Every finding on record at Scenic Wellness and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when Certified Nurse Aide (CNA) A struck Resident #1 on the right upper arm. The physical contact frightened Resident #1 and caused the resident to cry. The facility census was 159.On 08/04/26, the Administration was notified that the deficient practice would be cited as Past Noncompliance. The facility identified and corrected the deficient practice prior to the survey. The facility initiated an investigation on 08/01/26, assessed Resident #1, removed CNA A from resident care, and subsequently terminated CNA A. The facility also initiated corrective actions that included in-service education related to abuse and neglect which were verified during the onsite visit on 08/04/26. The facility corrected the deficient practice on 08/01/26.Review of the facility's Abuse Prevention and Prohibition Program Policy, revised 10/24/22, showed residents had the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The policy prohibited staff from engaging in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. The policy required staff to receive abuse-prevention training during orientation and at least annually thereafter.Review of Resident #1's medical record showed the resident had diagnoses that included cerebral palsy, legal blindness, intellectual disability, schizoaffective disorder, major depressive disorder, agoraphobia with panic disorder, and skin-picking disorder. The resident's care plan identified the need for extensive assistance with activities of daily living and directed staff to approach the resident calmly, provide redirection and reassurance when the resident became upset, and use polite reminders when the resident engaged in skin-picking or other behaviors.Review of the facility's investigation dated 08/01/26 showed Licensed Practical Nurse (LPN) B was in the dining room when LPN B heard a smack and heard Resident #1 scream, Ow, you hit me. I'm telling you that's abuse. CNA A and Resident #1 then exchanged words regarding Resident #1 picking the resident's nose. LPN B removed CNA A from the area and initiated an investigation. Staff assessed Resident #1 and identified no physical injury. The Administrator, Director of Nursing (DON), physician, and Resident #1's family were notified. The facility substantiated the allegation of abuse and terminated CNA A on 08/01/26.Review of Dietary Aide (DA) C's written witness statement dated 08/01/26 showed DA C heard a smack, looked toward Resident #1, and observed CNA A passing by the resident. DA C heard CNA A tell Resident #1 to stop eating the resident's boogers. Resident #1 began crying and said CNA A had hit and frightened him/her. During an interview on 08/04/26 at 11:06 A.M., DA C verified the written statement.Review of CNA A's written statement dated 08/01/26 showed CNA A observed Resident #1 picking the resident's nose and preparing to eat the material. CNA A said he/she touched Resident #1's right arm in an attempt to stop the behavior. CNA A said Resident #1 became frightened, screamed, and stated the contact was abuse. CNA A apologized to Resident #1. During an interview on 08/04/26 at 11:17 A.M., CNA A acknowledged making physical contact with Resident #1's arm but denied intending to hurt or frighten the resident.Review of LPN B's written statement dated 08/03/26 showed LPN B heard a smack and then heard Resident #1 yell, Ow, you hit me. Why did you do that? That hurt me. Resident #1 said the contact was abuse and frightened the resident. LPN B immediately initiated the investigation, obtained statements, escorted CNA A from the premises pending investigation, and notified the Administrator, DON, physician, and Resident #1's family. During an interview on 08/04/26 at 12:46 P.M., LPN B verified the written statement.During an interview on 08/04/26 at 12:05 P.M., Resident #1 said the resident was eating dinner when CNA A slapped the resident's right arm hard. Resident #1 said the contact caused the resident to cry and frightened the resident because I am blind. Resident #1 said the resident believed hitting someone constituted abuse.During an interview on 08/04/26 at 10:25 A.M., the DON verified the facility's investigation findings. The DON said LPN B notified the DON on the evening of the incident and immediately initiated an investigation and obtained written statements. The DON said the investigation determined CNA A had made inappropriate physical contact with Resident #1. The facility immediately suspended CNA A from resident care and terminated CNA A following completion of the investigation. Complaint #MO3124995

Based on interview and record review, the facility failed to notify five residents (Residents #116, #123, #160, #170, and #186) out of 10 sampled residents when their resident trust fund account balances were within $200 of their Medicaid spend-down limit. This deficient practice had the potential to affect all residents receiving Medicaid benefits with a spend-down requirement. The facility census was 169. The facility did not provide a policy regarding spend-down notifications. Review of resident fund balance notification letters for Residents #116, #123, #160, #170, and #186 showed: - Letters were dated 05/13/26, and identified each resident by name; - The letters said, This letter is to notify you that your current resident fund balance is within $200 or exceeding what is allowable under Medicaid assistance. Please contact your Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits; - Each letter contained a resident acknowledgment signature line; however, none of the letters were signed by the residents. Review of the facility's Trial Balance Sheet, dated 04/30/26, showed: - Resident #116 had a balance of $6,965.42; - Resident #123 had a balance of $7,461.14; - Resident #160 had a balance of $7,585.85; - Resident #170 had a balance of $8,167.83; - Resident #186 had a balance of $7,814.35. Review of the facility Trial Balance Sheet, dated 05/31/26, showed: - Resident #116 had a balance of $6,884.49; - Resident #123 had a balance of $7,461.20; - Resident #160 had a balance of $6,758.92; - Resident #170 had a balance of $7,567.65; - Resident #186 had a balance of $7,968.43. Review of the facility Trial Balance Sheet, dated 06/16/26, showed: - Resident #116 had a balance of $7,283.55; - Resident #123 had a balance of $7,461.26; - Resident #160 had a balance of $6,958.98; - Resident #170 had a balance of $7,803.47; - Resident #186 had a balance of $9,148.51. During an interview on 06/18/26 at 1:26 P.M., Resident #123 said no one had informed him/her of the need to spend funds from the resident trust account and did not recall receiving any notification regarding the account balance. During an interview on 06/18/26 at 1:41 P.M., Resident #170 said he/she did not recall receiving a letter regarding the resident trust account balance or discussing the need to spend funds from the account with business office staff. During an interview on 06/18/26 at 1:55 P.M., the Business Office Manager said he/she was unaware the Medicaid resource limit had recently increased. Letters were provided to residents when account balances were within $200 of the spend-down limit. When asked why the letters provided for review were not signed by the residents, the Business Office Manager said he/she was unaware resident signatures were needed. The process was to review the resident account balances monthly, provide notification letters to residents requiring a spend-down, and notify the Social Worker so assistance could be provided with purchasing items to reduce account balances. During an interview on 06/18/26 at 2:02 P.M., the Social Worker said under the previous management company, funds could be withdrawn from resident trust accounts following approval, residents would sign for the funds, acknowledge receipt of the purchased items and any remaining change, and receipts would be submitted to the Business Office. The current management company assumed operations in approximately November 2025, and residents must now withdraw funds from their own accounts. Assistance would be provided with purchases or shopping arrangements as needed. Access to resident trust account balances was no longer available and a spend-down list was received approximately two to three weeks prior to survey. The facility had not yet begun addressing resident spend-down needs under the current management company and planned to begin reviewing account balances and exploring options, including prepaid burial arrangements, for residents requiring a spend-down. Residents with excess account balances had not been actively addressed since the current management company assumed operations in November 2025. During an interview on 06/18/26 at 3:15 P.M., the Administrator, Director of Nursing, and Regional Nurse Consultant said they would expect residents to be notified when they were within $200 of their spend-down limit.

Based on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment, review possible risks and benefits of bed rails or trapeze (an overhead assistive device with a suspended triangular handle), and obtain informed consent prior to installation or use for five residents (Residents #8, #84, #162, #172, and #173) out of 33 sampled residents. The facility census was 169.Review of the facility's policy, Bed Rails, revised 06/20, showed: - The assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rails that were attempted and how these alternatives failed to meet the resident's assessed needs; - Before installing a bed rail, the facility must assess the resident for the risk of entrapment from bed rails and ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed; - If the bed rail is used as an enabler, the resident/resident representative's informed consent will be obtained by a licensed nurse or the physician; - The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of needs will be met during the use of bed rails (e.g., repositioning, hydration, etc.); - After installation of bed rails, the IDT will document the review of the use of bed rails at a minimum of quarterly. Re-evaluations should include a discussion of any adverse effects of bed rails and attempts to eliminate the need for the bed rail if it is being used as a restraint. 1. Review of Resident #8's medical record showed: - admission date of 03/16/17; - Diagnoses of cerebral palsy (a lifelong physical disability that affects a person's movement, muscle control, balance, and posture), legal blindness, and morbid obesity; - An order for assist rails times two, dated 07/29/24; - Side Rail Resident assessment, completed on 11/05/25; - A side rail consent, signed by resident representative on 11/05/25; - Bed Rail Measurement assessment not completed. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment completed by the facility), dated 04/09/26, showed: - No cognitive impairment; - Impairment of lower extremities bilaterally; - Dependent on staff for bed mobility. Review of the resident's care plan, revised 04/16/26, showed side rail use was addressed. Observation on 06/15/26 at 3:26 P.M. showed the resident used the right rail to turn in bed while staff performed incontinent care. During an interview on 06/17/26 at 1:26 P.M., the resident said he/she used the side rails to help with turning in the bed. 2. Review of Resident #84's medical record showed: - admission date of 02/05/26; - Diagnoses of lumbago with sciatica (lower back pain that radiates down one or both legs), spinal injury, and chronic pain; - Signed informed consent explaining the risks and benefits for bed rail use, dated 06/17/26; - Side rail and trapeze assessment, dated 06/17/26; - Entrapment assessment completed for side rails only, dated 06/17/26; - Order for assist rails on 06/17/26; - No order for trapeze. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Impairment of upper and lower extremities bilaterally; - Moderate assistance by staff for bed mobility. Review of the resident's care plan showed: - Trapeze to bed to assist with bed mobility, dated 02/20/26; - Assist rails times two, dated 06/17/26. Observation of the resident showed: - On 06/15/26 at 1:40 P.M., the resident sat in a wheelchair beside the bed, which had a trapeze and bilateral grab bars; - On 06/17/2026 at 8:51 A.M., the resident used the trapeze bar during repositioning for care. 3. Review of Resident #162's medical record showed: - admission date of 10/07/25; - Diagnoses of chronic obstructive pulmonary disease (progressive lung disease that causes restricted airflow and breathing difficulties), respiratory failure (lung condition that causes a buildup of carbon dioxide in the blood), and heart failure (the heart muscle becomes too weak or stiff to pump enough blood and oxygen to meet the body's needs); - An order for assist rails times two, dated 10/7/25; - Side Rail Resident assessment, completed on 11/05/25; - A side rail consent, signed by resident representative on 11/05/25; - Bed Rail Measurement assessment not completed. Review of the resident's annual MDS assessment, dated 02/20/26, showed: - No cognitive impairment; - Impairment of lower extremities bilaterally; - Dependent on staff for bed mobility. Review of the resident's care plan, revised 05/21/26, showed side rail use was addressed. Observation on 06/17/26 at 5:40 A.M. showed the resident used the right rail to turn in bed while staff performed incontinent care. During an interview on 06/15/26 at 12:10 P.M., the resident said he/she used the side rails to help turn in bed to get changed. 4. Review of Resident #172's medical record showed: - admission date of 09/19/25; - Diagnoses of transient ischemic attack (temporary blockage of blood flow to the brain), stroke, and amputation of right leg above the knee; - An order for assist rail times one, dated 09/19/25; - Side Rail Resident assessment, completed on 11/05/25; - A side rail consent, signed by resident representative on 11/05/25; - Bed Rail Measurement assessment not completed. Review of the resident's quarterly MDS assessment, dated 03/11/26, showed: - No cognitive impairment; - Impairment on one side of lower extremities; - Supervision/touching assistance by staff for bed mobility. Review of the resident's care plan, revised 05/21/26, showed side rail use was addressed. Observation on 06/15/26 at 12:23 PM. showed the resident in bed used the right rail to turn. During an interview on 06/15/26 at 12:26 P.M., the resident said he/she used the side rail to help with transfers from the bed. No staff have ever come around to check to see if the rail is loose or to assess if he/she still used the rail. 5. Review of Resident #173's medical record showed: - admission date of 06/02/26; - Diagnoses of chronic pain, obesity (excessive or abnormal accumulation of body fat that increases the risk of health problems), and epilepsy (seizure disorder); - No order, safety evaluation, or consent for grab bars; - Care plan did not address grab bars. Review of the resident admission MDS assessment, dated 06/05/26, showed: - Moderate cognitive impairment; - Impairment of upper extremities bilaterally; - Dependent on staff for bed mobility. Observation of the resident showed: - On 06/15/26 at 11:53 A.M., the resident sat in his/her wheelchair with U-shaped grab bars on the bed bilaterally; - On 06/16/26 at 3:36 P.M., the resident lay in bed with U-shaped grab bars on the bed bilaterally. During an interview on 06/18/26 at 9:00 A.M., the Director of Nursing (DON) said everything regarding bed rails should have been done upon admission. They also obtained an order and added the grab bars to the care plan. Review of the documents provided by the DON on 06/18/26 at 9:00 A.M. during the interview showed: - A Safety Device Consent, dated 06/17/26 and signed by the resident; - A Safety Device Evaluation, dated 06/17/26. Review of the resident's medical record on 06/18/26 showed: - An order for assist rails times two, dated 06/17/26; - A care plan with assist rails times two, revised 06/17/26. During an interview on 06/17/26 at 3:52 P.M., the Maintenance Supervisor said he only does the zone inspection for bed rails when they are first put on the bed. He said there are gaps in the inspections because his assistant was putting rails on beds and not telling him the inspection was needed. During an interview on 06/18/26 at 10:38 A.M., the Maintenance Director said he checks to assure rails are tight with no gaps. The assessments were completed when they were applied and on the date of the entrapment list, which were different dates, because some had just been completed yesterday. He was not aware that the trapeze had to be assessed so it had not been done. During an interview on 06/18/26 at 3:15 P.M., the Administrator, DON, and Regional Nurse Consultant said they would expect risk assessments and consents to be completed regularly before bed rails or trapeze are installed and used.