Every finding on record at St Peters Rehab and Healthcare Center

Based on interview and record review, the facility failed to ensure staff utilized a gait belt and locked the wheelchair brakes prior to transferring one resident (Resident #4), in a review of 23 sampled residents. Staff did not put a gait belt on the resident when assisting the resident to from the toilet to the wheelchair. Staff did not lock the wheelchair brakes, the wheelchair moved as the resident went to sit in the wheelchair, and the resident fell to the floor. The resident fractured his/her proximal left humerus (the upper end of the upper arm bone, commonly known as a broken shoulder). The facility census was 83. On 06/11/26, the Administrator was notified of the past non-compliance which occurred on 02/23/26. Following the resident's fall on 02/23/26, the facility immediately assessed the resident, notified the resident's medical provider, and sent the resident to the hospital for evaluation. On 02/23/26, the facility conducted an investigation following the resident's fall. On 03/02/26, staff in serviced the certified nurse assistant (CNA) involved when the resident fell regarding gait belt use. On 03/30/26, the facility in serviced all staff on the facility's fall prevention policies. On 05/31/26, the facility in serviced all direct care staff on the facility's transfer policy which addressed pivot transfers using a gait belt and locking the wheelchair brakes prior to the transfer. The deficiency was corrected on 05/31/26. Review of the facility undated policy, Transfer Policy, showed the following:-Safe and efficient transfers are combination of the resident's physical ability and perceptual capacity, proper equipment, appropriate techniques and good planning;-Transfers may involve assistive devices. Assistive devices include gait belts (a device used to transfer residents from one position to another);-When conducting a pivot transfers: -Apply the gait belt around the resident's waist; -Place the resident's wheelchair at a slight angle; -Lock the wheelchair brakes; -Hold the gait belt and provide the necessary assistance to help the resident stand; -Help the resident to pivot to stand in front of the chair; -Instruct the resident to reach back for the arms of the chair and to sit when he/she felt the edge of the seat against the back of the legs; -Remove the gait belt when the resident is safely in the chair. Review of Resident #4's Care Plan, dated 10/28/25, showed the resident required assistance from one staff for toileting and transfers. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument), dated 02/18/26, showed the resident was cognitively intact, had a history of a stroke with hemiplegia (paralysis on ones side of the body), and required substantial/maximal assistance from staff to stand and to transfer to and from the toilet. Review of the resident's Nurses Note, dated 02/23/26 at 2:05 P.M., showed the resident was on the bathroom floor in his/her room. The resident said he/she attempted to transfer to his/her wheelchair after using the bathroom. The resident complained of pain and rated the pain in his/her left shoulder a 10 out of 10 (on a scale of zero to 10 with 10 being the most pain). The resident was sent to the hospital. During an interview on 06/10/26, at 1:52 P.M., the resident said he/she broke his/her arm because a CNA did not lock the wheelchair brakes, and he/she did not have a gait belt on. He/She went to sit down, and the wheelchair moved. The CNA was with him/her when he/she fell. During an interview on 06/10/26, at 2:30 P.M., CNA J said he/she was with the resident when the resident fell. He/She tried to get the resident positioned correctly. He/She went to go around the resident's wheelchair, and the resident fell down. He/She was not sure if the wheelchair was locked appropriately. The resident did not have a gait belt on during the transfer. The facility in-serviced him/her on gait belt use after the fall. Review of the facility investigation, dated 02/23/26, showed the following:-The resident had a fall with injury;-The resident transferred from the toilet to his/her wheelchair with the guidance of CNA J;-The resident said CNA J moved the chair toward the resident;-The resident said he/she went to sit in the wheelchair, the chair moved, and he/she fell to the floor;-The resident said he/she was not sure if CNA J locked the wheelchair brakes, the chair moved, and he/she fell to the floor;-The resident went to the emergency room, and the x-ray revealed a fracture to the resident's left proximal humerus;-Statement from the resident, dated 02/23/26, showed he/she was getting up off the toilet. He/She thought the wheelchair was not locked and it moved a lot, then he/she went down to the floor. CNA J and the resident confirmed they were ready for the transfer. The resident grabbed the grab bar and stood. The resident asked CNA J if he/she was angled toward the wheelchair and the CNA said, not yet, go a little more, so he/she did. The CNA said he/she would move the chair to the resident. CNA J moved the chair. The resident went to sit down, and the chair moved. The resident went down to the floor. The nurse took his/her vital signs and the staff put a gait belt on him/her. The staff said they were going to use the gait belt to get him/her up and they did. -Statement from CNA J, dated 02/23/26, showed he/she was getting the resident off the toilet. When the resident went to sit in his/her wheelchair, he/she wasn't in the wheelchair correctly. He/She told the resident to hold on as he/she walked around to get the resident situated better. By the time he/she got around the resident, the resident was on the floor. He/She did not see the resident fall.-Conclusion: The resident fell during a transfer with CNA J. The resident said his/her chair moved when he/she attempted to sit down and could not remember if his/her wheelchair brakes were locked. The resident was sent to the hospital and diagnosed with a fracture of the left proximal humerus; a. The facility initiated the following interventions related to the accident: b. Nurse Practitioner assessed the resident at the time of the incident; c. Head-to-toe assessment completed; d. Resident sent to the emergency room; e. X-ray results revealed a fracture of his/her left humerus; f. Resident was sent back to the facility with new orders; g. Therapy to evaluate; h. In-Servicing initiated to enhance facility processes.-The investigation included the resident's assessment and review of medical records;-In-service included in the investigation, dated 03/02/26, showed CNA J signed an in-service form that stated, Gait belt should be placed prior to transferring a resident.-In-service for fall prevention included in the investigation, dated 03/30/26, showed it reviewed fall prevention to include the following: a. Prevent falls by anticipating resident needs, the six P's: b. Pain, assess pain and provide intervention if needed; c. Potty, offer toileting assistance, never assume a resident will call; d. Possessions, ensure call light, phone, water, glasses, and personal items are in reach; e. Positioning, reposition for comfort and safety, and bed in lowest position; f. Personal needs, ask if residents need anything else before leaving; g. Pick up, are any items on the floor, look for trip hazards;h. Encourage the use of the call light, keep pathways clear of clutter, ensure non-skid footwear is on, anticipate needs before residents try to get up, consistent rounding prevents falls, resident safety starts with us;i. The in-service record included a note to review the fall policy and emails and electronic receipt to staff. Review of the facility's in-service documentation showed the facility conducted an in-service related to transfers for all direct care staff on 5/31/26. The in-service included a review of the transfer policy which addressed pivot transfers using a gait belt and locking the wheelchair breaks. During an interview on 06/10/26, at 4:12 P.M., the Director of Nursing (DON) said the following:-She was not the DON at the time the resident fell;-She expected staff to use a gait belt every time they assisted a resident with a transfer. Staff were to lock wheelchair brakes prior to transferring a resident to a wheelchair. MO3018141

Based on interview and record review, the facility failed to maintain documentation to show the facility used the services of a registered nurse (RN) in the facility for eight consecutive hours a day, seven days a week. The facility census was 83. During an interview on 06/11/26 at 5:37 P.M., the Administrator said the facility did not have a policy addressing RN coverage. Review of the facility assessment, updated on 07/20/25, showed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. Review of the facility provided timecard punches, payroll reports and schedules for Sunday, 04/05/26, showed no RN coverage. Review of the facility provided timecard punches, payroll reports and schedules for Sunday, 04/26/26, showed no RN coverage. During an interview on 06/18/26 at 10:31 A.M., the Scheduler said the following:-She was responsible for staffing and ensuring RN coverage for the facility;-She was aware there was to be an RN in the building for eight consecutive hours each day;-The facility employed three RNs and utilized agency staff when available;-She was aware there were times the facility did not meet the requirement due not being able to find an RN available to work. During an interview on 06/11/26 at 12:20 P.M., the Director of Nursing (DON) said the following:-She was aware of the requirement to have an RN for eight consecutive hours a day;-The Scheduler was responsible for scheduling the RNs;-She had reviewed the list of uncovered days the state agency provided, and she did not see the facility had RN coverage for the days listed. During an interview on 06/11/26 at 12:36 P.M., the Administrator said the following:-She was aware of the requirement to have an RN for eight consecutive hours a day;-The Scheduler was responsible for ensuring the facility met the RN coverage requirement;-She expected the facility to follow the regulations for RN coverage;-She had reviewed the list of uncovered days the state agency provided, and she did not see the facility had RN coverage for the days listed.

Based on interview and record review, the facility failed to complete a performance review for each nurse aide at least once every 12 months and provide regular in-service education based on the outcome of the reviews. The facility identified six CNAs were employed by the facility for more than a year. Four of six CNAs reviewed did not have the required performance review or documentation of in-servicing education based upon the outcome of the review. The facility census was 83. During an interview on 06/11/26 at 5:37 P.M., the Administrator said the facility did not have a policy to address nurse aide annual performance reviews. Review of the Facility Assessment Tool, dated 07/20/25, showed the following:-Required in-service training for nurse aides. In-service training must address areas of weakness as determined in nurse aides' performance reviews and facility assessment. 1. Review of Certified Nurse Assistant (CNA) AA's employee file showed the following:-He/She was hired on 04/08/25;-No documentation the facility completed an annual performance review for CNA AA since his/her date of hire. 2. Review of CNA BB's employee file showed the following:-He/She was hired on 05/07/25;-No documentation the facility completed an annual performance review for CNA BB since his/her date of hire. 3. Review of CNA Z's employee file showed the following:-He/She was hired on 03/11/25;-His/Her employer evaluation, dated 03/11/26, showed he/she received a fair rating for work quality and dependability. There were no additional comments to further explain the reason for the fair rating. The evaluation section did not include any additional comments or evidence of any additional in-servicing;-There was no documentation to show staff educated CNA Z based on the outcome of his/her annual performance review. 4. Review of CNA CC's employee file showed the following:-He/She was hired on 10/28/24;-His/Her employer evaluation, dated 10/28/25, showed he/she received a fair rating for dependability. There were no additional comments to further explain the reason for the fair rating. The evaluation section did not include any additional comments or evidence of any additional in-servicing;-There was no documentation to show staff educated CNA CC based on the outcome of his/her annual performance review. 5. During an interview on 06/11/26 at 09:20 A.M., the Director of Nursing (DON) said the following:-She assumed the role of DON in May 2026;-She was staff were to complete annual performance reviews and were to provide education on the areas the staff was found to be deficient in. During an interview on 06/11/26 at 12:36 P.M., the Administrator said she expected staff to complete an annual performance review for all CNAs. Human Resources, the department heads, and the Director of Nursing were responsible to complete the annual performance reviews. She was not aware staff did not complete the performance reviews.

Based on interview and record review, the facility failed to ensure staff training needs, as identified in the facility assessment and the annual in-servicing calendar, were not met for five of five staff reviewed. The facility failed to maintain documentation staff completed 12 hours of inservice training annually. The facility census was 83. During an interview on 06/11/26 at 5:37 P.M., the Administrator said the facility did not have a policy addressing 12-hours of annual training. Review of the Facility Assessment Tool, dated 07/20/25, showed the following:-Required in-service training must be sufficient to ensure the continuing competencies and be no less than 12 hours per year. Training topics included: -Communication; -Resident Rights and facility responsibilities; -Abuse, neglect and exploitation; -Infection Control; -Culture change; -Dementia care; -Caring for the cognitively impaired; -Changes in condition; -Cultural competency; -Person-centered care; -Activities of Daily Living; -Disaster planning and procedures; -Medication administration; -Measurements (blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output and urine test for glucose/acetone; -Resident assessment and examinations; -Caring for residents with Alzheimer's; -Caring for residents with mental and psychosocial disorders; -Specialized care. Review of the facility's Education Calendar showed the facility would provide the following trainings:-January: Incident/Accident Prevention, Safety/Elopement and Pain Management; -February: Resident Rights, Confidentiality and Dignity and Privacy; -March: Infection Control, Bloodborne Pathogens, HIV, Hep B, Handwashing; -April: Emergency Preparedness, Disasters, Safety, Active Shooter; -May: Body Mechanics, Transfer Techniques and Gait Belt Use; -June: Nutrition/Hydration, Weight Loss/Dental Care and Dementia Care; -July: Death/Dying, Psychological Aspects of Aging and Advanced Directives; -August: Grievances/Complaints, Effects of Meds on the Elderly; -September: Skin/Pressure Ulcers, Reporting, Care and Prevention; -October: Abuse/Neglect, Burn Out, Reporting Guidelines, QAPI and Facility Assessment; -November: Restorative Care and Restraint Free Environment; -December: Compliance/Ethics, Code of Conduct, Harassment/Communication and Cultural Competency; -The form was designed to be a staff member specific form, indicated with a place to put the employee name in a box at the bottom of the form and where documentation of completion of orientation, education fair and staff meetings for each month could be documented as completed;(The education calendar did not address the following training topics as identified on the facility assessment: person-centered care; measurements (blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output and urine test for glucose/acetone); resident assessment and examinations; caring for residents with mental and psychosocial disorders.) Review of the facility education binder showed staff provided the following in-services in 2025 and 2026:-03/28/25- Infection Control: Review of policy, enhanced barrier precautions, peri-care, and hand washing;-06/22/25 - Reporting abuse and neglect;-07/24/25 - Death and dying, aspects of aging, and advanced directives;-08/28/25 - Abuse/Neglect;-09/19/25 - Abuse/Neglect;-09/24/25 - Abuse/Neglect;-10/03/25 -Abuse/Neglect;-10/30/25 - Abuse/Neglect, burn-out, and reporting guidelines;-12/1/25 - Enhanced barrier precautions, handwashing, peri-care, and infection control;-12/10/25 - Customer service;-01/12/26 - Fall prevention;-01/14/26 - De-escalation of behaviors, resident rights, abuse and neglect;-01/17/26 - Location of fire extinguishers, evacuation protocol, and location of emergency preparedness binder;-02/01/26 - Enhanced barrier precautions, infection control, and handwashing;-02/19/26 - Privacy, dignity, resident rights, abuse and neglect;-03/19/26 - Infection control, prevention program, handwashing, vaccines, and personal protective equipment;-03/24/26 - Contact precautions;-The record contained a sign-in sheet for each in-service;-The sign-in sheet included a space for each employee in attendance to print his/her name, write his/her signature, list his/her title, and print which shift he/she worked. (The record did not include the hours of each in-service. The in-service binder did not show evidence the facility covered the topics identified on the Facility Assessment Tool or the Education Calendar.) 1. Review of Certified Nurse Assistant (CNA) BB's employee file showed the following:-His/Her hire date was 05/07/25;-No documentation he/she received 12 hours of inservice training annually. During an interview on 06/11/26 at 1:24 P.M., CNA BB said the following:-He/She did not regularly attend in-services;-He/She did not know when in-services were held;-He/She did not know he/she was required to attend 12 hours of in-service education each year covering specific topics related to the care of residents in a long-term care facility. 2. Review of CNA Z's employee file showed the following:-His/Her hire date was 03/11/26;-No documentation he/she received 12 hours of inservice training annually. 3. Review of CNA CC's employee file showed the following:-His/Her hire date was 10/28/24;-No documentation he/she received 12 hours of inservice training annually. 4. Review of CNA HH's employee file showed the following:-His/Her hire date was 07/08/24;-No documentation he/she received 12 hours of inservice training annually. 5. Review of CNA FF's employee file showed the following:-His/Her hire date was 04/11/25;-No documentation he/she received 12 hours of inservice training. 6. During an interview on 06/11/26 at 12:48 P.M., Assistant Director of Nursing (ADON) A said the following:-He/She and the Director of Nursing (DON) decided on the in-service topics or education to schedule;-Major in-services are held the last Thursday of every month;-Scheduled in-services should follow the education calendar and the facility assessment tool;-He/She kept all in-service training records, information, and attendance sign-in sheets in the in-service binder;-He/She did not track when individual certified medication aides (CMTs) and CNAs completed the required training. During an interview on 06/11/26 at 12:36 P.M., the Administrator said the following:-The facility should provide in-servicing for all staff on the topics listed in the Facility Assessment Tool and on the Education Calendar;-The ADON and DON provided most of the in-servicing. The ADON should track the in-service hours for each staff member to ensure they received the 12 hours of training as required by regulation.

Based on record review and interview, the facility failed to ensure compliance with the Federal requirement for nurse aide training when the facility made the nurse aides, employed by the facility, pay for the cost of the testing for the nurse aide training program. The facility census was 83. 1. Review of the Code of Federal Regulation, 42 CFR 483.152 Requirements for approval of a nurse aide training and competency evaluation program, showed the following:(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program. Review of the facility policy, Nursing Assistant (NA)/Certified Nurse Aide (CNA) Training Program, dated 03/20/25, showed the policy did not include who was responsible for paying for the training program or testing. Review of NA X's employee file showed he/she was hired on 04/09/26. He/She started the CNA training program on 03/09/26 and completed on-the-job training at the facility from 04/06/26 to 04/13/26. During interviews on 06/10/26 at 11:31 A.M. and 4:08 P.M., NA X said he/she began the CNA training program before he/she was hired at the facility, but he/she completed his/her on-the-job training at the facility. He/She passed his/her knowledge test, which he/she had to take twice and paid $35.00 each time to take but was waiting to take his/her physical test. He/She had to pay $103.00 to take the physical test. So in all, he/she had paid $173.00. No one told him/her he/she would be reimbursed for the cost of the testing. During an interview on 06/10/26 at 3:00 P.M., Human Resources said the facility paid for the CNA training program, but the staff had to pay for the testing. The facility paid the staff back for the testing once the staff passed the test. NA X had not tested yet. During interviews on 06/10/26 at 3:10 P.M. and 06/11/26 at 12:36 P.M., the Administrator said the facility paid for the CNA training program, but the staff had to pay for the testing. Once the staff passed the test, the facility reimbursed the staff. She wasn't sure if the staff member had to take a test more than once if the facility paid for each additional time or what. She was not aware the facility needed to pay for all aspects of the training program, including testing.

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect and provided care in an environment that promoted and enhancement of their quality of life. Staff did not assist three residents (Residents # 95, #28, and #34) when they requested staff assistance to use the bathroom. Staff stood while assisting one resident (Resident #89) to eat his/her meal. Residents reported unidentified staff yelled or spoke loudly, disrupting residents activities, refused to tell residents their names when requested, and spoke on their personal phone devices while providing care to residents. A sample of 23 residents was selected for review. The facility census was 83. Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect and provided care in an environment that promoted and enhancement of their quality of life. Staff did not assist three residents (Residents # 95, #28, and #34) when they requested staff assistance to use the bathroom. Staff stood while assisting one resident (Resident #89) to eat his/her meal. Residents reported unidentified staff yelled or spoke loudly, disrupting residents activities, refused to tell residents their names when requested, and spoke on their personal phone devices while providing care to residents. A sample of 23 residents was selected for review. The facility census was 83. Review of the facility policy, Privacy and Dignity, revised 10/24/22, showed the following:-The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality;-Staff assists the resident in maintaining self-esteem and self-worth;-The facility promotes independence and dignity in dining;-The facility respects the resident's private space and property;-Staff treats residents with respect including respecting their social status, speaking respectfully, and listening carefully;-Staff focuses on residents as individuals when they speak to them and address residents as individuals when providing care and services;-Residents are afforded a right to privacy and confidentiality. Review of the undated facility policy, Cell Phone and Personal Mobile Device Policy, showed personal cell phone use by staff is prohibited while providing direct resident care activities. On 6/11/26 at 5:37 P.M., the facility reported they did not have a policy for feeding residents. 1. Review of Resident #95's face sheet showed diagnoses of fracture of right ilium (the largest and uppermost bone of the pelvis), fracture of first, second, third and fourth lumbar vertebra (bones in the spinal column located in the lower back), fracture of the shaft of the right humerus (the long, middle section of the upper arm bone that connects the shoulder to the elbow) and radius (one of the two bones in the forearm, connecting the hand to the elbow), displaced (not in alignment) fracture of the fifth, sixth and seventh cervical vertebrae (bones in the neck), and displaced fracture of the right ulna styloid process (a small bone on the outer aspect of the ulna, at the wrist). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/17/26, showed the following:-The resident was cognitively intact;-He/She had severe depression;-He/She required moderate assistance for bed mobility and to transfer; -He/She was always continent of bowel and occasionally incontinent of bladder. Review of the resident's care plan, updated 5/29/26, showed the following:-The resident had an activities of daily living (ADL) self-care performance deficit related to multiple fractures;-Required assistance from one staff member to use the bathroom and to move between surfaces;-Anticipate and meet the resident's needs;-Had bladder incontinence;-Used disposable briefs, change as needed. Observation on 06/07/26 at 2:00 P.M. showed the resident lay in his/her bed. The resident wore an incontinence brief. During an interview on 6/07/26 at 2:00 P.M., the resident said the following:-He/She was recently in a motor vehicle accident resulting in multiple fractures;-She required staff to assist him/her to perform basic ADLs; -He/She needed staff to assist him/her to get in and out of bed and to go to the bathroom;-He/She experienced delays in care due to the long wait times, ranging from 30 minutes to 3 hours;-One unknown staff (he/she could not remember his/her name) told him/her to soil in his/her incontinence brief and the staff would clean him/her up later;-He/She was embarrassed and felt sad and worthless when staff told him/her to soil in his/her incontinence brief; -He/She was capable of using the bathroom, he/she just needed staff's help. He/She did not see a reason why staff could not help him/her go to the toilet. 2. Review of Resident #28's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-No behaviors or rejection of care;-Required partial to moderate assistance from staff with dressing, toileting, and transfers. During an interview on 06/08/26, at 10:58 A.M., the resident said a certified nurse assistant (CNA) who assisted him/her out of bed yesterday did not listen to him/her. He/She had to go to the bathroom urgently. The CNA wanted him/her to get dressed first. He/She could not wait so he/she took himself/herself to the bathroom. The CNA yelled at him/her and scolded him/her like a child because he/she didn't do it the way the CNA wanted. He/She did not tell anyone because he/she was intimidated by the CNA and did not know the CNA's name. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-No behaviors or rejection of care;-Required substantial/maximum assistance from staff for bed mobility, transfers, and toileting. During an interview on 06/08/26, at 10:32 A.M., the resident said the following:-Many of the staff were disrespectful;-Many staff were loud at night, during bingo, and in the television area when residents were trying to watch a program. The staff members' actions took away the enjoyment of activities because it was so disruptive. The staff did not respect the residents' rights to have a peaceful environment;-A night shift CNA told him/her more than once to soil himself/herself instead of using the bed pan, because the CNA did not want to clean it. He/She feared the CNA would retaliate if he/she told the CNA's name because they had been into it several times over the bed pan;-Staff wore ear buds connected to their phones and did not tell him/her they were wearing them. He/She might have said private things while staff were wearing the ear buds without knowing someone else could hear him/her. It seemed like a violation of his/her privacy and dignity. 4. During resident council meeting on 6/08/26 at 10:05 A.M., residents in attendance said the following: -Residents #37 and #49 said staff did not always wear their name badges. With the level of turnover and agency staff, it was difficult to know and remember everyone's names. Some staff, mostly agency staff, refused to share their names with the residents or rudely questioned the residents as to why they needed to know their names;-Resident #53 said a certified medication technician (CMT) refused to tell him/her what his/her medications were. The CMT told him/her they were the same as always and to just take them;-Call light wait times were long. Residents #83 and #10 said they were incontinent because they had to wait so long for staff to answer their call lights;-Residents #53, #49, and #83 said multiple staff wore their ear buds and had personal conversations using their ear buds while providing care. Administration addressed this in the past, but it was happening again, especially on the weekends. 5. Review of Resident #89's undated Face Sheet showed his/her diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and aphasia (impaired communication and ability to speak). Review of the resident's quarterly MDS, dated [DATE], showed the resident's cognition was severely impaired. Review of the resident's Care Plan, revised 08/29/25, showed the following:-He/She required assistance from staff with activities of daily living (ADLs);-He/She was able to consume meals independently after set up;-Encourage the resident to participate as much as possible during care activities;-He/She has impaired cognitive function; cue, reorient, and supervise as needed. Observation on 06/07/26 at 1:15 P.M. showed the following:-Certified Medication Technician (CMT) DD stood to the left side of the resident at the dining table while the resident was seated in his/her wheelchair;-CMT DD reached over the resident to grab the resident's fork and spoon and fed the resident while he/she stood over the resident;-CMT DD picked up the resident's cup and gave the resident a drink while he/she stood over the resident;-CMT DD leaned down, placed his/her forearms across the dining table, and talked to the resident while standing/leaning on the table. 6. During an interview on 6/15/26 at 4:39 P.M., Licensed Practical Nurse (LPN) Supervisor M said the following:-Staff should treat the residents as if the facility was their home. The residents had the right to tell staff what they want and need;-Staff should treat all residents with dignity and respect;-Staff should never yell at or speak down to a resident. They should communicate with the residents professionally;-Staff should always provide the resident with the amount of privacy they want and desire;-Staff should not have personal conversations or talk on their phone when providing care to the residents;-Staff should never tell residents to soil on themselves; it is not acceptable;-If staff was busy and unable to help the resident right away, it was staff's responsibility to find another staff to assist the resident. During an interview on 06/11/26 at 5:20 P.M., the Director of Nursing (DON) said the following:-Staff should treat residents with dignity and respect and should not stand to assist residents to eat in the dining room;-Staff should not tell residents to soil themselves;-Staff should not be on their personal phone or using ear buds when providing care to the residents. During an interview on 6/11/26 at 5:19 P.M., the Administrator said she expected staff to treat all residents with dignity and respect. Staff should not conduct personal conversations or phone calls while providing resident cares.

Based on observation, interview, and record review, the facility failed to ensure staff consistently provided assistance with showering/bathing and personal hygiene to five residents (Residents #3, #90, #88, #2, and #37), who required assistance with showers/bathing, in a review of 23 sampled residents. The facility census was 83. Review of the facility policy, Care and Services, revised 10/24/22, showed the following:-To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process;-Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility;-Care and services are provided in a manner that consistently enhances self-esteem and self-worth;-Once admitted , the resident receives an admission assessment where initial care and service needs are identified.-The IDT receives and reviews initial assessment information to ensure that members of the IDT interact with residents in a manner that enhances self-esteem and self-worth, such as activities related to bathing, grooming;-The IDT facilitates opportunities for residents to exercise choice and self-determination during activities of daily living (ADLs).-The IDT provides care and services to residents with reasonable accommodations of each resident's individual needs and preferences. Review of the facility policy, Shaving, revised 10/24/22, showed the following:-To increase cleanliness and improve the resident's self-image.-The Facility provides for the removal of facial hair as a component of the resident's hygienic program.-Male residents may be shaved daily and female residents may be shaved as needed. The facility did not provide a policy specific to showers and Activities of Daily Living (ADL) needs. 1. Review of Resident #3's care plan, revised 02/27/26, showed the following:-He/She was totally dependent on staff for showering/bathing;-Staff to check nail length and trim and clean on bath day and as necessary. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], showed the following:-He/She had severely impaired cognition;-He/She was totally dependent on staff for all activities of daily living including showering/bathing and personal hygiene. Observation on 06/08/26 at 2:25 P.M. showed the following:-The resident's hair was in knots and in a messy bun on top of his/her head;-The resident had white flakes in his/her hair; -The resident scratched at dug at his/her scalp. During an interview on 06/07/26 at 4:55 P.M. and 06/08/26 at 2:25 P.M., the resident's family member said the following:-Staff were not giving the resident his/her showers; -He/She had to ask staff a couple of weeks ago to give the resident a shower because the resident's skin was so dry and flaky. The resident was so itchy and scratching at his/her skin since it had been so long since he/she had a shower/bath;-He/She told staff a couple of weeks ago he/she would like the resident to receive a bath/shower every other day;-The resident only had one bath/shower in the last couple of weeks;-He/She had to clean and trim the resident's nails yesterday because they were so long and dirty and staff were not doing it;-The resident needed his/her hair washed. 2. Review of Resident #90's admission assessment, dated 02/11/26, showed the resident was cognitively intact and required partial/moderate assistance for bathing. Review of the resident's Care Plan, revised 02/20/26, showed the resident required assistance to shower/bathe. Review of the resident's Shower Sheets, dated May 2026, showed the resident did not get a shower between 04/30/26 and 05/5/26 (five days); 05/07/26 and 05/12/26 (five days) 05/14/26 and 05/18/26 (four days); and 05/21/26 and 05/27/26 (six days). Observation 06/07/26 at 1:15 P.M., showed the resident's hair was disheveled and greasy. During interview on 06/07/26 at 1:15 P.M., the resident said did not get his/her showers twice a week very often. Staff told him/her they looked at the schedule wrong and missed his/her shower. The staff did not make up his/her shower when he/she missed his/her showers. There were times when he/she went all week without a shower, but staff say his/her showers were documented. It was frustrating and he/she felt itchy when he/she did not get his/her showers. He/She felt like he/she didn't matter. He/She worried he/she stinks and may offend others. 3. Review of Resident #88's care plan, revised 12/30/25, showed the resident was totally dependent on staff for bathing/showering. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident had moderately impaired cognition;-The resident required substantial/maximal assistance from staff with showering/bathing. Review of the resident's shower schedule showed the resident's scheduled shower days were Mondays and Thursdays. Review of the resident's shower sheets for May 2026 showed Certified Medication Technician (CMT) W gave the resident a shower and cleaned the resident's nails on 06/04/26. Observation on 06/07/26 at 4:45 P.M. (three days since the resident's last documented shower) showed the resident's nails were approximately 1/2-1 inch long, curved, uneven, and dirty with brown debris underneath. Observation on 06/09/26 at 6:00 A.M. (five days since the resident's last documented shower) showed his/her nails were approximately 1/2-1 inch long, curved, uneven, and dirty with brown debris underneath, and his/her hair was disheveled and oily. During an interview on 06/23/26 at 11:27 A.M., CMT W said the following:-The resident never refused his/her showers;-The resident would not let him/her file or clean his/her nails; -The resident sometimes let him/her clean his/her nails in the shower, but the resident never let him/her file or trim his/her nails. 4. Review of Resident #2's Care Plan, revised 3/19/26, showed the following:-The resident had an activity of daily living self-care performance deficit related to fatigue, limited mobility, and pain;-The resident required maximum assistance from one staff with bathing/shower two times weekly. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident required maximum assistance for showering/bathing. During interviews on 6/08/26 at 1:15 P.M. and 6/11/26 at 9:29 A.M., the resident said the following:-He/She was scheduled for bathing on Wednesday and Saturday;-There were no scheduled shower aides on the weekends, so baths/showers scheduled for Saturday did not typically occur. -The regular shower aide was on a vacation last week;-He/She did not get his/her shower on Saturday (06/06/26) and did not get one earlier in the week because the shower aide was on vacation. 5. Review of Resident #37's care plan, revised 9/15/25, showed the following:-The resident had an ADL self-care performance deficit;-The resident was independent to supervision for bathing/showering; Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident required supervision for showering/bathing. During interviews on 6/7/26 at 2:16 P.M. and 6/8/26 at 1:03 P.M., the resident said the following:-He/She was scheduled to received a shower on Wednesday and Saturday;-He/She was supposed to get two showers per week, but he/she only received one shower a week over the last few weeks;-He/She generally did not get a shower on Saturdays due to staffing. 6. During an interview on 6/10/26 at 11:59 A.M., Certified Nurse Assistant (CNA) N said the following:-He/She was the full time shower aide for the 100, 200 and half of the 300 hall;-If he/she was not working it was the responsibility of the floor aides to complete the showers. During an interview on 6/15/26 at 4:06 P.M., CNA L said the following:-The full-time shower aide generally gave all the showers;-If there was not a shower aide scheduled, the aide assigned to the hall was responsible for giving the shower. During an interview on 6/15/26 at 4:39 P.M., Licensed Practical Nurse (LPN) Supervisor M said the following:-There was a full time shower aide scheduled for Monday through Friday;-The aide assigned to the residents' halls were responsible for giving showers on Saturdays. MO2997391

