Monarch Springs Wellness & Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident with a history of elopement was provided with adequate supervision and staff oversight (Resident #2). On 3/10/26 at approximately 11:20 A.M., staff observed through the window that the resident was outside, across the street from the facility. The resident had a wanderguard (device that sets off an alarm when the person wearing it attempts to exit the facility) on his/her wheelchair and was able exit the building unnoticed through one of two exit doors on the second floor, which were alarmed but did not have a wanderguard sensor. The facility identified 10 residents who were at risk for elopement. The sample was 4. The census was 58. Review of the facility's Wandering and Elopement Policy, dated 08/2020, showed the following:-Purpose: To enhance the safety of residents of the facility;-Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement;-Procedure: --The licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition to determine their risk of wandering/elopement;--The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition;--Response to Resident Elopement:---The licensed nurse most familiar with the incident will document in the resident's medical record how the elopement occurred. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/25, showed the following:-Moderate cognitive impairment;-No wandering behavior exhibited;-Mobility with a wheelchair;-Diagnoses included dementia, depression, Wernicke's encephalopathy (acute neurological disorder causing brain injury), heart failure, high blood pressure, and diabetes. Review of the resident's care plan, dated 10/14/25, showed the following:-Focus: The resident is at risk for elopement related to elopement evaluation risk score;-Interventions/tasks included elopement attempts from previous facility or hospital. Wanderguard, check for placement every shift. Supervise closely and make regular compliance rounds. Review of the resident's Elopement Risk Evaluation, dated 10/14/25, showed the following:-Imminent Risk;--Physical: Patient ambulates and propels self, and/or wanders. Patient has intentionally or unintentionally attempted to leave community: Yes;-Action: Implement elopement risk care plan. Interventions: Wanderguard and/or secure environment placement;-Comments: Resident elopement occurred, the resident returned to facility, staff on one to one (1:1) observation with the resident presently, wanderguard placed, notifications to the resident's responsible party and physician. Review of the resident's nurse's note, dated 3/10/26 at 5:04 P.M., showed staff documented the resident eloped outside of facility. The resident was escorted back into facility. A head to toe assessment was completed. The resident had zero bruising and no other changes noted. The resident's emergency contact and physician were made aware and the resident's vital signs were stable. The nurse's note did not specify how the resident eloped from the facility. Review of the second floor staffing sheets, dated 3/10/26, showed one nurse and one Certified Medication Technician (CMT) scheduled for day shift. No other staff scheduled for the second floor on day shift. Observation on 3/19/26 at 1:40 P.M., showed the resident seated in his/her wheelchair with a wanderguard device in the pocket of his/her wheelchair. During an interview, the residentsaid he/she did not remember getting out of the facility. He/She would like to go outside at times. During an interview on 3/20/26 at 10:29 A.M., CNA E said he/she was assigned to the resident on 3/10/26. The last he/she saw the resident was in his/her room at approximately 7:30 A.M. to 8:00 A.M. and he/she was asleep. CNA E thought the resident had eloped before but did not know the date. During an interview on 3/19/26 at 9:42 A.M., Licensed Practical Nurse (LPN) D said on 3/10/26, he/she was the nurse scheduled on the second floor. He/She received a text from the facility that the resident had gotten out. He/She saw the resident being escorted back inside the facility by staff. He/She never heard any alarm sound when the resident left the floor. During an interview on 3/19/26 at 12:35 P.M., the Director of Rehabilitation (DOR) said on 3/10/26, she was in the therapy room second floor working with a resident. She looked out the window and saw Resident #2 across the street, standing with his/her wheelchair. The DOR was the only one working in the therapy room on 3/10/26 and the door was closed and the music was loud. She did not hear any alarms sounding at the facility. If she or any of her staff would have heard any alarms, she would expect them to go and investigate. Observations of the second floor on 3/19/26, showed the following:-At 12:40 P.M., no staff visible on the second floor. During a test for staff responsiveness, conducted with the facility's Administrator, the exit door near room [ROOM NUMBER] was opened and an alarm sounded for approximately three seconds, then stopped, while the door remained open. No staff responded to the alarm. During an interview, the Administrator said from the exit door to where the resident was found outside, it appeared to be a distance of approximately 700 yards;-At 12:50 P.M., Housekeeper A was by the second floor dining room. During an interview, he/she said he/she had been on the second floor for about 10 minutes. He/She did not hear an alarm sound;-At 12:52 P.M., a test for staff responsiveness was conducted with the facility's Administrator at the exit door in the second floor dining room. The exit door was opened and an alarm sounded for approximately 30 seconds. No staff responded to the alarm;-At 12:55 P.M, Physical Therapist (PT) B and PT C were in the therapy room inside the second floor dining room. During an interview, PT B and PT C said they heard an alarm sound a couple minutes ago but they did not go and investigate the alarm. PT B said he/she did not know there was an exit door in the second floor dining room. PT B and PT C said they should have investigated the alarm. During an interview on 3/20/26 at 9:24 A.M, the Maintenance Director said the front door is the only door with a wanderguard sensor. All exit door alarms should sound for 20 to 30 seconds. He was not aware the exit door alarm near room [ROOM NUMBER] was not working properly by sounding for only a few seconds. During an interview on 3/20/26 at 1:02 P.M., the DON said the resident is an imminent risk for elopement, meaning he/she is at high-risk for elopement. The DON did not know how the resident got outside of the building. She expected the elopement policy to be followed as written. During an interview on 3/20/26 at 1:04 P.M., the Administrator there should be at least one staff member on the second floor at all times. The resident got out of the facility through one of the second floor exits. The Administrator did not know how long the second floor exit door near room [ROOM NUMBER] was malfunctioning. He expected staff to respond to any door alarms immediately and for staff to be on the floor as scheduled. He did not know why this did not happen on the day of the resident's elopement. 2801617

Based on interview and record review, the facility failed to notify one resident's legal guardian of a change of condition and transfer to a hospital (Resident #3). The sample size was 4. The census was 45.Review of the facility's Change of Condition Policy, dated 1/2025, showed the following:-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner;-Policy:- Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death;-I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an ACOC;-II. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:--A. An injury/accident;--B. A significant change in the resident's physical, cognitive, behavioral or functional status;--C. A significant change in treatment; and/or a decision to transfer or discharge the resident from the facility;-Procedure:-Family Notification: The Licensed Nurse will notify the resident, the resident's responsible party, or the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. Review of Resident #3's medical record, showed diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and major depression. Review of the resident's care plan, dated 11/2/25, showed the resident has a Public Administrator appointed as his/her legal guardian, who manages the resident's medical and financial needs. Review of the resident's medical record, showed documentation of the Public Administrator Guardianship, dated 8/20/25. Review of the resident's nurse's note, dated 12/24/25 at 6:34 A.M., showed the resident remains in the hospital. Review of the Complaint/Investigation Report, dated 12/26/25 showed, the reporter was contacted on 12/25/25 by the hospital psychiatrist asking mental health questions about the resident. The resident had been at the hospital since 12/23/25 and no one from the hospital or facility called to notify the resident's guardian that the resident had been sent out to the emergency room and admitted until two days later. Review of the resident's nurse's note, dated 12/27/25 at 6:16 P.M., showed the resident returned from hospital via ambulance. Further review of the resident's medical record, showed no documentation of the resident's change of condition or the resident's guardian being notified of the resident's change in condition. During an interview on 12/29/25 at 12:25 P.M. Licensed Practical Nurse (LPN) A said the Administrator, the Social Service Director and other management were present while the resident was having behaviors. LPN A was instructed to send the resident to the hospital. LPN A was working with an orientee at the time and assumed the orientee called the resident's physician and guardian and documented the incident. During an interview on 12/29/25 at 12:35 P.M., the resident said he/she went the hospital but was not sure when. He/She has a guardian but was not sure of his/her name. He/She did not know if the facility should contact his/her guardian regarding his/her care. During an interview on 12/30/25 at 9:50 A.M., LPN B said LPN A should have called the resident's physician and guardian about the resident going to the hospital. He/She was not sure if the guardian was notified. There was a lot going on at that time. On the day the resident went out to the hospital, LPN B was an orientee and it was his/her first day. Standard protocol for any facility is to call the resident's physician and get an order to send the resident to the hospital and to contact the guardian to make them aware. During an interview on 12/29/25 at 2:25 P.M. with the Director of Nursing (DON) and Administrator, the DON said LPN A should have called the resident's guardian and documented the call and the change of condition in the resident's medical record. LPN A did not do a proper follow-up. The DON did not know why this was not completed. The Administrator agreed with the DON. 2701154

Based on interview and record review, the facility failed to provide care and services to ensure one resident (Resident #1) was free from accident hazards when a Certified Nurse Aide (CNA) failed to secure the resident in bed before leaving to answer the call of another resident in a different room. The resident rolled of the bed and hit his/her head on the floor. The resident suffered two lacerations to the top of his/her head. The sample was four. The census was 44.
The Administrator was notified on 1/31/25 at 2:53 P.M., of the past non-compliance, which occurred on 1/16/25. The facility provided training and in-servicing for all staff regarding the facility's resident safety policy. The facility also updated the resident's care plan to ensure the resident's bed is in the lowest position with a mat next to the resident's bed. The deficiency was corrected on 1/20/25.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/21/24, showed the following:
-Severe cognitive impairment;
-Dependent with activities of daily living;
-Diagnoses of Alzheimer's Disease, depression and high blood pressure;
-History of one fall without injury.
Review of the resident's care plan, dated 1/20/24, showed the following:
-Problem: The resident is at risk for injury regards to fall, unsteady gait/balance, wheelchair bound and poor safety awareness;
-Intervention: Keep bed in lowest position with brakes locked.
Review of the resident's nurse's note, dated 1/16/25 at 4:57 P.M., showed the nurse was at the desk when the CNA yelled out and said that the resident had fallen out of the bed. The CNA had heard another resident yelling and he/she went to see about this resident and when he/she came back, the resident had fallen. Pressure was applied to the wound and 911 was called.
Review of the resident's hospital aftercare medical record, dated 1/16/25, showed the resident has a history of Alzheimer's disease, nonverbal at baseline, congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should), high blood pressure and severe malnutrition, who is coming in from his/her nursing home for a fall out of bed. The resident is unable to participate in gathering history however information from Emergency Medical Services (EMS) said he/she was found out of bed at his/her nursing home with a laceration to his/her head.
Observation on 1/27/25 at 10:07 A.M., showed the resident lay in a low bed with a mat on the floor. The resident had six sutures on the top of his/her head which measured approximately 4 centimeters (cm) by 3 cm.
During an interview on 1/27/25 at 9:45 A.M., CNA A said he/she started his/her rounds. He/She went into the resident's room to give care. CNA A said just as he/she raised the resident's bed to give care, he/she heard another resident screaming out his/her name for help. CNA A went to check on the other resident because he/she did not know if something happened. CNA A found the other resident sitting on the side of his/her bed. CNA A told this other resident he/she would be right back. When CNA A got back to the resident, he/she was on the floor. CNA A said he/she immediately got the charge nurse. CNA A did not secure the resident before leaving and the resident rolled off the bed. CNA A said he/she should have secured the resident before leaving. CNA A said he/she was recently inserviced on the importance of securing a resident before leaving the resident.
During an interview on 2/6/25 at 12:36 P.M., Licensed Practical Nurse (LPN) B said CNA A yelled for him/her to come to the resident's room. The resident had fallen out of bed. When LPN B got to the resident's room, the resident was on the floor bleeding from his/her head. LPN B used a towel stop the bleeding. After he/she got the bleeding under control and the DON arrived, he/she called 911. The resident should have been in a low bed with a mat to the floor. LPN B said when he/she entered the room, the bed was not in a low position and a mat was not on the floor. CNA A should have secured the resident before leaving the resident.
During an interview on 1/27/25 at 10:25 A.M., the Director of Nurses and Administrator said CNA A should have secured the resident before leaving the resident. The Administrator said all staff have been inserviced and tested with return demonstration on the importance of securing a resident before leaving the resident.
MO00248146
MO00248335

Based on observations, interviews, document review, and facility policy review, the facility failed to ensure cleanliness and ensure food stored in one of one kitchen and in the unit nourishment room, was labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for 49 census residents.
Findings include:
Review of the facility's undated job description titled, Dietary Manager indicated it was the responsibility of DM to ensure compliance with regulatory standards during food preparation, storage, and service.
Review of the facility's undated policy titled, Sanitation, indicated that the can opener should be cleaned after each use and unbolted from the table monthly to thoroughly clean the table where the base rests. Further review revealed that the ceilings need to be in good repair.
1. During an observation on 07/09/24 at 8:55 AM the following items were observed in dry storage and verified by [NAME] (C) 1 during the initial kitchen tour:
-Eight re-packaged bags of cereal with no label or date.
-Fourteen bowls of cereal with no label or date.
-Fifteen loaves of bread with no date.
-Eight packages of hamburger buns with no date.
During an observation on 07/09/24 at 8:55 AM the following was observed in cold storage and verified by C1 during the initial kitchen tour:
-An observation of the walk-in freezer's temperature log revealed missing temperatures from 07/03/2024 to 07/08/2024.
-There was water leaking from the walk-in refrigerator. Observation of the interior of the walk-in refrigerator revealed towels on the floor of the walk-in soaked in water.
-Additional observations revealed bottled maraschino cherries with a date of 11/29 (no year documented), sweet relish with a date of 04/16 (no year documented) and 33 thawed Ready Shakes with manufacturers instructions to use within 14 days of thawing. There were no dates as to when the shakes expired.
During an observation on 07/09/24 at 8:55 AM the following was observed in preparation areas and verified by C1 during the initial kitchen tour:
-There was a one-gallon bottle of pan cleaner and a spray bottle of Spic and Span stored on the shelf with cooking utensils.
-Cook1 tested the sanitizer bucket on the cook's table. The test strip indicated there was no sanitizer in the bucket. During an interview on 07/09/24 at 8:55 AM, C1 stated he used sanitizer from the pot sink in the bucket and did not know why it wasn't registering on the test strip.
2. During a second observation of the kitchen with the Dietary Manager (DM) present on 07/10/24 at 11:54 AM, there was water leaking from the walk-in refrigerator. Observation of the cook's preparation area revealed the tabletop can opener was dirty with black substance encrusted around the edge and base seams of the opener. Additionally, there were 12 water-stained ceiling tiles and three missing ceiling tiles above the preparation area exposing the pipes and venting.
During an interview on 07/10/24 at 1:23 PM, the Administrator stated that a work order had been placed for the walk-in refrigerator in the kitchen and they did not know what was causing the leak.
During an interview on 07/10/24 at 3:01 PM, the DM stated that items needed to be labeled and dated before placing them in storage and staff had been trained.
During an observation on 07/10/24 at 12:48 PM, the third-floor nourishment refrigerator revealed no thermometer and no temperatures documented. There were three ham and cheese sandwiches stored on top of the refrigerator with no date and no cooling mechanism. An observation of the interior of the refrigerator revealed sticky shelves and melted popsicles stuck to the ice in the freezer box.
During an interview on 07/12/24 at 12:38 PM, the Registered Dietitian (RD) stated that she was not aware there was not a thermometer in the nourishment refrigerator and agreed the temperature should have been monitored and the sandwiches refrigerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and facility policy review, the facility failed to ensure infection control measures were appropriately implemented and maintained for Legionellosis assessment and prevention in the facility. This failure has the potential to affect 49 of 49 census residents.
Finding Include:
Review of website for ASHRAE [he American Society of Heating, Refrigerating and Air-Conditioning Engineers] titled Risk Management for Legionellosis, dated 10/15, located https://www.ashrae.org/, indicated .The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors .Health-care facility with patient stays over 24 hours .Facilities designated for housing occupants over age [AGE] .The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system .
Review of facility's undated policy titled, Nursing Home Legionella Water Policy, revealed the objective of the policy is to minimize the risk of Legionella contaminations in our water system and to protect the health of our residents, staff, and visitors. The policy statement includes, Conduct a comprehensive risk assessment of all water systems within the facility at least annually to identify potential sources of Legionella growth and spread. The assessment will be carried out by qualified personnel or a third-party expert.
During an interview on 07/11/24 at 5:44 PM, the Administrator stated, The facility does not have a water legionella system, there was no diagram that provided information of the flow of the water, a comprehensive assessment had not been completed, nor has the water been tested. The administrator stated understanding the Water Legionella requirements for long term care, but the facility had not been following the requirements.
During an interview on 07/12/24 at 3:41 PM the Maintenance Director (MD) revealed not being aware of the water legionella program and requirements. When asked about the comprehensive risk assessment of the water systems in the facility, the MD indicated that he did not know what that meant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to ensure expired medications and supplies were removed from one of one treatment carts, one of one medication rooms and failed to ensure one of one treatment cart and one of two nurse carts were locked. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The unlocked carts had the potential to be accessed by unauthorized residents, staff, and visitors.
Findings include:
Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, indicated (2) The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and (3). If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.
During an observation of the medication room for Hall 300 on 07/10/24 at 9:48 AM, alongside the Licensed Practical Nurse (LPN) 1, the following expired items were found:
-One vial of ipratropium bromide albuterol sulfate (medication used for breathing treatments in a nebulizer) containing one vial, expired 02/23
-Five test tubes for viruses, mycoplasma, and chlamydia, expired on 04/12/21, the five swabs with the vials expired on 09/22.
-Two test tubes for viruses expired on 01/08/19 and the swabs expired on 03/20.
-Four [NAME] Brand test kits (used for testing for sexually transmitted diseases and to culture wounds) expired on 04/01/24.
-Four sterile testing swabs expired on 08/11/23.
-Two BD brand Eswab Collection and transport system for Aerobic, Anaerobic, and Fastidious bacteria expired on 05/31/23.
-Four Eswab collection and preservation kits for aerobic, anaerobic, and fastidious bacteria expired on 08/31/23.
-Five universal transport medium translucent with red cap tube format (utm-rt) 3ml test tubes w/o (without) beads transport and preservation medium for viral molecular diagnostic testing expired 01/31/24.
-Twenty-four tubes utm-3ml test tubes w/o beads transport medium for viral molecular diagnostic testing expired on 05/31/24.
-Thirty-nine-nine acetaminophen suppositories expired on 04/24.
-Six prochlorperazine 25 mg expired on 04/24.
During an interview on 07/10/24 at 9:48 PM, LPN1 verified the expiration dates and, that the testing supplies and expired medications were still available for resident use. LPN1 stated the night shift nurse should have checked the medication room. LPN1 did not know if the nurse was responsible for checking the medication expiration dates.
During an interview on 07/10/24 at 2:00 PM, the Director of Nursing (DON) stated each shift should have checked the medication room for expired medications and supplies. The DON verified the supplies in the medication room were still available for resident use.
During an observation on 07/10/24 at 3:42 PM, the treatment cart on Hall 200 was unlocked and parked in front of the elevator. The following expired items were located on the cart:
-Nine xeroform petrolatum two by two dressings expired on 03/23/24.
-One container of zinc oxide cream expired on 09/23.
-Twelve boxes of covid-19 tests with two tests per box expired on 11/07/23.
-One box of covid-19 tests with four tests inside it expired on 11/07/23.
During an interview on 07/10/24 at 3:55 PM, LPN2 stated she knew her cart should have been locked. LPN2 stated she thought it was ok to leave it unlocked if she was sitting at the nurses' station and could see it. LPN2 verified the expired covid-19 test kits, petrolatum dressings, and zinc oxide were still available for resident use. She stated the CDC (Centers for Disease Control and Prevention) gave an extension for the self-administering covid-19 tests that extended the expiration by seven months. LPN2 stated the tests came from the CDC and that extension expired the end of June 2024.
During an observation and interview on 07/11/24 at 8:57 AM, the nurse cart on Hall 300 was left unattended and unlocked. LPN3 was the charge nurse and stated she knew she should not leave the cart unlocked.
During an interview on 07/11/24 at 1:51 PM, the DON stated she expected the staff to keep the treatment and medication carts locked when they are not using them. She stated staff should not keep the carts unlocked even while sitting at the nurses' station.

Based on observation, interview, record review, and facility policy review, the facility failed to serve food that was palatable for three of four (Residents (R) 3, R12, and R24) reviewed for food palatability of 23 sample residents. This had the potential to affect 49 of 49 residents who consumed food that was prepared from the facility's kitchen.
Findings include:
Review of the facility's policy titled, Menus and Meal Preparation, with a revision date of 01/24, indicated Meals shall be prepared according [to] the facility approved menu. The menu shall be approved by the Licensed Registered Dietitian in the state of practice. Corresponding recipes shall be used in conjunction with meal service. When convenience or semi-convenience foods are prepared, the manufacturer directions shall be used in place of recipes.
1. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/24, located in the resident's electronic medical record (EMR) under the RAI (Resident Assessment Instrument) tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact.
During an interview on 07/09/24 at 10:50 AM, R24 stated the food served at meals was not good and the coffee and food served at meals was cold.
Observation on 07/10/24 at 1:05 PM revealed R24 had finished his lunch meal and was exiting the 300-hall dining room. During an interview at this time R24 stated his lunch meal was Terrible. R24 explained the noodles were not seasoned and the meat lacked flavor. R24 stated his food was warm today but tasted terrible. Observations of R24's finished lunch meal revealed he only took bites of the noodles and the beef patty with gravy that he was served at this meal.
2. Review of R12's quarterly MDS with an ARD of 06/29/24, located in the resident's EMR under the RAI tab revealed a BIMS score of seven of 15, which indicated the resident had severely impaired cognition.
During an interview on 07/09/24 at 10:37 AM, R12 stated the food did not always taste good and sometimes was not hot when served at meals.
Observation on 07/10/24 at 1:33 PM revealed R12 had finished his lunch meal and was exiting the 300-hall dining room. During an interview at this time R12 stated his lunch was not good. R12 explained the food he was served did not have any taste. R12 stated the noodles and beef patty with gravy that he was served at lunch lacked flavor. R12 added, The food just does not taste good here. Observations of R12's finished lunch meal revealed he only took bites of the noodles and the vegetables and ate about half of the beef patty with gravy that he was served at this meal.
3. Review of R3's annual MDS with an ARD of 06/14/24, located in the resident's EMR under the RAI tab revealed a BIMS score of 13 of 15, which indicated the resident was cognitively intact.
During an interview on 07/10/24 at 10:31 AM, R3 stated sometimes the food was good and sometimes it was not. The resident stated the food was not always hot at meals and she ate her meals in the dining room.
During an interview on 07/10/24 at 3:01 PM, the Dietary Manager (DM) stated that lunch was chopped pepper steak and buttered pasta noodles. The DM was asked to produce the recipe for the chopped pepper steak. The DM stated that they had used a recipe but could not locate it. The DM continued to search the menu book but could not locate a recipe for chopped pepper steak. The DM stated that recipes were just used as reference but just sometimes knew the recipe by heart.
During an interview on 07/12/24 at 12:38 PM, the Registered Dietitian (RD) stated that they did not require the use of recipes if the item was pre-made. The RD stated she would expect the staff to follow manufacturers' instructions for pre-made items. The RD stated the DM followed an order guide for each menu, so she was aware of what was being ordered for the menu. The RD could not recall if the pepper steak was a pre-made entrée. The DM stated there was no more pepper steak so they could not produce manufactures instructions.

