Every finding on record at University Health Lakewood Medical Center

Based on observation, interview and record review, the facility failed to notify the resident's responsible party when the resident was observed to have bruising and swelling near his/her right eye for one sampled resident (Resident #3) out of three residents sampled residents. The facility census was 134 residents.Review of the facility's policy titled Disclosure of Adverse Events to Patients and Families dated as revised 10/8/25 showed when an adverse event occurred, family members or resident representatives were entitled to a prompt explanation of what occurred and what action may be required as a result of the event. 1. Review of Resident #3's admission record printed 7/28/26 showed:-The resident was admitted to the facility on [DATE].-The resident had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes).-The resident had a designated responsible party that was a family member. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/5/26 showed the following assessment of the resident:-Had long-term and short-term memory impairment.-Was independent with walking.-Had a diagnosis of dementia. Review of the resident's care plan dated 5/14/26 showed the resident:-Had impaired cognitive function and thought processes related to dementia.-Was non-verbal most of the time and his/her verbalizations were incoherent. Review of the resident's nurse's note written by Licensed Practical Nurse (LPN) A dated 6/17/26 at 2:41 P.M. showed:-The resident woke up with his/her right eye swollen. -The nurse placed a cold compress on the resident's face to help with swelling. -There was no documentation that the resident's responsible party was notified of the swelling. Review of the investigation summary of the resident's incident dated 6/17/26 showed:-The resident's right eye was swollen when nursing staff got him/her up in the morning on 6/17/26.-Staff did not notice any bruising when getting him/her up. -Nursing staff notified the nurse practitioner (NP).-The NP noted the resident's right eye was swollen and there was some purple discoloration under his/her eye. -The resident's responsible party was not immediately notified of the findings until a fall he/she had a day later.-The resident was unable to explain what happened.-Staff were educated that upon discovery of an injury such as bruising and swelling, they were to contact the responsible party immediately. During an interview on 7/28/26 at 10:28 A.M., LPN A said:-He/She did not call the resident's responsible party the day the swelling and bruising was discovered.-He/She forgot to notify the resident's responsible party the day the swelling and bruising was discovered.-He/She spoke to the resident's responsible party the next time he/she saw him/her visiting the resident but was unsure when that was. Observation on 7/28/26 at 10:54 A.M. showed the resident was not interviewable. During an interview on 7/28/26 at 12:20 P.M., the Administrator said:-He/She was on vacation when the resident's swelling and bruising happened.-He/She just found out today that the nurse did not notify the resident's responsible party when the swelling and bruising was found. During an interview on 7/28/26 at 12:45 P.M., the Interim Director Of Nursing (DON) said:-The previous DON left in June 2026.-He/She became the interim DON in June 2026.-He/She was aware of staff finding swelling and bruising on the resident's right eye.-He/She was not involved with the incident or the investigation of the incident until the resident's responsible party visited the resident and was upset.-He/She thought the resident's responsible party came to the facility because he/she was notified of the bruising and swelling.-He/She was not aware until today that LPN A did not notify the resident's responsible party of the bruising and swelling the day it happened.-He/She started in-servicing staff today to ensure the nursing staff notify the resident's responsible party immediately when an incident like this occurred. During an interview on 7/29/26 at 12:54 P.M., the resident's responsible party said:-He/She was not notified of the resident having a black eye on 6/17/26.-He/She received a voice message on 6/18/26 at 7:30 A.M. from the facility that a staff member assisted the resident down to the floor at 2:00 A.M. because his/her feet were sliding and they did not say anything about the resident's eye.-He/She received a call from the facility on 6/18/26 at 10:00 A.M. and they said they were going to x-ray the resident's knee because of his/her arthritis and they did not say anything about the resident's eye.-On 6/22/26, he/she visited the resident at the facility and LPN A asked if he/she ever received a call from anyone about the resident's eye. -On 6/22/26, when he/she saw the resident, he/she had a black eye.-He/She had not received a call from anyone at the facility about the resident's eye any time before seeing the resident on 6/22/26. 3092866

Based on interview and record review, the facility failed to ensure six sampled residents (Residents #2, #5, #10, #11, #13, #14) out of 14 sampled residents were treated with dignity and respect and cared for in a manner that promoted maintenance or enhancement of their quality of life. The facility census was 130 residents. The Administrator and Director of Nurses (DON) was notified on 3/20/26 of Past Non-Compliance which occurred on 3/12/26. On 3/12/26 the facility administration suspended Certified Nurses Aide (CNA) A, begun an investigation, and notified appropriate parties. Facility staff and residents were interviewed. Facility staff in-services were started on abuse and neglect policy which included dignity for all employees. The deficiency was corrected on 3/13/26. Review of the facility's policy titled, Abuse and Neglect dated 8/11/23 showed:-Residents had the right to maintain good mental and psychosocial well-being.-Facility staff were required to ensure the prevention of use of verbal or nonverbal conduct that caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.The facility did not have a separate policy on dignity. 1. Review of Resident #2's care plan dated 1/13/26 showed:-The resident admitted to the facility on [DATE].-The resident required assistance by one staff to move between surfaces with partial assistance.-The resident required assistance with his/her cares due to Parkinson's disease (brain disorder causing unintended or uncontrolled movements), osteoarthritis (chronic degeneration of the joint cartilage), diabetes (Metabolic disease), and impaired balance. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/20/26 showed the following staff assessment of the resident:-Was admitted to the facility on [DATE].-Was moderately cognitively impaired.-Had clear speech.-Understood others and others understood him/her.-Was frequently incontinent of bowel and bladder.-Used a wheelchair.-Required partial/moderate assistance for going from sitting to standing and transferring to the toilet.-Some of his/her diagnoses included diabetes, Parkinson's disease, and arthritis (an inflammatory condition of the joints). Review of the resident's interview dated 3/12/26 conducted by facility staff showed the resident said:-CNA A was rough with him/her and his/her roommate.-A week ago, this resident told CNA A that he/she had to use the bathroom after dinner.-He/She could stand as long as he/she used the grab bar.-CNA A said his/her back didn't feel well.-He/She asked CNA A why he/she would not get him/her some help.-CNA A said to just get up in bed and that he/she had a diaper.-He/She told CNA A that he/she needed to have a bowel movement.-CNA A said to have it in his/her diaper.-CNA A said he/she was not going to tear his/her back up to help him/her use the bathroom.-CNA A knew he/she ended up having a bowel movement in his/her brief and his/her brief was not changed until the next morning.-The day before this incident, CNA A was changing his/her brief while he/she was still going to the bathroom.-CNA A said, You are still shitting on yourself.-He/She already felt bad that he/she was not independent and didn't need CNA A making him/her feel worse about himself/herself.-CNA A seemed burned out.-CNA A was impatient with him/her and rude. During an interview on 3/20/26 at 8:23 A.M. the Administrator said:-The resident told a family member who then reported it to facility staff that CNA A refused to assist the resident to the toilet and told the resident to have the bowel movement in his/her brief.-The resident was able to describe the events consistently several times during interviews. During an interview on 3/20/26 at 9:26 A.M., the resident said:-It seemed like CNA A was angry all of the time when he/she was taking care of him/her.-CNA A said things like, I don't have time to be walking all the way down here.-He/She was already in bed for the evening when he/she asked CNA A to take him/her to bathroom because he/she needed to have a bowel movement.-CNA A she said he/she could not hold the resident up to go to the bathroom.-The resident asked CNA A to go get some help.-CNA A said there was no one to help.-CNA A said he/she couldn't do it because his/her back and feet were hurting.-CNA A did not take him/her to the restroom and told him/her to just have the bowel movement in his/her brief.-His/Her brief was changed by someone else when he/she woke up the next morning.-CNA put him/her in bed kind of rough.-CNA A said things like shit and piss.-CNA A said he/she had to clean up the resident's shit or his/her roommate pissed all over the place.-He/She felt bad enough needing help, he/she didn't need CNA A making him/her feel worse.-He/She confirmed his/her written statement to the facility was accurate. During an interview on 3/20/26 at 4:15 P.M., the Administrator and Director of Nursing (DON) said:-This resident reported his/her concern about CNA A not taking him/her to the toilet and left to have a bowel movement in his/her brief to a family member who then reported to Administration.-This resident could be continent when put on the toilet.-This resident did have accidents and was incontinent at times.-This resident did not like CNA A saying he/she was shitting on or pissing on himself/herself.-CNA A should have assisted the resident to the toilet and not spoken to the resident that way. 2. Review of Resident #13's care plan showed:-The resident re-admitted to the facility on [DATE].-Revisions on 11/6/25 showed:--The resident had a colostomy (surgical procedure that brings one end of the large intestine out through the abdominal wall) related to neurogenic bowel (the loss of normal bowel function due to nerve damage from spinal cord injuries, certain neurological diseases, or stroke) and the colostomy bag was to be changed as needed.--The resident had Ogilvie syndrome, or acute colonic pseudo-obstruction (ACPO- a rare, sudden, and severe paralysis of the colon causing massive abdominal distension and gas buildup without a mechanical blockage. Commonly triggered by major surgery, trauma, or severe illness, it causes severe bloating, abdominal pain, nausea, and vomiting).--The resident was totally dependent upon staff for most cares.--The resident had diabetes, high blood pressure, balance problems, decreased mobility, traumatic brain injury, chronic pain and osteoarthritis (chronic degeneration of the joint cartilage).-Revisions on 1/23/26 showed:-- The resident had depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life), anxiety (psychiatric disorder that involve extreme fear, worry and nervousness), and schizoaffective (mental health condition that includes features of both schizophrenia and a mood disorder) disorder. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-admitted to the facility on [DATE].-Had clear speech.-Understood others and others understood him/her.-Cognitively intact.-Had range of motion impairment on one side of his/her upper extremity (shoulder, elbow, wrist, hand).-Had range of motion impairment on both sides of his/her lower extremities (hip, knee, ankle, foot).-Used a wheelchair.-Was dependent upon staff for all cares.-Had a catheter (a tube passed through the urethra into the bladder to drain urine) and a colostomy.-Some of his/her diagnoses included high blood pressure, diabetes, seizure disorder (a medical condition that is characterized by episodes of abnormal surges of electrical activity in one's brain leading to a sudden, violent involuntary series of contractions of muscles), anxiety disorder, and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's interview dated 3/11/26 conducted by facility staff showed the resident said:-CNA A was very abrasive, not very cooperative, and dishonest.-CNA A was not a good care giver.-CNA A seemed burned out and very argumentative.-CNA A would tell him/her no whenever he/she asked CNA A to do anything for him/her. During an interview on 3/20/26 at 3:11 P.M., the resident said:-CNA A was abrasive and not cooperative.-CNA did not want to do his/her job.-CNA argued with him/her and said he/she didn't feel like doing whatever he/she asked him/her to do such as taking him/her to the bathroom.-Once CNA A changed his/her colostomy bag in front of everybody at the nurses' station and it humiliated him.-Once CNA A didn't take him/her to the bathroom (before he/she started using a catheter) and he/she lied and told other staff that he/she did take him/her.-He/She confirmed his/her written statement to the facility was accurate. 3. Review of Resident #11's care plan dated with multiple dates from 2024 to 2026 showed:-The resident had expressive/receptive aphasia (loss of ability to produce or comprehend language due to brain injury) and kept paper and pen with him/her in case he/she was unable to get out the words he/she wanted.-He/She used a wheelchair.-He/She required physical assistance for dressing, personal hygiene, using the toilet, transferring from one surface to another.-Some of her diagnoses included a stroke, kidney disease, high blood pressure, diabetes, depression, anxiety, osteoarthritis, and neuropathic pain (a chronic, often severe type of pain caused by damage to or dysfunction of the nervous system).-Received diuretic (any medication that elevates the rate of urination) medication.-Had a stroke affecting his/her dominant side. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-The resident was admitted to the facility on [DATE].-Had clear speech.-Usually understood others and others usually understood him/her.-Was severely cognitively impaired.-Was always continent of bladder and bowel.-Some of his/her diagnoses included high blood pressure, diabetes, a stroke, hemiparesis (paralysis/weakness affecting one side of the body) or hemiplegia (complete paralysis on one side of the body), seizure disorder, and depression. Review of the resident's interview dated 3/13/26 conducted by facility staff showed the resident said:-His/her legs were so swollen that he/she was on strict bedrest.-He/She kept calling out to get his/her brief changed.-CNA A would answer his/her call but would not come down to change him/her.-When the nurse came in and saw that he/she was wet, he/she brought CNA A down to the room.-CNA A claimed he/she did not know this resident needed to be changed even though he/she had responded to the call light.-He/She was wet through his/her brief and his/her sheets were wet.-CNA A took him/her to the restroom and cleaned him/her up.-CNA A threw all of his/her blankets on the floor.-It was a disrespectful way to treat all of his/her belongings on the bed.-CNA A put him/her into bed naked and hanging halfway off the bed with the bed in a high position.-CNA A put a brief on him/her but did not fasten it fully, left the rest of him/her naked, and did not put any sheets on the bed.-CNA A was mean, rude, and dismissive.-CNA A acted like he/she did not want to be there.-CNA A wouldn't ask him/her what he/she wanted to eat and would just bring food and then got mad when he/she did not eat it because it wasn't what he/she wanted.-CNA A did not want to be bothered.-Whenever he/she asked CNA A for something, CNA A did not want to do it.-CNA A would come down to the room, say he/she would be right back but he/she never came back.-CNA A did that all the time and would turn off the call light.-CNA A got mad at him/her when it took him/her a long time to get his/her words out. During an interview on 3/20/26 at 3:21 P.M., the resident said:-He/She used the call light multiple times and yelled out for help multiple times after breakfast.-Resident #12 (Resident #11's roommate) said Resident #11 called out for help at least five times.-He/She was wet from urine and his/her legs were too swollen for him/her to get up and go to the bathroom on his/her own.-He/She was normally more independent but not during this time when his/her legs were so swollen.-His/her clothes and bedding were wet too.-CNA A said, You're too fat and I ain't gonna do you no more.-The nurse came down to administer medication around 12:30 P.M. and saw how wet he/she was and that the urine was all over the floor so the nurse told CNA A to change him/her.-CNA A raised this resident's bed and threw everything off the bed and onto the floor.-CNA A left him/her lying naked and half hanging off the bed.-CNA A refused to put the bed down and walked out of the room.-This resident called back for CNA A to finish helping her.-CNA A said, You're too heavy. -CNA said he/she's been down to his/her room three times already and was not going to come back again.-CNA A would not ask him/her what he/she wanted to eat. -CNA A would bring whatever he/she wanted to bring for their meals and would get mad at her for not eating the food he/she did not want.-He/She confirmed his/her written statement to the facility was accurate. During an interview on 3/20/26 at 3:21 P.M., with Resident #11's approval, Resident #12 (quarterly MDS dated [DATE] showed the resident was cognitively intact) said he/she witnessed everything Resident #12 said and it was all true. 4. Review of Resident #10's care plan dated with multiple dates from 2024 to 2026 showed:-The resident admitted to the facility on [DATE].-He/She used an electric wheelchair.-Some of his/her diagnoses include diabetes, Parkinson's disease, chronic kidney disease, glaucoma (a condition of increased pressure inside the eye which could lead to blindness), and polyneuropathy (a neurological disorder caused by damage to multiple peripheral nerves throughout the body, commonly resulting in pain, numbness, tingling, and weakness).-Required physical assistance with getting dressed and for using the toilet.-Required extensive physical assistance by staff to move from one surface to another.-Required setup and supervision for meals.-Had bladder incontinence related to impaired mobility. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-admitted to the facility on [DATE].-Had clear speech.-Understood others and others understood him/her.-Was moderately cognitively impaired.-Had no range of motion impairment in his/her upper extremities (shoulder, elbow, wrist, hand).-Had range of motion impairment on one side of his/her lower extremities (hip, knee, ankle, foot).-Used a wheelchair.-Was independent with eating.-Was dependent on staff for toileting hygiene, lower body dressing, going from sitting to standing, and transferring on and off the toilet.-Was occasionally incontinent of bladder.-Was always continent of bowel.-Some of his/her diagnoses included kidney disease, and diabetes. Review of the resident's interview dated 3/13/26 conducted by facility staff showed the resident said:-CNA A put his/her food tray on a table in the corner of his/her room.-He/She said he/she needed it on his/her bedside table.-He/She asked his/her name, but he/she wouldn't tell him/her because he/she said he/she didn't want him to get him/her in trouble.-He/She could not get to the table where CNA A put the food tray.-CNA A would not do the things asked or needed of him/her.-CNA A left him/her on the toilet but someone else eventually came.-CNA A cussed and said derogatory things.-In the mornings, CNA A would already be complaining about being tired.-CNA A had a nasty attitude.-CNA A's attitude was that he/she was lucky that he/she was waiting on him/her. During an interview on 3/20/26 at 3:36 P.M., the resident said:-CNA A was always a troubled person and was always negative.-CNA A put his/her food tray on a table in the corner of his/her room.-He/She told CNA A he/she needed it on his/her bedside table.-He/She asked his/her name, but he/she wouldn't tell him/her because he/she said he/she didn't want the resident to get him/her in trouble.-CNA A moved the tray after that.-CNA A always complained about being tired.-CNA A said, You expect too much.-He/She needed to go to the bathroom so he/she pushed the call button.-CNA A came into his/her room, put him/her on the toilet, and left.-He/She turned the light on when he/she was done and still on the toilet.-CNA A came in and said to turn the light off.-He/She said, No to CNA A.-CNA A said, turn the damn light off but he/she did not.-Someone else came and helped him/her.-After that, CNA A would not take care of him/her.-He/She confirmed his/her written statement to the facility was accurate. 5. Review of Resident #5's care plan dated with multiple dates from 2024 to 2026 showed:-He/She required assistance getting into bed.-Required dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein).-Required a mechanical sit to stand lift for transferring from one surface to another.-Required physical assistance with bathing/showering as necessary.-Required extensive physical assistance for dressing.-Was totally dependent on staff for repositioning and turning in bed.-Some of his/her diagnoses included heart failure, high blood pressure, diabetes, and kidney disease.-Received diuretic medication for edema and high blood pressure.-Was incontinent of bladder. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-admitted to the facility on [DATE].-Had clear speech.-Understood others and others understood him/her.-Was cognitively intact.-Used a wheelchair.-Had no range of motion impairment.-Was dependent upon staff for toileting hygiene, lower body dressing, and transferring from one surface to another.-Required partial/moderate assistance for bathing/showering.-Was occasionally incontinent of bladder and frequently incontinent of bowel.-Some of his/her diagnoses include heart disease, high blood pressure, kidney failure, and diabetes. Review of the resident's interview dated 3/13/26 conducted by facility staff showed the resident said:-When he/she took a shower, he/she told CNA A that he/she could not wash his/her legs, back, or feet but CNA A would not do it for him/her.-CNA A did not answer call lights in a timely manner.-CNA A could be very hateful in his/her attitude and expressions.-CNA A made excuses that he/she was too tired.-CNA A complained that he/she was too busy.-CNA A did not do his/her work.-CNA A did not want to care for him/her. During an interview on 3/20/26 at 3:46 P.M., the resident said:-He/She could not reach the back of his/her legs when showering.-CNA A would not help clean the back of his/her legs during showers, or if he/she did help, he/she would not do it well.-CNA A would not put fitted sheets on his/her bed and did not make the bed right.-CNA A did not answer the call light when he/she called.-CNA A didn't want to help him/her so he/she stopped asking him/her for help.-CNA A would always say he/she was too busy or too tired to do anything.-He/She confirmed his/her written statement to the facility was accurate. 6. Review of Resident #14's care plan dated with multiple dates from 2024 to 2026 showed:-He/She was able to complete most self-cares and call for assistance as needed.-Some of his/her diagnoses included diabetes, kidney disease, anxiety disorder, chronic pain, and high blood pressure. Review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident:-admitted to the facility on [DATE].-Had clear speech.-Understood others and others understood him/her.-Cognitively intact.-Used a wheelchair.-Had no range of motion impairment.-Was independent with most cares.-Was occasionally incontinent of bowel and bladder.-Some of his/her diagnoses included high blood pressure, kidney disease, diabetes, and anxiety disorder. Review of the resident's interview dated 3/13/26 conducted by facility staff showed the resident said:-CNA A was horrible and very mouthy.-He/She saw CNA A being rude at the nurses' station by answering the call light phone, hanging up, and then saying he/she was not that resident's aide and complained, That's not my job.-CNA A did not help the residents.-CNA A would not change his/her sheets on his/her shower days.-CNA A throws your plate down in front of you.-CNA A was not patient or kind and he/she hated to see CNA A coming. During an interview on 3/20/26 at 3:52 P.M., the resident said:-CNA A would not answer his/her call light.-Refer to his/her written statement he/she provided to the facility staff as it covered his/her concerns. 7. During an interview on 3/20/26 at 10:38 A.M., CNA A said:-He/She was wrongfully accused of talking badly to the residents, not cleaning residents, and refusing to do showers.-Administration said they had several complaints about leaving residents soiled.-He/She did not do any of those things.-He/She did not say that doing his/her work was breaking his/her back. During an interview on 3/20/26 at 12:06 P.M., CNA A said:-If he/she did what he/she was accused of, there surely would have been more previous complaints about him/her and there have not been.-He/She has not been rough or talked mean with any of the residents.-He/She has never told a resident to just have a bowel movement in their brief.-He/She knows better than that.-If a resident was unable to move, he/she usually put them in bed and cleaned them up while in bed.-He/She checked and changed residents every other hour if they were incontinent.-If a resident was continent, he/she took them to the bathroom.-He/She never said he/she couldn't take care of any of the residents.-He/She never said he/she didn't have time to take care of any of the residents. 8. During an interview on 3/20/26 at 4:15 P.M., the Administrator and DON said:-They interviewed multiple residents about CNA A during their investigation and several of them had the same type of concerns about how CNA A was not caring and not helpful.-CNA A had two other write-ups due to his/her demeanor and him/her being rude.-CNA A should have provided cares when asked.-They expected professional, approachable, caring, and respectful care from their employees and CNA A was not. 2802972

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 cabinets which had the potential to affect all residents within the facility. The facility census was 131 residents.Review of the facility's policy titled Medication Purchasing and Storage dated 1/10/24 showed:-Medications would be stored consistently with manufacturers' recommendations and in a manner that reduces the opportunity for a medication error to occur.-When medications were placed into active stock, expiration dates would be reviewed and stock rotated so products with the earliest expiration dates were dispensed first.1. Observation on 8/20/25 at 11:34 A.M. of the Three North (3N) Certified Medication Technician (CMT) medication cart showed:-37 Culturelle (a probiotic supplement to support digestive health) capsules that were outside of their original package and expiration dates could not be found on each packet.-18 Guaifenesin (a common expectorant drug that helps loosen and this mucus in the airways, making it easier to cough up and clear congestion) extended release (ER) 600 milligrams (mg) tablets that were outside of their original packet and expiration dates could not be found on each packet.-23 Allegra (allergy medication) 60 mg tablets that were outside of their original container and expiration dates could not be found on each packet.Observation on 8/20/25 at 11:45 A.M. of the 3N short hall licensed nurse medication cart showed:-Five disinfecting port protectors that expired on 4/15/25.-One tube of Nystatin ointment (used to treat fungal and yeast infections) United States Pharmacopeia (USP) 100,000 units per gram that expired in August 2024.-One tube of Nystatin ointment USP 100,000 units per gram that expired in February 2025.-One, one-ounce tube of original strength Benadryl (a cream used to temporarily relieve itching, pain, and other symptoms from minor skin irritations, such as insect bites, sunburn, minor burns, and rashes) that expired in April 2025.-One, two-ounce tube of hemorrhoidal ointment (used to treat hemorrhoids, which is a swollen vein or group of veins in the region of the anus) that expired in April 2025.-A package of Xeroform (a non-adherent, fine mesh gauze dressing impregnated with petrolatum and three percent bismuth tribromophenate, which was used to create a moist wound environment and prevented the dressing from sticking to the wound) that was opened and had expired on 10/31/24.-A package of Xeroform gauze dressing that expired on 10/31/24.-Five packets of povidone iodine swab sticks that expired in October 2023.-One packet of lubricating jelly that expired 12/31/24.-Five telfa non-adherent pads (used a wound dressing and helps absorb without sticking) that expired 3/1/23.During an interview on 8/20/25 at 11:53 A.M. the Assistant Director of Nursing (ADON) said the nurses and CMTs were to check the medication carts weekly for expired medications and supplies.Observation on 8/20/25 at 12:19 P.M. of the 3N medication refrigerator showed one bottle of mouth rinse solution with a beyond use date of 8/2/25.Observation on 8/20/25 at 12:35 P.M. of the Three South (3S) short hall licensed nurse medication cart showed:-One 16 fluid ounce bottle of betadine solution (a topical anti-septic used to prevent infections in minor cuts, scrapes, and burns) which expired in May 2025.-108 disinfecting port protectors that expired on 4/15/25.-Two 10 mg Dulcolax (a stimulant laxative) suppositories that expired in November 2022.Observation on 8/20/25 at 1:04 P.M. of the Two North (2N) over the counter (OTC) cabinet showed:-One four-ounce bottle of Robafen CF (a multi-symptom, OTC cough and cold medicine) that expired in July 2025.-One bottle of D3-50 (high potency vitamin D3 supplements) that expired in March 2024.-Two tubes of original strength Benadryl that expired in April 2025.-Two tubes of terbinafine hydrochloride cream one percent (used to treat fungal infections on the skin) that expired June 2025.-One bottle of ear wax removal drops that expired in May 2024.-Two bottles of multi-vite liquid and mineral supplement with antioxidant vitamins C and E that expired in April 2025.Observation on 8/20/25 at 1:36 P.M. of the 1 South (1S) medication cart showed:-One Age-Related Eye Disease Study (AREDS) 2 bottle that expired in July 2025.-One bottle of ear wax removal aid that expired on 2/28/25.During an interview on 8/22/25 at 12:46 P.M. CMT B said:-CMTs, nurses, and staff from the pharmacy looked at the medication carts and cabinets to ensure appropriate medication storage.-CMTs and nurses checked the carts daily for expired medications.-The facility did not have any specific system to ensure appropriate medication storage.-Expired medications and medical supplies should not be stored in the medication carts, refrigerators, or cabinets.-Any medication or supply that was found expired needed to be disposed of appropriately.During an interview on 8/22/25 at 1:00 P.M. Licensed Practical Nurse (LPN) B said:-Nurses and CMTs ensured medications were stored appropriately.-The staff who worked on the medication carts checked the carts daily for appropriate medication storage.-The facility's medication storage system included nurses and CMTs keeping each other accountable for appropriate medication storage.-Expired medications and supplies should not be stored in medication carts, refrigerators, or cabinets.-Any expired medication or supply needed to be taken out of the cart, refrigerator, or cabinet and disposed of appropriately.-He/She thought the medication carts, refrigerators, and cabinets were getting checked on a regular basis.During an interview on 8/22/25 at 1:25 P.M. Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) Coordinator A said:-Floor nurses, the ADON, and the Director of Nursing (DON) were responsible for ensuring appropriate medication storage.-He/She was unsure if there was a specific system in place to ensure appropriate medication storage.-Expired medications and supplies should not be kept in medication carts, refrigerators, or cabinets.-If expired medications and supplies were found then they needed to be disposed of appropriately.During an interview on 8/22/25 at 1:46 P.M. the DON said:-There was a system in place to ensure appropriate medication storage.-He/She checked all medication carts, refrigerators, and cabinets for expired medications and supplies each Monday.-He/She did not document or use a checklist when completing the Monday checks.-He/She was unsure of why staff were unaware of his/her system for medication storage.-Expired medications and supplies should not be stored in medication carts, refrigerators, or cabinets.-He/She expected staff to dispose of any expired medications or expired medical supplies if found.

