Every finding on record at Sunrise Nursing & Rehabilitation

Based on interview, and record review, the facility failed to ensure the rights of the one sampled resident's (Resident # 3) Durable Power of Attorney (DPOA) was exercised to maintain the resident safety when the facility allowed a family member who was not the POA to take the resident out of the facility out of 15 sampled residents. The facility census was 139 residents.Review of the facility's policy, Decision Making Capacity, dated 8/2020 showed:-Identifying a Surrogate Decision-maker: A person with legal authority to make medical treatment decisions on behalf of a resident was a person designated under a valid POA, a guardian, a conservator or a next of kin. The facility did not have a policy about an incapacitated resident leaving the facility. 1.Review of Resident #3's face sheet showed the resident had the following diagnoses:-Dementia (a decline in mental ability severe enough to interfere with daily living).-Psychosis (a disconnect from reality).-Altered mental status (a sudden change in a person's baseline awareness, cognition, or consciousness, ranging from mild confusion to unresponsiveness).-Aphasia (a disorder that impairs a person's ability to speak).-The resident's granddaughter was the DPOA.-Special instructions showed:-The resident was an elopement risk.-The resident was deemed incapacitated.-The resident could only be taken out of the facility by the DPOA. Review of the resident's DPOA for Health Care was signed on 2/9/24. Review of the resident's care plan showed:-The resident had impaired cognitive function/dementia or impaired thought processes related to dementia, dated 10/07/24.-The resident is an elopement risk/wanderer, disoriented to place.-History of attempts to leave facility unattended, impaired safety awareness.-Resident wanders aimlessly.-The care plan did not address obtaining permission from the DPOA before allowing relatives to take the resident out of the facility. Review of the resident's Brief Interview for Mental Status dated 4/13/26 showed he/she had a score of 4 indicating he/she was severely cognitively impaired. Review of the resident's DPOA report dated 4/22/26 showed: -On April 18, 2026 at approximately 3:15 P.M. the facility released the resident who was an elderly Dementia patient to a family member without the authorization from the DPOA. -This was not an isolated incident.-The facility has repeatedly failed to protect the resident allowing a relative to remove the resident from the facility on March 2, 2026 and again on April 18, 2026. -Concerns were raised with the facility staff. -The resident is a vulnerable adult with Dementia and documented history of wandering. -The resident required a secure supervised, environment at all times. Review of the Resident's Sign Out Sheet for April 2026 showed:-A family member signed the resident out of the facility on 4/18/26 at 1:59 P.M.-A family member signed the resident back into the facility at 4:11 P.M. on 4/18/26. During an interview on 5/20/26 at 10:30 A.M. the Receptionist said:-Any resident who was leaving the facility would have to sign the Sign Out Sheet.-There was a second book that showed who could take the resident out of the facility.-He/She automatically looks at the book to ensure they can leave the facility.-He/She was trained by the Business Office Manager. Review of the Receptionist's second book on 5/20/26 showed:-The resident was only allowed visitors.-The family member who took the resident out of the building was not on the list. During an interview on 5/20/26 at 10:45 A.M. the Business Office Manager said:-There was a receptionist on duty every day from 8:00 A.M. to 8:00 P.M. every day.-Sometimes they don't catch everyone to have them sign in and out. -The resident's Care Plan did not show he/she was only allowed to leave the facility with the POA, and it should have. -The Nurses on the locked Memory Care unit should have documented if one of the residents left the facility with someone and it was not done. -They do not have a check list for new hires to ensure they know what to do on the job.-The new hires sit with a seasoned employee for two days to learn the job. -The second book at the receptionist desk showed who was allowed to take a resident out of the facility.-The book showed the only person who was permitted to take the resident out of the facility was the DPOA. During an interview on 5/20/26 at 11:00 A.M. the Assistant Director of Nursing (ADON) who was acting Charge Nurse on the locked Memory Care Unit said:-He/She often works on the Memory Care Unit as the Charge Nurse.-Only certain family members were able to take the resident out of the facility.-They were identified on the second book at the receptionist desk or on the face sheet.-There were some family disputes going in with the resident's family. -The Nurse in the Memory care unit writes down when a family member takes a resident out, then throws the paper away when the resident was returned to the unit. -The Nurse should have documented in the Nurses' Notes when a resident left the locked unit for any reason.-There was no documentation either time when the resident had left with a family member.-The Care Plan should have shown the resident had a DPOA and that the resident could only leave the facility with him/her. It did not. -It was the Nurses' responsibility to ensure that only the people on the list were able to take a resident off of the unit. -The Receptionist should ensure every resident who leaves the facility was signed out and if they were from the memory care unit who were they going with.-This had not been done for this resident. During an interview on 5/21/26 at 1:00 P.M. the Social Worker said:-Staff should check with the Nurse as it was their responsibility to ensure if a resident left that they came back safely.-All residents should have signed out if they left the facility and signed back in every time.-She had provided education with the people at the reception desk to ensure everyone signs in and out and who they can leave with. -There should have been documentation in the resident's care plan that showed he/she could only leave the facility with the DPOA. There was not.-Under special instructions it showed who the resident could leave the facility with. -The receptionist has a second book that they should check with every time a resident leaves to ensure that they could leave and who they were leaving with.-The family member who took the resident out of the facility was not on the approved list. During an interview on 5/21/26 at 1:20 P.M. the Director of Nursing(DON) said:-Staff should have looked at the resident's face sheet to have seen who was authorized to take the resident out of the facility.-If there was a question the DPOA should have been called.-If a resident left the building the Nurses should have put a note in the Nurses Notes and the resident should have been signed out. This had not been done.-It should have been documented in the care plan if the DPOA only allowed certain people to take the resident out of the building. This had not been done. 2990695

Based on observation, interview, and record review, the facility failed to ensure appropriate storage and labeling of medications throughout the facility's medication carts and medication rooms which had the potential to affect all residents within the facility; and failed to ensure medications were stored in the medication cart/medication room for one resident (Resident #58) observed during the medication pass. The facility census was 134 residents. Review of the facility's policy titled Storage of Medications dated August 2020 showed: -Medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. -All medications dispensed by the pharmacy were stored in the pharmacy container with the pharmacy label. -Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without closures were immediately removed from inventory, disposed of according to procedures for medication disposal. -Expirations dates (beyond-use dates) of dispensed medications should be determined by the pharmacist at the time of dispensing. Review of the facility Medication Administration policy undated showed: -Medications will not be left at the bedside. A policy for self-administration of medications was requested and not received. 1. Observation on 6/24/25 at 8:55 A.M. of the 800-hall medication room showed: -Four soft silicone foam dressing-lite with adhesive border packages that expired on 6/22/25. -Three soft silicone foam dressing with adhesive border packages that expired 6/22/25. -Five humidifier connection tubes that expired on 12/2/24. -Eight female straight catheters that expired on 4/1/25. 2. Observation on 6/24/25 at 10:47 A.M. of the medication room of the 600/700 hall showed: -45 triple anti-biotic ointment packets that expired in May 2025. -One lubricating jelly packet that expired on 5/31/25. -Five sponge swab packages that expired in April 2025. -26 border gauze packets that expired 1/2/25. -One Foley catheter package that expired on 5/20/25. -Two Foley catheter packages that expired on 4/22/25. -One urinary leg bag-large 900 milliliters (ml) that expired 6/12/22. -One urinary drainage bag- 2000 ml that expired 11/28/24. -One urinary leg bag with built-in cover that expired 6/17/23. -Two urinary medium leg bags with easy-tap that expired in May 2024. During an interview on 6/24/25 at 11:12 A.M. Certified Medication Technician (CMT) B said expired medication supplies should not be stored in medication/treatment carts or rooms. 3. Observation on 6/25/25 at 10:29 A.M. of medication room three showed: -One PleurX drainage kit (a system that allows patients with recurrent pleural effusions or malignant ascites to drain fluid from their chest or abdomen at home) that expired 12/2/22. -One PleurX drainage kit that expired 11/27/22. -Eight medium foam wound dressing packages that expired in December 2024. -One medium foam wound dressing that expired 7/8/24. -One medium foam wound dressing that expired in October 2023. -One medium black foam wound dressing that expired 6/13/24. -One enteral administration kit that expired 3/1/24. 4. Observation on 6/25/25 at 10:40 A.M. of the 400-hall medication cart showed one bottle of Latanoprost solution 0.005% (used to treat certain kinds of glaucoma (a group of eye diseases that can damage the optic nerve, potentially leading to vision loss and blindness)) not stored in any container and only labeled with a first or last name. 5. During an interview on 6/25/25 at 2:54 P.M. CMT C said: -Expired medical supplies should not be stored in medication/treatment carts or medication rooms. -All medications, including eye drops, needed to be stored in the original container that they came in. -If a medication was found outside of its original container, then the medication needed to be disposed of. During an interview on 6/26/25 at 10:30 A.M. Licensed Practical Nurse (LPN) C said: -Expired medical supplies should not be stored in medication/treatment carts. -Expired medical supplies needed to be disposed once they are past the expiration date. -The nurses were responsible for ensuring that expired medications and supplies were destroyed or discarded appropriately. -He/She went through the medication carts and medication rooms periodically to check for expired medications and supplies. -The unit managers with a pharmacist would also go through the medication carts and rooms to ensure proper storage. -He/She was unsure if there was a regular schedule or process in place for going through the medication carts and medication rooms to check for appropriate storage. -Medications needed to be stored in their original container. -Eyedrops usually came in a box or bag, so the eye drops should never be in the cart by themselves. -If a medication was found outside of its original container it needed to be destroyed. During an interview on 6/26/25 at 11:33 A.M. Assistant Director of Nursing (ADON) A said: -Expired medical supplies should not be stored in medication/treatment carts or medication rooms. -Any expired medication or medical supply that was expired needed to be discarded. -The infection control nurse helped to ensure appropriate storage of medications and medical supplies. -He/She went through the medication carts and rooms sometimes to ensure appropriate storage of medications and medical supplies. -There was not a current schedule or process in place to ensure that all medication carts and medication rooms were checked to ensure appropriate storage of medications and medical supplies. -All medications needed to be stored in their original container and have an open date. -Any medication not stored in its original container needed to be destroyed. During an interview on 6/26/25 at 11:44 A.M. the Director of Nursing (DON) said: -Medication carts and medication rooms were audited once a week. -The infection control nurse was responsible for the audit. -He/She was unsure why there would be so many expired medical supplies because the facility performed full medication room audits. During an interview on 6/26/25 at 1:30 P.M. the DON said: -Expired medications and medical supplies should not be stored in medication/treatment carts or medication rooms. -All medications needed to be stored in their original container and destroyed if found outside of their original container. 6. Review of Resident #58's Physician's Order Summary (POS) dated June 2025 showed: -Biotene Dry Mouth Mouth/Throat Liquid (artificial saliva that moistens and cleans the mouth) (Mouthwashes), give 1 dose by mouth every morning and at bedtime, dated 10/24/24; the order did not include instruction that the resident could self-administer the Biotene and could keep the Biotine at his/her bedside. -Albuterol Sulfate HFA Aerosol Solution (a medication used to treat or prevent breathing difficulties) 108 (90 Base) micrograms (mcg) per actuation (a single dose of medication released from the oral inhalation device), two puffs every day and evening and every six hours as needed for shortness of breath, unsupervised self-administration, and no instruction that the resident could keep his/her Albuterol inhaler at his/her bedside, dated 3/23/22. Observation on 06/24/25 at 7:55 A.M. showed CMT D did not prepare or administer the following medications to the resident: -Biotene Dry Mouth Mouth/Throat Liquid. -Albuterol Sulfate HFA Aerosol Solution (a medication used to treat or prevent breathing difficulties) 108 (90 Base) micrograms (MCG) per actuation (a single dose of medication released from the oral inhalation device), two puffs. During an interview on 6/24/25 at 12:41 P.M. CMT D said. -He/she had not administered the resident's Biotine liquid mouth rinse and Albuterol inhaler. -The resident always administered his/her own Biotine liquid mouth rinse and Albuterol inhaler, which he/she kept those medications in his/her room. Observation on 6/24/25 at 12:46 P.M. showed the resident had the following medications in his/her room which he/she kept next to his/her bed in a small purse. -Biotine mouth rinse. -Albuterol Sulfate inhaler. During an interview on 6/24/25 at 12:46 P.M. the resident said: -He/she took his/her own Biotine in the mornings and evenings which he/she kept in his/her room. -He/she used his/her Albuterol inhaler as needed once or twice a day which he/she kept in his/her room. -The CMT's did not keep and did not administer his/her Biotine mouth rinse and his/her Albuterol inhaler. -The CMT's never asked him/her if he/she took the medications he/she kept in his/her room. -The licensed nurses knew he/she kept medication in his/her room and did ask him/her once in a while if he/she had self-administered his/her Biotin mouth wash and Albuterol inhaler. During an interview on 6/26/25 12:21 P.M. Licensed Practical Nurse (LPN) F looked at the resident's electronic medical record physician's orders and Medication Administration Record and said: -The resident did have a physician's order that he/she could self-administer his/her Albuterol inhaler but did not have a physician's order that he/she could keep his/her Albuterol inhaler at his/her bedside. -The resident had no other physician's orders for self-administration of medications other than his/her Albuterol Inhaler. -He/she had been pretty sure the resident had not kept any medications in his/her room. -He/she would have to ask the resident if he/she had any medications in his/her room. -He/she expected that if the resident had medications in his/her room and was self-administering the medications the CMT's would have to see those orders on the resident's MAR and if those instructions were not on the resident's MAR, he/she expected the CMT would tell him/her so he/she could get clarification of the physician's orders. -He/she expected if a CMT was aware that any resident had medication in their room, the CMT would inform him/her. During an interview on 6/26/25 at 1:10 P.M. the Director of Nursing (DON) said: -For a resident to self-administer medication and medications kept at their bedside, there would have to be a quarterly assessment of the resident's ability to self-administer those medications. -Assessments of a resident's ability to self-administer medications should be completed quarterly. -There would also have to be physician's orders for the resident to self-administer specific medications and the resident could keep those specific medications at their bedside.

Based on observation, interview, and record review, the facility failed to maintain plastic cutting boards and plate covers in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; and failed to store foodstuffs within their recommended acceptable temperature parameters, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 134 residents with a licensed capacity for 156 residents at the time of the survey. 1. Observation on 6/23/25 between 9:51 A.M. and 11:39 A.M. during a kitchen sanitation inspection showed the following: -There was a 6-pound (lb.) 12-ounce (oz.) can of chili con carne on the bottom row of a dispenser rack in the Dry Storage (DS) room that was heavily dented toward its top side. -An open 1-gallon (gal.) jug of teriyaki sauce approximately (app.) 1/8 full on a middle shelf of a baker's rack next to the manual can opener read Refrigerate After Opening on its label. -The red and green cutting boards on a top shelf of a baker's rack at the south wall were heavily scored to the point of plastic flaking off. -Five maroon plastic plate covers on a four-tiered rolling rack outside the meal pass-through window were chipped around their bottom edges. Review of the facility's undated four-week rotating menus used by their Dietary Department showed there were at least two meals during that time with oriental main dishes and several other meals with a vegetable or noodle side dish with which cooks and/or residents may use teriyaki sauce. Observation on 6/24/25 between 10:22 AM and 11:33 A.M. showed the following: -There was a 6-lb. 12-oz. can of chili con carne on the bottom row of a dispenser rack in the DS room that was heavily dented toward its top side. -An open 1-gal. jug of teriyaki sauce app. 1/8 full on a middle shelf of a baker's rack next to the manual can opener read Refrigerate After Opening on its label. -The red and green cutting boards on a top shelf of a baker's rack at the south wall were heavily scored to the point of plastic flaking off. -Five maroon plastic plate covers on a four-tiered rolling rack outside the meal pass-through window were chipped around their bottom edges. During an interview on 6/25/25 at 1:25 P.M. the Dietary Manager said the following: -He/She would expect if a foodstuff read store at a certain temperature on its label that it would be. -Damaged foodstuffs were separated out and returned to their food vendor for a credit or replacement. -He/She would expect food to be free of foreign substances. -Damaged food preparation items were discarded and replaced.

2. Review of Resident #12's admission record showed he/she admitted to the facility with the following diagnoses: -Low Back Pain. -Chronic Pain Syndrome (a condition characterized by persistent pain lasting longer than three months, significantly impacting physical, emotional, and social well-being). Review of the resident's Medication Administration Record (MAR) dated June 2025 showed a physician order for Lidocaine Patch 4%, apply to lower back topically in the morning for pain related to Chronic Pain Syndrome. Observation on 6/24/25 at 7:54 A.M. of the resident's Lidocaine 4% patch administration completed by Certified Medication Technician (CMT) B showed: -He/She had put on gloves and unlocked the medication cart without washing or sanitizing his/her hands before putting on the gloves. -He/She removed the Lidocaine 4% patch out of the medication cart and took the patch out of the wrapper. -He/She then labeled the patch with a marker and locked the medication cart. -He/She then knocked on the resident's door and entered the resident's room with the same gloves on and without washing or sanitizing his/her hands. -He/She then walked to the resident's bed and pulled up the resident's top in order to place the patch on the resident's lower back. -He/She then took the rest of the wrapping off of the patch and placed the patch on the resident's lower back. -He/She then exited the resident's room and returned to the medication cart with the same gloves on and without washing or sanitizing his/her hands before exiting the resident's room. During an interview on 6/24/25 at 11:09 A.M. CMT B said he/she would not have done anything differently during his/her administration of the resident's Lidocaine patch. 3. Review of Resident #130's MAR dated June 2025 showed: -The resident had a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -The resident had an order for Humalog Kwikpen Subcutaneous Solution Pen-injector 100 unit/milliliter (ml) (insulin Lispro- a fast-acting insulin), inject 12 units subcutaneously before meals for DM II. -Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (insulin Glargine- a long-acting insulin), inject 20 units subcutaneously one time a day for DM II. Observation on 6/24/25 at 8:10 A.M. of the resident's insulin administration completed by CMT C showed: -He/She was gathering the supplies for the blood sugar check and the insulin administration. -He/She placed the needles on the insulin pens without sanitizing the pen. -He/She went into the resident's room. -He/She then set all of the supplies on the resident's countertop without placing a barrier down first. -The supplies remained on the counter without a barrier during the blood sugar test and the insulin administration. -He/She exited the resident's room after administering the insulin. During an interview on 6/25/25 at 2:54 P.M. CMT C said: -He/She had missed a couple of steps when administering the resident's insulin. -He/She forgot to clean the insulin pens before use. -He/She forgot to place a barrier down when placing the blood sugar supplies on the resident's counter. -He/She was nervous and that was why he/she had missed those steps. 4. Review of Resident #24's admission Record showed he/she admitted to the facility with a diagnosis of Pressure Ulcer (an injury to the skin and underlying tissues resulting from prolonged pressure on the skin) of Left Buttock, Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed. Often includes undermining and tunneling). Review of the resident's Physician Order Sheet (POS) dated June 2025 showed a phyaican order for treatment to his/her left ischium, clean with wound cleanser, pat dry, apply calcium alginate (helps in the absorption of wound exudate), and cover with border silicone foam. During an interview on 6/25/25 at 1:36 P.M. Licensed Practical Nurse (LPN) D said: -The resident had been seen by the wound care doctor that morning. -The resident had a new wound and new wound care orders were in place. -The wound care order was to cleanse the area with wound cleanser, apply santyl (a topical enzyme medication used in wound care to remove damaged or dead skin), apply calcium alginate, and cover with border silicone foam. -The santyl was ordered, but had not arrived at the facility, so he/she would not be using santyl during the resident's treatment. Observation on 6/25/25 at 1:38 P.M. of the resident's wound care treatments completed by LPN D showed: -He/She entered the resident's room to start the treatment. -He/She completed the treatment to the resident's left ischium. -He/She then assisted in completing perineal care to the resident. -He/She then washed his/her hands and put on new gloves. -He/She cleansed the new wound to the resident's buttocks and placed the calcium alginate and border foam on the resident's wound area. -He/She then removed his/her gloves and sanitized his/her hands and assisted in the completion of the resident's perineal care. During an interview on 6/25/25 at 1:55 P.M. LPN D said: -He/She had forgotten to change out his/her gloves and perform hand hygiene in between the cleansing of the resident's new wound and putting on the dressing. -There was not a specific reason why he/she had forgotten the glove change and hand hygiene. -Hand hygiene needed to be done when gloves were removed and when completing different tasks during any type of resident care. 5. During an interview on 6/26/25 2:54 P.M. CMT C said: -Hand hygiene needed to be completed after every five residents during medication administration. -Hand hygiene should be performed before and after the use of gloves. -CMT B had not performed appropriate hand hygiene during Resident #12's Lidocaine 4% patch administration. -CMT B should have gathered his/her supplies first, then performed hand hygiene, then put on his/her gloves to get the patch ready. -CMT B should not have worn the gloves into the resident's room. -CMT B should have removed his/her gloves prior to entering the room, sanitized his/her hands upon entering the resident's room, then put new gloves on. During an interview on 6/26/25 at 10:15 A.M. LPN C said: -Hand hygiene needed to be performed before and after glove usage. -Hand hygiene needed to be performed when completing different tasks on the same resident during resident care, which included when cleaning a wound and placing a new dressing on a wound. -Hand hygiene should be performed after the completion of any resident care. -Hand hygiene should be performed before and after each resident during medication administration. -CMT B had not performed appropriate hand hygiene during Resident #12's Lidocaine 4% patch administration. -CMT B should have gathered his/her supplies first before putting on the gloves. -CMT B should not have worn gloves into Resident #12's room. -CMT B should have taken all the supplies needed into Resident #12's room and washed his/her hands before putting on new gloves. -CMT B then would have been able to apply Resident #12's Lidocaine 4% patch. -CMT B should have removed his/her gloves and washed/sanitized his/her hands before exiting Resident #12's room. -Insulin pens needed to be sanitized before use. -A barrier needed to be in place during blood sugar checks and insulin administration if supplies were going to be set down anywhere in the resident's room. -CMT C had not performed appropriate infection control measures during Resident #130's blood sugar check and insulin administration. During an interview on 6/26/25 at 11:12 A.M. Assistant Director of Nursing (ADON) A said: -Hand hygiene should be done before and after glove usage. -Hand hygiene needed to be done when performing different tasks during resident care. -LPN D had not performed appropriate hand hygiene during Resident #24's wound care. -LPN D should have removed his/her gloves and washed/sanitized his/her hands after cleansing the wound area. -LPN D should have put on new gloves before putting on the new dressing to Resident #24's wound area. -CMT B had not performed appropriate hand hygiene during Resident #12's Lidocaine 4% patch administration. -Gloves should never be worn into resident rooms. -CMT B should have sanitized/washed his/her hands and entered Resident #12's room with all of the supplies needed. -CMT B should have labeled the patch and then put on gloves, then placed the patch on Resident #12. -CMT B should have washed/sanitized his/her hands before exiting Resident #12's room. -CMT C had not performed appropriate infection control practices during Resident #130's blood sugar check and insulin administration. -CMT C should have cleaned the insulin pens before placing the needles on the pens. -CMT C should have placed a barrier on Resident #130's counter when he/she set the supplies down during Resident #130's blood sugar check and insulin administration. During an interview on 6/26/25 at 1:30 P.M. the Director of Nursing (DON) said: -Hand hygiene should be performed every three to five residents during medication administration. -Hand hygiene should be performed before and after any type of patch was administered. -CMT B had not performed appropriate hand hygiene during Resident #12's Lidocaine 4% patch administration. -Gloves should not be worn into resident rooms. -Hand hygiene should be performed before and after glove usage. -LPN D had not performed appropriate hand hygiene during Resident #24's wound care. -Hand hygiene needed to be completed between each step of the treatment during wound care. -LPN D should have started the dressing change over. -LPN D should have removed his/her gloves after cleansing the wound, washed his/her hands, and put on new gloves before placing the dressing to Resident #24's wound area. -Insulin pens needed to be sanitized before each use. -A barrier needed to be in place during blood sugar checks and insulin administration when setting down supplies in a resident's room. -CMT C had not performed appropriate infection control measures during Resident #130's blood sugar check and insulin administration. Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility; the facility failed to ensure appropriate hand hygiene was completed during wound care for one sampled resident (Resident #24); failed to ensure appropriate infection control measures were taken when performing a blood glucose (sugar) test (measures the amount of sugar in the blood) and during insulin (a hormone produces by the pancreas that plays a crucial role in regulating blood sugar levels) for one sampled resident (Resident #130); and failed to ensure appropriate hand hygiene and glove usage was completed during a lidocaine 4% (topical anesthetic) patch administration for one supplemental resident (Resident #12) out of 27 sampled residents and four supplemental residents; and the facility failed to ensure accurate time frames were adhered to for the administration of the two step tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) skin tests for four out of five residents sampled for TB testing (Residents #113, #80, #130, and #95) and for two out of 10 sampled staff (Employee #5 and Employee #10). The facility census was 134 residents with a licensed capacity for 152 residents at the time of the survey. Review of the facility's policy titled Administration Procedures for All Medications dated August 2020 showed: -Staff were to cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a medication pass, before handing medication, and before contact with a resident. -Staff were to use a barrier such as a clean disposable tray to carry medication containers into the resident's room and to separate the supplies and the over-the-bed table or other surface on which the supplies were placed when medications were administered. -When staff were finished administering medication to each resident, staff were to wash hands with antimicrobial soap and water or use facility-approved hand sanitizer. Review of the facility's policy titled Handwashing/Hand Hygiene dated August 2019 showed: -All personnel were to follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: --Before and after direct contact with residents. --Before preparing or handling medications. --Before handling clean or soiled dressings. --Before moving from a contaminated body site to a clean body site during resident care. --After contact with a resident's intact skin. --After removing gloves. A policy for resident TB testing was requested and not received by the end of survey. Review of the facility's Employee TB Screening and Interpretation of Results policy dated June 2020 showed: -Purpose: To ensure the facility adequately administers and interprets TB results for staff. -The facility will administer and interpret TB skin tests in accordance with recognized guidelines and pertinent regulations. -A qualified nurse or health practitioner interprets the TB skin test 48-72 hours (2-3 days) after administration. 1. Observation on 6/23/25 between 11:05 A.M. and 11:51 A.M. during the initial facility Life Safety Code (LSC) kitchen inspection showed there was a three-sink area, a chemical dish-washing machine, a hand-washing sink, with an ice machine and a steam table (Also referred to as a hot food table, specifically designed to hold food at steady, safe serving temperatures.) in the attached auxiliary kitchenette off the Main Dining Room (MDR). Observation on 6/24/25 between 12:07 P.M. and 3:19 P.M. during the facility LSC walk-through inspection with the Director of Maintenance (DOM) showed the following: -The building was equipped with full fire sprinkler systems with its incoming water supplied by the local water company. -There were three piped fire sprinkler riser rooms (A dedicated space for fire protection equipment) which served the whole facility's systems. -There were some housekeeping closets with a floor mop sink or ceramic service sink (Mop/service sinks were used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water) and water heaters throughout the eight resident room hallways. -There were at least 99 resident rooms with private or shared bathrooms and/or sinks. -There were commercial clothes washers in the laundry area. -There were at least seven bathhouses with toilets throughout the facility. -There was a Beauty Shop with a sink. -There were at least two inoperable water fountains. Review of the facility's 18-page (pg.) policy and procedure entitled Risk Management Plan for Legionella Control, last reviewed on 1/3/25 by and provided by the Administrator, showed the following: -Though the cover page had the facility's current name under the title, further down it read that the facility's name was the previous ownership's name. -At Chapter 2, Risk analysis, under Section 2.1, System description, Figure 1 appeared to be a generic flow chart that was not facility-specific and was described as the Schematic of (Facility name) water delivery system. -The schematic had no required written explanation of the water flow throughout the facility and did not indicate specific areas of potential growth, like dead ends or unused plumbing/pipes, with their rated likelihood of occurrence and a risk level for each. -Under Section 2.1, System description, sub-section 2.1.5, System details, the sixth bullet point read, Water is tempered using a mixing valve that is in the basement sprinkler room, when the building had no basement. -Under Section 2.2, Hazard identification and risk assessment, there were educational materials for performing that assessment, such as Table 3, Examples of potential hazardous event, Tables 4 and 4b, descriptions of possible qualitative measures of likelihood and impact, Table 4c, an explanation of a qualitative risk analysis matrix, and Table 5, an example of what a hazard identification and risk assessment table with possible control measures would look like, but nothing facility-specific. -At Chapter 3, Risk management, there was explanatory material for control procedures, operational monitoring, and verification of monitoring and possible responses with examples. -The Table of Contents page, and pages 1-3, 5, 7, 9, 11, 13, and 15 stated the plan was for a sister facility, which did have a basement, with their previous ownership's name in the footer. -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -No completed Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens was included. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was no documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 6/26/25 at 9:25 A.M. the Administrator said the following: -Their Legionella Plan should meet all CDC and CMS requirements. -The list of potential growth areas should include their level of likelihood and risk. -They were still affiliated with the sister facility named above. 6. Review of Resident #113's admission Sheet showed he/she was admitted to the facility on [DATE] from another long term care facility. Review of the resident's Electronic Medical Records showed: -No documentation of a TB skin test from his/her previous facility. -A TB skin test was administered on 4/29/25 with no read results. -A TB skin test was administered on 5/5/25 with no read results. Review of his/her Immunization Audit Report dated 6/24/25 showed: -A TB skin test was administered on 4/29/25 and read on 5/5/25, six days after administration,. -A TB skin test was administered on 5/5/25, the same day the previous test was read, and read on 5/7/25. -A TB skin test was administered on 6/24/25. 7. Review of Resident #80's admission Record showed he/she was admitted to the facility on [DATE]. Review of the resident's Electronic Medical Records showed: -A TB skin test was administered on 3/26/24, almost two months after the resident was admitted to the facility, and read on 3/28/24. -A TB skin test was administered on 4/2/24, five days after the first test was resulted, and read on 4/4/24. Review of his/her Immunization Audit Report dated 6/24/25 showed: -A TB skin test was administered on 3/26/24, almost two months after the resident was admitted to the facility, and read on 3/28/24. -A TB skin test was administered on 4/2/24, five days after the first test was resulted, and read on 4/4/24. 8. Review of Resident #130's admission Record showed he/she was admitted to the facility on [DATE]. Review of the resident's Electronic Medical Records showed: -A TB skin test was administered on 6/9/25, five days after admission to the facility, and read on 6/12/25. -A TB skin test was administered on 6/16/25, four days after the first test was resulted, and read on 6/18/25. Review of his/her Immunization Audit Report dated 6/24/25 showed: -A TB skin test was administered on 6/9/25, five days after admission to the facility, and read on 6/12/25. -A TB skin test was administered on 6/16/25, four days after the first test was resulted, and read on 6/18/25. 9. Review of Resident #95's admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the resident's Electronic Medical Records showed: -No documentation a two step TB test was administered or read upon admission on [DATE]. -A TB skin test was administered on 3/26/24, seven months after admission to the facility, and read on 3/28/24. -A TB skin test was administered on 4/2/24, five days after the first test was resulted, and read on 4/4/24. Review of his/her Immunization Audit Report dated 6/24/25 showed: -No documentation a two step TB test was administered or read upon admission on [DATE]. -A TB skin test was administered on 3/26/24, seven months after admission to the facility, and read on 3/28/24. -A TB skin test was administered on 4/2/24, five days after the first test was resulted, and read on 4/4/24. 10. Review of Employee #5's employee file showed his/her hire date was 10/2/24. -A TB skin test was administered on 9/25/24 and read on 9/27/24. -A TB skin test was administered on 10/3/24, six days after the first test was read, and resulted on 10/5/24 . 11. Review of Employee #10's employee file showed his/her hire date was 4/7/25. -A TB skin test was administered on 4/2/25 and read on 4/4/25. -A TB skin test was administered on 4/10/25, six days after the first test was read, and resulted on 4/12/25. 12. During an interview on 6/26/25 at 12:45 P.M., the Infection Preventionist said: -TB skin tests should be administered within 48 hours from admission. -TB skin test results should be read 48-72 hours after the test was administered. -A second step should be administered no sooner than seven days after the previous test was resulted. During an interview on 6/26/25 at 1:11 P.M., the DON said: -TB skin tests should be administered within 48 hours from admission. -TB skin test results should be read 48-72 hours after the test was administered. -A second step should be administered no sooner than seven days after the previous test was resulted.

