Every finding on record at Westview Nursing Home

Based on interview and record review, the facility failed to ensure staff treated residents with dignity and respect for four residents (Residents #1, #2, #3, and #6) in a review of nine sampled residents. Residents described staff as being rude, disrespectful and were loud, snappy, and yelled at them. Others described staff as talking down to them, scolding them and making them feel stupid while others said staff mocked and made fun of them, calling them a liar, and making them feel terrible, angry, frustrated, and not like home. The census was 56.Review of the facility policy, Resident's Rights - Missouri, last revised 7/2023 showed the following:-A resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote rights of each resident, including each of the following rights:- The resident has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished;-A resident has the right to be free from verbal, sexual, mental, and physical abuse;-A resident is treated with consideration, respect, and in full recognition of his/her dignity and individuality. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility, dated 06/10/25, showed the following:-Cognitively intact;-Ability to understand others and to be understood;-No delirium, no psychosis, and no behaviors;-Feeling down, depressed, hopeless two to six days;-Feeling bad about self, like a failure or have let self or family down seven to eleven days. Review of the resident's care plan, last revised 07/08/25, showed the following:-Diagnoses included anxiety disorder (persistent worry) and major depressive disorder (serious mood disorder);-Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others;-Acknowledge the resident's concerns. During an interview on 07/15/15 at 12:54 P.M., the resident said the following:-One (unnamed) staff speaks to him/her like he/she was five years old; -It made him/her feel like a child and like he/she had been scolded;-Licensed Practical Nurse (LPN) C was horrendous and had a horrible bedside manner;-LPN C yelled, cursed, and targeted residents; -LPN C was always disrespectful when speaking to him/her and others; -He/She had observed/heard Nurse Assistant (NA) D talk down to Resident #4 when the NA yelled, Why did you pee yourself again? You know better! This happened in the hallway; he/she was the only witness to this incident;-The Administrator had called him/her a liar; -It made him/her feel terrible. 2. Review of Resident #1's annual MDS, dated [DATE], showed the following:-Ability to understand others and to be understood;-Cognitively intact;-No delirium;-No psychosis, no behaviors. Review of the resident's care plan, last revised 05/28/25, showed the following:-Diagnoses included major depressive disorder and anxiety;-Monitor, document, report any signs of depression including hopelessness, anxiety, sadness, verbalization or tearfulness, loss of pleasure and interest in activities, risk to harm self or others. During an interview on 07/15/25 at 10:20 A.M., the resident said the following:-Staff in general could be rude and disrespectful;-NA D was loud and snappy at times;-All staff talked to resident like they were stupid;-Some staff yelled and mocked him/herself and other residents; -He/She had not reported as he/she would be threatened, and it would be held against him/her; -Staff treatment of residents upset him/her and made him/her feel like he/she was in a concentration camp, not a home;-LPN C was the worst of all. 4. Review of Resident #2's annual MDS, dated [DATE], showed the following:-Cognitively intact;-Ability to understand others and to be understood;-No delirium;-No psychosis, no behaviors;-Feeling down, depressed, hopeless two to six days;-Feeling bad about self or like he/she was a failure or has let self or family down seven to eleven days. Review of the resident's care plan, last revised 07/15/25, showed the following:-At risk for impaired social interaction and ineffective coping skills related to bipolar diagnosis;-Emotional distress triggered by overwhelming emotions or feelings or memories;-Allow time to vent with staff of any concerns or feelings;-Provide opportunities for expression of feelings related to situational stressors. During an interview on 07/15/25 at 12:45 P.M., the resident said the following:-Staff, including the administrator, yelled and cursed at him/her and other residents; -LPN C was the worst by far. LPN C mocked and made fun of residents. LPNC will make accusations and laugh at residents making sure they could hear him/her. -LPN C had just done this to him/her;-Staff had called him/her a liar; -It made him/her angry and frustrated;-Everyone had reported staff treatment, but nothing changed. 5. Review of Resident #6's quarterly MDS dated [DATE] showed the following:-Moderately impaired cognition;-No delirium, no psychosis. During an interview on 07/15/25 at 9:55 A.M., the resident said about two weeks ago, he/she overheard and witnessed Certified Medication Technician (CMT) B yell at a resident in the dining room. CMT B could have an attitude. This made him/her feel upset for the other resident and him/herself. 6. Review of Resident #5's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Ability to understand others and to be understood;-No delirium, no psychosis;-Feeling down, depressed, hopeless two to six days;-Feeling bad about self, like a failure or has let self or family down seven to eleven days. Review of the resident's care plan, last revised 07/15/25, showed his/her diagnoses included generalized anxiety disorder. During an interview on 07/15/25 at 12:40 P.M., the resident said the following:-Staff talked down to residents like they were children; -He/She had experienced it by many staff;-The worst was LPN C. 7. During an interview on 07/15/25, an anonymous staff member said the following:-A lot of residents had reported they were afraid to ask CMT B for anything due to his/her reaction to them;-CMT B talked down to residents and was aggressive;-One resident said CMT B was aggressive and he/she would not ask this staff for anything because of the way CMT B spoke to and treated him/her and other residents. He/She would refuse to take his/her medications from CMT B;-He/She had never reported this to anyone because he/she was afraid to lose his/her job. 8. During an interview on 07/17/25 at 2:18 P.M., the Director of Nursing said the following:-Staff should speak to residents in an appropriate tone, professionally and respectful;-Staff should not curse at or in front of residents;-Staff should not mock residents or talk down to them like they are toddlers;-No residents/staff had reported incidents of staff mistreatment to him/her; -Residents should not be fearful of retaliation;-Staff receive resident rights and abuse/neglect training with orientation and quarterly, or more often. During an interview on 07/17/25 at 2:30 P.M., the Administrator said the following:-Staff should speak to residents with dignity and respect. They have been in-serviced on this multiple times;-Staff should not curse at residents or in front of them;-Staff should not mock, yell or talk down to residents like they are toddlers;-Resident #3 had complained of LPN C talking to him/her like he/she was a toddler this morning; -All staff are given a copy of resident rights and abuse/neglect policy upon hire, and they sign they have reviewed and understand. 1588544

Based on observation, interview, and record review, staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not handle, seal, label, or date food items in order to prevent potential contamination. Staff did not practice proper handwashing, glove hygiene, and consumption and storage of personal food and beverage items. Staff did not ensure dishes and utensils were in good condition, or that they were cleaned, stored, and handled in a sanitary manner. Staff did not maintain surfaces and equipment to be free from a buildup of debris and ensure trash cans were covered when not in use. Staff failed to ensure equipment was in good working order. The facility census was 56. 1. Record review of the facility policy, Dietary - Receiving and Storing Food and Supplies, revised 6/30/23, showed the following: -Eggs shall be checked for cracks and any cracked eggs shall be disposed of; -Dry Storage: Any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids or Ziploc bags, plastic film, or tape. Cleaning supplies must be stored in a separate area away from all food. Observation on 5/19/25, from 8:09 A.M. to 8:32 A.M., during the initial kitchen tour, showed the following: -In the dry storage room, an unsealed 25-pound bag of rice and an unsealed box of rice sat in a large food storage container. There was no lid on the container. There was food and trash debris on the floor around the container. An approximate 1-inch by 8-inch section of the wall corner in this area was damaged and the surface was not smooth. A large container of dry fish batter was not securely sealed and the lid was raised 0.5-inches in one corner; -In the walk-in cooler, two open packages of butter were not sealed and were open to the air. A cracked egg stuck to an open egg carton located above an open egg carton containing approximately 24 eggs. Two of the eggs sat in dried egg debris and broken shells; -In the walk-in freezer, a box of sausage did not have the inner plastic sealed and the food items were exposed to air. Observation on 5/20/25 at 11:12 A.M., in the kitchen chest freezer, showed an unsealed, unlabeled, and undated bag of frozen food items that resembled breaded patties. Observation on 5/20/25 at 11:31 A.M., in the kitchen, showed a cardboard container of instant cereal sat next to a bottle of oven cleaner on the bottom shelf under the food preparation sink. The top of the cereal container had drips of clear liquid resembling water on its surface. During an interview on 5/21/25 at 11:54 A.M., the Dietary Manager said she expected food to be stored, served, and prepared in a safe and sanitary manner. Food should be stored away from moisture and cleaning products. Food should be sealed, labeled, and dated. 2. Record review of the facility policy, Hand Washing and Glove Use, revised 4/26/24, showed the following: -Policy: Guidelines for hand washing and glove use to promote safe and sanitary conditions throughout the department; -Hands must be washed when working with different food substances (i.e. raw chicken to fresh fruit), following contact with any unsanitary surface (i.e. touching hair, opening doors); -Washing procedure: Wet hands, apply soap, lather (vigorously rubbing hands together for approximately 20 seconds), rinse hands to remove soap and debris, dry hands with a disposable paper towel, utilize paper towels to turn off the faucet; -Gloves must be worn when touching any ready-to-eat food; -When gloves are used, hand washing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed. Gloves may be used for one task only; -Important to remember that gloves can often give a false sense of security and can carry germs same as our hands. Record review of the facility policy, Dietary - Receiving and Storing Food and Supplies, revised 6/30/23, showed to wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and objects that have been touched by hands. Wash and sanitize all surfaces, equipment, and utensils that have come in contact with raw meats before using for any other food to prevent cross-contamination. Record review of the facility policy, Dietary - Equipment Operations, Infection Control, and Sanitation Policy, revised 2/2/24, showed the following: -All surfaces and equipment shall be washed with a sanitizing solution; -Sanitizing cloths shall be placed in the sanitizing buckets to be used in sanitizing all work surfaces and equipment; -Cups, glasses, bowls, and plates shall be handled without contact with inside surfaces or surfaces that contact the user's mouth. Observation on 5/19/25 from 11:50 A.M. to 12:43 P.M., in the kitchen during the lunch meal service, showed the following: -Cook R used his/her bare hands to pick up a bun that fell out of a package onto the steam table and placed the bun back into the package; -He/She put on gloves and used a soiled dry cloth to wipe the steam table counter and left the dry cloth on the counter; -Without washing his/her hands or changing his/her gloves, he/she served food onto residents' plates at the steam table; -He/She removed his/her gloves, rested his/her bared hands on the preparation counter, touched his/her hair restraint and face, touched the trash can lid, put on oven mitts and moved food items from the stove; -Without washing his/her hands, he/she put on gloves and prepared food items in the food processor, took the dirty food processor container to the dishwashing room, and returned to the food preparation area where he/she ladled gravy over pureed food items. Observation on 5/20/25, from 11:12 A.M. to 12:28 P.M., in the kitchen, showed the following: -Cook R used his/her gloved hands to grasp a long plastic sleeve of raw ground meat with a knife and opened it into a pan in the food preparation sink; -He/She removed his/her gloves, discarded the plastic sleeve in the trash can, turned on the faucet handle at the food preparation sink, filled the pan of meat with water and carried it to the stovetop where he/she turned the knob on the stove; -Without washing his/her hands, he/she put on gloves and chopped celery at the food preparation counter. Observation on 5/20/25 from 11:33 A.M. to 11:41 A.M., showed the following: -Cook R washed his/her hands at the handwashing sink and used his/her clean hands to turn off the faucet handle; -He/She put on gloves, handled meal tickets, touched meat as he/she added the meat to the food processor, touched the food processor control knobs, obtained food from the walk-in cooler, and took dirty food containers to the dishwashing room; -He/She washed his/her hands at the handwashing sink again and used his/her clean hands to turn off the faucet handle; -He/She put on gloves, used oven mitts to obtain food from the oven, removed the oven mitt, and prepared additional food at the food processor. Observation on 5/20/25 at 11:20 A.M., in the kitchen, showed the following: -Dietary Aide P ate food from a disposable bowl as he/she walked across the kitchen from the serving counter area and near the food preparation counter where staff served pieces of cake into individual bowls; -He/She discarded the bowl in the trash can. His/Her bare hands touched the inside of the trash can liner; -He/She washed his/her hands at the handwashing sink and turned the faucet handles off with his/her clean hands; -He/She obtained a napkin from a napkin dispenser and wiped the surface of the serving counter. Observation on 5/20/25 at 11:23 A.M., in the kitchen, showed the following: -Dietary Aide Q picked up a paper towel from the floor, discarded the paper towel in the trash can, and left the kitchen; -He/She returned to the kitchen, did not wash his/her hands, and made coffee at the beverage counter; -He/She washed his/her hands at the handwashing sink and turned the faucet handles off with his/her clean hands; -He/She went to the dishwashing room where he/she touched and removed clean cups from the dishwashing machine dish rack and placed them on the clean dish storage shelf. Observation on 5/20/25 at 11:59 A.M., in the kitchen, showed the following: -Dietary Aide P drank from an open cup in the food preparation and serving area; -He/She did not wash his/her hands and handed a clean cup to a staff member who was at the kitchen door to the adjacent dining room; -With his/her bare hands, he/she touched the inner eating surface of bowls of pre-portioned dessert and moved the bowls from a cart to the serving counter. Observation on 5/20/25 at 11:12 A.M., on the kitchen chest freezer, showed a staff's keys, cell phone, and open cup sat on the lid of the freezer. Observation on 5/20/25 at 11:23 A.M., in the kitchen, showed a staff's cell phone sat on a box of food wrap on the preparation counter next to an open pan of cake. Observation on 5/21/25 at 11:25 A.M., in the kitchen, showed [NAME] R used his/her bare hands to touch the food contact surface of serving utensils that hung on the wall as he/she selected utensils to use to serve the lunch meal service. During an interview on 5/21/25 at 11:25 A.M., Dietary Aide Q said staff should touch utensils, plates, and bowls by the outside edge (not the eating surface) of those items. During an interview on 5/21/25 at 11:54 A.M., the Dietary Manager said staff should handle food containers and utensils by the non-eating surfaces of those items. During an interview on 5/21/25 at 11:25 A.M., Dietary Aide Q said staff should wash their hands every time they change gloves, when they enter the kitchen, after picking up items from the floor, and after performing dirty tasks. When washing their hands, staff should not turn off the faucet with their clean hands but should use a paper towel to turn off the faucet. During an interview on 5/21/25 at 11:54 A.M., the Dietary Manager said staff should wash their hands after changing gloves, after completing dirty tasks, and before clean tasks. Staff should use a paper towel to turn off the faucet handle when washing their hands. 3. Record review of the facility policy, Dietary - Equipment Operations, Infection Control, and Sanitation Policy, revised 2/2/24, showed the following: -General daily and weekly cleaning schedules may be used or Cleaning Schedules by position may be used; -All surfaces and equipment shall be washed with a sanitizing solution; -Sanitizing cloths shall be placed in the sanitizing buckets to be used in sanitizing all work surfaces and equipment; -Dishwashing procedure: Scrape food garbage from dishes into garbage disposal, this can be done with a rubber scraper or pre-rinse sprayer; -Cups, glasses, bowls, and plates shall be handled without contact with inside surfaces or surfaces that contact the user's mouth; -Chipped and cracked dishes shall be discarded; -Remove spills, spillovers, and burned food deposits immediately. Wipe oven exterior weekly; -Walk-In Refrigerator: Weekly - thoroughly sweep all floor areas and corners, mop floor and drain area, scrub any hard-to-clean areas using a sanitizing solution and scouring pad; -Counters: Weekly - use a mild detergent and water, rinse shelves with a clean rag and dry. Record review of the facility policy, Dietary - Receiving and Storing Food and Supplies, revised 6/30/23, showed the following: -Dry Storage: Dishes and Utensils: Storage areas will be cleaned and sanitized. Bowls, pans, cups, and steam table pans will be stored upside down when not in use. Trash cans should be closed when not in use. Observation on 5/19/25 at 8:21 A.M., in the kitchen, showed the following: -In the clean dish storage area, five of 12 beverage pitchers were chipped and missing several 1-inch chunks of the lids; -On the food preparation table, approximately 30 small white plates and three divided plates were not inverted or covered. Observation on 5/20/25 at 12:34 P.M., showed Dietary Aide P dropped a package of silverware on the floor, picked up the package, and placed it back in the bin of clean packages of silverware. Observation on 5/20/25 at 11:12 A.M., in the kitchen, showed oven mitts visibly soiled with dried food debris sat directly on and made contact with clean scoops and serving utensils in a bin under the preparation table near the stove. Observation on 5/20/25 from 11:20 A.M. to 11:59 A.M., in the kitchen, showed the trash can by the stove was uncovered. No staff were using the trash can. 4. Record review of the facility's Daily Dietary Checklist showed the following: -A.M. and P.M. Cook: clean stove top, griddle, and deep fryer if used; -A.M. and P.M. Dietary Aide: sweep and mop. Observation on 5/19/25, from 8:09 A.M. to 8:32 A.M., during the initial kitchen tour, showed the following: -The sides and back top area of the deep fryer were coated with a heavy accumulation of yellow grease; -The stove top had a moderate accumulation of dried food and encrusted debris across its surface; -The food preparation, serving, and steam table legs, shelves, and frames were covered in bits of dried food, splatters, and other debris. The floor around these items had crumbs, splatters, and food debris visible across the floor's surface. -The walk-in freezer showed an excess buildup of ice, food debris, and trash on the floor. During an interview on 5/21/25 at 11:54 A.M., the Dietary Manager said staff were to regularly clean items such as the kitchen and walk-in floors, preparation counter shelves, and appliances. The dietary aides and cooks had cleaning schedules they were to follow. 5. Record review of the facility policy, Dietary - Equipment Operations, Infection Control, and Sanitation Policy, revised 2/2/24, showed the following: -Dish Machine: Clean dish machine interior and exterior with de-liming solution weekly. -Recording of dish machine temperatures: low temperature dish machine wash temperature 120-140 degrees Fahrenheit (F), rinse temperature 120-150 degrees (F), or follow manufacturer's directions if different. Observation on 5/21/25 at 9:33 A.M., 9:40 A.M. and at 11:18 A.M., in the dishwashing room, showed Dishwasher S used the dishwashing machine to wash dishes. The maximum temperature shown on the dishwashing machine temperature gauge was 100 degrees F. A label on the machine read, 'Wash Temperature: 120 degrees F Minimum, Rinse Temperature: 120 degrees F Minimum.' The dishwashing machine showed a heavy accumulation of white crusty and food debris in and on the surface of the machine. During an interview on 5/21/25 at 9:33 A.M., Dishwasher S said he/she was unsure what the temperature needed to be on the dishwashing machine. Staff logged the sanitizer chemical level on a log sheet but not the temperature. During an interview on 5/21/25 at 11:54 A.M., the Dietary Manager said the dishwashing machine temperature should be at least 120 degrees F and was unaware it was not reaching this temperature. 6. Observation on 5/20/25 at 12:00 P.M., at the kitchen steam table, showed the following: -Cook R removed pans of food items from the oven and placed them into three of the five bays on the steam table; -He/She placed the remaining food pans on top of the lids of the remaining two bays (not within the bays). Observation on 5/21/25 at 11:20 A.M., at the kitchen steam table, showed drips of water ran down the back side of the steam table and into a half-full plastic tub of water. Water also pooled on the metal steam table shelf (below the steam table) near several cardboard boxes of beverage mix. During an interview on 5/20/25 at 12:00 P.M., [NAME] R said two of the steam table bays leaked so he/she was unable to use them to keep food warm during meal services. During an interview on 5/20/25 at 12:28 P.M., the Dietary Manager said she was unsure how long the two steam table bays had issues with leaking. Some of the other bays leaked occasionally. Maintenance staff had tried fixing the bays with new valves but they still leaked. 7. Observation on 5/21/25 at 9:25 A.M., of the walk-in cooler and freezer, showed the following: -The cooler door was rusted on the inside and the seal was torn in an approximately 2-foot long section. The latch would not engage in the frame and the door remained open approximately 0.25 inches when closed; -The freezer door latch handle was broken with a section of the handle missing. The interior portion of the latch, where the handle was once located, had a sharp edge and was difficult to open. During an interview on 5/21/25 at 9:25 A.M., the Dietary Manager said the walk-in cooler door had been that way (rusted interior, torn seal, broken latch) for a long time. Sometimes the temperature in the walk-in cooler reached 48 degrees Fahrenheit. The walk-in freezer door latch handle had been broken approximately three years. 8. Observation on 5/21/25 at 9:31 A.M., showed [NAME] R filled a pan of vegetables with water from the three-compartment dishwashing sink. During an interview on 5/21/25 at 9:31 A.M., [NAME] R said the food preparation sink only had cold water, so he/she had to use the three-compartment dishwashing sink to fill up the pan of vegetables with hot water. During an interview on 5/21/25 at 11:50 A.M., the Dietary Manager said the food preparation sink did not have hot water running to it and never had since she worked at the facility. 9. Observation on 5/21/25 at 9:34 A.M., under the dishwashing machine sink, showed a cloth was inserted into a pipe that went through the wall. An electrical cord with wire nuts on three wires (originating from the cord) lay on the ground. During an interview on 5/21/25 at 9:33 A.M., Dishwasher S said it would be nice if the garbage disposal was replaced. Staff were to put food waste in the trash can prior to rinsing dishes in the sink but sometimes the sink got clogged. During an interview on 5/21/25 at 9:25 A.M., the Dietary Manager said there used to be a garbage disposal where the wires and pipe were under the dishwashing sink but it had been removed about a year ago. During an interview on 5/21/25 at 2:32 P.M., the Maintenance Director said the garbage disposal was removed prior to him starting at the facility in September 2024. The facility was on a septic system and he was told that the plumbing system was unable to support a garbage disposal. 10. Observation on 5/21/25 at 11:50 A.M., of the food preparation sink showed a 1.5-inch drain pipe entered an approximately 6-inch by 6-inch open floor drain. During an interview on 5/21/25 at 11:50 A.M., the Dietary Manager said the drain to the food preparation sink overflowed two to three times per month when morning staff arrived to work. When this happened, staff had to clean up the drain water before they could start working and preparing food for the day.

Based on interview and record review, the facility failed to conduct pre-employment screenings, including the criminal background check (CBC), the employee disqualification list (EDL) and/or the family care safety registry (FCSR) which would included both the CBC and EDL screenings, and/or the Nurse Aide (NA) registry, as directed by facility policy, for seven of 10 sampled newly hired employees reviewed. The facility census was 56. Review of the facility's Abuse and Neglect Policy, dated 10/25/22, showed the following: -The facility would not employ individuals who have been convicted of abusing, neglecting, or mistreating individuals; -Potential employees are screened for a history of abuse, neglect, or mistreating of residents. Review of the facility's Applicant, Employee, Volunteer, and Vendor Screening Policy, last reviewed/revised on 05/14/24, showed the following: -Corporation was committed to compliance with Federal and State regulations regarding the screening of individuals who may be in contact with residents or providing services that are, in a whole or in part, payable by a government health care program; -Human Resources (HR) department would conduct pre-employment screens on applicants to determine whether thee applicant had committed a disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States, and if applicable is duly licensed or certified to perform the duties of the position for they applied; -HR staff would conduct the following screens on potential employees prior to hire; -Criminal History: using the request for criminal records check, a criminal background check would be done through the Missouri Highway Patrol's Missouri Automated Criminal History; -Family Care Safety Registry: screening would check the sex offender, EDL, and other Missouri data bases automatically. The company should ensure the applicant submits the paperwork and the fee to the FCSR. Registration and background check must be completed within 15 days of the first date of employment; -EDL must be checked for every applicant. The results must be printed with the original initialed and dated by the person who conducted the check; -CNA Registry: The CNA Registry must be checked for all applicants regardless of the position for which they are applying. The results must be printed with the original initialed and dated by the person conducted the check. 1. Review of the Administrator's employee file showed the following: -Date of hire 12/18/23; -No record staff checked the FCSR, CBC, EDL, or NA Registry prior to hire. 2. Review of Licensed Practical Nurse (LPN) A's employee file showed the following: -Date of hire 01/02/25; -No record staff checked the FCSR, CBC, EDL, and NA Registry prior to hire. 3. Review of Nurse Aide (NA) C's employee file showed the following: -Date of hire 01/03/25; -No record staff checked the FCSR, CBC, EDL, or NA Registry prior to hire. 4. Review of Registered Nurse (RN) B's employee file showed the following: -Date of hire 01/17/25; -No record staff checked the FCSR, CBC, EDL, or NA Registry prior to hire. 5. Review of [NAME] F's employee file showed the following: -Date of hire 02/03/25; -NA Registry was checked after hire date on 02/27/25. 6. Review of Certified Medication Technician (CMT) E's employee file showed the following: -Date of hire 02/16/25; -NA Registry was checked after hire date on 02/28/25. 7. Review of the Director of Nursing's employee file showed the following: -Date of Hire 04/23/25; -No record NA Registry was checked prior to hire. 8. During interview on 05/20/25 at 4:00 P.M., the Human Resources (HR) Manager said the following: -He had been in the position for one month; -He realized there was a lot of information missing from the new hire files; -If the information was not in the employee's file, then it was not completed and/or there was no record of being completed. During interview on 05/21/25, at 5:00 P.M., the Administrator said the following: -She expected staff to check the FCSR, CBC, EDL, and Nurse Aide Registry for all new hires; -She realized they were not current on the proper documents needed.

Based on observation, interview and record review, the facility failed to ensure two staff (Nurse Aide (NA) J and the Environmental Services (EVS) Director), providing transportation for two residents who had elected Full Code status including (Resident #47 and #43) of 18 sampled residents, maintained current cardiopulmonary resuscitation (CPR -an emergency lifesaving procedure performed when the heart stops beating) certification for healthcare providers as required. The training must be obtained with a provider in accordance with the accepted national standards, through a CPR provider whose training included hands-on practice and in-person skills assessment and as facility policy directed. The facility failed to ensure four additional staff, (Certified Occupational Therapy (COTA) Program Director, Administrator, Activity Director and the Business Office Manager/Human Recourses (BOM/HR), in a review of eighteen staff, maintained current CPR certification for health care providers through a CPR provider who who met the requirement for in-person demonstration of skills. The facility also failed to ensure a resident's code status was accurately and consistently documented for communication to staff for one sampled resident, (Resident #37) and one additional resident (Resident #36). The facility census was 56. Review of the facility policy, Communication of Code Status, revised [DATE], showed the following: -It is the policy of this facility to adhere to residents' rights to formulated advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive; -When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: -Full Code; -Do Not Resuscitate; -The nurse who notates the physician order is responsible for documenting the direction in all relevant sections of the medical record; -The designated sections of the medical record are: -Physician Orders; -Care Plan; -Additional means of communication of code status include a black dot on door/name plate; (the policy did not indicate what the black dot meant); -In the absence of an Advance Directive or further direction from the physician, the default direction will be Full Code; -The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services; -The Social Services Director shall maintain a list of residents who have an Advance Directive on file; -The resident's code status will be reviewed at least quarterly and documented in the medical record. Review of the facility policy, Cardiopulmonary Resuscitation/CPR Policy, revised [DATE], showed the following: -The facility will follow current American Heart Association (AHA) guidelines regarding CPR; -CPR certified staff will be available at all times; -Staff will maintain current CPR certification for health care providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification, which includes an on-line knowledge component, yet still requires in-person skills demonstrations to obtain certification or recertificatio is also acceptable. The policy did not address if a zoom (a videoconferencing) to demonstrate hands-on competency was appropriate. Review of the facility policy, Fleet Management Program: Driver Authorization, Driver Safety and Maintenance Requirements, revised [DATE], showed no documentation of requirements for drivers to have CPR certification for transporting Full Code residents. 1. Review of www.nationalcprfoundation.com showed National CPR Foundation is an online certification provider for healthcare providers, workplace individuals and the community (the online certification provides no hands on portion to this training and refers those who are required to complete a hands-on component or a skills-check, please visit CPRNearMe.com). Review of www.cprnearme.com showed no hands-on component or skills-check for health care providers within fifty miles of the facility. 2. Review of Resident #14's medical record, including his/her face sheet, physician orders (dated [DATE]) and care plan (revised [DATE]), showed the resident elected to be full code. 3. Review of the Resident #47's medical record, including his/her face sheet, physician orders (dated [DATE]) and care plan (revised [DATE]), showed the resident elected to be full code. 4. Review of Resident #25's medical record, including his/her face sheet, physician orders (dated [DATE]) and care plan (revised [DATE]), showed the resident elected to be full code. 5. Review of Resident #43's medical record, including his/her face sheet, physician orders (dated [DATE]) and care plan (revised [DATE]), showed the resident elected to be full code. 6. Review of NA J's employee file on [DATE] at 1:00 P.M., showed no CPR certification in the employee's file. There was no evidence to show NA J maintained current CPR certification for health care providers through a CPR provider who evaluated proper technique through in-person demonstration of skills as the facility policy directed. During an interview on [DATE] at 1:11 P.M. and [DATE] at 8:35 A.M.,11:00 A.M. and 3:24 P.M., NA J said the following: -His/Her CPR card had expired; -He/She did not know when his/her card expired; -He/She had transported Resident #14 from the hospital to the facility; -He/She had transported Resident #43 to his/her wound care appointment; -The Environmental Services (EVS) Director and he/she had transferred Resident #25 together; -He/She had taken an online CPR course today, [DATE], and finished around 1:45 P.M.; -He/She had completed hands on skills test by using Zoom during the CPR course on [DATE]. Review of NA J's Certificate of Completion for CPR, dated [DATE], showed he/she had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. NA J's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. 7. Review of the EVS Director's employee file on [DATE] at 1:00 P.M., showed no CPR certification in the employee's file. There was no evidence to show the EVS Director maintained current CPR certification for health care providers through a CPR provider who evaluated proper technique through in-person demonstration of skills as the facility policy directed. During an interview on [DATE] at 11:11 A.M. and 1:55 P.M., the EVS Director said the following: -He had been responsible for most all of the facility transfers from [DATE] until [DATE]; -He thought his CPR card had expired in [DATE]; -He and NA J had transferred Resident #25 together; -He had taken an online CPR course today, [DATE], and finished around 11:06 A.M.; -He had completed a hands on skills test by using Zoom during the CPR course on [DATE]; -He was aware a transporter should be CPR certified if transporting full code residents. Review of EVS Director's Certificate of Completion for CPR, dated [DATE], showed he had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. The EVS Director's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. 8. Review of the medical record clerk's employee file on [DATE] at 1:00 P.M., showed no CPR certification in the employee's file. There was no evidence to show the medical record clerk maintained current CPR certification for health care providers through a CPR provider who evaluates proper technique through in-person demonstration of skills as the facility policy directed. During an interview on [DATE] at 9:45 A.M., the medical record clerk said the following: -She lost her CPR card; -She did not know if her CPR card had expired; -She had been transporting residents for the last two months; -She had transported Resident #25 to an appointment; -She had transported Resident #43 to a wound care appointment; -NA J had accompanied her on a transfer in the past; -She had taken an online CPR course on her phone on [DATE]; -She had completed the hands on skills test by using Zoom during the CPR course on [DATE]. Review of medical records clerk's Certificate of Completion for CPR, dated [DATE], showed she had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. The medical records clerk's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. 9. Review of the facility's list of residents transports showed the following: -On [DATE], Resident #14 was transported by NA J from the hospital to the facility; -On [DATE], Resident #47 was transported by the medical records clerk from the hospital to the facility; -On [DATE], Resident #43 was transported by the medical records clerk from the facility to a physician's office; -On [DATE], Resident #25 was transported by the medical records clerk from the hospital to the facility; -On [DATE], Resident #25 was transported by the medical records clerk from the facility to a physician's office; -On [DATE], Resident #43 was transported by the medical records clerk from the facility to a physician's office; -NA J and the medical record clerk had transported full code residents without any CPR certification. 10. Review of the COTA Program Coordinator's Certificate of Completion for CPR, dated [DATE], showed she had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. The COTA Program Coordinator's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. No evidence to show the COTA Program Coordinator had maintained current CPR certification for health care providers through a CPR provider who evaluated proper technique through in-person demonstration of skills as the facility policy directed. 11. Review of the Administrator's Certificate of Completion for CPR, dated [DATE], showed she had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. The Administrator's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. No evidence to show the Administrator had maintained current CPR certification for health care providers through a CPR provider who evaluated proper technique through in-person demonstration of skills as the facility policy directed. 12. Review of the Activity Director's Certificate of Completion for CPR, dated [DATE], showed she had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. The Activity Director's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. No evidence to show the Activity Director had maintained current CPR certification for health care providers through a CPR provider who evaluated proper technique through in-person demonstration of skills as the facility policy directed. 13. Review of the Business Office Manager/Human Recourses (BOM/HR) Director's Certificate of Completion for CPR, dated [DATE], showed she had successfully met the requirements for certification by completing the cognitive training skills evaluation in the specified course. The course was provided by NationalCPRFoundation. The BOM/HR Director's CPR certification was an on-line knowledge component. There was no evidence of documentation of a hands on/in-person portion to the training. No evidence to show the BOM/HR Director had maintained current CPR certification for health care providers through a CPR provider who evaluated proper technique through in-person demonstration of skills as the facility policy directed. 14. During an interview on [DATE] at 12:12 P.M., 1:15 P.M. and 3:48 P.M., the BOM/HR Director said the following: -He was responsible for tracking staff CPR certifications. He was new to the position and had not been tracking the CPR certifications for proper certification or expiration; -Copies of the CPR cards should be in the employee files. During an interview on [DATE] at 9:08 A.M. and [DATE] at 10:41 A.M., the Director of Nursing (DON) said the following: -He did not know who was responsible for transporting residents to and from the facility or know about facility policies regarding code status or CPR certification; -All staff members who provided transportation for residents should be CPR qualified; -He did not know the policy regarding hands-on skill testing CPR requirements. During an interview on [DATE] at 9:06 A.M. and [DATE] at 5:00 P.M., the Administrator said the following: -Staff should have hands on skill evaluations when completing CPR courses as facility policy directs; -Staff should be CPR qualified when transporting residents with a full code status; -She expect the BOM to ensure an employee file contained current CPR certification for health care providers through a CPR provider who evaluates proper technique through in-person demonstration of skills and was responsible for tracking CPR certification expiration dates. 15. Review of Resident #37's face sheet showed he/she was his/her own person and had elected to be full code. Review of the resident's physician orders (dated [DATE]) and care plan (revised [DATE]) showed the resident had elected to be full code. Observation on [DATE] at 8:40 A.M. of the resident's photo/name plate, outside of his/her room, had a black dot, indicating a Do Not Resuscitate code status. During an interview on [DATE] at 9:30 A.M., the resident said he/she wished to be a full code. The resident's code status was not consistent throughout the resident's medical record and facility documentation. 16. Review of Resident #36's face sheet showed he/she had a guardian and had elected a code status of DNR. Review of the resident's care plan (revised [DATE]) and physician orders (dated [DATE]) ,showed the resident had elected a code status of DNR. Review of the Code Status binder at the nurse's station, on [DATE] at 9:41 A.M., showed the resident's name listed on the DNR list. Observation on [DATE] at 10:35 A.M. and [DATE] at 11:00 A.M., of the resident's photo/name plate outside of his/her room, had no black dot, which would indicate the resident had elected a full code code status. During a telephone interview on [DATE] at 9:48 A.M., the resident's guardian confirmed the resident was a DNR. The resident's code status was not consistent throughout the resident's medical record, facility documentation and signage. 17. During an interview on [DATE] at 9:41 A.M., NA O said the following: -He/She did not know what a black dot indicated if it was by a resident door; -He/She would check the binder at the nurse's station, before starting CPR. During an interview on [DATE] at 11:00 A.M., NA J said the following: -He/She knew of one resident (Resident #40) with code status of DNR; -He/She thought the red dot by the resident's door was DNR; -He/She did not know what the black dot stood for by a resident door; -He/She would check the binder at the nurse's station, before starting CPR. During an interview on [DATE] at 8:51 A.M.,Certified Nurse Assistant (CNA) H said he/she was unsure about what the dots on a resident's photo/name plate meant. During an interview on [DATE] at 8:50 A.M.,Certified Medication Technician (CMT) I said the following: -He/She thought that the black dot on a resident's photo/name plate meant the resident was a registered sex offender; -A red dot on a resident's photo/name plate meant full code; -He/She was unsure how DNR was coded; -He/She would check the binder at the nurse's station, if unsure. During an interview on [DATE] at 8:52 A.M., Licensed Practical Nurse (LPN) A said the following: -The red and black dots on the nameplates/door stood for Full Code and DNR; -He/She was unsure which color was for which code status; -He/She would look at the dot on the door first in an emergency, then check the EHR, (face sheet and or care plan) and if they did not match, he/she would go talk to the Director of Nurses (DON). During an interview on [DATE] at 9:08 A.M. and [DATE] at 10:41 A.M., the DON said the following: -A resident's code status should be consisted throughout the resident's medical record and facility documentation; -He did not know where he would expect staff to look to find a resident's code status. During an interview on [DATE] at 9:06 A.M. and [DATE] at 5:00 P.M., the Administrator said the following: -The facility no longer used the red dots; -The red dot was a stop system to mean the resident could not be taken down during a behavior emergency; -The black dot indicated DNR code status; -She would expect staff to know the the black dot meant DNR code status; -She would expect all code status communications to match (dot on nameplate/door, DNR binder and EHR); -Medical Records was responsible for updating the dots and nameplate/door.

Based on observation, interview, and record review, the facility staff failed to develop and provide an individualized activity program to meet the residents' needs and interests to support their physical, mental, and psychosocial well-being for three residents (Residents #25, #18, and #3), in a review of 18 sampled residents. The facility failed to develop a care plan to identify the residents' preferences to ensure an ongoing program to support their choice of activities. The facility census was 56. Review of the facility policy, Activities, revised 07/19/23, showed the following: -The purpose of this policy is to ensure that all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being; -The Life Enhancement Director coordinates section F of the comprehensive assessment and ensures that activities are designed to promote and enhance the emotional health, self esteem, pleasure, comfort, education, creativity, success and independence for all residents, based on interview and assessing the resident's likes and dislikes; If the resident requires more intensive interventions for activities, 1:1 programming that is relevant to the resident's specific needs, interests, culture, and history/background, then an individualized activities plan of care will be developed to enhance their psychosocial well being; -To ensure than an ongoing program of activities is designed, The Life Enhancement Director will monitor large and small group activities, 1:1 programming and self directed activities. The Life Enhancement Director will modify the care plan interventions to resident centered approaches to promote self expression; -The activity calendar will be posted on each unit and will include activities that are appropriate for the general therapeutic milieu population that meets the specific needs, cognitive impairments, interests and supports the quality of life while enhancing self esteem and dignity; -Section F of the MDS 3.0 comprehensive assessment will be reviewed on all residents to ensure that the facility identifies resident's interests and needs and has a plan in place for individual 1:1 self-directed activities; -Under the direction of the Life Enhancement Director/Activities Director, documentation will be completed on each resident's activity within the facility daily. Documentation will note participation in activities and specific resident-centered individualized programming that will include but not limited to; the emotional health, physical, cognition, promotion of self esteem, pleasure, comfort, education, creativity, success and independence. All mentioned documentation is done electronically on point click care (pcc). 1. Review of Resident #25's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 12/10/24, showed the following: -Intact cognition; -It was somewhat important to do his/her favorite activities. Review of the resident's care plan, last reviewed/revised on 3/20/24, showed the resident was an active participant in activities. (The care plan did not include any specific information about the resident's preferred activities.) Review of the facility's activity calendar, dated 5/18/25 (Sunday), showed activities scheduled for 05/18/25 included 9:00 A.M. coffee club and 10:00 A.M. church. Review of the facility's activity attendance log, dated 05/18/25, showed the following: -Seven residents, include Resident #25, attended coffee club; -Church was canceled; -There were no other activities documented on the activity log sheet. During an interview on 05/19/25 at 8:20 A.M., Nurse Aide (NA) C said there was no church held on 05/18/25 because the minister did not show up. Review of the facility's activity calendar, dated 05/19/25, showed activities scheduled for 05/19/25 included 9:00 A.M. coffee club, 2:00 P.M. karaoke, and transportation week. Review of the facility's activity log, dated 05/19/25, showed no documentation the resident attended any scheduled activities on this date. Review of the facility's activity calendar, dated 05/20/25, showed activities scheduled for 05/20/25 included 10:00 A.M. coffee club and 2:00 P.M. shopping. Review of the facility's activity attendance log, dated 05/20/25, showed the resident did not attend any activities on this date. During an interview on 05/20/25 at 8:20 A.M., the resident said the following: -There had not been many activities for about a month or so; -Sometimes there were activities on the weekends, but not very often; -He/She was bored and would like more to do. 2. Review of Resident #18's admission MDS, dated [DATE], showed the following: -Intact cognition; -It was very important to do his/her favorite activities; -No rejection of cares. Review of the resident's care plan, dated 03/27/25, showed no documentation related to activities. Observation on 05/18/25 at 12:55 P.M. showed the resident sat on the edge of his/her bed with the bedside table over his/her lap coloring a coloring page with colored pencils. During an interview on 05/19/25 at 2:00 P.M., the resident said the following: -Laying in bed, coloring and smoking was about the extent of the resident's activities; -He/She and his/her roommate smoked because there was nothing else to do; -The facility rarely had the activities that were on the activity calendar; -Staff always say they are going to do an activity, and then it doesn't happen. Review of the facility's activity calendar, dated 05/20/25, showed activities scheduled for 05/20/25 included 10:00 A.M. coffee club and 2:00 P.M. shopping. Review of the facility's activity attendance log, dated 05/20/25, showed the resident did not attend any activities on this date. During an interview on 05/20/25 at 5:40 P.M., the resident said the following: -They did not have any activities today; -They always say they are going to do something and it doesn't happen. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's diagnosis list, dated 02/11/22, showed vision loss in both eyes. Review of the resident's care plan, revised 01/29/24, showed the following: -Encourage the resident to become engaged in facility life through group activities, meals in dining rooms, and therapeutic groups if applicable to needs; -He/She did not actively participate in facility activities; -Minister here every Sunday and does one-on-one bible study with the resident; -The resident needed one-on-one bedside/in-room visits and activities if unable to attend out of room events; -Provide one-on-one activity program two times a week. Observation on 05/18/25 at 1:45 P.M. showed the resident lay in bed awake. The room was quiet. During an interview on 05/18/25 at 1:45 P.M., the resident said the following: -His/Her radio was broken or on the wrong station because he/she had not been able to listen to it for a while; -All he/she did for activities was listen to his/her radio; there wasn't much else to do; -His/Her minister was supposed to be here today, but did not come. Observation on 05/20/25 at 8:18 A.M. showed the resident lay in bed awake. The room was quiet. During an interview on 05/20/25 at 8:18 A.M., the resident said no one had fixed his/her radio. 4. Review of the facility's activity calendar, dated 05/20/25 at 7:30 A.M., showed the following: -10:00 A.M. coffee club; -Shopping with no time provided; -There were no additional activities scheduled. Review of facility's activity attendance logs, dated 05/20/25, showed the following: -No documentation residents attended coffee club; -No documentation residents participated in shopping; -There was no documentation of any other activities. Review of the Activity calendar, dated 05/21/25, showed the following: -At 10:00 A.M., coffee club; -At 2:00 P.M., arts and crafts. Observation of activities on 05/21/25 at 2:00 P.M. showed the arts and craft activity was not held on this day/time. Review of facility's activity attendance logs, dated 05/21/25, showed the following: -No documentation residents attended coffee club; -No documentation residents attended arts and crafts; -There was no documentation of any other activities. During an interview on 05/20/25 at 10:40 A.M., the Activity Director said the following: -She started as Activity Director in March 2025; -She was very limited on access to supplies for activities. She had to purchase supplies in bulk, and it was a difficult transition to learn how to plan activities; -If she needed funds for activities, she had to use the administration fund which was shared with other departments; -If another department needed something more important, then that request would be granted and she would not receive items she needed/requested for an activity; -The shopping activity consisted of residents filling out a list of what they would like. Activity staff then went to the store and purchased the residents' requested items. The residents did not physically go shopping; -Weekend activities consisted of church and a folder located outside his/her office door with activities such as word searches the residents could complete and turn in for prizes out of the treat cart; -Activity staff were scheduled on weekends, but they had some staffing issues recently. During an interview on 05/21/25 at 5:00 P.M., the Administrator said the following: -Staff should follow the activity calendar as written; -There had been some budget cuts and changes in ordering of supplies which made it challenging to schedule activities due to the limited supplies on hand. 45563

Based on observation, interview, and record review, the facility failed to maintain the prevention of communicable disease in regards to Tuberculosis (TB; a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) when the facility failed to ensure Tuberculin Skin Tests (TST) for five employees in a review of ten newly hired employees reviewed, were completed in accordance with the general requirements for TB testing for long-term care employees. The facility also failed to ensure staff utilized Enhanced Barrier Precautions (EBP), as required by facility policy, when providing care to one resident (Resident #39), in a review of 18 sampled residents, who required the use of personal protective equipment (PPE) while providing care. Facility census was 56. Review of the facility's Tuberculosis Testing policy, last reviewed 06/29/2023, showed the following: -Upon hire, a new employee will receive a 2-step PPD (purified protein derivative/TB) skin test; -All TB tests records will be kept on file in the according areas (employee files). 1. Review of the Administrator's employee file showed the following: -He/She was hired 12/18/23; -No evidence of TB testing or results. 2. Review of Laundry Aide G's employee file showed the following: -He/She was hired 08/19/24; -No evidence of TB testing or results. 3. Review of Licensed Practical Nurse (LPN) A's employee file showed the following: -He/She was hired on 01/02/25; -No evidence of TB testing or results. 4. Review of Nurse Assistant (NA) C's employee file showed the following: -He/She was hired 01/03/25; -No evidence of TB testing or results. 5. Review of Registered Nurse (RN) D's employee file showed the following: -He/She was hired 01/27/25; -No evidence of TB testing or results. 6. During an interview on 05/21/25 at 10:00 A.M., the Human Resources (HR) Director said the following: -He was responsible for ensuring employees were up to date with TB testing; -He started as HR Director a month ago and had been going through employee files to address what the previous HR Director did not complete, including ensuring employee TB testing was completed upon hire. During an interview on 05/21/25 at 5:00 P.M., the administrator said TB testing was to be completed on all new hires. HR was responsible for tracking, but the Assistant Director of Nursing (ADON) was responsible for completing the TB testing. During an interview on 06/02/25 at 3:55 P.M., the ADON said the following: -The previous DON and Business Office Manager monitored the employee TB testing, but they quit in January 2025; -In reviewing employee files, it was discovered there were several staff who were not up to date with TB testing; -She and the corporation's regional nurse were reviewing and administering TB testing when they could, but had not completed all of them. 7. Review of the facility policy, Enhanced Barrier Precautions, revised 05/18/24, showed the following: -Enhanced barrier precautions (EBP) is a strategy in nursing homes to decrease transmission of Centers of Disease Control and Prevention (CDC)-targeted and epidemiologically important multidrug-resistant organisms (MDROs) when contact precautions do not apply. EBP uses PPE and recommends gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO transmission. EBP expands the use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. EBP uses gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Gown and gloves must be used for high-contact resident care activities for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -High-contract resident care activities include, but are not limited to, dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care; -Wounds that require EBP are chronic wounds, including, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. These are wounds that generally require a dressing; -Make gowns and gloves available immediately near or outside of the resident's room; -Facility should ensure that all staff know which residents require EBP. Facility has the discretion on how to communicate to staff. A sign about EBP is attached which may be used. 8. Review of the Resident's #39's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/13/25, showed the following: -The resident had a one stage II pressure ulcer (Partial thickness loss of dermis/middle later of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough. May be present as an intact or open/ruptured blister) not present upon admission; -The resident required pressure ulcer care. Review of the resident's Physician's Order Summary, dated 05/01/25 to 05/31/25, showed the following: -Resident on EBP for history of ESBL ((Extended-spectrum Betalactamase) (common antibiotic-resistant organism) of the urine (02/27/25); -Apply barrier cream with Calmoseptine (ointment used to treat minor skin irritations) or equivalent to open area and buttocks every shift (04/07/25). Review of resident's skin assessment, dated 05/17/25, showed the resident had a 0.7 centimeter (cm) by 1.1 cm by 0.9 cm stage II pressure ulcer of the left buttock. Review of the resident's care plan on 05/18/25 showed no documentation the resident required EBP due to history of ESBL of the urine and/or presence of a stage II wound of the left gluteus. Observation on 05/20/25 at 8:20 A.M. showed there were no EBP signs and/or PPE on the resident's door. During an interview on 05/20/25 at 8:20 A.M., Nursing Assistant (NA) C said the following: -The resident was dependent with care; -The resident had a small healing wound on his/her bottom. Observation on 05/20/25 at 2:05 P.M. showed the following: -NA C and Certified Nursing Assistant (CNA) H entered the resident's room to assist the resident to bed; -NA C and CNA H did not wear gowns; -NA C and CNA H assisted the resident to bed with the mechanical lift; -The resident was incontinent of bowel and bladder; -The resident had a small pressure ulcer on his/her left buttock; -NA C and CNA H provided incontinence care without wearing gowns. During an interview on 05/21/25 at 8:10 A.M., CNA H said the following: -He/She was not 100% sure if the resident was supposed to be on EBP; -He/She would look for the germ sticker on the resident's picture by the door, but did not particularly remember if the resident had one or not; -Residents who had any kind of wound, chronic infection, indwelling devices were on EBP and required use of gown, gloves, booties, and face shields if needed. During an interview on 05/21/25 at 8:21 A.M., NA C said the following: -There were signs on residents' doors that directed if the residents were on EBP and required use of PPE during cares; -He/She did not think the resident was on EBP. There was no sign on the outside of the resident's door; -If a resident was on EBP then he/she should wear a gown and gloves when providing care. Observation on 05/321/25 at 8:25 A.M. showed no signs and/or germ sticker on the resident's door to indicate the resident was on EBP. There was no PPE located outside of the resident's room. During an interview on 05/21/25 at 2:00 P.M., the administrator said the following: -The resident was supposed to be on EBP; -CNAs removed the signs, including the germ sticker from resident's picture, and PPE because they thought the resident was not on EBP; -She expected residents to have signage indicating the resident required EBP; -PPE was readily available near the resident's room if he/she required EBP. 47008

