P.M., resident utilized side rail on right side to reposition self. 4. Review of Resident #22's quarterly MDS assessment, dated [DATE], showed: - Cognitively intact; - Extensive assistance with bed mobility requiring two staff members; - Total dependence with transfers requiring two staff members; - Diagnoses include heart failure, hypertension (high blood pressure), coronary artery disease (condition that affects the arteries which supply blood to the heart), and COPD. Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: - On [DATE] at 11:55 A.M., resident laid in bed with half rails up on both sides; - On [DATE] at 01:56 P.M., resident laid in bed with half rails up on both sides; - On [DATE] at 10:25 A.M., resident laid in bed with half rails up on both sides. 5. Review of Resident #24's medical record showed: - Impaired cognition; - Limited assistance with bed mobility, x 1 staff member; - Limited assistance with transfers, x 1 staff member; - Diagnoses of heart failure, dementia, anxiety depression, bipolar and post traumatic stress disorder (PTSD- mental health condition triggered by a terrifying event, either experienced or witnessed). Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: - On [DATE] at 1:55 P.M., resident laid in bed with half rails up on both sides; - On [DATE] at 10:56 P.M., resident sat in wheelchair beside his/her bed with half rails up on both sides; - On [DATE] at 4:25 P.M., resident laid in bed with half rails up on both sides. 6. Review of Resident #30's medical record showed: - Cognitively intact; - Limited assistance with bed mobility, x 1 staff member; - Limited assistance with transfers, x 1 staff member; - Diagnoses of heart failure, renal failure, diabetes mellitus, lymphedema of lower extremities (build-up of lymph fluid in the fatty tissues just under the skin), and morbid obesity. Review of the resident's medical record showed: - No physician's order for side rails. Observations of the resident showed: - On [DATE] at 10:55 A.M., resident sat on the edge of the bed with half rails up on both sides; - On [DATE] at 3:20 P.M., resident sat on the edge of the bed with half rails up on both sides; - On [DATE] at 10:36 A.M., resident sat on the edge of the bed with half rails up on both sides. 7. Review of Resident #35's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Total dependent with bed mobility, x 2 staff members; - Total dependent with transfers, x 2 staff members; - Diagnoses of anxiety, bipolar disorder, schizoaffective disorder (a mental health condition that can be a combination of symptoms such as depression or mood disorder) and quadriplegia (inability to control or move muscles from the neck and down). Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: - On [DATE] at 11:46 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 10:00 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 8:20 A.M., resident laid in bed with quarter rails up on both sides. 8. Review of Resident #52's admission MDS, dated [DATE], showed: - Moderately impaired cognition; - Limited assist x 1 staff member for bed mobility; - Limited assist x 1 staff member for transfers; - Diagnoses of Huntington's disease (an inherited condition in which nerve cells in the brain break down over time effecting voluntary movement as well as other areas), dementia and depressive disorder. Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: -On [DATE] at 11:45 A.M., resident laid in bed with quarter rails up on both sides; -On [DATE] at 10:09 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 8:26 A.M., resident laid in bed with quarter rails up on both sides. 9. Review of Resident #73's annual MDS, dated [DATE], showed: - Moderately impaired cognition; - Limited assist x 1 staff member for bed mobility; - Limited assist x 1 staff member for transfers; - Diagnoses of dementia, anxiety and major depressive disorder. Review of the resident's medical record showed: - No physician's order for side rails; - Side rails not addressed on care plan. Observations of the resident showed: - On [DATE] at 11:40 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 10:10 A.M., resident laid in bed with quarter rails up on both sides; - On [DATE] at 8:28 A.M., resident laid in bed with quarter rails up on both sides. 10. Review of Resident #248's medical record showed: - Resident admitted on [DATE] and MDS assessment not yet due; - No physician's order for side rails; - Side rails addressed on baseline care plan. Observation on [DATE] at 09:53 A.M. showed the resident sat on the edge of the bed with half rails up on both sides. During an interview on [DATE] at 4:40 P.M., the Maintenance Director said he/she never assessed the rails for the risk of entrapment as part of a routine maintenance program. The Maintenance Director said the nurses and housekeeping report if there are any loose bed rails. Maintenance requests are reported by word of mouth. There is not a maintenance log. The requests used to be able to be sent to the maintenance computer but the application (app) does not work. During an interview on [DATE] at 12:36 P.M., Registered Nurse (RN) B said the resident should have an order for side rails and it should be added to their care plan. During an interview on [DATE] at 1:20 P.M., Licensed Practical Nurse (LPN) E said he/she would expect a resident to have a physician's order for side rails and the rails should also be addressed on the resident's care plan. During an interview on [DATE] at 3:08 P.M., the Administrator said he/she would expect side rails to have a physician's order. The Administrator said he/she would expect side rails to be on the care plan for monitoring.

