Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner, when one staff member (Social Services Director (SSD)) would not allow one resident (Resident #1) to smoke after the resident displayed behaviors. The facility census was 49. Review of the facility policy titled Resident's Rights, undated, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States; -The resident has the right to be free of interference, coercion, discrimination and reprisal form the facility in exercising his/her rights, and be supported by the facility in the exercise of his/her rights. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 01/21/25; -Diagnoses included transient cerebral ischemic attack (disruption of blood flow to the brain), dementia (loss of memory), major depressive disorder, severe with psychotic symptoms (person experiences sadness and a loss of contact with reality), anxiety disorder (feelings of worry and fear), post-traumatic stress disorder (PTSD - mental health condition that can develop after experiencing or witnessing a traumatic event). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information: -Moderate cognitive impairment; -Behaviors; -Independent with eating and required set up with oral hygiene; -Substantial assistance required with toileting hygiene, showers, and upper/lower body dressing; -Dependent on staff for personal hygiene. Review of the resident's care plan, last revised on 04/01/25, showed the following: -Resident had history of verbal and physical aggression towards staff related to underlying psychiatric disorder and cognitive impairment. Staff to speak softly and avoid confrontational or punitive language, and redirect if the resident becomes physically aggressive; -Resident ad diagnosis of dementia, persistent mood (affective) disorder as evidence by persistent forgetfulness and disorientation. Have anxiety, fear and paranoia associated with memory loss; -Resident had chronic pain in back, knees, and ankles. Also muscle spasms. He/she takes narcotics; -Resident was unable to perform all activities of daily living (ADL) functions without extensive assistance of one to two staff due to weakness and impaired use of left leg, arm, and hand. Review of the resident's progress note dated 04/16/25, at 2:40 P.M., showed the SSD documented he/she and another staff took the resident to the social security office. The resident was throwing a fit in the social security office. The resident blurted out he/she had gotten two facilities closed down and was working on the current facility next. The resident would not quit with his/her yelling so staff could write down what paperwork the resident needed from the facility in order to get the resident's money to come to the facility. Workers and clients in the office could hear the resident yelling and causing an ugly scene. We were outside and the resident yelled give me my goddamn cigarette. The SSD replied the resident would not get a cigarette because he/she caused a whole scene in the building and outside the building. The resident's smoke breaks were taken away for the rest of the day. During interviews on 04/30/25, at 9:17 A.M. and 1:30 P.M., the resident said the SSD took away his/her smoke breaks. During an interview on 04/30/25, at 12:15 P.M., the SSD said the following: -If a resident had a guardian and the guardian has given permission, one smoke break can be withheld from the resident for having bad behaviors; -The resident was having behaviors at the social security office and missed his/her 11:00 A.M., cigarette, but had them the rest of the day. During an interview on 04/30/25, at 11:40 A.M., Certified Nurse's Aide (CNA) A said the following: -Staff can't take away a resident's smoke breaks if they don't have a guardians; -Taking away a resident's privileges, such as smoking, is against their rights; -The resident was his/her own person. He/she was not aware of staff taking away the resident's smoke breaks. During an interview on 04/30/25, at 11:50 A.M., CNA B said the following: -When a resident had a guardian and the guardian gave permission, the resident's smoke breaks could be taken if they have behaviors; -If the resident was their own person, staff were not allowed to take away their smoke breaks; -Taking away a resident's smoke break as a punishment would be against their rights; -He/she didn't know if the resident had smoke breaks taken away. During an interview on 04/30/25, at 12:05 P.M., Certified Medication Tech (CMT) D said the following: -Staff were not allowed to take away a resident's smoke breaks when the resident misbehaves. That would be taking away their rights; -He/she knew of one occasion when the resident's smoke break was taken away. During an interview on 04/30/25, at 12:25 P.M., Registered Nurse (RN) E said the following: -It would not be appropriate to withhold a resident's smoke break as punishment. This would be against their rights; -He/she knew they tried to withhold the resident's cigarette break at least once, but staff was told they couldn't do that. He/she didn't know the date. During an interview on 04/30/25, at 12:50 P.M., the Business Office Manager (BOM) said the following: -If a resident had a guardian, and it was okay with the guardian, a resident's smoke break could be withheld; -If a resident was their own person, like the resident, staff can not take the smoke break; -He/she was not aware of the resident missing any smoke breaks. During an interview on 04/30/25, at 12:30 P.M., the Director of Nursing (DON) said the following: -Staff didn't have the right to take away a resident's smoke break when they have behaviors. That would be against their rights; -It did happen one time with the resident, but it was a miscommunication as one side of the building didn't know the resident was his/her own person and did not have a guardian; -All staff know that only those with guardians, that give permission to withhold smoke breaks, can have those smoke breaks taken away; -Only social services, administration, or nurses can decide when a smoke break was taken; -It was not appropriate for the SSD to withhold the resident's smoke break on 04/16/25. During an interview on 05/01/25, at 10:15 A.M., the Administrator said the following: -He/she had told staff when residents are their own person, they can not withhold smoke breaks; -He/she was not aware of the resident missing any smoke breaks; -On 04/16/25, the SSD encouraged the resident to get into the vehicle as they were on a time frame and it there wasn't a scheduled smoke break. The resident did smoke when he/she arrived back to the facility. MO00253134

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report two allegations of abuse involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 49. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -The Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event involved abuse or resulted in injury. -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Physical abuse is defined as hitting, slapping, pinching, kicking, biting, etc. It also includes controlling a resident's actions through personal punishment; -Report immediately, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 01/21/25; -Diagnoses included transient cerebral ischemic attack (disruption of blood flow to the brain), dementia (loss of memory), type II diabetes, (body doesn't produce enough insulin), major depressive disorder, severe with psychotic symptoms (person experiences sadness and a loss of contact with reality), anxiety disorder (feelings of worry and fear), post-traumatic stress disorder (PTSD - mental health condition that can develop after experiencing or witnessing a traumatic event). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information: -Moderate cognitive impairment; -Behaviors; -Independent with eating with set up assistance with oral hygiene; -Substantial assistance with toileting hygiene, showers, and upper/lower body dressing; -Dependent on staff for personal hygiene. Review of the resident's care plan, last revised on 04/01/25, showed the following: -Resident had history of verbal and physical aggression towards staff related to underlying psychiatric disorder and cognitive impairment. Staff to speak softly and avoid confrontational or punitive language, redirect if becomes physically aggressive, -Resident had diagnosis of dementia, persistent mood (affective) disorder as evidence by persistent forgetfulness and disorientation. Resident had anxiety, fear, and paranoia associated with memory loss; -Resident had chronic pain in back, knees, and ankles and muscle spasms. Resident takes narcotics; -Resident was unable to perform all ADL functions without extensive assistance of one to two staff due to weakness and impaired use of left leg, arm, and hand. Review of the resident's progress note dated 03/31/25, at 11:54 A.M., showed SSD documented he/she went to the resident and sat down to list to what the resident had to say. The resident said that two staff members were abusing him/her and he/she had bruising all over his/her body. SSD replied well I have to take a look at your complaint and see bruising and SSD had the charge nurse look as well. There was no bruising found by the SSD or the charge nurse. The two staff members the resident accused had not been at work. (The SSD did not document notification of facility administration or DHSS of the allegation of abuse.) Review of DHSS records showed the facility did not report the allegations of abuse. Review of the resident's progress note dated 04/16/25, at 2:40 P.M., showed the SSD documented he/she and another staff took the resident to the social security office. The resident was throwing a fit in the social security office. The resident blurted out he/she had gotten two facilities closed down and was working on the current facility next. The resident said we abuse him/her and leave residents in the floor. (The SSD did not document notification of facility administration or DHSS of the allegation of abuse.) Review of DHSS records showed the facility did not report the allegation of abuse. During an interview on 04/30/25, at 12:15 P.M., the SSD said the following: -When staff are told a resident is being abused, they come to him/her; -He/she talked to the resident to see what's going on and what type of abuse was being alleged; -On 03/31/25, the resident came to him/her and said staff were hitting and abusing him/her and he/she had bruises on his/her body; -He/she got the charge nurse and they assessed the resident and he/she did not have bruises on him/her; -He/she went to the Administrator and let him/her know what was going on; -The charge nurse documented in the chart an assessment of the skin was completed; -The resident did not know the names of the staff that abused him/her; -He/she didn't know if the incident was reported to the state, but should be reported in either 24 or 2 hours; -On 04/16/25, he/she took the resident to the social security office. The resident yelled in the office that staff abused him/her, don't do anything for the resident, and they were starving the resident. The resident had never been abused at the facility; -The Administrator looked into the allegations, but the SSD didn't know if the allegations were reported to the state. During an interview on 04/30/25, at 11:40 A.M., Certified Nurse's Aide (CNA) A said the following: -If a resident accuses staff of abuse, and he/she was in the room and believes it's a misunderstanding, he/she would speak to the resident to explain that it wasn't abuse; -If he/she witnessed abuse, or was told by the resident they've been abused, he/she would speak to the SSD and the charge nurse; -Allegations of abuse are to be reported to the state in less than 24 hours. During interviews on 04/30/25, at 11:50 A.M., CNA B said the following: -If a resident reported abuse, he/she told the charge nurse and the nurse called the state within two hours. -The resident accused him/her of abuse. He/she didn't recall when that was, but he/she wasn't working the day the resident made the accusations; -The resident has said staff hit him/her. During an interview on 04/30/25, at 12:00 P.M., Certified Medication Technician (CMT) C said the following: -If a resident reported abuse, he/she notified the charge nurse; -He/she assumed it should be reported to the state, possibly in two hours. During an interview on 04/30/25, at 12:05 P.M., CMT D said the following: -When a resident reported abuse, he/she told the charge nurse; -The charge nurse tells the Administrator and Director of Nursing (DON) and the state is called within two hours. During an interview on 04/30/25, at 12:25 P.M., Registered Nurse (RN) E said the following: -If a resident reported abuse, he/she reported it to the DON or the Administrator. The state is notified in two hours; -They have training on abuse at most in-services; -The resident had not reported abuse to him/her. He/she heard other staff talk about the resident accusing staff of abuse that wasn't working or no longer worked at the facility; -He/she didn't know if the allegations were reported to the state. During an interview on 04/30/25, at 12:50 P.M., the Business Office Manager (BOM) said the following: -Allegations of abuse were reported to the DON and Administrator, or the supervisor; -The Administrator reported to the state in two hours. During an interview on 04/30/25, at 12:30 P.M., the DON said the following: -Abuse allegations should be reported to the charge nurse, DON, and Administrator; -The allegations of abuse are reported to the state if the abuse allegations are valid. He/she didn't know for sure what the time frames of reporting the abuse; -The resident had made allegations of abuse; -Skin assessments were completed and there was no bruising; -On 3/31/25, he/she believed the Resident accused the two evening shift people, the SSD talked to the staff, the next time they were in the building. He/she doesn't know if the SSD documented anything. It was not reported to the state; -On 4/14/25, he/she was not aware of the resident made allegations of abuse on this date. During an interview on 05/01/25, at 10:15 A.M., the Administrator said the following: -He/she did remember the one event, possibly from 03/31/25, where the SSD and a nurse interviewed the resident saying an aide put him/her to bed too hard. A skin assessment was done and they did not find anything; -He/she was not aware of allegations of abuse from 04/16/25; -When abuse is alleged, staff are to tell him/her and he/she investigates, speaks with the resident, and other residents and staff, and calls the state within two hours; -The two incidents were not reported to the state. MO00253134

Based on interview and record review, the facility staff failed to complete and document a full investigation of all allegations of abuse with steps taken to protect residents during the investigation documented when staff failed to fully investigate two allegations of abuse made by one resident (Resident) alleging abuse by staff. The facility census was 49. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Physical abuse is defined as hitting, slapping, pinching, kicking, biting, etc. It also includes controlling a resident's actions through personal punishment; -During an investigation, if a staff member is accused, that person will be suspended immediately, pending investigation, and all staff on duty need to complete witness statements and cannot leave until they complete one. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 01/21/25; -Diagnoses included transient cerebral ischemic attack (disruption of blood flow to the brain), dementia (loss of memory), type II diabetes, (body doesn't produce enough insulin), major depressive disorder, severe with psychotic symptoms (person experiences sadness and a loss of contact with reality), anxiety disorder (feelings of worry and fear), post-traumatic stress disorder (PTSD - mental health condition that can develop after experiencing or witnessing a traumatic event). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information: -Moderate cognitive impairment; -Behaviors; -Independent with eating and required set up help with oral hygiene; -Required substantial assistance with toileting hygiene, showers and upper/lower body dressing; -Dependent on staff for personal hygiene. Review of the resident's care plan, last revised on 04/01/25, showed the following: -He/she had a history of verbal and physical aggression towards staff related to underlying psychiatric disorder and cognitive impairment. Staff to speak softly and avoid confrontational or punitive language, and redirect if resident becomes physically aggressive, -He/she had diagnoses of dementia and persistent mood (affective) disorder as evidence by persistent forgetfulness and disorientation. Resident had anxiety, fear, and paranoia associated with memory loss; -He/she had chronic pain in back, knees, and ankles and muscle spasms. He/she took narcotics; -He/she was unable to perform all ADL functions without extensive assistance of one to two staff due to weakness and impaired use of left leg, arm, and hand. Review of the resident's progress note dated 03/31/25, at 11:54 A.M., showed the SSD documented he/she went to the resident and sat down to listen to what the resident had to say. The resident said that two staff members were abusing him/her and he/she had bruising all over his/her body. The SSD replied well I have to take a look at your complaint and see bruising and SSD had the charge nurse look as well. There was no bruising found by the SSD or the charge nurse. The two staff members the resident accused had not been at work. Review of the facility records shows the facility did not provide a documented full investigation, to include interviewing other residents and staff. Review of the resident's progress note dated 04/16/25, at 2:40 P.M., showed the SSD documented he/she and another staff took the resident to the social security office. The resident was throwing a fit in the social security office. The resident blurted out he/she had gotten two facilities closed down and was working on the current facility next. The resident said the staff abuse him/her and leave residents in the floor. Review of the facility records shows the facility did not document an investigation of the allegations of potential abuse. During an interview on 04/30/25, at 12:15 P.M., the SSD said the following: -When staff are told a resident is being abused, they come to him/her; -He/she talked to the resident to see what's going on and what type of abuse was being alleged; -On 03/31/25, the resident came to him/her and said staff were hitting and abusing him/her and he/she had bruises on his/her body; -He/she got the charge nurse and they assessed the resident and he/she did not have bruises on him/her; -He/she went to the Administrator and let him/her know what's going on; -The charge nurse documented in the chart an assessment of the skin was completed; -The resident did not know the names of the staff that abused him/her; -If the Administrator knew the names of the accused staff, he/she will suspend them pending an investigation; -On 04/16/25, he/she took the resident to the social security office, the resident yelled in the office that the facility abused him/her, don't do anything for the resident, and were starving the resident; -The Administrator looked into the allegations. During an interview on 04/30/25, at 11:40 A.M., Certified Nurse's Aide (CNA) A said the following: -If a resident accused staff of abuse, and he/she was in the room and believed it was a misunderstanding, he/she would speak to the resident to explain that it wasn't abuse; -If he/she witnessed abuse, or was told by the resident they had been abused, he/she would speak to the SSD and the charge nurse; -The accused staff would be suspended pending the outcome of the facility investigation. During an interview on 04/30/25, at 11:50 A.M., CNA B said the following: -If a resident reported abuse, he/she told the charge nurse and the nurse; -He/she didn't know if the accused staff was suspended. He/she did know the facility was supposed to investigate;. -The resident accused him/her of abuse. He/she didn't recall when that was but he/she wasn't working the day the resident made the accusations; -He/she was not suspended, however the Director of Nursing (DON) did ask him/her questions. During an interview on 04/30/25, at 12:00 P.M., Certified Medication Technician (CMT) C said the following: -If a resident reported abuse, he/she notified the charge nurse; -He/she believed the facility suspended the staff that's been accused and investigates. During an interview on 04/30/25, at 12:05 P.M., CMT D said the following: -When a resident reported abuse, he/she told the charge nurse; -The charge nurse told the Administrator and DON, and they begin an investigation. During interviews on 04/30/25, at 12:25 P.M., Registered Nurse (RN) E said if a resident reported abuse, he/she reported it to the DON or the Administrator, and they complete an investigation. The accused staff was sent home. During an interview on 04/30/25, at 12:50 P.M., the Business Office Manger said the following: -The administrator investigates allegations of abuse; -He/she didn't know of any physical or verbal abuse allegations the resident had made against staff. During an interview on 04/30/25, at 12:30 P.M., the DON said the following: -Abuse allegations should be reported to the charge nurse, DON, and Administrator; -The resident is interviewed to find out what's going on, as well as the roommate, and the staff member; -The accused staff is suspended, an investigation is completed, including interviews with other staff and residents; -The resident has made allegations of abuse. Skin assessments were completed and there was no bruising; -On 03/31/25, he/she believed the resident accused the two evening shift people and the SSD talked to the staff, the next time they were in the building. He/she didn't know if the SSD documented anything. The two staff were not suspended; -On 04/14/25, he/she was not aware of the resident making allegations of abuse on this date. During an interview on 05/01/25, at 10:15 A.M., the Administrator said the following: -He/she had not completed an investigation for abuse on the resident. He/she knew the SSD did one or two. He/she was not certain the dates on those; -He/she was not aware of allegations of abuse from 04/16/25; -When abuse is alleged, staff are to tell him/her and he/she investigates, speaks with the resident and other residents and staff. If he/she knew the names of the staff, he/she would suspend them; -He/she was not aware of whether the two incidents were investigated. MO00253134