Based on observation, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience by serving beverages in disposable cups, and food on disposable plates at meals for one Resident (R) 24 and one of two dining rooms of 23 sample residents. This failure had the potential to affect all residents who were served meals prepared in the facility's one of one kitchen.
Findings include:
Review of the facility's policy titled, Dinnerware and Dining Services, revised 01/24, indicated, To ensure residents receive meals served consistent with proper dining expectations, in a clean and attractive setting and with oversight to support feeding needs. To comply with federal and state regulations governing dining services.
1. Observation on 07/09/24 from 12:35 PM to 1:25 PM, revealed residents in the 300-hall dining room were being served and eating their lunch meals. Further observations of the 300-hall lunch meal service revealed 18 of 22 residents eating in this dining room were served frosted cake on a small disposable Styrofoam plate and 15 of 22 residents were served beverages in disposable Styrofoam cups.
2. Observation on 07/11/24 from 12:33 PM to 1:22 PM, revealed residents in the 300-hall dining room were being served and eating their lunch meals. Further observation of the 300-hall lunch meal service revealed 19 of 23 residents eating in this dining room were served a brownie for dessert on a small disposable Styrofoam plate and 15 of 23 residents were served beverages in disposable Styrofoam cups.
3. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/24, located in the resident's electronic medical record (EMR) under the RAI (Resident Assessment Instrument) tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact.
Observation on 07/09/24 at 12:40 PM revealed R24 was in the facility's 300 hall dining room waiting to be served his lunch meal. Observation revealed staff served R24, two beverages in disposable Styrofoam cups and a piece of cake on a small disposable Styrofoam plate.
During an interview on 07/09/24 at 3:51 PM, R24 stated at meals the facility served desserts on disposable Styrofoam plates and beverages in disposable Styrofoam cups. R24 stated he would prefer to receive his food on regular dishware and beverages in regular cups instead of Styrofoam.
Observation on 07/10/24 at 12:50 PM revealed R24 was in the facility's 300 hall dining room eating his lunch meal. Observation revealed staff served R24 a beverage in disposable Styrofoam cup.
Observation on 07/11/24 at 12:50 PM revealed R24 was in a facility's 300 hall dining room eating his lunch meal. Observation of the resident's meal revealed he was served cake on a disposable Styrofoam plate and two beverages in disposable Styrofoam cups.
During an interview on 07/10/24 at 3:01 PM, the Dietary Manager (DM) stated the kitchen did not have enough regular plates and cups for the entire resident meal service, so at meals the dietary staff served resident food on disposable plates and beverages in disposable cups.
During an interview on 07/12/24 at 12:38 PM, the facility's consultant Registered Dietitian (RD) stated residents should not be served food and beverages in disposable plates and cups at meals because it was a dignity issue. The RD stated more regular dining service dishware would be ordered, so residents would not be served food on disposable plates and beverages in disposable cups.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a clean and comfortable environment for two of the two dining rooms. This failure had the potential to affect all residents who ate meals in the facility's two dining rooms.
Findings include:
Review of the facility's undated policy titled, Housekeeping, indicated Cleaning Schedule and Protocols: Regular Cleaning: Specify the frequency and procedures for daily cleaning of resident rooms, common areas, bathrooms, and high-touch surfaces. Deep cleaning: Outline the procedures for periodic deep cleaning of carpets, upholstery, and other surfaces.
1. Observations of the facility's 300 hall dining room, during resident meal service, revealed the following concerns with the dining room's environment:
a. Observation on 07/09/24 from 12:35 PM to 1:25 PM, revealed 22 residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were unclean with what appeared to be dried food, and window curtains were unclean and stained.
Observation on 07/09/24 from 1:10 PM to 1:25 PM, revealed Certified Nurse Assistant (CNA) 3 fed a randomly observed resident her lunch meal in the 300-hall dining room at a table which was very unbalanced. The table was observed to rock up and down as CNA3 fed the resident her lunch meal.
b. Observation on 07/10/24 from 12:48 PM to 1:33 PM revealed residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were unclean with what appeared to be dried food, and window curtains were unclean and stained.
c. Observation on 07/11/24 from 12:33 PM to 1:02 PM, revealed 23 residents were in the facility's 300 hall dining room being served and eating their lunch meals. Observations of the dining room's environment revealed chairs were stained and unclean with dried food spills, walls were unclean with what appeared to be dried food, and window curtains were unclean and stained.
2. Further observations of the facility's two dining rooms on 07/12/24, prior to the resident lunch meal service, revealed the following:
a. Observation of the facility's 300 hall dining room on 07/12/24 at 10:57 AM, with the Administrator present, revealed 10 of 20 dining room chairs were stained and had dried food spills present, fourteen of sixteen window curtains were stained and unclean, four of 20 dining room chairs were unbalanced, and three of 12 dining room tables were unbalanced. One of the unbalanced dining room tables had a very loose base which did not touch the floor. This dining room table was fully supported by two of its sides being placed directly on top of the two tables positioned next to it which elevated the table's base off the floor.
During an interview on 07/12/24 at 10:57 AM, the Administrator confirmed the above observations of the environment of the 300-hallway dining room. The Administrator stated the housekeeping staff and dietary staff were responsible for cleaning the dining rooms and the maintenance staff were responsible for ensuring dining room tables and chairs were balanced and in good repair.
Review of the facility's 300 hallway maintenance book revealed an uncompleted Maintenance Request, dated 03/10/24, regarding a dining room table being wobbly.
During an interview on 07/12/24 at 11:20 AM, the Maintenance Director (MD) revealed he was not aware of the unbalanced tables and chairs that were currently in the 300-hallway's dining room. The MD also stated he was also not aware of the uncompleted Maintenance Request dated 03/10/24 that was in the 300 hallway's maintenance book regarding a dining room table being wobbly.
b. Observation of the facility's 200 hall dining room on 07/12/24 at 11:15 AM, with the Administrator present, revealed 4 of 8 dining room chairs were stained and had dried food spills present.
During an interview on 07/12/24 at 11:15 AM, the Administrator confirmed the four unclean and stained chairs that were in the facility's 200 hallway dining room and stated it was the housekeeping department's responsibility to clean the chairs in the facility's dining rooms.
During an interview on 07/12/24 at 11:25 AM, the Housekeeping Supervisor (HKS) stated the cleaning of the chairs in the facility's dining rooms on the 200 and 300 hallways was not on the housekeeping's schedule for routine cleaning. The HKS also stated she did not know when the chairs and curtains were last cleaned in the facility's dining rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of three residents (Resident (R) 3) reviewed for Preadmission Screening and Resident Review (PASARR) of 23 sample residents. This failure placed the residents at risk of having unmet care needs and services.
Findings include:
Review of the facility's undated policy titled, PASARR Policy and Procedure. indicated In Missouri, PASARR (Preadmission Screening and Resident Review) is an essential process designed to ensure that individuals with serious mental illness (SMI) or intellectual disabilities (ID) receive appropriate care in nursing homes.
Review of the Resident Assessment Instrument (RAI) Manual 3.0, dated 10/19, revealed .If an Minimum Data Set (MDS) assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected .
Review of R3's Face Sheet found under the Resident tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with a diagnosis of schizophrenia.
Review of R3's annual MDS assessment, located in the EMR under the RAI tab, with an Assessment Reference Date (ARD) of 06/14/24 indicated R3 had an active diagnosis of schizophrenia and had not been evaluated by level II PASARR and determined to have a serious mental illness and/or mental retardation or a related condition.
During an interview on 07/12/24 at 9:00 AM, the facility's Social Service Director Assistant (SSDA) stated R3 was previously evaluated by level II PASARR. The SSDA explained she located a PASARR Level II evaluation for R3 in the resident's paper file.
Review of the paper copy of R3's Level II PASARR evaluation, dated 01/17/23 and provided by the SSDA specified, The PASRR Level II Evaluation indicated that your needs at this time CAN be met in a Nursing Facility.
During an interview on 07/12/24 at 4:00 PM, the MDS Coordinator (MDSC) stated she completed the PASARR section on R3's 06/14/24 annual MDS. The MDSC explained since R3's PASARR level II screening was not available in the resident's EMR she would not have known the resident had a PASARR evaluation completed. The MDSC confirmed R3's annual MDS of 06/14/24 inaccurately assessed the resident's PASARR status. The MDSC stated she would correct R3's annual MDS assessment to reflect the resident had a PASARR Level II evaluation completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interview, and facility policy review, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level and failing to keep a clean field clean during wound care for two of two residents (Resident (R) 3 and R8) reviewed for professional standards of 23 sample residents.
Findings include:
Review of the facility's policy titled, Obtaining a Finger Stick Glucose Level, dated 2001, revealed . (8) Obtain a blood sample by using a sterile lancet (a spring-loaded lancet or manual lancet). Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results.
Review of the facility's policy titled, Wound Care, dated 2001, revealed (4). Put on exam glove. Loosen tape and remove dressing. (5) Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly.
1. Review of R3's Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] which included diagnosis of type two diabetes mellitus with neuropathy, unspecified.
Review of R3's annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 06/14/24, located under the Resident Assessment Instrument RAI tab of the EMR, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R3 was cognitively intact.
Review of R3's care plan, dated 06/27/24 and located under the Care Plan tab of the EMR, indicated R3 has type 2 diabetes and receives insulin and oral hypoglycemics. She is at risk for adverse consequences such as hyper/hypoglycemia and bruising due to injections. Approaches on the care plan included monitoring for signs and symptoms of hyper/hypoglycemia and monitoring blood sugars as ordered.
Review of R3's active orders for July 2024, located under the Orders tab of the EMR, did not indicate how many times a day R3 should have had her blood sugar checked.
During an observation and interview on 07/10/24 at 4:36 PM, Licensed Practical Nurse (LPN) 1 checked R3's blood sugar. LPN1 did not discard the first drop of blood prior to checking the blood sugar. LPN1 stated she should have discarded the first drop of blood prior to checking the sugar.
During an interview on 07/11/24, at 3:37 PM, the Director of Nursing (DON) stated you should introduce yourself, explain what you are going to do, and gather your supplies. The DON stated you then cleanse the finger with alcohol, let it air dry, stick the finger with the lancet, discard the first drop of blood with gauze and not the alcohol pad, and then use the next drop for the test sample.
2. Review of R8's Face Sheet located under the Resident tab of the EMR revealed R8 was admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, Alzheimer's, reduced mobility, and unspecified protein calorie malnutrition.
Review of R8's annual MDS, dated [DATE] and located under the RAI tab of the EMR, revealed R8 had a BIMS score of four out of 15 indicating R3 was severely cognitively impaired.
Review of R8's care plan with an edited date of 05/02/24 and located under the Care Plan tab of the EMR, indicated R8 was at risk for and had a history of pressure ulcers/pressure injury r/t immobility, incontinence, and comorbidities. Approaches for wound healing on the care plan included administering wound treatment as ordered.
Review of R8's current physician orders, dated July 2024, revealed the following order, dated 03/11/24: apply skin prep to the right hip, allow to dry, and cover with a foam dressing.
During an observation on 07/11/24 at 9:08 AM, LPN3 removed the old dressing from the right hip and placed it on the paper towels with the clean supplies.
During an interview on 07/11/24 at 9:27 AM, LPN3 stated she should not have placed the old dressing on the clean field. LPN3 stated the old dressing should have been placed in a trash bag or trash can.
During an interview on 07/11/24 at 1:53 PM, the DON stated the staff should use a trash can or trash bag for dirty items. The DON stated the dirty items should not be placed on the clean field.

Based on observations, interview, and facility policy review, the facility failed to ensure the facility's dumpster container lids were kept closed when not in use for 49 census residents.
Findings include:
The facility's undated policy titled, Sanitation indicated The Dietary Department will hold, transfer, and dispose of waste in a manner that does not create a nuisance or a breeding place for insects and rodents, or otherwise permit the transmission of disease .keep dumpster lids closed at all times and keep dumpster and dumpsite area clean and free of debris.
During an initial tour observation on 07/09/24 at 8:55 AM, the dumpster container area, located on the side of the building, was observed. The dumpster container had two separate lids. One lid was observed open. Inside the dumpster there were multiple bags of garbage. The container was full, and the bags were visible over the top of the bin. Further observation revealed there was garbage on the ground around the bin. There was an odor around the area of the garbage bin.
During an observation with the Dietary Manager (DM) on 07/10/24 at 3:01 PM, both lids to the bin were open exposing several bags of garbage in the bin and garbage on the ground around the bin. During an interview, the DM stated, I can see that. The lids should be closed.
During an observation on 07/12/24 8:33 AM, the outside garbage bin remained open, with garbage on the ground around the bin. Staff were observed disposing of garbage without closing the lid.

Based on interviews, and document review, the facility failed to ensure that a facility with more than 120 beds employed a full time qualified social worker which included a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience. This failure has the potential to cause residents to not receive the necessary services to maintain as normal a possible lifestyle.
Findings include:
Review of the facility's undated job description titled, Social Worker Job Description, revealed The Social worker and/or social worker designee in a nursing home setting plays a crucial role in providing comprehensive social services to residents, their families, and caregivers. They assess residents' psychosocial needs, develop care plans, and coordinate services to enhance residents' quality of life and ensure their well-being.
During an interview on 07/10/24 at 1:15 PM with the Administrator and Director of Nursing (DON), the Administrator revealed the facility was currently working with the local office to decrease the number of beds to 118 and they were currently licensed for 130 beds. The Administrator stated they currently did not have a full-time license social worker. She stated the current Social Service Director (SSD) had a certification as a social service designee in long-term care facilities.
During an interview on 07/12/24 at 1:13 PM, the Social Service Director (SSD) revealed not being a licensed social worker but was functioning in the full-time position as the social worker. The SSD stated she had a certification for a social service designee in long-term care facilities. The SSD stated she did not have a degree.
Review of the certification for Social Service Director (SSD), revealed a Certificate of Attendance, dated December 2017 for the satisfactory completion of the 36-hour basic online course for Social Service Designee in long-term care facilities. The program was recognized by the Missouri Department of Health and Senior Services.

