Every finding on record at Rosewood Rehab and Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure staff were counting the residents' narcotic medications (a drug that relieves pain, dulls the senses, and induces sleep) at the beginning and end of each shift, failed to ensure the residents' prescribed medications that had been discontinued were returned to the pharmacy in a timely fashion, and failed to ensure a resident's narcotic medication had been disposed of timely for a resident who had passed away more than a week previously out of 16 sampled residents The facility census was 250 residents.Review of the facility's policy, Controlled Medication Storage, dated 2007 showed:-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (a drug or chemical whose manufacture, possession, and use were tightly regulated by the government due to risks of abuse, addiction and dependence) were subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations.-The Director of Nursing (DON) and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications.-A controlled medication accountability record was to have been prepared when receiving inventory of a Scheduled II medication (substances as having a high potential for abuse, with use potentially leading to severe psychological or physical dependence).-At each shift change or when keys were surrendered, a physical inventory of all Scheduled II (medications) was to have been conducted by two licensed nurses or per state regulation and was to have been documented on the controlled substances accountability record or verification of controlled substances count report.-Any discrepancy in controlled substance medication counts was to have been reported to the DON immediately.-The DON or designee investigates and makes every reasonable effort to reconcile all reported discrepancies while the nurses remain on duty.-The DON in a report to the Administrator, documents irreconcilable discrepancies.-Current controlled medications accountability records were kept in the Narcotic book.-Controlled medications remaining in the nursing care center after the order has been discontinued were retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. 1. Observation of medication storage on [DATE] at 9:34 A.M. with Registered Nurse (RN) A showed the Medication Room on 3 South had more than 100+ cards of discontinued residents' medications. 2. Observation of the 3 South Medication Cart on [DATE] at 10:00 A.M. with RN A showed two medications for a resident that the RN A reported had expired more than a week ago was still being stored in the Medication Cart:-Morphine (a strong pain medicine used to treat severe pain such as surgical pain) had 26.5 Milliliters (ml) in the bottle.-Lorazepam (a medication used for anxiety disorders) had 26.5 ml in the bottle.-Both bottles had been opened. 3. Observation on [DATE] at 9:40 A.M. and review of the Narcotic Card Count from [DATE] to [DATE] for 3 North nurse's cart with RN A showed that the Narcotic Card Count Sheet was not signed by two nurses on each shift. From [DATE] to [DATE] the 3 North nurse's cart Narcotic Card Count showed:-Ten blanks (no signature) out of 96 opportunities.-Nine card counts did not show the number of cards counted.-On [DATE] the card count started with 21 cards; 14 cards were added for a total of 35 cards.-Between [DATE] through [DATE] 13 cards were subtracted for a total of 22 cards, (35 - 13 =22). The count of the cards of narcotic medications stored in the nurse's medication cart showed 24 cards. During an interview on [DATE] at 9:50 A.M. RN A said:-The bottles of Morphine and Lorazepam belonged to a resident that had expired more than a week ago, and the medication should have been taken out of the medication cart that same day.-The Pharmacy makes three deliveries to the facility daily.-Discontinued medications should have been returned to the Pharmacy at least within the week if not sooner.-The 100+ discontinued medications were about a month or so worth of medications.-There was a discrepancy on [DATE] and the Staff Development Coordinator had provided education on how the off going nurse and the oncoming nurse were to count the narcotics together and sign at the same time.-Staff were still not signing the narcotic count sheet after the education provided on [DATE].-He/She did not know who was responsible for auditing the narcotic count sheet to ensure two staff members were counting and signing at the same time, maybe the DON. Observation on [DATE] at 10:00 A.M. and review of the Narcotic card count from [DATE] to [DATE] for 3 North Certified Medication Technician (CMT) cart with CMT A showed:-32 blanks (no signature) out of 102 opportunities.-Seven shift changes showed the same signature off going as on coming.-Six card counts were blank.-On [DATE] the card count was 19, 11 cards were subtracted which should have totaled 8 (19-11=8). Between [DATE] through [DATE] 16 cards were added the total should have been 24 (16+8=24).-On [DATE] the count of the cards of narcotic medications stored in the CMT medication cart showed 20 cards. During an interview on [DATE] at 10:10 A.M. CMT A said:-He/She counts with the other person then they both sign the narcotic count sheet.-There should not have been any blanks.-If a resident passed away their remaining medication should have been removed and destroyed by the next day.-The Pharmacy comes three times a day.-There was an issue, and an evening staff member was let go recently.-The staff development nurse had provided education in the past couple of weeks concerning two staff members counting the narcotics and signing together.-Other staff members were still not signing at shift change.-There should not have been 100+ medication cards in the medication room waiting to be returned to pharmacy maybe a day or two but not 100+ that would have been at least a month's worth of medications.-Probably the DON was responsible for ensuring the narcotic card count was correct, narcotics were destroyed if a resident had passed and returning the medications to pharmacy. During an interview on [DATE] at 11:00 A.M. RN B said:-Pharmacy comes twice a day Monday through Friday.-There was a CMT and a nurse who had recently left employment at the facility.-They have not had a unit manager for a while and just last week they hired one.-The unit manager was responsible for sending medications back to the pharmacy which should have been done at least weekly.-If there were 100+ medication cards waiting to go back to pharmacy then they had not been sent back for at least a month.-If someone passes away their medication should have been removed from the medication cart that day not waiting more than a week.-He/She has had to argue with staff to get them to count the narcotics with him/her.-If the count was not correct then he/she would not accept the keys and would have called the DON and they both would have stayed at work until it was figured out.-They have recently had education on two staff counting the narcotics, but it looked like staff were still not doing that.-The unit manager was responsible for ensuring the narcotic card count was correct and he/she just started. 4. Observation on [DATE] at 11:15 A.M. and review of the Narcotic Card Count from [DATE] to [DATE] on 3 South CMT medication showed:-Seven blanks (no signature) out of 106 opportunities.-Eight shift changes showed the same signature off going as on coming.-On [DATE] the card count was 22 cards; 15 cards were added for a total of 37 cards.-Between [DATE] through [DATE] eight cards were subtracted which should have totaled 29 cards.-On [DATE] the count of the cards of narcotic medications stored in the CMT medication cart showed 30 cards. During an interview on [DATE] at 12:10 P.M. the Assistant Director of Nursing (ADON) said:-There should be one nurse on coming and one nurse off going counting the narcotic cards.-He/She provided education to the staff on [DATE].-No one has been auditing the narcotic cards since [DATE] but they should have been.-The unit manager should start doing audits. During an interview on [DATE] at 12:15 P.M. the Staff Development/LPN and the Third-floor Unit Coordinator said:-There should be two nurses counting one off going and one on coming to count the number of narcotic cards and the number of pills on each card.-Both staff should count together and sign the sheet at the same time.-If a resident passed away it was expected their medication should have been removed by the next day.-There should not have been 100+ medication cards to have been returned to pharmacy.-The medication cards should have been returned a couple of times a week.-There had been an issue where there was an unsubstantiated report of a resident's narcotic pills had gone missing.-The Staff Development/LPN had completed an investigation.-He/She had provided education to the staff on [DATE] about ensuring two staff members signed off on the narcotic count sheet after counting.-He/She said they had not done any audits to ensure staff were actually counting the narcotics with a second person.-The unit manager said he/she had just started but had not been made aware of this issue of two staff not counting together. During an interview on [DATE] at 1:00 P.M. the Interim DON said:-The pharmacy comes daily and there should not have been 100+ medication cards waiting to have been returned to pharmacy.-If a resident passes away his/her medication should have been removed and returned to the pharmacy no later than the next day.-The oncoming nurse and the off going nurse should have counted the narcotics and signed at the same time, the card count should have been correct, or they should not have left.-Audits should have been in place after the ADON provided staff with education on [DATE] about two nurses signing the narcotic count sheet.-To date no audits were done.-He/She was aware that the staff were still not counting the narcotics and signing with a second person During an interview on [DATE] at 1:05 P.M. the Unit Manager on 3 South said:-He/She had just started at the facility a week ago.-He/She had not been informed that there had been an issue with missing narcotics or staff not counting the narcotics with the off going shift.-He/She was not told he/she would need to complete ant audits on the narcotic count sheets. 3077310

Based on interview, and record review, the facility failed to thoroughly investigate a report of missing resident narcotics for one sampled resident (Resident #15) out of 16 sampled residents. The facility census was 250 residents.Review of the facility's policy, Incident Investigation, dated October 24, 2022 showed:-Purpose: To ensure the facility tracks incidents that take place at the facility in an effort to increase the quality of care provided to the residents.-In the event of an incident, a Licensed Nurse or the individual who first encountered or witnessed an incident would have completed Form A Incident/Accident Report Form or a substantively similar form which would have included: the resident's name, the day and shift during which the incident occurred, type code, injury code, location code, severity code, medication or treatment error code.-Interviews with staff members and other witnesses would be documented.-Upon completing the code, the Director of Nursing (DON) would submit the monthly incident log to the Quality Assessment and Assurance (QAA) Committee.-The QAA Committee would help the appropriate department director in defining issues, planning and implementing actions, and ensure monitoring and follow up. 1. Review of Resident #15's face sheet showed:-He/She had Dementia (a decline in memory, thinking, and social abilities that interferes with daily life).-Disseminated Malignant Neoplasm (a cancer that has spread widely from its original site to distant parts of the body).-Osteoarthritis (breakdown of protective cartilage -a tough, flexible tissue that cushions joints, bone changes and joint pain) left shoulder.-He/She had a guardian. Review of the resident's July 2026 Physician's Order Sheet (POS) showed the following order:-Oxycodone Hydrochloride (medication used for severe pain) Capsule 5 Milligram (MG) give one capsule every six hours as needed for moderate to severe pain, dated 6/16/26.-He/She had the potential for pain and was on scheduled Tylenol related to Osteoarthritis. Review of the facility's Investigation dated 7/2/26 showed:-The facility had interviewed the nurse that had made a report that the resident was missing a second card of Oxycodone (with possibly four pills on it).-The facility interviewed the resident. The resident was oriented to self only.-The narcotic count for the resident was completed and verified as correct.-Education was completed with licensed nurses on narcotic counts, narcotic administration and handling.-There was no documentation that other residents narcotic card counts had been verified.-There was no documentation that other staff were interviewed about missing pain medications.-There was no documentation that an Incident Form had been filled out.-There was no documentation of witness statements from the nurse who had alerted the facility of the issue or other nursing staff.-There was no documentation of audits which should have been conducted after education was provided.-There was no documentation any staff was responsible to audit the narcotic card counts.-There was no documentation the resident's guardian, physician or pharmacy had been notified.-There was no documentation the incident was discussed at QAA meeting. Review of the Staff Education Sign In Sheet dated 7/2/26 showed:-At every shift change or when (medication cart) keys change from one staff to another count all narcotics with the off going nurse or Certified Medication Technician (CMT).-Check correct medication, correct count, and correct documentation.-Both staff must sign off.-Do a total card count, if correct, then proceed to counting each individual narcotic.-If something does not match stop immediately.-Recount.-Check the Medication Administration Record (MAR) and the narcotic sheet.-Notify the nurse supervisor or DON right away.-Never ignore a discrepancy. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning, dated 7/19/26 showed:-He/She was taking an Opioid (a class of drugs prescribed for moderate to severe pain).-His/Her Brief Interview for Mental Status (BIMS) score was 9 indicating he/she was moderately mentally impaired. Review of the resident's undated care plan showed:-He/She had a self-care deficit requiring staff assistance with his/her activities of daily living needs related to impaired cognition.-He/She had impaired cognitive function related to dementia, with memory loss, confusion, and disorientation. During an interview on 7/22/26 at 12:10 P.M. the Assistant Director of Nursing (ADON) said:-There was a report that the resident was missing a narcotic card with four pills in it.-He/She had completed the investigation and was not able to substantiate the complaint.-At the time of the complaint the staff who had not been counting the narcotics had been disciplined.-No one has been auditing the narcotic cards since 7/2/26 but they should have been. During an interview on 7/22/26 at 1:15 P.M. the Interim DON said:-They had done an investigation where they had talked to the staff.-They did not have documentation of the staff interviews.-There was no documentation of staff drug tests or suspensions.-Staff who had not been counting and signing off the narcotic count sheets had been disciplined.-Someone should have been doing audits on the count sheets after education had been provided but no one has been, the staff were still not counting the narcotics and signing with a second person. -No staff member was assigned to audit the narcotic card counts.-They were not able to substantiate who would have been taking the narcotics as many people were not signing the narcotic sheet.-The off-going and on coming staff should have counted and signed together.-Education had been provided by the ADON. 3077310

Based on observation, interview and record review, the facility failed to keep one sampled resident (Resident #17) out of 23 sampled residents safe from physical abuse. On 3/5/26 Resident #18 struck Resident #17 multiple times in the face, resulting in bruising and cut above Resident #17's left eye. The facility census was 251 residents.The Administrator was notified on 3/19/26 of Past Non-Compliance which occurred on 3/5/26. An all-staff in-service on Abuse and Neglect was completed by 3/6/26. The deficiency was corrected by 3/6/26. Review of the facility's Abuse Prevention and Prohibition Program revised 10/24/22 showed each resident had the right to remain free from abuse and neglect, including abuse from other residents. 1. Review of Resident #17's facility admission Record showed the resident was admitted on [DATE] with the following diagnoses:-Unspecified Dementia without behaviors- (a diagnosis used when a patient shows clear symptoms of cognitive decline-such as memory loss or impaired reasoning-but the specific cause or the precise severity has not yet been determined).-Auditory Hallucinations- (the false perception of sounds, such as hearing voices, music, or noises in the absence of an external stimulus).-Psychotic disorder with hallucinations- (a severe mental health condition where a person loses touch with reality, experiencing false sensory perceptions-such as hearing voices, seeing, or feeling things that are not present). Review of Resident #17's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 2/5/26 showed he/she:-Was not cognitively intact.-Had moderate issues with mood.-Inattention and disorganized thinking were continuously without fluctuation.-Was independently ambulatory. Review of Resident #18's facility admission Record showed the resident was admitted on [DATE] with the following diagnoses:-Unspecified Dementia with Agitation.-Anxiety.-Psychotic Mood Disorder- (a severe mental health condition where a primary mood disturbance-such as extreme depression or bipolar disorder-is accompanied by symptoms of psychosis, including hallucinations, delusions, or paranoia).-Stroke. Review of Resident #18's admission MDS dated [DATE] showed he/she:-Was not cognitively intact.-Had moderate issues with mood.-Showed physical behaviors one to three days per week such as hitting, kicking, pushing, scratching, and/or grabbing others. Review of Resident #18's Behavior Note dated 3/5/26 at 5:40 P.M., showed:-Occupational Therapy Assistant (OTA) A walked into the resident's room and observed Resident #18 kneeling over Resident #17 and hitting him/her in the face.-Licensed Practical Nurse (LPN) A ran into the room and assisted in separating the residents and ensure their safety.-Resident #18 said a man/woman came into his/her room and said he/she owed him/her money. He/she was confused because he/she didn't know he/she owed any money. Then he/she hit him/her on his/her shoulder, and he/she let him/her have it.-Blood was noted on both residents and the floor. Review of Resident #17's Nurse's Notes dated 3/5/26 at 11:50 P.M., showed:-Resident #17 wandered into Resident #18's room.-OTA A walked by the room and noted the residents were on the floor and Resident #18 was hitting Resident #17 in the face.-OTA A yelled for help and Certified Nurse's Aide (CNA ) A ran to the room and summoned LPN A who came and helped CNA A and OTA A separate the residents.-Blood was noted on both residents and on the floor.-Resident #17 stated, I was beat up.-Bruising and bleeding were noted above and below Resident #17's left eye and a laceration was noted to the resident's left thumb. Review of the facility's Abuse Investigation dated 3/5/26 showed:-On 3/5/26 at approximately 11:30 A.M., (OTA) A walked by Resident #18's room.-Resident #17 was in Resident #18's room and the residents were having an altercation in the room.-OTA A immediately called for help and CNA A came to help.-OTA A and CNA A separated the two residents and CNA A called the Assistant Director of Nursing (ADON) and the facility Administrator who both responded.-The ADON assessed both residents and found that Resident #17 had a small cut on his/her left eyebrow and a small red area on the left side of his/her face.-A small amount of first aid was required for Resident #17 and the resident complained of no pain.-Resident #18 had a small cut below his/her lip, requiring no first aid.-The majority of the incident was not witnessed by any staff or residents.-Both residents resided on the locked dementia unit, and both had a history of dementia.-Resident #18 was unable to recall the incident. Review of Resident #17's Skin assessment dated [DATE] at 12:00 P.M., showed:-The resident had a skin tear on his/her left thumb.-He/she had bruising/hematoma (a localized collection of clotted or partially clotted blood trapped in an organ, tissue, or space, usually caused by a broken blood vessel) under his/her left eye.-He/she had a laceration (cut) on his/her left eyebrow. Review of Resident #17's Medication Administration Record (MAR) dated 3/5/26 at 12:30 P.M., showed the resident received 500 milligrams (mgs) of Tylenol (a medication used to treat mild pain). Review of Resident #17's Nurse Practitioner (NP) note dated 3/5/26 at 7:39 P.M., showed:-He/she was seeing Resident #17 for a follow-up after an altercation with Resident #18 that occurred when the resident wandered into another resident's room.-The resident sustained multiple facial injuries during the incident, including a contusion ( to his/her left cheekbone and right temple area, a small cut above the left eyebrow lateral to the outer canthus ( and a small cut to his/her right thumb.-The altercation began when Resident #17 wandered into another resident's room and that resident apparently started hitting him/her. Review of Resident #17's NP progress note dated 3/6/26 at 8:35 P.M., showed:-Resident #17 was seen for a follow-up after a recent altercation with Resident #18.-The resident continued to have bruising and contusions (to his/her face in multiple areas following the incident. During an interview on 3/7/26 at 2:15 P.M., Resident #18 said he/she did not recall any altercation between him/her and any other resident. Observation and interview of Resident #17 on 3/7/26 at 2:30 P.M., showed:-He/she was unable to answer any questions about the altercation due to his/her dementia diagnosis.-The resident had an approximately five centimeter (cm) long purple/blue bruise under his/her left eye where the lower portion of the resident's glasses were.-He/she had a small, two cm cut in his/her left eyebrow where the upper portion of his/her glasses were. During an interview on 3/18/26 at 9:40 A.M., OTA A said:-He/she was coming onto the unit and heard what sounded like yelling coming from Resident #18's room.-He/she went to Resident #18's room and found Resident #18 on top of Resident #17 and both residents were punching on each other.-He/she yelled for help and CNA A came running into the room and assisted in separating the residents.-He/she saw blood on both residents. During an interview on 3/19/26 at 10:56 A.M., CNA A said:-When he/she heard the call for help, he/she ran to Resident #18's room and found Resident #17 and Resident #18 fighting with each other, both of them throwing punches.-He/she and OTA A intervened to separate the two residents. During an interview on 3/19/26 at 11:06 A.M., the ADON said:-He/she responded to the incident and the residents had been separated.-Resident #17 had some bleeding above his/her left eye and the beginning of a bruise under his/her left eye. During an interview on 3/19/26 at 12:30 P.M., the Administrator said:-He/she responded to the incident right after it happened.-Resident #17 had a history of wandering but was unaware of any violent behavior.-He/she felt the altercation was more territorial in nature instead of an abusive situation and neither resident was cognitively intact.-He/she believed that since Resident #17 wandered and Resident #18 was newer to the dementia unit, it likely startled Resident #18 and he/she was just defending his/her room and territory.-He/she felt that since Resident #18 was new, the incident could not have been predicted by the staff.-He/she did not believe that either resident meant to harm the other. 2797635

The Administrator was notified on 3/19/26 of Past Non-Compliance which occurred on 3/5/26. An all-staff in-service on Abuse and Neglect, as well corporate administrative staff completed education with the facility Administrator on 3/6/26. The deficiency was corrected by 3/6/26. Review of the facility's Abuse Prevention and Prohibition Program revised 10/24/22 showed:-The purpose of the policy was to protect residents and ensure a standardized methodology for addressing abuse and neglect.-Each resident had the right to remain free from abuse and neglect, including abuse from other residents.-The facility Administrator was responsible for coordinating the facility's abuse and neglect programs and systems.-The facility was responsible for reporting any incident of abuse that resulted in significant resident injury within two hours of the injury, to all required entities including the Department of Health and Senior Services (DHSS). 1. Review of Resident #17's facility admission Record showed the resident was admitted on [DATE] with the following diagnoses:-Unspecified Dementia without behaviors- (a diagnosis used when a patient shows clear symptoms of cognitive decline-such as memory loss or impaired reasoning-but the specific cause or the precise severity has not yet been determined).-Auditory Hallucinations- (the false perception of sounds, such as hearing voices, music, or noises in the absence of an external stimulus).-Psychotic disorder with hallucinations- (a severe mental health condition where a person loses touch with reality, experiencing false sensory perceptions-such as hearing voices, seeing, or feeling things that are not present). Review of Resident #18's facility admission Record showed the resident was admitted on [DATE] with the following diagnoses:-Unspecified Dementia with Agitation.-Anxiety.-Psychotic Mood Disorder-( a severe mental health condition where a primary mood disturbance-such as extreme depression or bipolar disorder-is accompanied by symptoms of psychosis, including hallucinations, delusions, or paranoia).-Stroke. Review of the facility's Abuse Investigation dated 3/5/26 showed:-On 3/5/26 at approximately 11:30 A.M., Occupational Therapy Assistant (OTA) A walked by Resident #18's room.-Resident #17 was in Resident #18's room and the residents were having an altercation in the room.-OTA A immediately called for help and Certified Nursing Assistant (CNA) A came to help.-OTA A and CNA A separated the two residents and CNA A called the Assistant Director of Nursing (ADON) and the facility Administrator who both responded.-The ADON assessed both residents and found that Resident #17 had a small cut on his/her left eyebrow and a small red area on the left side of his/her face.-A small amount of first aide was required for Resident #17 and the resident complained of no pain.-Resident #18 had a small cut below his/her lip, requiring no first aide. During an interview on 3/18/26 at 9:40 A.M., OTA A said:-He/she was coming onto the unit and heard what sounded like yelling coming from Resident #18's room.-He/she went to Resident #18's room and found Resident #18 on top of Resident #17 and both residents were punching on each other.-He/she yelled for help and CNA A came running into the room and assisted in separating the residents.-He/she did see blood on both residents.-CNA A reported what was happening to Licensed Practical Nurse (LPN) A and the Assistant Director of Nursing (ADON). During an interview on 3/19/26 at 10:56 A.M., CNA A said:-When he/she heard the call for help, he/she ran to Resident #18's room and found Resident #17 and Resident #18 fighting with each other, both of them throwing punches.-He/she and OTA A intervened to separate the two residents.-The two residents had never had an issue with each other in the past, but Resident #17 wandered a lot and Resident #18 was newer to the unit, so probably didn't like Resident #17 coming into his/her room.-He/she immediately reported the incident to LPN A and the ADON. During an interview on 3/19/26 at 11:06 A.M., the ADON said:-He/she responded to the incident and the residents had been separated.-Resident #17 had some bleeding above his/her left eye and the beginning of a bruise under his/her left eye.-He/she told the Administrator. The Administrator was the abuse coordinator and responsible for reporting. During an interview on 3/19/26 at 12:30 P.M., the Administrator said:-He/she responded to the incident right after it happened.-Resident #17 had a history of wandering but was unaware of any violent behavior.-He/she felt the altercation was more territorial in nature instead of an abusive situation and neither resident was cognitively intact.-He/she believed that since Resident #17 wandered and Resident #18 was newer to the dementia unit, it likely startled Resident #18 and he/she was just defending his/her room and territory.-He/she felt that since Resident #18 was new, the incident could not have been predicted by the staff.-He/she did not believe that either resident meant to harm the other.-He/she did not think the event was abuse and did not report. 2797635

