Based on interview and record review, the facility failed to ensure residents were free from neglect when staff failed to provide necessary services to avoid physical harm. On 5/26/25, Certified Nursing Assistant (CNA) D provided care to Resident #1, who had limited mobility after a stroke affecting his/her dominant side and an above the knee amputation. The resident had been assessed as needing total dependence on staff for personal hygiene and required substantial/maximal assistance to roll left to right. Resident #1 was left unattended in a raised bed when CNA D walked away to change his/her gloves. The resident fell out of the elevated bed onto the floor and was transported to the emergency room. The resident sustained a fracture to his/her right femur, a contusion to his/her shoulder, and the resident expressed feelings of being scared due to the traumatic event. The sample size was 12. The census was 108. The Administrator was notified on 6/18/25 at 5:05 P.M., of an Immediate Jeopardy (IJ) which began on 5/26/25. The IJ was removed on 6/18/25 as confirmed by surveyor onsite verification. Review of the facility's Abuse Prevention and Prohibition Program Operational Manual, Abuse and Neglect policy, revised 8/2020, showed: -Purpose: To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: -Each resident has the right to be free from mistreatment, neglect, and abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors; -The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: -Training: All employees, contractors and volunteers will be trained through orientation and ongoing training sessions, no less than annually, on the following topics: -Who is a covered individual responsible for reporting; -Abuse prevention; -Identification and recognition of signs and symptoms of abuse/neglect; -Protection of residents during an abuse investigation; -Investigation; ` -Reporting and documentation of abuse and neglect; -Reporting requirements of staff related to allegations of abuse/neglect without fear of reprisal; -Follow-up from the facility; -Prevention: -Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring; -The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met; -Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict; -Identification: -The facility provides facility staff with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect: -Physical Neglect: -Inadequate provision of care; -Caregiver indifference to resident's personal care and needs; -Leaving someone unattended who needs supervision. Review of the facility's Care and Services policy, revised 6/2020, showed: -Purpose: To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process; -Policy: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem ad self-worth; -Procedure: -The facility will have sufficient staff to provide services to residents with the appropriate competencies and skill sets to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being as determined by individualized resident assessments and plans of care. Review of the facility's Care Planning policy, revised 6/2020, showed: -Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident based on their individualized assessed needs; -Each resident's comprehensive care plan will describe the following: -Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; -Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; -Resident Rights-Care planning: -The resident has the right to receive the services and/or items included in the plan of care; -The interdisciplinary team will revise the Comprehensive Care Plan as need at the following intervals: -As dictated by changes in the resident's condition; -To address changes in behavior and care; and -Other times as appropriate or necessary. Review of the facility's undated Fall Management Program, showed: -Purpose: To prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program; -Policy: The facility will provide the highest quality care in the safest environment for the residents residing in the facility. The facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation; -Procedure: -Assessment: -The licensed nurse will assess each resident for their risk of falling upon admission, quarterly, and with a significant change in condition; -Based on the information gathered from the history and assessment of the resident, the nursing staff and interdisciplinary team, with input from the attending physician, will identify and implement interventions to reduce the risk of falls; -Care Planning: -The nursing staff will develop a plan of care specific to the resident's care needs with interventions to reduce the risk of falls; -The interdisciplinary team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response; -Functional Mobility: -Reassess patient's mobility status daily; -Determine the safest use of side rails; -Post-Fall: -Following a resident's fall, the licensed nurse will complete an incident report and a post-fall assessment and investigation within 24 hours or as soon as practicable; -The licensed nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated; -The Interdisciplinary Team Committee will meet within 72 hours of a fall. The IDT Committee will review and document: -Summary of events following a fall; -Root cause analysis; -Referrals, as necessary; and -Interventions to prevent future falls; -Documentation: -The Interdisciplinary Team Committee will document findings and recommendations in the resident's medical record; -Nursing staff will document the resident's response to interventions being utilized in the resident's medical record; -The resident's care plan will be updated as necessary; -Education: -Staff are in-serviced to the Fall Management Program at a minimum annually as well as immediately after any changes/up-dates to this program; -Interim in-services is provided, as needed, based on frequency and severity of falls; -In-service records are maintained to document that all staff attends in-service on all aspects of the fall program at least annually. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/25, showed: -Cognitively intact; -Used a wheelchair; -Roll left to right - substantial/maximal assistance; -Impairment on one side -upper extremity; -Impairment on both sides - lower extremity; -Toileting hygiene/Shower/bathe - dependent; -Diagnoses included depression, heart failure, diabetes, and non-Alzheimer's dementia. Review of the resident's medical record, showed diagnoses included muscle wasting and atrophy (the thinning or loss of muscle tissue) to the right and left shoulders, hemiplegia (inability to move on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting the right dominate side, disorder of bone density and structure, muscle weakness, dementia, and Alzheimer's disease. Review of the resident's care plan, showed: -Focus initiated 8/22/24: The resident has an activity of daily living (ADL) self-care performance deficit related to right side hemiplegia; -Goal: Maintain current level of ADL function; -Interventions/Tasks: -Initiated on 8/22/24, personal hygiene/oral care: The resident is totally dependent on staff for personal hygiene and oral care; -Initiated on 5/2/25, roll left to right: Substantial/maximal assistance. Review of the resident's progress notes, showed: -5/26/25 at 8:53 A.M.: at 6:15 A.M., CNA reported resident rolled off bed. Staff entered the room and noted the resident lying on the floor on the right side of the bed. Resident positioned halfway on the left side and back. Resident stated he/she slid off the bed and landed on the left shoulder and hit his/her head. Resident complained of pain moving his/her upper arms, left leg, and right thigh. Pain is causing limited range of motion to all extremities. Obtain vital signs: Blood pressure 168/96 (normal 90/60 through 120/80), temperature 97.8 (normal 97.8 through 99.1), heart rate 88 (normal 60 through 100), respirations 16 (normal 12 through 18). Notified 911, resident sent to the hospital. Notified the physician. New orders for x-ray and keep bed in low position; -5/26/25 at 3:53 P.M., resident returned from the hospital at 2:00 P.M., resident diagnosed with closed fracture of the neck of the right femur and contusion to the left shoulder. Physician notified; new orders received. Review of the resident's hospital records, for date of service 5/26/25, showed: -Chief complaint: Patient presents with fall: 9:34 A.M., patient with a history of right above the knee amputation, presenting to the emergency department via emergency medical services (EMS) complaining of pain all over after apparently falling out of bed at the nursing home earlier this morning. Apparently, nursing home staff found him/her on the floor just after 6:00 A.M. this morning. They assisted him/her back to bed without event, but he/she apparently began to complain of pain all over. He/She recalls rolling out of bed. He/She states he/she landed on his/her left shoulder and right thigh. He/She notes that he/she has phantom limb pain (pain felt in extremities that have been amputated) in the right lower extremity. He/She relates a mild headache and neck stiffness. He/She denies any chest pain, rib pain, abdominal pain, or back pain. He/She denies any nausea, vomiting, visual changes, or acute neurologic changes. He/She states he/she is never ambulatory and does not use a prosthetic right leg; -Musculoskeletal: Positive for arthralgias (pain in one or more joints), myalgias (muscle pain), and neck stiffness; -Neurological: Positive for headaches; -Closed fracture of neck of right femur; -Contusion of left shoulder. Review of the resident's Trauma Screen, effective 5/27/25 at 11:13 A.M., showed: -Has the event caused you to feel very scared, helpless, or horrified - Yes; -Has the event caused you to be constantly on guard, watchful, or easily startled - Yes; -Have you tried hard not to think about the event or went out of your way to avoid situations that remind you of it - Yes; -Summary of care provided: He/She has not had any past trauma in his/her life, but this fall has scared him/her, and he/she tries not to think about it, and he/she hopes it does not ever happen again. Review of the resident's progress notes, showed on 5/27/25 at 11:28 A.M., social worker met with the resident to do a trauma screen with him/her. The resident explained that he/she had not had any trauma before in his/her life, but because of his/her fall, he/she was scared because this had never happened before. Review of the facility's Initial Reporting form, dated 5/26/25, showed: -Alleged Victim - Resident #1; -Steps taken to protect resident: Assessment was conducted and was noted to have pain on exam that limited mobility in the affected left (L) shoulder and right (R) leg. Vitals obtained and resident was placed in bed in low position until the ambulance could arrive; -Witness - Blank; -Report Submission: Interim Director of Nursing (DON) on 5/26/25 at 1:15 P.M.; -No facility investigation, summary, witness statements, and/or findings provided at the time of the investigation. Review of CNA D's Correction Action Memo, showed: -Dated 5/26/25; -Type of violation: -Violation of policy or procedure; -Carelessness; -Employer Statement: -You were doing rounds and providing cares when it was reported that a resident fell out of the bed. Also, during this shift there has been an allegation of drug and alcohol abuse while working. Spoke with CNA D at 1:40 P.M. and he/she was suspended, pending investigation; -Action Being Taken: Suspension; -Employee Statement: He/She stated that he/she was providing cares and he/she got bowel movement on his/her gloves. He/She then went to change them and that is when the resident rolled out the bed; -Employee signature - Verbal by phone on 5/26/25 at 1:40 P.M.; -Supervisor signature - dated 5/26/25; -Witness signature - blank; -Dated 5/29/25; -Type of violation: -Violation of safety rules; -Unsatisfactory performance; -Carelessness; -Employer Statement: You were assisting a resident with cares, alone, and when you turned and changed gloves, the resident fell out of bed onto the floor and a fracture was indicated on his/her scans; -Action Being Taken: Termination; -Objective/Solution: This resident needed 2-person assist for transfers/bed mobility/and ADLs. There was no assist bar to help with rolling and due to stepping away, CNA D left the bed up and the resident rolled out and an injury occurred. This would have been prevented if CNA D were using 2 staff; -Supervisor signature dated 5/29/25. During an interview on 6/17/25 at 12:11 P.M., Licensed Practical Nurse (LPN) I said he/she knew the resident. The resident had passed away. The resident had a femur (upper leg bone) fracture. The fall happened on the night shift. The resident was being changed and somehow rolled out of bed. He/She did not know the name of the staff who had provided the care but knew him/her by face. The staff was a night shift aide. LPN I said he/she was just coming into work. In shift report, he/she was told the resident had been assessed and sent to the hospital. The resident was total care. The resident needed help in bed sometimes, but could move himself/herself around in bed. The resident's bedrails were to be up all the time, except when he/she was receiving care. The bedrails were for reposition assistance. The resident was an amputee. He/She was not sure if the resident could stop a fall. He/She expected staff to use two people if the resident was supposed to have that and it was never ok to turn their back to or walk away from a resident when the bed was in a high position. During an interview on 6/17/25 at 1:19 P.M., Certified Medication Technician G said it took two people to assist the resident. During an interview on 6/17/25 at 1:23 P.M., CNA H said he/she knew the resident. He/She found out the resident had fallen out of bed on Memorial Day. He/She did not talk with the resident about the fall and didn't know how the resident had fallen out of bed. When he/she came back to work, the resident was gone. CNA H said it took two people to transfer the resident. It took one person to provide care and to reposition him/her. During an interview on 6/17/25 at 1:27 P.M., LPN I said the number of staff to provide care for the resident depended upon whether or not he/she had just come from dialysis. Sometimes the resident was weak. It would take two people then but regularly, only one or two staff. He/She expected the staff to follow the resident's care plan. During an interview on 6/17/25 at 3:48 P.M., CNA C said he/she was familiar with the resident. He/She worked the night the resident fell out of bed. CNA D was assigned to the resident. He/She