Based on observation, record review, and interview, the facility failed to ensure the daily posted nurse staffing information contained complete information which included the total number and actual hours worked of licensed and unlicensed staff on duty. This failure had the potential to affect all residents and visitors to the facility.
Findings include:
Observation on 07/12/24 at 1:15 PM revealed the facility's nurse staffing information was posted in the facility's front lobby behind the receptionist's desk. Review of the posted 07/12/24 staffing information revealed it only contained information regarding the total number of licensed and unlicensed staff who were on duty during the Day Shift and did not contain any information for the Night Shift for Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Medication Technician (CMT), and Certified Nurse Assistant (CNA) staff.
During an interview on 07/12/24 at 1:15 PM, the Receptionist (R) 1 stated the receptionist filled out the facility's daily nurse staffing information, posted it at the front lobby receptionist desk and retained copies of prior postings.
Review of the facility's daily posted nurse staffing information from 06/01/24 to 07/11/24, which were provided by R1, revealed these postings only contained the number of licensed and unlicensed staff on the Day Shift, and contained no information for the night shift for RN, LPN, CMT, and CNA staff.
During an interview on 07/12/24 at 1:20 PM, the Human Resource Manager (HRM), confirmed the facility's daily posted nurse staffing information only included the number of the licensed and unlicensed staff who worked on the Day Shift and did not include any staffing information for the Night Shift.
During an interview on 07/12/24 at 1:34 PM, R1 stated she was not aware she needed to include information on the daily posted staffing information sheet for the night shift but would include this information on future postings.
During an interview on 07/12/24 at 3:29 PM, the Administrator confirmed the facility's daily posted nurse staffing information only contained the number of licensed and unlicensed nursing staff on duty during the day shift and did not contain any staffing information for the night shift. The Administrator stated the facility did not have a policy for the daily posting of nurse staffing information, but it was expected the posting would include all required information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident behavior triggers, which may have predisposed the resident's aggression, were adequately monitored and addressed. Staff did not develop interventions to address the resident's behavior to deter him/her from responding aggressively towards other residents and staff (Resident #1). The sample was 3. The census was 51.
Review of the facility's Comprehensive Care Plan policy, revised 09/2010, showed:
-Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident;
-Enhance the optimal functioning of the resident by focusing on a rehabilitative program;
-Reflect currently recognized standard of practice for problem area and conditions;
-Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident;
-Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician or primary healthcare provider is integral to this process;
-Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change;
-The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans:
-When there has been a significant change in the resident's condition;
-When the desired outcome is not met;
-When the resident has been readmitted to the facility from a hospital stay;
-At least quarterly;
-Reflect the resident's expressed wishes regarding care and treatment goals.
Review of Resident #1's care plan, dated 8/11/23, showed:
-Problem: Resident at risk for angry, hostile, defensive noncompliant behaviors and loss of control of behavior;
-Goal: Prevention of behavior escalating into a dangerous one for self or others by attempting to defuse the situation;
-Approaches:
-Resident will go to a quiet place to calm himself/herself, dated 9/25/23. Staff will point to their wrist as a gesture to go to a quiet place and calm himself/herself, dated 9/25/23;
-Acknowledge concerns, frustration. Do not dismiss feelings. Use statements such as I understand that. or That must be hard/frustrating ., dated 8/11/23;
-Keep a neutral and open stance with hands visible in a non-threatening and non-aggressive manor;
-Keep 2-3 feet away, dated 8/29/23;
-Maintain a calm demeanor, use a level, firm, tone of voice. Do not raise voice or speak with sarcasm or in a clipped irritated manor, dated 8/29/23;
-The care plan did not show staff included the resident in creating the care plan;
-The care plan did not show staff identified triggers for the resident's care planned behavioral symptoms (e.g. angry, hostile, defensive noncompliant behaviors, loss of control).
Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed:
-Cognitively intact;
-Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) - behavior not exhibited;
-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) - behavior of this type occurred 1 to 3 days;
-Mobility: Walker;
-Diagnoses- Other specified anxiety disorders with depression or;
-Mood disorder due to known physiological condition with depressive features.
Review of the resident's social service notes, showed:
-On 8/11/23 at 2:23 P.M., the resident said he/she was nervous and had very high anxiety. He/she because tearful during the admission process. The resident said he/she got very depressed and had a hard time getting out of bed at times. admission paperwork was reviewed and signed;
-On 8/28/23 at 12:41 P.M., the reporter (Social Worker H) received a phone call from the resident representative and asked about behavior's that the facility had seen with his/her family member. The resident's representative said he/she had wondered when the facility would start to see the resident's behaviors;
-Staff did not document action steps and/or interventions in the medical record.
Review of the resident's progress notes, showed:
-On 2/12/24 at 12:57 P.M., resident getting upset because he/she could not wait to be served in the dining room by staff. Called Certified Nurse Assistant (CNA) a bitch. Nurse informed resident to stop yelling and calm down. Staff have to make sure all residents are in the dining room and that the CNA was new. Resident escorted out of the dining room. Resident is difficult to direct at times;
-On 2/26/24 at 7:35 A.M., resident at front desk crying and yelling stating, I should be able to smoke whenever I want. They're my cigarettes. Receptionist states resident walked out of the front door, but came back in. Explained to resident that there are scheduled smoking times for safety purposed, however, resident continued crying and yelling. Eventually returned to floor to eat breakfast.
Review of the resident's Positive Support Contract, dated 2/27/24, showed:
-The resident voluntarily agreed to participate in an award agreement;
-The facility has agreed to purchase one pack of cigarettes every four (4) days for the positive behavior and/or until the resident's financial benefits are approved;
-Signatures included the resident's, Social Worker H's, and the Director of Nursing's (DON);
-Staff did not document other interventions in the resident's medical record.
Review of the resident's care plan, showed:
-No documentation staff reviewed and/or revised the implemented interventions when the desired outcomes were not met after each documented verbal or behavioral aggression;
-The Positive Support Contract was not documented as an intervention.
During an interview on 5/1/24 at 10:21 A.M., the Administrator said the resident's behaviors were explosive. He/She yelled, screamed, and was agitated. The Administrator said the resident wasn't getting what he/she needed, so she created a positive reinforcement agreement for the resident, whereby if the resident didn't display behaviors for a certain amount of time, the facility would purchase him/her cigarettes. The Administrator said the resident didn't have any money and said no money to purchase cigarettes contributed to the resident's behaviors. She knew the contract was frowned upon, but it worked for a while.
Review of the resident's progress note, showed on 3/11/24 at 8:04 P.M., the resident had an outburst in the dining room, stating the TV was too loud. Nurse conversed with the resident the TV is low, and the residents wants to watch the news. Resident stated, cut the damn TV down to another resident. The other resident stated, The TV is not loud. Resident started getting aggressive and wanted to approach the other resident. Nurse extended his/her arms while resident tried to approach the other resident and touched the nurse. Nurse tried to calm resident down and separated both residents. Informed both to stop arguing in the dining room in front of other residents at mealtime. The resident was sent to the behavior unit at the hospital for evaluation. DON, psychiatry, primary care physician (PCP), and daughter aware resident sent to the hospital.
Review of the resident's after visit hospital summary, dated 3/11/24, showed:
-Diagnosis: Aggressive behavior;
-Understanding Mood Disorders (Depression and Bipolar Disorder), what causes mood disorders, and how daily issues affect your health;
-The resident was seen by Psychiatry as well and deemed stable for discharge. No indication for emergent psychiatric admission. Resources are below to help with outpatient psychiatry follow-up for management of your mood disorder and aggressive behaviors;
-Not documented on care plan;
-Eight psychiatric services resources provided;
-Nine therapy and counseling resources provided.
Review of the resident's medical record, showed no documentation staff reviewed or implemented any of the hospital recommended resources.
Review of the resident's progress notes, showed:
-On 4/8/24 at 11:08 A.M., the resident started yelling and deflecting the conversation. While yelling he/she stated that he/she would just go jump out a window. When asked if the resident was suicidal, he/she stated no, I'm homicidal. The resident then stated, just you try and send me to the hospital, I'm not going. He/She stormed out the room, the Administrator followed him/her. This reporter called the power of attorney (POA) and informed him/her of the situation. This reporter then called the psych Nurse Practitioner, who stated he/she would be in on Thursday, 4/11/24 to see the resident. No new orders. The resident received medication for anxiety. After further conversation, the resident stated he/she was upset because he/she had been out with family the prior weekend and it reminded him/her what it was like to live in the community, and he/she felt like she/she was missing out on life;
-On 4/11/24, psychiatric progress note, showed:
-Staff report that he/she has been doing adequately from a behavioral standpoint. He/She has been socializing with peers and most of the time appears to be in a good mood;
-The possibility of a bipolar mood disorder cannot entirely be excluded.
-On 4/21/24 at 7:09 P.M. a progress note showed, it was reported to this nurse that the resident attacked the receptionist. DON and Administrator immediately notified. Resident sent to the hospital for evaluation per psychiatrist recommendation;
-On 4/22/24 at 6:10 P.M., a progress note showed, on 4/23/24 late entry documented, this reporter returned a call from the resident's family member who told this reporter the resident told him/her about the incident with the receptionist but stated it was the receptionist who had hit him/her. This reporter asked the family member if he/she knew if something else was going on with the resident since they had been noticing that while the resident's outburst have been less, they seem to be more explosive and threatening. The family member said the resident has had problems with behaviors forever and every time the resident gets somewhere, he/she leaves before help/treatment can be provided to him/her;
-On 4/23/24 at 5:52 P.M., a progress note recorded as late entry, on 4/21/24, this reporter returned to the facility regarding an alleged incident between this resident and the receptionist. This incident was witnessed by 10 residents and one staff member who all recounted witnessing the resident swinging at the receptionist over being upset about the wait time for getting cigarettes. The altercation resulted in the resident knocking the box of cigarettes out of the receptionist's hands and caused the receptionists to hold up his/her arms to prevent the resident from striking him/her in the face. As the resident was swinging, he/she was hitting the receptionist's arms with his/her closed fist. Since the receptionist was the only staff member in the immediate area, 2 other residents intervened by yelling at the resident to stop and attempting to get in between the resident and the receptionist.
During an interview on 5/1/24 at 10:21 A.M., the Administrator said the physician reviewed the resident's medical records and thought the diagnosis may be incorrect. She didn't know how to maintain, how to predict, or handle the resident's behavior and had concerns about how to keep the other residents safe. The resident had behavioral concerns when he/she was admitted to the facility and interventions had been care planned at that time, but the interventions should have been reviewed and updated since 9/25/23.
During an interview on 5/1/24 at 1:57 P.M., Certified Medication Technician (CMT) D said the resident's care needs were in a care book, but he/she didn't know if the resident had a behavior support plan. CMT D would get information about the resident during shift report. The resident was not patient and wanted things right away. CMT D said he/she could calm the resident down by talking to the resident, listening to the resident, and letting the resident vent. He/She said the resident was frustrated but once the resident got it out of his/her system, he/she went back to normal.
During an interview on 5/1/24 at 2:13 P.M., CNA C said he/she would go the charting system to look at the resident's care needs and for what to do when the resident had behaviors. He/She said it was not the first time the resident had an altercation, and the resident would go on [NAME]. He/She would try to talk to the resident to calm him/her down or re-direct him/her. CNA C would get information about the resident during shift report.
During an interview on 5/1/24 at 3;00 P.M., the Administrator said the resident's outbursts were always the same and the resident could be mean with words. She expected staff to document the resident's behaviors. The documentation should be accurate. He/She expected staff to follow the resident's care planned interventions and said staff had been in-serviced recently. She thought staff could have handled the situation better, but that was after the fact. The staff wanted to help the resident, but he/she was unpredictable. The Administrator had not previously reviewed the suggested resources provided in the resident's 3/11/24 After Visit Hospital Summary. She expected any hospital summary information related to recommendations for physical and/or verbal aggression to have been documented and care planned, if applicable. However, the Administrator said none of the resources applied to the resident and did not say why.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise and/or update one resident's care plan after each event of verbal and/or physical aggression, failed to update/revise interventions, and failed to train facility staff how to properly implement the residents current care planned interventions (Resident #1). The sample was 3. The census was 51.
Review of the facility's Comprehensive Care Plan policy, revised 09/2010, showed:
-Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident;
-Enhance the optimal functioning of the resident by focusing on a rehabilitative program;
-Reflect currently recognized standard of practice for problem area and conditions;
-Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident;
-Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making. No single discipline can manage the task in isolation. The resident's physician or primary healthcare provider is integral to this process;
-Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change;
-The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans:
-When there has been a significant change in the resident's condition;
-When the desired outcome is not met;
-When the resident has been readmitted to the facility from a hospital stay;
-At least quarterly;
-Reflect the resident's expressed wishes regarding care and treatment goals.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed:
-Cognitively intact;
-Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) - behavior not exhibited;
-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) - behavior of this type occurred 1 to 3 days;
-Mobility: Walker;
-Diagnoses included other specified anxiety disorders (Intense, excessive, and persistent worry and fear about everyday situations) with depression or mood disorder (Illness that affect the way you think and feel) due to known physiological condition with depressive features.
Review of the resident's care plan, dated 8/11/23, showed:
- Problem: Resident at risk for angry, hostile, defensive noncompliant behaviors and loss of control of behavior;
-Goal: Prevention of behavior escalating into a dangerous one for self or others by attempting to defuse the situation;
-Approaches:
-Resident will go to a quiet place to calm himself/herself, dated 9/25/23. Staff will point to their wrist as a gesture to go to a quiet place and calm himself/herself, dated 9/25/23;
-Acknowledge concerns, frustration. Do not dismiss feelings. Use statements such as I understand that. or That must be hard/frustrating , dated 8/11/23;
-Keep a neutral and open stance with hands visible in a non-threatening and non-aggressive manor;
-Keep 2-3 feet away, dated 8/29/23;
-Maintain a calm demeanor, use a level, firm, tone of voice. Do not raise voice or speak with sarcasm or in a clipped irritated manor, dated 8/29/23;
-The care plan did not show the resident was involved in creating the care plan;
-The care plan did not show any identified triggers for the resident's care planned behavioral symptoms (e.g. Angry, hostile, defensive noncompliant behaviors, loss of control);
-The care plan did not show staff reviewed and/or revised the implemented interventions when the desired outcomes were not met after each documented verbal or behavioral aggression.
Review of the resident's progress notes, showed:
-On 2/12/24 at 12:57 P.M., resident getting upset because he/she could not wait to be served in the dining room by staff. Called Certified Nurse Assistant (CNA) a bitch. Nurse informed resident to stop yelling and calm down. Staff have to make sure all residents are in the dining room and that the CNA was new. Resident escorted out of the dining room. Resident is difficult to direct at times;
-No documentation related to event and/or intervention revision/update in the resident's care plan;
-On 2/26/24 at 7:35 A.M., resident at front desk crying and yelling stating, I should be able to smoke whenever I want. They're my cigarettes. Receptionist states resident walked out of the front door, but came back in. Explained to resident that there are scheduled smoking times for safety purposed, however, resident continued crying and yelling. Eventually returned to floor to eat breakfast;
-No documentation related to event and/or intervention revision/update in the resident's care plan;
-On 3/11/24 at 8:04 P.M., resident had an outburst in the dining room, stating the TV was too loud. Nurse conversed with the resident the TV is low, and the residents want to watch the news. Resident stated, cut the damn TV down to another resident. The other resident stated, The TV is not loud. Resident started getting aggressive and wanted to approach the other resident. Nurse extended his/her arms while resident tried to approach the other resident and touched the nurse. Nurse tried to calm resident down and separated both residents. Informed both to stop arguing in the dining room in front of other residents at mealtime. The resident was sent to the behavior unit at the hospital for evaluation. DON, psych, PCP, and daughter aware resident sent to the hospital;
-No documentation related to event and/or intervention revision/update in the resident's care plan.
Review of the resident's after visit hospital summary, dated 3/11/24, showed:
-Diagnosis: Aggressive behavior;
-Understanding Mood Disorders (Depression and Bipolar Disorder ), what causes mood disorders, and how daily issues affect your health;
-The resident was seen by Psychiatry as well and deemed stable for discharge. No indication for emergent psychiatric admission. Resources are below to help with outpatient psychiatry follow-up for management of your mood disorder and aggressive behaviors;
-Not documented on care plan;
-Eight psychiatric services resources provided;
-Nine therapy and counseling resources provided.
Review of the resident's medical record, showed none of the resources provided by the hospital were reviewed, implemented by staff or added to the care plan.
Review of the resident's progress notes, showed:
-On 4/8/24 at 11:08 A.M., the resident started yelling and deflecting the conversation. While yelling he/she stated that he/she would just go jump out a window. When asked if the resident was suicidal, he/she stated no, I'm homicidal. The resident then stated just you try and send me to the hospital, I'm not going. He/She stormed out the room, the Administrator followed him/her. This reporter called the power of attorney (POA) and informed him/her of the situation. This reporter then called the psych Nurse Practitioner, who stated he/she would be in on Thursday, 4/11/24 to see the resident. No new orders. The resident received medication for anxiety. After further conversation, the resident stated he/she was upset because he/she had been out with family the prior weekend and it reminded him/her what it was like to live in the community, and he/she felt like she/she was missing out on life;
-The care plan did not show any documentation related to this event and/or intervention revision/update:
Psychiatric progress note, dated 4/11/24, showed:
-The staff report that he/she has been doing adequately from a behavioral standpoint. He/She has been socializing with peers and most of the time appears to be in good mood;
-The possibility of a bipolar mood disorder cannot entirely be excluded;
-On 4/21/24 at 7:09 P.M., it was reported to this nurse that the resident attacked the receptionist. Director of Nursing (DON) and administrator immediately notified. Resident sent to the hospital for evaluation per psychiatrist recommendation;
-The care plan did not show any documentation related to this event and/or intervention revision/update:
-On 4/23/24 at 5:52 P.M., recorded as late entry, on 4/21/24, this reporter returned to the facility regarding an alleged incident between this resident and the receptionist. This incident was witnessed by 10 residents and one staff member who all recounted witnessing the resident swinging at the receptionist over being upset about the wait time for getting cigarettes. The altercation resulted in the resident knocking the box of cigarettes out of the receptionist's hands and caused the receptionists to hold up his/her arms to prevent the resident from striking him/her in the face. As the resident was swinging, he/she was hitting the receptionist arms with his/her closed fist. Since the receptionist was the only staff member in the immediate area, 2 other residents intervened by yelling at the resident to stop and attempting to get in between the resident and the receptionist.
During an interview on 5/1/24 at 10:21 A.M., the Administrator said the resident's behaviors were explosive. He/She yelled, screamed, and was agitated. The Administrator said the resident wasn't getting what he/she needed, so she created a positive reinforcement agreement for the resident, whereby if the resident didn't display behaviors for a certain amount of time, the facility would purchase him/her cigarettes. The Administrator said the resident didn't have any money and said no money to purchase cigarettes contributed to the resident's behaviors. She knew the contract was frowned upon, but it worked for a while. The physician reviewed the resident's medical records and thought the diagnosis may be incorrect. She doesn't know how to maintain, how to predict, or handle the resident's behavior. She had concerns about how to keep the other residents safe. The Administrator said the behaviors since admission should have been care planned, but they had interventions in place in the care plan to address the resident's behaviors. The DON said the resident participated in coming up with the interventions on the care plan, but the care plan did not show the resident's involvement.
Review of the resident's care plan, showed staff did not include the positive reinforcement agreement as an intervention.
During an interview on 5/1/24 at 1:57 P.M., Certified Medication Technician (CMT) D said the resident's care needs were in a care book but he/she didn't know if the resident had a behavior support plan. CMT D would get information about the resident during shift report. The resident was not patient and wanted things right away. CMT D said he/she could calm the resident down by talking to the resident, listening to the resident and letting the resident vent. He/She said the resident was frustrated but once the resident got it out of his/her system, he/she went back to normal.
During an interview on 5/1/24 at 2:13 P.M., CNA C said he/she would go the charting system to look at the resident's care needs and for what to do when the resident had behaviors. He/She said it was not the first time the resident had an altercation, and the resident would go on [NAME]. He/She would try to talk to the resident to calm him/her down or re-direct him/her. CNA C would get information about the resident during shift report.
During an interview on 5/1/24 at 3;00 P.M., the Administrator said the resident's outbursts were always the same and the resident could be mean with words. The physician reviewed the resident's medical record and thought the diagnosis may be incorrect. She expected staff to use the resident's care planned interventions and to document the resident's behaviors. The documentation should be accurate. He/She expected staff to follow the resident's care planned interventions and said staff had been in-serviced recently and thought they could have handled the situation better, but that was after the fact. They wanted to help the resident but he/she was unpredictable. The Administrator had not previously reviewed the suggested resources provided in the resident's 3/11/24 After Visit Hospital Summary. She expected any hospital summary information related to recommendations for physical and/or verbal aggression to have been documented and care planned, if applicable. However, the Administrator said none of the resources applied to the resident and did not say why.

Based on interview and record review, the facility failed to provide a resident with an appropriate involuntary transfer discharge when they transferred one sampled resident (Resident #1) to the hospital and would not allow him/her to return, out of three sampled residents. The facility census was 51 residents.
Review of the facility's admission Criteria policy, revised 03/2019, showed:
-Our facility admits only residents whose medical and nursing needs can be met;
Policy Interpretation and Implementation:
-The objectives of our admission criteria policy are to:
-Admit residents who can be cared for adequately by the facility;
-Assure the facility receives appropriate medical records prior to or upon the resident's admission;
-Prior to or at the time of admission, the resident or representative is informed of any service limitations or special characteristics of the facility;
-Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident;
-The acceptance of residents with certain conditions or needs may require authorization or approval by the Medical Director (MD), Director of Nursing Services (DON) and/or the Administrator;
Review of the facility's Transfer or Discharge, Facility-Initiated policy, dated 10/2022, showed:
Policy Statement: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation specified in this policy;
-Facility-Initiated Transfer or Discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences;
-Documentation of Facility-Initiated Transfer or Discharge is when a resident is transferred or discharged from the facility, the following information is documented in the medical record:
-The basis for the transfer or discharge;
-If the resident is being transferred or discharged because his/her needs cannot be met at this facility, documentation will include:
-The specific resident needs that cannot be met;
-The facility's attempt to meet those needs; and
-The receiving facility's service(s) that are available to meet those needs;
-If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to:
-Determine if the resident still requires the services of the facility and is eligible for Medicare skilled nursing facility or Medicaid nursing facility services;
-Ascertain an accurate status of the resident's condition;
-Find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility;
Appealing Transfer or discharge: Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals.
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/14/24, showed:
-Cognitively intact;
-Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) - behavior not exhibited;
-Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) - behavior of this type occurred 1 to 3 days;
-Mobility: Walker;
-Diagnoses included other specified anxiety disorders (Intense, excessive, and persistent worry and fear about everyday situations) with depression (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and mood disorder (Illnesses that affect the way you think and feel) due to known physiological conditions with depressive features.
Review of the resident's physician order sheet, order dated 2/4/24, for Target Behavior: symptoms of mood disorders. At the end of each shift mark frequency-how often behavior occurred and Intensity-how resident responded to redirection. Intensity Code: 0=Did not occur, 1=Easily Altered, and 2=Difficult to redirect.
Review of the resident's medical record, showed:
-On 4/3/24 at 2:48 P.M., staff documented mood, verbal expressions of distress, persistent anger with self or others - 1 easily altered;
-Action taken to alter persistent anger with self or others=redirect;
-On 4/12/24 at 1:49 P.M., staff documented mood-apathetic, anxious, sad appearance, repetitive movements - difficult to redirect;
-Action taken to alter mood-apathetic, anxious, sad appearance, repetitive physical movement one-on-one, given food/fluids, other;
-On 4/12/24 at 1:49 P.M., staff documented mood-apathetic, anxious, sad appearance, showed, repetitive physical movements;
-Actions taken to alter repetitive physical movement.
Review of the resident's care plan, dated 8/11/23, showed:
-Problem: Resident at risk for angry, hostile, defensive noncompliant behaviors and loss of control of behavior;
-Goal: Prevention of behavior escalating into a dangerous one for self or others by attempting to defuse the situation;
-Approaches:
-Resident will go to a quiet place to calm himself/herself, dated 9/25/23;
-Staff will point to their wrist as a gesture to go to a quiet place and calm himself/herself, dated 9/25/23;
-Acknowledge concerns, frustration. Do not dismiss feelings. Use statements such as I understand that. or That must be hard/frustrating , dated 8/11/23;
-Keep a neutral and open stance with hands visible in a non-threatening and non-aggressive manor. Keep two to three feet away, dated 8/29/23;
-Maintain a calm demeanor, use a level, firm, tone of voice. Do not raise voice or speak with sarcasm or in a clipped irritated manor, dated 8/29/23.
Review of the resident's progress notes dated 3/11/24 at 8:04 P.M., showed, resident had an outburst in the dining room, stating the TV was too loud. Nurse conversed with the resident the TV is low, and the residents wants to watch the news. Resident stated, Cut the damn TV down to another resident. The other resident state, the TV is not loud. Resident started getting aggressive and wanted to approach the other resident. Nurse extended his/her arms while resident tried to approach the other resident and touched the nurse. Nurse tried to calm resident down and separated both residents. Informed both to stop arguing in the dining room in front of other residents at mealtime. The resident was sent to the behavior unit at the hospital for evaluation. DON, psych, PCP, and daughter aware resident sent to the hospital.
Review of the resident's After Visit Hospital summary, dated 3/11/24, showed:
-Diagnosis: Aggressive behavior;
-Understanding mood disorders (Illnesses that affect the way you think and feel) depression, (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and bipolar disorder (sometimes called manic-depressive illness, a disorder associated with episodes of mood swings ranging from depressive lows to manic highs what causes mood disorders, and how daily issues affect your health);
-The resident was seen by Psychiatry as well and deemed stable for discharge. No indication for emergent psychiatric admission. Resources are below to help with outpatient psychiatry follow-up for management of mood disorder and aggressive behaviors;
-Eight psychiatric services resources provided;
-Nine therapy and counseling resources provided.
Review of the resident's medical record and care plan, showed staff did not document implementation of any of the psychiatric or therapeutic services recommended in the After Visit Hospital summary.
Review of the resident's medical record showed:
-A progress note dated 4/8/24 at 11:08 A.M., showed, the resident started yelling and deflecting the conversation. While yelling he/she said that he/she would just go jump out a window. When asked if the resident was suicidal, he/she said No, I'm homicidal. The resident then said Just you try and send me to the hospital, I'm not going. He/She stormed out the room, the Administrator followed him/her. This reporter called the power of attorney (POA) and informed him/her of the situation. This reporter then called the psych Nurse Practitioner, who stated he/she would be in on Thursday, 4/11/24. No new orders. The resident received medication for anxiety. After further conversation, the resident stated he/she was upset because he/she had been out with family the prior weekend and it reminded him/her what it was like to live in the community, and he/she felt like she/she was missing out on life;
-Record review showed no additional interventions;
-A psychiatric progress note, dated 4/11/24, showed the staff report that he/she has been doing adequately from a behavioral standpoint. He/She has been socializing with peers and most of the time appears to be in good mood;
-Depression with anxiety: Doing better;
-Recommendations:
-Continue the current psychotropics (drug(s) that affect a person's mental state) as he/she seem to have made significant improvement;
-The possibility of a bipolar mood disorder cannot entirely be excluded;
-A progress note on 4/21/24 at 7:09 P.M. showed, it was reported to this nurse that the resident attacked the receptionist. DON and Administrator immediately notified. Resident sent to the hospital for evaluation per psychiatrist recommendation;
-A late entry progress note dated 4/23/24 at 5:52 P.M., showed on 4/21/24, this reporter returned to the facility regarding an alleged incident between this resident and the receptionist. This incident was witnessed by 10 residents and one staff member who all recounted witnessing the resident swinging at the receptionist over being upset about the wait time for getting cigarettes. The altercation resulted in the resident knocking the box of cigarettes out of the receptionist's hands and caused the receptionists to hold up his/her arms to prevent the resident from striking him/her in the face. As the resident was swinging, he/she was hitting the receptionist's arms with his/her closed fist. Since the receptionist was the only staff member in the immediate area, two other residents intervened by yelling at the resident to stop and attempting to get in between the resident and the receptionist;
-A progress note dated 5/2/24 at 5:22 P.M., showed, on 4/21/24 at approximately 7:35 P.M. the DON made the primary care physician (PCP) aware resident was discharged to the hospital for aggressive behaviors and not to return per the PCP's recommendation which I (physician) agree with plan of action.
Review of the Resident Transfer Form, dated 4/21/24 at 7:00 P.M., showed:
-Sent to the hospital;
-Contact person notified of transfer: Non applicable;
-Clinician ordering transfer: Physician A and Physician B;
-Reason for transfer: This nurse was informed resident allegedly attacked receptionist outside during smoke break (behavior);
-Unplanned transfer;
-At risk alerts: None;
-Capabilities of the facility to care for this resident: Other- resident given emergent discharge from facility;
-Facility would be able to accept resident back under the following conditions: Other-resident given emergent discharge from the facility;
-Resident has had many behaviors since admission to facility on 8/11/23. Diagnosis-depression with anxiety and followed by psych;
-No bed hold;
-The form did not show what attempts the facility made to meet the resident's needs prior to discharging the resident.
Review of the facility's Emergency Discharge letter, dated 4/21/24, showed;
-Due to your verbal and aggressive behavior, the facility has found it necessary to issue this emergency discharge letter on 4/21/24. Today at the last smoke break you became upset because you stated that there was no seating available for you to sit. You became verbally abusive and then became physically aggressive toward a staff member that was trying to assist you. You have had several episodes in the past where you have been verbally aggressive. We have had conversations regarding these behaviors and put in place a positive behavioral agreement with which you voiced your satisfaction back in March. You have demonstrated that you are a risk to others. Therefore you will be discharged on 4/21/24 to the hospital.
Review of the facility's admission and Discharge Report, dated 4/1/24 -4/30/24, showed:
-4/21/24 discharged Return Not Anticipated: resident discharged to home or self-care (routine discharge).
During an interview on 4/25/24 at 2:26 P.M., a hospital representative said the resident received an immediate discharge from the facility on 4/21/24. The hospital representative spoke with the Administrator on 4/24/25 to see if the facility would reconsider taking the resident back. He/She also told the Administrator the resident was filing an appeal because he/she loved living at the facility and wanted to return. The hospital representative said the Administrator said they would not take the resident back, even with the appeal. The facility would take a regulatory citation instead. Therefore, the resident had to remain at the hospital for new placement. The resident was basically dumped at the hospital for a new disposition to be put in place. He/She said the facility sent the resident to the hospital with a complaint of aggressive behavior after he/she was verbally aggressive and then attacked the facility's receptionist.
During a telephone interview on 5/2/24 at 10:46 A.M., Receptionist F said the resident came downstairs for the last smoke break around 6:03 P.M. on 4/21/24, and he/she began to pass out the cigarettes around 6:15 P.M. When the resident came downstairs, he/she wanted people to stop whatever they were doing to help the resident. The resident knocked the cigarettes out of his/her hand. Receptionist F said he/she went to tell the Administrator and DON what happened. He/She wasn't told about any other ways to calm the resident down.
During an interview on 5/1/24 at 10:21 A.M., the Administrator said the resident's behaviors were explosive. He/She yelled, screamed, and was agitated. The Administrator said the resident wasn't getting what he/she needed. She created a positive reinforcement agreement for the resident, whereby if the resident didn't display behaviors for a certain amount of time, the facility would purchase him/her cigarettes. The Administrator said the resident didn't have any money. Not having money to purchase cigarettes contributed to the resident's behaviors. She knew the contract was frowned upon, but it worked for a while. The physician reviewed the resident's medical records and thought the diagnosis may be incorrect. She didn't know how to maintain or how to predict the resident's behavior. She was not sure how to handle the resident's behaviors or how she could keep the other residents safe.
During an interview on 5/1/24 at 3:00 P.M., the Administrator said she wasn't officially told the resident was going to or had filed an appeal, so she wasn't involved. The appeal information was hearsay to her but was aware that the resident had the right to come back to the facility pending the outcome of his/her appeal. The Administrator said she was concerned that the resident had no repercussions and didn't want him/her to think there was no consequences related to his/her behavior. The Administrator, MDS Coordinator and DON all said they were concerned if the resident were allowed to come back to the facility he/she would go after the other residents who helped the receptionist.
MO00235209
MO00235280