Based on interview and record review, the facility failed to offer and/or administer the pneumococcal vaccine as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for five residents (Resident #18, #23, #37, #50, and #39), in a review of 18 sampled residents. The facility census was 56. Review of the facility policy, Influenza and Pneumococcal Immunizations, revised on 05/14/24, showed the following: -The purpose of this policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable diseases; -The resident or their legal representative will be informed that the pneumococcal immunization will be offered upon admission per CDC guidelines. The pneumococcal immunization will not be given if the immunization is medically contraindicated, the facility has evidence to support the resident received the immunization, or the resident or their legal representative has refused the immunization. All CDC recommendations for the pneumococcal immunization will be followed; -The resident or their legal representative will be required to sign the revolving consent form attached to this policy. The resident or their legal representative will be told this form provides consent for the pneumococcal immunization as needed unless those immunizations are medically contraindicated. Review of the CDC's Pneumococcal Vaccine Timing for Adults, updated October 2024, showed the following: -For adults [AGE] years or older who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV15, PCV20, or PCV21; -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15. If the PPSV23 is not available, the PCV20 or PCV21 may be used; -If PCV20 or PCV21 is administered, regardless of which vaccine is used, their pneumococcal vaccinations are complete; -For adults [AGE] years or older who received the PPSV23 only at any age, administer the PCV15, PCV20 or the PCV 21 at least one year after the PPSV23 was administered; -For adults [AGE] years or older who received the PCV13 only at any age, administer the PCV20 or PCV21 at least one year after the PCV13 was administered; -For adults [AGE] years or older who received the PCV13 at any age and the PPSV23 when less than [AGE] years of age, administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose; -For adults [AGE] years or older who received the PCV13 at any age and the PPSV23 at [AGE] years or older, the individual and their vaccination provider may choose to administer the PCV20 or PCV21 after at least five years after the last pneumococcal vaccine dose. (Refer to the CDC's Shared Clinical Decision-Making PCV20 or PVC21 Vaccination for Adults [AGE] years or Older for additional information on clinical decision making.) Review of the CDC's Pneumococcal Vaccine Timing for Adults 19-[AGE] years of age with chronic health conditions, updated October 2024, showed the following: -Chronic health conditions include; alcoholism, chronic heart disease, congestive heart failure, chronic liver failure, chronic lung disease, chronic obstructive pulmonary disease, emphysema, asthma, cigarette smoking, and diabetes; -For adults ages 19-[AGE] years of age who have never received any pneumococcal vaccine or whose previous vaccination history is unknown, administer PCV 15, PCV20, or PCV21. -If PCV15 is administered, administer a dose of PPSV23 at least one year after the dose of PCV15; -For adults 19-[AGE] years of age or older who received the PPSV23 only, administer the PCV 15, PCV20, or PCV 21 at least one year after the PPSV23 was administered; -For adults 19-[AGE] years of age who received the PCV13 only at any age, administer the PCV20 or PCV21 at least one year after the PCV13 was administered; -For adults 19-[AGE] years of age who received the PCV13 and the PPSV23, no vaccines are recommended at this time. Review pneumococcal vaccine recommendations a again when the the adult turns [AGE] years of age. 1. Review of Resident #18's Face Sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She was greater than [AGE] years of age; -He/She had diagnoses that included diabetes, alcohol abuse, tobacco use, congestive heart failure and chronic obstructive pulmonary disease; -He/She was his/her own responsible party. Review of the resident's Physician Orders, dated 03/26/25, showed he/she may have the pneumococcal vaccine every five years with written or verbal consent. Review of the resident's electronic health record (EHR) showed the following: -No documentation the resident received any pneumococcal vaccinations prior to admission; -No documentation the facility offered, the resident received or refused any pneumococcal vaccinations. (The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/02/25, showed the following: -Intact cognition; -The resident's pneumococcal vaccination was not up to date; -The resident was not offered the pneumococcal vaccination. During an interview on 05/20/25 at 1:50 P.M., the resident said he/she wanted the pneumococcal vaccination and it had not been offered. 2. Review of the Resident #23's Face Sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She was less than [AGE] years of age; -He/She had a diagnosis of diabetes; -He/She was his/her own person. Review of the resident's immunization record showed the resident received pneumovax (PPSV23) on 01/04/19. Review of the resident's Physician Orders, dated 05/19/20, showed he/she may have the pneumococcal vaccination as directed every five years. Review of the resident's EHR showed the following: -No documentation the resident received one dose of PCV15, PCV20, or PCV21 one year after PPSV23; -No documentation the facility offered, the resident received, or refused any additional pneumococcal vaccinations. (The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) Review of the resident's annual MDS, dated [DATE], showed the resident's pneumococcal vaccination was up to date. During an interview on 05/21/25 at 9:38 A.M., the resident said he/she wanted the pneumococcal vaccination. 3. Review of Resident #37's Face Sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She was greater than [AGE] years of age; -He/She had a diagnosis of diabetes; -He/She was his/her own person. Review of the resident's Physician Orders, dated 01/07/24, showed he/she may have the pneumococcal vaccine every five years with written or verbal consent. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident's pneumococcal vaccination was not up to date; -The resident was not eligible for the pneumococcal vaccination (medically contraindicated). Review of the resident's electronic health record (EHR) showed the following: -No documentation the resident received any pneumococcal vaccinations prior to admission; -No documentation the facility offered, the resident received, or refused any pneumococcal vaccinations; -No documentation the pneumococcal vaccination was medically contraindicated for the resident. (The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) During an interview on 05/21/25 at 9:30 A.M., the resident said he/she wanted the pneumococcal vaccination. 4. Review of the Resident #50's face sheet showed he/she was over [AGE] years of age. Review of the resident's EHR showed the resident's diagnoses included diabetes mellitus, renal insufficiency due to end stage renal disease (kidney failure), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), and emphysema (chronic respiratory disease). Review of the resident's undated immunization record showed the following: -No documentation the resident received any pneumococcal vaccinations; -No documentation the facility offered, the resident received, or refused any pneumococcal vaccinations. (The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was intact; -The resident's pneumococcal vaccination was not up to date; -Pneumococcal vaccination was not offered. Review of the resident's Physician Orders, dated May 2025, showed he/she may have the pneumococcal vaccination every five years with written or verbal consent. During an interview on 05/20/25 at 1:20 P.M., the resident said he/she wanted to stay current on immunizations, including the pneumococcal vaccination. He/She would consent to the vaccination if it was offered, but no one had offered the vaccination. During an interview on 05/21/25 at 12:45 P.M., the Assistant Director of Nursing (ADON) said the resident did not receive the pneumococcal vaccination. He/She was unsure why the resident did not receive the vaccine. 5. Review of the Resident #39's face sheet showed he/she was over [AGE] years of age. Review of the resident's EHR showed the resident's diagnoses included diabetes, heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs), acute respiratory failure with hypoxia (results from acute or chronic impairment of gas exchange between the lungs which causes low oxygen level in the blood), and chronic obstructive pulmonary disease (COPD) (chronic respiratory disease which impairs breathing). Review of the resident's immunization record showed the resident received a pneumococcal vaccination of unknown type on 11/13/21. Review of the resident's undated immunization record showed no documentation the facility offered, the resident received, or refused any further pneumococcal vaccinations. (The resident was not up to date on the pneumococcal vaccination per CDC recommendations.) Review of the resident's annual MDS, dated [DATE], showed the following: -The resident's pneumococcal vaccination was not up to date; -Pneumococcal vaccination was not offered. 6. During an interview on 05/21/25 at 12:45 P.M., the ADON said the following: -Nursing and administrative nursing staff reviewed the status of residents' vaccinations; -The facility obtained the residents' vaccination histories from the discharge paperwork from previous facilities and/or hospital admissions; -The facility did not utilize any other outside records to verify what vaccinations a resident received; -Resident #50 did not have pneumococcal vaccination. He/She was unsure why the resident did not receive one. During an interview on 05/21/25 at 4:58 P.M., the administrator said the following: -All immunizations should be up to date per the CDC guidelines/recommendations; -The ADON and and Director of Nursing (DON) were responsible to track immunizations and document them in the EHR.

Based on observation, interview, and record review, the facility failed to consistently implement interventions to address weight loss, including providing assistance with eating to prevent unplanned weight loss for one resident (Resident #47), in a review of 18 sampled residents. The facility census was 56. Review of the facility policy, Weight Monitoring, revised 05/07/24, showed the following: -Purpose: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise; -Weight can be a useful indicator of nutritional status. Significant, unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem; -The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: -Identifying and assessing each resident's nutritional status and risk factors; -Evaluating/analyzing the assessment information; -Developing and consistently implementing pertinent approaches; -Monitoring the effectiveness of interventions and revising them as necessary; -Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: -Identified causes of impaired nutritional status; -Reflect the resident's personal goals and preferences; -Identify resident-specific interventions; -Time frame and parameters for monitoring; -Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new causes of nutrition-related problems are identified; -If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate; -The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences; -Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status; -Documentation: -The physician should be informed of a significant change in weight and may order nutritional interventions; -Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed; -If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietitian, Dietary Manager, or the nursing department may initiate this process; -The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress note; -Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate; -The interdisciplinary plan of care communicates care instructions to staff. 1. Review of Resident #47's admission weight, dated 10/03/22, showed the resident weighed 163.0 pounds. Review of the resident's diagnoses list, dated 10/05/22, showed the resident's diagnoses included white matter disease (a rare, progressive neurological disorder that damages the brain's white matter that can lead to various neurological symptoms like memory problems, balance issues, and mobility difficulties), personal history of transient ischemic attack (TIA; a temporary disruption of blood flow to the brain, leading to stroke-like symptoms that usually disappear within minutes or hours), cerebral infarction (a serious medical condition where blood flow to the brain is blocked, leading to brain tissue damage or death), muscle weakness, benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that can cause urinary issues), and localized swelling, mass and lump, lower limb. Review of the resident's care plan, revised 08/02/24, showed the following: -He/She was at risk for self-care deficit and decline in functions related to his/her diagnosis of white matter disease; -He/She required extensive assistance with his/her activities of daily living (ADL) tasks; -He/She could perform some of the task with supervision, set up and cues; -Allow time for him/her to complete the task and intervene as needed; -Monitor for decline in functions; -Provide supervision, assistance, set and cues as needed; -Determine level of assistance needed based on ADL evaluation; -He/She was on a mechanical soft diet; -Ensure he/she had appropriate portions at meals and offer seconds; -He/She was on a mechanical soft/thin liquid diet due to aspiration and choking risk; -He/She used weighted utensils, double handled cups, and a scoop plate to assist with eating independently; -Notify therapy if he/she required assistance with eating or needed other utensil modifications to keep independence. Review of the resident's documented weights, located in the electronic medical record, showed the following: -On 11/11/24, the resident weighed 175.2 pounds; -On 12/10/24, the resident weighed 174.1 pounds; -On 01/10/25, the resident weighed 189.2 pounds; -On 02/02/25, the resident weighed 190.0 pounds; Review of the resident's physician's orders, dated 03/06/25, showed a new order for regular diet with mechanical soft texture. Review of the resident's documented weights, dated 03/07/25, showed the resident weighed 157.0 pounds. (A loss of 33 pounds in one month; a 17% weight loss in one month.) Review of the resident's nutrition/dietary note, dated 03/11/25 at 3:29 P.M., showed the following: -He/She continued on a regular/mechanical soft diet with thin liquids and no snacks from the vending machine; -No indication of recent intake available; -Weight was 157 pounds, down 33 pounds in one month (-17.4% loss), down 17 pounds in three months (-9.7% loss), and down 15 pounds in six months. Current BMI (body mass index, tells whether one has too much, too little or a healthy amount of body fat) is 24.6 - normal; -Question accuracy of weights. Pattern has varied significantly over the past year; -Continue current plan of care, monitor oral intake on current diet and weight for significant changes; -Registered dietician will follow and be available as needed. Review of the resident's documented weights, dated 04/16/25, showed the resident weighed 158.0 pounds. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 04/19/25, showed the following: -Severely impaired cognition; -Required supervision or touch assistance with eating; -Required mechanically altered diet; -Weight 158 pounds; -Had a weight loss of 5% or more in last month or 10% or more in last six months. Review of the resident's nutrition/dietary note, dated 04/23/25 at 8:04 P.M., showed the following: -The resident remained on a mechanical soft diet with weighted silverware, and double handed cups; -The resident's weight was 209 pounds, up 20 pounds in three months (10.6% gain), up 37 pounds in six months (21.5% gain), BMI = 32.7 class I obesity weight range; -Unsure of weight accuracy; -Will continue to monitor and be available as needed. Review of the resident's documented weights, dated 04/29/25, showed the resident weighed 167.0 pounds. (A gain of nine pounds in 13 days.) Review of the resident's progress note, dated 04/29/25, showed staff notified the physician of the resident's weight loss. Repeat labs, urine, chest x-ray, and Boost (high protein nutritional supplement) three times daily ordered. Review of the resident's physician orders, dated 05/07/25, showed a new order for Boost with meals. Review of the resident's documented weights showed the following: -On 05/09/25, the resident weighed 143.4 pounds; -On 05/12/25, the resident weighed 142.0 pounds. Review of the resident's physician orders, dated 05/12/25, showed an order for weekly weights to be obtained every Monday. Review of the resident's physician orders for May 2025, showed the following: -Boost (high protein nutritional supplement) with meals; -Weekly weight (every Monday); -Regular diet, mechanical soft texture; -May use weighted silverware, double handed cups, white scoop plate during meals. Observation on 05/18/25 at 12:10 P.M. showed the following: -The resident sat in the dining room; -Staff served the resident a mechanical soft diet which included hamburger with gravy, mashed potatoes and gravy, pudding parfait, and koolaid; -The resident used weighted silverware, a separated/scoop plate and a double handled cup; -The resident attempted to feed himself/herself with the weighted silverware. As he/she took a bite of food to his/her mouth, the food fell from the silverware to the resident's clothing; -NA M walked over to the resident and gave the resident a bite of food; -The resident consumed approximately 50% of his/her meal. Review of the resident's medical record showed no documentation staff monitored the resident's oral intake from his/her meals on 05/18/25. During an interview on 05/18/25 at 1:00 P.M., the resident said the food was not good. Staff do not provide him/her with a alternate when he/she did not like what was served. Review of the resident's documented weights, dated 05/19/25, showed the resident weighed 144.0 pounds. Observation on 05/19/25 at 5:25 P.M., showed the following: -The resident sat in his/her wheelchair in the dining room. The resident held his/her hand up and said, Help; -Staff were in the dining room and served other residents trays and offered feeding assistance to other residents. Staff did not attend to the resident's request for help; -The resident attempted to feed himself/herself with the weighted silverware. As he/she took a bite of food to his/her mouth, the food fell from the silverware to the resident's clothing; -After several attempts of raising his/her hand and saying help, Nurse Assistant (NA) L wiped the food off of the resident's shirt and pants and placed a clothing protector around the resident's neck and walked away. (NA L did not ask the resident why he/she asked for help and did not assist the resident to eat his/her meal); -The resident removed his/her clothing protector and said, I'm done; -The resident said he/she was full; -The resident ate/spilled approximately 25% of his/her meal; -Staff did not offer an alternative or offer to assist the resident; -The resident wheeled himself/herself out of the dining room and into the hallway. During an interview on 05/19/25 at 5:45 P.M., the resident said he/she would like staff to assist him/her with eating. Review of the resident's medical record showed no documentation staff monitored the resident's oral intake from his/her meals on 05/19/25. Observation on 05/21/25 at 12:15 P.M. showed the following: -The resident fed himself/herself in the dining room; -He/She used weighted utensils, divided/scoop plate and a double handled cup; -He/She held his/her hand up with his/her spoon for assistance, and no staff came to assist him/her; -While he/she tried to feed himself/herself, he/she dropped food and did not get the food to his/her mouth; -The resident held his/her hand in the air and asked for a napkin; -NA M brought the resident a napkin and put a clothing protector on the resident. NA M did not offer to assist the resident to eat; -The resident ate all of his/her goulash and all of his/her chocolate mousse dessert and left all of his/her green beans; -He/She took off his/her clothing protector and wheeled himself/herself out of the dining room; -He/She said he/she didn't like green beans; -No staff offered the resident seconds as directed on his/her care plan. During an interview on 05/21/25 at 3:15 P.M., the resident said the following: -He/She would eat more and actually asked for double portions but didn't get it when he/she asked; -He/She was usually still hungry after meals. Review of the resident's medical record showed no documentation staff monitored the resident's oral intake from his/her meals on 05/21/25. During an interview on 05/21/25 at 11:40 A.M., NA C said the resident required more assistance with eating lately. During an interview on 05/21/25 at 11:40 A.M., NA L said the resident required a lot more assistance with eating recently. During an interview on 05/21/25 at 2:00 P.M., the Registered Dietician said the following: -Last month's review did not signal a weight loss for the resident, so she was just now seeing the resident's current weight loss; -Looking at her notes, she saw a note where staff were unsure of the accuracy of the resident's weight because the resident actually triggered for weight gain last month; -She always followed up on the following month with any weight gain or weight loss. The resident was on her list to be seen; -The staff were having issues with the resident wanting regular food and he/she was on a mechanical soft, so they were going to work on a diet waiver; -The resident started on Boost with meals (three times daily) on 05/07/25; -She was going to have to look into the resident's percentage of intake and see if double portions would be appropriate. During an interview on 06/05/25 at 2:00 P.M., the Assistant Director of Nursing (ADON) said the following: -Meal intake documentation was completed as needed and was a task the Director of Nursing (DON) had to trigger to be completed; -Once the DON triggered the task, the certified nurse assistants (CNA)s were responsible to chart how much the resident ate during the meals; -The resident's meal intake was not charted because the previous DON never triggered the task for the CNAs to chart. During an interview on 05/21/25 at 4:58 P.M., the Administrator said staff were to assist the resident if he/she needed help with eating.

Based on observation, interview, and record review, the facility failed to assess a dialysis fistula ( a connection that a surgeon makes between an artery and a vein to make it possible for a person to receive hemodialysis) before and after dialysis treatments and to monitor for bruit (audible vascular sound associated with turbulent blood flow) and thrill (a vibration caused by blood flowing through the fistula) every shift as directed in facility policy for one resident (Resident #50), in a review of 18 sampled residents. The facility failed to develop a care plan to address the care and monitoring of the resident's fistula. The facility identified two residents who received dialysis treatments. The facility census was 56. Review of the facility's dialysis policy, last reviewed on 03/18/22, showed the following: -The facility will ensure residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -The facility would ensure each resident received care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including: -Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; -Ongoing assessments and oversight of the resident before and after dialysis treatments; -To prevent injuries, ensure care plan and certified nursing assistants care plan indicate no blood pressure measurements, venipunctures, and or injections on the affected side. When blood flow through the vascular access was reduced, it could clot; -The nurse would monitor bruit and thrill every shift and document on the resident's Treatment Administration Record (TAR); -Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency; -Auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicated patency; -After dialysis, assess the vascular access for any bleeding or hemorrhage. 1. Review of Resident #50's electronic health record showed the resident's diagnoses included end stage renal disease (ESRD; permanent kidney failure) and dependence on renal dialysis. Review of the resident's care plan, last revised on 01/06/25, showed the following: -His/Her diagnoses included renal insufficiency (poor function of the kidneys) related to ESRD and absence of one kidney; -He/She required dialysis every Monday, Wednesday, and Friday; (The care plan did not include the resident had a dialysis fistula. The care plan did not address the care of the fistula, including contraindication to taking blood pressure measurements in the arm with the fistula, venipunctures, and/ or injections on the affected side, and did not address monitoring the fistula, including assessment for bruit and thrill every shift, as directed in facility policy.) Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 03/27/25, showed the following: -His/Her cognition was intact; -Diagnoses included ESRD; -He/She required dialysis. Review of the resident's physician's orders, dated May 2025, showed no orders related to the resident's dialysis treatments and/or monitoring of the dialysis fistula. Review of the resident's TAR, dated May 2025, showed no documentation staff monitored bruit and thrill every shift, as directed in facility policy. During an interview on 05/20/25 at 1:20 P.M., the resident said the following: -He/She had dialysis treatments on Monday, Wednesday, and Friday; -He/She had dialysis yesterday (Monday); -He/She had a fistula in his/her left arm; -Some staff did not check his/her fistula after dialysis. Observation on 05/20/25 at 1:20 P.M., showed the resident had a bandage over the fistula located in his/her left arm. (The resident received dialysis treatment the day prior on 05/19/25.) During an interview on 5/20/25 at 1:30 P.M., Licensed Practical Nurse (LPN) A said the following: -The resident went to dialysis on Mondays, Wednesdays, and Fridays; -There was no specific assessment he/she needed to complete when the resident returned except to monitor for increased bleeding; -He/She only assessed for bleeding and made sure the site was clean and dry. During an interview on 05/21/25 at 8:40 A.M., LPN B said he/she was unaware of any specific protocols to follow when a resident returned from dialysis. During an interview on 05/20/25, at 3:00 P.M., the Assistant Director of Nursing (ADON) said the following: -Resident #1 received dialysis treatments and had a fistula in his/her arm; -Nursing staff were to obtain weights, vital signs (blood pressure, pulse, temperature, oxygen level) on the day of dialysis treatment and assess for bleeding at the fistula site; -Nursing staff were not expected to feel for bruit (audible vascular sound associated with turbulent blood flow) and/or thrill (a vibration caused by blood flowing through the fistula) of the fistula. During an interview on 06/03/25 at 10:20 A.M., the Director of Nursing said staff were to follow the facility's policy and procedure for monitoring residents who received dialysis treatments, including monitoring the site for bleeding, thrill, bruit, and signs of infection.

Based on observation, interview, and record review, the facility failed to serve food that accommodated one resident's (Resident #12) preferences and allergies, in a review of 18 sampled residents. The facility census was 56. The facility did not have a policy for preferences/allergies/substitutions. 1. Review of Resident #12's face sheet showed he/she was lactose intolerant. Review of the resident's diagnoses list, dated 11/03/22, included gastro-esophageal reflux disease (GERD) (a chronic condition where stomach contents, including acid, reflux back into the esophagus causing symptoms like heartburn, chest pain, and other digestive issues). Review of the resident's care plan, revised on 01/11/24, showed the following: -He/She was lactose intolerant; -He/She would not receive items he/she was allergic to; -He/She was on a regular diet. No bread per resident request; -Dietary department will monitor diet monthly to ensure proper dietary recommendations; -He/She will request special foods from dietary then refuse and say that there was something wrong with it and will refuse to eat it. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 02/13/25, showed the resident's cognition was intact. Review of the resident's diet card, undated, showed the following: -Diet: Regular; -Allergies: Lactose; -Beverages: soy milk; -Notes: lactose intolerant, no bread, no pasta; -Dislikes: white bread. Review of the resident's physician orders, dated May 2025, showed the following: -Allergy: Lactose intolerance; -Regular diet; -No bread. During an interview on 05/18/25 at 1:54 P.M., the resident said the following: -He/She was lactose intolerant and staff served him/her regular milk; -He/She would prefer gluten-free bread options, but the facility did not offer it; -Staff did not accommodate his/her allergies nor his/her preferences. Observation on 05/20/25 at 8:20 A.M. showed the resident had a full bowl of puffed rice cereal in milk on his/her tray on the bedside table. During an interview on 05/20/25 at 8:20 A.M., the resident said the following: -The Dietary Manager told him/her if he/she wanted lactose-free milk, he/she would have to buy it himself/herself; -The puffed rice cereal came from the kitchen with the milk already in the bowl. Since it was regular milk, he/she could not eat the cereal. During an interview on 05/21/25 at 8:58 A.M., the Dietary Manager said the following: -If the facility had what the resident requested, they would provide it for him/her; -Dietary staff used to order almond milk for the resident, but stopped. Now the resident wanted it, and the facility didn't have it; -No one told the resident he/she had to buy the almond milk himself/herself; -The facility served the resident regular milk, because they did not have almond milk; -It would not be appropriate to serve the resident regular milk if he/she was lactose intolerant; -The resident didn't eat white bread and the facility did not keep gluten-free bread; -Staff do not serve any type of bread to the resident; -It would be appropriate to have lactose-free and gluten-free options for the resident; -The administrator told him/her that lactose-free and gluten-free alternative items weren't in the budget. During an interview on 05/21/25 at 9:15 A.M., the administrator said the following: -The facility did not have a special milk or gluten-free breads because the resident wasn't drinking/eating them; -When the resident didn't eat/drink what he/she requested, it affected the budget; -She expected the facility to adhere to the resident's allergies and preferences.

Based on observation, interview, and record review, the facility failed to update and revise the comprehensive care plan for two residents (Resident #26 and #14), in a review of 18 sampled residents. The facility failed to update Resident #26's care plan to address the resident's use of antipsychotic, antidepressant, and antianxiety medications, failed to update Resident #47's care plan to address the resident's need for a mechanical lift transfer, and failed to update Resident #14's care plan with interventions for wound care and enhanced barrier precautions (EBP). The facility census was 56. Review of the facility's policy, Comprehensive Care Plans, revised on 10/31/2024, showed the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; -The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record; -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: -The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan; -A registered nurse with responsibility for the resident; -A nurse aide with responsibility for the resident; -A member of the food and nutrition services staff; -The resident and the resident's representative, to the extent practicable; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; -The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed; -Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. Review of Resident #26's electronic health record showed the resident's diagnoses included bipolar disorder (mental health disorder that causes extreme mood swings), major depressive disorder, anxiety disorder, and paranoid personality disorder (mental condition in which a person has a long-term pattern of distrust and suspicion of others). Review of the resident's psychiatric assessment, dated 02/28/25, showed the following: -The resident had a history of anxiety and auditory hallucinations; -Medications included Trazodone (a medication to treat major depressive disorder) 50 milligram (mg), quetiapine rumarate (an antipsychotic medication) 200 mg, divalproex sodium (anti-seizure medication used to treat certain types of psychiatric conditions) 250 mg, and aripiprazole lauroxil syringe (long-acting injection to treat psychiatric conditions). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 03/05/25, showed the following: -Cognition was intact; -He/She received antipsychotic medications seven out of the previous seven day look back period; -He/She received antidepressant medications seven out of the previous seven day look back period; -He/She received antianxiety medications seven out of the previous seven day look back period. Review of the resident's Care Plan, last reviewed on 03/12/25, showed the following: -No documentation the resident had a history of hallucinations; -No documentation the resident received anti-depressant medications, antipsychotic medications, or anti-anxiety medications. Review of the resident's Physician's Orders, dated May 2025, showed the following: -Quetiapine fumarate 200 mg (order dated 09/16/24); -Aristada (long-acting injection to treat psychiatric conditions) prefilled syringe 882 mg/3.2 milliliter (ml) (order dated 11/2/24); -Divalproex Sodium ER 250 mg (order dated 11/2/24); -Trazodone 50 mg (order dated 02/19/25); -Duloxetine HCl (an antidepressant medication) delayed release sprinkle 60 mg (order dated 04/27/25). During an interview on 05/19/25 at 2:00 P.M., the resident's responsible party said the following: -The resident had inappropriate behaviors with residents of the opposite gender; -He/She expected staff to monitor for those inappropriate behaviors and redirect the resident. During an interview on 05/20/25 at 8:20 A.M., Nurse Aide (NA) C said the following: -The resident had a history of inappropriately touching residents of the opposite gender; -Staff instructed the resident to keep his/her hands to himself/herself; -Staff were to monitor the resident for these behaviors. Review of the resident's care plan showed no documentation the resident had inappropriate behaviors towards other residents, no interventions to address these behaviors, and no system for monitoring for these behaviors. During an interview on 05/21/25 at 2:00 P.M., the Assistant Director of Nursing (ADON) said antipsychotic medication use should be included in the resident's care plan. During an interview on 05/21/25 at 2:00 P.M., the Regional Registered Nurse said antipsychotic medications use should be included in the resident's care plan. 2. Review of Resident #47's diagnoses list, dated 10/05/22,showed the resident's diagnoses included white matter disease (a rare, progressive, and genetic neurological disorder that affects the brain's white matter), history of transient ischemic attack (TIA) (a temporary disruption of blood flow to the brain, leading to stroke-like symptoms that usually disappear within minutes or hours) and cerebral infarction (a serious medical condition where blood flow to the brain is blocked, leading to brain tissue damage or death), history of falling, unsteadiness on feet, and muscle weakness. Review of the resident's care plan, revised 08/02/24, showed the following: -He/She has an activity of daily living (ADL) self-care performance deficit related to disease process: Stroke; -He/She has limited physical mobility related to stroke. Review of the resident's quarterly MDS, dated [DATE], showed he/she was dependent on staff for transfers. Review of the resident's care plan showed it had not been updated since 08/02/24 to show transfer status and the resident required a mechanical lift for transfers. Observation on 05/20/25 at 1:05 P.M. showed Nurse Aide (NA) L brought a mechanical lift to the resident's room and Certified Nurse Aide (CNA) H and NA C transferred the resident from his/her wheelchair to his/her bed via the lift. During an interview on 05/20/25 at 1:45 P.M., NA L said that staff never transfer the resident without the mechanical lift. During an interview on 05/20/25 at 2:15 P.M., CNA H said the resident's transfer status should be on the care plan. During an interview on 05/20/25 at 2:12 P.M., Licensed Practical Nurse (LPN) A said the resident was a mechanical lift transfer and the transfer status should be found somewhere in the electronic health record (EHR). During an interview on 05/21/25 at 12:00 P.M., the Certified Occupational Therapy Assistant (COTA) Program Coordinator said the following: -The resident required a two person maximum assist with mechanical lift for transfers; -The resident had a significant decline about two to three months ago; -The resident has been a two person maximum assist transfer with a mechanical lift for two to three months. During an interview on 05/20/25 at 5:15 P.M., the DON said the following: -If the charge nurse has a new admission, they were responsible for starting the care plan; -The baseline care plan was a group effort; -The MDS Coordinator worked off site; -The MDS Coordinator was responsible for completing the comprehensive care plan; -The ADON and DON were responsible for updating the care plan. During an interview on 06/05/25 at 3:00 P.M., the MDS Coordinator said the following: -She worked remotely and was not in the building to be a part of morning meetings and care plan meetings; -She helped to update a care plan if she noticed something that needed and update; -It was the DON's and interdisciplinary team's responsibility at the facility to update the care plans. During an interview on 05/21/25 at 4:58 P.M., the Administrator said the following: -The care plans were not updated to reflect the current needs of the resident because the MDS Coordinator worked remotely and was not at the facility; -When the MDS Coordinator was in house and was responsible for completing the care plans, it made it easier because she was here for morning meetings and care plan meetings; -Now that the facility no longer had an in-house MDS Coordinator, the DON and ADON were working on slowly getting the care plans updated. 45563 Surveyor: [NAME], Konnie 47008

Based on interview and record review, the facility failed to accurately transcribe physician orders received from a transferring facility upon admission to the facility for one resident (Resident #18), in a review of 18 sampled residents. The resident admitted with physician orders to receive medications to treat anxiety and depression, and did not receive the medications for 14 days. The resident reported experiencing depressed mood and significant mood fluctuations as a result of not receiving the medication. The facility census was 56. Review of Drugs.com on 06/05/25 showed the following: -Buspar is an anti-anxiety medicine that affects chemicals in the brain that may be unbalanced in people with anxiety; -Take Buspar exactly as prescribed; -If switching anxiety medication, the resident may need to slowly decrease the dose of the other medication rather than stopping suddenly; Some anxiety medications can cause withdrawal symptoms when you stop taking them suddenly after long-term use; -Depakote affects chemicals in the body that may be involved in causing seizures; also used to treat manic episodes related to bipolar disorder (manic depression); -Do not stop using this medicine without physician's advice; stopping suddenly may cause a serious, life-threatening type of seizure; -Take exactly as prescribed. Review of the facility policy, Admission Process, Assignment of Primary Diagnosis, revised on 12/01/22, showed the following: -A Licensed/Registered Nurse will ensure that all admission paperwork, including physician orders and medications are followed; -All physician orders are noted and followed per policy. Review of the facility policy, Transcription of Orders/Following Physician Orders, revised 05/18/24, showed the following: -The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physician orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician orders. -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in the orders section; -Clarification of physician orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the physician orders. 1. Review of Resident #18's referral packet, dated 03/03/25, showed the following: -The resident had a physician's order for Buspar HCL (a medication used to treat anxiety disorder) tablet 5 milligram (mg), give one tablet twice daily for anxiety (original order dated 02/12/25); -The resident had a physician's order for Depakote (a medication used to treat seizure disorder that is also used to treat mood disorders) tablet delayed release 125 mg, give one capsule one time a day for depression (original order dated 02/12/25). Review of the resident's admission record showed the following: -He/She admitted to the facility on [DATE]; -His/Her diagnoses included post-traumatic stress disorder (PTSD; a mental health condition that can develop after experiencing or witnessing a traumatic event that involves actual or threatened death, serious injury, or a threat to physical integrity), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, emptiness, and a loss of interest or pleasure in activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry or fear that is disproportionate to the actual threat or situation), and borderline personality disorder (a personality disorder characterized by a pattern of unstable relationships, self-image, and emotions, leading to difficulties with interpersonal relationships, impulsivity, and self-harm). Review of the resident's progress notes, dated 03/26/25 at 7:06 P.M., showed Licensed Practical Nurse (LPN) A documented the following: -The resident arrived to the facility at 4:00 P.M. via facility transportation; -He/She arrived with his/her medications from his/her previous facility; -His/Her orders were put into the electronic health record. Review of the resident's physician's orders, dated March 2025, showed no documentation staff transcribed the orders for Buspar HCL and Depakote upon the resident's admission to the facility. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed the following: -No documentation the resident received Buspar on 3/26/25 through 3/28/25; -No documentation the resident received Depakote on on 3/26/25 through 3/28/25. Review of the resident's progress notes, dated 03/28/25 at 2:10 P.M. showed the resident told the Social Services Director (SSD) that he/she had not received all of his/her medications. During an interview on 05/29/25 at 12:40 P.M., the SSD said the following: -The resident reported to her that he/she had not been getting some of his/her medications, and she reported it to the charge nurse (LPN A) right away; -The resident seemed more depressed; the resident was in a new facility and it was much smaller, in a more rural area than the resident expected, and the resident said there was nothing to do. Review of the resident's MAR, dated March 2025, showed the following: -No documentation the resident received Buspar on 03/29/25 through 03/31/25; -No documentation the resident received Depakote on 03/29/25 through 03/31/25. Review of the resident's physician's orders, dated April 2025, showed no documentation staff transcribed the orders for Buspar HCl and Depakote received upon the resident's admission to the facility. Review of the resident's MAR, dated April 2025, showed the following: -No documentation the resident received Buspar on 04/01/25 through 04/08/25 (a total of 14 days); -No documentation the resident received Buspar on 04/01/25 through 04/08/25 (a total of 14 days). Review of the resident's psychiatric note, dated 04/09/25, showed the following: -The resident presented as guarded and displayed limited engagement; -He/She reported experiencing depressed mood and significant mood fluctuations; -He/She expressed concern about not receiving his/her previously prescribed medications, specifically Buspar and Depakote, which he/she said were effective for him/her at his/her previous facility; -His/Her guarded presentation suggests underlying distress; -Given his/her reported history and current symptoms, the following medications were restarted: Buspar 5 mg by mouth twice daily for anxiety and depakote sprinkles 125 mg, two capsules at bedtime for mood stabilization and depressive symptoms. Review of the resident's physician orders, dated April 2025, showed the following: -Buspar HCI oral tablet 5 mg, give one tablet by mouth two times a day related to major depressive disorder (order dated 04/09/25); -Depakote oral tablet delayed release 125 mg, give two capsules by mouth at bedtime related to major depressive disorder (order dated 04/09/25). During an interview on 05/19/25 at 2:00 P.M., the resident said the following: -He/She didn't receive Depakote or Buspar for several weeks after he/she first arrived at the facility; -He/She had behaviors and depressed mood because of not receiving his/her medications; -He/She told staff about the missing medications and they did nothing about it. During an interview on 06/03/25 at 8:28 A.M., LPN A said the following: -He/She entered the physician orders the resident brought with him/her into the electronic medical record; -He/She wasn't aware the resident was missing any orders for medications; -The resident nor the SSD reported to him/her that any medications were missing; -The resident had not reported any increased depression. During an interview on 06/03/25 at 10:57, the Assistant Director of Nursing (ADON) said the charge nurse (LPN A) was responsible for ensuring the admission paperwork, including the physician orders for the resident's medications, were entered and followed. During an interview on 05/21/25 at 2:25 P.M., the Medical Director said the following: -Buspar or Depakote should not be be stopped abruptly; -If the resident was on the medications at another facility, both of the medications should be continued upon admission; -If there was any question or discrepancy in orders, he would have expected the nurse to call him to clarify.

Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #4), in a review of eight sampled residents. Resident #4, who resided on the facility's locked unit, had a history of elopement. Resident #4 obtained the fenced courtyard door access code and left the facility without staff knowledge, unaccompanied and without prior authorization. He/She returned 20 minutes later, using the same door code access to regain entry into the facility courtyard, without staff knowledge. The resident used the front door access code to leave through the locked unit courtyard door; the door codes were the same and had not been changed to two different codes every week per the facility's procedure. The resident said he/she had planned to hitch-hike, but the weather was too cold, so he/she returned to the facility. The facility census was 59. Review of the facility policy, Elopements and Wandering Residents, revised 06/12/24, showed the following: -The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement, receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk; -Elopement occurs when a resident leaves the premises or a safe area without authorization (for example, an order for discharge or leave of absence) and/or any necessary supervision to do so; -The facility is equipped with door locks/alarms to help avoid elopements; -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -Adequate supervision will be provided to help prevent accidents or elopements. 1. Review of the facility staffing schedule for 02/18/25 showed Certified Nurse Aide (CNA) A and CNA D were assigned to the locked unit and responsible for Resident #4 (no specific shift or time frame). 2. Review of Resident #4's admission record face sheet, undated, showed the following: -The resident admitted to the facility on [DATE]; -The resident had a legal guardian; -2. Diagnoses included bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs-mania or manic-to extreme lows-depression), moderate intellectual disabilities (a condition characterized by significant limitations in intellectual functioning and adaptive behaviors) and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities). Review of the resident's admission elopement evaluation, dated 10/08/24, showed the following: -The resident had a history of elopement or an attempted elopement while at home; -The resident had a history of elopement or attempted leaving the facility without informing staff; -A score value of one or higher (one yes response) indicated risk of elopement; -The resident was identified as a risk for wandering/elopement. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/31/24, showed the following: -Cognitively intact; -Exhibited wandering behavior one to three days of the seven day look back period; -Independent for mobility; -Received antipsychotic (psychiatric medications used to treat psychosis, a collection of symptoms that can make it difficult to distinguish reality), antianxiety, antidepressant and hypnotic (psychoactive medications that help people fall asleep). Review of the resident's quarterly elopement evaluation, dated 01/09/25, showed the following: -The resident did not have a history of elopement or an attempted elopement while at home; -The resident did not have a history of elopement or attempted leaving the facility without informing staff; -The resident was not identified as a risk for wandering/elopement. During an interview on 03/06/25 at 12:35 P.M., the resident said the following: -He/She did not want to be at the facility, so he/she left (no specific date or time other than about three weeks ago); -He/She wished he/she could be at a facility closer to his/her family; -He/She had watched the staff put in the door access code to the front locked unit doors; that was how he/she knew the code and how to open the locked door and get out/off the locked unit; -He/She said the code to the front and back door was 1492; -He/She tried to bundle up before he/she left because it was very cold that day; -He/She thought it was about one degree below zero, so he/she wore jeans, a hooded sweatshirt, socks and tennis shoes; -He/She walked to the highway and tried to hitchhike to get away; -He/She came back to the facility because he/she was cold and he/she let himself/herself back into the courtyard with the same access code he/she used to leave by; -He/She left over the lunch hour, and no one knew he/she was gone; -He/She had not told any staff he/she was leaving that day; -He/She could not recall the staff that was on the unit at the time he/she left; it was lunch time, so everyone was up at the front of the unit; -The staff on the locked unit did not do regular face checks on residents; -All of this should be on camera because he/she saw it was recording him/her; he/she had looked up at the camera. During an interview on 03/10/25 at 11:20 A.M., the resident's legal guardian said the following: -The resident was an elopement risk; -The resident had been unhappy at the facility since his/her admission and wanted to go to a facility that was closer to his/her family; -The administrator called her on 02/18/25 and told her that the resident entered the access code for the courtyard door off the locked unit and started to go out the door but was redirected by the administrator and the resident did not leave; -She was not aware the resident had left the facility unaccompanied and unauthorized, on 02/18/25 and was gone for 20 minutes; -She would not have given the resident permission to leave; the resident had been out during Christmas with family and came back with contraband; -He/She was in a locked unit because of previous behaviors and elopement attempts, even from home when the resident lived with his/her parent. Observation of a facility monitoring/video recording, of 02/18/25, showed the following: -The resident can be seen standing alone, facing the outside facility fenced courtyard door of the locked unit on 02/18/25 at 12:24:29 P.M.; -The resident wore a hooded sweatshirt, jeans and tennis shoes; -The video frame showed Motion sensor, human detected, on the unit courtyard; -No facility staff were with the resident; -No other residents were seen on the video; -The resident looked up at the camera and then back at the courtyard door; -The resident did not appear on camera at 12:25:47 P.M. on 02/18/25; -The video frame showed Motion sensor detected, on the unit courtyard; -The resident was then seen entering the locked unit fenced courtyard door from the facility parking and back into the locked unit's courtyard at 12:45:02 P.M. on 02/18/25; -The video frame showed Motion sensor, human detected on the unit courtyard; -The resident pulled the fenced courtyard door shut behind him/her and then walked back into the locked unit (a code was not required to re-enter the facility at the facility door); -No facility staff were with the resident when he/she came back through the locked unit fenced courtyard door; -There was snow on the ground of the unit courtyard; -The resident had been gone from the facility for 20 minutes per the time stamp of the video recording. During an interview on 03/06/25 at 11:15 A.M., Resident #5 said the following; -He/She lived on the locked unit with Resident #4; -He/She (Resident #5) had known the door codes to the front and outside (courtyard) door of the locked unit for some time; -The facility staff were not very careful when they put the door codes in, so the residents could see the numbers; -Resident #4 came to his/her room when Resident #4 got back to the facility the day he/she eloped, around lunchtime, and told him/her that he/she (Resident #4) had left but came back because it was cold outside; -Resident #4 pulled his/her pant legs up and had him/her touch Resident #4's legs; Resident #4's legs were like ice; -The temperature outside that day was really cold, like negative one degree; -The staff did not know Resident #4 left because the staff do not do regular face checks on the residents on the locked unit; -There are cameras on the unit and in the back courtyard so the staff would have seen this on video. During an interview on 03/10/25 at 11:15 A.M., an anonymous employee said the following: -A resident from the locked unit told him/her that Resident #4 left the facility and came back; this was a couple of days after it had happened; -The fenced courtyard door on the locked unit opens to the facility parking lot; -This event occurred on 02/18/25 at 12:24 P.M.; -He/She remembered it was very cold the day Resident #4 left the facility. During an interview on 03/07/25 at 9:00 A.M., CNA A said the following: -He/She was on the locked unit on 02/18/25; -Sometime in the afternoon, Resident #4 made a statement that he/she was going to leave the facility; -He/She had another staff member go and get the administrator right away; the administrator was right outside the locked unit door; -The administrator came into the locked unit and saw that Resident #4 had just opened the fenced courtyard door using the code; -The administrator had the maintenance director change the access code to the courtyard door right away; -He/She had a good rapport with the resident, and the resident had never made a statement before that he/she was going to leave; -The resident had never attempted to elope from the facility before; -He/She was not aware on 02/18/25 that the resident had tried and was successful at leaving the facility around 12:24 P.M.; -He/She remembered it was freezing cold on 02/18/25. During an interview on 03/10/25 at 12:55 P.M., CNA D said the following: -He/She always worked the locked unit; -He/She was not aware that Resident #4 was an elopement risk; -When Resident #4 got upset, he/she would often say that he/she would just leave the facility, but staff didn't think much of those threats because the resident had never eloped; -He/She was not aware on 02/18/25 that the resident had tried and was successful at leaving the facility around 12:24 P.M. During an interview on 03/07/25 at 9:33 A.M., the maintenance director said the following: -It was his responsibility for changing the door access codes to the front and back (fenced courtyard) locked unit doors, as well as all the door keypads in the facility; -He tried to change the access code for all the locked doors every Monday, but it is grueling to get all the door codes changed, so sometimes some doors got missed. He always tried to be sure the locked unit doors were changed; -The administrator asked him to change the locked unit's back (fenced courtyard) door access code on 02/18/25 because a resident had tried to elope; -The fenced courtyard door of the locked unit opens to the facility's parking lot. During an interview on 03/06/25 at 7:15 P.M., 03/10/25 at 5:45 P.M., and 03/20/25 at 10:09 A.M., the administrator said the following: -Resident #4 had been unhappy at the facility since he/she was admitted because the resident wanted to be in a facility closer to his/her family; -Sometimes the resident would talk about leaving, but he/she could be redirected when he/she was upset; -The resident had not tried to elope before; -She was not sure why the resident's admission elopement evaluation showed the resident was an elopement risk, but the resident's quarterly elopement evaluation indicated the resident was not an elopement risk; -The front and back doors of the locked unit had keypads with a different number for each door; -The door keypads had a covering over them to prevent others from watching numbers being put in; -It was the maintenance director's responsibility to change the keypad codes to the locked unit every week; -The maintenance director would send the door codes out to the facility staff in a secured group chat; -She saw the resident (she was on the unit) putting in a door code to the fenced courtyard door off the locked unit during the afternoon of 02/18/25, around 2:00 P.M.; -The resident got the door open and put one foot out the door, but when she called his/her name, the resident turned and came back in; he/she did not leave the facility; -The resident told her he/she got the front door access code by watching the staff key in the numbers; -She was not sure why the front door access code worked on the courtyard door, each door was supposed to have its own number; -She had the maintenance director change the door access code right away when this occurred; -She was unaware the resident had left the facility for 20 minutes on 02/18/25 at 12:25 P.M.; -She would expect staff to use the covers provided over the door keypads to prevent residents from seeing the access codes put in; -She would expect staff not to share the door access codes with residents or anyone else. Observation of facility door access codes during on-site visits showed the following: -On 02/25/25: locked unit front door 1492; -On 03/06/25 (the day the elopement investigation began by the state agency), locked unit front door 1492 (this code had not been changed on Monday, 03/05/25 as the Maintenance Director indicated in his interview that he changed codes weekly on Monday), back door 3860 (same code as the Maintenance Director reported as being the code on 02/18/25; the code had not been changed on 02/24/25 or 03/03/25 per the report that codes were changed every Monday). Review of the outside temperatures by wunderground.com for the city where the resident resided, when he/she eloped on 02/18/25, was four degrees Fahrenheit at 11:54 A.M. and six degrees Fahrenheit at 12:54 P.M. MO00250497