Based on observation, interview, and record review, the facility failed to ensure proper settings were in place for pressure reducing and relieving low air loss (LAL) mattresses (mattress that provided a constant flow of air in the mattress to help prevent pressure ulcers) to prevent the potential for development and worsening of pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or friction) for three residents (Residents #8, #44 and #70) in a review of three residents reviewed for pressure ulcer care. The facility census was 83. Review of the Resident Assessment Instrument (RAI) manual, updated 10/2025, showed the following:-Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: Skin temperature (warmth or coolness); Tissue consistency (firm or boggy); Sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.-Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.-Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.-Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling.-Unstageable pressure wound - Slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined.-Suspected deep tissue injury - Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Review of the facility policy, Support Surface Guidelines, revised 10/24/22, showed the following:-The facility will select the appropriate pressure reducing and relieving devices for residents at risk of skin breakdown;-Pressure Reducing Support Surface (also known as Pressure Redistribution Support Surface) is a surface designed to prevent or promote the healing of pressure ulcers by distributing pressure over a larger surface area of the body in an effort to reduce or eliminate tissue pressure in a more circumscribed location.-The facility will provide care and services to promote the prevention of pressure ulcer development.-Low-air-loss mattresses are giant air-permeable pillows that are continuously inflated with air. The air flow has a drying effect on tissues. Low air loss mattresses will be set per manufacturer guidelines or per resident's preference/comfort. Review of the undated user manual for the facility's low air loss mattresses showed the pump and mattress are intended to reduce the incidence of pressure ulcers while optimizing patient comfort. (The User Manual did not address the weight settings for the pump and mattress.) 1. Review of Resident #8's annual Minimum Data Set (MDS, a federally mandated assessment instrument), dated 04/03/26, showed the following:-He/She had moderately impaired cognition;-He/She required partial/moderate assistance from staff for bed mobility rolling left to right;-He/She had one or more unhealed pressure ulcer/injuries;-He/She received pressure ulcer/injury care;-He/She used a pressure reducing device for his/her bed. Review of the resident's care plan, revised 05/29/26, showed the following:-He/She required a low air loss mattress with bolsters to promote wound healing;-He/She needed a low loss air mattress to protect the skin while in bed;-He/She needed monitoring and assistance to turn/reposition. Review of the resident's wound evaluation and management summary, dated 05/29/26, showed the following:-Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) of the left ischium (lower and back part of the hip bone) full thickness;-Wound size: 7.5 centimeters (cm) length, 5.4 cm width, 3.7 cm depth;-Duration: greater than 92 days;-Support surface: bed - group two (a pressure-reducing mattress system that is medically required to treat or prevent advanced bed sores);-Wound progress: exacerbated;-One or more signs of clinical infection;-Recommended for transfer to hospital for further care. Review of the resident's progress note, dated 06/04/26 at 6:57 P.M., showed he/she returned to the facility from the hospital with a diagnosis of osteomyelitis (bone infection) of sacrum (triangular bone located above the coccyx) and was on antibiotics with a wound vac (vacuum-assisted closure used to conduct negative pressure wound therapy to promote healing) in place. Observation on 06/07/26 at 2:30 P.M. showed the following:-The resident lay on his/her back in bed on a low air loss mattress (LAL);-The LAL mattress pump was set at 308 pounds. During an interview on 06/07/26 at 2:30 P.M., the resident did not respond when asked if his/her bed was comfortable. Review of the resident's electronic health record, dated 06/08/26 at 1:59 P.M., showed the resident's current weight was 157.2 pounds. Observation on 06/09/26 at 6:10 A.M. showed the following:-The resident lay on his/her back in bed;-The LAL mattress pump was set at 308 pounds. During an interview on 06/22/26 at 12:48 P.M., the resident's responsible party said the resident complained about the pain in his/her buttock/leg area a lot when he/she sat or laid on his/her bottom. 2. Review of Resident #44's Care Plan, updated 10/22/25, showed the following:-Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) right buttock -The resident preferred to be positioned on his/her back;-The resident required pressure relieving/reducing device on bed/chair;-Turn and reposition. Review of the resident's annual MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Diagnoses include osteomyelitis (infection in the bone);-Dependent on staff to roll left and right;-Weight 102 pounds;-One or more unhealed pressure ulcer/injury;-One stage III and one stage IV pressure ulcer, not present on admission;-Pressure reducing device for bed. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Weight 106 pounds;-One stage IV pressure ulcer not present on admission;-Pressure reducing device for bed. Review of the resident's Care Plan, updated 02/24/26, showed LAL mattress to the resident's bed. Review of the resident's Care Plan, updated 03/10/26, showed the resident has a stage IV pressure ulcer to his/her sacrum. Review of the resident's Care Plan, dated 03/10/26, showed a deep tissue injury to the resident's left lateral plantar foot (the bottom, outer edge of the foot). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Weight 104 pounds; -One or more unhealed pressure ulcer/injury;-One stage IV pressure ulcer not present on admission, one unstageable deep tissue injury (new) not present on admission;-Pressure reducing device for bed. Observation on 06/09/26 at 6:30 A.M., showed the following:-The resident lay on his/her back in his/her bed;-The resident's LAL mattress pump was set to 220 pounds. Observation on 06/09/26, at 10:37 A.M., showed the following:-The resident lay on his/her back in his/her bed;-The resident's LAL mattress was set to 220 pounds;-The Corporate Wound Nurse, the Director of Nursing (DON) and the Wound Physician were present to assess the resident's wound;-The Corporate Wound Nurse turned the resident on his/her right side;-There was an open wound, approximately the size of a ping pong ball;-The Wound Physician measured the wound and said it measured 3.5 cm in length, 3.3 cm in width, and 1.7 cm in depth. The wound also had 2.2 cm of undermining (tissue beneath the skin's edges dies and erodes away, creating a hidden pocket or gap beneath the surface) at the top of the wound;-The dressing had a moderate amount of greenish drainage, and the wound bed was a dull pink with muscle and fascia (connective tissue) was visible. 3. Review of Resident #70's Care Plan, dated 05/21/24, showed the following:-The resident had potential/actual impairment to skin integrity;-Pressure relieving mattress to protect the skin while in bed.-An update on 12/23/25, showed the resident had a stage III pressure ulcer on his/her right heel;-An update on 03/17/26 showed the resident had a stage III pressure ulcer on his/her first right metatarsal head (end of the long bone in the foot near the toe). Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment. The weighed 152 pounds and had one unhealed stage III pressure ulcer. Review of the resident's Care Plan, updated 04/07/26, showed the stage III pressure ulcer on the resident's first right metatarsal head was resolved. Review of the resident's Care Plan, updated 04/14/26, showed the right heel stage III pressure ulcer was resolved. Review of the resident's weight record, dated 06/01/26, showed the resident weighed 155.8 pounds. Observation on 06/08/26 at 9:52 A.M., showed the resident lay in bed on a LAL mattress. CNA D and CNA E positioned the resident on his/her back. The LAL pump on the end of the resident's was set at the highest setting past 300 pounds. The LAL mattress was firm and barely flexed when pressure was applied. The resident's right heel was reddened. CNA D said the resident's right heel felt squishy. Observation on 06/09/26 at 6:30 A.M., showed the resident lay on his/her back in his/her bed. The resident's LAL mattress felt firm and did not flex with pressure. The LAL mattress pump was set at the highest setting past 300 lbs. 4. During an interview on 06/09/26, at 10:40 A.M., the Wound Physician said he expected staff to set the LAL mattress to the resident's weight unless the resident was uncomfortable, then staff should adjust the setting to the resident's comfort. Setting the mattress to the resident's weight was preferred and gave the most pressure reduction. During interviews on 06/09/26 at 10:45 A.M. and on 06/11/26 at 5:19 P.M., the Director of Nursing (DON) said the LAL mattress pumps should be set to the resident's weight and to manufacturer guidelines to ensure pressure reduction and promote wound healing. The mattress should not be set on the highest setting and could cause more pressure. During an interview on 06/22/26 at 1:03 P.M., the Medical Director said the following:-The higher weight setting would be a much harder surface than he would expect for wound healing;-He expected staff to set the LAL mattress at the proper weight for the residents. MO2997391

Based on observation, interview, and record review, the facility failed to ensure medications for two residents (Resident #54 and #11), in a review of 23 sampled residents, were securely stored behind a locked compartment and not left in the resident's room without a physician's order to self-administer or to keep at bedside. The facility census was 83. Review of the facility policy, Storage of Medication, dated 01/2021, showed the following:-The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications;-The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia. Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or suitable containers;-In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 1. Review of Resident #54's Physician Order Sheet (POS), dated June 2026, showed an order for lidocaine external cream 4 percent (%), apply to right shoulder topically two times a day for pain. Apply 2 grams to the right shoulder, order date of 04/21/26. There was no order for a lidocaine 4% topical patch and no order to keep any medications at bedside. Observation on 06/09/26 at 6:50 A.M., showed the following:-Certified Medication Technician (CMT) R entered the resident's room to administer the resident's A.M. medications;-An unopened lidocaine 4% topical patch lay on the resident's bedside dresser;-CMT R asked the resident why he/she still had a patch left on his/her dresser and asked the resident if the shower aide had not put the patch on the resident yesterday after his/her shower;-The resident said he/she could not remember. During an interview on 06/09/26 at 7:10 A.M., CMT R said the following:-CMT W was to give the resident a shower yesterday;-He/She gave CMT W the patch to put on the resident after the resident's shower;-He/She was not aware CMT W had not put the patch on the resident and had left it in the resident's room. During an interview on 06/10/26 at 2:37 P.M., CMT W said the following:-CMT R always gave him/her the resident's patch to apply after the resident's shower on shower days;-He/She must have sat the patch on the resident's bedside dresser and forgot to apply the patch. 2. Review of Resident #11's June 2026 POS showed an order for fluticasone propionate (Flonase) nasal suspension 50 micrograms, one spray in each nostril one time a day for allergies. The resident did not have a physician order to keep medication at his/her bedside or an order to self-administer medication. Observation on 06/09/26 at 7:41 A.M. showed two open bottles of Flonase nasal spray sat on the counter in the resident's room. During an interview on 06/09/26 at 7:45 A.M. and 06/10/26 at 3:00 P.M., the resident said the following:-He/She gave himself/herself his/her own nasal spray and usually administered one spray to each side of his/her nose a day;-Sometimes staff administer the nasal spray in the morning;-Even if staff administer the spray, sometimes he/she administers the spray to himself/herself, so he/she sometimes takes it more than once a day. During an interview on 06/10/26 at 2:38 P.M., CMT S said the following:-He/She was aware the resident had an order for a nasal spray;-When he/she administered the nasal spray, he/she got it from the medication cart;-The resident did not self-administer his/her nasal spray. During an interview on 06/10/26 at 2:42 P.M., CMT T said the following:-He/She administered the resident his/her nasal spray;-The resident's nasal spray was kept in the top drawer of the medication cart;-The resident did not self-administer the nasal spray. Observation of the back hall medication cart on 06/10/26 at 4:44 P.M. showed the top drawer contained a bottle of Flonase, labeled for the resident. 3. During an interview on 06/10/26 at 10:45 A.M., the Director of Nursing (DON) said the following:-Staff should always lock and secure medications;-Staff should not leave medications in a resident's room without an order allowing the resident to keep the medication at bedside;-Neither resident had an order to self-administer. During an interview on 06/11/26 at 12:36 P.M., the Administrator said she expected staff to lock and secure all medications and not to leave medications in a resident's room without an order allowing them to keep at bedside or to self-administer.

Based on observation, interview and record review the facility failed to ensure recommendations from the pre-admission screening and resident review (PASRR, a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) Level II determination and evaluation report were incorporated into the resident's care plan for two residents (Resident #41 and #2), in a review of four residents. The facility census was 83. Review of the facility policy, Pre-admission Screening and Resident Review (PASRR), revised 07/27/23, showed the following:-A positive PASRR Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be completed and submitted to the Central Office Medical Review Unit (COMRU);-A record of the prescreening should be retained in the resident's medical record. Review of the facility policy, Care Planning, revised 10/24/22, showed the following:To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs;-The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. The Baseline Care Plan will include at least the following information: -Initial goals based on admission orders; -Physician orders; -Dietary orders; -Therapy services; -Social services; -PASARR recommendations, if applicable;-Each resident's Comprehensive Care Plan will describe the following: -Any specialized services including rehabilitative service as a result of PASARR recommendations. If the Facility disagrees with PASARR findings, rationale will be notated in the resident's medical record. 1. Review of Resident #2's face sheet showed the following:-admitted [DATE];-His/Her own responsible party. Review of the resident's Level I PASRR, dated 08/09/22, showed a Level II screening was required and referred to Department of Mental Health (DMH) on 08/09/22. Review of the resident's electronic medical record showed no documentation of the resident's Level II PASRR. During an interview on 06/09/26 at 3:18 P.M., the Administrator said the facility did not have a copy of the resident's Level II PASRR. Review of the resident's Level II PASRR, provided by the state agency, dated 08/17/22, showed the following:-The resident's diagnoses included schizoaffective disorder (mental health condition that include features of both schizophrenia and a mood disorder), post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event), borderline personality disorder (a serious mental health condition characterized by severe instability in emotions, self-image, and relationships), dependent personality disorder (a mental health condition characterized by an excessive, pervasive need to be taken care of, leading to extreme submissiveness, clinging behaviors, and a profound fear of abandonment), bipolar disorder, major depression, long-term prescription opiate use and cannabis use;-The resident had a history of sexual abuse; -The resident had a burn injury to a large area of his/her body at age [AGE]; -The patient reported history of paranoia, auditory hallucinations, and manic symptoms;-If admitted to a nursing facility, the individual needs or continues to need the following supports and services-Provision of a structed environment: -Provide for individual personal space; -Establish consistent routines; -Provide schedule of daily tasks/activities; -Provide instructions at the individual's level of understanding;-Development of Personal Support networks: -Assess, plan, and develop appropriate personal support network through community and social connections. Review of the resident's care plan, revised 07/20/25, showed the following:-The resident used psychotropic medications related to depression, bipolar and schizophrenia;-Monitor/Document/Report as needed any adverse reactions of psychotropic medications;-Monitor/Record the occurrence of any targeted behavior symptoms per facility protocol;-The resident had depression;-Monitor/document/report as needed adverse reactions to antidepressant therapy;-The resident had anxiety;-Monitor/record/report to physician as needed acute episodes of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills;-Monitor/record/report to physician as needed mood patterns and signs/symptoms of depression and anxiety;-Arrange for psychiatry consult as needed;-Monitor/document/report as needed any risk for harm to self;-Monitor/record/report to physician as needed any risk for harming others. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The had moderately severe depression;-The resident was always socially isolated;-The resident rejected evaluation or care one to three days in the look-back period;-The resident received antipsychotic, antidepressant, opioid, hypoglycemic, and anticonvulsant. During an interview on 6/11/26 at 9:29 A.M., the resident said the following:-He/She did not feel like the facility and staff were fully aware of his/her past history with trauma and mental health struggles;. -He/She had a diagnosis of PTSD related to a house fire/explosion and sexual assault;-The house fire/explosion occurred when he/she was [AGE] years old and his/her 4 month old child was with him/her when it occurred;-He/She experienced burns over 85% of his/her body and required skin grafts;-He/She denied having any triggers related to the fire, but experienced a traumatic event that he/she was regularly reminded of by the appearance of his/her skin;-He/She was sexually assaulted when he/she was younger;-He/She denied any current triggers related to the sexual assault, but in the past was uncomfortable with male caregivers;-He/She felt it would help for the facility staff to be aware of his/her past traumas to have a better understanding of his/her mental health struggles and why he/she required regular mental health support. Review of the resident's care plan showed no documentation the resident had PTSD or interventions to minimize triggers and to provide support for the resident's mental health related to his/her trauma. 2. Review of Resident #41's Level II PASRR evaluation, dated 03/19/25, showed the following:-Diagnoses of major depressive disorder, personality disorder, bipolar disorder , mood disorder, intermittent explosive disorder, and substance abuse including alcohol, cannabis, and nicotine;-History of suicide attempt, suicidal and homicidal ideations;-History of overdose on fentanyl;-The resident needs or continues to need the following supports and services: -Provision of specific services to address the individual's mental health and behavior needs:-Trauma informed services, related to depression, suicidal ideations, and withdrawal; -Crisis Intervention Services, assess and plan for crisis intervention that provides emotional support, education, safety planning and case management to handle an immediate crisis; -A crisis plan should be developed to create clear steps that are to be taken to support client during a behavioral health crisis including who to contact for assistance, how to work together with client during the crisis, and how to determine when the crisis is over; -The plan should also identify a physician and emergency medical services that should be contacted; -History of suicidal ideations. Review of the resident's face sheet showed the following:-admitted [DATE];-He/She was his/her own responsible party;-Diagnoses included acute pain due to trauma, bipolar disorder (mood disorder that can cause intense mood swings), and seizures. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 04/01/26, showed the following:-The resident was cognitively intact;-The resident had no symptoms of depression;-The resident had no behaviors. Review of the resident's care plan, updated 06/08/26, showed the following:-He/She had been verbally aggressive to staff;-The resident had a behavior problem;-Psychosocial follow up as needed;-Assist the resident in developing/provide the resident with a program of activities that is meaningful and of interest;-Monitor/document/report as needed any risk for harm to self;-Monitor/record/report to physician as needed for risk of harming others. The resident's care plan did not indicate the resident had a positive Level II PASARR, did not address the needs for trauma informed services, history of suicide or suicide precautions, and did not indicate the development of a crisis intervention plan. 3. During an interview on 06/11/26 at 12:07 P.M., the Social Services Director said the following:-She was responsible to ensure the facility had a copy of the Level I and II PASRR;-Resident #2's Level II PASRR was completed prior to her taking this position. She was not aware the facility did not have a copy;-The Care Plan Coordinator was responsible for adding recommendations from the PASRR to the care plan. During an interview on 6/11/26 at 12:37 P.M., the MDS/Care Plan Coordinator said the following:-She was primarily responsible for completing and updating the care plans;-She care planned all pertinent diagnoses and interventions, but did not indicate a resident's PASRR status; -She was not aware if a resident had a positive Level II PASRR or of the recommendations on the PASRR, unless staff shared the PASRR and results with her;-She was not aware of Resident #2 and #41's positive Level II PASRR status or of the recommendations on the Level II PASRR. She would have included the information on the care pan had she been made aware. During an interview on 6/11/26 at 5:19 P.M., the Administrator said the following:-She expected all residents the facility to keep a copy of the Level II PASRR;-She expected staff to incorporate the information and recommendations from the Level II PASRR into the resident's care plan.

Based on observation, interview, and record review, the facility failed to account for and reconcile Ativan (a schedule IV narcotic controlled substance medication for anxiety) maintained in the facility's emergency medication kit. The facility census was 83. Review of the facility policy, Ordering and Receiving Controlled Medications, dated 01/2020, showed the following:-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations;-The director of nursing and the consultant pharmacist monitors for compliance with federal and state laws and regulations in the handling of controlled medications;(The policy addressed individual resident controlled substance record/receipt/log for each controlled substance medication prescribed, but did not address the record/receipt/log for controlled substances maintained in the facility's emergency medication kit.) Review of a pharmacy delivery manifest report, dated 06/04/26 at 1:54 P.M., showed E-Kit (emergency kit) Ativan was delivered to the facility. Observation of the back nurses station medication room on 06/09/26 at 5:56 A.M. showed the medication room refrigerator contained a lock box, labeled E-Kit #20. The lock box contained two 2 milligram (mg) vials of injectable Ativan and two 30 milliliter (ml) bottles of liquid oral Ativan. Review of the back nurses station narcotic control log book showed no documentation staff accounted for or reconciled (counted) the Ativan maintained in the emergency medication kit. During an interview on 06/09/26 at 6:32 A.M., Licensed Practical Nurse (LPN) I said the following:-He/She was in charge of the medication room and supplies for the night shift;-He/She was not aware the refrigerator in the medication room contained E-Kit Ativan;-He/She did not complete an inventory count or accountability page in the narcotic control log for the Ativan when he/she came on duty the evening of 06/08/26;-When the facility received narcotic medications from the pharmacy, staff were to log the medications in the narcotic log book for accountability and were to count the medications (reconcile) each shift. During an interview on 06/09/26 at 7:00 A.M., the Director of Nursing (DON) said the following:-She was not aware Ativan was stored in the emergency kit in the back nurses station medication room;-When the facility received narcotics, including narcotics for the emergency kit, staff were to log the medication in the narcotic log book for accountability and were to count the medications each shift. During an interview on 06/11/26 at 12:36 P.M., the Administrator said she expected staff to account for all narcotic controlled substances and to reconcile the narcotic medications every shift.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #54), in a review of seven residents observed during medication administration, was free from a significant medication error when staff failed to follow physician orders and applied a topical patch instead of a topical cream for pain control. The facility census was 83. Upon request, the facility did not provide a policy related to following physician orders. Review of the on-line Certified Medication Technician Student manual- Missouri Center for Career Education, dated 05/14/10, showed the following:-The Five Rights of medication administration are foundational guidelines used by Certified Medication Technicians (CMT) to prevent medication errors and ensure resident safety. They should be verified three times during the preparation and administration phases;-The Five Rights Breakdown included: -Right Drug (Medication): Check the medication label against the medication administration record (MAR) to ensure it exactly matches the physician's order and the pharmacy label; -Right Dose: Confirm the dosage is correct based on the order. Ensure you measure liquids or doses accurately using standardized devices. Review of Resident #54's Physician Order Sheet (POS), dated June 2026, showed an order for lidocaine external cream 4 percent (%), apply to right shoulder topically two times a day for pain. Apply 2 grams to the right shoulder (original order dated 04/21/26). The resident did not have an order for a lidocaine 4% topical patch. Review of the resident's Medication Administration Record (MAR), dated June 2026, showed lidocaine external cream 4%, apply to right shoulder topically two times a day for pain. Apply 2 grams to the right shoulder, scheduled for the A.M. and P.M. medication pass. Observation on 06/09/26 at 6:50 A.M., showed the following:-Certified Medication Technician (CMT) R reviewed the resident's MAR for the A.M. medication pass;-CMT R removed a box of 4% lidocaine topical patches from the medication cart. There was not a pharmacy label on the box, and the box was not identified as being for any specific resident;-CMT R removed a single 4% lidocaine patch from the box, entered the resident's room, and applied the patch to the resident's right shoulder. During an interview on 06/09/26 at 7:10 A.M., CMT R said the following:-The resident did not have his/her own supply of lidocaine, so staff used the stock patches;-He/She had not paid attention that the order read to apply a cream and did not mention a patch;-He/She just thought the cream was in the patch;-He/She felt like the order read to apply 4% lidocaine, and that was what the patch read;-He/She did not know what apply 2 grams meant.(CMT R documented he/she applied lidocaine six days between 06/01/26 through 06/09/26 for the A.M. medication pass.) During an interview on 06/10/26 at 2:38 P.M., CMT S said he/she always applied a lidocaine patch on the resident and had never applied a cream. (CMT S documented he/she applied lidocaine two days between 06/01/26 through 06/09/26 for the A.M. medication pass.) During an interview on 06/10/26 at 2:42 P.M., CMT T said he/she always applied a lidocaine patch on the resident and had never applied a cream. (CMT T documented he/she applied lidocaine two days between 06/01/26 through 06/09/26 for the P.M. medication pass.) During an interview on 06/10/26 at 10:45 A.M., the Director of Nursing (DON) said the following:-When administering medications, staff should follow physician orders;-An order for a cream would not be the same as an order for a patch. During an interview on 06/11/26 at 12:36 P.M., the Administrator said she expected staff to follow physician orders as the orders were written. Staff applying a patch would not be the same as applying a cream. During an interview on 06/18/26 at 3:10 P.M., the pharmacist with the facility's pharmacy said the following:-The facility sent the order for the lidocaine 4% cream on 04/21/26. The pharmacy notified the facility it was not in their contract to provide over-the-counter medications since insurance did not cover them; (they did not have a specific date and time or staff they spoke to but confirmed it was a phone call). The facility did not fill the order for lidocaine 4% cream for the resident;-Lidocaine 4% cream and a lidocaine 4% patch do not deliver the same dose. Both contain a 4% concentration of lidocaine, but the patch delivers a controlled release of the medication over up to 12 hours, whereas 2 grams of 4% cream is released rapidly over a shorter duration;-A lidocaine patch contains 700 mg to 750 mg of lidocaine;-Two grams of 4% cream contains 80 mg of lidocaine;-If the facility staff applied a patch instead of applying the cream, the resident would receive more of the medication than what was ordered.