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), would be provided if such care was needed per the resident's choice, and would only be provided to a resident subject to related physician orders and resident choice. The facility failed to have a system to ensure resident code statuses are obtained, ensure code status matched the resident's wishes, and ensure code statuses were accurately documented. The facility failed to obtain an ordered code status for 2 residents and failed to have congruently documented code status for 2 residents, out of 37 residents investigated for advanced directives. One resident had an order for full code, but a face sheet indicated do not resuscitate (DNR). The resident said he/she wanted to be a full code (Resident #4). One resident had an order for full code, but a face sheet that indicated DNR. The resident's representative said the resident was a DNR (Resident #3). One resident had a face sheet that showed DNR, a signed code status for DNR, but no ordered code status. The face sheet in the code status binder showed full code (Resident #5). One resident had no ordered code status, a signed code status sheet for DNR, and the face sheet showed DNR. The resident representative said the resident is a DNR (Resident #6). The census was 37.
The administrator was notified on [DATE] at 10:30 A.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification.
1. Review of the facility's Do Not Resuscitate Order policy, revised [DATE], showed:
-Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect;
-Policy Interpretation and Implementation: Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record;
-A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record;
-DNR orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order;
-Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request;
-Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet;
-The Attending Physician must be informed of the resident's request to cease the DNR order;
-The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives;
-The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.
2. Review of the facility's Cardiopulmonary Resuscitation policy, revised February 2018, showed if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's order not to administer CPR.
3. Review of Resident #4's face sheet, showed:
-admitted on [DATE];
-DNR code status.
Review of the resident's code status sheet, dated [DATE], showed DNR checked and signed by the resident on [DATE].
Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed:
-Moderately impaired cognition;
-Diagnoses included heart failure, high blood pressure, atrial fibrillation (irregular heart rate), diabetes and schizophrenia (disorder that affects the ability to think, feel, and behave clearly).
Review of the resident's Physician's Orders Sheet (POS), dated [DATE], showed an order dated [DATE], for full code.
Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status.
During an interview on [DATE] at 3:00 P.M., the resident said staff did not talk to him/her about the code status. He/she would prefer to be a full code.
4. Review of Resident #3's face sheet, showed:
-admitted on [DATE];
-DNR code status.
Review of the resident's Outside the Hospital Do-Not-Resuscitate (OH-DNR) order, dated [DATE], showed DNR checked and signed by the resident on [DATE].
Review of the resident's quarterly MDS, dated [DATE], showed:
-Severely impaired cognition;
-Diagnoses included high blood pressure, Alzheimer's disease and depression.
Review of the resident's POS, dated [DATE], showed an order dated [DATE], for full code.
Review of the resident's care plan, in use during the survey, showed:
-Problem: Resident is a DNR effective [DATE] per patient and family wishes;
-Goal: The facility will respect the resident's decision to be a DNR;
-Approach: If there is an absence of vital signs, do not call 911 or initiate CPR.
During an interview on [DATE] at 3:20 P.M., the resident's family member said the resident's code status is DNR. He/She spoke to staff last month just to clarify and they went over the code status with him/her.
Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status.
5. Review of Resident #5's face sheet, showed:
-admitted on [DATE];
-DNR code status.
Review of the resident's annual MDS, dated [DATE], showed:
-Cognitively intact;
-Diagnoses included high blood pressure and anxiety.
Review of the resident's undated code status sheet, showed DNR checked and signed by the resident.
Review of the resident's POS, dated [DATE], showed no order for code status.
Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status.
6. Review of Resident #6's face sheet, showed:
-admitted on [DATE];
-DNR code status.
Review of the resident's OH-DNR order, dated [DATE], showed DNR checked and signed by the resident's Power of Attorney (POA) on [DATE].
Review the resident's quarterly MDS, dated [DATE], showed:
-Severe cognitively impairment;
-Diagnoses included high blood pressure, kidney failure, diabetes, Alzheimer's disease, dementia, depression and schizophrenia.
Review of the resident's POS, dated [DATE], showed no order for code status.
Review of the resident's care plan, in use during the survey, showed:
-Problem: The resident is a DNR;
-Goal: The facility will respect the resident's decision to be a DNR;
-Approach: If the resident is found unresponsive and has no pulse and not breathing do not initiate CPR and do not call 911.
Review of the facility's Emergency Evacuation binder, showed a POS, dated [DATE] through [DATE], with a full code status. No face sheet was found.
During an interview on [DATE] at 4:30 P.M., the resident's POA said he/she was aware of the resident's DNR code status and the resident wanted to be a DNR.
7. During an interview on [DATE] at 1:50 P.M., Certified Nurse Aide (CNA) A said if he/she had to find the resident's code status quickly, it is found in the code status binder at the nurse's station. It was the only place he/she knew to look.
During an interview on [DATE] at 1:52 P.M., Licensed Practical Nurse (LPN) B said he/she would find the resident's code status on the face sheet. If there is nothing there, he/she would initiate CPR.
Observation and interview on [DATE] at 2:02 P.M., Restorative Aide (RA) C said every month he/she receives a print off of all the resident's codes status from their orders and that is where he/she would look for a code status. Every resident has a code status on his/her list. If the resident was a new admit or not on the list, there is a binder at the nurse's station. RA C looked through a binder and did not find any code status and said the binder was a cheat sheet for the nurses. Normally the code statuses would be in the binder.
Review of RA C's print off list, showed:
-No documentation of Residents #4 and #5 on the list;
-Resident #6 showed a DNR code status;
-Resident #3 showed a DNR code status.
During an interview on [DATE] at 3:22 P.M., Certified Medication Aide (CMT) D said he/she would check the binder at the nurse's station for code statuses. He/she was pretty sure it is updated, but he/she was not responsible for updating it. He/she will also check the Medication Administration Record (MAR) in the medical record. If there was no code status, he/she would get the nurse.
During an interview on [DATE] at 5:15 P.M., the Administrator in Training and Director of Nursing (DON) said when a resident is admitted to the facility, they are a full code unless they sign a DNR. It is a part of the admission packet. The code status is also on the POS. If there are changes in the resident's code status, the charge nurse is responsible for updating it in the medical record. If there is a care plan meeting, quarterly or significant change, the code status is reviewed with the resident. They review it and sign it. There is a red piece of paper in front to notify the DON that the code status was changed at the care plan meeting. The MDS coordinator changes the code status since they are present during the care plan meeting. If hospice speaks to the resident about their code status, they are to notify the DON. The charge nurse is expected to change it. They keep a copy of the code status sheet in hard files and it is uploaded to the electronic medical record. In order to find the resident's code status, they look in the electronic medical record, on the header where their picture is found. If the resident is a full code, it is green and DNR is in red. The binder with the code status is not at the nurse's station. The binder with the code statuses are in the facility's emergency evacuation binder. The resident's face sheets are in the binder with their code status at top of face sheet. It is updated quarterly and as needed if new admission or changes. The binder is located in the DON's office. The DON was unsure if staff were aware the binder was in the DON's office. The binder is updated by the DON. It was updated within the last 3 months. The Administrator in Training said she would expect resident's code status on the face sheet, POS and signed code status sheet to all match. They recently had an audit. All residents should have an order for DNR if they are a DNR, but for residents who are a full code, the administrator in training said she would need to follow up with DON. She did not believe they would need an order for full code. If staff were unable to find a resident's code status, they would treat them as full code.
During an interview on [DATE] at 5:40 P.M., the Administrator confirmed that POS were not checked during the audit. She would expect staff to check the POS during their audits. It should be reflected on their care plans. All resident's code status are expected to match and have an order on the POS.
NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. 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 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).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident was free from physical and verbal abuse and involuntary confinement (Resident #1). On 5/14/23 between 1:00 P.M. and 1:30 P.M., during lunch in the dining room, Certified Nursing Assistant (CNA) CNA A was observed by the Dietary Supervisor (DS), Dietary Aide (DA) B and Residents #3, #6, #2, #5 and #4 either hitting the resident in the head, raising his/her arms to the resident, yelling/cursing at the resident, and/or forcefully grabbing the resident's wheelchair to prevent the resident from exiting the dining room to go to his/her room and lay down. The DS and DA B failed to immediately intervene by separating the resident from the CNA and reporting what they witnessed to Nurse C. The CNA eventually took the resident out of the dining room to the nurse's station where the resident told Nurse C the CNA hit him/her in the head. Nurse C did not immediately separate the resident from the CNA, did not report what the resident said to the Director of Nurses (DON) and did not separate the CNA from residents, pending an investigation. The CNA finished his/her shift which was approximately five more hours. The CNA was assigned to provide care to 13 residents, including Resident #1. In addition, Nurse C called the Psychiatric Nurse Practitioner (NP) after the incident occurred, informing him the resident was aggressive, grabbed the CNA's arm and scratched the CNA, but did not inform him the resident said the CNA hit him/her in the head. The NP increased the resident's risperidone (an antipsychotic medication used to treat behavioral disorders). In addition, the facility policies did not show how the facility would protect the resident once an allegation of abuse was made. Six residents were sampled. The census was 38.
The administrator was notified on 6/6/23 at 11:30 A.M. of an Immediate Jeopardy (IJ) which began on 5/14/23. The IJ was removed on 5/25/23, as confirmed by surveyor onsite verification.
Review of the facility's Resident Abuse Policy and Procedures, revised on 8/31/18, showed:
-Purpose:
-This facility maintains a no tolerance policy on any form of abuse towards residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors and friends, or other individuals;
-Definitions:
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish;
-Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or in their hearing distance, regardless of their age, ability to comprehend, or disability;
-Physical abuse including hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment;
-Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation;
-Involuntary seclusion is defined as separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative;
-The facility prime directive towards resident abuse is to develop and operationalize policies and procedures for screening and training all staff, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, in an effort to prevent occurrences of resident abuse;
-Training: All staff will be trained through orientation and quarterly in-services that focus on issues related to abuse prohibition practices which include but not limited to:
-Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents;
-How staff should report their knowledge relating to allegations without fear of reprisal;
-What constitutes abuse, neglect and misappropriation of resident property;
-Prevention:
-Residents, families, volunteers and staff are provided with the necessary information through the New admission Handbook on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Individuals can make their concerns anonymously by filling out a grievance form and placing it under the Administrator's door and/or social worker's office door. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of the resident property is or likely to occur;
-Identification and Investigation:
-The direction of an abuse investigation will be determined following the identification of suspicion of alleged abuse including but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse;
-1. Staff, residents, family members and visitors are to report any suspected abuse to any of the following persons:
a) Administrator - Grievance Officer;
b) Director of Nursing;
c) Charge Nurse;
d) Social Worker - Grievance Officer;
e) Any Member of Management (Minimum Data Set (MDS) Coordinator, Dietary Manager, Human Resource Manager);
-2. Investigation shall follow facility's Incident Reporting Policy:
-The timeliness of the Investigation:
-The facility must begin the investigation in order to collect accurate data related to the incident. Any delay in starting the investigation can cause valuable information to be either lost or altered;
-Thoroughness of the Investigation:
-Federal law requires the facility to do a thorough investigation of the incident. In order for the facility to provide evidence of the thoroughness of the investigation the information must be recorded. A thorough investigation may require (2) phases of the fact gathering:
-Phase I: Must be completed and reported no later that 2 hours after an allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If Phase I is not successful in determining a reasonable cause, an extended phase must follow;
-Phase II: The investigation should end with the identification of who is involved in the incident, and what, when, where, why and how the incident happened, including probable or reasonable cause. It should also allow the facility to determine if the allegations were true or not;
-Each phase of a thorough investigation includes: Data collection and data analysis.
Review of the facility's undated policy, Incident Reporting Policy, showed:
-All staff are required to understand what constitutes as abuse, neglect, mistreatment of residents, injury of an unknown origin and misappropriation of their property which are outlined in Resident Rights and Abuse & Neglect Policy which are accordance to Federal and State law;
-Staff must protect residents from harm, immediately report incidents as required by federal and state law, and begin investigation as soon incident is made known. It is [NAME] Park's responsibility to immediately:
-Protect resident(s) from reoccurrence; and
-Take any action necessary to treat the ill effect(s) experienced by the resident(s) as a result of the alleged incident(s);
-The policy does not show how the resident will be protected from any alleged perpetrator(s).
Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/23, showed:
-Adequate hearing and vision;
-Speech Clarity: Unclear speech - slurred or mumbled words;
-Makes Self Understood: Usually understands - difficulty communicating some words or finishing thoughts but is able if prompted or given time;
-Ability to Understand Others: Understood - clear comprehension;
-Severely impaired cognition;
-Physical behavioral symptoms directed toward others (e.g.; hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days (over the past 7 days);
-Verbal behavioral symptoms directed toward others (e.g.; threatening others, screaming at others, cursing at others): Behavior of this type occurred 1 to 3 days;
-Rejection of care: Behavior not exhibited;
-One person physical assistance required for transfers, locomotion on the unit;
-Mobility Devices: [NAME] and wheelchair;
-Diagnoses of non-traumatic brain dysfunction (brain injury that is not caused by any external force, instead the cause is due to medical conditions and illnesses that disturb the normal functioning of the brain) and stroke.
Review of the resident's care plan, undated, showed:
-Problems:
-Behavioral Symptoms: Resident noted to have physical and verbally aggressive behaviors;
-Falls: Resident will attempt to transfer self from wheelchair to bed and bed to wheelchair;
-Activities of Daily Living Functional Status: Resident requires assist of 1 with pivot transfer. He/She is nonambulatory and propels himself/herself independently in the wheelchair;
-Mood State: Receives antidepressants and antipsychotics for mood disorder;
-Approaches:
-Monitor/supervise resident in more frequent intervals as needed;
-Provide clear and concise boundaries;
-Redirect as needed and remove from situations that are harmful to him/her or others;
-Maintain a calm environment and approach to the resident;
-Maintain a calm, slow, understandable approach with the resident;
-Provide assistance with transferring. Encourage resident to ask for assistance;
-Monitor behavior every shift;
-The resident's care plan did not identify a problem/intervention with the resident frequently requesting/wanting to lay down after he/she finished eating.
Review of the facility Administrator's initial report, on 5/15/23 at 12:11 P.M., showed the following:
Summary of Alleged Incident:
-On 5/14/23, it is alleged CNA A hit Resident #1 in the back of the head with his/her fists and roughly pulled the resident up to the dining room table. The incident was witnessed by the Dietary Supervisor who reported the incident;
-Incident Information:
-On 5/15/23 at approximately 11:00 A.M., the DON was reviewing another investigation when the DS approached the DON and handed her some paper saying You need to read this. The DON discovered the paper was a statement signed Anonymous and regarded an allegation that CNA A physically assaulted the resident in the dining room during lunch on 5/14/23 (The DS later acknowledged she was the author of the anonymous statement). She said during lunch on 5/14/23, she witnessed CNA A get frustrated with the resident and forcibly push his/her wheelchair into the table. The resident was trying to go to his/her room and the CNA stopped him/her and started wrestling with the resident. The resident put his/her hands up to block the CNA and the CNA started punching the resident in the back of the head. The CNA then grabbed the resident and started swinging the resident around and the resident was halfway out of his/her wheelchair;
-At approximately 11:15 A.M. (5/15/23), the DON immediately notified the Administrator and Administrator in Training (AIT) regarding the DS's statement. An investigation was immediately started;
-The DS was immediately interviewed over the phone by the Administrator (the Administrator was at home, the DS was at the facility) with the AIT and DON who were present at the facility with the DS.
-DA B said he/she saw the resident scratching CNA A when he/she was trying to take the resident to his/her room. The CNA was trying to stop the resident from agitating the other residents while eating and the resident became upset.
-CNA A was interviewed by phone. He/She said he/she tried to redirect the resident because the resident was bothering other residents while they were eating and the resident was going to the steam table (a heated table used to keep food hot). The resident was not able to be redirected and since he/she was done eating he/she tried to remove the resident from the dining room. The resident did not want to go and was upset because he/she would not allow him/her to bother the other residents. When he/she tried to remove the resident, the resident started scratching his/her arm and then tried to hit him/her. He/She tried to keep the resident's hands away from him/her so the resident would not injure him/her. He/She said he/she would never hit a resident and he/she was not angry with the resident. He/She said there were dietary staff and residents in the dining room at the time. Once he/she was able to get the resident out of the dining room, he/she took the resident to Nurse C who was behind the nurse's station;
-The DON and AIT interviewed 12 residents, None of their statements were consistent with the DS's statement. One resident (Resident #3) said CNA A was grabbing the resident's arm to prevent the resident from hitting him/her. Resident #3 did express the CNA may have been a little too aggressive;
-Conclusion:
-Due to the inconsistencies of the statements, it could not be determined whether the allegation was founded. However, there was evidence CNA A did not handle the situation appropriately and as a result was terminated. All employees received an inservice about mandated reporting of abuse and anyone failing to report abuse of any kind will also be held accountable.
Review of the facility completed investigation e-mailed to DHSS on 5/22/23, showed:
-A written statement from the DON dated 5/15/23: When she reported to work on 5/15/23, at approximately 11:00 A.M., as she was exiting the elevator the DS handed her a statement signed anonymous. Upon discovering alleged abuse (regarding CNA A and Resident #1), she immediately notified the AIT, and they notified the Administrator. An investigation was launched; interviewing residents and staff; followed by in-depth inservicing of staff was started on 5/15/23 and is on-going;
-The anonymous note was given to the DON by the DS on 5/15/23: On Sunday 5/14/23 at 12:50 P.M. some residents were done eating their food and started to move around the dining room. Resident #1 was trying to go to his/her room. CNA A was upset with the resident and he/she pushed the resident's wheelchair with so much force back to the table. Moments passed and the resident tried leaving out of the dining room again but this time the CNA was really upset and started to wrestle with the resident. The resident then put his/her hands up trying to block CNA A from hitting him/her in the head. The CNA's fists were balled up and he/she was hitting the resident in the head and face. The CNA then started to grab onto the resident's shirt with force slinging the resident around in the wheelchair, pushing on the resident, and handling the resident with the most disrespectful force until the resident was almost on the floor. The CNA then grabbed the resident by the front of his/her shirt and pushed threw the resident back into his/her wheelchair. Then the CNA started to swing the wheelchair forcefully against the door and wall and said to the resident don't play with me I'll lose this job from fucking you up. The resident got very upset and I was yelling at the CNA to leave the resident alone, then Resident #4 was yelling at the CNA to leave the resident alone. The other CNAs were not in the dining room when this happened. A few minutes later people said they wasn't going to report the incident/abuse because they are too short staffed. The CNA told Nurse C the resident was trying to scratch him/her so he/she wouldn't have any consequences following this. I wanted to call the police on the CNA but she figured you all should know first. She is reporting this now. It was very horrible what she witnessed.
Signed: A very concerned witness - anonymous;
-During the facility investigation the DS confirmed she had written the anonymous note;
-The DS's written statement dated 5/15/23, completed after giving the DON the anonymous statement:
As some residents were done eating their food and started to move around to leave out of the dining room, Resident #1 kept trying to go to his/her room. CNA A was getting upset with the resident and he/she pushed the resident's wheelchair with so much force against the table. The resident tried leaving again and this time the CNA was very upset and was trying to get the resident to stop but the resident tried to keep going and the CNA balled up his/her fist and hit the resident a few times. She asked the CNA to stop and he/she wasn't listening, then the resident was asking the CNA to stop as well. She then left to go back to the kitchen after being in shock after what she had witnessed. The very next day she reported it to the DON;
-A typed statement from the Administrator dated 5/17/23: On 5/15/23 the Administrator (at home) interviewed the DS by phone (DS was at the facility). The following questions were asked during the interview:
Question (Q): What staff were present? Answer (A): DA B, CNA A and the DS;
Q: How did CNA A hit the resident, how many times, where? A: A few times, in the back of the head with his/her fists;
-DA B's undated written statement (per interview with the Administrator, DA B's statement was written and given to Nurse C on 5/14/23): CNA A was taking Resident #1 out of the dining room. The resident started fighting the CNA. The CNA never put his/her hands on the resident. The resident started swinging on the CNA;
-A written statement from Nurse C, dated 5/15/23: On 5/14/23, during lunch meal, Resident #1 was brought to the nurse's station by CNA A. This nurse asked the resident again what happened and the resident said the CNA hit him/her. When asked where the CNA hit him/her, he/she said in the head. When asked where in the head, he/she said he/she didn't know. This nurse assessed the resident's head, no redness, swelling, or open areas. This nurse asked the CNA if anyone else was in the dining room during the incident and he/she said DA B. DA B was asked to come to the nurse's station. This nurse asked him/her if he/she had seen the incident between the CNA and resident. He/She said he/she had. When the CNA tried to push the resident out of the dining room he/she started scratching the CNA;
-A written statement from the Housekeeping Supervisor (HS) dated 5/17/23: She was at the front desk talking to Receptionist H on 5/15/23 around 7:30 A.M The DS came to the front desk and sat in a chair. The DS stated CNA A was pulling and hitting Resident #1. She asked the DS if she stopped the CNA from hitting the resident and he/she said no. She asked the DS if she called anyone and she said no because Nurse C was standing there. I asked the DS if she called the DON or Administrator and she said that is what she is waiting for them to come in so she can tell them. That was about 7:45 A.M. on 5/15/23;
Resident statements, dated 5/15/23:
-Resident #2: CNA A was pulling Resident #1's wheelchair and Resident #1 was resisting;
-Resident #3: CNA A and Resident #1 were fighting. The CNA was grabbing the resident arms trying to stop the resident from hitting him/her. The CNA was pulling on the resident's wheelchair trying to get the resident out of the dining room. He/She (Resident #3) felt like the CNA was being a little too aggressive;
-Resident #5: CNA A was trying to stop Resident #1 from messing with other people and the resident got upset. The resident was then trying to go to the steam table and the CNA tried to pull the resident's wheelchair away. The resident got aggressive and started swinging at the CNA. The CNA was just trying to get the resident out of the dining room. The resident was swinging at the CNA;
-Resident #6: He/She saw CNA A pulling Resident #1's wheelchair. The CNA was pulling it kind of hard because the resident was pushing against the CNA. He/She did not see any hitting.
Review of the resident's electronic medical record, showed an Events Detail form completed by Nurse C on 5/17/23 at 8:18 P.M., which included the following:
-When Occurred: 5/14/23 1:30 P.M.;
-Progress Note: At approximately 1:30 P.M. during lunch meal, the resident started propelling around the dining room touching other residents while they were eating. Third assignment CNA requested resident to stop touching others, however behavior continued. He/She attempted to escort the resident out of the dining room. The resident then grabbed his/her arm and started scratching him/her. The resident was brought to nurse's station for close supervision. When asked why he/she (resident) did the above, the resident said they lying on me. Psychiatric Nurse Practitioner (NP) informed of behavior. New order received for risperidone 0.5 milligrams (mg) every morning. Physician and DON informed of behavior and new psych recommendation.
Review of the resident's Physician's Order Sheet, showed:
-An order dated 2/3/23, for risperidone 1 milligram (mg) daily at hour of sleep (HS) med pass 7:00 P.M. - 11:00 P.M.;
-An order dated 5/14/23 for risperidone 0.5 mg daily during the A.M. med pass (7:00 A.M. - 11:00 A.M.).
Review of the resident's medication administration record (where nurses initial a medication has been administered per physician orders), for May 2023 and June 2023. showed:
-An order for risperidone 0.5 mg at A.M. med pass and initialed as administered daily from 5/15/23 thru 5/31/23, and 6/1/23.
During an interview on 5/25/23 at 8:40 A.M., the Administrator said the facility investigation sent to DHSS on 5/22/23 was complete and she had nothing more to add. CNA A is the shower aide but was working the floor as a CNA on 5/14/23. He/She was assigned a group of residents to care for that day, which included Resident #1. CNA A worked his/her 12 hour shift on 5/14/23, from 6:30 A.M. to 6:30 P.M.
Review of CNA A's time sheet, dated 5/14/23, showed he/she clocked in at 6:50 A.M. and clocked out at 6:30 P.M.
During an interview on 5/25/23 at 10:40 A.M., Resident #1 said staff treat him/her good and no one has been mean or abusive to him/her. He/She said he/she did remember CNA A would not let him/her leave the dining room one day, but could not recall what day that was. He/She wanted to lay down. The CNA grabbed his/her wheelchair and wouldn't allow him/her to leave. That made him/her mad. He/She thinks the CNA may have hit him/her in the front of his/her head, but he/she is not sure. The resident was not afraid of the CNA that day, he/she just wanted to lay down. He/She had not had any problems with the CNA prior to that day.
During an interview on 5/26/23 at 9:15 A.M., the DS said on 5/14/23 during lunch, she, DA B and CNA A were in the dining room. Resident #1 was in his/her wheelchair and trying to go back to his/her room. The resident was trying to wheel himself/herself out of the dining room to the hall that leads to his/her room and the CNA was getting frustrated with the resident telling him/her that he/she couldn't leave the dining room. The CNA grabbed the resident's wheelchair hand bars and dragged the resident backwards back into the dining room multiple times. The DS heard a commotion and turned to see the CNA hit the resident. The CNA had his/her fists balled up and hit the resident in the back of the head more than one time. The resident had his/her hands up trying to block the CNA from hitting him/her. The CNA very loudly told the resident you don't know me, I'll lose my job and that he/she did not have time to keep bringing him/her back. The DS told the CNA that's enough, you need to stop it. The resident kept saying he/she wanted to go to his/her room. The resident had slipped down in his/her wheelchair and the CNA grabbed a hold of his/her shirt and pushed the resident back into the wheelchair seat. After that, the CNA took the resident to the nurse's station. The DS did not report what she saw because Nurse C was standing in the hall at his/her cart and she assumed the nurse saw what happened. She did not see the nurse intervene or say anything to the CNA. The DS did not speak to the nurse about what happened, she went downstairs. She is the one that wrote the anonymous letter and gave it to the DON. The DS wrote it anonymously because she wanted to avoid confrontation or retribution.
During an interview on 5/25/23 at 9:15 A.M., DA B said on 5/14/23, it was CNA A, the DS, and DA B in the dining room during lunch. The resident had no behaviors while he/she was eating. After the resident finished eating, he/she saw the resident going and talking to other residents. The resident always does this. The resident did not appear to be bothering anyone and the other residents were not complaining. It was after this when the resident told the CNA he/she wanted to go to bed. The CNA told the resident he/she was not going to take him/her to bed. This is when the resident began to get upset. The resident was trying to wheel himself/herself out of the dining room. The resident got to the doorway and the CNA brought the resident back. The resident did not want to come back, saying he/she wanted to go to his/her room. The CNA grabbed the resident's wheelchair by the handles, preventing the resident from leaving. The resident was trying to go one way and the CNA was making him/her go another. That's when the resident began swinging at the CNA. He/She did not see the resident scratch the CNA, but the resident was swinging his/her arms at the CNA who was standing behind the resident's wheelchair. DA B saw the CNA put his/her arms up and the CNA was swinging his/her arms. He/She did not see the CNA hit the resident in the head, but it could have happened because the CNA had his/her arms up too. He/She heard the DS say if the resident wants to go to his/her room, let him/her go to his/her room. The entire incident lasted approximately 6 or 7 minutes. DA B did not say anything to anyone because he/she thought CNA A would tell Nurse C what happened.
Review of Resident #6's annual MDS, dated [DATE], showed:
-Adequate hearing;
-Vision impaired - sees large print, but not regular print in newspapers/books;
-Speech Clarity: Clear speech - distinct intelligible words;
-Makes Self Understood: Usually understands - difficulty communicating some words or finishing thoughts but is able if prompted or given time;
-Ability to Understand Others: Understands - clear comprehension;
-Cognitively intact.
During an interview on 5/26/23 at 12:38 P.M., Resident #6 said he/she was in the dining room at lunch on 5/14/23. CNA A got real loud with Resident #1 because the resident wanted to stay in the dining room, he/she did not want to leave the dining room. He/She saw the CNA swinging on the resident. The CNA hit the resident, but he/she did not see where he/she hit the resident. The resident was using his/her feet to stop the CNA from pushing his/her wheelchair. The CNA was very aggressive and jerking the resident's wheelchair around. The resident was yelling at the CNA to stop and the CNA was yelling at the resident.
Review of Resident #2's quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Speech Clarity: Clear speech - distinct intelligible words;
-Makes Self Understood: Understood;
-Ability to Understand Others: Understands - clear comprehension;
-Cognitively intact.
During an interview on 5/25/23 at 11:03 A.M., Resident #2 said he/she was in the dining room on 5/14/23 during lunch. The CNA was trying to pull Resident #1's wheelchair and the resident did not want to be pulled. The resident was putting his/her feet down on the floor to stop the CNA from pulling him/her. Resident #2 thinks the resident was mad because he/she was kind of swinging at the CNA. The CNA did not swing at the resident that he/she saw.
Review of Resident #5's quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Speech Clarity: Clear speech - distinct intelligible words;
-Makes Self Understood: Understood;
-Ability to Understand Others: Understands - clear comprehension;
-Cognitively intact.
During an interview on 5/26/23 at 12:30 P.M., Resident #5 said he/she was in the dining room on 5/14/23 during lunch. Resident #1 was trying to leave the dining room and CNA A kept pulling the resident back into the dining room. The resident seemed to be getting upset as he/she was swinging his/her arms.
Review of Resident #4's quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Speech Clarity: Clear speech - distinct intelligible words;
-Makes Self Understood: Understood;
-Ability to Understand Others: Under