Based on interview and record review, the facility failed to develop and implement behavioral health interventions to ensure the physical and psychosocial well-being of two residents (Resident #1 and #2), in a review of four sampled residents. Staff identified Resident #1, who had diagnoses of anxiety and depression, had a language/communication barrier and became agitated when unable to communicate effectively and was not aggressive unless provoked. The facility failed to identify meaningful interventions to address the root cause of the resident's behaviors, and the facility did not ensure an effective means for the resident to communicate his/her needs which resulted in increased agitation. On 2/24/24, the resident became agitated when unable to have a second slice of pizza. Staff administered a medication (that was not ordered to treat the resident's anxiety) to treat the resident's agitation. Staff failed to identify the root cause of the resident's behavior and develop interventions to address the root cause. On 3/9/24, the resident was involved in a physical altercation after Resident #2 (roommate) would not move from the doorway as Resident #1 entered the room. Resident #2 pushed Resident #1 which resulted in Resident #1 hitting Resident #2 multiple times in the head and upper body. During evaluation at the hospital on 3/9/24, Resident #1 reported Resident #2 had exposed himself/herself and performed self-sexual activities in front on him/her and attempted multiple times to touch him/her and his/her possessions afterwards. This made Resident #1 very upset. Resident #1 felt uncomfortable around Resident #2 and as a result became agitated. Resident #1 was placed on an antipsychotic medication for agitation and sleep. Prior to the incident on 3/9/24, staff identified Resident #2 took Resident #1's belongings, which upset Resident #1, however, no interventions were implemented to prevent further incidents. Staff identified Resident #2 instigated incidents and provoked other residents. The facility failed to identify meaningful interventions to address the resident's behaviors directed towards other residents. Staff discussed imposing interventions with the resident's increased behaviors, including setting limits on activities the resident enjoyed. The facility census was 60. Review of the facility policy, Initial Psychosocial History, last reviewed/revised on 1/19/22, showed the following: -Purpose of the policy was to ensure that a comprehensive social history was completed on all residents. The social history was imperative to provide key information to develop an individualized plan of care that addressed the resident's physical, mental, and psychosocial well-being; - The social services director (SSD) would complete the initial psychosocial history on all residents within 72 hours of admission, excluding weekends and holidays; -The facility would recognize that each person was unique and were entitled to basic rights. The SSD would adopt a holistic perspective by recognizing that each resident had individualized needs that interplay to a positive wellbeing which included social, psychological, physical, and spiritual; -The initial psychosocial history form included identifying information, family and relationships, occupational and educational history, marital history, activities of daily living skills and preferences, psychosocial assessment, socialization and support systems, legal history, admission to facility, medical and psychiatric history, special considerations, and discharge planning; -The SSD, to ensure a holistic approach, would also review and include pertinent information in the initial psychosocial history from the PASARR (if applicable), nursing assessment, history and physical, resident interview, and family/guardian interview; -Once the initial psychosocial history was completed, the SSD would meet with the administrator and/or the director of nursing (DON) to communicate findings, discuss plan of care needs and ensure all immediate care needs were met; -Each weekday morning, the SSD would bring completed initial psychosocial history forms or a list of completed in the electronic medical record (EMR) to the morning meeting and review with the interdisciplinary team (IDT) to address development of the individualized plan of care. Review of the facility's policy, Behavioral Emergency, dated 1/5/23, showed the following: -Purpose of the policy was to provide safe treatment and humane care to the resident in a behavioral crisis, to ensure that the resident was not being coerced, punished, and disciplined for staff convenience; -The guardian would be notified and imposed limitations may be placed on the resident, including hospitalization or other special directives; -Documentation of behavior emergencies would include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, not identifying or attempting to identify the root causes of the behavior and not revising the plan of care with measurable goals and interventions to address the care and treatment for a resident with behavioral and/or mental/psychosocial symptoms; The licensed nurse would document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines a) B = Behavior; define the behavior; b) I = intervention; document interventions, note behavior emergency policy and document interventions from the behavioral emergency policy; c) R = Reaction/Response; document reaction and response of resident after interventions; d) P = Plan; continue current plan of care, continue observation/monitoring of resident; e) E = Evaluation; f) E = Evaluation; g) E = Evaluation; h) E = Evaluation. 1. Review of Resident #1's level one Preadmission Screening and Resident Review (PASARR), a screening process for individuals prior to admission into a nursing facility to determine if they have a serious mental illness and/or intellectual disability/developmental disability, dated 12/11/20, showed the following: -Recent medical incidents included a Grade II left temporal (highly associated with memory skills. Left temporal lesions result in impaired memory for verbal material) meningioma (meningioma is a tumor that grows from the membranes that surround the brain and spinal cord, called the meninges) status post craniotomy (is the surgical removal of part of the bone from the skull to expose the brain) with residual effects including altered mental status; -His/Her primary language was Spanish; -He/She was oriented to person and place; -His/Her memory was fair; -Diagnoses included anxiety disorder, depressive disorder, malignant (cancerous) neoplasm of the cerebral meninges, and aphasia following cerebral infarction (stroke); -Medication regimen included duloxetine (antidepressant medication) and trazodone (anti-anxiety medication); -He/She showed no signs of mental illness; -He/She had not received intensive psychiatric treatment in the previous two years. Review of the resident's hospital records, dated 12/20/23, showed the resident's medical history included peripheral artery disease ( the narrowing or blockage of the vessels that carry blood from the heart to the legs), stroke, resection of meningioma, altered mental status, aphasia (loss of ability to understand or express speech, caused by brain damage), and encephalomalacia ( is a localized softening of the substance of the brain, due to bleeding or inflammation); Review of the resident's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -He/She was his/her own responsible party. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 1/8/24, showed the following: -The resident was admitted to the facility on [DATE]; -Cognition was not documented; -He/She had no speech; -He/She was understood; -He/She understood others; -No psychosis or behaviors affecting others. Review of the resident's care plan, dated 1/3/24, showed the following: -He/She had a communication problem related to aphasia and language barrier; -He/She would be able to make basic needs known by sign language daily; -He/She would maintain current level of communication function by how, with what assistance i.e., making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, and writing messages; -Allow him/her time to respond, repeat as necessary, do not rush him/her; -Request clarification from him/her to ensure understanding; -Ask yes/no questions if appropriate; -Use simple, brief, and consistent words/cues; -He/She was able to understand English, but responded using sign language; -He/She had a diagnosis of aphasia related to stroke; -Allow resident time to process and understand what was being said to him/her and allow time to answer; -Give him/her alternate communication options; pen and paper and/or communication board; -He/She had impaired coping; -Ensure him/her to verbalize feelings regarding fear and/or anxiety. (The care plan did not identify any other coping skills for the resident.) (Review of the resident's care plan showed no documentation regarding behaviors or agitation directed towards others.) Review of the resident's medication administration record (MAR), dated 1/1/24 to 1/31/24, showed no documented behaviors for this time frame. Review of the resident's physician's orders, dated February 2024, showed the following: -Monitor for behaviors every shift; -Hydroxyzine (antihistamine medication used also to treat anxiety) 25 milligrams (mg), give one tablet every six hours as needed (PRN) for itching; -Duloxetine (an antidepressant medication) 60 mg, give one capsule daily for depression. Review of the resident's nursing progress note, dated 2/24/24 at 1:25 P.M., showed the resident was very upset at lunch due to not being able to have a second slice of pizza. He/She become very angry and started yelling and threw his/her plate at the wall. The nurse attempted to calm him/her down, but other staff came and started to talk to him/her also. The resident became angrier and swiped drinks off the table onto the floor. Staff assisted him/her to leave the dining room to calm down. The resident become physically aggressive with staff and sat on the floor in the doorway. The nurse convinced the resident to go to his/her room and calm down. The resident sat on his/her bed and apologized. A PRN dose of hydroxyzine was administered, and the resident later fell asleep. No other behaviors were noted. Review of the resident's MAR, dated February 2024, showed the following: -Hydroxyzine 25 mg tablet; one tablet every six hours as needed for itching; -Staff administered hydroxyzine 25 mg on 2/24/24 at 1:25 P.M. (Staff administered hydroxyzine for the resident's behaviors and not for itching as indicated in the resident's physician's orders.) -Monitor for behaviors every shift; -There were no behaviors documented from 2/1/24 to 2/29/24. Review of the resident's medical record showed no documentation staff attempted to identify the root cause of the resident's behavior on 2/24/24 or developed interventions to address the root cause for the resident's behavior. Review of the resident's progress notes, dated 3/9/24 at 7:44 A.M., showed at approximately 6:20 A.M., a code green (code used to alert staff for behavioral event and need for intervention) was called for a resident-to-resident altercation. Staff reported they saw the resident punching Resident #2 because he/she was mad over a phone charger. The resident tossed his/her coffee filled cup on the floor. He/She was sent to the hospital for further management and care. Review of the resident's hospital medical records, dated 3/9/24, showed the following: -admitted to the emergency room with chief complaint of moderate aggression; -He/She presented to the emergency department complaining of aggression with a one-day onset. He/She presented from the nursing home where he/she reportedly got into a physical altercation with another resident, striking him/her. The resident had been having progressively worsening issues with aggression according to the nursing home staff; -Exam showed no gross motor deficits, no neurological deficits, and he/she was alert and oriented to person, place, and time; -He/She was calm and cooperative; -He/She was a non-English speaking and had the additional impediment of previous stroke causing significant aphasia. Attempted to converse with the resident using a translator and were unable to get any kind of significant information from him/her besides the fact that someone was messing with his/her phone charger; -Social services assessment showed he/she reported that he/she had been in an argument with his/her roommate over a phone charger that he/she believed the roommate took from him/her. He/She hit his/her roommate. He/She had a history of a stroke and had trouble with communicating, but was able to understand. The facility reported that he/she was getting upset more often and this was the first time that he/she had hit anyone. The facility reported that he/she had gotten upset because they ran out of pizza and he/she threw his/her plate across the room and started picking arguments with other residents. The facility reported no mental health history and he/she was not on medications for mental health; -Psychiatric consult note: the resident was a poor historian due to not able to speak English, stroke history, and intellectual disability. He/She used gestures, signs, and talked gibberish. He/She denied previous psych history. He/She said his/her roommate exposed himself/herself in front of him/her and attempted to touch him/her multiple times. He/She felt uncomfortable around him/her and as a result became agitated. Recommendation included to start Seroquel (antipsychotic medication) 25 mg every bedtime for agitation and sleep; -It had eventually come out that the roommate was performing self-sexual activities in front of him/her and then trying to grab his/her possessions afterwards. This made the resident very upset; -Telepsychiatry recommended initiation of Seroquel 25 mg at bedtime which was added to the resident's discharge orders; -Discharge instructions included to take Seroquel 25 mg one tablet daily at bedtime, and to continue all other medications as directed by the originating prescriber. Review of the resident's nursing progress note, dated 3/9/24 at 11:00 A.M., showed that upon his/her return from the hospital, he/she was moved to the behavioral unit and placed on 15-minute safety checks. Education was provided to the resident on facility policies and peer-to-peer contact, as well as appropriate behavior and coping mechanisms. Review of the resident's care plan showed no documentation staff updated the resident's care plan with coping mechanisms and/or interventions to address aggressive behaviors after the altercation with Resident #2 on 3/9/24. Review of the facility's investigation, dated 3/11/24, showed the following: -On 3/9/24, the Director of Nursing (DON) and the Administrator were notified of a resident-to-resident altercation between the resident and Resident #2. It was stated that the altercation started in the bedroom of the two residents; -Staff on duty witnessed the resident (Resident #1) trying to enter the room, but was unable to due to Resident #2 sitting in his/her wheelchair in front of the doorway. The resident attempted to go around Resident #2 and accidentally stepped on Resident #2's foot; -Resident #2 become visibly upset, yelling, cursing, and pushed the resident causing him/her to fall onto the bed; -The resident got up and started to hit Resident #2 multiple times in the head and upper body; -When Resident #2 was asked what had happened, he/she stated that he/she pushed the resident for stepping on his/her foot and the resident hit him/her; -The resident was sent to the hospital for evaluation and treatment; -Care plan interventions included residents were separated in different locations of the building for safety, psychological evaluation, and treatment, placed on 15-minute safety checks, and education was provided to the resident on facility policies and peer to peer contact, as well as appropriate behavior and coping mechanisms. Review of a resident contract signed by the resident, dated 3/11/24, showed that he/she agreed to not have any verbal or physical altercations with fell ow residents. Failure to abide by this contract would lead to limitations being placed for him/herself or being discharged to another facility. Review of the resident's MAR, dated 3/1/24 to 3/31/24, showed the following: -Seroquel 25 mg; one tablet at bedtime related to anxiety disorder was started on 3/11/24 (order was obtained from the hospital on 3/9/24); -Staff documented Seroquel 25 mg; one tablet at bedtime was administered on 3/11/24. During an interview on 3/12/24 at 10:30 A.M., the Administrator said the following: -The resident had never had physical behaviors since he/she was admitted ; -The resident could understand English, but had difficulty making himself/herself understood; -The resident becomes frustrated when he/she is unable to understand, but had never been aggressive; -There was an incident last weekend when he/she became upset when staff did not understand him/her, and he/she threw his/her plate and coffee on the floor; -The resident was roommates with Resident #2 , but Resident #2 could not communicate well with Resident #1. The resident attempted to maneuver around Resident #2 who was blocking the doorway to their room. The resident ended up on Resident #2's foot. Resident #2 become upset and pushed the resident, and he/she fell on the bed. The resident then got up and struck Resident #2. The resident was sent to the hospital and returned with new order for Seroquel; -The resident was moved in with Resident #2 approximately a week ago because they both had problems with their previous roommates; -Earlier in the week, prior to the altercation, the resident said Resident #2 had touched his/her personal belongings and he/she did not like Resident #2 touching his/her personal belongings. Review of the resident's medical record showed there was no evidence to show staff implemented interventions to address Resident #2 touching Resident #1's personal belongings prior to the altercation on 3/9/24. During an interview on 3/12/24 at 11:10 A.M., Certified Nurse Assistant (CNA) A said the following: -On 3/9/24, he/she came out of another room when he/she saw the resident step on Resident #2's foot as he/she tried to maneuver around Resident #2 who was blocking the doorway. Resident #2 shoved the resident on the bed and the resident jumped up and struck Resident #2.; -He/She was unaware of any previous issues between the two residents; -The resident was not usually aggressive. Observation of on 3/12/24 at 1:00 P.M. showed the resident lay in his/her bed calmly listening to music on his/her phone. He/She appeared happy as evidenced with smile on his/her face. During interview with the resident on 3/12/24 at 1:00 P.M., showed it was difficult to communicate due to the communication barrier. He/She pointed to his/her scar on his/her head to show where he/she had previous surgery. He/She picked up his body spray and sat it back down and responded yeah yeah yeah when asked if someone had taken his/her body spray. He/She responded yeah yeah yeah when asked if it was his/her previous roommate (Resident #2). During an interview on 3/12/24 at 4:00 P.M., Certified Medication Technician (CMT) B said the following: -The resident spoke minimal English and communicated by using his/her hands; -The resident became frustrated because others didn't know what he/she was trying to communicate; -He/She had not seen the resident be physically aggressive. During an interview on 3/12/24 at 4:01 P.M., the Maintenance Director said the resident was mellow until provoked, then he/she would become agitated. During an interview on 3/12/24 at 4:15 P.M., the Care Plan Coordinator said the following: -The resident only became physically aggressive if he/she was provoked; -He/She had never seen the resident lash out for no reason; -The resident was normally quiet and kept to himself/herself in his/her room. During an interview on 3/13/24 at 1:00 P.M., Licensed Practical Nurse (LPN) C said the following: -On 2/24/24, the resident was sitting at the dining room table with a peer who had received more pizza. The resident was told there was no more when he/she had asked for more. The resident became frustrated, staff tried to redirect and calm him/her down, but only made him/her more agitated; -He/She administered hydroxyzine because it could also be used for anxiety; -The resident had a language barrier. The resident did not have a problem understanding, but had difficulty communicating to others what he/she wanted; -The resident was usually nice and tried to keep to himself/herself; -He/She noticed a behavior one time and that was because another resident had instigated the issue; -The resident attempted to get out of the room, but his/her roommate Resident #2 was blocking the doorway. The resident accidentally stepped on Resident #2's toes which caused Resident #2 to become angry and he/she pushed the resident on the bed. The resident got up and struck Resident #2; -Resident #1 went to the hospital and was evaluated by psych; -The hospital reported to him/her that the resident said Resident #2 had performed self-sexual behaviors in front of Resident #1 and then Resident #2 wiped his/her hands on Resident #1, all of which he/she reported to management staff; -Resident #1 did not communicate Resident #2's inappropriate sexual behavior to the facility staff; -Resident #2 was known to be an instigator and cause problems; -Resident #1 and Resident #2 should not have been roommates because of Resident #2's history with other roommates and/he she reported that to management staff, but the resident's remained in the same room; -Resident #2 would accuse Resident #1 of taking his/her stuff, when it was Resident #1's stuff that Resident #2 had originally taken. During an interview on 3/14/24 at 2:30 P.M., the administrator said she was unaware that Resident #2 had performed self-sexual behaviors in front of Resident #1 and then Resident #2 wiped his/her hands on Resident #1. She felt like Resident #1 would have told staff if that had occurred. She was aware Resident #1 did not like Resident #2 touching his/her belonging and would make Resident #1 upset when Resident #2 touched his/her things. She spoke with Resident #2 and explained that he/she could not bother other resident's belongings and Resident #2 said he/she would not do it again. During an interview on 3/14/24 AT 7:40 A.M., Registered Nurse (RN) D said the following: -The resident had aphasia and spoke Spanish which caused difficulty understanding and being understood; -The resident's communication barrier caused difficulty between the resident and most of the staff; -The resident was easily irritated which could be caused from staff and/or other peers not understanding him/her; -The facility did not know much about the resident's history due to the communication barrier. -The resident was involved in an altercation with a peer and was sent to the hospital for physical aggression. He returned from the hospital with a new order for Seroquel to calm him/her down and aid with sleep. During an interview on 3/13/24 at 10:00 A.M., the Social Services Director said the following: -The resident's primary language was Spanish, but he/she could understand English; -There was an incident between the resident and the Dietary Manager approximately one month ago. The resident wanted more coffee and he/she started yelling. Not sure if the communication barrier caused the resident's increased agitation, but it could have played a role in it; -The root cause of the resident's behaviors was his/her communication skills; -Overall, she had not seen the resident be aggressive. The resident was normally smiling and appeared happy/cheerful; -The facility was working on being able to meet the resident's psycho-social needs. The resident tried to tell his/her story, but she could not understand him/her. -The resident was admitted directly from a hospital after his/her former facility refused to let him/her return. She did not know any other details regarding the resident. During an interview on 3/14/24 at 11:00 A.M., the Dietary Manager said the following: -The resident had an episode in the dining room when he/she wanted something and wanted it immediately; -The resident seemed frustrated a lot and she was not sure if the resident's actions were due to inability to understand, to be understood, or a behavior; -The resident became frustrated when trying to communicate and would use the gesture to forget it when he/she could not communicate what he/she wanted/needed. During an interview on 3/14/24 at 12:15 P.M., the resident's physician said the following: -The facility did not provide him/her with any of the resident's medical history; -He would expect the facility to reach out to the previous facility and obtain the resident's history and/or background before accepting the resident so they could have better knowledge about the resident's needs; -The resident had a history of a head injury and spoke Spanish. It was unclear how much the resident understood; -The resident was usually calm when he saw the resident; -The resident was in an altercation recently with a peer and was sent to the emergency room . The resident saw tele psych and was recommended that he/she start on Seroquel. It was reported that the resident appeared agitated on a frequent basis. He did not feel that the resident needed the medication due to the degree of provocation. The Seroquel was continued to prevent further incidents of aggression. During an interview on 3/26/24 at 3:25 P.M., the Director of Nursing said the following: -The resident's communication was quite different. The resident made up his/her own sign language which made it difficult for staff to understand him/her and for him/her to understand the staff; -Staff should have contacted the physician for an order to administer the hydroxyzine for increased anxiety/agitation and not take it upon themselves to administer without contacting the physician first. The physician may have recommended some other intervention. During interview on 4/10/24 at 2:13 P.M., the Administrator said the following: -The resident was started on Seroquel on 3/11/24 after the incident with Resident #2; -The resident's diagnosis for Seroquel use was anxiety; -The root cause of the resident's behavior on 3/9/24 was that Resident #2 provoked him/her by shoving him/her; -The root cause of previous incidents involving the resident and behaviors was due to his/her communication barrier. 2. Review of Resident #2's Preadmission Assessment and Resident Screening (PASARR), a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability. , dated 9/6/22, showed the following: -His/Her diagnoses included major depressive disorder, recurrent severe psych features, adjustment disorder (is an emotional or behavioral reaction to a stressful event or change in a person's life) with depressed mood, alcohol-induced mood disorder, stimulant abuse with stimulant-induced mood disorder, antisocial personality disorder, opioid use, meth dependence, alcohol intoxication abuse, and cannabis use; -His/Her estimated intellectual function level was average; -He/She had a history of a closed traumatic brain injury (TBI) with loss of consciousness (an injury to the brain from external mechanical force), post-traumatic stress disorder (PTSD, is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) secondary to TBI; -History of withdrawn, depressed, suspicious and paranoid, anxiety, abnormal thought process. Oriented to person, place and situation but not time, impaired procedural, and situational memory. Required guardianship and had a history of incarceration; -Multiple previous psychiatric treatments, including incarceration, hospitalization s, and outpatient; -Aggressive/assaultive behaviors included fire setting, yelling, and cursing when frustrated; -Required physical assistance with toileting, personal hygiene, bathing, and dressing/undressing; -Use of wheelchair, unassisted; -He/She was open and honest with others and would curse when he/she got frustrated; -He/She felt worthless; -He/She had thoughts about hurting and/or killing himself/herself in the past when he/she was not seeing his/her children. He/She thought he/she would be better off dead; -He/She had thoughts about hurting or killing someone only when people threatened him/her; -Assessment and implementation of behavioral support plan included monitoring of behavioral symptoms and provision of behavioral support; -Medication therapy and monitoring services included psychiatric follow up to prescribe and manage medications; -Provide for individual personal space; -Establish consistent routines; -Provide schedule of daily tasks/activities; -Provide instructions at the individual's level of understanding; -Assess and plan for the level of supervision required to prevent harm to self or others; -Safety plan to address potential risk to self or others, -Plan should identify clear steps that would be taken to support the individual during a crisis, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services, and/or law enforcement should be contacted; -Personal support should include to assess and plan for meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc. Review of the resident's face sheet showed he/she was admitted to the facility on [DATE]. Review of the residents quarterly MDS, dated [DATE], showed the following: -Staff did not complete the areas to assess the resident's cognitive pattern or mood; -The resident had no behaviors in the previous seven days. Review of the resident's care plan, last revised on 1/9/24, showed the following: -He/She had a behavior problem related to his/her disease process, resisting care, and having altercations with peers; -Administer medications as ordered, anticipate, and meet the resident's needs; -Caregivers to provide opportunity for positive interaction and interaction. Stop and talk with him/her when passing by; -If reasonable, discuss the resident's behavior and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident; -He/She had decreased activity involvement related to immobility and physical limitations; -Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. (Review showed no documented interventions to meet his/her psychosocial needs, no documentation to address meaningful socialization and recreational activities to diminish tendencies toward isolation, withdrawal, etc., and to provide for individual personal space as indicated on the resident's PASARR, and no documentation to address how staff were to respond when the resident had behaviors directed towards others.) Review of the resident's quarterly MDS, dated 1/

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of individual needs for one resident (Resident #1), in a review of sampled four residents. The facility failed to address the resident's communication barrier, provide effective communication tools, and ensure all staff were aware of the communication tools necessary to determine the resident's needs. The facility census was 60. Review of the facility's policy for communication with persons with limited English proficiency (LEP), last reviewed on 6/30/23, showed the following: -Purpose of the policy was to ensure that all residents receive care in a language that they understand; -Facility would take reasonable steps to ensure that persons with LEP had meaningful access and an equal opportunity to receive skilled nursing care and participate in activities and programs; -The policy of the facility was to ensure meaningful communication with LEP residents involving their medical conditions and treatment; -The policy also provided for communication of information contained in vital documents, including but not limited to, admission agreements, consents, and (do not resuscitate) DNR forms; -Language assistance would be provided through use of competent bilingual staff, staff interpreters, contracts, or formal arrangements with local organizations provided interpretation or translation services, or technology and telephonic interpretation services; -Identifying LEP residents and their language: -The facility would promptly identify the language and communication needs of the LEP resident. If necessary, staff would use a language identification card (or I speak cards available on-line at www.lep.gov) to determine the language. During the admission process, the facility shall ensure that it identified any resident who is a LEP person; -If the facility had a LEP resident, staff will at may have direct contact with LEP resident would be trained in effective communication techniques, including the effective use of an interpreter; -Obtaining a qualified interpreter: -The administrator was responsible for keeping a list of any name, language, phone number of any bilingual staff and for contacting the appropriate bilingual staff member to interpret, if an interpreter was needed, if an employee who spoke the needed language is available and was qualified to interpret; - In the alternative, the administrator, in consultation with the Regional Director and in house counsel, would ensure that arrangements were made for in-person or telephonic interpretation through a contract with qualified interpreters; -Providing written translations: -When translation of documents was needed, the facility would submit documents to be translated by a qualified medical translation service; -The administrator, in consultation with Regional Director and in-house counsel would ensure that arrangements and contracts were made all needed translations; -Monitoring language needs: -On an ongoing basis, facility would assess changes in demographics or other needs that may require reevaluation of this policy and its procedures. In addition, facility would regularly assess the efficiency of these procedures, including but not limited to mechanisms for securing interpreter services, equipment used for the delivery of language assistance, and feedback from residents. 1. Review of Resident #1's level one (I) Preadmission Screening and Resident Review (PASARR), a screening process for individuals prior to admission into a nursing facility to determine if they have a serious mental illness and/or intellectual disability/developmental disability, dated 12/11/20, showed the following: -Recent medical incidents included a Grade II left temporal (highly associated with memory skills. Left temporal lesions result in impaired memory for verbal material) meningioma (meningioma is a tumor that grows from the membranes that surround the brain and spinal cord, called the meninges) status post craniotomy (is the surgical removal of part of the bone from the skull to expose the brain) with residual effects including altered mental status; -His/Her primary language was Spanish; -He/She was oriented to person and place; -His/Her memory was fair; -Diagnoses included aphasia following cerebral infarction (stroke). Review of the resident's face sheet showed the following: -He/She was admitted to the facility on [DATE]; -He/She was his/her own responsible party. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 1/8/24, showed the following: -The resident admitted to the facility on [DATE]; -Cognition was not documented; -He/She had no speech; -He/She was understood; -He/She understood others; -He/She was not of Hispanic Latino/a, or Spanish origin; -He/She spoke English; -He/She did not want an interpreter to communicate with physicians and/or healthcare staff. Review of the resident's care plan, dated 1/3/24, showed the following: -He/She had a communication problem related to aphasia and language barrier; -He/She would be able to make basic needs known by sign language daily; -He/She would maintain current level of communication function by how, with what assistance i.e., making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, and writing messages; -Be conscious of the resident's position when in groups, activities, and dining room to promote proper communication with others; -Allow him/her time to respond, repeat as necessary, do not rush him/her; -Request clarification from him/her to ensure understanding; -Face him/her when speaking, make eye contact, and turn off TV/radio to reduce environmental noise; -Ask yes/no questions if appropriate; -Use simple, brief, and consistent words/cues; -He/She was able to understand English, but responded using sign language; -He/She had impaired coping; -Ensure him/her to verbalize feelings regarding fear and/or anxiety; -He/She had a diagnosis of aphasia related to stroke; -Allow resident time to process and understand what was being said to him/her and allow time to answer; -Give him/her alternate communication options; pen and paper and/or communication board. (The resident's care plan did not address the resident spoke Spanish and /or the need for an interpreter or interpreter devices to assist the resident in communicating with staff/residents.) Review of the resident's hospital medical records, dated 3/9/24, showed the following: -The resident presented from the nursing home where he/she reportedly got into a physical altercation with another resident, striking him/her. The resident had been having progressively worsening issues with aggression according to the nursing home staff. The resident spoke very little English; therefore, translation services were utilized; -He/She was a non-English speaking and had the additional impediment of previous stroke causing significant aphasia. Attempted to converse with the resident using a translator and were unable to get any kind of significant information from him/her; -It was difficult to decide if he/she understands and cannot respond secondary to his/her dysphasia (he/she was able to respond to some things verbally) or a language barrier; -He/She had a history of a stroke and had trouble with communicating, but was able to understand. -Psychiatric consult note: the resident was a poor historian due to not able to speak English, stroke history, and intellectual disability. He/She used gestures, signs, and talked gibberish. During an interview on 3/12/24 at 10:30 A.M., the Administrator said the following: -The resident had a communication barrier. She thought he/she spoke Spanish and had his/her own sign language to communicate; -The resident could understand English, but had difficulty making himself/herself understood; -The resident becomes frustrated when he/she was unable to understand; -There was an incident last weekend when he/she became upset when staff did not understand him/her, and he/she threw his/her plate and coffee on the floor; -There was one nurse on night shift (Registered Nurse D) who could speak some Spanish, but she thought that was the only staff who could converse in Spanish with the resident; -Staff obtained a picture book approximately one week ago to assist staff/resident communication, but the resident threw it in the trash; -The book was now kept in the Social Service Director's (SSD's) office; -The resident was roommates with Resident #2 , but Resident #2 could not communicate well with the resident. During an interview on 3/12/24 at 11:10 A.M., Certified Nurse Assistant (CNA) A said the following: -The resident had his/her own way to communicate which could usually be understood; -The resident spoke minimal English; -He/She communicated with the resident by asking yes/no questions; -One nurse, who worked night shift, could converse with the resident in Spanish and the resident still wouldn't respond sometimes. Observation of on 3/12/24 at 1:00 P.M. showed the resident lay in his/her bed calmly listening to music on his/her phone. There was no communication board and/or ring with pictures located in his/her room. During interview with the resident on 3/12/24 at 1:00 P.M., it was difficult to communicate due to the communication barrier. When asked if he/she had ring of pictures for communication, the resident used hand gestures around his/her eyes, and responded yeah yeah yeah when asked if he/she needed glasses to see. During an interview on 3/12/24 at 4:00 P.M., Certified Medication Technician (CMT) B said the following: -The resident spoke Spanish; -The resident spoke minimal English; -The resident communicated by using his/her hands; -The resident became frustrated because others didn't know what he/she was trying to communicate; -He/She was not aware of any special communication tools, including picture ring or communication book, to aide in communication with the resident. During an interview on 3/12/24 at 4:01 P.M., the maintenance director said the following: -The resident's language was Spanish; -He/She spoke some Spanish and tried to converse with the resident, but the resident would not converse back; -The resident used his/her own sign language to communicate his/her wants/needs; -He/She was not aware of any special book or translation techniques used to assist with communicating with the resident, but wished the facility had something like that because it would help a lot. During an interview on 3/12/24 at 4:15 P.M., the care plan coordinator said the following: -The resident's primary language was Spanish; -The resident had aphasia; -The resident could understand English, but could not communicate it back very well; -The resident communicated by pointing and using hand gestures; -He/She had only been at the facility since February, and had not had a chance to review the resident's care plan. The resident's primary language should be addressed on the care plan along with any special tools needed for staff/resident communication; -He/She was not aware of any special communication tools being used at this time. During an interview on 3/13/24 at 1:00 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident had a language barrier. The resident did not have a problem understanding, but had difficulty communicating to others what he/she wanted; -The resident used his/her own gestures and staff had to learn what those gestures meant. It would be hard for someone who was not familiar with the resident to communicate as they may not know what the resident was trying to communicate; -He/She was not aware of any communication tools used, including a picture ring or communication book, but that would help if they were available. During an interview on 3/14/24 AT 7:40 A.M., Registered Nurse (RN) D said the following: -The resident had aphasia and spoke Spanish which caused difficulty understanding and being understood; -He/She spoke some Spanish and could communicate some with the resident, but the resident only spoke single words not full sentences; -The resident mostly used his/her own sign language to communicate; -The resident's communication barrier caused difficulty between the resident and most of the staff; -He/She was not sure if there were staff on other shifts who could communicate with the resident in Spanish; -He/She was unaware of any communication tools used to aid staff with communicating with the resident; -The resident was easily irritated which could be caused from staff and/or other peers not understanding him/her. During an interview on 3/13/24 at 10:00 A.M., the SSD said the following: -The resident's primary language was Spanish, but the resident could understand English; -She purchased a flip picture book for staff to use to communicate with the resident, but the resident threw it in the trash. She took the book to her office for staff to obtain when needed. Staff would not have access to her office unless she was there or call her to let them in to obtain the book. Staff were aware of resident's communication barrier and the key ring with the pictures; -She was not aware of any staff who spoke Spanish; -She was not aware the resident spoke Spanish when he/she was accepted as a resident; -She was not involved with the admission/acceptance process. The facility's Admission Coordinator obtained all information prior to acceptance of the resident; -She had not reached out to any interpreters to assist, but it would be a good idea. She was still in the learning phase of her position; -She had not investigated any translation applications that could be used on cell phones. The transportation driver told her about an app that he/she used to translate, but nothing was used facility-wide; During an interview on 3/14/24 at 11:00 A.M., the Dietary Manager said the following: -The resident seemed frustrated a lot and she was not sure if the resident's actions were due to inability to understand, to be understood, or a behavior; -The resident became frustrated when trying to communicate and would use the gesture to forget it when he/she could not communicate what he/she wanted/needed; -Staff were learning to communicate with the resident via the resident's own sign language, but it was difficult at times; -The resident had cards with pictures that the SSD gave him/her to use to communicate, but the resident said he/she needed glasses and could not see it, and threw the book in the trash; -She wished staff could do more to understand the resident to help him/her quicker. During an interview on 3/14/24 at 11:24 A.M., the Admission Coordinator said the following: -He was told the resident could speak some English. He was not aware of the need for any special communication tools to communicate with the resident; -He reviewed the resident's information the hospital provided and did not see any indication that the facility could not meet the resident's needs. He forwarded the referral to the facility's interdisciplinary team (IDT) for review. During an interview on 3/14/24 at 12:15 P.M., the resident's physician said the following: -Staff had not reached out to him for guidance for better communication with the resident; -The resident had a history of a head injury and spoke Spanish. It was unclear how much the resident understood; -He expected the facility to have some means to communicate with the resident such as an English to Spanish app for a phone to understand his/her needs or how would they know what he/she wanted and/or needed. During an interview on 3/14/24 at 2:10 P.M., Nurse Aide (NA) F said the following: -The resident spoke Spanish, but could understand English; -The resident spoke minimal English; -The resident had a hard time communicating, but would eventually get out what he/she was trying to say; -The resident used hand gestures to communicate. A lot of the staff took it as the resident was being aggressive when he/she talked with his hands, but he/she was not. During an interview on /26/24 at 3:25 P.M., the Director of Nursing said the following: -She expected staff, who provided care for the resident, be familiar of his/her communication deficits and/or barrier, and have knowledge of the tools needed to assist with communication; -The resident's communication was quite different. The resident made up his/her own sign language which made it difficult for staff to understand him/her and for him/her to understand the staff; -The SSD provided a ring with pictures to assist with resident communication; -Staff were made aware of this ring of pictures, but the facility had several new staff which might not be aware; -Communication tools should be documented on the resident's care plan; -Staff should have access to the communication tool and it should not be stored where the staff were unable to access it.

Based on observation, interview, and record review, the facility failed to ensure one resident (Residents #1), in a review of four sampled residents, was free from unnecessary psychotropic medications. The facility administered a medication ordered for itching to the resident following an incident of agitation which staff identified was a response to the resident's communication barrier. The facility failed to ensure an appropriate indication for use of a newly ordered antipsychotic medication implemented following an incident where the resident responded with physical aggression after another resident pushed him/her onto the bed. The facility census was 60. Review of the facility's Psychotropic and Antipsychotic PRN (as needed)) Medication Orders Guideline, dated 11/28/17, showed the following: -While there may be isolated situations where pharmacological intervention was required first, these situations do not negate the obligation of the facility to develop and implement non-pharmacological interventions; -Psychiatric disorders or expressions and/or indications of distress, as with all symptoms, it was important to seek the underlying cause of the distress. Some examples of potential causes included delirium, pain, psychiatric or neurological illness, environmental or psychological stressors, dementia, or substance intoxication or withdrawal. Non-pharmacological approaches, unless clinically contraindicated must be implemented to address expressions or indications of distress. However, medications may be effective when the underlying cause of a resident's distress has been determined, non-pharmacological approaches to care were ineffective or expressions of distress had worsened. Medications may be unnecessary and are likely to cause harm when given without a clinical indication, at too high of a dose, for too long after the resident's distress had been resolved, or if the medications were not monitored for efficacy, risks, benefits, and revised as necessary; -Regarding PRN medications, it was important that the medical record included documentation related to the attending physician's or other prescriber's evaluation of the resident and indications, specific circumstances for use, and the desired frequency of administration for each medication; -As part of the evaluation, gathering and analyzing information helps define clinical indications and provide baseline data for subsequent monitoring of psychotropic medication use; -When psychopharmacological medications were used as an emergency measure, adjunctive approaches such as individualized, non-pharmacological approaches and techniques must be implemented. Review of the facility policy, Medication Administration and Monitoring, last reviewed/revised on 9/20/23, showed the following: -Purpose of the policy was to ensure a process was in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications; -Medications were to be administered per physician's orders. 1. Review of Resident #1's level one (I) Preadmission Screening and Resident Review (PASARR), a screening process for individuals prior to admission into a nursing facility to determine if they have a serious mental illness and/or intellectual disability/developmental disability, dated 12/11/20, showed the following: -Recent medical incidents included a Grade II left temporal (highly associated with memory skills. Left temporal lesions result in impaired memory for verbal material) meningioma (meningioma is a tumor that grows from the membranes that surround the brain and spinal cord, called the meninges) status post craniotomy (is the surgical removal of part of the bone from the skull to expose the brain) with residual effects including altered mental status; -His/Her primary language was Spanish; -He/She was oriented to person and place; -His/Her memory was fair; -Diagnoses included anxiety disorder, depressive disorder, malignant (cancerous) neoplasm of the cerebral meninges, and aphasia following cerebral infarction (stroke); -He/She showed no signs of mental illness; -He/She had not received intensive psychiatric treatment in the previous two years. Review of the resident's hospital records, dated 12/20/23, showed the following: -Chief complaint for admission was homeless; -Medical history included stroke, altered mental status, aphasia (loss of ability to understand or express speech, caused by brain damage), and encephalomalacia ( is a localized softening of the substance of the brain, due to bleeding or inflammation). Review of the resident's face sheet showed the following: -He/She admitted to the facility on [DATE]; -He/She was his/her own responsible party. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 1/8/24, showed the following: -The resident was admitted to the facility on [DATE]; -Cognition was not documented; -He/She had no speech; -He/She was understood; -He/She understood others; -No psychosis or behaviors affecting others. Review of the resident's care plan, dated 1/3/24, showed the following: -He/She had a communication problem related to aphasia and language barrier; -He/She would maintain current level of communication function by how, with what assistance i.e., making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, and writing messages; -Allow him/her time to respond, repeat as necessary, do not rush him/her; -Request clarification from him/her to ensure understanding; -Ask yes/no questions if appropriate; -Use simple, brief, and consistent words/cues; -He/She was able to understand English, but responded using sign language; -He/She had a diagnosis of aphasia related to stroke; -Allow resident time to process and understand what was being said to him/her and allow time to answer; -Give him/her alternate communication options; pen and paper and/or communication board; -He/She had impaired coping; -He/She was encouraged to verbalize feelings regarding fear and/or anxiety. (No other coping skills were identified in the resident's care plan.) Review of the resident's medication administration record (MAR), dated 1/1/24 to 1/31/24, showed no documented behaviors for this time frame. Review of the resident's physician's orders, dated February 2024, showed the following: -Monitor for behaviors every shift; -Hydroxyzine( (an antihistamine) 25 mg, give one tablet every six hours PRN for itching. Review of the resident's nursing progress note, dated 2/24/24 at 1:25 P.M., showed the resident was very upset at lunch due to not being able to have a second slice of pizza. He/She become very angry and started yelling and threw his/her plate at the wall. The nurse attempted to calm him/her down, but other staff came and started to talk to him/her also. The resident became angrier and swiped drinks off the table onto the floor. Staff assisted him/her to leave the dining room to calm down. The resident become physically aggressive with staff and sat on the floor in the doorway. The nurse convinced the resident to go to his/her room and calm down. The resident sat on his/her bed and apologized. Staff administered a PRN (as needed) dose of hydroxyzine and the resident later fell asleep. No other behaviors were noted. Review of the resident's MAR, dated February 2024, showed the following: -Hydroxyzine 25 mg tablet; one tablet every six hours as needed for itching; -Staff administered hydroxyzine 25 mg on 2/24/24 at 1:25 P.M. (Staff administered hydroxyzine for the resident's behaviors and not for itching as indicated in the resident's physician's orders.); -Monitor for behaviors every shift; -There were no behaviors documented from 2/1/24 to 2/29/24. Review of the resident's progress notes, dated 3/9/24 at 7:44 A.M., showed at approximately 6:20 A.M., a code green (code used to alert staff for behavioral event and need for intervention) was called for a resident-to-resident altercation. Staff reported they saw the resident punching Resident #2 because he/she was mad over a phone charger. The resident tossed his/her coffee filled cup on the floor. He/She was sent to the hospital for further management and care. Review of the resident's hospital medical records, dated 3/9/24, showed the following: -admitted to the emergency room with chief complaint of moderate aggression; -He/She presented to the emergency department complaining of aggression with a one-day onset. He/She presented from the nursing home where he/she reportedly got into a physical altercation with another resident, striking him/her. The resident had been having progressively worsening issues with aggression according to the nursing home staff; -Exam showed no gross motor deficits, no neurological deficits, and he/she was alert and oriented to person, place, and time; -He/She was calm and cooperative; -Social services assessment showed he/she reported that he/she had been in an argument with his/her roommate over a phone charger that he/she believed the roommate took from him/her. He/She hit his/her roommate. He/She had a history of a stroke and had trouble with communicating, but was able to understand. The facility reported that he/she was getting upset more often and this was the first time that he/she had hit anyone. The facility reported that he/she had gotten upset because they ran out of pizza and he/she threw his/her plate across the room and started picking arguments with other residents. He/She was on hydroxyzine which was ordered from his/her primary physician. The facility reported no mental health history and he/she was not on medications for mental health; -Psychiatric consult note: the resident was a poor historian due to not able to speak English, stroke history, and intellectual disability. He/She used gestures, signs, and talked gibberish. He/She denied previous psych history. He/She said his/her roommate exposed himself/herself in front of him/her and attempted to touch him/her multiple times. He/She felt uncomfortable around him/her and as a result became agitated. Recommendation included to start Seroquel (antipsychotic medication) 25 mg every bedtime for agitation and sleep; -It had eventually come out that the roommate was performing self-sexual activities in front of him/her and then trying to grab his/her possessions afterwards. This made the resident very upset; -Telepsychiatry recommended initiation of Seroquel 25 mg at bedtime which was added to the resident's discharge orders; -Discharge instructions included to take Seroquel 25 mg one tablet daily at bedtime, and to continue all other medications as directed by the originating prescriber. Review of the facility's investigation, dated 3/11/24, showed the following: -On 3/9/24, the Director of Nursing (DON) and the Administrator were notified of a resident-to-resident altercation between the resident and Resident #2. The altercation started in the bedroom of the two residents; -Staff on duty witnessed the resident (Resident #1) trying to enter the room, but was unable to due to Resident #2 sitting in his/her wheelchair in front of the doorway. The resident attempted to go around Resident #2 and accidentally stepped on Resident #2's foot; -Resident #2 become visibly upset, yelling, cursing, ,and pushed the resident causing him/her to fall onto the bed; -The resident got up and started to hit Resident #2 multiple times in the head and upper body; -When Resident #2 was asked what had happened, he/she said he/she pushed the resident for stepping on his/her foot and the resident hit him/her; -The resident was sent to the hospital for evaluation and treatment. Review of the resident's MAR, dated 3/1/24 to 3/31/24, showed the following: -Seroquel 25 mg; one tablet at bedtime related to anxiety disorder was started on 3/11/24 (order was obtained from the hospital on 3/9/24); -Staff documented Seroquel 25 mg; one tablet at bedtime was administered on 3/11/24. During an interview on 3/12/24 at 10:30 A.M., the Administrator said the following: -The resident had never had physical behaviors since he/she was admitted ; -The resident was roommates with Resident #2 , but Resident #2 could not communicate well with Resident #1. The resident attempted to maneuver around Resident #2 who was blocking the doorway to their room. The resident ended up on Resident #2's foot. Resident #2 become upset and pushed the resident, and he/she fell on the bed. The resident then got up and struck Resident #2; -The resident was sent to the hospital and returned with new order for Seroquel. During an interview on 3/12/24 at 11:10 A.M., Certified Nurse Assistant (CNA) A said the following: -On 3/9/24, he/she came out of another room when he/she saw the resident step on Resident #2's foot as he/she tried to maneuver around Resident #2 who was blocking the doorway. Resident #2 shoved the resident on the bed and the resident jumped up and struck Resident #2.; -He/She was unaware of any previous issues between the two residents; -The resident was not usually aggressive. Observation of on 3/12/24 at 1:00 P.M. showed the resident lay in his/her bed calmly listening to music on his/her phone. He/She appeared happy as evidenced with smile on his/her face. During an interview on 3/12/24 at 4:15 P.M., the care plan coordinator said the following: -The resident only became physically aggressive if he/she was provoked; -He/She had never seen the resident lash out for no reason; -The resident was normally quiet and kept to himself/herself in his/her room. During an interview on 3/13/24 at 1:00 P.M., Licensed Practical Nurse (LPN) C said the following: -On 2/24/24, the resident was sitting at the dining room table with a peer who had received more pizza. The resident was told there was no more when he/she had asked for more. The resident became frustrated, staff tried to redirect and calm him/her down, but only made him/her more agitated; -He/She administered hydroxyzine because it could also be used for anxiety; -He/She did not recall contacting the physician and just gave the medication in the moment because he/she felt it was appropriate to use in that situation; -The resident was usually nice and tried to keep to himself/herself; -He/She noticed a behavior one time and that was because another resident had instigated the issue; -The resident attempted to get out of the room, but his/her roommate Resident #2 was blocking the doorway. The resident accidentally stepped on Resident #2's toes which caused Resident #2 to become angry and he/she pushed the resident on the bed. The resident got up and struck Resident #2; -The resident went to the hospital and was evaluated by psych. During an interview on 3/14/24 AT 7:40 A.M., Registered Nurse (RN) D said the following: -The resident's communication barrier caused difficulty between the resident and most of the staff; -The resident was easily irritated which could be caused from staff and/or other peers not understanding him/her; -The resident had an order for hydroxyzine to be administered for itching. He/She would have to contact the physician and obtain an order to give it for any other indication such as for increased behaviors; -The resident was involved in an altercation with a peer and was sent to the hospital for physical aggression. He returned from the hospital with a new order for Seroquel to calm him/her down and aid with sleep. During an interview on 3/14/24 at 12:15 P.M., the resident's physician said the following: -He expected staff to contact him for further direction if a medication such as hydroxyzine could be used for agitation/anxiety if it was indicated on the orders for itching; -The resident was in an altercation recently with a peer and was sent to the emergency room . The resident saw tele psych and was recommended that he/she start on Seroquel. It was reported that the resident appeared agitated on a frequent basis. He did not feel that the resident needed the medication due to the degree of provocation. The Seroquel was continued to prevent further incidents of aggression. During an interview on /26/24 at 3:25 P.M., the Director of Nursing said she would not expect staff to administer hydroxyzine for increased anxiety/agitation if was indicated for itching on the resident's physician's orders. Staff should have contacted the physician for an order to administer for increased anxiety/agitation and not take it upon themselves to administer without contacting the physician first. The physician may have recommended some other intervention. During interview on 4/10/24 at 2:13 P.M., the Administrator said the following: -The resident was started on Seroquel on 3/11/24 after the incident with Resident #2; -The resident's diagnosis for Seroquel use was anxiety; -Hospital psych evaluated the resident for the use of Seroquel; the facility did not assess the need for the medication and if the diagnosis was appropriate for use; -The root cause of the resident's behavior on 3/9/24 was that Resident #2 provoked him/her by shoving him/her; -The root cause of previous incidents involving the resident and behaviors was due to his/her communication barrier.

Based on observation and interview, the facility failed to maintain a sanitary environment in the kitchen, failed to ensure food items in storage and in the refrigerators/freezers were properly labeled, dated, and sealed to protect from potential contamination, and failed to ensure an air gap between the ice machine and the floor drain. The facility census was 53. Review of the facility's policy, Receiving and Storing Food and Supplies, dated as last reviewed [DATE], showed the following: -Dry food storage: Storage area shall be easily accessible for receiving new items. The walls, ceiling, and floor shall be maintained in good repair and regularly cleaned. Any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids or Ziploc bags. Open products may also be sealed utilizing plastic film or tape. -Frozen foods: Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil, plastic film, or special laminated papers, date and label a received date. -Food storage: All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers according to the timetable in the Dry, Refrigerated and Freezer Storage Chart found in this section. Leftovers shall be dated according to the Leftovers policy. -Refrigerated Leftover storage: Cover with non-absorbent lid or material. Date container (lids may be misplaced). Label unless easily identifiable without removing cover - such as sliced peaches in glass jar. 1. Observation on [DATE] at 10:05 A.M. during the initial kitchen tour showed the following: -A 15-pound box of onion flakes, located in the dry food storage area, was open and the plastic wrapping around the onion flakes was not securely sealed; -A 25-pound box of rice, located in the dry food storage area, was open and the plastic wrapping around the rice was not securely sealed; -A 11.25-pound box of wheat rolls, located in the walk-in freezer, was open and the plastic around the rolls was not sealed; -A 20-pound box of Italian blend vegetables, located in the walk-in-freezer, was open and the plastic around the vegetables was not sealed; -A bowl covered with plastic wrap, located in the walk-in freezer, contained a red colored food item. The item was not labeled or dated; -A pan of gravy was in the walk-in cooler and was dated [DATE]; -A pan of cooked noodles, located in the walk-in cooler, was not dated; -A pan of chicken salad, located in the walk-in cooler, was not dated; -A pan containing a yellow liquid, located in the walk-in cooler, was not labeled or dated; -A bowl containing a reddish brown liquid, located in the walk-in cooler, was not labeled or dated. 2. Observation on [DATE] at 10:14 A.M. showed the floor in the walk-in freezer was sticky and dirty. Miscellaneous items, such as plastic, paper, a plastic spoon, and trash lay on the floor. Observations on [DATE] between 9:47 A.M. and 2:00 P.M., showed the following: -An approximately 2 foot by 2 foot area of the wall, located under the preparation counter containing the microwave, toaster, and food processor, was torn and peeling; -The wall between the preparation counter and the deep fat fryer and range was soiled with food debris and splatters. The paint on the wall in this area and in other areas throughout the kitchen was peeling and was not easily cleanable; -The area of wall that connected to the backsplash for the three-compartment sink was peeling. An approximately 6 inch by 4 inch area of a mold-like substance was on the wall under the sanitizer dispenser; -The wallboard behind the dish drying rack near the dishwashing area was pulled away from the all; -The wall and the tile along the wall between the kitchen exit door and the walk-in cooler were damaged. Tiles were missing and pulled away from the wall and the wall was damaged and peeling in areas; -The floor and the wall under the dishwashing counter were heavily soiled with black, mold-like debris. Portions of the floor tile along the wall and on the floor under the counter were broken and no longer attached to the wall and floor. A six inch tile was missing from the floor under the sanitizer buckets. The water lines and drains under the counter were heavily soiled with a black, mold-like debris; -A 1 foot by 1 foot area of the floor tile by the dishwasher and the kitchen door was broken or missing. The grout on the floor in this area was missing in several areas and food debris was settled between the tiles; -Grease buildup and debris on the floor under and behind the deep fat fryer; -The floor throughout the kitchen was soiled with a buildup of debris in the grout between the tiles and a buildup of dark debris around the edges of the room where the wall met the floor; -The floor in the dry food storage room was soiled with loose food particles, and had a buildup of dark debris along the edges of the room and under the shelves; -The floor tiles in front of the walk-in cooler were broken and/or missing and the floor was heavily soiled. -The drywall ceiling near the main kitchen door to the dining room was cracked along the seam in multiple places; -Food splatters and debris were scattered throughout the ceiling in the kitchen; -The ceiling vent near the main kitchen door to the dining room was heavily soiled with a buildup of dust and debris; -The ceiling vent by the dietary manager's office was heavily soiled with a buildup of dust and debris; -A buildup of condensation and water droplets on the ceiling vent located over the steamtable; -A buildup of black debris on the counter-mounted can opener and on the blade; -Staff washed dishes at the dishwasher. A fan blew in the direction of the clean dishes, and had a buildup of dust and debris on the blades and cover; -The metal shelving unit in the dishwashing area, used as a drying rack, was rusted and pitted; -The metal shelving unit in the kitchen near the main door to the dining room was rusted and pitted. A thin rubber-type shelf liner with holes was on each of the four shelves and was soiled. Staff stored drink pitchers and bowls inverted on one of the shelves; -The metal trash can, located at the handwashing sink, was soiled and rusted; -A buildup of black dusty debris on the cooler fan covers in the walk-in cooler. The fans were blowing in the direction of a cart containing uncovered drinks for the residents' meal. During interviews on [DATE] at 11:40 A.M. and 2:00 P.M. showed the following: -The facility was supposed to paint the kitchen. She was to pick a date in September to deep clean the kitchen so maintenance could paint. She hadn't set a date yet. The walls definitely need painted; -Staff should label and date all food items; -Staff are to look for expired food items in the cooler every three days and discard any leftover food items that are over three days old; -Staff are to ensure items in dry food storage are covered with plastic and sealed; -The floor in the dishwashing area is in bad condition; -Staff mop the floors in the kitchen at least twice a day, but it was difficult to clean the grout and the areas between the tiles; -Staff wipe down the cooler fans in the walk-in cooler and freezer at least once a week; -Staff are to wash the can opener between shifts; -Condensation forms on the ceiling vents when it is humid; -Staff do not clean the shelf liners on the metal shelving units; -The dietary department if short staffed. Staff are able to clean but not as good as he/she would like. She posted a cleaning schedule so staff know what is expected. 3. Observation on [DATE] at 10:30 A.M. showed a buildup of clear yellow grease on the filters in the rangehood, located over the deep fat fryer and the six-burner range. Review of the vendor tag on the rangehood on [DATE] showed the rangehood was last professionally cleaned on [DATE]. During interview on [DATE] at 10:34 A.M., the dietary manager said the facility staff do not remove the filters out of the rangehood because they are sharp. The vendor comes once every six months to clean the rangehood. 4. Observation on [DATE], at 8:02 A.M., of the ice machine located in the dining room, showed various dried white drips and a 0.25 inch piece of moist brown material on the interior surface of the front door. When the door closed, the soiled surface was located approximately 3 inches above the ice that was located in the storage bin area of the ice machine. During an interview on [DATE], at 5:58 P.M., the Dietary Manager said it was his/her responsibility to clean and sanitize the interior portion of the ice machine door on a daily basis. He/She was not always able to complete this task due to his/her other work duties. During an interview and observation on [DATE], at 3:31 P.M., showed the following: -The Maintenance Director said a contracted company came every 60 days to change the filters and perform detailed cleaning and sanitization of the ice machine; -The Dietary Manager wiped down the ice machine in between the contracted company visits; -Two 1 inch diameter PVC pipes, originating from the ice machine area located in the dining room, entered through a wall into an adjacent mechanical room; -The Maintenance Director said these pipes were likely connected to the ice machine, as the other items in the area (a snack machine and a bottled beverage dispensing machine) did not require a drain; -The back side of the ice machine was inaccessible and the Maintenance Director said only the contracted company pulled the unit forward out of its location; -When viewed from the adjacent mechanical room, the two 1 inch PVC pipes each connected to PVC 90 degree elbows that each connected to an approximate 3 inch vertical section of 1 inch diameter PVC pipe; -The vertical sections of PVC pipe extended approximately 1.5 inches below the flood rim level of the approximate 4 inch flanged drain pipe; -The Maintenance Director said the ice machine drains should contain air gaps but he/she was unaware they did not. During an interview on [DATE], at 2:14 P.M., the Administrator said he/she expected the ice machine to be clean and have a sufficient drain air gap to prevent backflow of liquids back into the unit.