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) that included specific assessments and contents, 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 medication administration for one sampled resident (Resident #90) and one supplemental resident (Resident #59); the facility failed to ensure one sampled resident's (Resident # 81) insulin pen rubber seal was wiped with an alcohol swab before attaching a needle to the insulin pen during medication pass out of 26 sampled residents and one supplemental resident; and the facility failed to follow appropriate infection control practices to ensure facility wide infection control surveillance logs were maintained for twelve months to monitor, track, and identify trends of infections in the facility . The facility census was 131 residents with a licensed capacity for 188 residents at the time of the survey. 1. Review of the facility's policy and procedure entitled Water Management Program, last Current Revised Approval Date listed as 10/12/23 and provided by the FD, showed the following:-No 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.-A completed CDC Legionella Environmental Assessment Form was missing.-There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens.-Though the last review was listed as 10/12/23 on the Document Metadata page with the next review scheduled for 10/12/26, the first page under the heading WATER MANAGEMENT PROGRAM, sub-section Policy read that the program will be reviewed annually. Observation on 8/19/25 between 10:50 A.M. and 1:27 P.M. during the initial facility Life Safety Code (LSC) walk-through inspection with the Facilities Director (FD) and the Corporate Director of Safety (CDS) showed the following:-The facility was comprised of three separate resident floors, one, two, and three, with one resident room hall on the first floor, two on the second, and four on the third.-The building was equipped with a full fire sprinkler system with its incoming water supplied by the local water company. -There was a fire sprinkler riser room (A dedicated space for fire protection equipment) on the ground floor which served the whole facility's sprinkler system, which in turn was connected to the overall whole campus' system.-There were some housekeeping closets with floor mop sinks or ceramic service sinks (Mop/service sinks are 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 approximately (app.) 10 resident rooms with private or shared bathrooms and/or sinks on the first floor, 25 on the second floor, and 50 on the third.-There were at least three bathhouses throughout the facility. -There were two dining rooms with sinks, ice machines, and steam tables (also referred to as hot food tables, specifically, steam tables are designed to hold food at steady, safe serving temperatures, but not designed to cook or warm foods from a raw state). During an interview on 8/20/25 at 3:21 P.M. the FD said the following:-He/She was a voting member of the water management team for policy updates. -They had also helped create the policy itself.-He/She had been educated on the program's requirements by virtual seminars and a monthly magazine from the American Society for Healthcare Engineers (ASHE). During an interview on 8/21/25 at 11:09 A.M. the Administrator said the following:-He/She had been working at this facility as their Administrator for about a year.-They had not yet had the chance to review the Legionella water management program here.-They were familiar with all the CMS requirements for it. 2. Review of the facility's policy titled Eye Drop Administration in Long Term Care dated 7/30/25 showed:-Hand hygiene was to be completed before and after the task.-The policy did not indicate when staff were supposed to put on gloves during the procedure. Review of the facility's policy titled Transdermal Medication Patches dated 9/11/24 showed:-Hand hygiene was to be completed before and after the task.-The policy did not indicate if gloves needed to be worn during the procedure. Review of Resident #90's admission record showed he/she admitted to the facility with the following diagnoses:-Diabetes Mellitus (DMII- 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) With Hyperglycemia (high blood sugar).-Chronic Kidney Disease (a condition where the kidneys are damaged and cannot filter blood effectively, leading to buildup of waste in the body), Stage 5. Review of the resident's Physician Order Sheet (POS) dated August 2025 showed an order for Refresh Tears Ophthalmic (related to the eye) Solution, instill two drops in both eyes every morning and at bedtime for dry eyes. Observation on 8/20/25 at 8:15 A.M. of the resident's medication administration completed by Certified Medication Technician (CMT) A showed:-He/She sanitized his/her hands and prepared the resident's other medications.-He/She entered the resident's room and grabbed gloves.-He/She gave the resident his/her oral medications and put on gloves.-He/She gave the resident water that was at his/her bedside.-He/She then administered the resident's eye drops with the same gloved hands.-He/She then removed his/her gloves and exited the resident's room. 3. Review of the facility's policy titled Hand Hygiene dated 9/13/23 showed:-Hand hygiene was the most important means of preventing the spread of infection.-Hand hygiene needed to be completed:--Before resident contact.--Before an aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) task.--After body fluid exposure risk.--After resident contact.--After contact with the environment. Review of Resident #59's admission record showed he/she admitted to the facility with a diagnosis of Parkinson's Disease (a progressive neurodegenerative disorder that primarily affects movement). Review of the resident's POS dated August 2025 showed an order for Aspercreme Lidocaine External Patch 4%, apply to affected area topically, on in the morning, and off at night for pain. Observation on 8/20/25 at 8:33 A.M. of the resident's medication administration completed by CMT A showed:-He/She sanitized his/her hands, prepared the resident's medication, and unpackaged the patch.-He/She put on gloves and labeled the resident's patch.-He/She gave the resident their oral medications and assisted the resident in taking them.-He/She then applied the resident's patch with\ the same gloved hands.-He/She then removed his/her gloves and sanitized his/her hands. 4. During an interview on 8/20/25 at 8:45 A.M. CMT A said he/she would not have done anything differently during Resident #90's and Resident #59's medication administration. During an interview on 8/22/25 at 12:51 P.M. CMT B said:-Hand hygiene during medication administration needed to be done before and after each resident and in between each route of medication for the same resident.-CMT A had not performed hand hygiene correctly during Resident #90's and Resident #59's medication administration.-CMT A should have removed his/her gloves, sanitized his/her hands, and put on new gloves before administering Resident #90's eye drops.-CMT A should have removed his/her gloves, sanitized his/her hands, and put on new gloves before placing Resident #59's patch. During an interview on 8/22/25 at 1:03 P.M. CMT A said:-He/She thought he/she had performed hand hygiene correctly during Resident #90's and Resident #59's medication administration.-He/She thought he/she had removed his/her gloves and sanitized his/her hands and put on new gloves prior to administering Resident #90's eye drops.-He/She thought he/she had removed his/her gloves, sanitized his/her hands, and put on new gloves before placing the patch on Resident #59. During an interview on 8/22/25 at 1:23 P.M. Licensed Practical Nurse (LPN) A said:-Hand hygiene during medication administration needed to be done before and after each resident and in between each route of medication for the same resident.-CMT A had not performed hand hygiene correctly during Resident #90's and Resident #59's medication administration.-CMT A should have removed his/her gloves, sanitized his/her hands, and put on new gloves before administering Resident #90's eye drops.-CMT A should have removed his/her gloves, sanitized his/her hands, and put on new gloves before placing Resident #59's patch. During an interview on 8/22/25 at 1:46 P.M. the Director of Nursing (DON) said:-He/She expected staff to perform hand hygiene before and after each resident and in between different routes of administration during medication administration.-CMT A had not performed hand hygiene correctly during Resident #90's and Resident #59's medication administration.-He/She would have expected CMT A to have removed his/her gloves, sanitized his/her hands, and put on new gloves before administering Resident #90's eye drops.-He/She would have expected CMT A to have removed his/her gloves, sanitized his/her hands, and put on new gloves before placing Resident #59's patch. 5. Review of the facility Insulin Injection Administration policy dated 11/11/23 showed:-Swab the rubber cap with an alcohol wipe prior to attaching the needle to the insulin pen. Review of Resident #81's POS dated August 2025 showed:-He/She had a diagnosis of DM II. -Insulin Lispro Junior KwikPen subcutaneous (under the skin) Solution Pen injector 100 units (U) per milliliters (ml), inject 10 units under the skin with meals for DM II, dated 7/9/25. Observation on 8/20/25 at 7:45 A.M. showed:-LPN C removed the cap from the resident's insulin pen.-He/She did not wipe the rubber seal on the resident's insulin pen with alcohol.-He/She attached a needle to the resident's insulin pen.-He/she then dialed the resident's dose of insulin and administered the resident's insulin. During an interview on 8/20/2025 11:33 AM LPN C said:-He/she had not wiped the rubber seal on the resident's insulin pen with an alcohol swab prior to attaching the needle to the resident's insulin pen.-He/she usually did wipe the rubber seal with an alcohol swab before attaching the needle to the pen.-He/she had forgotten to use the alcohol swab because he/she was nervous due to being observed. During an interview on 8/22/25 at 1:45 P.M. the DON said:-He/she expected licensed nurses to wipe the rubber seal on insulin pens with an alcohol wipe prior to attaching the needle to the pen.-The facility policy did not address insulin pens, but he/she expected the rubber seal on insulin pens be wiped with alcohol just as he/she expected the seal on insulin vials (bottle) be wiped with alcohol prior to inserting the needle into the vial. 6. Review of the facility's Antibiotic Stewardship Program revised 7/17/24 showed:-The facility would monitor use, stewardship actions, and outcomes related to antibiotic use to guide practice change and track Antibiotic Stewardship Program (ASP) impact.-What would be measured/tracked:--Antibiotic use: antibiotic starts; days of therapy.--Stewardship actions: record-keeping protocol compliance, use of antibiotic reviews, compliance with urine culture specimen submission guidelines.--Outcomes: identified the infection-The Infection Preventionist (IP) would have developed a protocol for tracking antibiotic use.-The protocol would include tracking of specific key aspects of antibiotic use data for each resident.-Antibiotic use data would be complied monthly and reviewed by the consulting pharmacist.-Consulting pharmacist and IP would interpret the monthly data, define any necessary action steps, and information for the Monthly ASP Tracking Report.-Outcomes data will be complied monthly by IP, who would interpret monthly data, define any necessary action steps, and compiled information for the Monthly ASP Tracking Report. Review of the facility's Infection Prevention and Control Program revised 3/21/25 showed the infection prevention program process included a system for identifying, reporting, investigating, and controlling infections and communicable diseases within the facility. Review of the facility's facility-wide tracking and trending Infection Control Logs by units showed:-The One South unit showed:--A map of the unit for the month of July 2024 with no infections written on it.--A map of the unit for the month of August 2024 with nine infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.---None of the required documentation from the Antibiotic Stewardship policy. --A map of the unit for the month of September 2024 with three infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.---None of the required documentation from the Antibiotic Stewardship policy. --A map of the unit for the month of October 2024 with no infections written on it.--A map of the unit for the month of November 2024 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.---None of the required documentation from the Antibiotic Stewardship policy. --A map of the unit for the month of December 2024 with no infections written on it.--A map of the unit for the month of January 2025 with no infections written on it.--A map of the unit for the month of February 2025 with no infections written on it.--A map of the unit for the month of March 2025 with no infections written on it.--A map of the unit for the month of April 2025 with no infections written on it.--A map of the unit for the month of May 2025 with no infections written on it.--A map of the unit for the month of June 2025 with no infections written on it.--There was no tracking for the month of July 2025.-The Two North unit showed:--A map of the unit for the month of July 2024 with no infections written on it.--A map of the unit for the month of August 2024 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of September 2024 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of October 2024 with 10 infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of November 2024 with two infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of December 2024 with no infections written on it.--A map of the unit for the month of January 2025 with no infections written on it.--A map of the unit for the month of February 2025 with no infections written on it.--A map of the unit for the month of March 2025 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of April 2025 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of May 2025 with two infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--There was no infection tracking for June 2025 and July 2025.-The Three South unit showed:--A map of the unit for the month of July 2024 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of August 2024 with 14 infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of September 2024 with four infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of October 2024 with three infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of November 2024 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of December 2024 with one infection depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of January 2025 with two infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of February 2025 with no infections written on it.--A map of the unit for the month of March 2025 with three infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of April 2025 with seven infections depicted by room number.---No antibiotic listing report.---No laboratory reports or X-ray reports.--A map of the unit for the month of May 2025 with no infections written on it.--There was no infection tracking for June 2025 and July 2025.-The Three North Unit showed no infection tracking for any month from July 2024 to July 2025.-For the month of August 2025, all the units were combined and showed 18 residents had infections with no lab or X-ray results. During an interview on 8/21/25 at 1:27 P.M., the IP said:-He/She had been asked to be the IP three weeks ago.-The infection tracking material he/she provided was all the prior IP had left. -He/She knew that items like lab and X-ray results were not included.-He/She knew the infection tracking book was not complete and was deficient.-He/She was starting over with the infection tracking book starting from when he/she assumed the position. -The facility had recently hired an IP and that person would be taking over the infection tracking for the facility. During an interview on 8/22/25 at 1:30 P.M., the DON said:-It was the IP's job to maintain the infection prevention responsibilities and that included the infection tracking book. -The current IP had only been in the position for three weeks.-The facility had hired a new staff member who would assume the IP position. -The previous IP did not have an infection tracking book. -The infection tracking book should have in it:--A map of each unit that showed where the infections were and all residents on enhanced barrier precautions (EBP).--The required reports from the ABS policy.--The monitoring criteria for infections.--Lab and X-ray results.--A list of residents on antibiotics and which antibiotics were being used.--Any education provided when trends were identified. -He/She was responsible for ensuring the infection tracking book was done and for auditing the infection tracking book.-He/She was unaware the infection tracking book was not being done, because the IP had all the information and reports for meetings.

Based on observation, interview, and record review, the facility failed to ensure medications were administered with an error rate of less than five percent (%). Two medication errors were detected out of 38 observed opportunities resulting in a medication rate of 5.26 %. One error involved administration of insulin (medication used to treat high blood sugars) with an insulin pen (an injection device that delivers preloaded insulin by dialing a desired dose) and one error involved the correct method for measuring the quantity of a liquid medication). In addition, the facility failed to have a policy that addressed insulin pens, including to follow manufacturers' instructions regarding how many units of insulin to use in priming differed insulin pens. The facility census was 131 residents.Review of the facility Insulin Injection Administration policy dated 11/11/23 showed:-Use of insulin pens (an insulin delivery system that generally looked like a large pen, used an insulin cartridge rather than a vial, and used disposable needles for injection of insulin) was not addressed in the policy.Review of https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, dated July 2023 showed the following instructions:-Pull the pen cap off.-Wipe the rubber seal with an alcohol swab.-Check that the liquid in the pen is clear and colorless.-Attach a new needle to the pen.-Prime the pen before each injection.-Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly.-To prime the pen, turn the dose knob to select 2 units.-Hold the pen with the needle pointing up.-Tap the cartridge holder gently to collect air bubbles at the top.-Continue holding the pen with needle pointing up. -Push the dose knob in until it stops, and 0 is seen in the dose window.-Hold the dose knob in and count to 5 slowly.-You should see insulin at the tip of the needle.- If you do not see insulin, repeat the priming steps, no more than 4 times.-If you still do not see insulin, change the Needle and repeat the priming steps.-Turn the dose Knob to select the number of units you need to inject.-Check the number in the dose window to make sure you have dialed the correct dose.1. Review of Resident #81's Physician's Order Sheet (POS) dated August 2025 showed:-He/She had a diagnosis of type 2 Diabetes Mellitus (DM II a chronic condition in which the body either didn't produce enough insulin or didn't use it effectively resulting in high blood sugar levels). -Insulin Lispro Junior KwikPen subcutaneous (under the skin) Solution Pen injector 100 units (U) per milliliters (ml), inject 10 units under the skin with meals for DM II, dated 7/9/25.Observation on 8/20/25 at 7:49 A.M. showed:-Without first priming the resident's Lispro insulin pen with 2 units of insulin, he/she dialed the dose selector to 10 units.-He/she then administered the resident's insulin.During an interview on 8/20/25 at 11:33 A.M. Licensed Practical Nurse (LPN) C said:-He/she had not primed the resident's insulin with two units of insulin before dialing the resident's insulin pen to 10 units and administering the resident's insulin.-He/she had not ever heard or read anything regarding priming insulin pens.-He/she had never primed insulin pens before dialing the intended units of insulin he/she administered.2. Review of Resident #35's POS dated August 2025 showed:-He/She had a diagnosis of Percutaneous Gastrostomy Tube status (PEG tube a surgically created opening in the stomach through which a tube could be placed and used for feeding, providing fluids and for administration of medications).-His/Her physician ordered Levetiracetam (medication for preventing and controlling seizures) oral solution 100 Milligram (mg)/ml, give 11 ml via his/her PEG tube every 12 hours.Observation on 8/20/25 at 9:08 A.M. showed:-LPN C poured the resident's liquid Levetiracetam into a graduated medication cup (a plastic cup with increasing markings for measuring liquids in ml, including a marking for 10 ml followed by the next increase to 15 ml and no markings for 11 ml) to slightly above the line for 10 ml.-LPN administered the resident's Levetiracetam via the resident's PEG tube.During an interview on 8/20/25 at 11:33 A.M. LPN C said:-He/She always used a medication cup to measure the resident's Levetiracetam.-The resident's physician's order was for 11 ml's of Levetiracetam. -The medication cup he/she used did not have a mark for 11 ml.-He/she poured the resident's Levetiracetam to a little over the marking for 10 ml's.--That was the way he/she had always measured the resident's Levetiracetam.-He/she could have used a syringe to measure the resident's Levetiracetam. -He/she had never used a syringe to measure the resident's Levetiracetam.3. During an interview on 8/22/25 at 1:45 P.M. the Director of Nursing said:-He/she expected licensed nurses to prime insulin pens.-The facility practice was to prime all insulin pens with one unit of insulin.-He/she expected licensed nurses to use a syringe to measure 11 ml's of a liquid medication; that would be the only way to accurately measure the correct dose of the resident's Levetiracetam.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #31) was invited to their care plan meeting out of 26 sampled residents. The facility census was 131 residents.A facility policy related to care plan invitations was requested and not received prior to exit.1. Review of Resident #31's admission record showed he/she admitted to the facility with a diagnosis of Hemiplegia (paralysis to one side of the body) and Hemiparesis (partial weakness affecting one side of the body) following Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain) affecting the left non-dominant side.Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) note dated 6/12/25 at 4:51 P.M. completed by MDS Coordinator B showed he/she had reached out to the resident's Durable Power of Attorney (DPOA- a legal document that gives a designated person the authority to make medical, financial, or legal decisions for the person who created the document) related to scheduling a care plan meeting.Review of the resident's MDS note dated 6/12/25 at 5:16 P.M. completed by MDS Coordinator B showed he/she had heard back from the resident's DPOA and they declined a care plan meeting at that time.Review of the resident's annual MDS dated [DATE] showed the resident was cognitively intact. During an interview on 8/19/25 at 9:46 A.M. the resident said:-He/she had not been getting invited to his/her care plan meetings.-He/she could make his/her own medical decisions.During an interview on 8/20/25 at 10:14 A.M. MDS Coordinator A said:-The resident's DPOA had not been enacted.-He/She had read the MDS note that was completed by MDS Coordinator B.-He/She thought MDS Coordinator B may have thought the resident's DPOA had been enacted.-The resident should have been invited to his/her care plan meeting.During an interview on 8/21/25 at 2:35 P.M. MDS Coordinator B said:-The resident was his/her own person.-The resident had initially declined a care plan meeting.-The resident had asked that his/her family member be invited to the care plan meeting.-He/She did not give residents written invitations to care plan meetings.-He/She normally documented the invitations in a note in the residents' charts.-He/She dropped the ball and should have documented a better note related to the care plan invitation.During an interview on 8/22/25 at 12:40 P.M. Certified Medication Technician (CMT) B said:-The resident was his/her own person.-The resident was able to make his/her own medical decisions.-Social Services and the MDS Coordinators invited residents to their care plan meetings.-He/She thought that the invitations were written and that residents signed the invitation.-The resident should have been invited to his/her care plan meeting.During an interview on 8/22/25 at 12:55 P.M. Licensed Practical Nurse (LPN) B said:-He/She was unsure if the resident was his/her own person.-He/She was unsure if the resident could make his/her own medical decisions.-He/She was unsure of who invited residents to care plan meetings.-Residents could be invited to their care plan meetings by phone call or written invitation.-The resident should have been invited to his/her care plan meeting.-It was important that residents were a part of their care plan meetings because the care about them.During an interview on 8/22/25 at 1:10 P.M. LPN A said:-The resident was his/her own person.-The resident was able to make his/her own medical decisions.-The MDS Coordinators were responsible for care plan invitations.-He/She was unsure if the resident was invited to his/her care plan meeting.-He/She had given MDS Coordinator B a format on 8/21/25 on how to invite residents to their care plan meetings.During an interview on 8/22/25 at 1:46 P.M. the Director of Nursing (DON) said:-The resident's DPOA had not been enacted.-The resident was his/her own person.-He/She thought the resident had been invited to his/her care plan meeting.-MDS Coordinator B's note should have been written better to indicate the resident had been invited.-Care plan meeting invitations needed to be written.-All residents who were their own responsible party should be invited to their care plan meetings.