Based on interview and record review, the facility failed to implement their Resident Abuse Policy and Procedures by failing to initiate immediate corrective actions to prevent abuse when the Dietary Supervisor (DS) and Dietary Aide (DA) B failed to immediately report witnessing Certified Nursing Assistant (CNA) A hitting a resident (Resident #1) in the dining room on 5/14/23 between 1:00 P.M. and 1:30 P.M. On 5/14/23 around 1:00 P.M. to 1:30 P.M., the resident was taken to the nurse's station by the CNA. The resident told Nurse C the CNA hit him/her in the head. Nurse C failed to immediately initiate an investigation, separate the resident from the CNA, failed to send the CNA home pending an investigation, and failed to inform the Director of Nurses (DON) during a telephone call shortly after the resident alleged the CNA hit him/her. The facility allowed the CNA to continue working until his/her shift was over at 6:30 P.M. The CNA was assigned to provide care to 13 residents, including Resident #1. Six residents were sampled. The census was 38.
Review of the facility's Resident Abuse Policy and Procedures, revised on 8/31/18, showed:
-Purpose: This facility maintains a no tolerance policy on any form of abuse towards residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors and friends, or other individuals;
-Definitions:
-Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish;
-Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or in their hearing distance, regardless of their age, ability to comprehend, or disability;
-Physical abuse including hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment;
-Mental abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation;
-Involuntary seclusion is defined as separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative;
-The facility's prime directive towards resident abuse is to develop and operationalize policies and procedures for screening and training all staff, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, in an effort to prevent occurrences of resident abuse;
-Training: All staff will be trained through orientation and quarterly in-services that focus on issues related to abuse prohibition practices which include but not limited to:
-Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents;
-How staff should report their knowledge relating to allegations without fear of reprisal;
-What constitutes abuse, neglect and misappropriation or resident property;
-Prevention: Residents, families, volunteers and staff are provided with the necessary information through the New admission Handbook on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Individuals can make their concerns anonymously by filling out a grievance form and placing it under the Administrator's door and/or Social Worker's office door. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of the resident property is ore likely to occur;
-Identification and Investigation: The direction of an abuse investigation will be determined following the identification of suspicion of alleged abuse including but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse;
1. Staff, residents, family members and visitors are to report any suspected abuse to any of the following persons:
a) Administrator - Grievance Officer;
b) Director of Nursing (DON);
c) Charge Nurse;
d) Social Worker - Grievance Officer;
e) Any Member of Management (Minimum Data Set (MDS) Coordinator, Dietary Manager, Human Resource Manager);
2. Investigation shall follow facility's Incident Reporting Policy:
-The timeliness of the Investigation:
-The facility must begin the investigation in order to collect accurate data related to the incident. Any delay in starting the investigation can cause valuable information to be either lost or altered;
-Thoroughness of the Investigation:
-Federal law requires the facility to do a thorough investigation of the incident. In order for the facility to provide evidence of the thoroughness of the investigation the information must be recorded. A thorough investigation may require (2) phases of the fact gathering:
-Phase I: Must be completed and reported no later that two hours after an allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If Phase I is not successful in determining a reasonable cause, an extended phase must follow;
-Phase II: The investigation should end with the identification of who is involved in the incident, and what, when, where, why and how the incident happened, including probable or reasonable cause. It should also allow the facility to determine if the allegations were true or not;
-Each phase of a thorough investigation includes: Data collection and data analysis.
On Monday 5/15/23 at 12:11 P.M., the facility Administrator notified the Department of Health and Senior Services (DHSS) of the following initial abuse and neglect report:
-Summary of Alleged Incident: On 5/14/23, it is alleged CNA A hit Resident #1 in the back of the head with his/her fists and roughly pulled the resident up to the dining room table. The incident was witnessed by the DS who reported the incident;
-Incident Information:
-On 5/15/23 at approximately 11:00 A.M., the DS approached the DON and handed her some paper saying You need to read this, you don't have to read it right now, you just need to read it. The DON discovered the paper was a statement signed Anonymous regarding an allegation that CNA A physically assaulted Resident #1 in the dining room during lunch on 5/14/23. The DS acknowledged she was the author of the statement. She said during lunch on 5/14/23, she witnessed CNA A get frustrated with the resident and forcibly push his/her wheelchair into the table. The resident was trying to get to his/her room and CNA A stopped him/her and started wrestling with the resident. The resident put his/her hands up to block CNA A. CNA A started punching the resident in the back of the head. CNA A then grabbed the resident and started swinging the resident around and the resident was halfway out of his/her wheelchair;
-At approximately 11:15 A.M. (on 5/15/23) the DON immediately notified the Administrator and Administrator in Training (AIT) regarding the DS's statement. An investigation was immediately started.
Review of Resident #1's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 2/17/23, showed:
-Adequate hearing and vision;
-Speech Clarity: Unclear speech - slurred or mumbled words;
-Makes Self Understood: Usually understands, difficulty communicating some words or finishing thoughts but is able if prompted or given time;
-Ability to Understand Others: Understood, clear comprehension;
-Severe cognitive impairment;
-Physical behavioral symptoms directed toward others (e.g.; hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days (over the past 7 days);
-Verbal behavioral symptoms directed toward others (e.g.; threatening others, screaming at others, cursing at others): Behavior of this type occurred 1 to 3 days;
-Rejection of care: Behavior not exhibited;
-One person physical assistance required for transfers, locomotion on the unit;
-Mobility Devices: [NAME] and wheelchair;
-Diagnoses included non-traumatic brain dysfunction (brain injury that is not caused by any external force, instead the cause is due to medical conditions and illnesses that disturb the normal functioning of the brain) and stroke.
During an interview on 5/25/23 at 8:40 A.M., the Administrator said CNA A was the shower aide through the week, but was not a shower aide on 5/14/23. He/She was assigned a group of residents to care for that day, which included Resident #1. The CNA worked his/her 12 hour shift on 5/14/23, from 6:30 A.M. to 6:30 P.M.
Review of the CNA's time sheet dated 5/14/23, showed the CNA clocked in at 6:50 A.M. and clocked out at 6:30 P.M.
During observation and interview on 5/25/23 at 10:40 A.M., Resident #1 was dressed and laying down in bed. He/She said staff treat him/her good and no one has been mean or abusive to him/her. He/She said he/she did remember CNA A would not let him/her leave the dining room one day. He/She wanted to lay down. CNA A grabbed his/her wheelchair and wouldn't allow him/her to leave. That made him/her (resident) mad. He/she thinks CNA A may have hit him/her in the front of his/her head, but he/she is not sure. He/She had not had a problem with CNA A before that day.
During an interview on 5/26/23 at 9:15 A.M., the DS said on 5/14/23 during lunch, she, DA B and CNA A were in the dining room. Resident #1 was in his/her wheelchair and tried to go back to his/her room. The resident was trying to wheel himself/herself out of the dining room to the hall that led to his/her room. The CNA was getting frustrated with the resident and told the resident he/she couldn't leave the dining room. The CNA grabbed the resident's wheelchair hand bars and dragged the resident backwards back into the dining room multiple times. She heard a commotion and turned to see the CNA and the resident. The CNA had his/her fists balled up and hit the resident in the back of the head more than one time. The resident had his/her hands up trying to block the CNA from hitting him/her. The CNA very loudly told the resident You don't know me, I'll lose my job and he/she did not have time to keep bringing him/her back. She told the CNA that was enough, he/she needed to stop it. The resident kept saying he/she wanted to go to his/her room. The resident had slipped down in his/her wheelchair and the CNA grabbed a hold of his/her shirt and pushed the resident back into the wheelchair seat. The CNA then took the resident to the nurse's station. She did not report what she saw because Nurse C was standing in the hall at his/her cart and assumed the nurse saw what happened. She did not see the nurse intervene or say anything to the CNA. She did not speak to Nurse C about what happened. The DS went downstairs.
During a telephone interview on 5/31/23 at 2:50 P.M., CNA A said the resident was assigned to him/her on 5/14/23 for the entire 12 hours shift. During lunch that day he/she was the only nursing staff in the dining room. DA B was also in the dining room. He/she did not recall the DS being in the dining room. The resident had eaten and he/she always wanted to lay down after he/she eats. The resident started to wheel himself/herself out of the dining room and into the hall where the elevators are. He/She got the resident and took him/her back to the table and locked his/her wheels. He/She told the resident as soon as another nursing staff came into the dining room he/she would lay him/her down. The resident unlocked his/her wheelchair and rolled around touching other residents and went towards the steam table. The resident left the table three times and the CNA went and got the resident each time and took him/her back to the table. The resident was not mad. Eventually he/she took the resident to the nurse's station because the resident kept rolling around touching other residents. Nurse C was sitting at the nurse's station. The resident told the Nurse the CNA had hit him/her. CNA A told the nurse and resident that was not true. He/she denied hitting the resident, being aggressive with the resident, yelling at or threatening the resident. He/She did not curse or jerk the resident around in his/her wheelchair. The resident remained assigned to CNA A until he/she left around 7:00 P.M.
During an interview on 5/25/23 at 9:15 A.M., DA B said on 5/14/23 he/she, CNA A, and the DS were in the dining room during lunch. He/She and the DS were in the serving area. The resident was his/her normal self and had no behaviors while he/she ate. After the resident finished eating, DA B saw the resident go around and talk to other residents. The resident always did this. The resident did not appear to be bothering anyone and the other residents were not complaining. Then the resident told the CNA he/she wanted to go to bed. The CNA told the resident he/she was not going to take the resident to bed. The resident began to get upset. The resident tried to wheel himself/herself out of the dining room. The resident got to the doorway and the CNA brought the resident back. The resident did not want to come back and said he/she wanted to go to his/her room. The CNA grabbed the resident's wheelchair by the handles, preventing the resident from leaving. The resident tried to go one way and the CNA made him/her go another. The resident began swinging at the CNA. He/She did not see the resident scratch the CNA. The resident was swinging his/her arms at the CNA who was standing behind the resident's wheelchair. He/She saw the CNA put his/her arms up and the CNA swung his/her arms as well. He/She did not see the CNA hit the resident in the head, but it could have happened. The entire incident lasted approximately 6 or 7 minutes. He/She did not say anything to anyone because he/she thought CNA A would tell Nurse C what happened.
During an interview on 5/25/23 at 8:06 A.M., Nurse C said he/she was the nurse on duty on 5/14/23. He/She was sitting at the nurse's station around 1:00 P.M. to 1:30 P.M. and he/she heard loud voices coming from the dining room area. Then CNA A brought the resident to the nurse's station, saying the resident had grabbed his/her arm and scratched him/her. The CNA did have some minor scratches on one of his/her arms. The resident denied scratching the CNA. The resident said the CNA hit him/her. At first the resident did not know where the CNA had hit him/her, then eventually said in the head. The CNA, who was present while Nurse C questioned the resident, said to the resident, you know that's not true. Nurse C assessed the resident's head and found no marks. The resident has a poor memory.
During an interview on 5/26/23 at 7:23 A.M., Nurse C said on 5/14/23, he/she called the DON about the incident, but he/she did not tell the DON the resident said the CNA had hit him/her in the head because the resident has a history of making statements that were not true. On 5/15/23, he/she spoke to the DON and told her about the resident's statement. The DON told him/her to add that to his/her written statement. Nurse C should have told the DON on 5/14/23 that the resident said the CNA hit him/her in the head. Nurse C should not have allowed the CNA to be present when he/she was questioning the resident. He/She could see how that could be intimidating to the resident.
During an interview on 5/25/23 at 12:16 P.M., the DON said she was not at the facility on 5/14/23. Nurse C called her that day after CNA A brought the resident to the nurse's station. The nurse told her the CNA said the resident had scratched him/her. The nurse did not tell her the resident said the CNA had hit him/her in the head when he/she interviewed the resident. The nurse should have told her that during the phone conversation. Had she been made aware of what the resident alleged, she would have told the nurse to get a statement from the CNA, then send the CNA home pending an investigation. The nurse should never have allowed the CNA to stand at the nurse's station while the nurse questioned the resident. On 5/15/23 she arrived to work at approximately 8:30 A.M. At around 11:15 A.M., the DS gave her an anonymous note. The facility began an investigation at that time and notified DHSS. About an hour to hour and a half later she confirmed the anonymous note was written by the DS. She would have expected the DS to have immediately intervened between the resident and CNA and to have immediately reported what she witnessed to the nurse.
During an interview on 5/26/23 at 1:40 P.M., the Administrator said she expects all staff to follow their abuse policies and procedure policy, especially the DS because she is a supervisor. The DS and DA B should have immediately provided safety for the resident, separated the resident from the CNA and reported what they witnessed to Nurse C. When the CNA took the resident to the nurse's station and the resident told the Nurse the CNA hit him/her in the head, she would have expected the Nurse to have separated the resident from the CNA immediately, obtain a statement from the CNA, then send the CNA home pending an investigation. She would have expected the nurse to have contacted either her or the DON and report it immediately. The CNA should never have been allowed to finish his/her shift that day.
During a telephone interview on 6/2/23 at 2:06 P.M., the Medical Director said he expects the facility to follow their abuse and neglect policy.
MO00218474