Based on interview and record review, the facility failed to ensure a Family Care Safety Registry (FCSR) screening was completed per facility policy for three newly hired employees (Employee #1, #2, and #4) out of 10 newly hired employees. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 134 residents. Review of the facility Background Check Policy dated 2/2025 showed: -Candidates for all staffing positions are subject to background checks. -The Department of Human Resources is responsible for the general administration and implementation of this policy. 1. Review of Employee #1's Employee File showed: -His/Her hire date was 8/28/24. -A FCSR was completed on 9/24/24, one month after the employee was hired. 2. Review of Employee #2's Employee File showed: -His/Her hire date was 7/24/24. -A FCSR was completed on 9/24/24, two months after the employee was hired. 3. Review of Employee #4's Employee File showed: -His/Her hire date was 10/2/24. -No documentation a FCSR was completed for this employee. 4. During an interview on 6/26/25 at 11:39 A.M., the Administrator said: -He/She had no documentation a FCSR was completed on Employee #4. -He/She thought it was missed because the employee had a name change around the time he/she was hired. -He/She was not sure why Employee #1 and Employee #2's FCSR were not completed prior to hire, they were just run late. -He/She would expect all background checks, including the FCSR, to be completed prior to the employee's date of hire. During an interview on 6/26/25 at 12:11 P.M., the Human Resources Director said: -He/She was responsible for completing all FCSR checks prior to the employee's start date. -He/She submitted the employee's information to a third party vendor to complete the FCSR. The third party vendor would email him/her if no information was found so he/she could update the employee file. -When the checks come through, he/she would update, print, and place in the employee file. -All background checks, including FCSR, should be completed before the staff person started working. -He/She could not find a FCSR for Employee #4. He/She thought there may have been a communication error due to the employee having a name change.

Based on observation, interview, and record review, the facility failed to ensure that professional standards were met when Certified Medication Technician (CMT) B pre-popped and signed as given prior to administration the medications for three supplemental residents (Resident #6, #56, and #400) out of four supplemental residents. This practice had the potential to affect all residents in the 700 hall. The facility census was 134 residents. Review of the facility's undated policy titled Medication-Administration showed: -The purpose of the policy was to provide practice standards for safe administration of medications for residents in the facility. -The time and dose of the drug or treatment administered to the resident would be recorded in the resident's individual medication record by the person who administered the drug or treatment. -There was no specific policy related to pre-popping medications. 1. Review of Resident #6's admission Record showed that he/she admitted to the facility with a diagnosis of Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Observation on 6/24/25 at 7:59 A.M. of the resident's medication pass completed by CMT B showed: -CMT B removed the resident's medications out of the top drawer of the medication cart. -The resident's medications were in a 30 milliliter (ml) cup and the cup was labeled with the resident's room number and/or last name. -The resident's medications were already marked as administered in the resident's Electronic Medical Record (EMR) prior to the medications being given to the resident. 2. Review of Resident #56's admission Record showed he/she admitted to the facility with a diagnosis of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Observation on 6/24/25 at 8:03 A.M. of the resident's medication pass completed by CMT B showed: -CMT B checked the resident's blood pressure. -CMT B returned to the medication cart and removed the resident's medications out of the top drawer of the medication cart. -The resident's medications were in a 30 ml cup and the cup was labeled with the resident's room number and/or last name. -The resident's medications were already marked as administered in the resident's EMR prior to the medications being given to the resident. 3. Review of Resident #400's admission Record showed he/she admitted to the facility with a diagnosis of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Observation on 6/24/25 at 8:06 A.M. of the resident's medication pass completed by CMT B showed: -CMT B returned to the medication cart and removed the resident's medications out of the top drawer of the medication cart. -The resident's medications were in a 30 ml cup and the cup was labeled with the resident's room number and/or last name. -The resident's medications were already marked as administered in the resident's EMR prior to the medications being given to the resident. -The resident began to crush the resident's medications. 4. Observation on 6/24/25 at 8:08 A.M. of the top drawer of the 600/700 hall medication cart showed what appeared to be all of the 700 hall residents' medications pre-popped and placed in 30 ml cups and were labeled with the residents' room numbers and/or last names. During an interview on 6/24/25 at 8:08 A.M. CMT B said that he/she had pre-popped all of the residents' medications prior to beginning his/her 700-hall medication pass. 5. During an interview on 6/24/25 at 8:14 A.M. Assistant Director of Nursing (ADON) A said: -What CMT B did was not acceptable. -Medications should never be pre-popped and need to be signed as given after they are admistered to the resident. During an interview on 6/24/25 at 11:09 A.M. CMT B said: -He/She had marked all of the residents' medications as administered prior to starting the 700-hall medication pass. -He/She usually marked medications such as eye drops and supplements as administered before his/her medication pass because those were the medications that the residents were guaranteed to take. -He/She usually waited to mark blood pressure medications as administered until he/she knew that the resident needed the blood pressure medication. -He/She normally did not pre-pop his/her medications prior to starting his/her medication pass. -He/She did not have a reason as to why he/she decided to pre-pop the medications before the medication pass that day. -Medications should not be pre-popped before starting a medication pass. -Medications should be taken out of their containers or packets at the time of each resident medication administration. During an interview on 6/25/24 at 2:54 P.M. CMT C said: -Medications should never be pre-popped before the start of a medication pass. -If medications were pre-popped, it could lead to medications errors. -Medications should be marked as administered after the medication was given and not before because residents could refuse their medications. During an interview on 6/26/25 at 10:17 A.M. Licensed Practical Nurse (LPN) C said: -Medications should never be pre-popped before the start of a medication pass. -Pre-popping medications could lead to medication errors. -Medications should not be marked as administered prior to administering the medications. -Residents could refuse their medications or could not need a medication based off of their vital signs, which would be why the medications should not be pre-popped or marked as administered prior to giving them. During an interview on 6/26/25 at 1:30 P.M. the Director of Nursing (DON) said: -Medications should never be pre-popped. -There were multiple safety concerns that could lead to negative resident outcomes if medications were pre-popped before medication pass. -Pre-popping medications was against facility policy. -Medications should be taken out of their original containers and packages at the time of administration. -Medications should not be marked as administered prior to the resident getting the medication. -The reason why medications should not be marked as given prior to administering the medications was residents could refuse the medication or simply not be given at all.

Based on observation, interview, and record review, the facility failed to store nebulizers (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) and a nasal cannula (a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose) in a bag for three sampled residents (Resident #48, #41, and #105); and failed to complete a periodic assessment for one sampled resident's (Resident #63) ability to self-administer his/her respiratory care, including tracheostomy (trach - an opening surgically created through the neck into the windpipe; a tube is usually placed through this opening to provide an airway and to remove secretions) out of 27 sampled residents. The facility census was 134 residents. Review of facility policy titled Respiratory Care Policy revised January 2025 showed: -Ensure that residents had comprehensive respiratory care provided to enhance resident safety and promote optimal respiratory health. -Respiratory care included services prescribed by a physician or a non-physician practitioner for the assessment, diagnostic evaluation, treatment, management and of residents with deficiencies and abnormalities. -Ensure proper storage of all respiratory equipment. 1. Review of Resident #48's admission Record showed he/she was admitted to the facility on [DATE]. Review of the resident's care plan dated 5/8/25 showed that the resident's use of a nebulizer was not addressed. Review of the resident's Order Summary Report (OSR) dated June 2025 showed a physician order for DuoNeb 0.5 milligram (mg)-2.5 mg/3 milliliter (ml) (a medication that works by opening your airways and reducing inflammation in your lungs to help you breathe) give one vial every six hours for upper respiratory infection. Observation on 6/22/25 at 12:55 P.M. in the resident's room showed the nebulizer laying on a bedside table not stored in plastic bag, but the plastic bag was next to the nebulizer. Observation on 6/23/25 at 10:13 A.M. in the resident's room showed the nebulizer laying on the resident's bedside table not in a plastic bag. Observation on 6/23/25 at 11:05 A.M. in the resident's room showed the nebulizer not in plastic bag just sitting on the bedside table. 2. Review of Resident #41's admission Record showed he/she was admitted to the facility on [DATE]. Review of the resident's care plan dated 5/22/25 showed: -Supplemental oxygen was not addressed in the care plan. -Whether the resident was compliant or noncompliant with storage of his/her nasal cannula was not addressed. Review of the resident's Order Summary Report dated June 2025 showed an order for oxygen at two to five liters per minute via a nasal cannula as needed to maintain oxygen saturation above 90% and the order was dated 12/15/24. Observation on 6/22/25 at 10:53 A.M. showed the resident's nasal cannula was wrapped around the resident's walker handle no plastic storage bag was visible. Observation on 6/23/25 at 10:30 A.M. showed the resident's nasal cannula was wrapped around the resident's walker handle no plastic storage bag was visible. Observation on 6/24/25 at 11:25 A.M. showed the resident's nasal cannula was wrapped around the resident's walker handle no storage bag was visible. 3. Review of Resident #105's admission Record showed he/she was admitted to the facility on [DATE]. Review of the resident's Order Summary Report dated June 2025 showed: -Order for oxygen at two to five liters per minute via a nasal cannula as needed to maintain oxygen saturation above 90% and the order was dated 2/6/25. - DuoNeb 0.5 mg-2.5 mg/3 ml give one vial four times a day for every six hours for Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation) or shortness of breath. Review of the resident's care plan dated 6/20/25 showed: -The resident received DuoNeb four times a day. -Did not show whether the resident was compliant or non-compliant with storage of the nebulizer. Observation on 6/22/25 1:36 P.M. showed the resident's nebulizer was not stored in a plastic bag, but laying on the bedside table. Observation on 6/23/25 at 10:45 A.M. showed the resident's nebulizer was not stored in a plastic bag but was on the resident's bedside table. Observation on 6/23/25 at 2:57 P.M. showed the resident's nebulizer was not stored in a plastic bag but was on the resident's bedside table. 4. During an interview on 6/26/25 at 9:00 A.M., Certified Nurse's Aide (CNA) A said: -Nebulizers and nasal cannulas were to be stored in a plastic bag when not in use. -The bag would be dated and changed out weekly. -When one was found not in a plastic bag the item would be replaced and placed in the plastic storage bag. -When a resident was not compliant with the storage of the respiratory item the resident would be educated about the importance of it, and the nurse would be notified so the care plan could then be updated. During an interview on 6/26/25 at 9:04 A.M., Certified Medication Technician (CMT) A said: -Nebulizers and nasal cannulas were to be stored in a plastic bag. -When a nebulizer or nasal cannula was found not in a plastic bag he/she would replace it and place in the plastic bag. -When a resident was noncompliant, with respiratory equipment storage, the resident would have been educated and the nurse notified so the care plan could be updated. During an interview on 6/26/25 at 9:09 A.M. Licensed Practical Nurse (LPN) A said: -Nasal cannulas and nebulizer were to be stored in a dated plastic bag. -When the nebulizer of nasal cannula were not stored in the plastic bag he/she would get a new nasal cannula or nebulizer and place it in the plastic bag. -The Director of Nursing (DON) would be informed that resident was noncompliant on the storage of nasal cannulas or nebulizers and was educated. -The residents care plan would need to be updated. -The DON or Assistant Director of Nursing (ADON) updated the care plan. During an interview on 6/26/25 at 10:50 A.M., LPN B said: -Nasal cannulas and nebulizer would be stored in a dated plastic bag a when not in use. -When a nasal cannula or nebulizer was found not stored in a plastic bag the resident was educated on the importance of this, and the items replaced -The DON and ADON would be notified to have the care plan updated. During an interview on 6/26/25 at 1:05 P.M., the DON said: -It was his/her expectation that nasal cannulas and nebulizers were to be stored in dated plastic bags. -It was his/her expectation that staff would have educated the resident on the importance of storing nasal cannulas of nebulizers in plastic bags when not in use. -When a resident was non-compliant with the storage that he/she would be notified so the care plan would be updated. 5. Review of Resident #63's respiratory care plan dated 2/27/25 showed: -An original trach and respiratory care plan date of 3/23/22. -Instruction that he/she had physician's orders for him/her to self-administer his/her trach and respiratory care. -Licensed nurses were to monitor him/her for signs/symptoms of respiratory distress. -There was no instruction regarding frequency of assessment and documentation of his/her ability to self-administer his/her trach and respiratory care. Review of the resident's electronic medical record dated 6/1/24 through 6/24/25 showed no documented assessment of the resident's ability to self-administer tracheostomy and respiratory treatments. Observation of the resident on 6/23/25 at 10:24 A.M. showed: -The resident was seated in his/her room. -His/her trach area was clean, and he/she had no signs of respiratory difficulty. Observation on 6/24/25 10:41 A.M. showed: -The resident was seated in his/her room. -Numerous respiratory care items were stored in a plastic bag near his/her sink, in his/her dresser drawers, and on his/her dresser drawers. --All items were orderly and unopened. During an interview on 6/24/25 at 10:41 A.M. the resident said: -He/she had been taking care of his/her trach and respiratory treatments himself/herself for a long time. -He/she had all the supplies he/she needed and was able to do all his/her own trach and respiratory care with the exception that he/she had the licensed nurses fasten his/her trach collar (a soft, padded fabric placed around the neck used to secure a tracheostomy tube in place). -A couple of months ago a licensed nurse watched him/her do his/her trach and respiratory care. -He/she had been taking of his/her trach for a long time; he/she knew what he/she was doing; he/she had not had any problems with his/her trach and had not had any infections. -A licensed nurse came to his/her room at least three to four times a day to see how he/she was doing. -He/she declined for the surveyor to observe him/her complete his/her trach care. During an interview on 6/24/25 at 12:14 P.M. LPN G said: -The resident had been taking care of his/her trach and respiratory care for a long time. -He/she had observed that the resident was able to self-administer his/her trach and respiratory care, but he/she had not ever documented his/her observations. During an interview on 6/26/25 at 1:10 P.M. the DON said for residents who self-administered trach/respiratory care there should be a quarterly documented assessment of the resident's ability to self-administer the care completed by a licensed nurse.

Based on observation, interview, and record review, the facility failed to follow Federal, State, and Local Laws to ensure the facility van was licensed to ensure legal transport of residents to and from the facility. This failure had the potential to affect all residents who required transportation to and from the facility for appointments. The facility census was 134 residents. A policy related to vehicle maintenance and licensure was requested and not received during survey. 1. During an interview on [DATE] at 12:41 P.M., the Director of Nursing (DON) said: -The facility had two vans in the parking lot. -One van had a sister facility's name on the side that the facility had not used due to the van having mechanical issues. That van had expired tags. -The second van had the facility's name on the side of the van. This was the van they used to transport residents to and from appointments. That van should have current license plates. Observation on [DATE] at 8:45 A.M. showed a van with the facility name parked under the awning in front of the front doors of the facility. The van's engine was running with the van doors open. The license plate on the van expired [DATE]. During an interview on [DATE] at 8:46 A.M. the Administrator said: -The van under the awning in front of the building was waiting to board a resident to take to an appointment. -That was the van the facility used to transport residents. The other van was in the back of the parking lot and had mechanical issues so it was not in use. -He/She did not realize the license plates to the van the facility used were expired. -The van was leased so it was the leasing company's responsibility to ensure the license plates were renewed. -The van was still covered by insurance. -He/She did not think it was a problem to drive a vehicle with expired license plates. -He/She thought the vehicle was still legal to drive despite the expired license plates. Observation on [DATE] at 2:00 P.M. showed the license plates on the second van in the parking lot with the sister facility's name on the side expired [DATE]. During an interview on [DATE] at 12:06 P.M., the facility driver said: -He/She knew the plates on the facility van were expired. -He/She told the other facility driver, who was no longer employed with the facility, around five months ago. -He/She assumed the former driver was taking care of the license issues. -He/She transported residents to and from dialysis, radiation appointments, and other outside appointments in the facility van. -The other van in the parking lot had been out of service for a long time due to it not working.

Based on interview and record review, the facility failed to notify a resident's responsible party when changes to his/her medication orders were changed for one sampled resident (Resident #80) out of 27 sampled residents. The facility census was 134 residents. Review of the facility's Change of Condition Notification policy dated June 2020 showed: -Purpose was to ensure residents and resident representatives are notified of changes in condition in a timely manner. -A change of condition included changes in treatment. -Staff were to document the notification in the resident's medical records. 1. Review of Resident #80's admission Record showed he/she: -Was admitted to the facility on [DATE]. -Had a medical Power of Attorney (POA- a person previously identified to make decisions for an individual in the event of inability to make wishes known). -Had diagnoses that included stroke, dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), and a state of decline due to chronic medical conditions leading to weight loss, decreased appetite, poor nutrition, and inactivity. Review of the resident's Consultant Pharmacist Recommendation to Physician dated 12/18/24 showed: -The resident had been using Sertraline (an antidepressant) 50 milligrams (mg) every day since 2/2/24. If this therapy was required to prevent future depressive episodes, please document to that effect in your progress notes. -A check mark was next to Change Sertraline therapy as follows: Sertraline 25 mg every day, indicating a positive response to the recommendation. -The form was signed by the primary care provider and dated 12/18/24. Review of the resident's Telephone Order Sheet (TOS) dated 12/29/24 showed: -Telephone order from the resident's physician to discontinue Sertraline 50 mg at bedtime for depression with a reason of Gradual Dose Reduction (GDR). -Telephone order from the resident's physician to start Sertraline 25 mg in the evening for depression, GDR from 50 mg. Review of the resident's electronic medical record dated December 2024 and January 2025 showed no documentation the facility staff notified the resident's responsible party Sertraline was decreased from 50 mg daily to 25 mg daily. Review of the resident's Consultant Pharmacist Recommendation to Physician dated 3/25/25 showed: -The resident had been taking Quetiapine (an atypical antipsychotic used to treat depression) 50 mg twice daily and Rexulti (an atypical antipsychotic that could be used to treat depression) 2 mg daily since 9/2/24. -An X was next to Reduce the dose of Quetiapine to 25 mg twice daily, indicating a positive response to the recommendation. -An X was next to Reduce the dose of Rexulti to 1.5 mg (1 mg tablet + 0.5 mg tablet) daily, indicating a positive response to the recommendation. -The form was singed by the primary care provided but was not dated. Review of the resident's TOS dated 4/3/25 showed: -Discontinue Quetiapine 50 mg twice daily with a reason GDR. -Start Quetiapine 25 mg twice daily for mood/behavior GDR from 50 mg. -Discontinue Rexulti 2 mg daily for agitation with a reason GDR. -Start Rexulti 0.5 mg and start Rexulti 1.5 mg to equal 1.5 mg daily for agitation, GDR from 2 mg. Review of the resident's electronic medical record dated March 2025 and April 2025 showed no documentation the facility staff notified the resident's responsible party Quetiapine was decreased from 50 mg daily to 25 mg daily or Rexulti was decreased from 2 mg to 1.5 mg daily. Review of the resident's Consultant Pharmacist Recommendation to Physician dated 5/20/25 showed: -The resident had been using Mirtazapine (an antidepressant that could be used as an appetite stimulant) 7.5 mg at bedtime since 5/8/24. The resident's weight was 130 pounds (lbs), a 10 lb gain in the last six months. -An X was next to Change Mirtazapine to 7.5 mg every other day at bedtime, indicating a positive response to the recommendation. Review of the resident's TOS dated 5/23/25 showed: -Discontinue Mirtazapine 7.5 mg every night for depression. -Start Mirtazapine 7.5 mg every other day for depression GDR from every night at bedtime. Review of the resident's electronic medical record dated May 2025 and June 2025 showed no documentation the facility staff notified the resident's responsible party Mirtazapine was decreased from 7.5 mg every night to 7.5 mg every other night. During an interview on 6/26/25 at 10:59 A.M., Licensed Practical Nurse (LPN) E said: -The Assistant Director of Nursing (ADON) completed the monthly drug reviews. -Any change in medication should be documented in the resident's electronic medical record. During an interview on 6/26/25 at 12:04 P.M., ADON B said: -Monthly Drug Regimen Reviews (Consultant Pharmacist Recommendation to Physician) are reviewed by him/her each month. -He/She would look for physician notes related to recommendations and would document family notification if there were any changes. -Family and/or responsible party's should be notified when there was a change in medication therapy. -Notifications should be documented in the resident's electronic medical record. -He/She could not find any documentation the resident's responsible party was notified of any of the medication changes in December 2024, March 2025, or May 2025. During an interview on 6/26/25 at 1:05 P.M., the Director of Nursing (DON) said: -He/She initially received any pharmacy recommendations, then he/she forwarded the recommendations to the ADON of the unit the resident resided on for follow up. -He/She expected family and/or the resident's responsible party to be notified of any changes in medications. -He/She expected staff to document the notification in the resident's electronic medical record.

Based on interview and record review, the facility failed to ensure quarterly smoking assessments were completed per facility policy for one sampled resident (Resident #24) out of 27 sampled residents. The facility census was 134 residents. Review of the facility's policy titled Smoking by Residents dated November 2023 showed: -Residents who wanted to smoke would be assessed for their ability to smoke safely prior to being allowed to smoke independently in the designated smoking areas. -Residents who were not able to smoke independently and safely would be accompanied by facility staff while smoking. -All residents who smoked were to be assessed related to smoking safety at the time of admission and then at least quarterly thereafter. 1. Review of Resident #24's admission Record showed that he/she admitted to the facility with the following diagnoses: -Quadriplegia (paralysis of all four limbs). -Tobacco use. Review of the resident's Safe Smoking Evaluation dated 1/3/25 showed: -The resident currently smoked. -The resident was not able to independently light smoking materials safely. -The resident could not extinguish smoking materials completely in an appropriate receptacle. -The resident could not dispose of ashes or other tobacco-related residue appropriately. -The resident required direct supervision while smoking. Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 4/19/25 showed the resident currently used tobacco. Review of the resident's care plan dated 5/9/25 showed: -The resident smoked and had the following interventions in place. --The resident required a cigarette holder while smoking. --Protective gear was given and demonstrated to the resident. --The resident required supervision while smoking. During an interview on 6/25/25 at 2:04 P.M. the resident said: -He/She currently used tobacco. -He/She did not smoke at every designated smoke time. -He/She did not have a normal schedule that he/she followed related to his/her smoking habits. -He/She had to be supervised while smoking and wore an apron. During an interview on 6/26/25 at 10:12 A.M. Licensed Practical Nurse (LPN) C said: -He/She was unsure if the resident currently smoked, but the resident had smoked in the past. -The smoking assessments needed to be completed quarterly. -Nurses could perform the smoking assessments. -The resident should have had another smoking assessment completed by the time of the interview. During an interview on 6/26/25 at 10:57 A.M. Assistant Director of Nursing (ADON) A said: -The resident smoked from time to time. -He/She did the smoking assessments. -The smoking assessments were done upon admission and quarterly thereafter. -The electronic medical charting system that the facility used had been reset at the beginning of the year which could have affected the timing of the smoking assessments. -When the smoking assessments were due, they usually auto-populated, but the staff had been editing the schedules once they realized certain assessments were not showing up on the charting system appropriately. -The resident should have had an additional smoking assessment completed by the time of the interview. During an interview on 6/26/25 at 11:44 A.M. the Director of Nursing (DON) said: -The facility's electronic medical charting system had been updated at the beginning of the year. -All of the residents' assessments needed to be re-triggered in the system due to the update. During an interview on 6/26/25 at 1:30 P.M. the DON said: -He/She was unsure when the resident's last smoking assessment had been completed. -He/She was unsure if the resident still smoked because he/she had not physically seen the resident smoke in over a year. -The smoking assessments were completed quarterly. -He/She did not think that the resident needed another smoking assessment completed because he/she did not think the resident smoked at that time. -If the resident still smoked then another smoking assessment would need to be completed.

Based on observation, interview and record review, the facility failed to ensure hand hygiene during catheter (a hollow, partially flexible tube inserted into the bladder to drain urine) care; and failed to ensure the catheter bag was maintained below the level of the bladder for one sampled resident (Resident #37) out of 27 sampled residents. The facility census was 134 residents. Review of the facility undated Catheter Care policy showed: -A resident with a catheter receives care and services to prevent infections to the extent possible. -Wash hands and put on gloves prior to handling the catheter, drainage system or bag. -Position the catheter drainage system and bag utilizing gravity to facilitate drainage. -Always keep the urine collection bag below the level of the bladder. Review of the facility Handwashing/Hand Hygiene policy dated August 2019 showed: -Use an alcohol-based hand rub, or soap and water before and after handling an invasive device, including a urinary catheter. 1. Review of Resident #37's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of neuromuscular dysfunction of bladder (bladder control problems caused by nerve damage affecting the communication between the brain, spinal cord, and bladder). Review of the resident's care plan dated 10/3/23 showed: -He/she had a catheter. -Position the catheter bag below the level of his/her bladder. -He/she refused to have his/her catheter bag lowered. -He/she hung his/her catheter bag off the side of his/her wheelchair. -He/she had been educated on the importance of keeping his/her catheter bag below his/her bladder level. Review of the resident's Physician's Summary Report (POS) dated June 2025 showed catheter care every shift. Observation on 6/19/25 at 1:35 P.M. showed: -The resident was seated in his/her wheelchair in the main dining room. -His/her catheter bag was attached to the arm of his/her wheelchair above the level of his/her bladder. Observation on 6/23/25 at 12:05 P.M. showed: -The resident was seated in his/her wheelchair in the main dining room. -His/her catheter bag was attached to the arm of his/her wheelchair above the level of his/her bladder. Observation on 6/24/25 at 10:34 A.M. showed: -The resident was seated in his/her wheelchair in the main dining room. -His/her catheter bag was attached to the arm of his/her wheelchair above the level of his/her bladder. -Certified Nursing Assistant (CNA) C completed hand hygiene and put on gloves, placed the resident's catheter bag onto his/her lap and hooked it onto a gait belt around the resident's mid-torso and assisted in transferring the resident to his/her bed and then removed the resident's lower clothing and brief. -Without first removing his/her gloves, washing/sanitizing his/her hands and putting on new gloves, CNA C completed the resident's catheter care and then assisted in putting on a new brief and the resident's lower clothing. During an interview on 6/24/25 at 10:57 A.M. CNA C said: -He/she had not removed his/her gloves, washed his/her hands and put on new gloves just before he/she completed the resident's catheter care. -He/she usually did wash his/her hands and put on gloves right before doing a resident's catheter care. He/she had been nervous because of being watched. -He/she hooked the resident's catheter bag onto the gait belt so that the catheter tubing would not pull on the resident's catheter. -He/she should have hooked the resident's catheter bag onto his/her bedframe so that it would be below his/her bladder. -The resident's catheter bag should be attached low on his/her wheelchair. -The resident always wanted his/her catheter bag hooked on his/her wheelchair arm. During an interview on 6/26/25 Licensed Practical Nurse (LPN) F said: -The resident's catheter bag should always be below the level of his/her bladder. -The resident refused to have his/her catheter anywhere else but hooked on the arm of his/her wheelchair or on top of his/her bed during the day shift. -He/she had spoken to the resident about keeping his/her catheter bag below the level of his/her bladder but had not documented it in the resident's medical record. -Before touching and cleansing the resident's catheter staff were always to remove gloves and perform hand hygiene, then put on clean gloves. -The CNA's should always keep the resident's catheter bag below the level of his/her bladder during all care. Review of requested documentation over a twelve month period of teaching the resident the importance of keeping his/her catheter bag below the level of his/her bladder showed one document dated 6/25/25 showed the Assistant Director of Nursing (ADON) had reeducated the resident on the importance of keeping his/her catheter below the level of his/her bladder. During an interview on 6/26/25 at 1:10 P.M. The Director of Nursing (DON) said: -The resident's catheter bag was to be below the level of his/her bladder at all times. -The licensed nurses should document they had done teaching with the resident regarding the importance of keeping his/her catheter bag below the level of his/her bladder at least once a month. -During catheter care, nursing staff should always complete hand hygiene and put on clean gloves just before cleansing the insertion site and the resident's catheter.

Based on interview and record review the facility failed to ensure as needed controlled mediation (drug or other substance that was tightly controlled by the government because it may be abused or cause addiction) were signed out on the Controlled Drug Administration Record and in the Nurse's Medication Administration Record (MAR) for two sampled residents (Resident #48 and #113) out of 27 sampled residents. The facility census was 134 residents. Review of facility policy titled Administration Procedures for all Medications revised 8/2020 showed: -After administration, return to the cart, document administration in the MAR or Treatment Administration Record (TAR) and if the mediation was a controlled substance sign out the record. Review of the undated facility policy titled Medication Administration showed: -Medication will be administered by a licensed nurse per the order of an attending physician. -No medication will be used for any resident other than the resident whom it was prescribed. -Medication must be given to the resident by the licensed nurse preparing the medication, or as consistent with state law. -Nursing staff would have kept in mind the seven rights of medication when administering medication: --The right medication. --The right amount. --The right resident. --The right time. --The right route. --The right indication. --The right outcome. -The licensed nurse would chart the drug; time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR. 1. Review of Resident #48's admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of chronic (long term) pain. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/29/25 showed: -The resident was cognitively intact. -The resident was using opioids (a class of natural, semi-synthetic, and synthetic drugs that include both prescription medications and illegal drugs). Review of the resident's care plan dated 5/8/25 showed that the resident had pain and used opioids. Review of the resident's Order Summary Report (OSR) dated June 2025 showed a physician order for Hydrocodone-Acetaminophen (narcotic used to treat pain a controlled substance which had a high risk for addiction and dependence) 5-325 milligram (mg) give one tablet as needed every six hours order was dated 5/20/25. Review of the resident's Nurses' MAR dated June 2025 showed the resident received Hydrocodone-Acetaminophen on: -June 1st at 8:26 P.M. for a pain level of seven out of 10. -June 6th at 9:40 A.M. for a pain level of eight out of 10. -June 7th at 9:51 A.M. for a pain level of eight out of ten. -June 7th at 4:50 P.M. for a pain level of eight out of 10. -June 9th at 12:06 P.M. for a pain level of six out of 10. -June 12th at 8:51 P.M. for a pain level of six out of 10. -June 13th at 11:13 P.M. for a pain level of seven out of 10. -June 22nd at 9:01 P.M. for a pain level of five out 10. -June 23rd at 10:48 P.M. for a pain level of six out of 10. -June 24th at 11:31 P.M. for a pain level of five out 10. Review of the resident's Controlled Drug Administration Record for Hydrocodone-Acetaminophen dated 6/21/25 to 6/25/25 showed: -One tablet was given on 6/21/25 at 9:00 P.M. -One tablet was given on 6/22/25 at 4:00 A.M. -One tablet was given on 6/23/25 at 5:00 A.M. -One tablet was given on 6/24/25 at 8:00 P.M. -One tablet was given on 6/25/25 at 2:00 A.M. -One tablet was given on 6/25/25 at 2:00 P.M. During an interview on 6/26/25 at 9:09 A.M., Licensed Practical Nurse (LPN) A said: -When giving a controlled medication it needed to be signed out in the Nurse's MAR and the Controlled Drug Administration Record once the medication was given to the resident. -He/She would not give a controlled medication and not sign the Controlled Drug Administration Record and then chart on the Nurse's MAR. -It was his/her expectation that any nurse that gave controlled medication would chart in the Nurse's MAR and sign the Controlled Drug Administration Record. During an interview on 6/26/25 at 10:50 A.M., LPN B said: -When a resident needed pain medication, he/she would have verified that it was time that the medication could be given. -He/She would have assessed the resident for pain. -He/She would have verified the medication. -He/She and sign it out on the Controlled Drug Administration Record under the resident's name and then give the medication and sign it out on the Nurse's MAR in the computer. During an interview on 6/26/25 at 1:05 P.M., Director of Nursing (DON) said: -It was his/her expectation that when controlled medication was given it would be signed out on the Controlled Drug Administration Record and in the computer on the Nurse's MAR. -It was never appropriate to give a controlled substance and not sign it out on the Controlled Drug Administration Record and in the computer on the Nurse's MAR. -The Assistant Director of Nursing (ADON) was to perform audits on the Controlled Drug Administration Record and the Nurse's MAR in the computer to ensure both matched. 2. Review of Resident #113's admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of arthritis. Review of the resident's Physician Order Sheets dated May 2025 showed a physician order for Hydrocodone-Acetaminophen (a narcotic pain medication) 5-325 milligrams (mg) every 4 hours as needed for pain dated 4/28/25 and discontinued on 5/12/25. Review of the resident's MAR dated May 2025 showed: -Hydrocodone-Acetaminophen 5-325 mg every 4 hours as needed for pain dated 4/28/25 and discontinued on 5/12/25. -No documentation the medication was administered during this month. Review of the resident's Controlled Drug Administration Record showed: -Hydrocodone-Acetaminophen (Norco) 5-325 mg every 4 hours as needed for pain. -30 tablets were sent to the facility on 4/30/25. -One tablet was removed on 5/22/25. --NOTE: The resident's Norco was discontinued on 5/12/25. The resident did not have a valid order at the time the medication was removed from the medication supply. The medication was not documented on the resident's MAR as being administered on 5/22/25. Review of the resident's Physician Order Sheets dated June 2025 showed Hydrocodone-Acetaminophen 5-325 mg every four hours as needed for pain dated 6/9/25 and discontinued on 6/18/25. Review of the resident's MAR dated June 2025 showed: -Hydrocodone-Acetaminophen 5-325 mg every 4 hours as needed for pain dated 6/9/25 and discontinued on 6/18/25. -One tablet was documented as administered on 6/16/25. Review of the resident's Controlled Drug Administration Record showed: -Hydrocodone-Acetaminophen (Norco) 5-325 mg every 4 hours as needed for pain. -30 tablets were sent to the facility on 4/30/25. -One tablet was removed on 5/26/25 and was written over to show 6/16/25 over the same date. -One tablet was removed on 6/19/25. --NOTE: The resident's Norco was discontinued on 6/18/25. The resident did not have a valid order at the time the medication was removed from the medication supply on 6/19/25. The medication was not documented on the resident's MAR as being administered on 6/19/25. During an interview on 6/26/25 at 11:00 A.M., LPN E said: -If a narcotic was removed from the Controlled Drug Administration Record it should also be documented on the resident's MAR. -Staff should not be able to administer a medication if it was discontinued, the electronic medical record would not show the medication available to document it was administered. -Staff should not administer a medication without a valid physician's order. During an interview on 6/26/26 at 1:08 P.M., the DON said: -Staff should document on the Controlled Drug Administration Record when a narcotic was removed from the supply and document the medication was administered on the resident's MAR. -The MAR and the Controlled Drug Administration Record should match. -Staff should not administer a medication without a valid physician's order.