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #1 and #2) out of 10 sampled residents were free physical and mental abuse from Certified Nurse Aide (CNA) A. On 4/17/25, Certified Nurse Aide (CNA) A grabbed Resident #1's arm, resulting in bruising and calling the resident a name. Additionally, CNA A refused to take the resident to the toilet and told the resident to be quiet. Later the same day, Resident #2 was heard asking CNA A to let the water warm up before being showered. CNA A said he/she didn't have time and placed the resident into the shower and sprayed him/her with cold water and then left him/her alone in the shower room partially naked for approximately five minutes while the resident was heard repeatedly yelling loudly for help and that he/she was cold while in the shower room and heard crying following the shower. The facility census was 134 residents. On 4/30/25 at 4:26 P.M., the Administrator was notified of the immediate jeopardy (IJ) past noncompliance that occurred on 04/17/25. Corrective measures began immediately. The CNA was suspended. All staff were re-educated on abuse and neglect. The IJ was corrected 4/18/25. Review of the facility's Abuse and Neglect policy, revised 7/26/24 showed: -The facility will prohibit abuse. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish. -The individual must have acted deliberately. -Physical abuse included hitting, slapping, pinching, kicking and controlling behaviors through corporal punishment. -Involuntary seclusion is separation of a resident from others, from his/her room, or confinement against the resident's will. -Mental abuse included but was not limited to humiliation, harassment, threats of punishment, or deprivation. It may occur through verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately, remain with the resident, and do not leave the resident unattended. -Immediately summon for assistance by repeatedly calling for help until help arrives. -The facility will protect residents from further harm during an investigation, provide a safe environment, and assign a representative to monitor the resident's feelings concerning the incident. Review of the facility's Resident Abuse and Neglect training, dated 3/22/25, showed: -CNA A signed the in-service roster indicating he/she had attended the training. Review of the Staffing Schedule sheet for 4/17/25 showed CNA A worked on one hall during the day shift (7:00 A.M. to 7:00 P.M.) and was scheduled on a different hall on 4/17/25 during the night shift from 7:00 P.M. until 11:00 P.M. 1. Review of Resident #1's admission Record showed he/she admitted to the facility on [DATE] with diagnoses including: -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). -Cerebral infarction (a type of stroke where brain tissue dies due to lack of oxygen caused by lack of blood flow) affecting left non-dominant side. Review of the resident's comprehensive care plan report, undated, showed the resident: -Had an Impaired Cognitive Functioning and Thought Processes care plan, initiated 9/29/24, related to dementia and stroke history. Staff were to cue, reorient and supervise as needed; keep routine and caregivers as consistent as possible to decrease confusion, and assist resident with decision-making. -Had a Communication Problem care plan, initiated 9/29/24, related to dementia and stroke history. Staff were to monitor for physical and non-verbal indicators of discomfort and/or distress and follow-up as needed. -Had a Behavioral care plan, revised 10/14/24, showing a history of agitation, anxiety, and frustrations that can present as hitting, yelling, grabbing, and making derogatory statements at staff. He/She has increased frustration when minority staff were assisting with his/her cares. Staff were to anticipate the resident's needs, offer tasks which divert his/her attention, and attempt to determine underlying cause considering location, time of day, persons involved, and situation. -Had an Activity of Daily Living (ADL) Self-Care Deficit care plan, initiated 1/10/25, related to dementia. Staff were to provide physical assistance with showers, dressing, personal hygiene, toileting, and extensive physical assistance for transfers between surfaces. -Had a Stroke care plan, initiated 1/15/25, showing it affected the resident's left side. Staff were to provide assistance as needed. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/27/25, showed the resident: -Was severely cognitively impaired with fluctuating disorganization. -Had no physical or verbal behaviors towards others, did not refuse cares, and did not have other behaviors. -Required substantial/maximal assistance (the helper does more than half the effort) for most ADLs (dressing, grooming, bathing, eating, and toileting) and for all transfers, including transfers to the toilet. -Was frequently incontinent of urine and occasionally incontinent of bowel. Review of the resident's two most recent Skin Assessments showed: -A skin assessment dated [DATE] showed skin was within normal limits and there were no areas of concern. -A skin assessment dated [DATE] showed the resident had an area of concern involving bruising to his/her right forearm. Review of the resident's Abuse/Neglect Investigation Summary, dated 4/23/25, written by the facility Administrator showed: -On 4/18/25 the Assistant Director of Nursing (ADON) verbally reported abuse towards Resident #1. -The allegation was given to him/her verbally by a staff member (Certified Medication Technician-CMT A) who wanted to remain anonymous due to fear of retaliation by the perpetrator (CNA A). -CNA A used foul language toward Resident #1 during cares. -Conclusion: Resident #1 sustained a bruise to his/her right arm that he/she alleged was done by CNA A. -Action Plan: CNA A was suspended until the investigation by Human Resources (HR) is complete. Review of the Document of Just Culture Assessment, dated 4/18/25, showed: -The worksheet was used to help gather information. -On 4/18/25 a resident showed the Director of Nursing (DON) bruises on his/her arm and stated a CNA pulled his/her arm. -Policy and Procedure: Residents are treated with respect and care that doesn't harm the resident. Gait belts are used for safe transfers. Residents are not transferred by their arms. Policy and procedure show residents have the right to be cared for with dignity and respect and to not be harmed. -CNA A refused to give a statement. -Abuse/Neglect education was part of the employee's initial orientation. Most recently Abuse/Neglect education was presented formally in the March meeting in which CNA A was a participant. -Algorithm analysis of duties and expectations showed the resident was physically harmed by CNA A. The employee had a duty to avoid causing unjustifiable risk or harm and to follow procedural rule. The employee chose reckless behavior. -Punitive consequences would be determined in collaboration with HR (the facility's Employee Relations partner). On 4/18/25 the facility recommended separation of employment. Review of a written Statement, dated 4/18/25, signed by the Quality and Safety Nurse (RN A) and the ADON showed: -On 4/18/25 at 4:20 P.M., RN A and the ADON conducted an investigation interview with CNA A regarding an incident that was anonymously reported that same day. CNA A was informed an investigation had been initiated. -CNA A confirmed he/she was assigned to Resident #1's hall. -CNA A was informed he/she would need to provide a written statement which CNA A declined to provide, stating he/she would consult his/her union representative before proceeding. The ADON informed CNA A the written statement could be submitted by e-mail. -CNA A was informed he/she would need to clock out due to the open investigation and CNA A left the facility immediately following the interview. During an interview on 4/29/25 at 10:05 A.M., the ADON said: -The incident was reported by CMT A the day after it happened on the afternoon of 4/18/25. -He/She pulled CNA A into his/her office and CNA A initially refused to write a statement. He/She was sent home immediately. -CNA A sent the statement on 4/22/25. The incident happened on 4/17/25. Observation on 4/29/25 at 11:47 A.M., showed: -Two fading dark purple dots on the resident's right forearm in the shape of fingertips. -One dot was approximately one-half inch in diameter. The other was approximately one-fourth inch in diameter. During an interview on 4/29/25 at 11:48 A.M., Resident #1 said: -The bruising was almost gone. -Staff from upstairs grabbed his/her arm hard. The resident asked the staff what he/she was doing to his/her arm and the staff said he/she didn't like the resident, because he/she talked to all the white people. -The staff held on to the resident after grabbing him/her. -The resident told the staff he/she was going to tell and the staff said he/she didn't care what he/she did. -When CNA A grabbed his/her arm it hurt. That was about a week or so ago. -CNA A had never hurt him/her before and he/she had never seen the staff do anything like that before to anyone else. His/Her arm was sore for days. -When CNA A grabbed him/her, he/she was so surprised. He/She didn't expect anything like that. He/She was angry when CNA A said, CNA A didn't like him/her because he/she talked to white people. -Staff know it was CNA A who hurt him/her. He/She told staff it was CNA A. (It should be noted the resident never explicitly said CNA A, but did point at CNA A.) Review of Restorative Aide (RA) A's written statement, dated 4/30/25, showed: -He/She was at the desk. -Resident #1 was upset. CNA A was talking to Resident #1 disrespectfully, calling him/her a lesbian. -The resident said, look at my arm and he/she had three small marks on his/her arm. During an interview on 4/29/25 at 2:25 P.M., RA A said: -He/She left the facility at 3:30 P.M. on 4/17/25. -He/She noticed CNA A was rough and quick-tempered that day and snapped at Resident #1 towards the end of his/her shift, somewhere between 1:00 P.M. and 3:00 P.M. It might have been between 2:30 P.M. and 3:00 P.M. CNA A's tone of voice was irritated and angry. He/She could tell by the tone of CNA A's voice he/she had snapped at the resident, but he/she couldn't hear what had been said. How CNA A spoke to the resident was very unprofessional. -He/She happened to be at the nurses' station charting. -CNA A was not a regular on the floor and usually worked a different hall. It was unusual for him/her to work on the floor Resident #1 resided on. -The resident just kind of snapped back like he/she was upset, but he/she couldn't hear the resident because he/she was busy charting. -Before he/she left for the day the resident showed him/her, their arm. He/She was still in the recliner and the resident held his/her arm up and said, look! He/She grabbed my arm indicating it was CNA A who had done it. -He/She saw marks like redness on his/her arm. He/She didn't see CNA A grab the resident. CNA A's back was towards him/her and his/her body was in front of the resident. -He/She didn't make a big deal about it, because he/she wasn't sure at the time what had happened, so he/she didn't report it to anyone. -CMT A was there near the resident, but he/she couldn't remember who else was in the area, but he/she thought at least two staff were there. Since there were others there, he/she didn't report it and went back and finished charting. He/She didn't know if a nurse was in the area at the time. Review of CMT A's undated and unsigned written statement showed: -On 4/17/25 he/she witnessed CNA A saying to Resident #1 you're a f__ing lesbian. I should call the police on you and tell them you molested me because you grabbed my butt. -Resident #1 asked to go to the bathroom and CNA A yelled across the room I just took you and grabbed his/her purse and left the unit. During an interview on 4/29/25 at 2:45 P.M., CMT A said: -He/She got back from lunch between 12:00 P.M. and 2:00 P.M. on 4/17/25. -When he/she got to the unit he/she saw Resident #2 was upset. He/She could tell by his/her body language. The resident was shooing CNA A away and saying, leave me alone and the resident looked visibly upset like he/she was very frustrated. -CNA A said you're a lesbian to the resident. The resident said he/she wasn't a lesbian to CNA A. CNA A said yes, you are, and you raped me because you touched my butt. CNA A was being very rude and his/her tone of voice was very rude. -CMT A said, what's wrong and the resident said, he/she hurt me, meaning CNA A. The resident raised his/her right arm and there were three red marks on the resident's upper forearm. They looked like fingertip circles. -After he/she came to the resident, CNA A walked away and went to the nurses' station. The resident said he/she needed to go to the bathroom and CNA A yelled across the room, I already took you and grabbed his/her purse and left the unit to go to lunch. -CMT A took the resident to the bathroom. -From afternoon onwards for the rest of the shift until 7:00 P.M. CNA A was argumentative and loud in general and had an angry look all afternoon. He/She was rough in speech with all the residents like they were inconveniencing him/her. -CNA A normally worked on a different floor. -He/She was in shock of what happened and didn't report it that evening and told the ADON the next day. Review of CNA A's e-mailed written statement, dated 4/22/25, showed: -He/She was responding to an allegation that he/she pulled a resident's arm on 4/17/25. The resident was in bed when he/she arrived on the unit. CNA B got the resident up out of bed. -Before breakfast he/she was transferring the resident into the chair where he/she eats. During the transfer the resident said his/her arm was hurt by an aide from upstairs who worked with him/her overnight and had pulled his/her arm. -As CNA A was getting clarification as to what the resident said, another aide (a name was mentioned for the CNA in the write up, but nobody by that name was on the schedule for 4/17/25 and the DON confirmed that person did not work on that day) asked what the resident said. -CNA A reported to that aide (the aide who was in the area at the time), Licensed Practical Nurse (LPN) A, and he/she thought CMT A, were all witness to what the resident had said. -The resident repeated the staff from upstairs pulled his/her arm. -CNA A asked the resident about the race of the person who bruised his/her arm and the resident confirmed the race. -CNA A said to the resident so, he/she looks like you pertaining to race and the resident said yes. -Again, what the resident said was reported to LPN A at the nursing station who overheard the conversation -We all (staff who were in the area at the time) went about our day and it wasn't brought up anymore. -CNA A hadn't done any cares on the resident at that time. CNA A's only interaction with the resident was assisting him/her in the chair to eat which is when the resident reported the pulling of his/her arm. -CNA A wasn't sure at which point the allegation switched to him/her. -The only interaction he/she had with the resident was caught on camera. It can be clearly seen by camera where CNA A was by the resident's chair talking with him/her and they were speaking to others (meaning staff) behind the nurses' station. During a phone interview on 4/29/25 at 3:45 P.M., CNA A said: -The resident told him/her it someone who worked the night shift prior to the 4/17/25 day shift that pulled his/her arm. At the time LPN A, a CNA, and a CMT were at the nurses' station. -He/She was transferring the resident and he/she said it was the girl last night who pulled his/her arm. The resident didn't mention a name. -He/She never pulled or grabbed the resident's arm. -He/She didn't call the resident a lesbian and wasn't yelling at him/her. -He/She was asked to write a statement on 4/18/25 and had been off work since then. -Resident #1 wasn't upset. He/She was transferring the resident when he/she said the girl from night shift bruised him/her. The resident mentioned the person's presumed race. Review of CNA B's statement, undated, showed: -Throughout the day Resident #1 was continuously ignored by CNA A to the point other staff had to take the resident to the bathroom and found his/her brief wet and he/she still needed to go. -Instead of taking the resident, CNA A yelled at him/her Be quiet. I already took you. This kept happening all day until CNA A clocked out. During an interview on 4/30/25 at 3:10 P.M., CNA B said: -He/She didn't know anything about a bruise on anyone's arm. -On 4/17/25 CNA A refused to toilet Resident #1 all day. -The resident kept calling out to use the restroom and CNA A kept telling him/her he/she had already toileted him/her and to shut up. CNA A did this all throughout the morning, afternoon, and early evening hours and kept telling the resident to stop asking. -Other CNAs took the resident throughout the day. -He/She reported the resident requesting to be taken to the bathroom and CNA A refusing to do so to both LPN A and LPN B. -He/She knew the resident was upset and he/she tried to comfort him/her. When Resident #1 gets upset he/she gets verbally agitated. That shift the resident was talking about leaving the facility. He/She does this when he/she was upset. -The resident didn't say what he/she was upset about, except for not being taken to the toilet. During an interview on 4/30/25 at 5:00 P.M., the DON said: -He/She first heard about the incident with Resident #1 when the ADON reported it either mid-morning or in the afternoon on 4/18/25. -CMT A had reported it to the ADON on 4/18/25. -He/She asked the resident if he/she could show his/her arm. The resident lifted his/her arm and said, that boy/girl pulled my arm. I don't like the way he/she treats me. -He/She assured the resident CNA A wouldn't be working with him/her anymore and he/she was safe. The resident smiled and nodded. -He/She thought the bruising on the resident's arms was physical abuse and the psychological abuse was not taking the resident to the toilet and telling him/her to be quiet. During an interview on 4/30/25 at 5:30 P.M., the Administrator said: -Staff reported verbal abuse of Resident #1 on 4/18/25. -The Administrator agreed there was verbal abuse. -Intentionally handling a resident in a rough manner leading to bruising would be physical abuse. It seems like something happened to create the bruises on the resident's arm. Staff didn't witness how the bruises got on the resident's arm. -CNA A was most recently educated in March, 2025 on abuse and neglect. He/She would have been educated on abuse and neglect upon hire and twice a year in the skills fair. 2. Review of Resident #2's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). -Fibromyalgia (a long-term condition that involves widespread body pain and tiredness). -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Review of the resident's comprehensive Care Plan Report, undated, showed the resident had a Self-Care Deficit care plan, initiated 1/9/25, related to Parkinson's disease. Staff were to provide needed physical assistance with showers, dressing, and toileting and limited assistance with transfers between surfaces. Review of the resident's annual MDS, dated [DATE], showed the resident: -Was cognitively intact with no disorganization or inattention. -Had no verbal or physical behaviors toward others, did not refuse cares, and had no other behaviors. -Said it was very important to have choices about daily preferences including choosing what to wear and his/her bedtime and shower protocol. -Required partial to moderate assistance (the helper does less than half the effort) with showers and lower body dressing and supervision and/or assistance with steadying for transfers. -Was diagnosed with arthritis (swelling in one or more joints causing pain and/or stiffness). Review of the resident's Abuse/Neglect Investigation Summary, dated 4/23/25, written by the facility Administrator showed: -On 4/18/25 the ADON verbally reported an allegation of abuse towards Resident #2. -The allegation was given to him/her verbally by a staff member (CMT A) who wanted to remain anonymous due to fear of retaliation by the perpetrator (CNA A). -The allegations involved verbal abuse towards Resident #2 in the shower. -CMT A accounted overhearing the perpetrator using foul language toward the resident and overhearing the resident asking the perpetrator to allow the water to run longer to avoid getting a cold shower. -The perpetrator would not allow the water to run longer thus giving the resident a cold shower. -Conclusion: Resident #2 was adamant about what happened to him/her in the shower involving CNA A and his/her account of the verbal abuse and cold shower. Review of the Document of Just Culture Assessment, dated 4/18/25, showed the worksheet was used to help gather information, showing: -On 4/18/25 Resident #2 called the Administrator and reported to the ADON his/her CNA forced him/her into a cold shower and was verbally abusive. -Policy and Procedure: Residents should be treated with respect and care that doesn't harm the resident. Showers should be warm before residents enter. Policy and procedure show residents have the right to be cared for with dignity and respect and will not be harmed. -CNA A refused to give a statement. -Abuse/Neglect education was part of the employee's initial orientation. Most recently the Abuse/Neglect education was presented formally in the March meeting in which CNA A was a participant. -Algorithm analysis of duties and expectations showed the resident was given a cold shower against his/her wishes. The employee had a duty to avoid causing unjustifiable risk or harm and to follow procedural rule. The employee chose reckless behavior. -Punitive consequences would be determined in collaboration with HR. On 4/18/25 the facility recommended separation of employment. Review of Resident #2's statement, dated 4/18/25, written by the ADON showed Resident #2 stated the following: -Staff didn't give him/her a shower the previous day. -CNA A put him/her in the shower chair and said, go ahead; shower yourself since you want this shower so damn bad. -He/She told CNA A he/she wanted the water to run for a little bit to warm up. -CNA A said, I don't have time and sprayed him/her with cold water and only washed under his/her breast and bottom. -The shower was cold, the water was too cold, and he/she was shivering. -The staff put him/her back in the bed and stated he/she would get him/her some socks and never came back. During an interview on 4/29/25 at 10:30 A.M., Resident #2 said: -CNA A told him/her the morning of 4/17/25 he/she would give him/her a shower and asked how much of it he/she could do by himself/herself. -He/She told CNA A he/she couldn't do much and CNA A said he/she didn't believe that. -CNA A came in at 7:00 P.M. or a little before to give him/her a shower and told him/her CNA A had an appointment outside the building earlier in the day and that was why he/she was so late in getting his/her shower. -He/She told CNA A it had to run a long time to get warm enough or it would be cold. -CNA A put him/her in the shower and turned the water on immediately. It hit his/her feet first and he/she said, oh, it's too cold and he resident was crying and hollering and said it was too cold and to get him/her out of here. -CNA A said he/she was getting on his/her nerves crying like that and he/she was in there now and he/she was going to take his/her shower and stop all that crying. -CNA A just turned the water off without actually having washed him/her. CNA A was going to dry his/her back, but he/she told the CNA it wasn't wet. CNA A never washed him/her at all. -The resident wiped under his/her breast with a washcloth to show he/she could do something. -CNA A said he/she was making his/her bed and left him/her naked in the shower room a long time. He/She might have had a towel around his/her shoulders, but not his/her legs and he/she was cold. He/She told the CNA he/she needed his/her socks. He/She was left alone in the shower room about 10 minutes. -He/She kept hollering and crying. Nobody came into the shower room. There was a call light in the shower room, but he/she never put it on because he/she thought CNA A would come back and be mad. -CNA A dressed him/her in the shower room and brought him/her back into his/her room and said he/she was going to look for socks. CNA A left the room and he/she never saw CNA A again. He/She didn't think the CNA would come back because it was about 10 minutes past 7:00 and his/her shift was over. -He/She was angry when CNA A did that. He/She just couldn't believe he/she was doing that. He/She felt shocked and scared, but more angry than anything. -He/She was still hollering and crying after CNA A left. -Another nursing staff member put his/her socks on after he/she was back in his/her room and he/she reported to him/her what had happened. -He/She was really upset when the ADON came to talk with him/her about it the next day. During an interview on 4/29/25 at 2:10 P.M., the ADON said: -Resident #2 left a voice message on his/her voice mail saying he/she didn't get a shower the previous day. -He/She asked CMT A if he/she would shower the resident and that was when CMT A opened up and told him/her what he/she had observed. Review of CMT A's undated and unsigned written statement showed: -On 4/17/25 CNA A didn't give Resident #2 a shower all day long and waited until the resident was upset about it. CNA A said, come on (resident's name), you want your shower so bad let's get started and rushed the resident in the shower. -The resident said, can you let the water run? It's going to be cold. -CNA A said, I aint got time to be letting the shower run. Hurry up so I can get off this floor. -CNA A then said, here; wash yourself. There aint no reason you can't wash yourself and left the resident in the bathroom crying, help me, Jesus! because he/she was cold and left alone to shower himself/herself. -While the resident was crying CNA A was yelling outside the door, okay (resident's name); damn! I aint got no patience. -This was taking place at 6:15 P.M. During an interview on 4/29/25 at 5:30 P.M., CMT A said: -He/She was in Resident #2's room maybe around 5:30 P.M. or 6:00 P.M. -The resident mentioned CNA A still hadn't given him/her a shower. -He/She asked if the resident wanted him/her to get CNA A to give him/her a shower. The resident said he/she would wait. -A short while later CMT A told CNA A the resident wanted his/her shower and CNA A said, come on (resident's name), you wanted your shower so bad so let's go. It was close to 7:00 P.M. before he/she started the shower. -The resident asked CNA A if he/she could let it run a so it warmed up and CNA A said, we aint got no 30 minutes to wait for that water to warm up. -At the time CMT A was in the resident's hallway passing medications. -The shower room door was open when he/she came down the hallway and he/she saw the resident sitting in the shower chair with his/her pants off. His/Her top was on at the time. He/She saw CNA A hand the resident a rag and tell him/her to wash himself/herself. The resident told CNA A he/she needed help. -CMT A heard the water come on and the resident was crying and yelling, help me, Jesus! Help me, Jesus real loud. -CMT A gives the resident showers and knew the water was cold and had to let it run during the time he/she made the resident's bed and gets the resident's clothes ready. That warms the water up. It probably takes five minutes. It still isn't super warm then. -CNA A said, okay, hurry up. Let's get this done so I can leave the unit. He/She was saying this in a loud tone of voice. -When CNA A noticed CMT A in the hallway CNA A said, I'm sorry; I aint got no patience for this. CNA A wasn't really talking to CMT A or to the resident, he/she was just talking out loud. -CNA A got the resident out of the shower room. He/She had left him/her in there probably five minutes by himself/herself. -Resident #2's body stiffens. He/She needed staff to wash him/her. The resident can reach his/her upper body. The resident's legs will lock up on him/her, so he/she does the shower for the resident when he/she gives it. -The resident was dressed when he/she was brought out of the shower room. He/She didn't know if the resident dressed himself/herself that evening. -The resident told him/her after CNA A left that CNA A didn't even shower him/her. -CNA A leaves at 7:00 P.M. It was close to that before he/she started the shower. CNA A had all day to shower the resident. -CNA B was also working the floor during the time Resident #2 was being showered. -He/She was just so much in shock and couldn't believe it was happening. -The next day the ADON told him/her the resident didn't get his/her shower the previous day and asked him/her to give it. That was when he/she told the ADON what happened the evening before and the DON asked him/her to write a statement. Review of CNA A's e-mailed statement, dated 4/21/25, showed: -He/She was replying to accusations made against him/her. One being he/she gave a resident a cold shower. -He/She was assigned to two showers. -Upon arriving there were several residents still down. He/She began to get residents up and was not done until after all dining rooms had already been served. That pushed back his/her morning routine. -After breakfast he/she took residents that were supposed to be toileted to the bathroom and began his/her first shower. As he/she predicted, that shower took quite a while because the resident continued getting up several times throughout the shower and trying to walk off so much so that he/she had to call for assistance to finish him/her. He/She says all that to say by the time he/she finished the first shower and took his/her first 15-minute break it was already lunch time. -He/She then went to the resident who made the accusation of the cold shower and notified him/her he/she would get to the resident's shower after lunch when he/she was done with his/her lay-downs and afternoon rounds. The resident said, okay. -Once lunch was over and he/she completed his/her other duties he/she went to try and do the shower. The resident was already in an upset state and said he/she did not want to do it at that time because he/she fell recently and was hurting and the nurs