Based on interview and record review, the facility failed to conduct quarterly Quality Assessment and Assurance (QAA) committee meetings. The facility census was 53. Review of the facility's QAPI Plan Policy, last reviewed 07/09/21, showed the following: -This QAPI plan provided guidance for the facility overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within the facility. Decisions would be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions; -QAPI activities are integrated across all parts of the facility. Each department would have a representative on the QAPI committee. If a representative is not available, the department area will still be addressed through committee discussions. The QAPI activities would cross departments and staff across all departments wouldl work together to assure the facility addresses all concerns and strives to continuously improve the provided services. The facility strives to employ evidence based practices related to performance excellence in all management practices, clinical care, and resident and family satisfaction; -QAPI meeting would be held on a monthly basis; -The medical director, consulting pharmacist would provide QAPI leadership by being on the QAPI committee; -Records of the actions taken at each meeting would be kept using the attached form Instructions for IDP/CP/QAPI QA Meetings; -Minutes should document what was reviewed, issues/problems addressed, plan of correction, the monitoring process and the results; -At least quarterly, all disciplines should have a representative at the QAPI meetings. During an interview on 8/21/23 at 12:30 P.M., the administrator said the QA committee was supposed to meet formerly every quarter with the interdiosciplinary team which included the pharmacist and physician. They discuss issues with the physician weekly when he was at the facility and also discussed issues with the pharmacist when they were in the facility. There had been no formal quarterly QA meeting for past year since she had been acting administrator. There was a huge staff turn over and they had been working on correcting deficient areas.

U4413 Based on record review and interview, the facility failed to keep residents from going into a negative balance which allowed the residents to spend another resident's money without written authorization for 32 residents (Resident #4, #5, #11, #12, #15, #17, #18, #19, #20, #22, #23, #25, #31, #35, #36, #38, #40, #43, #45, #46, #48, #50, #51, #53, #58, #59, #60, #62, #403, #404, #405 and #406). The facility managed funds for 46 residents. The facility census was 53. 1. Record review of the facility maintained Trust - Current Account Balance Report as of 11/30/2022, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 11/2022. Resident Amount #11 <$9.75> #20 <$50.00> #36 <$24.11> #40 <$4.03> #43 <$0.16> #405 <$30.00> #406 <$35.74> 2. Record review of the facility maintained Trust - Current Account Balance Report as of 12/31/2022, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 12/2022. Resident Amount #17 <$9.07> #20 <$65.00> #23 <$29.60> #25 <$9.11> #36 <$8.41> #38 <$2.86> 3. Record review of the facility maintained Trust - Current Account Balance Report as of 01/31/20223, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 01/2023. Resident Amount #5 <$5.00> #17 <$69.07> #20 <$90.00> #22 <$21.69> #38 <$12.86> #50 <$9.92> 4. Record review of the facility maintained Trust - Current Account Balance Report as of 02/28/2023, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 02/2023. Resident Amount #4 <$23.29> #5 <$45.00> #15 <51.70> #17 <$113.07> #20 <$114.00> #22 <$5.99> #25 <$14.11> #38 <$34.86> #46 <$10.00> #50 <$116.92> #51 <$34.72> #403 <$89.47> #406 <$8.69> 5. Record review of the facility maintained Trust - Current Account Balance Report as of 03/31/2023, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 03/2023. Resident Amount #4 <$23.29> #5 <$78.00> #15 <$96.73> #17 <$19.67> #20 <$114.00> #25 <$26.80> #31 <$4,959.98> #36 <$3.39> #38 <$34.86> #46 <$10.00> #48 <$2,616.39> #50 <$164.02> #51 <$34.72> #403 <$208.12> 6. Record review of the facility maintained Trust - Current Account Balance Report as of 04/30/2023, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 04/2023. Resident Amount #4 <$23.29> #5 <$137.66> #15 <$163.61> #20 <$114.00> #25 <$51.80> #31 <$4,959.98> #38 <$34.86> #46 <$33.51> #48 <$2,701.39> #50 <$164.02> #51 <$34.72> #403 <$323.60> #404 <$42.26> #406 <$6.95> 7. Record review of the facility maintained Trust - Current Account Balance Report as of 05/31/2023, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 05/2023. Resident Amount #4 <$23.29> #5 <$137.66> #12 <$35.00> #15 <$146.59> #17 <$31.67> #18 <$6.74> #19 <$12.89> #20 <$94.00> #22 <$11.71> #23 <$13.45> #25 <$153.80> #31 <$4,959.98> #35 <$41.43> #38 <$34.86> #46 <$33.51> #48 <$2,811.39> #50 <$164.02> #51 <$34.72> #403 <$419.04> #404 <$42.26> 8. Record review of the facility maintained Trust - Current Account Balance Report as of 06/30/2023, dated 09/01/23, showed the following residents were allowed to go into a negative balance for 06/2023. Resident Amount #4 <$23.29> #12 <$35.00> #15 <$101.59> #17 <$41.67> #20 <$94.00> #22 <$11.71> #23 <$53.45> #25 <$143.80> #31 <$4,959.98> #35 <$38.43> #38 <$34.86> #46 <$73.51> #48 <$2,841.39> #50 <$174.02> #51 <$34.72> #53 <$2.00> #403 <$369.04> #404 <$42.26> 9. Record review of the facility maintained Trust - Current Account Balance Report as of 07/31/2023, dated 09/07/23, showed the following residents were allowed to go into a negative balance for 07/2023. Resident Amount #17 <$5.00> #22 <$15.00> #25 <$35.00> #31 <$4,959.98> #45 <6.65> #48 <$236.99> #50 <$5.00> #53 <$2.00> #58 <$248.00> #59 <$21.94> #60 <$0.06> #62 <$47.73> 10. Record review of the facility maintained Resident Trust Policy, last reviewed date of 09/17/21, on 09/07/23, showed When a resident requests a cash withdrawal from his/her personal funds, the petty cash clerk will first verify that the funds are available. Record review also showed, If any resident has a negative balance on the last day of the month a positive adjustment must be posed in AHT to make their balance zero. 11. During an interview on 08/24/23 at 1:54 P.M. and 2:58 P.M., the Regional Business Office Manager (BOM) said the facility has paid back, and is in the process of paying back, any fund discrepancies to the residents and Regional staff would be conducting an audit of the facility's resident trust fund. 12. During an interview on 09/01/23 at 1:01 P.M., the Corporate Business Office Director said the facility's former BOM made multiple fund errors and received re-education, trainings, and write-ups regarding these discrepancies. 13. During an interview on 09/07/23 at 1:56 P.M., the Corporate Business Office Director said the following: -The former facility BOM allowed residents to have negative fund balances; -Corporate staff re-educated the former BOM on the process and the facility policy several times; -The former BOM did not keep accurate resident fund balances and did not check resident balances prior to issuing money or going shopping for residents; -In one of the larger negative balances, the former BOM paid room and board for a resident who didn't owe room and board but this was funded back to correct the error; -Corporate staff performed an audit on the facility's resident fund account, all negative resident balances were funded, and as of 09/07/23 there were no negative balances; -A new facility BOM was hired and is being trained for tasks in the position.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility managed funds for 46 residents. The facility census was 53. 1. Record review of the facility maintained reconciliation forms, dated August 2022 through July 2023, showed the facility attempted to reconcile by inserting numbers, to make it appear as though the reconciliation showed a zero balance for the following months. -August 2022: fund facility error $4.31, $11.87, $147.17 and $306.16; fund negative balance $28.60 and $20; fund missing funds $500; -September 2022: fund facility error $306.16; fund missing funds $500; fund unknown debit $453.39; -October 2022: fund unknown debit $453.39; -November 2022: fund unknown debit $453.39; fund check 5011 error #321; -December 2022: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21; -January 2023: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21 and $510; -February 2023: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21 and $510; fund cash discrepancy $1,441.58; -March 2023: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21 and $510; fund cash discrepancy $1,441.58 and $2,848.34; -April 2023: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21 and $510; fund cash discrepancy $1,441.58, $2,848.34, and $1,475.18; -May 2023: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21 and $510; fund cash discrepancy $1,441.58, $2,848.34, $1,475.18, and $3,297.79; -June 2023: fund check 5011 error $321; fund negative balances $51.13; posting error-fund $645; paid from wrong acct-fund $1,709.87; fund petty cash discrepancy $1,576.21 and $510; fund cash discrepancy $1,441.58, $2,848.34, $1,475.18, $3,297.79, and $1,930.11; -July 2023: fund cash discrepancy $1,930.11; fund negative balances $1,784.03 and $2,682.40. 2. Record review of the facility's attempted reconciliations, dated August 2022 through July 2023, also showed the facility was attempting to reconcile the resident trust fund bank statement to the Resident Trust (RT) Module instead of the Trust - Current Account Balance, listed by resident name and dollar amount for the following months. Month RT Module RT Current Account Balance 09/2022 $23,126.10 $29,344.10 10/2022 $31,152.22 $31,172.22 11/2022 $62,864.39 $62,879.48 12/2022 $34,466.98 $34,212.98 02/2023 $47,363.28 $47,378.28 03/2023 $38,765.54 $38,945.54 06/2023 $72,703.12 $72,541.62 07/2023 $47,544.81 $48,883.81 3. Record review of the facility maintained Resident Trust Policy, last reviewed date of 09/17/21, on 09/07/23, showed the Resident Trust Bank Reconciliation should reconcile only the bank statement, checkbook and AHT Trust Funds module monthly. The Trust - Current Account Balance is not listed as part of the reconciliation policy. 4. Record review and email correspondence, sent on 09/01/23 by the Corporate Business Office Director, showed the following: -An email from the Corporate Financial Management Staff with the following information: -A deposit of $15 hit the bank 05/25/23 and is not posted; -Check #5051 says it is for Resident #9 but it is not posted; -Difference between Walmart purchases and what is posted is $115.92; -Difference between Dirt Cheap purchases and what is posted is $533.26; -Difference in checks written for cash and what was posted is $2,648.61; -I know the last three will have to be funded, but just letting you know where you are .the first two should be corrected in Point Click Care (PCC); -The Corporate Business Office Director said the fund cash discrepancies were not all for one month; -For May 2023, $3,297.79 was funded to the resident fund due to documentation not able to be located. 5. During an interview on 08/24/23, at 10:57 A.M., the facility Business Office Manager (BOM) said the following: -He/She did not conduct the resident fund reconciliations and was unfamiliar with entries, such as 'fund cash discrepancy,' 'fund negative balances,' etc., or what they meant on the monthly reconciliations; -The Corporate Financial Management Staff conducted reconciliations of the resident funds account; 6. During an interview on 08/24/23 at 1:54 P.M. and 2:58 P.M., the Regional Business Office Manager (BOM) said the following: -The discrepancy entries shown on the monthly resident fund reconciliations were due to errors made by the facility's BOM; -The facility BOM started in November 2022; he/she was not sure if the errors started then or not; -He/She discovered the errors about three weeks ago when he/she started in his/her current position; -The facility has paid back, and is in the process of paying back, any fund discrepancies to the residents; -Regional staff would be conducting an audit the following week of the facility's resident trust fund. 7. During an interview on 09/01/23, at 12:52 P.M., the Corporate Financial Management Staff said he/she conducted the facility's monthly resident trust fund reconciliations. 8. During an interview on 09/01/23, at 1:01 P.M., the Corporate Business Office Director said the following: -The Corporate Financial Management Staff conducted the monthly resident funds account reconciliations and reconciled them to the bank statements; -The facility's former BOM made multiple fund errors and received re-education, trainings, and write-ups regarding these discrepancies; -The Corporate Financial Management Staff emailed the Corporate Business Office Director on a monthly basis regarding resident fund discrepancies. 9. During an interview on 08/28/23, at 2:14 P.M., the Administrator said he/she expected staff to ensure a full, complete, and separate accounting of resident funds per generally accepted accounting principles, including accurate and timely reconciliation.

Based on observation, interview, and record review, the facility failed to ensure four residents (Residents #1, #2, #8, and #9) were free from verbal and mental abuse. The Director of Nurses (DON) yelled at Resident #9 and pursued the resident into his/her bathroom. The resident was upset and crying and made threats to harm himself/herself as a result of the DON's actions towards him/her. The DON continued to provide care to one resident, Resident #2, who was visibly upset and did not want the DON to provide his/her care. The DON continued to provide care for the resident despite the resident's response and refusal. The resident reported the DON was verbally abusive to him/her during care. This upset the resident who then made comments of self-harm. The DON failed to remain sensitive to Resident #8, when discussing plans for discharge when he/she told the resident he/she would not see his/her family. The resident had a history of becoming emotional when he/she could not see his/her family and a history of attempts at self-harm. The resident said he/she tried to strangle himself/herself with his/her hands after the DON said he/she would not see his/her family. The DON verbally abused Resident #1 when he/she spoke to the resident abruptly and through gritted teeth. The facility census was 56. The administrator was notified of the Immediate Jeopardy (IJ) on 5/25/23 at 12:55 P.M. which began on 5/3/23. The IJ was removed on 5/25/23 as confirmed by surveyor onsite verification. Review of the facility policy, Abuse and Neglect, dated 1/5/23, showed the following: -Mistreatment, neglect, or abuse of residents is prohibited. This included verbal abuse and mental abuse; -Verbal abuse - using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples include harassing a resident, mocking, insulting, ridiculing, yelling at a resident with the intent to intimidate, threatening residents, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends, and isolating the resident from social interaction or activities; -Mental abuse is the use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 1. Review of Resident #9's face sheet showed the following: -The resident had a guardian; -Diagnoses included anxiety disorder and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's Preadmission Screening and Resident Review (PASRR; a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in a nursing facility), dated 11/30/22, showed the following: -The resident's psychiatric history began in childhood. He/She was suicidal as a teenager. The current facility does not know any historical details except for bipolar diagnosis. They report the resident was mostly asymptomatic, however, he/she can be manipulative at times; -The resident needs monitoring of behavioral symptoms and provision of behavioral support to address manipulative behaviors, medication therapy and monitoring, and a structured environment. Review of the resident's Care Plan, dated as revised on 1/24/23, showed the following: -The resident was at risk for impaired social interaction and ineffective coping skills related to diagnosis of bipolar disorder; -Allow the resident time to vent with staff of any concerns or feelings; -Maintain a low stimulus environment. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/3/23, showed the following: -Cognition was intact; -No behaviors directed toward self or others. During interviews on 5/3/23 at 3:14 P.M. and on 5/4/23 at 2:34 P.M., the resident said this morning (5/3/23) he/she was talking with Physical Therapy Assistant (PTA) E by the therapy area about how the Director of Nursing (DON) overrides his/her physician orders. As the resident said the DON's name, the DON came around the corner (from the DON's office) and started yelling and screaming at the resident. The DON yelled, You need to come here and tell me what you said! The DON followed him/her down the hall and continued to yell this and the resident's name as she followed the resident. She followed the resident into the resident's room and then into the resident's bathroom. She continued to yell at the resident as the resident sat on the toilet to use the bathroom. The DON did not ask if he/she wanted to talk now or wait until later. At this point, the resident decided to tell the DON what he/she had told PTA E about the DON overriding orders. The resident's roommate, Resident #8, was in the room. PTA E and other staff and residents who were around the nurses station also observed the DON yell and scream at the resident. The DON was yelling and screaming at the resident. This made the resident very upset and it was so bad the resident wanted to cut himself/herself, which he/she had not done since he/she was a teenager. The DON triggered this feeling, because he/she was so abusive. He/She did not feel safe around the DON because his/her verbal and emotional abuse, towards the resident was so bad the resident wanted to cut and kill himself/herself. The DON had argued with him/her, yelled and screamed at him/her prior to today (5/3/23). The DON did this to everyone, including other residents. The DON was belligerent, disrespectful, disgraceful, talks down to residents, and was verbally and emotionally abusive. The resident started seeing a counselor last week as a result of how the DON spoke/treated him/her. During an interview on 5/4/23 at 1:55 P.M., PTA E said he/she was outside the therapy room when the resident walked by. He/She asked the resident if he/she was okay. The resident said he/she wasn't feeling well and that he/she kept telling the DON, but the DON was ignoring him/her. As they were talking, the DON came from around the corner, and said, What did you say. I heard my name. The resident walked down the hall (toward the nurses station). The DON yelled at the resident down the hall, Stop! I know you can hear me! The resident continued down the hall. During an interview on 5/4/23 at 10:09 A.M., Resident #8 (the resident's roommate), said the DON entered his/her room yesterday screaming at Resident #9. He/She did not remember what the DON said to the resident. The DON walked right into the room right after the resident was in the bathroom and yelled at Resident #9. The resident was crying. During an interview on 5/4/23 at 12:55 P.M., Certified Occupational Therapy Assistant (COTA) I said on 5/3/23, he/she was in the therapy room with a resident. He/She heard Resident #9 talking to PTA E about having headaches and confusion. The resident was frustrated. The DON said the resident's name and you hear me, you hear me. During interview on 5/4/23 at 10:26 A.M., Laundry Staff D said he/she was walking down the hall yesterday morning when he/she heard the resident talking to PTA E outside therapy. She was not sure what they were saying. After he/she had walked past the resident, he/she heard the DON say, What just came out of your mouth? It was the DON's tone of voice that caused him/her to turn around. The DON was always loud, but his/her tone was sharp. The resident walked away and did not say anything. The DON continued to yell the resident's name and say, What did you say? Do you have something to say? Since the resident ignored the DON, Laundry Staff D thought it was okay and he/she continued to laundry. Later, he/she saw the resident outside smoking. The resident was crying. The resident said the DON yelled at him/her and he/she couldn't even go to the bathroom without the DON yelling and screaming at him/her. The resident was still crying at the 3:30 P.M. smoke break and said he/she was tired of living this way with the DON always yelling. The resident was really bothered by this. During interview on 5/4/23 at 10:35 A.M. and 2:55 P.M., Dietary Staff G said during smoke break (on 5/3/23), the resident said the DON was yelling at him/her as he/she went into his/her room and bathroom. The resident was crying and said he/she was so upset, he/she was going to cut his/her wrist. The DON was always yelling. He/She felt bad for some of the residents. 2. Review of Resident #2's PASRR Level II Screening, dated 1/30/12, showed the following: -The resident's diagnoses included bipolar affective disorder and borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships); -The resident's history included periods of depression with periods of mania and problems with interacting with others (poor relationship with family). Review of the resident's face sheet showed the following: -He/She was his/her own responsible party; -Diagnoses included schizoaffective disorder, urinary tract infection, gram-negative (a type of bacteria) sepsis (the body's extreme response to an infection), enterocolitis (inflammation in the intestines) due to clostridium difficile (c. diff; a bacteria that causes diarrhea and inflammation of the colon). Review of the resident's Care Plan, dated 11/14/22, showed the following: -Allow the resident to make decisions about treatment regime to provide a sense of control; -Educate the resident of possible outcomes of not complying with treatment or care; -Give clear explanation of all care activities prior to and as they occur during each contact; -If possible, negotiate a time for activities of daily living (ADLs) so that the resident participates in the decision making process. Return at the agreed time; -If the resident resists with ADLs, reassure the resident, leave and return 5-10 minutes later and try again. -Update on 3/28/23, the resident was placed on isolation related to c-diff. The resident has an indwelling urinary catheter related to urinary tract infection (UTI). -Update on 5/1/23, the resident has a diagnosis of sepsis related to UTI. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition was intact; -No mood symptoms; -No behaviors directed toward self or others; -Did not reject care. During interview on 4/26/23 at 2:15 P.M., the resident said the following: -He/She did not like the DON at all. The DON made him/her feel mad and fierce (angry), this made him/her want to hurt the DON; -He/She avoided the DON and did not speak to him/her. He/She told the DON to leave him/her alone (the resident raised his/her voice when speaking and clenched his/her fists); -Yesterday, the resident was hanging out in the hall with other residents, and the DON yelled, Get the hell out of the hallway! During interviews on 5/4/23 at 10:05 A.M. and 2:50 P.M., the resident said last night, he/she didn't want the DON to do his/her treatment and he/she was upset the DON came into his/her room. He/She did not like the DON. He/She told her he/she didn't want her in his/her room and the DON kept doing the treatment. She got after the him/her for pulling out the PICC (peripherally inserted central catheter; a thin, flexible tube inserted into a vein for intravenous therapy) line and he/she did not do this. This made him/her feel terrible. The DON jumped on his/her case and told him/her no one wanted to be around him/her, he/she bothered people. The DON told him/her to shut up and not to say anything else. The DON was nothing but trouble. He/She was tired of the DON picking on him/her. He/She has been here one month, and can't take it here anymore and wants to leave because the DON isn't nice to him/her. The DON chews him/her out when he/she hasn't done anything. During an interview on 5/4/23 at 12:40 P.M., the Business Office Manager (BOM) said the resident had been refusing treatments all day (on 5/3/23) and finally agreed for the DON to empty his/her catheter bag around 4:30 and 5:00 P.M. When the DON asked the resident to put on a mask (due to isolation precautions related to infection), the resident immediately started cussing at the DON and was almost jumping out of his/her chair at him/her. The resident was so upset. The DON noticed the resident's PICC line wasn't in place, so he/she tried to look for it. The resident was cursing at the DON and he/she told him/her they had to find it since he/she was on a blood thinner. The resident's behaviors and cursing went on for approximately ten minutes. The BOM had never seen the resident act like this. The resident told the BOM that he/she did not like the DON. The resident was talking about how he/she did not want to live and would harm himself/herself. During interview on 5/4/23 at 10:46 A.M., Laundry Staff D said the resident stopped him/her first thing at breakfast this morning and told him/her that the DON was 'smart with him/her' and yelled at him/her last night. The DON told him/her to stay away from people, because no one wanted him/her around. The resident was mad. The resident was usually upbeat and happy. During interview on 4/26/23 at 3:30 P.M. and 5/4/23 at 1:40 P.M., Licensed Practical Nurse (LPN) A said the following: -The DON would tell Resident #2 to get up and do it himself/herself when he/she (Resident #2) asked for assistance with care. This made the resident very angry. 3. Review of Resident #8's PASRR, dated 10/25/22, showed the following: -The resident had two children. -Diagnoses included major depressive disorder, bipolar disorder with current episode of severe depression with psych features, unspecified mood disorder, post-traumatic stress disorder (PTSD), and mild mental retardation; -He/She had bipolar disorder and was withdrawn and depressed. He/She had PTSD and was suspicious and paranoid; -He/She had impaired insight, judgement, and decision-making. He/She expressed his/her emotions in maladaptive ways such as lays on the floor, injures self, etc. Review of the resident' face sheet showed the following: -The resident was his/her own responsible party: -Diagnoses include persistent mood (affective disorder) and major depressive disorder. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition was intact; -No mood symptoms present; -No behaviors toward self or others. Review of the resident's care plan, dated 12/9/22, showed the following: -Per PASRR, the resident suffers from a long history of major depression, bipolar, unspecified mood disorder, PTSD, and MMR. The resident's symptoms include behavioral problems. He/She pulls his/her own hair out with his/her hands and will put his/her hands around his/her neck in an attempt to choke himself/herself. Unable to be redirected at these times. -Allow time to voice feelings and concerns; -Redirect as needed. Review of the resident's significant change MDS, dated [DATE], showed the following: -Staff did not assess the resident's cognition, short or long-term memory, decision making skills, or mood symptoms; -The resident did not have any behaviors toward himself/herself or others. During interview on 5/4/23 at 10:09 A.M. and 2:25 P.M., the resident said he/she did not like the DON and had tried to commit suicide three times because of the DON. She tried to strangle himself/herself with his/her hands a couple months ago after the DON told him/her that he/she couldn't see his/her family anymore. No one else heard what the DON said to him/her. The resident and the DON were discussing the resident and discharge. The resident told the DON he/she was wanting to discharge, but there were some things he/she would need to work on first, so they didn't know how long he/she would have to be at the facility. The resident got upset, because he/she can't see his/her family and his/her child who lived out of state. The DON told him/her, Maybe you won't see your family again. The DON sounded mean to him/her. This hurt his/her feelings. After this, he/she went into the hallway and tried to choke himself/herself with his/her hands. 4. Review of Resident #1's annual MDS, dated [DATE], showed the following: -Resident was unable to complete interview for mental assessment; -Adequate hearing; -Usually understood and understands others; -No behavioral symptoms exhibited; -Diagnoses included aphasia (a disorder that affects how you communicate), cerebral vascular accident (CVA or stroke), anxiety, manic depression and schizophrenia. Review of the resident's care plan, revised 3/14/23, showed the following: -When the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, if response was aggressive, staff to calmly walk away and reproach later; -When the resident begins yelling, address his/her needs calmly asking the resident what he/she needs. Observation on 4/26/23 at 1:20 P.M., showed the following: -The resident was in his/her room and yelled loudly, he/she could be heard in the hall; -The DON entered the room abruptly and through gritted teeth said, Will you stop it! She abruptly moved the resident's wheelchair back and said, You want up, okay you will get up! The DON exited the room; -(The state surveyor was directly across the hall. The state surveyor walked across the hall, the resident was the only one in his/her room at the time. The resident was partially positioned in bed (which was in low position) and his/her legs were on a floor mat, which was positioned directly beside the resident's bed. The resident was upset and yelling. The resident calmed quickly, smiled and laughed at the state surveyor when spoken to in a calm voice). During interview on 4/26/23 at 3:30 P.M. and 5/4/23 at 1:40 P.M., LPN A said the following: -Resident #1 yells and laughs which was his/her only way of communication. When the resident hollered out, the DON told him/her to stop yelling down the hall. What are you yelling for? and would tell the resident to shut up. This upset the resident and he/she would become frustrated with the DON for yelling at him/her and the resident yelled back; -If staff spoke calmly to Resident #1, he/she would speak calmly back to the staff. 5. During interview on 4/26/23 at 2:52 P.M., Certified Nurse Assistant (CNA) A said the DON raised her voice and talked down to the residents. During interview on 4/26/23 at 2:45 P.M., Laundry Staff B said the DON was loud and rude to the residents. The DON told residents to shut up if they were being loud. During interview on 4/26/23 at 3:30 P.M. and 5/4/23 at 1:40 P.M., LPN A said the following: -The DON was loud and boisterous; and was always rude to residents; -The DON talked down to the residents and would tell residents to shut up if they were being loud; -When residents were waiting to smoke or at the desk waiting for their medication, the DON would yell, Get out of here. We have had this discussion. Go back to your room!. During interview on 5/5/23 at 12:39 P.M., the acting administrator said based on his investigation, he felt the allegation of abuse was unsubstantiated. MO217920 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed follow their policies and procedures to report to the administrator and to conduct an investigation of staff to resident abuse for two residents (Residents #2 and #9) and implement interventions to protect residents from abuse at the facility. On 5/3/23, Resident #9 reported to staff the Director of Nursing (DON) yelled and screamed at him/her. On 5/4/23, Resident #2 reported the DON yelled at him/her. Staff did not report the allegations of abuse to the administrator, and the DON continued to work on 5/3/23 and 5/4/23. The facility census was 56. The administrator was notified of the Immediate Jeopardy (IJ) on 5/25/23 at 12:55 P.M. which began on 5/3/23. The IJ was removed on 5/25/23 as confirmed by surveyor onsite verification. Review of the facility's policy, Abuse and Neglect, dated 1/5/23, showed the following: -Verbal abuse - using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples include harassing a resident; mocking, insulting or ridiculing; yelling at a resident with the intent to intimidate; or threatening residents; -Mental abuse - the use of verbal or nonverbal conduct with causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. -Employees are required to immediately report any occurrences of potential mistreatment including alleged violations, mistreatment, neglect, or abuse they observe, hear about or suspect to a supervisor or the administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential mistreatment to a supervisor or the administrator or the compliance hotline. -The facility does not condone abuse by anyone. It is the responsibility of employees to promptly report any incident or suspected incident of abuse/neglect/misappropriation of funds to the facility management immediately. -Upon learning of the report of abuse or neglect, the administrator shall initiate an incident investigation. -The facility will take steps to prevent mistreatment while the investigation is underway. Employees who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by the administrator. If the alleged abuse is by the Administrator or the Director of Nursing, at the direction of the management Executive [NAME] President/Chief Operating Officer or the [NAME] President for Operations, the Administrator or DON may remain at the facility but are only permitted to be in non-resident areas or his/her office and should have no resident contact pending the outcome of the investigation. Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. 1. During interview on 5/3/23 at 3:14 P.M., Resident #9 said on 5/3/23 he/she was talking with Physical Therapy Assistant (PTA) E by the therapy area about how the DON overrides his/her physician orders. As the resident said the DON's name, the DON came around the corner (from the DON's office) and started yelling and screaming at the resident. The DON yelled, You need to come here and tell me what you said! The DON followed him/her down the hall and continued to yell this and the resident's name as she followed the resident. She followed the resident into the resident's room and then into the resident's bathroom. She continued to yell at the resident as the resident sat on the toilet to use the bathroom. The DON was not cursing, but she was yelling and screaming at the resident. This made the resident very upset and was so bad that the resident wanted to cut himself/herself. The resident reported this incident to the administrator in training (who no longer works at the facility), Laundry Staff D, and Dietary Staff G, who told him/her to call 'state.' During interviews on 5/4/23 at 10:26 A.M. and on 5/25/23 at 1:14 P.M., Laundry Staff D said he/she was walking down the hall yesterday morning (5/3/23) when he/she heard the resident talking to PTA E outside therapy. After he/she had walked past the resident, he/she heard the DON ask, What just came out of your mouth? It was the DON's tone of voice that caused him/her to turn around. The DON was always loud, but his/her tone was sharp. The resident walked away and did not say anything. The DON continued to yell the resident's name and say, What did you say? Do you have something to say? Since the resident ignored the DON, Laundry Staff D thought it was okay and he/she continued to laundry. Later, he/she saw the resident outside smoking. The resident was crying. The resident said the DON yelled at him/her, and he/she couldn't even go to the bathroom without the DON yelling and screaming at him/her. The resident was still crying at the 3:30 P.M. smoke break, and said he/she was tired of living this way with the DON always yelling. He/She reported the resident crying to the Client Services Liaison, but did not remember exactly what he/she reported. He/She told the resident to tell the interim administrator or the Client Services Liaison about what happened. He/She assumed the resident reported it since the resident walked toward their offices. During interviews on 5/4/23 at 11:15 A.M. and 1:48 A.M., the Client Services Liaison said he/she was not aware of any incident involving the resident and the DON. Staff should have reported when the resident said the DON yelled at him/her. No one reported this to him/her. During an interview on 5/4/23 at 10:32 A.M., Certified Medication Technician (CMT) K said the resident was crying and told him/her that the DON followed him/her into the bathroom and yelled at him/her. He/She did not report this to anyone. He/She would consider this abuse and should have reported it. During interview on 5/4/23 at 10:35 A.M. and 2:55 P.M., Dietary Staff G said during smoke break (on 5/3/23), the resident told him/her and Dietary Staff J that the DON was yelling at him/her as he/she went into his/her room and bathroom. The resident was crying and said he/she was so upset, he/she was going to cut his/her wrist. He/She did not report this to anyone, because the DON was always yelling. During interview on 5/25/23 at 1:40 P.M., Dietary Staff J said at smoke break (on 5/3/23), the resident was upset and told him/her that the DON was in his/her face yelling. He/She told the resident to report it. He/She did not report it, because he/she felt the resident could report it himself/herself. Review of a document provided by the facility showed the DON worked on 5/3/23 and on 5/4/23. Observations on 5/4/23 showed the DON was at the facility working and was out of his/her office in resident use areas. Review on 5/4/23 showed no evidence the facility investigated the allegation of abuse. 2. During interviews on 5/4/23 at 10:05 A.M. and 2:50 P.M., Resident #2 said last night (5/3/23), he/she didn't want the DON to do his/her treatment and he/she was upset the DON came into his/her room. He/She did not like the DON. He/She told the DON he/she didn't want her in his/her room and the DON kept doing the treatment. She got after him/her for pulling out the PICC (peripherally inserted central catheter; a thin, flexible tube inserted into a vein for intravenous therapy) line and he/she didn't. This made him/her feel terrible. The DON jumped on his/her case and told him/her no one wanted to be around him/her, he/she bothered people. The DON told him/her to shut up and not to say anything else. During an interview on 5/4/23 at 12:40 P.M., the Business Office Manager (BOM) said the resident had been refusing treatments all day (on 5/3/23) and finally agreed for the DON to empty his/her catheter bag around 4:30 P.M. and 5:00 P.M. When the DON asked the resident to put on a mask (due to isolation precautions related to infection), the resident immediately started cussing at the DON and was almost jumping out of his/her chair at her. The resident was so upset. The DON noticed the resident's PICC line wasn't in place, so she tried to look for it. The resident was cursing at the DON and she told him/her they had to find it since he/she was on a blood thinner. The resident's behaviors and cursing went on for approximately ten minutes. The BOM had never seen the resident act like this. The resident told the BOM that he/she did not like the DON. He did not hear the DON say anything rude/inappropriate to the resident, but he was more focused on how the resident was yelling at the DON. During interviews on 5/4/23 at 10:46 A.M. and 5/25/23 at 1:14 P.M., Laundry Staff D said first thing at breakfast on 5/4/23, the resident told him/her that the DON was 'smart' with him/her and yelled at him/her. The resident said the DON told him/her to stay away from people, because no one wanted him/her around. Laundry Staff D told the Client Services Liaison that the resident and the DON 'had words' and she (the Client Services Liaison) needed to talk to the resident. The Client Services Liaison was on her way to see the resident so he/she (Laundry Staff D) did not tell her any details. During interviews on 5/4/23 at 11:15 A.M. and 1:48 P.M., the Client Services Liaison said Laundry Staff D told her (on the morning of 5/4/23) that the resident was upset with the DON but did not tell her any specifics. She went to talk to the resident, and the resident said he/she did not like the DON and did not want her to talk to him/her, but the resident did not tell her why he/she felt this way. She gave the resident the corporate hotline number for him/her to call with his/her concerns, because the resident feels like he/she needs the highest person possible to listen to his/her concerns. The resident did not tell him/her about the incident involving the DON. Review on 5/4/23 showed no evidence the facility investigated the allegation of abuse. 3. During an interview on 5/4/23 at 12:39 P.M., the acting administrator said no one had reported any concerns with how the DON treated residents. He was not aware of the incidents involving Residents #2 and #9 until the state agency (SA) started the investigation on 5/4/23. During interview on 5/5/23 at 12:39 P.M., the acting administrator said no one had reported any concerns with how the DON treated residents. No one told him the DON yelled at Resident #9. He was not aware of this incident prior to 5/4/23. He did not feel the DON's actions were verbal or emotional abuse. Based on his investigation, he felt the allegation of abuse was unsubstantiated. During an interview on 5/25/23 at 6:30 P.M., the Administrator said she expected staff to report allegations of abuse to someone, everyone, until they see something happen. Staff cannot just tell their charge nurse regarding allegations of abuse. She had an open door policy, so staff can call her to report the allegations. (The administrator was out of the facility on leave at the time of the abuse.) NOTE: At the time of the recertification survey, the violation was determined to be at the immediate jeopardy level K. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to follow hospital discharge orders for two residents (Resident #1 and Resident #2) in a review of 19 residents. Resident #1 was admitted to the hospital on 12/29/22 with lithium (medication used for a mood stabilizer) toxicity which required hemodialysis (a treatment to filter wastes and water from your blood) to correct and high potassium levels and was discharged back to the facility with orders to discontinue lithium, haloperidol (used to treat certain mental/mood disorders such as schizophrenia, schizoaffective disorders), benztropine (used to treat tremors) and clonazepam (used for the acute management of panic disorders and seizure disorders). Hospital discharge orders also stated Austedo (used to treat a type of involuntary movements which is a side effect of antipsychotic medications) was to be held until follow up with psychiatry and lisinopril (used to treat high blood pressure) was to be held until follow up with his/her primary care physician; Start taking Olanzapine (used to treat schizophrenia) and Norvasc (used to treat high blood pressure). The facility continued to give the discontinued medication to the resident for seven days, gave medications that were to be held and did not start new medications. On 1/10/23 lithium lab values showed the resident was on the high end of the normal range. Resident #2 was taken to the hospital on 12/13/22 with altered mental status secondary to seizure activity and high potassium levels. He/She was discharged back to the facility on [DATE] with orders to discontinue potassium along with other medications. The facility continued to administer the discontinued medication to Resident #2 for five days. Resident #2 returned to the hospital on 12/19/22. He/She was unresponsive, had twitching movements and continued high potassium levels. The facility census was 52. The Administrator was notified on 1/11/23 at 4:30 P.M. of the Immediate Jeopardy (IJ), which began on 12/15/22. The IJ was removed on 1/13/23, as confirmed by surveyor onsite verification. Review of the facility Transcription of Orders/Following Physician's Orders policy, dated 7/9/21, showed the following: -The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. That a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be written on the Physician's Order Sheet; -The RCC/Unit Director/Licensed Practical Nurse (LPN)/Director of Nursing (DON)/designee will audit all physician's orders daily to ensure all new physician's orders are recapped and followed completely and accurately. On weekends, the Registered Nurse (RN) Supervisor will check all charts in the facility to ensure that all new orders received have been transcribed accurately and implemented; - The RCC/Unit Director/LPN/DON/RN Supervisor/designee will document the audit on the Daily Physician's Order Review Form, which will include initial of reviewer, date, and notation that the chart was checked. -Further review of the facility policy showed it was directed towards paper charting and not electronic charting that the facility now utilized. The policy did not address hospital discharge order verification. Review of the facility's Medication Administration and Monitoring policy, dated 9/17/21, showed the following: -The purpose is to ensure a process is in place for proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects to medications. To provide guidelines and systems for following procedures for medication errors including defining a medication error and the levels of medication errors. To ensure therapeutic guidelines are monitored in drugs that require laboratory and diagnostic studies; -Medications are to be given per physician's orders. 1. Review of the Resident #1's face sheet showed the following: -The resident had diagnoses that included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), extrapyramidal and movement disorder (involuntary or uncontrollable movements. tremors. muscle contractions), and chronic kidney disease (gradual loss of kidney function). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 9/26/22, showed the following: -The resident's cognition was intact; -The resident did not have any impairment to upper or lower extremities; -The resident was independent with transfers, ambulation, dressing, eating, bathing and toileting; -The resident had clear speech. Review of the resident's care plan, revised on 10/26/22, showed the following: -The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance or cognitive/behavioral impairment; -Administer psychotropic medication as ordered by the physician; -Monitor for side effects and effectiveness every shift; -Monitor, document and report as needed any adverse reactions of psychotropic medications; unsteady gait, tardive dyskinesia (a movement disorder characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person; -The resident will maintain current level of function through the review date; -Monitor, document and report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course and decline in function; -The resident is at risk for decreased cardiac output and impaired activity tolerance related to his/her diagnosis of hypertension (high blood pressure); -Give anti-hypertensive medication as ordered; -Obtain blood pressure reading prior to giving anti-hypertensive medications. Review of the resident's physician progress note, dated 12/27/22, showed the following: -The resident's complaint for being seen was increased tremors; -Staff reported increased tremors; -Tremors are not debilitating; -Start taking Austedo 6 mg give one tablet every day; -Continue to monitor and assess the resident for health status changes, contact the physician with any changes. Review of the resident's December 2022, medication administration record MAR showed the resident was given Austedo 6 mg on 12/29/22 at 7:00 A.M. and then went to the hospital later that day. Review of the resident's progress notes, dated 12/29/22 at 6:57 A.M., showed the following: -The resident mumbled his/her words; -The resident needed help getting dressed. Review of the resident's progress notes, dated 12/29/22 at 8:58 A.M., showed the following: -A certified nurse aide (CNA) noted the resident on his/her knees trying to get into bed; -The resident had altered mental status; -The resident's speech was unclear; -The resident was very diaphoretic (sweating heavily), his/her hair was completely wet along with his/her shirt; -The nurse called 911 and the resident left the facility by ambulance. Review of the resident's emergency room (ER) records, dated 12/29/22, showed the following: -The resident arrived to the ER with altered mental status; -The resident's heart rate was 42 beats per minute (normal range 60-100); -A dopamine infusion (used to treat the symptoms of low blood pressure and low cardiac output and improves blood flow to the kidneys) was started; -The resident had to have emergent hemodialysis due to lithium toxicity; -The resident was admitted to the intensive care unit. Review of the hospital laboratory records, dated 12/29/22 at 10:30 P.M., showed the resident's lithium level was 2.3 and was critically high. Review of the resident's hospital records, dated 12/30/22, showed the following: -The resident was bradycardic (slow heart rate), likely due to renal insufficiency and drug effects; -The resident continued on the dopamine infusion and hemodialysis; -The resident's lithium level had normalized. Review of the hospital laboratory records, dated 12/30/22 at 7:24 P.M., showed the residents lithium level was 0.8. Review of the resident's telepsychiatry visit, dated 1/4/23, while at the hospital showed the following: -Continue with trazadone (antidepressant) 75 mg every night at bedtime; -Discontinue lithium, haloperidol, and benztropine; -The resident will need to follow up with his/her outpatient psychiatrist. Review of the resident's hospital course/pertinent physical findings, dated 1/4/23, showed the following: -The resident's renal function had improved; -After emergent hemodialysis lithium levels have been 0.8 with normal range 1.0 - 1.2; -The resident's mentation had improved, he/she was at baseline; -On this date the resident felt well and had no complaints. Review of the hospital discharge orders, dated 1/4/23, showed the following: -STOP taking the following medications: --Haloperidol (antipsychotic medication) 10 mg oral tablet; one tablet orally once a day at bedtime, --Benztropine (used to treat tremors) 1 mg oral tablet two times a day; --Clonazepam (used to treat or prevent seizures and reduce anxiety) 0.5 mg oral tablet; take one tablet orally once a day in the evening; --Lithium carbonate (used to treat manic episodes of bipolar disorder) 300 mg orally two times a day; -These medications are CHANGED: -- Austedo (used to treat a type of involuntary movements which is a side effect of antipsychotic medications) 6 mg oral tablet once a day. HOLD until follow up with psychiatry, --Lisinopril used to treat high blood pressure) 20 mg oral tablet orally once a day HOLD until follow up with primary care physician; -Start taking the following NEW medications: --Olanzapine (antipsychotic used to treat schizophrenia) 5 mg oral tablet two times a day --Norvasc (used to treat high blood pressure) 2.5 mg oral tablet once a day. Review of the resident's progress notes, dated 1/5/23 at 3:29 P.M., showed the following: -The resident arrived to the facility by the facility van; -Lab values are back to normal at this time. Review of the resident's Physician Order Sheet (POS) from 1/5/23 to 1/11/23 showed the following: -Austedo (used to treat a type of involuntary movements which is a side effect of antipsychotic medications) tablet 6 milligrams (mg), give one tablet by mouth one time a day related to extrapyramidal and movement disorder. Order date: 12/28/22; -Benztropine (used to treat tremors) tablet 1 mg, give one tablet by mouth two times a day for anxiety. Order date: 10/20/22; -Clonazapam (used to treat or prevent seizures and reduce anxiety) tablet 0.5 mg, give one tablet by mouth in the evening for anxiety disorder. Order date: 10/20/22; -Haloperidol (antipsychotic medication) tablet 10 mg, give one tablet by mouth at bedtime related to schizophrenia. Order date: 10/20/22; -Lisinopril (used to treat high blood pressure) tablet 20 mg, give 20 mg by mouth one time a day related to essential hypertension. Order date: 12/09/22; -Lithium carbonate (used to treat manic episodes of bipolar disorder) capsule 300 mg, give one capsule by mouth two times a day related to bipolar disorder. Order date: 10/20/22; -Norvasc (used to treat high blood pressure) tablet 2.5 mg, give one tablet by mouth one time a day related to essential hypertension. Order date: 1/11/23; -Olanzapine (antipsychotic used to treat schizophrenia) tablet 5 mg, give one tablet by mouth two times a day related to schizophrenia. Order date: 1/11/23. Review of the resident's progress notes, dated 1/5/23 at 11:16 P.M., showed the following: -The resident did not seem to be at baseline mentation, he/she seemed confused at times and had to be reoriented; -A message was left with the facility's physician's office questioning them if the resident's lithium should be discontinued, but did not hear back from them. Will inform the morning staff to follow up. There was no documentation found in the resident's record for January 2023 to show staff followed up on the resident's lithium order with the facility physician. Review of the resident's medication administration record (MAR), dated 1/5/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed staff administered the medication at 8:00 P.M.; -Benztropine 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Norvasc and Olanzapine were not on the MAR to be administered. Review of the resident's MAR, dated 1/6/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed staff administered the medication at 800 P. MM.; -Benztropinee 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lisinopril 20 mg, give 20 mg by mouth one time a day related to hypertension (high blood pressure). Start date 12/10/22, the MAR showed staff administered the medication at 8:00 A.M.; -Norvasc and Olanzapine were not on the MAR to be administered. Review of the resident's progress notes, dated 1/6/23 at 2:21 P.M., showed the following: -The resident noted to be confused since admission; -Needs attended to; -Will continue to monitor. Review of the resident progress notes, dated 1/6/23 at 2:23 P.M., showed the following: -Called the on call clinic regarding lithium, if the resident is still to continue and still waiting for any orders; -Long Term Psych Management (LTPM) informed regarding lithium medication. The resident is included for tomorrow's tele psych visit. Review of the resident's MAR, dated 1/7/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed staff administered the medication at 8:00 P.M.; -Benztropine 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lisinopril 20 mg, give 20 mg by mouth one time a day related to hypertension (high blood pressure). Start date 12/10/22, the MAR showed staff administered the medication at 8:00 A.M.; -Norvasc and Olanzapine were not on the MAR to be administered. Review of the resident's MAR, dated 1/8/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00P. MM; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed staff administered the medication at 8:00 P.M.; -Benztropine 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Austedo 6 mg tablet, give one tablet by mouth one time a day for movement disorder. Start dated 12/29/22, the MAR showed staff administered the medication at 7:00 A.M.; -Lisinopril 20 mg, give 20 mg by mouth one time a day related to hypertension (high blood pressure). Start date 12/10/22, the MAR showed staff administered the medication at 8:00 A.M.; -Norvasc and Olanzapine were not on the MAR to be administered. Review of the resident's MAR, dated 1/9/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed staff administered the medication at 8:00 P.M.; -Benztropinee 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Austedo 6 mg tablet, give one tablet by mouth one time a day for movement disorder. Start dated 12/29/22, the MAR showed staff administered the medication at 7:00 A.M.; -Lisinopril 20 mg, give 20 mg by mouth one time a day related to hypertension (high blood pressure). Start date 12/10/22, the MAR showed staff administered the medication at 8:00 A.M.; -Norvasc and Olanzapine were not on the MAR to be administered. Review of the resident's laboratory results, dated 1/10/23, showed his/her lithium level was 1.2, which is the high end of the normal therapeutic range of 1.0 - 1.2. Review of the resident's MAR, dated 1/10/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M.; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed staff administered the medication at 8:00 P.M.; -Benztropine 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M.; -Lisinopril 20 mg, give 20 mg by mouth one time a day related to hypertension (high blood pressure). Start date 12/10/22, the MAR showed staff administered the medication at 8:00 A.M.; -Norvasc and Olanzapine were not on the MAR to be administered. -Austedo was not administered on this date. The MAR showed 9 in the box to be checked if given. 9 = Other/See Progress Notes. Review of the resident's progress notes showed no evidence of documentation regarding the missed dose of Austedo on 1/10/23. Review of the resident's MAR, dated 1/11/23, showed the following: -Clonazepam 0.5 mg tablet, give one tablet by mouth in the evening for anxiety disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 4:00 P.M. and discontinued the medication at 5:51 P.M.; -Haloperidol 10 mg tablet, give one tablet by mouth at bedtime related to schizophrenia. Start date was 10/20/22, the MAR showed the medication was discontinued at 5:49 P.M.; -Benztropine 1 mg tablet, give one tablet by mouth two times a day for anxiety. Start date was 10/21/22, the MAR showed the medication was administered at 7:00 A.M. and 4:00 P.M. and discontinued at 5:50 P.M.; -Lithium carbonate 300 mg capsule, give one capsule by mouth two times a day related to bipolar disorder. Start date was 10/21/22, the MAR showed staff administered the medication at 7:00 A.M. and 4:00 P.M. and discontinued it at 5:11 P.M.; -Austedo 6 mg tablet, give one tablet by mouth one time a day for movement disorder. Start dated 12/29/22, the MAR showed the medication was was not given at 7:00 A.M. and was discontinued at 5:55 P.M.; -Lisinopril 20 mg, give 20 mg by mouth one time a day related to hypertension (high blood pressure). Start date 12/10/22, the MAR showed staff gave the medication at 8:00 A.M. and put the medication on HOLD at 5:56 P.M. until 1/17/23; -Norvasc and Olanzapine were not on the MAR to be administered. Review of the resident's progress notes from 1/7/23 through 1/11/23 showed no documentation regarding the resident's confusion, lithium orders, or tele psych visit. During an interview on 1/11/23 at 1:00 P.M., Activity Aide A said Resident #1's speech had gotten worse and he/she was harder to understand lately. During an interview on 1/11/23 at 1:08 P.M. Nurse Assistant B said the resident was totally independent before he/she got sick and went to the hospital. During observation and interview on 1/11/23 at 6:19 P.M., Resident #1 said the following: -He/She felt stronger at the hospital before he/she was discharged back to the facility; -He/She was feeling weak again since he/she has been back to the facility and sometimes had to use the wheelchair to help him/her get around. -During an interview, the resident's speech was slurred and he/she was moderately difficult to understand. Review of the resident's progress notes, dated 1/12/23, showed the following: -The resident was seen by Long Term Psych Management (LTPM) via tele health with orders to start a new medication. There was no documentation that showed anything regarding the orders for medications upon discharge from the hospital; -There was no documentation that showed the resident's medications were verified with the physician. Review of the resident's January 2023 progress notes and physician order sheet showed no evidence the facility documented the staff clarified the medication orders with the physician. During an interview on 1/11/23 at 11:56 A.M., Medical Records Staff E said the following: -He/She only got three pages of records from the hospital when the resident was discharged ; -He/She did not have a copy of hospital discharge records. During an interview on 1/11/23 at 3:19 P.M., LPN C said the following: -He/She started the admission of the resident and did not have paper orders; -The orders that came from the hospital were three pieces of paper, but they didn't have medication orders on them; -He/She got report from the hospital nurse who told LPN C there were no new orders; -He/She asked the hospital nurse again about orders and the nurse told him/her there were no new orders and the resident was going back to the facility on medications he/she had been on; -He/She put all the medications back on the resident's MAR that he/she was on before going to the hospital; -Usually the hospital sent paper orders to the facility for the residents. During an interview on 1/11/23 at 2:05 P.M., the Director of Nursing said the following: -Prior to the resident going to the hospital, he/she had tremors and had gotten weaker and did not want to stand; -He/She had to start using a wheelchair before going to the hospital; -The physician's office said to refer to the LTPM for lithium orders; -The LTPM psychiatric physician called and said they were sick and wouldn't be able to see the resident on 1/7/23; -The DON did not make a follow up call to LTPM to get another appointment scheduled for the resident, because she thought they would call back to make an appointment. During an interview on 1/11/23 at 11:56 A.M., 1:32 P.M. and 4:33 P.M., the administrator said the following: -She remembered the facility admitting nurse got verbal report from the hospital and there were no changes to the resident's medication; -She had to retrieve the hospital discharge records from the off-site customer service coordinator (she printed them to bring to the surveyor for review); -The facility did not have a system in place for a second staff member to check new orders or discharge orders from a hospital; -She was not aware the resident should not be taking lithium or that there were other medication's the resident had discontinued at the hospital; -She was not aware there were other medications that were supposed to be on hold until the resident was seen by his/her psychiatrist and primary care physician; -She would make changes to the resident's chart to reflect the orders from the hospital. 2. Review of Resident #2's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -No rejection of care; -Diagnoses of diabetes, depression, manic depression, and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing); -Received a diuretic (causes increased passing of urine) daily. Review of the resident's care plan, revised 12/7/22, showed the following: -Per the Preadmission Screening and Resident Review (PASRR) the resident suffers long history of mild mental retardation, depressive disorder, impulse control, post traumatic stress disorder (PTSD), anxiety and bipolar disorder; -Symptoms include delusions, confusion, crying spells, visual hallucinations and depressive symptoms; -Follow up with physician and psych as needed; -Medication provided as prescribed. Review of the resident's progress notes, dated 12/13/22 at 1:55 P.M., showed the following: -Saw resident's upper extremities twitching and disorientation since this morning with following vital signs: temperature 97.2 (normal is 98.6), blood pressure 100/60 (normal is 120/80), respirations 21 (normal is 12 to 16 at rest), pulse rate 108 (normal is 60 to 100 at rest), oxygen saturation 91% (normal is 95% to 100%), and blood sugar 308 (normal is 60 to 120); -Sent out at about 2:09 P.M. to hospital via EMS (emergency medical services). Review of the resident's hospital records, dated 12/13/22 through 12/15/22, showed the following: -The resident's potassium level on 12/13/22 at 3:15 P.M. was 5.5 (high, normal range is 3.6 to 5.2. Levels greater than 5.5, left untreated, can lead to fatal abnormal heart rhythms); -The resident's potassium level on 12/14/22 at 5:07 A.M. was 4.5; -The resident's potassium level on 12/15/22 at 4:54 A.M. was 5.3 (high); -The resident's potassium level on 12/15/22 at 8:56 A.M. was 5.1. Review of the resident's hospital physician note, dated 12/15/22, showed the following: -The resident had a primary medical history of congestive heart failure (CHF), COPD, seizure disorder, hypertension, diabetes and bipolar disorder who was admitted with altered mental status suspected to be secondary to seizure activity; -During hospitalization he/she was noted to have high potassium levels; -Discontinue the potassium supplement at discharge; -Resident was consulted to the psychiatry service with recommendation to discontinue lorazepam (anti-anxiety medication). Review of the resident's hospital discharge orders, dated 12/15/22, showed the following: -Stop taking the following medication: -- Ibuprofen (pain medication) 200 mg oral tablet: two tabs orally every 6 hours as needed with food; --Levetiracetam (seizure medication) 250 mg oral tablet: one tab orally two times a day; --Lorazapam 0.5 mg oral tablet: one tab orally two times a day; --Potassium chloride (supplement) 20 milliequivalents (mEq) oral tablet, extended release (ER): one tab orally once a day; -These records were found in the resident's facility EHR (electronic health record) under the miscellaneous tab. Review of the resident's progress notes, dated 12/15/22 at 6:34 P.M., showed the resident returned at 3:50 P.M. via Emergency Medical Service (EMS) from the hospital with diagnosis of altered mental status and seizure. Review of the resident's December 2022 physician's orders showed the following: -Ibuprofen 200 mg give two tablets by mouth every 6 hours as needed for pain start 10/7/22; -Levetiracetam 250 mg tablets give one tablet by mouth two times a day start 10/7/22; -Lorazepam 0.5 mg tablet give one tablet by mouth two times a day start date 10/7/22; -Potassium chloride 20 mEq give one tablet once daily start date 10/8/22. Review of the resident's December 2022 MAR showed the following: -Staff documented the resident received potassium chloride ER 20 mEq by mouth once daily from 12/15/22 through 12/19/22; -Staff documented the resident received lorazepam 0.5 mg by mouth two times daily from 12/15/22 through 12/19/22; -Staff documented the resident received levetiracetam 250 mg by mouth twice daily from 12/15/22 through 12/19/22. Review of the resident's progress notes, dated 12/19/22 at 6:03 P.M., showed the following: -Resident unresponsive and noted to have twitching movements to extremities at approximately 5:00 P.M.; -Able to arouse with verbal stimuli without coherent responses; -Unable to answer questions; -Unable to open eyes; -No grip to bilateral upper extremities or pedal pushes; -Sweat noted to hair; -Skin damp and clammy to touch; -Vitals signs: temperature 96.5, respirations 20, pulse 97, blood pressure 87/44, oxygen saturation 95% on 2 liters per minutes/nasal cannula. Blood glucose 195; -Call placed to physician with orders to send to emergency room (ER) for further treatment and evaluation; -Ambulance pick up and transfer to ER at approximately 5:40 P.M. Review of the resident's hospital physician progress note, dated 12/19/22 at 6:33 P.M., showed the following: -Resident with acute kidney injury, hyperkalemia (high potassium levels), hyponatremia (low sodium levels), creatine kinase (CK total) (measures the amount of creatine kinase in the blood. Elevated CK levels may indicate skeletal muscle, heart or brain damage or degeneration-either chronic or acute) ordered; -3 liter saline bolus (one of the most commonly used IV fluids used for most hydration needs) ordered, insulin (hormone used to treat diabetes), dextrose (a sterile solution used to provide the body with extra water and carbohydrates), sodium bicarbonate (a medication primarily used to treat severe metabolic acidosis (buildup of acid in the body due to kidney disease or kidney failure)), albuterol (medication used to prevent and treat wheezing and shortness of breath caused by breathing problems) ordered. This is for reduction of hyperkalemia; -Resident's altered mental status may be secondary to uremic encephalopathy (progressive dysfunction

Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) from sexual abuse by another resident (Resident #2). Resident #2 had a history of sexually inappropriate behavior, and was off the secured, locked unit, unsupervised. Resident #2 walked into the dining room where Resident #1 was seated and exposed his/her genitalia to Resident #1. Resident #2 then touched Resident #1's leg and genital area over the top of his/her clothing. Resident #2 then asked to touch Resident #1's breasts. Resident #1 said he/she had a history of sexual abuse as a child and cried for days following the event. A sample of seven residents was selected for review. The facility census was 51. On 10/25/22 at 4:16 P.M., the facility's acting administrator was notified of the immediate jeopardy which occurred on 10/19/22. Resident #2 was discharged from the facility on 10/19/22. On 10/25/22 management staff began in-servicing all staff and residents on the secured unit of the expectation residents on the secured unit were not to leave the unit unaccompanied or be off the unit unmonitored at any time. Staff also received in-service education on the facility's abuse and neglect policy. The IJ was removed on 10/26/22. Review of the facility's abuse and neglect policy, dated 9/17/21, showed: -Sexual abuse is non-consensual contact of any type with a resident; -Sexual abuse includes but is not limited to the following: Unwanted intimate touching of any kind, especially of breasts and perineal area and forced observation of masturbation and/or pornography. 1. Review of Resident #2's Pre Admission Screening and Resident Review (PASARR), dated 1/21/16, showed: -Diagnoses included mood disorder, impulse control disorder, major depressive disorder, and personality change secondary to brain injury in 2010; -The resident had problems with depression, agitation, and had several hospitalization s since 2010; -The resident had severely impaired insight and judgement; -The resident's current condition and symptoms included agitation, irritability, anxiety, depression, attention seeking behaviors, and sexually inappropriate behaviors; -The resident would benefit from the care of a secured nursing facility. Review of Resident #2's care plan, dated 10/3/22, showed: -admitted [DATE]; -Per the PASARR, the resident had a history of behavioral challenges that require protective oversight in a secured setting; -Diagnoses include mood disorder, impulse control disorder, personality change due to a brain injury, poor judgement, and poor decision making; -The resident required medication and behavior monitoring and placement in a structured, secured, skilled nursing facility; -Follow up with the physician and psychiatrist as needed; -Pharmaceutical interventions and one on one interventions as needed; -The resident was highly functional and able to complete his/her own activities of daily living with supervision and cues; -The resident displayed behavioral problems related to restlessness and agitation and at times became angry and displayed verbal and physical aggression towards staff and others; -Intervene as necessary to protect the rights and safety of others. Approach in a calm manner and divert attention; -The resident displayed impaired thought processes related to a diagnosis of developmental delay. The resident had difficulty making decisions related to a head injury. The resident violates covenant guidelines, liked to trade favors for other things (claims others have sex with him/her for trades such as marijuana for sex and he/she did not receive the marijuana); -Ask yes/ no questions; -Cue, reorient, and supervise as needed; -Discuss concerns with the resident; -Administer medications as prescribed and monitor for effectiveness. Review of Resident #1's care plan, dated 10/2/22, showed: -Diagnoses included diabetes, heart failure, major depressive disorder, anxiety, bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), mild intellectual disabilities, and muscle weakness; -The resident was at risk for delusional thought processes and inappropriate behaviors related to diagnoses of bipolar disorder and anxiety; -The resident had a history of audible hallucinations and delusions. The resident often fabricated stories about peers having sexual behaviors. The resident had delusional thinking about his/her family coming to visit and stated he/she can hear them but can't see them. The resident becomes angry at staff; -Ensure the safety of resident and others; -Establish boundaries and limits; -Monitor for cognitive factors that may contribute to behaviors or delusions; -Provide redirection as needed; -The resident was at risk for increased depression and self-social isolation related to a diagnosis of major depression; -Follow up with the physician and psychiatrist as needed; -Provide medication as ordered; -Monitor for increased depression; -Monitor for self-social isolation; -The resident had self-care deficits and required assistance with activities of daily living. Review of Resident #2's nurse's notes, showed: -On 10/3/22 at 11:13 P.M., the resident was calm but with manipulative behaviors noted and sexual behavior noted; -On 10/4/22 at 11:17 P.M., the resident was independent with activities of daily living and walking. Sexual behavior towards female staff noted but redirected. Review of Resident #2's care plan, updated 10/5/22, showed: -The resident had inappropriate sexual behaviors. The resident made inappropriate comments and touched female staff; -Educate to appropriate and inappropriate behaviors as needed; -Guardian to be notified as needed; -Monitor for inappropriate behaviors and redirect as needed. Review of Resident #2's nurse's notes showed: -On 10/7/22 at 3:54 P.M., while a female staff member was on the secured unit putting clothes away, the resident attempted to grab the staff member's breasts. The female staff member was able to jump back but the resident did touch his/her left breast. The resident was told by the staff member to stop and not to touch him/her again in that manner. The resident looked at the staff member and said What are you going to do about it? The resident continued to follow the staff member around and tried to grab the staff member's buttocks. The staff member took the laundry cart and left the secured unit. During an interview on 10/25/22 at 12:18 P.M., the housekeeping supervisor said Resident #2 was always flirting, trying to touch him/her, and talking about his/her breasts since his/her admission to the facility. The housekeeping supervisor took clothes into Resident #2's room a couple of weeks prior. Resident #2 whispered in the housekeeping supervisor's ear that he/she wanted to talk with him/her. Resident #2 followed the housekeeping supervisor into the hallway and jumped in front of him/her and said I just want to talk to you, [NAME]. Resident #2 then reached out and tried to touch the housekeeping supervisor's breasts. The housekeeping supervisor was able to jump out of the way. Resident #2 then tried to grab the housekeeping supervisor's buttocks. Resident #2 did not make contact with his/her buttocks but did manage to grab his/her breast at that point. The housekeeping supervisor went straight to the administrator and reported what happened. The administrator brought Resident #2 to the office and spoke with him/her. Resident #2 had made inappropriate comments to other staff prior to this incident and continued to make inappropriate comments after this incident. Review of Resident #2's nurse's notes showed: -On 10/11/22 at 11:46 A.M., the resident was seen by the physician with new orders to start Depo Provera (a hormone-suppressing drug which lowers testosterone levels, thereby decreasing sex drive) 150 milligram injection monthly; -On 10/19/22 at 11:33 A.M., the resident was in the main dining room talking to another resident (Resident #1). Resident #2 began to rub the other resident's leg over his/her clothing, according to both residents involved. When Resident #2 began to touch the other resident it became inappropriate and the other resident did not want Resident #2 to touch him/her. Review of the facility's investigation, dated 10/23/22, showed the following: -On 10/19/22, there was an allegation of abuse involving Resident #1 and Resident #2; -Resident #1 said Resident #2 touched him/her inappropriately over his/her clothing while Resident #1 was in the dining room; -Resident #1 said there was no one there to witness the incident; -Resident #1 reported the incident to the therapist, who immediately reported to management; -Resident #1 was offered support and security away from Resident #2; -An in-service completed 10/19/22 to all staff that residents on the step down (secured, locked unit) must be accompanied by staff when out of the unit. During an interview on 10/25/22 at 9:28 A.M., Resident #1 said he/she cried for several days and was not happy in the facility because he/she was upset about the incident with Resident #2. Resident #1 was in the dining room when Resident #2 (of the opposite gender) sat down next to him/her. Resident #2 told Resident #1 he/she was gorgeous. Resident #2 then exposed his/her genitals to Resident #1. Resident #2 touched Resident #1's genitals over his/her clothing. Resident #1 said he/she was very uncomfortable. Resident #2 asked Resident #1 if he/she could touch Resident #1's breasts and Resident #1 said no. Resident #1 said there was no one else in the dining room at this time. Resident #2 continued to sit at the table and talked to Resident #1. A staff member came by and told Resident #2 he/she needed to go back to the unit but Resident #2 continued to sit there. The staff member had to tell Resident #2 several times to come on, you have to go back. Resident #2 finally got up when the staff member came towards him/her. Resident #1 said he/she was upset and scared about the incident and he/she reported it to a staff member. Resident #1 said he/she was sexually abused as a child. Resident #1 said he/she is afraid this situation will occur again with a different resident. During an interview on 10/25/22 at 2:16 P.M., Hall Monitor C said he/she let Resident #2 off the unit to go to vending when the incident occurred with Resident #1. Hall Monitor C did not accompany Resident #2 to the dining room because staff were not doing so at that time. Resident #2 was always making sexual comments to staff, saying things like you're so sexy etc. During an interview on 10/25/22 at 2:02 P.M., the dietary manager said he/she saw Resident #1 and Resident #2 in the main dining room. Resident #1 was painting his/her fingernails at a table and Resident #2 sat next to him/her. The dietary manager did not observe any physical contact between the two at that point. The dietary manager asked Resident #2 what he/she was doing in the dining room. Resident #2 said he/she was getting his/her sunglasses and he/she had come off the unit to use the vending machine. The dietary manager walked Resident #2 back to the secured unit. Resident #1 did not say anything to the dietary manager about what happened. Resident #2 had never said anything inappropriate to the dietary manager but the dietary manager had heard Resident #2 made inappropriate comments to other staff. During an interview on 10/25/22 at 10:08 A.M., the therapy director said he/she saw Resident #1 sitting alone in the main dining room. The therapy director went to get Resident #1 for therapy. Resident #1 told the therapy director there was another resident who had been in the dining room and grabbed me down there. The therapy director asked Resident #1 to describe the resident and Resident #1 described Resident #2. Resident #1 said Resident #2 also exposed his/her genitalia and asked to touch Resident #1's breasts. The therapy director immediately reported this to a management staff person. The therapy director brought Resident #1 to the manager's office and Resident #1 described the incident to the management staff. The therapy director said Resident #2 had been doing some cat calling to some of the female staff members. The therapy director did not feel Resident #2 did well around people of the opposite sex. Resident #2 was very impulsive. The therapy director thought Resident #2 had left the secured unit for the coffee club group or to go to vending when the incident occurred with Resident #1. Resident #2 was discharged from the facility the same day as the incident. During an interview on 10/25/22 at 9:47 A.M., Hall Monitor B said residents on the unit could walk to the vending machines, which were off the unit in the main dining room, daily at 10:30 A.M. and 3:00 P.M. Hall Monitor B holds the unit door open for the residents and would ask another staff member, not working on the unit, to walk with them. Usually a Certified Nurse Aide (CNA) or a nurse would walk with the resident. Residents were not supposed to be off the unit unattended. Coffee club was held every weekday morning in the main dining room. One of the chaplains escorts the residents. During an interview on 10/25/22 at 1:00 P.M., Chaplain A said he/she did the coffee club group in the mornings Monday through Thursday. They go to the main dining room. Chaplain A said he/she walked with the residents to and from the secured unit. During an interview on 10/25/22 at 1:30 P.M., the Corporate Licensed Practical Nurse (LPN) D said it was the expectation that residents on the secured unit would be monitored by staff at all times when they were off the secured unit. During an interview on 10/25/22 at 1:35 P.M., the Client Services Liaison said the expectation was for the aide on the locked unit to get another staff member to accompany residents off the unit to vending or group activities and then escort them back to the unit. Residents from the locked unit should be monitored by staff at all times when off the locked unit. During an interview on 10/25/22 at 1:40 P.M., the acting administrator said it was the expectation that staff would monitor residents from the locked unit at all times when the residents left the locked unit. MO208698 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure one resident (Resident #2), was free from a significant medication error. The resident had an order, dated 9/6/22, for Invega Sustenna (antipsychotic) 234 milligrams (mg)/ 1.5 milliliters (ml), injected intramuscularly (IM) every 28 days. Staff administered the injection to the resident on day shift on 9/6/22. Staff administered the injection a second time to the resident on night shift on 9/6/22 and a third time on day shift on 9/7/22. Staff identified the error on 9/8/22. The resident developed low blood pressure on 9/9/22 and was sent to the emergency room for evaluation and treatment where he/she was diagnosed with a drug overdose of Invega. A sample of 12 residents was selected for review. The facility census was 43. On 9/22/22 at 11:25 A.M. the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 9/6/22. On 9/9/22 the administrator identified the significant medication error. Upon discovery, facility placed the resident on intensive monitoring. All residents' injection orders were reviewed and ensured all orders were correctly entered in the electronic medication administration system. An injection calendar was created for all residents receiving injections. Licensed nurses were in-serviced on how to correctly enter orders in the electronic system and on the medication administration policies and procedures. The nurse 24 hour report sheet was updated to include a section for any injections administered to ensure proper communication between shifts. The IJ was removed and corrected on 9/9/22. Review of the facility's policy Transcription of Orders/Following Physician's Orders, revised 7/9/21, showed the following: -Upon receiving a physician's order it will be written on the physician's order sheet (POS); -The purpose of the policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physician' orders are followed and that a process is in place to monitor nurses in accurately transcribing and following physicians' orders; -All treatment orders are to be transcribed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR); -Any new orders that are noted on the POS are to be documented in the nurse's notes and noted on the 24 hour report sheet; -The Resident Care Coordinator (RCC), Unit Director, Licensed Practical Nurse (LPN), Director of Nursing (DON), or designee will audit all physician's orders daily to ensure all new physician's orders are recapped and followed completely and accurately. On weekends, the Registered Nurse (RN) Supervisor will check all charts in the facility to ensure all new orders received have been transcribed accurately and implemented; -The RCC, Unit Director, LPN, DON, RN Supervisor, or designee will document the audit on the Daily Physician's Order Review Form, which will include initial of reviewer, date, and notation that the chart was checked; -The RCC, Unit Director, or designated nurse will review all MAR's and TAR's daily to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. 1. Review of Resident #2's face sheet showed the following: -Original admitted [DATE]; -Diagnoses included schizophrenia, major depressive disorder, anxiety, and history of traumatic brain injury. Review of the resident's care plan, revised 4/5/22, showed the following: -The resident had a diagnosis of schizophrenia; -Administer medications as ordered and monitor/document for side effects and effectiveness. Review of the resident's Physician Order Sheet (POS) for September 2022 showed Invega Sustenna 234 mg/1.5 ml. Inject 234 mg IM every 28 days (order date 9/6/22). Review of the resident's Medication Administration Record (MAR) for September 2022 showed the following: -On 9/6/22 (day shift) staff administered the Invega 234 mg injection to the resident; -On 9/6/22 (night shift) staff administered the Invega 234 mg injection to the resident; -On 9/7/22 (day shift) staff administered the Invega 234 mg injection to the resident. Review of the resident's nurse's note, dated 9/8/22 at 7:09 P.M., showed during shift change report, the off going nurse said the Invega injection that this nurse reported giving to the resident, he/she had given as well. This nurse questioned how he/she also gave the injection and he/she said it appeared on the medications to give in the electronic MAR. The resident was assessed and stable at that time. The resident's physician was notified of the medication error and orders to monitor for changes in mental status received. Long term psychiatric management notified and again orders to monitor for changes received. Neurological checks were started. Administrator and management made aware. Review of the facility's investigation, dated 9/9/22, showed the following: -Date and time notified: 9/9/22 at 5:30 P.M.; -On 9/9/22 the Regional Specialist was notified the resident had received three doses of Invega injection this week. The administrator reported that on 9/6/22 the resident received the first Invega injection on day shift per Licensed Practical Nurse (LPN) B, as it showed up on the Medication Administration Record to administer. On 9/7/22 LPN D told LPN C that he/she administered the injection as it came due. LPN C then said he/she administered the injection as well on 9/6/22 on night shift; -Upon investigation all three LPN's had administered the Invega Sustenna 234 mg to the resident in two days; -The primary physician and the long term psychiatric nurse practitioner were notified immediately; -The resident was placed on immediate intensive monitoring with neurological checks completed every 15 minutes for close observation; -On 9/9/22, LPN B notified the Director of Nurses (DON) the resident's blood pressure was 96/46 millimeters of mercury (mmHg, normal blood pressure is 120/80 mmHg). The resident was immediately sent to emergency room for evaluation and treatment; -The resident returned to the facility with no adverse reactions and returned to intensive monitoring every 15 minutes; -Upon investigating, the resident's initial order for the Invega was placed under the treatment tab in the electronic records system and was noted for time and frequency as other (which placed the order to be given each shift daily), thus the reason for it to show up on each shift for the nurses to administer; -In conclusion, it was determined this was an error on inputting the medication in the orders. Review of the resident's emergency room Discharge Instructions, dated 9/9/22, showed the resident was diagnosis of an accidental medication overdose. During an interview on 9/21/22 at 6:54 A.M. LPN B said on 9/6/22 the Invega injection came up on the resident's MAR for administration. The injection was to be administered every 28 days. LPN B was off for a couple of days and when he/she returned to work he/she was told the resident was sent to the hospital because he/she had been given three injections of Invega. The Invega order was not transcribed in the electronic computer system correctly which caused the Invega order to come up as being due for administration every shift. During an interview on 9/23/22 at 7:30 A.M. LPN C said he/she administered the resident's Invega injection on 9/6/22 on the night shift (7:00 P.M. to 7:00 A.M.). LPN C was not aware the resident had already received the Invega injection previously on day shift. The day shift LPN did not tell LPN C that the Invega injection was administered that day. The resident's Invega injection showed up on the electronic MAR as due for administration. The error was not identified until LPN C arrived for work on the night shift on 9/7/22 when LPN D said he/she had administered there resident's Invega injection on the day shift. LPN C reviewed the MAR and found the resident's Invega injection stilled showed up on the electronic MAR as being due for administration. The resident appeared to be at baseline and was walking and talking as he/she normally did. LPN C contacted the physician and began monitoring the resident with neurological assessments every 15 minutes. LPN C said the staff cannot see what previous shift members have administered. The electronic MAR only showed what was due for administration on the selected shift. LPN C had to select a previous shift on the electronic MAR to see what had previously been administered. During an interview on 9/21/22 at 3:34 P.M. the facility's Regional Nurse said she investigated the medication error that occurred with the resident's Invega injection. The initial order had been entered incorrectly into the electronic system because the nurse entering the order did not specify a time frame for the medication to be administered. This caused the injection to appear on the electronic MAR as being due for administration every shift. The Regional Nurse provided education for the all the licensed nurses including step by step instruction on how to appropriately enter an injection order into the electronic system. These directions were laminated and placed at the nurses station for reference. The Regional Nurse reviewed all other injection orders for residents in the facility to ensure all other injection orders were accurate. During an interview on 9/21/22 at 3:45 P.M. the resident's primary physician said the resident receiving the three Invega injections was a significant medication error. Invega was a long acting, sedative, antipsychotic medication and the error had the potential to cause a negative outcome for the resident. During an interview on 9/21/22 at 9:32 A.M. the administrator said the resident had been in and out of the hospital which triggered the pharmacy to re-send his/her medication, causing the resident to have three Invega injections in the medication cart. The order was not entered into the MAR correctly and triggered the injection to show up as being due for administration each shift. An in-service was conduct with all nursing staff on inputting orders properly. An injection calendar was created showing all ordered injections (except insulin) for residents and when they were due for administration. Due to the medication error, now only Registered Nurses were able to administer injections in the facility. MO206786

Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #1 and #8), and three additional residents (Resident #10, #12 and #15), received care and services in accordance with professional standards of practice. Staff failed to administer an ordered nebulizer (device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) treatment for one resident (Resident #1), who experienced shortness of breath and required treatment in the emergency room . The facility failed to ensure two residents (Resident #8 and #12), received their ordered medications, which included antipsychotic medication, medications to control blood pressure and antibiotic medication. The facility also failed to ensure three residents (Residents #10, #12, and #15), received their ordered morning medications on time. A sample of eight residents and seven additional residents was selected for review. The facility census was 43. Review of the facility's Transcription of Orders/Following Physician's Orders, revised 7/9/21, showed the following: -Upon receiving a physician's order it will be written on the physician's order sheet (POS); -The purpose of the policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physician orders are followed and that a process is in place to monitor nurses in accurately transcribing and following physicians' orders; -All treatment orders are to be transcribed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR); -Any new orders that are noted on the POS are to be documented in the nurse's notes and noted on the 24 hour report sheet; -The Resident Care Coordinator (RCC), Unit Director, Licensed Practical Nurse (LPN), Director of Nursing (DON), or designee will audit all physician's orders daily to ensure all new physician's orders are recapped and followed completely and accurately. On weekends, the Registered Nurse (RN) Supervisor will check all charts in the facility to ensure all new orders received have been transcribed accurately and implemented; -The RCC, Unit Director, LPN, DON, RN Supervisor, or designee will document the audit on the Daily Physician's Order Review Form, which will include initial of reviewer, date, and notation that the chart was checked; -The RCC, Unit Director, or designated nurse will review all MAR's and TAR's daily to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. Review of the facility's undated policy and procedure on Medication Administration and Monitoring showed the following: -Purpose: To ensure a process is in place for the proper administration of medications, techniques of administering medications, effective monitoring of residents for adverse consequences associated with side effects of medication. To provide guidelines and systems for following procedures for medication errors including defining a medication error and the levels of medication errors. To ensure therapeutic guidelines are monitored in drugs that require laboratory and diagnostic testing; -Medications are to be administered per physicians' orders; -All medications are recorded on the Medication Administration Record (MAR) and signed immediately after the resident has taken the medications; -The nurse or Certified Medication Technician (CMT) will check each medication to the MAR noting the correct name of medication, correct resident, correct dose, correct time, and correct route of administration; -The nurse or CMT should note if a medication is refused or not available; -The Director of Nursing (DON) or Registered Nurse (RN) will be notified immediately regarding the resident not receiving the medication. It will then become the DON or RN designee's responsibility to ensure the medication is received and the Licensed Practical Nurse (LPN) or CMT distributes the medication to the resident; -The back-up pharmacy or primary pharmacy will be notified and the medication will be received; -The physician will be notified if medication is given late and the nurse's notes will indicate why the medication has a discrepancy. This will not only include medications but treatments as well; -The nurse or CMT will also note any side effects to the refusal or medication not given and notify the physician and DON of issues related to the medication discrepancy; -It is imperative that all medications are given using the six rights of medication administration, right resident, right medication, right time, right route, right dose, and right form, and ensure that documentation is correct in the MAR. Review of facility's durable medical equipment renting and purchasing policy, revised 9/17/21, showed the following: -Purpose: To ensure a system is in place when facilities are renting or purchasing durable medical equipment; -The policy applies to any request to rent or purchase Durable Medical Equipment (DME) including, but not limited to, wheelchairs, hospital beds, mattresses, walkers, bolster cover, bed scale, resident lift scale Hoyer (mechanical lift), wheelchairs cushion, floor mat, oxygen concentrators, crutches, ventilators, oxygen equipment, and continuous positive airway pressure equipment (CPAP); -All DME rentals and purchases require the approval of the purchasing department manager; -Purchasing equipment: The administrator, DON, or other nurse is required to contact the facility central supply director when there is a need to purchase DME; -The facility central supply director will contact the purchasing department manager so that options can be discussed; -If the purchasing department manager approves the purchase, the facility central supply director will arrange for the purchase. 1. Review of Resident #1's emergency department record dated 8/27/22 at 3:06 A.M., showed the following: -Chief complaint: concern for low oxygen; -Duration: prior to arrival; -Onset: sudden; -Severity: moderate; -The resident was brought to the emergency department by EMS (emergency medical services) for concern of low oxygen onset for one day; -The resident was at the nursing home where the nursing staff was concerned the resident was having difficulty maintaining adequate oxygen saturations, noting his/her oxygen to be in the 90's; -The resident does endorse (support) some minimal shortness of breath at that time, however reports that when his/her oxygen was placed, his/her symptoms resolved; -Resident currently taking medications as of 8/26/22 11:49 A.M. documented in structured notes: -Ipratropium-albuterol (breathing treatment) 0.5mg-2.5mg/3ml inhalation solution, 3 ml (miiliters) inhaled every four hours; -Ipratropium-albuterol 0.5mg-2.5mg/3ml inhalation solution, 3 ml inhaled every two hours, as needed, shortness of breath or wheezing, status active; -Disposition: discharge to home (facility); -Primary clinical impression: shortness of breath; -Continue any current medications as directed by the originating prescriber; -Discharge diagnosis: shortness of breath at rest; -Date and time completed 4:51 A.M. Review of the resident's physician's order sheet dated 8/1/22 - 9/30/22 showed: -Admit to skilled care 8/27/22; -Diagnoses included diabetes, essential hypertension, acute myocardial infarction, asthma, bipolar disorder, sleep apnea, pneumonitis (inflammation of the lung) due to inhalation of food and vomit, and nicotine dependence, cigarettes; -Ipratropium-albuterol solution (control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema. It is also used to treat air flow blockage and prevent the worsening of chronic obstructive pulmonary disease (COPD) (comes as a solution (liquid) to inhale by mouth using a nebulizer (machine that turns medication into a mist that can be inhaled) 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml) inhale 3 ml orally every four hours; -Ipratropium-albuterol 0.5-2.5 (3) mg/3 ml inhale 3 ml orally every two hours as needed for wheezing, SOB (shortness of breath); -Metoprolol tartrate (high blood pressure) 25 mg, give one tablet by mouth two times a day related to essential hypertension; -Nicotine patch (use to aide in smoking cessation) 24 hour 21 mg/24hr, apply 1 patch transdermally in the morning related to nicotine dependence, cigarettes; -Olanzapine (used to treat mania or mixed episodes that is part of bipolar disorder (manic-depressive illness) tablet 5mg give 1 table by mouth two times a day related to bipolar disorder. Review of resident's progress notes dated 8/27/22 at 12:28 P.M., showed the following: -Hospital report from registered nurse regarding resident's discharge from ER (emergency room ); -Resident has nonproductive cough, treat with albuterol inhalation; -SPO2 (measurement of how much oxygen your blood) 94-100% (normal 96-99%) on room air (while in the ER). Review of resident's progress notes dated 8/27/22 at 2:06 P.M., showed the following: -Discharge instructions (from ER) received 1:55 P.M.; -Emergency department diagnosis was shortness of breath at rest; -Continue current medication as prescribed; -Follow up with primary care physician, call tomorrow 8/28/22 to schedule appointment; -New script levofloxacin (antibiotic) 750 mg. Review of resident's progress notes dated 8/27/22 at 3:29 P.M., showed the following: -SPO2 93% on room air; -Diminished lung sounds lower and middle right with wheezing heard in the upper right lobe. Review of resident's medication administration record (MAR) schedule for August 2022 showed the following: -Ipratropium-qlbuterol Solution 0.5-2.5 (3) mg/3ml 3 ml inhale orally every four hours at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. (order date 8/27/22 start time 4:00 P.M.); -No documentation staff administered the medication on 8/27/22 at 4:00 P.M. Review of resident's progress notes dated 8/27/22 at 4:22 P.M., showed the following: -Resident returned from hospital ED (emergency department) following evaluation with diagnosis of shortness of breath at rest; -New orders for levofloxacin for four days; -Per hospital report, chest X-ray showed possible pulmonary edema (condition caused by too much fluid in the lungs); -Background: Resident was admitted to the long term care facility 8/26/22 from the hospital after 7:30 P.M.; -Upon admittance (to the facility on [DATE]), O2 decreased to upper 80s to low 90's. Per physician resident was sent to hospital ED by EMS for further evaluation. Resident returned to the facility from the hospital on 8/27/22 at approximately 3:00 P.M. Review of the resident's MAR showed the following: -On 8/27/22 at 8:00 P.M. staff documented the resident's oxygen saturation 91%; -No documentation staff administered the ipratropium-albuterol on 8/28/22 at 12:00 A.M. Review of the resident's progress notes dated 8/28/22 at 2:01 A.M. showed there was no equipment (nebulizer machine) to administer the resident's ipratropium-albuterol. Review of resident's progress notes dated 8/28/22 at 3:09 A.M., showed Licensed Practical Nurse (LPN) L documented the following: -Resident continues to complain of discomfort/distress with breathing with wet nonproductive cough; -Oxygen 91% at two liters by nasal cannula; -Head of bed elevated at 90 degrees and is on oxygen two liters by nasal cannula; -Resident requested to go to the ER due to discomfort with breathing; -Nurse educated resident the facility must try and meet his/her needs in the facility; -Resident tearful and said he/she would like to go to the nearest hospital; -Resident did agree to let staff try and make him/her as comfortable as possible and give the antibiotic time to work. Review showed no documentation the physician was notified of the resident's complaint of breathing discomfort/distress and wanting to go to the hospital. Review of resident's MAR showed no documentation staff administered the resident's ipratroprium-albuterol medication on 8/28/22 at 4:00 A.M. and referred to the progress note. Review of the resident's progress notes dated 8/28/22 at 4:34 A.M., showed LPN L documented unable to give treatment (ipratroprium-albuterol). Review of resident's MAR showed the following: -No documentation staff administered ipratroprium-albuterol on 8/28/22 at 8:00 A.M., 12:00 P.M., or 4:00 P.M.; -No documentation staff administered the medication on 8/29/22 at 12:00 A.M. and 4:00 A.M., and referred to the progress note. Review of resident's progress notes dated 8/29/22 at 1:08 A.M. and 3:58 A.M., showed staff documented no equipment (nebulizer machine) available to give the medication (ipratroprium-albeterol). Record review showed no documentation the facility notified the resident's physician regarding the ipratroprium-albuterol was not administered as ordered. Review of the resident's MAR for 8/29/22 at 7:00 A.M. showed CMT (Certified Medication Technician) E documented the resident's 7:00 A.M. dose of nicotine patch, olanzapine, and metoprolol tartrate were not given due to resident being in the hospital (resident did not go to the hospital until after 9:05 A.M.). Review of the resident's MAR for 8/29/22 at 8:00 A.M., showed CMT E documented the 8:00 A.M. dose of ipratroprium-albuterol was not given due to resident being in the hospital (resident did not go to hospital until after 9:05 A.M.) Review of resident's progress notes dated 8/29/22 at 2:53 P.M., showed the following: -At 9:05 A.M. the resident's call light was on; -Resident had labored breathing on oxygen SPO2 75%; -Resident claimed that he/she could not breathe; -Increased oxygen to six to seven liters per oxygen mask; -Called 911, ambulance took the resident to the hospital for further assessment; -At 2:45 P.M. received resident back from the hospital; -Resident was diagnosed with sinus congestion. Review of resident's emergency department record dated 9/29/22 at 9:56 A.M. showed the following: -Chief complaint: sinus congestion; -Duration: PTA (prior to arrival); -Onset: gradual; -Severity: moderate; -Additional history and physical information; -Resident reports he/she felt like he/she could not catch his/her breath and was unable to receive his/her albuterol treatment because the nursing home did not have it; -Per nursing home staff the resident's SPO2 was 77%; -Per EMS SPO2 was 100% and the resident was given albuterol treatment with improvement; -Ipratropium-albuterol 0.5mg-2.5mg/3ml inhalation solution: 3 ml inhaled every four hours, status active; -Ipratropium-albuterol 0.5mg-2.5mg/3ml inhalation solution: 3 ml inhaled every two hours, as needed, shortness of breath or wheezing, status active; -Disposition: discharge to home (facility); -Primary clinical impression: sinus congestion; -Continue any current medications as directed by the originating prescriber; -Discharge diagnosis: sinus congestion; -Date and time completed 2:11 P.M. Review of resident's MAR for 8/29/22 at 4:00 P.M., showed CMT E documented the 4:00 P.M. dose of metoprolol tartrate, olanzapine and ipratropium-albuterol was not given due to resident being in the hospital (resident returned from hospital at 2:45 P.M.) Review of resident's MAR showed no documentation staff administered the resident's ipratroprium-albuterol on 8/29/22 at 8:00 P.M. Review of resident's MAR showed the following: -No documentation staff adminsitered the resident's ipratroprium-albuterol on 8/30/22 at 12:00 A.M. and 4:00 A.M.; -No documentation staff administered the medication on 8/30/22 at 8:00 A.M. and 12:00 P.M. and referred to the progress note. Review of resident's progress notes dated 8/30/22 at 6:27 P.M., showed there was no equipment (nebulizer machine) available to give the medication to the resident and the nurse was notified. Review of resident's medical record showed the following: -Two nebulizers ordered on 8/31/22 (four days after the medication order for resident); -To be shipped to the facility by ground (delivery). During interview on 9/21/22 at 4:04 P.M., the resident's family member/ POA (power of attorney) said the resident was sent to the facility without a nebulizer for his/her breathing treatments. During interview on 9/22/22 at 9:00 A.M. LPN L said he/she did not administer the resident's nebulizer treatments because there was no nebulizer equipment at the facility for the resident to use. During interview on 9/20/22 at 4:15 P.M. LPN M said the following: -The resident needed a nebulizer when he/she returned from hospital; -There were no extra nebulizers at the facility and one of the nurses went to his/her home and brought one back for the resident to use. During interview on 9/22/22 at 6:25 A.M. LPN C said the following: -He/She worked 7:00 P.M. until 7:00 A.M. and worked the night of 8/30/22; -The resident needed a nebulizer machine and the facility did not have one so he/she went home and brought his/her own machine back to the facility. During interview on 9/21/22 at 2:35 P.M., the administrator said the facility did not have an extra nebulizer in the building, but had the albuterol medication for nebulizer treatments. 2. Review of Resident #12's Physician Orders for September 2022 showed the following: -Diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), high blood pressure, chronic kidney disease, diabetes, schizoaffective disorder, stroke, polyp of colon, urinary tract infection (UTI); -Apixaban (medication to prevent blood clots) 5 milligrams (mg) by mouth twice a day at 7:00 A.M. and 4:00 P.M.; -Pantoprazole (medication used to treat gastric reflux) 30 mg by mouth daily; -Vitamin E (supplement) 180 mg capsule by mouth daily; -Vraylar (antipsychotic) 3 mg by mouth daily; -Multivitamin (supplement) tablet by mouth daily; -Olanzapine (antipsychotic) 10 mg by mouth daily; -Furosemide (diuretic) 40 mg by mouth daily; -Amlodipine (blood pressure medication) 10 mg by mouth daily; -Aspirin (blood thinner) 81 mg by mouth daily; -Isosorbide (blood pressure medication) 30 mg by mouth twice a day at 7:00 A.M. and 4:00 P.M.; -Linzess capsule (used to treat certain bowel problems by increasing fluid in your intestines and helping speed up movement of food through the gut) 145 micrograms (mcg) by mouth one time daily for polyp of colon (start date 8/18/22, discontinued 9/16/22); -Coreg 12.5 mg by mouth two times a day for high blood pressure (6:00 A.M. and 6:00 P.M.); -Keflex (antibiotic) 500 mg by mouth twice a day for seven days for UTI at 6:00 A.M. and 6:00 P.M. (start date 9/14/22); -Hydralazine HCL 75 mg by mouth every six hours for blood pressure (start date 8/18/22). Review of the resident's MAR for September 2022 showed the following: -On 9/1/22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/2/22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/3/22 the 5:00 A.M. dose of Linzess 145 mcg was left blank; -On 9/6/22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/9/22 the 5:00 A.M. dose of Linzess 145 mcg was left blank; -On 9/9/22 the 6:00 A.M. dose of Coreg 12.5 mg was left blank; -On 9/9/22 the 6:00 A.M. dose of hydralazine 75 mg was left blank; -On 9/10/22 the 5:00 A.M. dose of Linzess 145 mcg was left blank; -On 9/11/22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/12/22 22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/13/22 the 5:00 A.M. dose of Linzess 145 mcg was left blank; -On 9/15/22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/16/22 at 5:00 A.M. staff documented Linzess 145 mcg was not administered; see progress notes; -On 9/18/22 the 6:00 A.M. dose of Coreg 12.5 mg was left blank; -On 9/18/22 the 6:00 A.M. dose of hydralazine 75 mg was left blank; -On 9/18/22 the 6:00 A.M. dose of Keflex 500 mg was left blank; -On 9/20/22 at 6:00 A.M. staff documented Keflex 500 mg was not administered; see progress notes. Review of the resident's progress notes for September 2022 showed no documentation why medications were not documented as administered on the resident's MAR in September 2022. Observation on 9/20/22 at 12:05 P.M. showed the Director of Nurses (DON) administered Resident #12 the following medications: -Amlodipine (blood pressure medication) 10 mg by mouth daily; -Apixaban (medication to help prevent blood clots) 5 mg by mouth twice a day; -Aspirin 81 mg by mouth daily; -Olanzapine (antipsychotic) 10 mg by mouth daily; -Pantoprazole 40 mg by mouth daily; -Multivitamin tablet by mouth daily; -Vraylar (antipsychotic) 3 mg by mouth daily; -Furosemide (diuretic) 40 mg by mouth daily; -Hydralazine (blood pressure medication) 25 mg -Isosorbide (blood pressure medication) 30 mg by mouth twice daily. During an interview on 9/20/22 at 12:10 P.M. the DON said the resident's ordered Vitamin E 180 mg by mouth daily was not available and she was unable to administer this to the resident. All of the medications he/she had just administered to Resident #12 were his/her morning medications except for the hydralazine 25 mg which was scheduled for 12:00 P.M. The facility used block times for medication administration and morning medications could be passed from 7:00 A.M. to 10:00 A.M. Review of the the resident's MAR for September 2022 at 3:16 P.M. showed the DON documented the resident's morning medications were administered except for the Vitamin E which was left blank on the MAR. There was no documentation on the MAR the morning medications were administered late at 12:05 P.M. on 9/20/22. Review of the resident's progress notes on 9/20/22 showed no documentation the resident's morning medications were administered late or that the physician was contacted regarding the late medications or when to administer the next dose of medications scheduled more than once daily. Observation on 9/28/22 at 12:08 P.M. showed Registered Nurse (RN) A prepared Resident #12's morning medications. The electronic MAR showed the morning medications were past due (colored red). During an interview on 9/28/22 at 12:10 P.M. RN A said he/she had several more residents to administer morning medications to and he/she had not administered any morning medications yet for residents living on the Special Care Unit (SCU). 3. Review of Resident #8's Physician Orders for September 2022 showed the following: -Diagnoses included bipolar disorder, paranoid schizophrenia, major depressive disorder, delusional disorder, autistic disorder, adjustment disorder with mixed anxiety and depressed mood; -Risperdal 4 mg by mouth every morning and at bedtime (order date 9/17/22). Review of the manufacturer's prescribing guidelines for Risperdal showed the following: -Used in treatment of schizophrenia in adults and irritability associated with autistic disorder Review of the resident's MAR for September 2022 at 3:11 P.M. showed the following: -On 9/19/22 at 7:00 A.M. the DON documented the medication was not administered, see progress notes; -On 9/19/22 at 8:00 P.M. Registered Nurse (RN) A documented the 4 mg of Risperdal was administered; -On 9/20/22 the 7:00 A.M. dose of 4 mg of Risperdal was left blank. During an interview on 9/20/22 at 10:33 A.M. the resident said he/she had been out of his/her Risperdal for a couple of days now. The resident wasn't sure if the medication had come in yet. The resident said he/she did not receive the ordered Risperdal last night and had not yet received it today. Review of the resident's progress notes dated 9/21/22 at 9:30 A.M. showed the following: -Physician informed that Risperdal was not covered by the resident's insurance, the physician asked staff to call the psychiatrist about this medication; -Reached nurse practitioner, he/she wanted this medication to be given to the resident; -Pharmacy clarified that this medication was yet under review for precertification; -The review might take 72 hours to a week to reach a determination. Review of the resident's progress notes dated 9/21/22 at 10:21 P.M. showed the following: -Seen by Long Term Psychiatric Management (LTPM) via telehealth consultation with new orders; -Endorsed to follow up availability of Risperdal. During interview on 9/28/22 at 11:33 A.M. the resident said the following: -He/She missed several days of his/her Risperdal; -The facility didn't have the right dose in the Emergency Kit (E-kit); -He/She was worked up when he/she didn't have his/her Risperdal; -His/Her anxiety was high. 4. Review of Resident #10's Physician Order Sheet for September 2022 showed the following: -Diagnoses included aphasia (loss of ability to understand or express speech) following a stroke, high blood pressure, schizophrenia, bipolar disorder, anxiety, and major depressive disorder; -Aspirin 81 mg by mouth daily; -Ferrous Sulfate (iron supplement) 325 mg by mouth in the morning for anemia; -Sertraline (antidepressant) 100 mg by mouth daily; -Vitamin C 500 mg by mouth daily; -Lorazepam (antianxiety medication) 1 mg by mouth three times a day for restlessness and agitation at 7:00 A.M., 11:00 A.M. and 4:00 P.M.; -Boost (nutritional supplement) two times a day at 7:00 A.M. and 4:00 P.M.; -Carbamazepine (for treatment of bipolar disorder) 300 mg by mouth twice a day at 7:00 A.M. and 4:00 P.M.; -Colace (stool softener) 100 mg by mouth twice a day at 7:00 A.M. and 4:00 P.M.; -Haloperidol (antipsychotic) 20 mg by mouth three times a day 7:00 A.M., 11:00 A.M. and 4:00 P.M. Observation on 9/20/22 at 11:55 A.M. showed the resident's electronic MAR showed medications were due for the 7:00 A.M. to 10:00 A.M. pass. The DON administered the following medications to Resident #10: -Aspirin 81 mg by mouth; -Carbamazepine 300 mg by mouth; -Haloperidol 20 mg by mouth; -Sertraline 100 mg by mouth; -Ferrous Sulfate 325 mg by mouth; -Vitamin C 500 mg by mouth; -Lorazepam 1 mg by mouth; -Boost 1 carton by mouth; -Colace 100 mg by mouth. Review of the resident's MAR on 9/20/22 at 3:15 P.M. showed the DON documented the resident's morning medications were administered. There was no documentation on the MAR the morning medications were administered late at 11:55 A.M. on 9/20/22. Review of the resident's progress notes on 9/20/22 showed no documentation the resident's morning medications were administered late or that the physician was contacted regarding the late medications or when to administer the next dose of medications scheduled more than once daily. During an interview on 9/20/22 at 11:00 A.M. the DON said he/she was scheduled as the nurse to pass medications in the facility today (9/20/22). The DON was not familiar with the facility's system and had only passed medications in the facility once before. The DON said he/she was running late with the morning medication pass. 5. Review of Resident #15's Physician Orders for September 2022 showed the following: -Diagnoses included high blood pressure, aphasia (loss of ability to understand or express speech), stroke, hemiparesis (muscle weakness or partial paralysis on one side of the body), and depression; -Venlafaxine (antidepressant) 37.5 mg by mouth daily; -Lorazepam (anxiety) 1 mg by mouth three times daily; -Tramadol (pain reliever) 50 mg by mouth three times a day; -Lisinopril (blood pressure medication) 5 mg by mouth daily; -Tegretol-XR (medication to treat bipolar mania) Extended release 12 hour, 200 mg by mouth twice daily; -Aspirin EC 325 mg by mouth daily; -Famotidine (used to treat heartburn) 20 mg by mouth twice daily; -Pregabalin (nerve pain medication) 100 mg by mouth daily; -Vitamin C 500 mg by mouth daily. Observation on 9/28/22 at 2:20 P.M. showed RN A prepared Resident #15's morning medications. The resident's electronic MAR showed the morning medications were past due (colored red). Observation on 9/28/22 at 4:38 P.M. showed RN A continued to pass morning medications to residents on the SCU. During an interview on 9/28/22 at 4:38 P.M. RN A said he/she usually worked night shift and was not familiar with the morning medication pass. RN A was covering a call-in and got a late start on the medication pass because he/she arrived at 8:45 A.M. No other staff had started the morning medication pass (7:00 A.M. to 10:00 A.M.). Other nursing staff was busy with their own assignments and not able to assist with the medication pass. During an interview on 9/22/22 at 11:52 A.M. CMT E said he/she had a hard time getting the morning medication pass completed on time. Morning medication could be administered between 7:00 A.M. and 10:00 A.M. Today (9/22/22), CMT E was able to complete the morning medication pass for residents at 11:00 A.M. CMT said about three months ago a new system started where the CMT or medication nurse passed all of the residents' medication on day shift. It was very difficult to get the morning medication passed on time as the morning medication pass was very heavy. During an interview on 9/20/22 at 12:20 P.M. LPN B said sometimes the morning medication pass was not completed until 2:00 P.M. or 3:00 P.M. LPN B felt that medications had been omitted because of this because how could staff administer the morning dose of a medication if it was already time for next administration of that same medication. During an interview on 10/17/22 at 10:14 A.M. Resident #1, #8, #10, and #15's physician said he expected facility staff to administer medications as ordered by the physician and medications should be administered within the required timeframes, especially for medications which were ordered to be administered more than once a day. The physician expected to be notified if the facility did not have an ordered medication or equipment to administer an ordered medication available so the physician could change the order of the medication or the route. Resident #1 should have received his/her ordered nebulizer treatment and not receiving the ordered nebulizer could have contributed to Resident #1 requiring treatment in the emergency room for complaints of shortness of breath. The physician did not recall being notified that residents received their morning medications late on 9/20/22 and 9/28/22 and would have expected to be notified. The physician was aware residents not receiving medications on time was an issue in the facility. During interviews on 9/29/22 at 3:11 P.M. and 10/17/22 at 12:19 P.M. the administrator said she had spoken with management about adding an additional staff person to day shift to assist with getting the morning medications passed on time as he/she had recognized this as an issue. MARs and TARs should be checked by the charge nurse at the end of the shift, looking for omissions and follow up documentation on as needed medications. Any issues should be discussed in the daily nurse meeting. Medication audits should be conducted weekly by nursing staff. The electronic medication administration system had been in place since the administrator took the position. The administrator was made aware Resident #1 did not have the needed nebulizer equipment after his/her admission. As soon as the administrator was aware she ordered the nebulizer machine. The administrator was not sure what date the nebulizer was ordered. It was not her expectation that staff would use their personal equipment from home. The administrator expected staff to notify the resident's physician anytime a medication could not be administered. Staff should document why the medication or treatment was not administered as well as follow up about what was done to correct the