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during perineal care (washing the genital and anal areas of the body) for three residents (Residents #69, #77, and #137) out of seven sampled residents. The facility failed to implement enhanced barrier precautions (EBP) and proper infection control practices when accessing the Peripherally Inserted Central Catheter (PICC - a thin, soft, flexible tube that is placed in a vein that leads to the heart) for one resident (Resident #1) out of three sampled residents. The facility failed to maintain infection control practices during saline flush administration via a gastrostomy tube (G-tube - a surgically placed tube that provides direct access to the stomach for feeding, fluids, or medications) for one resident (Resident #7) out of one sampled resident. The facility's census was 169. Review of the facility's policy titled, Enhanced Barrier Precautions, dated January 2026, showed:- Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk for MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter – a tube inserted into the bladder to drain urine, feeding tube, endotracheal or tracheostomy tube – a surgically created hole in the front of the neck that leads directly into the windpipe, vascular catheters – a thin, flexible tube inserted into a blood vessel) and wounds or presence of unhealed pressure ulcers (an area of damaged skin and tissue that occurs when sustained pressure restricts blood flow);- For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator (a life-support device that breathes for a patient). Review of the facility's policy titled, Nurses' Infusion Manual for Long Term Care Facilities, dated December 2014, showed:- Vigorously cleanse the needleless connector (medical valve attached to the end of an intravenous [IV – in the vein] line) with alcohol. Allow to dry;- Maintain asepsis (the state of being free from disease-causing microorganisms), attach flush syringe to needleless connector. Verify venous (related to the vein) access patency (open, unobstructed, and freely accessible). Flush with prescribed flushing agent. Remove syringe;- Vigorously cleanse the needleless connector with alcohol. Allow to dry. Attach administration set to needleless connector. Review of the facility's policy titled, Perineal Care, revised 06/20, showed: - Wash hands; - Put on gloves; - Wash the pubic area; - Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area; - Remove wet linens; - Place dry linens or briefs or both underneath resident; - Remove gloves. Wash hands or use alcohol-based hand sanitizer. (Do not touch anything with soiled gloves after procedure); - Put on clean gloves; - Place soiled linen in proper container; - Remove gloves. 1. Observation on 06/16/26 at 3:56 P.M. of Resident #137's peri care showed: - Certified Nursing Assistant (CNA) I and CNA J entered the resident's room, washed hands, and put on clean gloves; - CNA I used the bed remote to raise the bed to waist height, picked up the trash can and moved it to the foot of the resident's bed; - CNA J opened the resident's closet, retrieved wipes and a clean brief with his/her left hand, and put a clean glove on his/her left hand without performing hand hygiene; - CNA I and CNA J uncovered the resident, and CNA I removed the positioning wedge from under the right side of the resident and placed it in the resident's Broda chair (a specialized type of wheelchair); - CNA I and CNA J held the resident in position while CNA I cleaned the resident's front peri area; - CNA I removed the soiled brief and placed it in the trash can; - With the same soiled gloves, CNA I cleaned the resident's buttocks and put the clean brief on the resident while CNA J held the resident in position; - CNA I and CNA J removed gloves, washed hands, and put on clean gloves; - CNA I obtained pants from the resident's closet and CNA I and CNA J put the pants on the resident; - CNA I and CNA J positioned a lift sling under the resident, and CNA J put heel protector boots on the resident; - CNA I gathered the trash, touched the trash can, and placed the bag on the floor; - CNA I and CNA J attached the sling to the lift and CNA I used the lift control to lift the resident out of bed while CNA J positioned the resident into his/her Broda chair; - CNA J unhooked the lift sling from the lift while CNA I put the heel protector boots back on as they had fallen off onto the bed when they raised the resident in the lift; - CNA J retrieved a shirt from the resident's closet and both removed the resident's gown; - CNA I put the gown and the resident's pillow that had fallen on the floor in a trash bag; - CNA I and CNA J placed the shirt on the resident; - CNA I and CNA J removed gloves. CNA J got a new trash bag, put it in the trash can and handed CNA I the bag containing the trash; - CNA I set the bag of trash down and moved the lift out of the way; - CNA I and CNA J washed hands, and CNA I exited the room with the trash bags while CNA J pushed the resident down the hall for dinner. During an interview on 06/16/26 at 4:20 P.M., CNA I and CNA J said they should wash before and after care and with glove changes. If they touch something dirty, they should take their gloves off and wash their hands. They should wash and change gloves after touching items in the room, like the trash can, before touching the resident to perform peri care. 2. Observation on 06/17/26 at 5:18 A.M. of Resident #1's medication administration and PICC line care showed:- Signage posted inside of the resident's room instructed staff to wear gown and gloves for resident care; - Resident #1 had a PICC line;- Licensed Practical Nurse (LPN) A entered the resident's room to disconnect medication;- LPN A did not perform hand hygiene and applied clean gloves;- LPN A failed to put on a gown prior to accessing the PICC line; - LPN A disconnected the tubing from the PICC access;- The PICC line connector hub rested on the resident's bed;- LPN A attached the syringe to the hub without disinfecting the hub before placing the lock cap. During an interview on 06/17/26 at 5:25 A.M., LPN A said EBP are for residents with wounds and catheters. Gowns don't need to be worn when connecting or disconnecting tubing from a PICC line. 3. Observation on 06/17/26 at 5:21 A.M. of Resident #69's peri care showed: - CNA K put on a gown and gloves and entered the resident's room; - CNA K lowered the bed, rolled the resident onto his/her right side and unfastened brief; - CNA K cleaned fecal matter from the resident's buttocks and tucked the soiled brief and linens under the resident; - CNA K placed a clean brief under the soiled brief and linens; - CNA K rolled the resident to his/her left side and removed the soiled brief and linens; - CNA K exited the room to obtain clean linens without changing gloves or sanitizing hands; - CNA K replaced linens, turned on warm water, placed a clean washcloth in the sink, and touched the resident's wheelchair handle; - CNA K changed gloves without washing or sanitizing hands; - CNA K picked up the washcloth from the sink, performed peri care, placed clean brief, and covered the resident with a blanket; - CNA K took the soiled linens to the hallway, removed gloves without washing or sanitizing hands, and then took trash to dirty hamper after gloves were removed. 4. Observation on 06/17/26 at 6:11 A.M. of Resident #77's peri care showed: - CNA D and CNA E entered the room without washing hands and put on gloves; - CNA E lowered the bed, and CNA D removed the resident's brief; - CNA E cleaned the resident's front perineal area; - CNA D held the resident in position while CNA E cleaned the resident's buttocks. CNA D placed a clean brief on the resident; - CNA D removed gloves, gathered trash, placed new trash bag, left room with trash and did not wash hands before leaving the room; - CNA E removed gloves, did not wash hands, adjusted the bed, placed call light, turned overhead light out, pushed bedside table closer to the bed and assisted the resident to get a drink from his/her cup, touching the straw, then washed hands. During an interview on 06/17/26, at 6:20 A.M., CNA E said he/she should have washed hands after providing care and before touching items such as the call light and resident's cup/straw, but he/she was just nervous. 5. Observation on 06/17/26 at 8:00 A.M. of Resident #7's G-Tube flush showed: - LPN C entered the room, washed hands, and put on gloves and a gown; - LPN C touched the faucet, filled a cup with water, then used the controller to raise the resident's bed; - With the same soiled gloves, LPN C attached a clean syringe to the end of the G-Tube, unclamped tubing, checked residual (contents left in stomach), then pushed residual back into tubing; - With the same soiled gloves, LPN C withdrew 50 milliliters (ml) of water from the cup and flushed into the G-tube; - LPN C clamped tubing, removed gown and gloves, and washed hands. During an interview on 06/17/26 at 8:10 A.M., LPN C said he/she should have sanitized and changed gloves after touching the faucet and raising the bed with the controller but was concerned that the resident wasn't feeling well and was wheezing and coughing. During an interview on 06/18/26 at 11:15 A.M., Assistant Director of Nursing G said that he/she would expect all staff to change gloves and wash or sanitize hands between dirty to clean care. During an interview on 06/18/26 at 1:36 P.M., Unit Manager L said residents with chronic wounds, PICC lines, foley catheters, tracheostomies, current or a history of MDROs are on EBP. Staff should put on appropriate PPE such as a gown, gloves, or mask when providing direct patient care. He/she was unsure if staff needed to put on PPE if they were just disconnecting IV tubing from a PICC line. During an interview on 06/18/26 at 1:40 P.M., Infection Preventionist (IP) K said residents with G-tubes, catheters, open or chronic wounds, PICC lines, and central lines are put on EBP. If staff are providing direct care, they should put on a gown, gloves, and/or a mask. If staff are disconnecting IV tubing from the PICC line, staff should put on a gown and gloves. When staff are disconnecting IV tubing from the PICC line and flushing the line, staff should perform hand hygiene, put on gown and gloves, and disconnect the tubing from the PICC connector, scrub the PICC connector, connect flush, use push-pause method, disconnect flush, disinfect PICC connector, and apply disinfectant cap. He/she educated staff on disinfecting the PICC connector before and after connecting anything to the PICC line. During an interview on 06/18/26 at 3:15 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to change gloves and sanitize hands between dirty and clean, change gloves after touching items in resident rooms and before starting a procedure. Staff should also wash hands before leaving the room. The DON said she would expect staff to wear a gown and gloves when providing direct care to a resident with a PICC line. She said staff should disinfect the hub of the PICC line before and after accessing the line.

Based on observation and interview, the facility failed to maintain the physical environment of the bathrooms and showers in a safe, clean, and sanitary manner. This deficient practice had the ability to affect all residents who use the bathrooms and showers. The facility census was 169. The facility did not provide a policy regarding cleaning the bathrooms and showers. Observation on 06/17/26 at 11:00 A.M., of the 500 Hall women's shower room showed: - The area around the floor drain located in the center of the room with multiple cracked, broken, and missing floor tiles, deteriorated grout surrounding the drain, and an uneven floor surface around the drain; - The shower floor drain located within the shower area with a wet tissue-like substance and black residue/debris on and around the drain cover with cracked, broken, and missing surrounding floor tiles, and deteriorated grout surrounding the drain; - The hanging shower curtain with black discoloration/staining on the lower portion of the curtain; - Black and green discoloration/residue along the floor-to-wall junction throughout the shower area and similar black and green discoloration/residue along the floor-to-wall junction underneath the sink and in other areas of the bathroom; - Caulking/sealant along the floor-to-wall junction and shower threshold deteriorated with gaps and areas of separation. Observation on 06/18/26 at 11:55 A.M., of the upstairs men's shower room showed: - Debris overflowing from two large trash cans in the first stall in front of the toilet; - The second stall toilet with an open gap around the base where the fixture met the floor and dark discoloration within the gap and along the floor-to-wall junction next to the toilet; - Black and brown discoloration along the floor-to wall junctions throughout the bathroom. Observation on 06/18/26 at 11:57 A.M., of the upstairs women's shower room showed: - Black and brown discoloration along the floor-to-wall junction throughout the bathroom; - Black and brown discoloration throughout the floor and lower portion of the wall; - A wet tissue-like substance and black residue/debris on and around a shower chair in the corner of the room. During an interview on 06/18/26 at 2:32 P.M., Resident #185 said the bathrooms could be cleaner. During an interview on 06/18/26 at 2:50 P.M., Resident #124 said he/she wished the bathroom was cleaner. There was mold everywhere and staff should scrub it off. The curtains were also moldy and needed to be changed. He/She thought staff tried to clean the shower rooms daily. Sometimes the shower chairs would have a little stool around the rim, and the staff would try to assist him/her to the chair, and he/she would have to request it to be cleaned first. During an interview on 06/18/26 at 3:00 P.M., the Housekeeping Supervisor said she would expect shower rooms to be cleaned daily. Debris and other residue should be addressed daily by housekeeping staff. If housekeeping was unable to address the issue or concern, a maintenance request was submitted. During an interview on 06/18/26 at 3:15 P.M., the Administrator, Director of Nursing, and Regional Nurse Consultant said they would expect the bathrooms/shower rooms to be clean and sanitary.