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report all allegations of resident-to-resident abuse to the State Survey Agency (Department of Health and Senior Services- DHSS) within the required two hours when staff did not report multiple allegations of sexual abuse by one resident (Resident #1) towards other residents to DHSS. The facility census was 49. Review of the facility policy, titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -The Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event involved abuse or resulted in injury. -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident that includes all unwanted intimate touching of any kind especially of breasts or perineal area and nudity. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 08/01/24; -Diagnoses included schizoaffective disorder (mental health condition including delusions and hallucinations), anxiety, and bipolar disorder (mood swings ranging from depressive lows to manic highs), alcohol abuse and pyelonephritis (chronic kidney infections). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/08/24, showed the following information: -Cognitively intact; -Independent with bed mobility, transfer, dressing, toilet use, and personal hygiene; -Used a walker or wheelchair for ambulation; -Physical behavioral symptoms directed at others exhibited. Review of the resident's care plan, revised 11/14/24, showed the following information: -The resident had a history of being sexually inappropriate with peers; -Staff will accompany the resident when going outside; -The resident may need additional monitoring at times; -The resident may become sexually inappropriate at times; -Remove the resident from public area when behavior is unacceptable. Review of the resident's progress note dated 11/18/24, at 8:46 A.M., showed the following information: -The nurse documented observing Resident #1 grabbing Resident #3's genitals; -Resident #3 said this has happened four times this weekend; -The resident has been redirected multiple times since admission for inappropriate behaviors with staff and residents. The resident does not respond or even act like she has been told not to do this; -The resident has had UTI's with behaviors which exacerbate the sexual behaviors, however, the behaviors are ongoing. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 11/18/24. Review of the resident's progress note dated 11/20/24, at 1:21 P.M., showed the following information: -The nurse documented that Resident #3 reported that Resident #1 propelled his/her wheelchair up to Resident #3 and asked him/her if he/she could touch his/her private area; -Resident #3 reported this immediately to staff and appeared to be upset by the behavior; -The nurse spoke with Resident #1 asking him/her if this happened. Resident #1 said yes it did, I'm horny. The resident was educated not to speak to other residents in that manner. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 11/20/24. Review of the resident's progress note dated 12/01/24, at 7:40 P.M., showed the following information: -The nurse documented that Resident #1 was observed standing in Resident #2's room, naked from the waist down; -The nurse redirected Resident #1 back to his/her room and reeducated the resident not to go in other residents' rooms and not to leave his/her room without clothing; -Resident #1 denied the behavior; -Staff notified the Director of Nursing (DON); -Staff notified the physician notified and received orders to send resident to hospital for psych evaluation and possible urinary tract infection (UTI); -Staff notified family; -The resident was transported to the hospital for evaluation. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 12/01/24. Review of the resident's progress note dated 12/09/24, at 4:45 P.M., showed the following information: -The nurse documented that another resident (Resident # 3) reported that while at supper in the dining room, Resident #1 propelled his/her wheelchair up to his/her table and asked Resident #3 if he would fuck her. Resident #3 told her no and Resident #1 went on his/her way; -The nurse spoke to Resident #1 who admitted to saying the above statement and didn't care or see why it was inappropriate; -Resident #1 ate his/her supper then stayed the remainder of the evening in his/her room. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 12/09/24. Review of the resident's progress note dated 12/17/24, at 4:42 P.M., showed the following information: -The nurse documented that the resident propelled his/her wheelchair up to Resident #3, reached out and grabbed his/her genitals; -Resident #2 began to scold Resident #1, until staff removed Resident #1; -Resident #2 was very upset and requested anxiety medication. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 11/18/24. During an interview on 01/15/25, at 10:15 A.M., Certified Nurse Aide (CNA) F said he/she would report any inappropriate behaviors to the charge nurse immediately and the charge nurse should report to state within two hours. During an interview on 01/15/25, at 10:00 A.M., CNA E said he/she would report any inappropriate behaviors to the charge nurse immediately so it could be reported to state within two hours. During an interview on 01/15/25, at 9:51 A.M., CNA H said when he/she saw abuse he/she notified the nurse immediately. He/she knew they [NAME] two hours to report to state. He/she considered Resident #1's sexually inappropriate behavior abuse. During an interview on 01/15/25, at 9:44 A.M., Certified Medication Tech (CMT) D said that abuse and neglect (A/N) is any kind of hitting or yelling at residents. Inappropriate touching and verbal is also considered sexual abuse. He/she would report any abuse immediately to the charge nurse and the charge nurse should report to DHSS within two hours. CMT D said that it is not his/her responsibility to report to DHSS, that only the charge nurse, DON or Administrator reports to DHSS. During an interview on 01/09/25, at 9:50 A.M., Registered Nurse (RN) A said he/she reported the sexual inappropriate behavior to the DON and did not think that he/she needed to report it to DHSS. Resident #1's behaviors was sexual abuse. During an interview on 01/09/25, at 12:45 P.M., Licensed Practical Nurse (LPN) C said Resident #1 was sexually inappropriate and very impulsive. Staff notify the physician when the resident has inappropriate sexual behaviors. They also notify the DON and the Administrator and document the behavior. LPN C said that it should have been reported to DHSS by either the DON or the Administrator. He/she considered the behaviors abusive. During an interview on 01/09/25, at 1:45 P.M., the said the Resident #1 had been inappropriate with staff and residents and staff know to keep an eye on him/her when he/she is out of his/her room. Resident #1 had patted butts and groped groins and asked other residents to have sex. This is considered abuse, and it should have been reported to DHSS. During an interview on 01/15/25, at 11:35 A.M., the Social Services Director (SSD) said he/she had told the resident that he/she cannot tell another resident that he/she wants to have sex with them and cannot touch them, especially on their butt or groin areas. The SSD told the resident that is considered abuse. He/she was not sure if these allegations were reported to DHSS or not, but said they should have been and if he/she had been told, he/she would have made sure they were reported to DHSS as he/she is aware that they have two hours to report. The SSD said that the Administrator is responsible for reporting all abuse and neglect allegations. During an interview on 01/15/25, at 11:50 A.M., the Administrator said that Resident #1 had been having inappropriate sexual behaviors for a couple of months. The sexual verbal comments from the resident to other residents at the facility was verbal abuse and that the comments should have been reported to DHSS. MO00247542, MO00247576, MO00247787

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of need for one resident (Resident # 39) when staff did not place the resident's call light where it could be accessed by the resident. The facility census was 39. Review of the facility policy titled, Use of Call Light, dated March 2015, showed the following: -Answer all call lights in a prompt, calm, courteous manner; -When providing care to the residents, be sure to position the call light conveniently for the resident's use; -Tell the resident where the call light is and show him/her how to use the light; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admission date of 06/04/24; -Diagnoses included stroke. Review of the resident's care plan, dated 06/04/24, showed the following: -Resident had a diagnosis of flaccid hemiplegia (a condition that occurs after a stroke and is characterized by a complete lack of voluntary movement in one side of the body) affecting left nondominant side that limit abilities, required maximum assistance with most activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Make sure the resident's call light is within reach at all times. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/10/24, showed the following: -Resident was severely cognitively impaired; -Resident was dependent on all other ADL's including dressing, toilet use, and personal hygiene; -Impairment on one side of the body; -Diagnosis of stroke. Observation on 09/10/24, at 10:16 A.M., showed the resident lay in bed with the call light clipped to the head of the bed on the resident's left side of the body (not accessible to the resident). Observation on 09/10/24, at 10:36 A.M., showed the resident's call light was clipped to the head of the bed on the resident's left side of the body (not accessible to the resident). Observation on 09/11/24, at 1:55 P.M., showed the resident's call light was clipped to the head of the resident's bed on the resident's left side of the body (not accessible to the resident). reach. During an interview on 09/11/24, at 3:45 P.M., Certified Nurse Aide (CNA) C said the following: -Call lights should be next to a resident; -He/She would pin them on the resident's chest; -Everyone should have a call light. During an interview on 09/11/24, at 4:02 P.M., CNA D said the following: -He/She would connect the call light to a resident or a resident's bed where a resident can reach it; -Everyone should have a call light; -He/She would give the resident his/her call light or connect it to his/her bed where he/she could reach it, not at the head of the bed. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the following: -Call lights should be attached to a shirt or a sheet where a resident can reach them; -The resident's call light should be on his/her shirt where he/she can reach it with his/her right hand because that is the resident's non-affected side; -The resident's call light should not be placed at the head of the bed. During an interview on 09/12/24, at 11:22 P.M., the Director of Nursing (DON) said the following: -Call lights should be pinned to a resident's chest or on the bed on a resident's non affected side; -All residents should have a call light in reach, or have it addressed in the care plan if they are not safe to have them. During an interview on 09/12/24, at 4:13 P.M., the Administrator said the following: -Call lights should be in reach; -All residents should have a call light; -Call lights should not be clipped to the head of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) prior to or upon admission to the facility for one resident (Resident #42). The facility census was 39. Review of the facility's admission Packet showed a checklist showing Obtain DA 124C (preadmission screening related to psychological diagnoses). Review showed the facility did not provide a written policy pertaining to PASARRs. 1. Review of Resident #42's face sheet (gives brief profile information) showed the following: -admission date of 05/10/24; -Diagnoses included personal history of suicidal behavior with attempted self-injury, burn of unspecified degree of head, face, and neck, anxiety disorder, paranoid schizophrenia with acute exacerbation (mental disorder with symptoms of distrust, suspicion, and fear of others without reason, delusions - belief in something unreal, hallucinations -hearing or seeing things not present, and confused thoughts), insomnia, high blood pressure, and type 2 diabetes. Review of the resident's care plan, last revised on 08/17/24, showed the following information: -Takes medications to treat paranoid schizophrenia and anxiety disorders. Staff to monitor for side effects. Resident to see tele-psych (virtual psychologist appointments); -History of confusion due to diagnoses of paranoid schizophrenia and anxiety. Resident able to make needs known. Resident has minimal socialization outside of his/her room. Staff to re-orient to the day/time/season etc. as necessary, encourage involvement in activities, monitor for signs/symptoms, and monitor for abnormal behaviors. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 08/17/24, showed the following information: -Cognition intact; -Diagnoses included anxiety disorder and schizophrenia; -Medications included anti-psychotic (given routinely only) and antianxiety. Review of the resident's Level I Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition, dated and submitted by the hospital on [DATE], showed the following: -Major mental illness diagnoses included schizophrenia, psychotic disorder, schizoaffective disorder, and bipolar disorder (fluctuating depressed/manic episodes); -Impairment regarding Adaptation to Change: serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interactions, agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, self-injurious, self-mutilation, suicidal (thoughts, gestures, threats, or attempts), physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability, or requires intervention be mental health or judicial system; -Within the last 2 years, the individual experienced one psychiatric treatment episode that was more intensive than routine follow-up care (such as had inpatient psychiatric care; was referred to a mental health crisis/screening center; had attended partial care/hospitalization or had received Program of Assertive Community (PACT) or Integrated Case Management Services); -Within the last 2 years, due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials; -Initial admission (to the hospital) on 04/14/24 for self-inflicted burns to face; -Corrections were requested by the state agency on 05/09/24; -Corrections made by the submitter on 05/10/24; -Correction requested on 05/13/24; -Application locked due to correction not made to the online application. During an interview on 09/12/24, at 9:31 A.M., the Director of Nursing (DON) said the MDS Coordinator is fairly new and only does MDS duties several days per week. The DON has a background in MDS completion and continues to help out while the MDS Coordinator is learning. The facility missed the email requesting further correction to the resident's Level I submission. During an interview on 09/12/24, at 3:30 P.M., the Corporate QA RN (Quality Assurance Registered Nurse) said the corporation did not have a policy pertaining to PASARRs. Staff was told to follow the regulations for completing them. During an interview on 09/12/24, at 4:13 P.M., the Administrator and the QA RN said the Level I PASARR should be completed prior to the nursing facility admission (usually by the hospital). The MDS Coordinator and DON would be responsible for submitting corrections or completing new assessments as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that each resident's written care plan was accurate and up-to-date, when staff failed to care plan hospice services for two residents (Resident #39 and Resident #2). The facility census was 39. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admission date of 06/04/24; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Resident on hospice services. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 06/04/24, for hospice evaluation and treatment. Observation on 09/12/24, at 9:36 A.M., showed a hospice book that indicated the resident received care from hospice). Review of the resident's care plan, dated 06/04/24, showed staff did not care plan related to the resident's referral for, or use of hospice services. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/10/24, showed staff did not document the resident received hospice services. During an interview on 09/12/24, at 8:54 A.M., Certified Nurse Aide (CNA) F said the resident received hospice services. He/She knew this because the hospice provider came in to give the resident baths. He/She would be able to know what the facility would provide and what hospice would provide by what was documented on the care plan. During an interview on 09/12/24, at 9:00 A.M., CNA G said the resident received hospice services and he/she knew this because the resident was in a special bed. He/she would provide the basic care that he/she provides to everyone and he/she was not sure what hospice would provide to the resident. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the resident was on hospice services and that hospice should be on the care plan. 2. Review of Resident #2's face sheet showed the following information: -admission date of 10/14/13; -Diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave), urinary tract infection, dysphagia (difficulty speaking), and falls. Review of the resident's Patient-Specific Letter of Agreement Inpatient and Respite Care Services, dated 04/12/24, showed hospice services were provided. Review of the resident's quarterly MDS, dated [DATE], showed the resident received hospice services. Review of the resident's current nurses' progress notes showed the following: -On 08/14/24, the Weekly Summary showed the resident continued on hospice services. -On 08/28/24, the Weekly Summary showed the resident continued on hospice services; -On 09/04/24, the Weekly Summary showed the resident continued on hospice services; Review of the resident's care plan, revised 06/19/24, showed staff did not care plan related to the resident's use of hospice services. During an interview on 09/11/24, at 11:53 A.M., RN L said that the resident was currently on hospice services and is being documented on a weekly progress note that the resident is on hospice. RN L said hospice should be care planned. During an interview on 09/11/24, at 11:56 A.M., RN H said that the resident was currently on hospice. RN H said that the nurses assess and document a weekly note that includes that the resident is on hospice. Hospice should be on the care plan. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said the resident was on hospice and he/she would expect it to be on his/her care plan. During an interview on 09/11/24, at 1:28 P.M., the Director of Nursing (DON) said the care plan should be updated with hospice services. The resident was on hospice. During an interview on 09/12/24, at 4:15 P.M., the Administrator said the resident was currently on hospice and had been for a while now. 3. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said care plans should be up-dated quarterly or as needed with any significant change. The MDS Coordinator and DON are the only staff that up-date the care plans. Hospice should be on the care plan. The MDS Coordinator said that he/she doesn't get to spend a lot of time on care plans as he/she is mostly working the floor as a charge nurse. 4. During an interview on 09/12/24, at 11:22 A.M., the DON said hospice should be addressed on the facility care plan. 5 During an interview on 09/12/24, at 4:13 P.M., the Administrator said hospice should be on the facility care plan.