Based on interview and record review, the facility failed to treat one resident (Resident #6), in a review of four sampled residents, with dignity and respect, when Licensed Practical Nurse (LPN) T raised his/her voice and called him/her a sex offender in the presence of others, including Resident #3. Interview and record review showed LPN T wrote a statement for Resident #3 with information Resident #3 said he/she did not relay to LPN T. Further interview showed other residents (Resident #2 and #5), said staff openly referred to them as sex offenders and these comments and interaction caused the residents distress, made them feel ashamed, belittled and angry. The facility census was 53. Review of a facility policy, revised 7/9/21, titled Dignity and Respect, showed the following: -AFFECTED PERSONNEL: All; -PURPOSE: To ensure that every resident is treated with dignity and respect; -PROCEDURE: Every resident has a right to be treated with dignity and respect; -All staff will speak to and treat all residents with dignity and respect. Review of a facility Expectations for Customer Service form, effective December 1, 1999, showed the following: -Purpose: To set the expectations for customer service; -Employees are required to treat all customers with dignity and respect. Customers include residents; -Appropriate conduct is required; -Courtesy and respect are required at all times; -Gossiping or speaking in any disrespectful manner concerning customers at any time will not be tolerated. Review of an undated, facility Code of Ethics for Employees form, showed the following: -The following actions are FORBIDDEN and could result in termination of employment: -Breach of the resident's privacy and confidentiality of information and records. 1. Review of Resident #6's undated face sheet showed the resident had diagnoses that included depression and anxiety disorder. Review of the resident's care plan, dated 2/22/22, showed the resident was a registered sex offender and had been placed at the facility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/3/22, showed the following: -Hearing: adequate; -Makes self-understood; -Able to understand others; -Cognitively intact; -No behaviors. During an interview on 6/12/22 at 10:00 A.M., the resident said the following: -He/She was on the sex offender registry, he/she had done his/her time and should be able to move on with his/her life; -The facility staff liked to remind those residents who were on the sex offender registry of their status by singling them out and placing them on a hall all together; -He/She felt like a prisoner at times due to this segregation. 2. Review of Resident #2's undated face sheet showed the resident had diagnoses that included major depressive disorder and anxiety disorder. Review of the resident's care plan, dated 4/7/22, showed the resident was a registered sex offender and had been placed at the facility. Review of the resident's admission MDS, dated [DATE], showed the following: -Adequate hearing; -Makes self-understood; -Able to understand others; -Cognitively intact. During an interview on 6/12/22 at 10:22 A.M., the resident said the following: -He/She was on the sex offender registry; he/she had done wrong in the past but that was the past. He/She thought the facility was to treat everyone like equals; -It felt like the facility staff punished those residents who were on the registry, or because of their status, by placing them on a hall all together. This was like being in prison; -He/She did not like constantly being reminded of his/her past; he/she was ashamed of his/her past and didn't like being reminded of it. 3. Review of Resident #5's face sheet showed the resident had diagnoses that included personality disorder, bipolar disorder and anxiety disorder. Review of the resident's admission MDS, dated [DATE], showed the following: -Hearing: adequate; -Makes self-understood; -Able to understand others; -Cognitively intact. During an interview on 6/12/22 at 10:40 A.M., the resident said the following: -He/She was on the sex offender registry; -He/She felt like staff treated him/her differently because he/she was a sex offender; -Staff knew he/she was a sex offender just by his/her placement in the facility. All of the residents that were sex offenders were on the 400 hall; -He/She felt like staff delayed care and did not answer his/her call light to punish him/her for being a sex offender. 4. Review of an Administrative Investigation Report, dated 6/12/22, showed the following: -Person/s involved in incident included Resident #6, Resident #2 and Licensed Practical Nurse (LPN) Y; -Witnesses included Resident #3; -Investigative Narrative Note: On 6/12/22 at approximately 9:45 P.M., the administrator received a call from the charge nurse LPN T. He/She said two residents, Resident #6 and Resident #2, had both gotten verbally aggressive toward him/her. LPN T said he/she had seen Resident #6 going down the 200 hall and asked him/her to please visit in the common area. He/She said Resident #6 got upset and asked him/her why couldn't he/she just go down the hall and not go in the room. LPN T reported that he/she let Resident #6 know that due to his/her past charges, he/she was to encourage him/her to stay off the 200 hall. LPN T said after he/she said that, Resident #6 got out of his/her wheelchair and got in his/her face, pointed his/her finger and told him/her that he/she could not harass him/her in that manner. LPN T then said that Resident #6 went to his/her room and told Resident #2 LPN T was harassing him/her. LPN T said Resident #2 came down the hall and started to verbally attack him/her regarding the conversation that he/she had with Resident #6; -The administrator received a call from Resident #6 and Resident #2 regarding LPN T. They reported LPN T was harassing them; -The administrator got a call from the Sheriff's Office reporting they had received a call from Resident #6 saying he/she wanted to press charges on LPN T for harassment; -Summary of Findings: After interviewing the residents and staff, the following is what can be determined: All residents were asked if any staff have been unprofessional/inappropriate toward them or if they have witnessed any staff be unprofessional/inappropriate towards others. Two residents (Resident #2 and #3) stated yes. Both said LPN T was unprofessional toward Resident #6. Resident #6 was not present for the interviews as he/she was out to the hospital for a procedure; -Resident #3 in a statement written with LPN T, said he/she did not witness LPN T say anything about Resident #6's offender status. This was contradictory to his/her verbal statement; -Resident #2 said LPN T was unprofessional toward Resident #6, but was not a witness to the alleged event. LPN T's statement did say that he/she told Resident #6 that he/she was asking him/her not to go down the hall due to his/her sex offender status. His/Her statement did not reveal how loud he/she said it to him/her; -Plan of Action: Educational Needs: All staff to be in serviced on Abuse and Neglect and Resident Dignity and Respect. Review of an undated, unsigned, written statement completed by Resident #6 showed the following: -LPN T told him/her he/she was not allowed on the 200 hall; -He/She had responded to LPN T that he/she was not on the 200 hall and asked why he/she was being so hard on him/her and that he/she had done nothing wrong; -LPN T told him/her he/she was a sex offender; -He/She told LPN T he/she could not say that and LPN T said it again. During an interview on 6/23/22 at 12:22 P.M., Resident #6 said the following: -The incident between he/she and LPN T made him/her really angry; -He/She had not gone on the 200 hall and LPN T jumped him/her for going on the hallway; -When he/she tried to ask LPN T why he/she was jumping him/her, that is when LPN T responded because Resident #6 was a sex offender; -Other residents and staff were around when LPN T said this; -He/She was embarrassed for others to know his/her status if they did not already know; -Calling him/her a sex offender made him/her feel belittled and just brought up his/her past which he/she had been forgiven of; -Living in the past or having past incidents brought up made his/her depression worse; -LPN T's comment made him/her so mad that he/she yelled at LPN T. 6. Review of Resident #3's face sheet showed the resident had diagnoses that included major depressive disorder and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Adequate hearing; -Makes self-understood; -Able to understand others; -Cognitively intact. During an interview on 6/23/22 at 11:00 A.M., Resident #3 said the following: -He/She had overheard LPN T yell at Resident #6, telling him/her that he/she could not go down the 200 hall because Resident #6 was a sex offender; -He/She did not think Resident #6 was actually on the 200 hall when this happened; -He/She did not know Resident #6 was a sex offender; -LPN T yelling this about Resident #6 made him/her uncomfortable; -LPN T asked him/her if he/she could write a written statement for him/her because he/she had been a witness to the incident. LPN T wrote a statement for him/her; he/she did not tell LPN T what to write, LPN T wrote it, he/she (Resident #3) signed the statement, but did not read what the statement said. Review of a written statement, signed and dated 6/12/22 by both Resident #3 and LPN T showed the following: -Resident #6 was arguing with staff about being a sex offender; -LPN T was trying to get Resident #6 off of the 200 hall; -He/She did not hear LPN T disrespect Resident #6; -He/She was sitting by the snack room door when this happened; -The statement was written for him/her with his/her consent by LPN T. Review of a written statement, signed and dated by LPN T on 6/12/22 showed LPN T, documented the following: -He/She saw Resident #6 pushing another resident in a wheelchair down the 400 hall and as Resident #6 got closer to the 200 hall, he/she told Resident #6 that he/she needed Resident #6 not to be on the 200 hall; -Resident #6 asked him/her why he/she couldn't be on the 200 hall and he/she responded due to him/her being a sexual offender; -Resident #6 became irrate stating his/her rights were violated by talking about that and that he/she felt harassed. During an interview on 6/22/22 at 5:55 P.M., LPN T said the following: -Residents that are sex offenders are mostly on the 400 hall; there are some on other halls, but they are either in a locked down unit or more bed bound and less mobile. The 200 hall was for opposite sex residents (opposite sex from the residents on the 400 hall); -Residents on the 400 hall are to be discouraged from being on the 200 hall because of their sex offender status; -Resident #6, who resides on the 400 hall, was in a relationship with a resident on the 200 hall; -He/She had observed Resident #6 going toward the 200 hall and he/she told him/her that he/she needed Resident #6 to stay off the 200 hall; -Resident #6 asked him/her why and he/she responded because he/she was a sex offender. Resident #6 then snapped; -He/She knew Resident #3 was nearby and he/she had written a statement for him/her regarding the incident that night because he/she knew there was probably going to be an investigation because of the way it turned out. During an interview on 7/13/22 at 7:32 P.M., LPN T said he/she had tried to write word for word what Resident #3 had said to him/her on the written statement He/She might have had to paraphrase some of the information, he/she could not recall. Resident #3 did not read the statement, but he/she read it to him/her when he/she was done writing it and Resident #3 signed the statement. During an interview on 6/14/22 at 3:18 P.M. and 4:25 P.M., the administrator said the following: -LPN T did comment to Resident #6 that he/she was a sex offender; -It was after this comment/referral that Resident #6 became aggressive; -Statements like this would be considered disrespectful and would not be providing good customer service; -The response to the resident's question should have been addressed quietly, privately and without identifying the resident's past; -Resident's of the opposite sex are not allowed on the opposite sex hallways, it has nothing to do with a sex offender status; -She expected staff to treat residents with dignity and respect.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of 11 sampled residents, was free from sexual abuse by another resident (Resident #2) who had a known history of hypersexuality, sexually inappropriate behaviors and cognitive impairment. Staff failed to implement interventions to protect Resident #1 from Resident #2's unwanted intimate touching. Resident #2 was found standing over Resident #1 with hands at Resident #1's exposed genitalia while he/she slept. Staff told Resident #2 to return to his/her side of the room, left the room, leaving the residents unattended to go to another unit to get the charge nurse. When the staff returned, Resident #2 was back at Resident #1's bedside with his/her hands at Resident #1's exposed genitalia. Staff directed Resident #2 back to his/her side of the room and observed Resident #2 walk over to Resident #1's bedside again. Resident #1 said Resident #2 had been to his bed five or six times previously and had touched his/her private areas before. Resident #1 said Resident #2 talked about sex all of the time, was inappropriate, and it made him/her sad. Resident #1 did not want Resident #2 to touch his/her genitalia. The facility census was 56. The administrator was notified on 10/5/21 at 9:00 A.M., of the Immediate Jeopardy (IJ) which began on 9/17/21. The IJ was removed on 10/6/21, as confirmed by the surveyor onsite verification. 1. Review of the facility policy Abuse and Neglect dated 9/17/21 showed the following: -The purpose was to outline procedures for reporting and investigating complaints of abuse, neglect and misuse of funds/property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and Director of Nursing (DON) or designee, outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all resident involved was completed; -Sexual abuse was non-consensual contact of any type with a resident. Sexual abuse included unwanted intimate touching of any kind especially of breasts or perineal area. All types of sexual assault or battery such as rape, sodomy and coerced nudity. Forced observation of masturbation and/or pornography and taking sexually explicate photographs and/or audio/video recordings of resident and maintaining and/or distributing them. This would include nudity, fondling, intercourse involving a resident. This also included failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -During orientation of new staff, the facility would cover at least sensitivity to resident rights and need and what constitutes sexual abuse. Staff obligations to prevent and report abuse. Reporting abuse and obligation under law when receiving an allegation of abuse; -The facility would identify and correct by providing interventions in which abuse was more likely to occur. This would include assessment of the physical environment, deployment of staff on each shift in sufficient numbers to meet the resident's needs and that the staff were knowledgeable of resident care needs. The facility would identify events, patterns and trends that might constitute abuse and investigate thoroughly, and notify the Administrator and the proper authorities. The facility desired to prevent abuse by establishing a resident sensitive and resident secure environment with a comprehensive quality management approach of concern identification and follow-up; -As part of the resident social history assessment staff would identify residents with increased vulnerability for abuse or who had needs and behaviors that might lead to conflict. Through the care planning process, staff would identify any problems, goals, and approaches which would reduce the chances of mistreatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -On a regular basis supervisors would monitor the ability of the staff to meet the needs of residents and staff understanding of individual resident care needs; -Employees and vendors were required immediately to report any occurrences of potential mistreatment including alleged violations, abuse, sexual assault they observe, hear about or suspect to a supervisor of the administrator. The facility did not condone resident abuse by anyone. It was the responsibility of staff, consultants, physicians, family members and visitors to promptly report any incident or suspected incident of abuse to facility management immediately. If such incidents occurred after hours the Administrator or designee and DON would be notified at home or by cell phone of any such incident; -The facility must ensure that alleged violations involving abuse were reported immediately but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency; -The facility would take steps to prevent mistreatment while the investigation was underway. Residents who allegedly mistreat another resident would be removed from contact with the resident during the course of the investigation The accused resident's condition should be immediately evaluated to determine the most suitable therapy, care approached, and placement considering his or her safety, as well as the safety of other resident and staff. The accused individuals not employed by the facility would be denied unsupervised access of the resident during the course of the investigation. Review of the facility policy Sexual Activity/Abuse and Neglect dated 12/20/18 showed the following; -The purpose was to ensure the facility provided protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the same time protecting their rights; -Residents that wished to engage in sexual activity/intercourse would be allowed to participate in these activities as long as both parties consented and had the ability to consent. Non-consensual acts and acts that imparted negatively on the resident community, such as public displays, shall not be allowed; -Determination of ability to consent included if the resident had a guardian or a physical/and or cognitive impairment, as assessment should be completed to determine the resident's ability to consent. The assessment would be completed by the interdisciplinary care team with the assistance of the resident's physician and/or psychiatrist as needed. The assessment should include the awareness of the relationship including awareness of who was initiating the relationship, identity of the other person and comfort level with sexual intimacy. The ability to avoid exploitation including the resident's values and ability to refuse unwanted advances and the awareness of potential risk associated with the relationship. The resident's guardian would be invited to provide guidance/opinion to the team; -Residents would be assessed for their capacity to consent to sexual activity if they had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -If a resident had been deemed to be unable to consent to sexual activity, the resident would be told they were not permitted to engage in sexual activity; -If non-consensual sexual activity occurred, the abuse and neglect policy would be followed. Review of the facility Administrative Investigation Report dated 9/20/21 showed on 9/17/21 Hall Monitor B noted Resident #2 standing over Resident #1's bed while Resident #1 was sleeping. The privacy curtain was pulled. Hall Monitor B pulled the privacy curtain and saw Resident #2 pull away from Resident #1's private area. Resident #1's pants and under clothing were open with the resident's genitalia exposed. Hall Monitor B told Resident #2 to get away from Resident #1 and Hall Monitor B took Resident #2 out of the room. The charge nurse, Licensed Practical Nurse (LPN) A was contacted and he/she informed the Director of Nursing (DON). Resident #2 was placed on a one-on-one staff observation and remained on continuous observation until discharged . Resident #1 was moved out of the room. Review of Hall Monitor B's written statement dated 9/17/21 showed at approximately 8:30 P.M. he/she walked into Resident #2's room to notify him/her of smoke time and saw Resident #1's curtain was pulled. Hall Monitor B knew Resident #1 was sleeping and the resident never pulled his/her curtain. Hall Monitor B quickly pulled the curtain back, Resident #2 startled back his/her hands, pulling away from Resident #1's crotch to reveal Resident #1's pants were undone/opened and under clothing was opened. Resident #1's genitalia was exposed. Resident #1 was asleep only moments before when Hall Monitor B had passed the room, Resident #1's curtain was in its usual pulled back state with Resident #1's pants done up proper while he/she slept. Hall Monitor B told Resident #2 to go back to his/her side of the room and stay there. Hall Monitor B went and got LPN A. Together they went back to Resident #1's room to find Resident #2 back next to Resident #1 with hands reaching. LPN A told Resident #2 to stop and Hall Monitor B and Resident #2 went out to smoke. Hall Monitor B told Resident #2 to stay with him/her until everyone was done smoking. They went inside, and after snack, Hall Monitor B walked Resident #2 back to his/her room and told Resident #2 again to stay on his/her side and not to touch Resident #1. Hall Monitor B then walked just down the hall to where he/she could still see Resident #1, but could not be easily seen from the resident's room. Not two minutes of waiting and Hall Monitor B watched Resident #2 go back to Resident #1 and reach for Resident #1's crotch area again. Hall Monitor B stopped Resident #2, but he/she continued to reach not listening to Hall Monitor B's commands. Resident #2 zipped Resident #1's pants up. Hall Monitor B grabbed Resident #2's arm and led him to his/her side of the room telling him/her to stay there and not to touch Resident #1, not to talk to Resident #1 and not to enter Resident #1's side of the room. Resident #1 was sleeping through all of this. Hall Monitor B told LPN A he/she had caught Resident #2 going for Resident #1 again and went back to keep a close eye on Resident #2. Hall Monitor B pulled Resident #1's curtain to block Resident #2 and put Resident #1's wheelchair in between the bed as a barrier to future attempts. Review of LPN A's written statement dated 9/17/21 showed, at around 8:30 P.M., Hall Monitor B notified him/her Resident #2 was fondling his/her roommate. LPN A assessed the situation and found Resident #2 standing at the bedside of Resident #1. Resident #1 was asleep. He/She separated the two residents by telling Resident #2 he/she did not want anything bad happening in the room and requested Resident #2 go outside with Hall Monitor B. Resident #2 went with Hall Monitor B. At 9:41 P.M., Hall Monitor B told LPN A Resident #2 was fondling Resident #1 again. At this time he/she notified the Resident Care Coordinator. The Director of Nursing then notified LPN A to move Resident #1 to another room down the hall. Resident #1 was awakened and moved. Resident #2 was sleeping. One-on-one observation was started of Resident #2. When LPN A questioned Resident #1 about sexual attempts towards him/her from Resident #2, Resident #1 said he/she would rather not talk about it. LPN A explained he/she needed to know the truth. Resident #1 said his/her roommate fondled him when he/she was in bed. He/She told Resident #2 to stop. LPN A notified Resident #1's family member (guardian) who said Resident #1 had called upset and said he/she was upset with his/her roommate. Review of Resident #1's Care Plan dated 3/30/21 showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Did not sleep well at night and said he/she woke up a lot and used to be a night owl. The resident would remain free of distress, symptoms of depression, anxiety or sad mood. Staff should assist in developing and provide a program of activities that were meaningful and of interest to the resident. Provide opportunities for exercise and physical activity. Monitor and report any risk for harm to self. Monitor and report any signs of depression including anxiety, sadness, and [CONDITION(S)]. Encourage the resident to express feelings. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 9/15/21 showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in mobility and activities of daily living (ADLs). Review of the resident's Nurses' Notes showed the following: -On 9/17/21 at 11:42 P.M. staff documented the resident was moved to a different room due to incompatibility with his/her roommate; -On 9/18/21 at 2:02 P.M. staff documented the guardian was informed the resident's roommate had talked to the resident sexually and the resident did not like it; -On 9/20/21 at 10:00 A.M. staff documented a late entry. On 9/18/21 the resident was brought to the office to get a statement on what happened 9/17/21. The resident said he was awakened by a staff member telling the resident's roommate to go back to his/her side of the room. When asked where the roommate was when the resident woke up, the resident said on the roommate's own side of the room. This happened twice. Then he/she was awakened by the nurse and hall monitor saying they were going to be moving him/her. The resident said something happened in the past. He/She woke up before with a sexual arousal and sometimes his/her crotch smelled like bad breath. The resident said he had not talked to the counselor about any roommate concerns. He/She did not want to get his/her roommate into trouble. Review of Resident #2's Preadmission Screening and Resident Review (PASRR) (a screening tool used to ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated 1/23/19 showed the following: -Serious mental illness and needed psychiatric rehabilitative services that could be provided by a nursing facility; -Implement plan to change behaviors, provide structured environment, develop personal support network, drug therapy and monitoring and implement ADL programs were recommended services; -Recommended secured placement; -Required a structured environment to assure the resident and others were safe due to impaired judgement/insight. The resident would benefit from structured placement to reduce stress of daily living, to assure basic needs were met and to provide round the clock supervision, support due to functional limitations; -Summary included lengthy history of psychiatric treatment and mental health issues. Prior records document first contact with psychiatric treatment occurred at age six. The resident reported history of sexual abuse by others when he was a child, had history of sexual molestation of others; -The resident's mood had significantly improved with current medication regimen. Still had some episodes of mild agitation. Taking medroprogesterone (a female hormone medication, in some cases used to reduce sexual urges in males) for sexually inappropriate behaviors, last exhibited 12/13/18. Review of the resident's Physician Order Sheet (POS) dated 8/21/21 showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor for behaviors every shift; -[MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)] and [CONDITION(S)] disorder) 400 mg at bedtime. Review of the resident's admission MDS dated [DATE] showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in mobility and ADLs. Review of the resident's History and Physical dated 8/31/21, showed the physician documented past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan dated 9/3/21 showed the following: -At the time of PASRR the resident was deemed safe for admission to a skilled facility. The resident would remain safe in the facility. Refer to PASRR for further information; -The resident had manifestations of behaviors related to his/her mental illness that might create disturbances that affected others. These behaviors included history of being hypersexual and had paranoid [CONDITION(S)]. The resident would minimize episodes of inappropriate behaviors that could affect others. Assist in addressing root cause of change in behavior or mood as needed. Face check on the top of the hour by the nurse and the one-half hour by the nurse aide staff. Psychiatric consult for medication adjustments as needed or ordered. Review of the physician's Progress Note dated 9/14/21 showed since the resident was admitted he/she had severe problems with abnormal sexual behavior. The resident entered other residents' rooms, both male and female and tried to have sex with them. This was a serious disturbance for other residents and difficult for the staff to control. Past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's nurses' note dated 9/14/21 at 1:02 P.M. showed staff documented the resident noted to have increased sexual behavior. The physician was notified during rounds and a new order was received for Depo-[MEDICATION(S)] ([MEDICATION(S)]) 150 mg intramuscularly (IM) monthly and increase [MEDICATION(S)] to 200 mg in the morning. Review of the resident's POS dated 9/14/21 showed the following: -[MEDICATION(S)] acetate suspension 150 milligrams per milliliter (mg/ml), inject 150 mg intramuscularly monthly for hypersexual behavior; -[MEDICATION(S)] 200 mg in the morning. Review of the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Staff documented [MEDICATION(S)] 150 mg IM administered; -Staff documented [MEDICATION(S)] 200 mg administered in the A.M. Review of the resident's care plan dated 9/16/21 showed the guardian did not want the resident to engage in sexual activities. Review of the resident's nurses' notes showed the following: -On 9/16/21 at 2:24 P.M. staff documented the resident's legal guardian did not wish for the resident to engage in sexual relationships in the facility; -On 9/17/21 at 10:20 P.M. the administrator documented staff witnessed the resident fondle his/her roommate's genitals. The resident was separated from peers and placed on one-on-one monitoring immediately. At 11:45 P.M. staff documented the resident was one-on-one monitoring due to incompatibility with roommate leading to the removal of the roommate from the room. Review of the resident's continuous one-on-one documentation dated 9/17/21 showed staff documented start time 10:30 P.M. and every 15 minutes the resident's location, current behavior and activity through 9/18/21 at 3:00 P.M. During interviews on 9/22/21 the administrator said the following: -At 9:45 A.M. she said the resident had hypersexuality and had discussed with the administrator previously, he/she wanted to have sex with anyone on the unit. She spoke with the resident's guardian following the incident and the guardian said he/she was aware the resident was hypersexual and tried to have sex with someone who was sleeping. The guardian had never reported this to the facility previously. The resident left his/her previous facility because he/she was having behaviors. He/She was hypersexual there as well. The previous facility transferred the resident to a psychiatric hospital for evaluation and released the resident back to the previous facility who transported the resident to this facility for admission; -At 1:10 P.M. she said Resident #2's referral was reviewed and they felt the resident was okay for admission. The transferring facility gave report that included he/she was sexually inappropriate with cognitive impairment. Staff requested a psychiatric evaluation but did not receive it prior to admission. During interviews on 9/22/21 Resident #1 said the following: -At 10:30 A.M. Resident #1 said Resident #2 came to his/her bed Friday night (9/17/21) and staff saw it, intervened and moved Resident #1 to a different room down the hall. Resident #2 talked about sex all the time, was over sexed and not appropriate at all. There was very little physical contact. Resident #2 just talked about sex a lot; -At 2:25 P.M. Resident #1 said his/her bed was always pushed with one side against the wall and his/her area was closest to the door. At night the curtains between the two sides of the room were sometimes open, the room door was left opened and the curtain near the door was open so staff could see him/her in bed. He/She slept in day clothing including zipped up pants and underclothing. Resident #2 could not control him/herself. Resident #2 told Resident #1 before, he/she had touched Resident #1's privates while Resident #1 was sleeping. Resident #1 knew Resident #2 touched his/her private parts. Resident #1 had woken up before aroused and smelled like someone else had been on his/her private parts. This had happened five or six times before. The sexual act was not consensual and Resident #1 did not want Resident #2 to touch his/her privates or perform sexual acts on him/her. Staff caught Resident #2 this time. Resident #2 was uncontrollable. It made him/her sad. During interview on 9/22/21 at 10:35 A.M., Resident Care Coordinator LPN C said Resident #2 was worried about his/her sexual tendencies and worried he/she would not be allowed to stay in the facility. The resident was worried about his/her sexual behaviors and history of sexual behaviors. LPN C informed the physician and Depo-[MEDICATION(S)] monthly injection was ordered. The resident received the first injection on 9/15/21. A week ago staff saw the resident in another resident's room on a different hall off of the locked behavioral unit. Since admission the resident had eaten meals in the main dining room due to a choking risk. The resident walked without staff supervision from the locked behavioral unit to the main dining room for meals until last week. Staff saw Resident #2 coming out of another resident's room. Staff started walking with the resident to and from the dining room for all meals after observing the resident leave another resident's room. The resident should not have entered any other resident's room. During interview on 9/22/21 at 2:05 P.M. Hall Monitor B said the following: -A week prior to the incident on 9/17/21 Resident #2 had asked him/her to do every 15 minute checks on the resident to prevent him/her from going into other residents' rooms and fondling them while they were asleep. Hall Monitor B told LPN A (charge nurse). The resident said he/she could not control him/herself; -On 9/17/21 Resident #1 was asleep in bed, dressed in slacks, buttoned and zipped. The room door was open. After the unit's resident smoke break and last medication pass, he/she noticed Resident #1's room door was closed. He/She opened the room door, pulled the curtain and saw Resident #2 standing over Resident #1 with his/her hands at Resident #1's crotch area. Resident #1's pants were unzipped, underclothing exposed and genitalia exposed. Hall Monitor B told Resident #2 to go to his/her side of the room. Hall Monitor B left the room to inform LPN A (charge nurse who was working on a different hall outside the locked behavioral unit). Hall Monitor B and LPN A returned to Resident #1's room and found Resident #2 was at Resident #1 bedside with his/her hands at Resident #1's crotch area again. LPN A told Resident #2 to go to his/her side of the room and Hall Monitor B took Resident #2 out to smoke. Following the unit smoke and snack break, Resident #2 returned to his/her room. At approximately 9:15 P.M. Hall Monitor B went down the hall where he/she could see Resident #1 in bed. Resident #2 went back to Resident #1, reached for his/her crotch area and zipped up his/her pants. Hall Monitor B returned Resident #2 to his/her side of the room, closed the privacy curtain between the two beds and placed a wheelchair between the bed as a barrier. Hall Monitor B thought he/she would hear Resident #2 move the wheelchair. Staff placed Resident #2 on one-on-one observation at 10:30 P.M. Resident #1 was moved down the hall to a different room. During interview on 9/22/21 at 2:20 P.M. LPN A (charge nurse) said on 9/17/21 Hall Monitor B came and told him/her there were sexual advances by Resident #2. Resident #2 was standing over Resident #1 and Resident #1's genitalia was exposed. Hall Monitor B took Resident #2 outside to smoke. About an hour later, Hall Monitor B said Resident #2 was sexually advancing again. LPN A notified RCC LPN C and then received a call from the Director of Nursing (DON). The DON said to move Resident #1 down the hall to a different room and place Resident #2 on one-on-one observation. The last time LPN A was in the room, Resident #1's pants were pulled up with zipper open. He/She could see Resident #1's under clothing. Hall Monitor B said Resident #2 said he/she was fondling another resident who was sleeping. Hall Monitor B told LPN A the previous week about Resident #2 requesting frequent checks because he/she was having increased sexual tendencies. He/She passed the information on in report. Resident #2 talked about going into two other residents' rooms down the hall. During interview on 9/22/21 at 2:45 P.M. Resident #6 (suite mate, shared the same bathroom as Resident #2) said Resident #2 masturbated all the time and asked Resident #6 to come to his/her room. During interview on 10/5/21 at 11:20 P.M. Resident #2 said his/her roommate, Resident #1, was sleeping when he/she performed a sexual act on Resident #1. After smoking, he/she went back and zipped up Resident #1's pants. The nurse aide told him/her to say away from Resident #1. After that he/she was one-on-one with staff. Before when he/she ate in the main dining room because he/she choked easily, he/she went into another resident's room and that resident exposed him/her self. Resident #2 unzipped his/her own pants and then staff came and said get to the dining room. After that he/she did not go to the dining room any longer, but stayed on the locked unit. During interview on 9/28/21 at 11:18 A.M. the resident's physician said the resident had mental illness that included hypersexuality. The resident's hypersexual behavior was part of his mental illness and not a libido problem. He ordered the Depo-[MEDICATION(S)] injection monthly to try to help reduce the resident's sexual tendencies. The resident had mental illness, was demented, and required constant supervision. During interview on 9/22/21 at 3:20 P.M. the administrator said the facility was aware Resident #2 had sexually inappropriate behaviors at the time of admission. No interventions were put into place to keep Resident #2 from being sexually inappropriate with other residents. Staff should not have left Resident #2 alone with Resident #1 following the sexually inappropriate behavior. Staff should intervene and immediately separate the residents and provide continuous one-on-one supervision to prevent the behavior from happening again. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s). MO 088

Based on record review and interview, the facility failed to ensure one resident (Resident #2) of 11 sampled residents with mental health disorders, received appropriate person-centered and individualized care and met their highest psychosocial well-being when the facility failed to implement care to address known exhibited behaviors of hypersexuality and sexually inappropriate behaviors. Resident #2 repeatedly fondled Resident #1's genitals without his/her consent causing Resident #1 to feel sad. The facility census was 56. Review of the facility policy, Behavioral Emergency Policy, dated 2/26/21 showed the following; -The purpose is to provide safe treatment and humane care to the residents in a behavioral crisis, to outline steps to follow to correctly care for the residents in a behavioral crisis and to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -It was the facility policy to provide a safe environment and provide humane care to all residents. If the resident exhibited extreme behaviors such as suicidal, homicidal, self-mutilation, elopement or resident to resident altercations the following steps would occur; -The licensed nursing staff/team leader would assess the resident who exhibited such behaviors, ensuring the safety of the resident and others was the first priority; -Each resident who had an increased potential for aggressive behavior toward self or others, or showed a history of harm to self or others would have an assessment completed upon admission or prior to the use of approved supportive take down techniques. Other supportive methods to control behaviors would be outlined in the plan of care individually for those residents in a behavior emergency crisis; -The Director of Nurses or designee and the Administrator or designee would be notified regarding assessment findings. The management team member on call with input from the Administrator would decide given the assessment findings as to whether the resident's needs could be met safely and whether the resident continued to be appropriate for placement at the facility; -In the event that the resident is unable to be redirected or is requesting an as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a PO (by mouth) PRN mood stabilizing medication, the licensed nurse must complete the PRN Intervention Form. If the resident receives an IM (intramuscular, injection given in the muscle) PRN for mood stabilization a RN Investigation will be completed including the PRN Intervention Form; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Documentation of the behavior emergency in the RN Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible, identifying or attempting to identify the root causes of the behaviors and revising the plan of care with measurable goals and interventions to address the care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] -The assessment team would meet and provide a pre-admission screening prior to the resident returning from a hospital. The readmission nurses notes would include that the Administrator or designee and Management Team Member on call felt the resident was appropriate for placement in the facility and that his/her needs could be safely met by the facility. 1. Record review of Resident #2's Preadmission Screening and Resident Review (PASRR) (a screening tool used to ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated 1/23/19 showed the following: -Serious mental illness and needed psychiatric rehabilitative services that could be provided by a nursing facility; -Implement plan to change behaviors, provide structured environment, develop personal support network, drug therapy and monitoring and implement ADL programs were recommended services; -Recommended secured placement; -Required a structured environment to assure the resident and others were safe due to impaired judgement/insight. The resident would benefit from structured placement to reduce stress of daily living, to assure basic needs were met and to provide round the clock supervision, support due to functional limitations; -Summary included lengthy history of psychiatric treatment and mental health issues. Prior records document first contact with psychiatric treatment occurred at age six. The resident reported history of sexual abuse by others when he/she was a child, had history of sexual molestation of others with prior incarceration time; -The resident's mood had significantly improved with current medication regimen. Still had some episodes of mild agitation. Taking medroprogesterone (a female hormone medication, in some cases used to reduce sexual urges in males) for sexually inappropriate behaviors, last exhibited 12/13/18. Record review of the resident's Physician Order Sheet (POS) dated 8/21/21 showed the following: -admitted [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor for behaviors every shift; -[MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)] and [CONDITION(S)] disorder) 400 mg (milligrams) at bedtime. Record review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 8/31/21 showed the following: -Cognitively intact; -No hallucinations or delusions; -Independent in mobility and activities of daily living (ADLs). Record review of the resident's History and Physical dated 8/31/21 showed the physician documented past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's care plan dated 9/3/21 showed the following: -At the time of PASRR the resident was deemed safe for admission to skilled facility. The resident would remain safe in the facility. Refer to PASRR for further information; -The resident had manifestations of behaviors related to his/her mental illness that might create disturbances that affected others. These behaviors included history of being hypersexual and had paranoid [CONDITION(S)]. The resident would minimize episodes of inappropriate behaviors that could affect others. Staff should administer and monitor medication including [MEDICATION(S)] (a female hormone medication, in some cases used to reduce sexual urges in males) 150 mg IM monthly. Assist in addressing root cause of change in behavior or mood as needed. Face check on the top of the hour by the nurse and the one-half hour by the nurse aide staff; -Psychiatric consult for medication adjustments as needed or ordered. Record review showed no documentation the resident received [MEDICATION(S)] 150 mg monthly as indicated in the resident's care plan or received psychiatric consultation for medication adjustments and no documentation the resident had received sexual counseling services for sexually inappropriate behaviors since admission on 8/21/21. Record review of the physician's Progress Note dated 9/14/21, showed since the resident was admitted he/she had severe problems with abnormal sexual behavior. The resident entered other residents' rooms both male and female and tried to have sex with them. This was a serious disturbance for other residents and difficult for the staff to control. Past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's nurse's note dated 9/14/21 at 1:02 P.M., showed staff documented the resident noted to have increased sexual behavior. The physician was notified during rounds and a new order was received for Depo-[MEDICATION(S)] (also called [MEDICATION(S)], a female hormone medication sometimes used to reduce male sexual urges) 150 mg IM (intramuscularly) monthly and increase [MEDICATION(S)] to 200 mg in the morning. Record review of the resident's POS dated 9/14/21, showed the following: -[MEDICATION(S)] acetate suspension 150 milligrams per milliliter (mg/ml), inject 150 mg intramuscularly monthly for hypersexual behavior; -[MEDICATION(S)] 200 mg in the morning. Record review of the resident's care plan dated 9/16/21 showed the guardian did not want the resident to engage in sexual activities. Record review of the resident's nurses' notes showed on 9/17/21 at 10:20 P.M., the administrator documented staff witnessed the resident fondle his/her roommate's genitals. The resident was separated from peers and placed on one-on-one monitoring immediately; Record review showed no documentation the resident received psychiatric consultation for medication adjustments and no documentation the resident had received sexual counseling services for sexually inappropriate behaviors. During interviews on 9/22/21 the administrator said the following: -At 9:45 A.M. she said the resident had hypersexuality and had discussed with the administrator previously, he/she wanted to have sex with anyone on the unit. She spoke with the resident's guardian following the incident and the guardian said he/she was aware the resident was hypersexual and tried to have sex with someone who was sleeping. The guardian had never reported this to the facility previously. The resident left his/her previous facility because he/she was having behaviors. He/She was hypersexual there as well. The previous facility transferred the resident to a psychiatric hospital for evaluation and released the resident back to the previous facility who transported the resident to this facility for admission; -At 1:10 P.M. she said the resident's referral was reviewed and they felt the resident was okay for admission. The transferring facility gave report that included he/she was sexually inappropriate with cognitive impairment. Staff requested a psychiatric evaluation but did not receive it prior to admission. During interviews on 9/22/21 the resident's roommate (Resident #1) said the following: -At 10:30 A.M. he/she said Resident #2 came to his/her bed Friday night (9/17/21) and staff saw it, intervened and moved Resident #1 to a different room down the hall. Resident #2 talked about sex all the time, was over sexed and not appropriate at all. There was very little physical contact. Resident #2 just talked about sex a lot; -At 2:25 P.M. he/she said Resident #2 could not control him/herself. Resident #2 said before he/she had touched Resident #1's privates while Resident #1 was sleeping. Resident #1 knew Resident #2 touched his/her private parts. Resident #1 had woken up before aroused and smelled like someone else had been on his private parts. This had happened five or six times before. The sexual act was not consensual and Resident #1 did not want Resident #2 to touch his privates or perform sexual acts on him/her. Staff caught Resident #2 this time. Resident #2 was uncontrollable. It made him/her sad. During interview on 9/22/21 at 10:35 A.M. Resident Care Coordinator LPN C said Resident #2 was worried about his/her sexual tendencies and worried he/she would not be allowed to stay in the facility. The resident was worried about his/her sexual behaviors and history of sexual behaviors. LPN C informed the physician and Depo-[MEDICATION(S)] monthly injection was ordered. The resident received the first injection on 9/15/21. A week ago staff saw the resident in another resident's room on a different hall off of the locked behavioral unit. Since admission the resident had eaten meals in the main dining room due to a choking risk. The resident walked without staff supervision from the locked behavioral unit to the main dining room for meals until last week. Staff saw Resident #2 coming out of another resident's room. Staff started walking with the resident to and from the dining room for all meals after observing the resident leave another resident's room. The resident should not have entered any other resident's room. During interview on 9/22/21 at 2:05 P.M. Hall Monitor B said the following: -A week prior to the incident on 9/17/21 Resident #2 had asked him/her to do every 15 minute checks on the resident to prevent him/her from going into other residents' rooms and fondling them while they were asleep. Hall Monitor B told LPN A (charge nurse). The resident said he/she could not control him/herself; -On 9/17/21 Resident #1 was asleep in bed. He/She noticed Resident #1's room door was closed. He/She opened the room door, pulled the curtain and saw Resident #2 standing over Resident #1 with his/her hands at Resident #1's crotch area. Resident #1's pants were unzipped, underclothing exposed and genitalia exposed. Hall Monitor B told Resident #2 to go to his/her side of the room. Hall Monitor B left the room to inform LPN A (charge nurse who was working on a different hall outside the locked behavioral unit). Hall Monitor B and LPN A returned to Resident #1's room and found Resident #2 was at Resident #1 bedside with his/her hands at Resident #1's crotch area again. LPN A told Resident #2 to go to his/her side of the room and Hall Monitor B took Resident #2 out to smoke. Following the unit smoke and snack break, Resident #2 returned to his/her room. At approximately 9:15 P.M. Hall Monitor B went down the hall where he/she could see Resident #1 in bed. Resident #2 went back to Resident #1, reached for his/her crotch area. During interview on 9/22/21 at 2:20 P.M. LPN A (charge nurse) said on 9/17/21 Hall Monitor B came and told him/her there were sexual advances by Resident #2. Resident #2 was standing over Resident #1 and Resident #1's genitalia was exposed. Hall Monitor B took Resident #2 outside to smoke. About an hour later, Hall Monitor B said Resident #2 was sexually advancing again. Hall Monitor B told LPN A the previous week about Resident #2 requesting frequent checks because he/she was having increased sexual tendencies. He/She passed the information on in report. Resident #2 talked about going into two other residents' rooms down the hall. During an interview on 9/28/21 at 11:18 A.M., the resident's physician said the resident had mental illness that included hypersexuality. The resident's hypersexual behavior was part of his/her mental illness and not a libido (sexual urge) problem. He ordered the Depo-[MEDICATION(S)] injection monthly to try to help reduce the resident's sexual tendencies. The resident had mental illness, was demented and required constant supervision. During interviews on 9/22/21 at 3:20 P.M. and 10/7/21 at 12:45 P.M., the administrator said the following: -The facility was aware the resident had sexually inappropriate behaviors at the time of admission; -No interventions were put into place to keep Resident #2 from being sexually inappropriate with other residents; -Staff should provide treatment and services specific for residents' needs; -Staff should review residents' PASRR and implement care and treatment according to each resident's individual needs; - Staff did not focus on Resident #2's hypersexuality in the beginning; - No treatment or counseling was provided to treat the resident's hypersexuality and behaviors. MO 088