Based on observation, interview, and record review, the facility failed to conduct regular inspections of all bed frames, mattresses, side rails and trapeze (an overhead assistive device with a suspended triangular handle) as part of a regular maintenance program for seven residents (Residents #8, #16, #84, #155, #162, #172, and #173) out of 33 sampled residents. The facility's census was 169. Review of the facility's policy, Bed Rails, revised 06/20, showed: - Before installing a bed rail, the facility must assess the resident for the risk of entrapment from bed rails and ensure the bed's dimensions are appropriate for the resident's size and weight. The manufacturer's recommendations and specifications for installing and maintaining bed rails will be followed; - Maintenance/Designee will assess the bed dimensions no less than quarterly by utilizing Maintenance Inspection Checklist- Resident Rooms. Maintenance will also check bed rails regularly to ensure they are still installed correctly, as rails may shift or loosen over time. 1. Review of Resident #8's medical record showed: - admission date of 03/16/17; - Diagnoses of cerebral palsy (a lifelong physical disability that affects a person's movement, muscle control, balance, and posture), legal blindness, and morbid obesity; - No maintenance assessment for side rails. Observation on 06/15/26 at 3:26 P.M., showed the resident used the right rail to turn in bed while staff performed incontinent care. During an interview on 06/17/26 at 1:26 P.M., the resident said he/she used the side rails to help turning in bed. 2. Review of Resident #16's medical record showed: - admission date of 06/28/24; - Diagnoses of fracture of the left lower leg, muscle weakness, need for assistance with personal care, and morbid obesity (a chronic, life-threatening disease characterized by excessive body fat); - No maintenance assessment for side rails. Observation of the resident showed: - On 06/15/26 at 12:55 P.M., the resident lay in bed with assist bars up on the left and right sides; - On 06/18/26 at 11:00 A.M., the resident lay in bed with assist bars up on the left and right sides. During an interview on 06/18/26 at 11:00 A.M., Resident #16 said he/she uses the assist bars to reposition and turn in bed. 3. Review of Resident #84's medical record showed: - admission date of 02/05/26; - Diagnoses of lumbago with sciatica (lower back pain that radiates down one or both legs), spinal injury and chronic pain; - Maintenance assessment for side rails, dated 06/17/26; - No maintenance assessment for trapeze. Observation of the resident showed: - On 06/15/26 at 1:40 P.M., the resident sat in a wheelchair beside the bed which had a trapeze and bilateral grab bars; - On 06/17/2026 at 8:51 A.M., the resident used the trapeze bar during repositioning for care. 4. Review of Resident #155's medical record showed: - admission date of 02/23/18; - Diagnosis of hemiplegia/hemiparesis (severe or complete paralysis of one side due to brain or spinal cord damage with mild to severe muscle weakness or partial loss of movement on one side of the body) following stroke affecting the left dominant side; - No maintenance assessment for side rails. Observation of the resident showed: - On 06/15/26 at 12:45 P.M., the resident sat in his/her wheelchair with assist bars up on the right and left sides of the bed; - On 06/18/26 at 10:50 A.M., the resident sat in his/her wheelchair with assist bars up on the right and left sides of the bed. During an interview on 06/18/26 at 10:50 A.M., Resident #155 said he/she uses the assist bars to turn in bed. 5. Review of Resident #162's medical record showed: - admission date of 10/07/25; - Diagnoses of chronic obstructive pulmonary disease (progressive lung disease that causes restricted airflow and breathing difficulties), respiratory failure (lung condition that causes a buildup of carbon dioxide in the blood), and heart failure (the heart muscle becomes too weak or stiff to pump enough blood and oxygen to meet the body's needs); - No maintenance assessment for side rails. Observation on 06/17/26 at 5:40 A.M., showed the resident used the right rail to turn in bed while staff performed incontinent care. During an interview on 06/15/26 at 12:10 P.M., the resident said he/she used the side rails to help turn in bed to get changed. No one has come around to check to see if the rails are loose. 6. Review of Resident #172's medical record showed: - admission date of 9/19/25; - Diagnoses of transient ischemic attack (temporary blockage of blood flow to the brain), stroke, and amputation of right leg above the knee; - No maintenance assessment for side rails. Observation on 06/15/26 at 12:23 P.M. showed the resident used the right rail to turn in bed. During an interview on 06/15/26 at 12:26 P.M., the resident said he/she used the side rail to help with transfers from the bed. No staff have ever come around to check to see if the rail is loose or to assess if he/she still used the rail. 7. Review of Resident #173's medical record showed: - admission date of 06/02/26; - Diagnoses of chronic pain, obesity (excessive or abnormal accumulation of body fat that increases the risk of health problems), and epilepsy (seizure disorder); - No maintenance assessment for assist rails (U-shaped metal handles attached to the bed used for repositioning). Observation of the resident showed: - On 06/15/26 at 11:53 A.M., the resident sat in his/her wheelchair with U-shaped assist rails on the bed bilaterally; - On 06/16/26 at 3:36 P.M., the resident lay in bed with U-shaped assist rails on the bed bilaterally. During an interview on 06/17/26 at 3:52 P.M., the Maintenance Supervisor said he only does the zone inspection for bed rails when the bed rails are first put on the bed. He said there are gaps in the inspections because his assistant was putting rails on beds and not telling him the inspection was needed. During an interview on 06/18/2026 at 10:38 A.M., the Maintenance Director said he checks to assure rails are tight with no gaps. The assessments were completed when they were applied and on the date of the entrapment list, which were different dates, because some had just been completed yesterday. He was not aware that the trapeze had to be assessed so it had not been done. During an interview on 06/18/26 at 3:15 P.M., the Administrator and Director of Nursing said they would expect bedrails and trapeze to be assessed regularly to ensure they are safely secured to the bed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured accurate dispensing, storage, and labeling of medications. This had the potential to affect all residents. The facility's census was 169. Review of the facility's policy titled, Medication - Administration, undated, showed: - Medication will be administered by a Licensed Nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law; - Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law; - Medications may be administered one hour before or after the scheduled medication administration time; - Medications will not be left at the bedside. 1. Observation on 06/18/26 at 9:15 A.M. of the [NAME] Hall Medication Cart showed six medication cups in the top drawer of the cart with multiple unidentified medications popped out into each cup and not labeled with the residents' name, date, or time. During an interview on 06/18/26 at 9:22 A.M., Certified Medication Technician (CMT) H said the medications that were in the top drawer were for residents that went to physical therapy. He/She was sorry and knew better than to prepare medications if the resident was not present and ready to take immediately after preparing. During an interview on 06/18/26 at 9:27 A.M., Assistant Director of Nursing G said he/she would expect staff to prepare medications right before administering and to never prepare early and leave unidentified medications in the cart to give later. During an interview on 06/18/26 at 3:15 P.M., the Administrator, Director of Nursing, and Regional Nurse Consultant said they would expect all medications to be administered immediately after being prepared for each resident, and there should be no medications being prepared early and left in the cart where they were unable to be unidentified.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during tracheostomy (surgical opening in the neck used to provide airway for breathing) care and g-tube (a medical device that delivers liquid nutrition directly to the stomach or small intestine through a flexible tube) medication administration for one resident (Resident #20) out of 32 sampled residents. The facility failed to maintain infection control practices when staff failed to wear proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) for two residents (Resident #20 and #97) out of 32 sampled residents. The facility's census was 161. Review of the facility's policy, Enhanced Barrier Precautions, dated 04/24, showed: - EBP are indicated for residents with infections or colonization with a CDC-targeted MDRO when contact precautions do not apply or for resident with wounds and/or indwelling medical devices without secretions/excretions that are unable to be covered/contained and are not known to be infected/colonized with any MDRO during high-contact resident care activities as these residents are at an increased risk of being infected; - EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices); - EBP only requires use of gown/gloves when performing high contact resident activities: Device care or use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator; - Duration: EBP are intended to remain in effect for the duration of the resident stay or until the wound is closed/medical device removed. Review of the facility's policy, Enteral Tube Medication Administration Procedures, dated 06/23, showed: - Check medication administration record (MAR)/electronic medication administration record (eMAR) for the prescribed medication, amount, and time of administration; - Verify type of enteral tube in place and select appropriate syringe for administration; - Prepare medications for administration, crush tablet and dissolve/mix in a small amount of water or other appropriate liquid; - Provide privacy and place resident in proper position; if in bed, elevate the head of bed; - Wash hands and apply gloves; - Verify tube placement per tube feeding policy, stop enteral feeding and flush tube with an approximate 15 milliliters (ml) of water prior to medication administration, administer each medication separately, flushing tube with approximately 15 ml of water after each dose unless fluid restricted; - Place the first medication into the syringe, allow flushes and medication to flow down tube via gravity, flush the tube with approximately 15 ml of water and clamp to prevent medication from clogging tube lumen (space within a tube); - Clean feeding syringe and return to bedside stand; syringes are replaced every 24 hours or as required by state regulation; - Restart enteral feeding; - Wash hands as per facility policy; - Document medication administration and chart water intake, if appropriate. 1. Observation on 04/09/24 at 11:30 A.M. of Resident #20's tracheostomy collar/mask, oxygen support system showed: - An EBP sign above the resident's bed and EBP supplies available in a hanging bin located on the resident's bathroom door; - Oxygen support tubing disconnected from trach collar and lying on the resident's floor in his/her room; - Trach collar shifted to the right side of the resident's neck and not centered over tracheostomy; - Licensed Practical Nursing (LPN) B entered the resident's room and donned a mask and gloves; - LPN B did not don a gown; - LPN B did not wash his/her hands; - LPN B picked up the oxygen tubing from the floor and reconnected the tubing between the resident's tracheostomy collar and the oxygen support system; - LPN B removed gloves and mask and exited the resident's room; - LPN B re-entered the resident's room, did not wash or sanitize hands and donned a mask and gloves; - LPN B opened a package with new oxygen support tubing; - LPN B replaced the part of the oxygen support tubing that had been previously on the floor; - LPN B removed gloves and mask and washed hands; - LPN B exited the resident's room. During an interview on 04/09/25 at 3:48 P.M., LPN B said he/she checked on the resident about an hour ago. Sometimes the oxygen tubing comes off when the aides move the resident around. Tubing should never be reconnected if it has been lying on the floor. He/She should have worn a gown, gloves, and mask and should have washed his/her hands when going to and from the resident's room. EBP should be worn when a resident has a urinary catheter, tracheostomy, feeding tube, bacteria in their urine, or open wounds. 2. Observation on 04/10/25 at 1:33 P.M. of Resident #20's medication administration via feeding tube showed: - LPN A did not wash or sanitize hands; - LPN A removed a pill from the nurse's medication cart and placed the pill in his/her bare hand; - LPN A placed the pill in a plastic sleeve and crushed the pill; - LPN A placed the medication in a small, plastic cup; - LPN A entered the resident's room; - LPN A obtained and opened a new syringe package; - LPN A placed syringe and plastic cup containing the medication beside the sink without a barrier; - LPN A donned gloves and gown; - LPN A filled cup containing the medication with water from the sink; - LPN A pulled the privacy curtain and lifted the resident's gown to access g-tube/feeding tube site; - LPN A removed cap to g-tube and pulled syringe back, no residual was noted; - LPN A removed the plunger from the syringe and emptied water containing the medication into the syringe, residual medication was noted in the cup; - LPN A placed the cup on the bedside table without a barrier; - LPN A closed the g-tube cap; - LPN A picked up the cup off of the bedside table and took it to the sink to obtain more water for the residual medication; - LPN A removed the cap to the g-tube, and administered the remaining water and medication; - LPN A reconnected the feeding tube into the g-tube and turned feeding tube pump on; - LPN A lowered the resident's gown and pulled covers up around resident's arms; - LPN A removed gown and gloves and washed his/her hands. During an interview on 04/10/25 at 1:45 P.M., LPN A said he/she should have washed or sanitized his/her hands prior to getting the medication out of the medication cart, and before he/she started administering the medication. He/She should absolutely not touch a pill barehanded. 3. Observation on 04/11/25 at 10:00 A.M. of Resident #97's wound care showed: - Signage hanging above the head of the bed showed the resident required EBP for care; - Registered Nurse (RN) C sanitized hands and gathered gauze, skin prep (a topical solution used as a barrier to protect skin), medication cup with gauze moistened by wound cleanser inside, and gloves from the treatment cart placed at the resident's doorway; - RN C entered the room without donning a gown and laid supplies on gloves on the bed as a barrier; - RN C donned gloves; - RN C positioned the resident's leg, and leaned against the bed without a gown as a barrier; - RN C removed the dressing from the left calf; - RN C wiped the wound with the wound cleanser moistened gauze; - RN C removed gloves, sanitized hands, and donned new gloves; - RN C wiped the wound with skin prep: - RN C removed gloves, sanitized, and obtained Mepilex border (an absorbent foam dressing) from the treatment cart; - RN C failed to don gloves and applied the Mepilex dressing with bare hands, touching the resident's leg and bed with his/her bare hands; - RN C sanitized hands and gathered gauze, skin prep, medication cup with gauze moistened by wound cleanser inside, and gloves from the treatment cart; - RN C donned gloves and removed dressing from the resident's left heel, - RN C removed gloves and repositioned the resident's foot with his/her bare hands; - RN C sanitized hands and donned gloves; - RN C wiped the wound with wound cleanser dampened gauze; - RN C removed gloves and sanitized hands; - RN C wiped the wound with skin prep; - RN C removed gloves and applied Mepilex dressing to the resident's heel with his/her bare hands, touching the resident and the resident's bed. During an interview on 04/09/25 at 3:25 P.M., the resident said staff occasionally wear a gown when performing care for him/her. During an interview on 04/10/25 at 12:30 P.M., RN C said he/she should have used EBP and worn a gown when performing a dressing change on a resident who required EBP. During an interview on 04/11/25 at 4:35 P.M., the Administrator and Director of Nursing (DON) said they would expect nurses not to handle medications with their bare hands and would expect nurses to replace tubing that has been lying on the floor and not to reconnect the tubing back to a machine. They said they would expect staff to wear gowns and gloves for residents on EBP. 49754