Based on observation, interview, and record review, the facility failed to ensure Resident #72 and #238 were free from abuse when the residents got into a resident to resident altercation. Staff failed to separate the residents in accordance with their policy after the altercation and the residents remained roommates for 48 hours. Both residents reported being scared of the other resident. Staff failed to ensure Resident #240 was free from abuse when the resident entered Resident #215's room leading to an altercation. Resident #240 had significant facial bruising and family reported the resident to be sad and would not come out of his/her room after an altercation with Resident #215. The facility failed to ensure five sampled residents (Resident #26, #38, #187, #238, and #240) were free from physical abuse from Resident #307 who had a known history of verbal and physical aggression. All residents resided on a locked memory care unit. Thirty five residents were sampled. The facility census was 259. Review of the facility's Abuse Prevention and Prohibition Program policy, dated 10/24/22, showed: -The purpose of the policy was to ensure the facility established, operationalized, and maintained an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized method for prevention, identification, investigation, and reporting of abuse, neglect and mistreatment, misappropriation of property and crime in accordance with federal and state requirements. -Each resident had the right to be free from mistreatment and abuse. -The facility had a zero-tolerance for abuse and mistreatment. -The administrator was responsible for coordination and implementing the facility's abuse prevention policies, procedures, training programs and systems. -The facility ensured protection of residents during an abuse investigation. -If the allegations were regarding a resident-to-resident altercation, the residents were separated immediately, pending the investigation. 1. Review of Resident #72's admission Record showed the resident admitted to the facility on [DATE] with the following diagnoses: -Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Bipolar Disorder (a mental health condition that causes extreme mood swings. These include emotional highs, also known as mania or hypomania, and lows, also known as depression). -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Depressive Disorder (a persistent mood disorder characterized by sadness and loss of interest or pleasure in daily activities). Review of Resident #72's care plan, dated 10/7/19, showed: -The resident was an elopement risk/wanderer and ambulates about the unit related to impaired cognition. -The resident had a behavior problem such as: --Sexually inappropriate behaviors. --Hallucinations. --Delusions. -The staff to monitor the resident and record/report to the physician any risk for: --Harming others. --Increased anger. --Labile mood or agitation. --Feels threatened by others. --Thoughts of harming someone. -Staff to intervene as appropriate. Review of Resident #72's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 3/14/25, showed the resident assessed as mildly cognitively impaired. No behaviors were documented. Review of Resident #238's admission Record showed the resident admitted to the facility on [DATE] with the following diagnoses: -Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning) NOS (Not otherwise specified). -Dementia. -Major depressive Disorder. -Anxiety Disorder. -Post Traumatic Stress Disorder (PTSD-a psychiatric condition that may occur in people who have experienced or witnessed a traumatic event or series of traumatic events. The individual often experiences the event or events as emotionally or physically harmful or life-threatening). -Mild Cognitive Impairment. -Muscle Weakness. -Unsteadiness on Feet. -Cognitive Communication Deficit. Review of Resident #238's admission MDS, dated [DATE], showed the resident assessed as mildly cognitively impaired. Hallucinations and delusions were noted. Review of Resident #238's care plan, dated 1/15/25, showed: -The resident had impaired cognitive function related to dementia. -Staff to cue, reorient and supervise as needed. -The resident had depression related to dementia. -The staff to keep environment noise at a minimum as possible. -The resident had a diagnosis of PTSD, which has affected his/her overall health/well-being. -Behaviors related to this trauma have included: --Hallucinations. --Delusions. --Paranoia. -- Seeing/hearing people. -Staff to ensure that other residents were not in the resident's room or invading his/her space. -Staff to redirect other residents from the resident's room or area. -Staff to make sure the resident remained safe. Review of Resident #238's progress note, dated 5/10/25 at 9:16 A.M., showed the patient in a physical altercation with another patient, patient does have a skin tear on his/her left arm and face. Patient stated he/she fell, started neuros, vital signs are stable per patient. Staff called his/her family, admin (administrator), and house supervisor. Review of Resident #72's progress note, dated 5/10/25 at 9:04 A.M., showed the patient in a physical altercation with another resident, patient said he/she was defending himself/herself. He/She had a skin tear on his/her left arm staff cleaned and covered, patient did not fall, family called and informed, house supervisor and administrator called as well, left note for the nurse practitioner in the binder. Review of the facility undated incident report showed: -On 5/10/25 it was reported Resident #72 and Resident #238 were in an unwitnessed disagreement. -Resident #72 stated Resident #238 came to his/her side of the room and threw water on him/her due to his/her television being too loud. -Resident #72 stated Resident #238 then threw his/her television on the floor and made contact with him/her, which resulted in both residents being on the floor. -Resident #238 stated he/she went to Resident #72's side of the room and told Resident #72 to turn his/her television down, and Resident #72 turned his/her television up louder. -Resident #238 stated he/she then threw water at Resident #72 and his/her legs gave out and he/she fell on the floor. -Resident #238 stated after he/she fell on the floor, Resident #72 made contact with him/her. -Resident #238 had a skin tear on his/her left forearm and an abrasion to his/her cheek (either side of the face, below the eye). -Resident #72 had a skin tear on his/her left forearm. -On 5/11/25, the house supervisor and the DON placed Resident #238 on frequent observations. Review of Resident #238's Weekly Skin Observation, dated 5/10/25 at 1:30 P.M., showed: -Abrasion to the right side of his/her chin, 0.1 x 2 centimeter (cm). -Skin tear to his/her left forearm, 1.6 x 2.1 x 0.1 cm. Review of Resident #72's Weekly Skin Observation, dated 5/10/25 at 7:11 P.M., showed the resident had a skin tear to his/her left forearm. Observation and interview on 5/12/25 at 11:10 A.M., with Resident #238 showed: -The resident was in his/her room with the curtains and door shut, watching television. -The resident had bruising on his/her left side of face, bruising around his/her mouth and lips, and a bandage on his/her left arm. -The resident said he/she and his/her roommate got in a fist fight this past Friday. He/She notified staff. He/She went to have the roommate turn down his/her television and he/she lost balance and fell to the floor. The resident said at that time, his/her roommate jumped on top of me, pinning me down on the floor, and began punching me. He/She was finally able to get from underneath Resident #72 (roommate) and pull himself/herself off the floor by using the resident's furniture. The resident to resident altercation was about 10 minutes long and then staff entered the room. He/She hit his/her head while falling to the floor during the altercation. -The resident cried while recalling the scenario and stated, I have been scared to even leave my side of the room. Observation and interview on 5/12/25 at 11:25 A.M., showed Resident #72: -The resident lay in his/her bed. -The resident said his/her roommate (Resident #238) came on his/her side of the room a couple days ago, asked him/her to turn down the television and started swinging on him/her. The roommate then threw his/her plastic cup of water on him/her and threw his/her television on the floor. The roommate lost his/her footing and fell on the floor, but was shortly able to get himself/herself up from the floor. Staff then came into the room. -The resident had visible bruising on his/her right arm. During an interview on 5/14/25 at 9:42 A.M., Certified Nurses Aide (CNA) F said: -He/She broke up the incident between the residents on 5/10/25 at about 9:15 A.M. -The residents were in their room when the resident to resident altercation occurred -Resident #238 was upset because another resident had come into their room. -Resident #238 put on the light because the other resident wandered into his/her room. He/she went in and assisted the other resident out of the room. Resident #238 was still upset. -Resident #238 wanted to talk to the social worker about the other resident coming into the room and he/she told Resident #238 there was no social worker on the weekend. -Resident #238 put the light on again. -He/She went into the resident's room. The whole floor was wet. Resident #72's belongings were also on the floor. Resident #238 was sitting in his/her recliner. Resident #72 was standing in the middle of the floor, trying to catch his/her breath. -Resident #238 had blood all over his/her face. -Resident #72 had a scratch on his/her lower arm. -He/She asked Resident #72 what happened and he/she responded Resident #238 attacked him/her and he/she was defending him/herself. -He/She asked Resident #238 what happened and he/she responded Resident #72 would not turn the television down and it was too loud, so he/she stated hammering on Resident #72 and then he/she fell to the ground. -He/She did not receive any further instruction on what to do with the residents to keep them both safe. -The supervisor went upstairs and got an extra CNA to sit with Resident #238 in his/her room. -Resident #72 stated right after the altercation, he/she was scared to go back in the room, because Resident #238 had attacked him/her. -He/She later entered the resident's room to check on Resident #238 who stated he/she was going to strangle Resident #72 if he/she came back in their room. -Resident #72 remained at the nurse's station for about 2 hours and then went back to his/her room unsupervised. During an interview on 5/12/25 at 12:31 P.M., the Director of Nursing (DON) said: -He/She was aware of the resident to resident altercation between Resident #72 and Resident #238, because he/she was notified by staff members when it occurred. -He/She was aware Resident #238 had bruising on his/her lips and mouth, and an abrasion to his/her left side of face, and a wound on his/her left arm. -He/She was aware Resident #72 had bruising on his/her left arm. -He/She would have expected the aggressor of the incident to be placed on 1:1 observation, the residents to be separated, and the family and physician to be notified. -Resident #238 was the aggressor and family of both residents had been notified. -The house supervisor notified him/her of the resident to resident altercation and it occurred because Resident #72 had his/her television on loud and Resident #238 asked Resident #72 to turn it down. Resident #238 then threw a water pitcher at Resident #72 and the two residents began punching each other. During an interview on 5/12/25 at 12:54 P.M., the Social Services Director said: -He/She received a notification about the resident to resident altercation. -He/She visited with Resident #238 on 5/11/25. -Resident #238 presented slightly agitated during his/her visit with him/her. -Resident #238 stated it was bullshit and that the zombies keep coming into my room. During an interview on 5/12/25 at 2:50 P.M., the DON said: -The residents have been together for a few months and this was their first incident. -Resident #238 was placed on 1:1 after the incident on 5/10/25 at 9:30 A.M., he/she was removed from 1:1 during the night shift related to staffing. -Resident #238 was placed back on 1:1 observation on 5/12/25, after facility staff were told that resident #238 expressed fear to the surveyor. -There was a plan to change rooms after the incident when he/she can find another resident who would be compatible with Resident #238. -Resident #238 would now remain on 1:1 observation until a room change occurred. -He/She was going to find out how Resident #238 got taken off 1:1 observation over the weekend. During an interview on 5/13/25 at 1:57 P.M., Regional Director of Operations said: -He/She was not working on 5/10/25. -He/She became aware of the resident to resident altercation on the evening of 5/10/25. -He/She was told that if a resident to resident was unwitnessed it was not reportable. -As far as he/she knew, the residents felt safe until 5/12/25. During an interview on 5/13/25 at 2:27 P.M., the Nurse Practitioner (NP) said: -He/She was not notified when the resident to resident incident occurred on 5/10/25. -He/She found out about the incident when he/she came to work on 5/12/25. -He/She saw both residents on 5/12/25. -He/She was under the impression Resident #72 had his/her television too loud and as a result, Resident #238 went over to Resident #72 and they ended up hitting each other. -On 5/12/25, he/she observed Resident #72 had red marks on his/her right forearm about 5 cm long. -On 5/12/25, he/she observed Resident #238 had purple bruises on his/her lips, and abrasion on his/her left eye, and a red mark on his/her right side of cheek. -From his/her observation, it appeared Resident #238 was hit in the face by Resident #72. During an interview on 5/14/25 at 10:37 A.M., the Physician said: -He/She was aware of the resident to resident altercation. -He/She could not recall when he/she was notified of the altercation. -He/She expects the facility to follow the policy after a resident to resident altercation. -He/She expects that all residents be made to feel and kept safe at all times. -The residents should have been separated and not behind closed doors after the incident. During an interview on 5/23/25 at 1:38 P.M., the DON said: -The abuse policy stated residents involved in resident to resident altercations should be separated, but did not say for how long. -He/she defined abuse as being done intently. On the memory care unit the facility had a lot of behaviors that arose and he/she would have to look up the guidelines on if those behaviors were considered abuse. -Willful intent was to hurt someone was main definition of abuse and that no negative outcome was needed to be classified as abuse. -All residents have the right to be free from abuse. -He/she did not identify the resident to resident incident between Resident #72 and Resident #238 as abuse. -Resident #72 and Resident #238 remained in the same room after the altercation on 5/10/25 through 5/12/25. 2. Review of Resident #240's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia. -Cognitive communication deficit (difficulty with communication stemming from problems with cognitive processes like attention, memory, and problem-solving). -Restlessness. -Depression. Review of Resident #240's admission MDS, dated [DATE], showed the resident assessed as cognitively impaired. No behaviors documented. Review of Resident #240's care plan, dated 4/10/25, showed: -The resident was an elopement risk/wanderer. -The resident was disoriented to place. -Staff to monitor the resident's location every 15 min and document. -Staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. -The resident was at risk for falls. -The resident had activities of daily living self-care performance deficit related to impaired cognition. -The resident had a behavior problem that caused him/her to wander into other residents' rooms related to his/her confusion. -The staff to intervene as necessary to protect the rights and safety of others. -The staff to remove the resident from situations and take to alternate location as needed when wandering. Review of Resident #215's Quarterly MDS, dated [DATE], showed the resident: -admitted to the facility on [DATE]. -assessed as cognitively impaired. -had a diagnosis of dementia. -had a history of verbal behaviors. Review of Resident #240's progress note, dated 4/27/25 at 5:00 P.M., showed Licensed Practical Nurse (LPN) D documented overhearing some commotion on west hall while residents were heading to dinner and on rushing over to investigate found resident lying prone next to Resident #215's doorway, shouting. On turning over the resident he/she was noted with a hematoma to his/her right eyebrow. Another resident was noted next to him/her, shouting at him/her too. Resident #240's range of motion was within normal limits. Bruising to bilateral knees noted and a small skin tear right wrist which was cleansed and covered. Some more bruising noted to left elbow. The resident stated he/she fell. The resident assisted up and walked to the nurse's station where neurological assessments were initiated. Ice pack applied to hematoma for 20 minutes. House supervisor, physician, and durable power of attorney notified. Review of Resident #240's progress note dated 4/27/25 at 5:52 P.M., showed LPN E was acting as house supervisor when the charge nurse caring for Resident #215 called him/her down to the unit. When he/she arrived at unit, was told Resident #215 had an altercation with another resident at approximately 5:00 PM. The other resident (Resident #240) sat at the nurse's station with a bump along the right eyebrow and a skin tear to the right wrist. Nurse stated no one witnessed the altercation, but the nurse stated he/she heard screams and observed the other resident (Resident #240) laying on the ground in front of Resident #215's room. When the nurse approached the situation, Resident #215 was heard saying Do you want another one. After assessing the injured resident (Resident #240), LPN E went to see Resident #215 to get his/her description of the incident. Resident #215 was asked what happened between him/her and the other resident and he/she stated, he/she came in my room. He/She was not supposed to be in my room, I didn't want him/her in there, so I pushed him/her out. LPN E asked how he/she pushed the resident out, if he/she could describe the motion and he/she stated, I pushed him/her out by the shoulders like this. While holding up his/her arms to meet either side of my shoulders without actually touching me. When LPN E asked the other resident (Resident #240) how he/she sustained the bump to his/her face, he/she stated it happened when he/she fell down. LPN E called the DON to notify him/her of the situation and was instructed Resident #215 needed to be sent out to be evaluated and to place Resident #215 on a 1:1 until he/she was taken out of the facility. Resident #215 was placed on a 1:1 immediately and LPN E called Resident #215's family member to notify him/her of what was going on. After explaining the situation and answering all questions he/she had, the family member stated he/she would come pick Resident #215 up and take him/her to the hospital. The DON notified the family member would be transporting the resident to the hospital. Resident will continue on 1:1 until he/she leaves with his/her family. Review of the facility Incident Report, dated 4/27/25, showed: -There was a resident to resident incident between Resident #240 and Resident #215. -Around 5:00 P.M., LPN D overheard a commotion on the west hall and upon entering the hallway, LPN D saw Resident #240 lying in a face down position on the floor next to Resident #215's room. -Resident #215 was standing next to Resident #240 and stated, Do you want another one? -Resident #240 told LPN D that he/she fell. -Resident #215 stated, he/she came into my room. He/She was not supposed to be in my room. I didn't want him/her there, so I pushed him/her out. -Resident #215 stated, I pushed him/her out by his/her shoulders. -Resident #240 had a hematoma above his/her right eye, a skin tear to his/her right wrist, bruising to his/her bilateral knees, and bruising to his/her left elbow. -Resident #240 was cognitively impaired. -Resident #215 was cognitively impaired. -The facility did not substantiate the incident as abuse due to being unwitnessed. Review of Resident #240's skin assessment dated [DATE] showed: --Bruising on the resident's left elbow. --Bruising on the resident's right knee. --Bruising on the resident's left knee. --Hematoma to the resident's right eyebrow. --Bruising to the resident's right upper arm. --Skin tear to the resident's right wrist. During an interview on 5/21/25 at 3:15 P.M., LPN D said: -He/She was working as the charge on 4/27/25 when the resident to resident altercation occurred between Resident #240 and Resident #215. -He/She heard commotion down the hall and upon arrival to the incident, he/she observed Resident #240 face down on the floor with Resident #215 standing over Resident #240 yelling at him/her and stated, Do you want another one? -He/She then helped Resident #240 up off the floor and started his/her nursing assessments, which included: --Head to toe assessment, pain scale, and neurological checks. -Resident #240 stated he/she was in pain. -He/She called the physician and the house supervisor to notify them of the resident to resident altercation. -Resident #215 was placed on one on one observation. -Resident #240's face was visibly bruised and swollen and he/she took Resident #240 to the nurse's station and applied ice to the resident's face for 20 minutes. -Facial bruising and noted injuries on the resident's skin assessment were all received from the resident to resident altercation that occurred the day prior on 4/27/25. During an interview on 5/21/25 at 9:35 A.M., LPN E said: -He/She was working as the unit manager on 4/27/25 when the resident to resident altercation occurred between Resident #240 and Resident #215. -He/She was the one who assessed the Resident #240's skin after the resident to resident altercation. The resident had bruising on his/her left elbow, his/her knees, and his/her upper arm, a hematoma on the eyebrow and a skin tear. -The injuries noted on Resident #240's skin assessment dated [DATE] were a result from the resident to resident altercation on 4/27/25. -He/She interviewed Resident #240 after the incident occurred who stated he/she fell. -He/She interviewed Resident #215 after the incident occurred who stated Resident #240 was coming in his/her room, so he/her pushed Resident #240. -He/She placed a progress note in the risk management system stating Resident #215 pushed Resident #240, which caused Resident #240 to fall and receive injuries. During an interview on 5/13/25 at 2:30 P.M., the NP said: -There was a resident to resident altercation between Resident #240 and Resident #215 a couple weeks ago that caused significant bruising on Resident #240's face. -The bruising was the result of Resident #240 being shoved by Resident #215, which caused Resident #240 to fall to the ground. During an interview on 5/14/25 at 9:58 A.M., Resident #240's Durable Power of Attorney (DPOA) A said: -He/She was aware Resident #240 went into another resident's room a couple weeks ago and the other resident pushed Resident #240 down and he/she bumped his/her head and twisted his/her knee. -He/She came to visit the resident a couple weeks ago, after the resident to resident altercation and saw significant bruising on the resident's face. -He/She denied the resident as having the facial bruising prior to the resident to resident altercation. -He/She visited the resident on a regular basis at least once per week. -The facility had the resident's knee x-rayed and there were no fractures noted on the x-ray after the altercation a couple weeks ago. -The facility contacted him/her and stated Resident #240 fell on 5/11/25. -The facility had not contacted him/her regarding any other resident to resident altercations. -He/She felt the resident had become increasingly sad and smiled less since being moved to the locked unit and the altercations. -The family does not feel the resident was safe from other residents on the locked unit. 3. Review of Resident #307's admission record showed the resident admitted to the facility on [DATE] and some of his/her diagnoses included dementia with agitation, unsteadiness on feet, PTSD, and selective mutism (an anxiety disorder where a person, capable of speaking, becomes unable to speak in specific situations or with certain people, despite speaking normally in other settings. It's not a choice, but rather an anxiety-related inability to speak). Review of Resident #307's baseline care plan, dated 3/5/25, showed the resident had the potential for behaviors and a diagnosis of PTSD. Review of Resident #307's care plan, developed on 3/7/25, showed: -The resident had a diagnosis of PTSD, which affected his/her overall health and well-being. -The resident had been in prison for 27 years. -Behaviors related to this trauma included agitation towards others and selective mutism. -The desired outcome was the resident would be provided assistance to address the effects of trauma during the review period as demonstrated by no trauma-related behaviors and expressions of feelings of safety and support. -Interventions included: --Evaluate recommendations of psychiatric and behavioral health professionals and implement as appropriate. -Another problem identified was the resident had impaired cognitive function related to dementia. -The desired outcome was the resident would maintain his/her current level of cognitive function through the review date. Review of Resident #307's admission MDS, dated [DATE], showed the resident had moderately impaired cognitive skills for decision-making and no behaviors documented. Review of Resident #307's Level I (initial screening of individuals who have or may have a mental illness and/or an intellectual disability or related condition prior to their admission to a nursing facility. A positive Level 1 screen necessitates an in-depth evaluation of the individual, by the state-designated authority, known as Level II , which must be conducted prior to admission to the facility), submitted 4/16/25, showed: -The resident had diagnoses of PTSD and dementia. -The resident did not have any area of impairment due to serious mental illness. -The resident experienced one psychiatric treatment episode that was more intensive than routine follow-up care. -Due to mental illness, the resident experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials. -The resident was moderately withdrawn/depressed. -The resident's aggression was documented as at maximum level. -The resident's unstable mental condition was monitored by a physician or licensed mental health professional at least monthly and behavior symptoms are currently exhibited or psychiatric conditions are currently exhibited. -The resident displayed consistent unsafe/poor decision-making requiring reminders, cues, or supervision at all times to plan, organize and conduct daily routines and has issues with memory, mental function, or ability to be understood/understand others. Review of Resident #26's admission record showed the resident admitted to the facility on [DATE] and some of his/her diagnoses included major depressive disorder, dementia, and PTSD. Review of Resident #26's care plan, updated 3/16/25, showed: -The resident had impaired cognitive function and required assistance from staff with his/her daily care needs related to his/her diagnosis of dementia. -The resident reported his/her roommate hit him/her while he/she was in bed. Review of Resident #26's quarterly MDS, dated [DATE], showed the resident assessed as cognitively intact. Review of resident #26's incident note, dated 3/16/25 at 11:00 A.M., showed: -Resident #26 reported that while he/she was lying in bed, Resident #307 punched him/her in the left side of his/her chin with a closed fist. -Resident #26 reported he/she got up to leave the room and Resident #307 stood with two closed fists in front of him/her staring at him/her. -There were no apparent injuries. Review of the facility investigation, dated 3/16/25, showed on 3/16/25 Resident #26 reported Resident #307 approached him/her while lying in bed and made contact with his/her head. During an interview on 5/21/25 at 1:05 P.M., LPN K said: -On 3/16/25, Resident #26 reported Resident #307 hit him/her in the face. -Resident #26 was alert and could tell what was going on. -There were no apparent injuries. During an interview on 5/16/25 at 12:57 P.M., CNA F said Resident #26 told him/her that Resident #307 hit him/her. During an interview on 5/14/25 at 2:36 P.M., Resident #26 said he/she felt safe now. He/She was unable to describe what happened on 3/16/25. During an interview on 5/23/25 at 1:50 P.M., the DON said no one witnessed Resident #307 hit Resident #26. 4. Review of Resident #238's admission record showed the resident admitted to the facility on [DATE] and some of his/her diagnoses included dementia, major depressive disorder, anxiety disorder (psychiatric disorder that involve extreme fear, worry and nervousness), and PTSD. Review of Resident #238's undated care plan showed he/she had a diagnosis of dementia and he/she was mostly independent with self-care needs. Review of Resident #238's quarterly, MDS dated [DATE], showed the resident assessed as having moderately impaired cognitive skills. Review of Resident #238's nurse's note dated 3/22/25 showed Resident #238 sat on the bed when Resident #307 was standing over Resident #238 grabbing Resident #238's hand trying to get Resident #238 out of bed. Review of the facility investigation, dated 3/22/25, showed: -Resident #238 said he/she was asleep in bed when Resident #307 began shaking him/her. -Resident #238 said it woke him/her up and he/she saw Resident #307 shaking his/her fist above him/her. -Resident #238 said Resident #307 attempted to swing at him/her, but missed. -Resident #238 said

4. A policy for Pharmacy Services was requested and not received by the exit date. Review of Resident #14's admission record showed he/she was admitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 4/18/25, showed he/she was cognitively intact. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed: -The order for Metformin 750 mg administer once daily. -The pharmacy dispensed Metformin 1000 mg administer one tablet daily. Review of the resident's Medication Administration Record (MAR), dated May 2025, showed Metformin 750 mg had been signed off as given daily from 5/1/25 through 5/22/25. Observation on 5/22/25 at 9:16 A.M., of the resident's medication cards showed Metformin 1000 mg 1 tablet daily was dispensed on 5/9/25 with 21 pills remaining in the card. Observation of the medication administration on 5/22/25 at 9:16 A.M., showed CMT B administered Metformin 1000 mg to the resident. During an interview on 5/22/25 at 3:28 P.M. the facility pharmacist said: -Metformin did not come in a 750 mg tablet. -The pharmacy dispensed Metformin 1000 mg on 4/12/25 and again on 5/9/25. -The pharmacy had not clarified with the physician. -Metformin 500 mg, give one and one-half tablets should have been dispensed. During an interview on 5/23/25 at 8:36 A.M., CMT B said: -Medication rights were right patient, right medication, right dose, right time, and right route. -Medication administration included hand hygiene, identify resident, check the medications against the electronic Medication Administration Record (EMAR) and administer to the resident and sign the EMAR as administered. -He/She would inform the nurse if a medication did not match the EMAR. -He/She would inform the nurse of the dosage discrepancy. -He/She was aware of the incorrect dose administered. -He/She reported to LPN G on 5/22/25 after finishing passing medications the wrong dosage of medication was given. -He/She was instructed by LPN G to give the medication. During an interview on 5/23/25 at 11:00 A.M., the Nurse Practitioner (NP) said: -He/She expected the pharmacy to dispense medications as ordered. -He/She expected the pharmacy to dispense the correct dosage of medication. -If the ordered dosage was not able to be filled, he/she expected pharmacy to call the facility or the physician for further instructions/orders. During an interview on 5/23/25 at 11:45 A.M., LPN B said: -He/She expected the CMTs to follow the policy and five rights when passing medications, including verifying the dosage was the same on the MAR and the medication card. -He/She expected the CMTs to notify him/her of any medication discrepancies. -He/She had not been notified of any issues with the resident's medications. -If there was a discrepancy with a medication, the pharmacy should have been called and notified of the discrepancy. During an interview on 5/23/25 at 11:48 A.M., the Assistant Director of Nursing (ADON) said: -He/She expected staff to follow the orders listed on the resident's MAR. -He/She expected staff to call the pharmacy if there was a discrepancy with a medication. -He/she was not aware of the resident having the wrong dose of medication. During an interview on 5/23/25 at 12:33 P.M., the Attending Physician said: -He/She expected the pharmacy to dispense medications as ordered. -He/She expected a charge nurse, unit manager, or nursing management to notify the pharmacy if the wrong dosage of a medication was received. -He/She expected the pharmacy to call for dispensing concerns. During an interview on 5/23/25 at 1:38 P.M., the DON said: -He/She expected staff to check the medication card against the EMAR. -He/She expected staff to verify the medication delivered was the same as ordered. -He/She expected staff to complete a medication card to medication card for verification. -He/She was not aware Resident #14's Metformin was filled at the incorrect dose since 4/12/25. Based on observation, interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff as per policy; and failed to ensure one sampled resident (Resident #14) had medications available as ordered out of 35 sampled resident's. The facility census was 259 residents. Review of the facility's Controlled Medication Storage policy, dated 2007, showed: -Medications classified by the Drug Enforcement Administration (DEA) as controlled substances were subjected to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. -The Director of Nursing (DON), and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled substances. -At each shift change, or when keys were surrendered, a physical inventory of all controlled substances, including refrigerated items, was conducted by two licensed nurses or per state regulation and was documented on the controlled substances accountability record or verification of controlled substances count report. 1. Review of the facility's Total Narcotic Package Count Log sheet, dated for 4/8/25 through 4/16/25, for 4 North nurses medication cart showed: -Three out of 25 opportunities where the end package count was not documented. -Seven out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. Review of the facility's Total Narcotic Package Count Log sheet, dated for 4/17/25 through 4/24/25, for the 4 North nurses medication cart showed: -One out of 25 opportunities where the narcotic count time was not documented. -Two out of 25 opportunities where the end package count was not documented. -One out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. -Two out of 25 opportunities where neither the on-coming or off-going nurse did not sign the count sheet. Review of the facility's Total Narcotic Package Count Log sheet, dated for 4/25/25 through 5/1/25, for the 4 North nurses medication cart showed: -Five out of 25 opportunities where the starting package count was not documented. -Eight out of 25 opportunities where the end package count was not documented. -Four out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. -Five out of 25 opportunities where neither the on-coming or off-going nurse did not sign the count sheet. Review of the facility's Total Narcotic Package Count Log sheet, dated for 5/1/25 through 5/11/25, for the 4 North nurses medication cart showed: -One out of 25 opportunities where the date of the narcotic count was not documented. -Two out of 25 opportunities where the narcotic count time was not documented. -Three out of 25 opportunities where the starting package count was not documented. -Two out of 25 opportunities where the end package count was not documented. -Four out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. Review of the facility's Total Narcotic Package Count Log sheet, dated for 5/12/25 through 5/20/25, for the 4 North nurses medication cart showed: -One out of 25 opportunities where the end package count was not documented. -Four out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. 2. Review of the facility's Total Narcotic Package Count Log sheet, dated for 4/26/25 through 5/5/25, for the 4 North Certified Medication Technician (CMT) medication cart showed: -One out of 25 opportunities where the date of the narcotic count was not documented. -Three out of 25 opportunities where the narcotic count time was not documented. -One out of 25 opportunities where the starting package count was not documented. -One out of 25 opportunities where the end package count was not documented. -Six out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. -One out of 25 opportunities where neither the on-coming or off-going nurse did not sign the count sheet. Review of the facility's Total Narcotic Package Count Log sheet, dated for 5/6/25 through 5/16/25, for the 4 North CMT medication cart showed: -Three out of 25 opportunities where the end package count was not documented. -Three out of 25 opportunities where either the on-coming or off-going nurse did not sign the count sheet. -One out of 25 opportunities where neither the on-coming or off-going nurse did not sign the count sheet Review of the facility's Total Narcotic Package Count Log sheet, dated for 5/16/25 through 5/20/25, for the 4 North CMT medication cart showed: -One out of 12 opportunities where the date of the narcotic count was not documented. -One out of 12 opportunities where the narcotic count time was not documented. -Two out of 12 opportunities where the starting package count was not documented. -Three out of 12 opportunities where the end package count was not documented. -Five out of 12 opportunities where either the on-coming or off-going nurse did not sign the count sheet. -One out of 12 opportunities where neither the on-coming or off-going nurse did not sign the count sheet 3. During an interview on 5/21/25 at 10:28 A.M., Certified Medication Technician (CMT) D said: -The narcotics were counted at the beginning and end of each shift with the oncoming nurse and off going nurse or Certified Medication Technician (CMT). -Both nurses and/or CMT signed the count sheet when the count had been completed to verify the count was correct. -The number of narcotic packages at the start and end of the count was to be recorded on the sheet. -The date would be listed for each narcotic count. -The time of the count was to be documented. -If the narcotic count was not signed by both the CMT and nurse then the count was not done. During an interview on 5/21/25 at 10:30 A.M., Licensed Practical Nurse (LPN) A said: -The narcotics were counted at the beginning and end of each shift with the oncoming nurse and off going nurse or CMT. -Both nurses and/or CMT signed the count sheet when the count had been completed to verify the count was correct. -The number of narcotic packages at the start and end of the count was to be recorded on the sheet. -The date would be listed for each narcotic count. -The time of the count was to be documented. -If the narcotic count was not signed by both the CMT and nurse then the count was not done. During an interview on 5/21/25 at 12:42 P.M., the DON said: -The oncoming and off going shifts would have counted the narcotics and signed the narcotics sheets each shift. -The number of packages or narcotics was to be recorded in the narcotics book. -The narcotic count should be dated. -The time of the count would have been documented. -The beginning and ending count of the cards would have been documented. -The unit mangers were to have audited the narcotic count books to ensure counts were done correctly and signed by both the oncoming and off going shifts with all columns filled out. During an interview on 5/21/25 at 12:42 P.M., Unit Manager A said: -The oncoming and off going shifts would have counted the narcotics and signed the narcotics sheets each shift. -The number of packages or narcotics was to be recorded in the narcotics book. -The narcotic count should be dated. -The time of the count would have been documented. -The beginning and ending count of the cards would have been documented. -All columns of the count sheet should have been filled out. -He/She was unsure who audited the count sheets to ensure the count sheets were filled out correctly and signed by the oncoming and off going nurse or CMT.

4. Review of the facility's policy, Standard and Enhanced Precautions, dated July 1, 2023 showed: -Standard precautions were to be used in the care of residents regardless of their diagnoses or suspected or confirmed infection status. -Standard precautions presume that blood, body fluids, secretions, and excretion, non-intact skin and mucous membranes may contain transmissible infectious agents. -Hand hygiene refers to hand washing with soap or using alcohol-based hand rub that did not require access to water. -Gloves (clean, non-sterile) were to be worn when direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material was anticipated. -A gown was to be worn to protect skin and prevent soiling of clothing during procedures and resident care activities that were likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling clothing. -Resident characteristics associated with a high-risk of Multi Drug Resistant Organisms (MDRO- micro organisms that were resistant to at least one class of antimicrobial agents, including antibiotics)s colonization and transmission include: -Presence of indwelling devices vascular catheter (a flexible tube inserted into a blood vessel for long-term access). -Wounds. -The Infection Preventionist (healthcare professionals who work to prevent the spread of infections) would follow the (infection control) guidance. Review of the facility's policy, Resident Isolation-Categories of Transmission-Based Precautions (a set of infection control measures used in healthcare), dated October 24, 2022, showed: -The purpose was to ensure that transmission-based precautions were used when caring for residents with communicable diseases or transmittable infections. -Transmission-based precautions were to be used accordingly when caring for resident who were documented or were suspected of having communicable disease or infections that could have been transmitted to others. -Contact Precautions; -Were to be implemented for residents known or suspected to have been infected or colonized with microorganisms that would have been transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident ' s environment. Examples included: -Skin or wound infections. -Conjunctivitis (Pink eye - inflammation or infection of the outer membrane of the eyeball and the inner eyelid). -Gloves should be worn when entering the room. -While caring for a resident, gloves were to be changed after contact with infective material. -Gloves were to be removed before leaving the room and hand hygiene was to be performed immediately. -A clean non-sterile gown was to be worn for interactions that may have involved contact with the resident or potentially contaminated items in the resident's environment. -The gown was to be removed and hand hygiene was to have been preformed before leaving the resident's environment. -The facility was to alert staff to the type of precaution a resident required. The Policy for Enhanced Barrier Precautions (EBP) was requested and not received. 5. Review of Resident #236's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dependence on Renal Dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys were unable to do so). -End Stage Renal Disease (ESRD- when the kidneys no longer function). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 2/28/25, showed: -He/She was cognitively intact. -He/She had ESRD. -He/She was on dialysis (a process to mechanically filter the blood from waste products and extra fluids). -He/She was on isolation for active infectious disease. -Central line (a thin flexible tube inserted into a large vein near the heart) was not checked. Review of the resident's Physician's Order Sheet (POS) dated May 2025 showed: -Monitor Dialysis site right upper chest; Central line dressing for drainage, bleeding or sign and symptoms of infection every shift, dated 12/26/24. -He/She was to receive dialysis on Monday, Wednesday, and Friday, dated 2/3/25. -The resident was on Enhanced Barrier Precautions (EBP - an infection control strategy that uses targeted gown and glove use during high-contact resident care activities to reduce the spread of multidrug resistant organisms), dated 4/7/25. -Wound care specialist was to evaluate and treat if indicated, dated 1/28/25. -Staff were to cleanse with hypochlorous acid (a product used in wound care to promote healing), pat dry, apply xeroform (a sterile wound dressing) and cover with bordered gauze (a dressing that helps secure the dressing in place, protects the surround skin, and can prevent fluid from leaking into the skin), left elbow, dated 5/15/25. -Staff were to cleanse with hypochlorous acid, pat dry, and apply xeroform and cover with bordered gauze every day shift, right medial wrist, dated 5/16/25. -There were no orders for EBP. Review of the resident's Care Plan, dated 5/7/25, showed: -He/She had a skin tear to his/her left elbow, dated 5/13/25. -He/She had a skin tear to the right medial wrist, dated 5/16/25 -He/She was on renal dialysis and had a central line to his/her right upper chest. -Interventions included provide treatments, change dressings as ordered. -There were no interventions specific to what Personal Protective Equipment (PPE - protective clothing worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was required while performing treatments. -The care plan did not show the resident was on EBP. Observation on 5/22/25 at 10:30 A.M., of the Wound Care Nurse/Registered Nurse (RN) B showed: -There was an EBP sign on the door, which showed the resident was on EBP and staff were to wear gown and gloves when providing care to the resident. -There was an isolation cart outside the door with PPE in it. -He/She was in the resident's room, changing the bandage on a skin tear on his/her left arm. -He/She was not wearing the appropriate PPE of a gown or gloves while doing the dressing change. During an interview on 5/22/25 at 10:30 A.M., the Wound Care Nurse/RN B said: -The facility had provided education about EBP and what PPE he/she should have worn when doing dressing changes on the resident since the resident had a central line for dialysis. -There was a sign on the door which indicated PPE should have been worn when working with the resident. -There was an isolation cart with PPE at the resident's door. -He/She should have wore a gown and gloves when doing the wound care. During an interview on 5/22/25 at 11:00 A.M., the Nurse Practioner (NP) said: -If a resident had an open area or central line there should have been an EBP sign on the door with an isolation cart at the door. -When staff performed any cares or wound care with the resident, the staff should have worn a gown and gloves. During an interview on 5/22/25 at 11:15 A.M., the IP said: -All staff have had education on EBP and when to wear PPE. -The resident had a skin tear requiring a dressing and a central line for dialysis. -There was a sign on the resident's door which showed the resident was on EBP. -There was a sign on the resident's door showing which PPE to wear when doing cares for the resident. -There was an isolation cart outside of the resident's door with PPE in it for staff use. -The staff should have worn PPE when doing cares for the resident. During an interview on 5/23/25 at 1:30 P.M., the DON said: -If a resident had a central line then the resident should have been on EBP. -There should have been a sign on the resident's door which showed he/she was on EBP. -The sign should have showed which PPE the staff should have worn when working with the resident. -There should have been an isolation cart outside of the resident's room with PPE in it for staff use. -The staff have had on-going education about EBP. -The IP was responsible for ensuring the staff had received education about EBP and did audits to ensure staff was wearing PPE when appropriate. 6. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Need for assistance with personal care. -He/She was on Hospice care. Review of the resident's Significant Change MDS, dated [DATE], showed: -He/She had impairment on one side. -He/She used a wheelchair. -He/She was always incontinent of bowel and bladder. -He/She was on oxygen therapy. -He/She was on Hospice care. Review of the resident's undated care plan showed: -He/She had self care performance deficit related to weakness and impaired mobility. -He/She needed assistance of one staff for personal hygiene. -He/She needed the assistance of two staff members for transfers. Review of the resident's weekly skin observation, dated 5/10/25 showed: -There was a skin issue. --There was no description of what the skin issue was. Review of the Consultation/Progress Note, dated 5/12/25, by the NP showed: -The resident was complaining of some exudate (fluid that leaks out of blood vessels into nearby tissues) and mattering (drainage) to his/her eye. -The resident's right eye had some erythema (reddening) noted with ectropion (a condition where the eyelid, typically the lower eyelid, turns outward away from the eyeball) as well. -The resident had some exudate and mattering. -Impression: right eye conjunctivitis (pink eye, is an inflammation of the conjunctiva, the thin membrane that lines the inside of the eyelid and covers the white part of the eye). -Resident was put on Tobramycin two drops both eyes four times a day for seven days. Review of the resident's Certified Medication Technician (CMT) Medication Administration Record (MAR) dated May 2025 showed: -Tobramycin Ophthalmic Solution (an antibiotic used to treat bacterial infections) 0.3 %. Instill two drops in both eyes four times a day for conjunctivitis (Pink eye - inflammation of the eye or eyelid easily spread) for seven days, dated 5/12/25. -The medication had been given for seven days. Observation on 5/12/25 at 3:00 P.M., showed: -The resident was in bed. -His/Her right eye was very red. -A Hospice staff member provided incontinent care and changed the resident's brief. -The Hospice staff member did not have a gown or gloves on. -There was no contact isolation sign on the resident's door. -There was no isolation cart with PPE at the resident's door. Observation on 5/13/25 at 1:00 P.M., showed: -The resident's right eye was very red. -There was no contact isolation sign on the resident's door. -There was no isolation cart with PPE at the resident's door. Observation on 5/16/25 at 9:26 A.M., showed: -The resident's right eye was very red. -There was no contact isolation sign on the resident's door. -There was no isolation cart with PPE at the resident's door. During an interview on 5/16/25 at 11:58 A.M., Licensed Practical Nurse (LPN) H said: -He/She was not aware the resident had conjunctivitis. -He/She had been in the resident's room providing cares without wearing PPE this last week. -The resident should have been on contact isolation. -There should have been a sign on the door which said the resident was on contact isolation and an isolation cart should have been outside the room with PPE in it. -Anyone who went into the resident's room should have worn a gown and gloves. -The fact that the resident had conjunctivitis and should have been on contact isolation should have been passed on during the change of shift report. During an interview on 5/16/25 at 12:09 P.M., CMT E said: -Staff reported to the next shift at change of shift, but it was not reported to him/her that the resident had conjunctivitis. -He/She had passed medications including eye drops to the resident. -He/She wore gloves when administering eye drops, but had not wore a gown. -The resident's order on the medication administration sheet showed the resident was to have eye drops in both eyes four times a day for conjunctivitis. -He/She did not know what Tobramycin Ophthalmic Solution was used for. -He/She did not know what conjunctivitis was. -He/She should have known what the medication was used for if he/she administered it to the resident but he/she had not known. -There was no sign on the resident's door indicating he/she was on contact isolation nor was there an isolation cart outside the door with PPE. During an interview on 5/16/25 at 12:20 P.M., the DON said: -He/She was not aware the resident had conjunctivitis. -The resident should have had a sign on his/her door stating he/she was on contact isolation and an isolation cart with PPE outside the resident's door. During an interview on 5/19/25 at 12:30 P.M., Certified Nursing Assistant (CNA) E said: -He/She had done cares with the resident last week. -Nothing had been passed on during report about conjunctivitis or contact isolation. -When he/she had changed the resident he/she wore gloves, but would not have worn a gown. -He/She had not worn PPE last week when working with the resident if he/she was adjusting their position in bed or assisting the resident with moving them in and out of bed. -There was nothing on the resident's door indicating he/she was on contact isolation or PPE at the doorway. During an interview on 5/19/25 at 1:50 P.M., Housekeeper A said: -He/She had cleaned the resident's room every day last week. -The resident was in his/her room while the room was cleaned. -He/She wore gloves when cleaning the resident's room, but did not change gloves after cleaning each room. -It was not reported to him/her that the resident was on isolation. -If a resident was on isolation there should have been a sign on their door showing which PPE staff was to have worn. There had not been a sign or PPE at the resident's door. -The facility had provided education about infection control a month or so ago. -If there was a sign on the door there were pictures that showed you which PPE to wear if you went into that room. -There had not been any education about conjunctivitis provided by the facility for this resident. During an interview on 5/21/25 at 10:00 A.M., the IP said: -He/She was responsible for reviewing new antibiotics that the residents had started on and he/she had missed the resident starting on Tobramycin. -The resident should have been put on contact isolation immediately on 5/12/25, with a sign on the door which indicated which PPE staff was to wear when entering the room, and an isolation cart outside the room with PPE. -Staff should have worn gloves and a gown when they worked with the resident. -If the staff touched any surface in the resident's room that the resident had touched after wiping his/her eyes they could have spread Conjunctivitis to other residents or staff. -The housekeeping should have changed gloves after cleaning each room. -He/She had provided education to the staff about infection control. -If a resident was on isolation it should have been passed on to the next shift during the report at shift change. -The nurse who took the order for Tobramycin also should have caught this and started contact isolation for the resident. During an interview on 5/23/25 at 1:30 P.M., the DON said: -The IP was responsible to ensure staff had education about EBP and Contact Isolation. -If a resident had conjunctivitis he/she should have been put on contact isolation immediately. -The staff should have worn a gown and gloves when they did anything in the resident's room or touched the resident. -Housekeeping should change their gloves after cleaning each room and wash their hands. -There should have been a sign on the resident's door stating he/she was on contact isolation and an isolation cart outside the door with PPE. -New information like a resident on isolation should have been on the Kardex so staff knew what was going on with the resident. -The nurse was responsible for providing new information to the staff. Based on observation, interview and record review, the facility failed to ensure Tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) two step skin tests were completed timely upon admission and within appropriate intervals per policy between steps for one supplemental resident (Resident #7) and contained the date the test was read per policy for one sampled resident (Resident #114) and one supplemental resident (Resident #7); failed to ensure infection control practices when staff did not use the appropriate Enhanced Barrier Precautions (EBP) during care for two sampled residents (Resident #236 and #9) out of 35 sampled residents and 31 supplemental residents. The facility census was 259 residents. Review of the facility's Tuberculosis-Screening policy, dated 10/24/22, showed: -The purpose of the policy was to ensure all residents were screened for Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) upon admission, readmission, and as indicated. -The facility screened referrals for admission and readmission for information regarding exposure to, or symptoms of, TB and checked results of recent tuberculin skin tests (TST-an injection just under the skin to determine exposure to TB) or chest x-rays. -Any resident without a documented negative TB test within the previous 12 months received a baseline two-step TST or chest x-ray upon admission. -When the first TST was negative, a follow-up TST was administered one to three weeks after the initial test was read. -The attending physician screened new admission for possible signs and symptoms of TB, including couth for more than three weeks, loss of appetite, fatigue, weight loss, night sweats, bloody sputum (a mixture of saliva and mucus coughed up from the lungs), hoarseness, fever and/or chest pain. -The facility conducted annual risk assessments for residents identified to be at risk. 1. Review of Supplemental Resident #7's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's Immunization Records showed: -The first step TB skin test was administered on 4/28/25, 25 days after his/her admission to the facility. The TB skin test was 0 millimeters (mm) induration with no date the test was read. -The second TB skin test was administered on 5/5/25, seven days after the first step was administered. The TB skin test was 0 mm induration with no date the test was read. During an interview on 5/22/25 at 2:45 P.M., the Infection Preventionist said Resident #7 refused to allow staff to administer the TB skin test upon admission to the facility. 2. Review of Resident #114's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's Immunization Records showed: -The first step TB skin test was administered on 9/16/24. The TB skin test was 0 mm induration with no date the test was read. -The second TB skin test was administered on 9/30/24. The TB skin test was 0 mm induration with no date the test was read. 3. During an interview on 5/22/25 at 2:45 P.M., the Infection Preventionist (IP) said: -He/She was responsible for TB testing of residents. -TB skin test should be administered upon admission to the facility. -TB skin tests should be read within 48 to 72 hours after administered and documented in the resident's electronic medical record. -The second step TB skin tests should be administered 7-21 days after the first dose. -He/She thought TB skin test wait times was between administration dates not read dates. During an interview on 5/23/25 at 2:50 P.M., the Director of Nursing (DON) said: -Nursing can do the resident TB skin tests within the first 24 hours after admission. -TB skin tests should include the date the test was read. -The second TB skin test should be administered 7-21 days after the first test is read.