Based on observation, interview, and record review, the facility failed to ensure a medication rate under five percent for three sampled residents (Resident #130, #58, and #21) with a medication error rate of 22.58%. The facility census was 134 residents. A policy on insulin pens was requested and not received by the time of exit. Review of the facility Medication Administration policy undated showed: -Medications will be administered per the order of an attending physician or licensed practitioner. -Medications will not be left at the bedside. -The time and dose of the drug or treatment administered to the resident will be recorded in the resident's medication record by the person who administers the medication. A policy for self-administration of medications was requested and not received. Review of https://www.novomedlink.com/diabetes/products/treatments/novolog/dosing-and-administration.html, dated April 2025 showed the following instruction [sometimes called priming the pen] regarding use of insulin aspart (a rapid-acting insulin that helps lower mealtime blood sugar spikes for persons with diabetes) pens: -Attach a new needle to the insulin pen. -Remove the needle cap. -Dial to 2 units on the dose selector. -Press the dose button. -Repeat until you see insulin come from the tip of the needle. -Repeat this process several times until you see insulin come from the end of the needle; if insulin does not come from the tip of the needle, change the needle and repeat the process until you see insulin come from the end of the needle. -Once you see insulin come from the end of the needle, dial and inject the desired dose. 1. Review of Resident #130's Medication Administration Record (MAR) dated June 2025 showed: -The resident had a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin (a hormone produced in the pancreas by the islets of Langerhans, which regulates the amount of glucose (sugar) in the blood) secretion in the pancreas or resistance to insulin). -The resident had an order for Humalog Kwikpen Subcutaneous Solution Pen-injector 100 unit/milliliter (ml) (insulin Lispro- a fast-acting insulin), inject 12 units subcutaneously before meals for DM II. -Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (insulin Glargine- a long-acting insulin), inject 20 units subcutaneously one time a day for DM II. -The resident had an order for staff to check the resident's fasting blood sugar (FSBS) using a glucometer (a medical device used to measure the approximate concentration of sugar in the blood). Observation on 6/24/25 at 8:10 A.M. of the resident's insulin administration completed by Certified Medication Technician (CMT) C showed: -He/She gathered the supplies needed to administer the resident's insulin. -He/She placed the needles on the resident's insulin pens. -He/She dialed the resident's Humalog Kwikpen to 12 units. -He/She dialed the resident's Lantus Solostar Subcutaneous Solution Pen-injector to 20 units. -He/She had not primed (this process removes any air bubbles from the needle and insulin cartridge) either pen. -He/She went into the resident's room with the blood sugar testing supplies and the insulin pens. -He/She then checked the resident's blood sugar and administered the resident's insulin. During an interview on 6/25/25 at 2:54 P.M. CMT C said: -He/She had missed a couple of steps during the insulin administration. -He/She had forgotten to prime the insulin pens. -He/She was nervous and that was why he/she had forgotten. -Priming insulin pens was important because it gets the air out of the needles to ensure the resident gets the right amount of insulin. -Insulin pens needed to be primed with two units of insulin. During an interview on 6/26/25 at 10:17 A.M. Licensed Practical Nurse (LPN) C said: -Insulin pens needed to be primed with two units of insulin prior to use. -Priming insulin pens was important because it ensured that the resident received the full dose of insulin. During an interview on 6/26/25 at 11:19 A.M. Assistant Director of Nursing (ADON) A said: -Insulin pens needed to be primed with two units of insulin prior to use. -Priming insulin pens ensured that the resident received the full dose of insulin by getting any air out of the needle During an interview on 6/26/25 at 1:30 P.M. the Director of Nursing (DON) said: -Insulin pens needed to be primed before use. -When an insulin pen is primed, it would ensure that any excess air gets out of the needle. -An insulin pen needed to be primed with two units. -CMT C did not give the insulin to Resident #130 correctly. 2. Review of Resident #58's Physician's Order Summary (POS) dated June 2025 showed: -Biotene Dry Mouth Mouth/Throat Liquid (artificial saliva that moistens and cleans the mouth) (Mouthwashes), give 1 dose by mouth every morning and at bedtime, dated 10/24/24 -Albuterol Sulfate HFA Aerosol Solution (a medication used to treat or prevent breathing difficulties) 108 (90 Base) micrograms (MCG) per actuation (a single dose of medication released from the oral inhalation device), two puffs every day and evening and every six hours as needed for shortness of breath, unsupervised self-administration, dated 3/23/22. -Ketotifen Fumarate Solution (eye drop used to relieve itchy eyes caused by allergies) 0.025 % Instill 1 drop in both eyes one time a day for eye itch relief), dated 7/2/22. -Prednisolone Acetate Suspension 1 % 1 drop in both eyes one time a day every other day for dry eye, dated 7/2/22. Observation on 6/24/25 at 7:55 A.M. showed CMT D prepared and administered 19 medications to the resident but did not prepare or administer the following medications to the resident: -Biotene Dry Mouth Mouth/Throat Liquid. -Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg per actuation two puffs. -Ketotifen Fumarate Solution (eye drops). -Prednisolone Acetate Suspension 1 % eye drops. During an interview on 6/24/25 at 12:41 P.M. CMT D said. -He/she had not administered the resident's Biotine liquid mouth rinse, Albuterol inhaler, Ketotifen Fumarate (eye drops) and Prednisolone eye drops. -The resident always self administered his/her Biotine liquid mouth rinse, Albuterol inhaler, Ketotifen Fumarate (eye drops) and Prednisolone eye drops which he/she kept those meds in his/her room. Observation on 6/24/25 at 12:46 P.M. showed the resident had the following medications in his/her room which he/she kept next to his/her bed in a small purse. -Biotine mouth rinse. -Albuterol Sulfate inhaler. During an interview on 6/24/25 at 12:46 P.M. the resident said: -He/she took his/her own Biotine in the mornings and evenings which he/she kept in his/her room. -He/she had but did not use the Albuterol Sulfate inhaler. as needed once or twice a day which he/she kept in his/her room. -He/she did not have and did not have and did not use Prednisolone eye drops; over one year ago his/her outside of the facility internist physician whom he/she saw outside the facility, at his/her office had told him/her to not use Prednisolone eye drops, which he/she had taken for short term use after eye surgery. -He/she had thrown away his/her Prednisolone eye drops a long time ago. -The CMT's never asked him/her if he/she had taken the medications he/she self-administered and kept in his/her room. During an interview on 6/26/25 12:21 P.M. Licensed Practical Nurse (LPN) F looked at the resident's electronic medical record physician's orders and MAR and said: -The resident did have a physician's order that he/she could self-administer his/her Albuterol inhaler but did not have a physician's order that he/she could keep his/her Albuterol inhaler at his/her bedside. -The resident had no other physician's orders for self-administration of medications other than his/her Albuterol Inhaler. -He/she had been pretty sure the resident had not had any medications in his/her room. -He/she would have to ask the resident if he/she had any medications in his/her room and if he/she had been self-administering any medications. -He/she expected that if the resident had medications in his/her room and was self-administering the medications the CMT's would have to see those orders on the resident's MAR and if those instructions were not on the resident's MAR, he/she expected the CMT would tell him/here so he/she could get clarification of the physician's orders. -If the CMT knew the resident had and self-administered some of his/her medications, the CMT would probably have to ask the resident if he/she had taken those medications; the CMT should not document those medications were administered without asking the resident if he/she had taken the medications the resident self-administered. During an interview on 6/26/25 at 1:10 P.M. the DON said: -For a resident to self-administer his/her own medication there would have to be an assessment of the resident's ability to self-administer those medications. -Assessments of a resident's ability to self-administer medications should be completed quarterly. -There would also have to be physician's orders for the resident to self-administer specific medications and that the resident could keep specific medications at bedside. 3. Review of Resident #21's POS dated June 2024 showed: -Physician's Orders for sliding scale insulin (a method of insulin dosing where the amount of insulin given varies based on a person's blood sugar level at a specific time, typically before meals), including to administer 19 units of insulin aspart (medication used to treat diabetes) including to give 19 units for a pre meal blood sugar of 256. Observation on 6/24/25 at 11:56 A.M. showed: -LPN G wiped the end of the resident's insulin Aspart pen, placed a needle on the end of the pen and without first priming the pen by dialing and expelling two units of insulin dialed the resident's insulin aspart pen to 19 units. -He/she then injected the insulin aspart into the resident's abdomen. During an interview on 6/24/25 at 12:14 P.M. LPN G said: -He/she would not have done anything different when administering the resident's insulin; he/she did the same thing he/she always did when using insulin pens. -He/she did not recall ever hearing anyone say anything about priming insulin pens. -He/she had never seen a policy or any drug reference information that instructed to put the needle on the insulin pen, then dial two units and expel the two units, watching for insulin at the needle tip, then dial the intended insulin dose. During an interview on 6/26/25 at 1:30 P.M. the DON said: -Insulin pens needed to be primed before use. -When an insulin pen is primed, it would ensure that any excess air gets out of the needle. -An insulin pen needed to be primed with two units. -LPN G did not give he insulin to Resident #21 correctly.

Based on observation, interview and record review, the facility failed to transfer one sampled resident (Resident #2) safely by failing to use a full body mechanical lift or a gait belt to transfer the resident safely from the shower chair to his/her bed, resulting in a hospitalization , left knee swelling,use of a knee brace and increased pain with movement out of five sampled residents. The facility census was 127 residents. A policy was requested and no policy was received by the facility. 1. Review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (a progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), lupus (a disease that occurs when your body's immune system attacks your own tissues and organs and causes inflammation in the body), pain, glaucoma (increased pressure within the eyeball, causing gradual loss of sight), anxiety, high blood pressure, and depression. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/17/24, showed the resident: -Was alert and oriented with no confusion. -Had impairment on both sides upper and lower extremities. -Used a wheelchair for mobility and did not walk. -Was totally dependent for transfers, bathing, dressing and hygiene; and needed maximum assistance for toileting, eating and hygiene. Review of the resident's Comprehensive Care Plan dated 9/2/23, showed the resident had a deficit with performing self-care, was at risk for falls and had impaired visual function. Interventions showed: -The resident required the extensive assistance of two persons for bed mobility (turning and repositioning), toileting, dressing, bathing/showering as necessary, personal hygiene as necessary. -The resident required a mechanical lift with the assistance of two persons for transfers. Review of the resident's Cardex (resident care card indicates how nursing staff is to provide care to the resident) showed: -The resident required extensive assistance of two staff to turn and reposition in bed. -The resident required a mechanical lift with two staff assistance for transfers. -The resident needed the extensive assistance of two persons to provide his/her bath/shower as necessary. -The resident required the assistance of two persons to get dressed. Review of the resident's Physical Therapy Evaluation dated 3/18/24 showed: -The resident lower extremity weight bearing status was weight bearing as tolerated. -The resident's precautions was fall risk, mechanical lift to get out of bed and the resident used a power chair. -Prior therapy showed the resident was dependent for transfers out of his/her bed and into his/her wheelchair and required maximum assistance for rolling (in his/her wheelchair). -The resident's functional mobility assessment showed the resident needed maximum assistance for rolling left to right in bed, sitting to lying in bed, from lying to sitting up on the side of his/her bed, and was dependent for transferring from sitting to standing, transferring from chair/bed to chair/bed and toileting. -The resident did not walk and used a power wheelchair for mobility. -The resident was referred for physical therapy due to a decline in out of bed mobility. Resident had generalized weakness and an inability to perform any bed mobility or transfers without assistance. Resident required maximum assistance from laying to sitting, transferring and scooting up in bed. He/She reported only getting out of bed every few weeks. Resident would benefit from physical therapy intervention. Review of the resident's Physician's Order Sheet (POS) dated 4/2024 showed physician's orders for: -Baclofen 10 milligrams (mg) twice daily for muscle relaxant (ordered 9/2/23). -Tylenol 500 mg every 6 hours as needed for pain (ordered 9/2/23). -Hydrocodone 7.5-325 mg every 12 hours as needed for pain (ordered 9/2/23). -Lidocaine patch 4% apply one half patch to both knees topically one time daily for pain, remove at bedtime and per schedule (ordered 10/23/23). -Physical Therapy three times per week for 30 days to maximize the resident's functional mobility and out of bed mobility (ordered on 3/18/24). Review of the resident's Medication Administration Record (MAR) dated 3/2024 showed: -The resident was administered Baclofen and Lidocaine patches as ordered. -The resident did not request or receive any as needed pain medication. Review of the resident's Nursing Notes showed on 3/28/24, the resident stated that during a transfer today, he/she heard his/her left knee pop. This knee is swollen and warm to the touch. The nurse notified the Nurse Practitioner and x-rays were ordered. Review of the resident's Narcotic Record showed on 3/28/24, the nurse administered Hydrocodone 7.5-325 mg to the resident at 12:30 P.M. Review of the resident's Radiology Report dated 3/29/24 showed the reason for the exam was for localized edema in the resident's left knee. Two views were taken. The x-ray results showed the resident's left knee joint was in alignment with narrowing of the joint space due to degeneration. There was also degeneration in the thigh and leg bones. Clinical or repeat examination follow up was advised. Review of the resident's Nursing Notes showed on 3/29/24, the resident was sent to the hospital for follow up evaluation due to the result of the x-ray showing osteonecrosis (develops when the blood supply to the femoral head is disrupted) of the thigh bone, leg and large joint effusion (build up of fluid around the joint). Review of the resident's Hospital Record dated 3/29/24 showed: -The resident was seen for a knee effusion. -The resident had fluid on the knee and was ordered Voltaren Gel 100 grams (gm) to be applied to the area four times daily. -There was no evidence of acute fracture, sprain, other issues or concerns. Review of the resident's POS dated 4/2024 showed a physician's order for Voltaren Arthritis Pain Gel 1% apply to bilateral knees topically every shift for joint pain not to exceed 16 grams daily (ordered on 4/4/24). Observation and interview on 4/10/24, showed the resident was laying in his/her bed awake and dressed in bed clothes. The resident's left knee was elevated on a pillow and the knee was swollen but without any redness or bruising. Across from the resident was a black knee brace that was on a dresser. The resident was alert and oriented and said: -On 3/28/24, around lunch time on, he/she had a shower and when the nursing staff brought him/her back to his/he room, they did not transfer him/her with the mechanical lift like they were supposed to. -During the transfer, he/she heard a pop and his/her leg began hurting. Certified Nursing Assistant (CNA) A and CNA B finished transferring him/her to bed. -CNA A said to CNA B that they should not have transferred him/her without using the lift. -He/She felt the CNA staff transferred him/her without a lift because they were in a hurry. -He/She was working with physical therapy staff and they put on/removed his/her brace. -The facility nurse sent him/her to the hospital and the hospital staff told him/her that his/her knee was bone on bone and he/she thought he/she had a fracture, but the hospital sent him/her back to the facility with pain medication and a knee brace. -At 12:50 P.M., Physical Therapy Assistant A came in the resident's room to put his/her knee brace on and said the resident did not have a fracture, but his/her knee was swollen and he/she was trying to maintain range of motion in his/her lower extremities, but he/she was not flexing the resident's knee too much due to pain. During an interview on 4/10/24 at 1:00 P.M., CNA A said: -He/She was working on the date the incident with the resident occurred, but was not assigned to the resident. -CNA B had given the resident's shower and he/she went to assist CNA B to transfer the resident back to his/her bed. -The resident was sitting in a shower chair and there was no sling under him/her so they did not use a mechanical lift to transfer the resident into his/her bed. -They should have transferred the resident with the mechanical lift because the resident is non-weight bearing and they had to manually lift the resident to his/her bed. -He/She asked CNA B how the resident was transferred into the shower chair and he/she told CNA B that he/she should have not transferred the resident into the shower chair without a sling and mechanical lift. -As he/she and CNA B transferred the resident to his/her bed, the resident winced and said he/she was hurting. -They put the resident into his/her bed and then he/she and CNA B went to tell the nurse that the resident was in pain. -He/She then went back to his/her hall. During an interview on 4/10/24 at 2:45 P.M., the Director of Nursing (DON) said: -The nursing staff know how to transfer the resident by looking at the resident's Cardex. -The resident should have been transferred using a mechanical lift. -If the staff did not use a mechanical lift, they should have used a gait belt when transferring him/her. -He/She did not know how the resident was transferred when he/she was taken to the shower, but staff typically used a shower bed, not a shower chair, so a lift would not need to have been used to transfer him/her. In this case the nursing staff would use a slide board. -The resident did not fall, but he/she was aware the resident complained of knee pain once he/she was transferred back into his/her bed, so they received physician's orders for an x-ray to be completed as a standard protocol to rule out injury. -The resident did not have any acute injuries to his her knee and was sent back to the facility. During an interview on 4/10/24 at 4:08 P.M., CNA A clarified his/her prior statement and said: -When he/she and CNA B transferred the resident, they did not use a gait belt because the resident was not wearing clothes and was wet. -The resident was in a shower chair, not a shower bed when they transferred the resident. -When they transferred the resident, they were on each side of the resident and he/she placed one arm under the resident's arm and the other arm around his/her waist to pivot transfer the resident to his/her bed. -They should have gotten a sling and transferred the resident with the mechanical lift. During an interview on 4/10/24 at 4:12 P.M., the resident said: -When he/she was taken to the shower room that morning around lunch time, CNA B did not use a gait belt or a mechanical lift. Nursing staff told him/her to hug him/her around his/her neck and then he/she picked the resident up and put him/her on the shower chair. -When he/she came back to his/her room is when CNA A and CNA B transferred him/her into bed and he/she felt pain in his/her leg. -He/She received Tylenol for pain but he/she had chronic pain and received scheduled pain medication for it, so he/she was not in more pain than usual. -Once he/she was in bed, he/she only had additional pain when they came in to move him/her to take the x-ray and when they moved him/her to go to the hospital. During an interview on 4/11/24 at 8:26 A.M., CNA B said: -On the day of the occurrence, he/she went to get the resident to take him/her to give the resident a shower. -He/She did not transfer the resident into the shower chair, the resident was already in the shower chair when he/she went to get the resident. -The resident did not have a sling in the shower chair. -He/She gave the resident a shower and CNA A assisted him/her to transfer the resident back into his/her bed. -They did not use a gait belt or a mechanical lift to transfer the resident. -He/She put one arm under the resident's arm and the other arm under the resident's leg (he/she did not remember if he/she was on the left or right) and lifted the resident into his/her bed. -He/She never heard a 'pop' sound from the resident, but CNA A said his/her knee popped as they were transferring the resident. -The resident said that his/her leg hurt once he/she was in bed so he/she and CNA A went to tell the charge nurse. -This was the first time he/she had ever transferred the resident and was unaware of how the resident was supposed to be transferred. During an interview on 4/11/24 at 12:35 P.M., Physical Therapy Assistant A said: -They were working with the resident for range of motion, bed mobility, activity tolerance, and strengthening. -The resident was supposed to be transferred using a full body mechanical lift because he/she was non weight bearing. -If the nursing staff used a stand and pivot transfer with the resident, they should always use a gait belt to assist with transferring him/her. -He/She had never seen the resident transferred with a stand and pivot transfer and had only known the resident to transfer using a full body mechanical lift. MO00324304

Based on observation, interview and record review, the facility failed to ensure the resident rights of one sampled resident (Resident #1) for self determination by inappropriately placing the resident on a locked unit without his/her consent and without evidence, rationale or documentation showing the resident was at risk for elopement, was exit seeking or had wandering behaviors or was a danger to self and needed a more secured placement out of 5 sampled residents. The facility census was 127 residents. Review of the facility's undated Transfer of Resident from Non-Secure Unit to Secure Unit showed this policy outlines the process for transferring a resident within our facility from a non-secured, non-locked unit to a secure, locked unit. The transfer criteria include specific assessments, documentation, and approval to ensure resident safety and well-being. The policy showed: -The resident must have a recent elopement assessment that indicates a triggering risk for elopement. -Documentation should clearly outline concerns related to elopement risk. -The facility must have documented evidence of Power of Attorney/Guardianship from the responsible party. -A confirmed dementia diagnosis must be documented in the resident's medical record. -The care plan should be revised to address possible ineffective coping related to relocation stress. -The transfer process showed the interdisciplinary team will review the resident's case. If the criteria are met, the resident will be relocated to the secure unit. The responsible party will be notified of the transfer and must provide written agreement. -After placement in the secured locked unit, the facility will closely monitor the resident for 72 hours. Signs and symptoms of ineffective coping will be documented and the interdisciplinary team will assess the resident's adjustment during this time. Review of the facility's Wandering and Elopement policy and procedure dated 8/2020, showed: -The Licensed Nurse will assess residents upon admission, readmission, quarterly and upon identification of significant change in condition, to determine their risk of wandering/elopement. -The resident's risk for wandering/elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the interdisciplinary team upon admission, readmission, quarterly and upon change in condition. -The interdisciplinary team may consider interventions listed in the Elopement Risk Reduction Approaches for residents identified to be at risk for elopement. -Residents with a history of wandering or who have been assessed for being at risk for wandering or elopement will have a photograph maintained in their medical record. 1. Review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including stroke with paralysis affecting the left side, muscle weakness, difficulty walking, lack of coordination, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), depression, and schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). The resident did not have a diagnosis of dementia or memory loss. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/31/24, showed the resident: -Was alert and oriented with significant confusion. -Showed little interest, feeling down/depressed, trouble falling asleep, tired with little energy, poor appetite, trouble concentrating and social isolation. -Had no hallucinations, delusions, physical/verbal behaviors towards others, no self destructive behaviors, and did not reject care. -Had no wandering. -Had range of motion impairment on one side of the upper and lower extremities. -Used a wheelchair for mobility. -Needed moderate assistance for toileting, bathing, dressing, personal hygiene, and transferring. -Needed set up assistance for eating and oral hygiene. Review of the resident's Medical Record showed documentation from the resident's transferring facility showed: -The resident transferred from another facility on 3/27/24. -The Resident's Level One Pre Admission Screening dated 9/18/16, showed the resident had a serious mental illness that did not require hospitalization or psychiatric treatment in the last two years. The resident had dementia, but did not trigger for a PASSAR Level II screening. -Nursing Notes from 2/20/24 to 3/20/24 showed there was no documentation of the resident wandering, attempted elopement or exit seeking. There was no documentation of the resident having behaviors of verbal or physical aggression or agitation. Review of the resident's Smoking assessment dated [DATE] showed: -The resident smoked, knew the location of the designated smoking area, was able to get to the area independently, was able to light smoking materials safely and extinguish smoking materials completely in the appropriate receptacle. -The resident did not have tremors while smoking, did not fall asleep, had no past accidents while smoking, had no visible burn marks and did not have finger dexterity problems. -The resident was able to smoke safely with minimal supervision and the evaluation had been explained to the resident and responsible party. Review of the resident's Physician's Order Sheet (POS) dated 4/2024 showed: -The resident did not show additional diagnoses to include memory loss or dementia. -Alprazolram 0.5 milligrams (mg) three times daily for anxiety (ordered 3/27/24). -Lorazepam 2 mg, give .25 mg under the tongue as needed for anxiety (ordered 3/27/24). -Zoloft 100 mg once daily for depression (ordered 3/27/24). -Depakote 125 mg give three tablets 3 times daily for schizophrenia (ordered 3/27/24). -Xanax 0.5 mg give every 6 hours as needed for anxiety for 14 days (ordered 3/29/24). Review of the resident's Elopement Risk assessment dated [DATE] showed: -The resident was not able to make decisions regarding tasks of daily living. -The resident was cognitively impaired and ambulated/propelled self. The resident may go outdoors on occasion but made no attempt to leave the grounds. -The resident ambulated, propelled self or wandered. The resident has intentionally or unintentionally attempted to leave the community. -The resident did not verbalize plans to leave the community. -The resident was at risk for elopement due to the results of the elopement evaluation. Review of the resident's Nursing Notes showed: -On 3/27/24 the resident was admitted to the facility and moved into room [ROOM NUMBER] (not on the locked unit). Documentation showed the resident had some confusion, and denied pain. -From 3/27/24 to 4/4/24 showed there was no documentation showing the resident had any wandering, exit seeking or elopement behaviors. There was no documentation showing the resident had any verbal or physically aggressive behaviors or agitation. Review of the resident's Social Services Notes showed: -From 3/27/24 to 4/5/24, there was no documentation showing the resident had any wandering, exit seeking or elopement behaviors and did not show the resident was referred or seen by the Social Service Designee for any verbal or physically aggressive behaviors or agitation. -On 4/5/24 the Social Service Designee documented he/she left a voice mail for the resident's Power of Attorney regarding the resident moving to room [ROOM NUMBER] (on the locked dementia unit) due to increased wandering. Review of the resident's Medical Record showed there was no documentation showing the resident had a history of elopement, exit seeking, wandering behaviors, physical or verbal aggression, or agitation. Review of the resident's Incident Report dated 4/6/24, showed: -The resident's room smelled of smoke and the nurse went to investigate. Staff found half of a cigarette laying on the resident's bedside table and the resident was rummaging in his/her closet. The nurse informed the resident that he/she could not smoke in his/her room and the resident began to yell and come towards the nurse, pushing him/her to the floor. -The resident was oriented to person and place and said the nurse couldn't tell him/her what to do and he/she could smoke when he/she wanted to. -Staff removed the resident from the area and monitored him/her, called for the nurse and called emergency services. -The resident had no injuries at the time of the incident or after the incident. -The report did not show that there were any predisposing environmental factors, physiological factors that affected the incident occurrence. -The predisposing situational factors showed the resident was smoking in his/her room due to the smell of smoke. The resident became agitated when the nurse informed him/her that his/her cigarette would have to be taken because he/she could not smoke in his/her room. The resident told the nurse he/she was going to smoke whenever he/she wanted and pushed the nurse down. -Immediate Interventions showed staff separated the resident from the nurse and was put on 15-minute checks. The nurse was sent to the hospital. The resident will be moved back to the main unit for flexible smoking protocol. -The summary showed the resident became agitated when the nurse approached him/her about smoking and the resident pushed him/her down. Staff intervened and separated the resident, placing him on 15-minute checks. He/She was moved onto the main unit for more liberal smoking, decreasing his/her anxiety. Since placement on the main unit the resident has had no aggression or agitation. The resident's room was not by the front door and staff has not observed the resident wandering or any exit seeking behavior. Review of the resident's undated Care Plan showed: -The resident was independent with bed mobility, toileting, personal hygiene and oral care, needed limited assistance with bathing, moderate assistance with transferring and set up assistance with meals and dressing. -The resident smoked and was able to smoke unsupervised. -The resident had a potential psychosocial problem due to recent admission to the facility. -The resident had poor impulse control and had the potential to be physically aggressive. -On 4/6/24 the resident would be moved for more flexible smoking. -The resident was at risk for elopement due to the resident's elopement risk score. During an interview on 4/10/24 at 10:30 A.M., with the Administrator and Director of Nursing (DON), the DON Said: -He/She was notified of the incident on 6/6/24 and was informed that the resident became agitated and had pushed Registered Nurse (RN) B after he/she addressed the resident smoking in his/her room. -RN B went to the hospital and was not able to be interviewed at the time. -Licensed Practical Nurse (LPN) A monitored the resident until LPN B came onto the unit and they placed the resident on 15 minute checks and LPN B notified the resident's physician and family of the incident. -The resident's family came and stayed with the resident for a limited time until he/she calmed down. -He/She tried to interview the resident, but he/she would not answer any questions about the incident or tell him/her what had occurred other than to say that he/she could smoke when he/she wanted to. -The resident was new to the facility and they had initially placed him/her on the main unit where he/she was able to freely move about the facility and could smoke whenever he/she wanted to. -When the resident was admitted , they were trying to place him/her where they thought he/she would best fit. -The resident had dementia, but he/she was not sure if there was any additional issues that that he/she exhibited that require placement on the locked unit. -He/She was not aware of any behaviors the resident had while he/she on the main unit. -The interdisciplinary team decided to move the resident to the locked memory unit and notified the resident and resident's responsible party on the day they moved the resident on 6/5/24. -He/She informed the responsible party that the move may not be permanent. -The resident and the resident's responsible party seemed to be in agreement with the resident moving onto the locked unit. During an interview on 4/10/24 at 10:48 A.M., the Social Service Designee said: -The resident was newly admitted from another facility and was initially placed on the main unit (which is not locked). -The resident began having wandering behaviors, wandering into other resident rooms and had taken another resident's shoes. Sometimes the resident was able to be redirected and sometimes he/she was not as easily redirectable. -The resident had dementia and some flight of thought. -The resident had no agitation, physical or verbally aggressive behaviors prior to moving to the locked unit. -He/She was part of the interdisciplinary team (Administrator, Director of Nursing, MDS Coordinator, Activities Director) who decided to move the resident to the locked unit due to wandering and safe smoking. -He/She contacted the responsible party by telephone on 6/5/24 to notify him/her of the decision to move the resident to the locked unit and followed up with an email on the same day. -They moved the resident on 6/5/24 to the locked unit and the resident's family came to visit the resident on the same day. -The primary issue the resident had was about smoking because on the main unit the resident was able to smoke whenever he/she wanted to (there were no limitations on smoking) and on the locked unit, they had designated smoking times. The resident wanted to be able to continue to smoke at will. -He/She was not in the facility at the time the incident occurred but he/she was informed of the incident. -The primary issue the resident the resident had cigarettes in his/her room and the nurse approached him/her about smoking in his/her room and to get his/her cigarettes and the resident became agitated and pushed the nurse, who fell , hit his/her head and was sent to the hospital. -After this incident the interdisciplinary team met and decided to give the resident another opportunity to live on the main unit and they would re-evaluate his/her ability to remain on this unit. -Since the resident moved back on the main unit, he/she was not aware of any further aggression or agitation from the resident and he/she had not heard of the resident wandering or exit seeking. -He/She did not know how nursing staff was monitoring him/her to ensure he/she was not exit seeking. During an observation and interview on 4/10/24 at 11:20 A.M., showed the resident was sitting in his/her wheelchair in his/her room on the main unit. The resident was wearing briefs. He/She was waiting for staff to come take him/her to shower because his/her family was coming to visit today. He/She was alert and oriented and said: -The nursing staff told him/her that he/she was moving to the locked unit on the day that they moved him/her. -He/she did not know why he/she was being moved to the locked unit and he/she did not want to be back there and told the nursing staff how he/she felt. -Once they moved him/her onto the locked unit, the nurse tried to take his/her cigarettes from him/her and told him/her that he/she could only smoke at certain times. -On the day of the incident, he/she was not smoking in his/her room but the nurse came to his/her room and said that he/she smelled cigarette smoke and tried to take his/her cigarettes. He/She told the nurse to get out of his/her room and he/she would not leave and he/she pushed him/her so I whooped (his/her) ass! -The nurse fell down and then the guards came and told him/her to calm down and he/she calmed down and went to his/her room. -His/Her family came up to visit him/her and he/she calmed down. -He/she was very angry because there was no reason he/she was locked up, no reason at all. -The staff moved him/her back to the main unit and, i'm okay now. -Now that he/she was back on the main unit, he/she was able to go out and smoke whenever he/she wanted to and has had no more problems. -The staff treated him/her nicely and they assisted him/her when he/she needed assistance. During an interview on 4/10/24 at 11:32 A.M. CNA C said: -He/She was not very familiar with the resident because he/she was new to the facility. -He/She was going to give the resident a shower today at the resident's request because the resident's family was visiting. -During the time the resident has been in the facility, he/she was not aware of the resident having any behaviors (wandering, exit seeking or aggression/agitation) since he/she was admitted . During an interview on 4/10/24 at 11:35 A.M. the Assistant Director of Nursing (ADON) said: -He/She was familiar with the resident from another facility. -The resident was impulsive and had an aggressive tone when speaking and anticipated aggression from others. The resident can be moody at times, but his/her response depends on how staff approach and interact with him/her which was important. -The resident liked to smoke and does not like that interfered with so when he/she was placed on the main unit, he/she could smoke whenever he/she wanted to and he/she was okay. -The resident began having issues when he/she was moved to the locked unit where they have scheduled and limitations on smoking. -He/She had not had any physically aggressive behaviors before this incident. -The resident had dementia and is forgetful, but he/she had not stated he/she wanted to leave the facility or trying to leave the facility before he/she was moved. During an interview on 4/10/24 at 11:48 A.M. LPN B said: -The resident was moved onto the locked unit on 4/5/24 with a couple other residents. -Nursing staff said the resident was moved onto the unit due to being exit seeking. -The resident was upset and stated that he/she did not want to be on the locked unit but he/she had no other behaviors until he/she went to get his cigarettes and informed him/her that he/she could not keep cigarettes on the unit and explained that on the locked unit the nursing staff kept the resident's smoking utensils, and had supervised and scheduled smoking times. -The resident became verbally aggressive toward him/her, so he/she notified the DON and the DON came onto the unit to check on the resident, but he/she did not take the resident's cigarettes. -He/She notified LPN A and planned to wait to try to approach the resident later to try to obtain his/her smoking utensils, but the resident had no further aggression or behaviors that day or evening. -He/She was working on the locked unit on the morning of the incident on 4/6/24 and had just gotten to work. -The incident had occurred right before the shift change and RN B was the night shift nurse that the resident pushed. -When he/she arrived to the locked unit, the police were in the building and the resident was cussing and yelling. The police said they could not take the resident's property, and the resident was stating that no one was going to take his cigarettes. -At around 9:00 A.M., the resident's responsible party and family came in and tried to calm the resident. -The resident's family said they didn't think the resident belonged on the locked unit, and though they were informed that he/she was going to be moved onto the unit, they were not going to take his/her cigarettes because the resident was already agitated because he/she was moved onto the unit. -After the incident, he/she placed the resident on 15 minute checks for the rest of the day, the resident calmed down and there were no further issues even though the resident was still unhappy that he/she was on the locked unit. -On 4/7/24, the resident got into an argument with his/her roommate and he/she was able to intervene before it escalated but she/she informed the DON and they moved the resident off of the locked unit back onto the main unit. -During the time the resident was on the locked unit, he/she was not exit seeking and did not wander. He/she was not sure why the resident was placed on the unit. During an interview on 4/11/24 at 8:07 A.M., CNA D said: -He/She worked on the locked unit from 7:00 P.M. to 7:00 A.M. on 4/5/24 and was on the unit when the incident occurred. -He/She was completing rounds on the morning of 4/6/24 around 6:50 A.M. when he/she smelled cigarette smoke coming from the resident's room. -He/She went to the resident's room and the resident was not actively smoking, but there was a cigarette butt on his/her bed. -He/She went to tell the nurse, RN B that the resident had been smoking in his/her room and RN B went to the resident's room to approach him/her about smoking and having smoking utensils in his/her room. -He/She heard RN B tell the resident that he/she could not smoke in his/her room and heard the resident tell RN B to get out of his/her room. -He/She saw RN B backing out of the resident's room as the resident was approaching RN B while yelling and then the resident pushed RN B and RN B fell backwards onto the floor. -One of the other nursing aides ran over to where the resident and RN B were standing between them while another male nursing staff took the resident to his/her room and then assisted RN B. -He/She called 911 and the police and then he/she was allowed to leave while the nurse stayed with RN B and staff was monitoring the resident. -The resident was still agitated but remained in his/her room. -He/She spoke with the DON about the incident on Monday and was asked to write a statement. During an interview on 4/11/24 at 8:35 A.M., LPN A said: -He/She was on the main unit on 4/6/24 when the incident occurred. -The incident occurred right before shift change and he/she was at the end of his/her shift when nursing staff from the locked unit came to tell him/her to come to the locked unit because the resident had pushed RN B down and he/she was on the floor. -He/She immediately went over to the locked unit and he initially saw RN B on the floor in front of the resident's room, laying on his/her left side. The resident was highly agitated and yelling inside of his/her room. -He called the DON to inform him/her of what happened, and the actions staff had taken at that time. -He/She asked the nursing staff what occurred and they told him/her that RN B had gone to the resident's room because the resident had been smoking in his/her room and the resident became agitated and pushed RN B down. -Nursing staff had already called 911 so he/she assessed RN B who complained of head injury and he/she provided an ice pack to his/her head and stayed with him/her until emergency services arrived. -RN B stated that she was informed the resident was smoking in his room and went to speak with the resident about it when he/she became agitated and then pushed him/her and he/she fell backward onto the ground. -The police also arrived and began to interview staff and the resident and RN B. The resident remained in his/her room. -After the ambulance took RN B out of the facility, he/she went to assess the resident and found he/she had no injuries. -The resident refused to state what happened, he/she continued to cuss and state that he/she could smoke whenever he/she wanted to. -The day shift nurse on the locked unit was on the unit and was aware of what had occurred so he/she went back to the main unit and continued to finish his/her tasks before giving report and going home. -Usually when resident's are placed on the locked memory unit, they have dementia but are also a high flight risk. -He/She did not know the resident very well, but the resident was initially on the main unit before being moved to the locked unit. -He/She was not aware of the resident having any wandering or exit seeking behaviors while he/she was on the main unit, but he/she was not familiar with the resident. -He/She was unaware of why the resident was moved to the locked unit, but after this incident the resident was moved back onto the main unit. -To his/her knowledge, the resident had not had any further incidents, aggression, wandering or exit seeking behaviors. During an interview on 4/11/24 at 12:48 P.M., CNA E said: -He/She came in to work on the locked unit as the ambulance staff was taking RN B out of the facility to the hospital. -Nursing staff informed him/her of what happened and the resident was still on the locked unit but he/she was in his/her room. -The resident was on 15 minute checks, but staff stayed with him/her throughout the day and the resident ate all of his/her meals in his/her room. -The resident did not have any additional behaviors while on the locked unit that he/she was aware of. -He/She had worked on the main unit when the resident was initially placed and he/she did not seem to be very confused, he/she did not wander and was not exit seeking. The resident was able to go to the designated smoking area and smoked safely and return to his/her room without staff assistance. -The resident did not seem to have any behavioral problems while he/she was on the main unit. -He/She did not understand why the resident was placed on the locked unit, the resident did not begin to act out until he/she was placed on the locked unit and was not able to go out to smoke when he/she wanted to. -Now that the resident is back on the main unit, he/she did not seem to have any behavior issues and was not wandering or exit seeking. Observation on 4/11/24 at 1:30 P.M. showed the resident was dressed for the weather, mobilizing in his/her wheelchair down the hallway toward the smoking patio. He/She was interacting with staff and interactions were pleasant. The resident went out onto the designated smoking patio to smoke. During an interview on 4/11/24 at 1:34 P.M. with the Administrator and DON, the DON said: -A resident is placed on the locked unit when the resident has impaired memory to the point they are not safe around others, if the resident was over-stimulated and will do better on a quiet environment, or at the request of the resident or family (preference). -Nursing staff reported that the resident had wandered out by the facility entrance which was not a designated smoking area and the ADON stated the resident had wandering behaviors but there was no documentation to support this. -There was no documentation in the records received from his/her prior facility that showed the resident had exit seeking/wandering behaviors or aggressive/agitation and the facility did not have a locked unit. -If there had been documentation showing the resident was at risk for elopement or had behaviors showing exit seeking/wandering, upon admission they would have initially placed the resident on the locked unit. -They determined that the resident had wandering behavior on 4/5/24 and decided to relocate the resident to the locked unit on 4/5/24. -Both the resident and his/he responsible party and family were also notified of the resident's relocation on 4/5/24 and he/she met with the resident's responsible party and family when they came to the facility on [DATE] and he/she informed them this may not be a permanent move and they were in agreement with the relocation. -After the incident, the interdisciplinary team met and decided to move the resident back to the main unit due to his/her agitation while on the locked unit and due to the freedom with being able to smoke on the main unit. -They have been monitoring the resident for wandering and the resident has not been observed wandering or exit seeking nor have they observed the resident have any aggressive behaviors or agitation since he has been back on the main unit. During a telephone interview on 4/17/24 at 9:51 A.M., RN B said: -He/She was working on the locked memory unit during the 7:00 P.M. to 7:00 A.M. shift on 4/5/24. -On the morning of 4/6/24 around 6:40 A.M., nursing staff told him/her that the resident was smoking in his/her room, so he/she went to the resident's room to speak with him/her. -When she got to the doorway of the resident's room she smelled cigarette smoke and saw half of a cigarette butt sitting on the resident's tray table. The resident was standing by his/her closet door. -He/She said to the resident that he/she was not allowed to smoke in his/her room and the resident immediately began yelling at him/her to get out of his/her face and he/she began approaching him/her. -He/She never touched the resident but as he/she was yelling for him/her to get out of his/ her room, the resident pushed him/her down. -The nursing staff came over to assist her and move the resident away from him/her. -The nurse came and stayed with him/her and got him/her ice for his/her head because he/she had hit his/her head on the floor and he/she had pain in his/her head. -He/she said he/she lost consciousness for a minute and when he/she aroused, he/she told the nursing staff to call 911. -LPN A stayed with him/her until the emergency service personnel came and took him/her to the hospital. -This was the first time he/she had any direct interaction with the resident. -He/She did not understand why the resident was moved onto the unit when the resident was used to smoking at will when he/she was on the main unit. -He/She did not know if the resident wandered or was exit seeking because he/she had not had any interaction with the resident during his/her shift other than the morning of 4/6/24. MO00234391