Based on observation, interview, and record review, the facility failed to follow infection control practices, facility policy, and the resident's care plan to prevent the development and spread of infection for one resident (Resident #8), in a review of 23 sampled residents. Staff failed to keep the resident's urinary catheter drainage bag off the floor, failed to wear proper personal protective equipment (PPE) during high-contact resident care activities, and failed to follow hand hygiene procedures when providing personal care to the resident. The facility census was 83.Review of the facility policy, Care of Catheter, revised 10/24/22, showed collection bags (urinary catheter drainage bags) should always avoid contact with the floor. Review of the facility policy, Hand Hygiene, revised 10/24/22, showed the following:-Facility staff must wash hands with soap and water in the following circumstances: -After contact with intact and non-intact skin, clothing and environmental surfaces even if gloves are worn; -In between glove changes alcohol-based hand hygiene products can and should be used to decontaminate hands; -Immediately upon entering a resident occupied area (single or multiple bed room, procedure or treatment room) regardless of glove use; -Immediately upon exiting a resident occupied area (e.g., before exiting into a common area such as a corridor) regardless of glove use; -After removing personal protective equipment (PPE);-Hand hygiene is always the final step after removing and disposing of personal protective equipment;-The use of gloves does not replace hand hygiene procedures. Review of the facility policy, Personal Protective Equipment, revised 07/01/23, showed the following:-Facility staff wear a gown whenever performing tasks that would likely soil the staff's clothing with blood, body fluids, secretions, or excretions.-Prioritizing use of gowns for care activities where splashes and sprays are anticipated, including high-contact resident care activities that provide opportunities for transfer of pathogens to the hands and clothing such as, providing hygiene, changing linens, and changing briefs; Review of the facility policy, Standard and Enhanced Precautions, revised 07/01/23, showed the following:-Enhanced standard precautions will be implemented for residents with a known multidrug-resistant organism (MDRO, a bacteria that developed resistance to at least three distinct classes of antimicrobial drugs) and who are at high-risk for colonization and transmission;-Presence of indwelling devices such as a urinary catheter;-Wounds or presence of pressure ulcer (unhealed);-Functional disability and total dependence on others for assistance with activities of daily living. Review of the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, dated 04/02/24, showed the following:-Enhanced Barrier Precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a MDRO or any resident who has a chronic wound and/or indwelling medical device) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization;-Enhanced Barrier Precautions shall be conducted during the following activities: -During high-contact resident care activities: -Bathing/showering; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Wound care: any skin opening requiring a dressing;-Gloves and gown prior to the high-contact care activity;-Face protection may also be needed if performing activity with risk of splash or spray. Review of Resident #8's care plan, revised 02/04/26, showed the following:-He/She required extensive assistance from one staff member for personal hygiene;-Meticulous hand hygiene before and after each encounter with resident and others;-He/She is on enhanced barrier precautions (EBP) for wound;-Staff will utilize PPE when required for performing high contact resident care; -Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling) on left ischium (lower portion of the hip bone) and uses a wound vacuum (vacuum-assisted closure used to conduct negative pressure wound therapy to promote healing);-Follow EBP. Put on gowns and gloves while providing cares. Must change PPE and perform hand hygiene between residents;-He/She had bowel and bladder incontinence. Clean peri-area with each incontinence episode. Review of the resident's Prospective Payment System (PPS) five-day Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 04/28/26, showed the following:-He/She was dependent on staff for toileting hygiene;-He/She was always incontinent of bladder and bowel;-He/She had one Stage IV (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining or tunneling) pressure ulcer. Review of the resident's physician orders, dated June 2026, showed the following:-Urinary catheter care every shift and as needed (PRN) with soap and water every shift for health maintenance;-When wound vac is not in place, cleanse wound with Vashe (wound cleanser) and pack dampened gauze roll with Vashe or saline into wound and cover with dry dressing two times a day and as needed every eight hours PRN for wound;-Calmoseptine external ointment 0.44-20.6% (menthol-zinc oxide); apply to sacrum/groin/buttock topically every shift for redness;-Amoxicillin-potassium clavulanate (antibiotic) tablet 875-125 milligrams (mg); give one tablet by mouth two times a day for wound infection for 8 days at 9:00 A.M. and 9:00 P.M. (original order dated 06/04/26). Observation on 06/07/26 at 2:30 P.M. showed the resident lay in his/her bed. The resident had a urinary catheter. The urinary catheter drainage bag was in a cloth bag and lay directly on the floor next to the resident's bed. Observation on 06/09/26 at 6:10 A.M. showed the resident lay in his/her bed. The resident's urinary catheter drainage bag was in a cloth bag and lay directly on the floor next to the resident's bed. Observation on 06/09/26 at 8:30 A.M. showed the following:-EBP signage hung outside the resident's room. PPE, including gowns, were in a three-drawer cart outside of the resident's room in the hallway.-Certified Medication Technician (CMT) S and Certified Nurse Aide (CNA) Y sanitized their hands, put on gloves, and without putting on a gown, repositioned the resident in bed;-The resident's urinary catheter drainage bag was in a cloth bag and lay flat on the floor beside the resident's bed. Observation on 06/09/26 at 10:25 A.M. showed the following:-CMT S and CNA Y sanitized their hands and put on gloves but did not put on gowns; -CMT S provided perineal care and catheter care for the resident, removed his/her gloves, and without performing hand hygiene, put on clean gloves; -The resident's urinary catheter drainage bag was in a cloth bag and lay flat on the floor on the beside the bed;-CNA Y assisted the resident to turn to his/her left side;-CMT S cleaned the resident's buttocks, removed the resident's incontinence brief, placed the soiled wipes and incontinence brief in the trash can, removed his/her gloves, and without performing hand hygiene, put a glove on his/her right hand; -The resident had a pressure ulcer on his/her tailbone with a wound vac in place over the pressure ulcer;-CMT S applied a barrier cream (skin protectant) to the resident's skin with his/her right gloved hand, removed the glove, and without performing hand hygiene, put on gloves;-CNA Y fastened the clean incontinence brief on the resident;-CMT S placed a pillow between the resident's legs and covered the resident with blankets. During an interview of 06/09/26 at 10:43 A.M., CNA Y said the following:-The EBP signage showed the PPE staff were to wear when residents had open wounds, infections, and catheters;-He/She should wear a gown and gloves when providing all cares with the resident. During an interview on 06/09/26 at 10:45 A.M., CMT S said the following:-He/She should wear a gown when providing care to the resident;-He/She should have performed hand hygiene in between dirty and clean tasks and in between glove changes;-The hook on the resident's urinary catheter drainage bag was broken, so staff should have place the bag in a pink plastic bucket. Staff should not put the urinary catheter drainage bag on the floor. During an interview on 06/11/26 at 5:20 P.M., the Director of Nursing (DON) said the following:-She expected staff to perform hand hygiene before going in and out of rooms, between dirty and clean tasks, and when they changed their gloves; -She expected staff to wear a gown when providing care to residents on EBP with a urinary catheter; -The resident's urinary catheter drainage bag should not be on the floor;-She expected the CNA to report the broken hook on the urinary catheter drainage bag to the nurse and the nurse to replace it. Staff should place the urinary catheter drainage bag in a tub until the nurse could address the broken hook. MO3018141

Based on observation, interview and record review, the facility failed to provide services necessary to address one resident's (Resident #1's) pressure ulcer treatment of six sampled residents. Resident #1 admitted to the facility on [DATE] with a Stage 4 pressure ulcer of the sacrum (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed. Often includes undermining and tunneling at the base of the spine) and diagnosis of osteomyelitis (a severe infection within the bone). The facility failed to follow physician orders for treatment of the sacral wound and failed to communicate the resident's condition including culture of the wound to consider for treatment. The facility failed to complete a weekly skin assessment per policy. The resident subsequently admitted to the hospital with the diagnoses of osteomyelitis and sepsis (life threatening response to infection). The facility census was 90.Review of the facility policy for Wound Management with a revision date of 10/24/22 showed:-A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers (PU) from developing;-A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly and as needed for each resident;-The attending physician will be notified to advise on appropriate treatment;-A Licensed Nurse will develop are car plan for the resident based on recommendations from dietary, rehabilitation and the attending physician;-Per attending physician order, the nursing staff will initiate treatment; -The attending physician and Interdisciplinary Team (IDT) will be notified of new PU or wounds, PU or wounds that do not respond to treatment, PU or wounds that worsen or increase in size; complaints of increased pain, discomfort or decreased in mobility by a resident; signs of ulcer sepsis, presence on exudates, odor or necrosis (dead tissue), residents refusing treatments;-Wound documentation will occur at a minimum of weekly until the wound is healed;-IDT will document discussion and recommendations for: PU and wounds that do not respond to treatment; PU or wounds that worsen or increase in size; complaints of increased pain, discomfort or decrease in mobility by the resident; signs of ulcer sepsis (a life-threatening, emergency condition occurring when an untreated ulcer-typically a pressure sore (bed sore) or a bleeding stomach ulcer-becomes severely infected, causing the body's immune system to release chemicals that trigger widespread inflammation and organ damage), presence of exudates (drainage), odor or necrosis;-Licensed Nurses will document effectiveness of current treatment in the residents' medical record on a weekly basis;-Document notifications following a change in the resident's skin condition. Review of the facility policy for Physician Orders with a revision date of 10/24/22 showed the following:-Purpose: to ensure that all physician orders are complete and accurate;-Policy: the Medical Records Department will verify that all physician orders are complete, accurate and clarified as necessary;-Documentation pertaining to physician orders will be maintained in the resident's medical record. Review of the facility policy for Laboratory, Diagnostic and Radiology Services with a revision date of 10/24/22 showed laboratory, diagnostic and radiology results will be maintained as part of the resident's medical record. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE] with diagnosis of multiple sclerosis (a chronic disease of the central nervous system), osteomyelitis (a severe infection within the bone, causing inflammation and destruction of bone tissue, usually caused by bacteria or fungi) of the vertebra, sacral (a triangular shaped bone at the base of the spine) and sacrococcygeal (refers to the anatomical region involving both the sacrum (the base of the spine) and the coccyx (the tailbone), diabetes, paraplegia (impairment or loss of motor and sensory function in the lower legs) due to trauma. Review of the comprehensive Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 12/2/25 showed:-Sometimes able to make self-understood and sometimes able to understand;-Dependent upon staff for all Activities of Daily Living (ADL's);-admitted with a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slouch. May also present as an intact or open/ruptured blister) and a Stage 4 pressure ulcer. Review of the resident's undated care plan for pressure ulcers showed the following:- The resident has pressure ulcers: Coccyx 11/18/25; right dorsal foot/heel 11/18/25; right knee 12/22/25; right posterior leg 12/22/25; left posterior leg 12/23/25; right heel 12/23/25; right lateral ankle 12/31/25; left dorsal (upper side foot) 1/15/26; left first toe 1/15/26; right ischium (curved bone forming the base of each half of the pelvis) 1/15/25-right first toe 1/15/26;-Goal: Affected areas will show signs of improvement through next review date;-Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician; -Monitor/document/report as necessary any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, length and depth and stage; -Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. Review of the resident's wound care provider's progress notes for the resident's Stage 4 pressure ulcer to the sacrum dated 01/13/26, showed the following:- At the request of the referring provider, a thorough wound care assessment and evaluation was performed today;-Resident presents with wounds on her left posterior leg; left lateral ankle; left dorsal foot; left first toe; right posterior leg; right anterior ankle; right dorsal foot; right first toe; right heel; sacrum; right ischium;-Past Medical History: muscle weakness, paraplegia, high blood pressure and osteomyelitis of vertebra, sacral and sacrococcygeal region;-Pressure ulcer of the sacrum Stage 4, healing potential poor; -Wound Size (L x W x D): 10 x 13.5 x 0.4 centimeters; Exudate: Moderate serousgranulation tissue 100 %; Pain Assessment: Described as mild;-Infection Assessment: One or more sign(s) of clinical infection;-Continue current treatment. Review of the resident's wound care provider's progress notes for the resident's Stage 4 pressure ulcer to the sacrum dated 1/20/26, showed the following:-Pressure Stage 4, measures 12 x 15 x 0.5 cm. Exudate moderate serosanguinous, exacerbated due to infection;-Pain Assessment: Described as moderate;-Infection Assessment: One or more sign(s) of clinical infection;-The progress of this wound and the context surrounding the progress were considered in greater detail today. Relevant conditions including infection were considered and addressed through treatment changes or investigations;- The wound is undergoing autolytic debridement (a natural, painless, and highly selective wound care method that utilizes the body's own enzymes (neutrophils and macrophages) and moisture to liquefy and remove necrotic tissue (eschar and slough);-Procedure today: Florescence imaging (a non-invasive, point-of-care tool that uses violet light to detect clinically significant bacterial in wounds in real-time) was performed today on this wound;-Dressing/treatment plan: Add mupirocin topical (antibiotic ointment) 2% twice daily and as needed;- Additional recommendations: Deep wound culture;- Stage 4 pressure wound of the sacrum assessed to have deviated from the expected wound healing trajectory;-Discussed the treatment of each wound, resident's noncompliance for offloading, signs suggesting sacral osteomyelitis and diagnostic tests with the resident and the Regional Wound Nurse Consultant. Review of the resident's physician orders dated 01/20/26 through 01/29/26 showed no order for mupirocin topical ointment. Review of the resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 01/20/26 through 01/29/26 showed no orders for mupirocin topical ointment or documentation staff applied the ointment Review of the resident's medical record dated 01/21/26 showed the resident admitted to hospice. Review of the resident's culture and sensitivity report of the resident's pressure ulcer to the sacrum dated 01/23/26 showed the following:-Culture collected on 01/20/26, received on 01/22/26, report date of 01/23/26 of the sacrum tissue;-Pathogens detected: Streptococcus agalactiae ( a harmless bacterium colonizing the gastrointestinal and genitourinary tract (asymptomatic carriers). Finegoldia [NAME] (a virulent pathogen that may cause life-threatening infections); Peptoniphilus harei, ivorli (Gram-positive, anaerobic, non-spore-forming cocci; they are part of the human microbiome (skin, vagina, gut) and act as opportunistic, often polymicrobial pathogens in soft tissue, bone, and joint infections); Proteus mirabilis (a Gram-negative, rod-shaped bacterium commonly found in the human gut and environment); Corynebacterium minutissimum, striatum, jeikeium (Gram-positive, rod-shaped bacteria, often part of normal human skin microbiota but increasingly recognized as opportunistic, multidrug-resistant pathogens; pseudomonas aeruginosa (a common, often multidrug-resistant bacterium thriving in moist environments that causes severe, opportunistic infections) and staphylococcus aureus (a bacterium commonly found on the skin);-First line treatment: Amoxicillin or cephalexin (antibiotics);-Alternative treatment: Doxycycline or levofloxacin or ceftriaxone (antibiotics);-Additional options: Mupirocin 2% ointment;-A handwritten note on the report will see during next rounds with initials of LP on the note. Review of the resident's medical record dated 01/21/26 through 01/30/26 showedno results from any wound cultures completed on 01/20/26 and no results of the biopsy that was done on 01/20/26. Review of the resident's physician orders dated 01/30/26, showed an order for mupirocin 2%, apply to sacrum topically as needed for wound care, cleanse with wound cleanser or Vashe (antiseptic cleanser containing hypochlorous acid used to clean, irrigate, and moisten acute and chronic wounds), apply mupirocin cream and calcium alginate (highly absorbent, biodegradable primary wound dressing), to wound bed, cover with dry dressing every day shift. Review of the TAR dated 01/30/26 showed a code of six (6) signed off on 01/30/26 and 01/31/26. The code six (6) indicated the resident was in the hospital. Review of the resident's medical record dated 01/21/26 through 01/30/26 showed no further documentation of the resident's wound to the sacrum. During an interview on 02/18/26 at 4:00 P.M. Licensed Practical Nurse (LPN) A said the following:-She was responsible for the wounds; she does the weekly rounds with the wound care provider;-The wound care provider last saw the resident on 01/20/26, he/she did not come the week of 01/26/26 due to the weather;-He/She monitored the wounds weekly with the wound care provider. Nurses were responsible for completing treatments on a daily basis; -The wound care provider did the resident's wound culture and the bone biopsy when he/she did rounds on 01/20/26;-The wound care provider was a physician;-He/She just got the results of the wound culture today (2/18/26);-She talked with the wound care provider last week, who said the pressure ulcer to the sacrum was infected, and the resident had osteomyelitis in the wound. She did not want to prescribe any antibiotics until she saw the resident; the wound care provider canceled her last visit and then the resident went on hospice care;-She did not notify the primary physician or the responsible party of the cancelled visit by the wound care provider, she did not think she had to;-There were no changes in any orders for wound care given in the absence of the wound care provider. During an interview on 02/18/26 at 10:00 A.M. the Director of Nursing (DON) said the following:-The wound care provider did a bone biopsy and wound culture on 01/20/26;-The wound care provider did not make rounds in the facility the week on 01/26/26 due to the weather;-She did not find any results from the wound culture or the bone biopsy in the resident's medical record. During an interview on 01/18/26 Regional Nurse B said the following:-The wound nurse (LPN A) and the wound care physician talked about the results of the wound culture on 01/23/26. The wound care physician did not want to order any antibiotics until he/she saw the resident;-A Nurse Practitioner saw the resident on 01/20/26 and ordered the mupirocin ointment to the sacral wound;-Then the resident went on to hospice services. During an interview on 02/20/26 at 8:30 A.M. Nurse Practitioner (NP) A said the following:-He/She does not work for the wound care provider;-He/She saw the resident for generalized pain;-He/She has never seen the resident's wounds;-He/She did not order mupirocin ointment for the wound. During an interview on 03/04/26 at 11:15 A.M. Regional Wound Nurse LPN C said the following:-He/She was with the wound care provider on 01/20/26 and did not recall if the provider gave an order for mupirocin topical ointment for the resident's sacral wound. If the order was written on the wound care provider's note, then the note would be available to the facility the next day and the facility wound nurse should have checked the report and followed through with any orders that were written. The wound care provider was a physician;-The wound care provider obtained a tissue sample for further diagnostic testing as well as a bone biopsy. These tests can take up to a week to process. The wound care provider receives the results and will then upload them in the resident's electronic medical record. The wound care provider did not upload them;-He/She would expect that any orders written by the wound care provider would be followed and any labs results should be followed up on; if not received, then the wound nurse should call the provider for the results;-If the resident was under the care of hospice for the wounds, then all information regarding the wounds should have been shared with the hospice provider for them to determine what they were going to treat. During an interview on 02/19/26 at 3:04 P.M. Hospice Registered Nurse (RN) C said:-He/She assumed the care of the resident's wounds on 01/26/26 when he/she received paperwork from LPN A with the measurements and treatment orders;-He/She did not see the wounds on 01/28/26 as LPN A did not have the time to go with him/her to show him/her the wounds. LPN A asked him/her to come back on 02/04/26 to do wound rounds then;-He/She was not aware of any wound culture reports or that a biopsy had been done;-If he/ she would have been made aware of the wound culture report, he/she would have consulted the hospice physician and started the resident on antibiotics for the infection in the sacral wound;-He/She did not have a chance to examine the resident as the resident went to the hospital on [DATE] and had not returned. During an interview on 02/20/26 at 10:56 A.M. LPN A said:-He/She did not remember what he/she said to the hospice nurse, he/she sent the resident's paperwork to the nurse with the measurements;-He/She was not with the wound physician when they took the culture of the resident's wounds or the biopsy;-He/She did not receive the results of the wound culture of the sacrum until the surveyor asked questions;-He/She obtained the results when he/she checked the resident's electronic record and saw the wound care provider notes uploaded into the resident's record. Review of the lab reports from a local hospital dated 01/30/26 showed the following:-WBC (white blood cells) 36.81 with normal of 3.8-9.90 ( is considered severely elevated, a condition known as leukocytosis (Leukocytosis is a high white blood cell count typically indicating the immune system is responding to infection, inflammation, tissue damage, or bone marrow disorders) (A result this high (over 3 times the upper limit of normal) indicates a significant reaction within the body that requires immediate investigation by a healthcare professional.);-Neutrophils abs (measures the total number of neutrophils-the primary, infection-fighting white blood cells-in your blood) 32.9 with a normal of 1.5 to 6.5;-Sepsis lactate with reflex (a blood test used to diagnosis if a resident is septic. Elevated lactate levels are a key indicator of sepsis) of 2.7 with a normal of 0.7 to 2.0. Review of the biopsy report of the resident's sacrum collected on 01/20/26 and reported on 02/04/26 showed diagnosis biopsy, sacral: acute and chronic osteomyelitis. Review of a progress noted dated 02/19/26 from the wound care provider showed:-The resident was admitted to the faciliy in November 2026 with miltiple chronic wounds involving the bilateral lower extremities, sacrum and ischium. Prior to admission to the facility the resident had completed a course of antibiotics for known sacral osteomyelitis. At the time of the initial evaluation on 01/13/26, the resident was under care of a different provider and was transitioned to this provider's care. Follow-up evluation was completed on 01/20/26;-A comprehensive wound reassessment was performed including PCR-based wound culture (to rapidly detect, identify, and quantify pathogens (bacteria, fungi) from wound swabs within 24-48 hours) and a bone biopsy of the sacral wound. The resident was receiving an aggressive local wound care regime, inclduing topical antimicrobial therapy, antimircrobial dressings, hypochlorous acid and twice-daily dressing changes;-Clinical findings at the time of the evaluation demonstrated chornic wounds with complicating factors. There were no consistent systemic signs of acute infection warranting immediate systemic antibiotic therapy.;-On 01/21/26, prior to availability of diagnostic results, the resident elected to transition to hospice [NAME] at which time the plan of care appropriately shifted to comfort-focused, conservative management approach. Wound cultures results (01/23/26) and bone biopsy results (02/04/26) became available after the transition to hospice and while the resident was hospitalized ;-Given the residents recent completion of IV antibiotics, absence of systemic infection indicators at the time of the evaluation on 01/20/26, active topic antimircrobial coverage, and subsequent transition to hospice-directed care, the decision to defer initation of system antibiotics during this provider's period of management was clinically appropriate and consistent with accepted standards of wound and palliative care. During an interview on 03/03/26 at 2:00 P.M. Family Member (FM) A said when the resident was admitted to the hospital, he/she had a severe infection in the pressure ulcer on the sacrum and the resident was septic requiring admission to the intensive care unit and extensive intravenous (IV) antibiotic therapy. The resident underwent several surgeries to remove the infection from the PU on the sacrum. During an interview on 02/20/26 at 3:00 P.M. the Administrator said the following:-She would expect any lab work results, cultures or biopsies be made available to the nursing staff so they can follow up for any orders or treatments;-She would expect any orders written and communicated by the wound care provider be followed up on at the time the orders were given;-She would expect of all the resident's record be made available to any contracted provider, such as hospice for them to review and make any recommendations they would want for the resident. During an interview on 02/18/26 at 11:00 A.M. the Medical Director said the following:-The resident was severely compromised due to the diagnosis of multiple sclerosis. The resident had a history of infected wounds;-He would expect any orders given by the wound care provider to be followed;-He would expect any lab work or biopsies to be reviewed and communicated. 2731000

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) in a review of 11 sampled residents, remained free from physical abuse when on Certified Nurse Aide (CNA) B aggressively moved the resident in bed, causing the resident to yell out for help, and report CNA B was too rough and hurt him/her. The resident was tearful, upset and said he/she did not want CNA B to come back after the incident. The resident sustained bruising to the right arm as identified on the facility skin assessment dated [DATE]. During an interview on 9/4/25, the resident said he/she was scared of CNA B. The facility census was 78.On 9/10/25 at 2:54 P.M. the administrator was notified of the past noncompliance which occurred on 8/25/25. On 8/25/25 CNA B physically abused Resident #1 while providing his/her care in an aggressive manner. Licensed Practical Nurse (LPN) A stopped the care and asked CNA B to leave the facility. CNA B was terminated. The administrator and regional nurse provided education to staff members on abuse and neglect. The deficiency was corrected on 8/26/25. Review of the facility's Abuse Prevention and Prohibition Program policy, updated 10/24/22, showed the following:-Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property;-The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse;-Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict; -The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect including:-Physical Abuse;a. Welts or bruises;-Possible signs and symptoms of psychological abuse or neglect;b. Paranoia;c. Inconsistent explanations for injuries;d. Anger. 1. Review of Resident #1's undated, face sheet showed the following:-The resident readmitted to the facility on [DATE];-He/She was his/her own responsible party;-Diagnoses included flaccid hemiplegia affecting left nondominant side (type of one-sided paralysis where the left side of the body is completely limp and lacks muscle tone, usually due to a brain or spinal cord injury), thrombocytopenia (blood has a lower-than-normal number of platelets), contracture (permanent shortening or tightening of muscles, tendons, or other soft tissues that limits the range of motion at a joint) of the left lower extremity, generalized anxiety disorder (chronic mental health condition characterized by excessive, persistent, and unreasonable worry or anxiety about various aspects of life), and Alzheimer's disease (progressive brain disorder that causes memory loss, confusion, and other cognitive decline). Review of the resident's care plan, dated 5/22/24, showed the following:-He/She had an activity of daily living (ADL) self-care performance deficit related to hemiplegia and generalized weakness;-He/She required maximal assist of one staff to turn and reposition in bed;-He/She was dependent on two staff for toileting;-The resident had impaired cognitive function due to diagnosis of Alzheimer's disease;-Cue, reorient and supervise as needed;-He/She had bowel incontinence;-Provide peri care after each incontinent episode;-The resident had an alteration in hematological status related to thrombosis (clot);-He/She may bruise easily. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/14/25, showed the following:-The resident had moderately impaired cognition;-He/She had functional limitations in range of motion with bilateral upper and lower extremities;-He/She was dependent on staff on toileting hygiene;-He/She required maximal assistance of staff with bed mobility;-He/She was always incontinent of bladder and bowel. Review of the resident's weekly skin observation, dated 8/21/25, showed the resident had bruising to the back of his/her left hand. There were no other areas of concern or bruising identified. Review of the resident's weekly skin observation, dated 8/26/25, showed the resident had a bruise to his/her right arm. Review of a statement sent by Licensed Practical Nurse (LPN) A to the administrator on 8/25/25 at 7:24 A.M., showed the following:-He/She observed that the resident's eyes were teary, and the resident yelled, help me and make him/her stop hurting me. CNA B came in and woke me up out of my sleep, scared me half to death, and was being rough with me;-LPN A tried to provide the resident comfort, then observed CNA B attempting to leave the resident soiled, with his/her incontinence brief completely off, while covering him/her with only a sheet;-When he/she said he/she was going to assist, put on gloves and approached the resident, CNA B suddenly grabbed the resident and forcefully turned him/her to his/her side, nearly causing the resident to fall out of bed. CNA B then began aggressively pulling linens and soiled pads from underneath the resident, which caused feces to spread throughout the room;-Recognizing how aggressive the aide was acting, he/she told CNA B to stop before he/she caused the resident to fall. At that moment, two aides entered the room after hearing the resident scream;-He/She instructed them to continue assisting the resident while he/she removed CNA B from the room. During an interview on 9/4/25 at 9:44 A.M., LPN A said the following:-CNA B wanted him/her to document the resident refused care;-He/She went into the resident's room to ask what was wrong;-The resident was half undressed and covered by a single sheet;-The resident was tearful and said, CNA B woke him/her up and it scared him/her;-While LPN A put on gloves, CNA B went over to the resident's bed and started to handle the resident aggressively, rolling/moving the resident around in bed without telling the resident what CNA B was doing and was using force;-CNA B pulled on the resident to roll him/her over and put the resident too close to the side of the bed, so LPN A told CNA B to stop and let him/her help;-CNA B continued and the resident yelled for CNA B to stop because he/she was hurting the resident, so LPN A told CNA B to leave the room;-Two CNAs came in the room and LPN A told them to take over;-LPN A and CNA B left the room;-CNA B overheard LPN A talking on the phone about sending him/her home and CNA B started to threaten LPN A;-LPN A said CNA B was rough and careless with the care he/she witnessed. During an interview on 9/4/25 at 9:31 A.M., CNA C said the following:-He/She was on break with another staff member when he/she heard Resident #1 yell, stop hurting me! and you're too rough!;-When CNA C entered the resident's room, the resident yelled, help me! to him/her;-LPN A was in the resident's room and CNA B stood on one side of the resident's bed with one hand on the resident's arm and the other hand on the resident's leg, bending the resident at the waist while trying to move the resident;-The resident had contractions and was limited on how far he/she could bend;-The resident said CNA B hurt him/her;-LPN A told CNA B to leave the room and CNA C and CMT D took over;-The resident was upset and tearful and said he/she did not want CNA B to come back;-CNA B was being unnecessarily rough and hurt the resident.-CNA told the administrator the resident yelled for help, said CNA B hurt him/her and the resident was upset. During interview on 9/4/25 at 9:52 A.M., the resident said the following:-CNA B was rough and hurt him/her;-He/She was scared of CNA B and didn't want CNA B to go near him/her. Review of the resident's next of kin's text message sent to the surveyor, dated 8/30/25 at 11:57 A.M., showed on 8/29/25, the next of kin spoke with the resident in the hospital, where the resident was being treated for pneumonia. The resident had bruising; the resident said the staff member was rough. Observation of a photo sent from the resident's next of kin to the surveyor of the resident's right arm, dated 8/30/25 at 11:57 A.M., showed the following:-The resident had purple discoloration of the skin of the upper arm approximately 10 centimeters (cm) in width, unable to determine the length because the edges were not visible;-There was a second area of purple discoloration of the skin on the right upper arm below the bend of the elbow that was approximately 6 cm in width, unable to determine the length because the edges were not visible;-There was a third area of purple discoloration of the skin on the lower right arm that was approximately 4 cm x 4 cm;-There was a fourth area of purple discoloration of the skin on the lower right arm, below and to the right of the third area and it was approximately 1 cm x 1 cm. During an interview on 8/29/25 at 2:50 P.M., and on 9/10/25 at 12:30 P.M. the Administrator said the following:-She worked in the facility at the time of the alleged abuse;-The alleged abuse occurred at 3:00 A.M. and the charge nurse, Licensed Practical Nurse (LPN) A an agency nurse said, CNA B worked with Resident #1 when he/she heard the resident wanted him/her to stop;-CNA B had the resident rolled over on his/her side and the resident said he/she didn't want CNA B taking care of him/her anymore;-Two CNAs came in the room and took over caring for the resident;-LPN A and CNA B left the resident's room and LPN A told CNA B to go home;-LPN A provided a statement and the investigation was begun;-The resident said CNA B scared him/her when CNA B woke him/her up and he/she didn't realize who it was at first moving him/her around in bed;-She completed an assessment on the resident immediately after the incident;-The resident had two bruises on the right arm, the upper one on the forearm was quarter sized, and the lower one on the forearm was not quite quarter sized. 26036502605591