2. Review of Resident #216's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Suicide attempt (an act in which a person tries to kill themselves but survives). -Alcohol abuse (a pattern of drinking that interferes with day to day activities). -Depression. -Adjustment disorder (a mental and behavioral condition that exhibits an extreme reaction to stress). Review of the resident's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact. -He/She took scheduled and as needed pain medications. Review of the resident's POS, dated May 2025, showed: -The resident did not have an order to self administer medications. -Norco Oral Tablet (a strong pain medication with the risk for addiction with Tylenol- an over the counter pain medication) 5/325 milligrams (mg), give one tablet by mouth every four hours as needed for pain. Not to exceed three grams (of Tylenol) per 24 hours. -Tylenol Oral Tablet 325 mg give two tablets by mouth every six hours as needed for pain, dated 4/23/25. Observation on 5/12/25 at 2:00 P.M., showed: -The resident was in bed asleep. -He/She had a cup with six round white pills at bedside. During an interview on 5/12/25 at 3:00 P.M., the Unit Manager said: -He/She had taken the medication (Tylenol) away from the resident as he/she did not have a physician's order to keep medications at bedside. -The resident did not say where he/she got the Tylenol if it was brought in, he/she had purchased it outside of the facility, or he/she had hoarded the medication. -Staff should have seen the cup of medication at his/her bedside and confiscated it. Review of the resident's care plan, dated 5/16/25, showed he/she had a behavior problem related to hoarding medication. Medications were removed from room, dated 5/16/25. During an interview on 5/20/25 at 1:00 P.M. the resident said: -He/She had some Tylenol and was able to take them every four hours. -He/She would not say if he/she had any more in his/her room. -He/She would not say how he/she had obtained the Tylenol. -He/She had pain from teeth issues. -The medication had been in his/her room more than an hour. -The resident would not say if the medication had been there a few days. -The CNAs that came in and out of his/her room did not ask him/her about the medication at bedside. 3. During an interview on 5/16/25 at 11:42 A.M., LPN H said: -None of the residents had an order to keep medications at bedside so they could self administer medications. -The resident would have had a physician's order for self administration and Resident #216 did not have a physician's order. -The Unit manager had found the Tylenol at bedside and took them away from the resident on 5/12/25. During an interview on 5/21/25 at 10:11 A.M., LPN F said: -It was not ok to leave any type of wound care treatments like creams, gels, or powders at a resident's bedside for the resident to apply at any time. -It may be ok if the resident was alert and orientated and had a physician's order to leave at bedside for resident to use. During an interview on 5/23/25 at 9:43 A.M., the Nurse Practioner (NP) said: -It's never appropriate for a nurse to leave any medications, creams, ointments, gels, or powder on a resident's bedside table unless there was Physician's order for the resident to self-administer. -The resident should be educated and observed to the correctness of self-administering. -Resident #167 and Resident #216 did not have orders for self-administration of mediations. During an interview on 5/23/25 at 9:55 A.M., LPN B said: -It was not appropriate to leave any type of medications, or treatment creams, ointments, gels, powders at the resident's bedside. -Would need a Physician's order and the resident must be assessed to be able to do by self. -Resident #167 and Resident #216 did not have orders for self-administration of mediations. During an interview on 5/23/25 at 10:51 A.M., LPN C said it was never appropriate to leave medications of any type at bedside unless there was a doctor's order, and the resident was assessed to do properly. During an interview on 5/23/25 at 1:38 P.M., the Director of Nursing (DON) said: -It was not ok to leave any type of medication at bedside for a resident to self-administer. -Residents should have a physician's order to leave medications at bedside and self administer medications. -The residents should be educated and assessed for self-administration if a resident would have an order to leave at bedside. -Resident #167 and Resident #216 did not have orders to leave medications at bedside or to self administer medications. Based on observation, interview, and record review, the facility failed to have an order for medications to be left at bedside or an assessment of the resident's ability to self-administer medications for two sampled residents (Resident #167 and #216) out of 35 sampled residents. The facility census was 259 residents. Requested a policy for medications left at bedside and resident self-administration and no policy was provided at the time of exit. 1. Review of Resident #167's Quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility staff for care planning), dated 4/14/25, showed: -He/she was admitted on [DATE]. -Was cognitively intact. -Diagnoses included: -Hypertension (HTN-abnormally high blood pressure). -Neurogenic bladder (the nerves that carry messages back-and-forth between the bladder and the spinal cord and brain don't work the way they should and may cause the bladder muscles to lose ability to hold urine). -Wound infection (the presence of multiplying microorganisms [like bacteria] in a wound, leading to tissue damage and delayed healing process. - Diabetes Mellitus [DM-condition that affects the way the body processes blood sugar (glucose)]. -Hyperlipidemia (high concentration of fats or lipids in the blood). Review of the resident's Physicians Order Summary (POS), dated May 2025, showed: -Clindagel External Gel 1 % (Clindamycin Phosphate (Topical) antibiotic used to treat infections). -Cleanse with hypochlorous acid (Antimicrobial, anti-inflammatory used to clean, disinfect and promote healing in various wounds including acute and chronic wounds). -Apply Clindamycin gel and Zinc ointment one time a day and every evening and night shift. -There was no order for self-administration of ointment or gel medications to wounds or lesions. Review of the resident's medical records showed no self-administration assessment. Review of the resident's Care Plan, dated 4/2/25, showed no care plan that addressed self-administration of medications. During an interview on 5/16/25 at 9:52 A.M., the resident said the wound care nurse left the cups of cream, gel, and powder at bedside for him/her to apply after toileting and using wet wipes. During an interview on 5/19/25 at 1:50 P.M., Licensed Practical Nurse (LPN) E said: -No type of cream, ointment, or powder should be left at bedside for a resident to self-apply. -Would need a physician's order to leave any type of medication at a resident's bedside. -Resident #167 did not have an order

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for two sampled residents (Resident #176 and #194), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 35 sampled residents. The facility census was 259 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: -Trauma-informed care shifts the focus from What's wrong with you? to What happened to you? -A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - in order to provide effective health care services with a healing orientation. -Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors. -Trauma-informed care seeks to: --Realize the widespread impact of trauma and understand paths for recovery. --Recognize the signs and symptoms of trauma in patients, families, and staff. --Integrate knowledge about trauma into policies, procedures, and practices; --Actively avoid re-traumatization. Review of facility policy entitled Social Service Assessment, revised October 24, 2022, showed: -The Director of Social Services or his/her designee would complete a Social Services Assessment for new residents within seven days of admission. -The Social Services Assessment would address the resident's physical and psychosocial (relating to the interrelation of social factors and individual thought and behavior) limitation that needed to be addressed in the resident's activity plan. -Information needed to complete the Social Services Assessment might have been obtained through a variety of sources, such as: --Interviews of the resident's family and significant others. --Observations of the resident. --For new admissions, the medical record would be reviewed and would include a review of the transfer record and history and physical. -The facility would use a multi-prong approach to identify a resident's history of trauma. -This would include asking a resident about triggers that might be stressors or might prompt recall of a previous traumatic event. -The facility would identify triggers which might re-traumatize residents with a history of trauma. -A trigger was a psychological stimulus that prompted recall of a previous traumatic event, if the stimulus was not traumatic or frightening. -The facility would collaborate with the resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals to develop and implement individualized interventions. 1. Review of Resident #176's admission Record showed he/she admitted to the facility on [DATE] with a diagnosis of PTSD. Review of the resident's Level One Pre-Admissions Screening and Resident Review (PASARR federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment), dated 8/23/23, showed the resident had a diagnosis of PTSD. Review of the resident's Trauma Informed Care assessment, dated 12/24/24, showed: -The resident had trauma in the past. -No triggers were listed. -No interventions were listed. Review of the resident's Trauma Informed Care assessment, dated 3/9/25, showed: -The resident had trauma in the past. -No triggers were listed. -No interventions were listed. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 4/9/25, showed: -The resident was cognitively intact. -The resident had a diagnosis of PTSD. Review of the resident's Trauma Informed Care assessment, dated 4/9/25, showed: -The resident had trauma in the past. -No triggers were listed. -No interventions were listed. Review of the resident's care plan, revised 4/21/25, showed: -He/She had experienced a past traumatic event. -The event was very stressful and still affected the resident. -He/She was assaulted/attacked with a bat that caused skull fractures years ago. -He/She had a diagnosis of PTSD. -PTSD was not addressed in the care plan. -The resident's triggers were not addressed. -The resident's interventions were not addressed. During an interview on 5/22/24 at 9:51 A.M., the resident said: -He/She was unsure if he/she had a diagnosis of PTSD. -He/She was anxious around loud sounds, people coming up behind him/her, and sudden movements. 2. Review of Resident #194's hospital records, dated 2/1/24, showed: -The resident was a veteran of the Vietnam War. -The resident had a diagnosis of PTSD. Review of the resident's Quarterly MDS, dated [DATE], showed: -The resident was mildly cognitively impaired. -Had PTSD. Review of the resident's admission Record showed the resident admitted to the facility on [DATE] with a diagnosis of PTSD. Review of the resident's Level 1 PASARR, dated 2/27/24, showed the resident had a diagnosis of PTSD. Review of the resident's Trauma Informed Care assessment, dated 1/30/25, showed: -The resident denied trauma in the past. -No triggers were listed. -No interventions were listed. Review of the resident's Trauma Informed Care assessment, dated 2/7/25, showed: -The resident denied trauma in the past. -No triggers were listed. -No interventions were listed. Review of the resident's care plan, revised 2/7/25, showed: -He/She had a diagnosis of PTSD. -The resident's triggers were not addressed. -The resident's interventions were not addressed. Review of the resident's Quarterly MDS, dated [DATE], showed: -The resident was mildly cognitively impaired. -Had PTSD. Review of the resident's Trauma Informed Care assessment, dated 5/7/25, showed: -The resident denied trauma in the past. -No triggers were listed. -No interventions were listed. During an interview on 5/22/24 at 10:05 A.M., the resident said: -He/She was unsure if he/she had a diagnosis of PTSD. -Loud sounds would set him/her off. 3. During an interview on 5/21/254 10:12 A.M., Certified Nurse's Aide (CNA) B said: -He/She was unfamiliar with either of the residents. -He/She was unsure if the residents had PTSD. -He/She did not know what either of the resident's triggers were, or what his/her interventions were. -The residents had not had any behaviors. -He/She would look on the care plan for the triggers and interventions. -He/She would have expected triggers and interventions to be on the care plan. -If the interventions and triggers were not in the care plan would have informed the nurse. -He/She did not know either of the resident's triggers or interventions. During an interview on 5/21/25 at 10:13 A.M., Licensed Practical Nurse (LPN) A said: -He/She was familiar with both residents. -The residents had not had any behaviors. -He/She was unfamiliar with either of the residents' triggers or interventions. -He/She knew the residents had a diagnosis of PTSD. -Triggers and interventions would be listed on the care plan. -The MDS Coordinator was responsible for care plans. -He/She had not noticed there were no triggers or interventions on the care plans. -He/She did not know either of the resident's triggers or interventions. During an interview on 5/21/25 at 12:39 P.M., the Director of Nursing (DON) said: -The MDS Coordinator was responsible for the PTSD care plan. -He/She did not know if either of the residents had a diagnosis of PTSD. -When a resident had a diagnosis of PTSD there would be triggers and interventions listed on the care plan. -He/She did not know either of the resident's triggers or interventions. -The information of the resident's triggers and interventions should be in the care plan. -Care plans were audited by the MDS Coordinator, Social Services Director, Unit Mangers, and the Inter-Disciplinary Team (IDT). During an interview on 5/21/25 at 2:47 P.M., Unit Manger A said: -When a resident had a diagnosis of PTSD the care plan should reflect he diagnosis. -The MDS Coordinator did the care plans. -The care plan should address the triggers and interventions. -The MDS Coordinator was responsible for care plan development. -The care plan should accurately reflect the resident's condition at the time it was developed along with diagnosis. -The IDT looked at behaviors in the risk management meetings. During an interview on 5/21/25 at 2:58 P.M., the MDS Coordinator said: -When a resident had a diagnosis of PTSD the triggers would have been listed. -The event that caused the PTSD would be addressed. -The interventions would be listed to mitigate the triggers. -He/She did the nursing portion of the care plan. -The Social Services Director did the PTSD part of the care plan. -He/She audited the care plans. -He/She was uncertain if either resident had a medical diagnosis of PTSD. During an interview on 5/21/25 at 3:06 P.M., Social Worker A said: -The triggers and interventions should be listed on the care plan for residents with PTSD. -The care plan needed to paint a complete picture of the resident and the resident's needs, and the PTSD diagnosis. -The MDS Coordinator did the care plan. -He/She was unsure who audited the care plans.

Based on interview and record review, the facility failed to provide appropriate treatment and behavioral health services per policy for one sampled resident (Resident #307) who had a known history of physical aggression and wandering. The resident admitted on [DATE], with a history of post-traumatic stress disorder (PTSD-can develop after experiencing or witnessing a traumatic event in which symptoms can include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event) to a locked memory care unit. The facility staff failed to consistently implement a plan of care related to behavioral health services to reduce resident behavior and maintain resident safety. The facility staff failed to update the plan of care after incidents of aggression with new interventions. The facility did not have a system in place to ensure the interdisciplinary team (IDT) was involved in assessing the resident's behavioral needs and implementing new interventions after each altercation. As a result of the facility failure to provide behavioral treatment and services for the resident has been sent the emergency room and hospitalized on multiple occasions and continued to have physical behaviors towards other residents. Thirty five residents were selected for sample. The facility census was 259 residents. Review of the facility's Behavior-Management policy, undated, showed: -The purpose of the policy was to: --Implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that were distressing to the resident and/or were decreasing or negatively impacting the resident's quality of life. --The facility was responsible for providing behavior health care and services that created an environment that promoted emotional and psychosocial well-being that met each resident's needs and included individualized approaches to care. -The key components of behavior management were: --Identification of residents whose behaviors may pose a risk to others. --Develop individual and practical care strategies base on assessed needs. --Implement the behavior management program. --Provide ongoing assessment, monitoring, and evaluation of effectiveness of behavior management program including the effectiveness of psychoactive drugs. -The goal of the IDT (a group of health care professionals with various areas of expertise who work together toward the goals of their clients) was to promptly identify behavior management issues and develop an effective management program. -When a resident displayed behavior symptoms (crying, yelling, hitting, etc.), Licensed Nursing Staff assessed the behavioral symptoms to determine possible causal factors, contacted the attending physician, and implemented non-drug interventions to alleviate the behavioral symptoms. -The facility must provide necessary behavioral health care and services which include: --Ensure that necessary care and services were person centered and reflect the resident's goals for care and maximize the residents' dignity, autonomy, privacy, socialization, independence, choice, and safety. --Ensure that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being. -Licensed nursing staff document the behaviors in the resident's medical record. -Staff document notification of the attending physician, notification of the resident's family and/or responsible party, and the incident within 24 hours of the incident. -The charge nurse assigns a staff member to monitor the resident as needed to protect the resident as well as others. -Nursing staff continues to monitor the residents' behavior to determine what events precipitated the behavior and document the following information: --Date and time of behavior. --Location of resident when the behavior occurred. --Description of the behavior. --What may have caused the behavior. --Any interventions used and the effect it had on the resident. -In assessing the resident for potential behavioral factors, licensed nursing staff consider factors and document in the medical record: --Physical condition of the resident (pain, discomfort, hunger or thirst, fatigue, toileting needs). --Environmental conditions (room temperatures, noise, overcrowding). --Psychosocial or emotional stressors (change in the resident's customary routine, frustration, fear of the unknown, possible abuse by other residents, incompatibility with roommate, inability to communicate needs). -Managing behavior problems includes building a positive and trusting relationship with the resident. --Use effective verbal and nonverbal communication techniques. --Redirect or divert the resident's attention to positive topic, activity, or object. 1. Review of Resident #307's admission record showed the resident admitted to the facility on [DATE] and some of his/her diagnoses included dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) with agitation, unsteadiness on feet, PTSD, and selective mutism (an anxiety disorder where a person, capable of speaking, becomes unable to speak in specific situations or with certain people, despite speaking normally in other settings. It's not a choice, but rather an anxiety-related inability to speak). Review of Resident #307's Level I Pre-admission Screening and Resident Review (PASARR-used to identify all individuals who have a mental illness and/or an intellectual disability or related condition prior to their admission to a nursing facility), submitted 3/12/25, showed: -The resident had diagnoses of PTSD and dementia. -The resident did not have any area of impairment due to serious mental illness. -The resident experienced one psychiatric treatment episode that was more intensive than routine follow-up care. -Due to mental illness, the resident experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials. -The resident was moderately withdrawn/depressed. -The resident's aggression was documented as at maximum level. -The resident's unstable mental condition was monitored by a physician or licensed mental health professional at least monthly and behavior symptoms are currently exhibited or psychiatric conditions are currently exhibited. -The resident displayed consistent unsafe/poor decision-making requiring reminders, cues, or supervision at all times to plan, organize and conduct daily routines and has issues with memory, mental function, or ability to be understood/understand others. Review of Resident #307's baseline care plan, dated 3/5/25, showed: -The problems identified included the resident had the potential for behaviors and had a diagnosis of PTSD. -Interventions included: --The resident will verbalize feelings associated with their past trauma through the next review. --Social Services visits as needed. --Provide and encourage favorite activities for distraction. --Medication as ordered. --Observe behaviors and try to determine cause. Review of Resident #307's social history and initial assessment completed by the former Social Worker, dated 3/7/25, showed: -The resident was in prison for 27 years. -The reason for the resident's admission to the facility was due to dementia with agitation and PTSD. -The resident was not able to write letters or sign documents. -The resident was not able to read or understand his/her own mail. -The resident was confused, had a flat affect, walked independently, was nonverbal, had good vision, and poor hearing. -There was no section to add triggers or care interventions. Review of Resident #307's trauma informed care, dated 3/7/25, showed the former Social Worker documented: -The trauma of being in prison for 27 years affected his/her overall health and well-being. -The resident's PTSD was due to being in prison for 27 years. -There was no section to add triggers or care interventions. Review of Resident #307's care plan, developed on 3/7/25, showed: -The problem identified was the resident had a diagnosis of PTSD, which affected his/her overall health and well-being. -The resident had been in prison for 27 years. -Behaviors related to this trauma included agitation towards others and selective mutism. -The desired outcome was the resident would be provided assistance to address the effects of trauma during the review period as demonstrated by no trauma-related behaviors and expressions of feelings of safety and support. -Interventions included: --Evaluate recommendations of psychiatric and behavioral health professionals and implement as appropriate. --Make sure the resident knows when someone enters his/her room. --Do not sneak up on the resident or startle him/her. --Write down your name and what you are doing on his/her communication board. --Back away slowly if the resident becomes agitated and make sure he/she is safe. --Psychiatric and behavioral health referrals. --Reassure the resident of his/her safety on the unit. -Another problem identified was the resident had impaired cognitive function related to dementia. -The desired outcome was the resident would maintain his/her current level of cognitive function through the review date. -Interventions included: --Administer medications as ordered. --Cue, re-orient, and supervise the resident as needed. --Write simple yes/no questions to determine his/her needs. --Inform Social Services of behavior episodes and attempt to determine underlying cause. -Another problem identified was the resident had a behavioral history of violence, being territorial, and agitation towards others. -The desired outcome was he/she would have fewer episodes of being agitated towards others. -Interventions included: --Intervene as necessary to protect the rights and safety of others. --Approach in a calm manner. --Divert the resident's attention. --Take him/her to an alternate location as needed. -Another problem identified was the resident had a diagnosis of PTSD and behaviors related to this trauma have included agitation towards others and selective mutism. -The desired outcome was he/she would be provided assistance to address the effects of trauma as demonstrated by no trauma-related behaviors and expressions of feelings of safety and support. -Interventions included: --Make sure the resident knows you are in his/her room. --Do not sneak up on or startle the resident. --Write on his/her communication board. --Back away slowly if the resident becomes agitated. --Make sure the resident is safe. Review of Resident #307's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 3/10/25, showed the following staff assessment of the resident: -Had adequate hearing and vision. -Did not speak. -Was rarely or never understood by others and rarely or never understood others. -Had short-term and long-term memory impairment. -Knew the location of his/her room. -Had moderately impaired cognitive skills for decision-making. -Displayed mood symptoms that indicated mild depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life). -Had no behavioral symptoms. -Had no range of motion limitations. -Walked with supervision. -Required supervision only for most self-cares. -Had diagnoses that included dementia and PTSD. Review of Resident #307's nurse's note, dated 3/16/25 at 5:15 P.M., showed: -Another resident (Resident #26) reported this resident approached him/her while he/she was lying in his/her bed and punched him/her in his/her chin at 11:00 A.M. -The other resident then reported he/she removed himself/herself from the room then turned around to get his/her cell phone and saw Resident #307 with both fists balled up staring at him/her. -New orders were received for Complete Blood Count (CBC - a test that gives information about blood cells), Basic Metabolic Panel (BMP - a blood test that measures sugar levels, electrolytes, fluid balance, and kidney function), and a urine analysis (UA - a test of urine used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes) for the next morning. -Resident #26 was moved to another room. -There were no apparent injuries observed to the resident. Review of the facility investigation, dated 3/16/25, showed on 3/16/25 around 11:00 A.M.: -Resident #26 reported Resident #307 approached him/her while he/she was lying in bed and made contact with his/her head. -Labs were ordered. -Resident #307 was provided with a private room. -They completed abuse and neglect in-servicing. -The training provided to employees included abuse and neglect. -Behavior management training was not documented as included in the training that was provided to staff. -Resident #307 was unable to give a description of what happened. Review of Resident #307's nurse's note, dated 3/16/25, showed Resident #307 was placed on one-on-one care at 12:30 P.M., because Resident #26 reported Resident #307 punched him/her in the chin. Review of Resident #307's behavior care plan, updated 3/16/25, showed a private room was provided and labs were ordered due to Resident #307 being aggressive with Resident #26. Review of Resident #307's nurse practitioner's (NP) note, dated 3/17/25, showed: -The resident had an altercation with another resident and was placed on one-on-one observation. -The resident was very confused and did not speak. -He/She did not see a one-on-one care giver and he/she would talk to nursing administration about that. -The resident had agitation, PTSD, and Alzheimer's disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills) with agitation. -Labs would be drawn including CBC, BMP, and UA CNS (culture and sensitivity) if indicated. -A new order for Ativan 0.5 milligrams (mg) every six hours as needed for 14 days. -He/She would find out about the one-on-one monitoring of Resident #307. Review of Resident #307's nurse's note, dated 3/18/25, showed the resident's primary care physician reviewed the resident's CBC and CMP results and gave no new orders. During an interview on 5/21/25 at 1:05 P.M., Licensed Practical Nurse (LPN) K said: -On 3/16/25, Resident #26 reported to him/her Resident #307 hit him/her in the face. -Resident #26 was alert and could tell you what was going on. -The Director of Nursing (DON) told him/her to move Resident #26 to another room and place Resident #307 on one-on-one observation and he/she did that. -Resident #307 didn't like anyone close to him/her. -Resident #307 got upset if anyone walked in his/her room. -Resident #307 would stand in his/her doorway and stare. -Resident #307 just wanted to be alone. -Resident #307 did not allow one-on-one supervision in his/her room, so staff had to sit outside his/her room. During an interview on 5/14/25 at 12:31 P.M., the DON said after Resident #26 reported Resident #307 hit him/her in his/her face while he/she was asleep in bed, new interventions for Resident #307 included a private room due to Resident #307 being territorial. During an interview on 5/23/25 at 1:50 P.M., the DON said: -No one witnessed Resident #307 hit Resident #26. -Resident #307 was territorial. Review of the resident to resident altercation note, dated 3/20/25, showed: -The altercation was discussed with the IDT. -Intervention included Resident #26 was moved to another room. Review of the facility investigation, dated 3/22/25, showed: -Resident #238 said he/she was asleep in bed when Resident #307 began shaking him/her. -Resident #238 said it woke him/her up and he/she saw Resident #307 shaking his/her fist above him/her. -Resident #238 said Resident #307 attempted to swing at him/her, but missed. -Resident #238 said he/she grabbed Resident #307's arms to keep him/her from attempting to hit him/her again. -Resident #238 said an employee entered the room and immediately separated the residents. -There were no apparent injuries. -Interventions included immediately separated residents, re-directed Resident #307 to his/her private room, and skin assessment. Review of Resident #307's March 2025 nurse's notes showed no documentation regarding 3/22/25. Review of Resident #307's care plan, updated 3/22/25, showed: -Resident #307 was in another resident's room being aggressive towards the other resident. -There were no new interventions documented on the resident's care plan after the 3/22/25 incident. During an interview on 5/23/25 at 10:30 A.M., Resident #238 said he/she was hit in the side of the head by somebody who was sick and confused and it made him/her mad. Review of the resident to resident altercation note, dated 3/24/25, showed: -The IDT discussed the resident to resident altercation. -The residents were separated. -Head to toe assessment was completed with no concerns noted. Review of Resident #307's behavior note, dated 3/24/25 at 8:00 A.M., showed: -Resident #307 was observed taking food from other residents at his/her table aggressively during breakfast. -Staff intervened and gently redirected Resident #307. -After breakfast, Resident #307 was found in several residents' rooms on multiple occasions and was kindly redirected to his/her room each time. -Resident #307 was found in another resident's room with the other resident's breakfast scattered on the floor. -Resident #307 was returned to his/her room with two staff assisting. -During Resident #307's shower, he/she became agitated and resisted assistance from the shower aide and refused to continue showering and attempted to leave the shower room. --Resident #307 was placed on one-on-one observation. Review of the facility investigation dated 3/24/25 showed: -Resident #307 took food from Residents #130, #139, and #215. -Resident #307 was in Resident #43's room with food scattered on the floor. Resident #43 was not in his/her room. -Resident #307 was placed on one-on-one care. -Resident #307 was sent out to the hospital on 3/24/25. -Resident #307 returned to the facility with new medication orders. -The facility worked on getting Resident #307 accepted to a psychiatric facility. -The cover page showed abuse and neglect in-servicing was completed, but the investigation showed no abuse and neglect in-servicing for 3/24/25. -Review of the investigation showed staff did not document that behavior management training was provided to staff. -There was no documented IDT meeting for 3/24/25. Review of Resident #307's behavior care plan, updated 3/24/25, showed facility staff updated the care plan with interventions that included one-on-one observation due to behaviors for an unspecified time and to send the resident to the hospital for a medication review (resident returned from the hospital on 3/25/25). Review of Resident #307's one-on-one records, dated 3/24/25, showed one-on-one observation was provided day, evening, and night shifts on 3/24/25. Staff did not document the time the resident left for the hospital and when he/she returned to the facility. During an interview on 5/16/25 at 12:19 P.M., Certified Nurse Aide (CNA) K said: -He/She saw Resident #307 in the dining room taking other residents' food on an unknown date. -He/She's never been assigned to do one-on-one observation with Resident #307. -They have had training on behaviors, but he/she didn't remember when. -The training he/she received regarding Resident #307 was to remove him/her from the area. -He/She didn't know any of Resident #307's triggers, but one of Resident #307's triggers may be when other residents wander into his/her room. -Resident #307 wandered and got into other residents' beds. -Mostly they did one-on-one observation or sent Resident #307 out for behaviors or aggression. -He/She doesn't feel like there's enough staff on their unit because they do have aggressive residents and a few residents with behaviors. -It's hard to keep track of the residents with behaviors and be able to prevent anything from happening. During an interview on 5/16/25 at 2:02 P.M., the former Social Worker said: -Resident #307 took food off other residents' trays. -To his/her knowledge, the facility did not provide any training/education on Resident #307's triggers and/or interventions for staff to use with Resident #307. -When Resident #307 had behaviors, they would go over them in risk management meetings weekly. -They did one-on-one observation of Resident #307 a lot of times to try to prevent him/her from getting into someone else's room. -They also sent Resident #307 out for evaluation in the emergency room or for psychiatric stays. -They didn't talk about how to minimize Resident #307's triggers or how to keep him/her calm. During an interview on 5/16/25 at 1:33 P.M., Certified Medication Technician (CMT) G said Resident #307 punched him/her in the arm when he/she was trying to get him/her to exit the dining room when the resident was taking food off trays. During an interview on 5/21/25 at 1:05 P.M., LPN K said Resident #307 at times would move to someone else's seat in the dining room and wasn't re-directable. Review of Resident #307's NP note, dated 3/24/25, showed: -The resident had resident-to-resident altercations over the weekend. -The resident was aggressive and agitated. -He/She tried to walk the resident to his/her room with another staff member and the resident tried to fight them. -The resident was now on one-on-one monitoring. -He/She consulted with the resident's primary care physician and they were adding Depakote 125 mg three times a day. -Nursing administration was in the process of getting the resident out for a psychiatric evaluation. Review of Resident #307's nurse's note, dated 3/24/25 at 4:45 P.M., showed Resident #307 left the facility via ambulance to a local hospital for a psychiatric evaluation. During an interview on 5/14/25 at 12:31 P.M., the DON said: -Resident #307 was sent to the hospital on 3/24/25, because he/she was going in and out of other residents' rooms, knocked a breakfast tray on the floor, and his/her aggression was ramping up. Review of Resident #307's nurse's note, dated 3/25/25 at 1:00 A.M., showed: -The resident returned from the hospital with two bottles of Trazodone (an antidepressant medication used to treat depression) 50 mg at bedtime for sleep and Depakote sprinkles (an anticonvulsant medication generally used to prevent seizures or as a mood stabilizer) 125 mg at bedtime for mood. -The resident was presently in his/her room sitting on his/her bed awake. Review of Resident #307's Medication Administration Record (MAR), dated March 2025, showed: -The following physician orders: --3/5/25: Trazodone 50 mg at bedtime for insomnia. --3/5/25: Quetiapine ((brand name Seroquel) an antipsychotic (class of medicines used to treat psychosis and other mental and emotional conditions) medication) 50 mg twice daily for mood. --3/17/25: Lorazepam (an anti-anxiety medication) 0.5 mg, give every six hours as needed for anxiety and agitation for 14 days. --3/24/25: Depakote Delayed Release 125 mg three times a day for agitation and behaviors. -Trazodone, Quetiapine, and Depakote were administered as ordered through 3/28/25. -Lorazepam was not administered 3/17/25-3/28/25 including after any of the resident to resident incidents. Review of Resident #307's attending physician's progress note dated 3/25/25 showed: -The resident had PTSD. -He/She was not aware of any breakthrough psychiatric issues at this time except for the fact he/she went out to a psychiatric facility after some violent behavior. -We are trying to get the resident to an in-patient psychiatric place. Review of the facility investigation, dated 3/27/25, showed: -Resident #230 was found on the floor in his/her room and Resident #307 was in Resident #230's bed. -It could not be determined whether Resident #307 pulled Resident #230 out of his/her bed or not. -Resident #230 was severely cognitively impaired. -Resident #230 was unable to give a description of what happened. -There was no documentation regarding whether staff attempted to interview Resident #307. -There was no documentation regarding having an IDT meeting to discuss the incident. -No additional interventions were added. -Resident #307 was sent to a psychiatric facility on 3/28/25. Review of Resident #307's behavior note, dated 3/27/25, showed: -The resident was found in another resident's room lying on his/her bed while the resident that resides in the room was lying on the floor. -Resident #307 was escorted out of the room and to his/her own room. -Resident #307 was placed on one-on-one monitoring. Review of Resident #307's care plan, updated 3/27/25, showed the resident was found in another resident's bed, no new interventions were added to the care plan. Review of Resident #307's care plan, updated 3/28/25, showed the resident was discharged to a psychiatric facility. During an interview on 5/16/25 at 12:19 P.M., CNA K said: -He/She found Resident #230 on his/her floor and Resident #307 was in Resident #230's bed. -He/She and the nurse helped get Resident #307 out of Resident #230's bed and walked Resident #307 out of Resident #230's room. -Resident #307 was placed on one-on-one observation after being found in Resident #230's bed. During an interview on 5/16/25 at 12:39 P.M., CMT F said: -He/She worked the evening on 3/27/25. -After Resident #307 was wandering into different resident rooms and found in another resident's bed, he/she was assigned one-on-one observation of Resident #307. -He/She was told to keep an eye on Resident #307 with one-on-one observation. -During his/her one-on-one observation of Resident #307 on 3/27/25, Resident #307 was in his/her room, went to the television area, and then tried to get into another unknown resident's room, so he/she re-directed Resident #307. -He/She said he/she told Resident #307 no and he/she followed his/her instructions. -They educated him/her to back up and not get too close to Resident #307. -He/She was trained to remove Resident #307 from the area in a situation like when he/she was found in another resident's bed. -He/She didn't know of any of Resident #307's triggers other than maybe when other residents wander into his/her room. -Resident #307 wandered himself/herself and got into other resident beds at times. -The facility's response to any of Resident #307's behaviors was usually doing one-on-one observation or sending him/her out to the hospital or other facility. -He/She doesn't feel like there's enough staff on their unit, because they have aggressive residents and a few residents with behaviors. -It's hard to keep track of all the residents and prevent everything. Review of Resident #307's Social Services Note, dated 3/28/25, showed: -The resident was having behaviors such as taking food off other residents' plates, pulling residents out of bed, and showing residents his/her fist. Review of Resident #307's discharge assessments showed the resident was discharged on 3/28/25 to an in-patient psych facility after a bed opened up. Review of Resident #307's behavior care plan, updated 3/28/25, showed the updated intervention included sending the resident to a geriatric psychiatric facility. During an interview on 5/14/25 at 12:31 P.M., the DON said the facility sent Resident #307 out to geriatric psychiatric facility for medication adjustment and evaluation in response to the events on 3/28/25. Review of Resident #307's Level I PASARR, submitted 4/16/25, showed: -The resident had diagnoses of PTSD and dementia. -The resident did not have any area of impairment due to serious mental illness. -The resident experienced one psychiatric treatment episode that was more intensive than routine follow-up care. -Due to mental illness, the resident experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials. -The resident was moderately withdrawn/depressed. -The resident's aggression was documented as at maximum level. -The resident unstable mental condition was monitored by a physician or licensed mental health professional at least monthly and behavior symptoms are currently exhibited or psychiatric conditions are currently exhibited. -The resident displayed consistent unsafe/poor decision-making requiring reminders, cues, or supervision at all times to plan, organize and conduct daily routines and has issues with memory, mental function, or ability to be understood/understand others. Review of Resident's #307's tracking forms showed the resident returned to the facility on 4/18/25. Further review of the resident's care plan, updated 3/28/25, showed staff did not update the resident's care plan with new interventions for his/her behaviors after he/she returned from the hospital. Review of Resident #307's MAR dated April 2025 showed: -A physician's order dated 4/18/25 for Trazodone 50 mg at bedtime for insomnia (the same order the resident had upon discharge on [DATE]) was administered 4/18/25-4/21/25. -A physician's order, dated 4/18/25, for Depakote Sprinkles 125 mg, three tablets, three times daily (increased from Depakote Delayed Release 125 mg three times a day for agitation and behaviors) was administered 4/18/25-4/21/25. -A new physician's order, dated 4/19/25, for Sertraline 25 mg, three tablets daily for PTSD was administered 4/19/25-4/22/25. -A physician's order, dated 4/23/25, for Seroquel 50 mg three times daily for PTSD was administered 4/19/25-4/21/25 (increased from two times a day to three times a day). -A new physician's order, dated 4/18/25, for Melatonin 3 mg, two tablets at bedtime for insomnia was administered 4/18/25-4/21/25. -A physician's order dated 4/18/25 for Trazodone 50 mg every 24 hours as needed at bedtime for insomnia was not administered 4/18/25-4/21/25. -As needed Lorazepam was not ordered. Review of the facility investigation, dated 4/21/25, showed staff documented on 4/21/25 around 11:15 A.M: -Resident #307 has selective mutism and dementia. -Resident #187 had Alzheimer's Disease. -Resident #307 was sitting in a chair watching television when Resident #187 walked by and stopped next to Resident #307. -Resident #307 was witnessed reaching up and hitting Resident #187 with a closed fist on Resident #187's right hip. -No words were exchanged between Resident #307 and Resident #187. -There were no apparent injuries. -Resident #307 was protective of his/her personal space. -It appeared Resident #187 stopped next to Resident #307 and he/she felt he/she needed Resident #187 out of his/her personal space, resulting in Resident #307 striking Resident #187 to get him/her to move out of his/her way. -Resident #307 was placed on one-on-one supervision. -The facility provided education on abuse and de-escalation of behaviors for residents with dementia. -There was no documentation regarding whether an interview was attempted with Resident #307 regarding the incident. -There was no documentation of an IDT meeting being held. Review of Resident #307's nurse's note, dated 4/21/25, showed: -Resident #307 was sitting in his/her chair when Resident #187 st