went to the resident's room to ask for CNA D's assistance with his/her resident and walked away back to his/her resident's room. A few minutes later, CNA D came to the door and said the resident is on the floor. The resident's bed was not against the wall, it was positioned in the room, so the floor was on both sides of the bed. The resident was a 1-person assist and fairly easy to roll. CNA C said when he/she got to the room, the resident was on his/her right side on the floor. The rails were not up on the bed on either side. The resident fell away from the side CNA D was on. He/She said CNA D said he/she went to change his/her gloves and that is how the resident fell. The bed was high when he/she went to ask CNA D for help. The resident just wanted them to get him/her up off the floor. The day the resident fell, he/she smelled alcohol on CNA D's breath when they were face to face, rolling a different resident in bed. CNA C reported this to the ADON (Assistant Director of Nursing). CNA D had come back from break smelling like weed and alcohol. He/She reported it to his/her supervisor (ADON). He/She called the ADON in the A.M. and told her CNA D couldn't work that hall. He/She said CNA D was lit and couldn't do anything. During an interview on 6/17/25 at 4:32 P.M., the Regional Nurse Consultant (RNC) said CNA D was no longer an employee after the resident's fall. Based on the investigation, CNA D did not have a 2nd person to assist with the resident's care. CNA D did not follow the resident's care plan. CNA D had been educated before. The resident was in bed and was non-weight bearing which is why he/she needed 2-people for care. The RNC said no one ever reported to her that CNA D smelled like alcohol or marijuana. She expected staff to follow the resident's care plan. During an interview on 6/18/25 at 6:46 P.M., the Interim DON said by the time the fall had been reported to her, CNA D was gone. She said it was reported to her in the past that CNA D had used alcohol/drugs while at work, but she did not have enough information to substantiate the allegations. She saw CNA D a few times, but did not smell drugs or alcohol on him/her. During an interview on 6/20/25 at 9:20 A.M., LPN F said Resident #1 told him/her the he/she bumped his/her head and he/she hit the floor hard. When he/she (LPN F) came back to work, after the fall, the resident was put on a pain management program because of the fall. LPN F said CNA D would be off the floor for long periods of time and take extended breaks. He/She said CNA D would not come back sometimes until it was time to provide care to the residents at the end of the shift. During an interview on 6/20/25 at 9:48 A.M., LPN A said he/she had worked with the resident before. He/She changed the resident alone on 6/1/25, after the resident had the fall, because they were short staffed with only one CNA and himself/herself. He/She knew the resident was 2-person assist. During an interview on 6/20/25 at 11:40 A.M., the ADON said she did not expect CNA D to turn his/her back or walk away from the resident to change gloves while the bed was still in high position. The resident required 2-person assist for transfers but that was because he/she used a mechanical lift. She was aware of the facility's in-service requiring the resident have 2-person assist for care. Based on the in-service, CNA D should have had an extra staff helping provide care to the resident. She expected CNA D to have gotten another staff member. The resident's fall could have been prevented. He/She asked the Interim DON to get a drug/alcohol test on CNA D but the Interim DON said she did not smell any alcohol on CNA D and could not tell if CNA D was impaired. During an interview on 6/18/25 at 12:09 P.M., the Interim DON said she did not know about the situation until about 10 or 10:30 A.M. the day of the fall. The nurse who had the resident had quite a few things going on, so that nurse did not tell her right away. She was originally told the resident fell out of bed. She talked with CNA D. She said CNA D told her the resident's bed was up about hip high. The resident had a large loose stool. He/she went to change his/her gloves, turned away from the bed, and changed gloves. Either way, no rail guards were up. She expected there to be 2-people providing care to the resident. The resident fell out of bed. CNA D was caring for the resident but was not following the care plan. The Interim DON said it was neglect because CNA D walked away without there being a 2nd person to assist with providing care. CNA D had already left the shift (worked nights) before she knew of the incident. She did not request an alcohol test because CNA D had already been gone a while and she did not know how long alcohol stayed in a person's system. She called CNA D a couple of times, because she needed to know what happened. She told CNA D he/she was suspended pending investigation, but he/she did not come back. He/She expected CNA D and all nursing staff to follow the resident's care plan. She expected all staff to follow the facility's policies. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions 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 the exit, the deficiency was lowered to the D level. This statement does not denote 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). MO00255229

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy when a resident experienced a change in condition. Resident #1 fell out of an elevated bed onto the floor and was transported to the emergency room on 5/26/25. The resident sustained a fracture to his/her right femur (thighbone), and a contusion to his/her shoulder, The resident was readmitted to the facility on [DATE], with discharge instructions identifying symptoms to monitor for that may require the resident to return to the hospital. Facility staff documented a change in condition consistent with the hospital discharge instructions, including vomiting and lethargy, beginning on 5/29/25. On 5/30/25, the resident's oxygen saturation and respiratory rate were low and the physician was notified with orders obtained for oxygen. The facility did not document notifying the physician of the resident's vomiting, lethargy, sweating, increased blood pressure, and elevated blood sugar. The resident continued to decline, eating less, increased lethargy and sleeping, pocketing food, unable to open eyes and inability to take oral pain medications. When the resident became unresponsive on 6/2/25, staff contacted emergency services and sent the resident to the hospital. The resident expired shortly after arriving to the hospital. In addition, the facility failed to ensure physician orders for wound care were followed for one out of three sampled residents (Resident #5). Resident #5's wound treatment was not completed for two days. The census 108. The Administrator was notified on 6/18/25 at 5:05 P.M., of an Immediate Jeopardy (IJ) which began on 5/29/25. The IJ was removed on 6/18/25 as confirmed by surveyor onsite verification. 1. Review of the facility's Change of Condition Notification policy, revised 6/2020, showed: -Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner; -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; -Members of the interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent and ACOC; -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: -An injury/accident; -A significant change in the resident's physical, cognitive, behavioral or functional status; -A significant change in treatment; and/or -A decision to transfer or discharge the resident from the facility; -The licensed nurse will notify the resident's attending physician when there is an: -Incident/accident involving the resident; -An accident involving the resident which results injury and has the potential for requiring physician intervention; -A significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications; -A need to alter treatment significantly -A decision to transfer or discharge the resident from the facility; -The licensed nurse will assess the resident's change of condition and document the observations and symptoms; -Notifying the Attending Physician: -The attending physician will be notified timely with a resident's change in condition; -Notification to the attending physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required; -Emergency Situations: -If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital; -Notify the nursing supervisor of emergency situation; -A licensed nurse will document the following: -Date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes; -The time the attending physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received; -Update the care plan to reflect the resident's current status; -The incident and brief details in the 24-hour report; -Complete an incident report per facility policy; -A licensed nurse will communicate any changes in required interventions to the IDT members involved in the resident's care; -A licensed nurse will document each shift for at least seventy-two (72) hours; -Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the 24-hour report. Review of the facility's Neurological Assessment policy, revised 2/2019, showed: -Purpose: To provide guidelines for the performance of a neurological assessment on residents; -Nursing staff will perform a neurological assessment in the following circumstances: -Upon attending physician order; -Following a fall or other accident/injury involving head trauma; or -When indicated by resident's condition; -The following information will be documented in the resident's medical record: -The date and time the procedure was performed; -All the assessment data obtained during the procedure, including: -Eye opening; -Verbal response; -Motor response; -Pupillary response; -Limb response; -If the resident refused the procedure, the reason(s) why and the intervention taken; -The signature and title of the person recording the data; -Notify the attending physician of any change in a resident's neurological status. Early signs of neurologic compromise include changes it the resident's level of consciousness and pupillary activity; -Report other information in accordance with facility policy and professional standards of practice. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/1/25, showed: -Cognitively intact; -Used a wheelchair; -Roll left to right - substantial/maximal assistance; -Impairment on one side -upper extremity; -Impairment on both sides - lower extremity; -Toileting hygiene/shower/bathe - dependent; -Diagnoses included depression, heart failure, diabetes, and non-Alzheimer's dementia. Review of the resident's medical record, showed diagnoses included muscle wasting and atrophy (the thinning or loss of muscle tissue) to the right and left shoulders, hemiplegia (inability to move on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke affecting the right dominate side, disorder of bone density and structure, muscle weakness, dementia, and Alzheimer's disease. Review of the resident's care plan, showed: -Focus: The resident has a history of stroke with right sided hemiplegia: -Goal: Be free from further complication from stroke through review; -Interventions included: Monitor level of consciousness, visual function changes, inability to communicate, aphasia (difficulty communicating), dizziness, weakness, and restlessness; -Focus: Impaired cognitive function related to unspecified dementia: -Goal: Maintain current level of cognitive function; -Interventions included: Monitor/document/report to the physician any changes in cognitive function, specifically changes in: Decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Review of the resident's progress notes, showed: -5/26/25 at 8:53 A.M., at 6:15 A.M., the certified nursing assistant (CNA) reported the resident rolled off bed. Staff entered the room, noted the resident lying on the floor on the right side of the bed. Resident positioned halfway on his/her left side and back. Resident stated he/she slid off the bed and landed on the left shoulder, and hit his/her head. Resident complained of pain moving his/her upper arms, left leg, and right thigh. Pain is causing limited range of motion to all extremities. Obtained vital signs: Blood pressure 168/96 (normal 90/60 through 120/80), temperature 97.8 (normal 97.8 through 99.1), heart rate 88 (normal 60 through 100), respirations 16 (normal 12 through 18). Notified 911, resident sent to the hospital. Notified the physician. New orders for x-ray and keep bed in low position. Review of the resident's emergency room paperwork, dated 5/26/25 at 9:34 A.M., showed: -Chief Complaint: Patient presents with a fall; -At 9:34 A.M., patient with a history of high blood pressure, diabetes, stroke, congestive heart failure (CHF), dementia, and right above-the-knee amputation, presenting to the emergency department (ED) via emergency medical services (EMS) complaining of pain all over after apparently falling out of bed at the nursing home earlier this morning. Apparently, nursing home staff found him/her on the floor just after 6:00 A.M. this morning. They assisted him/her back into bed without event, but he/she apparently began to complain of pain all over. He/She recalls rolling out of bed. He/She states he/she landed on his/her left shoulder. When asked to describe these specific areas where he/she hurts the most, he/she states it is his/her left shoulder and right thigh. He/She notes that he/she has phantom limb pain (pain occurring in extremities that have been amputated) in the right lower extremity. He/She relates a mild headache and neck stiffness; -Review of systems: Neurological: Positive for headaches; -Comment: Patient who rolled out of bed at the nursing home, complaining of headache, neck pain, left shoulder pain, and right thigh pain. Review of the resident's hospital After Visit Summary, dated 5/26/25 printed 12:59 P.M., showed: -Call 911 if any of these happen: -Confused or difficulty arousing; -Fainting or loss of consciousness; -Rapid or very slow heart rate; -Difficulty with speech or vision, weakness of an arm or leg; -When to seek medical advice: Call your healthcare provider right away if any of these happen: -Another unexplained fall; -Severe headache; -Nausea and vomiting. Review of the resident's progress notes, showed: -5/26/25 at 3:53 P.M., the resident returned from hospital at 2:00 P.M. Resident diagnosed with closed fracture of neck of the right femur and contusion to left shoulder. Physician notified, new orders received. No new concerns noted. Resident is resting in bed, morphine (narcotic pain medication) intramuscular (injected into the muscle) 4 milligram (mg) given at the hospital prior to return. Pain is rating of 7 on a scale of 0 to 10 (0 indicates no pain, 10 indicates the worse pain imaginable), stated he/she wants to sleep. Vitals blood pressure 117/71, heart rate 108, temperature 98.4, respirations 18, oxygen saturation (percentage of oxygen in the blood) 96% (normal 95% through 100%). Review of the resident's physician orders showed: -An order dated 5/26/25, low bed at all times; -An order dated 5/27/25, chart status post fall with injury every shift in progress notes; -An order dated 5/30/25, oxygen 2 liters as needed. Review of the resident's progress notes, showed: -5/27/25 at 11:28 A.M., Social Worker met with the resident to do a trauma screen. Resident explained that he/she has not had any trauma before in life, but because of his/her fall, is scared because this had never happened before; -5/27/25 at 2:14 P.M., incentive spirometry (device used for deep breathing exercises) daily/as needed (PRN) for 5 breaths. Resident will place the mouthpiece in mouth, sealing lips around it. Instruct the resident to breathe in slowly and deeply as possible, holding breath for 3-5 seconds. Exhale and rest between breaths, cough as necessary. Nurse to evaluate lungs sounds before and after use of the Incentive Spirometer, document achieved volume, heart rate, respirations, oxygen saturations and treatment time. Rinse the mouthpiece after each use. Every dayshift for shortness of breath related to chronic obstructive pulmonary disease (COPD, lung disease): Resident did not feel up to it; -5/29/25 at 2:21 P.M., nurse called to the resident's room. Resident had emesis (vomited) twice. Resident is alert, but is also lethargic (a state of extreme tiredness, sluggishness, and lack of energy), unable to swallow anti-emetic (medication or treatment that prevents or relieves nausea and vomiting) at this time. Denies any pain or discomfort at this time. Pain meds being held due to lethargy. Swelling to right hip and left shoulder. Is currently resting in bed, call light in reach. Will continue to monitor vital signs: blood pressure 110/75, heart rate 77, respirations 17, temperature 97.5, oxygen saturation 92%; -5/29/25 at 11:11 P.M., no nausea or vomiting this shift. Resident ate less than 25 percent for dinner, drank half a nepro shake (health shake for individuals with kidney failure). Denies any pain or discomfort at this time. Resident slept majority of this shift, currently resting in bed with call light in reach. Vital signs: blood pressure 103/76, heart rate 97, temperature 98.4, respirations 17, oxygen saturation 92%; -5/30/25 at 6:30 A.M., resident sensitive to touch, unable to tolerate vital signs check, yelling don't touch me, stop. Resident noted sweaty this morning, gown damp. Blood pressure 156/77 in left leg compared to reading in upper left arm/wrist blood pressure of 89/56, pulse 81, respiration 14, temperature 98.3, oxygen saturation 88%, blood sugar 214 (normal less than 140). Notified physician. Gave orders for oxygen 2 liters as needed and to monitor; -5/31/25 at 1:05 P.M., no nausea or vomiting this shift. Resident ate less than 25 percent for both meals. Denies any pain or discomfort at this time. Resident slept majority of this shift. Currently resting. No concerns noted at this time, will continue to monitor for any acute change in condition; -6/1/25 at 3:19 P.M., resident slept most of day shift. Noted to be pocketing food (holding food in the mouth and not swallowing). Given puree for lunch. Ate less than 25 percent. Resident is resting in bed at this time, call light in reach. Will continue to monitor; -6/2/25 at 5:51 A.M., resident continues on observation related to fall with injuries to neck of the right femur and contusion to left shoulder. Resident moaned like he/she was in pain when being repositioned and changed. This nurse attempted to give resident as needed pain medication, but resident would not open his/her eyes. Resident is sleeping deeply but does respond to pain stimulus when being moved. Resident in bed with bed in low position and call light within reach; -6/2/25 at 8:20 A.M., during medication administration, notified by Certified Medication Technician (CMT) that resident blood pressure was low, and pulse elevated. Upon assessment, resident noted to have labored breathing. Eyes glossy and non-reactant to light. Unable to obtain oxygen saturation. Head of bed elevated, and oxygen therapy applied. Resident had become non-responsive to verbal commands. But responded to physical touch. Call place to 911. Resident transferred to the hospital via EMS. Management and medical doctor made aware. Message left for responsible party and first emergency contact. Awaiting call back at this time; -6/2/25 at 9:09 A.M., responsible party states he/she received call from hospital stating resident had expired. Management and medical doctor made aware. Review of the resident's vital sign log in the medical record, showed: -6/2/25 at 2:10 A.M., blood pressure 141/63, lying/left arm; -6/2/25 at 8 A.M., blood pressure 95/41, lying/left arm; -No documentation related to history of low blood pressure found. During an interview on 6/17/25 at 3:34 P.M., CNA C said he/she saw the decline in the resident in just a couple of days. The resident could not sit in his/her wheelchair. Over the days after the accident, the resident would not eat. He/She tried to feed the resident, but the resident said he/she could not eat. The resident was barely eating after the fall. After the fall, the resident would not hardly open his/her eyes. He/She noticed the resident would not stay awake. During an interview on 6/18/25 at 2:23 P.M., Licensed Practical Nurse (LPN) B said he/she called the doctor to get medication and intramuscular (IM) injection because the resident vomited. He/She was not able to get the IM injection from the medication dispensing machine. He/She was alerted about the vomiting and decline on 5/29/25. He/She had contacted the doctor that day and should have documented in the resident's chart. They doctor did not order to send the resident out. LPN B said he/she was not aware of the information on the resident's after visit fall hospital discharge paperwork indicating reasons for sending the resident back to the hospital. Nursing was supposed to look at that paperwork. If he/she had seen the after visit summary paperwork, he/she would have made a note in the resident's record. Looking back now, he/she would have sent the resident out. During an interview on 6/20/25 at 9:20 A.M., LPN F said he/she did not see the resident's after visit hospital summary. He/She got updated reports from each shift when he/she came in. The resident told him/her that he/she bumped his/her head. The resident told LPN F he/she hit the floor hard. When he/she came back to work, the resident was put on pain management. The medication was strong and the resident was not used to all that medication. He/She would have sent the resident out when he/she vomited. During an interview on 6/20/25 at 9:48 A.M., LPN A said he/she did not know there had been a change in the resident. The resident was sleeping a lot, but he/she did not know if this was a change in his/her behavior. The resident's vital signs were fine, so he/she did not think there was a change. LPN A said the resident would not wake up to take his/her medicine. The resident would wake up a little before, but now the resident would not open his/her mouth up all the way. He/She did not feel safe giving the resident his/her medication, so it was held. LPN A said he/she got updates at shift change, but did not know anything about the resident vomiting or being lethargic. He/She looked over the resident's progress notes and said the facility should have sent the resident out because, looking back, moaning and not opening his/her eyes was a change in the resident's condition. During an interview on 6/20/25 at 10:47 A.M., LPN J said he/she was one of the nurses who reviewed hospital discharge paperwork for the facility. Nursing staff are to review the 24-hour report. All nurses have access to the 24-hour report. The 24-hour nursing report would have given indication of the resident's decline over time. During an interview on 6/20/25 at 10:51 A.M., LPN M said they are to report to the supervisor any change in condition. During an interview on 6/20/25 at 11:40 A.M., the Assistant Director of Nursing (ADON) said the resident should have been sent to the hospital after the change of condition. The ADON said the medical doctor was adamant about not sending the resident out, so the nurse did not send him/her out. The resident should have been sent out when he/she had emesis and was lethargic, but the medical doctor said not to. She expected all nurses to review the 24-hour nursing report and compare with the observations made. During an interview on 6/20/25 at 11:41 A.M., the Director of Nursing (DON) said if staff were concerned about a resident's change in condition and wanted to send him/her out, she would expect staff to send them out even if the physician refused, and then notify her. If they feel strongly about the resident's need for further care, she would want them to send the resident out and she would talk with the physician. She would rather them do that than do nothing and then something happens. She does not feel like the medical director got the full picture with the resident. She feels like the medical director would have sent the resident out if he had the full picture of what was going on with the resident. During an interview on 6/18/25 at 11:25 A.M., the Medical Director said he knew the resident, but could not remember what he was told about what happened to the resident. The resident's health was compromised. He/She was an amputee, on dialysis, had poor circulation, and was a very sick patient. He is not sure if staff called him, but he knew about the fall. He could not say what the cause of death was. He definitely expected staff to follow the level of care the resident had been assessed for. Staff should have called about the resident's blood pressure dropping because they cannot treat/maintain blood pressure at the facility. The resident had to be sent out for that. During an interview on 6/18/25 at 12:09 P.M., the Interim DON said she expected the doctor to be notified for any of the symptoms listed on the resident's hospital discharge paperwork. She expected the resident to have been sent out before he/she was. She did not know why the resident was not sent out. If the nurse thought it was an emergency, she expected the nurse to prioritize and send the resident out. The nurse that had the resident the morning he/she was sent out did not tell her right away about the resident's condition. There were two days she did not get to review the 24-hour notes. Maybe she would have caught the resident's decline. She expected the nurse managers to do that and report the information to her. She was not told about the resident's decline. She expected the nurse managers to review the 24-hour notes and report to her. At 12:50 P.M., the Interim DON said LPN A should have notified the doctor on 6/2/25 when he/she tried to give pain medication, but the resident would not open his/her eyes. Nurses have nursing judgement, and she was not sure why LPN A did not send the resident out at that time. That is what usually happens. The nurse use nursing judgement and notify the physician afterwards if they think a resident should be sent out and do not have time to call or cannot reach the doctor. 2. Review of the facility's Physician Order Policy, revised 6/2020, showed: -Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified is necessary; -Telephone Orders: -A Licensed Nurse will transcribe telephone orders with date, time and signature of the person receiving the order; -Orders will include a description complete enough to ensure clarity of the physician's plan of care; -Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline; -Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the medication administration record (MAR)/treatment administration record (TAR). Review of the facility's Wound Management policy, revised 6/2020, showed: -Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Arterial Ulcer- an ulceration that occurs as the result of arterial occlusive disease when no pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis (tissue death). Arterial/ischemic ulcers may be present in individuals with moderate-to-severe peripheral vascular disease, generalized arteriosclerosis, inflammatory autoimmune disorders, or significant vascular disease elsewhere. The arterial ulcer is characteristically painful, usually occurs in the distal portion of the lower extremity and may be over the ankle or bony areas of the foot; -Venous Insufficiency Ulcer- an open lesion of the skin and tissue of the lower leg, usually occurring in the area of the lower leg or above the ankle. Venous insufficiency ulcers may be caused by one (or a combination of) factor(s) including: loss of (or compromised) value function in the vein, partial or complete obstruction of the vein, and/or failure of the calf muscle to pump the blood; -Wound Management Principles Wound bed: -Remove devitalized tissue and foreign debris; -Maintain moisture; -Minimize tension/pressure on the wound; -Pack dead space lightly; -Control bacterial bioburden and infection; -Documentation: -New pressure injuries or wounds will be documented on the 24 Hour Log. Wound documentation will occur at a minimum of weekly until the wound is healed. Documentation will include: Location of wound; length, width, and depth measurements recorded in centimeters (cm); direction and length of tunneling and undermining (if applicable); appearance of the wound base; drainage amount and characteristics including color, consistency, and odor; appearance of wound edges; description of the peri-wound (skin surrounding the wound) condition or evaluation of the skin adjacent to the wound; presence of pain. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No upper body impairment; -Lower body impairment: 1 side; -Dependent (Helper does all effort. Resident does none of the effort to complete activity): Toileting, lower body dressing, and personal hygiene; -Total number venous and arterial ulcers: 1; -Treatments: Pressure reducing device bed, application nonsurgical dressing; -Diagnoses included heart failure, peripheral vascular disease (PVD, poor circulation), end stage renal disease (ESRD), malnutrition, and quadriplegia (paralysis of all four limbs). Review of the resident's care plan, revised 9/10/24, showed: -Focus: Resident has a venous ulcer of the right lower calf related to congestive heart failure, PVD; -Goal: Resident's ulcer will be healed by the review date. Resident will have no signs/symptoms of infection through the review date; -Interventions: Document location of wound, amount of drainage, peri-wound area, pain, edema (swelling), and circumference measurements per facility protocol. Evaluate wound. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Minimize exposure of skin to moisture from incontinence, wound drainage, or perspiration. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated 1/27/25-5/30/25, cleanse right lateral (side) lower leg with hypochlorous (wound cleanser that increases oxygenation of the wound site to improve healing). Apply calcium alginate (highly absorbent dressing) with silver, xeroform (non-adherent dressing) to wound bed. Cover with super absorbent dressing, kerlix (gauze wrap) and with ACE wrap. Daily and as needed (PRN) every dayshift for wound care; -An order, dated 5/30/25-6/4/25, cleanse right lateral lower leg with hypochlorous. Apply calcium alginate with silver, Gentamicin Ointment to wound bed. Cover with super absorbent dressing, kerlix and with ACE wrap. Daily and PRN every dayshift for wound care; -An order, dated 6/4/25, cleanse right lateral lower leg with hypochlorous. Apply calcium alginate with silver to wound bed. Cover with super absorbent dressing, kerlix and with ACE wrap. Daily and PRN every dayshift for wound care. Review of the resident's May 2025 TAR, showed the ordered treatment not marked as completed on 5/4/25, 5/8/25, 5/11/25, 5/16/25, 5/18/25, 5/21/25, 5/24/25, 5/25/25, and 5/26/25; Review of the resident's June 2025 TAR, reviewed on 6/18/25, showed the ordered treatment not marked as completed on 6/13/25, 6/15/25, and 6/16/25. Review of the facility's wound report, showed the following for the resident: -4/30/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7 cm, 2.5 width, depth 0.3 cm; -Wound status: subsequent-Stable; -Dressing change: Daily. Clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/7/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7 cm, 2.5 width, depth 0.3 cm; -Wound status: subsequent-Stable; -Dressing change: Daily. Clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/14/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 6.8 cm, 3 width, depth 0.3 cm; -Wound status: subsequent-Stable; -Dressing change: Daily clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/21/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7.3 cm,3.5 width, depth 0.3 cm; -Wound status: subsequent-Worsening; -Dressing change: Daily clean with normal saline. Xeroform, calcium alginate. Absorptive dressing, dry dressing; -5/28/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 8 cm,3.5 width, depth 0.3 cm; -Wound status: subsequent-Worsening; -Dressing change: Daily clean with normal saline, calcium alginate. Gentamicin (antibiotic) ointment. Absorptive dressing, dry dressing; -6/4/25 Wound location: Right Posterior Leg; Venous Insufficiency Ulcer; -Length: 7.5 cm, 4 width, depth 0.3 cm; -Wound status: subsequent-stable; -Dressing change: Daily clean with normal saline, calcium alginate. Absorptive dressing, dry dressing; -6/11/25 Wound location: Right Post

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure residents were free from abuse by Resident #3, who yelled, cursed and threatened them. Resident #3 was described as bullying residents and used racial slurs towards his/her roommate. Residents refused to go to activities or eat in the dining room to avoid being around the resident. The census was 120. The Administrator was notified on 3/3/25 at 11:15 A.M., of an immediate jeopardy (IJ) which began on 1/29/25. The IJ was removed on 1/30/25 as confirmed by surveyor on-site verification. Review of the facility Abuse Prevention and Prohibition Program policy, revised on 10/24/2022, showed: -Purpose: To ensure the Facility establishes, operationalizes, and maintains and Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, and other residents; -The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: -Training: Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics: Who is a covered individual responsible for reporting. Abuse prevention. Identification and recognition of signs and symptoms of abuse/neglect. Protection of residents during an abuse investigation. Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -Prevention: -Staff, residents and families will be able to report concerns, incidents and grievances without of retribution or retaliation; -Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect is at risk for occurring; -Residents identified by staff as exhibiting abusive behavior that requires professional services not provided in the Facility will be reviewed by the IDT (interdisciplinary team) and/or physician. Appropriate referrals will be made, and treatment plans will be modified; -The Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met; -The Facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse; -Resident Assessments and Care Planning are performed to monitor resident needs and address behaviors that may lead to conflict; -Identification: -The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect; -Possible Signs and Symptoms of Psychological Abuse or Neglect, includes depression, withdrawal, and anger; -Investigation: -The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of unknown source, or criminal acts; -The Facility has protocols for investigations; -If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, the Administrator or designee, may appoint a member of the Facility's management team to investigate the alleged incident; -Protection: The Facility protects residents from any harm that could result from abuse investigations. Review of the facility's Violence Between Residents policy, dated 8/2020, showed: -Purpose: To protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by the facility; -Policy: The Facility acts promptly and conscientiously to prevent and address altercations between residents; -Prevention: Facility Staff monitors residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or Facility Staff. Any occurrences of such behavior are promptly reported to the Charge Nurse, the Director of Nursing (DON), and the Administrator; -Response to an Altercation: Separate the residents, and institute measures to calm the situation. Determine what happened, including what might have led to aggressive conduct on the part of one or more residents involved in the altercation. Notify each resident's representative and Attending Physician of the incident. Review the events with the Charge Nurse and DON, including interventions staff can take to prevent additional incidents. Consult with Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem. Make any necessary changes in the Care Plan for any or all of the involved residents as necessary. Document in the resident's interventions and their effectiveness in the resident's medical record. Consult with psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a Care Plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Team. Complete the Incident report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the Facility, transfer the resident. Report incidents, findings, and corrective measures to appropriate agencies. Review of Resident #3's admission face sheet showed: -admission 6/6/24; -The resident was listed as his/her own responsible party. Review of the resident's progress notes, located in the electronic health record (EHR), dated 6/6/24 at 12:52 P.M., showed the resident arrived at 12:00 noon, alert and oriented x 4 (person, place, time and situation). Got off ambulance stretcher and walked to room with a steady gait. Review of the Guidelines for Resident Behavior, signed by the resident and co-signed by the Social Service Director (SSD) on 6/6/24, showed: -General Conduct: residents are expected to treat staff, other residents with respect, dignity and privacy. Conduct must be consistent with accepted community standards, local, federal and state laws. Unacceptable conduct includes but is not limited to physical abuse, verbal abuse. This conduct is not permitted on or about the facility; -Non-Compliance: if we determine that residents' behavior is contrary to these rules and is compromising their health care or that of other residents, these residents will be subject to administrative actions. Review of the resident's care plan, located in the EHR, showed: -Problem, 6/6/24: Resident has a mood problem, depression; -Goal: Resident will not experience any increase in signs and symptoms of mood disturbance. Interventions: Administer medications as ordered. Behavioral health consult as needed. Communicate with resident regarding mood state and treatment. Encourage resident to express feelings. Encourage resident to participate in activities of choice. Encourage to maintain as much independence and control/decision making as possible. Notify medical provider of increased episodes of mood disturbance; -Problem, 6/13/24: Resident has a behavior problem. Resident was noted to speak rudely to roommate, eating off other residents' plates, verbally aggressive with staff, disrespectful to staff; -Goal: resident will have fewer episodes of behaviors through review date. Interventions/Tasks (6/13/24); -Interventions: speak in calm manner. Behavioral health consults as needed. Communicate with resident regarding behaviors and treatment. Consult with Pastoral care, Psych services, and/or support groups. Minimize potential for behaviors by offering tasks that divert attention. Monitor behavioral episodes and attempt to determine underlying causes. Intervene as necessary to protect the rights and safety of others. Encourage not to curse or speak disrespectfully and/or aggressive to staff. Notify medical provider of increased episodes of behaviors. -6/14/24: Encouraged to speak to roommate respectfully and encouraged not to eat off of other resident's plates. Review of the resident's record showed there was no behavior management program or ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs documented. Review of the resident's progress note, dated 6/12/24 at 2:26 P.M., showed the resident's physician saw the resident at the facility. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/24, showed: -Speech Clarity: clear speech, distinct intelligible words; -Makes Self Understood: ability to express ideas and wants: understood; -Ability To Understand Others: understood; -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): behavior not exhibited; -Mobility Devices: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: supervision or touching assistance, helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of high blood pressure, diabetes mellitus (high blood sugar) and depression. Review of the resident's medication administration record (MAR, a form where nurse documents medication administration and behavioral episodes) dated 6/6/24 through 6/30/24, located in the EHR, showed: -6/6/24: Duloxetine HCI (antidepressant) 30 milligrams (mg) daily; -Behaviors: Verbally aggressive with staff: occurred 1 time on the evening shift (6/13/24); -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the evening shift (6/13/24); Review of the resident's progress notes, dated 6/13/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behavior on the evening shift of 6/13/24. Review of the resident's progress note, on 6/14/24 at 12:07 P.M., showed the SSD documented the resident said he/she was there short term and was just waiting on his/her apartment to be approved. Resident rights were reviewed including the facility guidelines for behavior, drugs, and smoking. Review of the resident's MAR, dated 7/1/24 through 7/31/24, showed no behaviors documented. Review of the resident's progress note, dated 7/3/24 at 6:59 P.M., showed: -Resident had verbal disagreement with another resident, nursing staff present at the time, no contact made. Resident separated from the other resident. Resident was calm sitting outside in the smoking area listening to music; -No SSD or IDT follow-up documented. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 7/10/24, showed: -Diagnoses: post-traumatic stress disorder (a mental health disorder that can develop after witnessing a traumatic event), nicotine dependence, cocaine use (in remission), other specific personality disorders, and persistent mood disorder; -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up, says he/she was still trying to make the best of his/her situation. Decides he/she does not want medication to help him/her stop flipping out. Discussed trying to stay calm and walking away from conflict, which I am not sure he/she was completely on board with. Denies symptoms of depression or anxiety. Just mood swings he/she says; -Objective: resident was engaged with examiner in a cooperative and polite manner. Mobility was within normal limits. Stream of mental activity was logical, relevant, coherent, and goal directed; -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's progress notes showed: -7/11/24 at 6:22 A.M.: the resident had a verbal altercation with roommate. Resident was loud, disturbing, and using profane language. The resident slammed the door behind roommate; -7/11/24 at 10:29 A.M., IDT note (Administrator, former Director of Nursing (DON), SSD and Nursing Manager): verbal disagreement with roommate. The resident called roommate a racial slur. Roommate did not like this and told the resident so. The resident became upset when staff intervened. The resident left the room shutting the door loudly. The resident educated to be considerate of others' feelings and preferences. The resident verbalized understanding; -7/11/24 at 3:04 P.M., completed by the SSD: spoke with the resident about his/her disagreement with roommate this morning. He/She said he/she closed the door but did not mean to slam it. Explained to him/her if he/she has a problem with his/her roommate just come and speak to them. Also spoke about changing rooms. He/She said he/she was happy with that; -7/13/24 at 11:17 A.M., documented by the Administrator: met with resident for psychosocial follow-up. Said he/she likes his/her new room and new roommates. Reinforced with resident that he/she must remain respectful with facility staff. Said he/she understands and was working on it. He/She feels that due to his/her size, he/she may come across as more upset than he/she actually was. Reeducated that he/she can bring any concerns to facility management, social service, this author, and will