Based on observation, interview, and record review, the facility failed to follow physician's orders for supplemental oxygen therapy for two residents (Residents #8 and #83) out of 19 sampled residents, and failed to follow physician's orders for one resident (Resident #83) with a tracheostomy (incision in the windpipe to relieve an obstruction to breathing) out of 19 sampled residents. The facility's census was 94. Record review of the facility's policy titled, Oxygen Administration, revised October 2010, showed: - Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident. 1. Review of Resident #8's medical record face sheet, dated 07/26/23, showed: - Diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dated 07/11/2019. Review of the resident's Physician's Order Sheet (POS), dated 07/26/23, showed: - Oxygen (O2) at 2 liters/minute (L/min) via nasal cannula while asleep - obtain and record oxygen saturation levels (O2 SAT) every shift, every day and night shift related to COPD, dated 06/05/23; Review of the resident's Medication Administration Record (MAR), dated July 2023, showed O2 SAT not obtained for the night shifts of 07/15/23 and 07/16/23, as per the POS. Observation of Resident #8 showed: - On 07/24/23 at 11:28 A.M., Resident in bed with eyes closed, oxygen concentrator on at 4L/min (POS indicated 2 L/min), nasal cannula laying on pillow, undated tubing, humidifier dated 07/07/23; - On 07/25/23 at 11:31 A.M., Resident in bed, head leaned to right side, eye mask on, nasal cannula at neck, O2 at 4L/min, undated tubing, humidifier dated 07/07/23; - On 07/26/23 at 10:06 A.M., resident in bed, eye mask over eyes, O2 at 3.5L via nasal cannula, tubing and humidifier dated 07/25/23; - On 07/27/23 at 09:46 A.M., Resident in bed with eye mask over eyes, O2 at 3.5L/min via nasal cannula, tubing and humidifier dated 07/25/23. 2. Review of Resident #83's POS, dated 07/27/23, showed: - Diagnoses of acute respiratory failure with hypoxia (condition where there is not enough oxygen in the body's tissues) and tracheostomy status; - An order for Bivona tracheostomy (trach) to be changed once monthly and as needed (PRN) on the 20th every month, dated 02/08/2023; - An order for oxygen at five liters via high humidity trach collar (HHTC) at 28% continuously; - Obtain and record O2 SAT levels every day and night shift, dated 02/08/23; - An order for oxygen and humidification tubing to be changed once weekly and PRN, dated 02/08/23. Review of the resident's MAR, dated June 2023, showed: - O2 SAT not obtained on day shift on 06/25/23; - Bivona tracheostomy tube changed on 06/20/23. Record review of the resident's MAR, dated July 2023, showed: - Oxygen saturation not obtained on night shift on 07/16/23; - Bivona tracheostomy tube not changed on 07/20/23 as ordered with a notation to see progress notes. Record review of the resident's progress notes, dated 07/20/23, showed: - An administration note to change the Bivona trach once a month and PRN on the 20th every month, changed on 06/26/23; - No evidence that the resident's trach was changed on 06/26/23 and no evidence the trach had been changed as ordered in the month of July. Observations of Resident #83 showed: - On 07/24/23 at 12:08 P.M., resident lay in bed with eyes closed wearing oxygen at 6 L via trach; - On 07/25/23 at 09:40 A.M., resident lay in bed with eyes closed wearing oxygen at 6 L via trach; - On 07/26/23 at 09:49 A.M., resident lay in bed with eyes closed wearing oxygen at 6 L via trach; - On 07/26/23 at 02:24 P.M., resident lay in bed wearing oxygen at 6 L via trach; - On 07/27/23 at 09:16 A.M., resident lay in bed wearing oxygen at 6 L via trach. During an interview on 07/26/23 at 02:24 P.M., Registered Nurse (RN) B said Resident #83's oxygen should be set on five liters. During an interview on 08/02/23 at 01:42 PM, the Administrator said she would expect staff to follow physician's orders. The facility did not provide a policy for tracheostomy care.

Based on observation, interview, and record review, the facility failed to develop and implement care plans for three residents (Residents #8, #13, and #36) out of 19 sampled residents. The facility's census was 94. Record review of the facility's policy titled Care Planning - Interdisciplinary Team, revised March 2022, showed: - The interdisciplinary team is responsible for the development of resident care plans; - Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team; - The IDT includes but is not limited to: the resident's attending physician; a registered nurse with responsibility for the resident; a nursing assistant with responsibility for the resident; a member of the food and nutrition services staff; to the extent practicable, the resident and/or the resident's representative; and other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; - The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions; - Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Review of Resident #8's Face Sheet showed: - admitted [DATE]; - Diagnoses of generalized anxiety disorder (persistent worry and fear about everyday situations) and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the resident's Physician Order Sheet (POS) dated 07/26/23, showed: - Oxygen at two liters via nasal cannula (medical device to provide supplemental oxygen therapy) while asleep - obtain and record O2 SAT every shift, every day and night shift related to Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dated 06/05/23; - Oxygen tubing to be changed once weekly and as needed (PRN) in the evening every Friday, dated 07/12/23; - Clonazepam (medication for anxiety) one milligram (mg) by mouth two times a day related to generalized anxiety disorder, dated 02/17/23. Review of the resident's care plan, last updated 07/26/23, showed: - No identification of the resident's anxiety disorder, anti-anxiety medications, triggers, or interventions; - No identification of the resident's use of oxygen. Observation of Resident #8 showed: - On 07/24/23 at 11:28 A.M., resident in bed with eyes closed, oxygen concentrator on at four liters via nasal cannula, nasal cannula on pillow beside resident; - On 07/25/23 at 11:31 A.M., resident in bed, head leaned to right side, eye mask over eyes, oxygen concentrator on at four liters via nasal cannula, nasal cannula at neck; - On 07/26/23 at 10:06 A.M., resident lay in bed with eye mask over eyes, oxygen at three and one half liters via nasal cannula in place; - On 07/27/23 at 09:46 A.M., resident lay in bed with eye mask over eyes, oxygen at three and one half liters via nasal cannula in place. 