Based on observation, interview and record review, the facility failed to ensure a 5% or lower error rate during medication administration by having an error rate of 6% that effected three supplemental residents (Resident #120, #14, and #501) out of 35 sampled residents and 31 supplemental residents. The facility census was 259 residents. Review of the facility's policy titled Medication Administration, revised October 2022, showed nursing personnel who were administering medications were to follow the following guidelines for safe administration: -The right medication. -The right amount. -The right resident. -The right time. -The right route. --Additional considerations included the Rule of 3, staff would perform 3 checks comparing the physician's order, the pharmacy label, and the Medication Administration Record (MAR). -Compare the Licensed Practitioner's prescription/order with the MAR (first check). -Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check). -Compare the pharmacy label and MAR (third check). -Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication. 1. Review of Resident #120's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 4/2/25, showed the resident was cognitively intact. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed Cholecalciferol Tablet 1000 unit give 2 tablets (2000 units) by mouth one time a day for supplement. Observation of the medication administration on 5/22/25 at 8:40 A.M., showed Certified Medication Technician (CMT) A administered Vitamin D 5 microgram (mcg) 1 tab. During an interview on 5/23/25 at 8:43 A.M., CMT A said: -Medication rights were right patient, right medication, right dose, right time, and right route. -Medication administration included hand hygiene, identify resident, check the medications against the EMAR and give to the resident and sign out as administered. -He/She was unaware of Resident #120's Vitamin D error. 2. Review of Resident #14's admission MDS, dated [DATE], showed the resident was cognitively intact and had a diagnosis of Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's POS, dated May 2025, showed Metformin 750 mg one tablet once daily in the A.M. for Diabetes Mellitus. Review of the resident's Medication Administration Record, dated May 2025, showed Metformin 750 mg had been signed off from 5/1/25 through 5/22/25. Observation of the medication administration on 5/22/25 at 9:16 A.M., showed CMT B administered Metformin 1000 milligram (mg) to the resident. During an interview on 5/23/25 at 8:36 A.M., CMT B said: -Medication rights were right patient, right medication, right dose, right time, and right route. -Medication administration included hand hygiene, identify resident, check the medications against the EMAR and give to the resident and sign out as administered. -He/She would inform the nurse if a medication did not match the MAR. -He/She would inform the nurse of a dosage discrepancy. -He/She reported to Licensed Practical Nurse (LPN) G the medication card and MAR dosages did not match. -He/She was instructed to give the Metformin by LPN G. -He/She was aware of the incorrect dose administered to Resident #14. 3. Review of Resident #501's admission Record showed he/she was admitted on [DATE]. Review of the resident's POS, dated May 2025, showed Magnesium Lactate Oral Tablet Extended Release 84 mg, give 84 mg by mouth two times a day at 8:00 A.M. and 8:00 P.M. for Hypomagnesemia (low magnesium level). Review of the resident's electronic Medication Administration Record (EMAR), dated May 2025, showed: -Magnesium Lactate ER 84 mg was signed as administered 5/13, 5/16, 5/17, 5/18, and 5/19/25 for the A.M. medication administration. -Magnesium Lactate ER 84 mg was signed as not administered 5/12, 5/14, 5/15, 5/20, and 5/21 for the A.M. medication administration as not available. -Magnesium Lactate ER 84 mg was signed as administered 5/12 through 5/22/25 for the P.M. medication administration. Observation of the medication administration on 5/22/25 at 9:26 A.M. showed CMT B did not administer Magnesium Lactate Extended Release (ER) 84 mg as it was not available. During an interview on 5/23/25 at 8:36 A.M., CMT B said: -Medication rights were right patient, right medication, right dose, right time, and right route. -Medication administration included hand hygiene, identify resident, check the medications against the EMAR and give to the resident and sign out as administered. -He/She was aware the Magnesium Lactate was not available in the facility. -He/She informed the nurse the Magnesium Lactate ER was not available and not given. 4. During an interview on 5/23/25 at 11:00 A.M. the Nurse Practitioner (NP) said: -He/She expected to be notified of medication errors. -He/She was not informed of the medication error for Resident #14. -He/She was not informed of Magnesium Lactate ER 84 mg not being available for Resident #501. -He/She expected to be informed of all medication issues. During an interview on 5/23/25 at 11:45 A.M., Licensed Practical Nurse (LPN) B said: -He/She expected to be notified of medication errors. -He/She would document the medication error, notify the supervisor and the physician. -He/She was not aware of Resident #14's medication error. -He/She was not aware of Magnesium Lactate was not available for Resident #501. During an interview on 5/23/25 at 11:48 A.M., the Assistant Director of Nursing (ADON) said: -If a medication was not available, the CMT would notify the nurse. -If it was house stock, the nurse would notify the supervisor and get the medication out of Central Supply. -The facility also utilized Rx Now for medications or over the counter (OTC) medications that were not available. -Rx Now did not stock Magnesium Lactate ER 84 mg. -The nurse should call the pharmacy if a medication or OTC was not available. -The facility only had Magnesium Oxide available. -He/She was not aware Resident #501 was not receiving the ordered Magnesium Lactate ER 84 mg twice daily. -The physician should be notified of medications not available. -He/She was not aware of Resident #14's medication error. During an interview on 5/23/25 at 12:33 P.M., the attending physician said: -He/She expected to be notified of medication errors. -He/She had not been notified of Resident #14's medication error prior to 5/23/25. -He/She was not aware Resident #501 had not been receiving Magnesium Lactate ER 84 mg. -He/She expected to be informed of all medication issues. During an interview on 5/23/25 at 1:38 P.M. the DON said: -He/She expected the medication administration pass to be done accurately with the resident rights. -He/She expected staff to check the medication card against the EMAR. -He/She was not aware Resident #14's Metformin was filled at the incorrect dose since 4/12/25. -He/She expected the pharmacy and physician would be notified if medications and OTCs were not available. -He/She was not aware of Resident #501's Magnesium Lactate ER 84 mg was not available.

Based on observation, interview, and record review the facility failed to ensure the call light in one sampled resident's room (Resident #15) was within reach of the resident, out of 35 sampled residents. The facility census was 259 residents. Review of the facility's Communication Call System policy, dated 10/24/22, showed: -The purpose of the policy was to provide a mechanism (Call Light-a bedside button typically tethered to the wall in a residence room that provided signals to the nursing station when a resident had a need or required attention) for residents to promptly communicate with nursing staff. -The facility provided a call system to help residents alert the nursing staff from their beds and toileting facilities. -Call light cords were placed within the resident's reach in each residents room. -Nursing staff answered call lights promptly. -If the call light was defective, it was reported immediately to maintenance and replaced immediately. 1. Review of Resident #15's quarterly Minimum Data Sheet (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 5/22/25, showed: -He/She was admitted to the facility on [DATE] with the following diagnoses: --Arthritis (swelling an tenderness in one or more joints, causing pain). --Dementia (a group of thinking and social symptoms that interferes with daily functioning). --Post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). --Traumatic brain injury (TBI - an injury to the brain caused by an external force). -He/She needed assistance with activities of daily living. -He/She was cognitively intact. Review of the resident's undated care plan showed: -The problem identified was the resident had an ADL self-care performance deficit related to weakness and TBI. -The resident's needed varied with his/her mood. -The resident was sometimes independent and other times he/she needed assistance. -Interventions included: --Assist the resident with wheelchair mobility as needed. --Provide set-up to limited assistance with bed mobility. --Provide set-up to limited assistance with grooming and oral care. --Provide up to limited assistance with toileting. --Provide extensive assistance at times with incontinence care. --Provide transfer assistance as needed. -The resident was at risk for falls related to poor safety awareness at times, weakness, history of falls, behaviors and medications he/she took. Observation and interview on 5/13/25 at 10:37 A.M., showed: -The resident was in bed. -His/her wheelchair was next to the bed. -The only call light in the room was across the room on the opposite wall from the resident's bed. -There was no place on the wall that the resident's bed was against to plug in a call light. -The resident's call light did not reach from the opposite side of the room to his/her bed. -The resident said he/she did not have a call light on the side of the room that his/her bed was on. -There was no place to plug a call light in near his/her bed. -He/She needed to have a call light to call for assistance when he/she wanted to get out of bed, needed a pain pill, or reach the TV remote. During an interview on 5/22/25 at 11:44 A.M., Licensed Practical Nurse O said: -There was no call light on the resident's side of the room where his/her bed was located. -He/She was not aware the resident was not able to reach his/her call light when in bed. During an interview on 5/22/25 at 11:47 A.M., the resident said: -He/She had to do without when he/she was in bed, because there was no call light available to use. He/She would not elaborate as to what he/she meant by do without. -He/She told the nurse sometimes he/she took his/her grabber and banged it on his/her over bed tray to get help. -He/She did not like to have to use his/her grabber on the bed tray. During an interview on 5/23/25 at 1:50 P.M., the Director of Nursing said: -The resident's call light should be within reach or they could try something else that Resident #15 could use to alert staff of his/her needing assistance. -Staff should have seen this issue before they left the room.

Based on interview and record review, the facility failed to provide the resident with an appropriate discharge notice and failed to allow one supplemental resident (Resident #307) to return to the facility after having been transferred to the hospital or found an alternate facility to accept him/her out of 31 supplemental residents. The facility census was 259. Review of the Transfer and Discharge Planning policy, dated 10/24/22, showed: -The purpose of the policy was to ensure adequate preparation and assistance was provided to residents prior to transfer or discharge from the facility. -Social Services staff participated and assisted the resident with transfers and discharges and preparing the Discharge Summary and Discharge Care Plans as part of the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients). -Social Services staff conducted a Discharge Planning Assessment and helped orient the resident to the impending discharge. -Social Services staff coordinated discharge with the IDT, the resident, and the residents' representative. -Social Services staff documented the discharge planning, preparation, and the resident's post discharge needs on the discharge planning assessment form in the electronic health record. -Social Services staff coordinated with the resident and the resident's family to discuss discharge needs. -Social Services staff assisted in developing the Discharge Summary and Discharge Care Plan that was developed by the IDT team. -The receiving provider will receive necessary information to facilitate a smooth transition and continuity of care. -A copy of the Discharge Summary was provided to the resident and/or the resident's family member upon discharge when return was not anticipated. -Summary of the resident's stay included diagnosis, course of illness, treatment, and pertinent lab, radiology, and other consultation results. -A copy of the discharge summary and discharge care plan was maintained in the residence medical record. 1. Review of Resident #307's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a group of thinking and social symptoms that interferes with daily functioning). Metabolic encephalopathy (a brain disorder that arises from electrolyte imbalances, organ dysfunction or toxic exposure). -Post Traumatic Stress Disorder (PTSD - when a person has difficulty recovering after an experience or witnessed a terrifying event). -Selective Mutism (a rare disorder that prevents a person from speaking). -Chronic kidney disease (When the kidneys could no longer filter the blood). -Suicidal ideations (Thoughts about or planning suicide). Review of Resident #307's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 3/10/25, showed the following staff assessment of the resident: -Had moderately impaired cognitive skills for decision-making. -Some of his/her diagnoses included Alzheimer's Disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), Dementia and PTSD. -Displayed mood signs and/or symptoms that indicated mild depression. Review of the resident's Nurse Practioner's Consultation, dated 3/17/25, showed: -The resident had a resident to resident altercation over the weekend and he/she was the aggressor. -He/She hit the other resident in the face. -He/She has had other issues prior to a recent evaluation at a Psychological facility. -He/She was currently sitting with a one to one staff member at the facility. Review of the resident's Brief Interview for Mental Status, dated 5/9/25, showed the resident was not able to complete the interview. Review of the resident's care plan, dated 5/11/25, showed: -He/She had a behavioral history of violence, being territorial and agitation toward others. -He/She was aggressive with his/her roommate, dated 3/16/25. -He/She was in another resident's room being aggressive toward him/her, dated 3/22/25. -He/She was aggressive with two other residents, dated 4/21/25. -He/She was aggressive with another resident, dated 5/11/25. -He/She was sent out to a Geriatric/Psychiatric (Geri/Psych Psych facility for elderly) facility on 3/28/25. -He/She was placed on one-on-one observation dated 4/21/25. -He/She was sent to a Geri/Psych facility for evaluation related to aggressive behaviors, dated 4/22/25. -He/She was placed on one-on-one observation dated 5/11/25. Review of the resident's Facility Transfer Form, dated 5/13/25 at 9:58 A.M., showed the resident was being transferred to a nearby hospital to obtain a medical clearance for Psychological admission due to combative and aggressive behavior. Review of the Notice of Proposed Discharge for the resident, dated as effective 5/13/25, showed: -The resident was being discharged to a nearby hospital because the discharge was necessary for his/her welfare, and his/her needs could not have been met by the facility. -The family member verbalized understanding of the document on 5/13/25. -The Social Services Director signed it on 5/14/25. Review of the Notice of the second Proposed Discharge for the resident, dated as effective 5/13/25, showed: -The resident was being discharged to a nearby hospital for the following reasons: --The discharge was necessary for his/her welfare, and his/her needs could not have been met by the facility. --The safety of individuals in the facility was endangered by his/her presence. -The family member verbalized understanding of the document on 5/13/25. -The Social Services Director signed it on 5/14/25. Review of the resident's nurse's note, dated 5/13/25, showed the resident was discharged to the hospital for evaluation for medical clearance for psychiatric admission due to combative and aggressive behaviors. Review of the resident's progress note, dated 5/13/25, showed: -The Assistant Director of Nursing (ADON) documented that he/she spoke with the resident's responsible party about his/her recent increased behaviors. -The resident was sent to the hospital during the day shift. -They were working with the hospital to find appropriate placement for the resident. -The facility did not feel it was capable of providing the care needed during this time. During an interview on 5/19/25 at 11:57 A.M., the Ombudsman said: -The facility normally emailed discharges to him/her. -Sending the resident to the hospital was not an appropriate location for a discharge. -He/She had not received an email for notification of discharge for the resident on 5/13/25. -He/She was not in the office, so he/she was not sure if the facility had sent it in the mail. Review of an email from the Ombudsman to the surveyor, dated 6/4/25 at 10:27 A.M., showed the Ombudsman said they never received any type of discharge notice regarding the resident. During an interview on 5/20/25 0 at 9:16 A.M., the ADON said: -They were working on trying to find alternate placement for the resident. -The Administrator had directed him/her to find alternate placement for the resident. -The Administrator had spoken with the Regional Director of Operations and the Hospital Liaison. -He/She was not in on the discussion of why they couldn't meet the resident's needs. -He/She had no part in making the decision to not allow him/her to return to the facility. -He/She was asked to call the family and inform them the resident was not coming back to the facility from the hospital. During an interview on 5/20/25 at 2:04 P.M., the Social Services Director said: -He/She did the discharge letters. -He/She usually found out after a resident went to the hospital that the resident was sent out of the facility. -He/She would always find out if there was verbal acknowledgement when the resident was sent out to the hospital and not to return to the facility, if not, he/she would reach out to inform the resident's family they were not coming back to the facility. -He/She was told the resident was going to the hospital after the resident's discharged on 5/13/25 -The next morning he/she was informed the resident was not coming back to the facility by other staff members. -On 5/13/25 he/she gave the discharge notice for 5/12/25 to go to hospital, so only one box was checked for reason, as he/she thought the resident would be returning to the facility. -The second discharge notice stated the resident was being discharged completely. -He/She did not know if it was a 30-day discharge notice or if it was an immediate discharge notice. -Later he/she heard from other staff it was supposed to have been an immediate discharge notice. -He/She would normally have helped with finding alternate placement for the resident. -He/She would have sent out referrals to other nursing homes. -He/She was told the resident was going to a nearby hospital, but then heard that he/she went to a different hospital. -He/She was not sure how to document the paperwork since the resident had already been discharged . -He/She sent referrals to 16 facilities on Friday 5/16/25. -In the referral he/she stated that the resident was in the hospital. -He/She had not talked to anyone at the hospital. -There was a Clinical Liaison who worked out of the facility that gave him/her a list of facilities to send the referrals to. -When the resident went to the hospital, he/she thought he/was just going to the hospital and would return so he/she had not sent any referrals at that point, because he/she thought the resident was just in the hospital. -On Friday 5/16/25 he/she was told to send out referrals to other facilities. During an interview on 5/21/25 at 2:35 P.M., the Clinical Liaison said: -The resident was at the hospital and he/she had been notified by the Administrator due to resident to resident altercations that after a psychiatric hospital stay, they were not going to allow the resident to return to the facility. -He/She notified the hospital they were not taking the resident back. -He/She gave the hospital some ideas of places for a referral. -He/She had not seen the resident while he/she was in the hospital. During an interview on 5/23/25 at 12:26 PM., the Hospital Case Manager said: -The resident was still at the hospital. -The Clinical Liaison said the facility refused to accept the resident back. -They were having a hard time finding a place that would accept the resident. During an interview on 5/23/25 at 1:50 P.M., the Director of Nursing (DON) said: -He/She was not in charge of the discharge notices. -He/She knew the facility was to allow the resident to return to the facility after a stay at the hospital. During an interview on 5/23/25 at 3:21 P.M., the Administrator said: -He/She was aware of the requirements for discharge notices and understood what it meant. -He/She knew they could not discharge a resident to the hospital and not take them back to the facility, they would have to take the resident back after he/she was discharged from the hospital. -He/She thought the resident was still at the hospital. -He/She would have to check with his/her admission people to see where the resident was. They were both gone for the weekend. -The clinical liaison was working with the hospital to try to find different placement for the resident. -They were not taking the resident back and they were aware of the requirement to let the resident return. MO00254351