Based on interview and record review, the facility failed to ensure one sampled resident (Residents #3) remained free from abuse, out of seven sampled residents. The facility census was 122 residents. On 10/17/23, the Administrator was notified of the past noncompliance which occurred on 10/15/23. The facility administration was notified on the same day the incident occurred and investigations were started. Facility staff were educated on the facility's abuse and neglect policy, resident interventions, and behaviors before the start of next shift. Resident care plans were updated. The deficiency was corrected on 10/16/23. Review of the facility Abuse Prevention and Prohibition Program, dated 10/24/22, showed: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. -Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. -The facility was committed to protecting residents from abuse by anyone, including but not limited to facility staff, and other residents. 1. Review of Resident #3's Admission Record showed the resident was admitted on [DATE] with the diagnoses: -Major depressive disorder (MDD - a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) with severe psychotic symptoms (a mental state involving loss of contact with reality and causing deterioration of normal social functioning); -Post Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a shocking, scary, or dangerous event). Review of Resident #3's Annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 7/18/23, showed the resident: -Was severely cognitively impaired; -Behaviors: Little to no interest in activities, appears depressed, sleep disturbances, appears tired, poor appetite, unable to concentrate, and short tempered; -Diagnoses: Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception), Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of Resident #4's Admission Record showed the resident was admitted on [DATE] with the diagnoses of metabolic encephalopathy (any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or degenerative conditions). Review of Resident #4's Quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired with wandering behaviors. Review of Resident #4's undated Care Plan showed he/she: -Had the potential to be physically aggressive related to impaired judgement and peers wandering into his/her room; -Increased anger, labile mood or agitation, feels threatened by others or thoughts of harming others, possession of weapons or objects that could be used as weapons. Review of Resident #3's Progress Notes, dated 10/15/23, showed: -Certified Nursing Assistant (CNA) A witnessed Resident #4 hitting Resident #3 in the head as he/she held onto Resident #4's shirt. -CNA A separated the two residents immediately and called out for assistance. -The charge nurse assessed Resident #3 for injuries and he/she was noted to have an abrasion to the forehead and a scratch on the right side of his/her face near the eye. -Staff administered first aid. Review of the facility Incident Report, dated 10/15/23, showed: -Resident #4 hit Resident #3 on the head in the hallway causing minor scratches. -CNA A observed the altercation. During an interview on 10/17/23 at 1:35 P.M., CNA A said: -He/She observed Resident #4 hit Resident #3, he/she separated them and called for assistance. -He/She was not sure what the altercation was about. -He/She did not feel anything would have prevented the altercation. -The staff had been doing training to prevent abuse and deescalate behaviors. During an interview on 10/17/23 at 1:51 P.M., Resident #4 said: -Resident #3 started cussing at him/her, so I hit him/her. -I'm the type that don't back down. -If I need it I'll get it. -No further conversation by the resident. During an interview on 10/17/23 at 2:15 P.M., the Director of Nurses & Administrator said: -He/She did not think this was abuse, but behavior based. -The allegations were reported as a self report on resident to resident abuse. -It was not appropriate for any resident to hit another resident. MO00225915

Based on observation, interview and record review, the facility dietary staff failed to observe and adhere to the sanitary and hygienic food practices as outlined in the professional standards of the U.S. Food and Drug Administration's (FDA) Food Code, when they prepared residents' meals by not wearing the required hair restraints. The facility had census of 112 residents. 1. Observation on 8/3/23 between 5:03 A.M. and 6:45 A.M. in the kitchen, showed: -At 6:10 A.M. a Dietary Aide (DA) was in the kitchen and prepared cold cereal on a food preparation table. -The DA did not have a total covering of his beard, mustache and sideburns. -At 6:35 A.M. the Dietary Manager (DMgr) entered the kitchen, had a full beard with a mustache, and was not wearing a beard/hair restraint. -At 6:38 A.M. the DMgr started to assist the Dietary Cook (DC) in preparing breakfast food items without donning a hair restraint. During an interview on 8/3/23 at 6:42 A.M. the DMgr said he/she would normally wear a hair/beard restraint while in the kitchen but was late in getting to the kitchen and helping out the DC thus, forgot to put one on. Observation on 8/3/23 between 10:00 A.M. and 10:45 A.M. showed at 10:35 A.M. the DMgr was assisting the DC in preparing the noontime meal, working around uncovered, raw, uncooked food, and was not wearing a beard/hair restraint. During an interview at 10:40 A.M., the DMgr said he/she: -Expected all staff to cover their facial hair using the supplied beard guards and hair nets. -Forgot to put one on then, went to obtain and donned one. 2. Observation on 8/7/23 at 8:53 A.M., of the DA showed he/she: -Was coming from the kitchen to the steam table area carrying two chocolate milk cartons. -Placed the two chocolate milk cartons on a food tray with uncovered food on the tray. -Had facial hair of a half-inch beard and mustache. -Did not have a beard net on and was working around uncovered food. Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code Chapter 2-402.11, showed, (A) Except as provided in (paragraph) (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. This section does not apply to FOOD EMPLOYEES such as counter staff who only serve BEVERAGES and wrapped or PACKAGED FOODS, hostesses, and wait staff if they present a minimal RISK of contaminating exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES.

Based on interview and record review, the facility failed to follow their policy to complete a background screening through the Certified Nurse Assistant (CNA) Registry prior to hire to determine if there was a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) for seven out of ten new employees whose files were sampled. This had the potential to affect any facility resident who received services from or whose medical records or belongings could have been accessed by one or more of the seven new employees. The facility census was 112 residents. On 8/7/23, the Administrator was notified of the past noncompliance which took place over a period of time to include 1/19/23 through 7/22/23. The Human Resource (HR)/Payroll Director discovered the missing background screenings on 7/21/23 during an audit of employee files. Background screenings through the CNA Registry were obtained on 7/22/23 for employees who were missing the screening. On 7/23/23 the HR/Payroll Director received education on background screening expectations. The deficiency was corrected on 7/23/23. Review of the facility's Abuse Prevention and Prohibition Program policy, revised October 24, 2022 showed: -The facility was committed to protecting residents from abuse by anyone, including but not limited to facility staff. -The facility would not knowingly employ anyone who had disciplinary action against his/her professional license or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment, or misappropriation or had been convicted of abusing, neglecting, or mistreating other people. Centers for Medicare and Medicaid Services (CMS) 42 CFR 483.13 (1) (ii) (A) (B) (iii) showed: (1) The facility must not (ii) employee individuals who have been: (A) Found guilty of abusing, neglecting or mistreating residents by a court of law; or (B) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and (iii) report any knowledge it has of actions by a court of law against an employee which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. 1. Review of Employee B's employee file showed: -The employee was hired on 2/1/23 as a Registered Nurse (RN). -The FI check through the CNA Registry was not completed until 7/22/23. Review of Employee C's employee file showed: -The employee was hired on 1/19/23 as a Hospitality Aide. -The FI check was not completed until 7/22/23. Review of Employee D's employee file showed: -The employee was hired on 4/12/23 as a Nurse Aide in Training. -The FI check was not completed until 7/22/23. Review of Employee E's employee file showed: -The employee was hired on 1/19/23 as Activities Aide. -The FI check was not completed until 7/22/23. Review of Employee F's employee file showed: -The employee was hired on 5/24/23 as a Certified Medication Technician (CMT). -The FI check was not completed until 7/22/23. Review of Employee G's employee file showed: -The employee was hired on 6/28/23 as a Housekeeper. -The FI check was not completed until 7/22/23. Review of Employee J's employee file showed: -The employee was hired on 2/1/23 as a Receptionist/Clerk. -The FI check was not completed until 7/22/23. Review of the facility's Performance Improvement Plan (PIP) documentation, dated 7/21/23 showed: -An area of concern was identified related to timelines for required background screenings. -The HR/Payroll Director received education on 7/23/23 from the Administrator on timelines for background screenings. This included ensuring the FI checks were completed through the CNA Registry prior to hiring a new potential employee. -Follow up would include regular audits to ensure compliance. During an interview on 8/7/23 at 10:04 A.M. the Administrator said: -The HR/Payroll Director was responsible for employee background screenings and was self-auditing all employee files when he/she realized several employees did not have the CNA Registry screenings. He/She reported these findings. -A third party was responsible for completing the CNA Registry screenings. -The HR/Payroll Director was educated on 7/23/23 that it was his/her responsibility to follow up with the third party to ensure the CNA Registry screenings were completed prior to an offer of employment. During an interview on 8/7/23 at 12:40 P.M. the HR/Payroll Director said: -He/she was responsible for ensuring required background screening results for all employees were completed prior to an offer of employment. -The CNA Registry check had not been completed for Employees B, C, D, E, F, and J prior to their hire date. -He/She did an audit of all employee files 7/21/23 and discovered that several files were missing the CNA Registry screenings for the FI. -CNA Registry screenings were completed on 7/22/23 for all employees found to be missing the screenings. -He/She received education from the Administrator on 7/23/23 related to required background screenings being completed prior to hire which included education for ensuring the CNA Registry screenings were completed prior to an offer of employment.

Based on interview and record review, the facility, failed to ensure residents' monthly Drug Regimen Review (DRR-thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) were completed by the pharmacy to ensure irregularities were identified so they could be acted upon for four sampled residents (Resident #23, #41, #90, and #84) out of 24 sampled residents. The facility census was 112 residents. Review of the facility's policy titled DRR revised 6/20/20 showed: -A pharmacist must review each resident's medication regimen at least once per month and document this in the resident's medical record. -If any irregularities were found, such as unnecessary mediations, excessive dose, excessive medication, excessive duration and/or inadequate monitoring, this must be communicated with the Director of Nursing (DON), the resident's physician, and the Medical Director. -The attending physician would respond to any irregularities in the report each month and document in the resident's medical record if any actions were taken. -If no action had been taken, the attending physician must document a rationale. 1. Review of Resident #23's Admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/1/23 showed the resident: -Was severely cognitively impaired. -Used antipsychotic medications (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) seven days out of the last seven days. -Used antianxiety medications (a class of medications used to prevent or treat anxiety symptoms or disorders) seven out of the last seven days. -Used opioid (pain medication) seven out of the last seven days. Review of the resident's Care plan revised 5/10/23 showed the resident received antianxiety medications, antipsychotic medications, and pain medications. Review of the residents Order Summary Report (OSR) dated 8/4/23 showed the following physician ordered medications: -Levothyroxine sodium oral tablet 25 micrograms (mcg) (used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone): give one tablet daily. -Lorazepam oral tablet 0.5 milligram (mg): give one tablet twice a day for anxiety. -Quetiapine Fumarate tablet 25 mg: give one tablet two times daily for anxiety. -Tramadol HCI tablet 50 mg: give one table three times per day for moderate to severe pain. Review of the resident's electronic medical record on 8/7/23 showed no documentation of the pharmacy DRRs being completed since the resident admission. 46890 2. Review of Resident #41's Annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Used antianxiety medication seven days out of the last seven days. -Used antidepressant (a class of medication used to prevent or treat depression) medication seven days out of the last seven days. Review of the resident's Care plan revised 4/1/23 showed the resident received antianxiety medication and antidepressant medications. Review of the resident's Order Summary Report dated 8/4/23 showed the following physician ordered medications: -Citalopram (used to prevent or treat depression) 30 mg every day. -Buspirone (used to prevent or treat anxiety) 2.5 mg twice a day. Review of the resident's electronic medical record on 8/6/23 showed only one documented DRR in the past twelve months. 19016 3. Review of Resident #90's Comprehensive Care Plan revised 4/10/23 showed the resident: -Received insulin (an anti-diabetic drug used to manage diabetes) and Diabetes Mellitus (DM a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) medications. -Received anticoagulant medications (a class of drugs that prevent or reduce coagulation of blood, prolonging clotting time). -Received antidepressant medications. -Received other psychotropic drugs (drugs which affect psychic function, behavior, or experience). Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Received insulin injections seven out of the last seven days. -Used antipsychotic medications seven days out of the last seven days. -Used antidepressant medications seven days out of the last seven days. -Used opioids seven days out of the last seven days. -Used an anticoagulant seven days out of the last seven days. Review of the resident's OSR dated 8/3/23 showed the following physician ordered medications: -Apixaban (an anticoagulant) oral tablet 5 mg: give one tablet two times a day related to acute embolism (blocked artery) and thrombosis (clotting of the blood in a part of the circulatory system). -Insulin Aspart Injection Solution (Insulin Aspart): inject 24 units subcutaneously (just below the skin) with meals related to Type 1 DM. -Lantus Subcutaneous Solution 100 unit/milliliter (ml) (Insulin Glargine): inject 29 units subcutaneously in the morning for DM. -Quetiapine Fumarate (an antipsychotic) tablet 50 mg: give one tablet two times daily for psychosis. Review of the resident's electronic medical record on 8/7/23 showed no documentation of the pharmacy DRRs being completed since the resident admitted to the facility. 4. Review of Resident #84's Comprehensive Care Plan revised 7/15/23 showed the resident: -Received antianxiety medication. -Received antidepressant medication. -Received anticoagulant medication. -Received a diuretic medication (any drug that elevates the rate of urination). -Received multiple black box drugs (U.S. Food and Drug required warnings for medications that carry serious safety risks). Review of the resident's Annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Used antianxiety medications six days out of the last seven days. -Used antidepressant medications six days out of the last seven days. -Used an anticoagulant medication two days out of the last seven days. -Used an antibiotic medication (an antimicrobial drug active against bacteria) seven days out of the last seven days. -Used opioid medication six days out of the last seven days. Review of the resident's OSR dated 8/4/23 showed the following physician ordered medications: -Aztreonam (an antibiotic) Injection Solution Reconstituted: use 2 grams intravenously (IV into or by means of a vein or veins) every six hours for prosthetic joint infection. 2 gram in 100 ml adapter (connection between the syringe and dispensing equipment). -Bupropion HCI Extended Release oral tablet 150 mg: give one tablet every 12 hours for depression. -Bupropion HCI tablet 5 mg: give one tablet three times a day for anxiety. -Duloxitine HCL capsule Delayed Release Particles 60 mg: give one time a day for depression. -Lasix tablet 20 mg: give one tablet two times a day for fluid retention. -Lisinopril tablet 40 mg: give one tablet a day for hypertension (high blood pressure). -Oxycodone HCL tablet 20 mg: give one tablet every four hours as needed for pain. -Vancomycin HCL Intravenous Solution: use one gram intravenously every 12 hours for prosthetic joint infection. 1000 mg intravenous every 12 hours. -Xarelto tablet 15 mg: give one tablet by mouth at bedtime to prevent Deep Vein Thrombosis (DVT). Review of the resident's electronic medical record on 8/7/23 showed no documentation of the pharmacy DRRs being completed since the resident admitted to the facility. 5. During an interview on 8/7/23 at 10:06 A.M., Certified Medication Technician (CMT) A said he/she did not know about DRR's. During an interview on 8/7/23 at 10:15 A.M., Licensed Practical Nurse (LPN) C said he/she did not handle the DRR's and thought nurse managers were responsible for DRR's. During an interview on 8/7/23 at 10:23 A.M., the Assistant Director of Nursing (ADON) said: -DRR's were printed off from an email received by the consultant pharmacist monthly. -He/she would go through them monthly with the medical director or the nurse practitioner. -He/she would then implement the DRR's if approved into the resident's electronic medical chart and update the nursing staff of changes. -All DRR's were completed by nursing management. -The DON was responsible to ensure monthly DRR's were completed. During an interview on 8/7/23 at 12:46 P.M. DON said: -The Pharmacy Consultant came in the facility monthly. -Pharmacy DRR's were submitted through email. -He/she reviewed DRR's with the physician. -The ADON would implement the DRR's and update nursing staff. -He/she was responsible to make sure the monthly DRR's were completed and documented in the resident's electronic medical chart.