Based on observation, interview, and record review, the facility failed to appropriately assess the use of bed rails for three residents (Resident #107, #133, and #462) of 32 sampled residents. The facility's census was 161. Review of the facility's policy titled, Side Rail Use Evaluation, dated 02/25, showed: - The resident's risk for entrapment should be assessed prior to installation of bed rails; - Complete the Side Rail Evaluation form; - Documentation should contain alternatives prior to implementation of any type of rail(s), risk and benefits reviewed with the resident or resident representative, and informed consent obtained from the resident or resident representative. 1. Review of Resident #107's medical record showed: - admitted on [DATE]; - Diagnoses of displaced fracture (two or more portions of broken bone come out of proper alignment) of second cervical (neck) vertebra (series of small bones forming the backbone), burst fracture (a serious spinal injury where the vertebra shatters and breaks in multiple directions) of fourth thoracic (the middle section of the spine starting at the base of the neck and ending at the bottom of the ribs) vertebra, hemiplegia (paralysis of the muscles of the lower face, arm, and leg on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply), dementia (a group of symptoms affecting memory, thinking and social abilities), metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood), type 2 diabetes (when the body cannot use insulin correctly and sugar builds up in the blood), hypertension (high blood pressure), and heart failure ( when the heart can't pump enough blood to meet the body's needs, leading to organs not working properly); - An order for assist rails on both sides of the bed, dated 03/28/25; - No side rail evaluation completed for the resident; - No documentation of an informed consent signed explaining the risks and benefits. Review of the resident's significant change Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 04/04/25, showed: - Moderate cognitive impairment; - Maximum assist from staff for bed mobility. Observation on 04/09/25 at 1:13 P.M. showed the resident eating lunch in bed with head of bed elevated and assist bars on both sides of the bed. During an interview on 04/11/25 at 11:30 A.M., the resident said he/she uses the assist bars to turn in bed. 2. Review of Resident #133's medical record showed: - admitted on [DATE]; - Diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), heart failure, and hypertension. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Independent for bed mobility. Review of the resident's Side Rail Evaluation, dated 01/14/25, showed: - Resident using assist rails on both sides; - No resident or family request to use side rails while in bed; - No interventions trialed before considering use; - No cause/medical symptom justifying use; - No benefits or risks listed; - No documented consent. Review of the facility's entrapment assessment binder showed an entrapment assessment not completed until 03/20/25. Observation on 04/08/25 at 12:12 P.M. and on 04/09/25 at 10:43 A.M. showed the resident up in a wheelchair and the bed with quarter rails on both sides in the up position. 3. Review of Resident #462's medical record showed: - admitted on [DATE]; - Diagnoses of nontraumatic intracerebral hemorrhage (bleeding within the brain that occurs without any prior trauma or injury), cerebral ischemia (a condition where the brain does not receive enough blood flow, resulting in a lack of oxygen and nutrients), hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation (a common heart rhythm disorder characterized by rapid, irregular beating of the heart's upper chambers), general anxiety disorder (a mental health condition characterized by persistent and excessive worry about various aspects of life, often about things that are not likely to happen), senile degeneration of brain (a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), and chronic kidney disease (a progressive condition where the kidneys are damaged and can't filter waste and fluid from the blood effectively); - An order for assist rails on both sides of the bed, dated 03/22/25. Review of the resident's significant change MDS, dated [DATE], showed: - Moderate cognitive impairment; - Dependent on staff for bed mobility. Review of the resident's Side Rail Evaluation, dated 03/22/25, showed no other interventions had been trialed before considering the use of side rails. Observation on 04/10/25 at 7:46 A.M. showed the resident lying in bed with half bed rails up on both sides of the bed. Observation on 04/11/25 at 10:15 A.M. showed the resident holding the left side rail while being held onto his/her left side during wound care. During an interview on 04/11/25 at 11:31 A.M., the resident said he/she uses the side rails when staff reposition him/her in bed. During an interview on 04/11/25 at 4:35 P.M., the Administrator and Director of Nursing said they would expect staff to try alternatives before installing side rails, side rail assessments to be completed on all side rails and assess for entrapment risk prior to installation, and the risk/benefits of side rails to be explained to the resident and informed consent obtained before installation. 47678 49999

Based on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for the resident) upon admission with specific interventions needed to care for resident, and failed to assure the resident and/or guardian received a written summary of the baseline care plan for two residents (Resident #151 and #261) out of 32 sampled residents. The facility's census was 161. Review of the facility's policy, Care Plans, dated 01/15, showed: - Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the team will provide care; - Responsibility of the nurse monitored by the Executive Director; - The Care Plan will be developed within two days; - The team along with the resident and/or family members will identify services needed, preferences, and ability and care level guidelines. 1. Review of Resident #151's medical record showed: - admitted on [DATE]; - Diagnoses of congenital malformation of the brain (a birth defect that occurs during development in the womb resulting in abnormal brain structure), borderline intellectual functioning (functioning on the border between normal intellectual functioning and intellectual disability), epilepsy (seizures) and hypothyroidism (when the thyroid gland does not make enough thyroid hormone). Review of the baseline care plan showed: - Not completed until 03/14/25; - No documentation that the care plan had been reviewed with the resident and/or resident's representative. 2. Review of Resident #261's medical record showed: - admitted on [DATE]; - Diagnoses of adult failure to thrive (a syndrome of global decline in older adults, characterized by frailty, weight loss, decreased appetite, and a decline in functional abilities), protein calorie malnutrition (a condition resulting from inadequate intake of protein and/or calories, leading to a deficiency in these essential nutrients), and depression. Review of the baseline care plan showed: - No completion date documented; - No documentation that the care plan had been reviewed with the resident and/or resident's representative. During an interview on 04/11/25 at 4:35 P.M., the Administrator and Director of Nursing (DON) said they would expect the baseline care plan to be completed within 48 hours of admission and a summary of the baseline care plan to be provided to the resident and/or resident's representative. 46460

Based on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pests out and/or to keep the garbage contained in the dumpster. The facility census was 159. The facility did not provide a policy regarding the dumpsters. Observations of two dumpsters, both with two lids, at the right side of the front entrance showed: - On 02/27/24 at 9:30 A.M., the dumpster on the left had both lids opened with visible trash bags, cardboard boxes, and other miscellaneous items; - On 02/28/24 at 4:00 P.M., the dumpster on the left had one lid opened with visible trash bags and other miscellaneous items; - On 02/29/24 at 8:10 A.M., the dumpster on the right had one lid opened. During an interview on 02/29/24 at 12:25 P.M., the Director of Nursing (DON) said housekeeping, dietary staff, and the night shift Certified Nursing Assistants (CNAs) are the people responsible for taking garbage out to the dumpsters and the dumpsters are emptied six days a week. During an interview on 02/29/24 at 2:45 P.M., the Dietary Manager said trash dumpster lids should be closed after staff discard trash and other miscellaneous items. During an interview on 03/1/24 at 10:09 A.M., the Housekeeping Supervisor said housekeeping empties trash each day and she would expect them to keep the lids closed on the dumpsters. During an interview on 03/01/24 at 3:45 P.M., the Administrator said he would expect the dumpster lids to be closed at all times.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for three residents (Resident #30, #48, and #55) out of 32 sampled residents. This failure had the potential to keep any resident on a psychoactive medication from receiving the lowest possible dosage of medication due to not monitoring if a medication is treating the target symptom. The facility census was 159. Review of the facility's policy titled, Behavior Management and Psychopharmacological Medication Monitoring Protocol, revised March 2018, showed: - Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dosage necessary to manage the resident's condition; - Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications and will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs; - There will be an established Behavior Management Committee that will meet routinely to review all residents mentioned above and others as the Committee deems appropriate; - Residents with behaviors that are displayed routinely, that affect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program; - During the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications; - When evaluating the resident's progress, the practitioner reviews the total plan of care, orders, the resident's response to medications, and determines whether to continue, modify, or stop a medication; - During the quarterly MDS review, the facility evaluates mood, function, behavior, and other domains that may be affected by medications; - The time frames and duration of attempts to taper any medication depend on the coexisting medication regimen, the underlying cause of symptoms, individual risk factors, and pharmacological characteristics of the medications. Some medications require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequences; - Within the first year in which a resident is admitted on an psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters, unless clinically contradicted; - After the first year, a GDR must be attempted annually, unless clinically contradicted; - For any individual receiving a psychotropic medication to treat a disorder other than expressions or indicators of distress related to dementia (schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered clinically contraindicated if the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability or be exacerbating an underlying psychiatric disorder or the residents target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale; - Before initiating or increasing an antipsychotic medication for enduring conditions (non-acute, chronic, or prolonged), the resident's symptoms and therapeutic goals must be clearly and specifically identified and documented; - The facility is to ensure the resident's expressions or indicators of distress are persistent and not due to medical conditions, environmental stressors, or psychological stressors. 1. Review of Resident #30's medical record showed: - admitted [DATE]; - Diagnoses of chronic pain, anxiety (persistent worry and fear about everyday situations), bipolar disorder (a mental disorder that causes unusual shifts in mood), schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), insomnia (difficulty sleeping), drug induced secondary parkinsonism (brain disorder that causes unintended and uncontrollable movements), and major depressive disorder (long-term loss of pleasure or interest in life); - An order for zaleplon (sleeping medication) 10 milligrams (mg) by mouth at bedtime for insomnia, dated 03/20/19; - An order for alprazolam (anxiety medication) 1 mg by mouth daily at 1600 for anxiety, dated 03/11/21; - An order for melatonin (sleeping medication) 5 mg one tablet by mouth at bedtime for insomnia, dated 05/15/19; - An order for hydrocodone-acetaminophen (pain medication) 7.5-325 mg tablet by mouth three times a day (TID) for chronic pain, dated 06/20/23; - An order for Invega trinza (antipsychotic medication) 819 mg/2.625 milliliters (mL) inject intramuscular (IM) every three months for schizoaffective disorder, dated 05/07/18; - An order for fluoxetine (antidepressant medication) 60 mg by mouth every day, dated 05/18/22; - An order for fluoxetine 20 mg by mouth at noon daily for other recurrent depressive disorders, dated 08/31/18; - An order for carbidopa-levodopa (medication to ease Parkinson symptoms) 25-100 mg tablet by mouth TID for drug induced secondary parkinsonism, dated 07/18/23; - An order for Mirapex (medication to ease Parkinson symptoms) 0.5 mg tablet by mouth TID for drug-induced secondary parkinsonism, dated 07/18/23; - No documentation of GDRs attempted; - No documentation of contraindications of medication adjustments. 2. Review of Resident #48's medical record showed: - admitted [DATE]; - Diagnoses of psychosis (a mental disorder characterized by a disconnection from reality), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), depressive disorder with psychotic symptoms (depressive illness in which mood disturbance is accompanied by either delusions, hallucinations or both) and schizoaffective disorder, and mood disorder symptoms; - An order for Risperodone (antipsychotic medication) 3 mg, one tablet by mouth, daily, with an original start date of 12/29/20; - An order for Effexor (antidepressant medication) extended release (ER), 150 mg, one capsule, by mouth, daily, with an original start date of 01/13/21; - No documentation of GDRs attempted since 09/20/22; - No documentation of contraindications of medication adjustments. During an interview on 03/01/24 at 2:46 P.M., the Pharmacist said the last GDR attempt for Resident #48 was in 2022. 3. Review of Resident #55's medical record showed: - admitted [DATE]; - Diagnoses of bipolar disorder, schizoaffective disorder, and major depressive disorder; - An order for Abilify (antipsychotic medication) 10 mg daily, dated 06/01/17; - An order for Duloxetine (antidepressant medication) 30 mg daily, dated 06/01/17 and discontinued 03/02/22; - An order for Duloxetine 40 mg daily, dated 03/02/22 and discontinued 06/13/22; - An order for Duloxetine 60 mg daily, dated 06/13/22 and discontinued 06/22/23; - An order for Duloxetine 30 mg in the morning (A.M.) and 60 mg in the evening (P.M.), dated 06/22/23; - An order for Lorazepam (anti-anxiety medication) 0.25 mg TID, dated 11/17/21; - No documentation of GDRs attempted; - No documentation of contraindications of medication adjustments. During an interview on 03/01/24 at 12:00 P.M., the MDS Coordinator said for the GDR date on Section N on the MDS, she will look in the paper chart under the tab with the Monthly Pharmacy Review and if there isn't a physician form there, she will look under the psychiatric tab to see when their last psychiatric visit was, and if it says the resident was stable on those meds, that is the date she will use for the last GDR. Not everyone's chart has a form signed by the physician on whether they agree or disagree with the pharmacist recommendation. She sees where there isn't really a good process in place for GDRs. During an interview on 03/01/24 at 12:42 P.M., the Infection Preventionist said she will sometimes GDR meds herself if she knows a resident needs it even without the pharmacist recommendation. She feels like the facility has a good system in place, but understands maybe they need better processes in place. The pharmacy will discontinue and restart meds for every resident annually and she sees how that could cause some confusion. She said the pharmacist keeps track of GDR recommendations, then the doctor should address them on whether to do a GDR on the medication, or if a GDR is contraindicated and the rationale for that decision. During an interview on 03/01/24 at 2:46 P.M., the Pharmacist said when GDRs are done, there is a review of the POS, psychotropic medications, and original order dates. If there were no changes or behaviors, a GDR letter would be sent. The GDR attempt is made with one drug at a time, if possible, to assess how that affected the resident. If a resident had a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), schizoaffective disorder, Tourette Syndrome (a nervous system disorder involving repetitive movements or unwanted sounds) or Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), he/she does not attempt a GDR as it is standard practice. During an interview on 03/01/24 at 3:45 P.M., the Director of Nursing (DON) said she would expect GDRs to be done per regulation. 46460 49152

Based on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff) for three residents (Resident #16, #30, and #56) out of 32 sampled residents. The facility census was 159. Review of the facility's policy, MDS Assessment, revised June 2023, showed: - The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations; - These regulations provide information on the resident's condition to facilitate development of an individualized plan of care as a means by which the facility can track changes in a resident's status; - The interdisciplinary team as designated will complete specific portions of the MDS. The registered nurse (RN) designated by the facility will assure that all disciplines have completed their portion of the MDS; - The interdisciplinary team member's signatures in Z0400 will attest to completion/accuracy of the assessment. 1. Review of Resident #16's medical record showed: - An admitted [DATE]; - Diagnoses of traumatic brain injury (TBI, injury that affects how the brain works), gastroesophageal reflux disease (GERD - digestive disease in which stomach acid or bile irritates the food pipe lining), hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), bipolar disorder (a mental disorder that causes unusual shifts in mood), dementia (group of thinking and social symptoms that interferes with daily functioning), hypertension (high blood pressure), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and coronary atherosclerosis (damage or disease in the heart's major blood vessels). Review of the resident's quarterly MDS, dated [DATE], showed TBI, GERD, and hypothyroidism not marked under Section I as diagnoses for the resident. 2. Review of Resident #30's medical record showed: - An admitted [DATE]; - Diagnoses of diabetes mellitus (disease that results in too much sugar in the blood), hypertension, GERD, anxiety, bipolar disorder, schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), hypothyroidism, heart failure (chronic condition where heart does not pump blood as well it should), insomnia (difficulty sleeping), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's Physician's Order Sheet (POS), dated February 2024, showed an order for zaleplon (a hypnotic medication) 10 milligrams (mg) by mouth at bedtime for insomnia, dated 03/20/19. Review of the resident's quarterly MDS, dated [DATE], showed: - Heart failure, GERD, and hypothyroidism not marked under Section I as diagnoses for the resident; - Hypnotic (sleeping pill) not marked under Section O. 3. Review of Resident #56's medical record showed: - An admitted [DATE]; - Diagnoses of anxiety, GERD, chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus, hypothyroidism, dementia, coronary atherosclerosis, convulsions (irregular involuntary body movements), cerebrovascular disease (condition that affects blood flow and blood vessels in the brain), human immunodeficiency virus (HIV, chronic immune disease that interferes with the body's ability to fight infection), atrial fibrillation (abnormal heart beat), osteoporosis (a condition causing loss of bone mass, predisposing a person to fractures), major depressive disorder, polyneuropathy (malfunction of many peripheral nerves throughout the body), and hypertension. Review of the resident's quarterly MDS, dated [DATE], showed atrial fibrillation, osteoporosis, hypothyroidism, and GERD not documented under Section I as diagnoses for the resident. During an interview on 03/01/24 at 10:28 A.M., the MDS coordinator said the MDS should accurately reflect the resident's current condition. If a resident had a diagnosis that could require medication but actively does not, then it would still be marked on the MDS unless a doctor says the diagnosis can come off. Most diagnoses that drop off are things like a urinary tract infection or something that requires an antibiotic. Once the antibiotic is done then the diagnosis would be taken off as an active diagnosis. During an interview on 03/01/24 at 3:45 P.M., the Administrator said he would expect the MDS assessment to accurately reflect the status of the resident.