communicate any future needs of concerns to the appropriate parties; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP. Review of the resident's progress note dated 7/16/24 at 2:06 P.M., and completed by the SSD, showed a care plan meeting was held with the resident to discuss verbal outbursts toward staff and other residents, and explain this is not a good fit for him/her. He/She continues to ask facility to give him/her another chance and he/she continues the same behavior. SSD has been asked to start looking for another facility. He/She gave SSD a few facilities to send his/her referral to. Review of the resident's care plan showed: -On 7/11/24, Observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs. Encourage to maintain as much independence and control/decision making as possible. Praise and indication of progress in behaviors; -On 7/29/24, Encourage to take all medications and notify physician of all refusals. Review of the resident's MAR, dated 8/1/24 through 8/31/24, showed: -Behaviors: Verbally aggressive with staff occurred 5 times on the day shift (8/3, 8/4, 8/7, 8/14, and 8/27), and cursing staff occurred 1 time on the evening shift of 8/23; -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (8/3, 8/4, 8/7, 8/24, and 8/27), and educated on reasons not to curse at staff on the evening shift of 8/23. Review of the resident's progress notes, dated 8/1/24 through 8/31/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behaviors on 8/3, 8/4, 8/7, 8/14, 8/23, or 8/27/24. Review of the resident's progress note, dated 8/7/24 at 12:00 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the resident's progress note, dated 8/10/24 at 1:20 P.M., completed by the SSD, showed the resident was informed during care plan meeting that was held that the facility was still trying to find him/her another facility, however no one has accepted him/her as of yet. They are still sending referrals out and once a facility had accepted him/her he/she will be informed. Review of the resident's progress note, dated 8/14/24 at 4:03 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the facility Resident Council meeting minutes, dated 8/15/24 at 2:00 P.M., showed: -Staff members present: the former DON, Activity Director (AD) and Activity Aide (AA) F; -18 residents attended, including: Resident #3, Resident #2, and Resident #14; -New Business: discussed Resident #3 was a bully. Always arguing with staff and peers; -There was no facility response to the Resident Council concerns regarding Resident #3's behaviors. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 8/27/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. He/She was still trying to make the best of his/her situation. Decides he/she does not want any further medication to help him/her from stop flipping out. Denies any symptoms of depression or anxiety at this time; -Objective: engaged with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's MAR, dated 9/1/24 through 9/30/24, showed; -Behaviors: -Verbally aggressive with staff: occurred eight times on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and four times on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Disrespectful to staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Cursing staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Educated on reasons not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24); -Encouraged not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24). Review of the resident's medical record, from 9/4/24 through 9/30/24, showed: -No documentation the resident's physician, psychiatrist and/or psychiatric NP were notified of the resident's behaviors after they occurred; -No documentation of SSD or IDT follow-up; -The care plan showed no new interventions/tasks implemented from 9/1/24 through 9/30/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others: behavior not exhibited; -Mobility Device: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: Supervision or touching assistance, independent. Review of the facility Resident Council meeting minutes, dated 9/20/24 at 10:00 A.M., showed: -Staff members present AD and AA F; -14 residents attended, including: Resident #3, Resident #2, Resident #4, and Resident #14; -Discussed: Activities spoke to Resident #3. He/She promised to stop bothering and cursing out staff and residents; -Resident Council Follow-Up completed by the former DON and signed on 9/24/24: Spoke to Resident #3 and he/she agreed to do better. Staff will keep watch. Review of the resident's behavior tracking located on the MAR, dated 10/1/24 through 10/31/24, showed; -Behaviors: -Verbally aggressive with staff: occurred 16 times on the day shift (10/8, 10/9, 10/10, 10/12, 10/13, 10/15, 10/16, 10/17, 10/22, 10/23, 10/24 and 10/26/24), and three times on the evening shift (10/23, 10/24 and 10/27/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff for all day and evening shift documented behaviors; -No behaviors identified on the evening shift on 10/22/24. Review of the resident's progress notes, from 10/1/24 through 10/31/24, showed: -On 10/22/24 at 7:48 P.M.: the resident noted yelling and cursing in the hallway walking from the front door, stating that they gone have to call the MF police because imma bust that MF down if they don't let me out this MF. They can't hold me no MF in here. They are treating us like we in jail and I've done my time. The resident educated on smoking times and policy. The resident acknowledged teaching, but stated he/she can sign out to smoke. The resident made aware that smoking on the front was prohibited. The resident stated we can't hold him/her hostage and stated his/her sister would be here to pick him/her up. The resident educated on signing out of the facility upon leaving. This nurse also spoke with the resident asking him/her to calm down and stop yelling and using profanity in such an aggressive tone in the hallway around all the other residents. The resident walked away and continued cursing, yelling and using profanity; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP; -10/22/24 at 8:27 P.M.: police called related to resident's behaviors. Police arrived and the resident appeared to be calm at this time. The resident continued to have other residents to come to his/her room and after one of the residents asked to leave, Resident #3 followed the other resident to that resident's room after being told it was after hours and resident's roommate are in bed and resting now and visiting was not allowed at this time. The resident stated, MOVE ME. Police called at this time, and arrived and resident calm stating I'm ok, y'all just want me to go off, and he/she walked away. Police stated the resident needs to be sent to the hospital for mental health behaviors and if needed call them back to assist with removing the resident from the facility. Physician called and new orders received to send resident out for behaviors and to follow up with psych immediately; -10/22/24 at 8:38 P.M.: the resident refusing to go to the hospital. Sitting up front at this time stating his/her sister in on his/her way; -No documentation the resident's physician was notified the resident refused to go to the hospital for his/her behaviors. No documentation the facility notified the physician the resident refused to go to the hospital as ordered; -10/23/24 at 5:39 P.M.: showed the resident continued to yell out in dining room cursing at staff and using profanity loud and in an intimidating tone to staff. Resident unhappy with meal and states They are feeding me like an animal so I'm going to act like an animal. Resident redirected on using inappropriate language in common areas and around all other residents. This nurse explained to resident this is disrespectful and unacceptable behavior. The resident continued to walk off yelling and using profanity; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP; -10/24/24 at 3:00 P.M.: the resident continued to yell, curse and be intimidating to staff and other residents. The resident educated on bullying and reminded that this is inappropriate behavior. The resident redirected and went on down the hall mumbling; -No documentation the resident's physician or psychiatrist/psychiatrist NP was notified; -Review of the resident's progress notes showed no SSD or IDT follow up regarding the resident's 10/22, 10/23, and 10/24/24. -No documentation regarding the resident's behaviors, except on 10/22, 10/23, and 10/24/24. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 10/19/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. Appears to be very particular, also has a big voice, tall. Asked him/her to not be as intimidating which he/she says he/she is just being him/her; -Objective: met with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's psychiatric NP notes, dated 10/1/24 through 10/31/24, showed: -10/22/24, late evening: Resident having disruptive behavior. Just recently saw the resident and will see on next visit. The resident repeatedly refuses to add additional medications. The resident constantly demanding and disruptive. Is supposed to be going to hospital; -10/23/24, evening: Another call, the resident was cussing and being disruptive. The resident refused to go to the hospital the night before. This time it was in the dining room. The resident was cussing at staff and yelling about food he/she doesn't like. Cussed and was loud walking back to room. Resident is very antisocial - hard to redirect. Will see at next visit, but the resident continually denies anything he/she has done and refuses medication changes; -10/24/24, afternoon: Disruptive and inappropriate to staff. Refuses to speak calmly. Will see at next visit, but resident refuses any wrongdoing to me. Further review of the resident's care plan showed no new interventions/tasks regarding the resident's behaviors implemented from 10/1/24 through 10/31/24. Review of the resident's behavior tracking located on the MAR, dated 11/1/24 through 11/30/24, showed; -Behaviors: Verbally aggressive with staff: occurred three times on the day shift (11/5, 11/7, and 11/9/24); -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff. Review of the resident's medical record from 11/5 through 11/9/24, showed: -No documentation the resident's physician, psychiatrist, and/or psychiatric NP were notified on 11/5, 11/7, or 11/9/24; -No documentation the SSD or IDT followed up regarding the resident's behavior on 11/5, 11/7, or 11/9/24; -The care plan showed the resident was put on a behavior contract on 11/18/24, for being aggressive with a peer. Review of the resident's psychiatric notes, completed by the NP, dated 11/16/24, showed: -Medications: duloxetine HCI 30 mg daily; -Subjective: seen for regular follow-up. Still talking about moving but says no one has found him/her a place. He/She had not been very proactive however in working with the facility, and places they have worked hard to find for him/her, he/she has declined. Denies symptoms of depression or anxiety. Again, tried to discuss medications for his/her mood, but he/she says that he/she did not feel the need, and says he/she was fine. It's everyone else that was messing with him/her. He/She had a large stature with a deep intimidating tone. Again, reminded him/her to try and be mindful towards others. He/She continued to say he/she isn't doing anything wrong; -Plan: will follow monthly. Discussed signs of depression, anxiety, changes in cognition, when to notify staff of symptoms. Discussed symptom management. Practice stress management. Review of the resident's progress notes showed: -11/16/24 (Saturday) at 8:32 A.M., completed by the Administrator, nurse responded to room after hearing the resident arguing with his/her roommate (Resident #4). Staff immediately separated both residents. The resident's roommate said that Resident #3 pushed his/her chest. Resident #3 denies this. Staff witnessed only arguing, no physical contact. Skin assessment completed. No marks, redness, swelling, or bruising noted. Physician made aware. New order to consult with psychiatrist and send Resident #3 out for psychiatric evaluation. Ambulance and police called to send resident out to psychiatrist evaluation; -11/16/24 at 2:46 P.M.: resident returned from hospital by ambulance. Resident very irate and cursing in the halls. This nurse asked resident to calm down and resident began to curse more. Resident is currently outside in the courtyard threatening to leave against medical advice. Oncoming nurse made aware. Will continue to monitor behavior. Review of the hospital after visit summary from the hospital, dated 11/16/24, showed no new orders. Review of the MAR, showed no documentation of behavior by staff on the day shift of 11/16/24. Review of the resident's progress note's showed: -11/18/24 at 6:48 P.M., documented by the SSD: SSD spoke with resident to see how he/she was feeling since Saturday. He/She stated he/she feels a lot better. He/She was watching TV with his/her friend and seems happy; -11/19/24 at 4:30 P.M., documented by the SSD: SSD spoke with the resident today. He/She was in a pleasant mood. He/She said he/she likes his/her new room and likes that he/she has more space. He/She was feeling much calmer since the incident with the other resident. Review of a Behavior Contract, dated 11/18/24, showed: -Behavior: the resident had a verbal altercation with his/her roommate; -Goals: Resident had agreed to come and speak to staff when there was a concern with another resident and refrain from raising his/her voice to residents and staff; -Date To Be Achieved: 2/18/25; -Resident refused to sign the Behavior Contract; -SSD signed the Behavior Contract 11/18/24. Review of the resident's care plan showed on 11/18/24 the resident was put on a behavior contract for being aggressive with a peer. Review of the facility Resident Council meeting minutes, dated 12/19/24 at 1:30 P.M., showed: -Staff members present: AD and AA F; -26 residents attended, including: Resident #2, Resident #4, Resident #7, and Resident #14; -Other Concerns: Residents are complaining about the Resident #3 bullying, cursing all the time, taking their cigarettes and nothing is being done; -No facility response to the Resident Council concerns. Review of the resident's behavior tracking located on the MAR, dated 12/1/24 through 12/31/24, showed no behaviors documented. Review of the resident's psychiatric notes, completed by the NP, dated 12/6/24, showed: -Medications: duloxetine HCI 30 mg daily; -Subjective: he/she denies any actions that are intimidating and always says other people just be messing with him/her; -Discussed medication, as he/she had