Based on observation, interview and record review, the facility failed to respond and adequately act upon and provide feedback related to resident concerns regarding call light wait times and response from staff from resident council meetings. The facility census was 93. Review of the facility policy for Resident and Family Council with a revision date of 10/24/22 showed the following:-Purpose: to promote the exercise of a resident's right to organize and participate in resident groups at the facility;-Policy: The purpose of the Resident and/or Family council is to provide a forum for discussion of resident's concerns; input in the operation of the facility;-Responsibilities of the Resident and/or Family council: providing feedback in the development of policies and procedures governing the operation of the facility; making recommendations for the improvement of resident services provided by the facility; reviewing reports submitted to the council and making recommendations and/or taking appropriate actions; studying problem areas and making recommendations for their solutions;-If the council raises an issue of concern, the Department responsible for the issue or service is responsible for addressing the item(s) of concern promptly;-The applicable Department should be able to demonstrate its response and rational for such responses;-The facility will respond in writing to written request or concerns of the family council in a prompt and timely manner. Review of the facility policy for Grievances and complaints with a policy revision date of 10/24/22 showed the following:-Policy: the facility advises residents and their representatives (including family, legal representatives, and advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints;-Any resident, representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, theft of property, etc., without fear of threat or reprisal;-Upon receiving a resident grievance, the Grievance Official or designee begins an investigation into the allegation;-The department director is notified of the complaint that an investigation is underway;-The Administrator will be provided a completed Resident Grievance within five working days of the incident;-The facility will inform the resident or his or her representative of the findings of the investigation and any corrective actions recommended in a timely manner. 1. Review of the Resident/Family Council Minutes dated 4/15/25 showed the following:-Old business - wait times still, especially on weekends.-New business - resident states call light not with reach. No resolution provided to the resident council for concerns of the wait times and call lights not within reach for the April meeting. Review of the Resident/Family Council Minutes dated 5/13/25 showed old business included call lights were not answered. Call lights being answered at the box and staff not physically going to rooms. No resolution provided to the resident council for concerns of the call lights not being answered or being answered at the box and not physically going to the rooms for the May meeting. Review of the Resident/Family Council Minutes dated 6/10/25 showed new business included call lights. No resolution provided to the resident council for concerns of the call lights for the June meeting. Review of the Resident/Family Council Minutes dated 7/8/25 showed the following:-Old business - call lights.-New business - call lights. No resolution provided to the resident council for concerns of the call lights for the July meeting. 2. Review of the grievance report form dated 7/28/25 filed by Resident #8 showed the following:-My roommate (Resident #9), fell out of bed around 4:00 A.M. and we pushed the call light, and no one came to help. I finally went to get help and could not find anyone in the front of the building. I waited after looking up and down the hallways and no one came, I finally went down to the other nurses' station and got a nurse who then looked for help and could not find either. This is concerning;-Action taken to address - In-service nurse on need for frequent rounding and trying to keep staff member present when other staff member on break;-Summary of findings: roommate was able to locate staff member at other nurses station and receive assistance;-Summary of Action taken - inservice was completed with charge nurse. During an interview on 8/5/25 at 1:30 P.M. Resident #8 said the following:-On 7/27/25 Resident #9, his/her roommate, was calling out for help;-Resident #9 had fallen off the bed and scooted on the floor to the bathroom and rang the call light in the bathroom because he/she could not reach the call light on the bed;-Resident #9 said that he/she had been on the floor for a while and could not get up;-He/She waited for about 30 minutes for someone to come, and when no one came, he/she got into his/her wheelchair and went to the nurses station to find someone. No one was at the nurses station so he/she wheeled up and down the hall and could not find anyone;-He/She then went to the back hall and found a nurse and told him/her that Resident #9 was on the floor;-The nurse tried to find someone to help, but could not find any staff either;-The nurse then called staff and they came to their room and got Resident #9 off the floor;-Resident #9 was on the floor for about an hour before anyone came to get him/her up. During an interview on 8/6/25 at 11:30 A.M. Resident #9 said the following:-He/She rolled off the bed on the right side;-As he/she was rolling off the bed, his/her arm hit the over the bed table and the radio came crashing down and hit him/her on the left side of his/her head by his/her eye;-He/She could not get up so he/she crawled to the bathroom and turned on the call light in the bathroom;-He/She waited for about 15-20 minutes, and nobody came, then his/her roommate got up in the wheelchair and went and found someone, the nurse from the other hall;-He/She was on the floor for about 45 minutes to an hour before someone helped him/her off the floor. 3. Review of Resident #11's face sheet showed the resident admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis (MS - is a chronic, often disabling disease that affects the central nervous system (brain and spinal cord). Observation on 8/5/25 at 10:05 A.M. showed the resident sitting in a wheelchair in the middle of the room. The resident's call light was on the floor approximately three feet behind the wheelchair. During an interview on 8/5/25 at 10:05 A.M. the resident said the following:-He/She could not reach the call light while he/she was in the wheelchair and the call light was on the floor;-He/She needed help from the staff to transfer and at times it takes the staff longer than 30 minutes to answer the call light especially at night. 4. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses of amputation of both lower extremities. During an interview on 8/5/25 at 10:10 A.M. the resident said the following:-This past Sunday, it took over two hours to get someone to answer his/her call light to empty his indwelling catheter (a tube inserted into the bladder to drain urine) bag;-He/She turned on the call light around 9:00 P.M., a short time later the call light was off at the board on the wall in his/her room, someone had to shut off the light at the nurses station so he/she turned on the call light again and no one came;-Around 10:00 P.M. he/she used his/her personal cell phone and called the facility to let them know he/she needed someone to come and empty the catheter bag;-It took them another hour to come and empty the catheter bag;-It made him/her angry when the staff do not answer the call light and he/she has to call on his/her phone for assistance. 5. Observation on 8/5/25 at 10:28 A.M. showed the call light on above the door for room [ROOM NUMBER]. Resident #3 laid in the bed with a sheet and light weight blanket on him/her and said I am cold, could someone please get me a blanket? Resident #4 sat in a wheelchair between the two beds. During an interview on 8/5/25 at 10:28 A.M. Resident #4 said the following:-He/She had turned on the call light for Resident #3 because the resident needed to go to the bathroom;-The call light had been on for about 20 minutes;-The call light was not lit up outside the door or on the panel on the wall;-The resident said, they must have turned it off and pressed the button to activate the call light again;-The light on the panel between the beds and the light outside the door lit up;-At 10:37 A.M. Certified Nurse Aide (CNA) A came in the room and shut the call light off;-Resident #3 said I need to get up and use the bathroom;-The CNA said that he/she would get the resident's aide, and left the room;-At 10:45 A.M. CNA B entered the room and provided incontinent care to Resident #3 (resident was incontinent after waiting to use the bathroom). During an interview on 8/5/25 at 10:50 A.M. Resident #4 said:-It takes the staff a long time to answer the call light, especially on the night shift, or they will just shut the light off at the desk;-He/She has been incontinent because he/she has had to wait;-This makes him/her angry because if the staff had come sooner, he/she would not have been incontinent. 6. During an interview on 8/6/25 at 1:10 P.M. Resident #6 said the following:-He/She will turn on the call light for his/her roommate and wait for over 30 minutes at times for the staff to answer the light, especially on the night shift;-He/She sees them walk past the door, usually they have earbuds in and cannot hear when you call out or they are on their phones and do not pay attention;-This makes him/her angry that he/she and his/her roommate cannot get help when they need it. 7.During an interview on 8/5/25 at 2:00 P.M. Resident #10 said the following:-He/She was the president of Resident Council and each month there were complaints about the call lights not being answered or being shut off and no one coming back;-The residents have complained about this and all they are told is that an in-service will be done;-The inservice was not working because it was still occurring. 8. During an interview on 8/6/25 at 10:30 A.M. the Activity Director said the following:-The residents have complained about staff not answering residents' call lights for months;-He/She takes the notes in the meetings, and will write down their concerns and present them to the appropriate department;-There had been no formal form done for their concerns until July;-The resolutions that nursing presented was to inservice the staff on answering the call lights, but the residents say it is a continued problem. During an interview on 8/6/25 at 3:00 P.M. and 8/19/25 at 4:15 P.M., the Administrator said the following:-She would expect staff to answer a resident's call light promptly and provide care or to get someone who can provide the care;-Prior to July 2025 there was no formal process for the resident's concerns at resident council to be addressed;-The Activity Director was to document the resident council concerns on a form, then give to individual departments. Those departments had seven days to come up with a resolution. The resolution was then reviewed with the individual resident who issued the concern and reviewed in resident council;-It was felt an inservice was adequate to address the call lights;-After the survey, there have been additional interventions put in place.

Based on observation, interview, and record review, the facility failed to follow their fall management policy and response to falls policy for one resident (Resident #9) of 12 sampled residents, who sustained falls. Resident #9 had two falls with no documentation including assessments or notifications at the time of the falls. The resident fell out of bed on 7/27/25 onto the floor and crawled to the bathroom to turn on the call light to alert staff. Staff did not respond to the call light for 45 to 60 minutes. When staff did respond, staff completed no assessment for injuries or documentation of the fall. The care plan was not updated with meaningful interventions based on the cause of the resident's falls sustained on 7/17/25 and 7/27/25. The facility census was 93.Review of the facility policy for Fall Management Program with a revision date of 10/24/22 showed the following:-Purpose: to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program;-The facility will provide the highest quality care in the safest environment for the residents residing in the facility. The facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation.-Assessment: the Licensed Nurse will assess each resident for their risk of falling upon admission, quarterly, and with a significant change in condition;- The nursing staff will develop a plan of care specific to the residents needs with interventions to reduce the risk of falls;-The Interdisciplinary Team (IDT) will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall;-Universal Fall Prevention Measures for all Resident: position call bell, urinal if applicable and bedside stand with reach; educate the resident on the use of the call light system and to ask for assistance.;-Post Fall: following the resident's fall, the licensed nurse will complete an incident report and a post fall assessment and investigation within 24 hours or as soon as possible. Review of the facility policy for Response to Falls with a revision date of 10/24/22 showed the following:-Purpose: to ensure the facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention;-Residents experiencing a fall will be promptly assessed and treated for injuries; the resident's physician and responsible party will be notified; after each fall a Licensed Nurse will complete a Post-Fall Assessment and investigation; any identified findings and the facility responses will be documented in the resident's medial record as appropriate; the IDT will review the investigative reports on a regular basis, as they may occur, and make systemic changes to reasonably limit future occurrences, consider change in Plan of Care (POC) intervention, system changes, etc.;-Immediate Post Fall Response: upon witnessing a fall or finding a resident in a position indicating a fall, stay with the resident and send another staff member to notify a Licensed Nurse if the first responder is not a licensed personnel;-Do not move the resident initially until after an assessment has been completed;-The Licensed Nurse will assess the resident and take the resident's vitals. Assess the resident's level of consciousness, position, possible injuries, head injuries, pain, tenderness, swelling, bruising, alignment, and range of motion (ROM);-If head and neck pain is reported or suspected, immobilize the cervical spine (the region of the spine located in the neck). Call Emergency Medical Services. Do not move the resident, do not place a pillow under his/her head, do not leave the resident unattended unless necessary;-If the resident is bleeding, has skin tears, abrasions, has fainted or exhibits similar problems, give proper emergency care;-The Licensed Nurse will notify the Attending Physician of the fall and implement any new physician orders;-The Licensed Nurse will notify the responsible party of the fall and any resulting interventions and/or treatments;-Following each resident fall, the Licensed Nurse will complete an incident repot and perform a Post-Fall Assessment and Investigation;-The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall or witnessed fall with known head injury for 72 hours following the fall;-Documentation: document all falls on the 24-hour report, document notification of the physician and responsible party; complete an incident report and detailed progress note; complete Neurological flow sheet for 72 hours; document the resident's condition in the resident's medical record every shift for 72 hours; revise the resident's care plan as needed. Review of the facility policy for Nursing Documentation with a revision date of10/24/2022 showed the following:-Purpose: to provide documentation of resident status and care given by nursing;-Policy: nursing documentation will be concise, clear, pertinent, and accurate;-Any communication with family, durable power of attorney (DPOA), or physician is to be noted in nurse's notes;-Alert charting: alert charting is documentation done to track a medical event for a period of 72 hours or longer;-Events may include but are not necessarily limited to: Fall with or without injury;-Alert charting describes what is going on: describes the resident's condition; describes what you have done with the resident and the resident's response to the actions. 1. Review of Resident #9's undated face sheet showed the resident admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD a progressive lung disease that makes it hard to breathe), diabetes, and muscle weakness. Review of the resident's care plan for falls dated 4/11/25 showed the following:-At risk for falls with a history of falls. On 6/1/24 rolled out of bed; -Approaches in part: 3/9/23 sleeping in bed and fell out of bed, bariatric mattress placed on bed; 6/1/24 adding bolsters to bed; 7/1/25 educate the resident on safe ambulation. Review of the resident's comprehensive Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff dated 7/18/25 showed the following:-Able to make self-understood and able to understand others;-Brief Interview for Mental status (BIMS - a cognitive assessment tool) of 15, indicating the resident was cognitively intact, with no impairment;-Independent with Activities of Daily Living;-Diagnoses of chronic obstructive pulmonary disease, diabetes, muscle weakness, coronary artery disease (CAD a condition where the heart's major blood vessels become narrowed or blocked), and seizure disorder. Review of the resident's nurses notes dated 7/22/25 at 1:37 P.M. signed by the Assistant Director of Nursing (ADON) showed the following:-Resident said he/she fell while assisting another resident into the shower room. Last Thursday (7/17/25), while he/she was unlocking the shower room door for another resident, he/she stepped backwards, lost balance, fell to floor landing on his/her buttocks. Assessed for injury with small bruise to left sacrum (triangular bone at the base of the spine) noted. The resident said he/she had a little low back pain. This nurse was made aware at this time, two staff members helped him/her off the floor. During an interview on 8/5/25 at 3:15 P.M. the Assistant Director of Nursing said the following:-He/She overhead the resident telling someone that he/she fell on 7/17/25;-He/She talked with the resident about the fall and he/she documented in the nurses notes and assessed the resident at that time;-The resident told him/her that there was a nurse who was there, but did not know that person's name;-He/She did not know who that nurse was;-He/She should have investigated the fall. Review of the resident's medical record from 7/17/25 through 7/22/25 showed no documentation of the resident's fall on 7/17/25 until 7/22/25, or assessment for any injuries. There were no additional interventions added to the resident's care plan after the fall on 7/17/25. During an interview on 8/6/25 at 11:30 A.M. Resident #9 said the following:-He/She rolled off the bed on his/her right side (on 7/27/25);-As he/she was rolling off the bed, his/her arm hit the over the bed table and the radio came crashing down and hit him/her on the left side of his/her head by his/her eye;-He/She could not get up so he/she crawled to the bathroom and turned on the call light in the bathroom;-He/She waited for about 15-20 minutes, and nobody came, then his/her roommate got up in the wheelchair and went and found someone, the nurse from the other hall;-He/She was on the floor for about 45 minutes to an hour before someone helped him/her off the floor;-He/She had a fall a couple of weeks ago, when he/she was helping a visitor into the bathroom in the center hall, when he/she lost his/her balance and fell backwards;-He/She cannot get up off the floor without help, two staff members came and helped him/her off the floor. 2. Review of a grievance report form dated 7/28/25 filed by Resident #8 showed the following:-My roommate fell out of bed around 4:00 A.M. and we pushed the call light, and no one came to help. I finally went to get help and could not find anyone in the front of the building. I waited after looking up and down the hallways and no one came, I finally went down to the other nurses' station and got a nurse who then looked for help and could not find either. During an interview on 8/5/25 at 1:30 P.M. Resident #8 said the following:-His/Her roommate Resident #9 woke him/her up calling out for help;-Resident #9 had fallen off the bed, and scooted on the floor to the bathroom to ring the call light in the bathroom because he/she could not reach the call light on the bed;-Resident #9 said he/she had been on the floor for a while and could not get up;-He/She waited for about 30 minutes for someone to come, and when no one came, he/she got into his/her wheelchair and went to the nurses' station to find someone. No one was at the nurses' station so he/she wheeled up and down the hall and could not find anyone;-He/She then went to the back hall and found a nurse and told him/her that Resident #9 was on the floor;-The nurse tried to find someone to help, but could not find any staff either;-The nurse then called staff and they came to their room and got Resident #9 off the floor;-Resident #9 was on the floor for about an hour before anyone came to get him/her up. 3. Review of the resident's medical record on 8/5/25 and 8/6/25 showed no documentation for the resident's fall or assessment that occurred on7/27/25. Review of the nurses' notes dated 7/27/25 at 8:40 A.M. signed by Registered Nurse (RN) D showed the following:-Resident informed this nurse that the resident had a fall overnight when he/she rolled out of the bed onto the floor. Resident rolled off the right side of the bed towards the window and when he/she fell the radio fell onto him/her causing a skin tear to the left arm. Upon assessment there was a bruise to the left cheek and a bruise on the left thigh. Director of Nursing, physician on call and family notified. Neuro checks initiated per protocol, order entered for skin tear and treatment applied. Review of the resident's care plan for falls dated 4/11/25 showed and update on 7/27/25 noted as Nurse Practitioner visit under approaches to prevent falls. There were no interventions added to address fall prevention for the resident. During an interview on 8/6/25 at 4:31 P.M. Certified Nurse Aide (CNA) C said the following:-He/She helped Resident #9 off the floor a couple of weeks ago when the resident had a fall in the hallway;-He/She does not remember a nurse being with the resident;-There was another staff member there, but he/she does not remember who that was;-He/She was not on duty when the resident had a fall on 7/27/25. During an interview on 8/6/25 at 4:03 P.M. Licensed Practical Nurse (LPN) F said the following:-He/She was not Resident #9's nurse on 7/27/25;-He/She was not aware that the resident's nurse had gone on break until Resident #8 came to him/her around 4:00 A.M. or 4:15 A.M. and told him/her that Resident #9 was on the floor;-He/She and two CNA's went to Resident #9's room;-The resident was sitting on the floor by the bathroom, he/she asked the resident if he/she had hit his/her head. The resident said no; he/she felt the resident's head and found no bumps or any injuries, so he/she told the CNA's to help the resident off the floor;-He/She then messaged RN G of the fall;-He/She assumed that RN G would complete the paperwork and document in the resident's record;-He/She was informed on 8/6/25 that he/she needed to document the information into the medical record. During an interview on 8/7/25 at 9:50 A.M. RN G said the following:-He/She had gone on break at 4:00 A.M. on 7/27/25 and informed the CNA on the 100 hall that she was going on break;-He/She was informed of Resident #9's fall around 4:30 A.M. when he/she came back from break;-He/She began medication pass and saw Resident #9 around 5:00 A.M.; he/she asked the if he/she was in any pain;-He/She assumed LPN F had completed the assessments and documented in the medical record;-He/She told RN D about the resident's fall at shift change around 6:00 A.M.;-He/She did not do an assessment or begin neuro checks;-He/She should have checked the medical record or asked LPN F if the assessment and documentation were completed. During an interview on 8/5/25 at 2:00 P.M. RN D said the following:-He/She was taking Resident #9's blood sugar before breakfast on 7/27/25 when the resident said he/she had rolled out of bed and fell on 7/27/25. The resident said he/she had gotten him/herself up off the floor;-The resident had a bruise to the left temple area, bruise to the left check and left thigh and a skin tear to the left forearm;-He/She did not know anything about a fall on 7/17/25. During an interview on 8/5/25 at 3:15 P.M. the Assistant Director of Nursing said the following:-He/She overhead the resident telling someone that he/she had a fall on 7/17/25;-He/she talked with the resident about the fall and he/she documented in the nurses notes and assessed the resident at that time;-The resident said there was a nurse who was there, but did not know that person's name;-He/She did not know who that nurse was;-He/She should have investigated the fall;-He/She was aware of the fall on 7/27/25 from a grievance report that was filed by Resident #8;-He/She investigated the grievance of the staff not answering the resident's call light but was not aware that the nurses did not document the fall at the time. During an interview on 8/5/25 at 3:45 P.M. the Director of Nursing said the following:-She had not reviewed/read documentation provided by the ADON regarding the resident;-Nursing had done a fall risk assessment on 7/22/25, not at the time of the fall. There was no incident report or documentation in the medical record of the resident's fall, or physician or responsible party notifications. During an interview on 8/6/25 at 3:00 P.M. the Director of Nursing and Administrator said the following:-They would expect the nurse who finds or responds to a resident who has fallen to complete an assessment of the resident, assess for any injuries and to document in the medical record the assessment, incident report and all other necessary documentation;-They would expect staff to follow facility policies. 2566939 and 2569007

Based on observation, interview, and record review, the facility failed to ensure nursing staff performed appropriate hand hygiene and changed gloves during the provision of care for one resident (Residents #2), and failed to follow the facility policy for Enhanced Barrier Precautions (EBP) for four residents (Residents #1, #2, #3, and #4), in a review of nine sampled residents. Staff failed to utilize Personal Protective Equipment (PPE) while providing high-contact care activities or wound care. The facility had identified 16 residents with wounds, six residents with indwelling catheters (a sterile tube inserted into the bladder to drain the bladder of urine) and three residents receiving Enteral tube feedings (a tube placed in the stomach to provide nutrition). The facility census was 81. Review of the facility policy for Perineal Care with a revision date of 10/22 showed the following: -Wash hands, put on gloves, provide perineal care to the resident, remove wet linen, place dry linens or briefs underneath the resident, reposition the resident; -Remove gloves and wash hands or use alcohol-based hand sanitizer. Do no touch anything with gloves after the procedure; -Put on clean gloves; -Clean and return any equipment to its proper place; -Place soiled linen in proper container; -Remove gloves; -Wash hands. Review of the facility policy for Hand Hygiene with a revision date of 10/22 showed the following: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors; -Facility staff must perform hand hygiene procedures in the following circumstances: before eating, after using the bathroom, when soiled with visible dirt or debris; contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood or other body fluids, wound drainage and soiled dressings after contact with intact or non-intact skin, clothing and environmental surfaces of residents with active diarrhea even if gloves are worn, before and after food preparations and before and after assisting residents with dining if direct contact with food is anticipated or occurs and in between glove changes; -Hand hygiene is always the final step after removing and disposing of person protective equipment. Review of the facility policy for Standard and Enhanced Precautions with a revision date of 7/23 showed the following: -Standard Precautions are used in the care of residents regardless of their diagnoses or suspected or confirmed infections status. Standard Precautions presume that blood, body fluids, secretions and excretions (except sweat), non intact skin and mucous membranes may contain transmissible infection agents; -Standard Precautions apply to the care of all residents regardless of suspected or confirmed presence of infectious diseases; -Standard Precautions include hand hygiene, gloves, masks and eyewear, gowns; -Enhanced standard precautions will be implemented for residents with a known Multi Drug Resistance Organism (MDRO) and who are at high-risk for colonization (refers to the presence of microorganisms on or within a person's body, where they are multiplying and growing, but without causing any noticeable symptoms or disease) and transmission; -Resident characteristics that are associated with a high-risk of MDRO colonization and transmission include presence of indwelling devices (e.g. urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters); wounds, or presence of pressure ulcer (unhealed; functional disability and total dependence on others for assistance with activities of daily living. 1. Review of Resident #1 undated face sheet showed the resident with diagnoses of multiple sclerosis (is a chronic, autoimmune disease that affects the central nervous system (brain and spinal cord). Review of the resident's nurses progress notes dated 2/5/25 showed the resident admitted to the hospital due to vomiting. Review of the resident's nurses progress notes dated 2/10/25, showed the resident readmitted to the facility with diagnosis of Influenza A and open areas on both buttocks. Consult outside wound care agency for treatment. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 2/13/25 showed the following: -Dependent upon staff for toileting and personal hygiene; -Incontinent of bowel and bladder. Review of the resident's facility wound report dated 2/25/25 showed the resident had an open area to the right and left buttock. Observation on 2/25/25 from 9:00 A.M. to 4:00 P.M., showed no sign on the resident's door posted for EBP or directing staff to wear personal protective equipment (PPE) when providing care to the resident. Observation on 2/27/25 at 7:24 A.M. showed the following: -No EBP sign posted on the resident's door to inform staff the resident was on EBP precautions and what PPE to wear; -Certified Nurse Aide (CNA) B and Nurse Aide (NA) C entered the resident's room without wearing gowns to provide incontinent care to the resident; -The resident had been incontinent of feces; -CNA B and NA C provided incontinent care, then gathered the dirty linens and took out of the room to the soiled linen barrel; CNA B and NA C did not remove their gloves and wash hands prior to leaving the resident's room; -CNA B and NA C returned to the room and washed hands. Observation on 2/27/25 at 9:00 A.M., showed the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) place a sign on the door to Resident #1's room that showed the following: -STOP Enhanced Barrier Precautions Everyone Must: clean their hands, including before entering and when leaving the room; -Providers and staff must also wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering transferring, changing linens, providing hygiene, changing briefs or assisting with toileting; device care of use: central line, urinary catheter, feeding tube, tracheostomy; wound care - any skin opening requiring a dressing; -Do not war the same gown and gloves for the care of more than one person. During an interview on 2/27/25 at 9:30 A.M. CNA B said the following: -He/She was not aware that Resident #1 was on EBP; -He/She was told after providing care the resident was on EBP and gowns should be worn when providing care; -The sign was not on the door when he/she provided care. During an interview on 2/27/25 at 10:00 A.M. ADON/IP said the following: -He/She was responsible for the facility's infection control program; -Resident #1 should have had a sign on the door alerting staff to the EBP; -Resident #1 was on EBP due to wounds. 2. Review of Resident #2's quarterly MDS dated [DATE] showed the following: -Diagnoses of stroke and aphasia (inability to speak); -Receives enteral feedings (a tube placed in the stomach to receive nutrition) for all nutritional needs. Observation on 2/25/25 from 9:00 A.M. to 4:00 P.M., showed no sign posted for EBP or directing staff to wear personal protective equipment (PPE) when providing care to the resident. Observation on 2/27/25 at 8:00 A.M. showed no sign posted for EBP or directing staff to wear personal protective equipment (PPE) when providing care to the resident. Observation on 2/27/25 at 8:17 A.M. showed the following: -CNA D enter the resident's room; CNA D did not don a gown, did apply gloves and told the resident he/she needed to change him/her; -CNA D removed the resident's urine saturated brief, placed the brief on the floor, and removed one wipe from a package and with a back and forth motion wiped the resident's genitals. CNA D then rolled the resident to his/her left side, obtained another wipe from the package and with a back and forth motion wiped the residents buttocks; -CNA D removed a urine soaked from under the resident and threw the pad on the floor, placed a clean pad under the resident and then placed a clean brief under the resident. Without removing soiled gloves and performing hand hygiene before applying a clean pair of gloves, CNA D took a tube of skin barrier ointment out of the nightstand drawer and with one hand squeezed some ointment on the other hand and rubbed the ointment on the resident's buttocks. CNA D then fastened the brief around the resident; -With the same soiled gloves, CNA D removed the resident's gown that was wet with urine, threw the gown on the floor, put a clean gown on the resident, removed the top sheet and threw it on the floor, then put a clean top sheet on the resident; -With the same soiled gloves CNA D picked up the dirty linen off the floor and put the dirty linen in a bag; -With a towel and wearing the same soiled gloves, he/she wiped the over the bed table off, opened the door using the door handle, took the dirty linen down the hall to a linen barrel; -CNA D then removed his/her soiled dirty gloves, obtained a new pair of gloves from the linen cart and began to put the gloves on his/her hands. The ADON/IP stopped CNA D and told him/her to wash his/her hands; -The ADON/IP then placed a sign on the resident's door indicating the resident was on EBP. During an interview on 2/27/25 at 9:15 A.M. CNA D said the following: -He/She did not know what EBP meant; -He/She would change his/her gloves when care was complete for the resident. 3. Review of Resident #3's quarterly MDS dated [DATE] showed the following: -Dependent upon staff for activities of daily living (ADLs); -Has an indwelling catheter and incontinent of feces; -Has a Stage III pressure ulcer ( full-thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed); -Diagnoses of Alzheimer's disease and dementia. Review of the resident's undated care plan for wound infection showed the following: -The resident has an infection of the coccyx (tailbone) wound; -Interventions to administer antibiotics, maintain universal precautions when providing resident care; -No interventions for EBP use. Review of the resident's undated care plan for the indwelling catheter showed the following: -The resident has an indwelling catheter; -Change catheter per physician orders; -No interventions for EBP use. Review of the resident's urinalysis with culture and sensitivity report dated 2/22/25 showed the following: -Urine sample collected on 2/18/25 and reported to staff on 2/22/25; -Two plus blood, three plus protein, three plus leukocytes with may bacteria (indicated urinary tract infection); -Sensitivity report (a test that will show what bacteria is in the urine) showed greater than 100,000 CFU/ml (shows the amount of bacteria grown in the urine) of Proteus Mirabilis (a bacteria that can cause urinary tract infections, and can be transmitted by coming into contact with contaminated objects like catheters. Observation on 2/27/25 at 11:50 A.M. showed the following: -The resident sat in a wheelchair in the main dining room with an indwelling catheter. The indwelling catheter bag and tubing touched the floor, there was dark yellow urine with sediment in the tubing; -The resident's arms and face were bright red and he/she complained of itching. Registered Nurse (RN) E pushed the resident to his/her room with the catheter bag touching the floor and the tubing to the catheter dragging on the floor; -An EBP sign was on the door to the resident's room alerting staff the resident was on EBP precautions; -RN E put on a pair of gloves and obtained a bottle of lotion, placed a large amount of lotion on his/her gloved hand and began to spread the lotion on the resident's arms and legs. When finished, RN E removed his/her gloves, washed his/her hands and pushed the resident back to the dining room. During an interview on 2/27/25 at 11:55 A.M. RN E said the following: -The resident was on EBP due to having a wound, an indwelling catheter and a current UTI; -He/She should have put on a gown along with the gloves before putting lotion on the resident. During an interview on 2/27/25 at 12:00 P.M. the ADON/IP said staff should have followed the EBP guidelines for the resident as he/she was at high risk for infections. 4. Review of Resident #4's face sheet showed the resident admitted to the facility on [DATE]. Review of the resident's comprehensive MDS dated [DATE] showed the following: -Dependent upon staff for ADLs; -Has an indwelling catheter and third degree burns (a serious wound that damages all three layers of the skin); -Diagnoses of cerebral palsy (is a group of disorders that affect movement, balance, and posture. It is caused by damage to the developing brain before, during, or shortly after birth. This damage can lead to permanent changes in the brain that interfere with the brain's ability to control muscle movement). Observation on 2/25/25 at 1:00 P.M. showed: -The resident laid in the bed with an indwelling catheter bag hanging on the side of the bed, there was dark yellow urine in the tubing and bag with no sign posted for EBP; -Several staff entered the resident's room to reposition the resident and wore no PPE. Observation on 2/27/25 at 9:00 A.M. showed the ADON/IP placed an EBP sign on the door. The ADON/IP said the resident should have been on EBP precautions due to the indwelling catheter and the third degree burns. During an interview on 2/27/25 at 11:30 A.M. the ADON/IP said the following: -Residents who have infections, indwelling catheters, enteral tube feedings, and wounds should be placed on EBP; -He/She is a little behind identifying who was on EBP, but the nurses should also identify and place a resident on EBP when the resident met criteria for EBP; -The facility has 15 residents with pressure ulcers, eight residents with indwelling catheters and three residents with enteral feeding; -In January there was five residents with wound infections and five residents with urinary tract infections; -As of February 18th there was three urinary tract infections documented on the Infection Control log. During an interview on 2/27/25 at 2:00 P.M. the Director of Nursing said the following: -She would expect staff to follow their policy for hand washing when providing care; -Nursing staff was aware prior to admission if a resident has an indwelling catheter, an enteral tube feeding, a wound or an infection that meets the criteria for EBP. She would expect the nurses to put EBP precautions in place at the time of admission, or when the resident meets the criteria. She would expect all staff to follow the facility policy for EBP. During an interview on 2/27/25 at 2:00 P.M. the Administrator said she would expect staff to follow their policy for hand washing and EBP. MO250092