Based on interview and record review, the facility failed to maintain an effective infection control program that included tracking and trending of facility resident infections. The facility census was 112 residents. Review of the facility policy titled Infection Prevention and Control Program revised October 24, 2022 showed: -The facility must establish an Infection Prevention and Control Program under which it identifies, investigates, controls, and prevents infections in the facility and maintains a record of incidents and corrective actions related to infections. -The Infection Preventionist (IP) collects, analyzes, and provides infection data and trends to nursing staff, physicians. -The IP will determine specific sites and pathogen trends. -The IP will at least on a monthly basis conduct an infection control audit to identify trends. -Infection data is analyzed to identify trends. -Infection rates are compared to previous months in the current year and to the same month in previous years to identify trends, patterns, or problems that reflect the development of healthcare-associated infections. 1. During an interview on 8/4/23 at 11:12 A.M., IP said: -He/she had been the IP for two weeks and the prior IP quit with no notice. -The previous IP took the infection surveillance book when he/she left. -The facility had no infection surveillance book. -The facility was not tracking infections and did not have a year of data available for review. During an interview on 8/4/23 at 11:17 A.M., the Director of Nursing (DON) said: -The previous IP had resigned with no notice on 7/17/23. -The current IP had only been in the position for two weeks. -The previous IP had taken the infection surveillance book. -The surveillance book had a running year of data for review. -He/she had been tracking infections since he/she was hired in April. -He/she had been looking for the book since the previous IP left. -There was no surveillance book to map out outbreaks of infections. -No information was available regarding review of facility infection data for identification of trends/patterns/rates of facility infections. -No permanent data was retained at the facility regarding trends/patterns/rates of facility infections. Review of the facility infection surveillance books showed the facility had no book. During an interview on 8/7/23 at 12:50 P.M. the DON said he/she expected the IP to have maintained in the facility at least one year of resident infection data including an analysis of trends/patterns/infection rates.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #2) of eight sampled residents, was free from resident-to-resident abuse. On 4/20/23 Resident #1 struck Resident #2 on the top of the head with a trophy resulting in Resident #2 receiving a dime-sized raised area. On 4/25/23, Resident #1 struck Resident #2 twice on the top of his/her head with a rock placed inside of a sock, resulting in Resident #2 receiving a laceration to the top of the head that required two staples. The facility census was 101 residents. The Administrator was notified on 4/28/23 at 1:40 P.M., of the Immediate Jeopardy (IJ), which began on 4/25/23. The IJ was removed on 4/28/23, as confirmed by surveyor onsite verification. Record review of the facility's Abuse Prevention and Prohibition Program policy showed: -Each resident had the right to free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. -The facility had zero tolerance for abuse, neglect, mistreatment and/or misappropriation of resident property. -Staff must not permit anyone to engage in verbal, mental, sexual or physical abuse, neglect, mistreatment or misappropriation of resident property. -The facility was committed to protecting residents from abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors -The administrator was responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs and systems. -Physical abuse included welts and bruises, abrasions or lacerations, fractures, dislocations or sprains of questionable origin, black eyes, broken teeth, improper use of restraints, sexual exploitation, rape, excessive exposure to heat or cold, involuntary seclusion, multiple burns or human bites. -Resident-to-resident altercations should be reported if the altercation was caused by a willful action that resulted in physical injury, mental anguish or pain. -The presence of a mental disorder or cognitive impairment did not automatically preclude a resident from engaging in deliberate or non-accidental behavior. 1. Record review of Resident #1's Admission Record face sheet showed he/she was admitted to the facility on [DATE]. Record review of Resident #1's Preadmission Screening and Resident Review (PASRR- a federally required screening tool to help ensure that individuals are not .inappropriately placed in nursing homes for long term care), dated 3/15/23, showed: -History of cocaine abuse. -Alcohol dependence with withdrawal/delirium, (a serious change in mental abilities resulting in confused thinking). -Alcohol abuse with alcohol induced psychotic disorder, (a mental disorder characterized by disconnection from reality). -Alcohol induced mood disorder. -Nicotine dependence, (addiction to tobacco products caused by the chemical nicotine). -Mood disorder due to physiological condition. -Depression, unspecified, (a mental health disorder characterized by persistent feelings of sadness). -History of CVA with left sided hemiparesis, (a stroke causing weakness or the inability to move the left side). -History of falling/muscle weakness/generalized unsteadiness on feet. -History of non-compliance with other medical treatments and regimens. -Past history of aggression, fighting. -Past history of homicidal ideation, (thinking about or considering a murder), when I get angry. -Anxiety, (intense, excessive worry or fear about everyday situations). -Some confusion at night. -No behavioral issues since admitted to the facility. Record review of Resident #1's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/27/22, showed he/she was moderately cognitively impaired and his/her Brief Interview Mental Status (BIMS) score was 12. Record review of Resident #1's undated Care Plan showed: -He/she had delirium or an acute confusion episode related to alcohol use/abuse. -Interventions included: providing medications to alleviate agitation as ordered by the physician, side effects and effectiveness were to be monitored; discuss concerns about delirium with the resident, family and caregivers; report abnormal lab results to the physician; use the resident's preferred name; face the resident when speaking and make eye contact; reduce distractions; the resident understood simple directive sentences; provide the resident with necessary cues; stop and return if he/she was agitated. -He/she used antidepressant medication related to depression. -Interventions included: administering medications as ordered by the physician, side effects and effectiveness were to be monitored; changes in behavior/mood/cognition, delusions/hallucinations, social isolation suicidal ideation were to be monitored; calm reassurance was to be given; non-medical interventions such as approach in a non-threatening manner, removal to a safe environment as needed for behavior, removal to a quieter environment as needed to decrease over stimulation were to be used; care should not be forced or rushed. Record review of Resident #2's Admission Record face sheet showed he/she was admitted to the facility on [DATE]. Record review of Resident #2's PASRR, dated 7/22/22, showed: -Bipolar, (a mental health condition that causes extreme mood swings), single manic episode, unspecified, (a state of mind characterized by high energy, excitement and euphoria). -Substance abuse, alcohol abuse, chronic alcohol use. -Major depressive disorder, recurrent, unspecified. -Anxiety. -History of CVA with hemiparesis and hemiplegia, (a stroke with weakness and inability to move). -History of seizures, onset at age 56. -Metabolic encephalopathy secondary to alcohol use (a problem in the brain caused by a chemical imbalance in the blood). -History of reckless behaviors. -Previous psychiatric treatment. -History of conflicts with neighbors. Record review of Resident #2's Quarterly MDS, dated [DATE], showed he/she was cognitively intact and his/her BIMS score was 15. Record review of Resident #2's undated Care Plan showed: -He/she smoked cigarettes. Behaviors that came with smoking included ramming his/her electric wheelchair into the door until it either opens or breaks. -Interventions included: a copy of the smoker's contract was placed in the resident's medical record, the resident was educated about smoking risks; the resident was an independent smoker. -He/she had behavior issues with kicking the front door if nobody was around to let him/her out; riding his/her scooter too fast down the halls; falling asleep on the scooter instead of going to bed, trying to do a wheelie with his/her scooter and almost hitting another resident with the scooter. -Interventions included: behavior episodes would be monitored and attempts made to determine underlying cause; behavior and potential causes would be documented; discussion should be attempted with the resident about why the behavior was unacceptable or inappropriate; intervention to protect the rights and safety of others should be made; removal from the situation and an alternative location should be made as needed. -Potential for aggression was added to the care plan after the 4/20/23 incident. Interventions included: -reassurance offered as needed when resident appears agitated; -safe interventions offered and coping skills encouraged to manage anger; -time of day, places, circumstances and triggers, as well as de-escalated behaviors to be analyzed; -give as many choices as possible about care and activities; -assess for contributory sensory deficits; -provide physical and verbal cues to alleviate anxiety, give positive feedback, -give assistance to set goals for more pleasant behavior, -encourage resident to seek out a staff person when agitated; intervention before agitation escalated, he/she to be guided away from the source of distress and engaged calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Record review of Resident#1's Progress Notes, dated 4/20/23 at 9:10 A.M., showed: -He/she was involved in a physical altercation with a male peer. -He/she informed the nurse he/she was lying in bed and heard what sounded like someone going through his/her drawers.#2 and Resident #3 leaving his/her room. -He/she got out of bed and checked his/her drawer and after going through his/her wallet could not find his/her money card. -He/she got out of bed and saw Resident -He/she then went outside to where both residents were to see what they knew. -He/she was upset that someone had stolen his/her money card, so he/she questioned Resident #2 about it, thinking he/she had stolen it. -He/she was heard by witnesses yelling and being accusatory that Resident #2 had stolen his/her card, walked toward him/her and hit him/her on the top of the left side of his/her head. Resident #2 responded by hitting Resident #1 back which caused him/her to fall to his/her knees. -Another resident went to get staff as soon as the incident began. -Staff immediately responded and separated the residents away from each other. -Resident #1 was assessed for injury and noted with a laceration to the forehead and skin tear to left hand and abrasion between his/her left index and ring finger. -Staff assisted him/her to his/her feet and he/she was taken in the building and sat in a chair. His/her laceration, skin tear, and abrasion were all cleaned and treated. -He/she was placed on 1:1 observation and 911 was called so he/she could be sent to the ER and be evaluated for his/her behaviors. Record review of Resident #2's Progress Notes, dated 4/20/23 at 9:10 A.M., showed: -Resident #2 stated Resident #1 was throwing a fit, because Resident #3 took his/her debit card to the store and lost it in the grass before he/she went to the store. -He/she stated Resident #1 said he/she was going to kick his/her and Resident #3's asses and came over and hit him/her on the head. -He/she stated he/she hit Resident #1 back on the head with his/her mug and he/she fell to his/her knees. -Staff came and took Resident #1 to the hospital. Record review of Resident #2's Progress Notes, dated 4/20/23 at 9:15 A.M., showed the Director of Nursing (DON) assessed Resident #2 for injury and found a slightly raised 2 centimeter (cm) diameter bruise on the top of his/her head on the left side for which he/she denied pain, even upon palpation. Record review of Resident #2's Progress Notes, dated 4/20/23 at 9:20 A.M., showed: -Resident #1 was sent to the hospital for evaluation related to the altercation and Resident #2 was started on 15-minute checks. -Resident #2 told the social worker he/she wanted to call the police. -The DON offered to call and Resident #2 insisted on doing so him/herself. He/she was provided the phone number and did call and report the incident. Record review of Resident #2's Progress Notes, dated 4/20/23 at 9:50 A.M., showed Officer A arrived at the facility and took Resident #2's statement and informed the DON he/she would get Resident #1's statement at the hospital. Record review of the Police Department Offense/Incident Report, dated 4/20/23 at 9:55 A.M., showed: -Officer A arrived on the scene on 4/20/23 at 10:24 A.M., to an assault not in progress at the facility. -At around 9:15 A.M. on that date, two residents were in a physical altercation. -Resident #2 said: --He/she was hit on the head by Resident #1. --He/she stated it all began on the night of 4/19/23. --He/she stated Resident #1 gave his/her social security credit card to Resident #3, who was not present at the facility during the police visit. --He/she stated Resident #3 lost the card, but Resident #1 believed either he/she or Resident #3 stole his/her card. --He/she stated that on 4/20/23, Resident #1 came outside and began threatening him/her and said he/she was going to kick your ass for fucking with my money. --He/she stated Resident #1 thought he/she was in on it in regard to the card. --He/she denied ever having possessed the card or stealing anything from Resident #1. --He/she stated that after Resident #1 threatened him/her, Resident #1 punched him/her with a closed fist on the top of his/her head. --He/she stated he/she defended him/herself by hitting Resident #1 in the face with a glass coffee mug he/she had in his/her hand, knocking him/her to the ground. --He/she stated he/she threatened Resident #1, when he/she was on the ground, and said, I'll kick you in the fucking face, but that he/she never kicked him/her. --He/she stated he/she never lost consciousness. -It was noted Resident #2 was in his/her wheelchair when the assault occurred. -A small swollen spot on the left side of Resident #2's head was observed. -Resident #2 declined medical attention, but stated he/she wanted to press charges for the assault. -Resident #7 Said: --He/she was a witness to the incident. --He/she stated on 4/20/23, he/she and Resident #2 were outside sitting on the bench in front of the facility. --He/she stated Resident #1 came outside and said, I'm going to beat someone's ass. --He/she stated Resident #1 was angry about the debit card situation, but Resident #7 did not know the extent of the situation. --He/she stated Resident #2 told Resident #1 to shut up and that is when Resident #1 punched Resident #2 on the head four times with closed fists. --He/she stated he/she tried to grab Resident #1's arm to prevent him/her from punching Resident #2, but got scared and ran inside. --He/she thought he/she observed a small trophy fly out of Resident #1's hand when he/she was punching Resident #2, but he/she was unsure whether or not he/she hit him/her with it. -Resident #1 was contacted at the hospital to obtain his/her statement. -Resident #1 said: --He/she stated he/she had loaned his/her social security debit card to his/her friend, Resident #3, to get him/her cigarettes on 4/29/23. --Resident #3 never returned the card and stated he/she lost it. --He/she stated that on 4/20/23 at around 7:00 A.M., he/she observed Resident #2 and Resident #3 in his/her room. --He/she asked them what they were doing in his/her room and they said they had found his/her debit card and were returning it. --He/she stated he/she did not believe them and believed they were trying to steal from him/her. --He/she stated later that morning, he/she went outside to find either of them and found Resident #2. --He/she stated Resident #2 was laughing and thought he/she was laughing at him/her and the debit card situation. --He/she admitted he/she hit Resident #2 first, with a trophy. I smacked him upside the head and Resident #2 smacked me. --He/she stated when Resident #2 hit him/her back, he/she fell down, since his/her balance was not that great. --He/she stated Resident #2 kicked him in the face and the laceration on the eye was from the kick. --He/she stated he/she did not know if the object Resident #2 hit him/her with caused a laceration. -An approximate one-inch laceration on Resident #1's left eye lid and a small mark of blood on his/her forehead were observed. -Resident #1 also showed his/her wrist which appeared swollen and cut, which he/she said he/she sustained when he/she was trying to get up off the concrete after the incident was over. -The conclusion of the report was that Resident #1 was the primary physical aggressor and assaulted Resident #2. Resident #2 defended him/herself by hitting Resident #1 with his/her coffee mug. -Resident #1 was issued summons #200780420 for assault. During an interview on 4/27/23 at 1:10 P.M., Certified Occupational Therapy Assistant (COTA) A said: -He/she was near the main nurses' station, toward the front, at the time of the incident on 4/20/23. -A resident said, I need help up here. -He/she went outside and Resident #1 was on the ground, bleeding from his/her head. -Resident #2 was on his/her scooter, trying to run over Resident #1. -They were both saying they were going to kill each other. -They could not initially get Resident #1 up, because Resident #2 was trying to run him/her over. -This went on about ten minutes. -They were able to get Resident #2 in the building. -They tried to get Resident #1 up in a wheelchair and Resident #2 came back out. -They were cursing and saying they were going to kill each other. -Resident #2 was never successfully able to run over Resident #1, because he/she was holding Resident #2's scooter back. -They were able to get Resident #1 to his/her room. Record review of Resident #4's Quarterly MDS, dated [DATE], showed he/she was cognitively intact and his/her BIMS score was 15. During an interview on 4/27/23 at 2:50 P.M., Resident #4 said: -Resident #1 came out to the smoking area cussing up a storm. -He/she was talking about someone stealing his/her credit card. -He/she said someone came in his/her room and stole his/her card. -Maintenance had found the card, which he/she dropped, but he/she would not hear that the card had been found. -Resident #2 told Resident #1 to shut up. -Resident #1 took his/her other and slugged Resident #2 on the left side of the head. -Resident #2 had his/her cup in his/her hand and hit Resident #1 back on the head. -There were a bunch of people around by then, unsure how many. -Resident #2 was only defending him/herself. Record review of the Police Department Offense/Incident Report, dated 4/25/23 at 7:20 A.M., showed: -Officer B arrived on the scene and contacted Resident #2, who was being loaded into an ambulance. -Resident head wound appeared to be large and there was a large amount of blood around it. -Resident #2 had visible injuries to his/her left hand and the top of his/her head. -Resident #2 said: --His/her stated he/she was sitting in front of the building in his/her electric scooter, smoking with other residents. --He/she stated he/she was struck from behind in the back of the head. --He/she stated he/she then realized it was Resident #1 who struck him. --He/she stated Resident #1 tried to strike him/her again, but he was able to raise his/her arm slightly to block the strike. --He/she stated he/she observed Resident #1 was striking him with a sock that appeared to have rocks inside of it. --He/she stated he/she then ran his/her scooter into Resident #1 and attempted to kick him/her twice in self-defense. --He/she was then transported to the hospital. -Resident #4 was then contacted and said: --He/she stated he/she was sitting outside with Resident #2 smoking. --He/she stated he/she observed Resident #1 come up behind Resident #2 and strike him/her in the head with a sock that had rocks in it. -He/she stated Resident #1 attempted to strike Resident #2 again, but Resident #2 was able to block it with his/her hand. --He stated Resident #1 would regularly imagine things that were not there and accuse people of stealing things from his/her room when he/she would lose them. -Resident #1 was then contacted in his/her room and said: --He/she stated that Resident #2 hit him/her on 4/24/23 causing him/her to get stitches in his her head. --He/she stated he/she was waiting to get Resident #2 for what he/she did to him/her. --He/she stated he/she found a sock with rocks in it on a chair in his/her room and then went outside and struck Resident #2 with it. --The police officer informed Resident #1 that a different police officer had come out the night before and determined that the resident had fallen out of bed, and that was how he/she was injured. --He/she then stated he/she did not fall out of bed and insisted he/she was struck. --He/she then stated he/she was going to hit the officer and kill everyone at the facility. --He/she was informed he/she would be released pending further investigation. --He/she was not taken into custody, because he/she was wheelchair bound and had other pre-existing medical conditions that would make him/her unfit for confinement. -The facility administrator was then contacted and advised of the ongoing situation with Resident #1. -The administrator stated he/she would be attempting to have Resident #1 permanently removed from the facility due to his/her ongoing aggressive behavior. -Another officer recovered the sock that contained a concrete rock and also contacted a witness. -Resident #6 was then contacted and said: --He/she said he/she was on his/her way outside when Resident #1 was also going outside. --He/she stated Resident #1 was aggravated and told Resident #6 he/she was attacked in his/her sleep. --He/she stated Resident #1 told him/her he/she was going to get Resident #2 back for attacking him/her. --He/she stated when they got outside, he/she saw Resident #1 strike Resident #2 with a homemade weapon twice in the head. --At that point, Resident #2 was trying to defend him/herself. --The sock with the concrete rock, which had broken in three pieces after impact with Resident #2, was placed into evidence. Record review of Resident #1's Progress Notes dated 4/25/23 at 10:58 A.M. showed: -At 8:45 P.M. on 4/24/23, the charge nurse was informed that the resident was bleeding on his/her forehead and was on the floor in his/her room. -When the charge nurse entered the room, the resident was found standing by his/her sink trying to clean the blood of his/her face. -The resident had a midline horizontal 4.5 cm laceration across his/her forehead. -The area was cleaned and a dressing applied until EMS arrived. Neuro checks and vital signs were within normal limits. -The resident was transferred to the hospital for evaluation and treatment. -The resident stated someone was hiding in his/her room and that he/she was hit on the head. He/she stated he did not see who did it. -Based on the midline, horizontal laceration to the forehead, he/she would have been hit by someone facing him/her, so the alleged assailant would have been seen. -His/her door and bathroom were visible at all times. -It appeared the resident may have dozed off while watching television and hit his/her head on the dresser. -The resident's preconceived perception that someone caused him/her to fall could not be substantiated. -Staff on the hall at the time he/she yelled out had not seen anyone else in the hall. -The resident returned to the facility from the hospital at approximately 2:00 A.M. -He/she had sutures to his forehead and the area was dry and intact. Record review of Resident #2's Progress Notes, dated 4/25/23 at 12:12 P.M., showed: -Resident #2 was involved in a physical altercation with a male resident at 7:45 A.M. that morning. -The resident's doctor, the DON, and the administrator were all notified immediately following the incident. -The resident was sent to the emergency department due to a laceration on the top of the head. Record review of Resident #1's Progress Notes, dated 4/25/23 at 12:28 P.M., showed: -Resident #1 was involved in a physical altercation with a male resident at 7:45 A.M. that morning. -The resident stated that someone came into his/her room the previous night and hit him/her on the head, causing him/her to fall, which resulted in a laceration to his forehead. -The resident claimed to have found a sock with a rock in it in his/her room, which was used on him/her last night. -He/she stated he/she did not know who hit him/her, but when he saw Resident #2 outside smoking that morning, he just knew it had been him/her who had been in his/her room last night. -Staff retrieved the sock with the rock in it, which Resident #1 brought to the nurses' station and it was thrown away. -A couple hours later, Resident #1 had another sock with a rock in it which he/she used to hit Resident #2 later than morning when he/she saw him/her outside smoking. -Based on resident and staff interviews, it could not be substantiated that someone went into Resident #1's room and hit him/her. He/she strongly believed someone went into his/her room and hit him/her, which caused him/her to fall, rather than believe he/she fell on his/her own. -The residents were separated for safety and Resident #1 was placed on 1:1 observation until his/her discharge home with family at 11:55 A.M. Observation of Resident #2 on 4/26/23 at 12:00 P.M., showed: -He/she had a small gash on the upper back part of the head closed with two staples. -He/she had a scabbed area approximately half the size of a dime on his/her left first knuckle. -He/she was sitting on a motorized scooter which he/she uses for transport around the facility. During an interview on 4/26/23 at 12:00 P.M., Resident #2 said: -Resident #1 gave his/her credit card to Resident #3, to buy him/her some cigarettes, because he/she was going to the store. -The card got lost in the grass. -When Resident #3 arrived at the store, he/she found he/she did not have the card, because it had been dropped. -Resident #1 came outside to the smoking area and threatened him/her and Resident #3 and said he/she was going to kill him/her. -Resident #1 hit him/her with a trophy on the left upper head four times, resulting in two bumps. -He/she in defense had a mug in his/her hand and knocked Resident #1 down. -When Resident #1 went down, he/she threw the trophy to Resident #7. -He/she did not know what Resident #7 did with the trophy. -Some staff got Resident #1 up and sent him/her to the hospital. -Then he/she went inside and some staff looked at his/her head. -The administrator was aware and took him/her back to his/her room. -Maintenance found the card outside the building, in the front of the building. -There were no staff present at the smoking area until the incident happened. -Afterward and until 4/25/23 he/she and Resident #1 talked again outside without issues. -He/she never went back to Resident#1's room. -Resident #1 thought he/she was hiding in his/her room during the night between 4/24/23 and 4/25/23 when Resident #1 had a fall. -On 4/25/23 morning, he/she was outside smoking. -There were a few other other residents also out at the smoking area. -He/she was just sitting there and felt a blow on the head. -He/she put his/her hand up and felt blood. -He/she was hit again, this time on the hand, which was shielding his/her head. -He/she turned his/her scooter around and knocked Resident #1 down and Resident #1 hit the ground. -Resident #1 said he/she was going to kill Resident #2. -He/she stayed outside and Resident #1 was in front of the facility door when staff came out. Two staff people broke them up. -No staff had been outside with them before that. -He/she went to the hospital. -He/she called the police on 4/20/23 and they left Resident #1 at the facility so he/she could kill him/her. -If the police had taken him the first time, he/she would not have had the chance to try to kill him/her the second time. -The police came again on 4/25/23 and did not take Resident #1 then, either. Record review of Resident #3's Quarterly MDS, dated [DATE], showed he/she was moderately cognitively impaired and his/her BIMS score was 12. During an interview on 4/26/23 at 1:40 P.M., Resident #3 said: -He/she saw Resident #1 hit Resident #2 on 4/20/23. -Resident #1 lost his/her debit card and thought he/she had it, because he/she was going to the store. -He/she would go to the store for everybody. -The card got dropped. -Resident #1 made all kinds of threats at him/her. -He/she just walked away from Resident #1. -Resident #1 thought Resident #2 had his money card. -The incident happened in the smoking area. -Resident #1 hit Resident #2 with the trophy. During an interview on 4/27/23 at 10:38 A.M., Certified Nursing Assistant (CNA) A said: -Resident #1 had fallen the night of 4/24/23 and hurt his/her head, and was sent to the hospital for evaluation. Resident #1 returned to the facility around 2:00 A.M. -He/she went to bed and was behaving normally. -The police had spoken to the resident before he/she went to the hospital. -A policeman came in and looked around the whole room and said it looked ok, that the resident had taken a fall. -The police came out related to the fall, because the resident said someone hit him/her. -Nobody went in the resident's room. -He/she was at the top of the hallway and did not see anyone walking in the hall. Everything was normal and everyone was asleep. -Not long before shift change, Resident #1 brought a sock with a rock in it to the nurse and said it was what he/she had been hit with. -The nurse took the rock from him/her. -He/she was clocked out on 4/25/23 and was sitting in his/her car, as it was exactly change of shift. -Resident #2 was having his/her regular morning smoke break, and drinking his/her Coke. -Resident #1 woke up that morning and probably was thinking about his/her idea that he/she had been hit. -He/she heard screaming and got out of his/her car to separate the two residents. -They were screaming the entire time and both saying, I'm going to kill you. -Resident #1 was on the ground. -Resident #2 had a cut, told him/her to call the police and he/she went inside. -Resident #1 stayed outside and sat in the chair and smoked a cigarette. -The injury from the fall on Resident #1's head had come open. -When he/she was breaking the two residents up, other staff who were coming to work came to help. -He/she left the facility for the day after that. During an interview on 4/27/23 at 11:10 A.M., Licensed Practical Nurse (LPN) A said: -He/she took Resident #1 home less than two hours after the second incident. -When he/she took him/her home, the resident kept going on with the delusion that people had been coming in his/her room. -The resident thought since somebody hit him/her, he/she needed to hit back. -He/she didn't know where the resident got the rock. -The resident would get agitated and hard to understand; he/she did not want to be challenged. During a telephone interview at 11:20 A.M., Resident #1 said: -He/she came to his/her room on 4/20/23 morning. -He/she saw that his/her debit card was missing and did not think he/she brought it back. -Resident #2 and Resident #3 were at his/her door then they all went out to smoke. -Resident #2 said, Fuck him/her. -This made him/her mad and he/she swung at Resident #2 and hit him/her. -He/she did not attack Resident #3, just Resident #2. -Resident #2 said, Give it back to him/her. -At night on 4/24/23, somebody was hiding in his/her room and hit him/her with a pipe or something, which knocked him/her out and he/she fell . -He/she could not see anyone. -He/she went to the hospital and had a scan on his/her head. He/she was not sure what happened at the hospital. -He/she brought the nurse a rock, because that was what he/she thought he/she had been hit with. -The next morning, on 4/25/23, he/she want outside Resident #2 was out there grinning and smiling. -He/she found a rock outside and put it in a sock and hit Resident #2, because they had gotten into it before, and he/she thought Resident #2 had hit him/her. -Resident #2 said he/she would kill him/her and knocked him/her down with his chair. -He/she told Resident #2 to take that back. -He/she thought it was a good idea to hit Resident #2 and would do it again. -They had gotten along after the first fight. During an interview on 4/27/23 at 1:45 P.M., Resident #1's Family Member A said: -Resident #1 had delusions at times.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) out of five sampled residents with known behaviors had appropriate individualized interventions in place to ensure his/her safety. On [DATE] another facility resident (Resident #2) hit Resident #1 in the face repeatedly with a coffee mug and caused a laceration that required stitches and this was the second incident between these residents. The facility census was 90 residents. Record review of the facility's undated Abuse, Neglect and Exploitation policy showed: -The policy of the facility was to provide protection for the health, welfare and rights of each resident. -The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, which would include increased supervision of the alleged victim and residents; room or staffing changes, if necessary, and examining the alleged victim for any sign of injury. -Employee training would include understanding behavioral symptoms of residents, such as aggressive reactions of residents, wandering, resistance to care, outbursts of yelling out, and difficulty in adjusting to new routines. -The facility would implement policies and procedures that would achieve identification, ongoing assessment, care planning for appropriate interventions and monitoring the residents with needs and behaviors that might lead to conflict or neglect. 1. Record review of Resident #1's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified dementia with behavioral disturbance (a mental disorder where a person loses the ability to think, remember, learn, make decisions and solve problems). -Cognitive communication deficit (difficulty with thinking and how language is used). Record review of the resident's Physician Order Sheet (POS), dated [DATE], showed the resident would reside on a secure unit. Record review of the resident's Care Plan, dated [DATE], showed: -The resident had a diagnosis of unspecified dementia with behavioral disturbance. -The resident had impaired cognitive function and thought processes related to dementia. -The resident resided in the facility's memory care unit. -The care plan was updated to describe an incident on [DATE] when the resident threw peri-wash (liquid cleanser that sanitizes the skin in the genital area) at another resident, after that resident yelled at Resident #1 to get out of his/her room. -The resident would be redirected if trying to enter another resident's room. -The resident's safety was to be maintained. -The resident would not harm him/herself or others. -The resident was to be monitored to ensure safety. -The resident was resistive to care, combative and verbally abusive to others. -The resident was taking anti-depressant, mood stabilizing and anti-anxiety medications. -The care plan was updated to describe an incident on [DATE] when the resident was verbally abusive to another resident. The behavior persisted and the other resident grabbed Resident #1's wheelchair and pushed it, causing Resident #1 to fall. -The care plan was updated to describe an incident on [DATE] between the resident and another resident resulting in a verbal and physical altercation. The residents were separated by moving the residents to different halls,. 2. Record review of Resident #2's Admission Record face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance. Record review of the resident's POS, dated [DATE], showed he/she would reside on a secure unit. Record review of the resident's Care Plan, dated [DATE], showed: -The resident resided on the memory care unit. -The resident had prior trauma related to being a former police officer and having dementia with no known triggers. -The resident had impaired cognitive function and thought processes related to dementia. -The resident had the potential to be physically aggressive. -The care plan was updated to include an incident on [DATE] where this resident shook the arm rests of Resident #1's wheelchair, causing Resident #1 to fall, after Resident #1 was verbally aggressive toward Resident #2. -The care plan was updated to include a verbal and physical altercation with Resident #1 on [DATE]. 3. Record review of a resident-to resident interaction report, dated [DATE], showed: -Resident #1 was calling Resident #2 names and saying antagonizing things to him/her. -Resident #2 asked Resident #1 to stop more than once. -Resident #1 continued verbally attacking Resident #2, so Resident #2 grabbed the handlebars of Resident #1's wheelchair and shook it. -Resident #1 fell from the wheelchair to the floor. -Staff intervened and separated the residents. -Resident #2 was easily redirected and stated he/she wanted Resident #1 to stop talking to him/her. -Neither party sustained injuries. -Responsible parties and physicians were notified. -The staff were very clear that Resident #1 was seeking out Resident #2 and being verbally aggressive. -The facility would complete an investigation. Record review of Resident #1's incident report dated [DATE] at 12:10 P.M., showed: -On [DATE] Resident #1 was in the dining room at evening mealtime sitting at a table with other residents. -He/she was getting verbal with Resident #2, sitting at the table calling him/her names, talking about getting that bitch out of our home, (referring to a third resident sitting close to Resident #2 at the table). -It was believed that Resident #1 thought Resident #2 was his/her spouse. -Resident #2 asked Resident #1 to stop calling him/her names and yelling at him/her. -Staff re-directed and moved Resident #1 away from the table a few times but he/she just kept going back to yell at Resident #2 and call him/her names. -Resident #2 stood up and grabbed Resident #1's wheelchair by the arms of the wheelchair and shook it causing Resident #1 to fall on the floor. -The nurse assessed Resident #1 on the floor for injury. -Resident #1 stated that his/her left shoulder was hurting. No visible abnormalities noted. -The nurse assisted Resident #1 back into his/her wheelchair and the wheelchair arm was found to have a plastic piece had broken off. -The wheelchair arm was padded for comfort and safety. -An x-ray was ordered, and no injury was found. Record review of Resident #1's Weekly Skin Check dated [DATE] showed he/she had no new wounds. In a written statement on [DATE], incident witness, Certified Medication Technician (CMT) A said: -Around 4:00 P.M., Resident #1 was sitting next to Resident #2. -He/she was whispering names and saying, Tell that bitch (Resident #2) to go on, to leave my home. -Resident #2 replied, Please be quiet. -Resident #1 got more upset, so CMT A moved Resident #1 and tried to redirect him/her to what he/she wanted for dinner. -Resident #1 wheeled him/herself back to the table where Resident #2 sat. -He/she told Resident #2 to ignore him/her. -Resident #1 kept calling Resident #2 names. -After dinner, Resident #2 got up and shook Resident #1's wheelchair, telling him/her to leave him/her alone. -After Resident #2 shook Resident #1's wheelchair, he/she got more upset. In a written statement on [DATE], incident witness, CMT C, said: -At 4:00 P.M., he/she heard people yelling. -He/she was at the nurses' station with his/her back facing the desk on the 700 hall. -He/she turned to see Resident #2 pick up a wheelchair with Resident #1 sitting in it. -Resident #2 shook the wheelchair causing Resident #1 to fall to the floor. -CMT A was the closest to the residents. -He/she exited the nurses' station to see what happened, and told CMT A to stay right where he/she was. -He/she asked Resident #2 to move away from the incident. -He/she left the area to call for a nurse and left the unit to meet with the nurse in the hallway. Record review of Resident #1's incident report dated [DATE] at 10:23 A.M., showed: -The resident was aggressive and antagonizing another resident (Resident #2). -Resident #2 hit Resident #1 in the head with a coffee cup, resulting in a laceration under the right eyebrow. -The residents were immediately separated. -The nurse practitioner ordered the resident be sent to the emergency department for evaluation and treatment. -The Assistant Director of Nursing (ADON), Director of Nursing (DON) and social worker called the Power of Attorney (POA) and the resident's adult child on a three-way call. -The family requested the resident be sent to the hospital. -The resident was transported to the hospital by ambulance. -The resident was unable to give a description of the incident. -The resident was alert and oriented to person. -The resident was confused with impaired memory. Record review of Resident #2's incident report dated [DATE] at 10:28 A.M., showed: -This resident struck Resident #1 with a coffee cup, because Resident #1 was agitating him/her and following him/her around. -Both residents have dementia and it appeared Resident #1 thought he/she knew Resident #2 and did not like him/her, for some reason. -Resident #1 received a laceration to the face. Resident #2 had no obvious injuries. -Resident #2 was not taken to the hospital, and was oriented to person. -Resident #2 was confused and had impaired memory. In a written statement on [DATE], incident witness, Housekeeper A, said: -He/she was cleaning a room on the 700 hall when he/she saw Resident #1 trying to fight with everyone. -The resident hit Resident #2 with a brassiere (bra) he/she was swinging. -Resident #2 got up and started hitting Resident #1 three or four times with a cup in his/her fist. -He/she yelled for Certified Nurses Assistant (CNA) B, who came quickly and took Resident #1 away. Record review of the resident's hospital record dated [DATE] showed Resident #1 had sustained a laceration across his/her right eyebrow and required sutures. During an interview on [DATE] at 10:15 A.M., the DON said: -Resident #1 had dementia. -His/her spouse, who was also his/her roommate, had recently died . -Some of the staff felt that Resident #1 targeted Resident #2 as his/her spouse. -Resident #1 would call Resident #2 bad names. -Resident #2 would typically tell Resident #1 to be quiet, and walk away. -Prior to the reported incident on [DATE], there was also a reported incident on [DATE]. -After the incident on [DATE], the staff moved Resident #1 to the 600 hall, but he/she was returned to the 700 hall the next day by a housekeeper who was unaware the resident had been moved. -That housekeeper subsequently quit his/her job because they did education with him/her about moving residents without notifying anyone. -The department managers were supposed to communicate changes to the staff. -In this case, the department manager was out sick that day. -The two halls are connected by a single nurses' station. -The staff would intervene when the residents were acting out by redirection. During an interview on [DATE] at 12:20 P.M., Housekeeper A said: -On [DATE], Resident #1 was in his/her wheelchair chasing everyone with a bra, which he/she got from a nearby laundry cart. -Resident #1 was talking loudly, which was a normal voice for him/her. -Resident #2 was sitting at a table finishing breakfast. -The nurses were at the nurses' station when the incident occurred. -Resident #1 started hitting Resident #2 with the bra. -Resident #2 responded by hitting Resident #1 with a coffee cup. -He/she was cleaning and the only staff person in the common area. -He/she called for help when Resident #2 hit Resident #1 with an empty coffee cup. -Resident #2 was moved to the 700 hall on [DATE]. -There was only a CNA and a CMT for both units on [DATE]. -If they needed a nurse, they would call the nurse from the rehabilitation unit. -He/She did not know what else to do, so he/she called for the nursing staff to assist. During an interview on [DATE] at 12:40 P.M., CMT B said: -There was no nurse back on the memory care unit on [DATE]. -Housekeeper A called for him/her and the CNA that was on duty. -They left the nurses station and asked Resident #2 to go to his/her room. -They put pressure on Resident #1's wound and called the DON. -Resident #1 was often confused and thought the unit's common area was his/her house, and called everyone names. -Resident #1 could move very fast in his/her wheelchair. -When Resident #1 was being verbally aggressive, the staff would try to keep him/her away from other residents by bringing him/her back to his/her room, or removing him/her to another area to help him/her calm down. During an interview on [DATE] at 2:03 P.M., the Administrator said: -The facility had been trying to keep Resident #1 and Resident #2 apart as much as possible. -Resident #1 was the aggressor in the incidents. -There were only two incidents between the two residents. -Both residents were to be on increased supervision. -When asked specifics it was noted that 15 minute checks for 72 hours were being done for Resident #1 after the first incident. -He/She was not able to provide any documentation that this was completed. During an interview on [DATE] at 3:35 P.M., ADON B said: -As far as he/she knew, there were only the two incidents between Resident #1 and Resident #2. -Resident #1 usually stayed in the common area of his/her unit, either sitting at a table by the nurses' station or wandering around, when he/she was not in bed. -All of the staff were aware they were to be monitoring Resident #1 and Resident #2. During an interview on [DATE] at 3:45 P.M., CNA A said: -Resident #1 thought Resident #2 was his/her spouse. -Resident #1 was aggressive toward all the residents and visitors. -If Resident #1 got aggressive, he/she would try to take him/her back to his/her room. -Resident #1 is often out in the unit's common area, cursing and complaining, unless he/she was in bed. -Resident #1's aggressive behaviors turn on and off very quickly. -He/she found out during his/her job orientation that Resident #1 was aggressive. -All of the staff knew about Resident #1's behavior. -He/she did not know that Resident #1 had changed rooms after the [DATE] incident. During an interview on [DATE] at 3:50 P.M., CMT B said: -He/she found out during orientation that Resident #1 could be aggressive. -He/she was not aware that the resident had been moved. During an interview on [DATE] at 3:55 P.M., CMT A said: -Resident #1 previously lived in a room on the 700 hall. -He/she knew Resident #1 could be aggressive. -He/she had seen Resident #1 interact with Resident #2. -On [DATE], Resident #1 was yelling at Resident #2, so he/she moved Resident #1 to a room on the 700 hall. -Resident #1 calmed down in the new room. -The next day, Resident #1 was back in his/her old room on the 600 hall. During an interview on [DATE] at 4:10 P.M., the Physician said if a nurse was aware a resident with dementia was having behaviors, he/she should call the Nurse Practitioner to have the resident sent to the hospital emergency room for a psychiatric evaluation. During an interview on [DATE] at 4:17 P.M., the Nurse Practitioner said: -Resident #1 was known to be aggressive. -The facility needed to have a staff member keep an eye on this resident at all times. -This resident was aggressive to all residents and staff, and could be triggered easily. -The staff could not really do a one-to-one observation with this resident continuously, but perhaps he/she could be kept close to the nurses' station. -After the second incident he/she thought a psychiatric evaluation may be needed but the family had taken the resident from the hospital against medical advice and had not returned him/her to the facility. -When asked specifically why this wasn't done after the first incident he/she responded that he/she could have added an as needed medication to address the residents behaviors prior. -He/she didn't think moving Resident #1 to a different hallway would make a difference without a psychiatric evaluation. -When a resident got aggressive, the staff should send them out for a psychiatric evaluation. During an interview on [DATE] at 10:10 A.M., CNA B said: -Resident #1 could be sweet or mean, often depending on how he/she slept the night before. -He/she wanted to fight and get aggressive with everyone, including pulling hair and lunging at people. -He/she could move very fast in his/her wheelchair. -After he/she got out of bed, he/she would typically stay in the common area. -He/she was very social, but his/her aggressive behaviors were unpredictable. -One-to-one activities could sometimes trigger his/her aggression. -He/she focused on residents of the opposite sex in general, because his/her spouse recently died . -If the staff saw him/her being aggressive, they would intervene. -All of the staff knew he/she was aggressive, though it might take new staff a few days to learn. -After the incident on [DATE], the Administrator and DON came to the hall. -The Administrator asked why the resident had been moved back to the 700 hall. -Resident #1 was crying after being hit with the coffee cup, and this upset him/her even more. -When he/she saw Resident #1 being aggressive, he/she tried to redirect him/her. -He/she had not been aware that Resident #1 had ever been moved to the 600 hall. -Poor communication between staff was an ongoing issue. -The facility could use more staff on the memory care units. -Sometimes the charge nurse from rehab is the only nurse for the memory care units. -Having more staff on the memory care wing would probably help, because if staff were busy, they would be unable to watch the residents. -It was possible there could be nobody watching the residents. -They were not always able to get an extra staff person to come watch the residents. -They had report between the shifts, but did not have a formal report sheet to communicate resident incidents with other staff. -There could be situations where nobody is watching the residents, because typically there was only one CNA and one CMT to staff both hallways. -The main way to keep aggressive residents from harming each other would be to have more eyes on them. -Resident #2 was moved to the 700 hallway on [DATE] after the second incident. -It would have been better to move Resident #2 to a different hallway sooner. -With the previous administrator, they had been in the process of doing room moves to reduce behaviors, and Resident #2 should have been moved at that time. -The new Administrator said to stop the room moves. During an interview on [DATE] at 10:55 A.M., CNA A said: -If the CMT and the CNA assigned to the units were busy, the residents in both units could be left with nobody watching them. -If there were an incident, there should be more frequent checks on the residents involved. -There are documents the staff could use to document more frequent checks, but he/she did not know who they would be given to. -Resident #1 was very verbally aggressive and could be heard at the nurses' station. There was no way to predict when he/she would act out. During an interview on [DATE] at 11:35 A.M., Licensed Practical Nurse (LPN) A said: -He/She was the charge nurse for the memory care unit today; it was typical for the rehab nurse to also be in charge of the memory care unit, as it was nearby. -Residents were not visible from his/her unit. -He/she was aware that Resident #1 was very aggressive. -Extra monitoring was not assigned, but he/she would hope the staff would keep a closer eye on more aggressive residents. -Even 15-minute checks might not be enough. -He/she did not know how to protect the aggressive residents from each other, except to keep them separated. -Resident #2 was not typically aggressive toward others, and did not refuse medications. -Resident #1 would refuse his/her medications at times. -When the CMT and CNA for the memory care units were busy, she would try not to be in a room when they were. -There have been times when residents were in the units' common areas and no staff are watching them. -It was possible that an incident between residents could escalate and no staff would see it right away. During an interview on [DATE] at 11:50 A.M., The DON said: -The facility tried to have two CNAs and a CMT on the memory care unit. -Sometimes there could be a situation where nobody was watching the residents. -The facility had the resident on 15-minute checks for 72 hours after the first incident, but they could not find the documentation sheets. -After the incident on [DATE], Resident #1 was supposed to be moved to the 600 hall, and that was supposed to be permanent. -It may not have made a difference, as the people on the 600 hall may not have put up with his/her aggressive behaviors. -The reason moving residents from one side to the other, initiated by the previous administrator, was stopped was because the facility planned to make separate men's and women's units. -The staff had not been going through the administrator when they were making room changes, so they did not know who was where. -The plan was to get more staff on the memory care unit. -The facility had started a new education in-service that day on dealing with aggressive behaviors. -She felt like the staff had been doing everything they could to keep aggressive residents apart. -Resident #1 had not had any kind of referral for psychiatric services after the incident on [DATE] or [DATE]. -Resident #1 was to have his/her medications reevaluated while in the hospital on [DATE]; but the family took him/her home. During an interview on [DATE] at 12:20 P.M., ADON A said: -Resident #1 was supposed to be moved to the 600 unit permanently, but did not feel the move would have made a difference in his/her aggressive behaviors. -The staff tried to keep aggressive residents apart, if they thought there could be a problem. -There could be a time when no staff are watching the residents if the CNA and CMT were busy. -There are always staff on the units, but might be busy and not watching the residents. -After the incident on [DATE], Resident #1 was put on 15-minute checks for 72 hours, but even that might not be enough to prevent aggressive behavior. -Resident #2 typically did not display aggressive behaviors, but acted out toward Resident #1 because he/she kept bothering him/her. -He/she didn't know if anything else could be done to keep aggressive residents apart. During an interview on [DATE] at 1:45 P.M., the Social Worker said: -Resident #1 was aggressive with everyone, and would curse and call names. -He/she refused her medications at times. -He/she thought any resident of the opposite sex would cause this resident increased agitation. -He/she heard the staff had done 15-minute checks on Resident #1 for 72 hours, but did not know any specific information. -He/she felt the staff were doing everything they could to deal with Resident #1's aggressive behaviors, using redirection or separating him/her from other residents. -Residents could be left unsupervised due to staffing. The facility had been trying to get other staff. -Resident #1 should go for a psychiatric evaluation, but they could not send a resident out without the DPOA's agreement, unless the resident was suicidal or homicidal. -Only after the incident on [DATE] was it brought up to the family that they wanted the resident to stay in the hospital to get his/her medications evaluated. -Resident #2 had never been aggressive before the incident on [DATE]. -He/she typically did not show aggressive behaviors. -It was better to move him/her, because it was his/her thought that Resident #1 would be aggressive no matter which hall he/she was on. During an interview on [DATE] at 12:30 P.M., the DON said: -When the staff discussed moving Resident #1 to another hallway, they felt he/she would just find someone else to target in the new location. -Resident #1 was aggressive toward everyone. -Resident #2 rarely had behaviors, but typically was quiet and laid back. -They would not expect Resident #2 to start up any aggression. During an interview on [DATE] at 2:45 P.M., LPN A said: -He/she had been educated on dementia and behavior de-escalation, but did not remember when. -He/she had worked at the facility for [AGE] years. During an interview on [DATE] at 2:46 P.M., CNA B said: -He/she had not had de-escalation or dementia training since she had worked at the facility. -He/she knew what to do because he/she had [AGE] years of experience. -He/she had been employed at the facility for nearly three years. -Moving Resident #2 sooner could have prevented the second incident. During an interview on [DATE] at 2:50 P.M., CNA B said: -He/she had worked at the facility [AGE] years. -He/she thought she may have had dementia training four or five months ago. During an interview on [DATE] at 2:55 P.M., CMT B said: -He/she started working the facility a week ago. -He/she had had no dementia or de-escalation training. During an interview on [DATE] at 3:00 P.M., with the Administrator said: -When he/she arrived at work on [DATE], the resident was still in his/her new room. -On [DATE], they had other room changes to be done, and the housekeeper who was working on this moved the resident back to his/her original room without telling anyone. -At that time, they had not determined if Resident #1's room change would be permanent. -He/she did not feel that a room change for Resident #1 would have made a difference in his/her aggressive behavior, because he/she was aggressive all the time. -Even when the resident was being taken away to the hospital, he/she was cursing at people and very verbally aggressive all the way out the door. -They did not have an opportunity to get a psychiatric evaluation on the resident after the incident on [DATE], because the family took him/her to their home. -He/she felt like everything was being done to keep aggressive residents safe from one another. -It was an issue that residents were being left without supervision, and the facility was working on staffing. -Typically it was the nurse on the rehab unit that would be the charge nurse for the memory care unit as well. -The facility had daily department meetings, and the department heads should be telling staff members what is going on in their units. During an interview on [DATE] at 10:05 A.M., Resident #1's POA said: -The family was aware of the resident's diagnoses and potential for behaviors before he/she was admitted to the facility. -When the resident would visit them at home he/she often would complain and curse. -The facility had not sent the resident for another psychiatric evaluation or offered onsite psychiatric services. -When the resident was moved, he/she would be more confused and have increased behaviors. -Neither the physician or the Nurse Practitioner had every discussed having a psychiatric evaluation done on the resident with the family. -Staff at the facility had not discussed any behavior interventions with the family. -He/she felt the physician or Nurse Practitioner should make medication adjustments for the resident's behaviors. -The family observed the resident's behaviors were decreased when he/she had her medications. -The resident had a gash under his/her right eye that require five stitches, due to the [DATE] incident. In an interview on [DATE] at 1:00 P.M., the DON said: -The facility did not have any in-house psychiatric providers available, but were looking to hire someone. -They had wanted the resident to have a medication and psychiatric evaluation while at the hospital, but the family took him/her home against medical advice. -Initially, the resident had an approximately 1-,d+[DATE] inch open gash when he/she was hit by the coffee cup. During an interview on [DATE] at 1:25 P.M., CMT C said: -At the time of the incident on [DATE], he/she was standing at the nurses' station with his/her back toward the common area. -He/she heard loud voices. -He/she saw Resident #2 shaking Resident #1's wheelchair. -He/she could not get to them fast enough to stop it. -He/she sternly told Resident #2 to back up away from Resident #1. -He/she told CMT A to stay with the residents. -He/she went to get the help, which arrived quickly. -The DON and Administrator came and he/she went to meet them in the hallway. -He/she did not know if anything could be done to prevent this incident. -Resident #1 would swing at people trying to help him/her at times. -At times, Resident #1 thought Resident #2 was his/her spouse. -After the nurse had assessed Resident #1, he/she took him/her back behind the nurses' station so the resident could be kept right near him/her. -He/she did not remember having any dementia training at the facility. MO00195995