Based on interview and record review, the facility failed to follow professional standards of practice and the facility's medication administration policy when Certified Medication Technician (CMT) A pre-poured (medications prepared in advance and stored until time for administration) evening medications for all residents residing on the 500 Hall. CMT A failed to administer the correct medications to one resident (Resident #1) when Resident #2's medications were administered to Resident #1. The facility census was 160. The Administration was notified on 07/28/23 of the Past Non-Compliance citation on 07/14/23. At the time of the event on 07/14/23, facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility completed a hall audit to ensure no other medication errors occurred, started an investigation, and assessed and sent Resident #1 for evaluation and treatment on 07/14/23. The facility started an in-service that covered pre-pouring medications and identifying the correct resident. The facility initiated a monitoring system to ensure staff did not pre-pour medications and were following the five rights of medication administration (the right patient, the right drug, the right time, the right dose, and the right route). The CMT received a written warning and was retrained on medication administration. The deficiency was corrected on 07/14/23. Review of the facility's policy titled, Medication Administration - General Guidelines, undated, showed: - Medications are administered in accordance with written orders of attending physicians, taking into consideration the manufacturer's specifications, and professional standards of practice; - Medications are administered at the time they are prepared for each resident. Medications are not pre-poured; - Residents are identified before medication is administered. 1. Review of Resident #1's Physician's Order Sheet (POS), dated July 2023, showed: -admitted on [DATE]; -Diagnoses of hypothyroidism (a decreased level of thyroid hormone), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), personal history of traumatic brain injury, hyperlipidemia (high blood level of cholesterol), convulsions (a burst of uncontrolled electrical activity between the brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), angina pectoris (chest pain or discomfort that keeps coming back), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), other specified inflammatory liver diseases, post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event), hypertension (high blood pressure), diabetes (DM) (a condition that affects the way the body processes blood sugar), mood disorder (a mental health problem that primarily affects a person's emotional state), allergic rhinitis (inflammation of the nose from allergies), insomnia (difficulty sleeping), mild cognitive impairment, dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), and quadriplegia (paralysis caused by illness or injury that results in the loss of use of all limbs and torso). Review of the resident's progress notes, dated 07/14/23, showed, at 7:34 P.M.: - The nurse received a report of Resident #1 had been administered the wrong medications; - Upon entering the resident's room the nurse noticed the resident drooling, called the resident's name and received no response, provided a sternal (center of the chest) rub (vigorously with the knuckles of a closed fist to create pain stimulus) to the resident with no response; - Vital signs were taken and results included a blood pressure 61/38, a pulse of 78 beats per minute, respirations of 17 breaths per minute, and an oxygen level of 97% on room air; - Staff left a message with on the call physician with a new order received to send the resident to the emergency room for an evaluation and treatment; - Emergency services were called and the resident was transferred. Review of the resident's hospital discharge papers, dated 07/18/23, showed: -Resident admitted to the hospital on 07/14/23 after being provided medications that were not prescribed to the patient on accident; -The accidental medications administered to the patient included clozapine (an antipsychotic medication used to treat schizophrenia); -Admitting diagnosis of poisoning by parasympatholytic drugs (drugs that block the effects of the parasympathetic nervous system (a network of nerves that relaxes your body after periods of stress or danger) through anticholinergic action (block the action of the neurotransmitter called acetylcholine) with signs and symptoms of sinus tachycardia (a regular heart rhythm in which the heart beats faster than normal), bilious (bile) vomiting with nausea, lactic acidosis (lactic acid build up in the bloodstream); -Likely clozapine toxicity with signs and symptoms of anticholinergic toxidrome (a syndrome caused by a dangerous level of toxins in the body) as evidenced by the patient presented with long QT syndrome (a heart rhythm disorder that can cause fast, chaotic heartbeats), sinus tachycardia, vomiting, encephalopathy (a decrease in blood flow or oxygen to the brain) and hypertension during his/her hospitalization ; -Resident discharged at his/her baseline condition on 07/18/23. Review of the facility's Medication Error Report, dated 07/14/23, showed: - The medication errors occurred on 07/14/23 at 5:30 P.M.; - The CMT (CMT A) administered Resident #2's medications to Resident #1; - The physician was notified on 07/14/23, with orders to send Resident #1 to the emergency room for an evaluation; - Medications involved were Allegra (antihistamine medication) 60 milligram (mg), glycopyrrolate (an anticholinergic drug used to decrease drooling) 1 mg, metoprolol (used to treat hypertension) 50 mg, montelukast (anti-inflammatory used to treat allergies and prevent asthma attacks) 10 mg, simvastatin (used to treat hyperlipidemia) 20 mg, tamsulosin (medication for benign prostatic hyperplasia) 0.4 mg, trazodone (an antidepressant and sedative) 50 mg, acidophilus (a probiotic) 250 mg, risperidone (antipsychotic medication used to treat schizophrenia) 4 mg, benztropine (an anticholinergic medication used to treat extrapyramidal and movement disorder) 2 mg, and clozapine 500 mg; - This event resulted in Resident #1 sent to the hospital for evaluation and treatment . Review of the facility's Category One Violation Employee Corrective Counseling Memorandum, dated 07/17/23, showed CMT A failed to follow the five rights of medication administration. During an interview on 07/28/23 at 11:10 A.M., with the Director of Nursing (DON) and Resident #1, the resident said he/she had to go to the hospital because CMT A gave him/her the wrong medications. During an interview on 07/28/23 at 1:07 P.M., the DON said staff notified her that CMT A administered Resident #2's medication to Resident #1 on 07/14/23. The CMT had pre-poured the medications and Resident #1's medications had been moved to a different section of the cart drawer. The CMT grabbed Resident #2's medications at the time of Resident #1's medication administration. He/she realized what happened upon returning to the cart to administer more medications and immediately told the charge nurse. Resident #1 quickly became symptomatic and was sent out to the hospital. The DON said staff should not pre-pour medications and should identify the resident prior to administering the medications. During an interview on 07/28/23 at 1:09 P.M., the Administrator said he would expect staff to follow the facility policy on safe medication administration. During an interview on 07/28/23 at 4:30 P.M., CMT A said he/she usually works in a completely different department, but, on 07/14/23, had stayed over to help pass medication on the 500 hall. CMT A said he/she pre-measured out each resident's medications for that pass and put them in the medication cart. Once he/she began passing medications, he/she would just reach in and get the cup of ready to give medications. CMT A said when it came time to administer Resident #1's medications, he/she grabbed the cups he/she thought belonged to that resident. When he/she got back to the medication cart for the next resident, CMT A realized he/she had given Resident #1 the medications belonging to Resident #2 and reported the error immediately. CMT A said he/she was aware pre-pouring medications prior to starting a medication pass was not a good practice. During a phone interview on 08/09/23 at 2:30 P.M., the Nurse Practitioner (NP) said he/she was aware of the medication error that occurred on 07/14/23. The facility immediately called 911, reacted in regards to the errors and made sure it wouldn't happen again. The NP was unaware of the facility's protocol with administering medications, but he/she would expect the staff to follow their policy and procedures. He/She would hope the facility did not prepare multiple residents' medications at the same time. Complaint MO#00221633

Based on observation and interview, the facility failed to ensure the residents' environment was free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and a community shower, which put residents at increased risk for [CONDITION(S)] caused by scalding water. This practice affected three residents (Residents #47, #68 and #86) out of 33 sampled residents and one resident (Resident #56) outside of the sample. This practice could have potentially affected all residents. The facility census was 168. Record review of the Burn Foundation website showed hot water causes third degree [CONDITION(S)] (full thickness [CONDITION(S)] which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: -In 1 second at 156 degrees F; -In 2 seconds at 149 degrees F; -In 5 seconds at 140 degrees F; -In 15 seconds at 133 degrees F. Observation on 9/21/22 at 11:25 A.M., Licensed Practical Nurse (LPN) M said that water is hotas he/she was washing his/her hands between changing gloves. 1. Observations of water temperatures on 9/21/22 from 4:59 P.M. through 6:30 P.M. taken with a digital thermometer showed: - Room 203 water temperature recorded at 125 at the sink; - Room 205 water temperature recorded at 133 at the sink; - Room 217 water temperature recorded at 132.8 at the sink; - Room 210 water temperature recorded at 124 at the sink; - Room 301 water temperature recorded at 133 at the sink; - Room 306 water temperature recorded at 132.6 at the sink; - Room 402 water temperature recorded at 128.6 at the sink; - All the rooms tested were occupied and sinks were for resident use; - The 500 hall women's shower room water temperature recorded 125 . Interviews with Residents #47, #68, #86 and #56 showed they did think their water got a little hot, but none had ever been burned or injured from using their sink. None of the residents had mentioned the hot water to any staff. During an interview on 9/21/22 at 5:24 P.M., the Maintenance Director (MD) said the water temperatures are to be maintained between 115 and 118 . He said the water temperatures are checked daily in two to three areas on each hall and in common areas. Temperatures were checked earlier today by the maintenance assistant. The MD said there has been no reports of hot water effecting resident or staff. Record review of the daily temperature check log, dated 9/21/22, showed fourteen resident rooms and the shop had water temperatures checked and all were within acceptable range from 110-115 degrees. During an interview and observation on 9/21/22 at 5:40 P.M. of the maintenance assistant checking water temperatures in room 203 showed: - The maintenance assistant turned the hot water on and set a timer for three minutes; - Using a digital thermometer, the thermometer placed under the running water, temperature recorded at 116 ; - The maintenance assistant said the thermometer is the same thermometer he/she used today to check the water temperatures; - The MD and the surveyor used their own separate thermometers, MD recorded 126.3 , the surveyor recorded 126.3 . - The MD said the thermometer previously used would be discarded. During an interview on 9/22/22 at 5:15 P.M., the Administrator said the water temperatures were remaining consistent after being monitored and adjusting the mixing valve. The plumber came today and checked out the system. The facility will continue daily water temperature monitoring and nursing will be in-serviced on how to check water temperatures as well. The staff will be educated to call the Administrator immediately should water temperatures be below 105 degrees or if temperatures are 120 degrees or above. The facility did not provide a policy related to maintaining appropriate water temperatures.