Based on observation, record review, and interviews, the facility failed to assist all dependent residents with activities of daily living to maintain good grooming when the facility staff failed to perform peri-care for one resident (Resident #41) following an episode of incontinence and toileting. The facility census was 39. 1. Review of Resident #42's face sheet (gives basic profile information about the resident) showed the following: -admission date of 05/14/24; -Diagnoses included metabolic encephalopathy (brain dysfunction that occurs due to a chemical imbalance in the blood) and congestive heart failure (CHF - irregular heart function). Review of the resident's care plan, last updated 08/15/24, showed the following: -Staff to assist with toileting; -Staff to provide changing and peri-care with each incontinent episode to keep skin clean and free from odor and breakdown; -Staff to apply barrier creams with each incontinent episode to maintain good skin integrity. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 08/21/24, showed the following: -Severely impaired cognition; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -Required substantial/maximal assistance for toileting hygiene. Observation on 09/10/24, at 2:05 P.M., showed the following: -Certified Nurse Aide (CNA) C and CNA D donned gloves and assisted the resident to walk to the toilet. The back of the resident's pants were wet. -The resident held onto the grab bar while the CNAs lowered his/her pants and wet brief; -The resident sat on the toilet. -CNA C removed his/her gloves and left the bathroom to retrieve a fresh brief and dry pants. -CNA C handed new gloves to CNA D and without performing hand hygiene, they both changed their gloves. -Without performing any peri-care, the CNAs placed the new brief and clean pants on the resident. -The CNAs ambulated with the resident back to his/her recliner. During an interview on 09/12/24, at 1:04 P.M., CNA J said staff should do peri-care whenever a resident is changed or after they use the bathroom. Staff should do peri-care regardless of whether or not there is any output. When toileting a resident staff should put gloves on, undue the brief, use two wipes to clean the resident's peri-area, take off the gloves to refasten brief or place new one. If the gloves become dirty, they should be changed. They don't do hand hygiene in between glove changes. During an interview on 09/12/24, at 12:51 P.M., CNA F said he/she would do peri-care when toileting a resident and every two hours regardless. Staff should put gloves on and use wipes to do peri-care. If the gloves get dirty, staff should wash their hands and put a new pair on. The clean, dry brief should be place using a clean pair of gloves. During an interview on 09/12/24, at 1:55 P.M., the Director of Nursing (DON) said staff should assist residents with peri-care and/or toileting. Staff should clean the front first, wiping from front to back, change gloves and sanitize their hands, and then clean the back side. Staff should sanitize their hands before touching other things, utilizing hand sanitizer, and wash their hands when they are finished caring for the resident. During an interview on 09/12/24, at 4:13 P.M., the Administrator and the corporate QA RN (Quality Assurance Registered Nurse) said staff should always perform peri-care with incontinence and/or toileting. Staff should change their gloves and sanitize their hands during care and sanitize hands before touching other things or re-dressing the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure staff followed acceptable standards of care when staff did not change gloves or sanitize their hands during care for the indwelling suprapubic catheter (tubing inserted directly into the bladder through the abdomen to drain to an exterior collection bag) of one resident (Resident #20). The facility census was 39. 1. Review of Resident #20's face sheet (gives basic profile information) showed the following: -admitted to the facility on [DATE]; -Diagnoses included bipolar disease (mental disorder causing alternating depressive and manic episodes), generalized anxiety disorder, insomnia, muscle weakness, history of urinary tract infection (UTI), benign prostatic hyperplasia (BPH; enlarged prostate gland) with lower urinary tract symptoms, testicular hypofunction, indwelling urethral catheter, impaired cognitive function and awareness, and schizophrenia (mental disorder including hallucinations and delusions). Review of the resident's quarterly Minimum Data Set (MDS; a federally mandated comprehensive assessment tool completed by facility staff), dated 07/04/24, showed the following information: -Cognition mildly impaired; -Indwelling catheter in place; -Continent of bowel. Review of the resident's physician order sheet, current as of 09/12/24, showed the following: -an order, dated 01/06/23, for an indwelling catheter, size 14 French with 10 milliliter (ml) bulb/balloon; -an order, dated 01/06/24, to change the catheter monthly; -an order, dated 01/06/24, for catheter care every shift. Review of the resident's care plan, last updated 07/06/24, showed the following: -Problem start date: 01/13/23 -Chronic suprapubic catheter, inserted due to diagnosis of BPH and urinary retention; goal to remain free of complications from BPH and chronic UTIs; empty catheter every shift and/or as needed; monitor and record output; perform catheter care every shift and as needed. Observation on 09/11/24, at 2:25 P.M., showed RN L donned a gown, gloves, and mask while in the hallway outside the resident's room, then turned the knob to open the door and enter the room. RN L explained the procedure to the resident, who rested on his/her bed. Without changing the contaminated gloves or performing hand hygiene, RN L lowered the resident's sweatpants to expose the abdominal (SP: suprapubic) insertion site of the catheter and removed the old gauze drain sponge surrounding the insertion site. The RN went to the sink and applied soap and water to a washcloth, then used it to clean around the SP insertion site. RN L secured the catheter tubing with one gloved hand and cleaned the tubing in a motion away from the body, did not change gloves or perform hand hygiene, and dried the tubing using a dry part of cloth. Still without changing gloves or performing hand hygiene, the RN placed a new drain sponge around site, replaced the waistband of pants, and then removed his/her gloves, gown and mask and washed his/her hands. During an interview on 09/11/24, at 3:00 P.M., RN L said staff should don gloves after washing/sanitizing their hands. Staff should change gloves after cleaning the catheter insertion site, but he/she did not remember to do so during the above observed catheter care. During an interview on 9/12/24, at 4:13 P.M., the Administrator and the corporate QA RN (Quality Assurance Registered Nurse) both said staff should wash/sanitize their hand prior to donning gloves. Staff should change gloves and sanitize their hands after cleaning a catheter, before touching clean items.

Based on record review, observation, and interview, the facility failed to provide care per standards of practice when staff failed to address one resident's (Resident #39) complaints of pain in a timely manner. The facility census was 39. Review of the facility's policy Pain Management Guidelines, dated January 2017, showed the following: -The goal of pain management will be to control pain so it will not interfere with the ability to have restful sleep patterns, perform activities of daily living (ADL's- dressing, grooming, bathing, eating, and toileting), participate in usual activities, or cause problems with mood or behaviors; -A licensed nurse or certified nurse aide (CNA) may assess and communicate degrees of pain to the person administering the pain medications to the residents; -Hospice residents will be provided pain medications according to the hospice program and physician orders; -The resident's description of his/her pain will be documented in the nurses progress notes/aide charting and/or on the MAR of the resident's medical record. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admission date of 06/04/24; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Resident on hospice services. Review of the resident's care plan, dated 06/04/24, showed the following: -Alert with episodes of fluctuating orientation related to behaviors with diagnoses of PTSD, anxiety, depression, and stroke; -Complains of pain and try to get pain medication, even when they are not due yet; -Goal of adequate pain control; -Staff to monitor for control of pain; -Staff to offer the resident as needed (PRN) pain medications with complaints of break-through pain; -Staff to offer non-pharmacological interventions, such as position changes or massage; -Staff to do quarterly and PRN pain assessments. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/10/24, showed the following: -The resident did not receive scheduled pain medications; -The resident had frequent pain; -The resident's pain frequently affected sleep patterns; -The resident's pain frequently affected his/her ability to complete day to day activities. Review of the resident's pain assessment and evaluation, dated 06/13/24, showed the following: -Resident had frequent pain in the last five days; -Pain made it frequently difficult for the resident to sleep over the last five days; -Pain frequently limited the resident's day-to-day activities; -The resident expressed pain through anxiety, agitation/restlessness, anger, sleep disturbance, and verbal reports; -The resident rated his/her pain as severe over the last five days; -The resident described his/her pain as shooting, stabbing, and throbbing; -The resident reported pain all times of the day; -Resident made vocal complaints of pain; -Resident was not on a scheduled pain regimen. Review of the resident's current Physician Order Sheet (POS) showed the following: -An order dated 07/12/24, for hydrocodone/acetaminophen (a narcotic that treats pain) 10/325 milligrams (mg), one tablet by mouth, every six hours, as needed; -An order, dated 07/12/24, for morphine concentrate (narcotic that can treat moderate to severe pain)100 mg/5 milliliters (ml), 0.25 ml by mouth, every two hours, as needed. Review of the resident's September 2024 Medication Administration Record (MAR) showed the following: -On 09/10/24, at 7:15 A.M. staff administered morphine concentrate for leg pain rated 7 out of 10. Staff documented resident resting after administration ; -On 09/10/24, at 11:15 A.M., staff administered morphine concentrate for leg pain rated 8 out of 10. Staff documented resident resting after administration. Observation on 09/10/24, of the resident, showed the following: -At 2:36 P.M., the resident yelled out. The resident lay in the bed complaining of pain to his/her left arm, both leg, and knees. The resident had a blanket and sheet placed across his/her midsection, but not covering his/her legs; -At 2:38 P.M., the resident began yelling for pain medication. The resident said, Nurse! I need something for pain; -At 2:42 P.M., the resident began moaning loudly in pain and rubbing his/her legs together. The resident said, I can't hardly stand it; -At 2:44 P.M., a staff member walked past the door and the resident began yelling for help; -At 2:46 P.M., the resident continued to moan loudly while still rubbing his/her legs together; -At 2:48 P.M., the resident began yelling, Nurse!; -At 2:53 P.M., the resident said, I'm still hurting bad, worse; -At 2:55 P.M., the resident yelled out, I'm freezing, I'm freezing, bring another blanket; -At 2:58 P.M., the resident began repeatedly saying please. He/she then said, sometimes you have to wait a minute, it feels like it's been 30; -At 3:00 P.M., the resident told a staff member in the hall, Nurse, that pain medicine didn't work, I'm still hurting like crazy; -At 3:06 P.M., the resident lay in bed rubbing his/her left arm and muttering to self; -At 3:14 P.M., the resident said he/she continued to hurt in his/her legs, knees, and arms; -At 3:17 P.M., the resident lay in bed talking to self. No staff entered in the room to check on him/her. -At 3:24 P.M., the resident said loudly he/she had pain in all his/her joints, hurts about every day. The resident complained of being cold. Certified Nurse Aide (CNA) C entered the room. CNA C said he/she heard the resident say he/she was cold. The CNA covered the resident with a blanket. The resident told the aide he/she had pain in his/her joints. CNA C said he/she thought the resident was on scheduled pain medication and did not know for sure if he/she could have anything right now. The CNA said he/she would check with the nurse and left the room. During an interview on 09/10/24, at 3:24 P.M., the resident said sometimes he/she could get up and do stuff. The pain did not usually affect or prevent him/her from doing daily activities. Sometimes, the pain affected his/her sleep. The resident said the pain was better. During an interview on 09/10/24, at 3:40 P.M., Registered Nurse (RN) H said he/she did not know the resident had complained of pain. The CNA did not tell him/her about the resident's complaints of pain. The resident was not on scheduled pain medication. The nurse said he/she could go give the resident something for pain. Review of the resident's September 2024 MAR showed the following: -On 09/10/24, at 4:00 P.M., staff administered morphine concentrate, for leg pain rated 7 out of 10. Staff documented the dose was not effective; -On 09/10/24, at 5:45 P.M., staff administered hydrocodone/acetaminophen for leg pain rated at 8 out of 10. Staff documented the dose was effective. During an interview on 09/11/24, at 2:41 P.M., Certified Medication Technician (CMT) E said the following: -No one reported the resident's pain to him/her on 09/10/24, or he/she would have given the resident a pain pill; -He/She gave the resident hydrocodone/acetaminophen on 09/10/24, at 5:45 P.M., when the resident sat at the desk yelling out that his/her legs hurt; -He/she said would assess a resident for pain when giving a pain pill, but he/she assumed the nurses were responsible for assessing pain. During an interview on 09/11/24, at 3:45 P.M., CNA C said the following: -He/She would report pain to the CMT and nurse immediately; -Staff can tell when the resident is in pain by nonverbal cues and other time he/she can verbally tell; -Regardless of the way the pain is communicated, he/she would report it; During an interview on 09/11/24, at 4:02 P.M., CNA D said that he/she would report a resident's complaint of pain immediately to the nurse or CMT. The resident can voice complaints of pain verbally. During an interview on 09/12/24, at 8:54 A.M., CNA F said the following: -He/She would report pain to the nurse or CMT immediately; -He/She knows when the resident is having pain because he/she yells out; -Pain pills do help the resident and normally work within 30 minutes; -The resident's pain affects him/her from getting up/going to meals; -The resident's pain affects his/her sleep. During an interview on 09/12/24, at 9:00 A.M., CNA G said the following: -He/She would reposition a resident complaining of pain to see if that relieves the pain. He/She would also report the pain to the nurse and the CMT immediately; -He/She knows the resident has pain because the resident yells out; -The resident's pain sometimes affects him/her going to meals; -Pain pills seem to help the resident sometimes, but if he/she has already been yelling for a long time they don't seem to work as well. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the following: -The nurses only assess pain when they give a PRN medication; -There is no routine pain assessments; -If a resident can verbally describe pain, he/she would use a pain scale of 1 to 10; -If a resident cannot verbally describe pain, he/she would look for nonverbal cues such as crying, grimacing, yelling, or rubbing a body part; -The resident can verbalize his/her pain; -The resident also has non verbal cues such as yelling and crying; -The pain medication helps sometimes; -Sometimes the morphine does not help, sometimes the Norco does better; -All of the resident's pain medications are PRN; -The resident's pain sometimes effects his/her ability to attend meals; -The resident's pain sometimes effects his/her sleep as the resident will yell out more when he/she is in pain. During an interview on 09/12/24, at 10:47 A.M., the resident's primary physician said the following: -Since the resident is on hospice, he would expect staff to give him/her pain medication; -The resident is on a starting dose of morphine, which he would consider low, and could be increased if not effective; -He would expect staff to notify him if the resident's pain medication was not effective. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said she would expect pain management to be on the care plan and that she would expect staff to follow the care plan. During an interview on 09/12/24, at 11:22 A.M., the Director of Nursing (DON) said the following: -The nurses assess for pain; -The residents should be assessed for pain when a resident says they are in pain, during the weekly skin assessment, and before and after a PRN medication is given; -If a resident has chronic pain, they should be assessed every shift; -The nurses document the pain assessment on the MAR or in the nurse's notes; -If a resident is verbal, they should be assessed using a 1 to 10 scale; -If a resident is non verbal, they should be assessed by looking for grimacing, crying, rubbing legs together, or holding body parts; -Staff can tell when the resident has leg pain because the resident will move his/her legs and cry out; -To assess the resident's pain, staff should ask him/her where if it hurts and where, and look for nonverbal cues; -When the resident is crying out or if he/she asked for pain medication, he/she would give it immediately; -The pain pills do a good job controlling his/her pain most of the time; -The resident's pain does not keep him/her from getting up for meals as far as she is aware; -The resident's pain does effect his/her sleep. During an interview on 09/12/24, at 4:13 P.M., the Administrator said nurses should be assessing pain, that it should be documented in a progress note, and he would expect pain to be treated in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all residents who were trauma survivors received care per standards of practice when staff did not address the the diagnosis of Post-Traumatic Stress Disorder (PTSD - disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) in the medication record or in the care plan, to include triggers and interventions, and failed to ensure care staff were aware of the PTSD history, to include triggers and interventions, for one resident (Resident #41). The facility census was 39. Review of the facility assessment, updated 10/25/23, showed the following information: -The facility may accept residents with, or who may develop, common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management including PTSD; -The facility will manage the medical conditions causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, and care of individuals with trauma/PTSD; -The facility will provide person-centered/directed care. Staff to find out what upsets him/her and incorporate this into he care planning process. Staff to make sure staff caring for the resident has this information. Review showed the facility did not provide a policy related to PTSD. 1. Review of Resident #41's face sheet (gives basic profile information about the resident) showed an admission date of 05/14/24. Review of the resident's PASARR Level II Evaluation (Preadmission Screening and Resident Review (PASARR) - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission), completed by hospital staff on 05/09/24, showed the following information: -No contact with his/her three children; -He/she and spouse started using drugs/alcohol together at an early age. Spouse currently supposed to be in alcohol/drug rehab program, but recently signed out of the program. At this time the spouse is not allowed to visit, per family's request; -Resident/spouse had a house that burned to the ground last year and now living in a bunk house on sibling's property; -Sibling reports he/she and siblings grew up in a very abusive home environment. Parent remarried to an abusive partner with heavy drug/alcohol involvement in the home. All siblings experienced significant mental/physical abuse and witnessed significant domestic violence in the home. All siblings, including this resident, reported they were sexually abused; -Sibling reported resident attempted suicide once by hanging and once by cutting him/herself. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/21/24, showed the resident's diagnoses included traumatic brain dysfunction, seizure disorder, and anxiety disorder. Review of resident's nurses' notes showed the following: -On 07/29/24, at 2:07 A.M., the resident returned from outing with family and had been punching, pushing, trying to bite, and kicking at staff and attempting to elope. Attempts to calm resident down and redirect have not been effective. Staff gave as needed medication, but resident still wound up. Staff following him/her around to prevent elopement, but aggressive behaviors continue. Staff contacted nurse practitioner and received order for Haloperidol (an antipsychotic medication) 1 milligram (mg) IM (injected in the muscle) given now. The medication has not stopped behaviors; -On 07/29/24, at 4:28 A.M., resident continued with aggressive behaviors and refused redirection. Staff received order from nurse practitioner to send resident out for evaluation. Emergency medical services (EMS) left with resident at 3:00 A.M. Review of the resident's face sheet showed on 08/02/24 the diagnosis of post-traumatic stress disorder was added. Review of resident's nurses' notes showed on 08/03/24, at 4:45 A.M., resident arrived back at the facility at 11:00 P.M. Resident reported he/she was glad to be back and have a pleasant affect. Resident placed on 15-minute checks. Review of the resident's care plan, last reviewed 08/15/24, showed the staff did not address the new diagnosis of PTSD, the resident's triggers for PTSD, or interventions related to PTSD. Review of the resident's quarterly MDS, dated [DATE], showed the resident's diagnoses included PTSD. Review of the facility provided matrix (a form requested on survey entrance with brief details of resident care needs), completed on 09/09/24, showed the staff identified the resident had PTSD/trauma. During an interview on 09/11/24, at 1:55 P.M., the resident's sibling said they have tried to educate the facility staff on the resident's emotional triggers. The resident and his/her siblings were molested as children and agitation will escalate if staff make him/her lie down for any personal care. During an interview on 09/12/24, at 11:28 A.M., Certified Nurse Aide (CNA) P, who was the designated shower aide for the day, said the resident gets agitated sometimes. The CNA thinks the family being present often over stimulates him/her; then he/she wants them there all the time. He/she was not aware of any psychological history for the resident or a diagnosis of PTSD. During an interview on 09/12/24, at 12:55 P.M., CNA G said he/she gets a report from the previous shift on the residents. Other staff should know and pass on information regarding a resident's triggers and care needs. He/she did not know of any specific triggers for the resident or his/her psychological background. During an interview on 09/12/24, at 1:04 P.M., Licensed Practical Nurse (LPN) K said he/she was contracted staff and had worked in the facility often, but hadn't been there for the past month. A CNA said the resident's spouse had come in drunk and upset the resident. The LPN was unaware of other triggers or psychological background for the resident. During an interview on 09/12/24, at 1:40 P.M., the MDS Coordinator said he/she did not know who added the diagnosis of PTSD. A diagnosis of PTSD should be listed under behaviors in the care plan. The MDS Coordinator was unaware of the resident's history, the reason for the PTSD diagnosis, or any triggers for the resident. He/she said they didn't think they'd need to list any specific triggers, just that there is a history of traumatic event, to inform the staff. During an interview on 09/12/24, at 1:55 P.M. the Director of Nursing (DON) said staff should have carried the diagnosis over to the care plan to identify and notify staff of history and triggers. He/she was not previously aware of the resident's history of being abused/molested as a child or the house fire. During an interview on 09/12/24, at 4:13 P.M., the Administrator and the corporate Quality Assurance Registered Nurse said a diagnosis of PTSD should be noted in the resident's care plan with specifics and triggers. The Administrator was unaware of the reason for the resident's PTSD diagnosis or any triggers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to complete appropriate hand hygiene and use PPE appropriately while providing wound care for one resident (Resident #32). Facility staff also failed to complete appropriate hand hygiene while providing indwelling suprapubic catheter (tubing inserted directly into the bladder through the abdomen to drain to an exterior collection bag) care for one resident (Resident #20). The facility census was 39. Review of the facility policy, titled Handwashing, dated 03/2015, showed the following information: -Purpose to reduce transmission of organisms from resident-to-resident, staff-to-resident, and resident-to-staff; -Wash hands with soap and water. Review of the facility policy, titled Enhanced Barrier Precautions (EBP) to Infection Control Guidance, updated 03/2024, showed the following information: -Policy purpose was to prevent broader transmission of multidrug-resistance organisms and to help protect patients with chronic wounds and indwelling devices; -EBP should be implemented until wounds have resolved or indwelling medical devices have been removed; -Staff are to use EBP when providing high-contact resident care activities such as performing wound cares; -Equipment include gloves and gown; -Conduct proper hand hygiene before starting care; -Gloves and donning and doffing of gown are required when conducting high-contact resident care activities such as wound care; -Gloves and gown should be removed and discarded after each resident care encounter; -Personal Protective Equipment (PPE) should be placed in proximity outside the resident's door and a trash can in the resident's room for disposal prior to leaving the room. Review of the facility policy, titled Wound Care and Treatment, dated 07/2015, showed the following information: -Handwashing and glove usage will be done according to guidelines; -Put on gloves; -Remove soiled dressing and place in trash bag; -Remove gloves and place in trash bag; -Wash hands and put on clean gloves; -Clean the wound according to the physician orders; -Remove gloves and place in trash bag. Put on clean pair of gloves (handwashing or alcohol gel usage if skin is contaminated when gloves removed); -Apply clean dressing; -Position resident comfortably with call light with-in reach; -Clean the environment with Sani/bleach wipes; -Discard trash; -Remove gloves and wash hands; -Document. 1. Review of Resident #32's face sheet (brief resident profile sheet) showed the following information: -admission date of 03/14/24; Diagnoses included stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) of sacral region (the triangular bone at the base of the spine that connects the lower back to the pelvis), heart failure, hypertension (high blood pressure), and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/16/24, showed the following information: -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 06/30/24, showed the following information: -Staff to use EBP when providing cares while in the resident's room; -Assist with repositioning and toileting; -Monitor skin for any signs of breakdown such as redness, blisters, and open areas. Review of the resident's current Physician Order Sheet showed the following information: -An order, dated 07/17/24, to cleanse wound with hypochlorous acid (no need to rinse from wound or skin, use to irrigate and scrub the wound bed, protect peri-wound with skin prep, lightly pack tunnel (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) with a long thin piece of Hydrofera Blue (antibacterial wound dressing) and cover with ABD pad (gauze) for moderate to heavy drainage. Treatment to be done every other day and as needed if soiled. -An order, dated 08/16/24, clean coccyx wound with Vashe (wound cleanser), place Puracol (collagen wound dressing) in wound, cover with gauze, then apply foam dressing to cover gauze, with skin prep around dressing, Place Suresite (transparent film dressing) over wound and surrounding area. Treatment to be done every other day. Observation on 09/11/24, at 10:38 A.M., showed the following information: -Registered Nurse (RN) L parked a treatment cart outside the resident's room with drawers facing the resident's room and gathered supplies; -RN L completed hand hygiene and donned gown, surgical mask, and gloves before entering resident's room; -RN L removed the old dressing and placed in biohazard bag; -RN L cleansed wound with wound cleanser and sterile Q-tip, then placed Q-tip in biohazard bag; -RN L changed gloves without performing hand hygiene; -RN L applied skin prep to skin around wound then placed Hydrofera Blue in wound; -RN L pulled his/her face mask down exposing his/her nose with gloved hand; -RN L changed gloves without performing hand hygiene; -RN L covered wound with ABD pad and secured with tape; -RN L changed gloves without performing hand hygiene; -The resident repositioned to left side; -RN L removed old dressing and placed in biohazard bag; -RN L cleansed wound with wound cleanser; -RN L while kneeled at the bedside near the wound, pulled his/her mask from face, fanned face with his/her hand and stated he/she was trying to get some air; -RN L applied skin prep to skin around wound; -RN L changed gloves without performing hand hygiene; -RN L applied Puracol dressing to wound; -RN L removed gloves (did not perform hand hygiene), left room with gown on, went to treatment cart to obtain ABD pad; -RN L returned to room, ABD pad placed without gloves and secured with tape; -RN L pulled mask from face, fanned face with his/her hand, and said he/she could not breath with the mask covering his/her face; -RN L removed gown and mask and washed hands. During an interview on 09/11/24, at 11:53 A.M., RN L said staff should use hand hygiene after changing gloves, but said I don't. I cleanse my hands good at the beginning and wash them again when I am all done with wound care. I change my gloves between dirty and clean and that should be good. During an interview on 09/11/24, at 11:56 A.M., RN H said staff should wash their hands or use hand hygiene before and after wound care and any time they change their gloves. During an interview on 09/11/24, at 1:28 P.M., the Director of Nursing (DON) said that staff is expected to wear gown, gloves and mask when providing cares on all EBP residents. The DON expected staff to wash hands or use hand hygiene before and after donning and doffing gloves and every time gloves are changed. The DON expected the mask to cover the nose and mouth of staff when performing cares and staff should not remove the face mask or pull the mask from the face while performing cares with a gloved hand. The DON expected staff to complete the wound care, then remove all PPE, including mask, and wash hands before leaving the resident's room. During an interview on 09/12/24, at 4:15 P.M., the Administrator said that he/she would not expect staff to pull face mask down and fan face while performing wound cares. He expected staff to wash hands or use hand hygiene after removing gloves. 2. Review of Resident #20's face sheet showed the following: -admission date of 03/24/23; -Diagnoses included history of urinary tract infection (UTI), benign prostatic hyperplasia (BPH - enlarged prostate gland) with lower urinary tract symptoms, and indwelling urethral catheter. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognition mildly impaired; -Indwelling catheter in place; -Continent of bowel. Review of the resident's physician order sheet, current as of 09/12/24, showed the following: -An order, dated 01/06/23, for an indwelling catheter; -An order, dated 01/06/24, to change the catheter monthly; -An order, dated 01/06/24, for catheter care every shift. Review of the resident's care plan, last updated 07/06/24, showed the following: -Chronic suprapubic catheter inserted due to diagnosis of BPH and urinary retention; -Goal to remain free of complications from BPH and chronic UTIs; -Staff to empty catheter every shift and/or as needed, monitor and record output, and perform catheter care every shift and as needed. Observation on 09/11/24, at 2:25 P.M., showed the following: -RN L donned a gown, gloves, and mask while in the hallway outside the resident's room, then turned the knob to open the door and enter the room; -RN L explained the procedure to the resident, who rested on his/her bed. Without changing the contaminated gloves or performing hand hygiene, RN L lowered the resident's sweat pants to expose the abdominal insertion site of the catheter and removed the old gauze drain sponge surrounding the insertion site; -The RN went to the sink and applied soap and water to a washcloth, then used it to clean around the SP insertion site. (The RN did not complete hand hygiene.); -RN L secured the catheter tubing with one gloved hand and cleaned the tubing in a motion away from the body without changing gloves or performing hand hygiene. RN L then dried the tubing using a dry part of the cloth; -Without changing gloves or performing hand hygiene, the RN placed a new drain sponge around site and replaced the waistband of pants. During an interview on 09/11/24, at 3:00 P.M., RN L said staff should don gloves after washing/sanitizing their hands. Staff should change gloves after cleaning the catheter insertion site, but he/she did not remember to do so during the above observed catheter care. During an interview on 9/12/24, at 4:13 P.M., the Administrator and the corporate QA RN (Quality Assurance Registered Nurse) both said staff should wash/sanitize their hand prior to donning gloves. Staff should change gloves and sanitize their hands after cleaning a catheter, before touching clean items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities based on residents' interests and abilities when the staff failed to provide a complete activity schedule with a variety of daily activities, failed to complete activities as scheduled, and failed to document steps taken to provide meaningful activities for nine residents (Resident #13, #17, #14, #39, #9, #16, #7,#40, and #16) out of a sample of 20 residents. The facility had a census of 39. Review of the facility policy titled, Activity/Recreational Therapy Manual last reviewed on 03/2012, showed the following: -The purpose was for the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident; -To enhance the quality of the residents daily life; -Upon admittance, annually, and upon significant change, an initial assessment was to be completed including background information, preference interviews, activity pursuit patterns, and additional pertinent information; -Quarterly assessments will be completed to evaluate the resident's current activity program and determine if changes need to be made; -The quarterly assessments include participation in activities, socialization patterns, resident preferences, and other factors; -The Activity Director charts progress notes in the residents' charts upon admission, quarterly, and with significant changes; -The progress notes should include resident interests, based on their feedback, response to activity, and activity involvement; -Resident participation is documented in the clinical record, on a daily basis by the Activity Director or designee and should include the resident's attendance, participation, refusal, and level of participation; -Activity Director should develop a monthly calendar based on resident's needs and interests; -Calendar should list the time of the activity; -Monthly calendar should be provided to each resident; -Plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility; -Schedule activities that will involve as many residents as possible; -Care plan will address resident's interests and needs. 