Based on observation, interview, and record review the facility failed to provide oversight and prevent injury for one resident (Resident #2), in a review of 18 sampled residents, when staff left the resident unattended in the shower room, resulting in the resident falling and sustaining a fracture. The facility census was 87. On 11/27/24 at 4:15 P.M., the administrator was notified of the past noncompliance which occurred on 10/12/24. On 10/12/24, the administrator became aware of the violation of resident safety when Resident #2 was left alone in the shower room by staff. Resident #2's care plan directed he/she required one staff assist for bathing, hygiene and dressing. Resident #2 attempted to dress him/herself and had a fall that resulted in a right hip fracture. Upon discovery, the facility conducted an investigation, notified appropriate parties and all facility staff were educated on assistance with showers, to provide assistance with showers per care plan. The deficiency was corrected on 10/22/24 after all staff had been inserviced. Review of the facility policy, Fall Management Program, revised October 24, 2022, showed the following: -Purpose: To prevent resident falls and minimize complications associated with falls through the development of a fall management program; -Policy: The facility will provide the highest quality care in the safest environment for the residents residing in the facility. The facility has developed a fall management program that strives to prevent resident falls through meaningful assessments, interventions, education and reevaluation; -The nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. 1. Review of Resident #2's care plan, with an initiation date of 12/13/22 showed to keep the resident's call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the resident's care plan initiated 5/23/23 showed the following: -The resident has an activities of daily living self-care performance deficit related to impaired balance; -The resident required limited assistance by one staff with bathing/showering two times weekly and as necessary, to dress, with personal hygiene and to move between surfaces as necessary. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 07/02/24, showed the following: -Functional limitations in range of motion; upper extremity impairment on one side; -Substantial to maximal assistance to shower/bathe; helper does more than half of the effort; -Partial to moderate assistance for upper body dressing; helper does less than half of the effort; -Partial to moderate assistance for lower body dressing; helper does less than half of the effort; -Substantial to maximal assistance for tub/shower transfers; helper does more than half of the effort; -Substantial to maximal assistance to walk 10 feet; -Uses a wheelchair. Review of the resident's nursing progress notes, dated 10/12/24, showed the resident was heard yelling for help from the shower room. The resident was found on the floor and said he/she fell because he/she was attempting to pull his/her pants up and was not able to do it without losing his/her balance. The resident said he/she fell on to her left hip and was sore. There were no open areas or bruising noted from fall. Review of the facility's investigation of the resident's 10/12/24 fall showed the following: -Date of incident: 10/12/24; -Type of incident: fall with major injury; -Incident: on 10/12/24 at 2:31 P.M., the resident was heard yelling for help from the shower room and was found on the floor. The resident said he/she fell because he/she was attempting to pull his/her pants up and was not able to do it without losing his/her balance. No open areas or bruising noted and the resident said he/she was sore from the fall. The resident was seen by the physician on 10/14/24 and noted to have pain with internal and external rotation of the right hip as well as tenderness over the greater trochanter (hip). The resident said staff took him/her to the shower room to give a shower and left the resident in the shower by himself/herself. The staff member gave the resident the call light and instructed him/her to press the light if he/she needed help and that the staff member would be right back; -Injury: physician ordered an x-ray of the right hip. X-ray completed and results reported to physician. Order to send the resident to the hospital for evaluation due to acute subcapital right femoral neck fracture (fracture that occurs in the neck of the big thigh bone, where the femoral head meets the femoral neck - the most common type of hip fracture). The resident was hospitalized from 10/15/24 - 10/18/24 and had a right hip arthroplasty (hip replacement); -Initial interventions: 2. Staff interview completed. 3. Resident interview completed. 6. Education with facility staff; -Root Cause Analysis: Resident attempting to dress himself/herself without assistance; -Conclusion: Resident experienced a fall with major injury due to weakness while getting dressed. Review of the resident's medical record showed x-ray was obtained on 10/14/24 with results provided on 10/15/24 and noted a right humeral neck fracture. Review of the resident's nursing progress notes, dated 10/15/24, showed x-ray reports were reported to the physician with orders received to send the resident to the local hospital for evaluation and treatment. Review of the resident's nursing progress notes, dated 10/18/24, showed the resident returned from the hospital. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Clear speech, makes self understood and understands others; -Diagnosis of fracture other than multiple trauma and hip fracture; -Recent surgery requiring skilled nursing facility care, surgical procedure hip replacement - partial or total; -Surgical wounds and surgical wound care. During an interview on 11/26/24 at 3:37 P.M., and 11/27/24 at 11:08 A.M., the resident said the following: -He/She had fallen on a Thursday in the shower room after a fall; -He/She fell in the shower room after staff (Nurse Aide (NA) D) had left him/her alone in the shower and said he/she would be right back; -He/She turned on the call light but got cold and decided to get dressed by himself/herself; he/she did not know how long he/she had waited for help; -When trying to put on his/her pants, he/she lost his/her balance and fell to the floor; -Initially he/she thought he/she was okay and was able to walk back to his/her room after staff checked him/her out; -He/She had pain all weekend but did not tell anyone until Monday after his/her fall; -He/She fractured his/her hip, was sent to the hospital and returned to the facility on [DATE] after surgery. During an interview on 11/27/24 at 1:53 P.M., Nurse Aide (NA) D said the following: -He/She was the staff member assigned to give the resident a shower the day the resident fell ; -He/She was assisting the resident with a shower and another staff member asked for his/her assistance to help with another resident; -He/She gave the resident the call light an instructed him/her to push the call light when finished with the shower; -He/She assumed Resident #2 was independent and could be in the shower alone; -He/She was unaware the resident needed assistance to shower and dress; -He/She found out later that the resident was not a self-assist and should not have been left alone; -The resident care plans are in the computer and staff have access to them for review; -He/She should not have left the resident alone in the shower; -He/She has been in-serviced on how to care for the resident and not leaving residents alone in the shower since the incident. During an interview on 11/27/24 at 2:15 P.M., the Assistant Director of Nursing (ADON) said the following: -Resident #2 should not have been left alone in the shower room; -If a care plan shows a resident needs assistance by one staff for a shower, they should not be left alone. During an interview on 11/27/24 at 2:42 P.M., the Director of Nursing (DON) said the following: -Resident #2 should not have been left alone in the shower room; -All nursing staff have been in-serviced related to the incident. During an interview on 11/27/24 at 3:10 P.M., the administrator said the following: -The care plan should be followed to direct the care a resident receives; -The care plan says one assist for hygiene/bathing/dressing at least one staff member should be present for those tasks and should not be left alone. MO244794

Based on observation, interview, and record review, the facility failed to respond to call lights in a timely manner for three residents (Resident #12, #3 and #8), in a review of 18 sampled residents. The facility census was 87. Review of the facility's policy, Communication - Call System, revised 10/24/22, showed the following: -The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities; -Nursing staff will answer call lights promptly; -Call lights located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly. 1. Review of Resident #12's admission record showed the resident's diagnoses included dementia, arthritis, muscle weakness, cognitive communication deficit, and other abnormalities of gait and mobility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/02/24, showed the following: -Moderate cognitive impairment; -Supervision or touching assistance for toileting; -Partial to moderate assistance with dressing and bed mobility; -Partial to moderate assistance with sit to stand transfers and chair/bed/toilet transfers; -Supervision or touching assistance with ambulation; -Occasionally incontinent of urine and frequently incontinent of bladder. Review of the resident's Care Plan, revised on 10/29/24, showed the following: -The resident was at risk for falls; -Ensure the call light is within reach and encourage the resident to use it for assistance as needed. Review of the resident's call light log for 11/01/24 through 11/26/24 showed the following: -On 11/1/24 at 3:58 P.M., call light activated for 15 minutes. Call light reactivated at 4:15 P.M.; call light activated for 17 minutes; -On 11/2/24 at 8:10 A.M., call light activated for 47 minutes; -On 11/2/24 at 10:24 A.M., call light activated for 20 minutes; -On 11/2/24 at 3:03 P.M., call light activated for 43 minutes; -On 11/2/24 at 6:15 P.M., call light activated for 23 minutes; -On 11/3/24 at 8:13 P.M., call light activated for 18 minutes; -On 11/4/24 at 5:59 A.M., call light activated for 1 hour and 21 minutes; -On 11/4/24 at 4:36 P.M., call light activated for 21 minutes; -On 11/4/24 at 8:33 P.M., bathroom call light activated for 18 minutes. Call light reactivated at 9:06 P.M.; call light activated for 16 minutes; -On 11/5/24 at 6:45 A.M., call light activated for 58 minutes; -On 11/5/24 at 2:18 P.M., call light activated for 29 minutes; -On 11/7/24 at 8:57 P.M., call light activated for 37 minutes. Call light reactivated at 9:27 P.M.; call light activated for 18 minutes; -On 11/8/24 at 12:37 P.M., call light activated for 23 minutes; -On 11/8/24 at 9:28 P.M., call light activated for 57 minutes; -On 11/9/24 at 8:00 P.M., call light activated for 1 hour and 3 minutes; -On 11/10/24 at 7:07 A.M., call light activated for 30 minutes; -On 11/15/24 at 7:33 P.M., call light activated for 47 minutes; -On 11/17/24 at 4:29 A.M., call light activated for 26 minutes; -On 11/17/24 at 4:35 A.M., call light activated for 21 minutes; -On 11/25/24 at 9:50 P.M., call light activated for 24 minutes. During an interview on 11/26/24 at 11:46 A.M., the resident said it took staff a while to answer his/her call light. Sometimes he/she had to push the call light two or three times before staff would come help. 2. Review of Resident #3's admission record showed the resident's diagnoses included multiple sclerosis, polyneuropathy (a condition that occurs when multiple peripheral nerves malfunction at the same time, causing weakness, numbness, and burning pain), repeated falls, muscle wasting and atrophy (a decrease in size or effectiveness of an organ or tissue), need for assistance with personal care, muscle weakness, and cognitive communication deficit. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion in both lower extremities; -Utilized a wheelchair for mobility; -Substantial to maximum assistance for toileting; -Substantial to maximum assistance for all dressing; -Substantial to maximum assistance with most mobility needs, including bed to wheelchair transfer; -Dependent for toilet transfers; -Occasionally incontinent of urine and frequently incontinent of bladder. Review of the resident's Care Plan, revised on 10/14/24, showed the following: -He/She had an activities of daily living (ADL) self-care deficit related to generalized weakness, poor coordination, and multiple sclerosis; -Encourage the resident to use the call light for assistance. Please answer call light promptly; -He/She was at risk for falls related to gait and balance problems and unaware of safety needs; -Ensure the resident's call light is within reach. Encourage the resident to use his/her call light and respond to all requests for assistance promptly. Review of the resident's call light log for 11/01/24 through 11/26/24 showed the following: -On 11/1/24 at 3:56 P.M., call light activated for 19 minutes; -On 11/2/24 at 7:01 A.M., call light activated for 36 minutes; -On 11/2/24 at 9:27 A.M., call light activated for 25 minutes; -On 11/2/24 at 2:13 P.M., call light activated for 18 minutes; -On 11/3/24 at 6:51 A.M., call light activated for 19 minutes; -On 11/4/24 at 5:58 P.M., call light activated for 34 minutes; -On 11/6/24 at 7:04 P.M., call light activated for 30 minutes; -On 11/6/24 at 7:39 P.M., call light activated for 25 minutes; -On 11/7/24 at 6:55 A.M., call light activated for 31 minutes; -On 11/9/24 at 5:02 A.M., call light activated for 1 hour and 27 minutes; -On 11/12/24 at 10:03 A.M., call light activated for 38 minutes; -On 11/16/24 at 7:00 A.M., call light activated for 1 hour and 40 minutes; -On 11/16/24 at 12:45 P.M., call light activated for 24 minutes; -On 11/18/24 at 12:13 P.M., call light activated for 40 minutes; -On 11/19/24 at 9:05 A.M., call light activated for 32 minutes; -On 11/19/24 at 6:25 P.M., call light activated for 39 minutes; -On 11/20/24 at 9:45 A.M., call light activated for 43 minutes; -On 11/20/24 at 12:29 P.M., call light activated for 32 minutes; -On 11/22/24 at 6:37 A.M., call light activated for 1 hour and 1 minute. During an interview on 11/25/24 at 12:34 P.M., the resident said the following: -Staff's response time to call lights was not very good; -Sometimes he/she had to wait up to 30 minutes for help; -Sometimes staff could not help right away, so they shut off the call light and left. It could take a while for staff to return or staff forget and did not return. 3. Review of Resident #8's Face Sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breathe), hearing loss, osteoarthritis of right knee (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and spinal stenosis (the narrowing of the spaces inside of the spine that can cause pain, numbness or weakness of the arms and legs). Review of the resident's Care Plan, revised on 07/06/24, showed the following: -The resident had an activities of daily living self-care performance deficit related to confusion, generalized weakness and spinal stenosis; -The resident required extensive assistance with bed mobility, dressing, toilet use, transfers with assist of one staff, and ambulation with a walker. -Encourage the resident to use call light to call for assistance. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Highly impaired hearing; -Clear speech, makes self understood and usually understands others; -Limited range of motion one side upper extremity; -Partial/moderate staff assist for upper body dressing, sit to stand transfer and chair/bed-to-chair transfer; -Substantial/maximum staff assist for toileting hygiene, personal hygiene, and toilet transfers; -Dependent on staff for lower body dressing and putting on/taking off footwear; -Frequently incontinent of bowel and bladder. Review of the resident's call light log for 11/01/24 through 11/26/24 showed the following: -On 11/02/24 at 9:33 A.M., call light activated for 18 minutes; -On 11/03/24 at 6:30 A.M., call light activated for 1 hour and 27 minutes; -On 11/03/24 at 4:07 P.M., call light activated for 32 minutes; -On 11/05/24 at 10:42 A.M., call light activated for 18 minutes; -On 11/05/24 at 3:01 P.M., call light activated for 24 minutes; -On 11/06/24 at 7:26 A.M., call light activated for 18 minutes; -On 11/06/24 at 6:17 P.M., call light activated for 24 minutes; -On 11/07/24 at 7:20 A.M., call light activated for 1 hour and 19 minutes; -On 11/07/24 at 1:06 P.M., call light activated for 22 minutes; -On 11/07/24 at 2:48 P.M., call light activated for 36 minutes; -On 11/08/24 at 2:25 P.M., call light activated for 49 minutes; -On 11/09/24 at 8:18 A.M., call light activated for 21 minutes; -On 11/09/24 at 3:33 P.M., call light activated for 18 minutes; -On 11/10/24 at 4:17 P.M., call light activated for 25 minutes; -On 11/11/24 at 9:06 A.M., call light activated for 20 minutes; -On 11/11/24 at 1:09 P.M., call light activated for 20 minutes; -On 11/11/24 at 2:01 P.M., call light activated for 27 minutes; -On 11/12/24 at 2:07 P.M., call light activated for 59 minutes; -On 11/13/24 at 5:20 P.M., call light activated for 30 minutes; -On 11/13/24 at 7:08 P.M., call light activated for 1 hour and 16 minutes; -On 11/15/24 at 11:45 A.M., call light activated for 24 minutes; -On 11/15/24 at 1:00 P.M., call light activated for 29 minutes; -On 11/15/24 at 3:49 P.M., call light activated for 1 hour and 17 minutes; -On 11/16/24 at 7:03 A.M., call light activated for 35 minutes; -On 11/17/24 at 8:37 A.M., call light activated for 50 minutes; -On 11/18/24 at 7:35 A.M., call light activated for 18 minutes; -On 11/18/24 at 9:10 A.M., call light activated for 33 minutes; -On 11/18/24 at 6:36 P.M., call light activated for 20 minutes; -On 11/19/24 at 7:37 A.M., call light activated for 26 minutes; -On 11/19/24 at 8:56 A.M., call light activated for 46 minutes; -On 11/20/24 at 7:10 A.M., call light activated for 25 minutes; -On 11/21/24 at 7:41 A.M., call light activated for 25 minutes; -On 11/21/24 at 3:48 A.M., call light activated for 32 minutes; -On 11/22/24 at 6:14 A.M. call light activated for 29 minutes; -On 11/22/24 at 7:18 A.M., call light activated for 18 minutes; -On 11/22/24 at 6:15 P.M., call light activated for 18 minutes; -On 11/23/24 at 7:36 P.M., call light activated for 31 minutes; -On 11/24/24 at 8:34 A.M., call light activated for 18 minutes; -On 11/24/24 at 2:39 P.M., call light activated for 21 minutes; -On 11/25/24 at 6:56 A.M., call light activated for 40 minutes. During an interview on 11/26/24, at 3:15 P.M., the resident said the following: -At times it took staff 45 minutes to an hour to answer his/her call light; -He/She felt like it was worse on the weekends, but it was bad all of the time; -Sometimes staff turned off his/her call light and said they would be right back, and they did not return; -If staff do not return within 15 or so minutes, he/she reactivated the call light. During an interview on 11/27/24 at 12:10 P.M., Licensed Practical Nurse (LPN) A said he/she expected staff to answer a call light to be answered in five minutes or less, if there were no emergent calls or activities occurring. During an interview on 11/27/24, at 10:53 A.M., Registered Nurse (RN) F said staff should answer a call light in less than five minutes if they were not taking care of an emergent situation. During an interview on 11/27/24, at 2:15 P.M., the Director of Nursing (DON) said she expected staff to answer a call light as quickly as possible and within 15 minutes barring no emergent situation. It was not acceptable for it to take 30 to 45 minutes or longer before staff answer a resident's call light. During an interview on 11/27/24, at 3:10 P.M., the Administrator said she expected staff to answer a call light within 15 minutes or as soon as possible as long as there was not an emergency occurring. It was not acceptable to her for staff to take 30 minutes to an hour to answer a call light. MO243484 MO243898 MO244336

Based on observation, interview, record review, and facility policy review, the facility failed to ensure two of 28 sampled residents (Resident (R)16 and R20) were free from abuse and neglect. On 4/7/24, Certified Nurse Aide (CNA) 7 refused to assist R16 out of bed, resulting in the resident laying in bed until the next shift arrived. On 4/8/24, R16 used her call light on the night shift to request help for repositioning. R16 continued to use her call light for assistance because no one came. R16 reported two agency staff members came into her room and said she was calling too much. When she informed the staff members that she would continue to call until someone helped her, one of the staff yanked the call light out of her hand, threw it on the floor, and told her that she would be sorry if she continued to call. On 4/7/24, the CNA assigned to R20 refused to help him/her get out of bed, told the resident to hurry up, and pushed her. When asked to not push her because she would fall down, the CNA told him/her to just hurry up then. R20 stated she felt like the incident was mental abuse. On 4/8/24, the night shift aide refused to help R20 into bed and provide incontinent care to him/her. R20 remained up in his/her wheelchair until 3:00 AM, and at that time, she told the aide that she would change her own brief. R20 stated she could not reach her briefs and remained in the same brief until the day shift when Nurse Aide (NA)1 changed his/her brief. R16 and R20 reported they had been neglected to facility staff; however, no action was taken. CNA 7 continued to work on R16's hall on 4/9/24, placing the resident at risk for continued abuse and neglect. The facility census was 82. The administrator was notified on 04/09/24 at 7:47 PM of the Immediate Jeopardy, which began on 04/07/24. Findings include: Review of the facility's policy titled, Abuse Prevention and Prohibition Program, revised 10/24/22, revealed, . Each resident has the right to be free from mistreatment, neglect, abuse . Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation . Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect . is at risk for occurring . Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met . Physical Neglect . Inadequate provision of care .Caregiver indifference to resident's personal care and needs . Facility Staff are Mandatory Reporters . 1. Review of R16's Admission Record, provided by the facility, revealed R16 was admitted to the facility on [DATE] with diagnoses that included contractures, difficulty walking, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) of the left side. Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/24, revealed R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R16 was cognitively intact. The MDS showed R16 required substantial to maximum assistance with transfers. During an interview on 04/08/24 at 10:50 A.M., R16 reported that on 04/07/24, during the morning hours on the day shift, she asked Certified Nurse Aide (CNA) 7 to help her get out of bed. R16 stated CNA7 replied, I don't want to, but I guess I have to. R16 reported that she asked CNA7 if that was not her job and that CNA7 replied, If you want to get up, you do it. R16 reported CNA7 refused to get her out of bed. R16 stated the CNA was hateful and it made her angry. R16 stated the CNA would not provide her name. R16 stated she remained in bed until the evening shift when LPN1 and an unidentified CNA helped her get out of bed. R16 stated she reported the allegation of neglect to Licensed Practical Nurse (LPN) 1 at that time. During an interview on 04/09/24 at 12:08 P.M., LPN1 confirmed that on 04/07/24, R16 had reported the allegation of neglect to her. LPN1 stated she and a CNA took care of R16, making sure she was clean, dry, and comfortable. LPN1 confirmed the facility's policy was to report allegations of neglect to nursing management and that the Assistant Director of Nursing (ADON) had been on call supervisor on 04/07/24. During an interview on 04/09/24 at 12:46 P.M., the ADON was asked who the CNA was that was assigned to R16 and her hall on 04/07/24. The ADON reviewed staffing schedules and the EMR of residents and stated three of the aides who worked on 04/07/24 were here on this day. During an observation and interview on 04/09/24 at 12:57 P.M., the ADON and surveyor observed CNA7 working in the facility, providing direct care to residents. CNA7 confirmed to the ADON and surveyor she was assigned to R16 and the other residents on the 100 hall on the day shift on 04/07/24. During an interview on 04/09/24 at 1:01 P.M., while confirming with R16 that CNA7 was the agency staff member who refused to get her out of bed on 04/07/24, R16 reported she had used her call light on the 04/08/24 night shift to request help for repositioning. R16 stated she continued to use her call light for assistance because no one came. R16 reported that two agency staff members came into her room and told him/her she was calling too much. R16 stated she did not know the staff members' names. R16 stated she informed the staff members that she would continue to call until someone helped her. R16 stated one of the staff yanked the call light out of her hand, threw it on the floor, and told her that she would be sorry if she continued to call. R16 stated she had not reported the incident to anyone, but that R20 had trouble on the shift as well. 2. Review of R20's Admission Record, provided by the facility, revealed R20 was admitted to the facility on [DATE] with diagnoses that included polyarthritis, muscle wasting, repeated falls, and need for assistance with personal care. Review of R20's annual MDS, with an ARD of 02/09/24, revealed R20 had a BIMS score of 15 out of 15, which indicated R20 was cognitively intact. The MDS recorded R20 required partial to moderate assistance with transfers. During an interview on 04/08/24, R20 stated on 04/07/24 on the day shift, around 12:00 P.M., the CNA assigned to her hall refused to help him/her get out of bed. R20 stated the CNA eventually helped her and kept telling her to hurry up and started to push her. R20 stated the CNA told her this was not her usual assignment and I was just stuck down here so if you could just hurry up. R20 stated she asked the CNA not to push her because she would fall down. R20 stated the CNA told him/her to just hurry up then. R20 stated she had written the aide's name down but could not find it. R20 stated she felt like the incident was mental abuse. R20 stated she had not reported the incident to anyone. During an interview on 04/09/24 at 1:06 P.M., R20 reported that the night shift aide on the previous shift had refused to help her into bed and provide incontinent care to him/her. R20 stated he/she remained up in his/her wheelchair until 3:00 AM, and at that time, she told the aide that she would change her own brief. R20 stated she could not reach her briefs and remained in the same brief until the day shift when Nurse Aide (NA)1 changed his/her brief. R20 stated she reported the incident to NA1. During an interview on 04/09/24 at 1:10 P.M., NA1 confirmed R20 had reported the allegation of neglect to her. NA1 stated the facility's policy was to report allegations of neglect; however, she did not take any further action. NA1 stated she felt R20's incontinent brief had not been changed since she had finished her shift on 04/08/24 because she had inadvertently torn the plastic on the top of the brief when providing care on 04/08/24, and the brief R20 was wearing on the morning of 04/09/24 was torn in the exact same place. The facility provided an acceptable plan for removal of the immediate jeopardy on 04/11/24 at 12:34 PM. The survey team validated the immediate jeopardy was removed on 04/11/24. The deficient practice remained at a D scope and severity following the removal of the immediate jeopardy.

Based on interview, record review, and facility policy review, the facility failed to ensure allegations of neglect were reported to supervisors and/or the facility's Abuse Coordinator for two of 28 sampled residents (Resident (R)16 and R20). R16 reported allegations of neglect involving Certified Nurse Aide (CNA) 7 to Licensed Practical Nurse (LPN) 1. LPN1 did not report the allegations to the on-call nursing supervisor, Director of Nursing (DON), or Administrator, who was the facility's Abuse Coordinator. R20 reported allegations of neglect to (Nurse Aide) NA1. NA1 did not report the allegations to her supervisor or the facility's Abuse Coordinator. The facility census was 82. The administrator was notified on 04/09/24 at 7:47 PM of the Immediate Jeopardy, which began on 04/07/24. Findings include: Review of the facility's policy titled, Abuse Prevention and Prohibition Program, revised 10/24/22, revealed, . Each resident has the right to be free from mistreatment, neglect, abuse . Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect . is at risk for occurring . Facility Staff are Mandatory Reporters . 1. Review of R16's Admission Record, provided by the facility, revealed R16 was admitted to the facility on [DATE] with diagnoses that included contractures, difficulty walking, and hemiplegia and hemiparesis of the left side. Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/24, revealed R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R16 was cognitively intact. The MDS recorded R16 required substantial to maximum assistance with transfers. During an interview on 04/08/24 at 10:50 A.M., R16 reported that on 04/07/24, during the morning hours on the day shift, she asked Certified Nurse Aide (CNA) 7 to help her get out of bed. R16 stated CNA7 replied, I don't want to, but I guess I have to. R16 reported that she asked CNA7 if that was not her job and that CNA7 replied, If you want to get up, you do it. R16 reported CNA7 refused to get her out of bed. R16 stated the CNA was hateful and it made her angry. R16 stated the CNA would not provide her name. R16 stated she remained in bed until the evening shift when LPN1 and an unidentified CNA helped her get out of bed. R16 stated she reported the allegation of neglect to Licensed Practical Nurse (LPN) 1 at that time. During an interview on 04/09/24 at 12:08 PM, LPN1 confirmed that on 04/07/24, R16 had reported the allegation of neglect to her. LPN1 confirmed the facility's policy was to report allegations of neglect to nursing management and that the Assistant Director of Nursing (ADON) had been the on call supervisor on 04/07/24. LPN1 confirmed she did not report the allegation of neglect to her supervisor, the on-call supervisor, or the Administrator. LPN1 stated she had overlooked notifying the on-call supervisor. During an interview on 04/09/24 at 12:30 PM, the ADON confirmed the facility's policy was to report allegations of neglect immediately. The ADON confirmed she had been the on-call supervisor on 04/07/24 and confirmed she did not receive a call regarding an allegation of neglect. 2. Review of R20's Admission Record, provided by the facility, revealed R20 was admitted to the facility on [DATE] with diagnoses that included polyarthritis, muscle wasting, repeated falls, and need for assistance with personal care. Review of R20's annual MDS, with an ARD of 02/09/24 and located in the EMR under the MDS tab, revealed R20 had a BIMS score of 15 out of 15, which indicated R20 was cognitively intact. The MDS recorded R20 required partial to moderate assistance with transfers. During an interview on 04/09/24 at 1:06 P.M., R20 reported that the night shift aide on the previous shift had refused to help her into bed and provide incontinent care to him/her. R20 stated he/she remained up in his/her wheelchair until 3:00 AM, and at that time, she told the aide that she would change her own brief. R20 stated she could not reach her briefs and remained in the same brief until the day shift when Nurse Aide (NA)1 changed his/her brief. R20 stated she reported the incident to NA1. During an interview on 04/09/24 at 1:10 PM, NA1 confirmed that R20 had reported the allegation of neglect to her. NA1 stated the facility's policy was to report allegations of neglect and confirmed she did not tell her supervisor, the Director of Nursing, or the Administrator. During an interview on 04/09/24 at 2:26 PM, the Administrator confirmed he was the facility's Abuse Coordinator and that all allegations of abuse and neglect should be reported to him. The Administrator confirmed the facility's policy was for allegations of neglect to be reported immediately. The Administrator confirmed he had not been informed of any allegations of neglect related to R16 and R20. The facility provided an acceptable plan for removal of the immediate jeopardy on 04/11/24 at 12:34 PM. The survey team validated the immediate jeopardy was removed on 4/11/24. The deficient practice remained at a D scope and severity following the removal of the immediate jeopardy.

Based on interview, record review, and facility policy review, the facility failed to provide pain management for one of four sampled residents (Resident (R) 20) reviewed for pain out of a total sample of 28 residents. R20 was without pain medication for three days. R20's pain was not assessed, the Director of Nursing (DON) was not notified, and non-pharmacological interventions to help relieve the resident's pain during the three-day period were not attempted. This failure resulted in actual harm for R20. The facility census was 82. Findings include: Review of the facility's policy titled, Pain Management, revised 10/24/22, revealed, . Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain . The Licensed Nurse will assess the resident for pain and document results on the MAR each shift . Review of R20's Admission Record, provided by the facility revealed R20 was admitted to the facility on [DATE] with diagnoses that included poly osteoarthritis, polyneuropathy, chronic pain, and fibromyalgia. Review of R20's Physician Orders, dated 12/01/22 and located under the Orders tab of the electronic medical record (EMR), revealed R20 was to receive hydrocodone-acetaminophen (Norco, an opioid analgesic) 10/325 milligrams (mg) two tablets by mouth every six hours as needed (prn) for moderate pain, not to exceed five tablets in a 24-hour period. Review of R20's Care Plan, dated 12/29/23 and located under the Care Plan tab of the EMR, revealed a focus related to pain medication therapy. The goal was R20 would be free of any discomfort or adverse side effects from pain medication. Interventions included administering analgesic medications as ordered by the physician. Review of R20's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/24 and located under the MDS tab of the EMR, revealed R20 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R20 was cognitively intact. It was recorded R20 was on a scheduled pain medication regimen, did not receive prn pain medications, was frequently in pain, her pain occasionally interfered with day-to-day activities, and R20 rated her pain at a 9 on a zero to 10 scale, with zero being no pain and 10 being the worst pain imaginable. Review of R20's physician Encounter Note, dated 02/19/24 and located under the Progress Notes tab of the EMR, revealed, . Patient states that her chronic pain is better with the 2 Norco at noon, she states at night she tends to have pain when she wakes up, she is in some pain, she was asking if something else could be done . I will change the Norco from 2 of the 10/325 at noon to 2 tablets at noon and 1 tablet at bedtime . Review of R20's Physician Orders, dated 02/19/24 and located under the Orders tab of the EMR, revealed R20 was to receive hydrocodone-acetaminophen 10/325 mg, two tablets by mouth in the afternoon for pain and one tablet by mouth at bedtime for pain. R20 continued to have the above referenced prn medication order. Review of R20's Progress Notes, dated 03/28/24 at 12:21 PM through 03/30/24 at 4:27 PM and located under the Progress Notes tab of the EMR, revealed the following: 03/28/24 at 12:21 PM - . HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 2 tablet by mouth in the afternoon for pain medication unavailable no script [prescription] for refill cant [sic] pull from ekit [emergency kit] . 03/28/24 at 6:51 PM - . HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth at bedtime for pain Unavailable. Awaiting new prescription. Request sent per day nurse . 03/29/24 at 1:11 PM - . HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 2 tablet by mouth in the afternoon for pain No Script, pharmacy and office for [physician name withheld] contacted for new script . 03/30/24 at 4:27 AM - . HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth at bedtime for pain not available on med [medication] cart rx [pharmacy] called, awaiting prescription, per rx md [physician] was contacted . 03/30/24 at 11:54 AM - . HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 2 tablet by mouth in the afternoon for pain on order, pharmacy aware, script is needed from MD . Review of R20's Medication Administration Records, dated 03/28/24 through 03/30/24, located under the Orders tab of the EMR revealed no documented evidence R29 received her hydrocodone/acetaminophen as ordered by the physician from 03/28/24 through 03/30/24. This was a total of six missed doses. There was no documented evidence R20's pain level was assessed from 03/28/24 through 03/30/24; during the time she did not receive her ordered hydrocodone/acetaminophen. There was no documentation of any non-pharmacological interventions that were attempted during that time to help with R20's pain. There was no documentation the Director of Nursing (DON) was notified R20 was without her pain medication. Review of R20's Care Plan, dated 04/09/24 and located under the Care Plan tab of the EMR, revealed a focus related to acute/chronic pain. The goal was R20 would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions included administering analgesia as per orders. During an interview on 04/08/24 at 12:25 PM, R20 stated her pain could be bad. R20 stated the pain was located in her shoulders; right leg, especially the knee; and she had rods in her legs. R20 stated when she received her pain medication, it would bring her pain down to about a 6, but when the pain medication wore off, it would get higher and higher. She stated her pain would be at a 9 or 10 when she woke up, but the pain medication did help to make the pain tolerable. R20 stated the pain kept her from sleeping or doing activities at times. R20 stated at the end of March 2024, there was a time when her pain medication was not available for some reason, and it was rough when that happened. R20 stated staff did not do anything different when she was without her pain medications, and she was not offered anything else. R20 stated she would just sit if she did not have her medication or if the pain level was too high. She stated it was too painful to move without her pain medication. R20 stated she did take a muscle relaxer and gabapentin for nerve pain, but it required all the medications to keep her pain tolerable. During an interview on 04/09/24 at 1:00 PM, Nurse Aide (NA) 1 was asked if R20 had pain. NA1 stated yes. She stated when R20 was experiencing increased pain, she would tell the nurse. NA1 stated R20 had been without pain medication not long ago, and R20 had not done much during that time, because she was hurting too bad. During an interview on 04/12/24 at 9:10 AM, the Director of Nursing (DON) reported that agency staff were assigned to R20's hall on this day. The DON stated the process for reordering narcotic medications was to fax the request to the pharmacy, and if a new prescription was required, the pharmacy would contact the physician. During an interview on 04/12/24 at 2:00 PM, the DON and Regional Nurse Consultant (RNC) 2 were asked if they were aware R20 had been without her pain medication from 03/28/24 through 03/30/24. The DON stated, No. They were asked what they would have expected staff to do. The DON stated, Call the doctor, and if he could not get that, give her something else, and notify me. The DON stated she would have called the doctor on the direct number she has for him. The DON confirmed R20 should not have gone three days without her pain medication. The DON was asked what staff did to help relieve R20's pain during that time. The DON stated she would have to research and get back to the surveyor with that information. No further information was provided before the end of the survey.