U4413 Based on record review and interview, the facility staff failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents refunds of their personal funds from the operating account in a timely manner for five residents (Resident #47, #50, #51, #52 and #53). Additionally, the facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for nine residents (Resident #6, #7, #9, #10, #11, #13, #18, #21 and #22) out of a sample of 22. Lastly, the facility failed to withdraw the correct monthly surplus for room and board which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for 12 residents (Resident #1, #3, #9, #11, #12, #13, #16, #18, #19, #20, #21 and #22) out of a sample of 12. The facility census was 168. 1. Record review of the facility's maintained Accounts Receivable Report for the period 09/01/21 through 09/20/22, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #47 $ 182.70 #50 $ 161.00 #51 $1,723.00 #52 $ 719.85 #53 $ 171.10 Total $2,957.65 During an interview on 09/20/22 at 11:42 A.M., the Business Office Manager said he/she was waiting for insurance to pay for Residents #50, #51 and #52 before issuing the refund and that all residents should be refunded. 2. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawals from Resident #6's account. Date Amount Description 04/26/22 $24.00 Cigarettes 08/31/22 $24.00 Cigarettes Record review on 09/21/22 of the facility maintained paperwork for Resident #6's Resident Trust Transactions, showed no written authorization by Resident #6 and/or financial guardian for the withdrawals. 3. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawal from Resident #7's account. Date Amount Description 07/10/22 $30.00 Cigarettes Record review on 09/21/22 of the facility maintained paperwork for Resident #7's Resident Trust Transactions, showed no written authorization by Resident #7 and/or financial guardian for the withdrawal. 4. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawals from Resident #9's account. Date Amount Description 12/22/21 $212.91 Guardian Receipts 06/16/22 $ 82.92 Guardian Receipt Record review on 09/21/22 of the facility maintained paperwork for Resident #9's Resident Trust Transactions, showed no written authorization by Resident #9 and/or financial guardian for the withdrawals. 5. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawals from Resident #10's account. Date Amount Description 06/16/22 $50.00 Cigarettes 08/09/22 $80.00 Cigarettes Record review on 09/21/22 of the facility maintained paperwork for Resident #10's Resident Trust Transactions, showed no written authorization by Resident #10 and/or financial guardian for the withdrawals. 6. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawal from Resident #11's account. Date Amount Description 05/06/22 $5,536.32 Mo Resource Payments Record review on 09/21/22 of the facility maintained paperwork for Resident #11's Resident Trust Transactions, showed no written authorization by Resident #11 and/or financial guardian for the withdrawal. 7. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawals from Resident #13's account. Date Amount Description 12/13/21 $3,745.96 Preferred Credit Bill 04/13/22 $ 48.12 Consumer Cellular 06/16/22 $ 49.08 Consumer Cellular Record review on 09/21/22 of the facility maintained paperwork for Resident #13's Resident Trust Transactions, showed no written authorization by Resident #13 and/or financial guardian for the withdrawals. 8. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawal from Resident #18's account. Date Amount Description 12/10/21 $3,382.20 NuMotion Custom Wheelchair Record review on 09/22/22 of the facility maintained paperwork for Resident #18's Resident Trust Transactions, showed no written authorization by Resident #18 and/or financial guardian for the withdrawal. 9. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawal from Resident #21's account. Date Amount Description 09/07/22 $24.00 Cigarettes Record review on 09/21/22 of the facility maintained paperwork for Resident #21's Resident Trust Transactions, showed no written authorization by Resident #21 and/or financial guardian for the withdrawal. 10. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the following withdrawals from Resident #22's account. Date Amount Description 04/13/22 $ 44.43 Micro-Dr [NAME] 08/16/22 $1,106.00 Resident Essentials Record review on 09/21/22 of the facility maintained paperwork for Resident #22's Resident Trust Transactions, showed no written authorization by Resident #22 and/or financial guardian for the withdrawals. 11. During an interview on 09/21/22 at 9:41 A.M., the Business Office Manager said online purchases and/or bills are paid from the residents trust account without written authorization from the residents and/or financial guardians. The only withdrawals with written authorization are for petty cash withdrawals. 12. During an interview on 09/21/22 at 9:42 A.M., the Business Office Assistant said only verbal authorization is obtained from the residents and/or financial guardians for the online purchases. 13. During an interview on 09/21/22 at 12:35 P.M., the Social Services Director said receipts are obtained for cigarette purchases but written authorization from the residents and/or financial guardians are not obtained. 14. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #1's account for room & board. Month Amount Withdrawn 09/2021 $1,621.50 10/2021 $1,621.50 11/2021 $1,621.50 12/2021 $1,621.50 01/2022 $1,699.50 02/2022 $1,699.50 03/2022 $1,699.50 04/2022 $1,699.50 05/2022 $1,699.50 06/2022 $1,699.50 07/2022 $1,699.50 08/2022 $1,699.50 09/2022 $1,699.50 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #1's Care Cost Surplus amount for room & board should be $1,512.90 from 01/01/20 through 08/31/22 for all months, except for the period 10/01/20 through 11/30/20. 15. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #3's account for room & board. Month Amount Withdrawn 09/2021 $794.52 10/2021 $794.52 11/2021 $794.52 12/2021 $794.52 01/2022 $859.52 02/2022 $850.81 03/2022 $850.81 04/2022 $850.81 05/2022 $850.81 06/2022 $850.81 07/2022 $850.81 08/2022 $850.81 09/2022 $850.81 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #3's Care Cost Surplus amount for room & board should be $695.53 from 01/01/21 through 08/31/22 for each month. 16. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #9's account for room & board. Month Amount Withdrawn 09/2021 $750.00 10/2021 $750.00 11/2021 $750.00 12/2021 $750.00 01/2022 $797.00 02/2022 $797.00 03/2022 $797.00 04/2022 $797.00 05/2022 $797.00 06/2022 $797.00 07/2022 $797.00 08/2022 $797.00 09/2022 $797.00 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #9's Care Cost Surplus amount for room & board should be $649.01 from 01/01/20 through 08/31/22 for each month, except for the period 11/30/20. 17. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #11's account for room & board. Month Amount Withdrawn 11/2021 $2,332.16 12/2021 $2,332.16 01/2022 $2,332.16 02/2022 $2,332.16 03/2022 $2,332.16 04/2022 $2,332.16 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #11's Care Cost Surplus amount for room & board should be $1,881.32 from 08/01/20 through 08/31/22 for each month. Record review on 09/21/22 of Resident #11's Resident Trust Fund Statement also shows a withdrawal on 05/06/22 in the amount of $5,536.32 to be applied to monthly resource payments, but does not indicate which months the withdrawal applied to. 18. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #12's account for room & board. Month Amount Withdrawn 09/2021 $1,153.00 10/2021 $1,153.00 11/2021 $1,153.00 12/2021 $1,153.00 01/2022 $1,224.00 02/2022 $1,224.00 03/2022 $1,224.00 04/2022 $1,224.00 05/2022 $1,224.00 06/2022 $1,224.00 07/2022 $1,224.00 08/2022 $1,224.00 09/2022 $1,224.00 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #12's Care Cost Surplus amount for room & board should be $1,138.01 from 02/01/20 through 08/31/22 for each month. 19. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #13's account for room & board. Month Amount Withdrawn 09/2021 $2,090.72 10/2021 $2,090.72 11/2021 $1,999.00 12/2021 $2,090.72 01/2022 $2,162.72 02/2022 $2,162.72 03/2022 $2,162.72 04/2022 $2,162.72 05/2022 $2,162.72 06/2022 $2,162.72 07/2022 $2,162.72 08/2022 $2,162.72 09/2022 $2,162.72 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #13's Care Cost Surplus amount for room & board should be $1,943.76 from 02/01/20 through 08/31/22 for each month. 20. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #16's account for room & board. Month Amount Withdrawn 09/2021 $1,815.43 10/2021 $1,815.43 11/2021 $1,815.43 12/2021 $1,815.43 01/2022 $1,880.43 02/2022 $1,880.43 03/2022 $1,880.43 04/2022 $1,880.43 05/2022 $1,880.43 06/2022 $1,880.43 07/2022 $1,880.43 08/2022 $1,880.43 09/2022 $1,880.43 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #16's Care Cost Surplus amount for room & board should be $1,669.83 from 01/01/20 through 08/31/22 for each month. 21. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #18's account for room & board. Month Amount Withdrawn 12/2021 $1,433.00 01/2022 $1,508.00 02/2022 $1,508.00 03/2022 $1,508.00 04/2022 $1,508.00 05/2022 $1,508.00 06/2022 $1,508.00 07/2022 $1,508.00 08/2022 $1,508.00 09/2022 $1,508.00 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #18's Care Cost Surplus amount for room & board should be $1,154.00 from 05/01/21 through 08/31/22 for each month. 22. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #19's account for room & board. Month Amount Withdrawn 09/2021 $1,982.15 10/2021 $1,982.15 11/2021 $1,982.15 12/2021 $1,982.15 01/2022 $2,099.10 02/2022 $2,099.10 03/2022 $2,099.10 04/2022 $2,099.10 05/2022 $2,099.10 06/2022 $2,099.10 07/2022 $2,099.10 08/2022 $2,099.10 09/2022 $2,099.10 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #19's Care Cost Surplus amount for room & board should be $1,801.00 from 06/01/21 through 08/31/22 for each month. 23. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #20's account for room & board. Month Amount Withdrawn 09/2021 $893.00 10/2021 $893.00 11/2021 $893.00 12/2021 $893.00 01/2022 $948.00 02/2022 $948.00 03/2022 $948.00 04/2022 $948.00 05/2022 $948.00 06/2022 $948.00 07/2022 $948.00 08/2022 $948.00 09/2022 $948.00 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #20's Care Cost Surplus amount for room & board should be $805.00 from 01/01/20 through 08/31/22 for each month. 24. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #21's account for room & board. Month Amount Withdrawn 09/2021 $400.00 10/2021 $424.00 11/2021 $424.00 12/2021 $424.00 01/2022 $452.00 02/2022 $452.00 03/2022 $452.00 04/2022 $452.00 05/2022 $452.00 06/2022 $452.00 07/2022 $452.00 08/2022 $452.00 09/2022 $452.00 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #21's Care Cost Surplus amount for room & board should be $287.00 from 01/01/20 through 08/31/22 for each month. 25. Record review of the facility maintained Resident Trust Fund Statement for the period 09/01/21 through 09/20/22, showed the incorrect withdrawals from Resident #22's account for room & board. Month Amount Withdrawn 09/2021 $766.00 10/2021 $766.00 11/2021 $766.00 12/2021 $766.00 01/2022 $814.00 02/2022 $814.00 03/2022 $814.00 04/2022 $814.00 05/2022 $814.00 06/2022 $814.00 07/2022 $814.00 08/2022 $814.00 09/2022 $814.00 Record review on 09/21/22 of the Cost Summary Settlement Report provided by Missouri HealthNet Division on 09/21/22, showed Resident #22's Care Cost Surplus amount for room & board should be $670.02 for the period 01/01/20 through 02/28/22 and $655.02 for the period 04/08/22 through 08/31/22 for each month. 26. During an interview on 09/21/22 at 10:16 A.M., the Business Office Manager said he/she knew the Medicaid surplus amount stopped increasing annually but was waiting for Medicaid to start increasing the surplus again and was continuing to deduct all monthly incoming Social Security and pension money minus the $50 monthly allowance.

Based on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBC) and Nurse Aide (NA) Registry were completed prior to the employment start date for three employees out of a sample of 10 employees. The facility census was 168. Record review of the facility's Human Resources Policies and Procedures Manual, effective date 5/1/14 showed: - It is the Facility's policy to verify possible criminal backgrounds of pending new hires prior to the commencement of employment; - A background check must be completed through an authorized vendor or state agency (vendor) for all pending new hires, including rehires and reinstated employees. 1. Record review of Certified Nurse Assistant (CNA) S's personnel file showed: - The employee was hired on 7/13/22; - The facility failed to check the CBC, EDL and NA Registry for CNA S. 2. Record review of CNA T's personnel file showed: - The employee was hired on 7/8/22; - The facility failed to check the CBC, EDL and NA Registry for CNA T. 3. Record review of Dietary Aide U's personnel file showed: - The employee was hired on 8/29/22; - The facility failed to check the CBC and EDL for Dietary Aide U. During an interview on 9/22/22 at 12:00 P.M., the Administrator said she would expect new or rehired employees to have completed CBC, NA Registry and EDL checks before they are employed.

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, for four residents (Resident #68, #89, #95 and #137) out of 33 sampled residents. The facility's census was 168. Record review of the facility's MDS Assessment Policy, dated 11/2017, showed: - The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations; - These assessments provide information on the resident's condition to facilitate development of an individualized plan of care as a means by which the facility can track changes in a resident's status. 1. Record review of Resident #68's medical record showed: - An admitted [DATE]; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No order for an anticoagulant (medication that delays or prevents blood clotting.) Record review of the resident's quarterly MDS, dated [DATE], showed: - Resident received anticoagulant medication; - The resident's MDS did not reflect an accurate assessment of the medications. 2. Record review of Resident #89's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No order for an anticoagulant medication. Record review of the resident's quarterly MDS, dated [DATE], showed: - Resident received anticoagulant medication; - The resident's MDS did not reflect an accurate assessment of the medications. 3. Record review of Resident #95's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Fall with fracture to the left neck on 6/13/22. Record review of the resident's quarterly MDS, dated [DATE], showed: - Falls since admission or prior assessment marked no; - Number of falls since admission or prior assessment with major injury, not marked; - The facility failed to mark the MDS for a fall with a major injury. 4. Record review of Resident #137's medical record showed: - An admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - A Preadmission Screening and Resident Review (PASRR) Level II evaluation completed in 2016. Record review of the resident's annual MDS, dated [DATE], Section A1500 PASRR - Has the resident been evaluated by a Level II PASRR and determined to have a serious mental illness or related condition? marked no. During an interview on 9/21/22 at 12:28 P.M., the MDS Coordinator said he/she would not expect a resident with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/22/22 at 4:50 P.M., the MDS Coordinator said he/she would expect a resident with a Level II PASRR to be reflected on the MDS in Section A1500. The facility had a traveling MDS person that traveled within the facilities for a while. During an interview on 9/22/22 at 5:33 P.M., the Director of Nursing said [MEDICATION(S)] should not be coded as an anticoagulant on a resident's MDS and he/she would expect the MDS to reflect the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure a proper diagnosis for an antipsychotic (a medication that affects brain activities associated with mental processes and behavior) medication for one resident (Resident #40) out of 33 sampled residents. The facility census was 168. Record review of Drugs.com, dated April 18, 2022, for [MEDICATION(S)] (an antipsychotic medication) showed: -Used to treat psychotic conditions such as [CONDITION(S)] (a long-term mental disorder that affects a person's ability to think, feel or behave clearly), [CONDITION(S)] disorder (mental disorder that causes unusual shifts in mood) and manic depression; -Drug not approved for use in older adults with dementia-related psychosis; -May increase the risk of death in older adults with dementia-related psychosis; -Watch for extrapyramidal (nerves associated with motor activity) effects; The facility failed to provide an Antipsychotic Medication Use policy. 1. Record review of Resident #40's Physician's Order Sheet (POS), dated 9/2022, showed: -An admitted [DATE]; -An order for [MEDICATION(S)] 2.5 milligrams (mg) one tablet by mouth once daily at bedtime for dementia. Record review of the resident's medical record showed no documentation of specific, targeted behaviors. Record review of the resident's comprehensive care plan, dated 9/2022, showed: -Takes daily [CONDITION(S)] medications and has poor safety awareness due to diagnosis of Alzheimer's disease (a condition with progressive mental deterioration); -No identification of specific, targeted behaviors with interventions; -No specific adverse effects of medications to monitor. Record review of the pharmacist recommendations, dated 3/22/22, showed: -The pharmacist asked for the physician to assess risk versus benefit and if the patient would benefit from a dose reduction of the following [CONDITION(S)] medications: [MEDICATION(S)] 2.5 mg daily, [MEDICATION(S)] 20 mg daily, and [MEDICATION(S)] 50 mg 1/2 tablet three times daily; -No documentation of the diagnosis for usage of the [MEDICATION(S)] by the physician on the recommendation report and/or in the medical record. The physician disagreed with the pharmacy recommendation due to the resident's severe anxiety. Observations of the resident from 9/19/22 through 9/22/22 showed: -On 9/19/22 at 9:30 P.M., the resident lay quietly in his/her bed; -On 9/20/22 at 12:00 P.M., the resident up in the dining room eating lunch; -On 9/20/22 at 4:45 P.M., the resident up in wheelchair and asking staff about going back to his/her home. Resident easily redirected by staff when staff speak about the resident's daughter coming to visit; -On 9/21/22 at 1:35 P.M., the resident lying in bed after the lunch meal and difficult to arouse for medication administration; -On 9/21/22 at 10:30 P.M., the resident up in the dining room lying on the couch watching television. During an interview on 9/22/22 at 3:00 P.M., Registered Nurse (RN) R said he/she thought the resident was on [MEDICATION(S)] due to behaviors. RN R said the resident does not have an appropriate diagnosis for the medication and the nurse practitioner does not feel comfortable giving the resident a diagnosis just for the medication. During an interview on 9/22/22 at 5:15 P.M., the Administrator and Director of Nursing (DON) said they would expect all medications to have a proper diagnosis for use.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 168. Observation on 9/20/22 at 11:05 A.M., 9/21/22 at 11:00 A.M. and 9/22/22 at 11:46 A.M., of the 400 hallway showed: - An 18-inch area of ceiling had peeled from the boarding above the door to Room 111; - Dark brown and black stains on the ceiling near Room 112; - A small brown ring area around a sprinkler head on the ceiling near Room 111; - Dark brown and black stains on the ceiling near Room 107. Review on 9/22/22 at 2:01 P.M., of the Departmental Work Orders, located at 100, 200 and 400 Hall nurse's station, showed no work orders regarding the ceiling on the 400 hall. During an interview on 9/22/22 at 11:11 A.M., the Maintenance Director (MD) said he/she would expect staff to write down any areas of concern for maintenance to be addressed in a timely manner. The MD said routine rounds and work orders should be put in place, but have not been done. The MD said this was his/her third day on the job and still getting familiar where everything is located at the facility. During an interview on 9/22/22 at 11:24 A.M., the Administrator said he/she would expect staff to write down any areas of concern for maintenance to address in a timely manner. The Administrator said staff should notify maintenance through a process other than verbal communication to ensure areas of concern are addressed and repaired as needed. The facility did not provide a policy related to environment.