2. Review of Resident #13's Face Sheet showed: - admitted [DATE]; - Diagnoses of muscle weakness, reduced mobility, low back pain, pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure) of sacral (region between the bottom of the spine and tailbone) region, unspecified, pressure ulcer of buttock, stage two, open wound, right foot, open wound, left foot, congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), type II diabetes mellitus (group of diseases that result in too much sugar in the blood), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of the resident's comprehensive admission MDS assessment (a federally-mandated assessment completed by the facility), dated 06/19/23, showed: - Section V0200A (care area assessments triggered by completion of MDS): delirium, cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, psychosocial well-being, activities, falls, nutritional status, dehydration/fluid maintenance, and pressure ulcer; - Section V0200B (care area assessments triggered by completion of MDS to be addressed in the care plan): cognitive loss/dementia, communication, urinary incontinence and indwelling catheter, activities, falls, nutritional status, and pressure ulcer. Review of the resident's care plan, revised 07/27/23, showed the facility did not develop a care plan within 21 days of admission, in the following areas: - Activities of daily living/weakness; - Falls; - Pain; - Skin breakdown/pressure ulcers; - Activities; - Communication; - Specific diagnoses including congestive heart failure, diabetes mellitus, depression, Parkinson's disease; - Indwelling urinary catheter; - Oxygen use; - Antidepressant use. During an interview on 07/24/23 at 11:27 A.M., the resident said he/she wears two liters of oxygen all of the time. Observation on 07/27/23 at 09:00 A.M. showed the resident lay in bed wearing oxygen at three liters per nasal cannula. 3. Review of Resident #36's face sheet showed: - admitted [DATE]; - Diagnoses included unspecified dementia (progressive or persistent loss of intellectual functioning), unspecified severity, with other behavioral disturbance. Review of the resident's POS, dated 07/27/23, showed orders for: - Lexapro (medication for depression) 10 milligrams (mg) one time a day, related to unspecified dementia, with other behavioral disturbance, dated 03/30/23, - Seroquel (antipsychotic medication used to treat schizophrenia, bipolar disorder, and depression) 25 mg by mouth at bedtime for agitation, dated 07/24/23. Review of the resident's progress notes showed: - Physician/Provider visit note, dated 01/04/23 - Depression: started on Lexapro five mg and working well. May need to increase dose soon. Dementia: family very involved. Lives with spouse. Has some sundowning (confusion occurring in the late afternoon and lasting into the night) - symptoms worse in the evenings. Will repeat questions frequently; - Physician/Provider visit note, dated 01/10/23 - Dementia: Lived with spouse. Sundowns every evening, Depression: Seems to be doing well on Lexapro at this time; - Health Status Note, dated 01/12/2023 - New orders received per nurse practitioner to increase Lexapro; - Physician/Provider visit note, dated 07/24/23 - Continues to want to go home. Continues to have anxiety in the evenings. Insomnia: Seroquel has been helping; will increase from 12.5 mg at bedtime to 25 mg at bedtime. Review of the resident's care plan, revised 07/27/23, showed the facility did not develop a plan for the following areas: - The resident's dementia problems, interventions, and goals; - The resident us of psychotropic (a group of medications that affects behavior, mood, thoughts, or perception and includes antidepressants, anti-anxiety medications, and antipsychotics) medication. During an interview on 07/27/23 at 03:08 P.M., the Administrator, Director of Nursing, and MDS Coordinator said they would expect the care plan to accurately reflect the resident's current status and to be individualized. 48247

Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNF ABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for one resident (Resident #84) out of two sampled residents who remained in the facility when benefits were not exhausted and failed to get the SNF ABN Form 10055 signed no later than two days before covered services ended for two residents (Resident #4 and #84) out of two sampled residents. The facility's census was 94. 1. Review of Resident #4's SNF ABN form showed: - The resident discharged from skilled Medicare services on 06/15/23, and remained in the facility; - The resident received and signed the form on 06/15/23; - The facility failed to provide the SNF ABN form to the resident at least two calendar days before the skilled Medicare services ended. 2. Review of Resident #84's medical record showed: - The resident discharged from skilled Medicare services on 04/11/23, and remained in the facility; - The facility failed to get verbal consent or provide the resident's representative with the SNF ABN form at least two days prior to services ending. During an interview on 07/26/23 at 10:10 A.M., the Administrator said he/she would expect the SNF ABN form to be completed and signed per the regulatory guidelines. During an interview on 07/27/23 at 3:08 P.M. , the Director of Operations said he/she would expect the SNF ABN form to be completed and signed at least two days prior to a resident's discharge from skilled Medicare services. The facility did not provide a policy.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 94. Observation on 07/24/23 between 10:42 A.M. and 03:00 P.M. showed: - A three foot section of cove base pulled away from the wall and lying in the floor between the bathroom and first bed in room [ROOM NUMBER]; - An approximately five-inch piece of cove base pulled away from the wall and lying in floor on the right side of the bathroom door in room [ROOM NUMBER]; - An approximately two and one half foot (ft) long and approximately one inch (in) wide divot in the drywall by the nutrition room window on 300 hall; - An approximately one foot square area of repaired but unfinished and unpainted drywall on the wall between the bathroom and the first bed in room [ROOM NUMBER]; - The 300 hall restroom door missing paint across an approximately two-foot section at the bottom and the unmarked wide door next to the 300 hall bathroom door missing paint across the middle one-third section. Observation on 07/24/23 at 12:45 P. M. showed a black substance around the top of the air vent of the unit in room [ROOM NUMBER]. Observation on 07/24/23 between 01:18 P.M. and 01:21 P.M. showed: - Two white chairs with a green inlay center, noted coming apart on the outside corner of the right chair arms, in the 200 hall common area; - Approximately 2.5 ft x 3 in base board and 11 in x 3 in base board in hall to right of room [ROOM