Based on interview and record review, the facility failed to ensure timely reporting of abuse allegations per the facility policy for two sampled residents (Resident #1 and #2) out of 10 sampled residents. Certified Nurse Aide (CNA) A was allowed to continue his/her shift on 4/17/25 and to work part of his/her shift on 4/18/25 potentially affecting all residents in his/her assignment. The facility census was 134 residents. On 4/30/25 the Administrator was notified of the past noncompliance which took place from mid-afternoon on 4/17/25 and 4/18/25. Corrective measures began immediately. The CNA was suspended. All staff were re-educated on abuse and neglect reporting. The deficiency was corrected on 4/18/25. Review of the facility's Abuse and Neglect policy, revised 7/26/24, showed: -The facility will implement an abuse prohibition program to include training of employees, identification of possible incidents or allegations which need investigation, protection of residents during investigations, and reporting incidents. -Training will be provided to all employees through orientation and at a minimum annually and will include how staff should report their knowledge related to allegations without fear of reprisal and what constitutes abuse, neglect, and misappropriation of resident property. -Preventing abuse includes providing staff with information on how and to whom they may report concerns without retribution. -Staff will identify events such as suspicious bruising that may constitute abuse. Anyone witnessing an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of resident property shall report the suspected abuse immediately to the Administrator. -The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. -Information concerning a report of suspected or alleged abuse, mistreatment, neglect, involuntary seclusion, or injuries of unknown origin will be investigated upon receipt to determine if abuse or neglect is suspected. -Immediately, not to exceed 24 hours, notify the SA, utilizing the Mandated Reporter Form if reporting between 12:00 A.M. and 7:00 A.M. If the resident sustains serious bodily injury report no later than two hours after forming the suspicion. Review of Resident Abuse and Neglect Training objectives, supporting the Abuse and Neglect policy, showed: -Staff should immediately communicate suspected abuse and neglect. -The phone numbers of the Administrator, Director of Nursing (DON), ADON, Evening Supervisor, and Weekend Supervisor for reporting purposes were included as part of the training. -The training showed staff could report in person, by telephone, or through e-mail and could do so anonymously. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included 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 the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/27/25, showed the resident was severely cognitively impaired with fluctuating disorganization. Review of the resident's Abuse/Neglect Investigation Summary, dated 4/23/25, written by the facility Administrator showed: -On 4/18/25 the Assistant Director of Nursing (ADON) verbally reported abuse towards Resident #1. -Allegations were given to the ADON verbally by Certified Medication Technician (CMT) A who wanted to remain anonymous due to fear of retaliation by CNA A. During an interview on 4/29/25 at 10:05 A.M. the ADON said: -Two allegations of abuse were was reported by CMT A the afternoon of 4/18/25. -CMT A alleged CNA A spoke abusively to Resident #1 and grabbed the resident's arm the afternoon of 4/17/25. -CMT A also reported he/she heard Resident #2 ask CNA A to let the water warm up and CNA A said he/she didn't have time to do that and sprayed the resident with cold water on 4/17/25 a little before 7:00 P.M. resulting in the resident yelling out for help and crying. CMT A alleged CNA A also spoke to Resident #2 in an abusive manner during the time of the resident's shower. -An abuse/neglect investigation was started immediately on 4/18/24 upon receiving the allegations. During an interview on 4/29/25 at 11:48 A.M., Resident #1 said: -A staff person from upstairs grabbed his/her arm hard. He/She asked the staff what he/she was doing to his/her arm, and the staff member said he/she didn't like the resident because the resident talked to all the white people. -When the staff member grabbed his/her arm it hurt. That was about a week or so ago. and it was sore for days. -He/She told staff right after it happened. During an interview on 4/29/25 at 2:25 P.M., RA A said: -On 4/17/25 he/she noticed CNA A was rough and quick-tempered that day and snapped at Resident #1 towards the end of his/her shift, somewhere between 1:00 P.M. and 3:00 P.M. It might have been between 2:30 P.M. and 3:00 P.M. -CNA A's tone of voice was irritated and angry. He/She could tell by the tone of CNA A's voice he/she had snapped at the resident, but he/she couldn't hear what had been said. How CNA A spoke was very unprofessional. -Before he/she left for the day the resident showed his/her arm. He/She was still in the recliner and the resident held his/her arm up and said, look! He/She grabbed my arm indicating it was CNA A who had done it. -He/She didn't make a big deal about it because he/she wasn't sure at the time what had happened, so he/she didn't report it to anyone. He/She didn't know if a nurse was in the area at the time, but he/she did not report it to a nurse or to administrative staff. -CMT A was there near the resident, but he/she couldn't remember who else was in the area, but he/she thought at least two staff were there. Since there were others there, he/she didn't report it and went back and finished charting. -He/She went to all the facility in-services. If something comes up we should have reported it to the charge nurse. From there he/she was supposed to go to the ADON or the DON if the charge nurse was busy. He/She didn't report it because he/she knew someone else who was in the area would report it. During an interview on 4/29/25 at 2:45 P.M., CMT A said: -When he/she got to the unit he/she saw Resident #1 was upset. He/She could tell by his/her body language. The resident was shooing CNA A away and saying, leave me alone and the resident looked visibly upset like he/she was very frustrated. -CNA A said you're a lesbian to the resident. The resident said he/she wasn't a lesbian and CNA A said yes, you are, and you raped me because you touched my butt. CNA A was being very rude, and his/her tone of voice was very rude. -CMT A said, (resident's name), what's wrong and the resident said, he/she hurt me, meaning CNA A. The resident raised his/her right arm and there were three red marks on the resident's upper forearm. They looked like fingertip circles. -After he/she came to the resident, CNA A walked away and went to the nurses' station. The resident said he/she needed to go to the bathroom and CNA A yelled across the room, I already took you and grabbed his/her purse and left the unit to go to lunch. -CMT A had been educated to report suspicions of abuse immediately, but was so stunned and caught off guard about what he/she had witnessed that he/she didn't report it at the time. He/She told the ADON the next day. During an interview on 4/30/25 at 5:00 P.M., the DON said: -He/She first heard about the incident with Resident #1 when the ADON reported it either mid-morning or in the afternoon on 4/18/25. -CMT A had reported it to the ADON on 4/18/25. -He/She asked the resident if he/she could show his/her arm. The resident lifted his/her arm and said, that boy/girl pulled my arm. I don't like the way he/she treats me. -All nursing staff were trained on reporting possible abuse and neglect. He/She would have expected the events of 4/17/25 to have been reported immediately for Resident #1. During an interview on 4/30/25 at 5:30 P.M., the Administrator said: -Staff reported abuse of Resident #1 on 4/18/25. -The allegations about the CNA A should have been reported immediately by CMT A and RA A to the charge nurse or they could have contacted the ADON, DON, or himself/herself (the Administrator). 2. Review of Resident #2's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact with no disorganization or inattention. Review of the resident's Abuse/Neglect Investigation Summary, dated 4/23/25, written by the facility Administrator showed: -On 4/18/25 the ADON verbally reported an allegation of abuse towards Resident #2. -The allegation was given to him/her verbally by a staff member (CMT A) who wanted to remain anonymous due to fear of retaliation by the perpetrator (CNA A). -The allegations involved verbal abuse towards Resident #2 in the shower. -The reporter (witness) accounts overhearing the perpetrator using foul language toward the resident and overhearing the resident asking the perpetrator to allow the water to run longer to avoid getting a cold shower. During an interview on 4/29/25 at 10:30 A.M., Resident #2 said: -CNA A came in at 7:00 P.M. or a little before to give him/her a shower. -He/She told CNA A it had to run a long time to get warm enough or it would be cold. -CNA A put him/her in the shower and turned the water on immediately. It hit his/her feet first and he/she said, oh, it's too cold and the resident was crying and hollering and said it was too cold and to get him/her out of here. CNA A said he/she was getting on his/her nerves crying like that and he/she was in there now and he/she was going to take his/her shower and stop all that crying. -CNA A just turned the water off without actually having washed him/her. -CNA A said he/she was making his/her bed and left him/her naked in the shower room a long time. He/She might have had a towel around his/her shoulders, but not his/her legs and he/she was cold. He/She was left alone in the shower room about 10 minutes. -He/She kept hollering and hollering and crying. Nobody came into the shower room. There was a call light in the shower room, but he/she never put it on because he/she thought CNA A would come back and be mad. -He/She was angry when CNA A did that. He/She just couldn't believe he/she was doing that. He/She felt shocked and scared, but more angry than anything. -He/She was still hollering and crying after CNA A left. -A nursing staff put his/her socks on after he/she was back in his/her room, and he/she reported to him/her what had happened. -The resident was really upset when the ADON came to talk with him/her about it the next day. During an interview on 4/29/25 at 2:10 P.M., the ADON said: -Resident #2 left a voice message on his/her voice mail saying he/she didn't get a shower the previous day. -He/She asked CMT A on 4/18/25 if he/she would shower the resident and that was when CMT A opened up and told him/her what he/she had observed. During an interview on 4/29/25 at 2:45 P.M., CMT A said: -On 4/17/25 between 6:00 P.M. and 7:00 P.M. he/she told CNA A that Resident #2 wanted his/her shower and CNA A said, come on (resident's name), you wanted your shower so bad so let's go. It was close to 7:00 P.M. before he/she started the shower. -The resident asked CNA A if he/she could let it run a so it warmed up and CNA A said, we ain't got no 30 minutes to wait for that water to warm up. -At the time he/she was in the resident's hallway passing medications. -The shower room door was open when he/she came down the hallway and he/she saw the resident sitting in the shower chair with his/her pants off. His/Her top was on at the time. He/She saw CNA A hand the resident a rag and tell him/her to wash himself/herself. The resident told CNA A he/she needed help. -CMT A heard the water come on and the resident was crying and yelling, help me, Jesus! Help me, Jesus real loud. -CMT A gives the resident showers and knew the water was cold and had to let it run to water up. It probably takes five minutes. It still isn't super warm then. -CNA A said in a loud tone of voice, okay, hurry up. Let's get this done so I can leave the unit and I'm sorry; I ain't got no patience for this. -CNA A left the resident alone in the shower room probably five minutes. -The resident told him/her after CNA A left that CNA A didn't even shower him/her. -On 4/18/25 the ADON told him/her the resident didn't get his/her shower the previous day and asked him/her to give it. That was when he/she told the ADON what happened the evening before. -He/She was just in so much shock and couldn't believe it was happening the evening of the shower. He/She was still processing what was happening is why he/she didn't report the incident at the time. During an interview on 4/30/25 at 1:47 P.M., the ADON said: -On 4/18/25 around lunchtime he/she noticed a voicemail message had been left from Resident #2. The resident said he/she didn't get his/her shower the previous night. -He/She told the resident he/she would ask CMT A to give his/her shower that day (4/18/25). -He/She asked CMT A if he/she could give the resident his/her shower and CMT A said the resident got a shower yesterday (meaning 4/17/25) and then told him/her what he/she had overheard while passing medications on 4/17/25. -He/She went back to the resident's room and asked the resident what happened yesterday evening after dinner and the resident said: --The resident asked CNA A for a shower the evening of 4/17/25 and the CNA said, you want your shower so damn bad, come on; let's get it over with. --The aide turned the water on and the resident told him/her to let it run to warm up, but CNA A sprayed him/her with cold water. --The resident didn't want CNA A to give him/her a shower again. -Staff should have reported the incident the evening it happened. Staff are all trained to report abuse/neglect and mistreatment. During an interview on 4/30/25 at 5:00 P.M., the DON said: -On 4/18/25 Resident #2 told the ADON about the shower incident and the ADON told him/her and the Administrator. -He/She spoke with the resident who restated the event. The resident said he/she was crying because he/she didn't get a shower and CNA A said, okay, you want your shower. Fine. The resident said he/she told CNA A he/she had to wait and let it warm up for a long time. CNA A said he/she didn't have time to wait and pushed the resident's shower chair into the cold shower. -The resident said he/she was cold and crying and that CNA A only washed under his/her breasts and sprayed cold water on him/her. -When the resident told the DON he/she was sprayed with the cold water he/she was crying and became emotional. He/She (the DON) hugged the resident to help calm him/her. -He/She told the resident CNA A wouldn't be caring for him/her anymore. -Staff were educated on abuse and neglect in the March, 2025 staff meeting. They were all educated upon hire and two additional times during the skills fair in June and December. The education included the protocol for all staff to report abuse and neglect. -He/She felt like the situation was abuse. The cold shower against the resident's will could be physical abuse, because it caused him/her discomfort. It was psychological abuse as well, causing emotional distress. -He/She would have expected staff to have reported any suspected abuse/neglect or mistreatment immediately to the Administrator, who is the Abuse/Neglect coordinator. If the Administrator is not here staff should report to him/her (the DON) or the ADON. At the very minimum they should report to the charge nurse who in turn should report to the Administrator so that they can address the issue right away. -Reporting should have happened on 4/17/25 as soon as the witnesses saw that something wasn't right. -When he/she asked CMT A why he/she didn't report immediately he/she said he/she feared CNA A would do something to him/her. All three employees should have followed protocol and CMT A, CNA B, and RA A should have reported their observations. If they told a charge nurse the charge nurse should have reported to the Administrator. During an interview on 4/30/25 at 5:30 P.M., the Administrator said: -CMT A first reported the incidents of the previous day to the ADON on the afternoon of 4/18/25. -Staff all know and are educated on abuse and neglect upon hire, twice yearly during the skills fair, and most recently in March of 2025. The education included how staff were to report suspicions of abuse and neglect. -He/She thought what happened to Resident #2 was verbal abuse. -His/Her expectation was the aides should have followed the chain of command and should have gone immediately to the charge nurse and reported what they witnessed. CMT A expressed fear of retaliation. That was probably why he/she didn't report it immediately. They also could have contacted the ADON, the DON, or himself/herself (the Administrator). They have all been told in Abuse/Neglect training they can contact any one of them and they can also contact the security person who is on duty. MO00252988 MO00252990 MO00253102

Based on interview and record review, the facility failed to ensure discharge/transfer documentation was completed to include reasons for the discharge/transfer, discharge plan and notification of the resident's responsible party, for one sampled resident (Resident #1), who was discharged to another facility, out of five sampled residents. The facility census was 147 residents. Review of the Facility's Transfer and Discharges/Notice of Proposed Discharge Policy revised on 6/27/24 showed: -Transfer and discharge will be handled appropriately to ensure proper notification and assistance to resident and families in accordance with federal and state specific regulations. -Procedure: --The transfer or discharge is necessary for the resident welfare and the resident needs cannot be met in their current placement in the facility. --When the health and safety of individuals in the facility is endangered due to clinical or behavioral status of the resident. -In an event that the resident requires transfer or discharge due to one of the above stated reason documentation's will be in the medical record to include: the basis for the transfer. The specific resident need that cannot be met, facility attempts to meet the resident needs and the services available at the receiving facility to meet the needs. -Documentation from the resident physician is needed when: the transfer or discharge is necessary due to the resident's welfare and needs being unable to be met in the facility. -A discharge summary must be completed. -Facility staff (nursing) were to explain transfer and reason to the resident and or representative and give a copy of signed transfer or discharge notice to the resident and or representative or person responsible of care. (If there is an emergency transfer, a Notice of Transfer or discharge form may be completed later, but within 24 hours. 1. Review of Resident #1's Face Sheet showed the resident admitted to the facility on [DATE] with diagnosis of: -Schizoaffective disorder, bipolar type (is a mental illness that can affect your thoughts, mood and behavior, include may have several days of extreme highs (mania), and you can have severe lows (depression)Dementia with agitation. -Had a Durable Power of Attorney for Healthcare Decision (DPOA, is a legal document that allows someone to make medical decisions for another person if they are unable to do so themselves) and listed the resident's family member as responsible party. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/12/24 showed: -The resident was severe cognitive impairment. -His/her vision was highly impaired. -No behaviors documented during assessment review. Review of the resident's care plan dated 8/20/24 showed: -The resident requires 24-hour care and supervision. -He/she and DPOA plan to remain in long term care with no plans for discharge. -The resident has a cognitive impairment. Review of the facility's typed summary of allegation of Resident-to-Resident altercation dated 9/5/24 was completed by Administrator showed the conclusion of the resident's altercation was witness by facility staff, as result of the resident's actions, he/she has been accepted to transfer to another facility as a better fit for his/her diagnosis and behaviors. Review of the resident's Social Services Progress Notes dated 9/9/24 (no time) showed: -Several nursing homes were sent medical records to find placement for the resident. -A nursing care facility accepted the resident and would pick the resident up. -NOTE: There was no documentation related to why the facility could not meet the needs of the resident, what attempts were made to meet the needs of the resident or notification of the residents DPOA. Review of the resident's physician's order dated 9/9/24 showed the resident may discharge the resident to another facility care center. Review of resident's nursing note dated 9/9/24 at 3:00 P.M. showed: -The resident left the facility with all belongings and medication via receiving facility transportation. This nurse attempted to contact the receiving facility with a resident report and was unable to reach a nurse at the other facility. -Note: There was no documented reason for transfer to another facility or nurse had notified DPOA. Review of the resident's medical record on 9/10/24 showed: -There was no documentation that the resident or Family member/DPOA had agreed to transfer and was informed of the resident or responsible party right to appeal the resident's transfer to another facility. During an interview on 9/10/24 at 1:15 P.M., Social Services Designee (SSD) said: -He/she had talked with the resident's family member/DPOA on 9/5/24 related to altercation. Later that day the resident was sent to hospital for evaluation and treatment related to his/her behavioral changes. The resident had returned back to the facility the same day. -He/she had been working on finding new placement for the resident that would be a better fit the resident needs and behaviors. -He/she had sent out request for alternate placement to five different facilities. -He/she verbally notified the resident's DPOA of the proposed plan to transfer the resident to a new facility. The DPOA verbally had agreed with the plan to find a facility in the metro city area. -He/she had received a call that another facility would accept the resident. -He/she had not documented any communication with the resident's DPOA related to the proposed transfer or reason/cause for transfer of the resident to another facility. -He/she was not aware of the facility process for documentation requirements of facility-initiated transfer/discharges to another facility. -He/she said on 9/9/24, the facility Social Services Worker (SSW) had completed the arrangements for the resident's transfer to the new facility for that afternoon. -The SSW would have been responsible for contacting the resident's DPOA related to the residents proposed transfer to another facility on 9/9/24. During an interview on 9/10/24 1:25 P. M., SSW said: -On 9/9/24, he/she had contact the DPOA about transferring the resident to another facility. -He/she asked the DPOA if he/she wanted to transport the resident to the new facility. -The receiving facility called and said they were ready for the resident to transfer there and were on way to the facility to pick up the resident. -The SSD and SSW had sent out referrals to several facilities and only one facility agreed to admit the resident. -He/she had been working on finding new placement for the resident that would be a better fit for the resident needs and behaviors. -The resident had one altercation with another resident. -He/she had sent out requests to five different facilities for the resident for placement that could met the needs of the resident. During an interview on 9/10/24 at 1:26 P.M., Administrator said: -The resident was transfer to another facility that could handle residents with behaviors and mental health diagnoses. -He/she was not aware of the facility needing to provide written notice to resident or family member for a transfer to another facility. During a telephone interview on 9/11/24 at 8:30 A.M., Family member/DPOA said: -The resident had a physical confrontation with another resident in the facility on 9/5/24. -The facility said they sent the resident to the hospital after the physical event. -When the resident returned the next day the facility they had put the resident in a different room. -He/she called the facility again on 9/9/24. -He/She spoke with SSW and was told he/she had 15 minutes to pick the resident up because the resident could no longer remain in the facility. The staff had found another facility that would accept him/her. -He/she did not want the resident to be transferred but the facility transferred the resident to another facility without his/her consent. -No one at the facility had informed him/her that they were planning to discharge the resident beforehand and did not discuss any alternatives to discharge with him/her. -He/she was very upset because he/she did not want the resident to remain at the new facility and felt facility did not follow correct protocol for discharging the resident. During an interview on 9/11/24 at 3:15 P.M., Administrator said: -The facility did not provide a 30-day notice, transfer/discharge or an emergency notice of discharge to the resident. -He/she not aware of the facility having a process in place to provide written letter of transfer/discharge notification related to when resident transfer to another facility. -He/she would expect SSD or SSW to document that the facility had provide written notification to resident or DPOA to include reason for transfer, and to incude the name of the facility the resident would be transfer to. During an interview on 9/11/24 at 3:47 P.M., SSW said: -He/she had a verbal agreement from both parties for the transfer to another facility. -He/she did not have written detail documentation in the resident medical record related to reason for transfer. During an interview on 9/11/24 at 4:12 P.M., Registered Nurse (RN) A said: -On 9/9/24 during the nursing report it was noted the resident may be transferring to another facility. Later that morning he/she received notice that the resident was leaving the facility on 9/9/24. -He/she was aware of the resident may transfer to another facility due to an altercation with another resident. -He/she obtained physician order and noted the resident will be transfer with medication and transported by other facility staff. -SSD and SSW would be responsible for arraignment and notification of family member and receiving facility. During an interview on 9/11/24 at 4:23 P.M., Administrator, Director of Nursing (DON) said he/she would expect facility staff to documented in the resident's medical record the proposed transfer/discharge planning, reason for discharge and notification of any responsible parties. Complaint# MO 00241863

Based on interview and record review, the facility failed to ensure an emergency discharge letter was provided to the resident's and/or the resident's representatives with Durable [NAME] of Attorney (DPOA) (a person who has the legal authority and responsibility to make decisions for another person) including the right to appeal the discharge and Ombudsman (a person who investigates, reports on, and helps settle complaints) contact information upon discharge for one sampled resident (Resident #1) out of 5 sampled residents. The facility census of 147 residents. Review of the Facility's Transfer and Discharges/Notice of Proposed Discharge Policy revised on 6/27/24 showed: -Transfer and discharge will be handled appropriately to ensure proper notification and assistance to resident and families in accordance with federal and state specific regulations. -Procedure: --The transfer or discharge is necessary for the resident welfare and the resident needs cannot be met in their current placement in the facility. --When the health and safety of individuals in the facility is endangered due to clinical or behavioral status of the resident. -In an event that the resident requires transfer or discharge due to one of the above stated reasons, documentation would be in the medical record to include: the basis for the transfer. The specific resident need that cannot be met, facility attempts to meet the resident needs and the services available at the receiving facility to meet the needs. -Documentation from the resident physician is needed when: the transfer or discharge is necessary due to the resident's welfare and needs being unable to be met in the facility. -A discharge summary must be completed. -Facility staff (nursing) were to explain transfer and reason to the resident and or representative and give a copy of signed transfer or discharge notice to the resident and or representative or person responsible of care. (If there is an emergency transfer, a Notice of Transfer or discharge form may be completed later, but within 24 hours. 1. Review of Resident #1's Admission Face sheet showed the resident admitted to the facility on [DATE] with diagnosis of: -Schizoaffective disorder, bipolar type (is a mental illness that can affect your thoughts, mood and behavior, include may have several days of extreme highs (mania), and you can have severe lows (depression) Dementia with agitation. -Had a Durable Power of Attorney for Healthcare Decision (DPOA, is a legal document that allows someone to make medical decisions for another person if they are unable to do so themselves) and listed the resident's family member as responsible party. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/12/24 showed the resident was severely cognitively impaired. Review of the resident's care plan dated 8/20/24 showed: -The resident was cognitively impaired. -The resident and DPOA had no plans to return to community. -The resident and DPOA had no plans for discharging from the facility. Review of the resident's Resident-to-Resident altercation dated 9/5/24 showed: -The conclusion of the resident's altercation was witness by facility staff, as result of Resident #1 actions, he/she has been accepted to transfer to another facility as a better fit for his/her diagnosis and behaviors. -NOTE: There was no documentation related to written notification of proposed plan of transfer letter with right to appeal provided to DPOA or resident. Review of the resident's Electronic Medical Record (EMR) dated 9/5/24 to 9/8/24 showed: -No documentation related to communication with resident's DPOA related to proposed transfer and reason for transfer to another facility. -No documentation of the resident's rights to appeal was provided to the resident or DPOA. -No documentation or copy of letter of notice of transfer provided to the resident or DPOA. Review of resident's nursing note dated 9/9/24 at 3:00 P.M. showed: -The resident left the facility with all belongings and medication via receiving facility transportation. -There was no documentation showing a notice or transfer and right to appeal the discharge was sent with the resident. Review of the resident's nursing notes on 9/10/24 showed: -Had no documentation of communication with family member related to a potential planning of a transfer/discharge to another facility. -Had no documentation by nursing staff that the resident's physician was notified, or an order was obtained to transfer the resident to another facility. -NOTE: There was no documentation related to the reason for transfer to another facility. Review of the resident's medical record on 9/10/24 showed there was no documentation of a written notification letter of proposed transfer/discharge. During an interview on 9/10/24 at 12:45 P.M., DPOA said: -He/she had not received any written notification or letter related to the resident rights and acknowledgement of proposed transfer. -He/she had not been offered the right to appeal the discharge. During an interview on 9/10/24 at 1:15 P.M., Social Services Designee (SSD) said: -He/she was not aware of the facility process for providing a written letter for emergency or 30-day notice for any proposed transfer, to the resident or resident's family member. -He/she was not aware of a facility written emergency transfer/discharge notice letter. During an interview on 9/10/24 1:25 P.M., Social Service Worker, (SSW) said: -He/she does not provide written notification of proposed transfer or discharge letters or the emergency or 30-day notice letters. -The business office would provide those notification. During an interview on 9/10/24 at 1:26 P.M., Administrator said: -The resident was transfer to another facility that could handle residents with behaviors and mental health diagnosis. -He/she was not aware of the facility providing any written notice to resident or family member for a transfer to another facility. During an interview on 9/11/24 at 3:15 P.M., Administrator said: -The facility did not provide a 30-day notice, written proposal for transfer/discharge or an emergency notice of discharge to the resident. -He/she not aware of the facility having a process in place to provide written letter of transfer/discharge notification related to when resident transfer to another facility. -The medical record had no documentation that the facility staff had reviewed the resident rights for transfer and right to appeal the transfer. During an interview on 9/11/24 at 3:41 P.M., Business Office Manager (BOM) said: -The facility normally only issued a 30-day notice for non-payment. The form did include who to contact for an appeals or any reference agency. -The BOM did not provide written notification of transfer/discharge to the resident. -SSD and SSW would make the arrangement for the resident's facility transfer and they would document details in the social services notes. -He/she sends list of discharge residents monthly to Ombudsman office. -He/she did not contact Ombudsman of the resident proposed plan transfer to another facility. During an interview on 9/11/24 at 4:23 P.M., Administrator and Director of Nursing said the resident and DPOA were not provided written documentation on the resident rights process for appealing the transfer/discharge. Complaint# MO 00241863