Based on observation, interview and record review, the facility failed to provide care for the highest practicable well being of a resident by not having properly qualified staff available in a choking emergency. The facility also failed to act in accordance with their policy by not immediately starting appropriate Cardiopulmonary Resuscitation technique on an unresponsive resident (Resident #1). The resident was a full code. The census was 145. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Clear speech and comprehension; -Brief Interview for Mental Status (BIMS, an assessment of cognitive function) score of 2; -Short/Long term memory problems; -Moderately impaired decision making skills; -Symptoms of [MEDICAL CONDITION] noted, including inattention and disorganized thinking; -Poor appetite or over eating nearly every day; -Required extensive assistance of two or more for bed mobility and transfers; -Required extensive assistance of one for dressing, toileting, bathing and hygiene; -Required limited assistance for locomotion on the unit; -No condition/chronic disease that may result in a life expectancy of less than six months; -No swallowing issues; -Eating required set up and supervision; -Weight of 224 pounds. Review of the resident's nurse notes, dated [DATE] at 1:50 P.M., showed the resident choked on food while having lunch. He/she was unable to breath and began to turn purple. The nurse performed the [MEDICATION NAME] maneuver (a first aid procedure that helps dislodge an obstruction from a person's airway) and was able to dislodge the food. He/she coughed and returned to his/her normal skin coloring. The resident grabbed his/her plate. Staff reminded the resident to eat slowly and chew the food up good. Staff supervised the remainder of the meal. The resident's family and physician were notified. Review of the resident's care plan, last updated on [DATE], showed: -Problem: Extensive assist with activities of daily living (ADLs) related to depression and anxiety. Interventions included speech therapy evaluation for swallowing, staff cueing the resident to slow down while eating and diet changed mechanical soft consistency; -Problem: Long term placement and skilled nursing services on the secure unit related to dementia. Interventions included resident code status was full code, if found unresponsive with no palpable pulse, no audible heartbeat per auscultation, began CPR (Emergent procedures that attempt to restore normal heart beat and breathing to an unresponsive person), have another staff member call 911, follow facility protocol, notify MD and family. Update code status as needed. Review of the resident's physician orders [REDACTED]. On [DATE], speech therapy evaluation and treatment was ordered. Skilled speech therapy ordered five times weekly to address swallowing deficits secondary to dysphagia (difficulty swallowing), oral phase secondary to dementia with behavior deficits and group treatment. On [DATE], the resident's diet order was changed to mechanical soft with thin liquids. Review of the speech therapy notes, showed: -[DATE], Progress Note: Resident assessed and treated in the areas of rate of presentation, ability to self monitor, alternating between solids and liquids, cohesive [MEDICATION NAME], and safely consuming a mechanical soft consistency. Nursing staff was educated on the plan of care and progress towards the goals was made. Education targeted compensatory strategies to decrease overloading food in the mouth. Staff educated on how to instruct the resident to take smaller bites/sip sizes to decrease risk of choking or aspiration. Good prognosis due to the resident's ability to follow routines, response to environmental stimuli and cueing and stable medical condition; -[DATE], Initial Assessment: During a bedside swallow evaluation, the resident displayed impulsivity and shoveled food into his/her mouth. He/she then guzzled liquids causing a loss of control of part of the [MEDICATION NAME]. He/she ate very large bites at an excessive rate. He/she drank 240 cc of liquid at one time. He/she was unable to control the liquids, causing signs and symptoms of aspiration; -[DATE], Progress Note: Resident provided with verbal instruction to slow down rate while eating by not shoveling food into his/her mouth, which increased risk of choking or aspiration. Resident prompted to increase self-monitoring ability by taking smaller bites/sips and slowing down his/her rate of presentation. Resident also provided with verbal and tactile instruction to alternate between solids and liquids to reduce amount of residue and decrease risk of choking. Nursing staff educated on the plan of care and progress was made. Staff education provided on safe swallow protocol and return demonstration completed. Resident's prognosis was excellent due to his/her ability to follow routines and imitate and response to cueing and environmental stimuli. Strong family support. Review of the resident's dysphagia medical work-up form, dated [DATE], showed: -Swallowing disorder involved the oral phase; -Dysphagia rehabilitation potential appeared to be good; -Resident exhibited a degree of alertness, cognition and motivation to participate in therapy and would benefit from the therapy; -History for risk of aspiration, choking or coughing during swallowing and neuromotor disturbances affecting the ability to swallow at the oral stage, while protecting the airway. Further review of speech therapy progress notes, dated [DATE], showed the resident required moderate verbal and tactile instruction to slow the rate of presentation at each meal and snack. He/she lacked carry over from snack to meal or when therapist is not sitting directly in front of the resident. Nursing staff were educated on plan of care, with a focus on the safe swallow protocol and how to decrease impulsive behaviors. Good prognosis due to the resident's ability to follow routines and self monitor and correct. Positive results from previous therapy. Responsive to cueing. Stable medical condition. During an interview on [DATE] at 12:51 P.M., Speech Therapist (ST) I said he/she saw the resident because he/she had an incident where the resident choked on some sort of food and the [MEDICATION NAME] was performed, so they decided to pick him/her up. The resident was on a regular diet but pocketed food and had residual food left in the mouth. ST I downgraded the resident's diet to mechanical soft. The resident also ate at a fast rate and displayed shoveling. Treatment took place five times weekly for about 45 minutes during one meal a day. The treatment included the resident alternating bites with liquids. The resident was independent and fed him/herself 100% of the time. He/she needed food cut up. ST I expected staff to continue use of the treatment techniques during meals eaten outside of speech therapy. He/she trained staff during the actual therapy sessions and completed an education log for staff training. Staff needed to give the resident verbal and tactile instructions during meals. The completed education logs were in the resident's chart as part of the speech therapy progress notes, in the patient/caregiver training section. ST I said a cold cut sandwich was part of the mechanical soft diet. However, he/she expected staff to provide supervision or at least line of sight to the resident if he/she had access to food due to his/her risk for choking and aspiration. During treatments, the resident had coughing episodes due to the rate of consumption and swallowing, but with cueing, he/she never got to the point of aspiration or needing the [MEDICATION NAME] maneuver. The resident started to respond to therapy more towards the end. Review of Resident #2's Admission MDS, dated [DATE], showed: -Clear comprehension; -Short/Long term memory problems; -[DIAGNOSES REDACTED]. Further review of Resident #1's nurses notes, dated [DATE] at 7:54 A.M., showed about 5:45 A.M., Resident #2 came up to Nurse A and reported there was a man/woman in the dining room not acting right. Nurse A went into the dining room, where he/she found Resident #1 slumped over to the right in his/her wheelchair. Nurse A rubbed Resident #1's shoulder and called out his/her name. The resident did not respond. Nurse A shook the resident harder and then pulled him/her upright. The resident's face was dark purple and sweaty and food was coming out of his/her mouth. The nurse instructed Certified Nurse Assistant (CNA) B to go and get CNA C for assistance. The nurse performed three mouth sweeps to remove food then attempted the [MEDICATION NAME] maneuver without results. The CNAs came into the dining room and the resident was taken to his/her room. As Nurse A left the dining room, he/she saw Nurse D through the window on the unit exit door. He/she went and got Nurse D. Nurse A and Nurse D went to the resident's room, where the resident was placed onto the floor and CPR was initiated. Nurse D and CNA C performed CPR, while Nurse A called 911. CPR was continued until Emergency Medical Technicians (EMTs) arrived and took over. The EMTs applied a heart monitor to the resident and got an asystole rhythm (flat line, no cardiac activity). EMTs called the emergency room to pronounce the resident's time of death, 6:01 A.M. The family, physician, Director of Nursing (DON) and the funeral home were all notified. During an interview on [DATE] at 7:04 A.M., Nurse A said around 5:15 A.M. on [DATE], Resident #2 got up and went into the dining room to get something to eat and drink. Nurse A saw Resident #2 do this, as he/she passed medicine from a cart located at the corner of the nurse station, outside of the dining room. About 5:25 A.M., Resident #1 came down the hall and Nurse A gave him/her medications then wheeled him/her into the dining room by the television. There were a couple of other residents present in the dining room at that time. Nurse A went back out into the hallway, where he/she heard an alarm going off on the west hall that other staff did not respond to quickly. By the time Nurse A made it to the end of the hall, the alarm was off. The resident with the alarm was up. Nurse A talked to that resident for a while. Then Nurse A helped him/her to the medication cart, gave him/her morning medications and walked him/her into the dining room. This resident asked for a cup of coffee. Since it was before breakfast time, Nurse A had to go to the clean utility room to get a warm cup of coffee. Nurse A took the resident the coffee, then gave medications to another resident he/she saw in the dining room. Back at the medication cart, Resident #2 came up to Nurse A and said to come and check on someone in the dining room because he/she was not acting right. Nurse A found Resident #1 slumped over to the right in his/her wheelchair. Nurse A said this behavior was not unusual for the resident because he/she picked at the floor all of the time. Nurse A rubbed the resident's back and called out his/her name, but he/she did not respond. The resident was a slow responder, so Nurse A was not alarmed when he did not respond. Nurse A pulled the resident upright in the wheelchair and he/she had stuff coming out of his/her mouth. The resident's face was purple/blue. The resident was a full code. Nurse A did mouth sweeps and the [MEDICATION NAME] maneuver but nothing happened. He/she yelled for CNA B because he/she knew CNA B had just come out of a room just down the hallway. Nurse A told CNA B to go get CNA C. While Nurse A waited for the CNAs to return, he/she swept the resident's mouth to get more food out. He/she checked for breathing and did not see anything. Nurse A did not check for a pulse. He/she was more concerned with the breathing. CNA C pushed the resident back to his/her room, on the opposite end of the unit. Nurse A saw Nurse D on his/her way to the resident's room. Nurse A stopped and asked for Nurse D's help as the CNAs took the resident to his/her room. The resident was laid on the ground and CPR was started. CNA C and Nurse D did CPR on the resident while Nurse A went to call 911. Nurse A said this whole process took about two to three minutes. Nurse A said the facility had a CPR policy, but was unsure what it was. He/she thought the facility policy for an unresponsive resident included finding the source behind the unresponsiveness. He/she did not perform CPR in the dining room because "the other residents would have been all over them." Nurse A never had this happen before. He/she thought the staff completed the appropriate steps to help the resident. Nurse A said when he/she left the dining room during the medication pass, no staff was present in the dining room. He/she was the only nurse. CNA B, CNA C and a new orientee CNA worked that night. He/she thought residents only had to be supervised during meal time in the dining room. Nurse A did not think residents needed to be supervised with access to food outside meal times. He/she was unaware that sandwiches were not supposed to be in the refrigerator. That information was never passed on to him/her, or he/she would have checked it and removed them daily. Prior to this incident, Nurse A never heard of Resident #2 giving other residents food or drinks of any kind. After this incident, other staff started saying they saw the resident trying to feed other residents and give them hot coffee. Nurse A started working on the unit the beginning of April. On [DATE] on 1:06 P.M., Nurse A said his/her CPR certification ran out in [DATE]. He/she was positive it took about two to three minutes to mouth sweep, perform the [MEDICATION NAME] maneuver and transport the resident to his/her room before starting CPR. During an interview on [DATE] at 7:44 A.M., CNA C said he/she got Resident #1 out of bed and into the wheelchair the morning on [DATE]. The resident was able to self-propel the wheelchair slowly. It took him/her about 15 to 20 seconds to secure the resident he/she was working with (after he/she was called), and then he/she ran to the dining room. CNA C said he/she saw the resident was in trouble. CNA C saw Nurse A cleaning the resident's mouth. CNA C saw Nurse A attempt the [MEDICATION NAME] maneuver. He/she did not remember if the nurse checked for a pulse. The resident did not have a self release belt, so he/she had to tilt the resident's wheelchair back to keep him/her from falling out of the chair in order to take him/her to the room. CNA C took the resident to his/her room, with Nurse A and CNA B trailing them. CNA C said he/she was currently CPR certified. He/she did not check for a pulse. He/she did not see the resident breathing in the dining room at all. CNA C said it took about 15 to 20 seconds to get the resident from the dining room to his/her room. They did not perform CPR on the resident in the dining room because it wasn't the appropriate place to do CPR, in front of other residents. CNA C believed the facility had a policy on emergencies involving unresponsive residents, but he/she did not know it. He/she had to go by instinct. Resident #1 should not have been left in the dining room unsupervised. CNA C saw Resident #2 go into the dining room and get items out of the refrigerator and give them to other residents before. The facility tried to keep Resident #2 independent. He/she said there was nothing he/she could do when this happened, but keep an eye on the other resident. He/she reported these incidents to an unknown night charge nurse and the day shift staff. Some of the other staff knew Resident #2 did this as well. If he/she came upon an unresponsive resident, he/she would perform CPR immediately. During a second interview on [DATE] at 7:53 A.M., CNA C said Resident #1 would grab anything. He/she would take things to eat and drink from other residents. It got so bad, staff had to separate him/her from others during meals. The resident had the ability to take him/herself to the dining room. He/she could walk, but just did not want to. The morning of this incident, Nurse A directed him/her