Based on interview and record review, the facility failed to complete and retain a Level 1 Nursing Facility Preadmission Screening and Resident Review (PASARR - a federally mandated program that requires all states to prescreen all people regardless of payer source or age seeking admission to a Medicaid certified nursing facility) which assured appropriate placement of persons known or suspected of having mental impairment(s) and that the individual needs of mentally impaired persons could be and were being met in the appropriate placement environment) for one sampled resident (Resident #140) out of 35 sampled residents and failed to submit a Level 1 timely for one supplemental resident (Resident #307) out of 31 supplemental residents. The facility census was 259 residents. Review of the facility PASARR policy, revised on 10/24/22, showed: -The purpose of the policy was to achieve placement for individuals in the least restrictive environment possible yet enable them to receive all services required by the physical and mental conditions. -The facility, as a Medicaid certified nursing facility, ensured that Level 1 of the PASARR was completed either by the transferring facility, upon admission, or as soon as practicable thereafter, by the facility for all applicants, regardless of payer, to determine if they have mental disorder or are intellectually disabled. -All applicants to the facility, whether they receive or are eligible for Medicaid, receive the Level 1 screen. -The facility was to print/save the PASARR and the letter generated and retain it in the resident's medical record. 1. Review of Resident #140's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Depression (a persistent mood disorder characterized by sadness and loss of interest or pleasure in daily activities). -Schizotypal Disorder (a psychiatric disorder characterized by deficits in social and interpersonal skills, highlighted by a reduced ability to form close relationships, occurring in the setting of eccentric behavior and cognitive or perceptual distortions). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Personality Disorder (a mental health condition that involves long-lasting, disruptive patterns of thinking, behavior, mood and relating to others). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 4/14/25, showed: -The resident was cognitively intact. -The resident had dementia. -The resident had anxiety. -The resident had depression (a common mental health condition characterized by a persistent feeling of sadness, loss of interest in activities, and a range of other physical, emotional, and cognitive symptoms). -The resident had schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). Review of the resident's medical record on 5/14/25 at 11:38 A.M., showed no documentation a Level 1 PASARR had been completed and/or retained. During an interview on 5/14/25 at 3:00 P.M., the Regional Director of Clinical Services said: -A Level 1 PASARR had not been requested for the resident and the facility did not have one on file. -A Level 1 PASARR was requested on 5/14/25 and a receipt for the request was provided. During an interview on 5/23/25 at 12:13 P.M., Social Worker A said: -Level 1 PASARR's should be done on all residents who had qualifying diagnoses upon admission into the facility. -The facility failed to have the resident's Level 1 PASARR when creating a care plan for the resident on admission, but had since requested one. -He/She was not sure how the resident's PASARR being obtained was missed by the facility. 2. Review of Resident #307's admission record showed the resident admitted to the facility on [DATE] and some of his/her diagnoses included dementia with agitation, unsteadiness on feet, post-traumatic stress disorder (PTSD-can develop after experiencing or witnessing a traumatic event in which symptoms can include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event), and selective mutism (an anxiety disorder where a person, capable of speaking, becomes unable to speak in specific situations or with certain people, despite speaking normally in other settings. It's not a choice, but rather an anxiety-related inability to speak). Review of the resident's baseline care plan, dated 3/5/25, showed the resident had the potential for behaviors and had a diagnosis of PTSD. Review of the resident's care plan, developed on 3/7/25, showed: -The problem identified was the resident had a diagnosis of PTSD, which affected his/her overall health and well-being. -The resident had been in prison for 27 years. -Behaviors related to this trauma included agitation towards others and selective mutism. -The desired outcome was the resident would be provided assistance to address the effects of trauma during the review period as demonstrated by no trauma-related behaviors and expressions of feelings of safety and support. -Interventions included: --Evaluate recommendations of psychiatric and behavioral health professionals and implement as appropriate. -Another problem identified was the resident had impaired cognitive function related to dementia. -The desired outcome was the resident would maintain his/her current level of cognitive function through the review date. Review of the resident's admission MDS, dated [DATE], showed the following staff assessment of the resident: -Had moderately impaired cognitive skills for decision-making. -Some of his/her diagnoses included Alzheimer's Disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), dementia, and PTSD. -Displayed mood signs and/or symptoms that indicated mild depression. Review of the resident's Level 1, submitted 4/16/25, showed: -The resident had diagnoses of PTSD and dementia. -The resident did not have any area of impairment due to serious mental illness. -The resident experienced one psychiatric treatment episode that was more intensive than routine follow-up care. -Due to mental illness, the resident experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials. -The resident was moderately withdrawn/depressed. -The resident's aggression was documented as, at maximum level. -The resident unstable mental condition was monitored by a physician or licensed mental health professional at least monthly and behavior symptoms are currently exhibited or psychiatric conditions are currently exhibited. -The resident displayed consistent unsafe/poor decision-making requiring reminders, cues, or supervision at all times to plan, organize and conduct daily routines and has issues with memory, mental function, or ability to be understood/understand others. -The application was not accepted. -The date of correction was 4/21/25. During an interview on 5/19/25 at 12:30 P.M., the Administrator said: -The Level 1 was returned for a correction. -The correction was made and the Level 1 was currently at Central Office Medical Review Unit (COMRU). -The Level 1 was still at COMRU and no completed copy was available in the resident's chart. During an interview on 5/23/25 at 11:51 A.M., MDS Coordinator B said: -The Level 1 should be considered when completing the care plan. -The resident's Level 1 was not available to consider when completing the resident's care plan. -The resident's care plan was completed and updated without considering the Level 1. During an interview on 5/23/25 at 1:38 P.M., the Director of Nursing said: -He/she would expect the Level 1 to be considered/used when completing the resident's care plan. -The resident's care plan was completed without the consideration of the Level 1. Review of an email dated 5/29/25 from COMRU's Supervisor/Registered Nurse Specialist showed: -The Level 1 correction on the resident was submitted on 4/21/25 from COMRU. -COMRU received the Level 1 corrections from the submitter on 5/16/25. -Level of Care was assigned on 5/23/25 and sent to the Department of Mental Health on 5/27/25 since the application triggered a Level two screening (confirms whether the applicant has a mental illness or intellectual/developmental disability, assesses the individual's need for nursing facility services and assesses whether the individual requires specialized services or specialized rehabilitative services). 3. During an interview on 5/23/25 at 11:51 A.M., MDS Coordinator B said: -PASRRs were completed by the Social Worker. -He/She would expect a PASRR to be completed, retrieved, and in a resident's medical record. -A resident's PASRR should be considered when planning care for resident's who had mental health diagnoses. During an interview on 5/23/25 at 12:13 P.M., Social Worker A said Level 1 PASRRs should be done on all residents upon admission into the facility. During an interview on 5/23/25 at 1:38 P.M., the DON said: -He/She was not aware of the facility's policy for the PASRR process. -He/She would expect a Level 1 PASRR to be completed and on file in a resident's medical record. -Social services was responsible for completing and retrieving the Level 1 PASRR for care planning of the residents. -He/She would expect a resident with a mental health diagnosis to have a Level 1 PASRR completed.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 216) had a follow up dental appointment to have multiple teeth removed, out of 35 sampled residents. The facility census was 259. Review of the facility's policy, Dental Services, dated October 24, 2022, showed: -All residents would receive appropriate oral care including denture care. -Assessment of the oral cavity and teeth was performed upon admission and as necessary. -The facility would assist residents with referrals for dental services. -The facility would refer and or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the resident. -Emergency dental services include but were not limited to; -Acute pain in teeth, gums, or palate. -Broken or damaged teeth. 1. Review of Resident # 216's face sheet showed: -He/she was admitted to the facility on [DATE]. -He/she needed for assistance with personal cares. -Diagnosis of Depression (a common mental health condition characterized by a persistent feeling of sadness, loss of interest in activities, and a range of other physical, emotional, and cognitive symptoms). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 4/10/25, showed: -He/She was cognitively intact. -He/She had taken scheduled and as needed pain medications. -Broken teeth was not checked. -Mouth pain was not checked. Review of the resident's Dental visit note, dated 4/28/25, showed: -The resident had the need to consult with an oral surgeon. -He/She had multiple teeth that needed to be removed in four to six areas of the mouth. -He/She had presented for upper and lower denture impressions. Review of the resident's Physician's Order Sheet, dated May 2025, showed: -Dental health care as needed, dated 6/27/24. -Norco Oral Tablet (a strong pain medication with the risk for addiction) 5/325 milligrams (mg), give one tablet by mouth every four hours as needed for pain. Not to exceed three grams per 24 hours. -Tylenol Oral Tablet 325 mg give two tablets by mouth every six hours as needed for pain, dated 4/23/25. -Amoxicillin Capsule 500 mg give one capsule by mouth three times a day for bacterial infection in teeth for 10 days, dated 4/24/25. Review of the resident's Certified Medication Technician (CMT) Medication Administration Record (MAR) dated May 2025 showed: -Norco 5/325 mg one tablet by mouth four times a day for pain not to exceed three grams of Tylenol in a 24 hour period include all medications, dated 11/15/24 and discontinued on 5/6/25. -Scheduled Norco was given 24 out of 24 opportunities from 5/1/25 to 5/6/25. -As needed Tylenol was give three times from 5/1/25 to 5/22/25. Review of the resident's undated Care Plan showed: -He/She had the potential for pain. -There were no specific areas of pain identified. Review of the resident's medical record showed no documentation that an appointment with an oral surgeon for a consult had been made. Observation and interview on 5/13/25 at 11:54 A.M., showed: -The resident's face on the left side jaw area was swollen. -The resident said he/she had seen the dentist and his/her face was swollen and painful. -He/She had been on antibiotics. -He/She was waiting to find out when his/her appointment was to see the oral surgeon to have his/her remaining teeth pulled so he/she could get a set of dentures. -He/She had seen the dentist maybe three weeks ago and so far no appointment had been made. During an interview on 5/19/25 at 2:00 P.M., the Unit Manager said: -Transportation made the dental appointments. -On 4/28/25 the resident was seen by a dentist. -The resident had several teeth that needed to be pulled. -The resident's teeth needed to be pulled by an oral surgeon. -The appointment should have been made in a day or two with 360 (a medical service). -The resident had been on Amoxicillin from 4/25/25 to 5/4/25. -An appointment should have been made before and it was not done. During an interview on 5/22/25 at 1:45 P.M., the Administrator said: -The resident did not qualify for services from 360. -An alternate dental service should have been contacted within a couple of days and it was not done. -The nurse would contact the transportation clerk and he/she would make the appointment. -Transportation makes the appointments and it was missed. During an interview on 5/23/25 at 9:00 A.M., the Transportation clerk said: -He/She was notified by the nursing staff the resident needed to see an oral surgeon. -He/She did not have any documentation of attempts of calling any other dental services for the resident. -He/She usually had an appointment date within a day or two of having been notified by the nursing staff that a resident needed to see a dentist or oral surgeon. -If they did not have funds to pay for dental services then he/she would have called a nearby hospital and obtain a date for a dental appointment within a day or two. -This resident was missed. During an interview on 5/23/25 at 1:30 P.M., the Director of Nursing said: -If a resident needed to see an oral surgeon after seeing the Dentist there should have been an appointment made within a day or so. -The resident had seen the Dentist on 4/28/25 this was now almost a month later and the resident still did not have a date to have his/her teeth pulled. -The Transportation clerk made the appointments, this one was missed.

Based on observation, interview, and record review, the facility failed to ensure there was communication going to the dialysis center (a medical facility where dialysis treatment were provided to patients with end-stage renal disease to filter a patients blood when their kidneys no longer can) such as the resident's vital signs and receive communication from the dialysis center after a resident's treatment such as vital signs, pre and post treatment weights, and anything unusual that may have happened during the treatment for one sampled resident, (Resident #236) out of 35 sampled residents. The facility census was 259 residents. Review of the facility's Dialysis Care policy, dated October 24, 2022, showed: -The facility would be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment. -The facility maintains a contract with a dialysis service provider which addresses communications between the facility and the provider. -Nursing staff would communicate pertinent information in writing to the dialysis staff. -The dialysis provider would communicate in writing to the facility. --Current vital signs. --Pre and post dialysis weights. --Any problems encountered while at the dialysis unit. -Nursing staff may us the Nurses Dialysis Communication Record to covey information to the dialysis unit. -All documentation concerning dialysis services and the care of the dialysis resident would be maintained in the resident's medical record. 1. Review of Resident #236's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -End Stage Renal Disease (ESRD when the kidneys can no longer filter the blood). -Dependence on renal dialysis (the process of filtering a persons blood). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning), dated 2/28/25, showed: -He/She had End Stage Renal Disease. -He/She was on dialysis. -He/She had a central line for dialysis use was not checked. Review of the resident's Physician's Order Sheet (POS), dated May 2025, showed the following orders: -Monitor dialysis site right upper chest central line dressing for drainage, bleeding or signs and symptoms of infection every shift. -The resident was to receive dialysis at nearby dialysis unit on Monday, Wednesday, and Friday. Review of the resident's care plan, dated 5/7/25, showed: -He/She would refuse to go to dialysis at times and had been educated on the risks and benefits of the dialysis process. -He/She had a central line to the right upper chest. -All labs were to be drawn at the dialysis unit weekly. -Staff were to request progress report from dialysis unit as indicated. -Weigh as ordered. Review of the resident's Dialysis notebook showed: -The upper portion was to be filled out by the facility with the resident's vital signs. -The lower portion was to be filled out by the Dialysis unit with the resident's pre and post dialysis weights, the resident's vital signs, any medication or treatment that was given at dialysis, and anything unusual that would have happened. -On 4/2/25 the facility's portion was not filled out (blank). -On 4/4/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/7/25 there was no form. -On 4/8/25 the facility's portion was not filled out. -On 4/9/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/11/25 there was no form. -On 4/14/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/16/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/18/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/21/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/23/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/25/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/28/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 4/30/25 the facility's portion was not filled out. -On 5/2/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 5/5/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 5/7/25 there was no form filled out by the facility (missing). An electronic form was sent by the dialysis unit. -On 5/9/25 the dialysis's portion was not filled out. -On 5/12/25 the post dialysis weight was not recorded by the dialysis unit. -On 5/19/25 the dialysis portion was not filled out. -On 5/21/25 there was no form. Observation on 5/21/25 at 12:00 P.M., showed the resident had a central line catheter for dialysis use located in his/her right upper chest. During an interview on 5/21/25 at 12:00 P.M., Licensed Practical Nurse B said: -The resident went out for dialysis treatments on Monday, Wednesday, and Friday. -He/She had just came back from dialysis. -He/She took a notebook to communicate to the dialysis unit, with him/her to dialysis. -They had a form (Dialysis Communication Form) they filled out before the resident went to dialysis with the resident's vital signs filled in by the facility's nursing staff. -When he/she came back from the dialysis unit, the dialysis staff should have filled out the bottom half of the form with the vital signs, before and after weights, and anything that was done at dialysis such as if the resident received blood. -Many times the bottom half of the form was not filled out by dialysis unit. -The Charge Nurse would have to call the dialysis unit to have the dialysis unit send the completed form. -He/She was the Charge Nurse, but he/she did not call the dialysis center to get the missing forms. During an interview on 5/22/25 at 3:00 P.M., the Assistant Director of Nursing said: -The staff were to fill out the top half of the dialysis communication form with the resident's vital signs. -The communication form was then sent with the resident to dialysis in their notebook, the dialysis staff should have filled out the bottom half of the form with the resident's vital signs, pre and post weights, and anything that may have happened at dialysis. -When the resident came back from dialysis the nurse should have ensured both halves of the communication sheet had been filled out. -The communication form was then sent to medical records to have been scanned into the resident's chart. -If the dialysis unit had not filled out the sheet the nurse should have called the dialysis unit to get the information sent to them electronically. -This had not been done on a regular basis. -The Charge Nurse on the floor was responsible for ensuring it was completed each time the resident came back from dialysis. During an interview on 5/23/25 at 1:30 P.M., the Director of Nursing said: -Nursing staff was to communicate with the dialysis unit via the dialysis communication sheet. -The facility would enter the resident's vital signs on the communication sheet, then put the sheet in the resident's notebook to take with them to dialysis. -The dialysis staff was to fill out the bottom half of the communication sheet, then put the sheet in the resident's notebook to take back to the facility. -The Charge Nurse was then to review the sheet to ensure that it was completely filled out by the facility staff as well as the dialysis staff. -If the dialysis portion was not completed the Charge Nurse should have immediately called the dialysis unit to have them send it electronically. -There should have been a communication sheet filled out for each time the resident went to dialysis. -If the resident refused to go to dialysis it should have been documented on the communication sheet. -The Unit Manager was responsible for ensuring communication with the dialysis unit was complete each time. They should have been doing audits to ensure communication was done timely. -He/She expected the communication form or electronic forms to have been completed no later than 24 hours after the resident returned from dialysis.

Based on observation, interview, and record review, the facility failed to ensure the dignity of one sampled resident (Resident #1) when on 11/29/24 at 5:37 A.M., Certified Nurses Aide (CNA) A argued and cursed at the resident out of three sampled residents The facility census was 258 residents. The Administrator was notified on 12/2/24 of Past Non-Compliance which occurred on 11/29/24. The facility had provided education to all staff prior to their next shift on customer service, abuse and neglect. The deficiency was corrected on 11/30/24. Review of the facility's policy titled Privacy and Dignity dated 10/24/22 showed: -The facility promoted resident care in a manner and an environment that maintained or enhanced dignity and respect, in full recognition of each resident's individuality. -Staff were to treat the residents with respect including respecting their social status, speaking respectfully, and listening carefully. 1. Review of Resident #1's admission Record showed he/she admitted to the facility with a diagnosis of Amyotrophic Lateral Sclerosis (ALS- a nervous system disease that weakens muscles and impacts physical function). Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/31/24 showed: -The resident was cognitively intact. -The resident was fully dependent on staff, (helper does all of the effort, resident does none of the effort to complete the activity.) Review of the resident's undated care plan showed: -The resident had an Activities of Daily Living (ADL) self-care deficit related to his/her diagnosis of ALS and had an electric wheelchair and was independent once in wheelchair. -The resident had difficulty expressing himself/herself and being understood and was better understood via writing, usually on his/her phone. Review of a video recording of the incident dated 11/29/24 at 5:37 A.M. showed: -CNA A was standing outside the resident's door frame to the bathroom in the resident's room and the resident was in his/her wheelchair in the doorframe to the bathroom and they were facing each other. -CNA A said, I will sue your ass and then hit me with that chair if you want to, I am pregnant and I will sue your ass, do you understand me, hit me with that chair. -The resident reached out towards CNA A and made contact with the CNA's right forearm with a swiping motion. -The resident again reached out to attempt to hit CNA A again and CNA A swatted the resident's hand away and said, don't put your hands on me. -CNA A turned towards the door to leave and told the resident put your hands on me and I will sue your ass, hit me again and exited the resident's room. -Once in the hallway, CNA A could be heard saying no wonder they stuck you in here and left you. -The resident then exited his/her room and CNA A could be heard saying don't try to hit me with your chair and put your hands on me, hit me while I am pregnant and I will sue your ass out of here, I will sue you. Review of the resident's behavior note dated 11/29/24 completed by Registered Nurse (RN) A showed: -The resident had wanted to get up and out of bed to use the restroom, but the nurse at the time was unable to understand the resident. -The resident became upset with the nurse and turned his/her TV up to the highest volume setting. -The nurse asked the resident to turn down the volume of the TV, but the resident refused. -Other residents on the unit began to complain about the volume. -During this time the resident tried to hit CNA A and had attempted to ram CNA A with his/her wheelchair. -The resident's sons were notified of the behavior. Review of the Investigation Summary dated 11/29/24 showed: -The resident had reported to the family that he/she had been hit on the top of his/her hand. -Upon further investigation it was noted that the resident was moving his/her electric wheelchair in the direction of the CNA A. -The CNA A told the resident not to hit him/her with the wheelchair because the CNA A was pregnant, and the CNA A would sue the resident. -The resident then grabbed the CNA A's arm. -The resident then attempted to grab the CNA A's arm again and the CNA A pushed the resident's arm away pushing the top of the resident's hand down. -The CNA A had not intentionally caused harm to the resident and the incident was not classified as abuse. Review of a Social Services note dated 11/29/24 at 8:45 A.M. completed by Social Services Designee (SSD) A showed: -CNA A had an attitude with the resident when helping him/her to the bathroom. -During that time, the resident had turned up the volume of his/her TV because he/she could here the staff talking about other residents on the hall. -The CNA A had told the resident to turn his/her TV down because it was too loud. -The resident attempted to use his/her phone to explain to the CNA A about why the volume was turned up, but that made the aide mad. -When the resident would not turn the volume down on the TV, the CNA A unplugged the resident's TV and left the room. -The CNA A then returned to the resident's room and the resident was positioned in front of the door. -The resident attempted to turn his/her chair around and began yelling at the resident Don't hit me with your chair and began cursing at the resident. -The resident thought the CNA A had something in his/her hands and attempted to reach for it because he/she thought the CNA A was gonna hit me with the item that the CNA A had in his/her hand and that was when the CNA A hit the resident on the top if his/her hand. -The resident denied any pain at the time of the interview. -The resident denied trying to hit the CNA A with his/her wheelchair but had admitted to attempting to block the door so that the CNA could not get into the resident's room. During an observation and interview on 12/2/24 at 10:45 A.M. the resident said: -He/She could not really say what happened, just that an incident between him/her and a CNA had occurred. -He/She pointed towards the camera and thought there might be video footage of the incident. -He/She communicated better using his/her phone and showed the on-site a text message that he/she had previously typed. -The text message was dated 11/29/24 and showed: --That it all started from his/her music. --He/She got up around 4:00 A.M. and turned his/her light on. --He/She went into hallway and didn't see a nurse or CNA. --They were sitting at desk; the nurse was mad at the resident because the nurse hated it when the residents were in his/her space. --The nurse told the resident to back out of his/her space. --The resident went back into his/her room and turned his/her music on. --The nurse come to door and told the resident to turn it off or close door. --The resident responded with no and one thing led to another. --The CNA came into the resident's room and climbed over the resident to unplug his/her TV. --The CNA hit his/her hand while exiting the room During an interview on 12/2/24 at 11:51 A.M. CNA A said: -The incident occurred on 11/29/24 in the morning. -He/She had not normally worked with the resident. -He/She started rounding on resident's around 4:00 A.M. -The resident was upset because the staff had not gotten the resident up. -The resident had been in his/her room and started to play music really loud. -The resident refused to turn the music down and the nurse went to talk with the resident. -The resident still refused to turn the music down, so the nurse asked him/her to unplug the resident's TV. -He/She followed the nurse's order and went into the resident's room to unplug the TV. -When he/she turned to leave the room. The resident had blocked him/her from leaving. -The resident was in the doorframe to the bathroom and was facing the wall. -The resident then rammed his/her wheelchair into his/her left leg. -He/She asked the resident not to hit him/her with the wheelchair. -The resident then rammed his/her wheelchair into his/her right leg. -That action caused the him/her to fall back, so he/she had to steady himself/herself on the wall. -The resident then swung at him/her and attempted to block the hit to prevent the resident from hitting his/her stomach. -The resident had made contact with the resident's right forearm. -He/She had heard the nurse coming down the hall and stated that the resident had hit him/her. -He/She then exited the resident's room. -The nurse handled the situation from then on. -He/She denied hitting the resident. -He/She denied cursing at the resident. -He/She had only told the resident not to hit him/her due to being pregnant. -He/She then left shortly after because the resident was attempting to record him/her. -That was the only interaction he/she had with the resident during that shift. -He/She was unsure if there was camera footage of the incident because he/she did not think the resident's camera was working during the time of the incident. During an interview on 12/2/24 at 12:36 P.M. SSD A said: -He/She had seen the video recording of the incident between the resident and CNA A. -The footage showed the resident and CNA A arguing and that the resident had been moving his/her wheelchair towards CNA A. -The footage also showed CNA A moving his/her hand in the direction of the resident, but he/she was unsure if contact had been made. -The resident's family had sent him/her the video footage. -CNA A had not responded to the situation appropriately. -CNA A should not have been arguing or cursing at the resident. During an interview on 12/2/24 at 1:00 P.M. the Director of Nursing (DON) said: -CNA A had not responded to the situation appropriately. -CNA A should not have cursed at the resident. -CNA A should have used de-escalation tactics during the incident and should have walked out of the resident's room after the resident had hit CNA A. -The way CNA A responded was not how staff were trained/educated. During an interview on 12/2/24 at approximately 1:10 P.M. the Administrator said: -CNA A had not responded to the situation appropriately. -CNA A had not responded the way he/she had been educated. -CNA A had been educated upon hire of the facility's customer service and dignity policies on 10/31/24. -CNA A should not have spoken to the resident the way he/she had. -CNA A should have used de-escalation tactics during the altercation. During an interview on 12/2/24 at 3:01 P.M. Registered Nurse (RN) A said: -He/She knew the resident liked to get up around 4:00 A.M. -He/She was unsure of why the resident had turned his/her music up so loud. -He/She went to the resident's room and told the resident to turn down his/her music. -The resident was trying to block the door from the nurse being able to enter the resident's room. -He/She was attempting to get into the resident's room to turn down the music. -He/She had CNA A go into the resident's room to turn down the music. -CNA A then reported to him/her that the resident was upset and had tried to hit CNA A with his/her wheelchair. -The resident did not report to him/her that CNA A had hit the resident. -CNA A should not have cursed or argued with the resident. -CNA A should have walked away from the situation after the resident attempted to hit him/her. MO00245863

Based on observation, interview, and record review, the facility to provide a safe, functional, sanitary, and comfortable environment for all residents, staff, and public when staff failed to maintain two beds and failed to keep flooring cleanable and sanitary. The facility census was 260. Review of the facility's policy titled Maintenance Services, revised 10/24/22, showed the following: -Purpose of the policy was to protect the health and safety of residents, visitors, and facility staff; -The Maintenance Department maintained all areas of the building, grounds,and equipment; -The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of the maintenance department may include, but are not limited to, maintaining a building free from hazards, establishing priorities in providing repair service, maintaining all mechanical, electrical, and patient care equipment in safe operating condition, providing routinely scheduled maintenance service to all areas, other services that may become necessary or appropriate; -The Director of Maintenance was responsible for conducting regular inspections that may include, but are not limit to, bed frames. 1. Observation on 11/25/24, at 12:16 P.M., of room [ROOM NUMBER]-L showed the following: -The bed was a high/low adjustable bed; -The base of the bed was made of round pipe with the edges of the pipe exposed on the side away from the wall; -An area approximately 3 foot (ft) X 3 ft, under the head of the bed, where the edge of the exposed pipe sat had deep gouges in the tile; -An area approximately 20 X 20, inside the 3 ft X 3 ft area, was missing tile that had been worn off from the edge of the pipe; -An area approximately 2 ft X 1 ft, under the foot of the bed, where the edge of the exposed pipe sat had deep gouges in the tile, -An area approximately 10 X 5, inside the 2 ft X 1 ft area, was missing tile that had been worn off from the edge of the pipe, -The pipe edges were missing the stoppers that kept the bed from moving freely on the floor. Observation on 11/25/24, at 2:42 P.M., of room [ROOM NUMBER]-R showed the following: -The bed was a high/low adjustable bed; -The base of the bed was made of round pipe with the edges of the pipe exposed on the side away from the wall; -An area approximately 1 ft X 2 ft, under the head of the bed, where the edge of the exposed pipe sat had deep gouges in the tile; -An area approximately 2 ft X 1 ft, under the foot of the bed, where the edge of the exposed pipe sat had deep gouges in the tile, -The pipe edges were missing the stoppers that kept the bed from moving freely on the floor. During an interview on 11/26/24, at 10:09 A.M., Certified Nurse Aide (CNA) F said the following: -The residents' rooms were cleaned daily; -Bed L in room [ROOM NUMBER] and Bed R in room [ROOM NUMBER] were missing the brakes/stoppers for the base of the bed; -The brakes/stoppers prevented the beds from moving freely on the floor and also protected the floors; -The floors, in the condition they were in, were not cleanable surfaces; -The bed bases, with exposed pipe edges, were a hazard to the resident; -He/she would report to maintenance that the beds were missing parts. During an interview on 11/26/24, at 10:57 A.M., the Unit Manager (UM) said the following: -The residents' rooms were cleaned daily; -The staff should report any floor or bed issues to the UM; -The UM reported maintenance issues to the Maintenance Director through an electronic system (TELS program); -Bed L in room [ROOM NUMBER] and bed R in room [ROOM NUMBER] were hazards to the residents, since the beds were missing parts; -The floors in room [ROOM NUMBER] and 211 were not cleanable surfaces. During an interview on 11/26/24, at 12:44 P.M., the Director of Nursing (DON) said the following: -Staff would notify the UM of any issues/concerns regarding the condition of equipment and floors; -The UM would notify maintenance using the TELS program of any issues/concerns; -The floors in rooms [ROOM NUMBERS] were not cleanable surfaces and needed to be striped and resealed; -The exposed base of bed L in room [ROOM NUMBER] and bed R in room [ROOM NUMBER] were a hazard to residents; -Housekeeping was ordering the brakes/stoppers for the beds in rooms [ROOM NUMBERS]. During an interview on 11/26/24, at 1:56 P.M., the Regional Maintenance Director (RMD) said the following: -The Maintenance Director and department heads were responsible for the upkeep of equipment and the building; -The facility used the TELS program for weekly, monthly, and quarterly routine inspections; -Work orders are put in the TELS program and assigned to one of the maintenance staff; -Work orders are assigned by priority; -No work order had been filed regarding the floors and beds in room [ROOM NUMBER] and 211 until today; -Housekeeping was ordering the brakes/stoppers for the beds in rooms [ROOM NUMBERS]. -Housekeeping would be removing the tiles and replacing them in rooms [ROOM NUMBERS]. During an interview on 11/26/24, at 2:30 P.M., the Administrator said the following: -Staff should report any maintenance issues to the UM; -The UM used the TELS program to enter a work order; -Management was responsible for following up on work orders to ensure the issue has been resolved; -All equipment should be set up per manufactures' recommendations and should not be a hazard to the residents; -All floors should be cleanable surfaces. MO00245514