Based on observation, interview, and record review, the facility failed to transcribe physician's orders and implement those orders, accurately assess, document, and provide prescribed treatments to the resident's wounds, resulting in the resident developing worsening wounds requiring amputation for one closed record resident (Resident #6). The facility also failed to accurately assess, document and provide prescribed treatments to the wounds of two sampled residents (Residents #7 and #8) out of 14 sampled residents and 5 closed records. The facility census was 100 residents. The Administrator was notified on 12/30/21 at 2:20 P.M. of an Immediate Jeopardy (IJ) which began on 12/10/21. The IJ was removed on 12/30/21, as confirmed by surveyor onsite verification. Record review of the facility undated Skin Assessment Policy showed: -It was the facility policy to perform a full body skin assessment as part of the systematic approach to pressure injury prevention and management. -A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. -The assessment may also be performed after a change of condition or after any new identified pressure injury. -Documentation of the skin assessment to include date and time of the assessment, staff members name and position title. -Document observations (e. g. skin condition, how the resident tolerated the procedure, etc.). -Describe wound (color, type of tissue in wound bed, drainage, odor, pain). -Document if the resident refused assessment and why. -Document other information as indicated or appropriate. Record review of the facility's undated Wound Treatment Management Policy showed: -To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. -In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. -Treatments will be documented on the Treatment Administration Record (TAR). Record review of the facility's undated Documentation of Wound Treatments Policy showed: -The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. -Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. -The following elements are documented as part of a complete wound assessment: --Type of wound (pressure injury, surgical etc.) and anatomical location. --Measurements include length in centimeters (cm) X width in cm X depth in cm, undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface) and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) in cm. --Description of wound characteristics: ---Color of the wound bed. ---Type of tissue in the wound bed (i. e., granulation (any soft pink fleshy projections that form during healing process in a wound that does not heal by first intention), slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture), eschar (a dry scab), and epithelium (thin tissue forming the outer layer of a body's surface). ---Presence, amount, and characteristics of wound drainage/exudate. ---Presence or absence of odor and pain. -Date and time of wound management treatments. -Weekly progress towards healing and effectiveness of current intervention. -Notification to physician and/or responsible party regarding wound of treatment changes. Record review of the facility's undated Physician/Practitioner Orders showed: -The attending physician shall authenticate orders for the care and treatment of assigned residents. -For all physician/practitioner orders received the nurse will: --Document the order noting the time, day, name and title of the person providing the order, and the signature and title of the person receiving the order. --Follow facility procedures for orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. 1. Record review of Resident #6's Admission Record showed: -He/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: - Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) with behaviors (agitation, physical and verbal aggression, wandering, general emotional distress, restlessness, delusions and hallucinations). -Type II Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Acute Osteomyelitis of right ankle and foot (inflammation of bone caused by infection). -Stroke. Record review of the resident's History and Physical from an outside provider sent with admission packet on 9/2/21 showed: -He/she was sent to the hospital on 6/15/21 with gangrenous (death to body tissue due to a lack of blood flow or a serious bacterial infection) right second and third toes. -Podiatry (foot) was consulted and opted to not perform any surgical interventions or amputation on the right leg and foot. -Podiatry felt he/she would actually be able to recover and salvage his/her right second and third toes over time. Record review of the resident's admitting Order Summary Report from transferring facility, dated 9/2021, showed the facility was to continue these orders: -Paint right foot second and third toes with betadine (a topical antiseptic that provides protection from infections and treats mild skin infection) every day and as needed (PRN) for skin integrity started 6/22/21. -Paint right foot second and third toes with betadine every day shift and PRN for skin integrity start 6/23/21. -Wash in between right second, third, and fourth toes with wound cleanser, pat dry, apply calcium alginate in between toes and cover with 4 X 4 gauze, wrap with Kerlix (woven gauze that is non-adhesive used to wrap wounds and burns), secure with tape every night shift start 6/20/21. --NOTE: These orders were not transcribed when admitted to facility. The treatments were not done from 9/2/21 to 10/10/21. Record review of the resident's Admission Assessment, dated 9/2/21, showed: -Skin Integrity color was normal, temperature was cool, and turgor was normal. -There were no skin issues. Record review of the resident's Physician's Orders, dated 9/2/21, showed the following orders: -Clopidogrel Bisufate (blood thinner) Tablet 75 milligrams (mg), give one tablet a day for Peripheral Vascular Disease (PVD narrowing of blood vessels reducing blood flow to the limbs) started 9/3/21. -Complete Braden assessment (a clinically validated tool that allows nurses and other health care providers to reliably score a patients/residents level of risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) upon admission, then weekly for four weeks, then monthly. -Weekly skin assessment one time a day every Thursday start 9/9/21. -Perform skin assessment UDA (User defined assessment in eCharting) weekly. -NOTE: No treatment orders documented for the diabetic ulcer on the right foot. Record review of the resident's TAR dated 9/2/21 showed: -No treatment documented for the diabetic ulcer. Record review of the resident's admission Physician's Progress Note, dated 9/3/21, showed: -History was taken primarily from reviewed records and staff interviews. -He/she was admitted for assistance with his/her activities of daily living. -Skin was warm and dry. -Admission medications and orders were otherwise reviewed and approved. -He/she would continue to monitor and follow closely. Record review of the resident's Care Plan, dated 9/3/21, showed: -He/she was at risk for or had potential/actual impairment to skin. -Follow facility protocols for treatment of injury. -Identify/document potential causative factors and eliminate/resolve where possible. -Monitor/document location, size and treatment of skin injury. -Weekly skin assessment done by a licensed nurse. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, drainage and any other notable changes of observations. -Report abnormalities, failure to heal, signs/symptoms of infection, maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) etc. to the physician. Record review of the resident's Admission Minimum Data Set (MDS, is a federally mandated assessment instrument to be completed by facility staff for care planning), dated 9/8/21, showed: -He/she was severely cognitively impaired. -Inattention comes and goes and changes in severity. -No behaviors of rejecting cares. -Diabetic foot ulcer with application of dressing to feet with/without topical medications. Record review of the resident's Weekly Skin Check, dated 9/9/21, 9/17/21 and 9/24/21, showed no new wounds identified during the skin check. Record review of the resident's Weekly wound monitoring for the month of September 2021 showed no wound tracking was done by the facility or outside Wound Company. Record review of the resident's Physician's Orders, dated 10/1/21, showed the following orders: -Clopidogrel Bisufate Tablet 75 mg, give one tablet a day for PVD, started 9/3/21. -Complete Braden assessment upon admission, then weekly for four weeks, then monthly. -Weekly skin assessment one time a day every Thursday start 9/9/21. -Perform skin assessment UDA weekly. -NOTE: No treatment orders for the diabetic ulcer on the right foot 10/1/21 through 10/11/21. Record review of the resident's Weekly Skin Check, dated 10/1/21, showed: -Notes: No open wounds. -No new wounds identified during this skin check. Record review of the resident's Physician's Orders, dated 10/1/21 through 10/31/21, showed: -The following was ordered by the physician on 10/5/21: --New orders vascular Doppler (a test that is used to estimate the blood flow through the blood vessels in the legs) study, one time only for wound. ---NOTE: This order was not processed, therefore the Doppler was never done. --X-ray of right foot 2 views. --Appointment for vascular surgery consult, one time only. --Consult for wound and surgical care to eval and treat. ---NOTE: The resident was never seen. --Doxycycline (antibiotic for infections) 100 mg, twice a day for infection. -New order on 10/15/21, apply iodine soaked gauze to right forefoot toes one, two, and three, secure with Kerlix gauze, change daily and PRN every 24 hours start 10/15/21. Record review of the resident's TAR, dated 10/1/21 through 10/31/21, showed: -Apply iodine soaked gauze to right forefoot toes one, two, and three, secure with Kerlix gauze, change daily and PRN every 24 hours start 10/15/21. -He/she did not receive the treatment to his/her right foot nine out of 17 opportunities. --NOTE: No documentation the physician was notified of the missing treatments. Record review of the resident's Radiology Exam Order, dated 10/6/21, showed subacute Osteomyelitis, right ankle and foot. Record review of the resident's Weekly Skin Check, dated 10/8/21, showed no new wounds identified during this skin check. Record review of the resident's Nurse's Note, dated 10/11/21, showed: -He/she was sent to the hospital for right foot and necrotic (localized death of living cells as from interruption of blood supply or infection) toes. Record review of the resident's outside Wound Company note, dated 10/13/21, showed: -The company was to see him/her for opinion on how to manage the resident's wounds. -Resident was not seen, was hospitalized for change in wound. Record review of the resident's discharge summary from the hospital, dated 10/14/21, showed: -He/she was admitted with a diabetic foot ulcer found to have dry gangrene on the first, second and third toes on the right foot. -There was an extremely foul odor noted. -No obvious drainage. -He/she would get combative with dressing changes, had tenderness to foot only during dressing changes, and reported it hurt a lot, but when left alone did not complain of any pain. -He/she was alert and oriented to self only. -X-ray of the right foot was obtained and showed cortical (outside layer of the bone) irregularity of the first and second toes consistent with Osteomyelitis as well as pathologic fracture (a broken bone caused by disease) of the second middle toe. -Doppler was performed which showed moderate vascular disease on the right side. -He/she was discharged back to the facility on [DATE], with a follow-up appointment with vascular surgery on 10/19/21. Record review of the resident's Admission skin assessment, dated 10/14/21, showed it was not filled out and was blank. Record review of the resident's admission Physician's Progress Note, dated 10/15/21, showed: -History was taken primarily from reviewed records and staff interviews. -He/she was admitted for assistance with his/her activities of daily living. -Skin was warm and dry. -Admission medications and orders were otherwise reviewed and approved. -He/she would continue to monitor and follow closely. Review of the resident's care plan, dated 9/3/21, showed the following: -On 10/15/21, Arterial (artery or arteries) disease related to diabetes mellitus type II. Right foot first, second, and third toes with arterial open wounds with dry gangrene. -On 10/27/21, he/she was resistive to care related to dementia. -Give clear explanation of all care activities prior to and as they occur during each contact. -If he/she resists with activities of daily living, reassure him/her, leave and return five to ten minutes later and try again. -Praise the resident when behavior is appropriate. -Provide resident with opportunities for choice during care provision. Record review of the resident's Weekly Skin Check, dated 10/25/21, showed: -Notes: Right foot wound, treatment in place. -No new wounds identified during this skin check. Record review of the resident's Weekly wound monitoring for the month of October 2021 showed no wound tracking was done by the facility or outside Wound Company. Record review of the resident's TAR dated 11/1/21 thru 11/30/21 showed: -Apply iodine soaked gauze to right forefoot toes one, two, and three, secure with Kerlix gauze, change daily and PRN every 24 hours start 10/15/21. -He/she did not receive the treatment to his/her right foot 21 out of 30 opportunities and refused treatment 4 out of 30 opportunities. --NOTE: No documentation the physician was notified of the missing treatments. Record review of the resident's Podiatry Consultation, dated 11/3/21, showed: -Unable to assess the right foot due to bandage over chronic wounds. Record review of the resident's Weekly Skin Check, dated 11/4/21, showed no new wounds identified during this skin check. Record review of the resident's Physician's Progress note, dated 11/5/21, showed: -He/she was asked to see the resident for a follow-up on his/her chronic pain issue prescription for his/her Oxycodone 5 mg tablet every six hours PRN for pain. -Physical examination showed the skin was warm and moist. -Plan was to provide a prescription for Oxycodone and fax to pharmacy. Reviewed current medications and approved. He/she would continue to monitor. Record review of the resident's Weekly Skin Check, dated 11/18/21, showed no new wounds identified during this skin check. Record review of the resident's Skin Monitoring Shower Review, dated 11/18/21, showed no skin issues. Record review of the resident's Weekly wound monitoring for the month of November 2021 showed no wound tracking was done by the facility or outside Wound Company. Record review of the resident's TAR, dated 12/1/21 through 12/31/21, showed: -Apply iodine soaked gauze to right forefoot toes one, two, and three, secure with Kerlix gauze, change daily and PRN every 24 hours start 10/15/21. -He/she did not receive the treatment to his/her right foot three out of nine opportunities and refused treatment one out of nine opportunities. --NOTE: No documentation the physician was notified of the missing treatments. Record review of the resident's Physician's Progress note, dated 12/6/21, showed: -He/she was asked to see the resident for a follow-up on his/her chronic pain issue prescription for his/her Oxycodone 5 mg tablet every six hours PRN for pain. -Physical examination showed the skin was warm and moist. -Plan was to provide a prescription for Oxycodone and fax to pharmacy. Reviewed current medications and approved. He/she would continue to monitor. Record review of the resident's Weekly Skin Check, dated 12/6/21, showed no new wounds identified during this skin check. Record review of the resident's Weekly Skin Check, dated 12/10/21, showed: -Notes: Skin warm and dry. No signs of redness, bruising or open areas. -No new wounds identified during this skin check. Record review of the resident's Nurse's Note, dated 12/10/21, showed: -He/she was called back to the resident's room. -The resident's eyes were open, nonresponsive to verbal commands. -He/she was not able to follow with eyes. -911 was called and he/she was transferred to the hospital. Record review of the resident's Hospital Report, dated 12/13/21, showed: -He/she was taken to the hospital due to altered mental status. -At baseline he/she had dementia and general condition had deteriorated. -He/she was not responsive and awake like he/she was before, this had been in the last two days. -He/she had been unable to take any medications or food and therefore had gotten weaker. -X-ray of the right foot showed: --Extensive areas of soft tissue gas involving the first, second, and third toes consistent with Osteomyelitis. --There was destruction of the second toe and a chronic fracture and/or partial obstruction to the third toe. --Erosion was present on the first toe. --Findings were consistent with acute and chronic Osteomyelitis. -Wound care consultation Note: --He/she suffers from peripheral vascular disease and diabetes mellitus type 2 and dementia. --He/she had a decline in mental status with altered mental status and encephalopathy (altered brain function), unresponsiveness, and gangrene of the right foot. -Physical examination: --Extremities exam shows gangrene of the right foot with [NAME] moist gangrene of the second and third toes, which were very mobile and appear almost ready to auto amputate from necrosis (death of most or all of the cells in tissue due to disease, injury, or failure of the blood supply) at their base. --Foul smelling, darkness of the foot extending to the mid foot, and painful to touch. -Plan: --Ordered quarter strength Dakin's (solution used to prevent and treat skin and tissue infections) dressings for the foul smelling gangrenous area of the right foot, with Kerlix gauze wrap and foam boot, change daily. --Consultation by surgery will likely require below or above the knee amputation. -Procedure: --Amputation of right leg above the knee done on 12/12/21. Record review of the resident's Admission Assessment, dated 12/14/21, showed no skin assessment had been done. Record review of the resident's Nurse's Note, dated 12/14/21, showed: -He/she was admitted from the hospital with a right foot below-knee amputation. -He/she was admitted to hospice. -Would continue to monitor. Record review of the resident's Physician's Progress Note, dated 12/15/21, showed: -Interim review of current medical problems. -Skin warm and moist. -The current medications and orders were otherwise reviewed and approved. -He/she would continue to monitor and follow closely. Record review of the resident's TAR, dated 12/1/21 through 12/31/21, showed: -New orders 12/15/21, right knee amputation, cleanse with normal saline, apply Xeroform (gauze wound dressing) and cover with ABD (abdominal thick wound dressing) pad, wrap with Kerlix, change daily and PRN start 12/15/21. -New orders 12/16/21, right knee amputation, cleanse with normal saline, apply Xeroform and cover with ABD pad, wrap with Kerlix, change daily and PRN every day shift, start 12/16/21. Review of the resident's care plan, dated 9/3/21, showed the following: -On 12/23/21, he/she had an amputation (removal) of right leg above the knee due to gangrene and Osteomyelitis. -Check and document on wound daily for signs/symptoms of infection, drainage, bleeding, any breakdown of skin, swelling, pain, and/or impaired circulation. -Encourage compliance with treatment regimen. -Surgical wound treatment as ordered. Record review of the resident's Weekly Skin Check, dated 12/17/21, showed: -Notes: Wound on leg and buttock. -No new wounds identified during this skin check. --Note: No description of the wounds. Record review of the resident's Weekly Skin Check, dated 12/21/21, showed no new wounds identified during this skin check. Record review of the resident's Weekly wound monitoring for the month of December 2021 showed no wound tracking was done by the facility or outside Wound Company. During an interview and observation on 1/3/22 at 1:33 P.M., Certified Nursing Assistant (CNA) A and B said: -The resident was blind and very aggressive so two staff member had to assist the resident during cares. -The facility did not have a wound nurse so the treatments did not get done. -He/she were the only two staff on the Memory Care Unit most of the time. A nurse was not staffed on this unit. -The Certified Medication Technician (CMT) usually worked 100 and 200 halls and comes back to the Memory Care to pass medications. -By the time the resident was transferred to the Memory Care Unit his/her wound on the right foot stunk badly. During an interview on 12/30/21 at 8:51 A.M., Registered Nurse (RN) A said: -He/she did see Resident #6's right foot wound during his/her skin assessment. -He/she charted what he/she saw in the computer and on paper. -When doing weekly skin assessments staff only put in on the Weekly Skin Check chart if the wound was new. -Preexisting wounds were not charted on this chart. -A weekly wound assessment was where the preexisting wounds were charted by the wound nurse. -He/she worked nights and the treatments were done on the day shift, so he/she did not get to see Resident #6's wounds only the once. -He/she would notify the physician if there were a change in the wound or the resident refused treatment. -The residents have the right to refuse treatment. During an interview on 12/29/21 at 3:10 P.M., the DON said: -He/she was notified that Resident #6 was unresponsive and was actively dying. -He/she went to assess the resident to see if he/she could find any mottling (pooling of blood) or if the skin was cool to touch. -He/she checked the resident's upper and lower extremities and did not see any wounds or mottling. -The resident did not have on any socks at the time of the assessment. -He/she did not see the necrotic toes or smell a bad odor on the right foot when he/she assessed the resident. -He/she was not aware the resident had wounds on his/her right foot. -The resident was sent to the hospital for altered mental status, because he/she was a full code. -He/she would have had the outside wound company evaluate and treat any wound on the residents. During an interview on 12/29/21 at 2:31 P.M., the Nurse Practitioner (NP) said: -He/she would expect the admitting nurse to read over all of the resident's orders and transcribe all of the orders to the computer for review and approval by the physician. -He/she had ordered an arterial Doppler, x-rays, antibiotic, and for wound care to evaluate and treat Resident # 6's right foot. -The arterial Doppler and wound care company orders were never processed and done. -The resident continued to decline and he/she ordered the facility to send the resident to the hospital on 10/11/21. -He/she was never notified of the right foot wound until 10/5/21. -He/she was not notified of any of the missed wound treatments and/or any changes to the resident's right foot wound. -He/she expected the facility staff to pull off any orders and get them processed as soon as possible and notify the pharmacy of the changes. -The facility staff should have called the wound care company and set up a consult as soon as possible. -He/she expected to be notified if a resident refused any treatments or medications the same day as the refusal. -He/she would expect the staff to call and get order clarification if needed. -He/she expected weekly skin assessment and weekly wound monitoring and document the findings in detail of each assessment. 2. Record review of Resident #7's undated Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE] with the following diagnosis of cellulitis (an infection of the deep skin tissue) of the right lower limb. Record review of the resident's Care Plan, dated 12/22/19, showed: -He/she was at risk for or had potential/actual impairment to skin. -Identify/document potential causative factors and eliminate/resolve where possible. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp of hard surface. -Skin checks per facility protocol. Record review of the resident's quarterly MDS, dated [DATE], showed: -He/she was cognitively intact. -He/she had no pressure ulcers, wounds, or cellulitis. Record review of the resident's Order Summary Report, dated 12/01/21, showed: -Wound company to evaluate and treat ordered 10/19/20. -New order cleanse right stump wound with normal saline, apply dry dressing, change daily every day shift start 12/10/21. Record review of the resident's TAR, dated 12/1/21, showed: -He/she did not receive treatment one out of 22 opportunities. Record review of the resident's Weekly Skin Check, dated 12/2/21, showed no new wounds identified during the skin check. Record review of the resident's Weekly Skin Check, dated 12/9/21, showed: -Notes: No open wounds. -No new wounds identified during the skin check. Record review of the resident's Weekly Skin Check for the weeks of 12/16/21 and 12/23/21 showed no weekly skin checks were done. Record review of the resident's Weekly Skin Check, dated 12/30/21, showed: -Notes: No new skin concerns noted. Continue with current treatment order for stump wound. -No new wounds identified during the skin check. NOTE: No observations of the site, type, length, width, depth, or stage. Record review of the resident's Weekly wound monitoring for the month of December 2021 showed no wound tracking was done by the facility or outside Wound Company. During observation and interview on 12/30/21 at 2:45 P.M., Licensed Practical Nurse (LPN) A said and did the following: -He/she was the wound nurse in training. -He/she put on gloves after he/she entered the resident's room with the DON. -The resident was sitting in a wheelchair on his/her side of the room. -LPN A removed the resident's dressing from the wound just above the resident's right leg amputation. -It was a small blackish area approximately 2 millimeters (mm) in diameter. -LPN A cleaned the wound with Vashe cleanser on gauze. -With the same gloves, he/she removed a pen from his/her lanyard around his/her neck, wrote his/her initials and date on the dressing. -He/she said the Vashe solution was something a wound doctor he/she worked with before used a lot. -LPN A removed his/her gloves, exited the room, went to the treatment cart and removed a container of anti-itch cream. -As he/she re-entered the room, the DON gave LPN A a pair of gloves. -LPN A said the resident's left leg had cellulitis which caused itching for the resident so they apply an anti-itch cream to the area. -LPN A donned the gloves, applied the anti-itch cream to the resident's left leg, removed his/her gloves and exited the room without washing or sanitizing his/her hands. Note: The resident did not have an order for anti-itch cream or Vashe cleanser. 3. Record review of Resident #8's undated Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis of non-pressure chronic ulcer of left heel and mid foot with fat layer exposed. Record review of the resident's Care Plan, dated 5/25/21, showed: -He/she had a surgical wound to his/her left heel. -Braden assessment per policy. -Weekly skin assessments done by a licensed nurse. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and drainage and any other notable changes or observations. -On 12/2/21 he/she had cellulitis of the right foot. -Give antibiotics for infection and mild pain medication to relieve discomfort as ordered by the physician. -Monitor/document healing of the cellulitis. Any new or worsening symptoms (red, swollen, tender skin, fever, reddened area begins to spread, small red spots that appear on the reddened skin, small blisters and swollen lymph glands) should be reported to the physician. Record review of the resident's Order Summary Report, dated 10/1/21, showed: -Wound care to eval and treat as indicated ordered 10/13/21 no start date. -Cleanse left heel wound with wound cleaner/normal saline, pat dry, apply skin prep to peri wound and allow 30 seconds to dry, cover with Hydrofera Blue (is a highly absorptive broad spectrum antibacterial foam dressing) moist with saline ABD pad and Kerlix every Monday, Wednesday, and Friday and as needed every 24 hours as needed start 10/15/21. -Cleanse left heel wound with wound cleaner/normal saline, pat dry, apply skin prep to peri wound and allow 30 seconds to dry, cover with Hydrofera Blue moist with saline ABD pad and Kerlix every Monday, Wednesday and Friday and as needed every day shift every Tuesday, Thursday and Saturday for wound care start 10/16/21. Record review of the resident's TAR, dated 10/1/21 through 10/31/21, showed: -Cleanse left heel wound with wound cleaner/normal saline, pat dry, apply skin prep to peri wound and allow 30 seconds to dry, cover with Hydrofera Blue moist with saline ABD pad and Kerlix every Monday, Wednesday and Friday and as needed every day shift every Tuesday, Thursday and Saturday for wound care start 10/16/21. -He/she did not receive the treatment to his/her left heel eight out of 13 opportunities. Record review of the resident's Weekly Skin Check, dated 10/7/21, showed: -Note: no open wounds. -No new wounds identified during this skin check. Record review of the resident's Weekly Skin Check, dated 10/14/21, showed: -No new wounds identified during this skin check. Record review of the resident's Weekly Skin Check, dated 10/21/21, showed: -No new wounds identified during this skin check. Record review of the resident's Weekly Skin Check,, dated 10/28/21 showed: -Note: Left heel wound treatment in place. -No new wounds identified during this