1. Review of the residents' activities sign in sheets, dated January 2024, showed the following: -Bingo held on 01/04/24, 01/09/24, and 01/30/24; -No other documented activities. Review of the residents' activities sign in sheets, dated February 2024, showed the following: -Bingo held on 02/08/24, 02/12/24, 02/20/24, 02/23/24, and 02/27/24; -No other documented activities. Review of the residents' activities sign in sheets, dated March 2024, showed the following: -Bingo held on 03/05/24, 03/08/24, 03/12/24, 03/19/24, and 03/26/24; -No other documented activities. Review of the residents' activities sign in sheets, dated April 2024, showed the following: -Bingo held on 04/04/24, 04/09/24, 04/16/24, 04/19/24, 04/24/24, and 04/26/24; -No other documented activities. Review of the residents' activities sign in sheets, dated May 2024, showed the following: -Bingo held on 05/09/24, 05/14/24, 05/21/24, 05/24/24, and 05/31/24; -No other documented activities. Review of the residents' activities sign in sheets, dated June 2024, showed the following: -Bowling held on 06/03/24; -Bingo held on 06/05/24; -Corn Hole held on 06/06/24, eight resident participated; -Karaoke held on 06/07/24, twelve residents participated; -Movies held on 06/10/24, ten residents participated; -Bingo held on 06/11/24; -Ring toss held on 06/12/24, ten residents participated; -Movies held on 06/17/24, ten residents participated; -Leisure time, read a book held on 06/19/24, five residents participated; -Bingo held on 06/21/24; -Movies held on 06/24/24, ten residents participated; -Bingo held on 06/25/24; -No other documented activities. Review of the residents' activities sign in sheets, dated July 2024, showed the following: -Bowling held on 07/01/24, eight residents participated; -Bingo held on 07/02/24; -Firework's display held on 07/04/24, 27 residents participated; -Karaoke held on 07/05/24, nine residents participated; -Bingo held on 07/09/24, 07/12/24, 07/19/24, 07/23/24, 07/26/24, and 07/30/24; -No other documented activities. Review of the residents' activities sign in sheets, dated August 2024, showed the following: -Bingo held on 08/27/24, seven residents participated; -Bingo held on 08/30/24, ten residents participated; -No other documented activities. Review of the residents' activities sign in sheets, dated 09/01/24 to 09/11/24, showed the following: -Bingo held on 09/03/24, nine residents participated; -Bingo held on 09/11/24, twelve residents participated. 2. Review of the facility activity calendar, posted in the television room at the facility, showed on 09/09/24, at 1:30 P.M., corn hole scheduled. Observation on 09/09/24, at 1:30 P.M., showed no corn hole activity was being done at the facility. 3. Review of the facility calendar posted in the television room at the facility, showed the following: -On 09/01/24, televised church, no time listed; -On 09/02/24, at 10:00 A.M. hydration; 10:30 A.M. phone calls; 12:00 P.M. lunch; 1:00 P.M. mail; and 1:30 P.M. movie; -On 09/03/24, Bingo, no time displayed; -On 09/04/24, at 10:00 A.M. hydration; 12:00 P.M. lunch; and podiatrist; -On 09/05/24, at 10:00 A.M., hydration; 12:00 P.M. lunch; 1:00 P.M., mail; and 1:30 P.M., leisure time; -On 09/06/24, Bingo, no time listed; -On 09/07/24, Activity of choice, no time listed; -On 09/08/24, televised church, no time listed; -On 09/09/24, at 1:30 P.M., corn hole; -On 09/10/24, no activity, in-service; -On 09/11/24, at 10:00 A.M. hydration; 12:00 P.M. lunch; and 1:30 P.M. basketball; -On 09/12/24, volley balloon, no time listed; -On 09/13/24, bingo, no time listed; -On 09/24/24, happy birthday; -On 09/15/24, televised church, no time listed; -On 09/16/24, hydration at 10:30 A.M.; phone at 12:00 P.M.; lunch at 1:00 P.M.; mail at 1:30 P.M.; and movie; -On 09/17/24, bingo, no time listed; -On 09/18/24, leisure time; -On 09/19/24, resident council, no time listed; -On 09/20/24, bingo, no time listed; -On 09/21/24, activity of choice; -On 09/22/24, televised church, no time listed; -On 09/23/24, hydration, phone calls, lunch, bowling for prizes, no times listed; -On 09/24/24, bingo, no time listed; -On 09/25/24, treats at activity and foosball, no times listed; -On 09/26/24, read a book, no time listed; -On 09/27/24, bingo, no time listed; -On 09/28/24, activity of choice, no time listed; -On 09/29/24, televised church, no time listed; -On 09/30/24, games for prizes, no times listed. 4. Observation on 09/10/24, at 9:49 A.M., of the activity room showed the following: -The room contained a basketball goal and foosball; -A shelf with various games; -A door with a sign on it that said remain locked at all times. Observation on 09/12/24, at 11:45 A.M., showed a lower cabinet in the 100 hall TV room contained three editions of Reader's Digest and three romance novels. The cabinet was at floor level and covered with a door. 5. Observation and interview on 09/11/24, starting at 10:34 A.M., showed the following: -Nurse Aide (NA) I passed out various drinks on 200 hall; -NA I said the hydration listed on the calendar was what he/she was doing. It consisted of going around to each resident who can have drinks and providing them Kool-aide, coffee, water or tea. This was done at 10:00 A.M. and 8:00 P.M. 6. Review of Resident #13's face sheet showed the following: -admission date of 07/18/14; -Diagnoses included above the knee amputation, diabetes, insomnia, schizoaffective disorder (combination mental disorder including delusions, hallucinations, depressed/manic periods), anxiety, limitation of activities due to disability, pain, and major depressive disorder. Review of the resident's Activity Assessment - Comprehensive, dated 07/03/24, showed the following: -Most common use of time: sleeping in his/her chair in his/her room; -Average time involved in activities (when awake and not receiving treatments or care): Some - from 1/3 to 2/3 of time; -Preferred activity settings: none of the above listed; -Hobbies: watching television; -Preferred program style: Refuses to participate; -Program time preference: does not like to participate in activities; -Participation barriers: none; -Participation strengths: social skills; -General activity preferences: reading/writing, watching TV; -Past interests included: animals/pets, board games, cooking, current events, dining out, drawing/painting, movies/theater, quilting/crochet, outdoor activities, resident council, and woodworking; -Focus of programming: no interest at all. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/11/24, showed the following: -Cognition intact; -Sometimes socially isolated. Review of the resident's care plan, last updated 07/11/24, showed the following: -Psychosocial well-being: Right leg amputated above the knee. Resident has constant worry that he/she may lose the other leg. Resident has episodes of depression related to these events; -Mood state: Loss of interest in things due to worrying and anxiety about health. Resident is anxious and depressed at times. Staff to encourage resident to get out of bed and come out of the room to socialize with others. Staff to spend 1:1 time with resident and allow resident to vent feelings. During interviews on 09/09/24, at 11:15 A.M., and on 09/10/24, at 1:43 P.M., the resident said he/she had been a resident for a long time and was tired of Bingo and Scrabble. He/she would be interested in doing something new, otherwise he/she would just stay in his/her room. The facility does not have enough activities, they play bingo a lot and they sometimes cancel the activities. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the resident could have money for activities, but he/she spends money on food instead. 7. Review of Resident #17's face sheet showed the following: -admission date of 10/02/23; -Diagnoses included schizoaffective disorder (combination mental disorder including delusions, hallucinations, depressed/manic periods), heart disease, diabetes, and presence of right artificial hip joint. Review of the resident's Activity Assessment- Comprehensive, dated 10/03/23, showed the following: -The resident was most active in the afternoon; -The resident was involved in some activities from 1/3 to 2/3 of the time; -Preferred setting was the day/activity room; -Preferred small groups; -Participated twice weekly; -No participation barriers; -Participation strengths included being self-motivated and social skills; -General activity preferences include watching television and talking/conversing; -Past interests include animals/pets, board games, cooking, current events, dining out, movies, outdoor activities, woodworking; -Focus of programming included outdoor activities and talk-oriented activities. Review of the resident's MDS, dated [DATE], showed the following: -Severely cognitively impaired; -The resident's activity preferences listed as somewhat important to have books, newspapers, and magazines to read, listen to music, be around animals, keep up with the news, do thing with groups of people, and go outside to get fresh air when the weather was good. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately cognitively impaired; -Preferences were not completed; -Required partial to moderate assistance with activities of daily living (ADL's) including dressing, toilet use, and personal hygiene. Review of the resident's social services and activity progress notes, dated 03/01/24 through 09/12/24, showed staff did not document regarding activities for the resident. Observation on 09/10/24, at 8:55 A.M., showed the resident lay in bed awake, the room dark, with the television off. Observation and interview on 09/11/24, at 1:40 P.M., showed 11 residents in the dining room playing bingo. Observation and interview on 09/11/24, at 1:46 P.M., showed the resident lay in bed, room dark, and television not on. The resident said staff did not tell him/her bingo was being played. He/she would like a deck of playing cards, but has never been offered them. He/she has never been given a calendar of what the activities for the month are. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the following: -He/she was not aware that the resident wanted playing cards, there are cards in the back room; -No one will play with the resident, because he/she picks His/her nose and makes it bleed. Review of the resident's care plan, last revised 09/12/24, showed the following: -Resident is to participate in at least one activity a week as he/she feels able and with staff assistance; -Post a calendar in the resident's room for staff to read to the resident; -Assist the resident to activities that may be of interest to the resident; -Encourage the resident to go to activities. 8. Review of Resident #14's face sheet showed the following information: -admission date of 11/29/23; -Diagnoses included developmental disorders of scholastic skills, schizoaffective disorder, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and hallucinations. Review of the resident's current physician order sheet showed an order, dated 11/29/23, for resident may participate in activities as tolerated. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Mildly cognitively impaired; -Preferences were not completed; -Sometimes socially isolated. Review of the resident's record showed staff did not complete an activity assessment for the resident. Review of the resident's care plan, revised 06/26/24, showed psychosocial well-being care planned. Facility staff to monitor frequently and report any changes in mood or behaviors to charge nurse. During an interview on 09/10/24, at 1:48 P.M., the resident said bingo was about the only activity they have. He/she would like more activities and has told the nurses. He/she gets bored and wishes there was more to do besides watch television and sleep. Observation and interview on 09/11/24, at 9:18 A.M., showed the resident laying on his/her bed watching television. The resident said that he/she was bored and would like to paint, but is currently out of painting supplies. There were no painting supplies in the activity room that he/she would be interested in. 9. Review of Resident #39's face sheet showed the following: -admission date of 06/04/24; -Diagnoses included chronic obstructive pulmonary disease (COPD- refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD-A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's admission MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Dependent on staff for ADL's -Activity preferences showed it as somewhat important to listen to music he/she liked, to be around animals, keep up with the news, do thing with groups of people, do his/her favorite activities, go outside to get fresh air when the weather was good, and participate in religious services or practices. Review of the resident's Activity Assessment- Comprehensive, dated 06/11/24, showed the following: -The average time resident involved in activities was unknown; -The resident had no preferred activity settings; -The resident's preferred program style was 1:1; -Program time preference was afternoon; -Participation barriers included ability to understand, mental status, and physical endurance; -The resident had no participation strengths; -General activity preferences included crafts/art, music, and watching television; -Past interests included animals/pets, board games, cooking, current events, dining out, drawing/painting, movies, quilting/crochet, outdoor activities, music, resident council, woodworking, and word games; -Focus of programing included group games and outdoor activities. Review of the resident's care plan, last revised 06/18/24, showed staff did not address the resident's activity preferences or an activity plan for the resident. Review of the resident's activity progress notes, dated 06/04/24 through 09/11/24, showed staff did not document regarding activity attendance, refusals, or participation. Review of the resident's social services progress notes, dated 06/04/24 through 09/11/24, staff did not document regarding activities preferences or activity attendance for the resident. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the following: -He/she provides activities specific to residents. He/she pulled out a bag of interactive hand toys for the resident and said the resident does come to bingo. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the resident liked to play with blocks and Legos. Since the resident was in the hospital the last time, the resident does not have much of an interest in them. During an interview on 09/12/24, at 11:22 A.M., the Director of Nursing (DON) said the resident liked to do things that involve his/her hands. The resident liked to play with Legos before going to the hospital. The resident does well with sitting at the desk talking to the nurse or certified medication technician (CMT) one-on-one. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said the resident liked to be included. The resident liked to go to bingo and karaoke. His/her care plan should include things the resident likes to do. 10. Review of Resident #9's face sheet showed the following information: -admission date of 05/11/16; -Diagnoses included schizoaffective disorder, Type II diabetes (blood sugar is too high), generalized anxiety disorder borderline intellectual functioning (below average cognitive ability), and chronic pain. Review of the resident's Activity Assessment, dated 08/20/24, showed the following: -Average time involved in activities, some from 1/3 to 2/3's of the time; -Prefers activities in the day/activity room; -Prefers large groups and in the afternoons; -Likes music, reading/writing, watching television, and talking; -Current interests included animals, board games, dining out, drawing, movies, music. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Very important to do things with groups of people; -Very important to do favorite activities. Review of the resident's current care plan, last revised 09/06/24, showed the following: -Resident needs staff to invite him/her to activities and assist to find the location; -Staff to provide resident 1:1 to decrease episodes of restlessness; -Resident liked games; -Resident has difficulty staying focused on task and liked to be around others. Review of the resident's medical record, dated 01/01/24 to 09/12/24, showed staff did not document related to the activities the resident participated in. Observation and interview on 09/10/24, at 1:43 P.M., showed the following: -Six residents were sitting in the television room; -The resident said they did not have corn hole yesterday; -He/she would like a paper activity calendar. During an interview on 09/11/24, at 3:31 P.M., the resident said the following: -He/she goes to bingo on Tuesdays and Friday; -He/she believed someone came and told him/her they were having bingo today; -The Activities Director and the laundry person do activities; -He/she would like to do other activities. 