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program when staff failed to follow the facility's infection control policies and guidance by the Centers for Disease Control (CDC) related to Coronavirus Disease 2019 (Covid-19 - an infectious disease caused by severe acute respiratory syndrome) when staff failed to complete follow-up Covid-19 tests for two residents (Resident #2 and Resident #4) who had shared rooms with residents who became positive for Covid-19 and when staff failed to follow infection control practices related to hand washing and personal protective equipment (PPE - items such as masks, gowns,and gloves) usage when working in areas/rooms with Covid-19 positive residents. The facility census was 260. Review of the CDC's website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 05/08/23, showed the following: -Asymptomatic patients with close contact with someone with SARS-CoV-2 (Covid-19) infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day one (where day of exposure is day zero), day three, and day five; -HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters (face masks) or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of facility policy titled, Hand Hygiene, revised 10/24/2022, showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors; -Facility staff, visitors, and volunteers mush perform hand hygiene, wash hands with soap and water or alcohol-based hand hygiene products can and should be used to decontaminate hands, immediately upon entering a resident occupied area and immediately upon exiting a resident occupied area; -Hand hygiene is always the final step after removing and disposing of personal protective equipment. Review of the facility's policy titled Covid-19 Testing & Quarantine, revised 06/13/23, showed the following: -Purpose of the policy was to prevent Covid -19 from entering nursing homes, detect cases quickly, and stop transmission; -The facility will test residents and facility staff, including individuals providing services under arrangement and volunteers, for Covid-19 in accordance with the CDC guidelines, unless more stringent state or local testing guidelines exist; -Close contact means someone who has been within six feet of a Covid-19 positive person for a cumulative total of 15 minutes or more over 24 hour period; -Covid-19 testing will be conducted in a manner that is consistent with current standards of practice; -The facility will perform testing for all residents and facility staff identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status; -Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative again after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3 and day 5. Review of the facility's policy titled Standard and Enhanced Precautions, revised 4/1/24, showed the following: -To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents; -The facility will utilize current guidance from the CDC and the Centers for Medicare & Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection; -Standard Precautions refers to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, no-intact skin, and mucous membranes may contain transmissible infectious agents. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/14/22; -Diagnoses included unspecified dementia, Covid-19, and hyperlipidemia (high levels of fat in blood). Review of the resident's care plan, undated, showed the following: -The resident had confirmed Covid-19 infection; -Encourage the resident back in his/her room as needed; -Encourage to wear a mask as needed; -Determination to discontinue isolation precautions will be as directed by state and/or local health department; -Meticulous hand hygiene before and after each encounter with the resident and others according to policy and procedure. Review of the resident's progress note dated 11/18/24, at 2:29 P.M., showed the social service staff called the resident's durable power of attorney (DPOA) and left a message informing them that the resident had Covid-19. Review of the resident's Covid-19 testing showed on 11/18/24 the resident tested positive for Covid-19. Review of the resident's progress note dated 11/26/24, at 6:24 A.M., showed Licensed Practical Nurse (LPN) B documented the resident remained on Covid-19 precautions. 2. Review of Resident #2's face sheet (resident's information at a quick glance) showed the following: -admission date of 03/24/21; -Diagnoses included unspecified dementia, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and major depressive disorder (mood disorder that is characterized by a low mood and negative emotions). Review of the resident's care plan, undated, showed the resident preferred to be in his/her room. Review of the resident's COVID-19 tests showed on 11/18/24 the resident tested negative for Covid-19. Review of the resident's progress note dated 11/18/24, at 2:10 P.M., showed the social service staff called the resident's DPOA and informed them that the resident moved to a different room. (The resident had been in the same room as Resident #1 who tested positive for Covid-19.) Review of the resident's Covid-19 tests showed on 11/25/24 the resident tested negative for Covid-19. (Staff waited seven days between COVID tests.) 3. Review of Resident #3's face sheet showed the following: -admission date of 07/05/24; -Diagnoses included Covid-19, chronic obstructive pulmonary disease (COPD- is a common lung disease that makes it difficult to breathe), and unspecified dementia. Review of the the resident's care plan, undated, showed the following: -The resident had confirmed COVID-19 infection; -Encourage the resident back in his/her room as needed; -Encourage the resident to wear a mask as needed; -Meticulous hand hygiene before and after each encounter with the resident and others according to policy and procedure. Review of the resident Covid-19 testing showed on 11/18/24 the resident tested positive for Covid-19. Review of the resident's progress notes showed the following: -On 11/18/24, at 2:34 P.M., the social service staff attempted a call to the resident's DPOA, but did not make contact; -On 11/26/24, at 6:45 A.M., LPN B documented that the resident remained on Covid-19 precautions; -On 11/26/24, at 10:13 A.M., LPN C documented that the resident remained on Covid-19 precautions. 4. Review of Resident #4's face sheet showed the following: -admission date of 01/24/24; -Diagnoses included unspecified dementia, unspecified severe protein-calorie malnutrition, and essential hypertension (high blood pressure). Review of the resident's Covid-19 tests showed on 11/18/24, the resident tested negative for Covid-19. Review of the resident's progress dated 11/18/24, at 2:25 P.M., showed the social service staff called the resident's DPOA and informed them that the resident moved to room a different room. (The resident had been in the same room as Resident #3 who tested positive for Covid-19.) Review of the resident's Covid-19 tests showed on 11/25/24, the resident tested negative for Covid-19. (Staff waited seven days between Covid-19 tests.) 5. During an interview on 11/25/24, at 5:37 P.M., Certified Nurse Aide (CNA) E said Resident #1 and Resident #3 had roommates that did not test positive for Covid-19 and were moved to different rooms. During an interview on 11/26/24, at 10:09 A.M., CNA F said both residents had roommates, Resident #2 and Resident #4, that were moved to different rooms after testing negative. Resident #2 and Resident #4 should be retested due to close contact with Resident #1 and Resident #3. During an interview on 11/26/24, at 10:27 A.M., the Unit Manager (UM) said the following: -Two residents, Resident #1 and Resident #3, were the only residents left that were Covid-19 positive; -Residents were tested weekly, if one resident tested positive and their roommate tested negative the roommate was moved to a different room and the Covid-19 positive resident was put on isolation; -The IP made the Covid-19 testing schedule for residents and staff; -Residents being moved out of Covid-19 positive rooms should be retested in 48 hours. During an interview on 11/26/24, at 11:33 A.M., the Infection Preventionist (IP) said the following: -Residents are tested every 24 hours, 72 hours, and the 5th day and then weekly after two weeks; -Resident #1 and Resident #3 tested positive for Covid-19 on 11/18/24. Each resident had a roommate; -Resident #2 and Resident #4 tested negative for Covid-19 on 11/18/24 and were moved to separate rooms with new roommate; -Resident #2 and Resident #4 were not tested for Covid-19 again until 11/25/24; -The new roommates of Resident #2 and Resident #4 were not tested for Covid-19 again until 11/25/24; During an interview on 11/26/24, at 12:44 P.M., the Director of Nursing (DON) said the following: -The facility was performing contract tracing on residents; -The residents are tested for Covid-19 on the 1st, 3rd, 5th day and every 3 to 7 days after that; -The IP handles the testing schedule and tells staff when they need to test; -Roommates of Covid-19 positive residents should be tested again after 24 hours, 72 hours, and the 5th day after moving to a new room away from the Covid-19 positive room; -All residents were monitored for signs and symptoms of Covid-19. During an interview on 11/26/24, at 2:30 P.M., the Administrator said the following: -He would consult with the DON and IP regarding the most current CDC guidelines in regard to when residents are to be tested for Covid-19; -He expected the IP to stay up to date on and follow CDC guidelines and facility policy regarding Covid-19. 6. Observations on 11/25/24, at 12:12 P.M., of Resident #1's door and the area around the door showed the following: -One sign that read keep door closed; -One sign that read droplet protection; -One sign that read contact precautions; -Two large bins, one for trash and one for linens; -A three drawer container with the following supplies: N-95 mask, bio hazard bags, face shields, and plastic gloves; -A basket containing clean, washable gowns. Observation on 11/25/24, at 12:23 P.M., of Resident #3's door and the area around the door showed the following: -One sign that read keep door closed; -One sign that read droplet protection; -One sign that read contact precautions; -Two large bins, one for trash and one for linens; -A three drawer container with the following supplies: N-95 mask, bio hazard bags, face shields, and plastic gloves; -A basket containing clean, washable gowns. Observations on 11/25/24, of Certified Medical Technician (CMT) D, showed the following: -At 3:22 P.M., CMT D walked down the hallway with two other staff. CMT D was not wearing a mask. CMT D put on his/her mask when he/she saw the surveyor; -At 3:23 P.M., CMT D walked into Resident #3's room, a Covid-19 isolation room, without donning PPE or sanitizing hands prior to and upon exiting the room; -At 3:24 P.M., CMT D walked into Resident #1's room, a Covid-19 isolation room, without donning PPE or performing hand hygiene prior to and upon exit of the room. During an interview on 11/25/24, at 5:21 P.M., CMT D said the following: -PPE included gowns, gloves, face shield, mask. and hand hygiene; -Staff are required to wear PPE anytime they enter a Covid-19 isolation room; -Staff have to perform hand hygiene, don a N-95 mask, gloves, and gowns prior to entering a Covid-19 isolation room; -Upon exiting the Covid-19 isolation room staff are to remove the PPE, dispose of it properly, and perform hand hygiene; -Staff are required to wear a KN-95 mask while working on the unit; -CMT D said that Resident #1 and Resident #3 were on Covid-19 isolation. During an interview on 11/25/24, at 5:37 P.M., CNA E said the following: -Staff are required to don PPE anytime they entered a Covid-19 isolation room; -Staff are required to wear KN-95 mask while working on the unit; -Hand hygiene is performed before donning gloves, when removing gloves, when entering a resident room, and when exiting a resident room; -Staff were told in report that Resident #1 and Resident #3 tested positive for Covid-19 and are on isolation. During an interview on 11/26/24, at 10:04 A.M., LPN C said the following: -Resident #1 and Resident #3 were on isolation for positive Covid-19 test; -Staff are required to don PPE anytime they enter an isolation room regardless of if they are or are not providing cares; -Staff are required to wear KN-95 mask while working on the unit; -Hand hygiene should be performed before donning PPE and after removing PPE, after using restroom, entering resident room, touching doors, providing cares and treatments. During an interview on 11/26/24, at 10:09 A.M., CNA F said the following: -Hand hygiene should be performed before/after providing care, entering/leaving room, and any contact with residents; -Staff are required to wear a KN-95 mask at all times on the unit because of Covid-19 positive residents; -Inservice had been provided recently on when to wear N-95/KN-95 mask and how to properly wear them; -Resident #1 and Resident #3 were on Covid-19 isolation. Observation on 11/26/24, at 10:26 A.M., of Resident #3's room showed the following: -The door to the resident's room, a Covid-19 isolation room, open and resident sitting in a wheelchair, in the room in front of a window; -A sign on the door read keep door closed; -Floor Tech G, the DON, and CNA E walked by the room and did not address the door being open; -Floor Tech G wore a KN-95 mask covering that did not cover his/her nose. During an interview on 11/26/24, at 10:31 A.M., Floor Tech G said the following: -He/she was wearing a KN-95 mask because the air in the Covid unit was not as filtered ; -The floor tech was not sure if there were any residents with Covid-19, but thought there might be two; -The floor tech was provided training on how to properly wear a KN-95 mask and it should be worn covering the nose and the mouth. Observation on 11/26/24, at 10:35 A.M., of Resident #3's showed the following: -The door to the resident's room, a Covid-19 isolation room, was open; -The Infection Preventionist (IP) donned PPE, wearing the N-95 mask over mouth and nose, but not unfold the mask to ensure a seal on the IP's chin. -The IP entered the room, spoke to the resident, exited the room, shut the door, removed PPE, and performed hand hygiene. Observation on 11/26/24, at 10:55 A.M., showed a hospice nurse stood on 2 south (a Covid-19 positive hall) with the KN-95 mask below his/her chin. During an interview on 11/26/24, at 10:27 A.M., the Unit Manager (UM) said the following: -Two residents, Resident #1 and Resident #3, were the only residents left that were Covid-19 positive; -Staff are required to wear a KN-95 mask while working on the floor; -Staff are to don PPE before and after entering Covid-19 isolation room. Hand hygiene is to be performed prior to donning PPE and after removal of PPE. During an interview on 11/26/24, at 11:33 A.M., the IP said the following: -Hospice staff are required to follow the facility's policy and procedures regarding PPE and masking when they are in the facility; -If staff see a Covid-19 isolation room with the door open, staff should don PPE, visit with the resident, address the resident's needs and close the door after exiting the room; -Staff are required to perform hand hygiene and don PPE anytime staff are entering a Covid-19 isolation room, regardless of how long staff will be in the room. During an interview on 11/26/24, at 12:44 P.M., the DON said the following: -Staff were to wear KN-95 mask properly and at all times while working on the unit while there are Covid-19 positive residents; -The IP was responsible for training new staff on the proper way to wear mask during orientation; -PPE is required anytime staff enter a Covid-19 isolation room regardless of time in room and cares provided; -Hand hygiene should be performed before donning PPE, after removing PPE, before and after providing care to resident; -Hospice staff are to follow the facility's guidelines on masking when in the facility. During an interview on 11/26/24, at 2:30 P.M., the Administrator said he expected all staff to follow facility policy regarding PPE and masking. MO00245514

Based on interview and record review, the facility failed to ensure two sampled residents (Resident #1 and #6) out of ten sampled residents received adequate supervision and assistance. On [DATE], staff did not check on Resident #1, who had a diagnosis of dementia and a known history of pulling his/her indwelling catheter, from 12:00 A.M. until 7:00 A.M. At 7:05 A.M., the resident was found lying on his/her side in a pool of blood, urine, and feces. EMS pronounced the resident deceased . On [DATE], CNA A transferred Resident #6 with a Hoyer lift (mechanical lift) by him/herself resulting in the resident sustaining an abrasion to the resident's foot. The facility census was 275 residents. The Administrator was notified on [DATE] at 5:18 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's undated Rounding Policy showed: -All residents are to be rounded on no less than every two hours. -This includes all independent residents as well. -If a resident is in need of attention, you must deliver that care. -There are certain residents that require more frequent rounding, please review the resident Kardex in Plan of Care and discuss with your charge nurse the expectations. 1. Review of Resident #1's Admission Record showed the resident admitted on [DATE], with diagnoses including: -Metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that can lead to personality changes). -Benign prostatic hyperplasia with lower urinary tract symptoms (a condition in men in which the prostate gland is enlarged and not cancerous resulting in difficulty with urination). Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE], showed the resident: -Severely cognitively impaired. -No behaviors. -Used a walker for mobility. -Required partial, moderate assistance with bathing, dressing, and bathroom privileges. -Required set up and supervision for meals and walking. -Had an indwelling catheter and was frequently incontinent of bowel. -Had diagnoses including: -- Obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). --Dementia. --Malnutrition. Review of the resident's Order Summary Report, dated [DATE], showed: -Catheter care every shift. -Catheter securement device in place every shift. -Foley Catheter (transports urine from the bladder to the outside of the body) 18 French, 30 cubic centimeter (cc) balloon, change as needed (PRN). Review of the resident's undated Care Plan showed: -Full Code Status. --If cardiac arrest, do CPR, call 911. -Resident has ADL (activities of daily living) self-care performance deficit related to impaired cognition. -The resident was at risk for falls related to an unwitnessed fall on [DATE]. ---Ensure call light within reach. -The resident had an indwelling urinary catheter due to obstructive uropathy. --Maintain patency and prevent acute urinary tract symptoms. ---Catheter care every shift. ---Monitor and report blood or excess debris in tubing or bag. Review of the resident's Nursing Note, dated [DATE] at 3:12 A.M., showed: -The resident was confused and restful. -Blood was noted on the floor from the bathroom to his/her bed. -He/she had pulled his/her Foley catheter from his/her urethra. -Call made to the provider. -To reinsert the catheter. -His/her room was cleaned. -His/her catheter was reinserted as ordered and the resident received a shower. Review of the resident's Medication Administration Record (MAR) dated [DATE] through [DATE], showed: -Catheter care and securement device in place documented as completed on [DATE] for the night shift. -Catheter change PRN documented as completed on [DATE] at 4:08 AM. Review of the facility Investigation Summary, dated [DATE], showed: -On [DATE] at approximately 7:05 A.M., Restorative Aide (RA) A arrived at the resident's room. -The resident was noted to be lying on his/her left side beside the bed. -The resident's catheter was noted to be dislodged with the bulb still inflated with blood noted on the resident and the floor. -RA A stepped in the doorway of room and called for assistance from (Registered Nurse) RN A. -RN A was unable to determine if the resident had a pulse. RN A obtained a pulse oximetry and readings reported were heart rate 37 beats per minute (normal range is 60 to 100 beats per minute) and oxygen 89% (normal range is 95% to 100%). -Licensed Practical Nurse (LPN) A contacted 911 while RN A was assessing the resident. -RA A left the room to obtain the automated external defibrillator (AED - a medical device designed to analyze the heart rhythm and deliver an electric shock to victims of ventricular fibrillation to restore the heart rhythm to normal). -RA A returned with AED, MDS Coordinator, and the crash cart. -RN A stayed with resident to monitor for changes and noted his/her vitals started to fluctuate. -EMS arrived. Review of the resident's Nursing Note, dated [DATE] at 5:36 P.M., showed: -At 7:10 A.M. on [DATE], the Assistant Director of Nursing (ADON) was notified by the MDS Coordinator there was an issue on 3 North. -ADON arrived at the facility at 7:20 A.M. and went directly to the unit. -Upon entering the room, the resident was noted to be lying on the floor beside the bed. -The resident was lying on his/her back with his/her knees bent up. -His/her Foley catheter bag with tubing and inflated bulb were on the floor at his/her feet. -The resident had on a t-shirt and a sheet beside him/her. -His/her pants and brief were beside his/her recliner. -There was blood and feces on the resident, floor, and bed. During an interview on [DATE] at 8:47 P.M., Certified Nursing Assistant (CNA) A said: -He/She was working the night shift on [DATE] through [DATE]. -He/She provided care for the resident around midnight. -The resident was in bed with his/her catheter in place. -He/She emptied the catheter while in the room. -The resident was alert and did not appear to be in any distress. -The resident was sitting on the edge of the bed, which was in a low position. -He/She had reported to the evening nurse and LPN A earlier the resident had some blood in his/her brief and catheter tubing. -Around 1:00 A.M. on [DATE] he/she was notified of break-ins in the parking lot, which included his/her car. -He/She left the facility between 2:00 A.M. and 3:00 A.M. -There was a supervisor present when he/she left the facility and he/she was aware he/she was leaving. -When he/she left there was one nurse and one aide to care for the residents on the unit. -He/She did not feel that was enough staff to meet the needs of the residents. -He/She was not aware of the resident's death until he/she was contacted by the ADON. During an interview on [DATE] at 8:16 A.M., CNA B said: -He/She worked the night shift of [DATE] through [DATE]. -There was another CNA (CNA A) with him/her on the shift until about 1:30 A.M. -Once the other CNA left, he/she was responsible for all the residents. -CNA A did not give report before leaving. -He/she was off the unit from about 1:30 A.M. to 4:45 A.M. after discovery of car break-in -Upon returning to the unit there were several call lights going off and the nurse was at the computer. -He/She did not recall seeing the resident throughout his/her shift. -He/She was answering call lights and had another resident fall early in the shift. -If a resident did not have the call light on, he/she did not have contact with the resident. -He/She did not have time to check on the residents, but it should have been done. -He/She said there was so much going on with the staff car break-ins and the call lights. -He/She was not aware of the resident's death until he/she was contacted by the ADON. -He/She was doing the best he/she could just to keep the call lights answered. -There were about five staff outside due to the break-ins, as well as him/her, talking about the break-ins, and then to the police. -There was not enough staff to provide the cares for the residents. During an interview on [DATE] at 7:53 P.M., LPN A said: -He/She was working a night shift on [DATE] through [DATE]. -He/She had not seen the resident throughout his/her shift. -He/She had been notified during oncoming shift report that the resident had pulled his/her catheter out and may have some blood in his/her urine. -He/She did not know the resident was in any kind of distress. -Unless the aides report concerns, he/she would not know if anything was going on. -The resident should have been checked on. -CNA A left the facility at 3:00 A.M. because someone broke into his/her car. -When CNA A was leaving, he/she just said he/she was leaving and no replacement came. -The house supervisor was aware of the CNA leaving for the remainder of the shift. -From about 3:00 A.M. was left with only one CNA (CNA B) to work the unit. -He/She observed CNA B busy checking on residents, was up and down the halls, and answering call lights. -He/She did not know when the last time the resident was seen alive. -Restorative Aide (RA) A found the resident. -The resident was laying on the floor covered head to foot with feces and blood all over the place. -He/She called 911 and brought the crash cart. -When EMS arrived they said that due to the resident's age and unknown time down they did not revive the resident. -He/She did not know if the resident was deceased , but the resident looked purple in color. -Emergency personnel told him/her the resident had been like that for at least two hours. -There was blood and feces smeared all over the resident's body. During an interview on [DATE] at 10:32 A.M., RA A said: -At 7:05 A.M., he/she entered the resident's room to provide restorative therapy services to the resident. -Upon entering the resident's room he/she noticed the resident unresponsive with blood on the floor. -The resident was laying on his/her side on the floor in front of the bed. -There was a catheter on the floor with the balloon inflated. -There was feces on the bed that appeared to be solidified. -There was a pungent odor of feces and blood in the room. -When he/she returned to the room with RN A, they turned the resident onto his/her back and noticed stiffness in the body. -The resident's shirt had blood all over the front and feces/urine on the front and back. -RN A assessed the resident to have a pulse and measured an oxygen level while the resident was still on his/her side. -The resident was pale with bluish purple discoloration to the side of his/her face. -RN A was checking the resident for a pulse and repeatedly calling the resident's name. -RN A told LPN A to call 911. -He/She ran to get another nurse and the crash cart. -The MDS Coordinator grabbed the AED and verified the resident was a full code with LPN A, shortly thereafter EMS arrived. -Once EMS had entered the room all facility staff exited the room. During an interview on [DATE] at 7:07 P.M., RN A said: -On [DATE] he/she arrived at the facility at around 6:40 A.M. and went to the nurses station. -He/She only saw LPN A from the night shift. -There was no unusual concerns during report from LPN A. -As they finished report RA A came to him/her asking for him/her to go to the resident's room. -Upon entering the resident's room at approximately 7:05 A.M., he/she realized there was something very wrong. -He/She first noticed blood splattered in a half-moon shape at the end of the bed. There was a strong odor of blood, urine, and feces in the room. -He/she noticed the resident laying on his/her left side in a dried pool of blood. -The resident was not wearing pants or undergarments. His/her catheter was pulled out and the balloon inflated. -There was no bedding on the bed and the bed was covered in feces and blood. -The chair had smeared blood on it. -The resident was covered in a layer of dried blood from his/her belly button down to his/her feet. -The resident was wearing a t-shirt covered in dried blood. -RA A checked for a radial pulse and was not able to obtain a pulse. -He/She left the room to get a pulse oximetry machine. -The readings on the machine said pulse of 37 and oxygen of 89%. -He/She asked LPN A to call 911 and RA A went to get help from the MDS Coordinator. -RA A and MDS Coordinator brought the AED and the crash cart to the room. -They turned the resident onto his/her back and noticed the entire side of the resident's face was purple. -The resident's legs were very stiff and remained in a bent position, even when turned on his/her back. -The pulse oximetry showed different numbers with movement. -When the resident was turned over the discoloration to his/her face moved and appeared to dissipate somewhat. -He/She believed the resident was still alive due to the readings on the pulse oximetry. -When EMS arrived he/she left to get a face sheet for the resident. -EMS placed EKG (electrical signals to the heart) leads on the resident and reported the resident to be in asystole (when your heart's electrical system fails entirely, which causes your heart to stop pumping). -He/She was told due to the resident's age, diagnoses, unknown amount of time the resident was down and rigor mortis (the post-mortem stiffening of muscles caused by the depletion of adenosine triphosphate (ATP) from the muscles) being present no lifesaving efforts were made by EMS. -He/She did not recall any responses from the resident during the assessment and contact with the resident. -He/She did not observe any chest wall movement during the assessment. -LPN A reported not seeing the resident throughout the entire night shift he/she worked. -LPN A reported a CNA left the floor around 3:00 A.M. -At 7:17 A.M. he/she contacted the Nurse Practitioner to report the resident's death. During an interview on [DATE] at 4:07 P.M., the Assistant Fire Chief said: -He/she confirmed there was a call from the facility about a resident with barely a pulse. -Upon arrival they found an obviously deceased person with a large amount of blood and feces on him/her and all over the room. -The dayshift had found the resident during morning rounds. During an interview on [DATE] at 9:54 A.M., the Paramedic said: -The resident was on the floor when they arrived. -The resident's Foley catheter was pulled out and on the floor. -There was a ton of blood on the bed and floor. -There was dried feces on the bed. -There were non-dried feces on the resident's floor and on the resident. -The overall concern was the condition the resident was found in. -The resident was expired upon their arrival. -The resident's catheter was pulled out once before, maybe the night before. During an interview on [DATE] at 3:16 P.M., the MDS Coordinator said: -He/She was in his/her office on the 3rd floor on [DATE] when RA A came to him/her to go to the resident's room. -RN A reported the resident having a pulse. -He/She took the AED to the room and was getting the crash cart and LPN A. -Staff did not put the AED on the resident. -EMS arrived within five minutes of the 911 call. -He/She saw blood and feces everywhere and the resident's catheter was out on the floor. -He/She did not know when the resident was last checked by staff. -The resident was pale and still on the floor on his/her side. -The resident was not wearing pants or undergarments. -There was blood and feces covering the resident from his/her legs down and on the floor. -His/Her main concern was the catheter due to it being pulled out and the balloon was still inflated. -He/she expected the staff to check the catheter during rounds frequently to ensure it was working and secured in place. -The policy and expectation was for residents to be checked around every two hours. During an interview on [DATE] at 2:09 P.M., the ADON said: -On [DATE] he/she received a call from the MDS Coordinator and EMS as the resident was not doing well. The MDS Coordinator denied there was a code blue event at that time. -Upon arrival to the facility EMS was exiting the building. -When he/she entered the resident's room the resident was laying on his/back with the left knee bent. -The catheter was on the floor at the resident's feet with the bulb inflated. -There was blood and feces on the floor and bed. -The resident was pale. -There was blood and feces on the resident. -There was blood smeared on the floor and seat of the recliner. -There were big droplets of blood on the floor, dark red in color. -It was his/her understanding the resident was last checked on around 1:00 A.M. on [DATE]. -He/She expected the staff to have checked the resident during the shift. During an interview on [DATE] at 5:00 P.M., the Administrator said: -On the night of the resident's death there was a lot of confusion in the facility due to cars being broken into. -If the resident was in need, the resident could've used the call light to get assistance. The staff would respond to residents using the call light system to check on them. -The expectation was for residents to be rounded on every two to three hours and call lights to be answered in a timely manner. During an interview on [DATE] at 11:46 A.M., the resident's Power of Attorney said: -The resident had seemed like he/she was doing well. -The resident had dementia which had gotten worse over the last few months. -The resident had been struggling with his/her blood sugars and it was suggested the resident go to a nursing home for rehab. -The resident's death was very unexpected. -He/She was told the resident was found in his/her bed during rounds nonresponsive and 911 was called. During an interview on [DATE] at 1:49 P.M., the Nurse Practitioner said: -He/She was notified of the resident's death immediately by RN A. -It was reported to him/her the resident was found on the floor with blood on him/her. -The staff called 911, EMS came to the facility and said the resident was deceased and rigor mortis had already set in prior to their arrival. -RN A reported the resident's face was purple. -He/She did not know what the cause of death was. -He/She said it would have taken longer than 15 minutes for rigor mortis to set in and would not be present at the time of EMS arrival if the resident had an acute change at or about 7:05 A.M. -He/She said the goal is to check on residents every two hours. -There was usually one nurse and two CNAs for ,d+[DATE] people on the unit. During an interview on [DATE] at 2:30 P.M., the Physician said: -The cause of death for the resident was hard to say and he/she had not signed the death certificate yet. -He/she felt the catheter being pulled out was not the cause. -Due to the resident's diagnosis of cardiovascular disease, it was likely the cause of death. -He/she expected staff to round like they are supposed to in a timely manner. -If the protocol was to round every two hours, then staff should have checked on the resident every two hours. -It is possible the resident expired at midnight and was not found until 7:00 A.M. 2. Review of the facility's Total Mechanical Lift policy, dated [DATE], showed the purpose of the policy was to instruct staff how to use a mechanical lift appropriately to facilitate transfers of residents. Review of Resident #6's Admission Record showed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side. Review of the resident's Quarterly MDS, dated [DATE], showed the resident: -Was cognitively intact. -Functional impairment on one side. -Wheelchair for mobility. -Required substantial/maximal assistance with bathing. -Dependent for chair/bed-to-bed transfer. -Dependent for tub/shower transfer. Review of the resident's undated Care Plan showed: -The resident was at risk for fall related to recent stroke. --The resident will have no injury falls. ---To transfer assist with Hoyer lift with two assist. -The resident had Activities of Daily Living (ADL) self-care performance deficit related to hemiplegia/hemiparesis, impaired balance and mobility. --The resident will remain at current ADL function. ---Transfers up to dependent assist with two with a Hoyer lift. -The resident had hemiplegia/hemiparesis related to stroke. --The resident will remain free of complications or discomfort related to hemiplegia/hemiparesis. During an interview on [DATE] at 7:37 P.M. CNA C said: -He/She was transferring the resident on [DATE] between 7:30 A.M. and 8:00 A.M. when the resident's foot was injured. -He/She was using the Hoyer lift alone. -As he/she was transferring the resident in the Hoyer from the shower chair to the resident's bed, the resident's foot got caught on the control box of the Hoyer, resulting in the injury. -He/She had the resident elevated in the sling and began to move the Hoyer lift. -Another CNA came into the room in the middle of the transfer after the foot was hit on the control box and assisted with completing the transfer. -He/She is aware the Hoyer is to be used with two staff. -The resident was becoming agitated while sitting in the shower chair and he/she decided to transfer the resident alone instead of waiting for another staff to help him/her. Review of the resident's Injury Investigation Report, dated [DATE] at 4:40 P.M., showed: -The resident's foot was brushed against the control box on the Hoyer lift during transfer post shower from shower chair to bed. -One CNA started to transfer the resident by him/herself in the Hoyer lift to assist the resident to bed. -In the middle of cares, a second CNA returned to assist. -The resident had an abrasion to his/her left toes. Review of the resident's Order Summary Report dated [DATE] showed abrasions to left dorsal foot: paint with skin prep, ensure surrounding areas is painted as well. Do not wash off between applications, one time a day and as needed if soiled or unscheduled removal. During an interview on [DATE] at 10:56 A.M. the resident said: -He/She sustained an injury on [DATE] while being transferred. -After his/her shower he/she was brought back to his/her room. -One CNA C was using the Hoyer to transfer him/her from the shower chair to his/her bed. -During the transfer with just one staff member his/her left foot got lodged on the control box on the Hoyer, pinching the top of his/her foot. -He/She said the injury was an accident. During an interview on [DATE] at 2:09 P.M., the ADON said: -He/She expects two staff to be present when using all mechanical lifts, Hoyer lifts. -Staff are expected to hook the lift up correctly, be sure to ask for assistance and be gentle. -Although the policy does not indicate two people are to be utilized for lift operation, the manufacturer's guidelines state two people are required to use the lift safely. During an interview on [DATE] at 5:00 P.M., the Administrator said he/she expected staff to follow the policy while using mechanical lifts. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00240194, MO240120

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free from accident hazards, when one resident (Resident #2) was not secured appropriately with a lap belt in the facility van during transport on 5/20/24. The van abruptly stopped and the resident flew out the wheelchair onto the floor of the van and suffered a femoral fracture of the right leg that required surgical repair. There were 14 residents selected for sample. The facility census was 260. The Administrator was notified on 6/17/27 at 5:30 P.M. of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 5/20/24. Prior to any further facility transports, immediate in-servicing was completed for proper placement in the van and safety belt use with each transport. The IJ was corrected 5/21/24. Review of the facility Fall Management Program Policy, dated 10/24/22, showed: -To prevent resident falls and minimize complications with falls through the development of a Fall Management Program. -The facility will provide the highest quality care in the safest environment for the resident residing the facility. Review of Van Driver A's undated employee training record showed: -All new transport drivers undergo a two day ride along with a current driver, followed by three days where the new employee drives while being observed by an experienced driver. -The new driver is not allowed to operate independently until they have demonstrated competency in all areas. -Completed training between 2/29/24 through 3/7/24. Review of the van maintenance records for 5/24 and 6/24 showed no concerns or needs for restraint systems. 1. Review of Resident #2's Admission Record showed the resident admitted on [DATE] with diagnoses including dependence on renal dialysis, acquired absence of left toes, unsteadiness on feet, muscle weakness, abnormalities of gait and mobility, displaced transverse fracture of shaft of right femur. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 5/31/24, showed: -The resident was cognitively intact. -Functional abilities were dependent on wheelchair for mobility, mechanical lift for transfers and impaired range of motion on both sides. Review of the resident's undated Care Plan showed: -Had activities of daily living (ADL) self-care performance deficit related to 2/21/24 Hoyer lift tipped. --Would remain at current ADL function through next review period. ---Staff provided training. ---Resident was propelled in wheelchair. ---Transfer with Hoyer lift and two assist. ---Resident was non-weight bearing. -Was at risk for falls related to impaired mobility. -4/12/24 fall in wheelchair van. --Will have no major injury falls through review. ---4/12/24 staff contacted wheelchair company to have driver educated on properly locking in a wheelchair. ---Different wheelchair was obtained. Review of the resident's Administration Note, dated 5/20/24, showed: -The resident left for dialysis at 9:47 A.M. Review of the resident's Nursing Note, dated 5/20/24, showed: -It was reported at 10:00 A.M. the resident had a fall while out on transport in one of the facility vans on the way to dialysis from the facility. -The driver had to make a hard stop inadvertently, causing the resident to slide out of his/her wheelchair and onto the van floor. -Driver called 911 and the resident was transported to the hospital by (emergency medical services) EMS for evaluation and treatment. Review of the Facility Investigation, dated 5/20/24, showed: -Fall while being transported in the facility van. -The resident was being transported to dialysis in the facility transport van. -Resident chair was properly secured and seat belt in place. -Mid-transfer a second vehicle cut off the transportation van causing the van driver to hit the brakes to avoid an accident. -Though there was no accident, when the vehicle was coming to an abrupt stop, the resident partially slid out of the wheelchair. -911 was called and EMS transported the resident to the hospital. Review of the resident's Hospital Record, dated 5/20/24, showed: -Presented to the emergency department on 5/20/24 due to right femoral diaphysis (main or midsection (shaft) of a long bone) fracture on the way to dialysis after an abrupt stopped vehicle. -On exam resident was sedated due to recent traction of right leg and unable to give any history. -Orthopedic service had been involved in open reduction, internal fixation (ORIF - a type of surgery used to stabilize and heal a broken bone) has been planned. -Right thigh visibly deformed. -Resident unable to provide much history because of pain. Review of the resident's Orthopedic Consult Note, dated 5/21/24, showed: -Reason for consult: fracture closed. -Extremity pain, extremity swelling, and joint swelling. -To operating room (OR) for Intramedullary nailing (IMN - surgery to repair a broken bone and keep it stable) right femur. Review of the resident's Hospital Discharge Summary, dated 5/23/24, showed: -Discharge diagnosis was acute right displaced right femoral fracture. -Presented on 5/20/24 due to right femoral diaphysis fracture on way to dialysis after an abrupt stop in vehicle while in wheelchair. -Orthopedic consult, IMN right femur 5/21/24. -Resident received one unit packed red blood cells likely related to injury and procedure. -Resident to discharge back to long-term care. Review of the resident's Progress Note, dated 5/28/24, showed: -Resident had recent fracture, apparently fractured his/her femur in the wheelchair van. -Required surgery. -Recent right femur fracture secondary to a fall, status post ORIF. During an interview on 6/13/24 at 9:51 A.M., the resident said: -He/She was riding in the facility van on 5/20/24. -The wheelchair was secured in place. -The driver slammed on the brakes causing him/her to fall out of the wheelchair. -As a result he/she broke his/her leg. -The fire department had to come help get him/her out of the van to go to the hospital. -He/She had to have an operation to repair the broken leg. -He/She was secured in the facility van with the single shoulder strap. -That is how he/she was always secured in the facility van, other drivers used two straps during transport. -He/She had come to the facility due to an infection in his/her left foot. -He/She got a broken leg riding in the van to dialysis, extending his/her stay. During an observation and interview on 6/13/24 at 1:38 P.M., Van Driver A said: -He/She pointed to the floor explaining how the wheelchair was to be secured in the mid-section of the van. -There were four points to secure each wheel of the wheelchair. -He/She used all four points to secure the resident's wheelchair. -He/She pointed out two separate straps to use to secure the resident in the wheelchair in the center of the van. -There was only one strap used to secure the resident, the shoulder strap, at the time of the resident was injured. -The shoulder strap extended from the top left to the lower right of the resident's body. -He/She could not use a lap strap due to the resident being too big to be placed in the back of the van. -During the demonstration, he/she was unable to locate and demonstrate the lap belt for the center of the van. -He/She had to slam on the brakes due to another driver pulling in front of the van. -Upon having to slam on the brakes, the resident came out of the wheelchair which resulted in a broken leg. -He/She contacted 911 to help get the resident to the hospital. -All residents being transported in the facility van which use a wheelchair were to be secured in the back of the van due to being more secure. -The shoulder and lap belt is connected, crossing the body from left to right, forming a v-shape in the back of the van. -He/She did not expect to have to slam on the brakes. -The lap belt was to keep the resident secured in place. -He/She said the resident falling out of the wheelchair and sustaining a broken leg was preventable. During an interview on 6/13/24 at 4:02 P.M. the Director of Nursing (DON) said: -The moment Van Driver A alerted staff of the incident on the bus the administrator was involved. -He/She was told the resident had fallen and EMS was called. -The administrator did an investigation. -The lap belt should have been used to prevent to injury. During an interview on 6/13/24 at 4:05 P.M., the Administrator said: -The lap belt should have been in place. -The resident falling out of the chair and sustaining a broken bone was preventable. -The purpose of the seat belts was to ensure the resident was secure and safe. During an interview on 6/17/24 at 3:09 P.M., the Nurse Practitioner said: -The resident broke his/her leg on the way to dialysis. -The resident ended up out of the wheelchair on the floor of the van. -The resident ended up at the hospital and had to have surgery to repair the broken leg. -He/She expected the resident to be secured in the van. -The resident was supposed to be restrained appropriately. -The incident could have been prevented and the lap belt should have been applied. During an interview on 6/18/24 at 12:56 P.M., the resident's spouse said: -The resident was not strapped in securely in the wheelchair in the facility van on 5/20/24. -He/She was told by the Administrator and the DON the lap belt was not in use when the van came to an abrupt stop, the resident flew out of the wheelchair and sustained a broken leg. -He/She wanted to make sure the facility has the appropriate restraints and training to securely and safely transport the residents of the facility. -He/She does not think the resident will fully recover as the resident cannot straighten his/her leg since the incident. MO00236642