Based on observation, interview, and record review the facility failed to ensure one of 23 sampled residents (Resident #1) with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (disorder in which a person experiences a combination of symptoms such as hallucinations or delusions and mood disorder symptoms such as depression or mania); paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and often the person feels distrustful and suspicious of others), received appropriate treatment and services when staff failed to develop interventions to address the resident's behaviors. Staff were aware of Resident #1's history of behaviors and were aware the resident was known to steal, make accusations, intimidate, and curse at other residents. Resident #2 reported Resident #1 cursed at him/her in the smoke area, entered his/her room on more than one occasion without permission, and took items from him/her. Resident #2 barricaded his/her room door at night due to being fearful of Resident #1 and said he/she was afraid Resident #1 would hurt him/her. Staff described Resident #1 as a bully who intimidated other residents. The facility census was 80. Review of the facility's Behavioral Assessment, Intervention and monitoring policy, last revised March 2019, showed the following: -The facility will provide and residents will receive behavioral health services needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment; -Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents; -Residents will have minimal complications associated with the management of altered or impaired behavior; -Behavior is the response of an individual to a wide variety of factors, these factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes; -Behaviors can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express symptoms that can be managed by treating underlying factors, and those that cannot; -The level II evaluation report will be used when conducting the resident assessment and developing the care plan; -As part of the comprehensive assessment staff will evaluate, based on input from resident, family caregivers, review of medical record and general observations, the resident's usual patterns of cognition, mood and behavior; -The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers. The resident's previous patterns coping with stress, anxiety and depression; -The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address factors that may have contributed in change in condition; -Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs; -If the resident is being treated for altered behavior or mood, the Interdisciplinary Team (IDT) will seek and seek and document any improvements or worsening in the resident's behavior, mood and function. 1. Record review of Resident #1's Preadmission Screening and Resident Review (PASSR; a federal assessment utilized to ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) Level II, dated 2/22/23, showed the following: -The resident was stable on his/her medications but he/she was labile (can change quickly), irritable, and unapproachable. The resident had multiple outbursts; -The resident had been receiving services through the Department of Mental Health since 1994; -Major mental illness included bipolar disorder and schizoaffective disorder; -Assessment and implementation of behavioral support plan include monitoring of behavioral symptoms and provision of behavioral supports; -Agitation should be addressed in the plan of care; -Medication therapy and monitoring services with psychiatric follow up to prescribe and manage medications; -Provide individualized personal space, establish consistent routines, provide schedule of daily tasks, provide instruction at the individual's level of understanding, assess and plan for the level of supervision required to prevent harm to others; -Assess, plan and develop appropriate personal support network through community and social connections. Review of the resident's care plan, last revised 5/12/23, showed the following: -The resident used anxiety medications related to anxiety disorder; -Document/report any adverse reactions to antianxiety medications such as mania, hostility, rage, impulsive or aggressive behavior or hallucinations -Arrange for psychiatric consult per orders, follow up as indicated; -The resident had behaviors related to bipolar disorder, depression and anxiety. The resident's condition can cause him/her to become manipulative, and he/she was known to make false accusations and curse at others; -Record/report to the physician as needed for harming others, increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; -Document and report any signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. Review of the resident's care plan, revised 5/16/23, showed the following: -The resident had a psychosocial well-being problem related to his/her psychiatric diagnoses. Allow the resident time to answer questions and to verbalize feelings, perceptions and fears; -Encourage participation from resident, who depends on others, to make own decisions. Review of the resident's care plan, dated 7/6/23, showed staff should avoid accusatory remarks or confrontation of any kind. Review of the resident's IDT note, dated 9/15/23 at 4:24 P.M., showed the following: -The resident had episodes of outbursts, cursed towards staff and had a tendency to be argumentative with other residents or raise his/her voice to them; -One minute the resident was happy, and the next minute sobbing or yelling; -Staff reported that they had witnessed the resident break his/her bipolar medication in half and destroy one half; -The resident's nurse practitioner was in the facility and staff spoke to him/her about options at this time due to increased episodes of outbursts; -Offered inpatient verses outpatient psychiatric intervention; -The resident agreed to take full ordered doses of medication; -If there were continued outbursts, staff may need to intervene sooner, if the resident did not follow physician recommendations for emotional, psychiatric support staff would request inpatient evaluation at that time. Review of the resident's psychosocial note, dated 9/26/23 at 10:42 A.M., showed the resident called Resident #2 a bitch three times. Staff spoke with two other residents that were in the smoke area and witnessed the remarks and it was confirmed, both residents said they were fearful of the resident. Review of the resident's care plan, revised 9/27/23, showed the following: -On 9/26/23 the resident was sent to the emergency room due to threatening to harm others and labile mood; -On 9/27/23 the resident was placed on one on one observation with assigned staff to monitor behavior for any risk of harm to others for the first 24 hours after his/her return from the hospital. Review of the resident's social service note, dated 9/28/23 at 11:03 A.M., showed the following: -The resident returned to the facility on [DATE]; -That morning, another resident expressed concern and fear that the resident was back in the building. Resident #2 hung a bell on his/her room door so he/she could hear if the resident entered his/her room; -At this time staff provided one on one supervision of the resident. Review of the resident's IDT note, dated 9/29/23 at 7:40 P.M., showed the following: -Discussed resident behaviors. The resident recently returned from the hospital with no new interventions, all previous psychiatric medication orders were resumed; -Set up appointment with psychiatrist as soon as possible. The resident has a mood disorder; -The resident had been one on one with staff supervision for the first 24 hours after return from the hospital due to other residents voicing fear and concerns; -The resident voiced frustration with being supervised so closely. Staff would continue to monitor behaviors and intervene as needed. There was no documentation found in the resident's record the facility attempted to set up an appointment with a psychiatrist for the resident or that the resident had ever refused any offered psychiatric treatment. Review of the resident's care plan showed no evidence staff updated or attempted to implement any additional interventions to address the resident's hostile and disruptive behaviors witnessed in the smoke room when the resident cursed at another resident on 9/26/23, other than staff providing one on one supervision of the resident for 24 hours. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 9/29/23, showed the following: -The resident was cognitively intact; -Verbal behaviors directed towards others (threatening at others, cursing at others, screaming at others) occurred daily; -Independent with eating, dressing and walking. Review of the resident's nursing note, dated 10/8/23 9:32 P.M., showed the resident was seen in another resident's room arguing with the resident and the nurse aide (NA). Review of Resident #2's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 11/15/23 at 7:50 A.M. Resident #2 said the following: -Resident #1 ran the halls all night long and he/she was afraid of Resident #1; -Resident #1 had taken things from him/her; -Resident #1 had come in his/her room twice in the night without permission and it frightened him/her; -Resident #1 was mean; -Resident #1 cursed at him/her in the smoke area; -The nursing staff basically let the resident do whatever he/she wanted to do; -Resident #1 was coming back to the facility and Resident #2 had his/her guard up so he/she didn't get hurt. During interview on 11/13/23 at 8:00 A.M. Certified Nurse Aide (CNA) K said the following: -Resident #1 was very manipulative and a bully; -The resident picked on residents and intimidated other residents by cursing, yelling and staring at them for long periods of time; -Resident #1 would stare at other residents and call them a bitch; -Resident #1 went all over the building. Staff tried to redirect the resident, but that didn't always work; -Resident #1 was inappropriate for the facility because of his/her behaviors; -Resident #2 barricaded his/her door at night because of Resident #1. Resident #2 would open his/her closet door so that he/she would hear if Resident #1 attempted to come into his/her room. The door to his/her room would hit the closet door and it would awaken Resident #2; -Resident #1 had entered Resident #2's room and cursed at him/her before. During an interview on 11/15/23 at 8:55 A.M. Certified Medication Technician (CMT) C said the following: -Resident #2 picked on other residents and intimidated them; -Resident #2 yelled and cursed at the residents when they smoked outside, he/she called other residents a bitch or would tell them shut the fuck up; -Administration did not know what to do with the resident; -He/She tried to avoid much interaction with the resident. CMT C passed the residents medications but that was it. During an interview on 11/14/23 at 10:45 A.M. the social service designee said the following: -The resident had severe mental illness and was a bully. The social service designee tried to redirect the resident's behaviors and the resident would immediately go back to what he/she was doing when he/she walked away; -The resident cursed at other residents. Staff tried to redirect the resident but he/she would continue with the behaviors; -The resident took things from residents; -The resident was very manipulative; -The resident cursed at Resident #2 in the smoke area often and also at other residents. Staff tried to redirect the resident but that was unsuccessful; -The resident needed to be in a mental health facility; -The resident was his/her own person and refused any psychiatric services. During an interview on 11/15/23 at 10:00 A.M. the Director of Nursing (DON) said the following: -The facility could not manage the resident's behaviors; -Resident #1 had severe mental illness and was not appropriate for the facility; -Facility staff did not have the training to care for Resident #1; -The resident bullied others and that was his/her baseline; -The DON had directed staff to basically provide care based on what the resident needed, but not to really speak with the resident; -The DON instructed the Assistant Director of Nurses to not allow the resident into his/her office to visit or to speak with her; -The resident was his/her own person. The DON would have to check to see if the resident was followed by any psychiatric services but that would be the resident's choice; -The DON was not sure if the resident was seen by the Department of Mental Health. During an interview on 11/15/23 at 2:15 P.M. the administrator said the following: -The resident was not appropriate for placement in the facility; -The resident needed to be in a mental health facility where staff were trained to manage his/her behaviors. MO227090

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #9 and #11), of twelve sampled residents, who required assistance with activities of daily living (ADLs), received care in a manner that enhanced the residents' quality of life and provided for a dignified existence. Staff failed, repeatedly, to respond to the residents' call lights in a timely manner resulting in both residents soiling themselves and laying in urine and/or feces for an extended amount of time. Resident #9 reported having to scream and yell for staff as they did not respond to the call light, while lying in feces for hours. This made the resident cry and caused him/her to be angry. Resident #11 lay in feces for 30 minutes before staff responded to his/her call light. The resident's skin was noted to be red with imprints of the resident's brief in his/her skin. The resident said his/her skin itched and was irritated as a result. The facility census 73. Review of the facility's policy, Answering the Call Light, dated March 2021, showed the following: -The purpose of this procedure is to ensure timely response to the resident's requests and needs; -When answering from the call light station, turn off the signal light; -Identify yourself and politely respond to the resident by his/her name; -If the resident needs assistance, indicate the approximate time it will take to respond; -If the request requires another staff member, notify the individual; -If the resident's request is something you can fulfill, complete the task as quick as possible; -If you are uncertain as to whether or not a request can be fulfilled or if you can cannot fulfill the resident's request, ask the nurse supervisor for assistance; -Document any significant requests or complaints made by the resident and how the request or complaint was addressed. Review of the facility's Resident Rights policy, revised December 2016 showed the following: -Employees shall treat residents with kindness, respect and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: -Dignified existence; -To be treated with respect, kindness, and dignity; -Self-determination; -Privacy and confidentiality. Review of the resident council meeting minutes, dated March 2023, showed a concern with nursing, call lights take too long to be answered. Review of the resident council meeting minutes, dated April 2023, showed nursing aides were taking too long to answer call lights. The residents were waiting for two hours for assistance. 1. Review of the Resident #11 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 3/23/23; showed the following: -Cognitively intact; -Total dependence of two staff members with bed mobility, transfers, and toilet use; -Extensive assistance of one staff member with personal care; -Functional limitation in range of motion in upper and lower extremities on one side; -Frequently incontinent of bowel and bladder; -Diagnoses included cancer, renal insufficiency, dementia, and diabetes. Review of the resident's care plan, last revised, 4/10/23 showed the following: -The resident was totally dependent on staff for incontinent care; -The resident was totally dependent on staff for transferring; -Encourage the resident to use call bell for assistance; -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the facility call light log for Resident #11 showed the following: -On 4/20/23 at 8:12 A.M., the call light was unanswered for one hour and three seconds; -On 4/20/23 at 2:41 P.M., the call light was unanswered for 56 minutes and 5 seconds; -On 4/22/23 at 5:39 P.M., the call light was unanswered for two hours and 39 seconds; -On 4/23/23 at 10:07 A.M., the call light was unanswered for one hour and 57 seconds; -On 4/24/23 at 11:23 A.M., the call light was unanswered for 42 minutes and 11 seconds; -On 4/24/23 at 6:31 P.M., the call light was unanswered for three hours and 36 seconds; -On 4/28/23 at 2:28 P.M., the call light was unanswered for two hours and 17 seconds; -On 4/30/23 at 2:12 P.M., the call light was unanswered for one hour and 11 seconds; -On 5/1/23 at 5:52 P.M., the call light was unanswered for one hour and 23 seconds; -One 5/2/23 at 12:01 P.M. the call light was unanswered for 27 minutes and 41 seconds. Observation on 5/2/23 showed the following: -At 12:01 P.M., the monitor at the desk showed the resident's call light was on; -At 12:29 P.M. nurse management entered the resident's room. The resident said he/she needed to be cleaned up (he/she had an accident and was incontinent of feces). Nurse management said he/she would get the resident some assistance and he/she exited the resident's room; -At 12:36 P.M., Certified Nurse Assistant (CMT) N entered the room and said he/she would go get supplies and get the resident changed. During interview on 12:40 P.M., the resident said his/her light had been on for 30 minutes. He/She had an accident in bed, he/she was upset that he/she had to wait that long. He/She waited over an hour at night for his/her call light to be answered. His/her skin was irritated and itched due to not being changed timely. Observation on 5/2/23 at 12:43 P.M. showed the following: -CMT N entered the resident's room washed his/her hands and put on gloves, CMT N pulled the resident's bed linens back. The resident was wearing an incontinence brief. A large amount of feces had leaked out from the resident's incontinence brief and covered the cloth pad and bed sheet under the resident; -CMT N washed the resident's skin with a wash cloth, the resident's skin was red and had imprints of the incontinence brief to his/her skin, due to the extended period of being left soiled. 2. Review of Resident #9's care plan, revised 2/28/23 showed the following: -The resident has an activities of daily living self-performance deficit related to impaired balance, limited mobility, limited range of motion and pain. The resident was totally dependent on one staff member for dressing; -The resident was at moderate risk for falls. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility, transfers and dressing; -Dependent on one staff member with toileting; -Always incontinent of bowel and bladder; -Diagnoses included cerebral vascular accident (CVA or stroke) diabetes and depression. Review of the facility call light logs for Resident #9 showed the following: -On 4/19/23 at 7:11 P.M., the call light was unanswered for one hour and 56 minutes; -On 4/19/23 at 2:31 P.M., the call light was unanswered for 52 minutes and 53 seconds; -On 4/19/23 at 5:03 P.M., the call light was unanswered for 39 minutes and 22 seconds; -On 4/20/23 at 2:31 P.M., the call light was unanswered for 47 minutes and 25 seconds; -On 4/20/23 at 4:55 P.M., the call light was unanswered for 44 minutes and 2 seconds; -On 4/22/23 at 5:36 P.M., the call light was unanswered for 35 minutes and 59 seconds; -On 4/23/23 at 1:03 P.M., the call light was unanswered for 43 minutes and 22 seconds; -On 4/23/23 at 8:12 P.M., the call light was unanswered for 44 minutes and 2 seconds; -On 4/24/23 at 5:56 P.M., the call light was unanswered for one hour and 2 seconds; -On 4/25/23 at 11:00 A.M., the call light was unanswered for one hour and 54 minutes; -On 4/25/23 at 7:27 P.M., the call light was unanswered for one hour and 29 minutes; -On 4/26/23 at 5:02 A.M., the call light was unanswered for two hours and 21 minutes; On 4/27/23 at 8:40 A.M., the call light was unanswered for one hour and 11 minutes; -On 4/27/23 at 2:31 P.M., the call light was unanswered for one hour and seven minutes; -On 4/28/23 at 7:21 A.M., the call light was unanswered for one hour and 2 minutes; -On 4/28/23 at 10:48 A.M., the call light was unanswered for one hour and 45 minutes; -On 4/28/23 at 5:54 P.M., the call light was unanswered for two hours and 13 minutes; On 4/29/23 at 11:27 A.M., the call light was unanswered for 56 minutes and 38 seconds; -On 4/30/23 at 7:56 A.M., the call light was unanswered for one hour and 8 seconds; -On 5/1/23 at 8:59 P.M., the call light was unanswered for three hours and nine seconds; -On 5/2/23 at 1:18 A.M., the call light was unanswered for 46 minutes and three seconds. During interview on 5/2/23 at 1:45 P.M. the resident said the following: -He/She often waited hours for his/her call light to get answered; -Sometimes staff answered his/her light and said they would be back, and he/she would wait for hours for them to return to assist him/her with cares; -He/She waited so long that when he/she saw staff walk by, he/she yelled out, please help me, he/she would scream at the top of his/her lungs for help; -He/She cried and it made him/her angry waiting for assistance; -He/She laid in feces for hours, the feces would dry on his/her skin and it made his/her skin sore. During interview on 5/2/23 at 4:10 P.M. the Director of Nursing (DON) said nursing staff should answer a resident's call light within ten minutes, staff should at least answer the lights and acknowledge it was on and when they will be back if assisting another resident. During interview on 5/16/23 at 1:35 P.M., the administrator said the following: -She would expect call lights be answered within 15 minutes to care for residents and meet their needs; -Nursing staff sometimes forget to turn off call lights when they leave a resident's room; -The nursing staff need education on timeframe's for answering call lights. MO217621

Based on observation, interview and record review, the facility failed to consistently follow one of twelve sampled resident's (Resident #7's), care plan for wandering and intrusive behaviors by providing pleasant diversions, structured activities, food, conversation, television, or a book and to keep the resident in a supervised area. The resident presented with diagnosis of dementia, wandered in and out of other residents' rooms uninvited and took food from other residents' plates. This disturbed residents including (Resident #6, #9, and #10), who reported Resident #7's behavior made them upset and angry. The census was 73. Review of the facility's policy titled Dementia-Clinical Protocol, revised November 2018, showed the the following: -The interdisciplinary team (IDT) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes; -The staff and physician will review the current physical, functional, and psychosocial status of individuals with dementia, and will summarize the individual's condition, related complications, and functional abilities and impairments; -For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life; -Nursing assistants will receive initial training in the care of resident's with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews; -The facility will strive to optimize familiarity through consistent staff-resident assignments; -Direct care staff will support the resident in initiating and completing activities and tasks of daily living. bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed; -The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise; -Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation; -Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT; -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician; -The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions. 1. Review of Resident #7's quarterly MDS dated [DATE] showed the following: -Short and long term memory loss; -Cognitive skill for daily decision making was severely impaired; -No behavioral symptoms exhibited; -Wandering occurred daily; -Wandering impact was not completed; -Extensive assistance of one staff member with transfers,; -Independent with locomotion on and off the unit with setup help only; -Independent with eating, required setup help only; -Utilized a wheelchair; -Diagnoses included dementia. Review of the resident's care plan, revised 2/24/23, showed the following: -The resident was an elopement risk due to behavior of wandering, related to impaired safety awareness. The resident wandered aimlessly and significantly intrudes on the privacy of activities; -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book (initiated on 11/9/22); -Keep in supervised area while he/she was up (initiated 2/24/23); -The resident had a wander guard (a monitoring device used for a resident at risk for wandering, an alarm sounds when a resident attempts to leave a safe area) (initiated 1/26/23); -The resident had a psychosocial well-being problem related to dementia and difficulty expressing self; -When need for new redirection occurs, remove resident to a calm safe environment and allow to vent/share feelings 2. Review of Resident #9's quarterly MDS dated [DATE] showed the following: -The resident was cognitively intact; -Vision was highly impaired; -Diagnoses included cerebral vascular accident (CVA or stroke) and depression. Observation on 4/30/23 at 3:50 P.M., showed the following: -Resident #7 sat in his/her wheelchair right up next to Resident #9's right side of his/her bed; -Resident #9 and his/her family member asked Resident #7 to please leave his/her room; -Resident #7 talked and ignored requests from Resident #9 to please leave his/her room; -Resident #7 remained in Resident #9's room until staff came in to remove Resident #7; -Resident #9 was visibly upset and tearful; -Resident #7 was not in a supervised area while up or provided with diversional activities as directed by the care plan. -Resident #7 wandered into Resident #9's room and remained there until staff came to remove him/her. During an interview on 4/30/23 at 3:50 P.M., Resident #9 said the following: -Resident #7 made him/her feel uncomfortable and he/she was scared; -There were four or five different residents that wandered into his/her room frequently and it terrified him/her because staff don't always respond; -The resident did not feel safe; -He/She could not close his/her room door because he/she felt claustrophobic. During an interview on 4/30/23 at 3:50 P.M., Resident #9's family member said the following: -Residents wandered into Resident #9's room frequently; -Resident #9 cannot close his/her door to stop it because he/she was claustrophobic; -Resident #9 called the family member crying all of the time and wanted out of the facility. During interview on 5/2/23 at 1:45 P.M., Resident #9 said the following: -Resident #7 wandered in his/her room. It scared and startled him/her especially at night; -He/She had poor vision in his/her right eye. Resident #7 would be right beside him/her before he/she knew the resident was in his/her room; -The resident turned on his/her call light so nursing staff could get Resident #7 out of his/her room. This happened often. The resident became tearful and said he/she felt helpless. Often staff didn't answer his/her call light for over an hour and the resident had to yell out when staff passed by to get Resident #7 out of his/her room. Observation on 5/2/23 at 12:08 P.M., showed Resident #7 eating his/her lunch at the table in the front dining room area. He/She picked up a bowl of applesauce off of the tray of the resident who was seated beside him/her, and ate the applesauce. There were no staff in the area to redirect the resident. Observation on 5/11/23 showed the following: -At 8:05 A.M., Resident #7 propelled his/her wheelchair into room [ROOM NUMBER] (not Resident #7's room), at the end of the hall. He/She picked up a stuffed animal at the end of one resident's bed while the resident slept. He/She pushed a wheelchair around in the resident's room; -At 8:18 A.M., Certified Nurse Aide (CNA) K walked into room [ROOM NUMBER] and pushed Resident #7 in his/her wheelchair out into the hall and told the resident he/she did not belong there. CNA K entered another resident's room and Resident #7 propelled himself/herself in the wheelchair, right back into room [ROOM NUMBER]. (Staff did not move the resident to a supervised area or provide him/her with a pleasant, diversional or structured activity as directed by the care plan); -At 8:24 A.M., Resident #7 propelled his/her wheelchair up to the dining room table where several residents ate their breakfast. He/She picked bacon up off of a resident's plate and began eating it. Various resident's yelled out, get away, get back, he/she eats off everyone's plate! Resident #6 yelled out Stop it, that's not your breakfast! Restorative Aide (RA) K responded and removed the plate from the table and redirected the resident to another table (where he/she placed a tray of food for the resident to eat). Staff failed to assure Resident #7 was in a supervised area during breakfast. RA K heard residents yelling and redirected the resident away from the table. 3. Review of Resident #6's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During interview on 5/11/23 at 1:15 P.M., the resident said the following: -Resident #7 was always stealing other resident's food from off of their tray. Resident #7 also went in other resident's rooms and stole food. Resident #7 wandered in his/her room and it made Resident #6 very angry; -The resident also went into other resident's rooms. It happens all the time. The next time Resident #7 took something, Resident #6 was going to call the police, it made him/her so angry. 4. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During interview on 5/2/23 at 11:00 A.M. Resident #10 said Resident #7 wandered in his/her room and would take his/her snacks and get in to his/her belongings, it was aggravating and Resident #10 said he/she would like privacy. Resident #7 wandered in his/her room at night and it startled him/her. During interview on 5/11/23 at 8:25 A.M. RA K said Resident #7 was confused and moved fast. Resident #7 ate food off other residents' plates. RA K tried to serve the resident his/her plate first if possible, so he/she would not bother other residents' plates. During interview on 5/11/23 at 8:15 A.M., Registered Nurse (RN) H said when Resident #7 got out of bed in the morning, he/she wandered the halls from front to back. Resident #7 wandered into resident rooms more in the evenings and on night shift. Some of the residents complained about Resident #7 touching things in their rooms or eating their snacks. Resident #7 was usually redirected and pleasant. During interview on 5/2/23 at 3:15 P.M. the Activity Director said Resident #7 wandered and was easily redirected. No residents have complained recently about him/her. The resident liked to take food because everyone gave him/her snacks. Staff members had stop signs they could put across the residents' doors if they asked for one. During interview on 5/11/23 at 3:40 P.M. the Director of Nursing (DON ) said the following: -She was not aware Resident #7 wandered at night or took food or snacks from other residents; -The facility had Velcro stop signs that could be put across resident's door that had issues with Resident #7 wandering in their room; -The resident was pleasant and usually easily redirected; -The facility needed to review the resident's interventions; -The resident may need to be moved to another facility or a memory care unit. During interview on 5/16/23 at 1:35 P.M. the administrator said the following: -Resident #7 needed to be in a locked dementia unit. The facility had made referrals but had not found one to accept the resident; -The resident's cognitive level made it hard for the resident to be redirected. When a resident in the facility reported having an issue with Resident #7, staff could put a Velcro stop sign across their room door.