to take the resident back to his/her room to do CPR. Nurse A followed CNA C to the resident's room. Once CNA C and Nurse A got the resident into his/her room, they put him/her in the bed, started CPR, and then switched down to the floor. The resident was in the bed for about 30 seconds before being put on the floor. He/she performed chest compressions on the resident. He/she could not say when Nurse D arrived in the room. However, when he/she got there, the resident was already on the floor and the crash cart was in the room. The crash cart was pushed down to the room as the resident went to the room. CNA C did not know what a speech therapy protocol was. The resident did not eat during the night. The resident ate food fast. Staff would try to keep him/her from getting foods not included on his/her altered diet. Staff would take food away from him/her that he/she took from someone else. During an interview on [DATE] at 7:37 A.M., CNA B said he/she just came out of a room, helping a resident out of bed when Nurse A called for him/her to go and get CNA C. CNA C was on the back hall (in the long hall farthest away from the dining room). CNA C ran into the dining room with CNA B trailing. Nurse A sat Resident #1 up in the wheelchair. The resident's face was blue. Nurse A tried to remove food from the resident's mouth. CNA C took the resident to his/her room. He/she could not remember but thought Nurse A might have gone to the resident's room first, then went to get the resident's transfer paperwork together. CNA B went to get the crash cart. When he/she got back to the room, CNA B and CNA C laid the resident onto the floor and CNA C initiated CPR. CNA B went to make copies and gave them to Nurse A. He/she then went to let the EMTs into the building. When he/she returned to the room, Nurse E was in the room. CNA B was not currently CPR certified. The resident was a full code. He/she did not know if the facility had a policy for emergencies involving unresponsive residents. During an interview on [DATE] at 12:35 P.M., Nurse D said on [DATE], he/she worked on west hall, just outside of the Memory Care Unit. Nurse A knocked on the doors and said he/she needed help and explained what happened with the resident. They went to the resident's room together. The resident was in bed. Nurse D told CNA C and the orientee (who were the only staff in the resident's room at the time) to get the resident down on the floor. Nurse D initiated CPR. Prior to him/her coming into the room, no one had initiated CPR. The resident was not breathing and had no pulse. When Nurse D started chest compressions, food came out of the resident's mouth. It looked like bread. Nurse D had trouble getting air into the resident's body so he/she told the other staff to go and get the crash cart because he/she needed an Ambi bag. After a few cycles of CPR, Nurse D went back to his/her hall to finish a medication pass. Nurse D was CPR certified. On [DATE] at 9:47 A.M., Nurse D said he/she did not see Nurse A or CNA H perform CPR on the resident while he/she was in the room. During an interview on [DATE] at 8:12 A.M., Nurse F said he/she worked on a different hall on [DATE], but came to assist in the emergency. CNA B came running, looking for help. He/she was unsure if the intercom was used to call a code because he/she was in a resident's room, where the intercom could not be heard. When he/she arrived in the resident's room, Nurse D and CNA C performed CPR on the resident. Nurse F stood in the room until the EMTs arrived. When the EMTs arrived, he/she helped transfer the resident to the bed and performed post mortem (after death) care. He/she then returned to his/her assigned hall. Nurse F was currently CPR certified and knew the facility's policy for calling a "Code Blue" for an unresponsive resident. If he/she had an unresponsive resident, he/she'd check code status, perform a sternal rub, check for a pulse and breathing, overhead page "Code Blue" and initiate CPR immediately. If a resident choked, he/she would check the airway, perform the [MEDICATION NAME] maneuver and if necessary, initiate CPR. During an interview on [DATE] at 7:52 A.M., Nurse G said he/she worked overnights on the rehabilitation unit. Nurse G worked on the Memory Care Unit before and was familiar with the resident's care. Nurse G was never there for meals. The resident got crushed medications put in applesauce in the morning and he/she took them fine. He/she had been able to ambulate, but declined to wheelchair use. The resident could self-propel the wheelchair, but usually did not. On [DATE], CNA B came over to his/her unit with paperwork and told him/her what happened. When Nurse G went to the resident's room, the resident was on the floor and Nurse D performed CPR. CNA C and CNA H took turns performing compressions on the resident. When CNA H did compressions, he/she straddled the resident. Nurse G took over providing breaths with the Ambi bag. It was hard to get air into the resident, he/she barely had chest rise and fall. Nurse G was CPR certified. EMTs arrived within a minute or two. During an interview on [DATE] at 12:44 P.M., CNA H said, on [DATE] around 6:00 A.M., while working on 500 hall, CNA B came and asked for his/her assistance because he/she was not CPR certified. CNA H was CPR certified in [DATE]. CNA H said the resident was in his/her room and Nurse D and CNA C performed CPR. Nurse D was to the left of the resident and CNA C was at the resident's head. CNA C gave the resident breaths. CNA H helped CNA C by tightly holding the face mask of the Ambi bag. Nurse D did compressions. CNA H switched with Nurse D for a couple of cycles of CPR. A white doughy substance came out of the resident's mouth during compressions. When CNA H performed chest compressions, he/she was positioned on the right side of the resident and pressed below the rib cage and sternum, around the diaphragm area. He/she did not remember if he/she straddled the resident to perform chest compressions. He/she did not remember who was delivering compressions when the EMTs arrived. Review of the ambulance report, dated [DATE], showed: -Call received: 5:49 A.M.; -Arrival time: 5:55 A.M.; -Primary Assessment: [MEDICAL CONDITION], airway obstruction with no chest expansion, no reaction to light in the pupils and ashen/gray, cool skin; -Narrative Notes: Upon arrival, the resident lay on the floor with CPR in progress by nursing staff. CPR noted as poor in position and rate. The nursing staff straddled the resident and used an upward motion on the chest and had minimal cardiac compression. The compression rate was approximately 60 to 80 compressions per minute. Staff used a bag valve mask to provide oxygen, but there was no chest rise and fall with ventilation. EMTs took over CPR with proper positioning and rate. Nursing staff continued ventilation with EMT instruction. While performing ventilation, EMTs repositioned the resident's airway and ventilation remained ineffective. The airway was completely obstructed with unknown food. Nursing staff said the resident ate a sandwich. The resident had been seen about five to ten minutes prior to eating the sandwich that caused him/her to choke. Nursing staff found the resident unresponsive. Resident skin was cool upon touch in initial assessment. Upon rhythm check, the resident was in asystole without cardiac movement. No peripheral pulses were noted. The EMTs contacted medical control and pronounced the resident's time of death at 6:03 A.M. During an interview on [DATE] at 9:05 A.M., EMT L said when they arrived to the room, the resident was on the floor with a staff member straddling the resident's pelvis, attempting to do CPR. Another staff member kneeled at the resident's head with a bag valve mask without oxygen. It appeared as if staff was having trouble with the airway. There was only slight chest rise and fall. He/she switched with the staff member and started chest compressions while his/her partner applied heart monitor leads. The resident's airway was readjusted and found occluded. They attempted to use forceps to remove the obstruction but it was too soft. Then they attempted to use suction to remove the obstruction but it was too thick. The monitor read asystole. The resident's skin was slightly cold to touch and pale, but no rigor. It appeared that the resident had been down for a little bit. He/she asked staff how long it had been since the resident was seen. Staff told him/her it had only been a few minutes since they'd seen him/her. The CPR technique performed by the staff member who straddled the resident's pelvis looked more like an abdominal thrust. His/her hands were in a low position on the sternum and the thrust was done in an upwards motion. When looking at what was going on with the resident, the staff member's CPR technique would have been helpful for an awake, choking resident, but not when CPR was needed. The resident's face was very pale and skin was cold to touch. The room wasn't cold, maybe between 70 to 80 degrees. It appeared the resident had been down for longer than the five minutes claimed and the chance of viable life was little. During an interview on [DATE] at 9:18 A.M., EMT M said when they arrived at the facility, the resident lay on the floor. When asked, the staff said the resident's downtime wasn't long, about ten minutes since they'd last seen him/her. Another resident had given him/her a sandwich and the resident had a choking history. The resident's skin was cool. The resident had to have been down longer than ten minutes, at least 20 minutes. The resident's heart rhythm was asystole on the monitor. They attempted to ventilate the resident, but he/she had no chest rise and fall. They attempted to remove the obstruction, but were unsuccessful. EMT M said he/she'd worked for the ambulance company for about [AGE] years. In his/her experience, cool extremities indicated blood had not been pumped there for a while. The resident's body had started to redden up a little. The person who performed CPR when they arrived did not do it correctly. The staff member pressed on the xyphoid process (the lower end of the breastbone) during compressions while straddling the resident's thighs. It appeared as if he/she performed the [MEDICATION NAME] maneuver. It was not effective in helping to pump blood to the heart. Review of the facility's investigation, undated, included the following: -Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -On [DATE], approximately 6:00 A.M., the resident was found unresponsive in the dining room with chewed up food coming out of his/her mouth. Nurse A performed a mouth sweep and was able to remove particles of chewed up bread. He/she immediately performed the [MEDICATION NAME] maneuver several times without success. CPR was initiated and 911 was called. EMTs arrived and the resident was pronounced at the facility; -The resident was care planned for food shoveling, eating quickly and was being treated by speech therapy; -Upon completion of the investigation, the staff acted accordingly and followed the plan of care. During an interview on [DATE] at 1:35 P.M., the Memory Care Unit Manager said during the day, the activities aide was always present in the dining room, including during lunch. The dining room was also supervised by other staff. Usually a member of staff was in the dining room. On occasion, snacks were left over and they kept them on the unit. She expected staff to be in the dining room if residents were in the dining room. If she found a resident unresponsive, she'd call for a nurse, check for a pulse and start CPR. If there was something in the mouth prior to starting CPR, she'd remove it. She did not know why the staff did not start CPR prior to moving the resident from the dining room. She believed that everyone was CPR certified or supposed to be. The staffing development coordinator did in-services on the "Code Blue" policy in orientation and then periodically. During an interview on [DATE] at 1:40 P.M., the DON said during dining times, staff stayed in the dining rooms and supervised the residents. If it was not a meal time, residents were not constantly supervised in the dining room. Tables in the dining room were set up a certain way, so that some residents had access to the kitchenette. She did not know why the resident's pulse was not checked and CPR was not initiated in the dining room, upon finding the resident unresponsive. Nurse A performed the [MEDICATION NAME] maneuver and called for help to initiate the facility's policy. She thought Nurse A did everything correctly. She would have done the [MEDICATION NAME] maneuver and started CPR if she found the resident. Any resident who was physically able could go into the kitchenette and get a snack, like Resident #2, as part of their culture change for residents. This was the reason it was not care planned for Resident #2 to go into the kitchenette and get food and drinks out of the refrigerator. She supposed it could be an activity the resident enjoyed. She was unaware of Resident #2 giving food to other residents prior to this incident. Resident #1 was physically unable to independently go and get anything out of the kitchenette. There were other residents in the facility, outside the unit, that had swallowing issues. Those residents were alert and oriented, with a higher cognitive level. The residents did not wander in and out of rooms. They would not give food to other residents who could not safely eat it. They usually had personal refrigerators. During an interview on [DATE] at 11:31 A.M., the DON said while it was not required that everyone was certified, there should be someone on every shift CPR certified. They were in the process of writing a better policy. During an interview on [DATE] at 2:46 P.M., the DON said she could not find CPR certifications for any of the staff on duty during this incident in the Memory Care Unit other than Nurse F and Nurse G. She could not find any documentation for the last time the CPR policy inservices were done. CPR policy in-services were due in [DATE]. During an interview on [DATE] at 9:31 A.M., the ADON said swallow protocols were done specific to each resident. Speech therapy in-serviced the nursing staff on the protocol then the protocol was placed in the speech therapy section of the resident's chart. Anything specific to the resident's treatment was also printed on the pocket care guides. The CNAs had access to the pocket care guides to be aware of the resident needs. The speech therapy swallow protocols should have been on the pocket care guide. A suction machine was definitely located on the unit's crash cart. She also thought there were suction machines in the dining room and the clean utility room on the Memory Care Unit. During an interview on [DATE] at 9:58 A.M., the Interim Administrator said she did the inservice of the CPR policy with the department heads. She read it out loud with them, asked if they understood what it meant and asked if they had any questions. She was unsure how the DON inserviced other staff members. She was comfortable with uncertified CNAs doing CPR as long as they took instruction from a certified nurse on the scene. The facility did not inservice on the [MEDICATION NAME]. As a goal, they were going to try and get everyone who worked there certified. When asked about CNA H's CPR technique, she said she was not a CPR instructor, so she didn't know if CNA H's technique was appropriate or not. If she found a resident unresponsive, she'd "walk up the rib cage and use two finger tips in the middle of the chest." Then she said she would have to physically demonstrate it. Her CPR certification was expired. During an interview on [DATE] at 9:07 A.M., Physician J said he was the resident's primary care physician as well as the facility's medical director as of [DATE]. He said the resident resided on the Alzheimer's Unit due to his/her fairly demented state. The resident had a paramount [DIAGNOSES REDACTED].