Based on observation, interview, and record review, the facility failed to implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended infection control practices in order to control and prevent the potential spread of COVID-19 (a new disease caused by a novel (new) coronavirus) among the facility residents and staff. The facility allowed staff who had tested positive for COVID-19 to work and provide care to residents who had tested negative for COVID-19 (Residents #9 and #10) and to provide care for one resident who had an insufficient specimen (Resident #14). The three residents without positive COVID-19 test results resided on the 800 hall, a locked memory care unit. Resident #10 had a change of condition, was admitted to the hospital on [DATE] where he/she tested positive for COVID-19. The facility failed to have staff change PPE as recommended by the CDC to prevent further spread of COVID. Three (Residents #9, #10 and #14) out of 35 sampled residents were affected by this practice. The facility failed to develop and implement a visitation policy to include screening visitors for COVID-19 signs and symptoms, requiring visitors to wear masks, and to ensure social distancing during visits. This affected seven (Residents #8, #15, #16, #19, #23, #24 and #25) out of 35 sampled residents who had open window visits. The facility census was 103 residents. The Administrator was notified on 8/21/20 at 5:40 P.M. of an Immediate Jeopardy (IJ) which began on 8/17/20. The IJ was removed on 8/25/20, as confirmed by surveyor onsite verification. Record review of the CDC Preparing for COVID-19 in Nursing Homes, dated 6/25/20 showed: -CMS recently issued Nursing Home Reopening Guidance for State and Local Officials, dated 5-18-20, showing phases of Opening Up America Again criteria: --In Phase 1, for facilities described as being in their highest level of vigilance, visitation was generally prohibited, except for [MEDICATION NAME] care situations. In those limited situations, visitors are screened and additional precautions are taken, including social distancing and hand hygiene (e.g. use of an alcohol-based hand rub). All visitors must wear cloth face covering or facemask for the duration of their visit. -The CMS guidance had been updated and reorganized according to Infection Prevention and Control practices that should remain in place even as nursing homes resume normal practices, plus additional strategies depending on the stages described in the CMS Reopening Guidance. This guidance is based on currently available information about COVID-19 and will be refined and updated as more information becomes available. -Depending upon the stages described in the CMS Reopening Guidance facility measures included: -Implementing aggressive social distancing measures (remaining at least six feet apart from others) and reminding residents to practice social distancing and to wear a cloth face covering if tolerated. -Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room. --Restricting all visitation to facilities except for certain [MEDICATION NAME] care situations, such as end of life. --Sending letters to families advising them that no visitors will be allowed in the facility except for certain [MEDICATION NAME] care situations. --Using alternative methods for visitation (e.g. video conferencing) and window visits. --Posting signs at facility entrances advising that no visitors may enter the facility. -If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections. Record review of the facility's COVID-19 Plan, dated 7/1/20, showed: -Visitation - At this time the facility has stopped all resident visitors with exception for residents that are actively dying or at the end of their life. -Work exclusion - staff who are confirmed or suspected to have COVID-19 must stay home. -For Asymptomatic Healthcare Personnel (HCP) with Confirmed COVID-19: --After returning to work, HCP should: ---Wear a facemask (non-cloth) at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer. ---A facemask for source control does not replace the need to wear an N-95 Mask (N95) respirator - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or higher-level respirator when indicated, including when caring for residents with suspected or confirmed COVID-19. -Crisis Capacity Strategies to Mitigate Staffing Shortages included- --When staffing shortages are occurring, healthcare facilities and employers (in collaboration with human resources and the Senior Vice president (SVP) for Clinical Services and/or the medical director) may need to implement crisis capacity strategies to continue to provide resident care. Crisis capacity will only be enacted by the SVP of Clinical Services. -When there are no longer enough staff to provide safe resident care, when not already done, allow asymptomatic HCP who have had an unprotected exposure to [MEDICAL CONDITION] that caused COVID-19. To continue to work - if these HCP develop even mild symptoms consistent with COVID-19, they must cease resident care activities and notify their supervisor or occupational health services prior to leaving work. -If shortages continue despite other mitigation strategies, consider implementing criteria to allow HCP with suspected or confirmed COVID-19 who are well enough to work but have not met all Return to Work Criteria to work. -If HCP are allowed to work before meeting all criteria, they should be restricted form contact with severely immunocompromised (having a weakened immune system; people who are immunocompromised have a reduced ability to fight infections and other diseases) and facilities should consider prioritizing their duties in the following manner: --If not already done, allow HCP with confirmed COVID-19 to perform job duties where they do not interact with others (e.g., residents or other HCP). --Allow HCP with confirmed COVID-19 to provide direct care only for patients with confirmed COVID-19, preferably in a cohort setting. --Allow HCP with confirmed COVID-19 to provide direct care for patients with suspected COVID-19. --As a last resort, allow HCP with confirmed COVID-19 to provide direct care for patients without suspected or confirmed COVID-19. -If HCP are permitted to return to work before meeting all Return to Work Criteria, they should still adhere to all Return to Work Practices and Work Restrictions recommendations described in the guidance including: --Wear a facemask for source control at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer. --After this time period, these HCP should revert to their facility policy regarding universal source control during the pandemic. --A facemask for source control does not replace the need to wear an N-95 or higher-level respirator (or other PPE when indicated), including when caring for residents with suspected or confirmed COVID-19. --They should be reminded that in addition to potentially exposing residents, they could also expose their co-workers. Record review of CDC information, updated 7/17/20, for people at increased risk for severe illness from COVID-19 showed: -People of any age with the following underlying medical conditions had an increased risk for serious illness from COVID-19: Cancer; [MEDICAL CONDITION] (CKD); immunocompromised state from solid organ transplant; obesity; serious heart conditions such as heart failure and [MEDICAL CONDITION]; [MEDICAL CONDITION] cell disease (a blood disorder); and diabetes. -People with the following conditions might be at increased risk of serious illness from COVID-19: asthma (a respiratory condition); Cerebral Vascular Disease (affects blood supply to the brain); [DIAGNOSES REDACTED] (a genetic disorder that mostly affects the lungs); Hypertension (high blood pressure); immunocompromised state; neurologic conditions (disorders of the nervous system); liver disease; pregnancy; [MEDICAL CONDITION] fibrosis (a disease causing lung tissue damage); smoking; [DIAGNOSES REDACTED] (a type of blood disorder); and diabetes. -Risk of severe disease also rises steadily with age. Record review of the CDC COVID-19 Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated 8/17/20, showed: -Contingency Capacity Strategies to Mitigate Staffing Shortages included, at baseline when staffing shortages are anticipated facilities must understand their staffing needs, be in communication with local healthcare coalitions, federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP when needed. -Crisis Capacity Strategies to Mitigate Staffing Shortages included that if HCP are tested and found to be infected with [DIAGNOSES REDACTED]-COV-2, they should be excluded from work until they meet all Return to Work Criteria, unless they are allowed to work considering prioritizing their duties in the following order: --If not already done, allow HCP with suspected or confirmed COVID-19 to perform job duties where they do not interact with others. --Allow HCP with confirmed COVID-19 to provide direct care only for residents with confirmed COVID-19. --Allow HCP with confirmed COVID-19 to provide direct care to residents with suspected COVID-19. -As a last resort, allow HCP with confirmed COVID-19 to provide direct care for patients without suspected or confirmed COVID-19. Record review of the Food and Drug Administration (FDA) N95 Respirators, Surgical Masks, and Facemasks, dated 8/20/20, showed: -An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. Note that the edges of the respirator are designed to form a seal around the nose and mouth. -If your respirator is damaged or soiled, or if breathing becomes difficult, you should remove the respirator, discard it properly, and replace it with a new one. A window visit policy was requested and not provided at the time of exit. 1. Record review of Resident #10's Face Sheet showed: -The resident was admitted to the facility on [DATE]. -The resident was [AGE] years old. -The resident had the following Diagnoses: [REDACTED]. --[MEDICAL CONDITION] Infarction ([MEDICAL CONDITION]). --Type II Diabetes Mellitus. --Hypertension. Record review of the resident's At-Risk for COVID-19 Care Plan, dated 8/10/20, showed: -The resident was at risk for COVID-19 respiratory infection due to co-morbidities (presence of two or more chronic (long-term) diseases or conditions) and infection in outside community. -Staff were to encourage frequent hand-washing, six foot distancing, and use of a mask when out of the room. Staff were to monitor for signs and symptoms of COVID 19 and notify the physician if needed. Record review of the resident's Activities of Daily Living (ADL - feeding, dressing, grooming) Care Plan, dated 8/10/20, showed: -The resident required extensive assistance by one staff for bathing and toileting. -The resident required limited assistance of one staff for personal hygiene and oral care. Record review of the resident's COVID-19 laboratory (lab) test documentation showed the resident was tested for COVID-19 on 8/10/20 and results showed no detection of COVID-19 on 8/13/20. Record review of the resident's Nursing Notes, dated 8/12/20 through 8/18/20, showed a note written on 8/12/20 at 10:58 P.M. that showed the resident rested all shift with no signs or symptoms of shortness of air (SOA) or discomfort. Record review of the resident's Respiratory Assessment, dated 8/19/20 at 6:50 A.M., showed: -A temperature of 98 degrees (*) Fahrenheit (F) (anything over 100.4 degrees F is considered a fever), pulse of 72 beats per minute (BPM - 60 to 100 is considered a normal resting heart rate), respirations of 18 breaths per minute (12 to 16 is normal for an adult at rest), blood pressure (BP - measurement of the force of blood pushing against artery walls) of 132/76 (normal ranges are below 120 for systolic (top number) and below 80 for diastolic (bottom number), and oxygen saturation (O2 sat - amount of oxygen circulating in the blood) at 97 percent. Normal pulse oximeter (measures the amount of the oxygen in hemoglobin) readings range from 95 to 100 percent. Values under 90 percent are considered low). -Right and left lung sounds were clear, respirations were even, the resident did not use oxygen supplementation, and there was no change in the resident's respiratory status. Summary notes showed the resident had increased weakness and poor appetite. Record review of the resident's Respiratory Assessment, dated 8/19/20 at 11:32 P.M., showed: -The resident had a temperature of 97.9 *F, pulse of 69 BPM, respirations of 18, BP of 106/75 and O2 sat at 97 percent. -Right and left lung sounds were clear, respirations were even, the resident did not use oxygen supplementation, and there was no change in the resident's respiratory status. -Summary comments showed the resident had no cough or signs or symptoms of respiratory concerns. Record review of the resident's Nursing Note, dated 8/19/20 at 4:29 P.M., showed the resident presented with increased weakness and fatigue, poor appetite and pocketing (holding in the mouth) food. No cough noted. Lungs clear. Afebrile (without fever). Denies pain or discomfort. Record review of the resident's Respiratory assessment, dated 8/20/20 at 7:32 A.M., showed: -The resident had a temperature of 97.9 *F, pulse of 72, respirations of 18, BP at 132/76, and O2 sat at 96 percent. -Right and left lung sounds were clear, respirations were even, the resident did not use oxygen, there was no change in the resident's respiratory status, and summary comments showed no respiratory symptoms. Record review of the resident's Nursing notes, dated 8/20/20, showed: -A note written at 4:06 P.M. showing the resident was not verbally responsive and grips were weak. The nurse was unable to obtain a blood pressure or 02 sat levels. The resident's pulse was weak and thready (scarcely perceptible). The Nurse Practitioner was notified. New orders were obtained to send the resident to the emergency room (ER) for evaluation. The resident's Power of Attorney (POA - person legally appointed to act on someone's behalf should they become incapacitated) was notified. -A note written on 8/20/20 at 4:30 P.M., showed the resident was sent to the hospital by Emergency Medical Services (EMS). During a telephone interview on 8/21/20 at 2:00 P.M., staff at the hospital where the resident was transferred said the resident tested positive for COVID-19 after being admitted into the hospital. During an interview on 8/21/20 at 2:55 P.M., the Administrator said they received notification from the hospital that morning that the resident tested positive for COVID-19. 2. Record review of Resident #9's Face Sheet showed: -The resident was admitted to the facility on [DATE] from an acute (short-term) care hospital. -The resident was [AGE] years old. -The resident had the following Diagnoses: [REDACTED]. --Occlusion and Stenosis of Unspecified Carotid Artery (complete blockage of carotid artery (blood vessels that carry [MEDICATION NAME] blood to the brain). --[MEDICAL CONDITION], Stage III (Moderate). --History of [MEDICAL CONDITION] (TIA) (a mini-stroke often [MEDICATION NAME] a few minutes) and Cerebral Infarction (an area of dead brain tissue resulting from blockage in the arteries supplying [MEDICATION NAME] blood to the brain) without Residual Deficits. -Hypertension. Record review of the resident's ADL Care Plan, dated 8/9/20, showed: -The resident required extensive assistance of two staff to dress. -The resident required extensive assistance of one staff for bathing, personal hygiene, oral care, toileting, transfers and locomotion. Record review of the resident's At-Risk for COVID 19 Care Plan, dated 8/10/20, showed: -The resident was at risk for COVID 19 respiratory infection due to co-morbidities and presence of infection in outside community. -Staff were to encourage the use of a mask when the resident was out of his/her room, frequent hand washing, and six foot distancing. Staff were to monitor for signs and symptoms of COVID 19 and notify the physician if needed. Record review of the resident's COVID 19 lab test documentation showed the resident was tested for the presence of COVID 19 on 8/10/20 and results on 8/13/20 showed COVID-19 was not detected. Observation on 8/18/20 at 8:15 A.M., showed CNA B, who was identified as COVID positive on 8/14/20, wheel the resident out of his/her room. 3. Record review of Resident #14's Face Sheet showed: -The resident was admitted to the facility on [DATE]. -The resident was [AGE] years old. -The resident had the following Diagnoses: [REDACTED]. --Unspecified Asthma. --Unspecified Dementia with Behavioral Disturbance. Record review of the resident's At Risk for COVID 19 Care Plan, dated 5/21/20, showed: -The resident was at risk of COVID 19 respiratory infection due to co-morbidities and presence of infection in the community. -The resident was unable to maintain social distancing due to cognitive deficits and staff were to encourage six foot social distancing and hand washing. -Staff were to monitor for signs and symptoms of COVID 19 and notify the physician if needed. Record review of the resident's COVID 19 lab test documentation showed the resident's specimen was collected on 8/10/20. Results on 8/13/20 showed the quantity was not sufficient for a COVID-19 result and a redraw was scheduled for the next routine lab day. A specimen was collected a second time on 8/22/20 and results on 8/25/20 showed no evidence that COVID 19 was detected. 4. Record review of COVID 19 test results for facility staff showed the following staff tested positive for COVID-19: -Certified Medication Technician (CMT) A's test was completed on 8/6/20 with results of positive on 8/8/20. -Certified Nursing Assistant (CNA) A's specimen was collected on 8/10/20 with results of COVID-19 detected called in to the Administrator and sent to the Medical Director on 8/13/20. -CNA B's specimen was collected on 8/11/20 with results of COVID-19 detected and called in to the Administrator and sent to the Medical Director on 8/14/20. -CNA C's specimen was collected on 8/11/20 with results of COVID-19 detected and called in to the Administrator and sent to the Medical Director on 8/14/20. -CNA D's specimen was collected 8/13/20 with results of detected sent to the Medical Director on 8/15/20. -Licensed Practical Nurse (LPN) A was tested for COVID-19 on 8/13/20. Results showed COVID-19 was detected and results were called in to Assistant Director of Nursing (ADON) A and sent to the Medical Director on 8/17/20. Record review of the staffing schedule for the dates 8/13/20 (when CNA A was first aware he/she had tested positive for COVID-19) through 8/23/20 (ten days following the test date for LPN A) showed the following staff worked on the 800 hall memory care unit (being used as a COVID-19 unit) on the following dates and shifts: -On 8/13/20 CNA A worked the evening shift (3:00 P.M. to 11:00 P.M.). -On 8/14/20 CNA C worked the day shift (7:00 A.M. to 3:00 P.M.) and CNA A worked the evening and night shifts (11:00 P.M. to 7:00 A.M.). -On 8/15/20 CNA A worked the evening and night shifts and CNA B worked the night shift. -On 8/16/20 CNA C worked the day shift, CNA A worked the evening and night shift and CNA B worked the night shift. -On 8/17/20 CNA A worked the evening and night shifts and LPN A worked the night shift. -On 8/18/20 CNA C worked the day shift, CNA A worked the evening and night shifts, and CNA B and LPN A worked the night shift. -On 8/19/20 CNA C worked the day shift, CNA A worked the evening shift, and CNA B and LPN A worked the night shift. -On 8/20/20 CNA A worked the evening shift and CNA B worked the night shift. -On 8/21/20 CNA A worked the evening shift and LPN A worked the night shift. -On 8/22/20 CNA A worked the evening shift and CNA B and LPN A worked the night shift. -On 8/23/20 CNA C worked the day shift, CNA A worked the evening shift and LPN A worked the night shift. Record review on 8/17/20 of residents who tested positive for COVID-19 showed: -Twelve COVID-19 positive residents were at the facility on 8/17/20, including one resident (Resident #12) who had been residing on the 600/700 memory care locked unit. -Eight residents who tested positive for COVID-19 were in the hospital. -Residents #9, #10 and #14 were shown as residing on the COVID-19 unit, but had not tested positive for COVID-19. -Five staff names were provided as having tested positive for COVID-19, CMT A and CNA A, B, C, and D. -On 8/17/20 a sixth staff person, LPN A had results of testing positive for COVID-19. During an interview on 8/17/20 at 11:25 A.M., the Director of Nursing (DON) said: -Twenty residents total had tested positive for COVID-19, some of which were in the hospital. -There were designated staff for the COVID-19 unit (normally used as the 800 hall locked memory care unit). -CNA A, who tested positive for COVID-19 and was asymptomatic, worked on the COVID-19 unit. During an interview on 8/17/20 at 11:58 A.M., CNA A said: -He/She worked 3:00 P.M. to 7:00 A.M. most days. -He/She was informed within the past week that he/she was COVID-19 positive and was allowed to work on the COVID-19 unit. -On 8/16/20 he/she vomited into his/her N95 mask after eating supper, but did not feel sick afterwards. He/She had eaten quickly and thought that was why he/she was sick to his/her stomach. -He/She asked Registered Nurse (RN) A about another mask, but one could not be found so he/she used a regular mask. -He/She used the same disposable gown while going into every resident room and put the gown in the trash at the end of his/her work day, because there were not many gowns at the facility. -He/She had not been educated on what to do with PPE when leaving a resident's room, but knew he/she was to wash his/her hands between working with each resident. During an interview on 8/17/20 at 12:52 P.M., the Administrator said: -The facility was contacted on 8/7/20 about a resident who had gone to the hospital who tested positive for COVID-19. -That same day the 800 hall memory care unit started being used as a COVID-19 unit. -They started testing facility staff and residents on 8/10/20. - Most of the staff testing was completed 8/10/20, 8/11/20, and 8/12/20. During an interview on 8/17/20 at 1:42 P.M., CNA E said: -The residents who tested negative for COVID-19 were moved from the 800 hall memory care unit, which was being used as a COVID-19 unit, to the Rehabilitation unit, which did not house COVID-19 positive residents and did not schedule COVID-19 positive staff. -He/She tested negative for COVID-19, but knew positive staff were allowed to work on the COVID-19 unit. -All PPE was available in the supply carts except for N95 masks, which could be hard to find. -On 8/14/20, the fibers inside of his/her N95 mask were coming off because he/she had worn the mask about five shifts. -Staff were unable to find another N95 mask in the Medication Room and the main Long Term Care (LTC) unit was contacted. -He/She was told someone would bring him/her another mask, but nobody ever showed up with the mask. -He/She continued to wear the N95 for the remainder of the shift. -He/She had noticed some staff not take off their disposable gown before exiting a resident's room and before entering another resident's room. -None of the residents wear a mask since all residents who tested COVID-19 positive were diagnosed with [REDACTED]. During an interview on 8/17/20 at 2:05 P.M., CMT B said: -He/She was tested the previous week for COVID-19 and results showed no COVID-19 was detected. -N95 masks were supposed to be kept in the Medication Room. During an interview on 8/17/20 at 2:30 P.M., CNA B said: -He/She tested positive for COVID-19 a few days prior. -He/She was told he/she could work as long as it was on the 800 hall memory care unit/COVID hall. -He/She had worked on the COVID-19 unit on 8/15/20 and was scheduled to work on the unit on 8/18/20. Observation on the COVID-19 unit on 8/17/20 at 2:50 P.M., showed CNA A, who was identified as COVID-19 positive on 8/13/20, enter the COVID-19 unit to start his/her work shift. During an interview on 8/18/20 at 6:37 A.M., CNA A said: -He/She came in to work on the COVID-19 unit on 8/17/20 at 2:50 P.M., worked the evening and night shifts exclusively on the COVID-19 unit, and planned to leave at 7:00 A.M. and would be back again later in the day at 3:00 P.M. to work the COVID-19 unit. -He/She thought every resident on the COVID unit had tested positive for COVID-19 and was not aware any test results that showed COVID-19 was undetected for any of the residents still residing on the COVID-19 unit, including results for Residents #9 and #10. During an interview on 8/18/20 at 6:43 A.M., LPN A said: -He/She found out the morning of 8/17/20 that he/she tested positive for COVID-19. -He/She was asymptomatic. -He/She came to work at 11:00 P.M. on 8/17/20, worked the entire night shift on the COVID-19 unit, and was getting ready to leave the facility on 8/18/20 at 7:00 A.M. During an interview on 8/18/20 at 6:55 A.M. LPN B, said: -As far as he/she knew everyone on the COVID-19 unit had positive results for COVID-19. -Residents who tested negative for COVID-19 had been moved off the COVID-19 unit on 8/13/20 when their COVID-19 test results came in and were moved to the Rehabilitation unit where there were no other residents who tested positive for COVID-19 and no COVID-19 staff were allowed to work. -A resident on the other locked unit tested positive for COVID-19 and was moved to the COVID unit that same day. -Administration was allowing staff who tested positive for COVID-19, but were asymptomatic, to work on the COVID unit. During an interview on 8/18/20 at 7:49 A.M., CNA C said: -He/She was informed on 8/14/20 that he/she tested positive for COVID-19. -He/She was asymptomatic. -He/She worked on the 800 halls/COVID-19 unit for his/her full eight-hour shift on 8/14/20 and 8/16/20 and planned to work eight hours on 8/18/20. -He/She was told in shift report that Residents #9 and #10 were tested for COVID-19 and found to have no detection of COVID-19. -He/She thought it posed a risk for Resident's #9 and #10 to have COVID-19 positive staff working with them and to be on a unit with other residents who tested positive for COVID-19. -Resident #9 was blind and needed staff assistance with eating, dressing and other cares. -Residents #9 and #10 were both incontinent and required staff assistance for incontinence cares. -Resident #9 and #10's ADL cares had to be completed by the CNA that was working on the COVID unit each shift (Note: this included him/herself, who was positive for COVID-19). -He/She had provided cares to Resident #9 and #10 on 8/14/20 and 8/16/20 and would need to do so on 8/18/20. -He/She was working on 8/18/20 from 7:00 A.M. to 3:00 P.M. with CMT B and LPN C. -The Administrator and the DON both told him/her that he/she could work the COVID unit. During an interview on 8/18/20 at 8:20 A.M., LPN C said he/she was informed by Management the previous week that Residents #9 and #10 (who currently still resided on the 800 halls/COVID-19 unit) had tested negative for COVID-19. During an interview on 8/18/20 at 8:40 A.M., CNA C said on 8/16/20 there had not been enough disposable gowns for him/her to change his/her gown after taking care of each resident. During an interview on 8/18/20 at 11:27 A.M., with the Administrator, DON and ADON A the following was said: -Staffing was dependent upon the census and resident acuity (level of care needed). -The 800 halls were first used as a COVID-19 unit beginning on 8/7/20. -Staff who test positive for COVID-19 and were asymptomatic could work on the COVID-19 unit. -COVID-19 positive staff were told if they wore their PPE, washed their hands and followed facility policy related to hygiene they could work. -The 800 hall locked memory care unit, currently being used as a COVID-19 unit, had a nurse and a CNA, and sometimes a CMT on the day shift. The evening shift had either a nurse or a CMT and a CNA. The night shift had at least one CNA. -The Nurse Managers (DON, ADONs, and the wound care nurse) or the Administrator filled in as needed when short-staffed so minimum staffing was always met. -Sister facilities did not have anyone to send to help them out with staffing. -The Corporation used the CDC and Department of Health and Senior Services (DHSS) COVID-19 guidance and developed a policy for COVID-19 positive staff working at the facility. -The DON said: --Staff working on the COVID-19 unit must wear an N95 mask and a gown while giving care. It didn't make any difference if a staff person wore their gown all day as long as it wasn't soiled since everyone on the unit was COVID-19 positive. Staff must sanitize their hands between residents and wear gloves if they could potentially be in contact with bodily fluids. --Either Central Supply or he/she needed to be contacted if staff couldn't find PPE. -He/She was not contacted over the weekend regarding staff not having access to PPE and was unaware there was a problem over the weekend. -The Administrator said: -He/She was not contacted when staff could not find PPE and was unaware there was a problem. -They used agency staff until the beginning of July, 2020 when the agency stopped sending referrals and the facility stopped scheduling and using agency staff. -The facility had hired some new staff prior to having COVID-19 in the facility. They had three job interviews scheduled that day. --He/She wasn't sure if CNAs and CMTs were educated on where to find N95 masks and other PPE. Charge nurses were educated on where N95 masks and PPE was located. He/She expected staff to let the nurse know if they can't find PPE. --Asymptomatic COVID positive staff were told they could work on the COVID-19 unit if they followed PPE and hand hygiene guidelines. He/She did not believe staff working on the COVID-19 unit put the residents, including the COVID negative residents at increased risk. --One of the physicians was aware COVID positive staff was working with COVID-19 positive residents. --The Medical Director was aware that their facility policy allowed it. --Some of the COVID-19 positive employees liked to work and were put on the staffing schedule. --He/She had not seen staffing numbers so low as in the last six months. Long before COVID-19 the facility had been offering sign on bonuses and they still had problems with staffing. --Staff had been educated regarding what signs and symptoms to report. --Staff were to wear N95 masks on the COVID-19 unit. During an interview on 8/18/20 at 1:53 P.M., the Medical Director said: -He/She was not aware COVID-19 positive staff were working with residents. -They were not supposed to be working if diagnosed with XREDACT