NUMBER] entry. Observation on 07/25/23 between 01:49 P.M. and 02:00 P.M. showed thresholds missing from Rooms 311, 315, 316, 317, 402, 403, 405, 406, 407, 408, and 409, as well as thresholds missing from the transition from carpet to vinyl floor on 300 hall and the transition from carpet to vinyl flooring on 400 hall. Observation on 07/26/23 between 10:09 A.M. and 10:41 A.M. showed: - Approximately 14 in x 2 in section of damaged drywall with a 5 in hole noted, below and to the left of the red outlet to the left of the bed in room [ROOM NUMBER]A; - Approximately 8 in x 4 in section of damaged drywall , left of the bed below and to the left of the red outlet to the left of the bed, with drywall dust noted on baseboard trim and floor in room [ROOM NUMBER]A; - Approximately 6 in x 2 in section of damaged drywall to the left of the bed in room [ROOM NUMBER]A; - Approximately 2.5 ft x 2.5 ft area of damaged dry wall, with discolorations noted, left of the bed against the wall in room [ROOM NUMBER]A; - Approximately 0.5 in x 0.25 in hole in drywall above the outlet right of the air unit, with air unit plugged into outlet, in room [ROOM NUMBER]B; - approximately 8 in x 4 in, area dry wall in disrepair with three other smaller areas of damage noted to wall behind left of headboard in room [ROOM NUMBER]B; - Approximately 4 in x 1 in damaged dry wall to the right of the headboard in room [ROOM NUMBER]B; - Approximately 12 in x 2 in damaged dry wall with hole through the dry wall, right of the headboard in room [ROOM NUMBER]B; - [NAME] colored dust buildup to front and rear grate of standing fan at foot of bed in room [ROOM NUMBER]B, fan in use; - Second vent in ceiling of 300 hall noted with brown ring to three sides of vent, 15 in x 2 in, 11 in x 2 in, and 8 in x 1 in, peeling noted to 11 in x 2 in area; - Approximately 4 in x 2.5 in divot in dry wall on the wall between room [ROOM NUMBER] and 309. During an interview on 07/26/23 at 4:40 P.M., the Maintenance Director said the nurses and housekeeping report any maintenance issues. Maintenance requests are reported by word of mouth. There is not a maintenance log. The requests used to be able to be sent to the maintenance computer but the application does not work. The Maintenance Director said he/she addresses any issues he/she finds when doing weekly and monthly rounds. During an interview on 07/27/23 at 12:36 P.M., Registered Nurse (RN) B said he/she would tell maintenance if there is an observed or reported issue. RN B was not aware of a maintenance log. During an interview on 07/27/23 at 12:47 P.M., Certified Medication Technician (CMT) C and CMT D said if there was a maintenance issue reported to them or observed, then the maintenance director was called or paged overhead. CMT C and CMT D said they were unaware of any maintenance log to report maintenance issues. CMT C and CMT D said maintenance issues were usually reported by word of mouth. During an interview on 07/27/23 at 1:20 P.M., Licensed Practical Nurse (LPN) E said he/she reported directly to maintenance if he/she noticed any facility issues. LPN E was not aware of a maintenance log. During an interview on 07/27/2023 at 03:08 P.M., the Administrator said she would expect resident rooms to have thresholds in place and thresholds in place leading into the common areas and hallway where flooring transitions occur, drywall repaired and painted, and baseboard (cove base) to be affixed to the walls.

Based on observation, interview and record review, the facility failed to document an accurate Minimum Data Set (MDS- a federally mandated assessment) for two residents (Resident #8 and #83) out of 19 sampled residents. The facility's census was 94. 1. Record review of Resident #8's MDS showed: - A quarterly MDS assessment, dated 04/16/23, oxygen not marked on Section O: Special Treatments and Programs; - An annual MDS assessment, dated 07/17/23, with pneumonia (an infection that inflames the air sacs in one or both lungs) coded on section I2000; oxygen not marked on Section O: Special Treatments and Programs. Review of the resident's Physician Order Sheet (POS), dated 07/26/23, showed: - Oxygen at 2L via nasal cannula (a tube delivering oxygen to a person's nose) while asleep - obtain and record O2 SAT every shift, every day and night shift related to Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dated 06/05/23; - Oxygen tubing to be changed weekly and as needed (PRN) in the evening shift every Friday, dated 07/12/23. Observation of Resident #8 showed: - On 07/26/23 at 10:06 A.M., resident lay in bed with eye mask over eyes, O2 at 3.5L/min via nasal cannula, tubing and humidifier dated 7/25/23; - On 07/27/23 at 09:46 A.M., resident lay in bed with eye mask over eyes, O2 at 3.5L/min via nasal cannula, tubing and humidifier dated 7/25/23. During an interview on 7/27/23 at 02:27 P.M., Licensed Practical Nurse (LPN) A, said Resident #8's chart showed the resident had a chest x-ray on 3/2/22, which showed nothing, no pneumonia; LPN A said he/she could not find where the resident had pneumonia, and the chart only showed suspected in March of 2022. He/she said there was no treatment ordered for the resident, and the diagnosis may be an old one they did not remove. During an interview on 7/27/23 at 02:30 P.M., Resident #8 said he/she had a chest x-ray at the facility and his/her lungs were clear, it had been a while back. He/she had went to the hospital, and they said he/she had pneumonia, but it's been a while back, like over a year. 2. Record review of Resident #83's POS, dated 07/27/23, showed: - No current or discontinued orders for a ventilator (a machine that moves air in and out of the lungs). Record review of the resident's MDS showed: - A comprehensive admission MDS assessment, dated 02/21/2023, with ventilator use coded on Section O0100F; - A quarterly MDS assessment, dated 04/24/23, with ventilator use coded on Section O0100F; - A quarterly MDS assessment, dated 07/19/23, with ventilator use coded on Section O0100F. During an interview on 07/27/23 at 12:05 P.M., the MDS Coordinator said Resident #83 has never had a ventilator since he/she has been here. It should not be coded on the MDS. During an interview on 7/27/23 at 03:08 P.M., the Administrator and MDS Coordinator said they would expect a resident's MDS assessment to accurately reflect the current status of the resident and would expect inactive diagnoses to not be coded on the MDS. The facility did not provide a policy, but follows the Resident Assessment Instrument (RAI) manual. 46460 48247