Based on interview and record review, the facility failed to maintain acceptable parameters of weight for two residents (Resident #32 and Resident #42 ), in a review of 17 sampled residents. Resident #32 experienced a weight loss of 38.8 pounds between (MONTH) 2019 and (MONTH) 2019. The resident continued to lose an additional 5.4 pounds from (MONTH) 2019 to (MONTH) 2019 for a total of 26% weight loss since admission to the facility. Resident #42 had insidious (proceeding in a gradual, subtle way but with harmful effects) weight loss, with a weight loss every month for a total of 23 pounds from (MONTH) 2019-December 2019,a 155% weight loss. The facility failed to document meal intake per their policy and to implement new interventions timely to prevent further weight loss. The facility also failed to offer one resident dependent on staff for accessing fluids and with a history of hospitalization for dehydration (Resident #32) sufficient fluid intake to maintain proper hydration and health. The facility census was 59. 1. Review of the facility policy Weight Loss revised 4/6/2017 showed the following: Purpose: To ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein level, unless the resident's condition demonstrates that this is not possible; Procedure: -The following parameters for weight loss require the physician to be notified, intervention for maintain or gaining weight, and dietician to consult on an as needed basis to ensure that proper nutritional guidelines are followed; -5% weight loss in 30 days will involve physician notification and possible orders for dietary supplement, the dietician may be notified; -7.5% weight loss in three months requires physician notification, dietician to consult and any orders to increase dietary intake, supplements, etc.; -10% weight loss in six months requires physician notification, dietician to consults, and any orders to increase dietary intake, supplements to be increased, changed etc.; -The dietician can be consulted at anytime, ensure that documentation with recommendations are charted after any consultation with the physician or dietician; -The nursing staff will follow all recommendations and physician orders, laboratory results such as serum [MEDICATION NAME] (low levels seen in inflammation, shock, malnutrition, and conditions where protein is not proper absorbed) levels will be called to the primary physician and the dietician will be notified of the results; -Residents with concerns for weight loss will be weighed as ordered by the physician and at least weekly, any weight loss issues will be addressed in weight loss meetings and will be added to the QA monthly. The ADON or designee will follow-up to ensure that weight losses meeting above parameters are followed and that the physician and dietician are consulted; -If the resident is refusing his/her meal or portions of his/her meal/snack then alternative foods will be offered to ensure that adequate intake is provided to the resident. The weight loss meeting will address offering other food choices and different types of snacks that continue to meet the residents required nutritional diet/intake. This should also be added to the resident care plan; -Accurate documentation of intakes on both meal sheets and snack sheets must be completed by the nursing staff. These sheets will be monitored by the Director of Medical Records for completeness; It will be the Resident Care Coordinator (RCC) or designee of each unit's responsibility to ensure that these sheets are being accurately completed; -Residents who have concerns for weight loss will be discussed in the meetings held weekly, this will involve reviewing intakes of both meals and snacks, and interventions for increasing nutritional intakes, the care plan coordinator will address concerns in the care plan as needed; -All residents weights will be monitored on a monthly basis as a minimum. If the resident triggers for a weight loss or gain, the resident will be placed on weekly weights. The facility will delegate the same licensed nurse/restorative aide/designee to consistently weigh the residents to ensure weight information accuracy. This process will be overseen by the RCC, dietary manager and Director of Nursing (DON). Review of the facility policy Hydration revised 4/6/17 showed the following: Purpose: The purpose of this policy is to ensure that a hydration program is in place in each facility, to monitor hydration of residents and to define clinical symptoms of dehydration. The policy will also address assessment of residents at risk for dehydration and put a plan in place to identify nursing interventions including an interdisciplinary team approach in addressing the resident who is at increased risk for dehydration or the resident that requires special assistance or special monitoring of fluid intake; Procedure: Dehydration occurs when the output of water exceeds water intake. Dehydration may result in deprivation of water, excessive loss of water and electrolyte imbalances. The following may be associated with dehydration:1. Recentt rapid weight loss; 2. Dry mucosal membranes including eyes/mouth; 3. Change in mental status; 11. Dizziness, lethargy, weakness, frequent falls; 12. Change in ability to carry out activities of daily living (ADLs); 13. Increase in combativeness/confusion; If resident has symptoms of dehydration the nurse should assess, care plan and document issues that could be causing the dehydration including: 1. Decreased fluid intake or increased output; 2. Change in mental status; 3. Weight loss of 3-5 pounds within 30 days; 5. Use of medications that promote excessive urination or affects sodium/potassium; Clinical conditions and factors that may increase the risk for dehydration: 1. Dementia or cognitive impairment; 5. Dependence on staff for eating or drinking; 6. Use of medications that can cause dehydration (e.g. diuretics); 11. Previous episodes of dehydration; 12. Difficulty or painful swallowing; 17. Chronic comorbidities (e.g. stroke, diabetes, [MEDICAL CONDITION]); Procedures to ensure decreasing the risk of dehydration:1. Fluidss will be passed every two hours with the exception of meal times and night shift. The night shift staff will ensure that fresh water is passed during the shift and ice water will be changed with clean containers; 2. One to one assistance will be provided to residents who require special assistance in consumption of fluids. This will include residents that depend on staff for assistance in consuming fluids, resident that require increased monitoring due to increased risk for aspiration, and special considerations in the consistency of fluids; 3. Accurate fluid intake and output being recorded on residents who are at risk for dehydration; 4. Assessment of residents at risk for dehydration including addressing care plans, physician involvement, dietician involvement, and documentation to show positive interventions to decrease risks for dehydration; 5. Monitoring [DIAGNOSES REDACTED]. 6. Review of residents who are on fluid restrictions including laboratory studies focusing on kidney function and electrolyte imbalance; 7. Monitoring changes in vital signs and body weight; Procedure for distribution of drinking water: c. Monitor residents who are not allowed to have water at bedside in room, ensure that correct consistency and amounts are provided to residents every two hours excluding meals and night shift. Review of the undated facility policy Nutrition Monitoring showed the following: Policy: Each resident's response to nutrition care is monitored; Monitoring included the following activities: 1. Recording the resident's percent consumption of food at each meal and the percent consumption of nutrition products; 2. Reviewing the resident's therapeutic regimen including the appropriateness of food and nutrition products and the administration route weekly; 3. Drawing conclusions and communicating them to those responsible for the resident's care; 4. Documenting conclusions and interdisciplinary conference results in the medical record; 5. Reassessing and revising the resident's nutrition therapy; 6. Reviewing residents who are not receiving adequate intake every 2-3 days. 3. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/26/19 showed the following: -Severely impaired cognitive skills for daily decision making; -No behaviors; -No rejection of care; -Required supervision with set up help only for eating; -169 pounds; -No weight loss; -No teeth; -Received diuretic seven of the last seven days; -[DIAGNOSES REDACTED]. Review of the resident's weight record for 2019 showed the following: -June 168.8 pounds; -July 165 pounds. Review of the resident's care plan dated 7/1/19 showed the following: -Resident has a [DIAGNOSES REDACTED]. -He/she has a legal guardian; -He/she has no natural teeth. He/she has dentures but chooses not to wear them; -Diet as ordered: pureed with nectar thick liquids; -Noncompliant with nectar thick liquids; -The care plan did address the risk for dehydration due to multiple psychiatric [DIAGNOSES REDACTED]. -The care plan did not address the risk of weight loss due to having no natural teeth and receiving a mechanically altered diet and liquids and a history of non-compliance with the diet and liquids. Review of the resident's weight record for 2019 showed (MONTH) weight of 160 pounds. Review of the resident's quarterly MDS dated [DATE] showed the following: -Moderately impaired cognition; -Inattention present, fluctuates; -No behaviors; -No rejection of care; -Was independent with eating requiring set up help only; -154 pounds; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months-not on physician prescribed weight loss regimen; -Received diuretic seven of the last seven days. Review of the resident's care plan updated 9/25/19 showed the following: -Resident non-compliant with diet and stealing food off other residents' plates; -Education provided about aspiration risks. Review of the resident's Certified Nurse Aide (CNA) care plan dated 9/30/19 showed the following: -Diet-pureed; -No fluid restriction; -Honey thickened liquids; -Weekly weights; -Assistive devices: dentures; -Hydration program every two hours. Review of the resident's weight record for 2019 showed the following: -September 154 pounds; -October 149 pounds; -November 130 pounds. Review of the resident's dietary notes dated 11/15/19 at 4:35 P.M. showed the following: -Resident initially admitted on [DATE], was sent out to hospital for pneumonia on 10/18/19, was readmitted on [DATE]; -Resident at nutrition risk due to [MEDICAL CONDITION], dementia, [MEDICAL CONDITION], major [MEDICAL CONDITION], anxiety disorder, [MEDICAL CONDITION] and significant weight loss; -Resident on a pureed diet, no added sodium and nectar thickened liquids, double hot cereal with breakfast and cottage cheese with a magic cup with lunch and supper; -Resident has a poor appetite, does not like the pureed food, needs encouragement to eat; -Height 73 inches, (MONTH) weight 130 pounds, down 19 pounds in one month, at 12.8% weight loss; down 30 pounds in three months, an 18.8% weight loss; down 39 pounds in five months since initial admit; -Weight loss is unplanned and not desirable; -Body mass index (BMI) 17.2-underweight weight range, resident is 71% of ideal body weight (IBW); -Labs and medications noted which includes [MEDICATION NAME] (antidepressant medication) and [MEDICATION NAME] (appetite stimulant) both started on 11/12/19 for appetite; -Recommend adding med pass supplement-120 cc twice daily at this time due to weight loss; -Will continue to follow and be available as needed. Review of the resident's fluid intake showed the following: -12/1/19: 960 cc; -12/2/19: 960 cc; -12/3/19: 960 cc; -12/4/19: 780 cc. Review of the resident's nurses' notes dated 12/5/19 at 12:55 [NAME]M. showed the following: -Last evening (12/4/19) resident fell around 7:45 P.M. when he/she attempted to get out of his/her wheelchair and fell ; -Resident then complained of pain to ribs and right hip, resident was able to move extremities freely, was assisted up to his/her bed, at 8:55 P.M. notified on call practitioner, he/she gave order for chest x-ray and x-ray of the hip tomorrow; -Called guardian and he/she said to go ahead and send the resident to the hospital; -At 9:30 P.M. ambulance here and transported resident to hospital. Review of the resident's nurses' notes dated 12/5/19 at 4:36 [NAME]M. showed at this time he/she called the hospital to check on resident, he/she was admitted with dehydration. Review of the resident's hospital discharge notes showed the following: -Discharge [DIAGNOSES REDACTED].>-On 12/4/19 Blood urea nitrogen (BUN)( blood test done to see how well kidneys are working. If your kidneys are not able to remove urea from the blood normally, your BUN level rises. Heart failure, dehydration, or a diet high in protein can also make the BUN level higher) 49.0 (8.4-25.7 mg/dl normal), creatinine (a chemical waste product in the blood that passes through the kidneys to be filtered and eliminated in urine) 1.79 (0.72-1.25 mg/dl normal), bilirubin (measures the amount of bilirubin in your blood. Test used to help find the cause of health conditions like jaundice, [MEDICAL CONDITION], and liver disease) 2.1 (0.2-1.2 mg/dl normal), [MEDICATION NAME] 3.0 (3.4-4.8 mg/dl normal); -12/6/19 BUN 28.0, creatinine 0.79. Review of the resident's hospital physician note dated 12/5/19 showed the following: -Weight loss greater than 10% in six months, greater than or equal to 20% in 12 months, 43% x eight months; -Body fat: severe depletion; -Muscle mass: severe depletion; -Meets severe malnutrition criteria; -Outcome summary: nutrition. Resident presents with severe chronic malnutrition present on admission. Resident reports he/she has a good appetite which Registered Nurse (RN) confirms. Despite good appetite, resident is noted with 70 pound/43% unintentional weight loss over the last eight months and is observed to have severe bilateral muscle wasting and subcutaneous fat loss. RN reports he/she was scheduled for a PEG tube (a tube passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) placement on (MONTH) 3rd. Review of the resident's physician's orders dated 12/6/19 showed the following: -Diet: pureed; nectar thick liquids; -Ensure twice daily between meals; -[MEDICATION NAME] 40 milligrams (mg) by mouth twice daily; -[MEDICATION NAME] 30 mg by mouth at bedtime. Review of the resident's fluid intake for 12/6/19 was 360 cc. Review of the resident's weight record on 12/6/19 showed a weight of 124.8 pounds. Review of the resident's care plan revised 12/6/19 showed the following: -Readmitted [DATE] with dehydration and severe malnutrition; 1. Refer to dietitian; 2. Diet at ordered: pureed with nectar thick liquids; 3. Offer snacks that he/she likes; 4. Supplements as ordered; 5. Offer gastrointestinal (GI) consult for PEG tube. Review of the resident's fluid intake showed the following: -On 12/7/19: 960 cc; -On 12/8/19: 960 cc; -On 12/9/19: 960 cc. Observation on 12/9/19 at 10:31 [NAME]M. in the resident's room showed the following: -The resident sat on the side of the bed rocking back in forth in attempt to stand; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -No fluids were available for this resident in the room. Review of the resident's physician progress notes [REDACTED]. -Weight loss; -Adult failure to thrive; -He/She is still waiting for gastric feeding tube. Observation on 12/10/19 at 8:48 [NAME]M. in the resident's room showed the following: -The resident lay in bed; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -No fluids were available for this resident in the room. Observation on 12/10/19 at 9:07 [NAME]M. in the hallway showed the following: -The resident sat in his/her wheelchair; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -Various staff members passed the resident in the hallway. Staff did not offer the resident any fluids. Observation on 12/10/19 at 12:10 P.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the dining room table; -The resident propelled him/herself across the room and asked the surveyor for some coffee with creamer; -The resident's lips were covered with a white sticky appearing substance; -The resident's tongue appeared dry; -The resident said, I'm thirsty and I want something to drink; -The resident propelled him/herself back to the table; -No staff offered fluids. Observation on 12/10/19 from 12:12 P.M. to 12:32 P.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -Two other residents at the table drank bottles of soda; -Staff served the resident's tablemates lunch; -At 12:32 P.M. the resident sat in his/her wheelchair at the table; -Staff served the resident's lunch tray which included 180cc chocolate milk, 240 cc water and 240 cc orange colored drink; -The resident immediately picked up the milk and started drinking. Review of the resident's fluid intake dated 12/10/19 showed intake of 960 cc. Review of the resident's medical record showed no documented meal intake. Observation on 12/11/19 at 6:12 [NAME]M. in the resident's room showed the following: -The resident sat up on the side of his/her bed rocking back and forth with his/her hands outstretched; -CNA [NAME] and CNA F provided personal care to the resident's roommate; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's tongue appeared dry; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The skin on the resident's arms was covered with white, scaly dry skin; -The resident's scratched at his/her hands and arms; -The resident's yelled out Nurse, nurse!; -The resident eventually laid back down in bed; -No fluids were available for the resident in the room. -At 6:43 [NAME]M. CNA [NAME] and CNA F assisted the resident from his/her bed to the wheelchair; -CNA [NAME] and CNA F toileted the resident and provided pericare; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's mouth and tongue appeared dry; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -Staff did not provide or offer fluids; -No fluids were available in the room for the resident. Observation on 12/11/19 at 7:50 AM showed the following: -The resident propelled him/herself in his/her wheelchair to the dining room; -The resident demonstrated continuous lip smacking and tongue rolling; -The resident's mouth, lips and tongue appeared dry; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The resident told the surveyor he/she was hungry and thirsty; -The resident propelled him/herself to the dining room table; -No fluids were available for the resident at the dining room table. Observation on 12/11/19 from 08:02 to 8:44 [NAME]M. in the dining room showed the following: -At 8:02 [NAME]M.thee resident sat in his/her wheelchair; -Staff served the resident's breakfast which including a bowl of oatmeal, bowl of pureed French toast., 240 cc milk, 180 cc orange juice, 120 house supplement and no water; -The resident began taking a few bites without assistance and drank fluids; -Three staff sat at the table fed other residents; -The resident continued to take bites occasionally, pushed him/herself back away from table, and rolled back and forth in his/her wheelchair; -An unknown CNA placed sweetener on the resident's oatmeal; -The resident pushed him/herself back from the table; -The resident asked the CNA for scrambled egg and toast and said he/she didn't want to eat the oatmeal and French toast; -At 08:23 AM the resident pushed him/herself away from the table; -The resident drank 120 cc orange juice and 120 cc supplement; -The dietary manager (DM) told the resident he/she could have egg and toast but they would have to be ground up; -At 8:38 AM to 8:44 [NAME]M. staff served the resident a bowl of pureed eggs and sausage; -The resident asked staff for chocolate milk and staff provided; -The resident did not eat any eggs or sausage; -The resident drank a few drinks of the chocolate milk and left the table; -Staff did not encourage the resident to eat or offer assistance. Observation on 12/11/19 at 10:38 [NAME]M. in the resident's room showed the following: -The resident sat on the side of his/her bed; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -The restorative nurse aide (RNA) assisted the resident from his/her bed to the wheelchair and from the wheelchair to the toilet; -No fluids were available for the resident in the room; -The RNA did not offer the resident fluids after providing care. Observation on 12/11/19 at 2:03 P.M. in the hallway showed the following: -The resident sat in his/her wheelchair; -The resident self-propelled up and down the hallway; -The resident's lips were covered with white scaly skin; -The resident's tongue was dry with a cobblestone appearance; -The resident's eyes were sunken with a hollow appearance, his/her cheeks were sunken in; -Various staff members passed the resident in the hallway and none offered fluids. Observation on 12/11/19 at 2:05 P.M. in the resident's room showed the following: -The resident sat in his/her wheelchair; -The resident propelled him/herself into his/her room; -The resident stood up and his/her alarm sounded; -Certified Medication Technician (CMT) G entered the resident's room and assisted the resident to sit down in the wheelchair; -No fluids were available in the resident's room; -CMT G did not offer the resident any fluids. During interview on 12/11/19 at 2:11 P.M. the resident said the following: -He/She was thirsty; -He/She does not have water in his/her room; -He/She would like to have water. Observation on 12/12/19 at 9:30 [NAME]M. in the resident's room showed the following: -The resident's tab alarm sounded; -The resident was walking without assistance; -The resident sat down on the bed; -CNA N entered the resident's room to silence the alarm; -No fluids were available in the resident's room; -CNA N did not offer the resident any fluids. During interview on 12/12/19 at 11:20 [NAME]M. CNA N said the resident does not have fluids in his/her room because he/she was on thickened liquids. During interview on 12/12/19 at 3:07 P.M. LPN A said the following: -The resident has no fluids at the bedside because he/she would fill the cup up with regular water; -If he/she was thirsty he/she could come ask staff; -The resident had lost weight because he/she doesn't like to eat a pureed diet; -The resident has had decreased appetite since his/her first hospital stay. During interview on 12/11/19 at 2:30 P.M. the dietary manager said the following: -The resident had lost weight, but she was not sure how much; -Staff try to give him/her anything that he/she will eat or drink; -The resident's favorite thing is soda; -If he/she drinks then he/she doesn't want to eat; -He/She gets supplements with each meal. During an interview on 12/17/19, at 10:41 [NAME]M., the director of nursing (DON) said the following: -The resident was at risk for dehydration; -Staff are expected to offer a drink every time they are in the resident's room; -The resident does not have a water pitcher because he/she was on thickened liquids; -Thickened liquids are available at all times; -If thickened liquids are not at bedside staff should get them from the kitchen; -The resident will refuse to eat and drink; -The resident wants a regular diet but he/she is not safe to eat regular food; -The resident has had multiple swallow studies to see if he/she could have a mechanical soft diet and he/she did not pass; -The resident just started progressively losing weight; -The resident receives supplements; -Staff add foods he/she likes; -Before the resident went to the hospital he/she had the magic cup, double hot cereal, and Ensure (nutritional liquid supplement) three times a day, she is not sure why those orders did not resume on readmission. 3. Review of Resident #42's weight record showed the following: -January 153 lbs.; -February 150 lbs. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Requires extensive physical assistance of one staff member for eating; -Mechanically altered diet; -Weighs 150 pounds (lbs.) -Triggered nutrition risk, will proceed with care plan. Review of the resident's care plan, dated 2/27/19, showed it did not address the resident's nutrition risk. Review of Nutritional Notification, dated (MONTH) 2019, showed; -The resident weighed 145 lbs; -Significant weight loss of 5 lbs in one month; -Mechanical soft diet; -Legal guardian notified and physician signed. Review of the resident's weight record showed the following: -March 145 lbs.; -April 144 lbs. Review of the Registered Dietitian Nutrition assessment, dated 4/9/19 showed the following: -[DIAGNOSES REDACTED]. -Diet order consistency mechanical soft; -Needs supervision, feeds self; -Edentulous (no teeth or dentures); -Difficulty swallowing; -Lab values include 11/9/18, 3.4 (low)L [MEDICATION NAME]; -Medications included multivitamin and [MEDICATION NAME] (diuretic medication). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Requires limited physical assistance of one staff member for eating; -Mechanically altered diet; -Weighs 143 lbs. Review of the resident's weight record showed the following: -May 143 lbs.; -June 142 lbs.; -July 141 lbs.; -August 139 lbs.; -September 137 lbs.; -October 135 lbs. Review of the resident's physician's order sheet, dated (MONTH) 2019, showed a diet order for mechanical soft consistency, plate guard, and spoon with built up handle to assist with maintaining food on plate. Review of the resident's quarterly MDS dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Requires limited physical assistance of one staff member for eating; -Mechanically altered diet; -Weighs 135 lbs.; -Weight loss not on physician prescribed weight loss plan. Review of the resident's care plan showed it did not address the resident's weight loss. Review of the resident's dietitian notes dated 11/15/19 showed the resident with insidious (proceeding in a gradual, subtle way but with harmful effects) weight loss and recommended health shakes two times daily with lunch and supper. Review of the resident's weight record showed the resident weighted 133 lbs in November. Review of the resident's physician's order sheet, dated 11/19/19, showed the resident started a health shake twice a day with lunch and supper. Review of the resident's weight record showed the resident weighted 130 lbs in December. The record showed the resident had weight loss every month, and did not include weekly weights. Review of the resident's care plan showed it did not address the resident's weight loss. Review of the resident's medical record showed no documented meal intake. Continuous observation on 12/9/19 from 12:35 P.M. to 1:21 P.M., showed the following: -The resident sat in a wheelchair in the main dining room at the dining room table; -His/Her left hand was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints); -At 12:35 P.M. staff served the resident a sandwich, mashed potatoes, green beans, orange slices and water. The resident had a plate guard, and regular silverware rolled in a napkin; -The resident consumed his/her sandwich and tried to unroll his/her silverware with his/her contracted left hand and his/her right hand, and did not get the silverware unrolled; -At 12:40 P.M. the resident scooped mashed potatoes with his/her fingers while DON talked to him/her and did not assist him/her with his/her silverware; -At 12:51 P.M. staff brought the resident a built up spoon, the resident did not have a fork; -At 12:54 P.M., staff served the resident a small glass milk or supplement; -The resident's plate guard opening was directly in front of the resident, the resident could only access the left side of his/her plate; -The resident attempted to load green beans on his/her spoon, and the green beans fell off his/her spoon before the resident could get the spoon to his/her mouth, he/she did not eat his/her green beans; -The resident could only reach the mashed potatoes on the left side of the plate, and scraped small bits of mashed potatoes on the plate guard; -At 1:04 P.M. LPN A put the resident's oranges in the center of his/her plate; -The resident continued to try to reach the mashed potatoes holding the end his/her built up spoon with the spoon straight down to get around the bowl of oranges; -At 1:10 P.M. the resident got one orange on his/her spoon to his/her mouth, the oranges fell off his/her spoon with several attempts; -At 1:19 P.M., the resident brought an empty spoon to his/her mouth 13 times when he/she attempted to eat his/her oranges; -Oranges were on the resident's lap, the table, and on his/her plate where they fell of his/her spoon; -The DON said to the resident, Are you just drinking the juice? and laughed; -The resident consumed his/her sandwich, 3/4 of his/her mashed potatoes, and two drinks of his/her supplement. Continuous observation on 12/10/19 from 12:17 P.M. to 1:00 P.M., showed the following: -The resident sat In a wheelchair in the main dining room at the dining room table; -His/Her left hand was contracted; -The restorative nurse aide (RNA) served the resident spaghetti with the plate guard opening on the side of the plate toward the center of the table, a bowl of fruit, and cake; -The staff gave the resident a

Based on observation, interview and record review the facility failed to provide adequate supervision and monitoring for one resident (Resident # 1) with a history of elopement at a previous facility and diagnosed with [REDACTED]. The resident resided on the locked unit and left the facility during a code green (facility protocol used when a resident displays behaviors) was called on another resident and staff were busy. The resident left the facility through an open door, climbed over a 10 foot fence and jumped to the ground, fracturing his/her leg. The resident called a family member, then walked approximately one half mile to a bean field and waited for the family member to arrive. The facility did not know the resident was missing until the resident's guardian contacted the facility. The resident was in a bean field approximately 0.5 mile east of the facility and across a two lane highway. The facility census was 58. 1. Record review of the facility's Elopement Policy and Procedure, dated 4/6/17, showed the following: -An elopement will be defined as any time a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown. -Procedure: The first person aware of an elopement will call a code white to the area of the believed elopement if known; -If the resident is believed to possibly still be inside the facility, the first person to be aware of the missing resident is to page for all units to search room to room for the resident. All room, closets, bathrooms, and work areas are to be searched; -As soon as pages have been made, the administrator is to be called immediately; -If the resident has in fact left the facility, notify the resident's family, or guardian. The person to notify the family or guardian will be designated by the Administrator; -The charge nurse on duty will initiate facility grounds search. The charge nurse on duty will call the police to report the elopement when the resident is not found in the building or grounds. The charge nurse will provide the police department with the resident's name. sex, age, time the resident was discovered missing, where the resident was last seen and when, height, race, color of hair and eyes, any physical impairments, mental impairments, spoken language, color and type of clothing worn, whether the resident is harmful to himself or others and home address of known family or friends; -The Administrator will initiate the emergency call list and coordinate the search; -As each person on the call list is notified they will call the next person and then go to the facility to assist with the search; -After the resident has been located and returned to the facility, notify the family or guardian; notify all persons involved in the search; -Perform a full body assessment; -Obtain vital signs; -Document all findings; -Notify the physician; -Complete the elopement intensive monitoring protocol upon return for attempted actual elopement; -Notification of state agencies will be at the discretion of the administrator. 2. Record review of the facility's Intensive Monitoring/Visual Check Policy and Procedure, dated 4/6/17, showed the following: -A licensed nurse will monitor residents who require intensive monitoring due to medical behavior/psychiatric symptoms and will be monitored with visual face checks; -Intensive monitoring is defined as hourly checks by a licensed nurse or one on one monitoring by a designated employee assigned by the licensed nurse; -Face to face check is defined by the employee visually seeing the face of the resident; -Residents who show poor impulse control including verbal/physical aggression, elopement ideation, suicide/homicide ideation, decompensation mentally or medically may also be placed on one to one or two to one (within eye site of the resident at all times) monitoring at the discretion of the administrative staff; -All residents on each unit will be monitored by visual face checks at least every two hours by a licensed nurse or more intensive monitoring by the licensed nurse every hour; -Special units will not be left unattended at any time; -CNAs (certified nurse assistants) will continue to monitor residents at the discretion of administration. This provides direction only to the CNAs, and the licensed nurse will be the only designated employee to guarantee face checks are provided unless the resident required one on one monitoring by the designated employee assigned by the licensed nurse; -CNAs can be provided direction to monitor the resident in a timely manner at the discretion of Administration or a medical or behavior decompensation; -The facility recognizes that the licensed nurse is the only truly dedicated employee to provide face checks every two hours, or if required more intensively every one hour. The facility will not depend on the CNAs to guarantee intensive monitoring checks. However, the Administration will continue to assign time checks with the understanding that the CNA's time may be based upon the needs of the resident and assigned duties in the facility. 3. Record review of Resident #1's Level II screening evaluation (PASRR/preadmission screening and resident review) dated, 4/6/17 (prior to admission to the facility) showed the following: -The resident had poor insight, poor judgement, lack of self-control and wandered; -The resident requires 24 hour oversight to ensure safety; -The resident was unable to be kept safe in his/her current placement as he/she leaves, consumes alcohol and puts himself/herself in harm's way. Record review of the resident's initial care plan dated 3/14/18 showed: -The resident had [DIAGNOSES REDACTED]. -The care plan directed staff to provide 1:1 attention (no time frame); -There was no documentation the resident was at risk for elopement. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/22/18 showed the following: -The resident's Level II PASRR showed the resident had serious mental illness; -The resident was admitted to the facility on [DATE] from another facility. Record review of the resident's initial psychosocial history dated 3/22/18 and signed by the administrator, DON (director of nursing), MDS (minimum data set) coordinator, and the Life enhancement director showed the following: -The resident's [DIAGNOSES REDACTED]. -The resident previously lived in a nursing facility; -The resident is ambulatory; -The resident requires psychiatric services; -The resident had a legal guardian; -Past history; elopement not identified; -Social services had reviewed the resident's PASRR. Record review of the resident's care plan dated 3/22/18 showed the following: -The staff should keep the resident's environment free of safety hazards; -The staff should monitor and document resident behaviors and report changes to the physician; -The care plan did not address the resident's elopement risk or how often the resident was to be monitored for his/her whereabouts. Review of the resident's quarterly MDS, dated [DATE] showed the following: -The resident had delusions; -The resident had verbal behaviors directed at others. Record review of the resident's Admission Elopement Assessment, no date, showed: -The resident had no history of elopement; -The resident had had two or more [DIAGNOSES REDACTED]. Record review of the resident's nurse's note dated 6/27/18 at 11:45 A.M. showed the following: -The resident's guardian contacted the facility and reported the resident had eloped from the facility; -A code white (facility protocol for a missing resident) was immediately called; -The response team was activated; -At 11:50 A.M., the local police were notified of the elopement; -The resident was reported to be at the emergency room ; -The resident was taken to the emergency room by a family member. Review of the police report for a missing person which was reported on 6/27/18 at 12:12 P.M. showed the following: -On (MONTH) 27 at approximately 11:51 A.M. the officer received a call from the facility; -The administrator said a resident of the facility had eloped from the facility; -The resident was believed to be injured and at the local hospital; -The resident's guardian was notified; -The resident's family member said he/she received a call from the resident and he/she wanted the family member to come and pick him/her up but would not disclose his/her location until the family member arrived in town; -The family member eventually found the resident in a field east of the city limits along the highway; -The resident told the family member he/she ran out the back door when staff training was called, jumped the fence, and made his/her way to the edge of town in an attempt to leave the facility. During an interview on 7/13/18 at 3:00 P.M., the police officer said the following: -The facility didn't seem to know what had happened; -The resident said as soon as the code was called he/she ran out the door; -No staff was watching; -The resident went over the fence and took off running; -The resident called a family member; -That family member called another family member who had to leave work and drive 70 miles to pick the resident up; -The resident wouldn't tell the family member where he/she was until the family member got to town; -This indicates the resident was gone from the facility for two hours. Record review of the facility's investigative narrative note, no date, showed the following: -The resident's guardian notified the facility the resident was missing; -A code white was called; -The resident's family member called the facility to say that he/she had the resident at the local hospital; -The local police were called and responded to the hospital to interview the resident; -The police officer said the resident jumped the fence after a code green; -The resident's family member said the resident contacted his/her sibling around 10:25 A.M., and the sibling called the family member at 10:45 A.M.; -The resident's family member contacted the resident's guardian to inform the guardian the resident was on his/her way to the emergency room ; -Licensed Practical Nurse (LPN) A said a code green (facility protocol for resident behaviors using crisis alleviation method and may involve multiple staff to resolve) was called on the unit; -LPN A said the resident was present when 10:00 A.M. face checks were completed; -LPN A was completing 11:00 A.M. hourly checks when a code white was called; -A head count was completed and every one was accounted for except the resident. Record review of the resident's nurse's note dated 6/27/18 at 7:00 A.M. through 7:00 P.M. showed the following: -The resident returned to the facility during shift change after leaving the facility earlier in the day unattended (without supervision); -The resident's right leg was in a splint and wrapped with an ace bandage. Record review of the resident's emergency department records from an area hospital dated 6/27/18 showed the following: -The resident arrived at the emergency room at 12:24 P.M.; -The resident sustained [REDACTED]. Record review of the resident's care plan dated 6/27/18 showed the following: -The resident eloped from the facility; -The resident had a hairline fracture to the right tibia. Record review showed no documentation the facility updated the resident's care plan to include elopement interventions. Record review of the Weather Underground showed at 10:35 A.M. on 7/27/18, the temperature was 81 degrees Fahrenheit; the humidity was 58 %. Observation on 8/1/18 at 3:00 P.M. showed a bean field next to an old school building approximately 1/2 miles west of the facility and across a two lane highway. Review of the written statement, dated 6/27/18 showed the resident said the following: -The resident was going through a lot of issues so he/she made the decision to jump over the roof; -It was about 10:00 A.M. or 10:30 A.M. when this happened. During an interview on 7/10/18 at 3:48 P.M., the resident said the following: -The facility has an open door to the outside all day; -At the spur of the moment, he/she decided to run; -The resident went outside and climbed over the fence and fell on his/her leg; -The resident ran into a bean field and called a family member; -He/she was outside for three hours; - It was very hot and he/she had no water; -The resident's family member called another family member who drove to town to pick the resident up. During an interview on 8/7/18 at 4:15 P.M. and 8/8/18 at 3:30 P.M., the resident's family member said the following: -The resident texted another family member at 10:13 A.M. (on 6/27/18); -That family member contacted this family member at 10:23 A.M.; -The family member left at 10:30 A.M. to pick up the resident; -The family member called the resident's guardian at 11:25 P.M.; -The guardian was not aware the resident had eloped; -The guardian called the facility and they were not aware the resident had eloped; -The family member found the resident in a bean field near an old school; -The resident was scared, upset and in pain; -The reporter arrived with the resident at the local hospital at 12:15 P.M.; -The reporter received a text from the administrator at 12:52 P.M. -The resident broke his/her leg. Review of the written statement dated 6/27/18 showed CNA C said the following: -CNA C saw the resident at 9:20 A.M. (on 6/27/18); -A code green was called (on another resident) around 9:40 A.M.; -CNA C gave personal care to another resident; -CNA C looked in the resident's room and thought he/she saw the resident in bed; -A code white was called and a head count was completed. During interview on 7/10/18 at 12:30 A.M. and 7/11/18 at 10:00 A.M. CNA C said the following: -The resident was antsy and paced but he/she didn't know why; -The resident was present when the code green was called (on another resident) at about 9:50 A.M.; -CNA C went down the hall to help another resident and when he/she came out of the resident's room the code white was called; -CNA C started the face checks at 10:20 A.M.; -He/she saw the resident laying in bed between 10:20 A.M. and 10:30 A.M.; -The resident was monitored every hour with face checks done by the nurse and the CNA; -The residents who are at risk for elopement are monitored more frequently. During interview on 7/10/18 at 12:20 P.M. The Human Resources Director said he/she saw the resident walking down the hall to his/her room after the code (green) was called and the residents were asked to go to there room. Review of the written statement dated 6/27/18 showed LPN A said the following: -At 9:40 A.M., a code (green) was called on the 300 hall; -At that time the resident was standing next to the resident who was involved in the code green; -Social services asked all the residents to go to their rooms; -The code was de-escalated and his/her the shift resumed at 10:00 A.M.; -At 10:00 A.M. face checks were completed; -At 11:00 A.M., LPN A returned to the 300 hall to give another resident an injection and begin accuchecks (blood glucose monitoring); -After the accuchecks were complete LPN A began to do 11:00 A.M. face checks when the code white was called and LPN A responded. During an interview on 7/10/18 at 11:15 A.M., LPN A said the following: -Social Services walked Resident #1 down the hall; -LPN A did not see the resident after the code was called at 10:00 A.M.; -LPN A left the 300 hall at 10:10 A.M. During an interview on 7/10/18 at 4:00 P.M., the resident's guardian said the following: -The resident had eloped from another facility; -That was why the Level II screening was done; -The resident's family member called the guardian and asked the guardian if he/she knew the resident had taken off (from the facility); -The family member said the resident jumped the wall (at the facility) and was in a field; -The guardian called the facility and the administrator sent staff to look for the resident; -It was a hot day. During interview on 7/10/18 at 9:10 A.M. the DON said the following: -The door to the courtyard is open from 6:30 A.M. until 10:00 P.M.; there is no code (door code) needed; -There was a code green called on the 300 hall; -As the code green progressed, the resident slipped out the door; -The staff was busy; -The resident said it was close to 10:30 A.M. when he/she left; -The code was called at 10:00 A.M. and this was when the resident was last seen for sure; -CNA C did the last face check; -Face checks are done hourly by the nurse (at the top of the hour) and the CNA does his/ her check at the half hour; -LPN A said the 10:00 A.M. face check was okay; -LPN A was going to do the 11:00 A.M. face check when the code white was called; -The resident said he/she grabbed the gutter on the building and worked his/her way up the wall; -The resident got on the roof and jumped; -The resident had not voiced his/her intention to leave the facility; -The resident was found one mile away in a field; -The resident said he/she called a family member who in turn called another family member, who came to pick the resident up. During interview on 7/10/18 at 12:42 P.M. the administrator said the following; -The police were called and went to the hospital to interview the resident; -The fence around the courtyard is 10 foot tall; -The resident said he/she did not use any furniture to get over the fence; -The resident said he/she put his foot on the door knob, grabbed the gutter, and went over the fence by the door; -The family member traveled from another town to pick the resident up; -The family member called the guardian. During interview the on 8/9/18 at 1:00 P.M. the DON and administrator said the following: -The facility did not identify the resident to be at risk for elopement; -All residents are monitored by the nurse and CNA hourly with face checks; -Residents who are identified to be at risk for elopement will be checked on first if a door alarm sounds, the staff will make sure the residents are where they are expected to be; -The facility was not aware the resident had a history of [REDACTED]. MO# 1 and MO# 2

Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) of eight sampled residents. Resident #1 presented with [DIAGNOSES REDACTED]. The resident had a recent history of verbally expressing to staff his/her desire to leave the facility. On 11/15/11, the facility allowed the resident outside privileges for 15 minutes without staff supervision and no system in place to monitor the resident or determine when the resident was expected back on the unit. The resident left the facility without staff knowledge, and the resident was unable to be located. The census was 51, with 18 residents on the secured unit. 1. Review of Resident #1's psychiatric evaluation dated 8/28/11, provided by the facility as information the facility reviewed prior to the resident's admission showed the following: -Resident hostile and aggressive with current placement, assaulted a wheelchair bound resident based on the belief the resident was speaking ill of Resident #1; -Resident reports an extensive psychiatric history, head trauma eleven years ago, having significant memory loss since the trauma; -Resident had a guardian when living in California, but is his/her own guardian at this time; -Diagnostic impression, paranoid schizophrenia; -Mental status exam showed paranoid delusions, poor impulse control, insight and judgment limited, prognosis guarded. Review of the resident's nurse's notes from prior placement dated 9/24/11-10/11/11, provided by the facility as information the facility reviewed prior to the resident's admission showed the following: -On 9/24/11 at 2000 (8:00 P.M.) resident repeatedly requesting to leave, stated "I don't care where I go"; -At 2130 (9:30 P.M.) facility received an order to send the resident to the hospital; -On 9/25/11 at 10:15 A.M. resident has been talking about leaving here, was told to come up with a plan so the facility could assist in finding resources; -On 10/3/11 at 2200 (10:00 P.M.) resident requesting to leave to go to some other place, but does not know where; -On 10/5/11 at 4:50 P.M. resident was witnessed out in the courtyard smoking cigarettes, placed on intense monitoring; -On 10/10/11 at 2300 (11:00 P.M.) resident said he/she wanted to leave, stated he/she did not know where; -On 10/11/11 at 2100 (9:00 P.M.) continues to repeatedly stated he/she wants to leave. Review of the resident's face sheet, showed the resident's current admitted was 10/17/11. Review of the resident's Minimum Data Set (MDS) assessment, a federal assessment required to be completed by facility staff history in a state database, showed some of the following MDS history: - Admission assessment, dated 07/25/11; - Discharge assessment-return anticipated, dated 08/26/11; - Entry record, dated 09/07/11, type of entry: reentry, entered from psychiatric hospital; - Discharge assessment-return not anticipated, dated 09/13/11; - Admission assessment, dated 09/20/11; - Discharge assessment-return not anticipated, dated 10/17/11; - Entry record, dated 10/17/11, type of entry: admission; - Admission assessment, dated 11/11/11. Review of the resident's October through November 2011 physician's orders [REDACTED]. Review of an undated elopement risk assessment completed by Registered Nurse (RN) D, showed the resident scored an eight, with a 1-15 as a low elopement risk. The assessment noted it should be completed on admission, quarterly and with any significant changes. Review of the resident's elopement/wandering risk assessment dated [DATE], showed the resident had impaired decision making and was at risk for elopement. Review of the resident's nursing admission checklist dated 10/17/11, showed the resident was an elopement risk. During interview on 11/29/11 at 3:45 P.M., RN D said he/she had completed the resident's elopement risk assessment on 10/17/11. RN D said he/she did not have much information on the resident. RN D said if he/she would have reassessed the resident after about one week at the facility, the resident's score would have been 16 which would have placed the resident at a medium elopement risk. RN D said he/she only updated the elopement risk assessments quarterly and not with any changes in the resident. Review of the resident's nurse's notes dated 10/17/11 - 11/15/11, showed the following: -On 10/17/11 the resident was admitted to the facility, assessed with [REDACTED]. -On 10/19/11 at 2:00 P.M. resident tearful and upset reports, "I don't need to be here"; -On 10/19/11 at 9:00 P.M. resident showing increased anxiety, resident expressed remorse over hearing voices, "Makes me do things I know are not right", will continue to monitor to ensure protective oversight; -On 10/20/11 at 12:00 A.M. resident showing increased signs/symptoms of anxiety and agitation. Resident voices concerns of wanting to leave the facility. Resident states he/she is his/her own guardian and can leave at this time if he/she wishes. Resident provided one on one attention, encouraged to stay at the facility and speak with management in the morning; -On 10/20/11 at 1:45 A.M. resident became agitated stating he/she wanted to leave the facility AMA (against medical advice). Resident became physically aggressive towards staff and CALM (Crisis Alleviation Lessons and Methods, an intervention utilized by staff to deescalate a potential crisis situation), technique utilized. Resident immediately placed on one on one supervision for protective oversight; -On 10/20/11 at 12:15 P.M. resident began to speak of leaving facility to find his/her previous home he/she lived in, did not know the name of the facility or where it was. Spoke to resident and Social Services Director; -On 10/20/11 at 8:30 P.M. resident placed one on one to due showing increased anxiety and agitation and striking another resident. Review of the resident's social service progress notes dated 10/21/-11/14/11, showed the following: -On 10/21/11 resident transported to the psychiatric hospital today. Last night had an altercation with another resident; -On 11/7/11 the resident has been expressing that she wants to leave here, but then says he/she really wants to stay, he/she just gets upset once and awhile, he/she can't make up his/her mind if he/she wants to stay or not; -On 11/14/11 resident told Director of Nurses (DON) and writer he/she does not want to be at the facility forever, he/she does not fit in with the rest of the residents. Review of the resident ' s care plan dated 11/15/11 showed the following identified problems and approaches: -Resident has a potential for elopement; observe for signs of potential elopement including verbalizing wanting to leave, and agitation, attempt to find out why the resident wants to leave; -Resident frequently will speak to staff stating he/she wants to leave the facility and then say he/she decided he/she wanted to stay; -Educate the resident he/she is his/her own responsible party and may leave; -Educate resident on safe environment, if resident decides he/she is going to leave, contact the physician; -Resident has ineffective coping mechanisms related to poor impulse control, due to [DIAGNOSES REDACTED]. -The resident may leave off the unit for activities, therapy and meals; -The resident may be off the unit on the premises two times each day for 15 minutes each time; -May leave the facility with staff. Review of the resident's five minute face check form dated 11/15/11, showed facility staff documented the resident was off the unit from 6:15 P.M. to 6:25 P.M. then from 6:30 P.M. till 6:55 P.M., was in the common room, and from 7:00 P.M. to 8:20 P.M. in his/her room. Review of the resident's nurses notes dated 11/15/11, showed the following: -At 8:10 P.M. this nurse made aware the resident did not return from outside privileges as scheduled and remains out of the facility at this time; -At 8:20 P.M. DON, administrator and management team member notified; -At 8:30 P.M. law enforcement notified. During interview on 11/30/11 at 2:15 P.M., CMT E said he/she worked the evening the resident eloped. CMT E said he/she had worked at the facility about one month prior to the resident's elopement. CMT E said the residents would write on a dry erase board when they left the unit but did not write when they were due back. CMT E said he/she worked the 3-11 shift and only one staff worked on the secured unit during the 3-11 shift. CMT E said he/she did have trouble getting everything done, face checks on everyone, two residents that required changing due to incontinency, pass medications, smoke residents and pass supper trays. CMT E said the CNA book had a list of the OSP privileges but it wasn't very accurate. CMT E said the resident had some behaviors over the weekend. On 11/15/11 the resident asked to go outside to smoke and told him/her that he/she had that privilege for 15 minutes, CMT E said he/she did not know the resident had that privilege. CMT E said the resident was asking for his/her OSP as soon as he/she arrived at work (3:30 P.M.) CMT E said the resident left the unit and then returned. CMT E said the resident ate supper in the main dining room (off the unit) and he/she had never done that before. The resident returned to the unit after supper about 6:00 P.M. and asked for another smoke break and he/she left. CMT E said about 7:00 P.M. as he/she was passing medications he/she noticed the resident had not returned to the unit. CMT E said the search then started for the resident. Review of the facility's RN (Registered Nurse) investigation report dated 11/15/11, showed the following: -At 6:15 P.M. the resident signed out for outside privileges using the current facility system of the sign out board, (dry erase board on the unit wall), and the resident advised Certified Medication Technician (CMT) A she was going to use her OSP(outside privileges) to smoke outside; -CMT began preparation for his/her 7:00 P.M. medication pass and at approximately 7:15-7:30 P.M. CMT A noted the resident remained off the unit; -Staff began a search of the facility and a search outside. Staff checked the local gas station and found the resident had been there and obtained a ride to Hannibal; -Law enforcement contacted; -The resident did not document a time on the sign out board when he/she would return; -The resident was his/her own responsible party and was capable of leaving the facility on his/her own judgment. During interview on 11/17/11 at 1:32 P.M., the administrator said the following: -The resident was admitted last month, was bipolar has TBI (traumatic brain injury), and was his/her own guardian; - The resident resided on the locked unit but had earned privileges to smoke off the unit for 15 minutes. The resident signed off the unit to smoke 11/15/11 and did not return. The resident was not supervised when smoking, other residents are not supervised either. The resident was smoking outside of the west entrance; there were no staff or residents with the resident; -The resident evidently walked to the gas station in town where he/she got a ride to Hannibal. An employee at the gas station heard the resident ask for a ride from an individual and saw the resident get in a car with the individual; - Once in Hannibal the resident was dropped off at another gas station. When the resident left the facility he/she was wearing a t-shirt and jeans, it was cool that evening. The individual at the gas station gave the resident a pink sweat shirt to wear; -The administrator said the facility did not know the resident was an elopement risk; they had no good history on the resident. The resident was admitted from another facility; -The resident signed out to smoke at 6:10 P.M., the facility had no system to monitor the residents for signing back in. The CMT that evening was brand new (2 weeks) and was passing medications. The CMT noted the resident was not available for medications between 7:15 and 7:30 P.M. (he/she had not checked to ensure the resident came back in after the 15 minute break to smoke); -The facility has tried to train staff. They had a white board on the unit that residents would note when they left by their room number on the board; -Residents can smoke off the south, north and west sides of the facility. There is a smoke room within the unit; -The resident left after dark with no money the facility was aware of. The resident was unpredictable, and could be extremely demanding; -The CMT/Certified Nurse Aides (CNA) run the unit on the evening shift. Review of a written document undated provided by the administrator, showed the following: -He could find no specific written policy on how staff was to know when a person came back from outside privileges; -The facility procedure was for residents to sign themselves back in to the unit on the white board where they had signed themselves out. Review of an undated written document provided by the administrator, showed the following: -He could find no specific written policy on how staff was to know when a person came back from outside privileges; -The facility procedure was for residents to sign themselves back in to the unit on the white board where they had signed themselves out. Review of the weather underground report, (a commercial weather service that provides real-time weather information via the Internet), showed the temperature on 11/15/11 at 5:54 P.M. was 55.9 degrees and the temperature at 6:54 P.M. was 48 degrees. The resident left the facility in a tee shirt, jeans and flip flops. Observation on 12/5/11 at 1:15 p.m., showed the resident crossed a secondary highway and walked 0.3 miles, 0.2 miles of which had no sidewalk, in the dark to a gas station where he/she found a ride to Hannibal Missouri. Complaint # MO *Higher classification merited due to the effect on the resident. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility initiated monitoring of residents when off the unit with assurance of sufficient staff to meet the need. The facility began inservicing of staff regarding the new procedure for residents signing in and out of the secured unit. The facility had yet to complete elopement assessments on all residents or inservice all staff on new policy and procedures regarding resident monitoring when off the secured unit and outside privileges. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to ensure that one of 19 sampled residents was free of significant medication errors when staff administered one resident (Resident # 19's) medication at the wrong time. The facility census was 40. 1. Review of Resident #19's Minimum Data Set (MDS), dated [DATE], showed he/she had [DIAGNOSES REDACTED]. Review of Resident #19's physicians orders from a transfer sheet from a local hospital dated 02/28/11, and signed by the physician showed an order for [REDACTED]. Observation on 03/09/11, during the 8:00 A.M. medication pass showed at 8:40 A.M., Registered Nurse (RN) D administered Resident #19 his/her medication [MEDICATION NAME] with 120 cubic centimeters (cc's) of supplement. The resident had already been served his/her breakfast tray. Review of the facility meal times list showed the following: -Breakfast- 7:00 A.M. to 7:30 A.M.; -Lunch-12:00 Noon to 12:30 P.M.; -Dinner (Supper)-5:00 P.M. to 5:30 P.M. Review of Resident #19's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., 12:00 Noon and 5:00 P.M. daily. (Staff administered at least 25 doses of the [MEDICATION NAME] with meals since his/her re-admission to the facility from 03/01 thru 03/09/11 at 8:00 A.M.) During interview on 03/09/11 at 10:20 A.M., the Director of Nursing (DON) said she had transcribed the physician's orders [REDACTED]. She said it should have been PO every AC and should have been administered to the resident before meals at 6:00 A.M., 11:00 A.M. and at 4:00 P.M. daily. During interview on 03/09/11 at 10:30 A.M., the resident said his/her stomach hurt all the time. During interview on 03/09/11 at 11:15 A.M., RN D said he/she should have given the [MEDICATION NAME] medication to the resident before meals, but gave it with meals because it was that way on the MAR indicated [REDACTED]. Review of the Taber's cyclopedic Medical Dictionary, Edition 14, second printing July 1981, showed the definition of a.c means before meals.