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed to prevent contamination and spread of infection for one sampled resident (Resident #4) who was on contact droplet isolation for Respiratory Syncytial Virus (RSV - a respiratory virus that infects the lungs and breathing passages and can be serious, especially for infants and older adults) out of two sampled residents who were on isolation on the third floor south unit. The sample was five residents. The facility census was 145 residents. Review of the facility's Isolation Precautions policy and procedure, dated 2/20/23, showed: -The facility will use contact precautions in addition to standard precautions based on the disease or infection transmission as outlined by the Department of Health and by the long term care federally regulatory agency to assist health care personnel in preventing and controlling the spread of organisms and communicable diseases. -Standard precautions include treating the blood, body fluids, and other potentially infectious materials such as contaminated equipment, linen, trash and supplies as if potentially infectious. The facility chooses personal protective equipment (PPE) appropriate for the task and the potential for exposure as barriers to protect them from the moist body substances of all patients. -Practice hand hygiene by washing hands with soap and water or using alcohol-based hand sanitizer before and after patient contact even if wearing gloves. -Appropriate use of Personal Protective Equipment Contact Attire: Don (to put on) gown and tie at neck and waist before entering the room. Remove before leaving the room. Gloves: perform hand hygiene then don gloves. Remove gloves and perform hand hygiene before leaving the room. Mask: Mask with shield or mask with goggles when there is anticipated exposure to sprays, blood or body fluids. Remove and discard mask before leaving the room. -Contact precautions: use gown gloves and mask with shield or mask with goggles when there is anticipated exposure to sprays, blood or body fluids. -Airborne precautions: use N95 mask, gown and gloves only as needed for standard precautions or with handling infectious materials. -Discontinuation of Contact Requirements: Modify the contact order after clearing of disease colonization, discontinuation may be done by the physician. The decision to discontinue airborne contact precautions in the absence of three negative tests can only be made by an attending physician and in consultation with a member of the long term care staff. 1. Review of Resident #4's Face Sheet showed he/she was admitted on [DATE], with diagnoses including diabetes, balance disorder, anemia (low iron), schizophrenia (a mental condition characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities) and myeloma (a tumor). Review of the resident's Nursing Notes on 3/23/24 showed the resident complained of cough, was lethargic and exhibited a low grade fever. The nurse called the physician and obtained a physician's order for Mucinex and swab (test for infection) this morning. The test result came back positive for RSV. The nurse called the physician (and informed him/her of the test result) and obtained a physician's order for Tylenol as needed, isolation and vital signs. The nurse informed the resident of the test result. Review of the resident's Infectious Serology Test dated 3/23/24 showed the resident tested positive for RSV. Review of the resident's Physician's Order Sheet dated 3/2024 showed a physician's order for contact and droplet isolation for 7 days. Complete vital signs (blood pressure, temperature, respirations and pulse) every shift with oxygen levels for 7 days for RSV (ordered on 3/23/24). Review of the resident's Nursing Notes dated 3/24/24 showed the resident continued on isolation for positive RSV. He/she has an occasional, non-productive cough. The resident stated he/she was feeling better, denied pain and discomfort and had a good appetite. Resident eats all meals in his/her room. Observation on 3/27/24 at 11:00 A.M. showed: -The door to the resident's room showed there was a stop sign that notified anyone entering that the resident was on isolation and showed instruction and diagram showing what PPE to put on and how to put it on. Beside the door was a cart that included disposable gowns, disposable gloves, masks, a stethoscope, and thermometer on the cart. The door to the resident's room was open (not closed for isolation). -Observation and interview of the resident showed the resident was laying in his/her bed, dressed for the weather and was alert and oriented and said that he/she was getting over an infection and could not come out of his/her room but he/she was feeling better. -At 11:06 A.M. the resident turned on his/her call light and Certified Nursing Assistant (CNA) A went to the resident's room wearing a mask, and without washing his/her hands or using sanitizer, putting on gloves or a gown. He/She did not close the door behind him/her. -At 11:10 A.M. CNA A came out of the resident's room and did not wash or sanitize his/her hands before leaving. He/she pulled the resident's door closed. During an interview on 3/27/24 at 11:10 A.M., CNA A said: -The resident had a respiratory infection last week and was on isolation, but he/she did not know for sure if the resident was still on isolation. -He/She always wore a mask but did not put on the gown and gloves because he/she did not think the resident was still on isolation precautions. During an observation and interview on 3/27/24 at 11:15 A.M., Licensed Practical Nurse (LPN) A said: -The resident was exhibiting symptoms and so they tested him/her for a possible infection and the test results were positive for RSV on 3/23/24. -RSV was a contagious infection. -They notified the physician who put the resident on isolation precautions. -When residents are placed on isolation for airborne infections, they should keep the door closed and they put the stop sign on the door instructing staff of the type of precautions and PPE they should use prior to entering the resident's room. -Staff should wash or sanitize their hands, glove, gown and put on a mask prior to entering the resident's room and remove them before leaving the resident's room and wash or sanitize their hands. -The resident was supposed to be on isolation for 7 days and would not come off of isolation until 3/29/24 at the earliest. -They would re-test the resident to ensure he/she was not still infected before removing him/her from isolation. -The resident's door should remained closed when they were on isolation, but the resident was a high risk for falls and that may be why the resident's door was open. -Observation at this time showed the resident turned his/her call light on. CNA A responded and he/she was wearing a mask but without washing or sanitizing his/her hands, he/she put on gloves and a gown prior to entering the resident's room. Upon leaving the resident's room he/she had discarded the gown and gloves inside of the resident's room and used hand sanitizer as he/she left the resident's room. -LPN A said CNA A should have washed or sanitized his/her hands prior to putting on the gloves and gown. During an interview on 3/27/24 at 11:35 A.M., CNA A said: -He/she had not put the appropriate PPE on the first time he/she entered the resident's room because he/she was not sure the resident was still on isolation. -He/she should have asked the nurse if the resident was still on isolation precautions before entering his/her room. -Sometimes when residents are no longer on isolation, they don't immediately remove the sign and PPE from the resident's door/doorway, so when he/she saw the resident's door was open, he/she thought he/she may not still be on isolation. -He/she did not wash or sanitize his/her hands before entering the resident's room , but he/she should have. During an interview on 3/27/24 at 1:55 P.M. the Assistant Director of Nursing (ADON) said: -When a resident was on isolation, they put a stop sign on the door with instructions for the PPE that is to be worn and type of isolation the resident is on. -He/she expected nursing staff to follow the instructions for wearing PPE and hand hygiene. -Staff should wash or sanitize their hands before putting on gloves, gown and going into the isolation room and they should discard the gown and gloves in the appropriate trash bag and wash or sanitize their hands before leaving the resident's room. During an interview on 3/27/24 at 2:40 P.M., the Director of Nursing (DON) said: -He/she expected the nursing staff to follow the infection control procedure for donning and doffing (to remove) PPE prior to entering a resident's room that is on isolation. -All staff should perform hand hygiene prior to putting on gloves to enter the room and before leaving the resident's room. -Usually for residents who are on isolation, their door should remain shut. MO00232764

Based on interview and record review, the facility failed to provide residents and/or the resident's responsible party's timely notifications (verbal and/or in writing) prior to a roommate change for three sampled residents (Residents #1, #2, and #3) out of five sampled residents. The facility census was 149 residents. Review of the facility's Resident Right's policy dated 11/16 showed: -Notification of changes: --A facility must immediately inform the resident, consult with the resident's physician; and notify, consistent with his/her authority, the resident representative(s) when there is a change in room or roommate assignment. Review of the facility's current Census List dated 2/27/24 showed Resident #1 and Resident #2 were currently roommates. 1. Review of Resident #1's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Care Center Resident's Rights dated 11/9/16 showed: -The resident had the right to receive notice before the resident's room or roommate in the facility is changed. -The Care Center Resident's Rights document was reviewed and a copy given to the resident on 2/23/23. Review of the resident's Progress Notes showed: -An undated noted timed at 2:30 P.M. showed the resident's family member/Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) arrived to the facility and was upset the resident now had a roommate. Staff explained to the DPOA that the resident had a double room and could have a roommate. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) met with the family member to discuss the situation. --Note: No documentation the resident's DPOA was notified verbally or in writing he/she would be getting a new roommate prior to Resident #3 being admitted to Resident #1's room on 12/28/23. -On 1/8/24 the resident's family member/DPOA was notified verbally he/she would be getting a roommate that week. -No documentation the resident's DPOA was notified in writing he/she would be getting a new roommate prior to Resident #2 being admitted to Resident #1's room on 1/10/24. During an interview on 2/27/24 at 9:14 A.M., the resident's DPOA said: -The resident had a roommate change several times in the past few months and he/she was not notified of the roommate changes prior to them moving in to the resident's room. -He/She was told by staff they did not need to notify him/her if the facility was moving someone into the resident's room. -He/She was not notified verbally or in writing of the new roommate a couple months ago. He/She only knew about it because a nurse stopped him/her before he/she entered the resident's room to let him/her know there was a roommate in the room now. -He/She denied being notified verbally or in writing of the new roommate that is currently in the resident's room when that resident was moved into the room in January 2024. During an interview on 2/27/24 at 11:20 A.M., Registered Nurse (RN) A said: -He/She wrote the undated Progress Note. He/She was not sure what day it was but it was not 12/25/23 (the date on the note above his/her progress note). -He/She is not sure why he/she did not date the note, he/she was usually good about making sure notes have dates and times when written. -The resident's family member/DPOA was upset when he/she came to visit the resident because the resident had a roommate. -The resident had a semi-private room, but did not have roommates prior to that day. -He/She tried to explain to the resident's DPOA that he/she should anticipate the resident could have a roommate at any time since the resident did not have a private room. -He/She did not notify the resident's DPOA verbally or in writing the resident was getting a new roommate. -He/She would verbally notify the responsible party of resident that is being moved of a room change. -He/She would not necessarily notify the responsible party of the resident that is getting the new roommate of the change. 2. Review of Resident #2's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Progress Notes showed: -On 11/16/23 the resident's DPOA was verbally notified the resident was moving to a new room. -On 1/8/24 the resident's DPOA was verbally notified the resident was moving to a new room. -On 1/10/24 the resident was moved to the new room. Review of the resident's medical record showed no documentation of a written notification of the resident's room and/or roommate changes on 11/16/23 and 1/10/24. During an interview on 2/27/24 at 12:54 P.M. the resident's DPOA said: -The resident's case manager was given verbal notifications of any room changes. -A written notification was not received from the facility regarding room changes. 3. Review of Resident #3's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Progress Notes showed: -On 12/23/23 the resident was transferred to the hospital related to a change of condition. -On 12/28/23 the resident was readmitted to the facility in a different unit upon return from the hospital. The resident's DPOA was present for part of the admission. -On 1/1/24 the nurse called report (to the resident's previous unit) to transfer the resident to his/her room he/she occupied prior to the hospital admission. No documentation by the facility staff the resident's DPOA was notified of the new room change. Review of the resident's medical record showed no documentation of a written notification of the resident's room and/or roommate changes on 12/28/23 and 1/1/24. During an interview on 2/27/24 at 11:53 A.M., the Quality Assurance/Performance Improvement (QAPI) Manager and the Administrator said: -The resident was originally on the first floor but then was sent to the hospital in December. -When the resident returned to the facility on [DATE], he/she was positive for COVID (a new disease caused by a novel (new) coronavirus) and was admitted to a room on the second floor with Resident #1. -When Resident #3 had completed his/her COVID isolation precautions, he/she was moved back to his/her original room on the first floor. During an interview on 2/27/24 at 2:23 P.M., the resident's DPOA said he/she was not notified either verbally or in writing of the resident's transfer on 1/1/24 from the 2nd floor to the 1st floor until he/she arrived at the facility to visit the resident. During an interview on 2/27/24 at 12:43 P.M., Licensed Practical Nurse (LPN) A said: -Resident #3's spouse was at the facility and knew the resident was changing rooms on 1/1/24. -He/She did not document the resident's spouse was verbally notified of the room change since he/she was already at the facility. -He/She does not do the notifications if a resident is moving rooms, but he/she thinks that both the person who is moving and the person who is getting a new roommate are verbally notified of the room change. 4. During an interview on 2/27/24 at 1:19 P.M., the Admissions Coordinator said: -When Resident #3 was readmitted to the facility from the hospital, he/she was told to put the resident in a room with another COVID positive resident (Resident #1). -He/She called Resident #3's DPOA to let him/her know of the room change upon readmission and that it would be a temporary room move. -He/She does not notify in writing either resident/responsible party (the one moving or the one getting a roommate) of room changes. -Usually verbal notification is given to the resident/responsible party of a room change to the person who is moving from one room to another. -He/She thought staff may give verbal notification to the resident getting a new roommate. -He/She did not document verbal notification of room changes. During an interview on 2/27/24 at 1:43 P.M., the QAPI Manager said: -When Resident #3 was readmitted to the facility from the hospital, he/she was positive for COVID. -The facility decided to admit the resident in a room currently occupied with a resident positive for COVID in the same timeframe for infection control/isolation protocol purposes, so he/she was admitted to the room Resident #1 occupied. -He/She would expect staff to verbally notify the resident/resident's responsible party prior to moving a resident from one room to another in the facility. -He/She would expect staff to verbally notify the resident/resident's responsible party when they are getting a new roommate or a roommate change. -He/She would expect staff to document the verbal notifications in both resident's medical record. -He/She had not given written notifications to either party when room/roommate changes were made. -He/She was not sure if Resident #1's family/DPOA were given verbal notifications when he/she received new roommates. During an interview on 2/27/24 at 1:50 P.M., the Social Worker said: -He/She would verbally notify the resident/resident's responsible party prior to the resident moving to a new room. -He/She would expect staff to notify the resident/resident's responsible party if they were getting a new roommate. -He/She was not involved with the room changes in December 2023, he/she was out on personal leave during that incident. He/She does not know if staff notified Resident #1's DPOA of the roommate at that time. -He/She does not always notify the resident/resident's responsible party prior to a new admission being moved into the resident's room. He/She thought they should know there was a possibility of a new roommate if the resident was in a semi-private room. -He/She expected room change notifications would be documented in the resident's medical record. -He/She had not given written notifications to either party when room/roommate changes were made. During an interview on 2/27/24 at 2:45 P.M., the Administrator said: -He/She had only given verbal notifications to the resident's who are being moved when a room change occurred. -He/She was not aware the resident getting a new roommate also required notification when a new roommate was admitted to the room. -He/She was not aware a written notification when a room/roommate change occurred. MO00231605

Based on interview and record review, the facility failed to ensure a resident's discharge notification contained the correct contact information for appeal rights for one sampled resident (Resident #1) out of 5 sampled residents. The facility census was 149 residents. On 2/27/24, the Administrator was notified of the past noncompliance which occurred on 10/31/23. The facility administration was notified during the resident's appeal process that the discharge notification contact information was incorrect. Inservices were provided to staff who were involved in preparing the discharge notification notices on 11/2/23. Discharge notices sampled after 11/2/23 contained the correct contact information for the appeal process. The deficiency was corrected on 11/2/23. Review of the facility policy Transfers and Discharges/Notice of Proposed discharge date d 3/5/19 showed: -Transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations. 1. Review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's 30 day discharge notice dated 10/31/23 showed: -The notice was sent to the resident's Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) with an effective date of 11/30/23. -The notice had incorrect contact information for a hearing request for the Department of Health and Senior Services (DHSS) Appeals Unit. -The notice did not include the contact information for the Missouri Protection and Advocacy Agency as required for Medicare and Medicaid certified facility residents with developmental disabilities. Review of the resident's Appeals Hearing results notification dated 11/6/23 showed the 30 day discharge notice was dismissed due to the following reasons: -The facility did not provide the correct contact information for a hearing request for the DHSS Appeals Unit. -The notice did not include contact information for the Missouri Protection and Advocacy Agency as required for Medicare and Medicaid certified facility residents with developmental disabilities. Review of the facility's Educations Program Attendance Record dated 11/2/23 showed: -The education was titled 30 Day Notice Education. -The purpose was for the correct process for 30 day notices. -Staff who prepare 30 day notices were in attendance. -A copy of the discharge regulation with the correct contact information to be included on 30 day notice letters was attached to the education provided to the staff who attended the inservice. During an interview on 2/27/24 at 2:35 P.M. the Operations Coordinator said: -He/She received education on the correct contact information for 30 day notice letters. -He/She provided a copy of the inservice handouts. -He/She ensured the contact information on any 30 day notices given to residents and/or the resident's responsible party was correct since the time of the education. During an interview on 2/27/24 at 3:30 P.M., the Administrator said: -A 30 day notice was given to the resident's responsible party on 10/31/23. -The 30 day notice had the incorrect contact information on the letter, which was discovered during the appeals process. -The facility provided education to the staff regarding the correct contact information for a 30 day discharge letter as soon as it was discovered. MO00231618

Based on interview and record review, the facility failed to ensure psychotropic medications (medications which affect psychic function, behavior, or experience) were administered for targeted behaviors, to monitor and document the targeted behaviors, and monitor for adverse reaction for medications for two sampled residents (Resident #87 and #112) out of 32 sampled residents. The facility census was 93 residents. Review of facility policy entitled Psychotropic Medication used in Long Term Care with an approval date of 7/20/18 showed: -Residents that received psychotropic medication would have appropriate evaluation, documentation and monitoring as defined by state and federal regulations. -Residents who have not used psychotropic medications were not given them unless it is necessary to treat a specific condition as diagnosed and documented in the clinical record. -The purpose was to ensure that psychotropic medications were ordered only if medically necessary to treat a specific diagnoses and documented conditions. -Residents who received psychotropic drugs would receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue use. -Residents would have behaviors addressed in the Overall Plan of Care meeting with interventions defined by the interdisciplinary team to assist with the management of the resident's behavior. -These interventions would extend beyond medication administration and observed for side effects. 1. Review of Resident #87's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Physician's Orders Medications and Treatments showed the following physician's orders: -Olanzapine (second-generation (atypical) antipsychotic medication) five milligrams (mg) take one tablet by mouth three times a day for 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) with behaviors order dated 6/23/23. -Quetiapine Fumarate (a class of medications called atypical antipsychotics) 100 mg take one tablet by mouth every morning and at bedtime for Dementia with behaviors order dated 12/19/22. -Quetiapine Fumarate 25 mg take one tablet by mouth in the afternoon (at 2:00 P.M.) for Dementia with behaviors order dated 12/19/22. -No specific behaviors were listed. -No monitoring for side effects was ordered. Review of the resident's Medication Administration Record (MAR) dated for September showed: -The resident received Olanzapine (an atypical antipsychotics medication) five mg three times a day. -The resident received Quetiapine Fumarate (an atypical antipsychotics medication) 100 mg twice a day. -The resident received Quetiapine Fumarate 25 mg every afternoon. -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's Treatment Administration Record (TAR) dated for September 2023 showed: -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of resident's care plan dated 9/7/23 showed: -The resident was at risk for adverse reactions related to psychotropic drug use associated with treatment of behavioral disturbances associated with dementia. -Observe and record behavior/mood status. -Observe and record unexpected change in neck and body posture. -Administer medication as ordered. -No other behaviors were listed in the care plan. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment toll required to be completed by facility staff) dated 9/11/23 showed the resident: -Had a diagnosis of 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). -Had a diagnosis of Parkinson's (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait) disease. -Antipsychotic medications were received on a routine basis only. Review of the resident's MAR dated for October 2023 showed: -The resident received Olanzapine five mg three times a day. -The resident received Quetiapine Fumarate 100 mg twice a day. -The resident received Quetiapine Fumarate 25 mg every afternoon. -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's TAR dated for October 2023 showed: -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's MAR dated for November 2023 showed: -The resident received Olanzapine five mg three times a day. -The resident received Quetiapine Fumarate 100 mg twice a day. -The resident received Quetiapine Fumarate 25 mg every afternoon. -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's TAR dated for November showed: -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. 2. Review of Resident #112's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Physician's Orders Medications and Treatments showed the following physician's orders: -Quetiapine Fumarate 25 mg take one and a half tablets (37.5 mg) by mouth at bedtime for Psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning) in Parkinson's disease order dated 12/19/22. Review of the resident's MAR dated for September 2023 showed: -The resident received Olanzapine 37.5 mg at bedtime every day. -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's TAR dated for September 2023 showed: -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's annual Minimum Data Set, dated dated dated [DATE] showed the resident: -Had a diagnosis of a stroke. -Had a diagnosis of Parkinson's disease. -Antipsychotic medications were received on a routine basis only. Review of resident's care plan dated 9/18/23 showed: -The resident was at risk for adverse reactions to psychotropic drug use associated with the treatment of psychosis. -The resident would remain free from drug-related behaviors: increased cognitive impairment, low blood pressure, discomfort or abnormal involuntary muscle movement. -Observed and record behavior/mood status. Observe and record unexpected change in neck and trunk posture. -No other behaviors were documented in the care plan. Review of the resident's MAR dated for October 2023 showed: -The resident received Olanzapine 37.5 mg at bedtime every day. -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's TAR dated for October 2023 showed: -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's MAR dated for November 2023 showed: -The resident received Olanzapine 37.5 mg at bedtime every day. -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. Review of the resident's TAR dated for November 2023 showed: -There was no monitoring for behaviors documented. -There was no monitoring for side effects documented. 3. During an interview on 11/13/23 at 10:25 A.M., Licensed Practical Nurse (LPN) A said: -When the physician's order read to monitor for behaviors the order should have what the actual behaviors were that were to be monitored for. -The monitoring would be done each shift for both behaviors and adverse reactions. -This would have been charted on the MAR/TAR by the nurse. -When asked to show the surveyor the documentation he/she said he/she could not because the facility was not doing this. -When he/she saw physician's orders for medication's that said monitor for behaviors he/she should have notified the doctor that he/she needed an order to specify what behaviors were to be monitored. -He/She should have contacted the doctor and received an order to monitor for adverse reactions each shift. During an interview on 11/13/23 at 10:31 A.M., Registered Nurse (RN) A said: -The order monitoring for behaviors should have had what the actual behaviors he/she was to monitor for. -He/She would be monitoring for adverse reactions for the medications. -He/She should have notified the physician that no monitoring of behaviors or adverse reactions was being done. During an interview on 11/14/23 at 11:16 A.M., Assistant Director of Nursing (ADON) said: -He/She had been the ADON since September 2023. -The behaviors should have been listed out so the nurses would know what behaviors were to be monitored for. -If the specific behaviors were known the staf would know if the medications were effective in treating the specified behaviors. -The monitoring would be performed every shift and as needed when the behavior occurred. -Adverse reactions should have been being monitored for every shift and that would be documented on the MAR. -When the monitoring was not documented on the MAR then it would be assumed that the monitoring was not being performed. During an interview on 11/14/23 at 1:36 P.M., Director of Nursing (DON) said: -It was his/her expectation that psychotropic medication would be monitored for adverse reactions. -It was his/her expectation that the monitoring for adverse reactions would be charted on the MAR. -If the monitoring for adverse reactions was not documented then the monitoring was not done. -When an order read monitor for behaviors the behaviors needed to be listed. -The behavior monitoring would be charted on the MAR. -It was his/her expectation that all the monitoring would be done every shift at a minimum by the nurses. -It was his/her expectation that if adverse reactions to medication were noticed that the nurse would notify the doctor immediately. -It was the DON or designee responsibility to audit charts for monitoring of behaviors, physician orders, and adverse reactions. -He/She said that he/she was ultimately responsible for the auditing of these items.