Based on interview and record review, the facility failed to provide a Level I Preadmission Screening and Resident Review (PASARR, a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for three residents (Residents #11, #24, and #35) out of 19 sampled residents. The facility's census was 94. The facility did not provide a policy regarding PASARR. 1. Review of Resident #11's medical record showed: - An admitted [DATE]; - Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life), bipolar disorder (mental disorder that causes unusual shifts in mood) and anxiety disorder (persistent worry and fear about everyday situations); - No level I PASARR. 2. Review of Resident #24's medical record showed: - An admitted [DATE]; - Diagnoses of major depressive disorder, bipolar disorder, anxiety disorder, and chronic post traumatic stress disorder (mental health condition that is triggered by a terrifying event, either experiencing it or witnessing it); - No level I PASARR. 3. Review of Resident #35's medical record showed: - An admitted [DATE]; - Diagnoses of anxiety disorder, major depressive disorder, bipolar disorder, schizoaffective disorder (a combination symptoms of schizophrenia-a disorder that affects one's ability to think, feel and behave clearly) and mood disorder (condition which can involve mania or depression); -No level I PASARR. During an interview on 07/27/23 at 1:42 P.M., the Administrator said he/she has requested the PASARRs for Residents #11, #24 and #35. The Administrator said the three residents should have a PASARR on file, but they are unable to find them. During an interview on 07/27/23 at 3:08 P.M., the Director of Operations said he/she would expect there to be a Level I PASARR for all residents. 42699

Based on observation, interview, and record review, the facility failed to show adequate indication for the use of psychotropic medication for two residents (Residents #36 and #78) out of 19 sampled residents. The facility's census was 94. The facility did not provide a policy on psychotropic medications. 1. Record review of Resident #36's Physician's Order Sheet (POS), dated 7/27/23, showed: - Diagnosis of unspecified dementia (loss of cognitive ability) with other behavioral disturbance; - An order for Lexapro (antidepressant) five milligrams (mg) once daily, related to unspecified dementia with other behavioral disturbance, dated 12/6/22 and discontinued 01/12/23; - An order for Lexapro 10 mg once daily, related to unspecified dementia with other behavioral disturbance, dated 01/13/23 and discontinued 03/29/23; - An order for Lexapro 10 mg once daily, related to unspecified dementia with other behavioral disturbance, dated 03/31/23. Record review of the resident's progress notes, dated 12/23/22 through 01/22/23, showed: - Physician Note, dated 12/28/22, Lexapro five mg started and working well for depression; - Physician Note, dated 01/04/23, Lexapro five mg and working well for depression. May need to increase dose soon; - Physician Note, dated 01/10/23, the resident seemed to be doing well on Lexapro for depression at this time; - Health Status Note, dated 01/12/23, new orders received nurse practitioner (NP) to increase Lexapro; - Physician Note, dated 01/16/23, depression, paranoia, talked with family that Lexapro can be scaled back if this persists (recently increased from five mg to 10 mg), discussed starting Seroquel (an antipsychotic). - No nursing documentation of the effectiveness of Lexapro or symptoms of depression, behavioral disturbances, or paranoia; - No record of monitoring for side effects of Lexapro. 2. Review of Resident #78's medical record showed: - Diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (persistent depressed mood or loss of interest), and anxiety (intense, excessive, and persistent worry and fear); - No documentation of specific, targeted behaviors. Record review of the resident's POS, dated July 2023, showed: - An order for Zyprexa (an antipsychotic medication) 2.5 mg twice a day for schizophrenia, dated 02/28/23. Review of the resident's care plan, last updated on 04/17/23, showed: - No antipsychotic medication use with interventions; - No identification of specific, targeted behaviors with interventions; - No monitoring for adverse reactions or side effects of Zyprexa. Observations of the resident showed: - On 7/24/23 at 11:20 A.M., the resident sat quietly in the dining room and ate; - On 7/25/23 at 8:21 A.M., and 1:01 P.M., the resident lay in bed quietly with his/her eyes closed; - On 7/26/23 at 8:06 A.M., and 2:00 P.M., the resident lay in bed quietly with his/her eyes closed. During an interview on 07/27/23 at 3:08 P.M., the Director of Nursing and the Administrator said they would expect residents with psychotropic medications to have their behaviors documented. They would also expect that residents who require psychotropic medications to have an appropriate diagnosis and documentation for psychotropic medications. 48247

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free from accident hazards as possible, when the facility failed to develop and implement of an emergency plan for one resident (Resident #1) of two reviewed residents with a locked restraint in use. Resident #1 had an ankle shackle attached to the end of the bed and applied to his/her ankle nightly restricting movement from the bed. The facility census was 83. Record review of Resident #1's physician's orders [REDACTED]. Review of the face sheet, dated 7/27/18, showed the justice system listed as the resident's guardian/responsible party. Record review of the Minimum Data Set (MDS), a federally mandated assessment completed by the facility staff, Kardex Report (baseline care plan), dated 7/27/18, showed staff did not identify the use of physical restraints. During an interview on 8/8/18 at 11:50 A.M., the Administrator said she had not seen the resident, but that he/she was in the custody of federal law enforcement, being guarded by two law enforcement officers at all times, and was hand cuffed. The Administrator said the facility had not developed a plan for the resident in case of emergency and/or need to evacuate the facility. Observation on 8/8/18 at 12:30 P.M., showed Resident #1 in bed. Two armed law enforcement officers sat at the bedside. An ankle shackle was attached to the foot of the bed frame with a chain. During an interview on 8/8/18 at 12:30 P.M., Resident #1 and the law enforcement officers said they cuffed one of the resident's ankles to the bed at night. Observation on 8/8/18 at 4:58 P.M., showed Resident #1 sat in a wheelchair with his/her ankle shackled to the foot of the bed. Complaint #MO 3 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time of exit. During the onsite visit, the facility administration found alternative placement for the resident, and new policies were written and put into place. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation.