This deficiency was uncorrected. For previous examples, refer to Statement of Deficiencies dated 3/11/11. Based on observation, interview and record review, the facility failed to ensure staff provided services to prevent pressure sore development and to promote healing for four of 14 sampled residents (Residents #3, #7, #10 and #12), by failure of staff to frequently reposition dependent residents, and failure to promptly identify new pressure sores and obtain physician orders [REDACTED]. The facility census was 41. 1. Review of Resident #12's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 03/08/11, showed the following: -Had moderate impairment with cognition; -Needed extensive assistance with one person physical assist with bed mobility, transfers and toileting; -Was occasionally incontinent of bowel and bladder; -No swallowing disorder or dental problems; -Was at risk of developing pressure sores with no pressure sores present on prior assessment; -Pressure reducing device bed and chair; -Nutrition or hydration intervention to manage skin problems. Review of Resident #12's care plan reviewed 03/08/11, and reviewed 04/22 and 04/27/11, showed the following: Nutritional status: Problem difficulty swallowing, Dx (diagnosis) dysphagia; Approaches/Interventions: -Ice cream with lunch and supper; -No caffeine after lunch; -House supplement at lunch; -Diet per order; -Encourage resident to eat small bites at a slow pace (swallow before next bite). Pressure ulcers: Problem actual skin breakdown, Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) sacrum and Stage I (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues) right hip; Approaches/Interventions: -Check every day for any redness/discoloration or open areas, notify charge nurse promptly if any present; -Monitor for signs/symptoms of potential breakdown; -Notify physician of any signs or symptoms of skin breakdown. Weekly skin assessments; -Approaches per Braden scale; -Frequent turning at least every 30 minutes, pressure reduction support surfaces (bed & chair), protect heels; -Turn and reposition per physician's orders [REDACTED]. -Manage moisture; -Avoid friction and shear; -Pressure relieving mattress to bed; -Bedrest; -Toilet with assist at least every two hours; -Treatments per order; -Assist with catheter care every shift and PRN (as needed); -Educate staff that the resident's skin is very fragile and prone to breakdown, bruising, and skin tears. Review of Resident #12's Braden Scale for predicting pressure sore risk showed the following: -Assessment date 03/31/11 was blank (the assessment was not completed); -On 04/13/11, showed a score of 14 (score of 14 was moderate risk). (The resident was in the hospital at this time 04/07/11 to 04/15/11); -On 04/15/11, showed a score of 12 (score of 12 at high risk). Review of Resident #12's physician order [REDACTED]. -The resident had [DIAGNOSES REDACTED]. -Mechanical soft diet; -Ice cream with lunch and supper; -House supplement with lunch. (This order was changed on 04/06/11, to house supplement 120 cc's TID (three times a day) with meals). Review of Resident #12's shower sheets for March, 2011, showed the following: -On 03/09/11, nail care done, hair shampooed, skin cream applied, no red/open areas; -Next date recorded was 03/06/11, resident refused; -On 03/20/11, nails cleaned, peri area clean, hair shampooed, skin cream applied, no red/open areas; -On 03/27/11, nail care done, peri area clean, no red/open areas. During interview on 05/03/11, at 9:40 A.M., CNA R said he/she had given Resident #12 his/her shower on 03/27/11, on a Sunday. He/she said he/she remembered that he/she laid the resident down to dry his/her skin off. He/she said the resident's skin was not discolored at all and did not appear to be red, blue or purple in color. He/she said there was nothing there. Review of Resident #12's nurses notes showed the following: -On 03/24/11 at 6:00 P.M., voices no pain, nor discomfort noted. Skin pale, warm, no red or open areas noted. Will continue to monitor; -On 03/30/11 at 10:00 A.M., Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) decubitus ulcer to coccyx that measured 4 cm length x 4.5 cm width with 3 cm depth. The wound bed was black with wound edges yellow and some surrounding areas pink, no drainage, mild odor. The wound was cleansed with sterile wound cleanser and wet to dry dressing applied and covered with gauze and secured with me-fix. (There was no documentation the resident's physician was notified of the pressure sore in this note); -On 03/31/11 at 12:00 A.M. (midnight) showed documentation resident resting and dressing intact, then a late entry note was added for 10:00 A.M., that said resident noted to have open area 03/29/11, and the physician was notified and to see note on TAR (treatment administration record). New orders were received. Consult for 04/01/11; -On 04/01/11 (untimed) Occupational Therapy note: Gel foam cushion in place created with electric knife to decrease pressure on coccyx. In addition, front of wheelchair frame has been raised. Staff documentation that a new order received for treatment to decubitus ulcer; (The physician order [REDACTED]. -On 04/02/11(untimed) order for [MEDICATION NAME] and [MEDICATION NAME] to coccyx done, Silver Alginate not available at this time, 4x4 [MEDICATION NAME]. Area with scant drainage, wet eschar with angry red peri-wound that was about 1.5 cm eschar to center of wound with 1 cm green slough. The resident complained of pain when up sitting, no complaints of pain during treatment. The resident up for meals and laid down pc (after meals); -On 04/08/11 at 12:00 Noon, treatment done to resident's coccyx as ordered. The physician was made aware that decubitus had foul brown drainage. A telephone order was received to send the resident to the hospital. Ambulance notified and resident left from building at 11:45 A.M. Review of Resident #12's treatment record showed the following: -On 03/24/11,(untimed) no red or open areas noted; -On 03/29/11, (untimed) resident noted to have open area at midline of coccyx 6 (six) cm x 4 (four) cm with "bl" tissue noted of wound bed. No drainage noted, surrounding tissue red. Fax sent to the physician awaiting new orders. New orders received per evening nursing staff for wet to dry dressing BID with surgical consult;(no further treatment notes until 04/06/11); -on 04/06/11 (untimed) unstable pressure area 11 cm x 7 cm with "bl" gray center and surrounding tissue, then pink red edges. Continue with daily dressing changes of [MEDICATION NAME] with [MEDICATION NAME] 1% cream and Silver Alginate and cover with [MEDICATION NAME] dressing. (On 05/04/11, the DON said this documentation were the weekly skin assessments). Review of Resident #12's hospital history and physical report showed the following from the physician: -The resident was admitted to the hospital from the nursing home on 04/08/11 with worsening decubitus ulcer on his/her sacrum. The patient's symptoms started developing sometime in the last month. The resident felt an increasing ulceration on his/her sacrum. About two weeks ago was contacted, and we started on local wound treatment and recommended a referral to a surgeon. The nurses at the nursing home got some advice from the wound nurses and we started that treatment and held off on the surgical referral. He/she saw the resident back on Wednesday (two days ago)(04/06/11), at which time the resident still had a lot of necrotic debris in his/her sacrum, although by pictures it looked a little bit better. He/she recommended at that time that we go ahead with the surgical debridement, and that was being set up. Today he/she got a call stating it was worse with the increased drainage, and the resident had a low grade fever. At this point he/she asked the resident be brought to the hospital for admission. The resident was not eating or drinking well at all. We did start nutritional supplements two days ago, and he/she got a [MEDICATION NAME] level back yesterday which was low. He/she increased the resident's nutritional supplements (120 cc's PO TID on 04/06/11); -Swallowing dysfunction but refuses thickeners and failed multiple swallow tests in the past; -Had [MEDICAL CONDITION], mild dementia, [MEDICAL CONDITION], chronic compression fracture of his/her spine; -Had been getting [MEDICATION NAME] cream and [MEDICATION NAME] cream mixed to cover with silver alginate and [MEDICATION NAME] dressing to his/her sacral decubitus since April 1, 2011, changed twice daily and has been on an air mattress; -The decubitus ulcer of the resident's sacral was quite large and deep. It had a greenish base with some holes draining. There is some purulent (forming or containing pus) material. Impression and plan: -Large sacral decubitus ulcer, Stage IV, with purulent drainage. We will treat the resident with local debridement, and will ask another physician to see the resident for that. The resident will be started on antibiotic therapy and for now start saline wet to dry dressing changes; -Nutrition: Encourage PO (by mouth) intake, which had been a problem, which may inhibit further healing of the ulcer. Review of Resident #12's hospital surgical consultation report dated 04/08/11, showed the following: -The resident had a history of [REDACTED]. The resident was brought to the emergency room today because of foul odor from the ulcer. On the resident's sacral coccygeal area there was a 4 cm decubitus ulcer which was covered with foul-smelling necrotic debris. Plan: -We will proceed with debridement of the sacral ulcer in the operating room. Review of Resident #12's progress notes from the hospital showed the following: -On 04/10/11, patient seen for follow up visit. Patient is not eating very well, is more alert and he/she refused the surgery adamantly yesterday for debridement of the sacral decubitus, some of his/her pills and dressing changes as well; -Addendum: Progress note dated 04/10/11, talked to the power of attorney today, and for now no surgery will be offered for the patient as per patient's wishes, as the guardian feels seems appropriate with his/her prior understanding of patient. We will continue treating with antibiotics and local wound treatment for [REDACTED]. We will then see in the future whether to re-hospitalize him/her or not based on his/her overall condition. He/she was told life expectancy is less than six months; -On 04/13/11 on his/her sacral decubitus those fibrous bands have really removed with the sealing wet to dry dressings changes and he/she is more open now all the way down to the bone with some periosteum (the fibrous membrane which forms the investing covering of bones) seen and it is a much more cleaner wound, less discharge; -On 04/14/11, he/she doing well, no new problems noted. Decubitus ulcer infected, continue IV antibiotics today and plan discharge to the nursing home tomorrow, if stable. He/she is eating a little bit better. Review of Resident #12's physician's orders [REDACTED]. -Re-admit to facility for wound care; -Saline wet to dry dressing change to sacral decubitus TID (three times a day); -Pressure relief mattress; -Keep out of chair; -Foley catheter to gravity drainage. Review of the facility's nurses notes showed the following: -On 04/15/11 at 5:30 P.M., the Speech Therapist evaluated the resident and changed his/her diet to pureed with liquids remaining thin. -On 04/15/11, a telephone order was received from the physician to change the resident's diet from mechanical soft to pureed, due to weakness and need for nutritional intake, liquids to remain thin at this time. Review of the facility's weekly skin assessments by RCC (Resident Care Coordinator), completed by RN D showed the following: -On 04/22/11, he/she assessed Resident #12's skin and documented the following: -Right hip bone prominence unblanchable redness, Stage I (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues) that was 1 cm wide x 0.7 cm length; -Sacral decubitus ulcer 5 cm width x 5 cm length and 3.4 cm depth. Review of the facility's weekly wound assessment report dated 04/22/11, issued by RN D showed the following pressure sore documentation: -Resident #12 had a Stage I pressure ulcer on his/her right hip prominence that was 1 cm x 0.7 cm in size, no exudate; -On the sacrum had a Stage III pressure sore that was 5 cm x 5 cm x 3.4 cm depth, small amount of sero-sanguinous exudate, wound bed was yellow beefy red, edges were macerated (to soften by steeping in a fluid), peri-wound was red. Observation on 04/27/11 at 1:30 P.M., showed the resident was lying on his/her right side, CNA R was sitting at the resident's bedside in a chair feeding the resident his/her noon meal. The food tray appeared to be a regular tray with ground meat. (It did not include ice cream or house supplement shake). Review of the menu submitted for Resident #12, for the noon meal on 04/27/11, showed the following: -Marinated pork roast; -Stuffing; -Yams; -Fruit crisp; -Bread and butter; -Milk and water. Review of Resident #12's diet card from the Dietary Manager showed the following: -The resident was on a mechanical soft diet; -Ice cream with lunch and supper. The diet card did not list any house supplements. During interview on 04/27/11 at 2:35 P.M., CNA R said Resident #12 received regular food and the meat was ground, yams. At 3:10 P.M., CNA R said the resident did not receive a pureed diet for lunch, nor did the resident receive ice cream or a house supplement with his/her meal. Observation on 04/27/11 at 3:30 P.M., showed the following: -RN D prepared supplies and CNA M assisted; -Staff explained to the resident what they were going to do; -The resident was positioned on his/her right side; -RN D removed the soiled dressing from the sacrum/coccyx area was removed, which had pinkish colored drainage; -The wound was circular and was approximately 5 cm x 5 cm. The wound bed was pink and clean with a muscular appearance at the deepest point, there was no slough, no foul odor noted. There appeared to be a small hole/tunneling area that was approximately 0.5 cm round that was positioned at approximately 6-7 o'clock position. The outer peri wound was pinkish/bluish in color. RN D sprayed the wound bed with wound cleanser, then cleansed the wound with sterile saline (did not use sterile gloves) gauze, then wet the 4 x 4 gauzes with saline, then opened each 4 x 4 gauze and packed each into the wound with a Q-tip. He/she used three 4 x 4 gauzes to pack the wound and then covered with dry 4 x 4's and placed [MEDICATION NAME] over the wound. RN D said the wound was a Stage III pressure sore. During interview on 04/27/11 at 3:25 P.M., the Dietary manager said Resident #12 was on a mechanical soft diet at his/her preference. The resident drinks liquids out of a nosey cup, gets ice cream at lunch and supper, then said she was not sure, received no caffeine after lunch, but could have with lunch. She said the house supplements come from the kitchen. She said whoever takes the orders from the physician was responsible to relay in writing any dietary changes to the kitchen. When the physician's orders [REDACTED]. During interview on 04/27/11 at 3:55 P.M., with the Administrator, the DON, and RN Z, they said that whoever took the orders off, should have been the one to relay in writing to the kitchen of the diet change. The DON said she was not aware of the new orders or that had not been relayed to the kitchen. During interview on 04/28/11 at 8:30 A.M., the Administrator said Resident #12's pressure sore was found on Sunday 04/03/11. She said on Monday, 04/04/11, they were actively seeking treatment. She said the resident's physician made rounds on the 5th (04/05/11) and he/she wanted the resident to have a surgical consult. The pressure sore had black eschar and couldn't be staged. She said they got a wound consultant and came up with a treatment to try for the rest of the week. She said on Friday, staff went to do a dressing change and noticed a foul odor and contacted the physician and the resident was sent to the hospital. She said they did antibiotic therapy. She said she spoke with a nurse at the hospital and the resident refused to have the surgical debridement and the treatment continued. During interview on 05/02/11 at 3:00 P.M., the DON said Licensed Practical Nurse (LPN) H found the pressure sore on Resident #12 on 03/29/11. She said the resident was on a mechanical soft diet with nosey cup for all liquids at meals, ice cream with lunch and supper and house supplement at lunch. She said she was not aware the house supplement orders had changed on 04/06/11, and she was not aware of the resident having any pressure sores prior to 03/29/11. During interview on 05/04/11 at 8:40 A.M., the resident's physician's nurse said the following: -The physician said he/she was first made aware of the resident's pressure sore on his/her sacrum on 03/29/11, and more than likely it didn't occur over a two day period. 2. Review of Resident #3's Braden scale for pressure sore development risk dated 11/5/10, showed the resident scored 12 (at high risk for pressure sore development). Review of Resident # 3's quarterly Minimum Data Set (MDS), dated 2/4/11, showed the following: -Severely impaired cognitive skills; -Total dependence with two person physical assist for transfers and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan dated 8/14/10 and updated 4/27/11, showed the following: -Turn and reposition every two (2) hours; -Extensive assist of two required for bed mobility, transfer and locomotion; -Dependent X2 with toileting; -Peri-care every shift and prn (as needed) related to incontinence; -Reposition every two (2) hours in bed or in wheelchair with two assist due to impaired mobility. Observation of the resident on 4/27/11, showed the following: -At 10:20 A.M., the resident sitting up in his/her wheelchair dressed in street clothes, out in the hall with a mechanical lift seat underneath the resident and folded up over his/her legs, a nutritional supplement infusing and plugged into the wall; -At 10:38 A.M., CNA R and CNA T pushed the resident into his/her room; -At 10:39 A.M., CNA R left the room, the resident remained sitting in his/her wheelchair; -At 10:40 A.M., CNA T pushed the resident back into the hall and plugged the nutritional supplement in the wall; -At 11:10 A.M., the resident remained sitting in his/her wheelchair in the hall; -At 11:25 A.M., the Administrator and the corporate nurse pushed the resident into the dining room (where an activity was in progress); -At 11:35 A.M., the resident remained sitting in his/her wheelchair in dining room; -At 11:45 A.M., the resident remained sitting in his/her wheelchair in dining room; -At 12:00 noon, the resident remained sitting in his/her wheelchair in dining room; -At 12:10 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 12:25 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 12:36 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 12:46 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 1:00 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 1:30 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 1:50 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 2:15 P.M., the resident remained sitting in his/her wheelchair in dining room; -At 2:45 P.M., CNA T and the Administrator assisted the resident into his/her room; -At 2:55 P.M., CNA T and the DON (Director of Nursing) assisted the resident into his/her bed. The wheelchair seat was wet, the mechanical lift seat was saturated with a strong smelling urine and the resident's pants were wet. There was not seat cushion noted in wheelchair. The resident had been incontinent of urine and bowel movement, his/her bottom coccyx area was red and slightly purple. No open areas noted. The resident's skin was blanchable. The facility staff had failed to keep the resident's skin clean and dry and failed to change the resident's position for at least 4 hours and 25 minutes. Record review of Resident #3's face to face check document dated 4/27/11, showed the resident in the common area from 9:45 A.M. until 12:30 P.M., and in the dining room from 12:45 P.M. until 1:30 P.M. During interview on 4/27/11 at 2:28 P.M., CNA R said that they are supposed to turn the resident at least every 2 to 3 hours and he/she is to be up in a chair for 2-3 hours a day. Staff were expected to provide incontinence care at least every two hours. He/she was not sure what time they had gotten the resident out of bed that day. During interview on 4/27/11 at 2:40 P.M. the DON said she expected facility staff to reposition residents every two hours when in bed or up in a chair. 3. Review of Resident #7's admission MDS, dated [DATE], showed the following: -Had both short and long term memory problem; -Made poor decisions; -Required extensive assistance of two staff for turning in bed; -Required total assistance of two staff for transfers; -Did not walk; -Had impaired range of motion and movement on one side of body; -Had an indwelling urinary catheter and a feeding tube; -Not on a scheduled pain medication regimen; -Had pressure reducing device on bed; -On turning and repositioning program; -At risk for developing pressure ulcers; -Had one Stage II pressure ulcer and one Stage II pressure ulcer on admission; -Had application of dressings to feet; -[DIAGNOSES REDACTED]. Review of Resident #7's Care Plan for Pressure Ulcers, reviewed and signed by MDS coordinator on 04/27/11, showed the following: Problem: Resident #7 had actual breakdown to ankles and feet and is at risk for friction and shear; Approaches/Interventions: -Turn and reposition every 1-2 hours with assistance times two; -Keep skin clean and dry; -Skin assessments weekly. Check daily for red areas and call physician for orders to treat; -Treatment as ordered. The following was handwritten: -Pressure relieving mattress to bed and wheelchair; -Position heels upon pillows while in bed or provide heel protection. Review of the CNA ADL book showed that on April1, 6, and 16th, Resident #7 had a shower. Staff had not filled out the skin assessment portion. Review of the facility Braden Scores (skin assessments to identify residents at high risk for developing pressure ulcers), showed that on 04/11/11, the facility identified Resident #7 as a score of 13 (13-14 is moderate risk for developing pressure ulcers). Review of the undated Braden Scale Interventions For Residents Identified as High Risk form showed the following for Resident #7 with score of 13 which was moderate risk for developing pressure ulcers: -On turn and reposition schedule; -Pressure relief in bed and chair; -Use positioning devices/pillows while in bed; -Need heel protectors or heels up off bed with pillows; -Incontinent; -Use barrier cream. Review of the Weekly Wound Assessment Report dated 04/22/11, showed Resident #7 was not included on the report. Review of the Weekly Skin Assessments by RCC (Resident Care Coordinator) report dated 04/22/11, showed Resident #7 was not included on the report. Review of the corrected Weekly Wound Assessment Report for Pressure Sores dated 04/22/11, showed Resident #7 added to the report with the following: -One pressure sore on left lateral ankle, Stage II, (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. This may also present as an intact or open/ruptured blister) on the resident's coccyx (tailbone). measuring 1.7 cm by 2.3 cm by 0.4 cm depth, scant small amount sero sanguinous (composed of serum and blood drainage, Allevyn dressing, and treatment had changed. The resident had pain; -Pressure sore on left lateral foot, Stage II, 2.8 cm by 2.2 cm by 0.7 cm depth, with a red-pink wound bed without slough (There was no documentation of the four Stage II pressure ulcers.) Review of the nurses notes dated 04/22/11 at 10:00 P.M., showed LPN AA noted two open areas on the resident's coccyx area. One open area measured 2 cm by 1 cm by 0 depth. The second open area measured 2 cm by 0.5 cm by 0 depth. TAO (Triple Antibiotic Ointment) and gauze was applied to the coccyx. Review of a physician telephone order dated 04/23/11, showed staff were to apply barrier cream to "abrasions on coccyx area" and to keep resident off area until healed. Review of the nurses note dated 04/24/11 at 10:00 A.M., showed RN D documented the dressing to the resident's left foot ulcers was C/D/I (Clean, Dry, and Intact). (There was no documentation of the Stage II pressure ulcers on the coccyx). Observation on 04/26/11 at 9:53 AM., showed Resident #7 in bed and said he/she was hurting. A nurse was in the room and said he/she could not give him/her anything more for pain right then due to the time. There was a visitor in the room. The resident then started asking the nurse for something to make him/her go to sleep and asked, "Can ya?" The nurse asked if they could move him/her around and the resident said, "Yes". (Staff did not turn the resident). The resident continued to ask for a pain pill and an CNA began talking to him/her about a family member. The resident asked for pain medicine again. Observation on 04/26/11 at 10:46 A.M., showed Resident #7 in bed wearing a hospital gown with white washcloth covering his/her forehead and eyes. A family member was sitting in a chair next to the resident's bed. The resident said his/her left side, left leg and ankle hurt all the time and said he/she had pain from "gas buildup" in his/her chest. During interview on 04/26/11 at 10:46 A.M., the family member said he/she had been with the resident since 7:40 A.M. and staff had not turned or gotten up the resident while he/she was there. He/she said the resident did not like to be moved due to his/her left leg hurting. During interview on 04/26/11 at 10:58 A.M., RN D said Resident #7 had pressure sores on the left foot and one on his/her coccyx. The resident had a treatment of [REDACTED]. The resident had [MEDICATION NAME] medication (for pain) given by mouth at 10:30 A.M. Staff were to put barrier cream on the "abrasions" on the resident's coccyx three times a day and PRN (as needed) and this had been started on 04/23/11. Observation on 04/26/11 at 11:15 A.M., showed there was a dressing on the resident's coccyx. The resident had a bowel movement which RN D used wet wipes to clean between the buttocks first and then removed the dressing on the coccyx. This revealed four open, red Stage II pressure ulcers on the resident's coccyx. During interview on 04/26/11 at 11:20 A.M., RN D said he/she did the pressure ulcer assessment last week and did not look at the resident's coccyx, only the resident's feet. He/she said he/she did not measure or assess the Stage II pressure ulcers on the coccyx. During interview on 04/26/11 at 11:25 A.M., the DON said they had ordered an air loss mattress for the resident and had been on this for a couple of days. They had also got a new air bed the previous Thursday. (This was five days previous). Observation on 04/26/11 at 11:45 A.M., showed the following: -On the resident's right side of coccyx (tailbone): 1.3 cm length by 1.5 cm wide, red with no drainage Stage II pressure ulcer; -On the resident's left side of coccyx: -One Stage II pressure ulcer that measured 1.8 cm by 1.5 cm; -One Stage II pressure ulcer that measured 0.6 cm by 0.7 cm diameter; -One Stage II pressure ulcer that measured 1.1 by 1.8 cm, (all four Stage II pressure ulcers were open, red with no drainage). During interview on 04/26/11 at 11:54 A.M., RN D said there was no treatment order from the physician for the pressure ulcers on the coccyx. Observation on 04/26/11 at 11:54 A.M., showed RN D and CNA J turned the resident to his/her left side in the bed. CNA J placed a wedge behind the resident's back. During interview on 04/26/11 at 12:04 P.M., CNA J said there was a turn schedule on the clock across from the nurses station. Staff were to turn residents to the left side at 12:00 Noon. Every resident was different because some of the residents could not lie on their back. Staff turned these residents from side to side. During interview on 04/26/11 at 12:11 P.M., the DON said LPN AA reported Resident #7 had abrasions on the coccyx the previous Thursday or Friday, April 21 or 22 (This was a time period of 4-5 days previously). Review of a physician order [REDACTED].M., showed staff may use [MEDICATION NAME] to dress ulcers to left foot until [MEDICATION NAME] (an antibiotic cream) comes in then resume previous SSD/[MEDICATION NAME] mixture order. (The four Stage II pressure ulcers on the coccyx were not addressed). Observation on 04/26/11 showed the resident remained on his/her left side between 11:54 A.M. and 4:30 P.M. (This was a time period of approximately 4 and 1/2 hours).Staff did not get the resident out of bed. 4. Review of Resident #10's MDS, dated [DATE], showed the following: He/she was admitted on [DATE]; -Was cognitively intact; -Needed extensive assistance with two persons physical assist with bed mobility, transfers and toileting; -Was frequently incontinent of bowel and bladder; -Was at risk for developing pressure ulcers; -Had a feeding tube; -Had one Stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) on admission. Review of Resident #10's care plan dated 03/14/11, showed the following: ADL (activities of daily living) Functional/Rehab Potential: Problem: Decline in ADL functioning related to illness. Required extensive assist and was non-ambulatory at this time. Approaches/interventions: -Required extensive assist of 2 (two) for bed mobility, transfer, toileting; Urinary incontinence/catheter: Problem: Incontinent of bowel and bladder related to use of diuretic and [DIAGNOSES REDACTED]. Approaches/interventions: -Change of position frequently to decrease risk of sacral breakdown. Nutritional Status: Problem: Refusing to eat. Peg tube (percutan

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for three of 19 sampled residents (Residents #7, #10, and #14). The facility census was 40. 1. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/18/10, showed the following: -Had both short and long term memory problem; -Made poor decisions; -Required extensive assistance of two staff for turning in bed; -Required total assistance of two staff for transfers; -Did not walk; -Had impaired range of motion and movement on one side of body; -Had an indwelling urinary catheter and a feeding peg tube; -Not on a scheduled pain medication regimen; -Received prn (as needed) pain medications; -[DIAGNOSES REDACTED]. Review of the care plan showed the following: -The care plan was undated, unsigned by facility staff; Problem: Dependent for cares related to mental and physical deficits due to cognitive loss and [MEDICAL CONDITION](stroke); Approaches/Interventions: -Siderails x two to assist with bed mobility and extensive assist x two with turning and repositioning; -Bears weight inconsistently. Transfer with extensive assistance of two staff and gait belt; -To receive a shower two times a week and prn (as needed). Extensive assistance of one staff; -Range of motion each shift; -Dependent for locomotion in wheelchair, dressing, eating, toileting, and personal hygiene; -Preventative and protective skin care ongoing due to incontinence; -Assist to activities of choice for socialization. Problem: Impaired mobility/ambulation due to left sided [MEDICAL CONDITION] from [MEDICAL CONDITION]; Approaches/Interventions: -Transfer, toileting, turning, repositioning with extensive assistance of two staff; -Up in wheelchair with extensive assistance of two staff. Problem: Stage II Decubitus. Superficial skin breakdown on left heel; Approaches/Interventions: -Turn and reposition every 1-2 hours with two staff assistance; -Keep skin clean and dry; -Skin assessments weekly. Check daily for red areas and call physician for orders to treat; -Treatment as ordered. Problem: Pain Management: [MEDICATION NAME]; Approaches/Interventions: -[MEDICATION NAME] ordered by physician; -Assess for signs and symptoms of pain such as facial grimacing, increased agitation, verbalizing pain; -Report signs and symptoms of breakthrough pain to physician; -Transfer with mechanical lift and two staff assistance; -Monitor for side effects of [MEDICATION NAME] per nursing drug handbook, including [MEDICAL CONDITION] (heart beat slowing), and respiratory depression. Review of the physician progress notes [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -[MEDICATION NAME] ([MEDICATION NAME]) tablet 4 milligrams (mg) one tablet by mouth every 4 hours as needed for pain and ordered by physician on 12/20/10 (Staff had not documented as administered to the resident during this time); -Patient Care Order Pain Assessment as needed, use 0-10 scale (The MAR indicated [REDACTED] -[MEDICATION NAME] ([MEDICATION NAME]) tablet 10-325 mg one tablet by mouth every 4 hours as needed for pain not to exceed 4 grams (gm) APAP(Tylenol) /24 hours and ordered by physician on 02/11/11. Review of the Mosby's Nursing Drug Reference 2010 handbook showed: -[MEDICATION NAME] was a combination of [MEDICATION NAME] and [MEDICATION NAME] and used for moderate to severe pain; -Onset effect of 15-30 minutes with peak effect in 1 hour, and had duration of 3-4 hours (Resident #7 requested pain medication frequently and his/her pain level remained high); -Side effects included constipation and precautions included bowel impaction (Resident #7 complained of being constipated and not feeling well). Review of the MAR indicated [REDACTED] -0n 02/24/11 at 5:30 A.M. (Staff did not document location and intensity of the pain, or the medication's effectiveness); -On 02/26/11 at 10:00 P.M. (Staff did not document location and intensity of the pain, and the medication's effectiveness); -On 03/01/11 at 9:00 A.M. (Staff did not document location and intensity of the pain, and the medication's effectiveness); -On 03/01/11 at 5:30 P.M. Staff documented "E" (effective)(Staff did not document location and intensity of the pain); -On 03/01/11 at 10:00 P.M. Staff documented "E" (effective) (Staff did not document location and intensity of the pain); -On 03/02/11 at 10:40 A.M. Staff documented "E" (effective) (Staff did not document location and intensity of the pain); -On 03/03/11 at 9:15 P.M. Staff documented "E" (effective) (Staff did not document location and intensity of the pain); -On 03/04/11 at 1:00 P.M. Staff documented "E" for effective and recorded the resident complained of pain all over and rated the pain 7 out of 10 on pain scale and then at 2:00 P.M., results were "no complaints"; -On 03/05/00 at 12:15 A.M. (Staff did not document location and intensity of the pain, and the medication's effectiveness); -On 03/06/11 at 9:30 A.M. and 1:30 P.M. (Staff did not document location and intensity of the pain, and the medication's effectiveness at either times of administration); -On 03/07/11 at 12:00 P.M. and 7:00 P.M. (Staff did not document location and intensity the pain, and the medication's effectiveness at either times of administration); -On 03/08/11 at 9:45 A.M. (Staff recorded the resident complained of abdominal pain and did not rate the intensity or severity of the pain, and at 11:00 A.M., the resident had no complaints and staff documented "E" for effective); -On 03/08/11 at 3:30 P.M. (Staff recorded the resident complained of left leg pain of 7 out of 10 on pain scale and at 5:00 P.M., staff documented "E" for effective); -On 03/09/11 at 6:00 A.M. (Staff recorded complaint of pain at 8 out of 10 on pain scale and did not record location of pain and then at 7:00 A.M., the resident had no further complaints and staff rated the pain 5 out of 10). Review of the physician orders [REDACTED]. -Additional [DIAGNOSES REDACTED]. -treatment of [REDACTED]. Review of the Daily Skilled Nurses Notes showed the following: -On 03/05/11 (untimed), Resident #7 had yelled out multiple times that day and complained of abdominal discomfort. The nurse held his/her tube feeding x 1(times one) hour with no improvement. The resident stated he/she felt constipated. The resident had no order for something for constipation. Staff notified a physician and received an order for [REDACTED]. The resident complained of pain and refused for staff to check his/her blood sugars at 12:00 Noon. Review of the PRN Medications MAR indicated [REDACTED]. Review of Resident #7's ADL (Activities of Daily Living) sheet for under Bowel Tracking showed the following: -On 03/05/11, on 7:00 A.M. to 3:00 P.M. shift, staff documented the resident had a small bowel movement. On the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shift, staff documented zero. (Staff failed to document whether the bowel movement was loose, firm, or soft). Review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 03/05/11 at 12:00 Noon, staff recorded an "R" (resident refused) in the blank space for the 12:00 Noon accucheck results. Review of the Daily Skilled Nurses Notes showed the following: -On 03/06/11 (untimed), Resident #7 yelled out numerous times for the nurse and complained of abdominal pain. Staff checked the resident's blood sugar at lunch and it was low. Staff did not hold the resident's tube feeding due to the low blood sugar. Staff administered the pain medication ([MEDICATION NAME]) twice. Review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 03/06/11 at 12:00 Noon, staff recorded the resident's blood sugar was 67 (normal blood sugar range is 70-120). Observation on 03/07/11 at 7:00 P.M., showed Resident #7 calling out for the nurse and said he/she "hurts". Staff answered call light and the resident said he/she was constipated. The staff went to tell the nurse. The resident had a tube feeding on the pump at 80 ml/hour. During interview on 03/07/11 at 7:00 P.M., Resident #7 said he/she was constipated and staff had administered a suppository for constipation yesterday (03/06/11) but the suppository did not work. The resident said his/her pain level on pain scale of 1-10 with 10 being the highest level of pain was a "10+" and constant pain. The resident said he/she had a big sore on his/her foot. Observation on 03/07/11 at 7:05 P.M., showed the nurse entered the room and gave pain medication through the feeding peg tube and then went to check on constipation medication for the resident. Review of Resident #7's ADL (Activities of Daily Living) sheet for Bowel Tracking showed the following: -On 03/07/11, on 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts, staff documented the resident had no bowel movement and on 11:00 P.M. to 7:00 A.M. shift, staff documented the resident had an "XLG" (extra large bowel movement and did not specify if the bowel movement was loose, firm, soft); Review of the nurses notes dated 03/07/11 at 6:45 P.M., showed the following: -The resident was awake and confused to time and place; -The resident complained of constipation; -Staff administered [MEDICATION NAME] suppository per prn (as needed) order and noted a small amount of soft bowel movement; -Staff administered [MEDICATION NAME] 10/325 mg per prn order for complaint of pain in left side; -Staff documented at 10:00 P.M. that the resident was resting quietly at present. Review of Resident #7's ADL (Activities of Daily Living) sheet for Bowel Tracking showed the following: -On 03/08/11, at approximately 2:45 P.M., staff had documented on 7:00 A.M. to 3:00 P.M. shift, the resident did not have a bowel movement, and had documented a "L" (large) bowel movement on the 3:00 P.M. to 11:00 P.M. shift and "O" for the 11:00 P.M. to 7:00 A.M. shift for 03/08/11. During interview on 03/08/11 at 2:45 P.M., LPN G said the 3:00 P.M. to 11:00 P.M. shift should not have recorded the "L" since staff were not there to work yet. LPN G was not sure why this was done. He/she had given a suppository to Resident #7 and large results were documented on the 11:00 P.M. to 7:00 A.M. shift. He/she had checked him/her and had felt soft bowel movement last evening (03/07/11). During interview on 03/08/11 at 9:30 A.M., Resident #7 said he/she had pain in his/her stomach and in his/her left leg and arm. The resident rubbed his/her abdomen. The resident said he/she hardly ever got up and had not been up today even though the physician wanted him/her to get up at least once a day. He/she said staff would not get him/her up out of bed. The resident said he/she can roll over a little. Observation on 03/08/11 at 9:40 A.M. showed Licensed Practical Nurse (LPN) G entered the room and the resident requested a pain pill from the nurse. The resident said he/she had pain in his/her "belly". LPN G did not ask the resident the intensity of the pain. LPN G went to get the pain medication. (The nurse did not assess the resident's abdomen.) Review of the MAR indicated [REDACTED].M. showed staff recorded administering [MEDICATION NAME] for pain. The resident complained of abdominal pain and did not rate the intensity or severity of the pain, and at 11:00 A.M., the resident had no complaints and staff documented "E" for effective. During interview on 03/08/11 at 11:35 A.M., Resident #7 said he/she had pain in his/her "belly" and down the left leg. The resident said his/her pain was at an "8" level on a scale of 1-10. The resident described the pain as "it comes and goes", "beating", "thumping" pain and sometimes the pain was steady. (Review of the MAR for 03/08/11 at 9:45 A.M., showed LPN G noted the resident complained of abdominal pain and at 11:00 A.M. no complaints and wrote "E" for effective). Observation on 03/09/11 at 8:50 A.M., showed LPN O did a water flush in Resident #7's stomach peg tub. While performing this procedure, Resident #7 said he/she felt a "little sick" and requested something for it. The resident said the pain pill would help. LPN O said the resident had pain medication recently but would check. During interview on 03/09/11 at 9:06 A.M., Resident #7 said his/her arm and leg hurt. He/she had been sick every morning for the last two weeks and had wanted to go to the hospital or see a physician because he/she felt bad in his/her stomach. During interview on 03/09/11 at 9:15 A.M., the Director of Nursing (DON) said the resident's physician had been to the facility on [DATE] to see his patients. (Review of Resident #7's physician progress notes [REDACTED]. Observation on 03/09/11 at 10:50 A.M., showed RN D entered Resident #7's room to administer [MEDICATION NAME] 10/325mg one tablet through the resident's peg gastrostomy tube (two hours after the resident asked for it). RN D asked the resident what his/her pain level was and the resident said, "10". (This was the highest level of pain on pain scale of 0-10). During interview on 03/09/11 at 11:01 A.M., Resident #7 said the physician was there a couple of weeks ago but didn't get to talk to him/her. The resident said the pain medication calms him/her down but his/her pain level at the moment was "8 or 9". Observation 03/09/11 at 11:15 A.M., showed Resident #7 lying flat on the bed with the tube feeding running at 80 ml/hr. The resident said, "I'm sick", while waiting for CNA S and CNA Q to return. Resident #7 asked for something for his/her stomach. Observation on 03/09/11 showed the following: -At 11:24 A.M., RN D entered the room to check Resident #7's blood sugar. The resident's head of the bed remained flat with the tube feeding running. Resident #7 said his/her "nose was sore" and his/her "stomach needs cleaned up". CNA Q used the mouthwash and mouth rinse and wiped mouth with one toothette with mouthwash and then another toothette with mouthwash. RN D waited; -Resident #7 said, "Oh, I'm hurting." RN D did not say anything but checked his/her blood sugar and left the room; -CNA Q put lotion on the resident's right leg and arm and asked if he/she could put lotion on his/her left arm. Resident #7 said his/her arm was "too sore" but said CNA Q could put a little bit of lotion on his/her arm and leg. The resident requested a medicated body powder on his/her groin area; -At 11:34 A.M., Resident #7 said he/she wanted something for his/her throat because "so much stuff back there he/she can't breathe". CNA Q put a pillow underneath the resident's left arm and the resident said he/she felt better; -At 11:35 A.M., CNA Q straightened the resident's left leg to place protective boot on. The resident said, "Ouch, it hurts". CNA Q put a wedge between his/her legs and said that they needed to move his/her left leg so he/she won't lose it. He/she covered the resident with a sheet. During interview on 03/10/11 at 5:20 P.M., LPN G said they had stopped giving [MEDICATION NAME] pain medication to Resident #7 because it did not work but that the resident probably could benefit from a pain patch (a topical pain medicine absorbed systemically on a continuous basis). 2. Review of Resident #10's admission sheet showed he/she was admitted to the facility on [DATE]. Review of Resident #10's current physicians order sheets dated 02/24 thru 03/23/11, showed he/she had [DIAGNOSES REDACTED]. Review of Resident #10's transfer order sheets dated 03/04/11 and signed by the physician showed the resident had an order for [REDACTED]. allergies [REDACTED]. Review of initial care plan dated 03/04/11, showed staff failed to address pain issues and skin issues and pressure sores on his/her heels. Review of the Skin Assessment for Admissions sheet dated 03/04/11 at 12:00 Noon, showed the following: -Both heels circled by staff and in the column for type of area, staff documented that the heels had "blistering to feet". (Staff did not document these heels had pressure sores, and did not assess, measure, and stage pressure sores on the resident's bilateral heels). Review of the Braden Scale for Predicting Pressure Sore Risk form dated 03/04/11, showed the resident had a total score of 11 which was at high risk for developing pressure sores. High risk for developing pressure sores was a total score of 12, Moderate risk was total score 13-14, and Low risk was 15-16 if under [AGE] years old or 15-18 if over [AGE] years old. Review of the Weekly Wound Assessment Report dated 03/04/11, showed Resident #10 was not listed on the report as admitted to the facility with pressures sores on both heels. Review of telephone order (undated) showed a pressure sore treatment of [REDACTED]. Observation on 03/07/11 at 7:10 P.M., showed Resident #10, lying in bed and groaning. During interview on 03/07/11 at 7:10 P.M., Resident #10 said he/she was having pain and had open area of feet and had a dressing change once daily on his/her left foot. During interview on 03/09/11 at 9:15 A.M., Resident #10 said the following: -His/her pain was continual; -He/she had sores on his/her heels and had acquired the pressure sores while in the hospital; -On a pain scale of 0-10, his/her pain was an eight on heels all of the time; -He/she stayed in bed most of the time. During interview on 03/09/11 at 2:45 P.M., Resident #10 said he/she had pain all of the time. Observation on 03/10/11 at 9:50 A.M., showed the following: -RN D and LPN H entered the resident's room to perform a dressing change; -RN D removed the bandage from the resident's heel, and as he/she was doing this the resident was observed to have facial grimacing; -There was an approximately quarter size open Stage II (a partial thickness loss of skin layers either dermis or epidermis that presents clinically as an abrasion, blister, or shallow crater) pressure sore with scant amount of brown colored drainage on the right heel; -LPN H asked the resident if he/she was in pain and the resident said yes, and that it was an eight and had pain of "8" all the time; -Neither RN D or LPN H offered the resident any pain medication and continued with the dressing change. During interview on 03/10/11 at 9:55 A.M. LPN H said the following: -Hospital reported to the facility upon 03/04/11 admission that Resident #10 had a blister on the right heel; -The resident slides to the end of his/her bed a lot. (LPN H and RN D lifted the resident up in the bed with the bed pad. (The HOB (Head of Bed) was up due to resident had a feeding tube). Review of Resident #10's MAR indicated [REDACTED].M. (Review of the MAR indicated [REDACTED]. 3. Review of Resident #14's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Did not feel down, depressed, or hopeless; -Did not think he/she would be better off dead, or of hurting self in some way; -Had no behaviors in previous seven days; -Independent with walking; -Required supervision and set up help only with dressing and personal hygiene; -[DIAGNOSES REDACTED]. Review of the initial care plan on date of admission, 12/15/10, showed the following: -Potential for infection and staff approaches of skin assessments and monitor vital signs: -Pain and staff approaches of pain assessment every shift; -Safety and staff approaches to monitor for safe room checks and provide protective oversight. (The care plan did not address any behaviors nor signs and symptoms of resident behavior before use of chemical and/or physical restraints). Review of the physician orders [REDACTED]. -[MEDICATION NAME] (an antipsychotic) 200 milligrams (mg) at bedtime; -[MEDICATION NAME] (an antipsychotic) 5 mg one tablet at 12:00 Noon; -Klonopin (for [MEDICAL CONDITION])1 mg twice a day; -[MEDICATION NAME] (for [MEDICAL CONDITION]) 500 mg twice a day; -[MEDICATION NAME] (for depression)75 mg ER (extended release) with 150 mg ER to = 225mg every day; -[MEDICATION NAME] (for [MEDICAL CONDITION]) 250 mg one at bedtime; -[MEDICATION NAME] (for [MEDICAL CONDITION]) 30 mg at bedtime; -[MEDICATION NAME] (antipsychotic) 5 mg po (by mouth) every four hours prn; -[MEDICATION NAME] 5mg IM (intramuscular) inject 1 ml every 4 hours prn; -[MEDICATION NAME] (for anxiety) 2 mg one po or 1 ml injection every 4 hours prn every 4 hours prn agitation/anxiety. Review of the care plan book for resident's on the unit showed staff failed to develop a comprehensive care plan for the resident after completion of the comprehensive assessment. Review of the nurses notes showed the following: -On 12/20/10 at 6:55 P.M., Resident #14 had signs and symptoms of increased agitation and verbal aggression toward staff and another resident related to rules on the unit. Staff provided 1:1 for protective oversight; -On 12/29/10 at 1:30 P.M., the resident had increased anxiety and was demanding. Staff provided 1:1; -On 01/23/11 at 6:00 P.M., Resident #14 had increased signs and symptoms of agitation and aggressive behavior towards self and others. The resident began hitting the walls with fists. The resident's aggressive behavior escalated and CALM (Crisis Alleviation Lessons and Methods to utilize recognized techniques in managing behavioral emergencies which focus on the safety of residents and staff) technique used. Staff administered PRN (as needed) [MEDICATION NAME] (an antipsychotic) 5 milligrams (mg) with and [MEDICATION NAME] (an antianxiety medication) 2 mg by injection in the resident's right buttock. The resident's guardian, a physician, and administrator were made aware; -At 6:15 P.M., staff escorted the resident to his/her room and placed on 1:1 monitoring. Staff noted reddened areas on bilateral knuckles and forehead. The resident was upset about the X/Box (interactive video game device) not working and his/her parent would not buy a new X/Box. Review of the Activities Progress Notes dated 01/23/11(untimed), showed the resident became agitated with telephone call and began punching walls and hitting head on floor. CALM technique implemented. (Staff failed to notify the physician of the resident's of behaviors for which staff used physical and chemical restraints.) Review of the Activities Progress Notes dated 02/14/11(untimed), showed the resident was upset at another resident and hit the window in his/her room and received a point reduction (if a resident is not following the unit rules, or has behaviors, points can be deducted). (Staff failed to notify to notify the physician of behaviors). Review of the nurses notes on 02/21/11 at 6:00 P.M., showed LPN G documented Resident #14 became agitated with other residents and had to be held back to prevent the resident from hitting another resident. (Staff failed to notify the physician.) Review of the nurses notes dated 02/22/11, showed the following: -At 4:30 P.M., LPN G documented Resident #14 had increased agitation and on floor trying to beat head on floor. STOP ( basically certain guidelines to look at, such as residents age and risk, then the CALM five man take down may not be done) program initiated; -At 4:45 P.M., LPN G administered [MEDICATION NAME] 5 mg/ml and [MEDICATION NAME] 2mg/ml IM (Intramuscularly) without incident. Resident placed on 1:1 for protective oversight due to making comments of suicide with wires on X/Box. X-Box locked in office and resident moved to room [ROOM NUMBER] for current time while on 1:1 (Staff failed to notify the physician of behaviors and administering IM medication and comments about suicide); -At 6:00 P.M., LPN G documented the resident had no further behaviors; -At 7:00 P.M., LPN G documented the resident continued 1:1 for behavior earlier this PM (evening); -At 9:00 P.M., LPN G documented the resident was resting quietly at present and continued 1:1; -At 11:00 P.M. LPN G documented 1:1 complete per (RCC) (resident care coordinator) LPN H, and Administrator. Staff would continue 5 minute face checks. Review of the nurses notes dated 02/23/11, showed the following: -At 10:30 A.M., RN D documented Resident #14 had been upset today due to game box being taken away for behaviors and upset roommate; -Behaviors did not escalate at this time; -At 4:45 P.M. LPN G documented the resident was up and did not voice complaints. The resident was in room playing X-Box and no behaviors noted. Review of the Activities Progress Notes on 02/25/11 (late entry)(untimed), showed Resident #14 threatened to commit suicide and roommate was removed. Staff notified the guardian. (Staff failed to notify the physician of behaviors). Observation on 03/09/11 showed the following: -At 4:00 P.M., several residents on the behavioral unit standing in line to receive their money from the Activities Director who was in charge of the resident trust fund accounts; -At 4:30 P.M., several staff hurried to Resident #14's room where yelling and cursing were heard in the hall. -The resident's room door was open and several staff including MDS/Care Plan Coordinator and LPN G (charge nurse) entered the room ; -The resident was bent at the waist with his/her elbows and hands being held down by Activity Director and CNA M; -Activity Director assisted with the hold and was the one talking to the resident to attempt to calm him/her; -Resident #14 yelled, "I'm tired of everything!" and said at one point, he/she would "bite them!" -The resident was by the end of the bed and then the Activity Director and CNA M walked the resident to a chair to sit down. The resident quieted and staff began to leave slowly a few at a time; -From out in the hall, the Activity Director could be heard with a raised voice say, " I have told you, I have told you, and I have told you" and mentioned his/her "X-Box" and "money". (Staff failed to notify the physician of the incident.) During interview on 03/09/11 at 4:40 P.M., the Activity Director said he/she calms Resident #14 down in 15 minutes. It all started when Resident #14 had gone in a room and slammed the door. During interview on 03/09/11 at 4:50 P.M., CNA L said staff take a pillow when Resident #14 has behaviors because he/she beats his/her head on the floor. Review of the nurses notes on 03/09/11 showed the following: -At 4:00 P.M., LPN G documented Resident #14 was upset due to missing personal snack time. The resident was trying to hit walls with fist. The Activity Director aware and doing 1:1 with resident (Staff failed to notify the physician of behaviors); -At 4:15 P.M., LPN G documented Resident #14 did not have any behaviors at present; -(There was no documentation in nurses notes regarding incident that occurred at 4:30 P.M.); -At 8:15 P.M. LPN G documented Resident #14 taking items off wall because upset with parent due to telephone conversation. The resident attempted to hurt self with push pin. Staff redirected and 1:1 given to resident by LPN G at present. The resident complained of being tired of waiting on everything such as parents coming to see him/her and buying things, upset due to parents' car needing repair and unable to visit this upcoming weekend. LPN G explained to resident it would all work out and asked when parents were able to come and the resident said next Wednesday. The resident was calmer after redirection from LPN G and ready for smoke time. (Staff failed to notify the physician of behaviors); -At 8:30 P.M., LPN G documented the resident was in smoke room trying to burn hair on arm with cigarette. LPN redirected the resident without difficulty and placed on 1:1 for protective oversight. RCC, DON (Director of Nursing), Administrator, and Facility Nurse Advisor aware of 1:1. (Staff failed to notify the physician of the behaviors). Review of the Activities Progress notes dated 03/10/11 for incident on 03/09/11 (untimed), showed Resident #14 was upset over his/her resident trust fund balance available. Staff were called in to help de-escalate the issue. During interview on 03/10/11 at 10:20 A.M., the Activity Director said he/she was on the behavioral unit to do "pay day" on 03/09/11. They do banking from 9:00A.M. to 4:30 P.M. He/she had given the residents their balances earlier from their resident trust fund accounts and Resident #14 was upset. The Activity Director did not understand why because he/she explained the previous transactions regarding a check was not in yet and the resident had made random or impulsive decision to take out money. The resident was upset about his/her parent not coming to see him/her until next Wednesday. The Activity Director said he/she felt the underlying upset was about the parent not visiting. The resident wanted to leave and get out of the facility and wanted to "punch" something which wouldn't help to get money in his/her account. Resident #14 "stormed" down the 300 hall to an empty room and slammed the door. This was the room next to the smoke room. The Activity Director followed him/her and the resident told him/her if he/she opened up the door again, he/she would damage or hit something. If the Activity Director did not get out, the resident said he/she would hit the window. The Activity Director approached the resident who went toward the window. The Activity Director said Resident #14 escalates fast so he/she told an aide to call for additional staff. CNA K, CNA L, and CNA Q came to the room door. CNA K came into the room. The resident lunged for the window with arms up "like a charge". CNA K and Activity Director each had a resident's arm and escorted the resident to a chair. CNA M replaced CNA K. The resident tried to hit his/her head on knees and the Activity Director requested a pillow for head safety. If he/she dropped down, the resident would hit his/her head. This resident does this. They talked the resident over to a chair and he/she sat down. They held his/her arm and kept wrist down so the resident would not hit his/her face. The resident began to calm down and his/her arms began to relax. The Activity Director asked if staff okay to leave. The Activity Director and CNA M stayed, DON and LPN N stayed. The Activity Director asked the resident if they could remove their arms, if he/she was calm, and the resident said yes. He/she asked if he/she wanted help to budget money and have coping skill group activities to allow better techniques for anger management. The resident stood up, hugged him/her, and apologized for behavior and said he/she was trying to work on his/her anger; -The Activity Director said he/she knew the level system and had worked with extreme behavior before at another facility with a behavior unit. He/she said the level system and focus were the same thing; -The Activity Director said Resident #14 played the X-Box 24 hours a day and it broke a month ago. During interview on 03/10/11 at 10:33 A.M., the Activity Director said staff were supposed to contact the physician if staff have to give an injection to the residents for behaviors. The type of restraint on Resident #14 was called a "Two Man Escort" since the resident was on the STOP program and can't take down with the 5 man take down. Review of the written statement by the Activity Director received on 03/10/11, showed the