Based on observation, interview, and record review, the facility failed to consistently implement, evaluate, and modify interventions, as necessary, to address falls for one resident (Resident #3), with a history of multiple falls, in a review of 12 sampled residents. The facility failed to complete consistent fall evaluations after each fall and to evaluate any contributing factors along with documentation of physical findings. Resident # 3 fell on [DATE] and sustained a two centimeter laceration requiring four sutures to the back of the head. The facility census was 73. Review of the facility's policy Assessing Falls, dated March 2018 showed the following: -The purposes of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff with identifying the causes of the fall; -Review the resident's care plan to assess for any special needs of the resident; -Equipment and supplies: -Equipment to assess vital signs; -Tools to assess resident's level of consciousness and neurological status if necessary; -If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities; -Complete an incident report not later than 24 hours after a fall occurs, the incident report should be completed by the nursing supervisor duty on at the time and submitted to the Director of Nursing (DON); -After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the resident was trying to do at the time the fall occurred; -Within 24 hours of the fall began to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairments, etc. - Evaluate chains of events and circumstances preceding a recent fall, including time of the fall time of the last meal, what the resident was doing, whether the resident was standing, walking, reaching or transferring from one position to another; -Whether the resident was among other person or alone, whether the resident was trying to get to the toilet, whether an environmental risk factors were involved (e.g., slippery floor, poor lighting, furniture or objects in the way, or whether there is a pattern of the fall for the resident; -When a resident falls, the following information should be recorded in the resident's medical record: -The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair); -Assessment data, including vital signs, and obvious injuries, interventions, first aid, or treatment administered, notification of the physician and family, as indicated, complete fall risk assessment, appropriate interventions taken to prevent future falls, the signature of the person recording the data; -Notify the following individuals when a resident falls, the resident's family, the attending physician, the director of nursing services and the nursing supervisor on duty. Review of the facility policy Fall Risk Assessment, dated March 2018, showed the following: -The nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information; -The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen; -The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL), capabilities, activity tolerance, continence, and cognition. 1. Review of Resident #3's fall risk assessment dated [DATE] showed the resident's fall risk score was 19, indicating a high risk for falls. Review of the resident's significant Change Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 3/22/23, showed the following: -Hearing was adequate; -Clear speech-distinct intelligible words; -Makes self-understood, rarely understands others; -Short and long-term memory problem; -Cognitive skills, severely impaired; -Inattention (difficulty focusing attention, easily distractible) and disorganized thinking (rambling or irrelevant conversation) continuously present; -No behavioral symptoms exhibited; -Total dependence on one staff member for bed mobility, transfers, dressing and toilet use; -Walking in room and corridor did not occur; -Locomotion on and off unit required supervision with one staff member physical assistance; -Not steady with moving from sitting to standing position, only able to stabilize with human assistance; -Walking and turning around and facing the other direction did not occur; -Moving on and off the toilet and surface to surface transfer, not steady only able to stabilize with human assistance; -No functional impairment in range of motion in upper and lower extremity; -Utilized a wheelchair; -Diagnoses included orthostatic hypotension (an increase in blood pressure upon assuming an upright condition) and dementia; -No falls since admission or previous assessment; Review of the resident's care plan, revised on 5/9/23, showed the following: -The resident was at high risk for falls related to deconditioning (changes in the body that occur during a period of time when you are not active), incontinence, psychoactive drug use, unaware of safety needs, vision and hearing problems. Be sure the resident's call light was in reach, encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance, ensure the resident is wearing appropriate foot wear, nonskid socks when mobilizing wheelchair, follow fall protocol (last revised 11/23/22); -The resident was at risk for falls, evaluate fall risk at admission and as needed, assist resident with ambulation and transfers, utilizing therapy recommendations; -Determine the resident's ability to transfer. If a fall occurred, alert provider, and initiate fall risk precautions; -When resident appeared anxious, move to area within field of vision of staff (initiated 12/20/22). Review of the resident's care plan, revised on 5/9/23, showed the resident attempted to stand in the dining room, unassisted on 4/24/23 and fell , no injury, provide three diversional activities (initiated 4/25/23). Review of the resident's nursing notes showed no evidence nursing staff documented the fall that occurred on 4/24/23, completed an assessment of the resident, or notified the family or the physician of the fall. Review of the resident's post fall evaluations showed no evidence staff completed a post fall investigation for the fall on 4/24/23 and evaluated for any contributing factors or potential root cause of the fall. Review of the resident's progress note dated 4/30/23 at 8:52 P.M., showed the following: -The resident was found on the floor in dining room. The fall was unwitnessed. The resident was assisted up from the floor by staff. Full body assessment completed. The resident had raised area above the right eye, unsure if area was there prior to fall; -Ice pack applied to the raised area. The resident was able to move extremities without difficulty or any complaints of pain. Neuro checks initiated. Staff transferred the resident to bed. Review of the resident's post fall evaluation, dated 5/1/23, showed the following: -Date and time of fall, 4/30/23 at 8:51 P.M.; -Reason for fall was left blank; -Pre-fall risk assessment and post fall risk assessment was left blank; -Did injury occur was left blank; -No documentation the provider was notified; -Was wheelchair involved or locked was left blank; -Footwear at the time of the fall was left blank; -No skin issues or pain; -Contributing factors, showed no change in environment; -No medication changes; -Physical findings note, was history of unsteady gait and weakness. (Documentation completed post fall showed the facility did not complete a thorough fall evaluation post fall to identify the possible root cause) Review of the resident's care plan, last revised 5/9/23 showed on 4/30/23 the resident fell , attempted to stand in dining room, no injury. (There was no evidence to show the facility updated the care plan with an intervention after the 4/30/23 fall). Review of the resident's progress note dated 5/4/23 at 9:58 P.M. showed the following: -Staff said they heard a noise and when he/she went down the hall, the resident was shaking the food cart and he/she ran to assist the resident, but the resident fell before staff got to the resident. The resident hit his/her head on the floor; -The resident was assisted and examined his/her head. The resident's head was bleeding. Vital signs were within normal limits.The resident was taken to the hospital. The physician could not be reached. The resident's family member was notified of the fall. Review of the resident's record showed no evidence a post fall evaluation was completed for the fall on 5/4/23, the facility did not evaluate for any contributing factors or root cause of the fall. Review of the resident's emergency department note dated 5/4/23 showed the following: -Laceration of occipital scalp (back of the head), closed head injury (nonpenetrating injury to the brain with no break in the skull), and fall; -Laceration repair, scalp location, occipital, 2 centimeters (cm) length by 10 millimeters (mm) depth, four sutures. Review of the resident's care plan dated 5/9/23 showed an entry to ask the physician to review medications (initiated 5/7/23). Review of the resident's care plan, revised 5/9/23, showed on 5/4/23 the resident fell in the hallway when the resident stood up and shook the food cart. The resident fell before staff could reach the resident and hit his/her head. Will add pommel cushion (a shaped cushion with a center pommel that is positioned between a resident's legs when the resident is seated on the cushion) to wheelchair once received from hospice (initiated 5/4/23). Review of the resident's progress note dated 5/5/23 at 3:37 A.M., showed the resident returned from the hospital around 3:05 A.M. The resident had four sutures in the back of his/head. Review of the resident's progress note dated 5/7/23 at 4:40 A.M., showed it was reported by a resident in the dining room that Resident #3 had gotten up out of his/her wheelchair and started to walk, and the other resident attempted to encourage Resident #3 to sit back down in his/her wheelchair. Per the resident in the dining room (witness to fall), that's when the resident fell towards the resident and bumped his/her knee and then fell to the floor and landed on his/her buttocks. Staff assessed Resident #3 and found no injury. The physician to be notified in the morning. Review of the resident's post fall evaluation, dated 5/7/23, showed the following: -Date and time of fall: 5/7/23 at 4:40 A.M.; -Pre-fall risk and post fall risk assessment was left blank; -Contributing factors was left blank; -Reason for fall, confusion, the resident forgets he/she can't walk. (Documentation completed post fall, showed the facility did not complete a thorough fall evaluation post fall to identify the possible root cause of the fall or any contributing factors to the fall). Review of the resident's progress note dated 5/7/23 at 3:14 P.M., showed the resident continued to stand and attempted to walk without assistance, constant redirection to stay in wheelchair was needed. Review of the resident's care plan last revised 5/9/23 showed staff would ask the physician to review the resident's medications (date initiated 5/7/23). Review of the resident's physician order dated 5/8/23 showed an order to decrease Trazodone (medication used to treat depression and anxiety) to 12.5 milligrams three times a day. Review of the resident's care plan, revised 5/9/23, showed on 5/8/23 fall in dining room with no injury. During an interview on 5/11/23 at 2:15 P.M., Nurse Assistant (NA) J said nursing staff watched the resident as close as possible. Staff never walked or got the resident up out of the wheelchair. The resident stayed in the dining room most of the time unless the resident needed to be changed. During interview on 5/11/23 at 2:15 P.M., Certified Medication Technician (CMT) M said the resident got up quickly and fell . Staff kept the resident up front in the dining room (by the nursing desk) to keep an eye on him/her. The resident needed to be one on one, but there wasn't enough staff for that. He/She was not aware of any activities the resident did or participated in. The resident sits in his/her wheelchair at the table in the dining room for most of the day, unless the resident needed to be changed. During interview on 5/11/23 at 3:18 P.M., the activity director said he/she did not do any activities with the resident due to the resident's cognition, the resident had no comprehension to do an activity. Occasionally the resident came up front for a movie or music, but he/she provided no one on one activities of any kind. Observations of the resident on 5/16/23, showed the following: -At 9:45 A.M., the resident sat in the dining room at the table with a salt shaker on the table, in front of the resident. There was no staff in the area, the resident attempted to move back in the wheelchair, the wheelchair brakes were locked. The resident was restless, reached toward the floor, picked up the salt shaker from off the table and sprinkled salt on the floor; -At 10:40 A.M., the resident remained at the dining room table, restless, looking around, no activity or diversional activity provided, no staff in the area; -At 11:15 A.M., the resident remained in the dining room, continued to look around, mumbled, pulled at wheelchair brakes, staff sat at desk, no diversional activities provided; -At 12:15 P.M., remained in dining room, no diversional activities provided by staff. During interview on 5/16/23 at 9:30 A. Licensed Practical Nurse (LPN) C said the following: -The resident has had a lot of falls, he/she was very confused and not redirectable due to dementia; -The resident was constantly trying to get up; -Other residents try to stop him/her from getting up; -Due to the resident's advanced stage of dementia, they were doing all they could do to keep the resident from falling, they could not watch the resident all day. During interview on 5/11/23 at 3:40 P.M., 5/25/23 at 10 :45 A.M. and 3:15 P.M. the Director of Nursing said the following: -The resident should have activities and should not just sit at a table, staff should report to the oncoming shift residents that were a high risk for falls, staff should refer to the care plan for any interventions for falls; -She would expect staff to document falls in the resident's progress note and complete a fall evaluation after each fall and include the details about a fall; -The facility had a daily morning meeting where the discussed any changes, including falls, and at that time the care plan was updated with any new interventions implemented; -The facility tried a pommel cushion the resident's wheelchair to slow the resident down. When the resident tried to stand up, staff just could not get to the resident fast enough. During interview on 5/16/23 at 1:35 P.M., the administrator said the following: -The resident fell at all different times and locations, the facility did not have the staff to be one on one with the resident; -She would expect a full assessment after a fall, and to call the DON for guidance, complete an incident report; -She would expect staff to follow care plan interventions for falls, diversional activities, have talked about ordering activities for resident's with dementia. MO218012

Surveyor: [NAME] Keen Based on observation, interview, and record review, the facility failed to protect one resident (Resident #2) from sexual abuse by another resident (Resident #1), in a review of ten sampled residents. Staff observed Resident #1 fondling Resident #2's genitalia and his/her own genitalia in Resident #2's room. Resident #2 did not have the ability to consent to sexual contact due to a diagnosis of dementia and impaired cognition. Resident #1 told facility staff during his/her admission assessment that he/she had touched his/her roommate inappropriately at his/her previous facility. Resident #3 said Resident #1 tried to touch him/her and made unwelcome advances towards him/her that made Resident #3 feel uncomfortable. Resident #3, Resident' #1's roommate at the time, chose to sleep in the common area as a result of Resident #1's inappropriate sexual behaviors. The facility census was 68. Review of the facility's Abuse and Neglect Prevention Program policy, revised April 2021, showed the following: -Resident have the right to be free from abuse. This includes sexual or physical abuse; -The program consists of a facility wide commitment to protect residents from abuse from anyone, including other residents; -The facility will develop and implement policies and protocols to prevent and identify abuse and mistreatment of residents; -Identify and investigate all possible incidents of abuse; -Protect residents from any further abuse during the investigation. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, psychotic mood disturbance, and anxiety. Review of the resident's care plan, dated 1/13/23, showed the following: -The resident has a history of sexually inappropriate behaviors; -The resident will maintain proper behavior at all times. Review of the resident's nurse's note, dated 1/17/23 at 10:51 A.M. (recorded as a late entry for 1/16/23, showed the following: -Resident #1 was in the writer's office and he/she was very nervous. Staff asked the resident what was wrong and Resident #1 said he/she was scared to tell staff. Resident #1 said when he/she was at the previous facility Resident #1 rubbed the head and back of his/her roommate and then moved on to the roommate's private area; -The staff member contacted the resident's previous facility and spoke with the social worker who said Resident #1 was under investigation and his/her family had taken the resident home and asked for all of the resident's information and did not return the resident to the facility; -Resident #1's family member did not inform the facility about the situation prior to admission on 1/13/23. Review of the resident's initial psychiatric consultation record, dated 1/17/23, showed the following: -Diagnoses included dementia with behaviors and anxiety; -The facility requested the practitioner to see the resident as he/she made sexual advances toward others at the previous facility; -The resident had been in this facility for a couple of days. The resident's roommate (Resident #3) was afraid to sleep in the room last night and came out to sleep in the day area as he/he is blind but did not report anything; -The resident said he/she was feeling bitchy and edgy lately and confused; -The resident remembered being at a previous facility and told the practitioner, I told them I did something and I touched my roommate and said he/she told on himself/herself; -The resident admitted doing this but said he/she wasn't sure why. He/She felt bad about it and the anxiety medication wasn't working because he/she was still very anxious; -If the resident exhibits any sexual behaviors the practitioner would consider Provera (medication that lowers testosterone levels and lowers sexual drive). Review of the resident's Minimum Data Set (MDS, a federally required assessment instrument required to be completed by facility staff) dated 1/19/23, showed the following: -room [ROOM NUMBER] B (roommate of Resident #3); -Diagnoses of dementia, anxiety, and depression; -Cognition was moderately impaired; -Independent with transfer and walking; -No limits to range of motion; -No behaviors exhibited. Review of Resident #1's nurse's note, dated 3/30/23 at 4:40 P.M. showed staff found the resident in another resident's room at 2:30 P.M. The resident was found with his/her hands in another resident's pants touching him/her inappropriately while touching himself/herself. Staff immediately removed the resident from the room. The resident's behavior was reported to the assistant Director of Nursing (ADON) and the administrator. The resident was moved to a private room for the time being. Will request psychiatric evaluation and treatment for behavior. Call placed to physician and awaiting a call back. Family has been notified. Review of the facility's investigation, dated 3/30/23, showed the following: -Staff was completing rounds when staff observed Resident #1 had his/her hands on Resident #2's private area; -Staff confronted Resident #1 and he/she put his/her hands on Resident #2's chest and said he/she was trying to wake up Resident #2; -Staff immediately removed Resident #1 from Resident #2's room and moved Resident #1 to a room by himself/herself; -Resident #1 was placed on 15 minute checks and was advised that he/she had to remain in a supervised area or in his/her room; -Assessment completed for Resident #2 showed no injury; -Social service staff interviewed Resident #1 who said he/she touched Resident #2; -Staff notified the police of the incident; -Staff were instructed to monitor Resident #2 at all times when not in his/her room. Review of a written statement from Certified Nurse Aide (CNA) D, dated 3/30/23, provided by the facility, showed the following: -CNA D was completing rounds and when he/she passed by Resident #2's room, he/she observed Resident #1 standing over Resident #2 with his/her hand in Resident #2's pants, rubbing Resident #2's private area; -Resident #1 was rubbing his/her own private area as well; -CNA D waved another staff member over to him/her to verify what CNA D was seeing; -Both CNA D and the other staff member were in shock; -The staff told Resident #1 to leave Resident #2's room; -CNA D reported this to the charge nurse and the assistant director of nursing. Review of the written statement by Nurse Practitioner (NP) E, dated 3/30/23, provided by the facility, showed the following: -NP E was walking down the hall when CNA D stopped him/her; -When NP E looked into Resident #2's room, Resident #2 was laying on the bed with his/her clothes on; -Resident #1 was on the side of the bed, physically rubbing Resident #2 on the genital area with both hands. Resident #2 was sleeping; -NP E asked Resident #1 what he/she was doing and Resident #1 immediately moved his/her hands up to Resident #2's chest, and told Resident #2 to wake up; -NP E and CNA D told Resident #1 that he/she needed to leave Resident #2 alone and Resident #1 exited the room. During an interview on 3/31/23 at 2:57 P.M. Resident #1 said he/she went into Resident #2's room and touched him/her. Resident #1 said he/she didn't know why he/she touched Resident #2, he/she just did. Staff came in and Resident #1 moved. Resident #1 said he/she didn't know what made him/her do it and Resident #1 knew it was wrong. Resident #1 said he/she had tried to touch his/her roommate at his/her previous facility. 2. Review of Resident #2's care plan, revised 1/26/23, showed the following: -admitted [DATE]; -Diagnoses included dementia without behavioral disturbance, psychotic disturbance, muscle wasting, major depressive disorder, malaise, and muscle weakness; -The resident required assistance of staff for activities of daily living; -The resident had a psychosocial well-being problem related to dementia and difficulty expressing self. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Long and short term memory problems; -No behaviors exhibited; -Required extensive assistance of one staff for transfers, toilet use, and hygiene; -Required limited assistance of one staff for dressing; -Utilized a wheelchair for mobility. Review of the resident's nurse's note, dated 3/30/23 at 5:01 P.M. showed another resident was found in this resident's room at 2:30 P.M., touching him/her inappropriately. There were no signs of trauma. Physician and responsible party made aware. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -room [ROOM NUMBER] A; -Diagnoses included high blood pressure, fracture, and dementia; -Cognition was severely impaired; -No behaviors exhibited; -Required extensive assistance of staff for bed mobility, transfers, and toilet use; -Independent with walking and hygiene. Review of the resident's care plan, revised 11/23/22, showed the following: -Impaired visual function related to being legally blind; -Avoid making unnecessary changes to the room or environment; -Remove possible barriers to ensure safety. Review of the resident's nurse's note, dated 1/17/23 at 12:04 A.M. showed the resident insisted on sleeping in the common area in front of the dining room. The resident made himself/herself a pallet with a blanket and a pillow and said he/she would rather lay on the floor than lay on the couch. During interview on 3/31/23 at 5:05 P.M. 4/5/23 at 12:55 P.M. Resident #3 said he/she had a previous roommate who tried to touch his/her genitals three different times while the resident was his/her roommate. Resident #3 told the resident no and to stay away from him/her. Resident #3 did not know the resident's name but was glad the resident no longer resided in the facility. Resident #3 slept on the couch in the common area for three nights when the roommate first arrived. Resident #3 said he/she did tell staff about this but he/she could not remember who he/she told. Resident #3 said he/she felt frustrated because Resident #1 was weird and kept on talking like that to him/her. 4. During an interview on 3/31/23 at 3:42 P.M. Licensed Practical Nurse (LPN) B said he/she was working on 3/30/23 when staff found Resident #1 in Resident #2's room touching Resident #2. Staff separated the residents and informed LPN B of what had occurred. Resident #1 was moved to a room without a roommate by the nurse's station for closer monitoring and placed on 15 minute checks. Since then Resident #1 had come out of his/her room a few times and had gone down other hallways. By the time LPN B would catch up with Resident #1, he/she would say he/she was just going to the shower and seemed to be covering up where he/she was really headed. During an interview on 3/31/23 at 5:14 P.M. Certified Nurse Aide (CNA) C said he/she was assigned to Resident 1's hall. No one had informed CNA C that Resident #1 needed to be monitored when out of his/her room and in common areas. CNA C was not aware of Resident #1's inappropriate sexual behaviors. During interview on 4/5/23 at 12:40 P.M. the Social Services Director said the following: -On 1/16/23 he/she interviewed Resident #1 completing the resident's MDS cognitive pattern assessment. The resident was nervous and fidgety and said at a previous facility he/she was caught touching his/her roommate and had his/her hands down the pants of that roommate. He/She had to leave the previous facility as a result. The resident said his/her family was aware of the behavior at the previous facility but did not share the behavior with the facility. SSD told administrative staff about the resident's behavior at the previous facility and was told to keep an eye on the resident, keep radar on the resident. Staff were aware of the resident's pervious behavior of touching a resident inappropriately; -Resident #3 was the resident's roommate on admission. Resident #3 slept on the couch in the common area for two or three days after Resident #1 moved into the room. He/She was unsure why Resident #3 slept on the couch. Resident #3 then resumed sleeping in the same room with Resident #1; -Staff did not move Resident #1 out of the room with Resident #3 after learning of Resident #1's previous behavior of touching another resident and placing his/her hands down a resident's pants; -On 3/30/23 staff observed Resident #1 with his/her hands down Resident #2's pants rubbing on the resident's genitals. At that time staff moved Resident #1 into a private room, placed the resident with one on one staff supervision when the resident went out of the room and every 15 minute checks while in the room. Staff only allowed the resident out of his/her room to eat in the dining room and to the shower room until transferred out of the facility for psychiatric evaluation; -He/She felt like Resident #1 targeted residents with dementia and confusion and was aware of his/her behavior; -Resident #2 was helpless and confused. During interviews on 3/31/23 at 5:29 P.M. and 4/5/23 at 1:20 P.M. the Assistant Director of Nursing said he/she was aware of Resident #1's admission on 1/17/23 of sexual behavior at the previous facility. Staff always supervised the resident and never noticed any inclination the resident had tendencies of sexual behaviors towards other residents. Resident #3 was Resident #1's roommate and never said anything sexual happened to him/her. If staff were aware Resident #1 had approached Resident #3 sexually, staff should have intervened, called the police and notified the resident's family and physician. He/She thought Resident #3 slept on the couch for three nights because Resident #1 snored. The ADON was not aware CNA C wasn't informed of the incident and to monitor Resident #1 on his/her shift on 3/31/23. The ADON expected staff members to inform each other regarding incidents. Resident #1's Kardex (system that gives a brief overview of each resident) was updated in the electronic record after the incident on 3/30/23. Staff would have to pull up Resident #1's Kardex individually to see the update. Resident #1's history of inappropriate sexual behaviors was listed on his/her care plan but there were no interventions listed or directions for staff regarding how to monitor the resident and those should have been on the resident's care plan. Touching another resident's genitals or attempting to approach another resident sexually was sexual abuse. The facility should follow the abuse policy regarding sexual abuse. During an interview on 4/5/23 at 2:00 P.M. the administrator said on 1/16/23 the SSD became aware of Resident #1's sexual abuse towards a resident at another facility. Resident #1 admitted the behavior while the SSD completed the MDS assessment. At that time the behavior was care planned and staff monitored the resident's behaviors. There was no sexual behaviors noted until 3/30/23. He/She was unaware of any other residents bothered by Resident #1 including the resident's roommate, Resident #3. He/She was unaware Resident #3 was approached by Resident #1 three different times. Resident #1's behavior was sexual abuse towards another resident. Staff should follow the facility abuse policy and protect the other residents. Resident #1 had a history of sexually abusing other residents and targeted confused residents. MO216261

Based on observation, interview, and record review, the facility failed to monitor the effectiveness of current fall interventions and modify the interventions as necessary to prevent further falls for one resident (Resident #1) in a review of five sampled residents, who fell four times from 5/17/16 to 5/20/16, with the last two falls resulting in a fractured ankle and a hemispheric subarachnoid hemorrhage (an abnormal condition in which blood collects in the membrane that covers the brain. The accumulation of blood in this space can lead to stroke, seizures, and other complications) and small right anterior parasagittal hematoma (a collection of blood in the space between the outer layer (dura) and middle layers of the covering of the brain (the meninges). The facility census was 87. 1. Review of the facility's Falling Stars Protocol, revised 5/17/16 showed the following: -Purpose: to promote and maintain a safe environment for those residents at risk for falls; -Policy: all residents with orders for personal, bed and/or chair mat alarms or any other device intended to decrease the risk of falls will be visually inspected at least once every shift by nursing personnel to assure compliance of physicians orders and appropriate equipment; -Procedure: A Falling Stars book containing any safety measures described above will be kept at the Division 2 nurses desk; -Any new order or change in existing orders for any safety measures will be communicated to the Director of Nursing (DON),Care plan Coordinator, Central Supply and Nurse Supervisor via communication form; -The safety orders will be transcribed to the Falling Stars book with the corresponding hall records by the individual initially implementing the new safety measure; -All residents will be considered at risk for falls; -The Division 2 Nurse for each shift will designate nursing personnel on that shift to do compliance rounds on all residents with safety measures; -The assigned nursing staff will take the log throughout the facility verifying that each resident listed has appropriate equipment, that the equipment is in working order, and that the device is on as designated according to the safety measures put into place; -Assigned nursing personnel will complete the log by initialing compliance or otherwise report immediately noncompliance to the charge nurse; -Compliance rounds will also be completed by nursing personnel on each individual hall and documented on the log located in the CNA resident documentation notebook; -Residents on the falling stars rounds are not to be left unattended when safety measures are not in place; -Nursing management will complete a monthly random audit to ensure compliance with the Falling Stars program and address any concerns identified; -The Falls Committee will evaluate current resident fall interventions with each quarterly assessment/change of status utilizing the monthly Minimum Data Set (MDS) schedule. 2. Review of Resident #1's Fall Risk assessment dated [DATE] showed the following: -History of one-two falls in the past three months; -Fall risk score of four; -Total score of 10 or above represents high risk. Review of the resident's medical record showed the following Diagnoses: [REDACTED]. -Syncope and collapse; -Muscle weakness; -Difficulty walking; -Lack of coordination; -Abnormal posture. Review of the resident's Admission Minimum Data Set (MDS), a federally mandated assessment instrument dated 4/29/16, showed the following: -Usually understood; -Usually understands; -Brief Interview for Mental Status (BIMS) score of five indicating severely impaired cognition; -Required limited staff assist of one for bed mobility, transfer and locomotion on/off unit; -Required supervision with set up help only for eating; -Moving from seated to standing position not steady but able to stabilize without staff assistance; -Walking not steady but able to stabilize without staff assistance; -Surface to surface transfer not steady but able to stabilize without staff assistance; -Moving on and off toilet not steady, only able to stabilize with staff assistance; -Occasionally incontinent of urine; -Always continent of bowel; -No fall history prior to admission; -No falls since admission. Review of the resident's care plan dated 5/5/16 showed the following: -The resident is at risk for falls; -He/she has a history of syncope with falls prior to admission; -The resident is also impulsive and refuses to use his/her call light for assist; -Assist the resident with one staff member for all ambulation; -Keep walker within the resident's reach at all times; -Remind the resident to ask for assist for ambulation; -Refer the resident to Physical Therapy (PT) evaluation; -Monitor for changes in the resident's condition that may warrant increased supervision/assistance and notify the physician; -The resident uses a wheelchair for long distance mobility. Review of the resident's nurses' notes dated 5/16/16 at 7:45 P.M. showed the following: -The resident was noncompliant with call light; -The resident will not use call light or wait for assistance. Review of the resident's May 2016 physician's orders [REDACTED]. Review of the resident's nurses' notes dated 5/17/16 at 1:16 A.M. showed staff documented the following: -At 12:45 A.M., heard a loud voice yelling from the hallway, rushed down and saw resident in a sitting position on the floor and the bed in the lowest position; -The resident voiced he/she slid off the bed while trying to get up and use the bathroom; -The resident denies hitting his/her head on the floor, has socks on his/her feet; -The resident was assessed, grip and push pull are within normal limits (WNL) for resident; -His/her range of motion (ROM) is WNL and the resident is alert with confusion; -He/she was transferred to the bed; -Staff noted a scratch to the resident's lower back; -His/her physician was notified; -Resident was re-educated about using his/her call light when calling for help. Review of the resident's Fall Investigation Form dated 5/17/16 showed staff must document measures implemented to deter further falls (alarms, new orders, therapy interventions) for each fall. The fall committee would meet weekly, discuss and document further interventions and /or progress. Review of the resident's Fall Investigation Form dated 5/17/16 at 12:45 A.M., showed staff documented the following for the resident's fall.: -The resident attempted to self toilet; -The fall was related to the resident having an unsteady gait; -The resident started Levaquin (an antibotic) for UTI. Review of the resident's nurses' notes dated 5/17/16 at 7:59 P.M. showed the following: -Non-compliant with use of the call light; -At around 7:30 P.M. this staff was walking down the hall; -The resident was in the doorway of his/her room. The locked wheelchair stood about five feet behind him/her and a walker stood open outside the door; -ROM was performed to all extremities; -No apparent injury noted; -The resident's family member made aware; -Also left message for physician. Review of the resident's Fall Investigation dated 5/17/16 at 7:50 P.M., showed staff documented the following: -The resident attempted to ambulate; -The fall was related to the resident having unsteady gait; -The resident started Levaquin (an antibotic) for UTI; -Abnormal behaviors prior to fall: combative. Review of the resident's care plan updated 5/17/16, showed the following: -The resident was found on the floor (does not specify which fall, the fall at 12:45 A.M. or 7:30 P.M.); -The care plan failed to document the resident had two falls on 5/17/16; -The care plan showed no evidence staff evaluated the effectiveness of current interventions or initiated new interventions to prevent future falls. Review of the resident's nurses' notes dated 5/18/16 at 3:04 A.M. showed the following: -The resident required assist of one for transfers, toileting and ADLs; -Continue monitoring for fall follow up; -Resident up at the start of this shift wanting to leave, yelling for his/her family member; -One on one as resident continually attempting to stand up from wheelchair; -The resident was hitting and scratching at staff as they guide him/her to a seated position for safety; -Continue antibiotic/UTI; -Continue close monitoring. Review of the resident's care plan updated 5/18/16 showed the following: -One hour checks initiated as resident has a urinary tract infection (UTI)/on antibiotics; -Very confused. Review of the resident's nurses' notes dated 5/19/16 at 9:11 P.M. showed the following: -Resident found on the floor in Division 2 dining room, lying on the floor with his/her head raised up; -No injury noted; -The resident said he/she was trying to clean the wheelchair and fell ; -The resident was very confused and refused to follow directions; -The resident kept getting up from his/her wheelchair unassisted and had an unsteady gait; -Staff called the responsible party at 8:20 P.M. and left a message; -Physician notified at 8:32 P.M. Review of the resident's Fall Investigation Record dated 5/19/16 at 9:11 P.M. showed staff documented the following: -The resident attempted to ambulate; -The fall was related to the resident having an unsteady gait; -The resident complained of pain prior to the fall; -The resident started Levaquin; -Abnormal behaviors prior to fall: Agitated; -The Director of Nursing (DON) documented, Resident had been educated on safety measures due to resident's inability to successfully retain this information he/she was started on one hour checks Review of the resident's care plan updated 5/19/16 showed the following: -The resident fell while cleaning his/her wheelchair; -One hour checks were initiated on 5/18/16 -The plan of care did not include new interventions to prevent further falls. Review of the resident's nurses' notes dated 5/20/16 at 4:28 A.M. showed the following: -Continue follow up fall with no injury; -Bed in low position; -Every one hour checks. Review of the resident's nurses' notes dated 5/20/16 at 7:26 A.M. showed the following: -Called to the resident's room by night shift Certified Nurse Assistant (CNA) who was getting the resident up for breakfast; -Resident's left ankle noted to be swollen and painful to touch; -Call placed to physician for x-ray order and responsible party notified of new condition; -X-ray to be done today. Review of the resident's nurses' notes dated 5/20/16 at 9:47 A.M. showed the following: -Heard someone yelling Help me; -Entered resident's room and found resident on the floor next to the bathroom door, sitting on his/her buttocks; -Called for assistance to get the resident up to the wheelchair after assessment; -Vital signs stable; -Noticed the wall behind resident's head had a dent in it; -Larger bruised area noted to back of resident's head; -Call placed to ambulance for transfer to hospital due to head injury; -Family member notified and made aware of fall and of resident being sent to ER; -Resident complained of right side pain as EMTs put him/her on the stretcher; -Report called into ER and informed of pain in right side; -Also informed of resident's left ankle needing to have x-ray done and treatment in addition to head injury with fall. Review of the CNA Assignment book on 5/20/16 at 2:09 P.M. showed staff signed off one hour checks on 5/18/16, 5/19/16 and 5/20/16. Review of the resident's care plan updated 5/20/16 showed the following: -The resident fell while attempting to self transfer; -Sent to ER due to hitting head and swollen left ankle. Review of the resident's Fall Investigation Form for 5/20/16 at 7:45 A.M., showed staff documented the following: -The resident attempted to self transfer; -The fall was consistent with a pattern of other falls; -The fall was related to the resident having unsteady gait; -The resident was complaining of left ankle pain prior to the fall; -On Levaquin for UTI; -Abnormal behavior prior to fall: Increased confusion; -The resident was sent to the ER; -No documentation related to the prevention of further falls. During interview on 5/20/16 at 2:41 P.M., the care plan Coordinator/Licensed Practical Nurse (LPN) F said the following: -Staff try to think of new interventions immediately after a resident falls; -The resident has a history of falls; -It was very hard to get the resident to use his/her call light; -The resident was too confused to comply with asking for staff assist; -There is a weekly fall meeting; -The resident's falls were discussed and the DON wanted him/her on hourly checks. Review of the resident's medical record showed he/she was admitted to the hospital on [DATE]. Review of the resident's hospital Admission History and Physical dated 5/20/16 showed the following: -Computed tomography (CT) scan of head revealed hemispheric subarachnoid hemorrhage (an abnormal condition in which blood collects beneath the arachnoid mater, a membrane that covers the brain. This area, called the subarachnoid space, normally contains cerebrospinal fluid. The accumulation of blood in the subarachnoid space can lead to stroke, seizures, and other complications) and small right anterior parasagittal hematoma (a collection of blood in the space between the outer layer (dura) and middle layers of the covering of the brain (the meninges). It is most often caused by torn, bleeding veins on the inside of the dura as a result of a blow to the head) without significant mass effect or shift; -Left distal fibula (ankle) fracture now with a cast due to a fall. Review of the resident's hospital Palliative Medicine Patient/Family Conference Note written by the physician dated 5/26/16 showed the following: -Upon reflection family notes he/she probably had been declining prior to fall, now dramatically worse; -The family member understands concern about swallow on this admission, asks:is the patient dying? -Discussed loss of swallow portends late stage dementia approaching, belief that trauma has accelerated his/her dementia; -Transition to comfort measures; -Referral to hospice. Review of the resident's medical record showed he/she was re-admitted to the facility on [DATE] with hospice services. Review of the resident's Significant Change MDS dated [DATE] showed the following: -Unclear speech; -Sometimes understood; -Sometimes understands; -Short and long term memory problems; -Severely impaired daily decision making; -Totally dependent on one staff member for bed mobility, personal hygiene and toilet use; -Required extensive assist of one staff member for eating and dressing; -Transfers, walk in room/hall and locomotion on/off unit did not occur; -Moving from seated to standing, walking, moving on and off toilet and surface to surface transfer did not occur; -Always incontinent of bladder and bowel; -Facial expressions of pain in the last five days; -Indicators of pain or possible pain 1-2 days of the last 5 days; -No falls since admission or prior assessment; -Hospice care. Observation on 6/7/16 at 10:12 A.M. in the resident's room showed the following: -The resident lay on his/her back in bed with his/her eyes closed; -The bed was in low position and a padded mat lay on the floor beside his/her bed. During interview on 6/7/16 at 2:08 P.M. CNA E said the following: -He/she laid the resident down around 9:00 P.M. on 5/19/16; -The resident didn't complain about his/her ankle at all when staff walked him/her; -The resident was acting up the entire evening; -The resident fell during the 2:00-10:00 P.M. shift unwitnessed by him/her. Review of CNA E's written statement dated 6/7/16 at 5:18 P.M. showed during evening shift on 5/19/16 while monitoring the resident CNA E and the nurse did one-on-one care until the resident calmed down. CNA E walked the resident back to his/her room where the resident laid down. During interview on 6/8/16 at 2:24 P.M., CNA C said the following: -He/she worked the night shift (10:00 P.M. to 6:00 A.M.) on 5/19/16; -CNA C was told in report the resident fell on the evening shift; -Nothing new was passed on in report as far as new interventions to prevent the resident from falling; -Staff had been checking on the resident every hour for a week or two. During interview on 6/8/16 at 12:20 P.M., LPN D said the following: -On evening shift (2:00 P.M. to 11:00 P.M.), 5/19/16 the resident was so restless; -He/she kept 1:1 on the resident throughout the shift; -The resident was really agitated; -He/she had just two aides; -Staff was doing 10-15 minute checks on the resident but not officially; -Staff was keeping a very close eye on the resident; -LPN D was sure he/she told night shift; -The resident is a fall risk and does not use the call light. During interview on 6/8/16 at 3:27 P.M., LPN B (night shift nurse) said the following: -After the resident fell on [DATE] staff were monitoring him/her more closely; -Staff were sitting on the hall watching him/her; -The resident had been up all night the night before; -The charge nurse is supposed to put down new interventions after a resident falls; -He/she did not add interventions to the care plan. During interview on 6/10/16 at 1:00 P.M., LPN A said the following: -He/she worked the day shift on 5/20/16; -No new interventions were passed onto him/her after the resident fell on [DATE]; -The resident was in bed and on 15 minute checks he/she thinks; -Fifteen minute checks were in the CNA book and the CNAs had already started doing them. During interview on 6/7/16 at 4:15 P.M., the DON said the following: -When a resident falls the nurse assesses for injury; -An incident report is filled out; -The charge nurse should put an intervention into place to prevent further falls; -The incident reports are reviewed on Wednesdays at the falls committee meeting. MO 944