Based on observation, interview, and record review, the facility failed to ensure one resident (Residents #1) out of two sampled residents, remained free of locked physical restraints, when the resident was confined to his/her room with leg shackles attached to the end of the bed and applied to the resident's ankle nightly. The facility census was 83. 1. Record review of the facility's restraint policy, dated 10/11/16, showed: - The policy's purpose was to prohibit the use of restraints for disciple or convenience. - The policy directed staff to assess residents prior to using any restraint. - The policy directed staff to obtain a physician's orders [REDACTED]. - The policy did not address the use of restraints for justice involved individuals. Record review showed Resident #1, identified as a federal prisoner with pending legal charges, entered the facility on 7/27/18 after receiving multiple gunshot wounds to the left flank, which resulted in a spinal cord injury and [MEDICAL CONDITION]. The resident could move the right leg, but had no movement in the left leg. Record review of the Minimum Data Set (MDS), a federally mandated assessment completed by the facility staff, Kardex Report (baseline care plan), dated 7/27/18, showed staff did not identify the use of restraints. During an interview on 8/8/18 at 11:50 A.M., the Administrator said the local sheriff approached the Federal Marshals concerning placement of the resident. The Federal Marshals toured the facility and talked with the Administrator. The Administrator accepted the resident. She had not seen the resident, but knew that the resident was in the custody of Federal Law Enforcement, being guarded by two law enforcement officers with guns at all times, and was hand cuffed. The Administrator said that when she asked about the use of hand cuffs, she was told it was a federal requirement. The facility had not developed a policy or plan to address justice involved residents. Observation on 8/8/18 at 12:30 P.M., showed Resident #1 in bed. Two armed law enforcement officers sat at the bedside. A leg shackle with a chain attached to the foot of the bed frame lay on the floor next to the bed. During an interview on 8/8/18 at 12:30 P.M., the resident and the law enforcement officers said the officers place the leg shackle around the resident's ankle at night. During an interview on 8/8/18 at 4:10 P.M., Registered Nurse (RN) D said he/she knew that it was unacceptable to have the resident in locked restraints. RN D reported concerns to administration, but no one listened. During an interview on 8/8/18 at 4:30 P.M., the Director of Nursing (DON) said she was unaware the resident was cuffed to the bed. Observation on 8/8/18 at 4:58 P.M., showed the resident sat in a wheelchair. The resident's left ankle had a leg shackle around the ankle and attached to the foot of the bed. The resident's head hung down and the resident did not make eye contact when staff spoke to him/her. Complaint #MO 3 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time of exit. During the onsite visit, the facility administration found alternative placement for the resident, and new policies were written and put into place. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to one (Resident #1) of four reviewed residents. The resident exhibited verbal and physical behavioral outbursts directed at three (Residents #2, #3 and #4) reviewed residents and one additional resident (Resident #5). The facility's census was 63. 1. Record review of Resident #1's behavioral/psychological progress note, dated 9/27/12 (completed prior to the resident's admission to the facility on [DATE]), showed the resident exhibited behavioral and conduct problems, interpersonal problems and confusion. The resident had exhibited recent agitated behaviors. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The physician ordered the administration of quetiapine (antipsychotic medication) 25 milligrams (mg) twice a day and the administration of [MEDICATION NAME] (antianxiety medication)1 mg four times a day as needed on 10/3/12 (the date of admission to the facility). Review of nurses' notes showed: - On 10/4/12 at 3:00 A.M., the resident appeared groggy and exhibited agitation with being awakened. - On 10/4/12 at 7:30 P.M., the resident refused to take medication. He/she became agitated with the nurse and became increasingly aggressive. The resident kicked, attempted to hit with fists and cursed at staff. He/she pushed the nurse and flushed medication down the toilet. - On 10/5/12 at 2:00 A.M., the resident sat in the common area by the TV and refused to allow staff to obtain vital signs and would not go to bed. - On 10/5/12 at 1:30 P.M., staff noted the resident was adjusting to the facility without difficulty. - On 10/5/12 at 10:00 P.M., the resident slept on the sofa in the common area. He/she became easily agitated and cursed. Staff left the resident on the sofa to decrease anxiety/agitation and prevent behavior from escalating. - On 10/6/12 at 10:00 A.M., staff noted the resident refused to sleep in his/her bed the previous night because he/she thought the bed was haunted. - On 10/6/12 at 12:30 A.M., the resident slept in a chair in the common area. The resident cursed and yelled when asked if he/she wanted a pillow and blanket. - On 10/7/12 at 11:10 P.M., the resident slept in a chair in the common area. Staff left the resident alone to prevent escalation of behavior. Review of a psychiatric evaluation, dated 10/10/12, showed the resident saw "spooks" who mostly told him/her good things, was irritable and refused medications. The psychiatrist ordered the continuation of quetiapine 25 mg twice a day and [MEDICATION NAME] 1 mg four times