Based on interview and record review, the facility failed to employ a qualified social worker on a full time basis. The census was 34.
Review of the State Operation Manual (SOM), showed a qualified social worker, for a facility with more than 120 beds defined as: An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human service field including but not limited to sociology, gerontology, special education, rehabilitation counseling and psychology and one years supervised social work experience in a health care setting working directly with individuals.
Review of the facility's license and certification records, showed the facility was licensed for 130 beds, of which 130 beds were certified for Medicaid and Medicare.
Review of facility's current employee roster, showed the Social Service Designee (SSD) date of hire was 2/2/22.
Review of the SSD's application, showed high school as the highest level of education attained.
During an interview on 12/14/22 at 7:25 A.M., the SSD said she started in her position on 2/2/22. She currently covers social services, human resources and activities. She worked in a residential care facility for 28 years. During that time she held several positions including the activity director, assistant administrator and was supervisor over the dietary department, housekeeping, maintenance and medication room. She is a certified nurse aide. She has some college, but does not have a bachelor's degree.
During an interview on 12/14/22 at 9:00 A.M., the administrator said a social worker had to have a bachelor's degree if the facility was licensed for more than 120 beds. She was not aware the facility was licensed for 130 beds.
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Based on facility document review, interviews, and review of facility policy, it was determined the facility failed to ensure 1 (Dietary Aide #17) of 46 staff were fully vaccinated against COVID-19 or had a qualifying exemption or reason for temporary delay.
Findings included:
Review of an undated facility policy titled, Ackert Park COVID-19 Up-to-Date Vaccination Policy, revealed, The purpose of the policy is to outline the facility approaches to encourage both staff and residents to receive their up to date with the latest COVID-19 vaccination and bivalent booster. All current and new hire staff are required to be up to date with the latest vaccination available. All staff will have an updated vaccination status sheet in their file and will have vaccination information and status completed during the new hire process.
A review of the facility vaccination tracking form for staff, an untitled and undated document, revealed Dietary Aide (DA) #17 had not filled out an exemption form nor had the staff member been vaccinated against COVID-19. The staff member was suspended until he obtained his vaccine.
A review of DA #17's vaccination card revealed the staff member was vaccinated on 12/07/2022.
On 12/07/2022 at 11:40 AM during an interview with the Administrator, she stated the Director of Nursing (DON) thought the dietary aide had a religious exemption. He/She was hired on 07/12/2022. She stated DA #17 had gone to get his/her vaccine before reporting to work today.
On 12/08/2022 at 10:51 AM during an interview with the DON, she stated DA #17 was hired 07/12/2022. She stated the staff member should have been vaccinated according to the policy within a reasonable time. She stated she did not know the time frame staff should be vaccinated. She stated she kept asking DA #17 to get vaccinated and he/she finally received his/her vaccination on 12/07/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to maintain all patient care equipment in safe operating condition for 1 of 4 mechanical lifts used in the facility to transfer residents. Observations revealed a mechanical lift was not properly working and staff failed to report the issue to maintenance staff. This deficient practice had the potential to affect nine residents in the facility who utilized mechanical lifts for transfers.
Findings included:
Review of a facility policy titled, Equipment Management Safe Medical Devices Act, undated, specified, Any device failure or user error that has had an adverse outcome the following procedure must be implemented: To ensure proper follow-up and investigation of the incident, the staff members who are aware of the incident will complete an incident report and forward it to the facility Administrator with (sic) 24 hours. The document further indicated Control settings, and any observed physical damage will be noted. Device to be impounded shall be tagged, bagged and sequestered including identifying number and date.
On 12/09/2022 at 5:01 PM, the Administrator (ADM) stated the facility policy titled, Equipment Management Safe Medical Devices Act, applied to all malfunctioning equipment and not only equipment involved in an accident.
A review of the Resident Face Sheet revealed the facility admitted Resident #3 with diagnosis that included multiple sclerosis.
A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was totally dependent on staff for transfers.
An observation on 12/07/2022 at 10:23 AM, revealed two staff safely transferred Resident #3 to a chair from the bed using a mechanical lift; however, it was observed Certified Nurse Aide (CNA) #9 manually lowered the lift after trying the remote control unsuccessfully.
On 12/08/2022 at 9:45 AM, Director of Nursing (DON) #1 was asked to check the function of the mechanical lift used to transfer Resident #3, which was charging in the hall on the third floor of the facility. DON #1 was unable to move the lift up or down using the remote. Additionally, the DON was unable to open the base legs of the lift. Another outlet and another battery were tried with the same results. DON #1 stated that all the lifts were checked about seven months ago when she came to work in the facility. DON #1 stated a lift should not be used if it is not functional. DON #1 further stated that she and maintenance should be notified if a lift was not functioning properly, and it should be removed from the floor.
On 12/07/2022 at 9:53 AM, CNA #9 stated they had noticed the base legs of the lift would not spread open earlier but were unsure when they had noticed. CNA #9 stated the remote was too slow, so they had manually lowered Resident #3 to get the transfer done more quickly for the resident's comfort.
On 12/07/2022 at 10:29 PM, CNA #16 stated that sometimes the legs on the mechanical lift opened and sometimes they did not, but it had never caused a problem with a transfer for them. CNA #16 stated they had noticed these issues with the lift for about two weeks.
On 12/08/2022 at 9:09 AM, the Administrator (ADM) stated the company evaluated lifts annually, but the documentation could not be found as the maintenance office was damaged in the flood and fire earlier in the year. The ADM stated she had hired a new maintenance person yesterday, and maintenance issues had been addressed by the maintenance staff from sister facilities over the past two weeks.
On 12/08/2022 at 4:14 PM, the ADM stated if staff noticed a mechanical lift was not functioning properly, she expected staff to report the malfunction, to log the problem in the maintenance log, and to remove the lift from being used.
On 12/09/2022 at 9:57 AM, the Maintenance Director stated he was certified to work with the mechanical lifts and trained the maintenance staff at each sister facility to check lifts every month. He stated the lift used to transfer Resident #3 would not lower at all, had been taken off the floor, and locked-out of use until it was repaired and rechecked. He stated staff should let maintenance know if a lift was not functioning properly, and the lift should be locked-out of use until the problem was addressed. He stated the most recent facility maintenance staff had been at the facility less than one year and left no documentation that could be found of routine maintenance or checks of mechanical lifts.

Based on interviews, record reviews, and policy review, it was determined the facility failed to ensure resident Minimum Data Set (MDS) assessments were completed and submitted timely for 3 (Residents #13, #8, and #22) of 3 residents reviewed for timely assessment transmission.
Findings included:
A review of the facility policy titled, Electronic Transmission of the MDS, dated September 2010, revealed, 5. MDS electronic submissions shall be conducted in accordance with current OBRA [Omnibus Budget Reconciliation Act] regulations governing the transmission of such data. 6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking.
A review of the facility policy titled, MDS Completion and Submission Timeframes, revealed, 1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS' QIES [Centers for Medicare and Medicaid Services Quality Improvement & Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. The following timeframes will be observed by this facility: the annual (comprehensive) assessment, significant change (comprehensive) assessment, and quarterly assessment Completion Date was 14 days after the Assessment Reference Date (ARD). According to the policy, the Transmission Date for an annual and significant change MDS assessment was 14 days after the Care Plan completion date and the Transmission Date for a quarterly MDS was 14 days after the MDS Completion Date.
1. A review of Resident #13's MDS, with an ARD date of 10/10/2022, revealed a quarterly assessment was in process and had not been completed within 14 days of the ARD nor had the assessment been submitted.
2. A review of Resident #8's MDS, with an ARD date of 09/23/2022, revealed an annual assessment was in process and had not been completed within 14 days of the ARD date and had not been submitted.
3. A review of Resident #22's MDS, with an ARD date of 09/29/2022, revealed a significant change assessment was in process and had not been completed within 14 days of the ARD date and had not been submitted.
During an interview on 12/08/2022 at 5:00 PM, Director of Nursing (DON) #1 stated the MDS Coordinator had resigned in November 2022 and had left assessments incomplete and not transmitted. DON #1 stated the last MDS submitted by the MDS Coordinator was on 11/10/2022. DON #1 reported the facility currently did not have an MDS Coordinator. DON #1 stated she was currently reviewing all the assessments and was completing and transmitting the late MDS assessments. DON #1 reported MDS assessments were required to be completed and transmitted within 14 days of the ARD.
On 12/09/2022 at 4:25 PM, the Administrator reported the facility was having communication issues with the previous MDS coordinator. The Administrator stated the previous MDS coordinator resigned prior to completing and transmitting residents' MDS assessments. The Administrator reported the DON was currently trying to complete and transmit all late MDSs. The Administrator also stated residents' MDS assessments should be completed and transmitted within 14 days of the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to provide pharmaceutical services to establish and maintain a system to ensure drug records were in order and that accounted for all controlled drugs. Specifically, the facility failed to ensure narcotic medications were reconciled and loss or potential diversion was identified for 3 (Residents #19, #22, and #180) of 18 residents reviewed who were receiving narcotic medications.
Findings included:
A review of the facility policy titled, Controlled Substance, last revised December 2012, revealed, Nursing staff must count controlled medications at the end of their shift. The nurse coming on duty and the nurse going off duty must make a count together. They must document and report any discrepancies to the Director of Nursing Services. The Director of Nursing Services shall investigate any discrepancies in narcotic reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. The Director of Nursing Services shall maintain and disseminate to appropriate individuals a list of personnel who have access to medication storage areas and controlled substance containers.
A review of the facility undated policy/procedure titled, Organizational Aspects, revealed, 3.d The consultant pharmacist provides pharmaceutical care services, including but not limited to the following: 6) Reviewing medication administration records (MARs), treatment administration records (TAR) and physician orders at least monthly to ensure proper documentation of medication orders and administration of medications to residents and 9) Working with the provider pharmacy to establish a system of records of receipt and disposition of all controlled substances that produces an accurate reconciliation and account of use on a periodic basis.
A review of the facility policy titled, Preparation for Medication Administration, last revised December 2012, revealed, Documentation, the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is give. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.
1. A review of Resident #19's Resident Face Sheet revealed the resident had diagnoses of chronic obstructive pulmonary disease, unspecified-hospice admission diagnosis (primary), right heart failure, and respiratory failure.
A review of Resident #19's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS revealed the resident had no pain in the previous five days. The MDS indicated the resident had not received an opioid medication in the previous seven days.
A review of Resident #19's physician Orders dated 11/14/2022 revealed an order for morphine concentrate (narcotic pain medication) 0.5 milliliters (mL) every two hours as needed for pain or shortness of breath.
A review of Resident #19's Care Plan, revised 11/28/2022, revealed the resident had morphine ordered for air hunger and shortness of breath through hospice and end of life support.
Resident #19's Medication Administration Record [MAR] dated 11/09/2022 through 12/09/2022, and the Controlled Substances Proof of Use form, dated 08/15/2022 through 12/07/2022, were reviewed. According to the controlled substances form, the facility administered morphine 0.5 mL to the resident on 11/14/2022 at 10:45 AM and 12:20 PM; however, the medication administration was not documented on Resident #19's MAR. Further review of the MAR revealed the facility administered morphine 0.5 mL on 11/15/2022 at 12:12 PM and the dose was not documented as administered on the controlled substances form. However, according to the controlled substances form, no discrepancy was identified in the amount of morphine that Resident #19 had available when medication was administered to the resident again on 11/20/2022.
Further review of Resident #19's Controlled Substances Proof of Use form revealed on 11/20/2022, the resident had 16 mL of morphine. However, on 11/24/2022, the resident had 14 ml of morphine with no documented evidence that two mL (four doses) of morphine had been administered to the resident. Licensed Practical Nurse (LPN) #6 signed that the count was correct on 11/24/2022 and did not include a co-signature. On 12/07/2022 at 2:45 PM, Resident #19's morphine was observed to contain 14 mL.
During an interview on 12/09/2022 at 11:00 AM, LPN #6 reported Resident #19's morphine sign-out sheet was corrected from 16 mL to 14 mL on 11/24/2022 during narcotic count with an evening shift agency nurse. LPN #6 reported the agency nurse failed to co-sign the corrected dose of 14 mL. LPN #6 stated he/she was unable to account for the four missing doses of 0.5 mL of morphine; however, LPN #6 reported he/she did not notify the Director of Nursing (DON) that the morphine dose was corrected from 16 mL to 14 mL. Further interview revealed LPN #6 was unaware of Resident #19's morphine not being documented as administered on both the MAR and the Controlled Substances Proof of Use form on 11/14/2022 and 11/15/2022.
2. A review of Resident #22's Resident Face Sheet revealed the resident had diagnoses of unspecified dementia with behavioral disturbance, bradycardia, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
A review of Resident #22's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1, which revealed the resident was severely impaired with cognition. The MDS revealed the resident had no pain in the previous five days. The MDS revealed the resident had not received an opioid medication in the previous seven days.
A review of Resident #22's physician Orders, dated 09/06/2022, revealed an order for morphine (narcotic pain medication) 0.25 milliliters (mL) every two hours as needed for severe pain, dyspnea, or air hunger.
A review of Resident #22's Care Plan, dated 09/16/2022, revealed the resident had multiple complaints of discomfort and anxiety when moved in the chair or touched.
Resident #22's Medication Administration Record [MAR], dated 11/01/2022 through 11/30/2022, and the Controlled Substances Proof of Use form, dated 09/20/2022 through 11/24/2022, were reviewed. The MAR revealed morphine was administered on 11/03/2022 at 10:21 AM, on 11/04/2022 at 1:03 PM, and on 11/22/2022 at 9:41 PM but was not documented as administered on the Controlled Substances Proof of Use form. Further, even though the controlled substances form did not show two doses (0.5 mL) of the medication had been administered on 11/03/2022 and 11/04/2022, the form indicated there were no discrepancies in the amount of medication Resident #19 had available on 11/04/2022 and 11/06/2022. Further review of the controlled substances form revealed morphine was administered on 11/03/2022 at 9:00 AM and on 11/04/2022 at 9:50 AM; however, a review of the resident's MAR revealed no documentation the medication was administered.
Further review of Resident #22's Controlled Substances Proof of Use form revealed on 11/18/2022, the resident had 23 mL of morphine. On 11/24/2022, Licensed Practical Nurse (LPN) #6 documented a correction of the morphine dose to 20 mL, a total difference of 12 doses of 0.25 mL of morphine unaccounted for. The corrected count signed by LPN #6 on 11/24/2022 did not include a co-signature. On 12/07/2022 at 2:45 PM, Resident #22's morphine was observed to contain 20 mL.
During an interview on 12/09/2022 at 11:00 AM, LPN #6 reported Resident #22's morphine sign-out sheet was corrected from 23 mL to 20 mL on 11/24/2022 during a narcotic count with an evening shift agency nurse. LPN #6 reported the agency nurse failed to co-sign the corrected dose of 20 mL. LPN #6 stated he/she was unable to account for the 12 missing doses of 0.25 mL of morphine but did not notify the Director of Nursing (DON) that the resident's narcotic count was incorrect. LPN #6 stated he/she was unaware that Resident #22's morphine was not being documented as administered on both on the MAR and on the Controlled Substances Proof of Use form on 11/03/2022, on 11/04/2022, and on 11/22/2022.
3. A review of Resident #180's Resident Face Sheet revealed the resident had diagnoses of cellulitis and abscess of mouth, altered mental status, hypertension, pain of the left leg, and osteoporosis.
A review of Resident #180's Care Plan, updated 11/23/2021, revealed the resident experiences intermittent phantom pain secondary to a right above the knee amputation.
A review of Resident #180's physician Orders revealed an order, dated 12/09/2022, for tramadol (schedule IV pain medication) 50 milligrams (mg), one tablet twice per day.
A review of Resident #180's Individual Residents Controlled Substance Record revealed 14 tramadol 50 mg tablets was refilled on 11/22/2022.
A review of Resident #180's Medication Administration Record revealed on 11/22/2022 during the evening medication pass from 4:00 PM to 8:00 PM that tramadol was Not Administered: Due to condition. However, a review of the resident's Individual Residents Controlled Substance Record revealed tramadol was administered to the resident on 11/22/2022 at 10:00 PM. Further review of Resident #180's MAR revealed the medication was administered on 11/24/2022 during the evening medication pass and was initially signed out on the resident's control substance record on 11/24/2022 at 4:30 PM; however, someone marked through the 11/24/2022 dose and wrote error.
Further review of Resident #180's Individual Residents Controlled Substance Record revealed a note documenting the medication was placed on hold on 11/27/2022 and according to the resident's MAR the medication was discontinued on 11/27/2022 and was not administered after that date. However, according to the controlled substance record, staff signed out a tramadol tablet for Resident #180 on 11/29/2022 at 6:00 PM, after the medication had been discontinued.
On 12/08/2022 at 10:00 AM, LPN #6 reported there were documented errors on Resident #180's Individual Residents Controlled Substance Record sheet, but the tramadol count was correct. LPN #6 reported the circled amount remaining was to ensure the count was correct. LPN #6 stated the error documented on the narcotic count sheet for 11/24/2022 was because the nurse signed the medication out before it was administered, but the resident refused the medication. LPN #6 reported he/she had no knowledge of the MAR and controlled substance reports not matching.
During an interview on 12/09/2022 at 11:00 AM, Director of Nursing (DON) #1 revealed the discrepancies/correction to the amounts of Resident #19's and #22's morphine doses were not reported immediately and should have been. DON #1 stated an immediate investigation should have been conducted for each incident. Furthermore, DON #1 revealed she was unaware that Resident #19's, #22's, and #180's medications were not documented as administered on both the MAR and a controlled substance sign out sheet.
On 12/09/2022 at 4:25 PM, the Administrator reported she was unaware that Resident #19's and Resident #22's morphine counts had been incorrect. The Administrator stated the LPN should have notified the DON immediately of any discrepancy, and an investigation should have been conducted. The Administrator reported the DON was responsible for reviewing narcotic sheets and correcting identified problems. The Administrator stated the incidents were a gross error of not following policy. Further interview with the Administrator revealed she was unaware that administration of Resident #19's and Resident #22's morphine was not documented on both the MAR and the Controlled Substances Proof of Use form, nor that Resident #180's Individual Residents Controlled Substance Record sheets and the MAR did not match. The Administrator reported the DON was responsible for reviewing narcotic sheets and correcting identified problems.
During an interview on 12/09/2022 at 8:32 AM, Pharmacist #15 reported he had been consulting with the facility for four months. Pharmacist #15 reported the last time he was in the facility was in October 2022, and he visited quarterly. Pharmacist #15 reported a nurse consultant also visited quarterly but was unsure if she had been in the facility recently. Pharmacist #15 stated he checked the medication carts when he visited, discussed his findings with the DON, and provided the facility a list of recommendations by mail and online. Pharmacist #15 stated he had not been notified of missing or unaccounted for morphine. He stated the DON should have conducted an internal investigation of any dose corrections. Pharmacist #15 reported that in his opinion, the dose corrections were not significant concerns and would not have been an issue for pharmacy.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure controlled substances were stored in separately locked, permanently affixed compartments in 1 medication room; failed to ensure medications and biologicals were labeled in accordance with accepted professional principles on 2 of 2 medication carts; failed to ensure expired medications were not available on 1 of 2 medication carts; and failed to ensure an emergency drug kit was locked.
Findings included:
1. A review of the facility policy titled, Controlled Substances, revised December 2012, revealed, 5. Controlled substances must be stored in the medication room in a locker container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents.
On 12/08/2022 at 10:22 AM, the medication room, located on the third floor, was observed. The medication room refrigerator was observed to contain a bottle of liquid Ativan (narcotic) with other medications. The refrigerator was locked; however, the bottle of liquid Ativan was not stored separately in a locked, permanently affixed compartment inside the refrigerator.
During an interview on 12/08/2022 at 10:22 AM, Licensed Practical Nurse (LPN) #6 reported he/she was unaware liquid Ativan was to be stored in the refrigerator separately in a locked box.
2. A review of the facility policy titled, Administering Medications, revised April 2010, revealed the expiration date on the medication label must be checked prior to administrating. When opening a multi-dose container, the date shall be recorded on the container.
On 12/07/2022 at 2:45 PM, two medication carts were observed, located on the third floor. Medication Cart #1 contained Latanoprost eye drops for three residents and Advair inhalers for two residents that were not labeled with the date they were opened. Medication Cart #2 contained glucose strips that were not labeled with the date they were opened. Further observation of Medication Cart #2 revealed expired medications that included one bottle of milk of magnesia that expired October 2022, a bottle of lorazepam liquid that expired 07/01/2022, and morphine pills that expired on 07/02/2022.
3. A review of the facility's undated policy/procedure titled, Organizational Aspects revealed 3. Consultant Pharmacist Services Provider-Requirements, included d. The consultant pharmacist provides pharmaceutical care services, including but not limited to the following: 1) Checking the emergency medication supply at least monthly to ascertain that it is properly sealed and stored and that the contents are not outdated. Further review revealed i. If exchanging kits, opened kits are replaced with sealed kits within 3 days of opening. If replacing used medications, the replacement doses are added to the kit within 3 days of opening.
On 12/08/2022 at 10:00 AM, an observation of the emergency medication kit located in the medication room revealed the kit was not locked.
During an interview on 12/08/2022 at 10:00 AM, Licensed Practical Nurse (LPN) #6 reported he/she was unaware the emergency medication kit was unlocked.
During an interview on 12/09/2022 at 8:32 AM, Pharmacist #15 revealed the emergency medication kit was to be kept locked and used for emergencies, then replaced after it had been opened.
A follow-up interview with Pharmacist #15 on 12/09/2022 at 10:00 AM, revealed he visited the facility quarterly and a pharmacy nurse consultant also visited the facility quarterly. He stated the medication carts were checked during the quarterly visit and was last checked in October 2022 and was unaware of any expired medications. He reported all eye drops and inhalers must have a date when opened. According to the Pharmacist, refrigerated narcotics did not have to be kept locked separately from other refrigerated medications.
During an interview on 12/09/2022 at 11:00 AM, Director of Nursing (DON) #1 reported she was unaware refrigerated narcotics were required to be stored in a separately affixed, locked box inside the refrigerator. She stated the pharmacy audited medication carts, and she was unaware there were expired medications, nor that eye drops, inhalers, and glucose test strips were not dated when opened. The DON stated she would have expected staff to make sure all medications administered were labeled when opened and not expired. Further interview with DON #1 revealed the emergency medication kit should have been locked. DON #1 reported she was unaware the emergency kit had been accessed/unlocked.
On 12/09/2022 at 4:25 PM, the Administrator reported it was the policy for all medications to be checked for expiration dates before they were administered. She stated the pharmacy usually checked the medication carts and the DON should also be doing medication cart and medication room checks. The Administrator stated medications should be labeled with the date they were opened but was unaware refrigerated narcotics should be in a separate locked box inside the refrigerator. Furthermore, the Administrator stated it was the DON's responsibility to ensure proper use of the emergency medication kit.