Based on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided consistently with professional standards of practice by failing to obtain physician orders to monitor and maintain a peripheral intravenous catheter (a thin, flexible tube placed into a vein using a needle to allow for the administration medications, fluids and/or blood products)and to individualize a comprehensive care plan for IV therapy on one sampled resident (Resident #71) out of 32 sampled residents. The facility census was 163 residents. Review of the facility policy and procedure for Intravenous Therapy Peripheral in Long Term Care reviewed 8/2/23 showed: -Assess IV site for erythema (redness), warmth, edema (collection of fluid causing swelling), and drainage. Document per routine ongoing assessment and as needed. -Clean needleless injection cap with 70% alcohol before accessing system. Scrub the needleless injection cap and allow to dry. -Inject 2mls (milliliters) of normal saline, unless contraindicated, through saline lock after each medication given through device or at least every eight hours. -Rotate IV site every 72-96 hours. IV may be maintained in the same location for a longer period based on patient assessment and status of IV site. A physician order is required and supportive documentation must be noted in the patient medical record. -IV site dressing should be changed if the dressing becomes damp, loosened or soiled. -Administration sets and needle-less connectors are to be changed every 72-96 hours, and tubing dated with date, time and initials. -Label, date and initial IV securement device and document in the medical record. 1. Review of Resident #71's Face Sheet showed: -He/She was admitted to the facility on [DATE]. -He/She had a diagnosis of polyarthritis (having arthritis in five or more joints at the same time). Review of the resident's significant change of status Minimum Data Set (MDS- a federally mandated assessment the facility staff complete for care planning) dated 9/11/23 showed: -He/She was cognitively intact. -He/She had three pressure related skin ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin). Review of the resident's care plan revised on 10/12/23 showed no problem statement/focus area, goal or interventions/tasks related the resident's peripheral intravenous therapy. Review of the resident's Physician's Order's Medication Treatment dated 11/23 showed: -Meropenem (an antibiotic) 500 milligrams (mgs) intravenously every eight hours for 14 days dated 10/24/23 for odorous wounds. -Flush IV with 10mls of normal saline before and after antibiotic dosing dated 10/24/23. -Peripheral IV related to antibiotic dosing dated 10/24/23. --NOTE: no physician orders to monitor site, rotate peripheral IV every 72- 96 hours, cleaning of needle-less connector, changing of administration set and needle-less connectors every 72-96 hours. Observation on 11/7/23 at 10:33 A.M., showed a IV in the resident's right lower top wrist area. Dressing intact, bubble of clear fluid at insertion site of peripheral catheter, no redness or swelling of right arm. Dressing not dated. Observation on 11/9/23 at 9:22 A.M., showed a IV in the resident's right lower top wrist area. Dressing intact, bubble of clear fluid at insertion site of peripheral catheter, no redness or swelling of right arm. Dressing not dated. During an interview on 11/9/23 at 9:22 A.M., resident said: -He/She was getting antibiotic to treat his/her wounds. -He/She had not had her IV site changed since starting the antibiotic. -He/She had no pain from her IV site. During an interview on 11/14/23 at 10:33 A.M., Licensed Practical Nurse (LPN) B said: -Nursing was responsible for getting IV orders from the physician. -He/She would flush a peripheral IV with normal saline before and after administering the antibiotic and chart on antibiotic flow sheet. -He/She would include IV assessment on antibiotic flow sheet. Documentation should include IV patency, that dressing is clean, dry and intact and no signs of drainage. -He/She would date the dressing. He/she was not aware that the resident's IV dressing was not dated. -He/She was not aware of IV site needing to be rotated every 72-96 hours. -He/She was not aware that the resident had no care plan related to peripheral IV antibiotic and it would be nursing and MDS nurse responsible for updating the residents care plan. -He/She did not know where policy and procedure would be for IV therapy and would ask her nurse manager or the DON if he/she had questions. During an interview on 11/14/23 at 11:05 A.M., MDS coordinator A said: -He/She would be responsible for updating resident care plans on a quarterly basis unless a significant change has occurred. -He/She should have included the resident's peripheral IV in the care plan. During an interview on 11/14/23 at 11:27 A.M., Assistant Director of Nursing (ADON) said: -Nursing and MDS coordinator were responsible for updating resident care plans. -He/She would expect orders for a peripheral IV include, documentation of site, resident tolerance, gauge of needle used, flush orders, rotating site orders, the dressing should be dated and orders would be obtained by nursing staff and located on the nursing Medication Administration Record (MAR). -He/She was not aware the resident's care plan was not updated and orders for IV were not done. During an interview on 11/14/23 at 1:36 P.M., Director of Nursing (DON) said: -He/She would expect nursing to follow the pharmacy policy and procedures for peripheral IV's that should include, assessment, dressing changes, site rotation, flushes. -It was the floor nurse responsibility to obtain IV orders from the physician. -It was his/her responsibility or designee to audit IV orders.

Based on observation, interview and record review, the facility failed to ensure physician's orders for two sampled resident's (Resident #37 and #112) who received Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure delivered by mask to keep breathing airways open during sleep )to ensure cleansing, sanitary storage and maintenance of the resident's CPAP nasal mask, machine and supplies, to assess and document the use of the resident's CPAP, ensure the resident's Minimum Data Set (MDS- a federally mandated assessment completed by the facility for care planning) included CPAP use and care plans addressed the use of CPAP, out of 32 sampled residents. The facility census was 163 residents. A policy and procedure was requested from the facility and was not provided prior to exit. 1. Review of Resident #37's Face Sheet showed: -He/She was admitted to the facility on [DATE]. -He/She had a diagnosis of heart failure (a chronic condition in which the heart does not pump blood as well as it should). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment completed by the facility for care planning) dated 7/31/23 showed: -He/she was cognitively intact. -He/she was not using a CPAP. Review of the resident's Physician Orders, Medication and Treatments dated 11/1/23 showed: -He/she had no physician orders for CPAP that would include: --Type of equipment; --Settings; --When to administer; --Cleaning, storage, maintenance; --Diagnosis. Review of the resident's care plan last revised 11/8/23 showed no problem statement/focus area, goal or interventions/tasks related the resident's CPAP. Observation on 11/7/23 at 11:07 A.M., showed the resident's CPAP machine was on his/her bed side table with mask in his/her bed uncovered and not in a dated protective plastic bag. Observation on 11/8/23 at 10:33 A.M., showed: -He/She was sitting up in wheelchair in room. -The CPAP mask was in his/her bed uncovered and not in a dated protective bag. During an interview on 11/8/23 at 10:33 A.M., the resident said: -He/She used the CPAP every night. -He/She would put on and take off his/her nasal mask. -He/She had not ever seen facility staff clean or cover the nasal mask. -He/She did not know when the machine had been last looked at by staff and did know anything about the settings. Observation on 11/9/23 at 9:20 A.M., showed the CPAP mask was hanging off his/her bed uncovered and not in a dated protective bag. Observation on 11/13/23 at 11:06 A.M., showed the CPAP mask was on his/her bed side table uncovered and not in a dated protective bag. During an interview on 11/14/23 at 10:33 A.M., Licensed Practical Nurse (LPN) B said: -He/She would need to have an order for CPAP that would include when to wear, the settings, and the water should be changed every so often. -He/She was aware that the resident was using a CPAP. -He/She had not known there were no physician orders for the CPAP. -He/She would think the MDS coordinator would be responsible for updating the care plan, although nursing staff could also update the care plans. -He/She would think CPAP should be in the resident's care plan. -He/She would find CPAP orders in the Treatment Administration Record (TAR). During an interview on 11/14/23 at 10:49 A.M., LPN C said: -He/She would get a physician's order for residents with CPAP that included when to wear, settings, when to clean and diagnosis. -He/She would expect the CPAP would be in the MDS assessment and the resident care plan. -He/She was not aware that resident #37 had a CPAP in his/her room. During an interview on 11/14/23 at 11:05 A.M., the MDS coordinator A said: -He/She was responsible for the resident MDS assessments and care plans. -He/She would put the CPAP in the resident's MDS assessment and care plan. -He/She was not aware that resident #37 had a CPAP in his/her room. -The CPAP orders should be on the resident physician's order sheet with settings, when to wear it. -The CPAP should be cleaned and placed in a dated bagged. -The CPAP machine should be maintained and filter changed periodically. During an interview on 11/14/23 at 11:27 A.M., Assistant Director of Nursing (ADON) said: -He/She would expect the resident's CPAP would have physician orders, cleaned and placed in a dated bag when not in use, bag should be changed weekly, settings and diagnosis for use. -Nursing staff would be responsible for obtaining physician orders for CPAP use. -He/She would expect resident #37 CPAP be addressed in his/her MDS and care plan. -Nursing and the MDS coordinator are responsible for updating resident care plans. -He/She was unaware who did audits of CPAP's. During an interview on 11/14/23 at 1:36 P.M., the Director of Nursing (DON) said: -He/She would expect nursing to follow policy and procedure for CPAP use, which would include a physician order with settings, use, cleaning and how machine is maintained. -Orders for nursing staff should be on the resident Treatment administration record (TAR) for nursing to follow. -He/She would expect the MDS coordinator to update the MDS assessments and care plans. -He/She or designee would be responsible to audit CPAP's in the facility. 43345 2. Review of Resident #112's Face Sheet showed: -He/She was admitted to the facility on [DATE]. -He/She had a diagnosis of obstructive sleep apnea (occurs when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout your sleep period). Review of the resident's Quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was not using a CPAP. Review of the resident's care plan last revised 9/28/23 showed no problem statement/focus area, goal or interventions/tasks related the resident's CPAP. Review of the resident's Physician Orders, Medication and Treatments dated 10/28/23 showed: -He/She had no physician orders for CPAP that would include: --Type of equipment; --Settings; --When to administer; --Cleaning, storage, maintenance; and --Diagnosis. During an interview on 11/8/23 at 10:33 A.M., the resident stated: -He/She used the CPAP every night. -He/She would put on and take off his/her nasal mask. -He/She had not ever seen facility staff clean or cover the nasal mask. -He/She did not know when the machine had been last looked at and did know anything about the settings. During an interview on 11/14/23 at 12:25 P.M., Registered Nurse (RN) B said: -When a resident had a CPAP there would be a physician's order for the CPAP. -The order would have the settings for the machine, the cleaning schedule of the machine and mask, and when to change the filter in the machine. -The order would be the same as per the manufactures recommendations. -When the resident had a CPAP and no orders the physician would be notified and orders received for the CPAP. -The nurses were responsible to get the correct physician's orders. During an interview on 11/14/23 at 12:29 P.M., LPN A said: -The CPAP needed to have orders. -The nurses were responsible to get the correct physician's orders. -The order would include the settings, when to clean the mask, and when to change the filter. -If a resident had a CPAP, and no orders were documented for the CPAP the physician would be notified and orders received. -When asked to show the CPAP orders for the resident the LPN was unable to show where the orders was documented in the residents' chart. During an interview on 11/14/23 at 12:18 A.M., MDS Coordinator A said: -He/She was responsible for the resident MDS assessments and care plans. -He/She would put CPAP in residents MDS assessment and care plan. -When a resident used a CPAP it would be in the MDS. -CPAP orders should be on the resident physician order sheet with settings, when to wear it. -The CPAP machine should be maintained and filter changed periodically.

Based on interview and record review, the facility failed to ensure there were physician orders for hemodialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood), for monitoring the resident's fistula (a surgically created connection between a vein and artery that allows access to the bloodstream for dialysis) and for monitoring the resident after dialysis for one sampled resident (Resident #43). Additionally the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding care and services for two sampled residents (Residents #43 and #121) out of 32 sampled residents. The facility census was 163 residents. Review of the facility's Dialysis for Patients on Long Term Care (LTC) policy/procedure, dated 2/8/17 and revised 12/14/22, showed the LTC Medical Director will coordinate with the Nephrologist (a medical doctor specializing in treating diseases of the kidney) for all dialysis needs of the resident and will write orders for the dialysis procedure. 1. Review of Resident #43's Face Sheet showed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Physician's Visit note, dated 5/23/23 showed the resident was diagnosed with End Stage Renal (related to the kidneys) Disease (ESRD) and had recently started hemodialysis on Mondays, Wednesdays and Fridays. Review of the resident's most recent monthly lab report from the dialysis facility, dated 7/26/23 showed tracking of six months of lab values from February, 2023 through July, 2023. There was no monthly documentation available of dialysis labs for August, September, or October, 2023. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 9/25/23 showed: -The resident was moderately cognitively impaired. -The resident received treatment for dialysis. Review of the resident's ESRD Care Plan, dated 9/25/23 showed: -The resident received dialysis treatments three times a week. -Care precautions included no blood pressure to be taken, no intravenous or intramuscular treatments, and no restraints in the shunt (fistula) extremity. -Monitor weight and vital signs per protocol and as needed and obtain labs as ordered. -Staff were to monitor the vascular access site, including: --Monitoring the bruit (whooshing sound indicating turbulent blood flow through the blood vessel) and thrill (a vibration felt in the blood vessel). --Observing and checking the color, warmth, drainage, and bleeding to area and checking the resident for edema. Notify the physician of abnormal findings. --Remove dressing from dialysis site as ordered by physician. Review of the resident's Physician's Orders Sheet(POS), dated October, 2023 showed: -Carefully remove dressing from dialysis site on dialysis days four hours after returning to unit for skin integrity, starting 9/29/23. -There were no orders for dialysis. -There were no orders for monitoring the dialysis access site such as checking the bruit and thrill and monitoring for signs and symptoms of infection and skin problems. -There were no orders for monitoring the resident for adverse symptoms following dialysis. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated October, 2023 showed there was no documentation the facility was doing the following: -Monitoring the resident for any adverse symptoms following dialysis. -Monitoring the bruit and thrill. -Assessing and monitoring the fistula for signs and symptoms of infection or other problems. Review of the resident's most recent Hemodialysis Treatment report from the dialysis facility for the month of 10/2/23 through 11/8/23 showed values for the resident's blood pressure (the force of blood pushing against the walls of blood vessels), pre and post dialysis weights and weight changes, temperature, blood flow rate, and peripheral blood volume (amount of circulating blood). The report was dated as received by the facility on 11/9/23, after the information was requested by the surveyor. Review of the resident's record on 11/9/23 showed there was no medical information provided to the facility after each dialysis treatment. Review of the resident's POS, dated November, 2023 showed: -Carefully remove dressing from dialysis site on dialysis days four hours after returning to unit for skin integrity, starting 9/29/23. -There were no orders for dialysis. -There were no orders for monitoring the dialysis access site. -There were no orders for monitoring the resident for adverse symptoms following dialysis. Review of the resident's MAR and TAR, dated November, 2023 showed there was no documentation the facility was doing the following: -Monitoring the resident for any adverse symptoms following dialysis. -Monitoring the bruit and thrill. -Assessing and monitoring the fistula access site for signs and symptoms of infection or other problems. Review of the resident's Nephrology (pertaining to the study and treatment of kidney diseases) report, dated 11/13/23 showed a procedure of a Fistulagram (X-ray images to detect a clot or narrowing of the fistula) and/or Percutaneous Thrombectomy (insertion of a catheter (a thin, hollow tube) to the site of an embolism (blood clot) using X-ray guidance in which the catheter is used to break up or extract the embolism). During an interview on 11/8/23 at 10:32 A.M. the resident was unable to say if information or communication was brought back to the facility following treatments at the dialysis facility. During an interview on 11/14/23 at 10:33 A.M. Licensed Practical Nurse (LPN) D said: -If there were any changes to the resident's status or in the resident's medications those would be communicated over the phone. One time the dialysis center called when the resident's blood pressure medications were changed and once when they took the resident off a medication. -The dialysis center sent vital signs (determination of temperature, pulse rate, rate of breathing, and level of blood pressure) and monthly labs on a monthly basis to the facility's Medical Records department. They had never called her about the resident's labs, vital signs or weights. -The facility sent a communication sheet with the resident prior to each dialysis session showing the resident's physician, diagnosis, family contact, fall risk and transfer status, and facility charge nurse contact. The dialysis center had never sent any post dialysis information or communication back with the resident following dialysis either on the communication sheet that is sent with the resident or on any other sheet. -There were no physician orders for dialysis. -The facility nurses did not check the bruit and thrill or the fistula for signs and symptoms of infection or complications each shift or on a daily basis. They wouldn't check the bruit and thrill for a fistula. -He/She did not see an order to show how often the fistula site should be checked. -They did not document how often the fistula site is monitored. -There was an order to take the bandage off the fistula access site four hours after returning from dialysis. The charge nurse should look for signs of infection such as drainage or warmth at that time, but they did not document when they check the site. If there were problems the charge nurse would document that in the nursing notes. -The charge nurse should ask the resident about his/her level of pain, nausea, and dizziness when he/she returns from dialysis. The nurse does not document if this monitoring is being done. There were no orders for this so they wouldn't document it on the TAR. Only if there were problems would the charge nurse document. In that case, it would be charted in the nursing notes. -The charge nurse was responsible for making sure the resident had all the orders he/she needed and should let the physician know if the resident had needs that were not being addressed. -He/She couldn't recall what education he/she received from the facility related to communication with the dialysis center and cares related to dialysis. He/She would talk with his/her supervisor if he/she had questions. -The dialysis center called him/her on 11/10/23 and said the fistula was clogged. That was why it was so important to take off the fistula dressing four hours after returning to the facility. The resident had surgery yesterday to address the issue. 43345 2. Review of Resident #121's Face Sheet showed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the resident's Physician's Visit note, dated 5/23/23 showed the resident was diagnosed with ESRD and had recently started hemodialysis on Mondays, Wednesdays and Fridays. Review of the resident's most recent monthly lab report from the dialysis facility, dated 7/26/23 showed tracking of six months of lab values from February, 2023 through July, 2023. There was no monthly documentation available of dialysis labs for August, September, or October, 2023. Review of the resident's annual MDS dated [DATE] showed: -The resident was moderately cognitively impaired. -The resident was not documented to have received dialysis. Review of the resident's Care Plan, dated 8/13/23 showed: -The resident received dialysis treatments three times a week. -Care precautions included no blood pressure to be taken, no intravenous or intramuscular treatments, and no restraints in the shunt (dialysis access site) extremity. -Monitor weight and vital signs per protocol and as needed and obtain labs as ordered. -Staff were to monitor the vascular access site, including: --Monitoring the bruit (whooshing sound indicating turbulent blood flow through the blood vessel) and thrill (a vibration felt in the blood vessel). --Observing and checking the color, warmth, drainage, and bleeding to area and checking the resident for edema. Notify the physician of abnormal findings. Review of the resident's Physician's Orders Medication and Treatments, dated 10/25/23 showed: -There were orders for dialysis on Tuesday, Thursday, and Saturday. -There were orders for monitoring the dialysis fistula such as checking the bruit and thrill. -There were no orders for monitoring the site for signs and symptoms of infection and skin problems. -There were no orders for monitoring the resident for adverse symptoms following dialysis. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated September, 2023 showed there was no documentation the facility was doing the following: -Monitoring the resident for any adverse symptoms following dialysis. -Assessing and monitoring the fistula for signs and symptoms of infection or other problems. Review of the resident's MAR and TAR, dated October, 2023 showed there was no documentation the facility was doing the following: -Monitoring the resident for any adverse symptoms following dialysis. -Assessing and monitoring the fistula for signs and symptoms of infection or other problems. Review of the resident's MAR and TAR, dated November, 2023 showed there was no documentation the facility was doing the following: -Monitoring the resident for any adverse symptoms following dialysis. -Assessing and monitoring the fistula for signs and symptoms of infection or other problems. During an interview on 11/8/23 at 10:17 A.M. the resident said he/she had no problems with his/her dialysis, but was able to say that a form was sent with him/her to dialysis but was brought back to the facility following treatments at the dialysis facility. Requested dialysis communication forms from the facility on 11/9/23, because there was no documentation in the residents chart During an interview on 11/14/23 at 10:32 A.M. LPN A said: -The dialysis site was assessed prior to the resident going to dialysis and upon the residents return from dialysis and every shift. -The dialysis site was assessed for signs of infection, thrill and Brui, and bleeding. -This would have been charted in the MAR/TAR, and if findings were found outside the normal findings, it would be charted in a nursing progress note and the doctor notified. -When asked to show where this was charted the nurse could not show where it was charted. -The only charting that was being performed was for the thrill and bruit. -The night shift filled out the appointment sheet that the resident took to dialysis facility. -Nothing was received back from the dialysis facility. -There was no return communication from dialysis center about what occurred at dialysis and any recommendations the dialysis facility had. -He/She thought if the dialysis had any requests or concerns the dialysis facility would call the nurse. During an interview on 11/14/23 at 10:52 A.M., Registered Nurse (RN) B said: -The dialysis site was assessed by listening to for thrill and bruit, size of extremity, redness, and bleeding. The dialysis site was assessed every shift and documented on the TAR. -When asked to show this documentation the nurse could only show the monitoring for thrill and brui no monitoring for signs and symptoms of infection or bleeding. -An appointment sheet was filled out by the night shift and sent with the resident. The facility should have received a form back from the dialysis center with vital signs and weights and any recommendations, but no communication was received back from the dialysis center. During an interview on 11/14/23 at 11:27 A.M. the Assistant Director of Nursing (ADON) said: -There should be communication related to weights and other medical information after each dialysis visit. -Staff should be looking for signs of infection and checking the bruit and thrill. -Staff should check the bruit and thrill for the resident since he/she had a fistula. Charge nurses have been educated on how to do that. -There should be orders for dialysis and orders for cares related to dialysis such as checking for signs of infection and skin issues and checking the bruit and thrill. -Nurses should document cares related to dialysis on the MAR or TAR. During an interview on 11/14/23 at 1:36 P.M. the Director of Nursing (DON) said: -He/She thought it was common knowledge that nursing staff should check the bruit and thrill. There should be an order to do that and it should be documented on the MAR or TAR when done. -The POS should show the days the resident goes to dialysis and which dialysis facility they are going to. -Charge nurses should check the dialysis access site for signs and symptoms of infection, bleeding or other problems and document the monitoring on the MAR or TAR. -Staff receive education on writing orders, checking the bruit and thrill and looking for signs of infection twice a year in their skills education class. -If a resident had a fistula staff would check the bruit and thrill. -Communication related to pre and post weights, vital signs, labs, medications given while at the dialysis center, any new orders, and any abnormalities should be sent from the dialysis center after every appointment. Staff can always call the dialysis center to get that information. -Staff should monitor the resident after he/she returns from dialysis for problems with blood pressure, nausea, dizziness, extreme fatigue, and anything else unusual. Monitoring should be documented on the MAR or TAR. -Monitoring related to dialysis should be done every shift. -He/She was responsible for auditing the resident medications and other needs related to dialysis.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of abuse when Resident #2 who had a history of aggressive behaviors struck the resident on the side of his/her face, causing ecchymosis (bruising) and a fractured to his/her right finger out of three sampled residents. The facility census was 157 residents. Record review of the facility's Abuse and Neglect policy dated 8/1/27 showed: -The facility would prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, injury or mental anguish. -Instances of abuse of all patients, irrespective of any mental or physical condition caused physical harm, pain or mental anguish. -Willful, as used in this definition of abuse, meant an individual must have acted deliberately. -Physical abuse included hitting, slapping, pinching, kicking, etc. It also included controlling behavior through corporal punishment. -Training would be provided to all employees, through orientation and a minimum of annually. -Actions to prevent abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property would include identifying, correcting, and intervening in situations in which abuse, neglect and/or misappropriation is more likely to occur. 1. Record review of Resident #1's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic paranoid schizophrenia (a serious mental disorder that can involve abnormal interpretation of reality). -Dementia (a syndrome in which there is a deterioration of cognitive function). Record review of Resident #1's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 10/2/22 showed he/she had a Brief Interview for Mental Status (BIMS-a tool to gain a snapshot of a resident ' s cognitive functioning) score of 6 out of 15, indicating he/she had impaired cognition. Record review of Resident #1's Care Plan updated 10/1/22 showed: -He/she was at risk for alteration in behavior related to a diagnosis of paranoid schizophrenia. -He/she has hallucinations and would yell out to him/herself at times. -He/she was to remain in a safe environment with whereabouts known to staff at all times. Record review of Resident #2's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Apraxia (inability to perform particular purposive actions as a result of brain damage), following cerebral infarction (disrupted blood flow to the brain). -Hemiplegia (paralysis) following cerebral infarction affecting right non-dominant side. -Dysphasia (a disorder affecting the ability to produce and understand spoken language) following cerebral infarction. Record review of Resident #2's quarterly MDS dated [DATE] showed he/she had a BIMS score of 13 of 15, indicating he/she was cognitively intact. Record review of Resident #2's History and Physical Report dated 4/19/22 showed: -He/she had a history of throwing oranges at his/her roommate, stealing and putting oil on the floor. -He/she had a history of aggressive behaviors. Record review of Resident #2's Inpatient Progress Note from local Medical Center dated 8/19/22 showed: -He/she had a history of throwing oranges at his/her roommate, stealing and putting oil on the floor. -He/she had a history of aggressive behaviors and stealing items. Record review of Resident #2's Progress Notes dated 11/29/22 showed: -On the day shift, the nurse was informed in report that the resident was abusive to his/her roommate. -The resident and his/her roommate were separated on different units in the early morning, prior to the shift change. -The Nurse Practitioner (NP) was notified of the resident's increased agitated behavior. -The NP tried to talk with the resident, but he/she became aggressive and tried to swing his/her hands at the NP. -The resident was placed on 1:1 observation. -Due to increased behaviors and refusal to let staff assist him/her, the resident was sent to the local emergency room accompanied by hospital security at 10:55 A.M. Record review of Resident #1's Emergency Department (ED) Final Note dated 11/29/22 showed: -The resident was assaulted by another resident. -He/she had been struck near his/her right eye while trying to block the blow with his/her right hand. -There was no loss of consciousness. -Pain was mild and localized to the sites of the injuries. -There was ecchymosis over the right zygoma (bony arch of the cheek) and to his/her lateral right eyelids. -There was ecchymosis to his/her right hand, especially his/her fifth finger. -There was a fracture to his/her fifth finger, which was splinted. -The resident was to return to long term care. Record review of the facility incident investigation dated 11/29/22 showed: -Resident #1 said Resident #2 came to his/her side of the bed and hit Resident #1 with something three times. -Resident #1 raised his/her hand to protect his/her face and his/her hand was hit at that time. -Resident #1 had not called the nurse because he/she knew the nurses were busy. Resident #1 described an object about the size of a shoe Resident #2 had hit him/her with. -Resident #1 said nothing happened to provoke the event. -Resident #2 said he/she did not know why he/she hit Resident #1. Resident #2 was not upset about anything. -Licensed Practical Nurse (LPN) B said he/she was working as a Certified Nursing Assistant (CNA) on the hall. -He/she was doing 1:00 A.M. rounds and performed cares on Resident #1 and noted the bruising to Resident #1's right eye and his/her right 4th and 5th digits. -Resident #1 was asleep but he/she woke Resident #1 up and asked what happened. -Resident #1 said Resident #2 hit him/her. -LPN E called the Director of Nursing (DON) at 1:30 A.M. on 11/29/22 and reported observation of bruising on Resident #1's right and 4th and 5th digits, and Resident #2 hit Resident #1. -The Social Worker (SW) said Resident #2's behavior had been more aggressive toward the staff, and Resident #2 was known to curse out the staff on occasion. -Direction was given to LPN B during the 1:30 A.M. phone call to notify the doctor and family and request Resident #1 be sent to the ED for examination. -Staff remained with Resident #1 until he/she was taken to the ED. -In the ED, it was found that Resident #1 had a fracture to his/her 5th digit, which was splinted. -Resident #1 was sent back from the ED and taken to a different unit in order to keep the two residents separated. -After Resident #1 was taken to the ED, Resident #2 remained asleep in his/her room throughout the night and did not leave his/her room. -The next morning, 1:1 observation was provided to Resident #2 until an order was received to have him/her sent to the ED for psychiatric examination. - A psychiatric evaluation was performed and it was concluded Resident #2 did not meet criteria for in-patient psychiatric treatment. An order for Haldol (antipsychotic) 5 milligram (mg) as needed (PRN) for agitation was recommended. -Resident #2 was noted to have thrown oranges at Resident #1 in the spring of 2022. During an interview on 11/29/22 at 11:30 A.M., the DON said: -Resident #1 said Resident #2 had come over to his/her side of the room, to his/her bed, and hit him/her three times. -Resident #1 put his/her hand up to protect his/her head and block the hits. -When Resident #1 came back from the ED, he/she was moved to another unit. -Resident #2 was aphasic (impairment of ability to use words). -Resident #2 hit Resident #1 with a shoe. -Resident #2 had aggressive behaviors with staff during cares. -This was the first time Resident #2 had hit Resident #1, although Resident #2 had thrown bed pads at Resident #1. -Resident #1 had never provoked anyone and said nothing to provoke this incident. -If Resident #2 had thrown oranges, bed pads,put lotion or oil on the floor then a behavior note should have been written, and the DON or social Worker should get copies. -Aggressive behavior should be noted in the care plan with updated interventions. Observation on 11/29/22 at 12:30 P.M. showed: -Resident #1's right hand, small finger was splinted. -Resident #1 had some right hand swelling with dark and discolored area on side of his/her hand with some bandaging. -Resident #1 had a darkened, discolored area on his/her right side of his/her face from below the eye socket up to his/her eye, under eye, on the eyelid and above the eyelid to the eyebrow. During an interview on 11/29/22 at 12:30 P.M., Resident #1 said: -Resident #2 came over to his/her bed and hit him/her. -He/she was awake at the time. -He/she did not know what his/her roommate hit him/her with, that it was something plastic. -He/she used his/her hand to shield his/her face. -They had been on good terms prior to this and had not been arguing. -Resident #2 had been mean to him/her before and threw candy at him/her because he/she was angry. -He/she did not know why Resident #2 was angry. -That happened in the dining room and other people saw it. -He/she did not tell anybody about his/her roommate hitting him/her the previous night because it was a simple thing and not a big deal. -He/she did not hit back or scream, but just told Resident #2 to, stop already, why don't you stop? -Resident #2 did not yell or shout at him/her when he/she was hitting him/her. -When he/she said that, Resident #2 stopped hitting him/her. -He/she did not think Resident #2 wanted to be his/her roommate any longer. -He/she felt safer when Resident #2 was not his/her roommate, and now that his/her roommate was moved, he/she felt safe. During an interview on 11/29/22 at 2:05 P.M., LPN B said: -He/she was the one who reported the latest incident between the residents. -He/she was [NAME] morning rounds and came to their room around 1:30 A.M. -Resident #1 was asleep and he/she woke him/her to provide cares. -He/she noticed Resident #1 had a bruise on his/her face. -He/she asked Resident #1 what happened and Resident #1 said Resident #2 hit him/her. -He/she assessed Resident #1 and noticed bruising on his/her hand, as well as on his/her 4th and 5th fingers. -He/she did not feel comfortable leaving Resident #1 in that room, so when he/she came back from the ED at about 5:00 A.M., they got report and moved Resident #1 to another unit. -Resident #1 did not know what he/she was hit with. -Resident #2 stayed asleep the whole time and was still asleep when he/she went home that morning. -He/she had heard Resident #2 hit Resident #1 with oranges several times, but had not heard of him/her being aggressive with staff or other residents. During an interview on 11/29/22 at 2:35 P.M., LPN D said: -One of the CNAs told him/her about the incident with Resident #2 throwing the oranges, which happened several months ago. -He/she was not present for this, but was told about it after he/she went home. -The Social Worker was told about this and they talked to the resident about it. -There was another incident where the resident threw washcloths and bed pads at Resident #1. -He/she took Resident #2 out of the room and talked to him/her. -The resident understood what he/she was doing. -He/she had heard Resident #2 got mad at Resident #1 for keeping lights on. -Resident #2 got upset with CNA C and struck out at him/her. -Resident #2 was upset because he/she was told not to unplug Resident #1's radio. -Changing the two residents' rooms had been discussed in the past, but nothing had been done about it. During an interview on 11/29/22 at 2:45 P.M., Resident #2 said: -He/she did not know why he/she got mad at his/her roommate. -He/she had been angry at his/her roommate at the time. -He/she did not want to hit him/her again. -He/she felt bad he/she did it. -He/she remembered throwing oranges at his/her roommate, but did not remember why. -He/she did not remember throwing candy at his/her roommate. -He/she remembered hitting CNA C. He/she didn't like him/her and did not want him/her in the room. -He/she did not remember putting oil, water or lotion on the floor. -He/she did not like it when his/her roommate played music or talked to him/herself. -He/she would like a quieter roommate. -He/she would not hit another roommate, but he/she would hit Resident #1 again. -He/she knew it was not a good idea to hit people. -He/she hit his/her roommate with a shoe. During an interview on 11/29/22 at 3:00 P.M., the facility Medical Director said: -He/she was aware of Resident #2's history of past aggression. -There was concern about Resident #1 being in proximity of Resident #2. During an interview on 11/30/22 at 10:57 A.M., LPN E said: -At 1:00 A.M., staff were doing round and it was noted Resident #1's right eye was red and swollen, and his/her hand and last two fingers were swollen and bruised. -Resident #1 said Resident #2 hit him/her. -Resident #1 could not state what he/she had been hit with. During an interview on 11/30/22 at 3:08 P.M., the Nurse Practitioner said: -He/she was not aware of Resident #2's previous aggressive behaviors toward Resident #1. -This had not been brought to the physician's attention. -In the past, the facility staff had consulted psychiatry in April or May of this year, due to Resident #2's aggression toward staff and depression. MO00210485