per day as needed. The psychiatrist ordered the addition of [MEDICATION NAME] (dementia medication) to be titrated to 10 mg per day. Review of nurses' notes showed: - On 10/10/12 at 5:00 P.M., the resident became angry and aggressive with staff attempts to administer medication. The resident cursed at and hit the nurse in the chest. The resident's outburst continued for 30 minutes. - On 10/10/12 at 8:00 P.M., the resident became very agitated, refused all care and loudly cursed in the hall. Staff could not redirect the resident. - On 10/11/12 at 5:00 A.M., the resident cursed at and threatened the nurse when asked to allow his/her blood glucose (sugar) level to be checked. The nurse blocked him/herself into another resident's room with the medication cart to get away from Resident #1. - On 10/11/12 at 1:00 P.M., the Care Plan Coordinator noted the resident had behavior complications as noted in previous nursing documentation. - On 10/15/12 at 4:35 P.M., the resident blockaded the door to his/her room and refused to take medication. Staff noted the resident had previously done this several times. - On 10/20/12 at 3:30 A.M., the resident became argumentative and threatened staff with a brick or sharp stick when they took his temperature. Staff noted all attempts to reassure or calm the resident were unsuccessful. - On 11/3/12 at 1:15 P.M., resident had a cigarette in his/her pocket. The resident told staff to leave him/her alone when questioned or the resident would give staff trouble. - On 11/3/12 at 2:45 P.M., the resident said that the facility was "not a place for old people but a crazy place" and told staff he/she did not intend to stay. Review of the Social Service Designee's (SSD) note, dated 11/5/12, showed the resident became upset with attempts to discuss the resident keeping cigarettes. The SSD did not further document or address the resident's behaviors. Review of nurses' notes showed: - On 11/6/12 at 4:45 P.M., the resident made inappropriate sexual comments to staff. - On 11/12/12 at 7:40 P.M., the resident said he/she planned to sleep on the couch in the common area and demanded the TV be turned off although other residents were watching TV. The resident became aggressive and angry. He/she took the remote from an unidentified resident and removed the battery. - On 11/18/12 at 12:00 P.M., the resident tried to strike an unidentified resident (later identified as Resident #5) with a walker. - On 1/1/13 at 5:00 P.M., the resident cursed nurses. Upon entering the dining room, the resident became argumentative with an unidentified resident and behaved in an threatening manner. - On 1/2/13 (time not noted), the resident became combative and argumentative when staff asked to shave him/her. - On 1/4/13 at 7:15 A.M., the resident cursed and called staff names. - On 1/4/13 at 4:00 P.M., the resident became verbally abusive to staff without provocation. - On 1/7/13 at 10:00 P.M., the resident cursed at staff with attempts to obtain vital signs. Staff could not redirect the resident. Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment tool to be completed by facility staff, dated 1/7/13, showed staff identified the resident as moderately cognitively impaired with verbal behavioral symptoms exhibited. Review of nurses' notes showed: - On 1/8/13 at 8:30 A.M., the resident cursed and called staff names with attempts to check blood glucose levels. - On 1/9/13 (time not noted), the resident barricaded self in room and cursed at staff. - On 1/9/13 at 10:30 A.M., the MDS/Care Plan Coordinator noted the resident had no significant changes. - On 1/11/13 at 9:00 A.M., the resident became agitated and cursed at staff without a specific trigger to behaviors. - On 1/12/13 at 11:00 A.M., the resident became belligerent with other residents. The resident cursed and threatened an unidentified female resident (later identified as Resident #3) when he/she got too close to Resident #1's walker. The resident also cursed at other unidentified residents and staff. - On 1/12/13 at 3:15 P.M., the resident and an unidentified resident (later identified as Resident #2) with a [DIAGNOSES REDACTED].#1. Resident #1 struck the resident on the left side of the face and chest with his/her fists and caused a skin tear to the resident's arm. Resident #1 threatened to hit anyone who came too close. - On 1/13/13 at 11:30 A.M., the resident threatened an unidentified resident with his/her fists while in the dining room. - On 1/14/13 (time not noted), the resident became verbally abusive with staff when attempted to administer medication. Review of the care plan, dated 10/20/12 and updated 1/14/13, showed staff identified the resident became easily agitated and aggressive. The initial care plan directed staff to walk away if the resident became agitated but did not included specific interventions to address the resident's behaviors. On 1/2013 (date not fully identified), staff noted, "Please redirect me if I become aggressive/agitated with another resident". The care plan did not contain further directions/interventions. Review of nurses' notes showed; - On 1/15/13 at 7:10 A.M., the resident cursed staff while in the dining room. Resident #1 picked up a napkin, dropped it in the floor and began yelling and cursing at two unidentified residents (one resident was later identified as Resident #4). - On 1/15/13 at 7:35 A.M., the resident yelled and cursed at staff during medication administration. Staff noted they could not redirect the resident. - On 1/15/13 at 2:00 P.M., the resident yelled and cursed at staff when requested to shower. During observation and an interview on 1/16/13 at 11:25 A.M., Resident #1 said he/she wanted to return to his/her home and would get there