11. Review of Resident #16's face sheet showed the following information: -readmission date of 12/21/15; -Diagnoses included paranoid schizophrenia (hallucinations, delusions and unusual ways of expressing themselves). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Preferences were not completed. Review of the resident's current care plan, last revised 09/06/24, showed staff did not address the resident's activity interests. Review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not document completion of an activity assessment or quarterly reviews of activity interests. Review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not document related to activities the resident participated in. 12. Review of Resident #7's face sheet showed the following information: -readmission date of 01/15/24; -Diagnoses included schizoaffective disorder, generalized anxiety disorder (excessive worry), and insomnia (difficulty falling and staying asleep). Review of the resident's Activity Assessment, dated 01/25/24, showed the following: -Average time involved in activities, some from 1/3 to 2/3's of the time; -Prefers activities in the day/activity room; -Prefers large groups and in the afternoons; -Likes crafts/arts and watching television; -Current interests include animals, board games, current events, dining out, drawing, movies, music, word games, and outdoor activities. Review of the resident's current care plan, last revised 07/22/24, showed staff did not care plan the resident's preferred activities. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Activity preferences was not completed. Review of the resident's medical record, dated 01/01/24 and 09/12/24, showed staff did not document progress notes documented related to activities the resident participated in. Observation and interview on 09/10/24, beginning at 1:43 P.M., showed the following: -Six residents were sitting in the television room; -The resident said they did not have corn hole on 09/09/24; -He/she doesn't know if they're having activities today; -He/she looks at the calendar on the wall; -Sometimes they cancel activities if there's not staff to do them; -Sometimes the Activity Director will do bingo, karaoke, and a movie if he/she has time. 13. Review of Resident #40's face sheet showed the following: -admission date of 04/24/24; -Diagnoses included high blood pressure, depression, insomnia, pain, and heart failure. Review of the resident's Activity Assessment- Comprehensive, dated 04/25/24, showed the following: -The resident is involved in activities most of the time, more than 2/3 of the time; -Preferred setting is the day/activity room; -Preferred program style is large groups; -Time preference is afternoon; -No participation barriers; -No participation strengths; -Activity preference is watching television; -Past interests included animals/pets, board games, cooking, dining out, movies, outdoor activities, music, resident council, and woodworking; -Program focus is outdoor activities. Review of the resident's admission MDS, date 05/1/24, showed the following: -Cognitively intact; -His/her activity preferences showed it as very important to have books, newspapers, and magazines to read, to do things with groups of people, and to get outside to get fresh air when the weather was good and somewhat important to listen to music he/she likes, to be around animals, to keep up with the news, to do favorite activities, and participate in religious services or practices. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Staff did not document activity preferences. Review of the resident's care plan, last revised 08/02/24, showed staff did not address the resident's activity preferences or interests or any plan for activities. During interviews on 09/10/24, at 9:49 A.M., and 09/12/24, at 10:32 A.M., the Activities Director said the resident knows the facility has books and where they're at. There are both fiction and non-fiction books. 14. Review of Resident #16's face sheet showed the following information: -readmission date of 12/21/15; -Diagnoses included paranoid schizophrenia. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Activity preferences not completed. Review of the resident's current care plan, last revised 09/06/24, showed staff did not care plan related to activity interests. Review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not complete an activity assessment or quarterly reviews of activity interests. Record review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not document related to activities the resident participated in. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the resident had been asked if he/she wants to be involved and he/she doesn't. He/she also hurt a scout's feelings and he/she does not feel that is right. 15. During an interview on 09/11/24, at 3:45 P.M., CNA C said he/she does not know if they do anything different for a resident that does not want to or cannot come out their room. Activities and restorative staff go around and tell the residents about the activity for the day. 16. During an interview on 09/11/24, at 4:02 P.M., CNA D said activities were listed on the calendar in the television room. Sometimes the CNAs will tell the residents about activities, sometimes activities will, and other times they will page overhead. 17. During an interview on 09/12/24, at 12:51 P.M., CNA F said the following: -Activities are posted on the board in the television room; -The Activities Director walks around and invites residents to activities; -He/she doesn't know anything about a paper calendar; -He/she is not sure if the staff ask residents which activities they prefer. 18. During an interview on 09/12/24, at 1:09 P.M., Licensed Practical Nurse (LPN) K said the following: -The facility used to hand out fliers for the week, but now they announce the activities daily and they have the board; -There was also a daily activity sheet that listed lunch and he/she hasn't seen that in some time either; -The Activity Director is responsible for activities and he/she also has a couple of helpers; -Residents complain all of the time about activities being canceled or not having enough; -It seems like movie night gets moved a lot, or they cancel Bingo because there isn't a staff to do it; -He/she has probably seen Bingo done about 20 times in the last nine months. 19. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the following: -The activities are posted on the calendar in the television room or announced on the intercom; -CNAs will remind the residents about the activity. Activities will come and remind them as well; -No written calendars are handed out; -There is no way to know what a resident's preferences are; -A resident's preferences are not documented anywhere; -A resident's participation in activities are not documented anywhere that he/she is aware of; -Staff is not instructed to do anything different for residents who do not participate in activities. 20. During interviews on 09/10/24, at 9:49 A.M., and on 09/12/24, at 10:32 A.M., the Activities Director said the following: -When hired, he/she was not given direction on how activities should be done; -Residents used to like to exercise, but they decided they didn't want that; -He/she tried to get them involved in other activities; -Some residents come to activities, mostly Bingo; -He/she does have another aide that's appointed to help, but they use him/her as an aide on the floor a lot; -He/she sits down with residents one-on-one to see what activities they want to do; -Residents like karaoke, corn hole, but several don't want to get out of bed; -He/she asked residents what time they want to have activities; -When he/she set up church, it was in the morning and the residents decided they didn't want mornings so it was moved to the afternoon and it was their nap time and no one came; -He/she completed an activity assessment when a resident was admitted and annually thereafter; -He/she provided puzzles and word books for various residents; -Some times aren't on the activity board. The afternoon activities are held at 1:30 P.M. He/she tells residents this and goes over it on admit; -If not enough residents show up, some activities can't be done; -He/she determines what activities to do, based upon how many residents show up for the activities; -The door is kept locked in the game room because residents have stolen. One time he/she put candy bars back there and a resident stole all of them; -If residents ask staff, they will unlock the door. Someone has a key at all times; -The activities listed on the calendar, such as hydration and lunch, are on the calendar because residents wanted to know when they were held; -He/she doesn't make calendars anymore. The residents throw them away and it's a waste of paper; -He/she said they're supposed to have Bingo, which he/she showed on the calendar, but they're having in-service today so they will make it up another day; -He/she had activities usually after the resident council meeting; -If residents refused or don't participation, he/she usually makes a note; -Since January he/she hasn't been making notes in resident's records about activities; -He/she keeps a log of who attends the activities; -He/she used to print out the calendars and put them on the resident's closet doors and they tore them off and threw them away. 21. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said the following: -The residents' activities care plan should have things the resident likes to do and what they have an interest in; -The care plan should say what they do and don't like; -The care plan should say if they don't participate in activities; -All care plans should say for everyone to encourage the residents to be involved 22. During an interview on 09/12/24, at 11:22 A.M., the DON said the following: -The activities calendar is posted in the television room; -Certain activities are announced overhead; -All residents are supposed to get a calendar in their rooms; -The CNAs or activities staff will go room-to-room and remind the residents before an activity; -If the residents do not want to participate in the activity for the day, they ask them if they can get them anything else; -Some residents just do not like to do anything; -She does not think it is documented anywhere if they do or do not participate in activities. -Activities should be on the care plan. 23. During an interview on 09/12/24, at 4:18 P.M., the Administrator said the following: -Activities should be part of the resident's care plan; -The Activity Director should've

Based on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the outside of the ice machine clean and failed to keep all light fixtures, vents, and ceiling areas clean. The facility census was 39. 1. Review of the facility's policy titled Ice Maker, dated May 2015, showed staff would clean the outside of the machine week. Staff would wash the outside of the ice machine monthly with a soft brush or cloth and dry. Review of the facility's Ice Machine Cleaning Schedule showed the machine was to be cleaned monthly. Staff last documented cleaning the ice machine on 08/31/24. Observations on 09/09/24, beginning at 9:13 A.M., of the ice machine in the kitchen showed the following: -The outside had white and brown buildup along the crevasses of the machine at the top; -The right side of the machine had three long streaks of white; -The left side of the machine had much of it covered with white streaks and a crusty white substance; -Above the door opening there was a dirty substance. Observations on 09/11/24, beginning at 8:50 A.M., of the ice machine in the kitchen showed the following: -Outside of the ice machine had white and brown buildup along the crevasses of the machine at the top; -The left side of the machine had much of it covered with white streaks and a crusty white substance. During an interview on 09/11/24, at 1:39 P.M., Dietary Aide (DA) A said the following: -Evening shift staff are responsible for cleaning the outside of the ice machine at the end of their shift; -Kitchen has a cleaning schedule for daily, weekly, and monthly items; -The ice machine is listed on the cleaning schedule. During an interview on 09/11/24, at 1:49 P.M., DA B said the following: -When he/she remembers, he/she wipes down the outside of the ice machine with a sanitizing rag nightly; -He/she will also clean above the door, but not as often. During an interview on 09/11/24, at 1:44 P.M., the Dietary Manager (DM) said the following: -Staff have a cleaning schedule for the kitchen, but cleaning the outside of the ice machine is not on the cleaning schedule; -Staff should be cleaning the outside of the ice machine once a day; -He/she is responsible for ensuring staff clean the ice machine. During an interview on 09/11/24, at 2:02 P.M., the Maintenance Director said dietary staff were responsible for cleaning the outside of the ice machine. During an interview on 09/11/24, at 1:56 P.M., the Administrator said the following: -He wasn't sure whose responsible it to clean the outside of the ice machine; -He would expect staff to keep the outside clean. The ice machine should not have white streaks or crust or grime on it; -The DM was responsible for making sure the ice machine was cleaned regularly. 2. Observations on 09/09/24, beginning at 9:13 A.M., and on 09/11/24, at 1: 39 P.M., of the kitchen showed the a florescent light, and ceiling around the light, located in front of the stove and above the table, had brown spots present. During an interview on 09/11/24, at 1:49 P.M., DA B said maintenance cleans the ceiling and lights on the ceiling. During an interview on 09/11/24, at 2:02 P.M., the Maintenance Director said the following . -He/she cleans the fluorescent lights in the kitchen when he/she changes out the bulbs. It is not on his/her cleaning schedule; -He/she doesn't clean the ceiling in the kitchen. During an interview on 09/11/24, at 1:44 P.M., the DM said the following: -Maintenance cleans the lights and the ceiling; -When kitchen staff find an issue, they write the issue on the clip board located at the nurses' station; -He/she doesn't know how often maintenance cleans the lights or ceiling; -He/she didn't notice the brown spots on the light or ceiling. During an interview on 09/11/24, at 1:56 P.M., the Administrator said the following: -He knew maintenance changed the bulbs out, but he wasn't sure if maintenance cleaned the lights and the ceiling; -He would expect the lights and ceiling to be clean; -Maintenance has a book at the nurses' station where any issues should be noted. 3. Observations on 09/09/24, beginning at 9:13 A.M., and on 09/11/24, at 11:42 A.M. and 1: 39 P.M., of the kitchen showed the ceiling vent, just before entering the kitchen, had fuzzy lint hanging from it. During an interview on 09/11/24, at 1:39 P.M., DA A said the following: -Maintenance was responsible for cleaning the ceiling vents; -He/she didn't think about looking at the ceiling and didn't notice the fuzzy lint on the vent. During an interview on 09/11/24, at 1:49 P.M., DA B said he/she doesn't do anything with the ceiling vents and doesn't know who is supposed to clean them. During an interview on 09/11/24, at 2:02 P.M., the Maintenance Director said he/she doesn't clean the vents and doesn't know who is supposed to clean them. During an interview on 09/11/24, at 1:44 P.M., the DM said the following: -He/she wasn't sure who was supposed to clean the vents on the ceiling; -He/she didn't realize the vent had fuzzy lint. During an interview on 09/11/24, at 1:56 P.M., the Administrator said maintenance should be taking care of the vents, ensuring they don't have fuzzy lint.

Based on interview and record review, the facility failed to complete performance reviews of every certified nurse aide (CNA) at least once every 12 months when staff failed to document competency evaluation and performance review for two staff (CNA N and CNA M). The facility census was 39. Review showed the facility did not provide a written policy pertaining to nurse aide competency reviews. 1. Review of personnel records showed the following CNAs had been employed for more than one year: -CNA N - Hire date of 12/20/22; Re-hire date of 04/26/23; -CNA M - Hire date of 01/27/23; Re-hire date of 06/28/23; -Staff did not have documentation of a yearly performance review for CNA N and CNA M. During an interview on 09/11/24, at 9:08 A.M., the Director of Nursing (DON) said the facility did scheduled monthly in-services for all staff, with some specific to nursing and the CNAs. They did not have documentation on annual performance reviews. During an interview on 09/12/24, at 3:30 P.M., the corporate Quality Assurance Registered Nurse (QARN) said the corporation did not have a specific written policy pertaining to the completion of CNA annual competencies. The facility should complete the competencies for all CNAs and include skills such as catheter care, transfers, peri-care (perineal; genital) with incontinence or toileting, hand washing, and glove use. During an interview on 09/12/24, at 4:13 P.M., the Administrator said the facility should be completing annual competencies for the CNAs with documentation on the performance reviews. The competencies should include skills such as catheter care, peri-care, toileting, assisted transfers and mechanical lifts.