Based on interview and record review, the facility failed to updated one sampled resident's (Resident #2) careplan to reflect their current care needs out of three sampled residents. The facility census was 157 residents. 1. Record review of Resident #2's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Apraxia (inability to perform particular purposive actions as a result of brain damage), following cerebral infarction (disrupted blood flow to the brain). -Hemiplegia (paralysis) following cerebral infarction affecting right non-dominant side. -Dysphasia (a disorder affecting the ability to produce and understand spoken language) following cerebral infarction. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 9/1/22 showed he/she had a Brief Interview for Mental Status (BIMS-a tool to gain a snapshot of a resident ' s cognitive functioning) score of 13 of 15, indicating he/she was cognitively intact. Record review of the resident's Care Plan updated 11/28/22 showed no identification of his/her past or present aggressive behaviors. Record review of the resident's History and Physical Report dated 4/19/22 showed: -He/she had a history of throwing oranges at his/her roommate, stealing and putting oil on the floor. -He/she had a history of aggressive behaviors. Record review of the resident's Inpatient Progress Note from local Medical Center dated 8/19/22 showed: -He/she had a history of throwing oranges at his/her roommate, stealing and putting oil on the floor. -He/she had a history of aggressive behaviors and stealing items. Record review of the resident's Progress Notes dated 11/29/22 showed: -On the day shift, the nurse was informed in report that the resident was abusive to his/her roommate. -The resident and his/her roommate were separated on different units in the early morning, prior to the shift change. -The Nurse Practitioner (NP) was notified of the resident's increased agitated behavior. -The NP tried to talk with the resident, but he/she became aggressive and tried to swing his/her hands at the NP. -The resident was placed on 1:1 observation. -Due to increased behaviors and refusal to let staff assist him/her, the resident was sent to the local emergency room accompanied by hospital security at 10:55 A.M. During an interview on 11/29/22 at 11:30 A.M., the Director of Nursing (DON)said: -Resident #2 had went over to his/her roommate side of the room, to the roommate bed, and hit his/her roommate three times. -Resident #2 was aphasic, (impairment of ability to use words). -Resident #2 had a history of aggressive behaviors with staff during cares. -This was the first time Resident #2 had hit his/her roommate, although the resident had thrown bed pads at his/her roommate. -If Resident #2 had thrown oranges, bed pads, put lotion or oil on the floor and or was aggressive with staff a behavior note should have been written, and the DON or Social Worker should get copies. -Aggressive behavior should be noted in the care plan with updated interventions. During an interview on 11/29/22 at 1:00 P.M., Certified Nursing Assistant (CNA) A said: -Resident #2 could get aggressive and had previously hit at staff. -He/she caught Resident #2 throwing oranges at his/her roommate in their room. -Resident #2 wanted his/her roommate to be quiet and started throwing the fruit. -He/she took the fruit away from Resident #2 and reported the incident immediately to Licensed Practical Nurse (LPN) D. -He/she charted the incident and talked to Resident #2 about his/her behavior. -Resident #2 did not say why he/she threw the fruit and when asked about it only said, I don't know. -Resident #2 would hide fruit in his/her chair to take to his/her room, so they had to ask the dietary department to put the fruit in an area where he/she could not get to it. -Resident #2 would also put baby oil or lotion on the floor so the staff would slip. -This was reported to LPN D immediately, and he/she charted it. -Resident #2 would get angry at his/her roommate for keeping the light on. -Staff would leave their room door open so they could keep an eye on the residents, and Resident #2 would sneak it shut and block it with the bathroom door, so he/she would hear it if staff came in. -Staff had previously discussed a room change to separate the two residents, but at the time, the facility was full, so there was no place to move one of them. -In around October 2022, CNA C caught Resident #2 pulling Resident #1's radio cord out of the wall because he/she wanted the radio turned off. -CNA C told Resident #2 he/she should not do this, so he/she blocked CNA C from leaving the room and hit him/her on his/her arm. -This was also reported to LPN D. During an interview on 11/29/22 at 1:25 P.M., Registered Nurse (RN) B said: -He/she chatted with Resident #2 and it would calm him/her down. -If a staff person saw any aggressive behavior from a resident, he/she should tell the charge nurse who would notify the Social Worker, the DON, the Administrator, the doctor and the family. During an interview on 11/29/22 at 2:20 P.M., the Social Worker said: -Resident #2 usually got more upset with staff, not other residents. -Resident #2 liked to take other people's things and would get angry if they were taken back. -He/she was aware that Resident #2 had cursed out some staff. -He/she was aware Resident #2 yelled at his/her roommate. -The whole resident care team was responsible for putting things on the care plans. During an interview on 11/29/22 at 2:30 P.M., LPN C said the MDS Coordinator would be responsible for putting things in the resident care plans. During an interview on 11/29/22 at 3:00 P.M., the facility Medical Director said: -He/she was aware of Resident #2's history of past aggression. -There was concern about the roommate being in proximity of Resident #2. -Resident #2's behaviors had been addressed with the nursing staff. -They were in the process of trying to figure out how to appropriately manage Resident #2, which had been a challenge due to the randomness of his/her behaviors. -If there had been room availability, it would have been appropriate to make a room change with one of the residents. -He/she would expect resident behaviors to be in care plans and that staff are appropriately trained to handle them. During an interview with the facility chief operating officer, the Administrator and the DON on 11/30/22 at 1:55 P.M., the DON said: -His/her expectation was that any prior incidents of aggression by Resident #2 should have been addressed in his/her care plan and the room change should have been done if indicated. -At the time of the incident with the oranges, staff could have separated the residents and created interventions for Resident #2's behaviors. -They could have worked with the physicians, including psychiatry, to develop and formalize a plan of care plan for him/her. -If they were not able to deescalate the resident's behaviors, they would have to come up with other solutions, like medication changes or possibly giving the resident a 30-day notice of discharge. -Every Friday the staff meet to discuss resident behaviors so that interventions can be implemented, including weekends and going forward. -Nothing regarding Resident #2 had been brought up in regard to his/her aggressive behaviors. -These prior incidents should have been brought up in the meeting and with risk management. During an interview on 11/30/22 at 3:08 P.M., the NP said: -He/she was not aware of Resident #2's previous aggressive behaviors toward his/her roommate. -This had not been brought to the physician's attention. -In the past, they had consulted psychiatry in April or May of this year, due to Resident #2's aggression toward staff and depression. -The only concern brought to his/her attention was Resident #2's wandering during the night. They wanted to put a guard for wandering on him/her, but he/she did not want it. -The resident felt he/she was still independent. -He/she followed up with Resident #2 that morning, and he/she did not remember the incident. -They would definitely follow with psychiatry regarding his/her behaviors. -If staff were aware of his/her aggressive behaviors, it should have been care planned. -He/she would expect the two residents would have been separated into different rooms, a psychiatric consult done on Resident #2, a medication review done and a determination made if it was in the resident's best interest to remain at the facility, if she posed a risk to herself or others. -He/she would expect the resident to be monitored closely, and probably placed in a room by him/herself. MO00210485

Based on interview and record review, the facility failed to follow facility policies and procedures for checking the nurse aide registry on all newly hired employees in accordance with federal requirements prior to employing four of nine employees sampled for the background screening process. The facility census was 171 residents. Record review of the facility's Abuse and Neglect policy and procedure dated 8/1/17, showed the purpose was to ensure facility staff was doing all that is within their power to prevent occurrences of abuse, mistreatment, exploitation, involuntary seclusion, injuries of unknown origin and misappropriation of property for all patients. It showed: -The facility will screen potential employees for a history of abuse, neglect, or mistreating patients, including checking with the appropriate licensing boards and registries. 1. Record review of the following employee records showed: -Certified Nursing Aide (CNA) F was hired on 7/7/21. There was no evidence to show the Nurse Aide Registry Check was completed. -Certified Medication Technician (CMT) D was hired on 10/25/21. There was no evidence to show the Nurse Aide Registry Check was completed. -Rehabilitative Aide A was hired on 10/25/21. There was no evidence to show the Nurse Aide Registry Check was completed. -Maintenance Worker A was hired on 3/21/22. There was no evidence to show the Nurse Aide Registry Check was completed. -Maintenance Worker B was hired on 7/12/21. There was no evidence to show the Nurse Aide Registry Check was completed. During an interview on 3/25/22 at 4:45 P.M., the Administrator said the background screening process should include completing the nurse aide registry for all employees to include staff who are not in nursing.

Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #1) was free from abuse, when a Certified Medication Technician (CMT) sexually abused the resident. The facility census was 121. 1. Record review of the facility's Abuse and Neglect policy, dated 11/1/16, showed the facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. The facility will implement an abuse prohibition program through the following: -Screening of potential hires; -Training of employees and ongoing training for all employees; -Prevention of occurrences; -Identification of possible incidents or allegations which need investigation; -Investigations of incidents and allegations; -Protection of patients during investigations; -Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. Record review of Resident #1's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Depression; -[MEDICAL CONDITION]; -Behavioral disturbance secondary to dementia; -[MEDICAL CONDITION] Dementia with depressive features (a group of conditions that cause a decline in cognitive skills caused by a blockage or lack of blood flow to the brain). Record review of the resident's History and Physical, dated 12/13/16, showed the resident's physician assessed the resident as: - [DIAGNOSES REDACTED]. - Non-verbal and did not follow commands; - Did not respond when questioned, but did look at the examiner. Record review of an addendum to the History and Physical, dated 12/14/16, showed Physician A documented the resident: -Was very confused, was transferred by two staff, used a Broda chair (tilt and recline positioning wheelchair) for seating, and was fed by staff; -Was unable to participate in group activities; -Was alert, calm, very confused, non-verbal, with a [MEDICATION NAME] affect (a reduction in the intensity of an individual's emotional response); -Had poor cooperation with the strength exam, and had rigidity of all four extremities. Record review of the resident's Progress Note, dated 5/1/17, showed staff documented: - He/she required total assistance with cares and required assistance with feeding; - He/she was non-verbal to any questions and was not alert and not oriented; - He/she had severe dementia and was unable to follow commands; - No verbal or significant non-verbal response. Record review of the resident's care plan, dated 5/16/17, showed staff documented: -He/she had a history of [REDACTED]. -He/she was alert and oriented to self only and was at risk for self-care deficits related to physical and cognitive limitations; -He/she had cognitive deficits related to dementia, Alzheimer's type. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff and used for care planning, dated 7/10/17, showed staff assessed the resident as: -Severely impaired cognitive skills for daily decision-making; -Totally dependent on two or more staff members for bed mobility, transferring, bathing, personal hygiene and dressing; -Required extensive assistance of one staff member for eating; -Incontinent of both bowel and bladder; -Had all of his/her teeth intact. Record review of a witness statement, dated 7/28/17, showed Certified Nurses Aide (CNA) A documented: -At 8:10 P.M., he/she was putting another resident to bed when Certified Medication Technician (CMT) A walked in and told him/her to check on another resident; -As he/she exited the other resident's room, he/she saw Resident #1's room lights were on and the door halfway cracked open. He/she knew that he/she already shut the door and turned off the lights in that room; -He/she entered the room and found CMT A standing over the resident's bed sexually assaulting the resident; -He/she said to CMT A, what the hell is going on here?; -CNA A left the room and turned back around to take a second look; -CNA A told CNA B to go to the resident's room and confirm what he/she just witnessed; -As CNA B walked down the hall, CMT A left the resident's room; -At about 8:15 P.M., CMT A approached CNA A and tried to tell him/her he/she needed to keep quiet about what he/she just saw; -CNA A told CMT A that he/she will not keep quiet about what he/she saw. At this point he/she feared CMT A might harm him/her; -CNA A called CNA B into a room to assist him/her even though he/she didn't need help, just so CMT A wouldn't approach him/her anymore; -Licensed Practical Nurse (LPN) B came in the room with CNA A and CNA B; -CNA A told LPN B everything he/she witnessed with CMT A; -CNA A told LPN B he/she feared CMT A would do something to him/her, that security needed to be called and CMT A needed to be removed as soon as possible; -The first chance CNA A had to be out of CMT A's sight, he/she went to the second floor to inform LPN A of the situation. Record review of a witness statement, dated 7/28/17 at 8:30 P.M., showed LPN B documented: -While doing blood sugars on 3 North, CNA A pulled him/her into a room and shut the door; -CNA A proceeded to explain that CMT A was literally caught sexually assaulting the resident; -LPN B immediately stopped what he/she was doing and called CMT A into the hospice room and before LPN B could even ask CMT A if this was true, he/she admitted to it, saying that he/she has had this problem for a while; -LPN B immediately made CMT A clock out and explained that if he/she saw CMT A again, he/she would have to call security; -LPN B then called the Assistant Director of Nursing (ADON) to report the incident. Record review of a second witness statement written by LPN B, dated 7/28/17 at 8:30 P.M., showed he/she documented: -He/she immediately went into the resident's room and assessed him/her after he/she was made aware of the incident; -The resident appeared to be resting peacefully with eyes closed, without any signs or symptoms of distress or trauma noted; -The resident's roommate appeared to be resting peacefully with eyes closed and without any signs and symptoms of distress or trauma. Record review of a written statement, dated 7/28/17 at 8:30 P.M., showed LPN A documented: -CNA A reported that he/she witnessed CMT A sexually assaulting Resident #1; -CNA A reported that CMT A immediately kind of laughed; -CNA A said he/she backed away horrified that he/she just saw this taking place; -CNA A said CMT A told him/her not to tell, that he/she would do anything; -CNA A said he/she reported the incident to LPN B; -CNA A said CMT A followed him/her around the unit begging him/her not to tell; -CNA A was fearful of CMT A, so he/she left the unit and came to 2 North to report to LPN A; -Upon hearing this, LPN A asked CNA A to come to the nurses station and write out his/her statement; -LPN A immediately notified the Director of Nursing (DON); -LPN A said CNA A also notified him/her that he/she asked CNA B to check on the resident. Observation on 7/31/17 at 4:00 P.M., showed: -The resident lay on his/her back in bed and the bed was in the low position; -His/her eyes were open and he/she stared at the corner of the room near the ceiling; -He/she did not respond to verbal stimuli. During an interview on 7/31/17 at 3:00 P.M., the Administrator said: -The incident happened on 7/28/17 at 8:10 P.M., on 3 North; -On 7/28/17 at 8:20 P.M., LPN A called the DON and placed CNA A on the phone to explain the incident; -CNA A reported he/she saw CMT A sexually assaulting the resident; -CNA A asked CNA B to check on the resident, reported the incident to LPN B and then to LPN A; -On 7/28/17 at 8:40 P.M., the DON notified the Administrator; -On 7/28/17 at 10:28 P.M., the Administrator reported the incident to the Elder Abuse and Neglect Hotline. During an interview on 7/31/17 at 3:20 P.M., Medical Director A said: -The facility administrator notified him/her of the incident the morning of 7/31/17 between 8:30 A.M. and 9:00 A.M.; -He/she knew the alleged perpetrator and never had any issues with him/her in the past and was shocked at what he/she had done; -The resident first came to the facility to the locked unit as he/she was an elopement risk upon admission; -The resident was never able to speak, but he/she was able to walk up until a year ago; -The resident was currently unable to speak, walk, eat or do any of his/her daily activities without assistance and required total care from the facility staff; -The resident was unable to follow commands; -The resident was incapable of consenting to any type of sexual activity. During an interview on 7/31/17 at 3:30 P.M., LPN A said on 7/28/17 between 8:20 P.M. and 8:25 P.M., CNA A came to 2 North to talk to him/her and said it was very important. CNA A started to cry and reported the following to LPN A: -CNA A said he/she walked in the resident's room; -CNA A saw CMT A sexually assaulting the resident; -CNA A said CMT A turned and saw him/her, chuckled and said, You caught me; -CNA A said that he/she was horrified and shocked and backed up, then went forward again; -CMT A said to CNA A, please don't tell anyone, I will do anything you want; -CNA A said he/she then left the room and told CNA B, who was at the nurses station, to check on the resident; -CNA A said that CMT A followed him/her around the unit asking him/her not to tell; -CNA A said he/she told LPN B before he/she came to tell LPN A, because he/she was fearful of being on the same floor as CMT A; -LPN A immediately took CNA A to write his/her account of the events and called the DON; -LPN A said he/she believed CNA A without a doubt; -LPN A said CNA A was concerned about his/her safety and his/her job; -LPN A reported it to the DON, who told him/her there is no need to call security or the nursing supervisor. During an interview on 7/31/17 at 4:45 P.M., CNA A said: -He/she clocked in at 7:20 P.M. on 7/28/17 and received his/her assignment from LPN B; -He/she made rounds on the residents; -As he/she made rounds, everyone was in bed except Resident #3 and Resident #1; -He/she continued working, doing vital signs, turning off lights and shutting doors; -At 7:55 P.M., he/she walked back to Resident #1's room, because the call light was going off; -CMT A told CNA A to put another resident to bed; -He/she put that resident to bed and proceeded to give another resident care; -He/she then walked back into Resident #1's room because the call light was on; -When he/she entered the room, he/she saw CMT A sexually assaulting the resident; -CMT A did not hear or see CNA A and did not know CNA A was there; -CNA A said What the hell are you doing?; -CNA A said CMT A turned and saw him/her, chuckled and said, You caught me; -CNA A said that he/she was horrified and shocked and backed up, then went forward again; -CMT A said to CNA A, Please don't tell anyone, I will do anything you want; -CMT A kept apologizing; -CNA A left the resident's room and told CNA B (who was at the nurses station) to go down to the room to verify what he/she saw, but at that same time, CMT A came walking out of the resident's room wiping his/her hands with a paper towel; -CMT A came up behind him/her and told him/her to keep quiet about what he/she saw; -CMT A followed CNA A and kept trying to bribe him/her; -CNA A said he/she was getting scared at this point; -He/she asked CNA B to assist him/her with another resident, so that CMT A would not come in the room with him/her, and would leave CNA A alone; -LPN B walked in the room and CNA A told him/her about the incident; -LPN B said he/she would handle it; -CNA A then went down to the second floor and told LPN A, who then made calls to those he/she was supposed to call. During an interview on 7/31/17 at 5:20 P.M., LPN B said: -He/she was preparing for night time blood sugar testing when he/she noticed CNA A and CNA B entered a room together sometime after 8:00 P.M., on 7/28/17; -He/she decided to follow them and once inside the vacant resident room, CNA A informed LPN B of the following: --CNA A said he/she noticed that Resident #1's light was on and the door was slightly open; --CNA A said he/she was in that room earlier and knew the light was turned off and the door shut, so he/she went to check on the resident; --When CNA A entered the resident's room, he/she saw CMT A sexually assaulting the resident; -LPN B was shocked and immediately went to find CMT A; -Once LPN B located CMT A, he/she started to question CMT A; -Before LPN B could ask CMT A what happened, CMT A said, It's true, I have had this problem for a while; -LPN B immediately told CMT A to get out of the building and proceeded to follow CMT A to get his/her backpack and leave the building; -LPN B saw CMT A re-enter the building a few minutes later and said he/she lost his/her keys; -LPN B once again told him/her to get out; -LPN B then called security to make sure that CMT A actually left the grounds; -Security called back soon after and said they did not see CMT A's car in the parking lot any longer; -LPN B then called the ADON to notify him/her of the incident. During an interview on 7/31/17 at 6:05 P.M., CNA B said: -He/she was sitting at the nurse's station when CNA A approached him/her; -CNA A told him/her that the light was on in the resident's room and the door was slightly open, so CNA A went to check on the resident; -When he/she entered the room, he/she saw CMT A sexually assaulting the resident; -CNA A told CNA B that he/she was running to tell the charge nurse what he/she saw; -CNA B did not personally see anything that happened. MO 113, MO 138 At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began immediately training the staff on identifying, assessing, reporting and putting interventions in place to protect and monitor residents. The facility conducted front line staff interviews to determine if any other residents were at risk. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to a D level.