wanted over the summer, but says he/she was doing fine and just wants to move. The resident was however not helping with this, and he/she was completely able to find placement on his/her own. Appears to want everyone else to do these things, and complains when things aren't done his/her way; -Resident was always calm, polite, pleasant to me, but it always seems like he/she was just telling me what I w[TRUN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a behavioral management program for one resident (Resident #3) who frequently yelled, cursed and threatened both residents and staff members. Staff failed to develop and/or implement a care strategy that focused on behavior prevention through on-going Social Service counseling sessions when other options failed. After a behavior occurred, staff failed to closely monitor the resident to ensure the safety of other residents, failed to consistently report behaviors to the physician, and/or psychiatrist/psychiatric Nurse Practitioner (NP) as per policy. The facility failed to ensure Social Services and/or the interdisciplinary team (IDT) consistently followed up on the resident's behaviors in a timely manner. The resident's behaviors triggered one resident's PTSD (post-traumatic stress disorder, a mental health condition that can develop after experiencing or witnessing a traumatic event) and resulted in other residents feeling bullied and intimidated. Residents refused to go to activities or eat in the dining room to avoid being around the resident. The census was 120. The Administrator was notified on 3/3/25 at 11:53 A.M., of an immediate jeopardy (IJ) which began on 1/29/25. The IJ was removed on 1/30/25 as confirmed by surveyor on-site verification. Review of the facility's Behavior-Management policy, undated, showed: -Purpose: -To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the resident's quality of life; -To ensure that Facility Staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and service that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care; -Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are: -a) Identifying residents whose behaviors may pose a risk to self and others; -b) Developing individual and practical care strategies based on assessed needs; -c) Implementing the behavior management program; -d) Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs; -The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program; -It is important to understand that behavior management is not behavior modification. Behavior management means the IDT seeks to accommodate the resident with behavioral problems as much as is practical in the facility; -When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.) Licensed Nursing Staff will assess the behavioral symptoms to determine possible causal factors, contact the Attending Physician, and implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s); -The facility must provide necessary behavioral health care and services which include: -a) Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; -b) Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being; -c) Providing meaningful activities which promote engagement and positive meaningful relationship between residents and staff, families, other residents and the community. Meaningful activities are those that address the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being; -d) Providing an environment and the atmosphere that is conducive to mental and psychosocial well-being; -Procedure: -I. Assess Causal Factors: A. When a resident exhibits adverse behavioral symptoms (e.g., crying, yelling, hitting, biting etc.), Licensed Nursing Staff will document the behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible casual factors and interventions attempted; B. Upon observing the adverse behavioral symptom, staff will do the following as indicated: i. Ensure the safety of the resident as well as all other residents; ii. Document notification of the Attending Physician; iii. Document notification of the resident's family and/or responsible party about the change in behaviors and the Attending Physician's response; iv. Document the incident on the 24-hour report; C. The Charge Nurse will assign a staff members(s) to monitor/shadow the resident as needed; i. Such monitoring is for the protection of the resident as well as all others, and is not meant to restrict their movement or mobility; D. Nursing Staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated: i. Date and time of behavior; ii. Location of resident when the behavior occurred; iii. Description of the behavior (e.g., what the resident said or did and if the behavior intensified); iv. Non-verbal cues (e.g., darting eyes may indicate anxiety or fear, crossed arms may signal withdrawal or fear, and tears may indicate sadness, frustration or fear); v. What seemed to cause the behavior; vi. Any interventions used and their effect; E. In assessing the resident for potential causal factors, Licensed Nursing Staff will consider the following factors and document their findings in the medical record; i. Physical conditions (e.g., pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence); ii. Environmental condition (e.g., inappropriate room temperature, noise, overcrowding); iii. Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition, financial concerns); iv. Medical conditions that require treatment; v. Mental health conditions, which may contribute to resident's behavior; F. It is also important for the facility to use an IDT approach that includes the resident, their family, or resident representative; -II. Implementation of Interventions to Alleviate Possible Causal Factors; A. Possible non-psychotherapeutic drug interventions to consider, include, but are not limited to: i. Physical comfort; ii. Environmental conditions; iii. Psychosocial stressors; iv. Medical conditions; B. In trying to manage the behavioral problem; i. Work to build a positive, trusting relationship with the resident; ii. Use effective verbal and non-verbal communication techniques; iii. Encourage independence in the resident; iv. Avoid arguing, having yes/no battles, or [NAME] with the resident; v. Redirect or divert the resident's attention to a positive topic, activity, or object; -III. Evaluation of Outcome of Non-Drug Interventions; A. In the evaluation of outcomes, Licensed Nursing Staff will do the following: i. Document observations, interventions and outcome; ii. Document the resident's progress or lack of progress on the shift/weekly nursing notes and interdisciplinary notes; iii. A Licensed Nurse will summarize the results of the medications and the behaviors on the monthly Behavioral Summary Form; B. Consider psychiatric consultation if appropriate. Review of the facility's Resident Council policy, revised on 6/2020, showed: -Purpose: To promote the exercise of a resident's right to organize and participate in resident groups at the Facility; -Policy: The facility encourages residents' involvement and input in the operation of the Facility through the Resident Council; -Responsibilities of the Resident Council: -Making recommendations for the improvement of resident services provided by the Facility; -Reviewing reports submitted to the Council and making recommendations and/or taking appropriate action; -Studying problem areas and making recommendations for their solution; -Maintaining minutes of all meetings and submitting a copy to the Administrator for review; -A Resident Council response form is utilized to track issues and their resolution; -If the Council raises an issue of concern, the Department responsible for the issue or service is responsible for addressing the item(s) of concern promptly; -The facility will respond in writing to written request or concerns of the resident council in a prompt and timely manner; -The Facility will respond to issues discussed by the Resident Council and may use Resident Council Department Response Form; -The Facility's Quality Assessment & Assurance Committee reviews the Resident Council minutes from the Resident Council as part of its quality review. Review of the facility's Resident Council Follow-Up form, showed: All complaints/concerns identified during resident council will be documented as a grievance on the grievance form. This will include a detailed description of the complaint. It will then be delegated to the appropriate department for resolution. This resolution will be documented on the grievance form as well. A designee will then meet with the resident to discuss the resolution and ensure all parties are satisfied. The completed grievance will then be forwarded to the Administrator for review and approval. These concerns will then be reviewed at the next resident council as Old Business to ensure that concerns have not persisted. Review of the Social Service Director (SSD) job description, undated, showed: -Position Description included: Responsible for identifying psychosocial, mental, and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs; -Principle Responsibilities: -Plans, organizes, implements, evaluates, and directs a comprehensive Social Services program; -Works with Social Services staff, IDT, and administration to promote and protect resident rights and the psychological well-being of all residents. Prevents and addresses resident/resident abuse; -Maintains accurate and timely documentation; -Participates in the development of a written, interdisciplinary plan of care for each resident that identifies the psychosocial needs/issues of the resident, the goals to be accomplished for those needs/issues, and the appropriate social worker interventions; -Works with the IDT and administration to promote and protect resident rights and the psychological well-being of each resident. Prevent and address resident abuse; -Document progress in meeting the psychosocial needs of residents; -Educate nursing personnel regarding the role of the social worker in the facility and the psychosocial needs of the residents; -Provide clinical interventions to address catastrophic events that occur during a resident's stay in the facility. Review of Resident #3's admission face sheet showed: -admission date of 6/6/24; -The resident was listed as his/her own responsible party. Review of the resident's progress notes, located in the electronic health record (EHR), dated 6/6/24 at 12:52 P.M., showed the resident arrived at 12:00 noon, alert and oriented x 4 (person, place, time and situation). Got off ambulance stretcher and walked to room with a steady gait. Review of the Guidelines for Resident Behavior, signed by the resident and co-signed by the SSD on 6/6/24, showed: -Any resident may exhibit problem behaviors, but the intent of the Guidelines is to address the volitional (done intentionally, not by accident) of those individuals who have the capacity to understand the consequences of their behaviors; -Resident Compliance: admission to a facility is based on a resident's need for care. A resident's compliance with his/her plan of care and cooperation with staff during the stay in the facility is encouraged; -General Conduct: residents are expected to treat staff, other residents with respect, dignity and privacy. Conduct must be consistent with accepted community standards, local, federal and state laws. Unacceptable conduct includes but is not limited to: physical abuse, verbal abuse. This conduct is not permitted on or about the facility; -Non-Compliance: if we determine that residents' behavior is contrary to these rules and is compromising their health care or that of other residents, these residents will be subject to administrative actions. Failure to comply with these rules may result in the initiation of the following administrative actions: A. The initiation of a Behavioral Management Plan between the resident and the facility. A Behavioral Management Plan should be developed under the guidance of trained professionals; B. Referral to local law enforcement agency; C. Discharge from the facility when the violations meet the thresholds of state and federal regulations (for example, if the violations are a danger to the resident or others). Review of the resident's care plan, located in the EHR, showed: -Problem, 6/6/24: Resident has a mood problem, depression. Goal: Resident will not experience any increase in signs and symptoms of mood disturbance. Interventions/Tasks: Administer medications as ordered. Behavioral health consult as needed. Communicate with resident regarding mood state and treatment. Encourage resident to express feelings. Encourage resident to participate in activities of choice. Encourage to maintain as much independence and control/decision making as possible. Notify medical provider of increased episodes of mood disturbance; -Problem, 6/13/24: Resident has a behavior problem. Resident was noted to speak rudely to roommate, eating off other residents' plates, verbally aggressive with staff, disrespectful to staff; -Goal: resident will have fewer episodes of behaviors through review date. Interventions/Tasks (6/13/24); -Approach, speak in calm manner. Behavioral health consults as needed. Communicate with resident regarding behaviors and treatment. Consult with Pastoral care, Psych services, and/or support groups. Minimize potential for behaviors by offering tasks that divert attention. Monitor behavioral episodes and attempt to determine underlying causes. Intervene as necessary to protect the rights and safety of others. Encourage not to curse or speak disrespectfully and/or aggressive to staff. Notify medical provider of increased episodes of behaviors. 6/14/24: Encouraged to speak to roommate respectfully and encouraged not to eat off of other resident's plates. Review of the resident's record showed there was no behavior management program or ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs documented. Review of the resident's progress note, dated 6/12/24 at 2:26 P.M., showed the resident's physician saw the resident at the facility. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/13/24, showed: -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: ability to express ideas and wants: understood; -Ability To Understand Others: understood; -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others): behavior not exhibited; -Mobility Devices: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: supervision or touching assistance, helper provides verbal cues or touching/steadying assistance as resident completes activity; -Diagnoses of high blood pressure, diabetes mellitus (high blood sugar) and depression. Review of the resident's medication administration record (MAR, a form where nurse documents medication administration and behavioral episodes) dated 6/6/24 through 6/30/24, located in the EHR, showed: -6/6/24: Duloxetine HCI (antidepressant) 30 milligrams (mg) daily; -Behaviors: Verbally aggressive with staff: occurred 1 time on the evening shift (6/13/24); -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the evening shift (6/13/24); Review of the resident's progress notes, dated 6/13/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behavior on the evening shift of 6/13/24. Review of the resident's progress note, on 6/14/24 at 12:07 P.M., showed the SSD wrote the resident said he/she was here short term and was just waiting on his/her apartment to be approved. Resident rights were reviewed including the facility guidelines for behavior, drugs, and smoking. Review of the resident's MAR, dated 7/1/24 through 7/31/24, showed no behaviors documented. Review of the resident's progress note, dated 7/3/24 at 6:59 P.M., showed: -Resident had verbal disagreement with another resident, nursing staff present at the time, no contact made. Resident separated from the other resident. Resident was calm sitting outside in the smoking area listening to music; -No SSD or IDT follow-up documented. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 7/10/24, showed: -Diagnoses: post-traumatic stress disorder (a mental health disorder that can develop after witnessing a traumatic event), nicotine dependence, cocaine use (in remission), other specific personality disorders, and persistent mood disorder; -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up, says he/she was still trying to make the best of his/her situation. Decides he/she does not want medication to help him/her stop flipping out. Discussed trying to stay calm and walking away from conflict, which I am not sure he/she was completely on board with. Denies symptoms of depression or anxiety. Just mood swings he/she says; -Objective: resident was engaged with examiner in a cooperative and polite manner. Mobility was within normal limits. Stream of mental activity was logical, relevant, coherent, and goal directed; -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's progress notes showed: -7/11/24 at 6:22 A.M.: the resident had a verbal altercation with roommate. Resident was loud, disturbing, and using profane language. The resident slammed the door behind roommate; -7/11/24 at 10:29 A.M., IDT note (Administrator, former Director of Nursing (DON), SSD and Nursing Manager): verbal disagreement with roommate. The resident called roommate a racial slur. Roommate did not like this and told the resident so. The resident became upset when staff intervened. The resident left the room shutting the door loudly. The resident educated to be considerate of others feelings and preferences. The resident verbalized understanding; -7/11/24 at 3:04 P.M., completed by the SSD: spoke with the resident about his/her disagreement with roommate this morning. He/She said he/she closed the door but did not mean to slam it. Explained to him/her if he/she has a problem with his/her roommate just come and speak to them. Also spoke about changing rooms. He/She said he/she was happy with that; -7/13/24 at 11:17 A.M., documented by the Administrator: met with resident for psychosocial follow-up. Said he/she likes his/her new room and new roommates. Reinforced with resident that he/she must remain respectful with facility staff. Said he/she understands and was working on it. He/She feels that due to his/her size, he/she may come across as more upset than he/she actually was. Reeducated that he/she can bring any concerns to facility management, social service, this author, and will communicate any future needs of concerns to the appropriate parties; -No documentation the facility notified the resident's physician, psychiatrist, and/or psychiatric NP. Review of a Behavior Contract, dated 7/16/24, showed: -Behavior: resident has had several verbal outbursts with staff; -Goal (must be measurable): resident will learn to stop with the verbal outburst and speak in a calm manner. If this behavior continues, resident can be at risk for discharge from facility; -Date To Be Achieved: 10/16/24; -SSD signed the Behavior Contract on 7/16/24; -Resident refused to sign the contract. Review of the resident's progress note dated 7/16/24 at 2:06 P.M., and completed by the SSD, showed a care plan meeting was held with the resident to discuss verbal outbursts toward staff and other residents, and explain this is not a good fit for him/her. He/She continues to ask facility to give him/her another chance and he/she continues the same behavior. SSD has been asked to start looking for another facility. He/She gave SSD a few facilities to send his/her referral to. Review of the resident's care plan showed: -On 7/11/24, Observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs. Encourage to maintain as much independence and control/decision making as possible. Praise and indication of progress in behaviors; -On 7/29/24, Encourage to take all medications and notify physician of all refusals. Review of the resident's MAR, dated 8/1/24 through 8/31/24, showed: -Behaviors: Verbally aggressive with staff occurred 5 times on the day shift (8/3, 8/4, 8/7, 8/14, and 8/27), and cursing staff occurred 1 time on the evening shift of 8/23; -Interventions: Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (8/3, 8/4, 8/7, 8/24, and 8/27), and educated on reasons not to curse at staff on the evening sift of 8/23. Review of the resident's progress notes, dated 8/1/24 - 8/31/24, showed no documentation the facility notified the resident's physician, psychiatrist, and/or the psychiatric NP about the resident's behaviors on 8/3, 8/4, 8/7, 8/14, 8/23, or 8/27/24. Review of the resident's progress note, dated 8/7/24 at 12:00 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the resident's progress note, dated 8/10/24 at 1:20 P.M., completed by the SSD, showed the resident was informed during care plan meeting that was held that the facility was still trying to find him/her another facility, however no one has accepted him/her as of yet. They are still sending referrals out and once a facility had accepted him/her he/she will be informed. Review of the resident's progress note, dated 8/14/24 at 4:03 P.M., showed the resident's physician saw him/her at the facility. No documentation staff updated the physician about the resident's behaviors. Review of the facility Resident Council meeting minutes, dated 8/15/24 at 2:00 P.M., showed: -Staff members present: the former DON, Activity Director (AD) and Activity Aide (AA) F; -18 residents attended, including: Resident #3, Resident #2, and Resident #14; -New Business: discussed Resident #3 was a bully. Always arguing with staff and peers; -There was no facility response to the Resident Council concerns regarding Resident #3's behaviors. Review of the resident's psychiatric note, completed by the psychiatric NP, dated 8/27/24, showed: -Medications: duloxetine HCI 30 MG daily; -Subjective: seen for regular follow-up. He/She was still trying to make the best of his/her situation. Decides he/she does not want any further medication to help him/her from stop flipping out. Denies any symptoms of depression or anxiety at this time; -Objective: engaged with examiner in a cooperative and polite manner. No unusual mannerisms or gestures. Mobility is within normal limits, uses walker at times. The resident was alert and oriented x 3 (person, place, time); -Plan: will follow monthly. Discussed symptoms management. Discussed signs of depression, anxiety, changes in cognition and when to notify staff of symptoms. Review of the resident's MAR, dated 9/1/24 through 9/30/24, showed; -Behaviors: -Verbally aggressive with staff: occurred eight times on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and four times on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Disrespectful to staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Cursing staff: occurred one time on the day shift (9/30/24), and one time on the evening shift (9/30/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff on the day shift (9/4, 9/5, 9/24, 9/25, 9/26, 9/28, 9/29 and 9/30/24), and on the evening shift (9/4, 9/5, 9/20 and 9/30/24); -Educated on reasons not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24); -Encouraged not to curse at staff on the day shift (9/30/24) and evening shift (9/30/24). Review of the resident's medical record, from 9/4/24 through 9/30/24, showed: -No documentation the resident's physician, psychiatrist and/or psychiatric NP were notified of the resident's behaviors after they occurred; -No documentation of SSD or IDT follow-up; -The care plan showed no new interventions/tasks implemented from 9/1/24 through 9/30/24. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Behavioral Symptoms: Verbal behavioral symptoms directed towards others: behavior not exhibited; -Mobility Device: walker; -Walk 150 feet (ft): once standing the ability to walk at least 150 ft in a corridor or similar space: Supervision or touching assistance, independent. Review of the facility Resident Council meeting minutes, dated 9/20/24 at 10:00 A.M., showed: -Staff members present AD and AA F; -14 residents attended, including: Resident #3, Resident #2, Resident #4, and Resident #14; -Discussed: Activities spoke to Resident #3. He/She promised to stop bothering and cursing out staff and residents; -Resident Council Follow-Up completed by the former DON and signed on 9/24/24: Spoke to Resident #3 and he/she agreed to do better. Staff will keep watch. Review of the resident's behavior tracking located on the MAR, dated 10/1/24 through 10/31/24, showed; -Behaviors: -Verbally aggressive with staff: occurred 16 times on the day shift (10/8, 10/9, 10/10, 10/12, 10/13, 10/15, 10/16, 10/17, 10/22, 10/23, 10/24 and 10/26/24), and three times on the evening shift (10/23, 10/24 and 10/27/24); -Interventions: -Encouraged not to speak disrespectfully and/or aggressive to staff for all day and evening shift documented behaviors; -No behaviors identified on the evening shift on 10/22/24. Review of the resident's progress notes, from 10/1/24 through 10/31/24, showed: -On 10/22/24 at 7:48 P.M.: the resident noted yelling and cursing in the hallway walking from the front door, stating that they gone have to call the MF police because imma bust that MF down if they don't let me out this MF. They can't hold me no MF in here. They are treating us like we in jail and I've done my time. The resident educated on smoking times and policy. The resident acknowledged teaching, but stated he/she can sign out to smoke. The resident made aware that smoking on the front was prohibited. The resident stated we can't hold him/her hostage and stated his/her sister would be here to pick him/her up. The resident educated on signing out of the facility upon leaving. This nurse also s

Based on observation, interview and record review, facility staff failed to follow the resident's diet orders for a resident on a puree diet. The resident had an order for a dysphagia puree diet and required supervision with eating. The activity assistant brought a whole donut into the resident's room, left the donut and did not verify the resident's diet order or ensure the resident had supervision while eating. This resulted in a choking incident for this resident (Resident #76). The census was 105. The administrator was notified on 1/27/22 at 3:15 P.M. of an Immediate Jeopardy (IJ), which began on 1/27/22. The IJ was removed on 1/28/22, as confirmed by surveyor onsite verification. During an interview on 1/28/22 at 10:32 A.M., the Dietary Manager said food provided by staff outside the dietary department, even if not on the written menu, is considered an alternate menu item. Activity staff provide their own snacks not obtained from the facility kitchen. These are alternates. Residents should always be provided food that is the proper texture and consistency. Review of the facility's diet Consistency Census Report, dated 1/27/22, showed four residents listed as receiving a dysphagia puree diet, to include Resident #76. Review of the facility's Activity Leader Position Description, dated June 2019, showed: -The position of activities leader provides individualized activity care and services for residents. This position functions as both a team member within the activities department and an interdisciplinary team member for an assigned unit(s) fostering team success. While focusing on delivery of quality care, the position must also manage assigned resources; -Job duties and responsibilities: -Leads a variety of activities: One on one and group activities on/off assigned unit(s), outside and/or in the community for a diversified population as assigned; -Provides supplies and equipment for residents to participate in individual activities as assigned; -Communicates and coordinates all plans for assigned actives with activity coordinator/activity director and other departments (schedules, food, room arrangements, escort assistance and transportation); -May assist residents with activities of daily living needs, i.e., transfer, toileting, feeding, etc.; -Qualification knowledge/skills and abilities: Must have the ability to make independent decision when circumstance warrant such action. Review of Resident #76's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/12/21, showed: -Cognitively intact; -Extensive assistance required for bed mobility, transfers, dressing and personal hygiene; -Total dependence on staff for locomotion on and off the unit and toilet use; -Supervision-oversight, encouragement or cuing required for eating; -Primary medical condition category stroke; -Diagnoses included diabetes and hemiplegia/hemiparesis (paralysis on one side of the body). Review of the resident's care plan, in use at the time of the survey, showed: -Focus initiated 12/5/20: Risk for stroke complications: -Goal: Will remain free of secondary complications; -Interventions: Monitor for signs/symptoms of aspiration. Monitor for signs/symptoms of dysphagia (difficulty swallowing); -Focus initiated 12/10/20: Resident has nutritional problems related to stroke, heart disease, dysphagia, chronic kidney disease, vitamin D deficiency, acute kidney failure and high cholesterol: -Goal: Resident will maintain adequate nutritional status; -Interventions: Monitor meal intake, offer substitutions if provided meal is declined, position resident properly for eating/swallowing; Provide meals per diet order, regular dysphagia puree, thin liquids diet; -Focus initiated 12/18/20: The resident