Based on observations, facility policy review, and interviews, it was determined that the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the kitchen and during one of one meal service observed. Specifically, observations revealed the facility failed to :
1. Remove dented cans from the dry storage area;
2. Maintain food and refrigerator temperature logs;
3. Sanitize the thermometer between food items during observations of meal service ; and
4. Perform appropriate hand hygiene while plating food during meal service.
This deficient practice had the potential to affect 33 of 36 residents of the facility that received food from the kitchen.
Findings included:
1. A review of the undated Food Ordering and Receiving policy revealed, Leaking or severely dented cans should be stored separately to prevent contaminating other foods. If damaged when delivered, follow distributor policy for credit.
During observations of the dry storage area of the kitchen on 12/06/2022 at 10:38 AM, seven dented cans were found among the canned goods.
-Two 6-pound (lbs.) cans of apples, received date written on can indicated 11/29/2022.
-Three 6 lbs. cans of sauerkraut, received date of 12/06/2022.
-One 6 lbs. can chili con carne with beans, no received date indicated.
-One 3 lbs. Campbell's vegetable soup, no received date indicated.
During an interview with the Dietary Manager (DM) on 12/06/2022 at 11:02 AM, she stated dented cans should be sorted, separated, set aside, and not incorporated into the canned goods used for resident meals. She stated particles and bacteria could get into the cans through the dented seals and contaminate the food inside. She stated the dented cans should be returned to the manufacturer for a credit.
During an interview with Dietary Aide (DA) #4 on 12/06/2022 at 11:42 AM, he/she stated he/she had been employed at the facility for five years. He/She stated he/she assisted with putting away food orders that included canned foods. He/She stated dented cans should be set aside to be returned to the manufacturer.
During an interview with the [NAME] on 12/06/2022 at 11:46 AM, he/she stated he/she had worked at the facility for a year and a half. He/She stated as orders were put away, the canned goods should be checked for dents and if found, the dented canned goods should be put aside and not used.
During an interview with the Administrator and Director of Nursing (DON) on 12/08/2022 at 3:39 PM, the Administrator stated cans should be screened for dents when the order arrived, removed from the dry storage area if found, and returned for a credit.
During a telephone interview with the Registered Dietitian (RD) on 12/08/2022 at 8:52 AM, she stated her last visit to the facility kitchen was in October 2022, and she did not recall any dented cans at that time. She stated dented cans should be returned for a credit and not used. She stated the food inside dented cans could be contaminated.
2. A review of the undated Storage of Frozen and Refrigerated Foods policy revealed that staff should, Use the following guidelines to maintain the proper temperature in freezers. The policy further indicated for freezers and refrigerators staff were to Record all unit temperatures daily on the Record of Refrigeration Temperatures (BE 436) and retain for three months.
A policy regarding recording meal temperatures was requested on 12/08/2022 at 1:33 PM and 12/09/2022 at 10:03 AM and was not provided before exit.
During an interview with the [NAME] on 12/06/2022 at 10:57 AM, he/she stated kitchen staff no longer logged food temperatures or quick-access refrigerator temperatures into a log. He/She stated they used to have a binder where the logs were kept and temperatures recorded, but the binder went missing.
During observations of the stand-alone dessert freezer and quick-access refrigerator in the kitchen on 12/06/2022 at 11:13 AM, no temperature logs were found posted on the units.
During an interview with the Dietary Manager (DM) on 12/06/2022 at 11:15 AM, she stated they had no temperature logs for either the stand-alone freezer or the quick-access refrigerator. She stated she always forgot to post the logs for those two units. She stated monitoring and documenting the temperatures of the stand-alone freezer and quick-access refrigerator were important for food safety and to make sure the food stored inside did not go bad.
A review of the food temperature log binder provided by Dietary Aide (DA) #3 on 12/06/2022 at 11:17 AM revealed no food temperature logs were included in the binder before 12/03/2022 . DA #3 stated the temperature of the food should be logged in the binder before serving meals.
During a follow-up interview with the DM on 12/06/2022 at 11:23 AM, she stated there were no other food temperature logs from before 12/03/2022. She stated many of the logs disappeared before she took over as the DM and the temperatures were not being recorded prior to that time.
During an interview with DA #4 on 12/06/2022 at 11:42 AM, he/she stated he/she had been employed at the facility for five years. He/She stated the kitchen had no temperature log books. He/She stated the binders had been removed from the kitchen because the pest company came to spray and the binders had not been returned to the kitchen.
During a follow-up interview with the [NAME] on 12/06/2022 at 11:46 AM, he/she stated he/she had worked at the facility for a year and a half. He/She stated the cooks were supposed to log the temperatures of the refrigerators and freezers. He/She stated no one had informed him/her he/she needed to record a temperature on the stand-alone freezer or the quick-access refrigerator, so he/she had not been checking or documenting the temperatures of those units. He/She further stated the kitchen staff used to log the meal temperatures on a He/She stated no one had told the DM the food temperatures needed to be recorded before meals.
During a follow-up interview with the DM on 12/07/2022 at 1:00 PM, she stated she started with the facility two years ago as a dietary aide and worked her way to DM in April 2022. She stated the previous DM provided no training on recording meal temperatures . She stated she could not find any of the past temperature logs, and the flood in July 2022 destroyed many of their paper records.
During an interview with the Administrator and Director of Nursing (DON) on 12/08/2022 at 3:39 PM, the Administrator stated temperature logs, for meals and food storage, should be kept up to date and filled out daily and at every meal.
During a telephone interview with the RD on 12/08/2022 at 8:52 AM, she stated she visited the facility once a month and worked remotely as well. She stated that on her visits to the kitchen she would complete an inspection, observe meal service, audit tray cards, and review nursing assessments. She stated her last visit to the facility kitchen was in October 2022. She stated she did not remember if the kitchen staff had been recording the meal, refrigerator, or freezer temperatures on her last visit, but they should be recording them daily. She stated during one of her audits, she identified tray tickets were being lost. She stated they were kept in a binder, so the binder was done away with, and the system changed. She stated the temperature logs could have been in there.
3. A review of the Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, dated April 2010, revealed, All food service equipment and utensils will be sanitized according to current guidelines and manufactures' recommendations.
During pre-meal service kitchen observations on 12/07/2022 at 11:53 AM, the [NAME] took the temperature of the foods to be sent to the third-floor steam table for lunch meal service. The lunch meal consisted of mashed potatoes with gravy, baked chicken, and carrots. The [NAME] failed to sanitize or wash the thermometer between the food items while taking the temperatures.
During an interview with the [NAME] on 12/07/2022 at 12:04 PM, he/she stated the thermometer should be washed or sanitized between food items. He/She stated he/she could not find the sanitizer wipes and should have washed the thermometer in the sink.
During temperature observations of the lunch meal on 12/07/2022 at 12:22 PM, DA #3 was taking the temperatures of the lunch meal. In between each food item, DA #3 would wipe the thermometer off with a paper towel.
During an interview with DA #3 on 12/07/2022 at 12:29 PM, he/she stated the thermometer should have been sanitized in between each food item. He/She stated it was important to sanitize the thermometer in between food items to make sure the temperature reading was correct, or it could cross contaminate food items and spread food allergies. He/She stated sanitizer wipes were usually in the bag with the binder and thermometer, but there were none in the bag that day. He/She stated he/she could get more sanitizing wipes from the nurses' station.
During an interview with the Dietary Manager (DM) on 12/08/2022 at 1:33 PM, she stated the thermometer should be sanitized in between each food item to prevent cross contaminations and to prevent any food allergies from being introduced to food items.
During an interview with the Administrator and Director of Nursing (DON) on 12/08/2022 at 3:39 PM, the Administrator stated the thermometer should be sanitized or washed in between each food item to prevent cross-contamination.
During a telephone interview with the Registered Dietitian (RD) on 12/08/2022 at 8:52 AM, she stated her last visit to the facility kitchen was in October 2022. She stated the thermometer should be sanitized in between each food item being served for food safety.
4. A review of the Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, dated April 2010, revealed, 7. Antimicrobial hand gel CANNOT be used in place of handwashing in food service areas. The policy also revealed, 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute proper hand washing.
During observations of the lunch meal on 12/07/2022 between 12:22 PM and 12:57 PM, Dietary Aide (DA) #3 was behind the steam table plating meals, while DA #4 was adding the plated meals to the meal trays to be sent out to residents in the dining room and those who ate in their rooms. Both DAs performed hand washing before beginning meal service. Observations revealed:
-At 12:37 PM, DA #3 doffed (removed) the gloves he/she was wearing, did not wash his/her hands, and donned (applied) a new pair of gloves.
-At 12:40 PM, DA #3 doffed the gloves he/she was wearing, did not wash his/her hands, donned a new pair of gloves, and continued meal service.
-At 12:45 PM, DA #3 doffed the gloves he/she was wearing, did not wash his/her hands, donned a new pair of gloves, and continued meal service.
-At 12:48 PM, DA #3 doffed the gloves he/she was wearing, used antibacterial hand sanitizer, donned a new pair of gloves, and continued meal service.
-At 12:53 PM, DA #3 doffed the gloves he/she was wearing, used antibacterial hand sanitizer, donned a new pair of gloves, and continued meal service.
During an interview with DA #3 and DA #4 on 12/07/2022 at 12:57 PM, DA #3 stated kitchen staff were to change gloves every four or five plates, use hand sanitizer before putting on new gloves, and continue serving. DA #4 stated it had been a while since he/she received hand hygiene and glove training. He/she stated as far as he/she knew hand sanitizer was alright to be used during meal service.
During an interview with the Dietary Manager (DM) on 12/07/2022 at 1:00 PM, she stated antibacterial hand sanitizer was not to be used in the kitchen or during meal service as it could contaminate the food. She stated she started with the facility two years ago as a dietary aide and worked her way to DM in April 2022. She stated the previous DM provided no training on specialized kitchen infection control or proper hand hygiene related to glove use.
During an interview with the Administrator on 12/07/2022 at 3:27 PM, she stated the facility believed hand hygiene and glove use was the same for kitchen staff as it was for nursing staff and should be performed in between glove changes. She stated she was not aware that antibacterial hand sanitizer could not be used in the kitchen as it did not kill all micro-organisms that could be transmitted from touch.
During a telephone interview with the Registered Dietician on 12/08/2022 at 8:52 AM, she stated antibacterial hand sanitizers should not be present and did not replace hand washing. She stated hand washing was crucial for food safety and hand sanitizer was not a replacement for kitchen staff. The RD stated she provided in-services to the kitchen staff about hand hygiene and glove use. She stated hand washing should be done in between tasks and glove changes. She stated gloves should be worn if there was going to be direct contact with the food being served. She stated she had no knowledge of the procedure for changing gloves every four to five plates.
Training records for all kitchen staff were requested on 12/08/2022 at 3:39 PM and 12/09/2022 at 10:03 AM. No records were provided by the facility.

Based on observations, interviews, record reviews, and review of facility documents, policies and Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to consistently implement infection control measures. Specifically, the facility:
1. failed to ensure staff were wearing appropriate personal protective equipment (PPE), per facility policy, when entering the room of 1 (Resident #13) COVID-19 positive resident of 5 sampled residents.
2. failed to ensure staff were wearing appropriate PPE, while handling soiled laundry in 1 of 1 laundry area to prevent potential cross-contamination of the staff member's clothing which could result in subsequent contamination of clean laundry. The facility census was 36.
Finding included:
1. A review of a facility policy and procedure titled, Infection Control for All Nursing Procedures, revised August 2012, revealed, transmission-based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection.
A review of a facility policy titled, COVID-19 Policy and Procedure, revised 09/29/2022, revealed, residents with signs or symptoms should be placed on transmission-based precautions (TBP) in accordance with CDC guidance. The policy further indicated that, for a resident confirmed positive for COVID-19, the procedure was to implement isolation procedures - PPE outside the door, room door closed, designated bathroom, limit transport and movement of resident outside the room, cohort residents with the same respiratory illness; implement droplet precautions.
Review of a care plan, updated 12/06/2022, documented revealed Resident #13 was positive for COVID-19 on 12/05/2022. The care plan indicated staff were to follow current CMS/Department of Human Services (DHS) guidelines and recommendations, including in-room isolation and PPE use as needed.
A review of a physician order, dated 12/06/2022, revealed COVID-19 isolation precautions were to be implemented.
On 12/06/2022 at 9:18 AM, Housekeeper #10 was observed carrying a mop into Resident #13's room without wearing a gown, goggles, or gloves. The housekeeper was observed to be wearing a surgical mask.
During an interview on 12/06/2022 at 9:30 AM, Licensed Practical Nurse (LPN) #6 reported staff were supposed to wear gloves, gowns, N-95 masks, and goggles when they entered a room of a resident who was positive for COVID-19.
During an interview on 12/06/2022 at 5:15 PM, after being informed of the surveyor's observation of Housekeeper #10, the Director of Nursing (DON) reported PPE was available for all staff and should have been worn upon entrance to the room of a resident who was COVID-19 positive.
During an interview on 12/07/2022 at 8:25 AM, the Housekeeping Manager (HM) stated that when housekeeping staff went into the room of a resident who was COVID-19 positive, the staff member should don (apply) an N-95 mask, gloves, gown, and goggles. The HM stated she was unaware of the housekeeping staff member entering the room without proper PPE use and was unsure as to why this happened.
During an interview on 12/09/2022 at 9:08 AM, Housekeeper #10 stated she was supposed to wear gown, gloves, an N-95 mask, and goggles when she entered a COVID-19 positive resident's room. Housekeeper #10 stated he/she did not remember entering the room but should have used an N-95 mask, gown, gloves, and goggles.
2. Review of a facility policy titled, Laundry and Bedding, Soiled, revised October 2018, revealed, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infections prevention and control.
A review of CDC guidelines titled, Table 4. Standard Precautions Recommendations, dated as last reviewed 11/05/2015, revealed the recommendations for textiles and laundry was to, Handle in a manner that prevents transfer of microorganisms to others and to the environment. Further review revealed gloves were recommended, For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin. The policy also indicated a gown was recommended, During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated. Additionally, the CDC recommended a mask, eye protection (goggles), or face shield, During procedures and patient-care activities likely to generate splashes or sprays of blood, body secretions, especially suctioning endotracheal intubation.
On 12/07/2022 at 10:14 AM, Laundry Staff #20 was observed handling soiled laundry. The staff member had on a surgical mask and gloves but no gown, as he/she unloaded a basket of soiled laundry into the washer. During an interview with Laundry Staff #20 at this time, he/she stated he/she would wear full PPE and the laundry would be washed separately if the laundry came in a red bag. He/She stated a red bag indicated the laundry came from a resident who was in isolation for COVID-19.
On 12/06/2022 at 3:34 PM, during an interview with Certified Nurse Aide (CNA) #16, he/she stated there should be a red bag for laundry in rooms where residents were in isolation.
On 12/07/2022 at 8:55 AM, during an interview with Housekeeper #19, he/she stated all laundry was bagged together and thrown down a chute to the laundry area.
On 12/06/2022 at 3:44 PM, during an interview with Licensed Practical Nurse (LPN) #6, he/she stated the facility treated all laundry as if it was contaminated and bagged all laundry in a thick trash bag.
On 12/09/2022 at 8:42 AM, during an interview with the housekeeping manager, she stated staff should be using red bags for laundry of residents who had COVID-19. She stated the red bags would let laundry staff know the resident had an infection, and the linens would be laundered separately. She stated laundry staff would also be expected to wear goggles, gowns, masks, and gloves.
On 12/06/2022 at 5:06 PM, during an interview with Director of Nursing (DON) #1, she stated laundry for residents who had COVID-19 would be individually bagged and taken to the laundry.
During a follow-up interview with the DON #1 on 12/08/2022 at 3:15 PM, she indicated laundry staff should follow protocols put in place by their department. She stated when COVID-19 first started, laundry used to go down in red bags. She stated if staff was unaware whether laundry was contaminated, she would expect the staff to wear full PPE.
On 12/09/2022 at 11:22 AM, during an interview with the Administrator, she stated she would expect laundry from a resident with COVID-19 to be done separately and indicated the staff should wear full PPE to launder those items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure medication self-administration was assessed for 1 (Resident #279) of 16 sampled residents. Observations revealed medications were left at Resident #279's bedside; however, the facility failed to assess the resident to ensure self-administration was clinically appropriate. The facility census was 36.
Findings included:
A review of the facility policy titled, Administering Medications, revised April 2010, revealed, Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Further review of the policy revealed, 12. The individual administering the medication must initial the resident's MAR [medication administrator record] on the appropriate line after giving each medication and before administering the next ones. Continued review of the policy indicated, 18. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.
A review of Resident #279's Face Sheet revealed the facility the resident had diagnoses of schizophrenia, depression, chronic pain syndrome, and mild cognitive impairment.
A review of Resident #279's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS revealed the resident had no behaviors and had no pain in the previous five days.
A review of Resident #279's Care Plan, last updated 11/03/2022, revealed the resident was at risk for adverse consequences related to receiving antipsychotic medications for treatment of schizophrenia.
A review of Resident #279's Orders, revealed an order for gabapentin (a medication to treat seizures and nerve pain) 400 milligrams (mg) g one capsule three times a day with a start date of 06/24/2021. There was no order for self-administration of medications.
On 12/06/2022 at 10:09 AM, during the initial tour of the facility, Resident #279 was observed to have an orange-colored pill in a disposable medication cup sitting on the over-the-bed table. Resident #279 stated the nurse left the pill for the resident to take at lunch time.
On 12/06/2022 at 11:20 AM, Resident #279 was observed to have an orange-colored pill in a disposable medication cup sitting on the table. The resident reported the pill was for pain and the resident took the pill at lunch. The resident stated the staff had told the resident they were short on staff, and they left the pill for the resident to take later. The resident reported staff left medication on the resident's table occasionally when they were short staffed.
A review of Resident #279's Medication Administration Record, dated 12/06/2022 at 11:30 AM, revealed the morning and mid-day dose of gabapentin had been administered. The system did not include the time of administration, only that the medication was administered.
During an interview on 12/06/2022 at 11:34 AM, Certified Medication Technician (CMT) #8 stated Resident #279 had already received the gabapentin for noon, and the resident received gabapentin three times a day. He/She reported he/she tried to administer the medication at 11:00 AM, but the resident did not want to take it at that time, and it was left on the resident's table to take at lunch. CMT #8 reported he/she was supposed to tell the nurse if a resident refused to take medications, but he/she did not report the incident with Resident #279. CMT #8 reported the medication should not have been left in the resident's room, and the CMT should have observed the resident take the medication.
During an interview on 12/06/2022 at 11:43 AM, Licensed Practical Nurse (LPN) #6 stated gabapentin was not a controlled substance in Missouri; however, medications were not to be left in a resident's room at the bedside. LPN #6 reported Resident #279 did not have a physician's order to self-administer medications. He/She stated no staff had reported medications being left in the resident's room.
During an observation on 12/06/2022 at 11:50 AM with LPN #6, medication was observed on Resident #279's table. LPN #6 asked the resident to take the pill, and the resident took the medication at that time.
During an interview on 12/07/2022 at 8:34 AM, Certified Nurse Aide (CNA) #9 stated he/she had never seen medication left in the room of any resident. He/She reported if he/she saw medications in a resident room, he/she would have told the nurse immediately.
During an interview on 12/09/2022 at 11:00 AM, Director of Nursing (DON) #1 reported medications were never to be left at the bedside of any resident unless they had an order to do so.
On 12/09/2022 at 4:25 PM, the Administrator also stated that medications were never to be left on the resident's bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of needs was met for 1 (Resident #3) of 3 residents reviewed for accommodation of needs. Observations and interviews revealed Resident #3 had a wheelchair that did not meet their positioning needs.
Findings included:
On 12/09/2022 at 5:01 PM, the Administrator (ADM) stated the facility had no policies related to the accommodation of residents' needs.
A review of the Resident Face Sheet revealed the facility admitted Resident #3 with diagnosis that included multiple sclerosis (MS). The Resident Face Sheet further indicated Resident #3 was dependent on a wheelchair.
A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS further indicated that Resident #3 required extensive assistance from one staff member with locomotion on and off the unit. The MDS indicated Resident #3 had no impairment of the upper extremities but had impairment of both lower extremities related to functional limitations. The MDS further indicated that Resident #3 used a wheelchair for mobility.
A review of Resident #3's Care Plan indicated a problem area related to activity of daily living (ADL) functional potential, dated 08/28/2021, that indicated Resident #3 was limited in wheelchair mobility related to MS. The care plan further indicated the resident no longer had a motorized wheelchair because the resident could not operate the motorized wheelchair safely. The care plan indicated the resident had a lateral lean. The interventions included to encourage upright positioning, provide a pillow for support as needed, and provide comfort for wheelchair mobility as needed. Further review of the interventions revealed an intervention that indicated Resident #3 had a manual wheelchair and was able to self-propel safely.
A review of a clinical assessment for smoking risk, dated 06/26/2022, revealed Resident #3 had severe problems with mobility. The assessment indicated the resident was unable to ambulate, used a manual wheelchair for mobility and depended on others to push the resident around.
A review of an email from the National Multiple Sclerosis Society (NMSS), dated 05/23/2022, indicated the society had begun working to help Resident #3 obtain a wheelchair.
During an interview with Resident #3 on 12/06/2022 at 9:27 AM, the resident was in their room on the bed. Resident #3 stated the resident did not have the strength to use the manual wheelchair to propel themselves.
Observations on 12/06/2022 at 1:38 PM revealed Resident #25 was assisting Resident #3 by pushing the resident in a manual wheelchair without a headrest in the facility.
An interview with Certified Nurse Aide (CNA) #16 on 12/07/2022 at 10:29 AM revealed Resident #3 could use their arms a little bit, but it takes the resident time. The CNA stated he/she thought the resident needed a head rest on their wheelchair to help with positioning.
On 12/07/2022 at 3:41 PM, the Physical Therapy Director (LPTA) stated Resident #3 could use their arms to wheel themselves, but they chose not to. The LPTA stated Resident #3's diagnosis put the resident's head in a cocked position.
On 12/08/2022 at 7:57 AM, the Administrator stated they knew Resident #3 needed a different wheelchair. The ADM stated the LPTA had been working with the NMSS to get another wheelchair for Resident #3 since May or June of 2022. The ADM stated the LPTA had requested a necessary evaluation from the doctor, but the doctor refused to comply.
On 12/09/2022 at 9:11 AM, the ADM and Social Service Department Head (SS) were interviewed together. The SS stated she had spoken with Resident #3 in May of 2022 about getting a new customized wheelchair. The SS stated Resident #3 reported that, previously, Resident #3 had a wheelchair with a higher back and the NMSS had helped the resident get a wheelchair before. SS stated they called the NMSS to get the process started to obtain Resident #3 another wheelchair. The ADM stated that while the doctor had written a prescription for a new wheelchair, according to the LPTA, the prescription was not adequate. The ADM stated the LPTA had requested the doctor to complete a face to face physical assessment, but the doctor had refused to do so. The ADM stated the LPTA should have let the ADM know earlier, so they could have become involved. The ADM stated they had spoken with the doctor, who had stated they had been confused about what was needed.
On 12/09/2022 at 11:03 AM, the LPTA stated that around the beginning of the summer, Resident #3 needed a new wheelchair. The LPTA stated the normal protocol required for getting a customized wheelchair required a face-to-face doctor's evaluation, a progress note with the diagnosis, and justification why the resident needed a customized wheelchair. The LPTA stated that as she did not work in the building full-time, she communicated with the doctor by placing notes in a particular folder. The LPTA stated she put handwritten notes in the communication folder a couple of times requesting specific information that was required to move forward with getting Resident #3 a new wheelchair. The LPTA stated she never heard back from the doctor, and she probably should have given the doctor a call.
On 12/09/2022 at 2:51 PM, Director of Nursing (DON) #1 stated that when she started working at the facility on 12/01/2021, Resident #3 had a friend who pushed the resident in their wheelchair. The DON stated the resident's head was not supported with the current wheelchair that the resident was using, and there was a process in place to get the resident a new wheelchair.