Based on interviews and record review, the facility staff failed ensure all allegations of possible abuse were reported timely when staff did not report an allegation of employee to resident abuse involving one resident (Resident #1) immediately to administration and within two hours of staff becoming aware of the allegation to the state survey agency (Department of Health and Senior Services - DHSS). The facility census was 32. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -The Administrator or designee must report to the State Survey Agency no later than two hours after the allegation is made if the event involved abuse or resulted in injury. Review of the facility policy titled Reporting, revised 11/2017, showed the following: -All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately; -Allegations of abuse must be reported within two hours after the allegation was made; -All employees of the facility are mandated reporters. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 02/01/23; -Diagnoses included pervasive development disorder (delays of social and communication skills), epilepsy (seizures), anxiety, and bipolar disorder (mood swings ranging from depressive lows to manic highs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/16/23, showed the following information: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Sometimes incontinent of bowel and bladder. Review of the resident's care plan, revised 11/16/23, showed the following information: -Provide resident with supportive care and services; -Staff will anticipate needs and ensure needs are met; -Staff will keep area around resident calm and quiet with minimal stimulation. Record review of the facility's initial facility reported incident to the Abuse and Neglect Hotline, dated 12/10/23, at 7:01 A.M., showed the following: -The Administrator reported to the Director of Nursing (DON) at 8:24 p.m. on 12/09/23 that the Dietary Manager had received a text message from Dietary Aide (DA G) that he/she believed Certified Nurse Aide (CNA) J had restrained the resident while taking him/her out of the dining room at supper time; -Later, the DA said he/she and cook, (DA H) seen this same CNA yelling at this same resident, and aggressively putting him/her to bed. Review of the facility's follow-up investigation report, dated 12/12/23, showed the following: -The victim was Resident #1 and the alleged perpetrator was CNA J; -DA G reported to his/her supervisor that he/she witnessed staff member CNA J wrap his/her arms around the resident from behind when the resident was screaming in the dining room at 6:00 P.M. Friday evening (12/08/23). CNA J quickly released the resident and then wheeled his/her wheelchair out of the dining room. DA G then witnessed CNA J helping the resident into bed at around 7:40 P.M. He/she claimed he/she felt that CNA J was being a little rough with the resident and that the resident hit his/her knee on the wall, but could not be sure; -The resident's guardian and physician were notified; -The allegation was reported to the facility Adminstrator at 8:30 P.M. on 12/09/23 (the day after the alleged abuse occurred). During an interview on 12/18/23, at 11:30 A.M., DA G said that he/she saw CNA J restraining the resident while in the dining room on Friday, 12/08/23, at approximately 5:30 P.M. CNA J was holding down the resident's arms while he/she was sitting in his/her wheelchair while in the dining room. Later that evening he/she witnessed CNA J aggressively throw the resident into the bed and yell at the resident to stay in the bed. DA G said that he/she did not report this to anyone until the next evening, Saturday, 12/09/23, at approximately 8:00 P.M. He/she notified his/her manager via text message. He/she said he/she was not aware that it should have been reported immediately. During an interview on 12/18/23, at 12:50 P.M., DA H said he/she was with DA G on 12/08/23, gathering trays from residents' rooms, when he/she heard CNA J yell at the resident to lay down and stay in bed. He/she did not see any abusive behavior in the room, stating he/she only heard the yelling from the resident's room then saw a CNA J leave the room and slam the door. He/she said he/she did not report it because he/she did not see anything to report. Abuse or neglect should be reported to the manager or the Administrator immediately. During an interview on 12/18/23, at 1:25 P.M., Dietary Manager I said that he/she received a text message from DA G on Saturday, 12/09/23, at approximately 8:09 P.M., regarding alleged abuse that had occurred the previous day. He/she immediately called the Administrator to report the allegation and forwarded him the text message. Dietary Manager I said that he/she has educated his/her staff on multiple occasions to notify him/her immediately of any abuse or neglect that is seen or heard. During an interview on 12/18/23, at 10:57 A.M., Housekeeper A said he/she was not aware of any recent allegations of abuse and has not had any recent abuse and neglect trainings or in-services. If he/she witnessed any abuse, he/she would report it immediately to his/her supervisor so that it could be reported to the state within two hours. During an interview on 12/18/23, at 10:59 A.M., Housekeeper B said that he/she has not witnessed any abuse including yelling or cussing or seen any staff being rough with the residents. He/she would report those things immediately to his/her supervisor. During an interview on 12/18/23, at 11:04 A.M., Housekeeper C said that he/she has not seen any abuse. He/she said that any abuse should be reported to all administration, including his/her Manager, Director of Nursing (DON) and the Administrator immediately. During an interview on 12/18/23, at 11:06 A.M., Registered Nurse (RN) D said that he/she has not seen any recent abuse. He/she would report any abuse immediately to the Director of Nursing and the Administrator. During an interview on 12/18/23, at 11:10 A.M., Nurses Assistant (NA) E said that if he/she witnessed any kind of abuse he/she would notify the charge nurse immediately. He/she said that the facility has two hours to report alleged abuse to the state. During an interview on 12/18/23, at 11:15 A.M., Certified Nurse's Assistant (CNA) F said that he/she has not witnessed any abuse from staff and if he/she does he/she will notify his/her charge nurse, DON, and Administrator immediately. During an interview on 12/18/23, at 1:30 P.M., the Director of Nursing (DON) said the Administrator had called him/her on Saturday, 12/09/23, at approximately 8:30 P.M., regarding alleged abuse that had occurred the previous day. The DON said that he/she lived close to the facility and came to the facility to immediately report the alleged abuse to DHSS. During an interview on 12/18/23, at 1:38 P.M., the Administrator said that he received a phone call from the Dietary Manager I on Saturday, 12/09/23, at approximately 8:25 P.M., regarding alleged abuse that had occurred the previous day. The Administrator said that he called the DON to report the abuse and the Administrator immediately started his/her investigation. He/she expects staff to notify him/her and the DON immediately of any allegations of abuse or neglect. The facility has two hours to report the allegations to DHSS. MO00228554

Based on interviews and record review, the facility failed to ensure that an allegation of possible abuse was immediately investigated with immediate steps taken to protect all residents during the investigation when staff failed to immediately report an allegation of abuse involving one resident (Resident #1) and a staff member. The facility census was 32. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property. Review of the facility policy titled Reporting, revised 11/2017, showed the following: -All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately; -All employees who have been alleged to commit abuse will be suspended immediately pending investigation. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 02/01/23; -Diagnoses included pervasive development disorder (delays of social and communication skills), epilepsy (seizures), anxiety, and bipolar disorder (mood swings ranging from depressive lows to manic highs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/16/23, showed the following information: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Sometimes incontinent of bowel and bladder. Review of the resident's care plan, revised 11/16/23, showed the following information: -Provide resident with supportive care and services; -Staff will anticipate needs and ensure needs are met; -Staff will keep area around resident calm and quiet with minimal stimulation. Review of the facility's initial facility reported incident to the Abuse and Neglect Hotline dated 12/10/23, at 7:01 A.M., showed the following: -The Administrator reported to the Director of Nursing at 8:24 P.M. on 12/9/23 that the Dietary Manager had received a text message from DA G that he/she believed CNA J had restrained the resident while taking him/her out of the dining room at supper time. Later, the DA said he/she and cook (DA H) seen this same CNA yelling at this same resident, and aggressively putting him/her to bed. Review of the facility's follow-up investigation report, dated 12/12/23, showed the following: -The allegation was reported to the facility admnistrator at 8:30 P.M. on 12/9/23 (the day after the alleged abuse occurred); -The victim was Resident #1 and the alleged perpetrator was Certified Nurse Assistant (CNA) J; -DA G reported to his/her supervisor that he/she witnessed staff member CNA J wrap his/her arms around the resident from behind when the resident was screaming in the dining room at 6:00 P.M. Friday (12/08/23) evening. CNA J quickly released the resident and then wheeled his/her wheelchair out of the dining room. DA G then witnessed CNA J helping the resident into bed at around 7:40 P.M. He/she claimed he/she felt that CNA J was being a little rough with Resident #1 and that the resident hit his/her knee on the wall, but could not be sure; -The resident's guardian and physician were notified; -The Administrator was responsible for completing the investigation. During an interview on 12/18/23, at 11:30 A.M., Dietary Aide (DA) G said that he/she saw CNA J restraining the resident while in the dining room on Friday, 12/08/23, at approximately 5:30 P.M. CNA J was holding down the resident's arms while he/she was sitting in his/her wheelchair while in the dining room. Later that evening he/she witnessed CNA J aggressively throw the resident into the bed and yell at the resident to stay in the bed. DA G said that he/she did not report this to anyone until the next evening, Saturday, 12/09/23, at approximately 8:00 P.M. He/she notified his/her manager via text message. During an interview on 12/18/23, at 12:50 P.M., DA H said he/she was with DA G on 12/08/23, gathering trays from residents' rooms when he/she heard CNA J yell at the resident to lay down and stay in bed. He/she did not see any abusive behavior in the room, stating he/she only heard the yelling from the resident's room then seen CNA J leave the room and slam the door. He/she said he/she did not report it because he/she did not see anything to report. During an interview on 12/18/23, at 1:25 P.M., Dietary Manager I said that he/she received a text message from DA G on Saturday, 12/09/23, at approximately 8:09 P.M., regarding alleged abuse that had occurred the previous day. He/she immediately called the Administrator to report the allegation and forwarded him the text message. During an interview on 12/18/23, at 1:30 P.M., the Director of Nursing (DON) said the Administrator had called him/her on Saturday, 12/09/23, at approximately 8:30 P.M., regarding alleged abuse that had occurred the previous day. The DON said that he/she lived close to the facility and came to the facility to immediately report the alleged abuse to DHSS. The DON said that CNA J was not on the schedule to work and would not be allowed to work during the investigation. During an interview on 12/18/23, at 1:38 P.M., the Administrator said that he received a phone call from the Dietary Manager I on Saturday, 12/09/23, at approximately 8:25 P.M., regarding alleged abuse that had occurred the previous day. The Administrator said that he called the DON to report the abuse and the Administrator immediately started his/her investigation. He/she said that CNA J was suspended until after the investigation was completed. The Administrator said that the facility must ensure resident safety and start an investigation. MO00228554

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two (Residents #9 and #23) of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 42. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC-form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Record review of Resident #9's SNF Beneficiary Protection Notification Review, dated 5/16/19, showed the following: -On 4/18/19, the resident started Medicare Part A skilled services; -5/15/19 was the last covered day of Medicare Part A services; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative a SNFABN, form CMS-10055, or alternate denial letter. 2. Record review of Resident #23's SNF Beneficiary Protection Notification Review, dated 7/23/19, showed the following: -On 7/10/19 the resident started Medicare Part A skilled services; -7/24/19 was the last covered day of Medicare Part A service; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -Facility staff did not provide the resident or his/her legal representative a SNFABN, form CMS-10055, or alternate denial letter. 3. During an interview on 10/22/19, at 11:39 A.M., the Business Office Manager (BOM) said she was responsible for issuing the SNFABN. She did not issue SNFABNs to Resident #9 or Resident #23 because they had qualifying stays and therapy orders from the hospital. She only issued a SNFABN if the resident did not have a qualifying stay from a hospital. 4. During an interview on 10/24/19, at 9:41 A.M., the Director of Nursing (DON) said the BOM should issue a SNFABN to the resident or responsible party when the resident discharged from Medicare Part A services and remained in the facility. She did not know the BOM was not issuing the SNFABNs. 5. During an interview on 10/24/19, at 11:00 A.M., the Administrator said the facility did not have a policy related to SNFABNs. The facility should follow guidelines set by CMS when a resident discharged from Medicare Part A skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to consistently document a resident's code status and failed to include the resident's code status in his/her care plan for one resident (Resident #9) in a selected sample of 17 residents. The facility census was 42. Record review of the facility policy titled, DNR Guidelines dated 9/2010, included the following information: -When a resident or legal representative decides to change the code status of the resident, the Social Services Designee will make the changes as soon as the OHDNR (out of the hospital do not resuscitate) form has been signed by the physician. -The Social Services Designee will complete the following: a green paper with Full Code (a person wanted all interventions needed to get his/her heart started. This may include chest compressions and defibrillation to shock the heart out of a life-threatening heart rhythm (cardiopulmonary resuscitation (CPR))) or a red paper with DNR (do not resuscitate) will be placed in the very front of the medical record in a plastic sheet protector. On the physician order sheet (POS) in the menu section located in the right upper corner of the POS, the Social Services Designee will add the code status: DNR or Full Code. -A green paper with Full Code or a red paper with DNR will be placed in the plastic sheet protector that contains the resident picture and identification information in front of the resident's MAR (medication administration record). -The Social Service Designee will then place a green dot for Full Code or a red dot for DNR next to the resident's name on the resident room plate. -The DNR/Full Code status shall be documented on the resident's care plan. -The resident code status will be periodically reviewed and renewed with the resident and/or legal representative, no less than quarterly during care plan review with the resident or resident representative signing the care plan. The Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) nurse and the ICP team will complete this task. -The Social Services Designee will monitor the resident code status monthly, with new admissions, readmissions, and as a resident's code status is changed to ensure all components of the program. 1. Record review of Resident #9's face sheet (general information about the resident) showed the following: -admitted to the facility on [DATE]. -Diagnoses included dementia, cognitive communication deficit, and weakness. -Full code. Record review of the resident's OHDNR (located in the front of the resident's medical record), dated [DATE] and signed by the physician on [DATE], showed the authorization to withhold or withdraw CPR from the resident in the event of cardiac or respiratory arrest. Record review of the resident's care plan, dated [DATE], showed staff did not include the resident's code status. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Short term and long term memory problems; -Required extensive assistance for bed mobility, transfer, dressing and personal hygiene; -Required limited assistance for walking in his/her room. Record review of the resident's nursing note, dated [DATE], showed a nurse documented the resident was a full code with no changes to his/her face sheet. Record review of the resident's [DATE] physician order sheet (POS) showed the resident's code status as full code. An observation, on [DATE], at 10:00 A.M., of the resident's nameplate, located on the outside of his/her room door, showed a red dot next to the resident's name. During an interview on [DATE], at 1:34 P.M., Certified Nurse Aide (CNA) B said residents' code status was located (on the nameplate) on each resident's door. A red dot indicated DNR and a green dot indicated full code. Staff could also find a resident's code status in the resident's care plan and in the front of the care plan book. During an interview on [DATE], at 3:43 P.M., Registered Nurse (RN) A said the following: -Staff could find a resident's code status on his/her face sheet in his/her medical record. -Staff could also find the resident's code status by looking at the colored dots on the outside of the resident's door. A red dot indicated no code (DNR) and a green dot indicated full code. -The business office manager was responsible for the code status paperwork. During an interview on [DATE], at 9:19 A.M., the Social Services Designee said the following: -All residents admitted to the facility are initially a full code. -The admit packet included a DNR form. If the resident wanted his/her code status as DNR, the resident or responsible party signed the OHDNR form. The signed form goes to the physician to sign. -Once the physician signed the OHDNR form, staff added the order to the resident POS and updated the resident's chart. -Social services was responsible for the code status process. An observation of the CNAs charting, located in the resident's electronic health record on [DATE], at 10:02 A.M., showed the resident's code status as Full Code. Record review of the facility's report of Advanced Directive and Codes Status, dated [DATE], showed the resident's code status as full code. During an interview on [DATE], at 12:03 P.M., the Director of Nursing (DON) said the following: -When a resident admitted to the facility, staff must obtain a new order for code status. The facility could not the code status from the hospital. All residents were a full code until an OHDNR was signed. -Social services reviewed code status when a resident admitted to the facility. If a resident wanted his/her code status as DNR, social services followed up on the OHDNR until the physician signed it. -Staff reviewed each resident's code status during every care plan meeting to ensure the facility followed the resident's wishes. -Staff could find a resident's code status in the resident's chart, in the electronic health record, and on the nameplate located outside of the resident's room. -Code status should be consistent in each of these places. During an interview on [DATE], at 2:08 P.M., the MDS Coordinator said the following: -He/she did not include the resident's code status in the care plan. -He/she would look at the top of the page in the resident's electronic health record to see resident's code status. -Staff could also find a resident's code status on the outside of the resident's door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility staff failed to obtain a physician order and provide proper cleaning and maintenance for a Bilevel Positive Airway Pressure (BIPAP - a machine used to help a person breathe) for one resident (Resident #37) out of a selected sample of 17 residents. The facility census was 42. Record review of the facility's BIPAP Administration policy, from the Nursing Guidelines Manual, dated March 2015, included the following: -Purpose to administer positive airway pressure to maintain open airway to the resident with obstructive apnea or respiratory problems breathing, primarily during sleep. -Care and use of BiPAP machine with cleaning mask, head gear, tubing and humidifier same as the CPAP (continuous positive