Based on observation, interview, and record review, the facility failed to ensure safety and adequate monitoring were provided to prevent falls and failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice for five residents (Residents #1, #3, #5, #6, and.#16), who had histories of falls, in a review of 19 sampled residents. The facility's census was 92. 1. Review of the facility's Falling Star Protocol, dated 8/18/11, showed the following: -Purpose: To promote and maintain a safe environment for those residents at risk for Falls and/or elopement; -Policy: All residents with orders for restraints, personal alarms, low beds, bed or chair mat alarms or any other device intended to decrease the risk of a fall will be visually inspected at least once every shift by designated nursing personnel to assure compliance of physician orders [REDACTED]. -Any new orders or change in existing orders received for any safety interventions will be communicated to DON, Care Plan Coordinator, Central Supply and Nurse Supervisor via communication form; -The order will be transcribed to the chart per protocol; -Residents identified as at risk are not to be left unattended when ordered measures are not in place (Must have visual supervision while on commode, in shower chair .); -Falls occurring (with or without injury) involving a resident on this program while unsupervised, or when proper equipment not utilized, may result in disciplinary action after investigation is completed; -All nursing staff are expected to be aware of assigned Falling Star residents and initiate the safety measures as ordered at the beginning of his/her shift, throughout the shift and at the end of each shift (ROUNDS); -The Falls Committee will evaluate current resident fall interventions with each quarterly assessment/change of status utilizing the monthly MDS schedule; -To preserve dignity and reduce environmental noise, the Falls Committee will focus on alarm utilization and/or elimination; -The Falls Committee will utilize the following criteria when considering the continued usage or elimination of interventions, i.e., alarms: Resident is consistently requesting staff assistance. Documentation reflects resident is not attempting to get up on own setting off alarms. No falls in the past 90 days. Medication review for changes in previous 14 days. Assessment of current mobility status. Cognitive changes, safety awareness. History of Urinary Tract Infections (UTI)'s related to falls; -Each resident due for an assessment will have documentation by nursing utilizing committee criteria times one week; -The Falls Committee will review the supportive documentation and make a decision at the weekly meeting. The care plan will update accordingly; -The Falls Committee minutes with current interventions will be placed in the nurses and CNA notebooks on each individual hall weekly at the completion of the meeting; -If an alarm is to be eliminated, it will be placed on hold and nursing will document for two weeks following the change. The documentation will be reviewed at the next weekly Falls Committee meeting. Updates will be made according to the information provided. 2. During an interview on 9/17/15 at 3:50 P.M. the Director of Nursing (DON) said the current system for evaluating fall interventions had not been effective. The facility was now trying to identify patterns related to resident falls. The facility had a fall committee that met weekly that consisted of herself, therapy, nurse managers from each unit, care plan coordinator and MDS coordinator, and medical records. The committee discussed what was working and what was not working regarding resident falls. Falls should be addressed in a resident's care plan, along with interventions to prevent falls. The care plan coordinator was responsible for updating the care plans with fall interventions. If a resident was able to remove or turn off an alarm she would not consider it to be an effective intervention to prevent falls. 3. Review of Resident #3's fall investigation report, dated 5/19/15, showed the resident fell in the bathroom when he/she attempted to transfer himself/herself to the toilet without assistance. The resident had been incontinent of bowel movement while in bed, attempted to transfer himself/herself to the bathroom in socked feet and slipped and fell . The intervention listed for the fall was to remind the resident to put on shoes or nonskid socks before transfers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/29/15, showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Independent with bed mobility, transfers, walking, and toilet use; -Balance was not steady, but able to stabilize without human assistance; -No limitations in range of motion; -Occasionally incontinent of bowel and bladder; -One fall without injury since the previous assessment on 3/9/15. Review of the resident's nurse's note on 6/3/15 at 2:06 P.M. showed the resident was independent with a wheeled walker, transfers and dressing. Staff heard the resident yelling it hurts and entered the resident's room. The resident complained of pain in his/her right knee and was unable to bear weight on the right leg. Upon staff assessment the resident was found with swelling to the right knee and the area was painful to touch. Staff assisted the resident to a wheelchair and administered as needed pain medication. The family and physician were notified. An order was received for an X-ray of the right knee and the X-ray showed acute fracture of the right knee. The physician was again notified and gave orders to transfer the resident to the emergency room for evaluation and treatment. Review of the resident's radiology report, dated 6/3/15, showed an acute fracture of the right knee. Review of a statement from the resident's physician regarding the resident's fracture on 6/3/15 dated 9/24/15, and sent by the facility, showed the resident developed a spontaneous fracture of the right medial tibia with no displacement or dislocation. There was no trauma to the area. The resident began complaining of pain and X-rays were obtained which showed a fracture and osteopenia (reduced bone mass). The fracture could be related to the osteopenia since there was no trauma. Review of the resident's nurse's notes showed the following: -On 6/4/15 at 2:37 A.M., the resident had returned from the hospital with new orders to wear a brace to the right knee. The resident refused to wear the brace. The resident's right knee remained swollen. Staff reminded the resident not to get up without assistance; -On 6/5/15 at 2:02 A.M., the resident remained on follow up for the right knee fracture. The resident required assistance with incontinent care; -On 6/6/15 at 6:15 P.M., staff found the resident on the floor on his/her back between the wheelchair and the bed. The resident had attempted to transfer himself/herself from the wheelchair to the bed without assistance. Staff assessed the resident and assisted him/her to bed. The resident was without injury but did complain of pain in the right knee; -On 6/17/15 at 2:41 P.M., the resident was discussed in the fall committee meeting. The resident now required assistance of two staff. Staff should encourage the resident to ask for assistance. Review of the resident's Significant Change in Status Assessment MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Cognition was severely impaired; -Required extensive assistance of one staff member for bed mobility, locomotion on and off the unit, dressing, and bathing; -Required extensive assistance of two or more staff for transfers, toilet use, and personal hygiene; -Balance was not steady and the resident required human assistance to stabilize; -Impairment in range of motion to the lower extremity on one side; -One fall without injury since the previous assessment on 5/29/15. Review of the resident's care plan, dated 6/22/15, showed the following: -Problem: The resident requires extensive assistance with transfers and uses a wheelchair as the primary mode of transportation. The resident was previously able to walk until a fracture. The resident can usually make his/her needs known but will not use the call light and often tries to do things on his/her own; -Goal: The resident's fracture will heal; -Approaches: Observe for unsafe actions and intervene as needed. Keep the call light in reach at all times. Offer assistance and encourage him/her to ask for assistance. The resident is receiving therapy services. Ensure the brace is on and locked in extension when upright and 90 degrees when seated; -Problem: The resident has a history of falls due to poor safety awareness and memory issues. The resident requires assistance of two staff. The resident wears a brace and is non weight bearing on the right leg. The resident has fallen a couple of times since the last assessment; -Goal: The resident's fracture will heal and he/she won't fall again; -Approaches: Observe for unsafe actions and intervene as needed. Ensure the resident's brace is on except during showers. Offer assistance and ensure the resident does his/her therapy. Review of the resident's nurse's notes showed the following: -On 7/22/15 at 9:09 P.M., the resident was receiving physical therapy (PT) and occupational therapy (OT) for transfers, walking, and strength. The resident was 50 percent weight bearing on the right leg. The resident required assistance with transfers and activities of daily living. Staff found the resident attempting to transfer himself/herself from the bed to the wheelchair and yelling for help; -On 7/24/15 at 4:35 P.M., the resident continued with PT and OT for 50 percent weight bearing on the right extremity, decrease in transfer ability, walking and strength. The resident required assistance of one staff for transfers; -On 7/27/15 at 2:07 P.M., staff heard the resident yelling for help and found the resident on the floor of his/her room. Staff assessed the resident and found no injuries and assisted the resident to bed. (No interventions were documented in the nurse's notes regarding the fall.) Review of the Incident Tracking Log, provided by the facility, showed the resident fell on [DATE] at 2:00 P.M. in his/her room. The resident fell out of the wheelchair, unwitnessed and neurological checks were initiated. (There were no interventions or a plan of action listed on the tracking log regarding the fall.) Review of the resident's nurse's note, dated 8/2/15 at 2:25 P.M., showed staff found the resident on the floor in his/her room. The resident said he/she was trying to get into bed. (No interventions were found in the nurse's notes regarding the fall.) Review of the Incident Tracking Log, provided by the facility, showed the resident fell on [DATE] at 2:05 P.M. in his/her room. The resident transferred himself/herself and was 50 percent weight bearing on the right leg. (There were no interventions or a plan of action listed on the tracking log regarding the fall.) Review of the nurses notes on 8/3/15 at 5:03 P.M., 8/9/15 at 7:38 P.M. and 8/14/15 at 6:33 P.M., showed the resident required assistance of one staff for transfers. (The resident's care plan did not reflect this change. The care plan directed staff to transfer the resident with assist of two staff.) Review of the resident's physician order [REDACTED]. May discontinue the leg brace. Review of the resident's nurse's notes showed the following: -On 8/17/15 at 7:44 P.M., the resident returned from an appointment with the physician. New orders were received and therapy was updated on the change in weight bearing status to weight bearing as tolerated; -On 8/27/15 at 8:42 P.M., the resident continued to receive therapy services for lower extremity weakness, activities of daily living, and transfers. The resident was weight bearing as tolerated. The resident continued getting in and out of bed without asking for staff assistance; -On 8/30/15 at 1:56 P.M., staff found the resident on the floor. (No interventions were found in the nurse's notes regarding the fall.) Review of the Incident Tracking Log, provided by the facility, showed the resident fell on [DATE] at 1:30 P.M. in his/her room. The resident attempted to transfer himself/herself from the wheelchair to the bed unassisted. (There were no interventions or a plan of action listed on the tracking log regarding the fall.) Review of the resident's nurse's notes showed the following: -On 9/7/15 at 5:10 P.M., the resident continued to receive therapy services for decline in transfers, walking, and strength. The resident required assistance of one staff for transfers and walking; -On 9/10/15 at 11:36 A.M., staff found the resident on the floor in his/her room. Staff assessed the resident and found no injury and reminded the resident to use the call light. Staff contacted the physician and received an order for [REDACTED]. Review of the Incident Tracking Log, provided by the facility, showed the resident fell on [DATE] at 9:20 A.M. in his/her room. Staff found the resident on the floor of his/her room. The resident had previously been in bed. Review of the resident's POS showed an order, dated 9/10/15, for a bed and chair alarm. Review of the resident's care plan, dated 6/22/15, showed no revision to show the addition of the bed and chair alarm. During an interview on 9/16/15 at 3:46 P.M., Certified Nurse Aide (CNA) S said the resident had fallen frequently. Fall interventions in place for the resident were to not let the resident be up in the wheelchair in his/her room because the resident would attempt to transfer himself/herself to bed. The facility recently began using a sensor alarm in the resident's wheelchair and bed. CNA S found out about falls and fall interventions from other CNAs and nurses and could also find fall interventions in the resident's care plan. During an interview on 9/17/15 at 7:20 A.M., CNA Q said he/she referred to a resident's care plan as well as information received at change of shift report to find out about a resident's care needs, including interventions to prevent falls. CNA Q said interventions in place to prevent falls for Resident #3 were to lay the resident down after meals and the bed and chair alarms. The facility failed to consistently evaluate the cause of the resident's falls and implement fall interventions after the resident had experienced multiple falls, and failed to update the care plan, including interventions to prevent falls for the resident. 4. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Short term memory problem; -Daily decision making ability was moderately impaired; -Sometimes made himself/herself understood; -Usually understood others; -Physical behaviors occurred one to three days out of seven; -Verbal behaviors occurred one to three days out seven; -Wandering occurred one to three days out of seven; -Required extensive assistance of two staff for transfers, toilet use, and hygiene; -Required extensive assistance of one staff for bathing; -No falls since the previous assessment on 3/13/15. Review of the care plan found in the resident's active medical record, no date, showed the following: -Problem: At risk for falls due to the [DIAGNOSES REDACTED]. The resident used a wheelchair and required assistance of two staff for transfers. The resident had not fallen since admission on 12/9/14; -Goal: The resident will not fall or hurt himself/herself; -Approaches: Encourage the resident to take medications, treatments, and labs as ordered by the physician. Observe for unsafe actions and intervene if needed. Two person assistance with transfers. Ask the resident if he/she would like to lay down during the day. Review of the resident's nurse's note, dated 6/25/15 at 2:20 P.M., showed the resident was in the dining room in a wheelchair. The resident leaned to the right and slid out of the wheelchair. The resident received a skin tear to his/her right elbow. (There were no interventions listed in the nurse's notes regarding the fall.) Review of the resident's nurse's note, dated 9/4/15 at 1:38 P.M., showed the resident was agitated after a shower. The resident was up in a wheelchair in the dining room. The resident attempted to hit a CNA who walked by and fell out of the wheelchair to the floor on his/her face. The resident obtained a laceration to the nose, a hematoma (localized collection of blood in tissue outside the blood vessels) to the left side of the forehead, and notable bruising to his/her face. The resident continued to be agitated and hit and kicked at staff. The resident was examined by a physician in the facility. Staff assisted the resident back to his/her wheelchair. The resident became more agitated and would not allow staff to provide first aide to his/her injuries. (There were no intervention listed in the nurse's notes regarding the fall.) Review of the Incident Tracking Log, provided by the facility, showed the resident fell on [DATE] at 12:45 P.M. in the dining room. The resident attempted to hit a CNA and fell forward from his/her wheelchair. (There were no interventions or a plan of action listed on the tracking log regarding the fall.) Review of the resident's nurse's note, dated 9/11/15 at 5:36 P.M., showed the resident continued to be non-compliant with not leaning forward in his/her wheelchair and continued to try and put himself/herself to bed without assistance. Observation on 9/14/15 at 4:12 P.M. showed the resident sat in a wheelchair at the nurse's station. The resident had facial bruising which covered the entire left side of his/her face and also under his/her right eye. Observation on 9/15/15 at 9:44 A.M. showed CNA M and CNA O attempted to transfer the resident to the toilet. The resident refused, became agitated, and attempted to hit CNA O. CNA M wheeled the resident to the nurse's station. The resident continued to be agitated and made loud, repetitive, incoherent, vocalizations. The bruising remained to the resident's face. During an interview on 9/15/15 at 9:50 A.M., CNA O said the resident was frequently combative during care. It was best to leave the resident alone when he/she was agitated, tell the charge nurse, and try again later. The resident had kicked, hit, and bitten staff in the past. The resident had recently fallen out of his/her wheelchair when he/she was upset and tried to hit a staff member who went by. CNA O was not aware of any interventions in place to prevent falls for the resident, other than leaving him/her alone when he/she was agitated. Review of the resident's care plan showed no revisions regarding how staff should address the resident when he/she was agitated. During an interview on 9/17/15 at 10:06 A.M., CNA Q said the resident became aggravated quite often, especially during care. The resident had been combative and made attempts to kick and bite staff caring for him/her. CNA Q was not aware of any interventions in place to prevent falls for Resident #1. The facility failed to implement interventions for the resident after two falls and failed to update the care plan, including fall interventions for the resident. 5. Review of Resident #6's care plan, dated 10/29/14 showed the following: -Problem: At risk for falls. Requires assistance with activities of daily living and transfers. The resident uses a wheelchair to get around. Occasional stress incontinence. The resident has a history of hip fracture; -Goal: The resident will not hurt himself/herself; -Approaches: Encourage the resident to ask for assistance. Keep the wheelchair locked at the bedside. Remind the resident where the call light is located and how to use it. May need extra encouragement at times. Restorative therapy three times a week. Bed alarm and automatic locks on the chair. Review of the resident's medical record showed no documentation showing the resident had received restorative therapy (which was an intervention identified to prevent falls and injury to the resident). Review of the resident's admission MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Cognition was intact; -Occasionally incontinent of urine; -Required limited assistance of one staff for bed mobility, transfers, toilet use, and hygiene; -Balance was unsteady and required human assistance to stabilize; -No falls since admission on 10/17/14. Further review of the resident's care plan, dated 10/29/14, showed the following: -On 11/11/14, fall with no injury. (There were no new interventions added to the care plan for this fall); -On 11/12/14, fall with no apparent injury. (There were no new interventions added to the care plan for this fall Review of the resident's physician order [REDACTED]. Further review of the resident's care plan, dated 10/29/14, showed the following: -On 1/4/15, fall with a skin tear to the left elbow. Staff were awaiting results of a urinalysis. The resident's bed was changed due to non-locking wheels and the resident had a bed alarm; -On 1/22/15, fall with no injuries. (There were no new interventions added to the care plan for this fall. ) -On 2/11/15, fall with a skin tear to the left forearm. (There were no new interventions added to the care plan for this fall.) Review of the resident's POS for March 2015 showed the following orders: -On 3/5/15, hold the bed alarm and document for one week; -On 3/8/15, discontinue the bed alarm. Review of the resident's fall investigation record showed the following: -On 3/12/15 at 3:45 P.M., the resident fell out of the recliner in his/her room. No alarms were in place; -On 3/23/15 at 5:20 P.M., the resident fell the resident had been in his/her wheelchair in his/her room. No alarms were in place. Review of the resident's fall investigation report, dated 3/23/15, showed the resident fell in his/her room from the wheelchair while getting up to wash his/her hands. The resident needed assistance at all times for mobility and transfers and was unstable on his/her feet. The resident was sent to the emergency room and returned to the facility with a soft splint in place. Bed and wheelchair alarms were applied and the resident's mobility status was changes to assist of one. Review of the resident's radiology report, dated 3/23/15, showed an acute right wrist fracture with soft tissue swelling. Review of the resident's nurse's note, dated 3/24/15, showed the resident returned to the facility with his/her family. The resident had new orders for pain medication and a soft cast to the right wrist. Review of the resident's POS for March 2015 showed orders, dated 3/24/15, to change mobility to assist of one. Chair and bed alarm due to a history of falls. Review of the resident's care plan, dated 10/29/14, showed a fall on 3/24/15, with a wrist fracture. Bed and wheelchair alarm. Review of the resident's Significant Change in Status MDS, dated [DATE], showed the following: -Cognition was moderately impaired; -Required limited assistance of one staff for bed mobility, transfers, and walking; -Required extensive assistance of two or more staff for toilet use, personal hygiene, and bathing; -Limitation in range of motion to the upper extremity on one side; -Balance was unsteady and required human assistance to stabilize; -One fall with major injury since the last assessment on 1/26/15. Review of the care plan found in the resident's current medical record, undated, showed the following: -Problem: The resident had fallen in the past and had recently fallen and fractured his/her wrist. The resident generally had good safety awareness, but liked to do things for himself/herself. The resident required assistance with most things; -Goal: The resident will not fall anymore or hurt himself/herself; -Approaches: Bed and chair alarm. Answer call light promptly. Review of the resident's fall investigation record showed the resident fell on [DATE]. The resident required assistance of one staff and had bed and chair alarms. The resident was non-compliant with transfer orders and had poor safety awareness. (There were no fall interventions listed on the investigation report.) Review of the care plan found in the resident's current medical record, undated, showed the following: -No entry listing the fall on 5/13/15 or any new fall interventions; -An entry, dated 6/26/15, that showed a lock was placed on the resident's bathroom door to remind the resident to ask for assistance. The resident continued to get up and unlock the door. Review of the resident's nurse's note, dated 8/18/15 at 10:45 A.M., showed a CNA heard the resident's alarm sounding and found the resident on the floor in his/her room. The resident obtained a large skin tear to the left upper arm and left lower leg. The resident was assessed and assisted back to bed. Review of the incident tracking log, provided by the facility, showed no documentation of the resident's fall on 8/18/15. Review of the care plan found in the resident's current medical record, undated, showed no entries or new fall interventions implemented for the fall on 8/18/15. Review of the resident's nurse's note, dated 9/7/15 at 7:37 A.M., showed staff responded to the wheelchair alarm sounding and found the resident on the floor of his/her room. Staff reported the resident would sometimes turn off his/her alarms. The resident obtained a skin tear. Review of the incident tracking log, provided by the facility, showed the resident fell on [DATE] at 3:30 A.M. in his/her room. The wheelchair alarm was off. Staff found the resident on his/her left side. Review of the care plan found in the resident's current medical record, undated, showed no entries or new fall interventions implemented for the fall on 9/7/15. Review of the resident's nurse's note, dated 9/10/15 at 3:24 A.M., showed the resident continued to transfer without assistance causing the alarm to sound. Observation and interview on 9/14/15 at 5:00 P.M. showed the resident sat in a wheelchair in his/her room with an alarm in place and automatic locks on his/her wheelchair. The resident had a lock in place at the top of his/her bathroom door. The resident said he/she could not open his/her bathroom door because he/she could not reach the lock. Observation on 9/15/15 at 9:20 A.M. showed the resident sat in a wheelchair in his/her room with an alarm in place and automatic locks. The resident's bathroom door was locked. During an interview on 9/16/15 at 6:20 A.M., CNA U said fall interventions for the resident were the bed and chair alarm. The resident would sometimes remove or turn off the alarms. The resident also had a lock on the bathroom door but he/she could stand up and unlock it if he/she really wanted to. Observation on 9/16/15 showed the following: -At 6:33 A.M., the resident's wheelchair alarm sounded. There were no staff present on the hall at that time; -At 6:38 A.M., the resident's wheelchair alarm continued to sound. CNA U entered the resident's room and assisted him/her to sit back down in the wheelchair; -At 9:47 A.M., the resident stood up from the wheelchair and unlocked his/her bathroom door. The resident's chair alarm sounded and CNA U responded and assisted the resident in the bathroom; -At 11:39 A.M., the resident was in his/her room in a wheelchair with an alarm in place and automatic locks. The resident's bathroom door was unlocked; -At 12:33 P.M., the resident remained in his/her room during lunch. The resident's bathroom door was unlocked; -At 3:42 A.M., the resident was in the dining room. The resident's bathroom door was unlocked. Observation on 9/17/15 showed the following: -At 7:55 A.M., the resident remained in bed. The resident's bathroom door was unlocked; -At 8:25 A.M., the resident was up in the wheelchair in his/her room eating breakfast. The resident's bathroom door was unlocked. During an interview on 9/17/15 at 9:10 A.M., CNA N said fall interventions for the resident were alarms, checking on the resident frequently, and a lock on the resident's bathroom door. CNA N said the resident could reach the lock on the bathroom door but was unable to undo it on his/her own. CNA N said the lock on the resident's bathroom door was to be locked at all times. Observation on 9/17/15 showed the following: -At 9:16 A.M., the resident was in a wheelchair in his/her room with an alarm in place and automatic locks. The resident's bathroom door was unlocked; -At 2:10 P.M., the resident was in a wheelchair in his/her room. The resident's bathroom door was unlocked. During an interview on 9/17/15 at 3:20 P.M., Registered Nurse (RN) T said the resident received therapy services due to falls during February 2015 and April 2015. The bed alarm was started on 11/13/14 and then put on hold on 3/5/15 and discontinued on 3/8/15. The resident fell and broke his/her wrist on 3/23/15 and a chair and bed alarm were initiated at that time. The resident also had a high/low bed and a mattress with raised sides to prevent falling. The resident also had a lock on his/her bathroom door. The resident had automatic locks on his/her wheelchair and a tennis ball on the call light to make it more accessible. The facility failed to implement and modify fall interventions after the resident had experienced multiple falls, and failed to update the care plan, including interventions to prevent falls for the resident. 6. Review of Resident #5's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment for daily decision making; -Did not reject care; -The resident was independent with bed mobility; -The resident required limited assist of one staff for transfer, walking in room and corridor, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene; -Was always incontinent of bladder; -The resident had a fall at sometime in the last month prior to admission/entry; -The resident had a fall in the last two to six months prior to admission/entry; -Had no falls since entry (1/17/15). Review of the resident's care plan, undated, showed the following: -Date admitted : 1/17/15; -Problem: The resident is at risk for falls related to the medications that he/she takes. He/she uses a wheelchair and self propels. He/she is independent with his/her activities of daily living (ADL)s/mobility/transfers. He/she is usually continent of bowel and bladder. He/she is on the walk to dine (walks from room to dining room). He/she has fallen once since admission; -Goal: He/she doesn't want to fall or hurt himself/herself; -Approaches: Make sure he/she takes his/her medications. Assist him/her as needed. Make sure he/she does his/her restorative. Review of the resident's fall investigation record, dated 2/5/15 at 10:20 P.M., showed the following: -Activity at time of fall: Attempting to self transfer from bed to wheelchair; -Was the fall related to the resident attempting to void? Yes; -Any current orders for psychotropic, cardiovascular or diuretics? Yes; -Any alarms (personal, chair, floor) ordered? Y