Based on observation and interview, the facility failed to ensure the walk-in refrigerator and walk-in freezer were maintained in good repair for four of four days of observation. This had the potential to affect all residents who were served food from the facility kitchen. The census was 66.
1. Observations on 8/14/19 through 8/16/19 and on 8/19/19, of the walk-in refrigerator in the kitchen, showed the following:
-On 8/14/19 at 2:45 P.M., the external dial thermometer read 48 degrees Fahrenheit (F) (recommended safe temperature: at or below 45 degrees F);
-On 8/15/19 at 9:30 A.M., the external dial thermometer read 50 degrees F. The thermometer inside the refrigerator read 46 degrees F;
-On 8/16/19 at 11:15 A.M., the external dial thermometer read 49 degrees F. The thermometer inside the refrigerator read 47 degrees F;
-On 8/19/19 at 9:20 A.M., the external dial thermometer read 50 degrees F. The thermometer inside the refrigerator read 48 degrees F. The surveyor's digital thermometer read 49.5 degrees F, when left in the refrigerator for two minutes.
Review of the facility's walk-in refrigerator temperature log dated 8/19, showed the following:
-On 8/14/19 through 8/16/18, open temperature 35 degrees F (taken in the morning when the kitchen opens) and the close temperature 40 degrees F (taken in the evening when the kitchen closes);
-On 8/17/19, open temperature 33 degrees F and the close temperature not documented;
-On 8/18/19, open temperature 35 degrees F and the close temperature not documented;
-On 8/19/19, open temperature 35 degrees F.
During an interview on 8/19/19 at 9:45 A.M., [NAME] D said he/she recorded the walk-in refrigerator temperature at 6:00 A.M. every morning when he/she came in, and the temperature was always good at that time. Another staff person recorded the temperature in the evening after dinner was done.
During an interview on 8/19/19 at 9:28 A.M., the dietary manager said she was aware the temperatures in the walk-in refrigerator were not where they were supposed to be and she let the director of maintenance know. The door to the walk-in refrigerator doesn't close all the way and seemed to be off just a little bit. The door sometimes stayed where it was supposed to, and sometimes it did not. Staff were constantly in and out of the walk-in refrigerator. The dietary manager said she let the director of maintenance know the refrigerator was not cold enough about two weeks ago.
During an interview on 8/19/19 at 10:30 A.M., the director of maintenance said he was only made aware of the issue with the walk-in refrigerator about ten minutes ago. When he left work on Friday 8/16/19, it was fine. He was aware there was an issue with the door not latching. When staff had an issue with equipment, they were supposed to fill out a work order, but he hardly ever received work orders from the kitchen. The kitchen staff usually told him about issues verbally and they did not follow protocol and fill out work orders.
During an interview on 8/19/19 at 9:55 A.M., the administrator said he was not aware of any issue with the refrigerator. Sometimes when he walked back to the food storage area in the kitchen, he has seen the door to the walk-in refrigerator cracked open. He also noticed when the kitchen received deliveries, staff would prop the door open.
2. Observations on 8/14/19 through 8/16/19 and on 8/19/19, of the walk-in freezer in the kitchen, showed the following:
-On 8/14/19 at 2:45 P.M., a sheet of folded fabric placed on the floor underneath the shelf in the back on the freezer. The fabric was soaked with water and beginning to freeze. The water appeared to be leaking from inside the freezer. Large bits of frost and ice covered the compressor fans, ceiling and the food on the self in the back of the freezer. The air in the freezer was thick with frost and made it hard to see;
-On 8/15/19 at 9:30 A.M., water dripped and leaked on to the floor underneath the shelf in the back of the freezer. Frost and ice covered the compressor fans, ceiling and boxes/bags of food on the shelf in the back of the freezer;
-On 8/16/19 at 11:30 A.M., frost and ice covered the compressor fans, ceiling and boxes/bags of food on the shelf in the back of the freezer. A puddle of water turned to ice on the floor underneath the shelf in the back of the freezer;
-On 8/19/19 at 9:21 A.M., frost and ice covered the compressor fans, ceiling and boxes/bags of food on the shelf in the back of the freezer. A puddle of water turned to ice on the floor underneath the shelf in the back of the freezer. A pipe covered with frost, ran along the ceiling and into the freezer. Water leaked from the pipe on to the floor in the kitchen food storage area.
During an interview on 8/19/19 at 9:30 A.M., the dietary manager said the director of maintenance was aware of the issues with the freezer and he was the one who put the sheet on the floor. When the door to the freezer was open, the fans stopped working. The director of maintenance cleaned the fans off every so often and it would work better. The ice and water seemed to be coming from the fan.
During an interview on 8/19/19 at 10:30 A.M., the director of maintenance said he was aware the walk-in freezer was having issues with frost build up. He was not sure what was caused it, but he was aware it needed to be addressed.
During an interview on 8/19/19 at 9:55 A.M., the administrator said he was aware the freezer was having issues with over freezing. He acknowledged the issue needed to be fixed before the problem became worse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to follow acceptable infection control practices to prevent the spread of infection for one resident (Resident #49) during perineal care (peri-care, cleansing the front of the hips and in between the legs and buttocks), allowing the urinary catheter (small rubber tube inserted in the urinary meatus (opening) in to the bladder to drain urine) drainage bag and tubing to drag on the floor for one resident (Resident #55), and using a comb and hair brushes on more than one resident. The sample size was 17. The census was 66.
1. Review of Resident #49's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/19, showed the following:
-Moderate cognitive impairment;
-Unable to ambulate;
-Dependent on staff for all mobility and personal care;
-Incontinent of bowel and bladder;
-Diagnoses included Alzheimer's disease, hemiplegia (paralysis on one side of the body) and diabetes.
Observation on 8/14/19 at 1:46 P.M., showed Certified Nurse Aides (CNA)s A and B entered the resident's room and donned gloves without washing their hands. The resident sat in a wheelchair and the CNAs assisted him/her to bed. CNA B released the front of the saturated with urine and feces brief, cleansed the front peri area and turned the resident to his/her right side, which exposed a moderate amount of soft feces. CNA B cleansed feces from the inner and outer buttocks, returned the resident to his/her back, and without washing his/her hands or changing his/her gloves, cleansed the front peri area. CNA B then dressed him/her in a clean brief, positioned him/her in bed and placed the oxygen tubing in his/her nose. Without washing hands or changing gloves, CNA B then obtained a wet cloth and cleansed the resident's eyes and face.
During an interview on 8/14/19 at approximately 2:00 P.M., CNA B said you should wash your hands before and after care and in between if needed such as if gloves get real messy. He/she said staff don't really need to change gloves after cleaning bowel movement (BM) unless there was a lot of BM on the gloves.
Review of the facility's undated Infection Control and Prevention Policy, included the following:
-Guidelines:
-Observe standard precautions;
-Wash your hands before and after procedures;
-Wash your hands before and after resident contact;
-Wear sterile or clean gloves when appropriate;
-Maintain sterility or cleanliness of the equipment and working field as necessary;
-Dispose of disposable equipment appropriately;
-Dispose of soiled linen appropriately (bagged and put in soiled utility room);
-Handwashing and glove usage:
-Wash hands before and after resident contact;
-Whenever visible soiled;
-Gloves are used in addition to handwashing not as a substitute;
-Essential that gloves be used in combination with hand washing;
-Wash hands or perform hand hygiene after removing gloves;
-Hands should always be washed with soap and water if hands are visibly soiled or exposure to spore-forming organisms is proven or strongly suspected, or after using the restroom;
-Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all residents. Hand hygiene is a major component of standard precautions and one of the most effective methods to prevent transmission of pathogens associated with health care. In addition, the use of personal protective equipment should be guided by risk assessment and the extent of contact anticipated with blood and body fluids, or pathogens.
During an interview on 8/19/19 at 10:00 A.M., the Director of Nursing (DON) said staff should always wash their hands when entering and when leaving a resident's room. She said hands should be washed when going from dirty to clean, and it was never okay to cleanse feces and not wash your hands and change gloves after doing so. She said to not cleanse your hands and change gloves was an infection control issue.
2. Review of Resident #55's quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for transfers and dressing;
-Impairment to one side of the upper body and both legs;
-Indwelling catheter;
-Diagnosis of neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem).
Review of the care plan, dated 7/17/19 and last updated on 7/25/19, showed the following:
-Problem: Indwelling catheter: Resident has a catheter secondary to a diagnosis of neurogenic bladder;
-Goal: Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infections or urethral trauma;
-Approaches: Administer Cranberry (medication used to prevent urinary tract infection (UTI)) as ordered and evaluate/record/report effectiveness and any side effects, avoid obstructions in the drainage, assess for continued need of catheter, assess color, amount and odor of urine output, observe for leakage, change catheter per physician's order, do not allow tubing or any part of the drainage system to touch the floor, encourage fluids, keep the catheter a closed system as much as possible, irrigate the catheter only if an obstruction is suspected, manipulate the tubing as little as possible, position the bag below the level of the bladder, provide catheter care every shift and as needed, report signs of UTI, store collection bag in a privacy bag and use a catheter strap.
Review of the electronic physician's order sheet (ePOS), in use during the survey, showed the following:
-An order, dated 5/28/19, to monitor catheter output every shift;
-An order, dated 5/29/19, to provide catheter care every shift;
-An order, dated 5/28/19 to administer Cranberry 500 milligrams (mg) one half tablet twice a day.
Review of the medical record, showed he/she was admitted to the hospital on [DATE] due to altered level of consciousness and fever. He/she returned to the facility on 5/28/19 with a diagnosis of UTI.
Observations on 8/14/19 at 11:06 A.M., 11:36 A.M. and 1:31 P.M., showed he/she sat in a wheelchair and propelled him/herself around the inside of the building and the outside courtyard. The catheter drainage bag, in a privacy bag, dragged on the floor along with approximately eight inches of catheter tubing that contained milky colored urine.
Observations on 8/15/19, showed the following:
-At 7:58 A.M., he/she lay in bed, the catheter drainage bag hung on the bed frame, not covered by a privacy bag and visible from the hallway;
-At 8:58 A.M., he/she sat in a wheelchair while a staff member rolled him/her outside to the patio. The catheter drainage bag hung in a privacy bag under the wheelchair and approximately 10 inches of catheter tubing drug across the floor.
Observations on 8/16/19, showed the following:
-At 10:50 A.M., he/she sat in a wheelchair, the catheter drainage bag hung under the chair and approximately 16 to 20 inches of catheter tubing lay directly on the floor with yellow, cloudy urine in the tubing;
-At 11:00 A.M., he/she sat in a wheelchair and exited the elevator. Approximately 20 inches of catheter tubing lay directly on the floor and dragged 14 feet on the floor when the resident self propelled his/her wheelchair into the television area.
Review of the facility's Catheter Care, Urinary Policy, last revised October, 2010, included the following:
-Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections;
-Maintaining Unobstructed Urine Flow:
-Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks;
-The drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back in to the urinary bladder;
-Infection Control:
-Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag;
-Be sure the catheter tubing and drainage bag are kept off the floor.
During an interview on 8/19/19 at 10:00 A.M., the DON said when the resident was in the wheelchair, the catheter bag should be in a privacy bag and hung under the wheelchair. She said neither the bag nor the tubing should ever be on the floor due to infection control.
3. Observations of the unlocked and open shower room across the hall from room [ROOM NUMBER] on 8/14/19 at 1:28 P.M. and 5:00 P.M., 8/15/19 at 6:30 A.M. and 11:30 A.M. and 8/19/19 at 7:30 A.M., showed two brushes and one comb on an open shelf. The comb had hair in the teeth and the brushes had hair in the bristles. Neither the brushes nor the comb were listed with a resident's name.
During an interview on 8/19/19 at 10:00 A.M., the DON said she would expect each resident to have their own brush and comb with their name written on them and those items should be kept in the resident's room. She said if a staff member saw a comb or brush without a resident's name, especially if it had been used, she would expect the staff member to throw it away. It was an infection control issue.

Based on observation, interview and record review, the facility failed to ensure potentially hazardous foods were stored at safe temperatures, at or below 45 degrees Fahrenheit (F), in the walk-in refrigerator for four of four days of observation. The facility also failed to ensure dented cans were removed from the food supply for four of four days of observation. These deficient practices had the potential to affect all residents who were served food from the facility kitchen. The census was 66.
1. Observations on 8/14/19 through 8/16/19 and on 8/19/19, of the walk-in refrigerator in the kitchen, showed the following:
-On 8/14/19 at 2:45 P.M., the external dial thermometer read 48 degrees F;
-On 8/15/19 at 9:30 A.M., the external dial thermometer read 50 degrees F. The thermometer inside the refrigerator read 46 degrees F;
-On 8/16/19 at 11:15 A.M., the external dial thermometer read 49 degrees F. The thermometer inside the refrigerator read 47 degrees F;
-On 8/19/19 at 9:20 A.M., the external dial thermometer read 50 degrees F. The thermometer inside the refrigerator read 48 degrees F. The surveyor's digital thermometer read 49.5 degrees F, when left in the refrigerator for two minutes;
-Milk, yogurts, cheeses and meats, were stored inside the refrigerator daily, throughout all four days of the survey.
Review of the facility's walk-in refrigerator temperature log dated 8/19, showed the following:
-On 8/14/19 through 8/16/18, open temperature (taken in the morning when the kitchen opens) 35 degrees F and the close temperature (taken in the evening when the kitchen closes) 40 degrees F;
-On 8/17/19, open temperature 33 degrees F and the close temperature not documented;
-On 8/18/19, open temperature 35 degrees F and the close temperature not documented;
-On 8/19/19, open temperature 35 degrees F.
Observation on 8/19/19 at 9:50 A.M., showed the following:
-A cup of milk, poured from a gallon stored inside the walk-in refrigerator, registered a temperature of 50.1 degrees F when tested with the surveyor's digital thermometer;
-An individual cup of yogurt, stored inside the walk-in refrigerator, registered a temperature of 50.5 degrees F when tested with the surveyor's digital thermometer.
During an interview on 8/19/19 at 9:45 A.M., [NAME] D said he/she recorded the walk-in refrigerator temperature at 6:00 A.M. every morning when he/she came in and the temperature was always good at that time. Another staff person recorded the temperature in the evening after dinner was done.
During an interview on 8/19/19 at 9:28 A.M., the dietary manager said she was aware the temperatures in the walk-in refrigerator were not where they were supposed to be and she let the director of maintenance know. The door to the walk-in refrigerator doesn't close all the way and seemed to be off just a little bit. The door sometimes stayed where it was supposed to, and sometimes it did not. Staff were constantly in and out of the walk-in refrigerator. The dietary manager said she let the director of maintenance know the refrigerator was not cold enough about two weeks ago. When the kitchen received deliveries, the walk-in refrigerator door stayed open more. She acknowledged the temperature of the food in the walk-in refrigerator was too high, and the food could not be served to residents.
During an interview on 8/19/19 at 10:30 A.M., the director of maintenance said he was only made aware of the issue with the walk-in refrigerator about ten minutes ago. When he left work on Friday 8/16/19, it was fine. He was aware there was an issue with the door not latching. When staff had an issue with equipment, they were supposed to fill out a work order, but he hardly ever received work orders from the kitchen. The kitchen staff usually told him about issues verbally, and they did not follow protocol and fill out work orders.
During an interview on 8/19/19 at 9:55 A.M., the administrator said he was not aware of any issue with the refrigerator. Sometimes when he walked back to the food storage area in the kitchen, he has seen the door to the walk-in refrigerator cracked open. He also noticed when the kitchen received deliveries, staff propped the door open.
2. Observations on 8/14/19 through 8/16/19 and on 8/19/19, of the dry food storage shelves, across from the walk-in refrigerator and freezer, showed the following dented cans:
-On 8/14/19 at 2:45 P.M. and on 8/15/19 at 9:30 A.M., a #10 can (approximately 109 ounces) of mandarin oranges, a #10 can of baked beans, a #10 can of baby lima beans, a 50 ounce can of cream of chicken soup;
-On 8/19/19 at 9:17 A.M., a #10 can of lima beans, a #10 can of fruit cocktail, a #10 can of pedasitos de pina (diced pineapple), a #10 can of baked beans and a 50 ounce can of cream of chicken soup.
During an interview on 8/19/19 at 9:30 A.M., the dietary manager said she was aware dented cans were not supposed to be used. Dietary aide E organized and put away the dry food items every Friday. The dietary manager said she inspected the cans herself. She was used to certain companies and she was still trying to become familiar with the company the facility used and their procedures for taking items back. Sometimes the cans came in closed boxes and the person who brought them was already gone by the time she noticed a can was dented. She usually held on to defective items in her office, so she could return them to the distributor. The dented cans should be stored in her office and not on the shelves because staff didn't all know not to use dented cans, and they could just grab what they see on the shelf and use it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to routinely assess, monitor and document on two residents receiving dialysis (process for removing toxins from the blood for individuals with kidney failure) regarding their shunts (artificial link between an artery and a vein) and/or fistulas (a real connection between an artery and a vein). The facility identified two residents as receiving routine dialysis treatments, both were sampled and problems were found with both (Residents #46 and #34). The sample was 17. The census was 66.
1. Review of Resident #46's annual MDS (Minimum Data Set, a federally mandated assessment instrument completed by facility staff), dated 7/1/19, showed the following:
-Severe cognitive impairment;
-Limited assistance from staff for toileting and personal hygiene;
-Diagnoses included stroke, heart failure and end stage renal disease;
-Special treatments received while a resident: Dialysis.
Review of the care plan, dated 7/10/19, and last updated 8/2/19, showed the following:
-Problem: Dehydration/fluid maintenance. Requires dialysis due to end stage renal disease;
-Goal: Will not exhibit signs of fluid volume excess;
-Approaches: Assure medications are administered before and after dialysis as ordered by the physician to ensure maximum effectiveness and to avoid adverse effects on the medication, check bruit/thrill (the thrill is the vibration you feel as blood flows through the fistula. The bruit is the sound you hear, heard with a stethoscope) per physician's order, obtain weight as ordered, carbohydrate controlled mechanically altered soft diet, Nepro (therapeutic supplement for people on dialysis) 273 milliliters (ml) three times a day, instruct resident on dietary restrictions, attends dialysis on Tuesday, Thursday and Saturday, monitor lab work and if lab work is completed at the dialysis clinic, request copies for facility medical record and report changes in mental status.
Review of the electronic physician order sheet (ePOS) in use during the survey, showed the following:
-An order, dated 3/29/19, for resident to have dialysis on Tuesday, Thursday and Saturday;
-Staff failed to obtain an order to assess the resident's site and how frequently.
Review of the resident's medical record, showed no documentation regarding nursing staff providing an on-going, thorough assessment of the resident's dialysis shunt, no documentation of assessing the resident's condition before and/after dialysis, no documentation of assessing the dialysis shunt for signs/symptoms of infection or bleeding, no documentation of assessing the shunt for bruit/thrill and no documentation of communication between the dialysis center or facility regarding the resident's dialysis treatments.
2. Review of Resident #34's quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Required staff supervision with dressing, eating, toilet use and personal hygiene;
-Diagnoses included high blood pressure, hemiplegia (paralysis on one side), depression, end stage renal disease, dependence on renal dialysis;
-Special treatments received while a resident: Dialysis.
Review of the resident's medical record, showed the following:
-An order, dated 9/11/18, for the resident to receive dialysis on Tuesdays, Thursdays and Saturdays;
-Staff did not obtain an order regarding the location of the site, the type of access (shunt, fistula or graft (looped, plastic tube that connects an artery to a vein), when to assess the resident's site, bruit and/or thrill;
-Staff did not include the resident's dialysis treatment on his/her care plan;
-Staff did not document any assessment of the resident's site before or after dialysis treatments or any communication with the dialysis provider.
During an interview on 8/14/19 at 1:21 P.M., the resident said he/she has an access site at his/her left groin. Staff never assessed his/her site before or after going out for dialysis treatment.
3. Review of the facility's undated Dialysis Services Policy, included the following:
-Professional standards of practice include:
-Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility;
-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services;
-Ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff is imperative in providing optimal care for the resident. The charge nurse is designated as the facility contact staff to communicate with the dialysis staff.
4. During an interview on 8/16/19 at 11:11 A.M., the Director of Nursing (DON) said nursing staff should assess the site before and after dialysis treatment. There should be an order for directing staff to do this. Nursing staff talk to the dialysis centers weekly to check on resident status, but this was not documented anywhere. It should be documented in the resident's medical record. They tried sending communication forms to the dialysis centers, but they did not get them back. As a result, they stopped sending them. The DON said she needed to develop a new system to improve communication. Dialysis should be covered on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the proper disposal of used razors for two residents (Residents #34 and #61) who shaved in their rooms. This had the potential to affect all residents who were able to move freely around the facility. The census was 66.
1. Observations of Resident #34's room on 8/14/19 at 1:48 P.M., 8/15/19 at 9:01 A.M., 8/16/19 at 12:35 P.M. and 8/19/19 at 8:20 A.M., showed three disposable razors on the resident's sink vanity.
During an interview on 8/14/19 at 1:48 P.M., the resident said he/she provides his own self care, including shaving. Staff provided the disposable razors when the resident requested one. Staff did not watch the resident shave. The resident threw the disposable razors away when finished.
2. Observations of Resident #61's room on 8/14/19 at 11:17 A.M., 8/15/19 at 12:36 P.M., 8/16/19 at 7:39 A.M., and 8/19/19 at 8:21 A.M., showed one disposable razor on the resident's sink vanity.
3. During an interview on 8/19/19 at 8:22 A.M., Housekeeper C said residents were not allowed to keep disposable razor blades in their rooms. If he/she saw one, he/she disposed of it.
4. Observations of the unlocked and open shower room across the hall from room [ROOM NUMBER], on 8/14/19 at 1:28 P.M. and 5:00 P.M. and 8/15/19 at 6:30 A.M. and 11:30 A.M., showed a razor on an open shelf and a razor in an unlocked cabinet.
5. During an interview on 8/19/19 at 8:25 A.M., the Assistant Director of Nursing said the facility did not allow residents to keep disposable razors in their room for a number of safety reasons, including the use of blood thinners and the high number of residents with psychiatric disorders. Some residents were allowed to shave on their own, once they were deemed safe to do so, but they must return the razor to staff when finished to be disposed of in the sharps container. Any staff member who sees a razor in a resident room is expected to dispose of it.
6. During an interview on 8/19/19 at 10:00 A.M., the Director of Nursing said razors should not be left out in the shower rooms for safety reasons. She would expect staff to dispose of them properly.