Based on observation, interview and record review, the facility staff failed to adequately monitor one sampled resident (Resident #4) with a history of falls and reevaluate the resident when he/she was noncompliant with staff interventions, resulting in an avoidable fall that resulted in a significant injury; ensure fall investigation documentation was complete and comprehensive to include identifying the root cause for two sampled residents (Resident #14 and #4); ensure nursing staff completed post fall follow-up monitoring documentation in the medical record for 72 hours for three sampled residents (Resident #10, #14 and #16); and ensure the care plan was updated with current fall interventions for three sampled residents (Resident #4, #10 and #14) out of 23 sampled residents. The facility census was 171 residents. Record review of facility policy dated 6/25/10, approved by the long term care Administrator, Medical Director and the Director of Nursing (DON) read: -All residents will have ongoing assessment for the risk of falling and interventions implemented to minimize the risk of falling. In the event of fall, guidelines will be followed by the long term care personnel. The purpose is to ensure the safety of residents by assessing and implementing interventions to reduce the potential for falls and injuries. It is also to provide a guideline for prompt assessment and interventions in the he event of a fall. By definition a fall is an event that results in the resident, or any part(s) of the resident's body coming to rest inadvertently on the floor or other surface; including any event where a resident is lowered to the floor by a staff member, or found on the floor and staff unable to account for his/her situation; -A resident will be assessed by a fall team to determine if they need to be placed on a fall program upon admission, quarterly and after any fall; -An assessment following a fall is to include the charge nurse to assess the resident for injury before moving and complete a full assessment. Neurological checks, vital signs and documentation is expected, along with the notification of the physician and implementation of orders. The nursing notes should include: -A description of the fall; -Position of patient when found; -Patient complaints; -A total assessment of the patient; -Any signs of injury and intervention; -Vital signs; and -Notification of the physician by name and any orders. -Documentation should be on the 24-hour report and be followed up on by the nurse for 72 hours; -Falls should be notified to the DON, Assistant Director of Nursing (ADON) and Registered Nurse (RN) weekend manager or Administrator; -Documentation should be made on the individual care plan by the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff and used for care planning) Coordinator or designee. 1. Record review of Resident #4's Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Care Plan dated 3/4/15, showed he/she had a cognitive deficit due to Alzheimer's disease, self care deficits and incontinence. It showed he/she ambulated with his/her walker independently but needed two persons to assist him/her to walk with his/her walker and with transfers, he/she used a wheelchair for long distances, nursing staff had to provide total assistance for toileting, and he/she had a fall potential due to his/her cognitive and physical impairments and use of psychotropic medications. Interventions instructed staff to: -Administer medications as ordered; -Encourage the resident to use assistive devices and handrails in the bathroom; -Keep the resident's personal belongings within his/her reach and keep his/her room/hallways free from clutter; -Ensure the resident had on proper footwear when he/she was out of his/her bed; -Provide an eye exam and rehabilitative therapy evaluation and treatment as ordered; -Allow the resident to wander in a safe environment; -Provide a scoop overlay mattress to his/her bed; -Ensure his/her alarms were on when he/she was in bed and while seated; -An update dated 4/7/15, showed the resident had a non-injury fall while at the nursing station annex due to sliding out of a reclining chair, and nursing staff would ambulate with the resident for 60 to 90 minutes when sitting while awake because the resident would sometimes attempt to stand and ambulate (without assistance) due to restlessness. Record review of the resident's Medical Record showed no MDS completed before 5/6/15. Record review of the resident's Fall Investigation dated 4/8/15, showed: -At 2:50 P.M., the resident was found laying on his/her right side in the television room with his/her head bent forward and his/her hands behind the back of his/her head. He/she was unable to explain what happened due to his/her dementia; -The incident huddle showed the resident was non-compliant and had an unsteady gait. He/she was not trying to go to the bathroom and was last toileted at 2:00 P.M. It showed the resident tried to transfer himself/herself independently. It also showed the resident had a recent fall history, was at high risk for falls, and did not have a physician's orders [REDACTED]. The resident's physician and responsible party were notified; -The resident's fall risk score was 11 (a score of 10 or above represented a high fall risk); -Results of the fall huddle showed the resident was on the fall program; there were physician's orders [REDACTED]. It showed the resident liked sitting in the television/day room to watch television in one of the recliners. The resident was capable of getting himself/herself up and ambulating with his/her roller walker, which helped to steady him/her since he/she tired easily and becomes weak. It showed staff would monitor the resident and try to redirect his/her unsafe behavior. Record review of the resident's Care Plan showed: -An update dated 4/8/15, showed the resident had a non-injury fall on 4/8/15 at 2:50 P.M., in the television room and he/she was found laying on his/her right side. It showed the resident's fall interventions were in place at the time of his/her fall and nursing staff had last toileted the resident at 2:00 P.M. Staff was educated on monitoring the resident every 30 minutes while he/she was awake and to keep him/her in sight at the nursing station; -The care plan did not show the resident was non-compliant with any of the interventions in place to prevent falls (frequently removing the clip alarm), and did not show how the staff would monitor the resident while he/she was sitting in the recliner to try to prevent him/her from falling since they were aware the resident would take the clip alarm off frequently and try to ambulate independently without assistance. Record review of the resident's Nursing Notes showed: -No nursing summary documented after the resident fell on [DATE], and there were no nursing post fall monitoring notes on 4/9/15; -On 4/10/15, the resident was using the wheelchair this morning as he/she refused to ambulate, but then got up unassisted and ambulated with one staff assisting to and from lunch. Nursing staff were documenting the resident's post fall monitoring; -On 4/11/15 at 6:29 A.M., the resident became agitated during care and was unable to bear any weight. Nursing staff used a wheelchair to transfer the resident. The resident calmed and nursing staff was able to complete his/her care. Nursing staff completed the resident's post fall monitoring; -On 4/11/15 at 11:30 P.M., the resident continued to have weak and unsteady gait. He/she ambulated with his/her roller walker and one to two nursing staff assisting. At times the resident would refuse to bear weight and was rolled to bed while sitting on the seat of his/her walker. The resident's posture was noted to be left leaning and the resident had moderate tremors of the upper extremities. He/she was cooperative with care and denied pain; -On 4/14/15 during the 7:00 A.M. to 3:00 P.M. shift, the resident did not ambulate and had increased confusion; -There were no nursing notes from 4/14/15 to 5/1/15. Record review of the resident's Physician's Telephone Orders dated 4/14/15, showed orders for physical and occupational therapy to evaluate and treat the resident for stabilizing and strengthening his/her gait, balance and with transfers; maximize his/her activities of daily living (how a person self-performs eating, grooming, walking, toileting, bathing, etc.) and to reduce the resident's fall risk due to recent falls. Record review of the resident's Nursing Notes showed on 5/1/15 at 1:30 P.M., the charge nurse needed the writer's assistance with the resident who had an unwitnessed fall in the television room. The charge nurse said the family member of another resident was visiting and as he/she walked past the television room, he/she saw the resident laying on the floor. The nurse immediately went to assist the resident and noted the resident had a hematoma (a collection of blood outside of a blood vessel) to the left side of his/her forehead and the resident complained of pain, pointing to his/her left hip when nursing staff attempted to move him/her. The nurse called for rapid response to come and further assess the resident. They assessed the resident and transferred the resident to the hospital. The nurse notified the resident's physician and responsible party of the resident's fall. Staff reported that they last saw the resident in the television room at 1:25 P.M., sitting in a chair talking to another resident prior to being found on the floor at 1:30 P.M. All of the resident's fall precautions were in place except the resident's clip alarm was not sounding. Staff stated the resident was non-compliant with keeping the alarm on and would frequently remove it. Record review of the resident's Fall Investigation dated 5/1/15, showed: -On 5/1/15 at 1:30 P.M., the resident fell on the floor while trying to ambulate unassisted. A visitor at the facility found the resident laying on the floor in the television room. The nurse assessed the resident and noted the resident could not move and complained of pain to his/her left hip. The resident was sent to the hospital; -The fall huddle showed the resident had an unwitnessed fall in the television room and was found at 1:30 P.M. The resident had an unsteady gait. The resident was last checked at 1:25 P.M. The resident had an ordered alarm that did not sound. The resident was often non-compliant with (wearing) his/her alarm. The resident had a fall history, after the resident's fall the resident sustained [REDACTED]. The resident had no changes to his/her mental health status or level of consciousness. The nurse notified the resident's physician and responsible party; -The fall huddle result showed nursing staff reported the resident had increased restlessness and attempts to ambulate and self-transfer. The nursing staff have been monitoring the resident more frequently (not defined) while the resident was awake, and have been ensuring his/her personal belongings were within reach prior to nursing staff leaving the resident's room or activity room. The plan was to request a rehabilitation consultation/evaluation upon the resident's return and there was a possibility that the resident would be transferred to another unit. Record review of the resident's Fall Risk assessment dated [DATE], showed the resident's fall risk score was 11 (a score of 10 or above was considered at high risk for falls). Record review of the resident's medical record showed he/she was sent to the hospital on [DATE] and was treated for [REDACTED]. Record review of the resident's Care Plan did not show any updates to his/her fall interventions from his/her fall on 5/1/15. On 5/6/15 the care plan update showed the resident had a new hip fracture and decline in function. It showed the resident was in a wheelchair for mobility and had acquired wounds to his/her heels (while in the hospital). It showed the resident was moved to another unit as of 5/16/15, and nursing staff was to monitor the resident for pain and give pain medications as needed, provide the resident with rest periods to prevent over tiring, and assist the resident with all activities of daily living. It showed if the resident was awake, staff should get the resident up before he/she tried to get himself/herself up and to continue to monitor the resident for any additional bruising/injury. Record review of the resident's MDS dated [DATE], showed he/she: -Was cognitively impaired; -Needed total assistance to transfer, ambulate, complete all bathing, dressing/hygiene and toileting needs; -Was at risk for developing wounds, and had one or more unhealed wound upon admission to the facility; -Upon the request of the resident's previous MDS assessment the surveyor was provided this MDS and a 30 day Medicare assessment dated [DATE]. Observation on 6/8/15 at 2:50 P.M., showed the resident was laying down in his/her bed asleep. The resident was laying on an air pressure mattress that was low to the floor and there was a foam mattress on the floor next to his/her bed. The resident was laying on his/her right side. He/she was wearing blue soft boots, there were positioning pillows around his/her head and a wedge cushion positioned against his/her back. The resident had a bruise underneath his/her left eye that was almost healed. There was a Broda chair (a specialized padded wheelchair that tilts and reclines to accommodate varied positioning and better pressure distribution) sitting next to his/her bed. Observation on 6/9/15, showed the resident was sitting up in his/her broad chair in the hallway. Nursing staff was pushing the resident into the dining area and stopped to reposition the resident in his/her chair. The resident was unable to assist with repositioning. He/she was alert and oriented with significant confusion. During an interview on 6/10/15 at 2:38 P.M., Licensed Practical Nurse (LPN) F said: -At the time of the resident's fall up to 5/1/15, the resident lived on the locked dementia unit and ambulated with a roller walker with one to two staff assisting; -Whenever the resident was in bed or sitting in a chair, they put a personal alarm on the resident because the resident was unsteady and would try to transfer himself/herself and ambulate without assistance; -The resident had previous falls and was at high risk for falling; -The resident had a history of [REDACTED]. -The resident enjoyed sitting in the recliner (in the television room)and they could monitor him/her better there than in his/her room; - When the resident fell on [DATE], the resident was sitting in the recliner in the television room and he/she tried to ambulate independently and fell . The clip alarm was not sounding but it was found next to the resident. He/she said he/she believed the resident removed the alarm. During an interview on 6/11/15 at 10:20 A.M., LPN N said: -He/she was one of the charge nurses that worked on the secured unit during the time the resident lived there, and was the charge nurse on 5/1/15 at the time the resident fell and sustained an injury to his/her hip; -The resident had began declining in memory and function and began needing more assistance to ambulate and with cares; -The resident was more unsteady on his/her feet though he/she was still able to ambulate with a roller walker; -Nursing staff was instructed to assist the resident (at least one person assisting) when he/she was walking and transferring because the resident began to fall and was not safe to ambulate independently. He/she said the resident would also forget to get his/her walker when he/she got up; -They decided to place the clip alarms on the resident whenever he/she was sitting in a chair or when he/she was in bed to try to signal the nursing staff when he/she was trying to transfer or ambulate without assistance to try to prevent him/her from falling; -The resident was non-compliant with the clip alarm and would frequently remove it; -Most of the time after meals the resident liked to go into the television room, sit in one of the recliners and watch television with other residents, so nursing staff would assist the resident into the television room and into the recliner where they could watch the resident; -The resident would still try to transfer and ambulate, but usually there was someone at the nursing station that could easily observe the resident and monitor all of the residents in the television room (which was across from the nursing station); -On 5/1/15 after lunch, the resident was sitting in a recliner in the television room watching television. They normally have someone in the television room with the residents or sitting at the nursing station across from the television room where they can easily monitor, but at the time he/she was passing medications down the hall that was across from the nursing station, one of the CNA's was on break, and the other CNA was providing incontinence care and assistance to other residents; -One of the visitors that was on the unit at the time walked past the television room, noticed the resident was on the floor and came to him/her to go to assist the resident. When he/she got into the television room, the resident was laying on his/her right side in front of the television, his/her walker was by the window next to the television, and the alarm was still in the recliner but it was not sounding. He/she took the resident's vital signs and the resident complained of pain to his/her left hip, so he/she notified LPN F and stayed with the resident until emergency response came, and they took the resident to the hospital. He/she then notified the resident's physician and responsible party of the incident; -They probably should have had someone either in the television room or at the nursing station to monitor all of the residents but they did not because everyone was busy. During an interview on 6/11/15 at 11:00 A.M., LPN L said: -The resident came to the unit after he/she returned from the hospital and was readmitted with a hip fracture, and he/she also had bruising to the left side of his/her face and eye area. He/she said the resident was not ambulating or bearing any weight on his/her feet and he/she also had wounds on both of his/her heels (that were being treated); -The resident was in a Broda chair with a clip alarm, and they also implemented a hi/low bed (a type of bed that can be raised or lowered), an air pressure mattress with bumpers, and a mat on the floor next to the bed with a pressure alarm (when the resident was in bed the bed was to be in the low position with the mat next to him/her on the floor and the alarm in place); -The resident's care plan was kept at the nursing station and was updated as needed by the nursing staff with any new interventions or change in condition because it was a working care plan. The MDS Coordinators updated the care plans quarterly; -The nurses made handwritten updates on the care plan as the resident's condition or care changed, and all of the resident's fall interventions and updates before and after he/she changed units should be on the care plan. During an interview on 6/11/15 at 2:05 P.M., the DON said: -They had been monitoring the resident's falls and trying to provide interventions that would help prevent him/her from falling even though the resident was still ambulatory with his/her walker; -The resident was in the television/activity room when he/she fell (on 5/1/15); -The nursing staff was able to monitor the residents better when they were in the television/activity room because of the location (closer to the nursing station) and because it was a high traffic area, and staff could watch the resident as they passed through the area; -They were providing the necessary monitoring to the resident as they were not able to provide one-to-one monitoring to anyone at the facility; -They did not know what more they could have done to prevent the resident from falling. 2. Record review of the Resident #14's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's undated Care Plan showed he/she: -Was to have the hi-low bed in the lowest position while in bed; -Was to have a fall mat on the floor around the bed when he/she was in bed. Record review of the resident's Medication and Treatment record dated 6/1/15 through 6/30/15, showed he/she had physician's orders [REDACTED]. -Mood Disorder (a variety of conditions characterized by a disturbance in mood as the main feature); -Cerebrovascular Accident (CVA- stroke); and -Impaired cognition. Record review of the resident's progress notes showed: -During dinner on 6/6/15 at 5:40 P.M., he/she attempted to self-ambulate while trying to sit back down in the wheelchair, missed and sat down on the floor. A minor injury was noted to the left pinky finger due to it being cut while sliding down the metal edge of the wheelchair frame; -The physician and durable power of attorney was contacted; -The incident was witnessed by staff and other residents; -There was only one entry for this incident. Record review of the resident's fall risk profile showed: -On 5/5/15, showed he/she to be a potential risk for falls with a score of 8 (potential risk scoring was anything equal to 6 and less than or equal to 9); and -On 6/6/15 he/she scored a 9. During on observation on 6/8/15 at 2:45 P.M., showed the resident: -Was in bed in the high position in his/her room; -Alert and awake; -Had no fall mat in visible sight on either side of the bed or propped in the room. During an observation on 6/9/15 at 12:15 P.M., showed the resident: -Was up in bed in the high position in his/her room and had just received his/her lunch; -Alert and awake; -Had no fall mat in visible sight on either side of the bed or propped in the room; -Reported he/she had fell in the bathroom on his/her knees. During an observation on 6/10/15 at 9:00 A.M., showed the resident: -Was up in wheelchair in his/her room and had finished his/her breakfast; -Alert and awake; -Had no fall mat in visible sight on either side of the bed or propped in the room. During an interview on 6/10/15 at 1:30 P.M., LPN M said: -The resident should have his/her bed in a low position and a fall mat at the bedside per the resident's care plan. During an interview on 6/10/15 at 2:20 P.M., regarding the resident's falls on 6/6/15 at 5:30 P.M. and 6/9/15 at 9:50 A.M., LPN F said: -The 6/6/15 fall was witnessed, the resident had stood to reach her condiments at the dining table, missed the chair when sitting down and sat on the floor; and the resident chart was documented on 6/6/15 at 6:00 P.M.; -The 6/9/15 at 9:50 A.M. fall was unwitnessed, the resident had tried to get on the toilet and fell to his/her knees, the resident was found by an LPN, and he/she had toileted one hour before. 3. Record review of the Resident #16's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's fall risk profile dated 11/25/14, showed he/she to be a high fall risk with a score of 13 (high risk scoring was anything equal or greater than 10). Record review of the resident's progress notes showed he/she: -Was found on the floor by a Certified Nursing Assistant (CNA) on 5/11/15. He/ she had a bruise and swelling above the left eye. The physician and the resident's family were notified, and orders for a cat scan and urine analysis were placed; -On 5/11/15, three entries were completed by the 7:00 A.M. to 3:00 P.M. shift and one entry by the 3:00 P.M. to 11:00 P.M. shift; -On 5/12/15, two entries were completed by the 7:00 A.M. to 3:00 P.M. shift. The entries reported follow-up to the fall with neurological checks; -On 5/13/15, a single entry at 3:00 P.M. reporting follow-up to the fall. Record review of the resident's fall risk profile dated 5/12/15, showed he/she to be high risk with a score of 12 (high risk scoring was anything equal or greater than 10). Record review of the resident's Medication and Treatment record dated 6/1/15 thru 6/30/15, showed he/she had the following Diagnoses: [REDACTED]. -Depression; -Dementia; -Degenerative joint disease (DJD; a type of arthritis caused by inflammation, breakdown and eventual loss of the cartilage of the joints); -Ataxia (a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement). Record review of the resident's annual MDS dated [DATE], showed he/she: -Had cognitive deficits; -Needed limited assistance of one person for transfer, ambulation, dressing, personal hygiene and bathing; -Was incontinent of the bladder and occasionally the bowel. Record review of the resident's fall risk profile dated 6/8/15, showed he/she to be high risk with a score of 15. During an interview on 6/10/15 at 2:20 P.M., LPN F said regarding a fall on 5/11/15 at 5:45 A.M.: -The fall was unwitnessed resulted in an injury with swelling above the resident left eye; -The resident explanation was he/she was trying to get form the wheelchair to the bed while in his/her room; -The root cause of the fall determined was a discontinuation of medication for the resident. During an interview on 6/10/15 at 1:15 P.M., the DON said: -All fall incidents/investigations should be followed-up for 70 hours after the incident; -The expectation was charted daily in the progress note; -A medical record should have 9 entries during the 72-hour charting unless the shift was 12 hours, then there would be a minimum of five entries of documentation, three entries per shift. During an interview on 6/10/15 at 1:30 P.M., LPN M said: -All residents after a fall incident should be assessed with [REDACTED]. Neurological checks would be expected to be completed every fifteen minutes four times, then every thirty minutes four times, following every two hours for four times and then twice at 24-hours. 4. Record review of the Resident #10's Facility Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of resident's POS dated 6/1/15 to 6/30/15, showed he/she had a [DIAGNOSES REDACTED].>-Dementia; -Bipolar Disorder (a mood disorder characterized usually by alternating episodes of depression and mania); -The resident's physician's orders [REDACTED]. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was usually able to make self-understood and was able to understand others; -Had moderately impairment cognition with short-term, long-term memory problems; -Had disorganized thinking and impaired daily decision making; -Required the limited assistance of one staff member for ambulation; -Required the extensive assistance of one staff member for dressing, personal cares, toileting and bathing; and -Had no falls during the look back period. Record review of the resident's Care Plan with handwritten updates dated from 2013 to 5/8/15, showed he/she was at risk (potential had be mark out and risk had been hand written in) for falling related to physical and cognitive. Interventions included; -Encourage the resident to use his/her assistive devices such as a hand rails in the bathroom; -The staff was to ensure that the resident's clip alarm is on while in bed and up in wheelchair; -The resident was to ask for assistance with transfers; -The staff had hand written updated related to a fall on 2/27/15, the resident to was to have physical therapy (PT) and occupational therapy (OT) for evaluation and for treatment, also to check the resident wheelchair brakes; -The staff had hand written updated related to a fall on 4/13/15, the staff were to encourage the resident to wear non-skid socks on his/her feet and ensure the fall mat are beside the residents bed; and remind the resident to call for assist; staff to monitor for pain and provide medication as needed; -The staff had hand written updated related to a fall on 4/26/15, the staff are to do frequent rounds to redirect unsafe behaviors, ensure his/her call light was within reach, and to remind the resident to use the call light; -The staff had hand written updated related to a fall on 5/8/15, included to remind the resident to call for assistance; and staff were to monitor for pain and provide medication as needed. Record review of the resident's Fall Risk Profile dated 5/8/15, showed he/she would be at high risk for potential falls, had falls in the past 30 days and falls in the past 31 to 180 days marked. Record review of the resident's Nurse's Progress Notes dated 5/8/15 at 11:30 A.M., showed he/she: -Was observed on the floor by medication technician; -Was calling out for help; -Said he/she was attempting to take his/her shirt off with his/her jacket on over the shirt; -Said he/she did not hit his/her head, and the nurses assessment showed the resident had no bruising at that time; -Had normal range of motion of all of his/her extremities, and was assisted to a standing position and placed into his/her wheelchair; -Was provided education by staff on the importance of using his/her chair alarm and to ask for assist from staff; -Had neurological (neuro) checks initiated by nursing staff and his/her neuro-assessment was within normal limits; -Staff placed a call to notify the resident's Durable Power of Attorney (DPOA, an agent to manage your financial affairs, make health care decisions, or conduct other business for you during your incapacitation); and -On 5/8/15, the last nursing note documented in the resident nurse progress note related to the resident fall on 5/8/15. Record review of the resident medical record for the post fall follow up documentation for a fall on 5/8/15, showed: -The nursing staff had not documented in the resident's nurses progress notes for his/her post fall monitoring for a 72 hour period. Record review of the resident's Neurological Parameter Flow sheet (Neuro Checks) dated 5/8/15 to 5/11/15, showed: -The initial Neuro checks included vital signs and neuro assessment of the resident had been initiated on 5/8/15 at 11:30 A.M.; -The flow sheet had no documentation of the resident's neuro checks section for 5/8/15 at 3:15 P.M. to 5/8/15 at 10:15 P.M.; -The resident flow sheet did not have any documented assessment for the resident, including vital signs and neuro checks from 5/9/