Based on observation, interview, and record review, the facility failed to provide a safe transfer for one sampled resident (Resident #1) which resulted in an injury to his/her left lower extremity requiring 18 stitches and on-going wound care treatments out of three sampled residents. The facility census was 246 residents. Record review of the facility's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, transferring, and toileting) policy/procedure, dated 11/1/21, showed: -The facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -Care and services would be provided for daily living including transfer and ambulation. -A resident who was unable to carry out activities of daily living will receive the necessary services according to their needs. -The facility would maintain individual objectives of the care plan and periodic review and evaluation. The facility had no facility policy for the transfer of residents. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Myocardial Infarction (heart attack). -Neuropathy (numbness and pain, usually in the hands and feet due to nerve damage). Record review of the resident's Admission Minimum Data Set (MDS - an assessment tool used for care planning), dated 12/16/21, showed the resident: -Was cognitively intact and did not resist cares. -Required extensive two person assistance for transfers and one-person extensive assistance with bed mobility, dressing, and hygiene. -Was only able to stabilize with human assistance when transferring from surface to surface. -Used a wheelchair for mobility. Record review of the resident's Care Plan Conference Note, dated 12/21/21, showed he/she required assistance of two facility staff persons with transfers and had an order for a stand lift (also called a stand up lift or sit-to-stand lift - a mechanical device specially designed to secure a person during a transfer to enable a safer lifting and transfer for both the resident and the caregiver). Record review of the resident's Skilled Charting note, dated 12/23/21, showed therapy recommended the resident use a sit-to-stand lift for all transfers. Record review of the resident's Self-Care Performance Deficit Care Plan, revised 12/31/21, showed he/she utilized a sit to stand-up lift with assistance of one staff for transfers. Record review of the resident's physician orders for December and January 2022 showed no order for a stand lift. Record review of the resident's Incident and Injury Report, dated 1/19/22 at 10:00 P.M., showed: -Agency Certified Nurse Assistant (CNA) A reported the resident sustained a big tear on the left lower extremity and didn't know how it happened. -It was approximately seven centimeters (cm) by 10 cm and deep inside with not much bleeding. -Vital signs (measures of respiration, pulse, temperature and blood pressure) were completed and white roll gauze was applied to stop the bleeding and keep the wound clean. -All required parties were informed and the resident was sent to the emergency room (ER). -The injury was most likely due to pressure applied to the resident's leg during a transfer. -The only witness was Agency CNA A who said the resident stated that during the transfer from his/her wheelchair to his/her bed something happened to his/her left lower extremity, but Agency CNA A could not see what had happened to cause the injury. -Agency CNA A's written statement showed he/she was putting the resident to bed. He/she had his/her hands around the resident's waist and was pivoting the resident when the resident said his/her leg was dripping. When he/she took down the resident's pants he/she saw the gash on his/her leg and notified the nurse. He/she had not seen an injury on the resident's leg prior to the transfer. -Agency CNA A received education on the resident's transfer status and to check the residents' care plans for each resident's transfer status. -The Resident Profile sheet (a tool utilized by staff providing guidance to the resident's care needs) was unavailable and the third floor printer was not working to print more. Record review of the resident's nursing notes, dated 1/19/22 and 1/20/22, showed: -A note dated 1/19/22 at 11:50 P.M. showed: -A call was received from the ER showing: --The wound was repaired with Steri-Strips (thin, adhesive bandages) and sutures to be removed in seven to 10 days. --The resident was given Fentanyl (a powerful narcotic (opiate) pain medication) 50 micrograms (mcg) for pain control and a script for pain medications. --Xerofoam gauze (wound dressing that maintains a moist environment and promotes healing) and Coban (an elastic wrap) was applied to be changed daily. --A Tetanus (a bacterial infection) shot was given. -The resident returned to the facility on [DATE] at 1:12 A.M. with new orders for Hydrocodone (an opioid) 5/325 mg every six hours as needed for pain. -A note dated 1/20/22 at 3:58 A.M. showed the resident had eighteen total sutures, five in size four and 13 in size three (large sutures). During an interview on 1/21/22 at 11:00 A.M., the former Director of Nurses (DON) said: -The evening of 1/19/22 the resident was being transferred from his/her wheelchair to his/her bed by Agency CNA A. -Agency CNA A didn't see what the resident's leg hit or scraped, but saw the resident had sustained a skin tear. -The resident was supposed to have been transferred by one staff with the use of a stand lift, but the stand lift had not been used during this transfer. -The resident was immediately checked for injuries. Skin and wound assessments were completed on 1/20/22. During an interview on 1/21/22 at 12:15 P.M., the resident said: -He/she had a large injury six inches or bigger on his/her outer, back left calf. A staff person he/she didn't know was transferring him/her without a stand lift when the injury took place. -Multiple staff had routinely transferred him/her using one staff person and with no stand lift when transferring from his/her bed to the wheelchair and from his/her wheelchair to bed. Staff often lift him/her off the floor, swing him/her in the air and when he/she lands he/she had repeatedly hit his/her ankle or parts of his/her legs. Observation and interview on 1/21/22 at 12:35 P.M., showed: -Restorative Aide (RA) A said: --He/she wasn't sure of the resident's current transfer status, but he/she did a maximum assistance of two staff (the resident's weight was partially supported by two staff) or a sit-to-stand lift while transferring the resident. --If he/she wasn't sure about a resident's transfer status he/she would ask a charge nurse or therapist. --He/she wasn't sure if a resident's transfer status was in POC (Plan of Care), the portion of the resident's electronic record available to CNAs. He/she would go into the resident's electronic POC to see if it had the resident's transfer status. -RA A was observed to access the resident's POC portion of his/her record and said the POC did not have the resident's transfer status, but the paper profile should have it. -RA A showed where on the shelving slot the resident profiles were kept and said he/she couldn't find the manual where the resident profiles were kept. -RA A asked Licensed Practical Nurse (LPN) A if he/she knew where the resident profiles were and LPN A told him/her to check a specific physical file. -RA A checked the file and found a Resident Profile sheet for the resident's hall. The paper profile showed the resident was to be transferred using a gait belt and one to two staff. The resident profile was undated. -RA A said on 1/20/22 he/she transferred the resident on his/her own and he/she supported 75 to 100 percent of the resident's weight. Given the resident's physical abilities he/she would prefer to do a two-person transfer with the resident. Going from a higher surface to a lower surface was easier to do a one-person transfer. Going from a wheelchair to a bed should be a two-person transfer or if only one person was available they should use a sit to stand lift. During an interview on 1/21/22 at 1:25 P.M., the resident said: -When he/she sustained the left calf injury only one staff person was transferring him/her. The staff person told him/her to give them a bear hug. -He/she could hear his/her skin rip as he/she was being lifted into the air during the transfer. -Staff got something to stop the bleeding. -After the injury he/she heard staff discussing what they were going to do with him/her. He/she told the staff he/she wanted to go to the ER. -He/she gets out of bed for every meal. He/she dreaded when the staff do the bear hug transfers. They do them every day. Sometimes staff would hit his/her ankles when transferring him/her. During an interview on 1/21/22 at 1:00 P.M. LPN A said two CNAs assist the resident during transfers or one person can use a sit to stand lift. During an interview on 1/21/22 at 1:35 P.M. the Nurse Practitioner (NP) said: -The resident's left calf wound was a completely new area of skin damage. -The Night Shift supervisor reported the resident's calf laceration. -He/she thought the resident had both inner and outer sutures. A layered closure would make sense given the depth of the wound. -He/she suspected the calf might have been damaged on some part of the resident's wheelchair. It resembled other wounds he/she had seen caused by hitting or scraping against parts of the wheelchair, but he/she couldn't say what really happened. (At this point the resident said the calf had been hit on the wheelchair, but was unable to provide details except that it hurt at a pain level of nine out of 10 when it happened). -He/she was not sure of the resident's transfer technique status, but the CNAs should know it. During an interview on 1/21/22 at 2:14 P.M., Agency CNA B said: -Nobody told him/her how to transfer the resident. -He/she asks the residents how they wanted to be transferred if they can respond. -He/she had transferred the resident with a one-person pivot transfer, but the resident was unable to pivot. -He/she puts the wheelchair close to the resident's bed and had to pick the resident up a little off the floor to transfer him/her, but he/she never had trouble transferring him/her. -He/she did not have sign-on access to the residents' electronic records, because he/she was an agency staff so he/she couldn't see how they were supposed to be transferred. He/She just had to figure it out. -There was no paper showing CNAs each resident's transfer status. During an interview on 1/21/22 at 2:20 P.M., Agency CNA C said: -He/she had helped agency CNA B transfer the resident once. They had to lift him/her a little bit although the resident's feet still touched the floor. -A while back he/she had been given a sheet of paper showing residents' transfer needs on another unit, but had never been given any such information when working on the resident's unit. -If he/she wasn't sure how to transfer a resident he/she would ask the nurse. During an interview on 1/21/22 at 2:28 P.M., LPN A said: -He/she told everyone what their assignments were at the beginning of the shift. -Resident profiles for each resident hall were set out that morning. CNAs need to grab them themselves. He/she had told the CNAs about the profile sheets. -Profile sheets were not reviewed with the CNAs that morning. During an interview on 1/21/22 at 2:53 P.M., Physical Therapist (PT) A said: -PT recommended nursing staff use a sit-to-stand lift with the resident for all transfers for his/her safety. -While the resident worked on two-person transfers as well as sit-to-stand transfers in therapy sessions, the transfer technique must be consistent across all care givers and nursing staff must be consistent in how they transfer the resident. -The CNAs should report to the charge nurse if the resident was not bearing weight. -PTA A educated nursing staff on 1/17/22 on the resident's sit-to-stand transfer technique. -After newly admitted residents were evaluated by therapy and when there are changes in a resident's transfer status therapy asked the charge nurse to update the resident profile sheets to reflect their transfer status and other ADL needs. -The profile sheet for the resident's hall should show the resident required a sit-to-stand for transfers. -The resident was discharged from Physical Therapy on 1/18/22, because he/she had met his/her highest practical level towards his/her goals. During an interview on 1/21/22 at 3:11 P.M., Agency CNA A said: -He/she transferred the resident at around 7:00 P.M. The resident had his/her hands around his/her waist and he/she had his/her arms around the resident's waist. After the transfer the resident said Honey, my leg is leaking. At first he/she didn't know what the resident was talking about, because it was the first time he/she had ever worked with the resident. He/she wondered if tea had spilled. -The resident was fully dressed and was wearing pants. When he/she pulled down the resident's pants he/she saw the wound. It looked as if the resident's leg tissue had burst. It was open, but had little to no blood at all. -He/she couldn't see anything in the room that might have caused such an injury. -He/she wrapped the resident's leg with a wet towel and got Registered Nurse (RN) A who had him/her write a statement. -RN A told him/her to use a sit-to-stand lift when transferring the resident. -He/she didn't know the resident's transfer status at the time of the transfer. The facility uses sheets with that information, but none were available on that day. He/She heard the copier had been down and there were no resident profile sheets available. He/she didn't know any resident's transfer status. During an interview on 1/24/22 at 12:52 P.M., Agency CNA D said: -At the start of his/her shift he/she was given a resident profile sheet. -He/she got the resident up before breakfast himself/herself using a gait belt. -The resident bears very little weight on his/her feet. Most of the resident's weight was on the person transferring him/her. During an interview on 1/24/22 at 1:03 P.M., LPN B said: -CNAs used the resident profile sheets as a guidance when providing cares. He/She didn't know who updated the information. -If there was a discrepancy between the resident's Care Plan and Resident Profile sheet information he/she didn't know who clarified the discrepancy, but he/she would use the most dependent transfer type documented. -He/She would likely contact the House Supervisor for clarification. During an interview on 1/24/22 at 1:30 P.M., PTA A said: -He/She had told nursing staff from the beginning the resident had a sit-to-stand lift status. The nurse was supposed to update the Resident Profile accordingly. -PT A does each resident's initial and subsequent evaluations and communicates with the nurse about the resident's needs. -The resident was initially evaluated on 12/10/22 and received PT services until 1/18/22. -PT sometimes transferred the resident with two staff as they worked on the resident's goals. Due to the resident's inconsistencies in transfer abilities a sit-to-stand transfer technique was recommended for all nursing staff transfers. -Nursing staff were expected to be consistent with all transfers, except in those situations where the nurse decides a more dependent transfer was required such as when a resident was sick and feeling weaker. During an interview on 1/24/22 at 2:10 P.M., Agency CNA A said: -He/she used a gait belt during the transfer the evening of 1/19/22. -He/she put his/her leg between the resident's legs to assist in bearing most of the resident's weight. -The resident had not tripped and he/she was unaware if the resident hit or scraped his/her leg on anything in the room. During an interview on 1/24/22 at 2:33 P.M. RN A said: -Another nurse was on duty and reported at around 7:00 P.M. that Agency CNA A said the resident had sustained a skin tear. -He/she asked him/her if he/she would look at the injury. -The injury was significant and he/she thought the resident needed stitches. The doctor and family were notified. The physician wanted the resident to be sent to the ER. -Agency CNA A said he/she didn't know how the injury happened. Together he/she and Agency CNA A looked at the bed frame, wheelchair wheels and pedals, and the bedside table and didn't see anything with blood on it. -The resident had blood on his/her pant leg, but it was not saturated with blood. His/her skin is very thin. The wound had a watery discharge. -He/she thought the resident's leg might have been injured by dragging or sliding against something during the transfer. -He/she educated Agency CNA A on the resident's sit-to-stand transfer status and to follow the residents' care plans. -The Resident Profiles used by the CNAs are a group effort. If there are any newly admitted residents or changes in a resident's care status the nurse should update the profile sheet immediately. During an interview on 1/24/22 at 3:30 P.M., MDS Coordinator A said: -Facility staff met with the resident's family during the resident's care plan meeting a few weeks ago. -The Director of Therapy said PT recommended nursing staff use a sit-to-stand device for the resident's transfers. -He/she told the charge nurse PT recommended the sit-to-stand for the resident's transfers, but it must not have ever gotten changed on the Resident Profile sheet. -It used to be the MDS Coordinator made sure the resident's information was updated on the Resident Profile with each resident's quarterly review. The facility had recently been short MDS Coordinators and was just now fully staffed again with four MDS Coordinators, although one of the four was currently off. During an interview on 1/24/22 at 3:45 P.M., RN A (now the Interim DON) said: -Any shift or supervisory nurse can update the Resident Profiles. -They were also supposed to be checked for accuracy by the MDS Coordinator when a resident had their quarterly review. -Therapy lets the charge nurse know the resident's needs once their evaluations were completed. -The Director of Therapy comes to all care plan meetings and communicates the resident's needs. -Every resident's profile information should be kept updated and correct. -Nursing staff were educated by therapy staff regarding a resident's transfer and other needs prior to the resident being discharged from therapy. -CNAs had access to the residents' care plans through the electronic POC. -Agency staff, even those who only work for one day, are given a log-in to the POC. -The Resident Profile information should match that of the electronic POC. MO00196150

Based on interview, and record review, the facility failed to follow its policies and procedures to ensure residents were free from sexual abuse. The facility failed to assess residents to determine risks, including capacity to consent to sexual contact. The failure impacted one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia. Twice the resident was found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205), who was also unclothed, and once was found on top of Resident #126. The failure also impacted one unknown resident, when Resident #290, a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice also impacted two closed record sampled residents, including Resident #289 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Lastly, the facility failed to ensure an unidentified resident was not sexually abused by Resident #222, who had severe cognitively impairment. An unknown resident reported Resident #222 took all of his/her clothes off and touched the resident on the chest and genital areas. Resident #222 admitted to taking an unidentified resident's brief off. A sample of 37 residents and six closed records were reviewed. The facility census was 250 residents. The Administrator was notified on 12/8/21 at 3:40 P.M. of an Immediate Jeopardy (IJ) which began on 12/6/21. The IJ was removed on 12/9/21 as confirmed by surveyor onsite verification. Record review of the facility's Resident Rights policy, dated 8/11, in the undated facility admission packet showed that residents should not be subjected to physical, verbal, sexual, emotional and mental harm or abuse. Record review of the facility's Sexual Intimacy policy, dated 8/16, showed: -When residents with dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) or impaired cognition express their sexuality by engaging in intimate and/or sexual behavior with another resident, the facility has an obligation to the residents involved, their designated responsible parties, and staff to assess the residents' abilities to consent and participate in sexual intimacy to avoid negative outcomes and maintain protective oversight. -The definition of capacity: the ability to understand the nature and effect of one's acts in a specific moment in time; an individual may have capacity in one area and not in another. -The definition of competency: refers to global function in making personal decisions across a wide range of domains; a legal finding conducted to allow the court to determine an individual's mental capacity. -The definition of intimacy: expression of the natural desire for people to be connected. Physical closeness includes physical touching, such as nonsexual touching, hugging and caressing. Intimacy is not a synonym for sex; however sexual activity frequently occurs within an intimate relationship. -The definition of protective oversight: 24 hour a day awareness of the location of the resident, ability to intervene on behalf of the resident, supervision of all aspects of care and responsibility for the welfare of the resident except when the resident is on voluntary leave. -The definition of sexual abuse: subjecting another person to sexual contact by force. It includes, but is not limited to sexual harassment, coercion and assault. -Each resident has the right to fulfill his/her need to have social interactions with other people as they wish, unless having the relationship is clinically contraindicated based upon a documented assessment. -Residents will be assessed to determine their capacity to consent to engage in sexual activity, as appropriate, if they suffer from dementia or impaired cognition. -Residents are presumed to have the capacity to consent, absent evidence to the contrary based upon physical and psychological assessments. -Residents have the right to be protected from nonconsensual physical contact of a sexual nature which does not necessarily involve sexual intercourse. -The form in Appendix A, Sexual Intimacy History Assessment, is to be completed upon admission. -When residents are found engaging in some type of sexual contact when they have not been assessed for their ability to consent staff must respond by following the Abuse and Neglect policy; notifying the Administrator, Director of Nursing or his/her designee, residents' physicians and responsible parties for each of the residents; completing an investigation; and documenting an account of the incident and investigation. -Residents who have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Nursing staff will notify the residents' responsible parties of an encounter as soon as possible when the Assessments and care planning process have not been initiated. -Residents who have questionable ability to consent to sexual expression have the right to an assessment to evaluate their competence in making such a decision and, when necessary, for their responsible party to be involved in decisions about their sexual expression. -Interdisciplinary Team (IDT) meetings including each resident and his/her responsible party separately should be scheduled no later than 72 hours from the initial notification of the DON (Director of Nursing) and social services staff. -The IDT meeting should include a discussion involving a determination of the residents' past values and if the relationship is consistent with life-long values; a determination regarding whether past values fully apply in the present situation; a determination, based upon current levels of cognition, if the residents involved have the same rights to privacy and free association as other residents who have no cognitive impairments; a determination regarding the extent that others should be allowed to make decisions about this relationship; a determination if each resident is capable of entering into a relationship without coercion; and the results of the Sexual Consent Assessment will be utilized in further decision-making and care planning. -The facility shall provide initial staff orientation and on-going staff training regarding intimacy and/or sexual expression as well as sensitivity awareness about residents' sexual rights, sexual abuse, and staff responsibilities. -The facility shall obtain consultation regarding intimacy and/or sexual expression in cases that are considered to be complex or controversial. Record review of the facility's Abuse Prevention Program policy, dated 3/18, showed: -The facility affirms the right of their residents to be free from abuse (verbal, mental, sexual, or physical) and prohibits acts of abuse against its residents. -Sexual abuse is defined as non-consensual sexual contact of any type with a resident. -Prevention of abuse will include facility assessment to determine risks that contribute to abusive situations; resident assessment to ensure person-centered care approaches are individualized and communicated to facility staff; and a review of incident patterns to ensure resident safety. 1. Record review of Resident #126's face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Dementia. -Generalized Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Cognitive Communication Deficit. Record review of the resident's medical record showed no documentation a Sexual Consent Assessment was completed. Record review of the resident's care plan, dated 8/18/20 with the last update on 11/23/21, showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. -The staff should allow the resident to make simple decisions about his/her care and clothes to provide a sense of control. -The resident was an elopement risk/wanderer related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident had a communication problem due to his/her dementia related to a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident had impaired cognitive function related to Alzheimer's and Dementia. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facility staff for care planning), dated 8/20/20, showed he/she: -Was severely cognitively impaired with a BIMS (brief interview for mental status) of six out of 15. -Did not have behaviors such as abusing others sexually, pacing, rummaging, public sexual acts, or disrobing in public. -Behaviors did not put the resident at risk for illness or injury and did not impact others. -Did wander 1 - 3 days during the look back period. -Wandering did not put the resident at risk. Record review of the resident's Behavior Notes, dated 9/1/20, showed: -The resident was found with an unidentified resident on top of him/her in another resident's room. -The resident said the other resident just touched his/her chest and tried to remove an article of clothing. -The residents were separated and he/she was escorted out of the room and placed on 15 minute checks. -No injuries were sustained. -The house supervisor and the physician were notified. A message was left for the residents' responsible parties. Record review of the resident's incapacity letter, dated 9/15/20, showed: -The resident's physician (Physician A) signed the letter, which stated the resident is unable to receive and evaluate information or communicate decisions to such an extent that he/she even with appropriate services and assistive technologies, lacks capacity to manage essential requirements for food, clothing, shelter, safety, or other care; such that serious physical injury, illness or disease is likely to occur, and to such an extent that he/she lacks the ability to manage financial resources without supervision or assistant. -The letter also stated it is the resident's physician's opinion that the power of attorney for the resident should be allowed to serve in that capacity to meet his/her needs. Record review of the resident's behavior note, dated 11/27/21 at 8:45 P.M., showed: -Resident #126 was found undressed and in bed with Resident #205, who was also naked. -The resident resisted but did go back to his/her room. -The DON was notified and the resident's family was called with a message left. -Resident refused skin assessment, but staff reported no issues when he/she was getting dressed. -The resident was pacing around the halls trying to get back to the other resident's room. Staff redirected the resident. Record review of the undated facility investigation of the 11/27/21 incident showed: -The investigation included a soft file check list which included a face sheet, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .), and any other applicable documents (grievance forms, resident council minutes, etc.) --Witness statements and resident interviews were highlighted with a note beside the resident interviews for the Social Services Designee (SSD) to do an intimacy assessment. --Documentation of follow up actions had a notation beside it that was highlighted for 15 minute checks. -An updated care plan for the resident, dated 11/30/21, showed the resident had a consensual relationship with another resident and both residents were agreeable and consenting to the relationship. -A sexual intimacy history for the resident, dated 11/30/21, showed the resident identified Resident #205 as a person he/she was in a relationship with. -No documentation a Sexual Consent Assessment was completed per facility policy, although the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of 15 minute check sheets from 11/27/21 through 12/3/21 showed: -The 15 minute checks started on 11/27/21 at 7:00 P.M. -There were no initials on 11/28/21 at 6:30 A.M. and 6:45 A.M. -The 15 minute checks were completed through 11/30/21. -The 15 minute checks resumed on 12/1/21 at 10:30 P.M. with no documentation as to why and ended on 12/3/21 at 6:30 A.M. Record review of the resident's care plan, dated 11/30/21, showed the resident had a consensual relationship with another resident and both residents were agreeable and consenting to the relationship. Record review of the resident's social services note, dated 11/30/21, showed: -SSD A spoke with the resident's family member concerning the incident over the weekend involving the resident. -The resident's family member stated as long as there was no harm and the resident agreed with the contact from the other resident, he/she had no concerns. -The resident's family member spoke about resident dating life and laughed and told jokes. Record review of the resident's Sexual Intimacy History, dated 11/30/21, showed: -The resident answered yes to the following questions: --Are you comfortable giving or receiving affection such as a soothing touch, hug, or a kiss? --Are you accustomed to sleeping alone in bed? --Are you currently involved in a relationship? --Are you seeking to have a relationship with someone in the facility? If so, explain. The form indicated Resident #205. -The resident answered no to the following questions: --Do you have any concerns regarding your interactions with this person. If so, explain. --Any known history of abuse, mistreatment, or trauma: sexual, physical, emotional, verbal. --Do you have any known history of sexually transmitted infections? -The resident did not have a Sexual Intimacy History prior to 11/30/21. -No documentation a Sexual Consent Assessment was completed per facility policy, although the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's behavior note, dated 12/4/21 at 12:20 A.M., showed: -The resident was found in bed with a resident. -The resident was half way naked and the other resident was naked. -The resident was asked to put his/her top on and was escorted to his/her room. -The supervisor was notified. During an observation and interview with the resident on 12/6/21 at 2:15 P.M., showed:-The resident had a hold of Resident #237's hand and attempted to pull him/her to his/her room. -The resident said Resident #237 was his/her boyfriend/girlfriend. -Resident #126 did not know Resident #237's name. -The resident eventually released Resident #237's hand and went to his/her room. -He/She said he/she did not remember going into another resident's room or another resident coming into his/her room. -He/She did not recall being undressed or in bed with another resident. During an interview on 12/6/21 at 2:20 P.M., Certified Medication Technician (CMT) B said the resident wanders into everyone's rooms, and staff have to redirect him/her frequently. During an interview on 12/6/21 at 5:20 P.M., the resident's family member said: -The facility staff called him/her and said his/her family member was found in a room with a member of the opposite sex, but that it was an innocent interaction. -He/She said the staff told him/her the resident was able to recall the entire interaction, which he/she thought was strange due to the resident's dementia and the resident not able to recall or remember certain family members. -He/She said it was ok as long as his/her family member was not harmed, he/she wanted the resident to have friends at the facility. -He/She was not aware the resident and the resident he/she was found with were undressed at the time. -The resident would not have consented to this before his/her dementia and would not have done something like this prior to his/her dementia. -The resident did not have the cognitive ability to consent to an intimate relationship and he/she believed the resident would not have wanted that kind of contact if he/she had the ability to make decisions. -He/She was contacted about a similar situation about six months ago, but to his/her knowledge it was also an innocent interaction and the residents were fully dressed. -He/She was not aware of any other situations with the resident being in other resident rooms, being undressed, or being found in bed with members of the opposite sex. During an interview on 12/07/21 at 8:48 A.M., Social Services Designee (SSD) A said: -He/she went to an Inter-Disciplinary Team (IDT) meeting about the event on 11/26/21, which included the DON, Assistant Director of Nursing (ADON), and he/she could not remember who else was present. -He/she was told Resident #126 needed an assessment but the situation wasn't specified. He/she read about it in the nurse's notes. -Nursing attempted to contact the resident's family members the same day of the event, but neither family responded that day. -He/she called Resident #126's next of kin the following day and told the next of kin the resident was found under the covers, undressed, with another resident of the opposite sex. -Resident #126 had an inactive Durable Power of Attorney (DPOA) because it was missing signatures, but the DPOA only addressed finances. -He/she was not aware of any attempts to obtain DPOA for any reason other than finances. -Resident #126's DPOA reacted normal when told of situation, spoke of Resident #126's history, laughed and joked. -The DPOA said Resident #126 could have a significant other. -He/she was only aware of the sexual behaviors on 11/26/21. -The two residents involved referred to each other as girlfriend/boyfriend. -Resident #126 has a history of wandering. 2. Record review of Resident #205's face sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Alzheimer's Disease. -Dementia. -Anxiety Disorder. -Depression. -[CONDITION(S)] Disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the resident's care plan, dated 10/7/19, and updated on 10/1/21 showed the resident was an elopement risk/wanderer related to impaired cognition. Record review of the resident's quarterly MDS, dated [DATE], showed the resident: -Was cognitively intact, with a BIMS of 14 out of 15. -Did not have behaviors such as abusing others sexually, public sex acts, or disrobing publicly. -Did not have behaviors that impacted self or others. -Did not wander. Record review of the resident's behavior note, dated 11/27/21, showed: -The resident was found in a another resident's room. -The resident was undressed in bed with Resident #126, who was also naked. -The resident resisted but did go to his/her room. -The resident was already on 15 minute checks when this incident occurred. -The DON was notified and the resident's family was called with a message left. -No documentation the resident's physician was notified or that the facility staff made contact with the resident's DPOA. Record review of 15 minute check sheets from 11/27/21 through 12/3/21 showed: -The 15 minute checks started on 11/27/21. -There were two sheets for 11/27/21. -One sheet showed 15 minute checks starting at 7:15 A.M. and the other sheet showed 15 minute checks starting at 3:30 A.M. -The sheet showing the 15 minute checks starting at 7:15 A.M. was missing initials at 12:45 P.M., 1:00 P.M., 1:15 P.M., 1:30 P.M., and 1:45 P.M. -There were no initials on 11/28/21 at 6:30 A.M. and 6:45 A.M. -The 15 minute checks were completed through 11/30/21. -The 15 minute checks resumed on 12/2/21 at 6:30 A.M. with no documentation as to why and ended on 12/3/21 at 6:30 A.M. Record review of the undated investigation of the 11/27/21 incident showed: -The investigation included a soft file check list which included a face sheet, POS, nurses notes, care plan, incident report, witness statements, resident interviews, skin assessment, lab or X-Ray if applicable, most recent BIMS - redo if a change, wander risk if applicable, summary, documentation of follow up actions if applicable (therapy evaluation, psychiatric (psych) referral, etc.), and any other applicable documents (grievance forms, resident council minutes, etc.) --Witness statements and resident interviews were highlighted with a note beside the resident interviews for the SSD to do an intimacy assessment. --Documentation of follow up actions had a notation beside it that was highlighted for 15 minute checks. -An updated care plan for the resident dated 11/30/21 showed the resident had a consensual relationship with a resident of the opposite sex and both residents were agreeable and consenting to the relationship. -A sexual intimacy history for the resident dated 11/30/21 showed Resident #126 was the resident identified that he/she was having a relationship with. - No documentation a Sexual Consent Assessment was completed per facility policy, although the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's care plan, dated 11/30/21, showed the resident had a consensual relationship with another resident and both residents were agreeable and consenting to the relationship. Record review of the resident's Sexual Intimacy History, dated 11/30/21, showed: -The resident answered yes to the following questions: --Are you comfortable giving or receiving affection such as a soothing touch, hug, or a kiss? --Are you accustomed to sleeping alone in bed? --Are you currently involved in a relationship? --Are you seeking to have a relationship with someone in the facility? If so, explain. The form indicated Resident #126. -The resident answered no to the following questions: --Do you have any concerns regarding your interactions with this person. If so, explain. --Any known history of abuse, mistreatment, or trauma: sexual, physical, emotional, verbal. --Do you have any known history of sexually transmitted infections? -The resident did not have a Sexual Intimacy History prior to 11/30/21. Review of the resident's behavior note, dated 12/4/21, showed: -The resident was found lying on his/her bed with a resident of the opposite sex (Resident #126). -The resident had no brief on and the other resident had no top on. -The other resident was redirected to his/her bedroom and the house supervisor was notified. During an interview on 12/6/21 at 1:41 P.M., Resident #205 said: -He/she wished he/she had a significant other there. -He/she and a resident were friends, but they ran his/her friend right out of his/her room. -The facility didn't let them have time alone together. -That's why he/she was ready to get out of there. -He/she didn't have a significant other he/she sees on a regular basis. -They frowned upon that there. -The unknown resident lived in the facility too. -He/she didn't know the last name of the resident or where the resident lives in the facility. -He/she didn't sneak into the other resident's room, because he/she didn't want to get in trouble. -Nobody other than staff and his/her roommate came into his/her room. 3. During an interview on 12/8/21 at 10:33 A.M., CNA U said: -A couple of weeks ago, Resident #126 was found in bed with Resident #205. -He/She was not sure which staff found the residents, but when he/she arrived to the room, both residents were fully naked in the bed with the blanket over them. -Resident #205 was leaning over the top of Resident #126, who was laying on his/her back on the bed), kissing Resident #126. -He/She separated the residents and had them get dressed. -They were not in either one of their rooms, but in the room and bed of another resident on the unit. -The roommate of the bed the residents were in yelled out that a member of the opposite sex was in his/her room. -That was when the other CNA working that day found the residents in another resident's bed. -The CNA that found them left them in the room together to come get him/her, and that was when he/she arrived to the room to separate the residents. -Resident #205 had also been seen approaching another resident, but that resident was able to tell him/her no. -Apparently Resident #205 was supposed to be on 15 minute checks prior to the incident, but that was not communicated to him/her or the other CNA that found the residents that shift. -He/She and the other CNA were agency staff and did not always get the information on how to care for the residents. During an interview on 12/8/21 at 4:50 P.M., CNA K said: -He/she had seen Resident #205 coming up the hall around 9:30 P.M. or 10:00 P.M., but could not remember the date. -A CMT had told Resident #205 he/she could sit on the couch. -He/she could not locate Resident #126 later and found him/her in Resident #205's room. -He/she did a room to room search and he/she saw four feet at the end of the bed. -Resident #126 was in Resident #205's bed and neither of the residents had any clothes on. -He/she believed the residents heard him/her coming because Resident #126 rolled over, grabbed a shirt, and covered his/her chest area. -Resident #205 was on the inside of the bed on his/her side and Resident #126 was on the outer side of the bed. -He/she asked what they were doing and Resident #126 started cussing him/her out and screaming to get out, and it was none of my business. -Resident #205 was naked, uncovered, and was visibly aroused. -He/she went to get the CMT on duty, but the CMT did not do anything. -There was no charge nurse available. -Another CNA came and helped get Resident #126 and take him/her out of the room. -He/she figured they would do an incident report and request a witness statement, but no one ever asked him/her to write one. -There was no licensed nurse to assess the residents at that time. -No one called the house supervisor and the residents were never assessed. During an interview on 12/6/21 at 11:45 A.M., the DON said: -It was his/her understanding that Resident #126 was found in Resident #205's room on 11/27/21. -It was his/her understanding that Resident #126's family gave permission for the resident to be sexually intimate with Resident #205. During an interview on 12/6/21 at 12:56 P.M., CMT B said: -Resident #126 loved going into other residents' rooms. -They brought Resident #126 into the common area to watch a movie or to do an activity with him/her when he/she went into other residents' rooms. -They charted Resident #126's wandering on the MAR. -Resident #126 was the only resident who wandered from room to room. -They placed Resident #205 on 15 minutes check for the incident on 12/4. -The nurse had the 15 minute check documents. -He/she thought they were still doing the 15 checks. During an interview on 12/06/21 at 1:09 P.M., Licensed Practical Nurse (LPN) B said: -He/she worked in all the units so he/she wasn't in this unit all the time. -Resident #126 had inappropriate sexual behaviors. -He/she tried to kiss another resident one time but they stopped it. -Someone placed Resident #126 on 15 minutes checks, but he/she thought those had been completed. -Someone also placed Resident #205 on 15 minute checks. -He/she had not experienced Resident #205 having any sexual behaviors. -He/she only heard about Resident #126's sexual behaviors. -If staff knew about any sexually inappropriate behaviors, staff should have told the DON and documented it somewhere. During an interview on 12/6/21 at 1:14 PM., CMT A said: -He/she had worked on the other side of the Secure Care Unit (SCU). -He/she did care for Resident #126 at times and knew this resident. -He/she had to keep re-directing Resident #126 out of other residents rooms. -Resident #126 would say he/she was going to go to bed with another resident and had to be re-directed. -Resident #126 was cognitively impaired. -He/she was not aware of sexual behaviors of the resident. -If he/she had found two residents together unclothed in bed, he/she would have the residents get dressed and report this to the charge nurse so the information could be documented in the medical record. -He/she did not think this would be sexual abuse and would be a behavior. During an interview on 12/6/21 at 1:15 P.M., CNA D said: -He/she worked the whole floor. -He/she worked for an agency. -He/she didn't know of any residents with sexually inappropriate behaviors. -Resident #126 wandered into others' rooms. -They just redirected him/her. -He/she told the charge nurse. -He/she documented the wandering in the Point of Care (POC) under the resident. -He/she would inform the charge nurse of any sexually inappropriate behaviors if he/she observed any. -He/she worked there for the past three weeks and nobody had told him/her anything about residents having relations or trying to have relations with each other. -Residents did occasionally wander into other rooms, but when that happened the residents were redirected. -If a resident exhibited sexually inappropriate behaviors he/she would have informed the charge nurse and documented in the computer health record under resident behaviors. During an interview on 12/06/21 01:36 P.M., CNA G said: -Resident #126 liked to go in resident rooms and kiss other residents. -If he/she were to find residents in an inappropriate sexual situation, he/she would notify the nurse, do 15 minute checks, and chart the sexual behavior. -Resident #126 had been on 15 minute checks frequently because of his/her sexual behaviors. -Resident #126 liked to go into other resident's rooms but was easily redirected. -Resident #126 just likes to kiss and caress residents of the opposite sex. During an interview on 12/06/21 at 1:41 P.M., CMT B said: -Resident #205 did not have a significant other at the facility. -He/she was friends with a resident of the opposite sex. -The facility does not allow the resident's to spend time alone with each other. -The family must approve of any residents being in a relationship. -Residents must be in a relationship prior to progressing it to a sexual relationship. -The only residents in the facility that were in a relationship were a married couple. During an interview on 12/6/21 at 1:46 P.M., SSD A said: -There was a situation that occurred with Resident #205 and his/her boyfriend/girlfriend, Resident #126. -Over a weekend, the residents were both found undressed in bed together. -He/she found this information out when he/she came in on Monday morning. -