Based on observation, interview, and record review the facility failed to ensure resident safety while smoking by failing to monitor to ensure residents were smoking in designated smoking areas; failed to ensure protective oversight by supervising the residents while smoking for residents who were known to sneak out of the facility to smoke at non-scheduled smoke times; failed to monitor to ensure facility staff kept all resident smoking materials when smoking was not occurring; failed to complete comprehensive assessments that accurately addressed the resident's potential risk for changes in smoking behaviors; failed to ensure quarterly smoking assessments were completed to ensure residents continued to meet safe smoking protocols; failed to communicate changes in resident behavior and provide adequate supervision. One sampled resident who had a history of [REDACTED].#83) and a second sampled resident (Resident #55) broke out a window on the locked Behavioral Health Unit (BHU) and caught bed linens on fire out of 22 sampled residents. The facility census was 84 residents. 1. Record review of the facility's policy, dated (MONTH) 2019, titled smoking policy showed: -The facility was a non-smoking building; -Smoking was ONLY permitted in designated smoking areas and supervised by staff during designated times; -The facility operated to balance the important need for fire safety with each resident's right for independence, highest practicable functioning and dignity; -Residents would be assessed for their ability to smoke safely upon admission, quarterly, annually and with a significant change in condition where such change might impact the prior assessment; -Residents MAY NOT keep lighter, matches, etc. in their possession at any time; -Facility staff would keep fire/flame materials needed for smoking; -Based upon the completed assessment, the interdisciplinary team would evaluate the resident's ability to safely smoke independently; -A plan of care would be developed to indicate the resident's ability, risk factors to smoke safely and assistive devices deemed necessary to assist the resident to smoke safely; -Staff would supervise during smoke times in designated areas; -The plan of care would be reviewed and updated as necessary and quarterly which could impact the resident's ability to smoke safely; -Resident non-compliance with the facility's smoking policy could result in up to and including a 30 day involuntary discharge from the facility; -Resident refusal to sign and abide by the facility policy could result in up to and including 30 day involuntary discharge from the facility. Record review of the facility's policy Resident Supervised Smoking, effective 1/24/2019, showed: -Supervised smoking in designated smoking area only (outside the front entrance to the right of the front door as you exit the building); -Staff member will stay with residents for up to 15 minutes each time; -Any staff may supervise from any department; -Must be ongoing seven days a week; -(The following is a list of which department is responsible for smoke breaks): -7:15 A.M. Nursing; -8:30 A.M. Housekeeping/Laundry/Floor Technician (Tech); -12:15 P.M. Housekeeping/Laundry/Floor Tech; -1:30 P.M. Housekeeping/Laundry/Floor Tech; -5:15 P.M. Evening housekeeper; -6:30 P.M. Nursing; -8:30 P.M. Nursing. Record review of the facility's (blank) admission packet with a revision date of 4/16/18 showed: -The staff were directed to fill out the smoking safety evaluation; -All residents must be supervised when they smoke; -Smoking is not allowed anywhere on the premises of the facility by residents; -Cigarette butts must be disposed of in provided receptacles. Record review of the National Fire Prevention Agency's policy Elimination of Sources of Ignition, section 11.5.1.1 dated 1999, showed smoking materials (e.g., matches, cigarettes, lighters, lighter fluid, tobacco in any form) shall be removed from patients receiving respiratory therapy. Record review of the 1/25/19 In-service titled Incident/Accident Prevention and Safety, which included the new smoking policy showed Registered Nurse (RN) A had attended the 7:00 A.M. educational meeting. Record review of Resident #83's face sheet showed he/she admitted to the facility on [DATE] and was re-admitted on [DATE]. Record review of the resident's medical record on, 2/22/19 at 7:00 A.M., showed: -He/She had signed the smoking policy on 1/30/19; -No smoking assessment was found in the electronic chart for the 1/30/19 admission and the 2/21/19 re-admission; -No smoking assessment was found in the paper chart for the 1/30/19 admission and the 2/21/19 re-admission. During an interview on 2/22/19 at 7:20 A.M., Assistant Director of Nusing (ADON) B said: -The admitting nurse usually does the smoking assessment; -If it is at the end of a shift it might be done by the next shifts charge nurse. Record review of Resident #83's Minimum Data Set (MDS a federally mandated assessment tool completed by the facility staff for care planning), dated 2/6/19, showed: -The resident was admitted on [DATE]; -The resident had adequate hearing and did not require a hearing aide; -The resident had unclear speech (slurred or mumbled); -The resident could respond to simple direct communications only; -The resident needed supervision for locomotion on or off of the unit (oversight, encouragement, or cueing); -The resident smoked; -The resident had the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION]; -The resident was able to make decisions for himself/herself. Record review of the resident's care plans showed no care plan for smoking prior to 2/22/19. Record review of the resident's physician's orders [REDACTED]. -The resident was to have oxygen as needed (PRN) from three to eight liters for hypoxemia (the absence of enough oxygen in the tissues to sustain bodily functions); -Keep oxygen level above 88 percent (%). Observation and interview of the resident on 2/22/19 at 5:20 A.M., showed: -He/She came outside the facility's front door by himself/herself unsupervised by staff; -He/She was sitting in a wheelchair; -He/She lit a cigarette and sat by himself/herself smoking unsupervised; -He/She had an oxygen tank attached to the back of his/her wheelchair, and oxygen tubing in his/her nose; -The oxygen was on (a slight hissing noise was heard coming from the tubing, indicating it was on); -When asked if he/she was smoking while he/she had oxygen on, the resident said no then took the oxygen tubing out of his/her nose and moved the tubing to the top of his/her head; -He/She smoked the cigarette down to the butt and then threw the cigarette butt onto the pavement; -He/She reapplied the oxygen tubing into his/her nose and went back into the building; -The oxygen tank was on and set at three liters; -There was no designated smoking area sign at the location where the resident was smoking; -There was no smoking receptacle located where the resident was smoking; -The smoking receptacle was located in front of the building 16 feet down the sidewalk from where the resident was smoking. During an interview on 2/22/19 at 5:30 A.M., RN A said: -He/She was coming to see if the resident was smoking; -The resident had told him/her that he/she was going outside for fresh air; -He/she had told the resident not to smoke; -The resident kept his/her own cigarettes and lighter in his/her possession. During an interview on 2/22/19 at 6:01 A.M., the resident said: -He/She only goes out to smoke once in a while (staff said he/she went out for every smoke break); -He/She did not know if there were regular smoking times or not (he/she had signed the smoking agreement on 1/30/19); -He/She told staff he/she was going out for air; -He/She knew the door code to get out of the front door. Record review of the Nurse's Progress Notes, written on 2/22/19 at 8:33 A.M., showed: -RN A had observed the resident going toward the front door of facility with his/her oxygen on; -The nurse followed the resident to the front door and warned him/her that he/she could not go outside to smoke with his/her oxygen on; -RN A was aware of the resident's previous non-compliance of smoking with oxygen on during his/her previous admission; -The resident stated he/she just wanted the cold air; -The nurse went to check on another resident taking five to seven minutes; -The nurse then stepped outside to check on the resident to make sure he/she wasn't smoking; -The resident was found to be smoking with his/her oxygen on; -The nurse then asked the resident to put the cigarette out; -The nurse asked the resident to come inside; -The resident complied. During an interview on 2/22/19 at 6:38 A.M., Certified Nursing Assistant (CNA) A said: -He/She worked the night shift last night on the same hallway as the resident; -He/She had worked with the resident before; -The resident goes out to smoke; -The resident was to be supervised when he/she goes out to smoke; -He/She did not know if the resident kept his/her cigarettes or lighter; -CNA A had been with the resident previously when he/she had smoked; -The resident did not go out to smoke last night; -The resident might have gone out this morning while he/she was getting other people up; -CNA A had provided care to him/her at 4:45 A.M. this morning; -The resident did not say he/she wanted to go out to smoke; -CNA A always punched the door code for the resident; -CNA A did not know if the resident knew the door code; -CNA A had seen the resident trying to sneak outside to smoke; -CNA A had caught him/her trying to use the door code, but did not get outside; -The residents should not smoke with oxygen on; -The staff should put the resident's oxygen on a stand; -The oxygen (tubing and tank) doesn't go outside with the residents. During an interview on 2/22/19 at 6:49 A.M., the Administrator said: -He/She went in to talk to the resident; -He/She had the resident turn in his/her lighter; -He/She had searched and there was no other lighter or matches in the resident's room; -The resident was allowed to keep his/her cigarettes with him/her; -The resident said he/she knew there were smoking times; -The resident had the paper with the smoking schedule on it. Record review of the Social Service Designee's (SSD) Progress Notes, written on 2/22/2019 at 6:57 A.M., showed: -The SSD had talked with RN C about the resident smoking outside with oxygen on; -RN C had searched the resident's coat pockets; -RN C had removed one black lighter with the resident's permission; -The ADON and the Administrator had searched his/her room with his/her permission; -No other lighters, matches, or etc. were found; -RN C reported back to the charge nurse that the resident's lighter was now in the possession of the Administrator. Record review of the SSD's Progress Notes written, on 2/22/2019 at 7:07 A.M., showed: -The resident was noted outside smoking with his/her oxygen on; -The SSD spoke with the resident; -The resident said he/she woke up that morning and really needed a cigarette; -The resident said he/she used the key pad in the front to go outside; -The SSD asked him/her about him/her still wearing his/her oxygen while smoking; -The resident said he/she forgot to take it off, but at home sometimes he/she wore it and smoked; -The resident said, It's only two liters; -Education was provided by the SSD on the facility's policy to smoke with supervision; -Education was provided by the SSD on the facility's scheduled smoking times; -The resident voiced his/her understanding of that policy; -The resident said when he/she wants to smoke he/she will smoke; -Education was provided to him/her about the risks and benefits of him/her smoking with his/her oxygen on. During an interview on 2/22/19 at 7:26 A.M. RN A said: -He/She had talked to the resident last night; -The resident was alert and oriented; -The resident was his/her own person; -The resident had smoked previously on each smoke break; -He/She did not not know how the resident got out of the building; -The nurse when admitting a resident should have done a smoking evaluation; -He/She was the admitting nurse; -He/She did not do the smoking evaluation; -RN A watched the resident go out this morning; -He/She told the resident he/she could not go out to smoke; -The resident replied he/she just wanted cold air; -The resident had the code to the door; -The resident was his/her own person; -The resident couldn't have been out more than five minutes as all he/she had was the butt left; -He/She said the facility smoking policy said if residents were their own person they could go out on their own to smoke when they want (this was not in the facility policy); -No smoking assessment had been done. During an interview on 2/22/19 at 8:00 A.M., RN B said: -He/She had worked with the resident before, mostly on the weekends; -Residents should not go out to smoke without supervision to make sure their oxygen is not on; -He/She believed the facility's policy said that the residents can only go out on supervised smoke breaks; -The smoking assessment was not done on 1/30/19 on admission; -The smoking assessment was not done on 2/21/19 on re-admission; -He/She saw the resident outside smoking about two weeks ago without supervision; -The oxygen tank was on the back of his/her wheelchair; -The resident was re-educated about not smoking with oxygen on; -The resident was re-educated about only going out during smoke break times with supervision; -He/She did not chart any of this. During an interview 2/22/19 at 9:15 A.M., the Administrator said: -He/She had met with the residents that smoked on 1/24/19; -He/She met with the residents to determine smoking times; -He/She said there would be no more independent smoking; -Smoking must be supervised; -The residents were not allowed to keep their lighters on them; -He/She had spoken with the resident upon admission regarding the new policy of supervised smoking only at scheduled times; -The resident said he/she smoked with oxygen on at home; -The resident said he/she forgot to take it off; -The new policy was posted at the nurses station. During an interview on 2/22/19 at 9:50 A.M., the Medical Director said: -The resident had signed a contract when he/she came in; -The medical director has seen it (the survey team had not been provided with a copy at the time of exit); -The resident was cognitively intact; -The resident was smoking when he/she wasn't supposed to; -The resident was smoking with oxygen on; -The resident had a lighter when he/she wasn't supposed to. During an interview on 2/22/19 at 10:05 A.M., ADON A said: -He/She knew they had a new smoking policy; -The residents had to be supervised while smoking; -He/She found out about the policy about a month ago; -The Administrator told him/her and the other ADON about the policy at the same time; -The Administrator sent out an email regarding the new policy. During an interview on 2/22/19 at 10:10 A.M., the Administrator said: -He/She verbally told staff about the new smoking policy; -He/She gave in-services about the new smoking policy. It was done but not listed on the agenda; -He/She posted the policy at the main nurse's station (closest to front door); -They have done some cleaning up of the nurse's station and may have taken it down; -The new smoking policy is posted in the copy room. Observation on 2/22/19 at 10:12 A.M., showed the new smoking policy, dated 1/25/19, was on the bulletin board in the copy room by the time clock. During an interview on 2/22/19 at 10:50 A.M., the Dietary Manager said: -The residents have scheduled times to smoke; -The residents were to smoke in the front of the facility by door; -If the resident wore oxygen, it needed to come off of the wheelchair (they can't wear it to go out to smoke); -Over the last three months, he/she had seen three or four residents sneak out to smoke (he/she was unable to remember who the residents were); -If staff saw any residents sneak out to smoke the staff were to go out with them; -The staff should supervise them while they smoked. During an interview on 2/26/19 at 2:40 P.M., the Administrator said: -The resident was transferred to the secured care unit; -When the resident goes out to smoke, he/she would have to have someone let him/her outside; -The staff would go outside with him/her to smoke; -The staff would keep his/her cigarettes. During an interview on 2/27/19 at 3:29 P.M., the Director of Nursing (DON) said: -He/She expected the staff to stay with a resident when they go out to smoke; -If the resident had oxygen the oxygen tank should be taken off of the wheelchair; -The oxygen tank should not go outside with the resident. 2. Record review of Resident #55's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. -Altered mental status; -Muscle weakness; -Unsteadiness on feet; -Abnormal gait and mobility; -Cognitive communication deficit; -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) without behavioral disturbance; -Tobacco use. Record review of the resident's Care Plan, dated 11/13/18, showed: - No documentation the facility staff developed a care plan for the resident's smoking and/or tobacco use. Record review of the resident's admission History and Physical, dated 11/15/18, showed the resident was a current tobacco smoker. Record review of the resident's admission MDS, dated [DATE], showed the resident: -Did not use tobacco products. Record review of the resident's medical records showed no documentation by the facility staff the resident was assessed for safe smoking from the time of the resident's admission on 11/12/18 until the resident was discharged from the facility on 12/1/18. Record review of the resident's admission MDS, dated [DATE], showed he/she: -Was a current tobacco user; Record review of the resident's revised care plan, dated 1/15/19, showed the resident: -Used anti-anxiety medications and to monitor and record the following targeted behavioral symptoms: pacing; wandering; disrobing; inappropriate responses to verbal communication; violence/aggression toward staff dated 1/23/19; -Was a smoker and was able to light his/her cigarettes without assistance, but required staff to keep his/her lighter related to poor safety awareness dated 1/24/19; -Instruct the resident about the facility smoking policy, locations, times, and safety concerns dated 1/24/19; -Notify the charge nurse immediately if it is suspected the resident had violated the facility smoking policy dated 1/24/19; -He/She required supervision while smoking dated 2/14/19; --NOTE: No documentation the facility staff assessed the resident for safe smoking from his/her readmission on 1/11/19 until 2/22/19. Record review of the resident's Social Service note, dated 2/19/19, from the Administrator showed: -Talked with the resident today and re-educated him/her on the facility's smoking policy; -He/She tends to go out to smoke between scheduled smoke times and without supervision; -The facility staff had attempted to contact the resident's family to inform the family member the resident could not have his/her own matches, lighters, etc.; -The call went straight to the family member's voicemail and the voicemail box was full. Record review of the resident's Smoking Assessment, dated 2/22/19, showed the resident: -Was safe to smoke without supervision; -Had cognitive loss; -Had dexterity problems; -Smoked 5-10 cigarettes a day; -Can light his/her own cigarette; -The facility needed to store the resident's lighter and cigarettes; -Had a plan of care to ensure the resident was safe while smoking; -Notes from the Interdisciplinary Team showed the resident was able to light his/her own cigarettes without attendance, but the facility policy was for staff to keep his/her lighter; -The team decision was the resident could smoke without supervision with a condition the resident required staff to provide a lighter. Record review of the resident's medical record showed the resident signed a facility smoking policy, dated 2/22/19. During an interview on 3/12/19 at 9:11 A.M., Receptionist A said: -He/She was sitting at the front desk on 3/10/19 when the resident came up to the desk in his/wheelchair; -The resident left and came back ambulating with his/her cane; -The resident seemed agitated at that time; -The resident walked behind the front desk and tried to open a utility closet saying he/she wanted to get out; -The resident then pushed open the front doors and got outside; -Nursing staff checked on the resident and left the resident outside; -He/She tried to keep an eye on the resident while he/she was outside, but since the resident was walking up and down the parking lot, he/she was not able to visualize the resident the entire time; -He/She thinks the resident may have gone outside to the parking lot unattended twice that day; -When the resident came back inside the second time, he/she started pacing up and down the halls and fiddling with signs on the staff doors; -He/She then heard what sounded like a door being shut, so he/she got up from the reception desk and checked the administrator's door again to verify it was locked; -Because the administrator's door was locked, he/she was not aware the resident was in the administrator's office; -LPN B then came down the hall and unlocked the administrator's door and removed the resident from behind the administrator's desk; -The administrator did have lighters in his/her desk; -He/She did not see staff confiscate anything from the resident when they removed him/her from the administrator's office. During an interview on 3/12/19 at 9:19 A.M., LPN B said: -The resident seemed to be okay earlier in the shift; -Around 1:00 P.M. on 3/10/19, he/she was told by a visitor the resident was outside in the parking lot smoking; -He/She went outside, found the resident in the parking lot, but did not see the resident smoking; -He/She asked the resident if he/she had been smoking and the resident denied smoking; -He/She reminded the resident of the facility smoking policy and had the resident come back into the facility to watch television; -About few minutes later, he/she saw the resident outside in the parking lot talking to an unidentified person in a car; -He/She saw the person in the car hand the resident a cigarette and the resident started smoking; -He/She assumed the person in the car was the resident's family, so he/she did not go out to intervene at that time; -He/She looked outside sometime later and noticed the resident was still outside, but the window to the car was rolled up and no one was in the car; -It was at that time, he/she realized the person in the car earlier was not a visitor or family of the resident, so he/she brought the resident back into the facility and confiscated a lighter from the resident; -The resident had gone to the nurse's station several times after being brought back into the facility, asking staff for a cigarette; -A little while later, he/she found the resident in the administrator's office going through the administrator's desk drawers; -He/She removed the resident from the administrator's office and called the DON; -The DON told him/her to take the resident to the (Behavioral Health Unit) BHU for the night for day care services and to notify the resident's physician and family; -He/She took the resident to the BHU around 1:30 P.M.; -He/She did not check the resident for lighters after the resident was removed from the administrator's office; During an interview on 3/12/19 at 8:32 A.M. and 12:46 P.M., LPN G said: -LPN B was responsible for the Resident #55's care on 3/10/19 and took the resident to the BHU; -LPN B told him/her the resident was being transferred to the BHU for the night on 3/10/19 and would be re-evaluated for placement the following morning (3/11/19); -He/She was not responsible for the resident's care before or after the resident was transferred to the BHU on 3/10/19. -He/She was the charge nurse on the 100/300 halls on 3/10/19; -LPN B was in charge of the resident when he/she was transferred back to the 600 hall; -He/She was the charge nurse for the other resident's on the 600 and 700 halls, which was located at the opposite side of the building from the main 100/300 halls; Record review of the resident's Smoking Assessment, dated 3/10/19 at 1:45 P.M., showed the resident: -Was safe to smoke with supervision; -Had cognitive loss; -Did not have dexterity problems; -Smoked 5-10 cigarettes a day; -Can light his/her own cigarette; -Required staff supervision for safety; -The facility needed to store the resident's lighter and cigarettes; -Had a plan of care to ensure the resident was safe while smoking; -Notes from the Interdisciplinary Team showed the resident had continually gone outside to attempt to smoke outside of scheduled smoking times; -The team decision was the resident could smoke with supervision with a condition the resident was to be transferred to the locked unit. During an interview on 3/14/19 at 3:03 P.M., CNA E said: -When the resident was transferred to the BHU for day care services, meaning he/she was not officially transferred to the BHU but was on the locked unit for monitoring and supervision, he/she was told the resident had tried to elope and was found in the administrator's office; -He/She was not told the resident had been seen outside of the facility smoking unattended outside of the designated smoking times; -He/She did not search the resident for lighters upon transfer to the BHU; -He/She confiscated a pack of cigarettes from the resident, but did not confiscate a lighter when the resident was transferred to the BHU; -LPN B told him/her the resident had a lighter when he/she transferred the resident to the BHU on 3/10/19 at 4:30 P.M.; -He/She gave report on the evening of 3/10/19 to LPN H; -The resident opened the dining room window about six inches and tried to climb out the window, but it would not lift any higher so he/she could not get out; -When he/she attempted to get the resident away from the window, he/she hit him/her with his/her cane; During an interview on 3/12/19 at 9:19 A.M., LPN B said: -Around 7:00 P.M., the fire alarm went off on the BHU; -He/She went to the fire alarm and found the resident in his/her room standing by a window with the room full of smoke; -He/She removed the resident from the room and had a CNA put the resident in a wheelchair and transfer him/her to the 700 hall; -The 600 unit had started to fill up with smoke, so the night charge nurse and CNA started evacuating the residents from the 600 hall to the 700 hall; -He/She saw the fire was outside the resident's window, the resident's window was broken and the window was lifted up about six inches; -He/She went outside to extinguish the fire; -When he/she came back inside from extinguishing the fire, he/she was told the resident broke a window out in the 700 unit; -He/She did not know how the resident broke out his/her window; -He/She was told the resident's cane was confiscated about an hour after he/she was transferred to the BHU; -The resident was transferred to the BHU around 2:30 P.M.; -He/She did not know how or where the resident got the lighter; -After the resident was evacuated to the 700 hall, staff found a lighter on the resident. During an interview on 3/12/19 at 12:20 P.M., LPN B said: -The resident was taken back to the 600 hall around 4:00 P.M. - 5:00 P.M. and not 1:30 P.M. as he/she previously reported; -He/She was not the charge nurse for the 600 and 700 hall that day; -He/She did not give report to the night shift nurse for the 600 and 700 halls that day; -He/She was not aware the resident tried to open a window in the dining room to try to climb out of the window; -He/She was not aware the resident had tried to hit staff and residents with his/her cane before the fire; --NOTE: LPN B documented in his/her nursing notes on 3/10/19 at 2:35 P.M., the resident had been observed outside smoking twice during the shift and was observed in the administrator's office going through his/her desk drawers and was transferred to the BHU until further notice. During an interview on 3/12/19 at 9:33 P.M., CNA H said: -He/She was the only CNA working the 600 and 700 halls with the night charge nurse (LPN H) on 3/10/19; -He/She had been on the 700 hall and went to the 600 hall to check on residents, when he/she smelled smoke from the nurse's station at the front of the 600 hall coming from the direction of the resident's room at the end of the 600 hall; -LPN H activated the alarm and they began evacuating the resident's from the 600 hall to the 700 hall; -He/She did not see the resident when he/she found the fire; -He/She found out the resident then broke a window on the 700 hall from another resident, however he/she did not hear the window break; -He/She did not hear a window break on the 600 hall prior to the fire; -He/She would not have been able to hear a window break while he/she was on the 700 hall or if he/she was in the shared nurse's station; -He/She did not know how the resident got the lighter to start the fire. During an interview on 3/12/19 at 9:39 A.M., LPN H said: -He/She came on duty at 6:30 P.M.; -The report he/she received was the resident was transferred to the BHU from the main unit for not following the facility's smoking policy; -While he/she was receiving report from the previous shift CNA, the resident was at the nursing station asking staff how to get out; -He/She told the resident he/she could not go out at that time; -The resident tried to hit LPN H with his/her cane, so he/she took the resident's cane; -The resident then ambulated with a wheelchair; -Around 7:00 P.M., he/she was on the 700 unit and heard the smoke alarm activated for the 600 hall; -He/She smelled smoke from the nurse's station and saw smoke coming down the hall from the resident's room at the end of the 600 hall to the front of the unit; -He/She went to the resident's room and found the resident in the doorway; -He/She saw the fire was outside the resident's window; -The resident's window had been broken and the window on the right was raised about six inches; -He/She called for the Code Red (fire alarm) and started moving the residents from the 600 unit to the 700 unit with the assistance of CNA H; -A resident reported the resident had broken the 700 unit window with his/her hands; -He/She did not know where the resident obtained the lighter; -Per the facility policy, residents are not allowed to have lighters or matches; During an interview on 3/12/19 at 10:18 P.M., CNA E said: -The resident was transferred to the 600 hall around 4:30 P.M. from the 200 hall; -The resident had tried to open the window in the dining room to climb out, but the window would only open around six inches, so he/she could not get out; -The resident hi

Based on observation, interview and record review, the facility staff failed to ensure a licensed nurse treated in a timely manner and assessed a resident after a fall that resulted in a skin tear prior to moving the resident, and affecting the condition of the skin tear, for one sampled resident (Resident #2) out of 21 sampled residents. The facility census was 125 residents. Record review of the facility's policy titled Fall Management revised 6/30/14, showed: -A licensed nurse will assess the resident for injury and necessary treatment/interventions following a resident's fall. 1. Record review of Resident #2's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff and used for care planning) dated 2/12/15, showed the staff assessed he/she: -Had moderately impaired cognitive skills; -Did not display any behaviors; -Required limited assistance with bed mobility, transferring from one surface to another, and walking; -Did not use a mobility device; -Had unsteady balance but was able to stabilize himself/herself without assistance; -Was always continent of bowel; -Was occasionally incontinent of bladder; and -Had [DIAGNOSES REDACTED]. Record review of the first page of facility's report of the resident's alleged incident/accident dated 4/4/15, showed: -The resident stated he/she was trying to get to the bathroom and slipped and fell ; -The incident occurred on 4/4/15 at 5:25 A.M.; -Staff observed him/her on the floor, face down; -He/she went to the emergency room for evaluation; -He/she had a laceration (cut) above his/her right eye; -He/she complained of pain at a level of nine out of ten with ten being the worst; -A CT (computed tomography-provides detailed images of internal organs) scan in the ER (emergency room ) was negative; and -No documentation regarding any skin tears. Record review of the second page of the facility's report of alleged incident/accident dated 4/4/15, showed: -Staff observed the resident on the floor, face down; -He/she had an injury of a skin tear; and -No documentation regarding the laceration above his/her right eye. Record review of the sixth page of the undated facility's report of alleged incident/accident and the seventh page dated 4/4/15, showed: -The resident had a laceration above his/her eye and would be followed by the wound nurse; -No environmental factors were found to have contributed to his/her fall; and -There was no documentation regarding his/her skin tears. Record review of the resident's telephone order dated 4/4/15 at 6:39 A.M., showed a physician's orders [REDACTED]. Record review of the resident's emergency patient record dated 4/4/15 at 6:40 A.M., showed his/her left forearm wound was cleansed and a wet to dry dressing was applied. Report review of the hospital history of present illness dated 4/4/15, showed the resident was seen for trauma from a fall and had a minor injury to his/her head and a skin avulsion (a serious, soft-tissue injury that occurs when a portion of the skin is partially or completely pulled away). Record review of the hospital after care instructions dated 4/4/15 at 9:23 A.M., showed the resident was seen for a head injury. Record review of the resident's daily and every shift charting dated 4/4/15 at 11:00 A.M. (there were no other notes since 4/3/15 at 2:00 P.M.), showed: -It was reported at 10:15 A.M. that he/she had a laceration to his/her face and a skin tear to his/her left forearm; and -He/she returned to the facility at 10:30 A.M. Record review of the resident's telephone order dated 4/4/15, showed a physician's orders [REDACTED]. Record review of the facility's report of the resident's alleged incident/accident dated 4/6/15 at 9:00 A.M., showed: -On 4/6/15, he/she had a large skin tear on his/her left forearm with skin folded over itself that was too dry to unroll to steri-strip; and -His/her skin tear was a result of a fall on 4/4/15. Record review of the resident's current care plan and his/her interdisciplinary team care plan review dated 4/6/15, showed the review for the 4/4/15 fall did not address his/her skin tear. Record review of the resident's consulting wound company report dated 4/9/15, showed: -He/she had trauma to his/her left forearm which the wound company was treating for the first time; -The wound bed was 30% yellow, 10% black and 60% pink; -It measured 5.00 centimeters (cm) x 6.10 cm x 0.10 cm with 3.0 cm undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface; and often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin) from 12 O'clock to 3 O'clock; -It had a scant (small) amount or serosanguineous (containing blood and watery drainage) drainage; and -The treatment was to clean the left forearm wound with saline, apply Vaseline gauze to wound, apply Santyl (an ointment used for the debridement (the removal of dead tissue) of pressure ulcers) to wound and undermining area, cover with dry dressing, secure with gauze wrap and tape, change daily and as needed. Record review of the facility's weekly non-pressure wound assessment dated [DATE], showed the resident's skin tear was on his/her left forearm, and this date was the first time the wound was documented on the weekly report. Record review of the resident's consulting wound company report dated 4/16/15, showed: -He/she had trauma to his/her left forearm; -The wound bed was 30% yellow, 10% black and 60% pink; -It measured 2.90 cm x 4.40 cm x 0.10 cm; -It had a scant amount or serosanguineous drainage; -The treatment was to clean the left forearm wound with saline, apply Vaseline gauze to wound, apply Santyl to the wound, cover with dry dressing, secure with gauze wrap and tape, change daily and as needed; and -Necrotic (dead) tissue was surgically excised. Record review of the resident's consulting wound company report dated 4/23/15, showed: -He/she had trauma to his/her left forearm; -The wound bed was 100% pink; -It measured 2.90 cm x 4.40 cm x 0.10 cm; -It had a scant amount or serosanguineous drainage; and -The treatment was to clean the left forearm wound with saline, apply collagen pad (promotes new tissues growth) to the wound, moisten with saline, cover with dry dressing, secure with gauze wrap and tape, change daily and as needed. Record review of the resident's consulting wound company report dated 4/30/15, showed: -He/she had trauma to his/her left forearm; -The wound bed was 100% pink; -It measured 2.40 cm x 3.10 cm x 0.10 cm; -It had a scant amount or serosanguineous drainage; and -The treatment was to clean the left forearm wound with saline, apply collagen pad to wound, moisten with saline, cover with dry dressing, secure with gauze wrap and tape, change daily and as needed. During an interview on 5/6/15 at 10:52 P.M., Certified Medication Technician (CMT) A said the following regarding the resident's fall on 4/4/15: -Certified Nursing Assistant (CNA) A told him/her the resident was on the floor; -He/she was face down on the floor between his/her bed and dresser; -He/she said he/she was trying to go to the bathroom; -He/she called the paramedics; -His/her left forearm skin tear was gushing blood and he/she had a abrasion above his/her eye; -He/she moved the dresser out of the way and they rolled him/her over and helped him/her sit up; -His/her skin on his/her left forearm was pulled back and his/her pink/red flesh was visible; -It looked like he/she hit his/her arm on a metal piece that stuck out from his/her bed where a side rail would go; -He/she cleaned around the resident's left forearm skin tear but did not touch the skin tear or open area; -The blood was bubbling from skin tear; -He/she cleaned the blood off the floor; -It took about ten minutes for the ambulance to arrive; -The paramedics wrapped his/her arm; -He/she did not know he/she was supposed to call a nurse to assess the resident; -No nurse assessed the resident before the paramedics arrived; and -No one did anything to his/her skin tear before the paramedics arrived. During an interview on 5/7/15 at 9:35 A.M., Assistant Director of Nursing (ADON) said: -They usually complete investigations of any falls and skin tears; -There are charge nurses in the building at all times; -The expectation is to have a charge nurse be called when a resident has fallen; -The charge nurse should go to the unit and assess the resident before they are moved; -He/she saw the resident's skin tear after he/she returned from the hospital; -He/she wondered why the hospital did not treat his/her skin tear; -They did not determine the cause of the skin tear; and -He/she did not know if there would have been anything that could have been done to improve the outcome of the skin tear before the ambulance arrived. Observation on 5/7/15 at 10:45 A.M., showed the resident had a skin tear that was pink in color and measured approximately 5.0 cm x 4.0 cm x 0.1 cm. During an interview on 5/7/15 at 10:45 A.M., the wound nurse said: -The bleeding from his/her skin tear should have been stopped; -His/her skin tear should have been approximated (reposition the skin back in the proper place as much as possible) at the time of occurrence; -His/her skin tear should have been steri-stripped and dressed prior to going to the hospital; -These things should have been done immediately to improve the outcome of the skin tear; and -The wound company personnel came and removed the necrotic flap from the skin tear recently. During an interview on 5/7/15 at 1:20 P.M., the resident's physician's nurse practitioner said: -A nurse should have been notified of the resident's fall; -A nurse should have assessed him/her after he/she fell ; -Basic first aid would be expected after the fall; -His/her physician prefers to do his/her manage his/her residents' wounds on his/her own; -The skin tear had to have been bad for the physician to call in a wound specialist for his/her skin tear; and -It most likely would have helped if the facility staff had provided first aid and tried to approximate the skin tear. During an interview on 5/11/15 at 7:50 A.M., the ADON said he/she did not know the resident was not assessed by a nurse and was sat up before an assessment was completed by a nurse, until it was brought up by the surveyor. During an interview on 5/11/14 at 11:18 A.M., CNA A said: -He/she found the resident face down between his/her bed and his/her side table during rounds; -He/she checked to see if the resident was breathing; -He/she called for the charge nurse (which was the CMT because they did not have a nurse scheduled on the unit); -He/she thought the resident scraped his/her arm on his/her bed frame; -CMT A checked the resident for bruising; -The resident was starting to roll over so he/she and CMT A assisted him/her to a sitting position; -CMT A called 911; -He/she thought CMT A lightly covered his/her skin tear but he/she was not sure; and -He/she and CMT A were the only two staff members with him/her since he/she fell and until the ambulance arrived.