one way or another as long as the train or bus ran. The resident put his fists in the air, shook them and said no one would mess with him/her or he/she would sock them a good one. During an interview on 1/16/13 at 11:45 A.M., Certified Medication Technician (CMT ) C said Resident #1 had a temper and on 1/15/13 screamed and cursed at residents. Resident #1 raised his hand to Resident #4 but did not strike him/her. CMT C said that over the weekend an incident occurred where Resident #1 hit Resident #2. During interviews on 1/16/13 at 12:40 P.M. and 1:36 P.M., Registered Nurse (RN) A said Resident #1 exhibited significant behaviors which included cursing, yelling, threatening and hitting staff and residents. On 11/18/12, Resident #1 tried to hit Resident #5 , who was in a geri-chair, with his//her walker. Staff documented and reported the resident's behaviors but no one did anything. RN A said that he/she thought the resident needed another psychiatric consult. During an interview on 1/16/13 at 12:40 A.M., Certified Nurse Aide (CNA) D said Resident #2 told him/her that Resident #1 hit him/her. CNA D said the resident's behaviors seemed to be worse in the mornings. During an interview on 1/16/13 at 12:47 A.M., RN B said the resident had been non-compliant with medication and care and said foul and ugly things to staff since admission. On 1/15/13, Resident #1 sat at the table with Resident #4. Resident #1 dropped his/her napkin in the floor and told Resident #4 to pick it up. Resident #1 drew back his/her hands as if he/she was going to hit but did not. RN B said that once the resident got going he/she could not be redirected. The resident had not recently been referred to the psychiatrist for a consult. During an interview on 1/16/13 at 1:05 P.M., the Director of Nurse's (DON) said Resident #1 had very volatile mood swings, cursed at residents and staff and had no tolerance for anyone in his/her space. The DON said the only interventions put into place were to try to run interference and direct other residents away from Resident #1's space. The DON said attempts to redirect the resident caused an escalation in behavior. During an interview on 1/16/13 at 1:35 A.M., the MDS/Care Plan Coordinator said he/she was not aware of any incidents concerning the resident's behavior except the incident on 1/15/13 concerning Resident #4. During an interview on 1/16/13 at 1:40 P.M., the Social Service Designee (SSD) said he/she did not think it was in anyone's best interest for the resident to be in the facility. The SSD first became aware of the resident's behaviors in a care plan meeting when Resident #4's family reported the incident which occurred on 1/15/13. The SSD said he/she had heard rumors that the resident cursed at staff and refused medication but had not been told the resident hit Resident #2. The SSD said the facility had no system in place to relay information concerning residents' psychosocial issues. During an interview on 1/16/13 at 2:20 P.M., the Administrator said she was aware of the resident's behavior of cursing and the confrontation with Resident #2. The Administrator said she contacted the Owner when the resident acted out and it would calm the resident. The Administrator said the facility did not have a formal system for communicating psychosocial issues to the SSD but verbalized concerns. During an interview on 1/17/13 at 10:10 A.M., the resident's Physician said staff informed him of the resident's hostile behavior and refusal of medication over the past couple of weeks but did not notify him of specific incidents. The physician said the resident needed psychiatric help. 2. Record review of Resident #2's quarterly MDS, dated [DATE], showed the resident as severely cognitively impaired and exhibited verbal behaviors. The resident required extensive assistance for mobility. Review of a nurse's note, dated 1/12/13 at 2:10 P.M., showed Resident #2 experienced slight redness under the left eye and a 4 centimeter (cm) by 2 cm skin tear to the right forearm after Resident #1 struck him. . During an interview on 1/16/13 at 11:30 A.M., Resident #2 said he/she did not recall being hit by anyone. The resident had no visible injuries. 3. Record review of Resident #3's face sheet showed [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], showed staff identified the resident as cognitively intact with no behaviors. Review of the medical record showed no documentation related to the incident on 1/12/13. During an interview on 1/16/13 at 11:35 A.M., the resident did not recall the incident. 4. Record review of Resident #4's face sheet showed a [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], showed staff identified the resident as cognitively intact with no behaviors. During an interview on 1/16/13 at 12:35 P.M., the resident said that one resident (identified as Resident #1) spoke ugly to others. Resident #1 sat at the table with Resident #4. Resident #1 picked up and threw Resident #4's napkin in the floor because Resident #1 said it touched his/her napkin. Resident #1 then told Resident #4 to pick up the napkin. 5. Record review of Resident #5's quarterly MDS, dated [DATE], showed staff identified the resident with moderate cognitive impairment, verbal behaviors and required extensive to total assistance for mobility. 6. Review of the facility's behavior assessment and monitoring policy showed the policy directed staff to identify, document and inform the physician about an individual's mental status, behavior and cognition. Review of the facility's abuse prohibition policy showed the policy identified that each resident had a right to be free from verbal and/or physical abuse for anyone, including other residents. Complaint MO