airway pressure) guidelines. Record review of the facility's CPAP Administration policy, from the Nursing Guidelines Manual, dated March 2015, included the following information: -Contact QA (quality assurance) nurse prior to placement for clarification of orders and support; -Use during periods of sleep: -Check the physician's order for pressure setting and method of administration; -CPAP machine should be placed on table near bed; -Fill humidifier with distilled water to appropriate level (optional may use tap water); -Assist resident as needed with applying and adjusting CPAP mask and head strap; -Clean or change the filter at the air intake of the machine to keep internal parts from accumulating dust; -Use a wet cloth or cleaning wipe to clean the outside of the CPAP machine; -Reusable filter: Remove the back of the filter from the CPAP machine. Clean the back filter weekly by running it under warm tap water, squeezing the water out of it until it runs clear of dust; -Blot the filter dry with a clean dry cloth, replace it in the machine. Replace this filter with a new one once a year; -Disposable filters are to be replaced monthly or whenever torn or discolored. The white disposable filters may not be washed. Not all machines have white disposable filters; -For safety, unplug the unit when cleaning. Begin with wiping the outside of the CPAP unit with a damp cloth. Let air dry; -Inspect the filters on the unit. One filter is usually a foam material that is easily taken out from the device by pinching the middle of the foam. The filter is normally found in the rear of the unit, but check the manual if it is not found. This filter should be cleaned with water and mild soap once every two weeks of use. The inner filter that is ultra fine should be replaced every 30 days of use. If it appears dirty before 30 days, replace it. Do not clean the white filter. -The tubing should be cleaned weekly. Particles from the air can gather in the tubing through use, and mold can even accumulate, which is dangerous to inhale. Remove the tubing from the device and rinse with water and mild soap, swishing the water back and forth through the tube and emptying. Rinse thoroughly and air dry. -The mask and nasal pillows connection can be wiped daily with a damp cloth and mild soap. Rinse and allow to air dry. -If the unit has a humidifier, check to make sure there is enough distilled/tap water in the unit. Clean the holding tank with a damp cloth and mild soap weekly. For disinfecting the holding tank, use vinegar and water mix and let sit in the holder for approximately 30 minutes. Rinse thoroughly and air dry. 1. Record review of Resident #37's face sheet (general resident information form) showed the following information: -admission date of 12/6/18 with a readmission date of 10/3/19; -Diagnoses included chronic obstructive pulmonary disease with acute (a severe and sudden onset) exacerbation (lung disease that causes obstructed airflow to the lungs), acute and chronic (long-developing) respiratory failure, and shortness of breath. Record review of the resident's care plan, dated 12/13/18, showed the following: -Chronic COPD with continuous oxygen; -discharged to the hospital on 9/23/19 for respiratory failure/COPD exacerbation; -Returned from the hospital with a BIPAP machine to use at night and oxygen continuously; -Sent to emergency room on [DATE] for respiratory failure/hypoxia (body or a region of the body deprived of adequate oxygen supply at the tissue level). Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/8/19, showed the following information: -Cognitively intact; -Independent with bed mobility and dressing; -Required supervision and setup with transfers; -Required supervision, oversight, and encouragement for walking in room/corridor, toilet use, personal hygiene, and bathing; -Used a walker for mobility. Record review of the resident's October 2019 physician order sheet (POS) showed the following: -No order for the resident to use the BIPAP machine; -No order for maintenance/cleaning of the BIPAP machine. -An order dated 10/3/19 for oxygen 2 liters per minute per nasal cannula, continuous. An observation on 10/21/19, at 10:10 A.M., showed the resident sat, on the padded seat of his/her rolling walker, near his/her bed. The resident had the BIPAP mask on his/her face. The BIPAP machine was on with the oxygen concentrator's tubing connected to the machine delivering 3.5 Liters per minute of oxygen. During an interview on 10/24/19, at 11:54 A.M., Registered Nurse (RN) A said the following: -The resident used a CPAP before he/she discharged to the hospital. He/she readmitted to the facility with a BIPAP. The respiratory services staff member, who delivers the BIPAP machine, sets it up and shows the nurse working the resident how to use the BIPAP machine. The nurse then passes that information to other nurses who also pass the information to nurses until all of the nurses know how to use the machine. -The nurse did not know if the physician wrote an order for the resident's BIPAP machine, but the resident should have a physician's order; -Staff should clean the BIPAP machine and there should be a policy related to the BIPAP. During an interview on 10/24/19, at 12:03 P.M., the Director of Nursing (DON) said the following: -The resident should have an order for his/her BIPAP machine; -When respiratory therapy staff set up the resident's BIPAP machine, he/she in-serviced the nurse on shift on how to use and maintain the BIPAP machine. Because the in-service did not include all nursing staff, there was probably a lack of communication for other nurses. -The DON educated the nurses, via a paper in-service, on how to use and clean the BIPAP machine, but not all of the nurses signed the paper. -The physician's orders for the use of a BIPAP machine should also include cleaning instructions. The charge nurse who admitted the resident should transcribe the cleaning orders to the treatment administration record (TAR) for staff to initial when completed. The DON and MDS coordinator could also enter orders into the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician's orders for side rail usage and failed to complete timely side rail assessments to include bed rail safety checks, and regular inspections/measurements on the potential entrapment zones of the mattress to bed frame for two residents (Resident #2 and Resident #241) in a selected sample of 17 residents. The facility census was 42. Record review of facility records showed the facility did not provide a policy regarding side rail assessment and assessments (measurements) of potential entrapment zones. 1. Record review of Resident #2's face sheet (general resident information form) showed the following information: -admission date of 4/4/16 with readmission date of 4/4/19; -Diagnoses included quadriplegia (paralysis of the arms, legs, and truck of the body below the level of an associated injury to the spinal cord), muscle weakness, epilepsy (seizures), and head injury. Record review of the resident's side rail assessment and consent, dated 3/31/17, showed the following: -Unable to walk; -Comatose, semi-comatose, or fluctuates in level of consciousness; -Poor bed mobility/difficulty moving to a sitting position on the side of the bed; -Difficulty with balance or poor trunk control; -Resident was in a vegetative state and prone to seizures; -Reasons marked for side rail usage: Assist with transfer, bed mobility (assist with turning side to side), and assist with medical conditions; -Half rails on the left and right sides when the resident laid in bed to assist with positioning or transfers. Record review of resident's care plan, dated 4/17/19, showed the following information: -Ensure padded side rails are up when the resident laid in bed; -Ensure seizure pads are on side rails when the resident laid in bed; -Ensure seizure alarm was working; -Footboard padded with sheepskin to protect the resident's feet when he/she moved his/her legs. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/18/19, showed the following information: -Cognitively impaired; -Dependent on two staff for bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene; -No impairment in range of motion for upper and lower extremity. Record review of the resident's October 2019 physician order sheet (POS) showed no physician's order for side rails/padded side rails. Record review of the resident's medical record showed: -No documentation staff completed side rail assessments after 3/31/17 -No documentation staff completed an assessment (measurements) of potential entrapment zones related to side rails use. Observations on 10/22/19 at 9:03 A.M.,10/23/19 at 8:31 A.M., and 10/24/19 at 1:08 P.M., showed the resident laid in bed with both full length, padded side rails elevated. During an interview on 10/24/19, at 11:54 A.M., Registered Nurse (RN) A said the resident had full-length side rails, in the up position, anytime he/she laid in bed. Staff padded the resident's side rails to prevent his/her feet and arms from getting stuck between the rails. During an interview on 10/24/19, at 1:14 P.M., Certified Nurse Aide (CNA) D said any time the resident laid in bed, staff elevated his/her side rails. During an interview on 10/24/19, at 2:08 P.M., the MDS Coordinator said the following: -Resident had full-length side rails on his/her bed, for seizure precautions, since admission. -The MDS coordinator did not know if any one measured the resident's side rails for entrapment because she did not work at the facility when the resident originally admitted to the facility. -She did not complete an assessment for entrapment including measuring the resident's side rails. 2. Record review of Resident #241's face sheet showed the following information: -admission date of 11/21/17 with a readmission date of 10/17/19; -Diagnoses included cerebral palsy (affects movement, muscle tone, and/or posture), abnormal posture, muscle weakness, and muscle contracture of multiple sites. Record review of the resident's side rail assessment and consent, dated 7/23/18, showed the following: -Unable to walk; -Poor bed mobility; -Used side rails to assist with transfers and bed mobility; -Quarter-length side rails to assist with positioning and transfers; -Staff completed the assessment of potential entrapment zones related to side rail use. Record review of the resident's medical record showed no documentation staff completed side rail assessments or assessments (measurements) of potential entrapment zones after 7/23/18. Record review of resident's care plan, dated 11/29/18, showed the following: -Poor safety awareness; -History of rolling out of bed; -Therapy applied a side assist rail to the resident's bed to provide safety and independence with transfers; -Staff to assist the resident with all transfers; -Encourage the resident to position self in the middle of the bed so he/she did not roll out of bed when asleep; -Poor insight into health conditions, limitations, and safety. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance for transfers; -Used a wheelchair for mobility. Record review of the resident's October 2019 POS showed no physician's order for side rails. Observations showed the following: -On 10/22/19, at 11:45 A.M., the resident laid in bed with the left quarter-length side rail, located at the top side of the bed, elevated; -On 10/23/19, at 3:41 P.M., the resident laid sideways, in bed, with the left half-length side rail, elevated. The resident's right hand laid between the side rail and mattress. During an interview on 10/24/19, at 11:54 A.M., RN A said he/she did not know how long resident had the side rail. He/she used the side rail to pull himself/herself up in bed. During an interview on 10/24/19 at 2:08 P.M., the MDS Coordinator said the following: -Therapy requested side rails for the resident's bed to assist with transferring and positioning; -He/she did not obtain measurements of potential entrapment zones. 3. During an interview on 10/24/19, at 12:03 P.M., the Director of Nursing (DON) said the following: -The facility has a side rail process, which included measuring the bed for safety purposes. -The MDS coordinator obtained the measurements when he/she completed the side rail assessment. -The MDS coordinator completed side rail assessments quarterly to ensure the resident was not at risk for entrapment; -Staff include side rail usage in the care plan; -Therapy assessed residents' need for side rails to assist with positioning. The DON did not know if therapy staff measured the mattress or side rails. 4. During an interview on 10/24/19, at 2:08 P.M., the MDS Coordinator said the following: -Residents should have a physician order for side rails; -She measured the side rails and bed frame when the side rails are installed and annually, when she completed the bed rail assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pneumococcal vaccines (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection) to four residents (Resident #6, #10, #14, and #38) following the residents' admission to the facility, and staff failed to obtain a consent prior to administering an influenza vaccine for two residents (Resident #5 and #39) The facility census was 42. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23) for all adults 65 years or older regardless of previous history of vaccinations with pneumococcal vaccines, and people 19 to [AGE] years old with certain medical conditions including chronic medical condition. Record review of the facility's policy titled Immunizations, dated April 2016, showed the following: -A signed consent by the resident or resident representative must be obtained prior to administering vaccinations; -A physician order will be obtained to administer the vaccine; -The facility will offer influenza vaccinations annually; -The facility will offer the Prevnar 13 and the Pneumovax 23 vaccinations; -If a resident's pneumococcal vaccination history is unknown, the resident will be offered the Prevnar 13, then wait one year and offer the Pneumovax 23; -If the resident has received a Prevnar 13 vaccination the Pneumovax 23 will be offered one year later. Record review of the facility's Immunization Consent or Refusal form, dated April 2016, showed the following: -If the resident or responsible party sign that consent is given for the immunization to be administered they will not have to resign the form for the remainder of the resident's stay at the facility. If there is a change in the decision to consent for the immunization they must notify the facility of this decision change. 1. Record review of Resident #6's face sheet, (a document that gives a resident's information at a quick glance) showed the following: -admitted on [DATE]; -Diagnoses included pulmonary edema (excess fluids in the lungs), and reduced mobility; -No contraindications to pneumonia vaccines. Record review of the resident's physician orders showed an order, dated 4/20/17, directing staff to administer Pneumonia vaccines, as needed, unless contraindicated or refused. Record review of the resident's Immunization Consent, dated 4/25/17, showed the resident's responsible party consented for the resident to receive the pneumococcal vaccines. Record review of the resident's Preventative Health Care Record, dated 4/20/17 to 10/23/19, showed the resident did not receive the Prevnar 13 or the Pneumovax 23 immunizations. During an interview on 10/22/19, at 9:45 A.M. the resident said he/she did not remember receiving any pneumonia vaccines at the facility. The resident wanted to receive the pneumonia vaccines. 2. Record review of Resident #10's face sheet showed the following: -admitted on [DATE]; -readmitted from hospital on 1/7/19 -Diagnoses included chronic obstructive pulmonary disease (COPD-a lung disease that blocks airflow and makes it difficult to breathe and heart failure). Record review of the resident's Immunization Consent, dated 10/8/15, showed the resident's responsible party consented for the resident to receive the pneumococcal vaccines. Record review of the resident's physician orders showed an order, dated 1/7/19, directing staff to administer Pneumonia vaccines, as needed, unless contraindicated or refused. Record review of the resident's Preventative Health Care Record, dated 10/8/15 to 10/23/19, showed the resident did not receive the Prevnar 13 or the Pneumovax 23 immunizations. 3. Record review of Resident #14's face sheet showed the following: -admitted on [DATE]; -Diagnoses included history of pneumonia, history of bronchitis (inflammation of bronchial tubes that carry air to and from the lungs), and history of respiratory infections; -No contraindications to Pneumonia vaccines. Record review of the resident's physician orders showed an order, dated 1/22/15, directing staff to administer Pneumonia vaccines, as needed, unless contraindicated or refused. Record review of the resident's Immunization Consent, dated 1/22/15, showed the resident's responsible party consented for the resident to receive the pneumococcal vaccines. Record review of the resident's Preventative Health Care Record, dated 1/22/15 to 10/23/19, showed the following: -On 4/29/18, staff administered a Prevnar 13 vaccine to the resident; -Staff did not administer a Pneumovax 23 immunization to the resident. During an interview on 10/22/19, at 8:47 A.M., the resident said he/she did not want to take any chances of getting pneumonia and wanted to receive all vaccines recommended to prevent it. 4. Record review of Resident #38's face sheet showed the following: -admitted on [DATE]; -Diagnoses included heart failure and weakness; -No contraindications to Pneumonia vaccines. Record review of the resident's physician orders showed an order, dated 9/27/19, directing staff to administer Pneumonia vaccines, as needed, unless contraindicated or refused. Record review of the resident's Immunization Consent, dated 9/27/18, showed the resident consented to receive the pneumonia vaccines. Record review of the resident's Preventative Health Care Record, dated 9/27/18 to 10/23/19, showed the resident did not receive the Prevnar 13 or the Pneumovax 23 immunizations. During an interview on 10/24/19, at 9:12 A.M., the resident said he/she wanted to receive any pneumonia vaccines that are recommended. 5. Record review of Resident #5's face sheet showed the following: -admitted on [DATE]; -Diagnoses included dementia and age-related debility. Record review of the resident's physician orders showed an order, dated 1/14/16, directing staff to administer the the influenza vaccine annually unless contraindicated or refused. Record review of the resident's Immunization Consent, dated 1/14/16, showed the resident's responsible party refused consent for the resident to receive the influenza vaccine. Record review of the Resident's Preventative Health Record, dated 1/14/19 to 10/23/19, showed on 10/05/19 staff administered an influenza vaccine to the resident. 6. Record Review of Resident #39's face sheet showed the following: -admitted [DATE]; -readmitted from hospital on 9/21/18; -Diagnoses included amputation between unspecified hip and knee, anxiety disorder, major depressive disorder, and insomnia. Record review of the resident's brief Interview for mental status (BIMS - an assessment tool completed by facility staff to determine resident's level of cognition), dated 10/8/19, showed the resident had no cognitive impairment. Record review of the resident's physician orders showed an order, dated 9/21/19, directing staff to administer the the influenza vaccine annually unless contraindicated or refused. Record review of the resident's Immunization Consent or Refusal, dated 7/28/14, showed the resident refused consent to receive the influenza and pneumococcal vaccines. Record review of the resident's progress notes, dated 10/14/18, showed a nurse documented the resident received an Influenza Vaccine in his/her left arm. During an interview on 10/23/19, at 2:38 P.M., the resident said he/she did not want to take the flu shot, but felt he/she had to so he/she would not have to wear a mask if another resident in the facility had the flu. 7. During an interview on 10/24/19, at 9:21 A.M., Registered Nurse (RN) RN A said the following: -The charge nurse, the Minimum Data Set (MDS) Coordinator, or the Director of Nursing (DON) administer immunizations to the residents by; -The MDS Coordinator and DON made a list of residents who needed a vaccination, after they checked the residents' consent forms; -Staff educate the residents on the risks and benefits of receiving the pneumococcal and influenza vaccines. 8. During an interview on 10/24/19, at 9:41 A.M., the DON said if a resident received pneumococcal or influenza vaccines prior to admission, staff should obtain and maintain that information in the resident's medical record. The facility followed the Centers for Disease Control's guidelines for providing pneumococcal vaccines to residents. The facility should offer and administer (if the resident consented) the Prevnar 13 and the Pneumovax 23 vaccines to the residents, waiting one year between the two vaccines. Staff should document all vaccinations in the resident's Preventative Health Record. Staff should check the resident's consent forms before administering the vaccines. If a resident or responsible party changed his/her consent, the resident or responsible party should sign a new consent form indicating the consent or refusal of the vaccines. If a resident or responsible party refused the vaccines, staff should not administer the vaccines to the resident.