Based on observation, interview, and record review, the facility staff failed to provide a safe environment free from accidents, hazards, and resident falls over which the facility had control; provide supervision and assistive devices to each resident to prevent avoidable accidents; identify, evaluate and analyze hazards and risks, and then implement interventions to reduce hazards and risks; monitor for effectiveness and then modify interventions on the care plan when needed for six sampled residents (Resident #8, #10, #15, #21, #22, and #24) out of sampled 27 residents who sustained multiple falls resulting in injuries including fractures. The facility identified 99 residents who had fallen, and 18 of these residents had fractures related with their falls. The facility census was 284 residents. Record review of the facility's Falls Policy and Procedure revised October 2011, showed preventing resident falls is everyone's responsibility, and residents are assessed for fall risk at admission, significant change, and quarterly reviews. Assessment guidelines will be followed when a resident has fallen or has been involved in an accident or incident. These guidelines should not be considered to be all-inclusive in providing urgent or emergency care. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and/or House Supervisor will review all falls to ensure proper care plan interventions. Fall Risk Assessment forms are completed by nursing at admission and with every Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff). The policy also said: -The MDS coordinator will complete Fall Risk Assessments for each quarterly review, and with every significant change. -The Morse Fall Risk (a method of assessing a resident's likelihood of falling used widely in health care settings) Assessment will be utilized as the assessment tool. -Nursing will initiate a "Potential to Fall" Care Plan on all admissions and readmission's. -MDS Coordinators will care plan fall interventions based on the resident's risk assessment score and individual needs at the time of the resident's assessment. -All falls will be reviewed by the DON, ADON, House Supervisor or Wound Care Nurse on a daily basis. -The Nurse Manager Quality Improvement Committee will monitor the efficacy of the interventions and assist staff to make changes as needed. -The resident's fall risk status is communicated with the resident and/or family upon admission and at the time of the quarterly care plan meeting. Realistic expectations of independence are discussed with the resident/family. -If a fall occurs at the facility but away from the resident care area, the resident will not be moved and the DON, Assistant DON or House Supervisor will be notified immediately for resident assessment. -Resident falls and un-witnessed falls are to be reported. When a resident is lowered to the floor for any reason, it is considered to be a fall requiring a full assessment and interventions to prevent future occurrences. -The person who observes or discovers a resident fall will immediately notify the nursing staff on the unit where the resident lives, and notify their supervisor. -Successful fall prevention requires a thorough clinical assessment of residents who fall or have a history of falls and their environment. -Gait belts are used for all assisted transfers. -Call lights are within reach of residents at all times when the residents are in their rooms. -Call lights are answered promptly. -Nursing staff responds promptly to resident requests that pose a safety risk; such as toileting, drinks, etc. -Full body mechanical lifts are used by at least two nursing staff members when transferring residents. -Residents wear shoes with non-skid soles when ambulating or transferring. -Bedside commodes are provided as needed. -Nursing staff makes frequent rounds to ensure that the resident's call light, water, telephone, and personal items are within reach. -Nursing staff checks residents frequently to ensure they are positioned correctly in chairs, beds and wheelchairs. -Wheelchairs and ambulation aids are included in the facility's maintenance program. -Alternative assistive devices are used to ensure proper sitting position, i.e., wedges, arm supports, half trays, etc. Record review of the facility's undated fall risk assessment document, "Morse Fall Scale" showed the following document key listed at the bottom of the page: -A score of 0-24 was at no risk of falling with the recommended action of good basic nursing care; -A score of 25-45 was at low to moderate risk of falling with the recommended action of implementing standard fall prevention interventions using the "Falling Leaf Program;" and -A score of 46 or higher was at high risk for falling with the recommended action of implementing high-risk fall prevention interventions using the "Falling Leaf Program." Note: According to the DON, the facility discontinued the use of the Falling Leaf Program and all residents were considered at risk of falling. The facility had no protocol to instruct facility staff on needed interventions to prevent falls. Record review of the facility's Fall Prevention Intervention suggestions dated April 2012, showed 57 suggestions for interventions that staff could implement for a resident at risk of falling or after experiencing a fall: -Frequent staff contact; -Orient the resident to his/her room, bathroom, unit, call light system, and location of the room light; -Offer scheduled snacks and drinks; -Place on a toileting schedule; -Encourage the resident to attend scheduled activities; -Schedule naps; -Reorientation as needed (PRN); -Request family come sit with the resident; -Staff one-on-one; -Verbal cueing or signage; -Frequent repositioning in bed; -Frequent repositioning in chair; -Scheduled turning program; -Review of medications for possible side effects; -Speech consultation for cognitive assessment; -Physical Therapy (PT)/Occupational Therapy (OT) consult; -Medical consult for change with medical disease process; -Psychiatric consult for change in mental disease process; -Adequate lighting; -Glare reduction; -Clear pathways, free of clutter; -Floors slip resistant and maintained to prevent trip or slip; -Effective eyewear; -Remind to wear eyewear, clean and properly fitting; -Call light in reach and in consistent location; -Strengthening exercises: transfer training; -Mobility devices used properly (wheelchair, walker, cane, etc.); -Side rail usage for functional transfer aide, evaluation, physician order [REDACTED]. -Use of assistive devices/adaptive equipment training; -Supportive non-skid shoes; -Non-slip socks; -High/low bed; mattress/padding on the floor next to the bed; -External hip protection pads; -Helmet/padded head gear; -Elbow and knee protectors; -Remove furniture or objects from the bedside; -Place the resident near nurse/staff for close supervision; -Move the resident to a room near the nurses station; -Assist with ambulation/transferring with gait belt usage; -Monitor blood pressure; -Assist the resident with dressing and undressing; -Assist the resident with putting shoes on/taking off shoes; -Assist the resident with putting socks on/taking socks off; -Remind the resident to ask for help when tired or weak; -Place grab bars in the bathroom; -Frequently inspect the toilet seat for proper fitting; -Frequent inspection of the bedside commodes in use for safety; -Monitor noise levels to reduce agitation or distractions; -Check chairs for proper sitting position and transfer needs; -Check the bed for correctly working wheel locks and correct height of the bed surface; -Properly fitting clothing for easy donning and removal; -Assess the wheelchair for anti-tip bars; -Maintain outdoor walkways; -Monitor pets for trip hazard; and -Post signs when floors are wet. 1. Record review of the Resident #8's Nurse's Notes dated 3/12/12 at 2:40 P.M., showed: -The resident was found lying on the floor in his/her bathroom. -There was blood on the back of the resident's head. -The resident was unable to be aroused. -Staff called 911 and the resident was sent to the hospital. -The resident's family and physician were notified. Record review of the resident's Nurse's Notes dated 3/12/12 at 9:00 P.M., showed: -The resident returned from the hospital with staples (to close a wound) in his/her head. -The resident was placed on neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs). Note: No new interventions were added to the resident's care plan to address the resident's. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Had intact cognition. -Was independent with transfers, ambulation, dressing, eating, bathing, and hygiene. -Was continent of bowel and bladder. -Had not fallen. Record review of the resident's Nurse's Notes dated 4/4/12 at 6:30 P.M., showed: -The resident was found on the floor in his/her bathroom in front of the sink. -The resident stated he/she was sitting on his/her walker and it started moving. -He/she slid from the walker and sat on the floor. -The resident was assessed and there were no injuries. -The resident's family and physician were notified. Record review of the resident's Interdisciplinary Care Plan Conference dated 4/24/12, showed: -Nursing, dietary, social services, and activities personnel were present for the meeting. -The resident declined to attend the meeting. -The resident had a fall and was seen by therapy. Note: There was no documentation related to fall behaviors. Record review of the resident's physician's orders [REDACTED]. -Neurontin 600 milligram (mg): Take one capsule four times per day for pain. Note: This showed the resident was receiving 2400 mg of Neurontin every day. Record review of the resident's Nurse's Notes dated 5/9/12 at 8:00 P.M., showed: -The resident was found sitting on his/her floor with his/her legs extended in front of him/her. -The resident stated he/she missed the chair when trying to sit down. -The resident did not have any injuries. -The resident's family and physician were notified. Record review of the resident's Incident/Event Intake form dated 5/9/12, showed: -The resident was found on his/her floor on his/her buttocks. -The resident was attempting to ambulate. -The resident was instructed on how to sit on a chair. -There was no documentation under the outcome/conclusion section. Record review of the resident's Nurse's Notes dated 5/13/12 at 8:00 P.M., showed: -The resident was found sitting on the floor beside his/her bed. -The resident had no injuries. -The resident's family and physician were notified. Record review of the resident's Incident/Event Intake form dated 5/13/12, showed: -The resident was found sitting on his/her floor next to his/her bed. -The resident said he/she slid from the bed. -The intervention was the resident was instructed on how to sit on the bed. -There was no documentation under the outcome/conclusion section. Record review of the resident's Nurse's Notes dated 5/18/12 at 8:55 A.M., showed: -The resident was found on the floor in front of his/her recliner. -The resident had slid from his/her recliner. -The resident had no injuries. -The resident's family and physician were notified. Note: There was no incident report completed by the staff related to this fall, and there were no new interventions added to the resident's care plan to assist the resident from falling. Record review of the resident's Nurse's Notes dated 5/20/12 at 4:00 P.M., showed: -The resident was found on the floor in front of his/her bed with a pillow under his/her head and a blanket covering him/her. -The resident said his/her non-skid socks did not grip and he/she went to the floor. -The resident had no injuries. -The resident's family and physician were notified. Record review of the resident's Incident/Event Intake form dated 5/20/12, showed: -The resident was found on the floor in front of his/her bed with a pillow under his/her head and a blanket covering him/her. -The intervention was to have the resident call for assistance with transfers. -There was no documentation under the outcome/conclusion section of the form. Record review of the resident's Nurse's Notes dated 5/23/12 at 12:45 P.M., showed: -The resident was found sitting on the floor. -The resident had no injuries. -The resident's family and physician were notified. Record review of the resident's Incident/Event Intake form dated 5/23/12, showed: -The resident was said he/she was going to get a drink and his/her legs gave out. -The intervention was to decrease the resident's Neurontin pain medication. -There was no documentation under the outcome/conclusion section of the form. Record review of the resident's POS dated 6/1/12, showed the following physician ordered medication: -Neurontin 800 mg: Take one capsule three times per day for pain. Note: The 6/1/12 POS showed the Neurontin order was changed, but the resident still received 2400 mg of Neurontin every day. Record review of the resident's Nurse's Notes dated 6/2/12 at 4:15 P.M., showed: -The resident was referred to the Physical Therapy (PT) department for three to four weeks for evaluation and treatment. Record review of the resident's PT evaluation, plan of care, and certification dated 6/2/12, showed the resident was referred to the PT department for loss of balance and falling backwards, and the resident was ambulatory. The therapy goals stated to: -Decrease lower back pain to a minimum so the pain would not interfere with activities of daily living (ADL's - how a person self-performs grooming, eating, toileting, etc.) -Be independent with safe sit-to-stand using good techniques to prevent twisting of his/her back. -To improve standing and gait posture to increase standing dynamic balance and good balance when using the roller walker. Record review of the resident's Falls: Morse Fall Scale dated 6/14/12, showed: -The resident had a score of 65; which indicated the resident was a high risk of falls. Record review of the resident's physician's Consultation/Progress Note dated 6/18/12, showed: -The resident was doing well and seemed to ambulate with his/her walker without any difficulty. -There was no documentation by the resident's physician regarding the resident's multiple falls or if the fall were related to "fall behaviors." Record review of the resident's Care Plan dated 6/19/12, showed the resident had a potential for falling, and staff were to use these approaches/interventions: -The Morse Fall Form needed to be completed by staff on a quarterly basis. -The resident's bed needed to be in the lowest position. -The resident needed to be monitored for weakness, unsteady gait, fatigue or falls. -Make sure pathways were well lit and free of obstacles. -Make sure the resident had proper shoes on and used his/her walker with ambulation. -Use wet floor signs in mopped areas. -Monitor for vision deficit or other medical conditions which may interfere with safety when walking. -Consult therapy for noted decline in skill levels which might add to falls. -Updated on 6/25/12: Frequent staff contact. -Updated on 7/10/12: Encourage the resident to ask for assistance when he/she was feeling tired. -Updated on 7/22/12: Encourage the resident to ask for assistance when wanting furniture moved in his/her room to clean his/her room. -Updated on 8/29/12: Use the call light for all ADL's. Record review of the resident's Nurse's Notes dated 6/25/12 at 3:30 P.M., showed: -The resident was found sitting on the floor beside his/her bed. -The resident had no injuries. -The resident's family and physician were notified. Note: The updated care plan stated frequent staff contact. Record review of the resident's PT Daily Notes and Weekly Summary dated 6/26/12, showed: -The resident had been discharged from therapy with goals met. Record review of the resident's Interdisciplinary Care Plan Conference dated 7/3/12, showed: -Nursing, dietary, and social services facility personnel were present for the meeting. -The resident's spouse, and the resident's family member were present for the meeting. -The resident decline to come to the meeting. -The resident had frequent falls and was otherwise stable. Note: There was no documentation by the staff to show that the resident's falls were related to fall behaviors. Record review of the resident's Nurse's Notes dated 7/10/12 at 11:00 P.M., showed: -The resident was found sitting on the floor beside his/her bed. -There were no obstacles. -The resident said he/she had been walking with his/her walker to go to the refrigerator and his/her legs and feet were tired. -The resident did not have shoes on at the time of the fall. -The resident had no injuries. -The resident's family and physician were notified. Note: The updated care plan stated to encourage the resident to ask for assistance when feeling tired. Record review of the resident's Incident/Event Intake form dated 7/10/12, showed: -The resident was observed on the floor between the bed and walker. -The resident was ambulating from the refrigerator to the bed and stated his/her legs were weak. -The resident denied slipping, tripping, or stumbling. -There were no new interventions listed. -There was no documentation under the outcome/conclusion section. Record review of the resident's Nurse's Notes dated 7/22/12 at 2:45 P.M., showed: -The resident was found sitting on the floor. -The resident had no injuries. -The resident's family and physician were notified. Note: The updated care plan said to encourage the resident to ask for assistance when moving furniture in his/her room. Record review of the resident's Incident/Event Intake form dated 7/22/12, showed: -The resident was found sitting on the floor in his/her room. -There were no new interventions listed. -There was no documentation under the outcome/conclusion section. Record review of the resident's Nurse's Notes dated 7/25/12 at 10:00 P.M., showed a new physician's orders [REDACTED]. Record review of the resident's Nurses Note's dated 7/30/12 at 4:20 A.M., showed: -A Certified Nurse Assistant (CNA) notified the nurse there was something wrong with the resident. -The nurse went to the resident's room. -The resident was found to be unresponsive. -The resident's blood pressure, oxygen saturations and blood sugar was within normal limits. -The resident's family and physician were notified. -Staff received new orders to send the resident to the hospital for evaluation and treatment. Record review of the resident's Nurse's Notes dated 7/30/12 at 8:20 A.M., showed: -A hospital staff member called and said the resident would be returning to the facility. -The hospital had completed some tests on the resident. -The resident was alert and oriented. -The resident was speaking. Record review of the resident's Nurse's Notes dated 7/30/12 at 10:00 A.M., showed: -The resident returned to the facility from the hospital. -There were no new orders from the hospital. -There were no findings from the tests that were completed at the hospital. Record review of the resident's POS dated 8/1/12 showed: -The following Diagnoses: [REDACTED]. --Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). --Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). --Osteoporosis (decrease in bone mass and density and enlargement of bone spaces producing fragility). --Arthropathy (progressive polyarthritis with joint swelling and bony enlargement, most commonly in the small joints of the hand but also affecting other joints). --Anemia (a decrease in hemoglobin in the blood to levels below the normal range). --Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). --Degenerative joint disease (DJD - degenerative arthritis of the joints). --Hypertension (HTN - high blood pressure). -The following physician ordered medications: --Carbidopa/Levo ER ,[DATE]: Take one tablet by mouth daily for Parkinson's Disease. --Divalproex DR 500 mg tablet: Take two tablets at bedtime for seizure activity. --Lasix 40 mg tablet: Take one tablet twice a day for edema (fluid swelling). --Lorazepam 0.5 mg: Take one tablet four times daily for anxiety. --Sertraline HCL 50 mg: Take one tablet by mouth daily for depression. Record review of the resident's Nurse's Notes dated 8/1/12 at 10:35 A.M., showed a new physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated 8/1/12 at 9:50 P.M., showed the resident had no complaints of syncope (dizziness) at that time. Record review of the resident's Nurse's Notes dated 8/3/12 at 3:00 A.M., showed: -The resident was up early cleaning things up his/her room. -The nurse would continue to monitor the resident for blacking out. Record review of the resident's Psychiatric Services notes dated 8/3/12, showed: -The resident had frequent attention seeking behaviors. -There was no documentation related to his/her fall behaviors. Record review of the resident's Nurse's Notes dated 8/8/12 at 11:45 P.M., showed: -The resident's call light was on and the CNA asked what the resident needed. -The resident told the CNA he/she was taking clothing to the bathroom, lost his/her balance, and sat in the trash can. -There was a small red line on the resident's buttocks. -The resident's family and physician were notified. Note: There was no new fall interventions documented on the resident's care plan. Record review of the resident's Nurse's Notes dated 8/8/12 at 11:50 P.M., showed: -The resident now stated he/she could not make it to the bathroom in time so he/she sat on the trash can and urinated. -There was a towel in the trash can with urine on it. Note: There was no new fall interventions documented on the resident's care plan. Record review of the resident's Nurse's Notes dated 8/13/12 at 1:30 P.M., showed the resident had a new physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated 8/16/12 at 10:20 A.M., showed: -The resident was found on the floor on his/her back. -The resident was assisted back to his/her chair and neurochecks were started. -The resident's family and physician were notified. Note: There was no new fall interventions documented on the resident's care plan. Record review of the resident's Nurse's Notes dated 8/16/12 at 11:30 A.M., showed: -The resident complained of right sided pain in his/her arm, shoulder, and leg. -New orders were received to send the resident out for evaluation and treatment at the hospital. Record review of the resident's Nurse's Notes dated 8/16/12 at 12:15 P.M., showed: -The ambulance had arrived. -The resident stood up and was told to sit down by nurses and ambulance staff. -The resident was transferred to the ambulance bed with a gait belt. Record review of the resident's Incident/Event Intake form dated 8/16/12 showed: -The resident was found sitting on the floor in his/her room on his/her back. -There was a liquid puddle next to the resident. -The resident was alert and oriented with confusion. -There were no new interventions listed. -The outcome/conclusion was the fall was a human issue. Record review of the resident's hospital History and Physical dated 8/16/12, showed the resident: -Had an unwitnessed event in his/her room at the facility. -Remembered eating breakfast, entering his/her room, then woke up lying on the floor. -Stated he/she had fallen in the past with no apparent reason. -Was a poor historian with dementia and schizophrenia. -Injured his/her ribs and tibia (lower leg bone) with a fall. Record review of the resident's hospital Discharge Summary dated 8/18/12, showed the resident had a cast of the right lower extremity, and an echocardiogram (a two-dimensional and three-dimensional images of the heart) was completed on the resident, and showed severely increased aortic valve thickness and critical stenosis. The resident was medically stable and needed to follow-up with a cardiologist. His/her [DIAGNOSES REDACTED]. -Syncope episode (dizziness), most likely due to severe versus critical [DIAGNOSES REDACTED] (a disease of the heart valves in which the opening of the aortic valve; the valve between the left ventricle of the heart and the aorta, which is the largest artery in the body and carries the entire output of blood; is narrowed). -Non-displaced right distal tibia fracture (broken lower leg bone). -Right rib fracture. -Dementia. -Schizophrenia. -Parkinson's Disease. -HTN. -Anemia. -Osteoporosis. -History of cerebrovascular accident (CVA, stroke), -Mild [DIAGNOSES REDACTED] (a relative decrease of platelets in blood). Record review of the resident's Nurse's Notes dated 8/19/12 at 12:20 P.M., showed: -The resident was readmitted to the facility after a hospital stay. -The resident was able to stand with the assistance of staff and a gait belt. -The resident could hold his/her leg cast up. -The resident used a wheelchair propelled by staff for mobility. Record review of the resident's Nurse's Notes dated 8/19/12 at 9:00 P.M., showed: -The resident was going to receive skilled services for a right tibia fracture and a fifth and sixth rib fracture. -The resident needed the assistance of one staff member for transfers and ADL's. -The resident had a toe touch weight bearing status to his/her right leg. Record review of the resident's Nurse's Notes dated 8/20/12 at 3:45 A.M., showed: -The resident had his/her call light on every 15 to 20 minutes. -The resident may have his/her days and nights mixed up. -The resident was told he/she could straighten up his/her room during the day time. -The resident was repositioned and assessed. Record review of the resident's Nurse's Notes dated 8/22/12 at 1:00 P.M., showed: -The resident was found on the floor in front of his/her wheelchair. -The resident had no injuries. -The resident's family and physician were notified. Record review of the resident's Incident/Event Intake form dated 8/22/12, showed: -The resident was found on the floor on his/her buttocks in front of his/her wheelchair. -The resident stated he/she was trying to get a coke out of his/her refrigerator. -There was a small broom and dust pan next to the resident. -There were no new interventions listed. -The outcome/conclusion was the fall was a human issue and was not documented or updated on the care plan. Record review of the resident's significant change MDS dated [DATE], showed the resident: -Had intact cognition. -Required the extensive assistance with transfers, dressing, hygiene and bathing. -Had limited range of motion to one lower extremity (leg). -Was continent of bowel and bladder. -Had two no injury falls. -Had two minor injury falls. -Had one major injury fall. Record review of the resident's Care Plan dated 8/29/12, showed he/she had restricted mobility, was a fall risk, was unable to ambulate related to a right leg fracture, and the resident had a cast (a hard shell used to immobilize an area after a broken bone injury) on his/her leg. Staff were to use these approaches/interventions: -Keep the resident's bed in the lowest position. -The resident was wheelchair dependent and could propel himself/herself. -Staff were to lock the wheelchair wheels when transferring the resident. -Monitor the resident for sliding or leaning in the wheelchair. -Answer the call light as promptly as possible. -Provide frequent staff contact. -Encourage the resident to ask for assistance when wanting furniture moved in his/her room to clean his/her room. -Updated on 9/15/12: Use a gait belt when transferring the resident. Record review of the resident's Falls: Morse Fall Scale dated 8/29/12, showed: -The resident had a score of 65; which indicated the resident was a high risk for falls. Record review of the Nurse's Notes dated 8/29/12 at 4:45 A.M., showed: -The resident was found on the bathroom floor in a sitting position between the commode and sink. -The resident stated he/she had lost his/her balance and grabbed a hold of the sink, but his/her hand slipped. -The resident was assessed with [REDACTED]. -The resident's family and physician were notified. Note: There were no new interventions documented on his/her care plan. Record review of the resident's Incident/Event Intake form dated 8/29/12, showed: -The resident was found on the floor on between the toilet and bathroom sink. -The resident had a previous right tibia and rib fractures. -There was a small broom and dust pan next to the resident. -There were no new interventions listed. -The outcome/conclusion was the fall was a human issue and was not documented on the care plan. Record review of the resident's Psychiatric Services notes dated 8/31/12, showed: -The resident had fallen and broken his/her tibia. -The resident continued to have passive aggressive behaviors (a long-term (chronic) condition in which a person seems to actively comply with the desires and needs of others, but actually passively resists them). -There was no documentation related to fall behaviors. Record review of the resident's Interdisciplinary Care Plan Conference dated 9/11/12, showed: -Nursing, dietary, and social services facility personnel were present for the meeting. -The resident's family member was present for the meeting. -The resident was not present at the meeting. -The resident had a fall and fractured his/her leg. The resident was being followed by psychiatry. Note: There was no documentation related to fall behaviors. Record review of the Nurse's Notes dated 9/15/12 at 9:00 P.M., showed: -The resident stated that during a transfer from the bathroom (toilet) he/she fell and the CNA picked him/her up. -The resident was assessed with [REDACTED]. -The resident's family and physician were notified. Note: The care plan was updated to use a gait belt while transferring the resident. Record review of the resident's Incident/Event Intake form dated 9/15/12, showed: -The resident was holding onto the hand bar in the bathroom and let go. -The resident had stood up so the CNA could clean the resident up. -The CNA grabbed hold of the resident pants and by the gait belt and put him/her into the wheelchair. -There were no new interventions listed. -The outcome/conclusion had been documented on the care plan. Record review of the resident's physician's Consultation/Progress Note dated 9/24/12, showed: -The resident had a recent fracture and had a full leg cast on his/her leg. -The resident was going to have a heart catheterization (a medical procedure used to diagnose and treat some heart conditions; a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart for diagnostic tests and treatments on the heart) in approximately one week. Record review of the resident's Psychiatric Services notes dated 9/27/12, showed no documentation related to fall behaviors. Record review of the Nurse's Notes dated 10/2/12 at 6:30 P.M., showed: -The resident returned from his/her orthopedic physician with new orders for half weight bearing status on his/her leg. -The resident had a cam boot (a lower extremity boot that provides support, protection and immobilization of the ankle after injury or surgery) on his/her leg. Record review of the resident's Nurse's Notes dated 10/11/12 at 4:00 P.M., showed: -The resident was found sitting on the floor. -The resident stated he/she had slid out of his/her chair. -The resident had no injuries. -The resident's family and physician were notified. Note: There was no new intervention documented on the resident's care plan. Record review of the resident's Incident/Event Intake form dated 10/11/12, showed: -A CNA went to the residents room and the resident was sitting on the floor. -There were no new interventions listed. -The outcome/conclusion was a human issue. Record review of the resident's Cardiovascular and Thoracic Surgeon summary dated 10/22/12, showed: -The resident had been referred for a possible aortic