has impaired cognitive function: -Goal: Be able to communicate basic needs on a daily basis. Will maintain current level of cognitive function; -Interventions: Observe/document/report to medical provider any change in cognitive function, specifically change in decision making ability, memory, recall or general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status; Provide a program of activities that accommodates abilities; -Focus initiated 2/20/21: Activities of daily living (ADL) self-care performance deficit, requires assistance with ADL, cognitive deficit, functional deficit. The resident is alert and able to communicate with staff: -Goal: Will maintain current level of function; -Interventions: Observe and anticipate resident's needs: Thirst, food, body positioning, pain and toileting needs. Requires physical assistance for oral intake. Has left side hemiplegia. Requires dysphagia puree diet; -Focus initiated 2/20/21: At risk for impaired communication related to stroke: -Goal: Resident is able to understand and verbalize basic communication with staff; -Interventions: Anticipate and meet needs. Observe for declines in communication. Observe/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed; -Focus initiated 5/13/21: The resident is dependent on nursing staff for activity engagement. Has forgetful and limited mobility: -Goal: Will show engagement in activity engagement. Forgetful and limited mobility; -Interventions: Assist with transport to activities as needed. Encourage attendance to entertainment programs, large and small groups, activities, volunteer demonstration and religious activities. Review of the resident's medical diagnoses list, showed diagnoses included stroke, heart disease, dysphagia and dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal) following stroke. Review of the resident's electronic physician order sheet (ePOS), for January 2022, showed: -An order dated 1/18/21, for regular diet, dysphagia puree texture. Thin consistency, super cereal (high calorie porridge) at breakfast for diet type; -An order dated 2/9/21, may allow moist mechanical soft solids as requested with CLOSE one on one supervisor, due to fast rate of intake; -An order dated 11/3/21, continue skilled speech therapy three times a day for four weeks to treat cognitive-linguistic deficits following recent change in status; -An order dated 11/26/21, discontinue skilled speech therapy due to plateau in progress. Review of the resident's speech therapy evaluation and plan of treatment, dated 7/14/21, showed: -Diagnoses: Stroke, dysphagia and cognitive communication deficit; -Short term goals: Resident will increase ability to safely swallow mechanical soft/chopped texture to within functional limits 10% verbal cues, 0% verbal cues and 0% tactile cues for implementation of compensatory strategies in order to safely consume least restrictive diet; -Long-term goal: Resident will improve swallow abilities to distant supervision as evidenced by ability to safely and efficiently swallow less restrictive diet with minimal signs and symptoms of oral dysphagia, coughing and/or wet vocal qualities post swallows in order to safely consume least restrictive diet; -Treatment approach may include: Treatment of swallowing dysfunction and/or oral function for feeding; evaluation of oral and pharyngeal (the part of the throat behind the mouth) swallow function; -Resident's goal: To eat better; -Current referral: Reason for referral: Resident referred to speech therapy due to exacerbation of decreased oral/pharyngeal function and cognitive impairment indicating the need for speech therapy to assess/evaluate least restrictive oral intake, enhance cognitive skills; -Intake/diet level: Puree consistencies, thin liquids, successive swallows; -Clinical bedside assessment of swallowing: Diet texture analysis: Soft diet-chopped = moderate; clinical signs and symptoms of dysphagia; anterior (front) spillage, biting cheek, excessive mastication (chewing) time, residue on palate (oral cavity) and/or tongue with clearance attempts and poor attention to task; -Behaviors impacting safety: Reduced attention to task, decreased safety awareness and poor self-monitoring skills; -Recommendations: Diet: puree consistency; liquids: thin liquids; supervision: distant supervision. Review of the resident's speech therapy notes, showed: -Date of service 7/15/21: Resident seen in room sitting upright in the wheelchair. Speech therapy presented trial tray of mechanical soft solids for lunch meal. Noted several impulsive rates of intake during meal and large bite sizes, requiring continuous verbal prompts for safe oral intake. The resident reported meat item chopped was too tough and attempted to expel food from the oral cavity following verbal request from speech therapy but was unable to expel food and ended up swallowing food times, indicating decreased safety awareness and increased risk for aspiration or choking. Resident presented with coughing towards end of session and attempted to place additional bites of solids in oral cavity while coughing, indicating poor safety awareness. Speech therapy requested the resident to perform additional swallows but required maximal verbal and tactile cues to refrain from continued oral intake; -Date of service 7/21/21: Resident in room sitting upright in wheelchair. The resident presented with severe impulsivity during meal, requiring constant verbal cues for slower rate of intake, setting down utensils between bites, clearance of oral cavity following each bite and liquid washes. Resident presented with adequate mastication, bolus manipulation and clearance of solids with mechanical soft solids, but due to severe impulsivity, the resident is unsafe with soft solids; -Date of service 8/13/21: Resident seen in room with trail of mechanical soft solids during session. Resident reported meat items being too difficult to masticate and expelled meat from oral cavity. Speech therapy removed meat items from tray and continued trail with side items. The resident consumed 75% of the side items served with meal, with moderate to maximal verbal cues for smaller bites/sips and slower rate of intake. Noted attempts to place additional bites of solids before clearance of previous bites, requiring verbal cues for clearance of each bite and use of liquids washes consistently. No noted signs or symptoms of airway penetration during meal but noted continued concerns for safety due to severe impulsive behaviors during intake without supervision. Noted poor carryover supervision from staff consistently, requiring continued diet downgrade due to need for maximal supervision with upgraded diets for safe oral intake. Staff reported not enough staff to monitor resident during all meals at this time; -Date of service 11/26/21: Resident seen in room sitting upright in wheelchair. Speech therapy updated resident on discharge plan and recommended for the resident to participate in activities in the facility following discharge of services for increased stimulation and continued use of visual aides and environmental aides for orientation and recall abilities. The resident verbalized agreement with recommendations. Speech therapy presented assessments to determine the resident's current cognitive status. The resident repeatedly reported having trouble focusing throughout assessment, likely impacting the resident's performance during assessment. The resident completed the brief interview for mental status and scored 11 out of 15, indicating moderate cognitive deficits. The resident also completed the St. Louis University Mental Status Examination and scored 14 out of 30, indicating severe cognitive deficits. The resident presented with difficulty processing information, as evidenced by need for self-talk and repetition of instructions. Review of the resident's Dietary Nutritional Assessment, dated 12/8/21, showed: -Diet: Dysphagia puree, thin liquids; -Swallowing disorders: No; -Dining skills: Limited assistance; -Potential for altered nutrition related to dysphagia as evidenced by need for mechanically altered diet. Observation on 1/27/22 at 10: 45 A.M., showed Activity Assistant DD propelled a cart down the hall and offered donuts to residents. At 10:53 A.M., a wet and gargled cough was audible in the hall. Observation down the hall, showed the resident sat in his/her room, up in a wheelchair and faced the door. There were no staff in the room at this time or in view of the resident. The bedside table was at his/her side. The resident coughed, held his/her neck, and appeared to choke. A donut and a cup of beverage sat on the bedside table, in reach of the resident. Certified Nursing Assistant (CNA) F immediately came down the hall and entered the resident's room, leaned the resident forward and patted his/her back as he/she told the resident, you're not supposed to have that. The resident was conscious and able to verbalize some, but with garbled speech. The resident swallowed the food item in his/her mouth and stopped coughing. At this time Registered Nurse (RN) I entered the room and asked the resident if he/she was ok and to open his/her mouth, then left the room. CNA F disposed of the donut and left the resident's room. During an interview on 1/27/22 at 10:56 A.M., the resident said that he/she just swallowed a big chunk of donut, but was ok. At 11:39 A.M., the resident remained up in a wheelchair in the room and was unable to say what type of diet he/she is on, but said they crush my pills. Review of the resident's progress notes, showed: -On 1/27/22 at 1:45 P.M., writer heard someone coughing and what sounded like choking. Writer walked into the resident's room and saw the CNA patting his/her back trying to get him/her to cough up the donut he/she had eaten. Resident eventually swallowed the donut. He/she remained conscience and was able to talk the entire time. Upon assessment, lungs are clear and oxygen levels within normal limits. No signs of distress noted; -Follow up note: At 2:36 P.M., physician called and made aware of event, new orders for speech therapy evaluation and treat, and STAT (immediate) chest x-ray two view. Resident's family called and message left. Awaiting call back; -On 1/27/22 at 6:32 P.M., family return call, made aware of event, no concern noted. Physician called and made aware of results of chest x-ray. No new orders noted. Review of the resident's Respiratory Data Gathering Tool, dated 1/27/21 at 2:21 P.M., showed: -Reason for review: Choking event; -Observed breathing pattern, normal; -Breath sounds, clear; -Description of cough, dry. Review of the resident's ePOS, showed: -An order dated 1/27/22, clarification order: Skilled speech therapy three times a week for four weeks for dysphagia; advance diet through modifications, instruct in use of strategies for safety with deglutition (the action or process of swallowing). Resident to remain on pureed diet/thin liquids; -An order dated 1/27/22, for chest x-ray, anteroposterior (AP, front to back view) and lateral (view from the side), STAT. Review of the resident's radiology results report, dated 1/27/22, showed: -Procedure: Chest, 2 views; -Date of service: 1/27/22; -Clinical information: Choked at lunch, shortness of break, lethargic (sluggish); -Results: The lungs are clear. During an interview on 1/27/22 at 11:46 A.M., the activity director said there are only two activity staff. Activity Assistant DD is the only one at the facility today. During an interview on 1/27/22 at 12:09 P.M., CNA F said the resident is on a puree diet. During an interview on 1/27/22 at 12:14 P.M., Activity Assistant DD said he/she had only been employed since December 2021. He/she provides activities, such as passing food three to four times a week. He/she does not know which residents are on diet restrictions. There is a list of residents, from dietary, that activity staff use to know diets. He/she does not have one today and he/she is still getting familiar with the residents. He/she was not told today who can and cannot have a donut. He/she just asks the resident and if they say they want one, he/she will go ahead and give it if he/she is familiar with the resident, otherwise, he/she will ask staff. If a choking incident were to occur, he/she would call the nurse and ask for assistance immediately. If a resident was on a puree diet, he/she could not provide them with a donut. During an interview on 1/27/22 at 12:40 P.M., the activity director said the activity department gets a list from dietary, maybe every six weeks, to show residents with diet restrictions. The list is usually on his/her desk and accessible to the activity staff. He/she does not have a list today, but will get it and will give Activity Assistant DD the list before he/she passes popcorn today. During an interview 1/27/22 at 1:15 P.M., RN I said he/she is the nurse assigned to the resident and responded to the choking incident. He/she assessed the resident after the incident and the resident was okay and stable at this time. He/she was not aware of the resident's diet prior to the incident. He/she is an agency nurse and it is his/her first day at the facility today. He/she saw the activity staff passing donuts. The activity staff did not ask about the resident's diet restrictions. During an interview on 1/27/22 at 1:39 P.M., the Medical Director said he/she would expect staff to follow diet orders including diets with specialized textures, including a dysphagia-pureed diet. Residents who had a stroke or dementia may be put on a pureed diet. If a resident was not eating well, the facility would have speech therapy evaluate them. The Medical Director did not recall if the resident had any problems with swallowing. One of the risks of giving a resident a whole donut, who is on a pureed diet, is the resident could aspirate (when something enters the lung or airway by accident). During an interview on 1/27/22 at 1:51 P.M., the Director of Nursing (DON) said she is not sure what training activity staff receive. The resident's diet is listed in the electronic medical record. Anytime activity staff do anything with food, they should meet with the nurse manager or herself. Lists of diets are bad because they may be old. No activity staff approached her today regarding donuts, to learn the resident's diets. If activity staff are passing food and do not know a resident's diet, they should meet with the unit manage or herself. Residents on a pureed diet cannot have a donut. The risk could include choking. She was not made aware of any choking incident today and that is something she would expect staff to inform her of. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation.