Based on observation, interview, and record review, the facility failed to ensure one resident with mental disorders (Resident #3) of 22 sampled residents, received individualized treatment and services to meet the resident's needs. The facility failed to implement interventions consistent with Resident #3's plan of care to address his/her behaviors and psychosocial needs. The resident refused medications off and on for a few months and became easily irritated and aggressive. This resulted in verbal and physical altercations with other residents. On 8/10/25, the resident threatened a staff member and another resident got involved. A physical altercation occurred between the two residents and Resident #3 sustained a fracture of the medial orbital wall (eye socket nearest the nose) on the right side. Staff failed to consistently identify the root cause for the resident's behaviors and implement interventions to meet the resident's psychosocial needs. The facility census was 174.Review of the facility policy Behavioral Health Services, dated 10/13/24, showed the following:-The purpose of the policy is to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning;-Mental disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities;-Non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being;-Behavioral health encompasses a residents' whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders;-The facility must ensure behavioral health services are provided;-The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Conditions that are frequently seen in residents and may require the facility to provide specialized services and supports based upon residents' individual needs, include, but are not limited to depression, anxiety and anxiety disorders, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves that can cause hallucinations, delusions and disorganized thinking including paranoia), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs);-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety;-Staff will monitor the resident closely for expression or indication of distress, evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable; assess and develop a person-centered care plan for concerns identified in the resident's assessment, share concerns with the Interdisciplinary Team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis, accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record, ensure appropriate follow up assessments if needed, and evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident;-The care plan shall have interventions that are person-centered, evidence based, trauma informed, and in accordance with professional standards of practice;-Non-pharmacological interventions include exercise, individualizing sleep and dining routines, supporting the resident through meaningful activities that match his/her individual abilities, interests and needs, focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities, offering verbal reassurance, especially in terms of keeping the resident safe and acknowledging the resident's experience is real to him/her, assisting residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem solving therapy, and providing support with skills related to verbal de-escalation, coping skills, and stress management. 1. Review of Resident #3's undated face sheet showed the resident had diagnoses that included insomnia (inability to sleep) due to other mental disorders, unspecified psychosis (a mental state where a person loses contact with reality, experiencing symptoms like hallucinations (seeing or hearing things not there) and delusions (false beliefs), along with disorganized thinking and speech) not due to a substance or known physiological condition, generalized anxiety disorder, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder, depressive type (a combination of symptoms of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and mood disorder, such as depression). Review of the resident's Preadmission Screening and Resident Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 11/15/19, showed the following:-The resident had a serious mental illness;-The recommended services were to implement plans to change inappropriate behavior, provision of a structured environment, drug therapy and monitoring, and crises intervention services;-Current psychiatric diagnoses of schizophrenia and schizoaffective disorder;-The resident was put under guardianship when he/she tried to poison a family member and walked around with a machete;-The resident had sleep disturbances, decreased concentration, isolation, grandiosity, anhedonia (inability to experience joy or pleasure), intrusive thoughts, hallucinations, thought disorganization, thought blocking, delusions, and paranoia;-The resident did not make good decisions, did not follow complex directions, could not stay on task or complete assignments;-The resident was dependent on staff for medication monitoring;-The resident had very little insight and he/she was in complete denial of his/her issues;-The resident should be monitored in a skilled nursing facility for refusal of food, refusal of cooperativeness with activities of daily living (ADLs), increase isolative behaviors, anger outbursts, and an increase in paranoia/psychosis that may signal an exacerbation of his/her illness. Promptly report to the resident's psychiatrist;-The resident should be monitored for the following; medication administration, address, report and implement a plan to manage the resident's refusal or noncompliance;-A secured unit was recommended. Review of the resident's quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/13/25, showed the following:-The resident was cognitively intact;-The resident had moderate depression;-The resident had no verbal, physical or other behaviors toward others;-The resident had no delusions or hallucinations;-The resident did not reject cares. Review of the resident's Physician Order Sheet (POS) showed the following orders:-Ariprprazole 10 milligrams (mg) for schizophrenia two times a day at 7:00 A.M. and 4:00 P.M., start date 10/28/24;-Buspirone 20 mg for general anxiety three times a day at 7:00 A.M., 11:00 A.M., and 4:00 P.M., start date 10/28/24;-Melatonin 3mg for insomnia due to other mental disorders in the evening, start date 3/16/25; -Quetiapine 50 mg for schizophrenia in the evening, start date 3/16/25;-Trazodone 50 mg for insomnia due to other mental disorders in the evening, start date 3/16/25. Review of the resident's Psychiatric Nurse Practitioner's note, dated 6/28/25, showed the following:-The resident was seen for follow up management of schizophrenia and anxiety;-The resident refused medications per the staff and refused care at times;-The resident reported to the Psychiatric Nurse Practitioner he/she was poisoned at his/her last visit to the hospital. The resident was responding to internal stimuli;-The resident was anxious, irritable/angry;-The resident had increased hallucinations, worsened delusions, fair to good judgement and limited to poor insight. Review of the resident's Medication Administration Record (MAR), dated 7/14/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 7/17/25, showed the resident did not exhibit any behaviors. Review of the resident's progress note, dated 7/19/25, showed the following:-A behavior symptoms and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's MAR, dated 7/20/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 7/22/25, showed the following:-The staff heard the resident yelling at his/her roommate in their room;-Staff responded immediately. The roommate sat on his/her bed and Resident #3 said the roommate stood at his/her bedside;-A proactive Code [NAME] (an overhead page that alerted staff a resident was having a behavioral emergency) was called because Resident #3 continued to yell and scream;-Resident #3 and his/her roommate were separated. Resident #3 was calmed down by staff. The roommate requested to move to another room;-No further concerns and no physical contact were made by either resident;-There was no documentation staff notified the Director of Nursing (DON), Administrator, physician, or guardian. Review of the resident's MAR, dated 7/23/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR, dated 7/24/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 7/26/25 at 4:38 A.M., showed the following:-A behavior symptom and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's progress note, dated 7/26/25 at 3:00 P.M., showed the following:-A Code [NAME] was called about 3:00 P.M.;-Resident #3 made verbal threats towards another resident because the other resident stared at Resident #3 and then he/she pushed the other resident;-The two residents were separated;-Resident #3 was redirected but he/she made delusional and irrational statements, had a loss of cognitive thought, paced back and forth, and continued to make verbal threats toward the other resident;-The psychiatric physician was called, and an order obtained to send the resident to the hospital for evaluation;-The resident left the facility about 6:00 P.M. Review of the resident's progress notes showed no documentation the resident returned to the facility, or if there were any new orders received, that staff completed an assessment of the resident or staff provided any additional monitoring of the resident upon return to the facility. Review of the resident's progress note, dated 7/27/25 at 11:13 A.M., showed the resident refused to meet with the Interdisciplinary Team (IDT) and no other attempts were made to meet with the resident. Review of the resident's MAR, dated 7/28/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record the staff notified the physician resident refused medication. Review of the resident's care plan, dated 7/30/25, showed the following:-The resident displayed impaired thought process related to mental illness;-Administer medications as ordered;-Intensive monitoring per unit protocol to ensure protective oversight;-Physician/psychological consult as needed;-Provide one-on-one visits as needed/requested for verbalization of feelings and concerns related to room, roommate, unit, and placement and attempt to resolve areas of upset promptly as needed/able;-The resident was at risk for alteration in mood/behavior related to schizophrenia. He/She had a history of auditory and visual hallucinations, delusional thoughts that his/her food was being poisoned, paranoid/angry, physically threatening, poor hygiene and medication noncompliance;-Attempt to redirect negative behavior to more positive behavior choices;-Monitor mood/behavior changes, report to physician as needed;-Notify guardian, physician, administration if behavioral emergencies occur;-The resident preferred morning medications administered at 11:00 A.M., evening medications administered at 4:00 P.M. and evening medications administered at 11:00 P.M.;-The resident had a history of behavioral challenges that require protective oversight in a secure setting;-Coping skills were sleeping, watching TV, and listening to music;-Non-pharmacological interventions were one-on-one as needed, listening to music, Xbox, outdoor activities, alone time in his/her room, and smoking;-Pharmaceutical interventions as needed;-The resident's safety plan included: warning signs are starting to get angry, review medications with the resident to ensure he/she understood what medication he/she took and why, review the symptoms of his/her diagnoses to ensure that the resident understood them and may be able to identify them, review the resident's diagnosis and provide education if he/she didn't understand, movies are a distraction and a method of comfort, the resident liked to read to expand his/her learning and work toward goals, exercising worked in the past during a crisis moment;-Closely watch the resident for signs of anxiety and act before he/she lost control;-Staff should avoid the following triggers; too much stimuli, yelling, verbal threats from peers, being told no, taking accountability, being told what to do, and having to clean his/her room;-The resident displayed manifestations of behaviors related to his/her schizophrenia that may create disturbances that affect others;-Assist the resident to address the root cause of change in his/her behavior or mood as needed;-Resident was listed as part of the focus interviews with administration; Review of the resident's progress note, dated 7/31/25 showed the following:-A proactive Code [NAME] was called;-Resident #3 was upset with another resident about a lost speaker and a phone that Resident #3 had traded;-Environmental rounds were completed and the phone and speaker found and given back to Resident #3;-No more concerns;-There was no documentation staff notified the DON, Administrator, physician, or guardian. Review of the resident's progress note, dated 8/1/25, showed the following:-During a care plan meeting the resident walked out of the meeting because he/she did not get approved to leave the facility;-There was no documentation staff attempted to talk to the resident about being upset or attempted to help the resident calm down and use his/her coping skills. Review of the resident's MAR, dated 8/1/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/2/25, showed the following:-A behavior symptom and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's MAR, dated 8/2/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR dated 8/5/25, showed the following:-Aripiprazole was on order and not available for administration; -The resident refused to take buspirone 20 mg at 11:00 A.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR, dated 8/6/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, entered on 8/13/25 at 4:25 A.M. as a late entry, for a Code [NAME] that occurred on 8/7/25, showed the following: -Licensed Practical Nurse (LPN) C responded to a Code [NAME] for Resident #3;-When LPN C arrived, Resident #3 paced on the hall and the other resident was behind closed double doors in the TV/dining room;-LPN C tried to calm Resident #3 down. Resident #3 was upset because the other resident changed the channel on the TV;-Resident #3 yelled at staff, went to his/her room, and slammed the door;-Ten minutes later Resident #3 was in the dining room to eat dinner and showed no aggression;-There was no documentation staff notified the DON, Administrator, physician, or guardian. Review of the resident's progress notes, dated 8/7/25 at 4:40 P.M. as a late entry, showed the following:-Resident #3 was the aggressor in an incident;-Staff asked the resident if he/she felt safe, and the resident said yea;-Staff asked the resident if he/she needed to talk with someone, and the resident said no;-Staff asked the resident if he/she could name at least one staff member the resident felt safe to share his/her thoughts and the resident said none of you;-Staff asked the resident if he/she had any aftereffects from the incident and the resident said No, leave me alone. I am going to my room;-Staff asked the resident if he/she had any other needs/items that he/she would like addressed and the resident said no. Review of the resident's MAR, dated 8/7/25, showed the following: -The resident refused to take aripiprazole 10 mg at 7:00 A.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/8/25, showed the following:-A behavior symptoms and cognitive performance was completed;-The resident did not have hallucinations or delusions;-The resident did not display physical, verbal, or other behaviors towards others;-The resident did not reject any care;-The resident's current behavior was the same as it usually was. Review of the resident's MAR, dated 8/8/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take Trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's MAR, dated 8/9/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/10/25, showed the following:-A Code [NAME] was called on Resident #3;-Resident #3 threatened CMT R and said he/she was going to hit CMT R and walked towards the CMT;-Resident #4 told Resident #3 to calm down and that is when Resident #3 went towards Resident #4 and swung at him/her. Resident #3 did not make contact with Resident #4. Resident #4 swung and hit Resident #3 in the right eye;-Resident #4 was escorted off the hall;-Resident #3 was assessed but refused a complete skin assessment;-Resident #3 was sent to the hospital about 3:30 P.M. for a psychiatric evaluation. Review of the resident's Psychiatric Nurse Practitioner's note, dated 8/10/25, showed the following:-The resident was seen for follow up management of schizophrenia and anxiety;-The resident was paranoid, delusional, physically aggressive and refused medications;-The resident denied mental illness diagnosis, reported no insight into his/her psychiatric condition and was a poor historian;-During evaluation the resident responded to internal stimuli and displayed overt paranoia and delusional thinking;-After the Psychiatric Nurse Practitioner left the resident's unit, staff reported Resident #3 approached Certified Medication Technician (CMT) R in an aggressive manner. The resident yelled and accused CMT R of poisoning another resident;-Another resident attempted to de-escalate the situation and Resident #3 swung at the other resident. The other resident swung and hit Resident #3 above the right, upper eyelid;-Due to continued acute psychosis, poor insight, noncompliance with medication, and escalating aggression toward staff and residents, Resident #3 was transferred to the hospital for further stabilization;-The resident's refusal of all prescription medications contributed to an acute psychiatric decompensation. His/Her current symptoms were paranoia, delusions, responding to internal stimuli, and impaired judgement;-The resident's conditions and symptoms showed imminent intent (a situation where there's a significant possibility that serious physical or mental harm, death, or severe injury could occur at any moment), increasing hallucination, worsened delusions, and deterioration. Review of the resident's hospital discharge note, dated 8/10/25 at 5:59 P.M. showed the resident had a fracture of the medial orbital wall (eye socket nearest the nose) on the right side. Review of the resident's MAR, dated 8/10/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record staff notified the physician the resident refused medication. Review of the resident's progress note, dated 8/11/25 at 2:00 A.M., showed the resident returned to the facility. The hospital reported a fracture to the resident's right orbital lobe (eye socket). Review of the resident's progress note, dated 8/11/25 at 9:36 A.M., showed the following:-The DON spoke with the resident about medication refusals and the incident from the weekend;-The resident's right eye was purple and swollen;-The resident was calm when the DON educated him/her on the importance of taking his/her medication;-The resident did not make sense when he/she answered the DON's questions;-The DON asked the resident to take his/her morning medication and the resident said he/she did not need to take them all the time because there was nothing wrong with him/her and he/she had no psychological issues;-The resident stopped talking to the DON. Review of the resident's progress note, dated 8/11/25 at 11:36 A.M., showed the resident was sexually inappropriate with the couch and was educated on appropriate behavior. Review of the resident's progress note, dated 8/11/25 at 12:49 P.M., showed the guardian was notified by email and in person of the resident's medication refusals. Review of the resident's progress note, dated 8/11/25 at 3:30 P.M., showed the following:-Resident #3 was the aggressor in an incident;-Staff asked the resident if he/she felt safe, and the resident refused to answer;-Staff asked the resident if he/she needed to talk with someone, and the resident refused to answer;-Staff asked the resident if he/she could name at least one staff member the resident felt safe to share his/her thoughts and the resident said leave me alone;-Staff asked the resident if he/she had any aftereffects from the incident and the resident said leave me alone;-Staff asked the resident if he/she had any other needs/items that he/she would like addressed and the resident said, leave me alone. Review of the resident's progress note, dated 8/11/25 at 3:34 P.M., showed the following:-The IDT attempted to meet with the resident about the incident that took place with him/her and Resident #4 and Resident #3's medication refusals;-Resident #3 told the IDT he/she did not have any psychological diagnoses and therefore he/she did not need any medication;-The facility will continue to attempt medication administration. Review of the resident's care plan, dated 8/11/25, showed the following:-The resident had a physical altercation where he/she was the aggressor;-The resident was one-on-one until he/she was sent to the hospital;-Allowed time for resident to vent and verbalize feelings;-The resident was educated on appropriate behavior and social skills;-The resident randomly refused medications, not with a particular staff member. He/She said they poison him/her and the resident only needed to take them sometimes because he/she was not a psychotic. The resident said the physician said he/she did not have to take his/her medications;-The resident was offered counseling and refused;-No as needed medications were utilized. Observation of Resident #3 on 8/11/25 at 3:58 P.M. showed the following:-The resident had a swollen right eye with purple bruising extending around his/her eye, to above the eyebrow and onto his/her nose;-The resident had about a quarter inch size cut on his/her left lower lip. During an interview on 8/11/25 at 3:58 P.M., Resident #3 said the following:-He/She tried to turn in an inhaler to CMT R;-CMT R got upset because he/she knew a physician wouldn't let CMT R touch the inhaler;-Resident #4 hit him/her in the face and Resident #4's twin stepped on his/her belly and tried to rip it open (Resident #4 did not have a twin in the facility). Review of the resident's MAR, dated 8/11/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M. and 4:00 P.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record the staff notified physician the resident refused medication. Review of the resident's progress note, dated 8/12/25 at 11:07 A.M., showed the following:-The IDT met with the resident;-The resident expressed delusions. Review of the resident's MAR, dated 8/12/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M. Review of the resident's progress note, dated 8/12/25 at 2:50 P.M., showed the following:-The facility received notice the resident was accepted for an inpatient psychological evaluation;-Staff informed the resident and he/she immediately became aggressive. The resident was very delusional and talked in different voices;-The resident did finally agree to go to the hospital and left with a driver and two other staff members. During an interview on 8/12/25 at 9:34 A.M. Resident #4 said the following:-He/She and Resident #3 had each other by the shirt and swung at each other;-He/She hit Resident #3;-He/She did not have a problem with Resident #3, he/she just defended himself/herself. During an interview on 8/13/25 at 8:30 A.M. Nursing Assistant (NA)/Housekeeper I said the following:-Resident #3 has cussed NA I out and not let him/her clean Resident #3's room;-When Resident #3 did not take his/her medications, he/she yelled, cussed, would not let housekeeping clean his/her room and walked down the hallway and randomly hit others. During an interview on 8/13/25 at 8:41 NA H said the following:-Resident #3 acted aggressive and snapped at the littlest of things on 8/4/25;-Resident #3 got upset when Resident #15 kept changing the channel on the TV;-Resident #14 stood up and took off his/her jacket and Resident #3 thought Resident #14 was going to hit him/her;-NA S walked Resident #14 to his/her room and Resident #3 followed but nothing happened between them;-Resident [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure one resident, Resident #5, in a review of 17 sampled residents, was free from abuse when staff physically took the resident down to the ground and caused injury. The resident sustained injuries including a bruised chin, a swollen sprained right ankle, and bruising to the right knee. The resident felt staff abused him/her. The facility census was 177. Review of the facility's Abuse and Neglect Policy, last revised 06/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident and resident to resident altercations;-Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner;-Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment, or management;-Physical abuse also includes but is not limited to hitting, slapping, punching, biting, and kicking;-Physical abuse also includes corporal punishment, which is physical punishment used to correct or control behavior. Review of the facility's policy Behavioral Emergency Policy, dated 06/26/24, showed the following:-The facility is to provide safe treatment and humane care to the resident in a behavioral crisis;-Staff is to follow steps to ensure they correctly care for the resident in a behavioral crisis to ensure that the resident is not being coerced, punished, or disciplined for staff convenience;-Any emergency interventions have the potential for (re)traumatizing individuals;-Despite best intentions, decisions concerning the use of physical holds, and the administration of medication are necessarily made under less-than-ideal circumstances (i.e., emergencies), and involve the urgent weighing of significant risks versus the benefits of physical safety;-Therefore, such emergency interventions as the use of physical holds and the administration of medication are to be avoided as possible.-Use of physical holds and the administration of medication is seen as a safety intervention of last resort, rather than a treatment intervention per se, and its usage should be a crisis event;-An organizational philosophy of giving the highest priority to all non-violence is to be articulated in all policies, procedures, and practices;-Practices that are sensitive to those with a history of trauma are to be in place;-Non-Physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention;-The facility's approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible;-Care will be guided by the resident's plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. Review of the facility's Crisis Assessment Linkage and Management (CALM) training manual, undated, showed the following:-Before beginning a discussion on the use of restraints it is important to consider the potential negative outcomes;-When it becomes necessary to physically control a client, the risk of physical and emotional trauma to both the resident and staff member was significant;-Without question the therapeutic relationship would suffer;-Careful consideration was necessary before involving the use of restraints;-Methods to prevent the use of restraint needed to be included in the policies as well as the expected behaviors of staff members;-Control positions, Seclusion or Restraint are never to be used for punishment. Review of the facility's Crisis Prevention Institute (CPI) training manual, dated 2023, showed the manual included no direction for staff to physically take a resident to the floor. 1. Review of Resident #5's Preadmission Screening and Resident Review, dated 09/14/21, showed the following:-Diagnoses included watershed brain damage (occurs when blood flow is reduced or blocked in the border zones between the major arteries supplying the brain) from seizures at the age of five years old, bipolar disorder (periods of mania and depression), anxiety, impulse control disorder, major depressive disorder, attention deficit and hyperactivity disorder (ADHD), oppositional defiant disorder (ODD is a condition where a person is defiant/argumentative), borderline intellectual functioning (having a low IQ);-The resident had self-harming behaviors and was aggressive with staff;-The resident has poor impulse control;-The resident can be verbally and physically aggressive towards the staff and others and required supervision;-The resident required behavioral therapy two times per week;-The resident required a Crisis Plan that should identify clear steps that will be taken to support individual during a crisis, specify who to contact for assistance, how staff should work together with individual during the crisis, as well as identify when the physician, emergency medical services and/or law enforcement should be contacted.-The facility may also wish to utilize DMH Behavioral Health Crisis Hotline: https://dmh.mo.gov/mentalillness/progs/acimap.html Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 04/13/25, showed the following:-Cognitively intact;-Moderate symptoms of depression;-No hallucinations, delusions, behaviors, or rejection of care;-Required supervision from staff for Activities of Daily Living (ADL);-Resident was 63 inches in height and weighed 139 pounds. Review of the resident's Care Plan, updated 04/22/25, showed the following:-The resident had a history of behavioral challenges that required protective oversight in a secure setting;-Can be verbally and physically aggressive;-CALM technique, if needed;-Coping skills included karaoke, bingo, yoga, and calls from family;-Non pharmaceutical interventions: One-on-one;-Pharmaceutical interventions as needed;-Behaviors include anxiety, poor decision-making, bad judgement, depression, agitation, and suicidal ideation;-If you see the resident exhibiting any behaviors listed in the current behaviors section, refer to preferred coping skills immediately;-Warning signs for the resident included the resident may start popping off at the mouth, saying I don't care, saying mean things to hurt others;-His/Her crisis moments are triggered when he/she was told no;-The resident can be distracted and comforted with sleeping, playing cards, or taking a shower;-The resident can expand his/her learning and work toward his/her goals by listening and coping;-During past crisis moments listening to music and watching the Golden Girls helped the resident;-Coping skills included watching television, listening to music, taking naps, word searches, and talking to his/her parent. Review of a facility surveillance video from 07/16/25 of an incident with the resident and staff showed the following:-The resident is seen standing and not showing signs of agitation; the resident appeared calm. The resident was not moving his/her body or displaying any type of threatening behavior with his/her body. The resident stood still. There was no sound, but there was no indication the resident was yelling or resisting staff in any way;- Night Shift Supervisor (NSS) D stood on the resident's left side next to the resident and had his/her right arm under the resident's left arm, NA G stood on the resident's right side with his/her left arm under the resident's right arm;-NA F came up behind the resident, knelt and held the resident's left leg (placement of his/her hands was not visible on the video);-Licensed Practical Nurse (LPN) H stood behind the resident and was not touching the resident.-NSS D looked behind the resident and nodded to NA F, then turned his/her head back around and nodded again;-At this time NSS D, NA G, and NA F moving quickly, all with hands on the resident, took the resident face down to the floor. The resident's head and right leg were not secured or protected by staff;After NSS D, NA G and NA F took the resident to the floor, LPN H quickly moved toward the resident. Review of the resident's Physician's Order Sheet, dated 07/16/25, at 10:45 P.M., showed an order for Chlorpromazine 25 milligrams/milliliter, inject 25 milligrams intramuscularly every 24 hours as needed for increased agitation/irritation for 14 days. During an interview on 08/06/25, at 1:43 P.M., the resident's family member said he/she met the resident at his/her physician appointment on 07/17/25. When the resident arrived at the appointment, the resident had a large bruise on his/her chin. The physician asked the resident about it several times and the resident seemed afraid to answer. The resident kept saying he/she didn't know how it happened. The resident told him/her later that NSS D did it when he/she took the resident to the floor and that the resident's right leg and ankle hurt. Review of the resident's Nursing Progress Notes dated 07/19/25, at 1:44 P.M., showed the resident had a new bruise on his/her chin that was acquired in house, it was unknown how long it had been present. Observation on 07/19/25, at 11:30 A.M., showed the resident in his/her room. The resident had a quarter to half dollar sized purple bruise on his/her chin; his/her right ankle was swollen from the lower shin to halfway down the resident's foot, his/her malleolus (ankle bone) was not visualized because of the swelling and his/her shoe caused an indentation into his/her skin due to swelling. During an interview on 07/19/25, at 11:30 A.M. the resident said the following:-He/She was mad and threw the cigarette box on the floor;-Staff called a code green (behavioral emergency);-NSS D, NA F, NA G, and LPN H were there;-The resident said NSS D told him/her, I dare you to do it again, and so he/she threw the cigarette box on the floor again because it made him/her angry;-That made NSS D angry;-NSS D and NA F took him/her down to the ground;-He/She hit the ground hard;-Staff did not protect his/her head or right leg;-When he/she went down it hurt his/her chin, right leg, and ankle because they put him /her down hard and he/she hit the floor hard;-He/She felt like NSS D did the take down hard on purpose, like he/she tried to hurt him/her to teach him/her a lesson;-He/She felt staff did not try to prevent his/her injury and that they were abusive to him/her. During an interview on 07/19/25, at 11:40 A.M. Resident #6 said the following:-He/She saw staff take Resident #5 to the floor, but was not close enough to hear what staff said;-Staff slammed the resident to the floor;-Staff used excessive force, and they didn't do it the right way;-Staff did not have hold of Resident #5's head and did not have one of the resident's legs;-It was too rough. During an interview on 07/19/25, at 11:44 A.M. Resident #7 said the following:-He/She saw NSS D, LPN H, NA F, and NA G take Resident #5 to the ground;-It looked like Resident #5 hit the floor hard. During an interview on 07/21/25, at 4:05 P.M., NA G said the following:-On the night of 07/16/25 the resident got upset because he/she wanted to smoke another cigarette;-The resident threw the cigarette box off the medication cart;-The resident threatened to throw the cigarette box and was yelling, he/she did not hear the resident threaten staff or other residents, just to throw stuff;-Someone called a code green;-NSS D and LPN H responded, NA G and NA F were already there;-He/She did not hear anyone attempt to offer the resident any of his/her coping mechanisms but he/she could not hear everything;-NSS D instructed staff to take the resident down;-NSS D had the resident's left arm and he/she had the resident's right arm;-LPN H and NA F were behind him/her to get the resident's legs but he/she could not visualize their position;-They are supposed to have five staff members to do a proper take down but there were four, there was no staff to secure the resident's head;-The resident went down faster than he/she was used to and might have hit the ground harder compared to other times h/she had been involved in a takedown maneuver;-He/She and NSS D, LPN H, and NA G held the resident on the ground for one minute;-The resident had not made a threat against other residents or staff. During an interview on 07/21/24, at 7:40 A.M., NSS D said the following:-He/She was called to the unit for a code green;-Staff reported Resident #5 wanted another cigarette and was throwing things;-When he/she arrived on the unit the resident attempted to go back into the smoke room, so he stood in front of the door;-The resident threated to knock off the cigarette box again;-That is when he/she took the resident's left arm, NA G took the resident's right arm;-They did a five person procedure and took the resident face first to the ground;-They held the resident on the ground for about a minute until the resident calmed down;- NA F, NA G, and LPN H were the other staff that performed the take down with him/her; five employees were not available for the procedure;-The team lead was supposed to secure the resident's head, but they did not have five staff;-The resident had not threatened staff or residents, but had a history of physical behaviors so he felt like the resident needed to be taken down for safety;-LPN H should have had the resident's right leg, NA F was expected to have the resident's left leg;-He/She did not think the resident hit his/her chin on the floor;-During the code green he/she was the only one speaking to the resident;-He/She was not aware of the resident having any type of crisis program and did not know what the resident's care plan directed for de-escalating behaviors. During an interview on 07/19/25, at 2:26 P.M. the Assistant Administrator (AADM) said the following:-He reviewed the video of staff taking the resident to the floor on 07/16/25;-Staff did not report to administration the code green or that they had physically taken the resident to the ground;-Review of the video showed three staff touching the resident during the take down;-He felt like staff did not execute the CALM five person take down as instructed in CALM training;-Staff are supposed to use CPI techniques but all the training was not done. During an interview on 07/19/25, at 3:07 P.M., and 07/24/25, at 10:25 A.M., the Administrator (ADM) said the following:-Staff had not reported the code green or take down;-NSS D said the resident had two cigarettes and wanted a third cigarette and, when staff denied the resident getting a third cigarette, the resident knocked the cigarette box off the medication cart;-NSS D made the call to take the resident to the ground;-LPN H then gave the resident an injection of Thorazine (antipsychotic medication);-Staff are expected to report code greens and use of physical and chemical restraints;-The staff did not report this incident to administration. Complaint #2565905 and #2570073

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders and administer medications for three residents (Resident #15, #12, and #17) in a review of 17 residents. Resident #15 had diagnosis of congestive heart failure (CHF) and missed several doses of medications for fluid retention prior to a hospitalization for fluid overload. Resident #12 experienced increased pain from missing ordered pain medications. The facility reported their pharmacy had not supplied the medications. Many of the medications were available in the facility's eKit (emergency medication supply), but staff did not use the available medications to ensure resident's received administration of ordered medications. The facility census was 177. Review of the facility's policy Transcription of Orders/Following Physician's Orders, dated 05/18/24, showed the following:-The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section;-The Licensed/Registered Nurse will check the emergency kit to verify if the medication is present in the facility to begin immediately. If the medication is not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication is unable to be started within 24 hours of the order, the prescribing physician will be notified, and further orders will be obtained. If a stat medication is ordered, the physician will be made aware of facility availability in the case that an alternative is needed;-The Licensed Nurse will review electronic Medication Administration Records (MARs) &electronic Treatment Administration Records (TARs) on a routine basis to monitor formedications that were not administered to the resident due to unavailability, refusal, omission, etc.-If a medication is marked as not given, the reasoning for not being given should beexplained in the progress notes and the RCC, the DON/ADON/RN, and the Administrator must be notified. The Physician and Legal Guardian (if applicable) must also be notified. The nurse's progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have.-For Electronic MARS/TARS: The medication will be documented as not given byselecting the corresponding chart code for the reason why it was not given, and aprogress note will be written.-If the medication is unavailable, the Licensed Nurse will contact the pharmacy and have the medication delivered. If the resident is not going to receive their scheduled medication per Physician's Order, the Licensed Nurse will contact the Director of Nursing, The Administrator, Physician and Legal Guardian, if applicable. The RCC/Unit Manager/Designated Nurse will then follow any further orders that may be provided by the Physician.-The facility may utilize a stat or emergency medication kit or back up pharmacy todeliver the medication to the resident before the primary pharmacy can deliver.-The Nurse or CMT in charge of medication administration must review all their designated MARs and TARs prior to the end of their shift to ensure that all medications/treatments scheduled to be given on their shift were administered according to the physicians' order and that all necessary interventions were taken in the event of an omission.-The RCC/ Unit Manager/Designated Nurse will review all electronic MARs/TARs and compare all medications to the medications available for each resident in the facility weekly to ensure availability. Review of the facility's Emergency medication list (E-kit) inventory dated 07/24/25, showed the following available medications:- Bupropion (medication for depression) 75 milligram (mg) one on hand;- Cardizem (medication for blood pressure, irregular heartbeat) 30 mg six on hand-Clonazepam (medication for seizures and anxiety) 0.5 mg seven on hand;-Clonazapine (antipsychotic medication) 0 on hand;-Depakote Sprinkles (medication for seizures sometimes used as a mood stabilizer): DR 250 mg five on hand, ER 250 mg six on hand, ER 500 mg five on hand, sprinkles 125 mg six on hand and DR 500 mg seven on hand;-Farxiga (medication for heart failure, diabetes, and kidney failure) not available;-Furosemide (medication used to remove excess fluid) 20 mg eleven on hand;-Lyrica (medication used for nerve pain) 50 mg 15 on hand;-Metformin (medication used to control blood sugar) 500 mg seven on hand;-Metolazone (medication used to removed excess fluid) not available;-Montelukast (medication to treat seasonal allergies) not available;-Pantoprazole Sodium (medication to reduce stomach acid) not available;- Potassium (medication to replace potassium) 10 milliequivalent (mEq) six on hand;-Pravastatin (medication used to lower cholesterol) not available;-Spironolactone (medication which helps the kidneys remove excess salt and water from the body while retaining potassium) not available;-Sacubitril-Valsartan (medication used to treat congestive heart failure by reducing strain on the heart, and improved blood flow to the heart), not available;-Terazosin HCL (medication used for high blood pressure or enlarged prostate), not available;-Trazodone (antidepressant medication) 50 mg six on hand;-Vrayfar (antipsychotic medication for hallucinations, delusions, and mood stability), not available. 1. Review of Resident #15's Care Plan, updated 06/24/24, showed the following:-Resident is his/her own guardian;-Resident is highly functional and can take care of most of his/her needs;-Diagnosis include major depression, diabetes mellitus (inability to regulate blood sugar), high blood pressure, chronic ischemic heart disease, congestive heart failure;-Potential for fluid deficit related to diuretic (fluid medication) use;-Resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor;-Administer medications as ordered;-Monitor fluid intake and output per facility policy;-Monitor vital signs as ordered;-Notify physician of significant abnormalities;-Resident has impaired circulation related to edema;-Will be free from signs and symptoms of complications of poor circulation through next review. The resident's care plan did not include possible complications from fluid overload, or how to monitor fluid overload including giving diuretics as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 05/14/25, showed the following:-Cognitively intact;-Diagnoses included heart failure, high blood pressure, diabetes mellitus (inability to regulate blood sugar), depression, shortness of breath, swelling (edema), pain in ankle and foot, and chronic ischemic heart disease (a condition where the heart muscle doesn't receive enough blood flow due to narrowed or blocked coronary arteries); -Moderate to severe depression symptoms;-No hallucinations, delusions, behaviors, or rejection of care;-Requires supervision from staff for Activities of Daily Living (ADL). Review of the resident's Physician's Order Sheet (POS), dated 07/01/25, showed the following:-Metformin (medication used to manage blood sugar levels in people with type 2 diabetes) 1000 mg capsule two times daily morning and bedtime;-Metformin 500 mg capsule two times daily in the evening.-Spironolactone (medication which helps the kidneys remove excess salt and water from the body while retaining potassium) 50 mg daily for high blood pressure and heart failure;-Sacubitril-Valsartan (medication used to treat congestive heart failure by reducing strain on the heart, and improved blood flow to the heart) 24-26 mg one tablet every 12 hours for heart failure;-Bupropion (medication for depression) 300 mg capsule daily. Review of resident's weight record, dated 07/01/25-07/03/25, showed the following: -7/01/25 no weight;-7/02/25 498.2 pounds (lbs.);-7/03/25 501.2 lbs. Review of the resident's POS, dated 07/03/25, showed metolazone (medication used to treat fluid retention), 2.5 mg one time (administered on 07/04/25). Review of the resident's POS, dated 07/03/25, showed metolazone 2.5 mg 1 tablet by mouth before meals for weight gain for two days. Review of resident's weight record, dated 07/04/25-07/05/25, showed the following:-7/04/25 502.6 lbs.;-7/05/25 505.4 lbs. Review of the resident's Medication Administration Record (MAR), dated 07/05/25, showed the following:-Metolazone 2.5 mg capsule 12:00 P.M. dose not administered and marked 5 (hold/see progress note);-Metolazone 2.5 mg capsule 5:00 P.M. dose not administered 5 (hold/see progress note); Review of the resident's Nurses Note, dated 07/05/25 at 5:11 P.M., showed waiting on the pharmacy for the resident's metolazone. Review of the resident's POS, dated 07/06/25, showed metolazone 2.5 mg one time. Review of resident's weight record, dated 07/06/25-07/08/25, showed the following:-07/06/25 502.2 lbs.;-07/07/25 498.4 lbs.;-07/08/25 502.1 lbs. Review of the resident's Nurses Note, dated 07/08/25, at 5:23 P.M., showed notified the cardiologist of the resident's weight gain, received orders for labs. Resident is compliant with medications. Review of the resident's weight record showed staff documented no weight for 07/09/25. Review of the resident's MAR, dated 07/09/25, showed the following:-Metformin 1000 mg capsule 7:00 A.M. dose not administered 5 (hold/see progress note);-Metformin 500 mg capsule 5:00 P.M. dose not administered 5 (hold/see progress note);-Spironolactone 50 mg 7:00 A.M. dose not administered 5 (hold/see progress note);-Sacubitril-Valsartan 24-26 mg 9:00 A.M. dose not administered 5 (hold/see progress note); Review of the resident's Nurses Note, dated 07/09/25 at 11:00 A.M., showed waiting on the pharmacy for delivery of the resident's spironolactone, Metformin, and Sacubitril-Valsartan. Review of the resident's Nurses Note, dated 07/09/25, at 2:07 P.M., showed the primary care physician was notified that medications were currently not available in the facility due to a delay from the pharmacy. Contact made with pharmacy, who reported the medications were expected to arrive today. Director of Nursing, administration, management have been made aware. Review of the resident's Nurses Note, dated 07/09/25 at 4:15 P.M., showed waiting on the pharmacy for delivery of the resident's Spironolactone, Metformin, and Sacubitril-Valsartan. Review of the resident's weight record, dated 07/10/25, showed the resident weighed 503.4 lbs. Review of the resident's MAR, dated 07/10/25, showed bupropion 300 mg capsule 7:00 A.M. dose not administered 5 (hold/see progress note). Review of the resident's Nurses Note, dated 07/10/25 at 10:54 A.M., showed waiting on the pharmacy for delivery of the resident's bupropion. Review of the resident's Nurses Note, dated 07/10/25 at 11:19 A.M., showed the resident has been medication compliant. Review of the resident's weight record, dated 07/11/25, showed two weights documented for the resident 502.1 lbs. and 493.8 lbs. Review of the resident's weight record, dated 07/12/25, showed the resident weighed 504.4 lbs. Review of the resident's weight record, dated 07/13/25, showed the resident weighed 508.6 lbs. Review of the resident's Nurses Note, dated 07/13/25 at 9:13 A.M., showed the resident was short of breath while talking, with movement oxygen saturation dropped to the 7O's (normal oxygen saturations range from 95-100%). Resident refused oxygen. Resident has had significant weight gain in the last two days. Notified primary care physician and received orders to send out to be evaluated. Review of the resident's Nurses Note, dated 07/13/25 at 5:10 P.M., showed the resident was admitted to the hospital for fluid overload. Review of the resident's Hospital Physician Discharge summary, dated [DATE] at 10:05 A.M., showed the following;-Date of admission [DATE];-Presented with four-pound weight gain over his/her set limit of 505 lbs.;-admitted to cardiology service for treatment of his CHF exacerbation;-Received intravenous (medication give via a tube in a vein) medication to remove fluid;-Obtain weight daily taking weight at same time each day;-Continue medications for fluid;-Report any increase in symptoms or rapid weight gain;-Added medication for related to weight gain. Review of the resident's Nurses Note, dated 07/16/25 at 1:42 P.M., showed the resident returned to the facility. During an interview on 07/24/25, at 3:15 P.M., the resident said the facility kept running out of his/her medications. He/She had severe CHF, and the facility had been running out of the medications that keep the fluid off or had to wait a long time to get new medications ordered. He/She was hospitalized for CHF. It was miserable when he/she could not breathe from not having his/her medications. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses included bipolar disorder (a mood disorder), high blood pressure, anxiety, depression, post-traumatic stress disorder, chronic obstructive pulmonary disease, thyrotoxicosis (a condition in which there is an excessive amount of thyroid hormone in the body), pain, atrial fibrillation, and shortness of breath;-Moderate depressive symptoms;-No hallucinations, delusions, behaviors, or rejection of care;-Requires supervision from staff for Activities of Daily Living (ADL).-No scheduled pain medication, PRN medications used for pain, the resident denied having pain on the pain interview. Review of the resident's Care Plan, last updated 07/02/25, showed the following:-Diagnosis include fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), pain, gastro-esophageal reflux disease;-Resident reports fibromyalgia pain all over;-He/She has as needed pain medications he/she can request;-Administer medications as ordered;-Assist with diversional activities/distraction techniques as needed;-Report worsening pain symptoms and notify physician as needed;-Ongoing assessment of pain status;-Consult the physician as needed. Review of the resident's POS, dated 07/01/25, showed the following:-Lyrica 100 mg three times daily for acute (present or experienced to a severe or intense degree) pain;-Montelukast (medication to treat seasonal allergies) 10 mg daily;-Pantoprazole sodium (medication to reduce stomach acid) 20 mg daily;-Vrayfar (antipsychotic medication for hallucinations, delusions, and mood stability) 3 mg daily. Review of the resident's MAR dated 07/09/25, showed the following:-Montelukast 10 mg, 7:00 A.M. dose not administered 14 (awaiting medication);-Pantoprazole sodium 20 mg, 7:00 A.M. dose not administered 14 (awaiting medication);-Vrayfar 3 mg, 7:00 A.M. dose not administered 14 (awaiting medication); Review of the resident's Nurses Note, dated 07/09/25, at 2:01 P.M., showed the primary care physician was notified that medications were currently not available in the facility due to a delay from the pharmacy. Contact made with pharmacy, who reported the medications were expected to arrive today. Director of Nursing, administration, management have been made aware. Review of the resident's MAR dated 07/10/25, showed pantoprazole sodium 20 mg, 7:00 A.M. dose not administered 14 (awaiting medication); Review of the resident's Nurses Note, dated 07/10/25, at 3:07 P.M., showed the primary care physician was notified that medications are currently not available in the facility due to a delay from the pharmacy. Contact made with pharmacy, who reported the medications were expected to arrive today. Director of Nursing, administration, management have been made aware. Review of the resident's MAR dated 07/14/25, showed pantoprazole sodium 20 mg, 7:00 A.M. dose not administered 14 (awaiting medication); Review of the resident's MAR dated 07/19/25, showed the following: - Lyrica 100 milligram (mg) capsule at 7:00 A.M. dose not administered 14 (awaiting medication);- Lyrica 100 mg capsule 11:00 A.M. dose not administered 14 (awaiting medication);- Lyrica 100 mg capsule 4:00 P.M. dose not administered 14 (awaiting medication). Review of the resident's Nurses Notes dated 07/19/25, at 11:07 A.M., showed Lyrica 100 mg three times a day related to acute pain, medication was missing. Review of the resident's Nurses Notes dated 07/21/25, at 08:03 A.M., showed the resident had an appointment with the pain clinic on 07/18/25, with orders to refill Lyrica 100mg three times a day for 90 pills and follow up with the clinic in one month. Review of the resident's MAR dated 07/23/25, showed Vrayfar 3 mg, 7:00 A.M. dose not administered 14 (awaiting medication); During an interview on 07/24/25, at 3:52 P.M., the resident said the following:-He/She had been out of his/her inhalers and out of Lyrica all day on 07/19/25 (a Saturday); -He/She had fibromyalgia and did not get three doses of his/her Lyrica which left him/her in a lot of pain;-With Lyrica his/her pain was 4 (on a 1-10 scale with 10 being the worst pain), without the three doses of Lyrica his/her pain was an 8 or 9;-He/She ran out on Friday afternoon (07/18/25).-On 07/21/25 a nurse pulled two days' worth of Lyrica out of the Ekit, it was available over the weekend, but no one checked so he/she didn't get the medication all weekend. 3. Review of Resident #17's quarterly (MDS, dated [DATE], showed the following:-Cognitively intact;-Diagnoses included high blood pressure, diabetes mellitus, schizophrenia (mental condition that causes racing thoughts, hallucinations and delusions at times), bipolar, chronic obstructive pulmonary disease, neuropathy (dysfunction of one or more peripheral nerves, typically causing numbness or weakness), and liver disease,-Moderate depressive symptoms;-No hallucinations, delusions, behaviors, or rejection of care;-Independent to supervision with all ADLs and transfers except requires substantial to maximum assistance with lower body dressing and bathing. Review of the resident's MAR, dated 07/09/25, showed the following:-Cardizem 60 mg, 11:00 A.M. dose not administered 5 (hold/see progress note);-Cardizem 60 mg, 4:00 P.M. dose not administered 5 (hold/see progress note);-Clonazapine 250 mg, 4:00 P.M. dose not administered, 5 (hold/see progress note);-Pravastatin 40 mg, 5:00 P.M. dose not administered, 5 (hold/see progress note);-Terazosin HCL 2 mg, 5:00 P.M. dose not administered, 5 (hold/see progress note);-Trazodone 200 mg, 5:00 P.M. dose not administered, 5 (hold/see progress note); Review of the resident's Nurses Notes/Administration Note, dated 07/09/25, at 10:45 A.M., showed the resident's Cardizem 60 mg was not administered, ‘waiting on delivery'. Potassium 20 mEq was not administered, ‘waiting on delivery'. Review of the resident's Nurses Notes/Health Status Note, dated 07/09/25, at 2:08 P.M., showed the resident's medications were currently not available in the facility due to a delay from the pharmacy. Contact made with the pharmacy who reported the resident's medications were expected to arrive today. Director of Nursing, administration and primary care physician have been made aware. Review of the resident's Nurses Notes/Administration Note, dated 07/09/25, at 3:24 P.M., showed the resident's Cardizem 60 mg was not administered, ‘waiting on delivery'. Clonazapine 100 mg administer 2.5 tablet (250 mg) was not administered, waiting on delivery. Potassium 20 mEq was not administered, ‘waiting on delivery'. Review of the resident's MAR, dated 07/10/25, showed the following:-Farxiga 10 mg daily, 7:00 A.M. dose not administered 5 (Hold/See Progress Notes);-Metolazone 5 mg daily, 7:00 A.M. dose not administered 5 (Hold/See Progress Notes);-Cardizem 60 mg, 7:00 A.M. dose not administered 5 (hold/see progress note);-Cardizem 60 mg, 11:00 A.M. dose not administered 5 (hold/see progress note). Review of the resident's Nurses Notes/Administration Note, dated 07/10/25, at 6:46 A.M., showed the resident's Farxiga 10 mg was not administered, ‘waiting on pharmacy to deliver'. Cardizem 60 mg was not administered, ‘waiting on delivery'. Metolazone 5 mg not administered, ‘waiting on pharmacy to deliver'.Review of the resident's Nurses Notes/Administration Note, dated 07/10/25, at 6:51 A.M., showed the resident received methocarbamol 750 mg because the resident was experiencing muscle spasms.Review of the resident's Nurses Notes/Administration Note, dated 07/10/25, at 12:00 P.M., showed the Cardizem 60 mg was not administered, ‘waiting on pharmacy to deliver'.Review of the resident's Nurses Notes/Health Status Note, dated 07/10/25, at 3:25 P.M., showed the resident's medications were currently not available in the facility due to a delay from the pharmacy. Contact made with the pharmacy who reported the resident's medications were expected to arrive today. Director of Nursing, administration and primary care physician have been made aware. Review of the resident's MAR dated 07/11/25, showed staff documented 14 (according to the codes on the [DATE] means ‘awaiting medication') for the resident's Clonazepam 0.5 mg tablet at 7:00 A.M. dose.Review of the resident's Nurses Notes/Administration Note, dated 07/11/25, at 4:14 A.M., showed staff administered two acetaminophen extra strength (generic Tylenol) 500 mg, for moderate pain all over his/her body; the resident rated his/her pain a seven on a one to ten scale (10 being worst pain ever felt). Review of the resident's Nurses Notes/Administration Note, dated 07/11/25, at 4:16 A.M., showed staff administered methocarbamol 750 mg for muscle spasms. Review of the resident's Nurses Notes/Administration Note, dated 07/11/25, at 10:37 A.M., showed ‘waiting on arrival from pharmacy', the note did not say what staff was waiting for from the pharmacy.Review of the resident's MAR, dated 07/16/25, showed the following:-Depakote Sprinkles 750 mg, 7:00 A.M. dose not administered, 14 (awaiting delivery);-Furosemide 40 mg, 7:00 A.M. dose not administered, 14 (awaiting delivery);-Depakote Sprinkles 750 mg, 4:00 P.M. dose not administered, 14 (awaiting delivery);-Furosemide 40 mg, 4:00 P.M., dose not administered, 14 (awaiting delivery); Review of the resident's Nurses Notes/Administration Note, dated 07/16/25, at 1:02 P.M., showed ‘waiting on arrival from pharmacy', the note did not say what staff was waiting for from the pharmacy.Review of the resident's Nurses Notes/Administration Note, dated 07/16/25, at 4:36 P.M., showed ‘waiting'.Review of the resident's Nurses Notes/Administration Note, dated 07/20/25, at 6:42 A.M., showed staff did not administer Vascepa 1 gram (gm), give two capsules for a dose of two grams, ‘waiting on pharmacy to deliver'.During an interview on 07/24/25, at 02:29 P.M., the resident said the following:-He/She has been out of medications three or four different days;-He/She did not receive his/her clonazepam one day, gabapentin one to two days and Depakote one day; -He/She had increased pain and anxiety; -The staff said it was a pharmacy problem and not their fault. 4. During an interview on 07/24/25, at 2:30 P.M., the Director of Nursing said the following:-She expected medications to be given as ordered;-Staff should use the e-kit if a resident needed a medication that was not available from the pharmacy;-Physician's orders should be followed;-If a medication was not available then staff were expected to notify the physician to see if any other orders or interventions were needed;-She has been working with the pharmacy to improve medication availability. During an interview on 07/24/25, at 4:45 P.M., the Administrator said the facility had been missing a lot of medications from the pharmacy. He expected staff to follow the facility policy for following physician orders. He expected the staff to utilize the Ekit for medications if they are needed. Complaint #2570073, #2560715 and #2566838

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize behavior triggers and provide early interventions of coping skills for two residents (Residents #13 and #14), in a review of 17 sampled residents, with mental disorders and who lived on a secured behavioral unit. Staff witnessed both residents in an argument during a smoke break and did not intervene or initiate coping skills. The residents left the smoke room and a verbal altercation ensued which led to a physical altercation where the residents hit each other. Resident #13 hit Resident #14 over the head with a laptop computer. Resident #14 obtained a laceration to his/her nose, a swollen and bruised eye, and an abrasion over his/her eyebrow. Resident #13 sustained a laceration on his/her finger. The facility census was 177. Review of the facility's Behavioral Emergency Policy, dated 06/26/24, showed the following:-The facility is to provide safe treatment and humane care to the resident in a behavioral crisis;-The facility's approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible;-Care will be guided by the resident's plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. 1. Review of Resident #13's Preadmission Screening and Resident Review (PASSAR), dated 08/13/20, showed the following:-The resident had a long history of aggression;-Diagnoses included attention deficit hyperactivity deficit (ADHD - a chronic condition including attention difficulty, hyperactivity and impulsiveness), conduct disorder, schizophrenia (mental illness with racing thoughts and hallucination and/or delusions), mild intellectual disorder, bipolar disorder (mental illness with mood swings from manic to depressive), mood disorder, post-traumatic stress disorder (PTSD; a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -The resident had delusions, confusion, and history of auditory hallucinations;-The nursing facility needed planning and case management to handle an immediate crisis;-Work with resident to develop a safety plan;-Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance, and how staff should work together with individual during the crisis. Review of the resident's Care Plan, last revised 04/22/25, showed the following:-The resident was at risk for alteration in mood related to diagnoses that include schizophrenia; -Goal: The resident will not cause harm to self or others through next review;-Behaviors included verbal aggression, physical aggression, poor insight, judgement, and impatience;-The resident suffered from auditory and visual hallucinations and was delusional;-If you see the resident exhibiting any behaviors listed in this section, refer to preferred coping skills and redirect behavior immediately;-Re-direct as able/needed to encourage positive behavior choices;-One-on-one intensive monitoring as needed/warranted for protective oversight;-One-on-one visits as needed/requested for verbalization and ventilation of concerns/feelings;-The resident's safety plan included reminding the resident of his/her diagnosis, validating his/her feelings, and allowing him/her to color;-Triggers for the resident were cigarettes, loud environment, and peers arguing/fighting;-If you observe a trigger happening to the resident, immediately refer to resident's preferred coping skills and redirect behavior;-Coping skills: Listens to music, talking with peers, doing his/her or peer's hair, walking, finding a quiet space/going to his/her room, and calling his/her family support;-If the resident was having behaviors and preferred coping skills were NOT effective, refer to CALM (Crisis Alleviation Lessons and Method, program for managing behaviors), de-escalation protocols. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 06/12/25, showed the following:-Cognitively intact;-No hallucinations, delusions, or behaviors directed toward self or others. Review of the resident's Nurses Notes, dated 07/23/25 at 6:38 A.M., showed residents (Resident #14 and another peer) were in the smoke room talking about how they thought some of their cigarettes were missing. They were not saying anyone's name, but the resident (Resident #13) thought they were talking about him/her. The peer (Resident #13) said something to the other residents about he/she had not stolen anything. One of the residents (Resident #14) told him/her (Resident #13) they were not talking about him/her. Resident #13 left the smoke room. The resident went into a peers' (Resident #18) room to talk to the peer. A few minutes later, peer (Resident #14) that was in the smoke room came into the room and called the resident (Resident #13) a name. A code green (facility alert for a behavioral crisis required response from staff) was called. Resident #13 struck Resident #14 with an object and Resident #14 struck Resident #13. Support staff arrived and residents were separated. Resident #13 immediately placed on one-on-one. Head to toe skin assessment completed with abrasion noted to the resident's finger. Review of the resident's Nurses Notes, dated 07/23/25 at 8:26 A.M., showed the resident said he/she thought his/her peers were accusing him/her of stealing their cigarettes and got into a verbal disagreement with them in the smoke room. The resident said he/she removed himself/herself from the situation because he/she didn't want to fight with anyone. Review of written statement, dated 07/23/25, provided by the facility, signed by the resident showed the residents were in the smoke room at 6:00 A.M. Resident #14 made some comments about how he/she was going to beat someone up if they kept trying to smoke his/her cigarettes. I said you ain't going to beat me up. I'm not smoking your cigarettes. Resident #14 said, you good then. Another resident did the crazy signal about me. I yelled at him/her and said, I'm not crazy and we argued. I said he/she was done and walked out of the smoke room and went to a friend's room. I was talking to his/her friend and heard Resident #14 yelling and looking for me. Resident #14 called me a bitch. Resident #14 saw me in his/her friend's room and walked in and hit me. I had my friend's laptop in my hand. After Resident #14 hit me, I hit him/her back with the laptop. We started fighting. Resident #14 threw me on the floor. More staff came and got Resident #14 out of the room. During an interview on 07/24/25 at 2:30 P.M., the resident said the following:-He/She and Resident #14 got into an argument; -He/She and Resident #14 ended up in Resident #18's room;-He/She hit Resident #14 over the head with Resident #18's laptop hard;-They both punched each other several times;-Resident #14 threw him/her on the floor;-He/She received a small cut on his/her finger from where he/she hit Resident #14 in the eye. Observation on 07/24/25 at 2:30 P.M. showed the resident had a small laceration on his/her right middle finger by his/her second knuckle. 2. Review of Resident #14's PASSAR, dated 07/29/20, showed the following:-Diagnoses included bipolar disorder, intellectual disorder, personality disorder, major depressive disorder, schizophrenia, and psychosis (mental condition with loss of reality);-Records state he/she traditionally displays angry outbursts, temper tantrums, yells, screams, and jumps up and down when he/she does not get his/her way;-Symptoms include mood lability (rapid and often unpredictable shifts in mood or emotional expression, hyperkinesis (excessive movement of muscles), rapid speech, mild flight of ideas, distractibility, impulsivity, intrusiveness, severely impaired insight, and judgment;-The resident had a history of episodes of paranoid ideation and verbal/physical aggression directed toward others;-The resident required daily nursing assessment of mood, thought process, behaviors to identify early changes that could lead to aggressive behaviors or agitation; -The resident required nursing assessment each shift in regard to mood, thought process, behaviors to identify any signs of psychotic thought process, and to identify any signs of increasing irritability or agitation; -Nursing facility to establish a behavior plan to address any verbal or physical aggression. Plan should include how to support client during a behavioral crisis, how to assure safety for client and others, de-escalation techniques, parameters for use of prn medications, one-on-one staff supervision until he/she calms. Review of the resident's Care Plan, updated on 02/06/23, showed the following:-The resident was at risk for alteration in mood related to diagnosis of schizoaffective disorder (bipolar, mental illness with periods of depression and periods of mania) and a history of medication non-compliance that can also lead to him/her becoming physically aggressive;-One-on-one intensive monitoring as needed/warranted for protective oversight;-One-on-one visits as needed/requested for verbalization and ventilation of concerns/feelings;-Allow resident to speak with someone of importance to him/her;-Assist the resident in using his/her coping skills;-Attempt to ascertain what the resident would accept/need to calm down and provide as able;-Re-direct as able/needed to encourage positive behavior choices;-Ongoing assessment for changes in mental status, behavior emergencies and impaired cognitive functioning;-The resident had a history of behavioral challenges that require behavioral challenges that require protective oversight in a secure setting;-Current behaviors: violently aggressive, temper tantrums, bizarre/erratic behaviors;-Behaviors from PASSR included anxiety, impatient/demanding, intrusive, verbally aggressive, verbally/physically threating, and paranoid;-Triggers for the resident include loud environments, arguing, and smoking;-If you observe trigger happening to resident, immediately refer to resident's preferred coping skills and redirect behavior; -If you see resident exhibiting any behaviors listed in this section, refer to preferred coping skills and redirect behavior immediately; -Coping Skills: Watching television, listening to music, hangout, coloring, watching unsolved mysteries, and talking with the other residents;-CALM technique if needed;-Pharmaceutical and non-pharmaceutical interventions as needed. Review of the resident's annual MDS, dated [DATE], showed the following:-Cognitively intact;-No hallucinations, delusions, or behaviors directed toward self or others. Review of the resident's Nurses Notes, dated 07/23/25 at 6:38 A.M., showed residents were in the smoke room talking about how they thought some of their cigarettes were missing. They were not saying anyone's name, but Resident #13 thought they were talking about him/her. Resident #13 said something to the other residents about he/she had not stolen anything. Resident #14 told Resident #13 they were not talking about him/her and Resident #13 left the smoke room. Resident #14 went out in the hall a few minutes later, and staff noted him/her to be calm. When Resident #14 went out in the hall, he/she went into a different resident's room (Resident #18) and called Resident #13 a name. It was reported that Resident #14's voice started rising. Code green was called, and staff attempted to get between the residents (Resident #13 and Resident #14). Resident #13 struck Resident #14 with an object and Resident #14 struck Resident #13. Head to toe skin assessment completed with abrasion noted to bridge of Resident #14's nose and swelling to right eyebrow with abrasion noted above eyebrow. Review of a typed statement, dated 07/23/25, provided by the facility, signed by Resident #14, showed he/she was sitting in the smoke room at the 6:00 A.M. smoke break. He/She discussed missing cigarettes with another resident. Resident #13 then stated he/she didn't smoke the cigarettes and had nothing to do with it. The resident told Resident #13 that they didn't say his/her name, and he/she was being paranoid. Resident #13 started arguing with Resident #14. Resident #13 left the smoke room. Then Resident #14 walked out of the smoke room and started walking down the hall. Resident #14 was upset because Resident #13 was yelling and cussing at the residents. When Resident #14 went down the hall and saw Resident #13 in another resident's room, he/she went in. Resident #14 was cursing at Resident #13, and they argued back and forth. Resident #13 grabbed a laptop and hit Resident #14 over the head with it. Resident #13 and Resident #14 started hitting each other. Staff were trying to separate them. Resident #14 knocked Resident #13 down a couple times. More staff came in and separated them. He/She was not trying to cause Resident #13 harm, he/she was just upset and let his/her temper get to him/her. During an interview on 07/24/25 at 3:49 P.M., the resident said the following:-The residents were in the smoke room, and he/she and his/her friend were talking about missing cigarettes;-Resident #13 was paranoid and thought they were talking about him/her but they were not. Resident #13 started yelling and cursing at them;-Resident #13 left the smoke room, and then he/she left the smoke room; -When he/she walked down the hall, Resident #13 was waiting for him/her by Resident #18's room, so he/she began yelling at Resident #13 and cursing at him/her; -Resident #13 went into Resident #18's room. Resident #13 grabbed Resident #18's laptop and hit him/her over the top of the head with the laptop. It shattered the screen of the laptop;-Resident #13 punched him/her in the eye and the nose which caused injuries; he/she also punched Resident #13 several times; -He/She then threw Resident #13 on the ground;-The staff called a code green but never tried to physically intervene until the fight was over. By the time the other staff responded and arrived at the unit, the fight was over; -The staff didn't intervene;-The Director of Nursing made him/her sign a statement that he/she and Resident #13 are friends and that everything was okay; -He/She was not Resident #13's friend and never has been. They don't hate each other but they are not friends;-Staff kept he/she and Resident #13 separated and then told them it was in their best interest to sign the statements. Review of the resident's Nurses Notes showed the following:-On 07/23/25 at 12:29 P.M., staff notified the physician regarding the resident's right eye swelling shut. Received orders to obtain facial x-rays. The resident was able to see out of the right eye when his/her eye lid was pulled up. The resident had an ice pack to his/her eye and denied pain at this time;-On 07/24/25 at 11:46 A.M., the resident's eyelid was swollen and reddish/purple. Abrasion to bridge of nose. Observation on 07/24/25 at 3:49 P.M., showed the resident in his/her room. The resident's right eye lid was red, purple, and swollen. His/Her eyelid protruded out from the swelling. The resident had an abrasion above his/her right eyebrow, and a laceration across the bridge of his/her nose. 3. Review of written statement, dated 07/23/25, provided by the facility, signed by Resident #18 (statement was typed and the resident signed it), showed the resident relayed he/she was laying in my bed, dozing off when Resident #13 came into my room and told me that I better not let them roll up on me. I asked him/her what he/she was talking about, and then I heard Resident #14 yelling and looking for Resident #13. Resident #14 came to my door, and they (Resident #13 and Resident #14) started yelling and cussing at each other. Resident #13 grabbed my laptop off my bed and hit Resident #14 on the head. They both started fighting and hitting each other. Staff had already called a code green. 4. Review of a written statement, dated 07/23/25, provided by the facility, signed by Nurse Assistant (NA) I, showed he/she wrote he/she had residents gathered for 6:00 A.M. smoke break, Resident #14 was discussing with his/her friend about people taking their things. While they were talking, Resident #13 thought they were discussing him/her. The residents tried to tell Resident #13 they were not talking about him/her. He/She let Resident #13 out of the smoke room. Then Resident #14 left the smoke room. NA F called a code. When he/she came out of the smoke room and went down the hall, Resident #14 was coming out of a resident room with a small cut across his/her nose. 5. Review of written statement, dated 07/23/25, provided by the facility, signed by NA F showed he/she was in the dining room when Resident #13 said Resident #14 and his/her friend were saying he/she stole their cigarettes. Resident #13 went to a peer's room (Resident #18). Resident #14 came out of the smoke room. Resident #14 was yelling looking for Resident #13. Resident #14 kept calling Resident #13 a bitch, and Resident #13 yelled back bitch. He/She was already calling a code and staying/walking with Resident #14 until support staff arrived. Resident #14 saw Resident #13, and they started fighting. Resident #13 had a laptop and hit Resident #14 to the face area and then they started exchanging blows and Resident #14 tossed Resident #13 to the floor. 6. During an interview on 07/24/25 at 10:14 A.M. and 4:40 P.M., the Director of Nursing (DON) said the following:-She investigated the resident-to-resident altercation between Resident #13 and #14 and felt like there was nothing the staff should have done differently;-She was not sure if the staff identified the residents' triggers or offered coping mechanisms for the residents prior to the physical altercation. During an interview on 07/24/25 at 4:40 P.M., the Administrator said the following:-He expected staff to recognize triggers for residents who had behaviors and respond with offering coping skills as instructed in the resident's care plan;-If there was a physical altercation, staff may have to wait for back up, but were to physically intervene to protect residents;-He expected staff to follow their training on how to deal with behavioral crisis. Complaint #2565905

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #10), in a review of 18 sampled residents, received care and treatment in accordance with professional standards of practice. Staff failed to assess and obtain treatment for seven days following the resident's complaints of urinary urgency (a sudden and strong need to urinate) and dysuria (difficulty urinating) and failed to obtain a urinalysis (a diagnostic laboratory procedure used to determine urinary changes and infection) as ordered by the physician. The resident was admitted to the hospital with acute pyelonephritis (a bacterial infection of the kidneys that caused inflammation. A severe urinary tract infection), and complicated urinary tract infection. Upon readmission staff failed to obtain and administer four doses of the physician ordered antibiotic for the resident. The facility census was 181. Review of the facility policy Notification of Changes, dated 5/14/24, showed the following: -The purpose was to ensure the facility promptly informed the resident and consulted the resident's physician when there was a change requiring notification; -Circumstances requiring notification were accidents, significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status that may included life-threatening conditions or clinical complications. Review of the facility policy Transcription of Orders/Following Physician Orders, dated 5/18/24, showed the following: -The purpose was to outline procedures in accurately transcribing physicians' orders and to ensure all physicians' orders were followed. To ensure a process was in place to monitor nurses in accurately transcribing and following physicians' orders; -Upon receiving a physician's order, it would be documented in the resident's electronic medical record in the order section; -The licensed nurse would check the emergency kit to verify if the medication was present in the facility to begin immediately. If the medication was not available, the facility may contact the backup pharmacy to deliver the medication sooner. If the medication was unable to be started within 24 hours of the order, the prescribing physician would be notified, and further orders would be obtained. If a stat (without delay) medication was ordered, the physician would be made aware of facility availability in the case an alternative was needed; -After laboratory testing, diagnostic testing or other services were ordered, the nurse would document orders in the resident's electronic medical record and fill out the corresponding requisition for the specific services to be obtained; -The licensed nurse would review electronic Medication Administration Records (MARs) on a routine basis to monitor for medications that were not administered to the resident due to unavailability, refusal, omission, etc. If a medication was marked as not given, the reasoning for not being given should be explained in the progress notes and Director of Nursing or supervising nurse and the Administrator must be notified. The physician must also be notified. The nurses' progress notes must document the plan/solution because of the medication not being administered and any adverse reactions that the resident may have. For electronic MARs the medication would be documented as not given by selecting the corresponding chart code for the reason why it was not given, and a progress note would be written; -If the medication was unavailable, the licensed nurse would contact the pharmacy and have the medication delivered. If the resident was not going to receive their scheduled medication per the physician's orders, the licensed nurse would contact the Director of Nursing (DON), the Administrator, and the physician. The nurse would then follow any further orders provided by the physician. 1. Review of Resident #10's annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 6/21/24, showed the following: -Cognitively intact; -Independent in activities of daily living; -Continent of bowel and bladder. Review of the resident's Care Plan, updated 6/24/24, showed the following: -Diagnoses of depression, shortness of breath, and urinary incontinence; -The resident was highly functional and able to complete activities of daily living with supervision. Staff should provide assistance as needed. Review of the resident's Care Plan showed the resident's urinary incontinence diagnosis was not addressed. Review of the resident's Physician Order Sheet (POS), dated 9/15/24, showed to obtain urinalysis with culture and sensitivity (diagnostic lab procedure used to identify the type of bacteria causing an infection). Review of the resident's nurses note, dated 9/17/24 at 1:32 P.M., showed staff documented the resident currently complained of urgency and dysuria. A urinalysis with culture and sensitivity was ordered and urine sample sent to the laboratory on 9/16/24. The results were currently not available. Review of the resident's nurses' notes showed staff documented the following: -On 9/18/24 at 1:00 P.M. the resident was continent of bowel and bladder; -On 9/19/24 at 1:45 P.M. the resident was continent of bowel and bladder, able to make needs and concerns known; -On 9/21/24 at 9:37 A.M. the resident believed an antibiotic was ordered on 9/19/24 for a possible urinary tract infection. No physician orders noted for an antibiotic, attempted to reach the physician at number provided with no answer and no voice mail set up; -On 9/21/24 at 11:28 A.M. attempted to reach the physician again with no answer and unable to leave a message. Review of the resident's POS, dated 9/21/24, showed an order from the resident's physician for Bactrim DS (antibiotic medication) 800/160 milligrams (mg) one tablet two times daily for urinary tract infection for seven days. Review of the resident's Medication Administration Record (MAR) dated September 2024 showed the following: -On 9/21/24 no documentation staff administered Bactrim DS 800/160 mg as ordered two times daily; -On 9/22/24 no documentation staff administered Bactrim DS 800/160 mg as ordered two times daily; -On 9/23/24 staff documented Bactrim DS 800/160 mg administered at 7:00 A.M. and 4:00 P.M. Review of the resident's nurses' notes showed staff documented the following: -On 9/23/24 at 8:55 P.M., the resident wanted to be sent out to the hospital, he/she did not feel right, was short of breath and his/her abdomen hurt due to a urinary tract infection. Temperature of 101.8 degrees (normal 98.6 degrees), blood pressure 141/111 (normal 120/80), heart rate 92 beats per minute (normal 60 to 80), respirations 18 breaths per minute (normal 12-18). Resident was sent by ambulance to the local hospital; -On 9/24/24 at 2:04 P.M., the resident was transferred from the local hospital to a regional hospital and admitted with fluid overload and urinary tract infection. Review of the resident's hospital Discharge summary, dated [DATE], showed the following: -Diagnoses of acute pyelonephritis (a bacterial infection of the kidneys that caused inflammation. A severe urinary tract infection), complicated urinary tract infection, hematuria (blood in the urine) likely secondary to infection, electrolyte derangements (imbalance of the electrolyte levels in the blood); -Intravenous (IV) ceftriaxon (antibiotic medication) treatment from 9/24/24 to 9/28/24; -Transition to cefpodoxime (oral antibiotic medication) on 9/28/24 to complete a 14-day course of treatment, end date of 10/7/24; -New medications cefpodoxime 200 mg, one tablet every 12 hours for ten days. Review of the resident's nurses note, dated 9/28/24 at 3:42 P.M., showed staff documented the resident returned from the hospital. Review of the resident's clinical admission note, dated 9/28/24 at 4:33 P.M., showed staff documented the resident arrived back at the facility. Denies urinary complaints, urine clear yellow. Currently on antibiotics. Review of the resident's POS, dated 9/28/24, showed cefpodoxime 200 mg one tablet every 12 hours for pyelonephritis for ten days. Review of the resident's MAR, dated September 2024, showed the following: -On 9/28/24 no documentation staff administered cefpodoxime 200 mg at 9:00 P.M.; -On 9/29/24 at 9:00 A.M. staff documented cefpodoxime 200 mg was not administered, see progress (nurses note) notes. Review of the resident's nurses notes dated 9/29/24 at 10:13 A.M., showed staff documented cefpodoxime 200 mg not administered, the medication had not arrived from the pharmacy. Review of the resident's MAR dated September 2024 showed on 9/29/24 at 9:00 P.M. staff documented cefpodoxime 200 mg not administered, see progress notes. Review of the resident's nurses note, dated 9/29/24 at 9:38 P.M., showed staff documented cefpodoxime 200 mg not administered, the medication had not arrived from the pharmacy. Review of the resident's MAR dated September 2024 showed on 9/30/24 at 9:00 A.M., staff documented cefpodoxime 200 mg not administered, see progress notes. Review of the resident's nurses note, dated 9/30/24 at 10:30 A.M., showed staff documented cefpodoxime 200 mg not administered, the medication had not arrived from the pharmacy. Pharmacy notified of missing medication. Review of the resident's medical record showed no documentation staff notified the resident's physician cefpodoxime 200 mg was not administered on 9/28/24 at 9:00 P.M., on 9/29/24 at 9:00 A.M. and 9:00 P.M. or 9/30/34 at 9:00 A.M. Review of the resident's nurses note, dated 9/30/24 at 7:20 P.M., showed the physician made rounds, discussed the antibiotic orders. Antibiotic changed to Cipro (oral antibiotic) for pyelonephritis. Review of the resident's POS, dated 9/30/24, showed the following: -Discontinue cefpodoxime 200 mg twice daily; -Cipro 500 mg two times daily for acute pyelonephritis for seven days. During an interview on 10/3/24 at 9:50 A.M., the resident said he/she had urinary symptoms about three weeks ago of burning and hematuria. He/She told staff and a urine sample was obtained. Two days later staff said the urine sample was sent to the wrong laboratory and he/she had to start over. Staff said an antibiotic was ordered but did not come from the pharmacy. After a few days the resident asked staff to call the physician for another antibiotic order which he/she did not receive. His/Her urinary symptoms continued to get worse. The resident did receive one dose of an antibiotic, was not improving, and asked to go to the hospital for treatment. The resident felt short of breath, his/her kidneys were not working very well, and his/her abdomen was hard. The resident felt like fluid was backing up in his/her kidneys and abdomen. Staff sent the resident to the hospital by ambulance. He/She did not receive the new antibiotic ordered on discharge from the hospital. The pharmacy did not send the antibiotic because his/her insurance did not cover the cost. The resident's physician changed the antibiotic that was started a few days after his/her hospital discharge. Staff did not assess the resident and try to get him/her treatment for the urinary symptoms and did not arrange for hospital transfer until the resident asked to go to the hospital. During an interview on 10/3/24 at 3:00 P.M. the DON said staff should have assessed and documented the resident's condition and complaints of urinary urgency and dysuria. Staff should have called the physician and obtained treatment and not delayed treatment. If a urinalysis was obtained and treatment provided, hospitalization might have been prevented. The resident had history of urinary tract infections. He expected staff to assess a resident's condition and obtain treatment orders from the physician. Staff should document the assessments, findings, and communication with the physician. If the physician was not reached, staff should notify the administrative nursing staff for assistance. The resident should have received treatment much sooner. During an interview on 10/3/24 at 3:15 P.M. the Administrator said he expected staff to assess residents for change in condition, call the physician and obtain treatment as indicated. Staff should document assessments, communication with the physician, and follow up assessments. Staff should have obtained a urinalysis for the resident as ordered by the physician and followed up with treatment to prevent hospitalization. The resident was aware of his/her symptoms and told staff. Staff should not delay a resident's treatment. During an interview on 10/10/24 at 8:15 A.M. the facility Medical Director said he was on call for the previous month and had not received notification of the resident's urinary symptoms. He expected staff to notify him of any change in a resident's condition in order to obtain testing and implement treatment as soon as possible. Staff should not delay a resident's treatment. He was not aware the resident had urgency and dysuria and not aware staff had not completed the urinalysis. Staff should have called and notified him of the resident's condition, obtained the urinalysis, and started treatment to prevent hospitalization and worsening of the resident's condition. MO 00242406

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #2) in a review of 13 sampled residents, who was monitored one on one by Certified Nurse Aide (CNA) F, was free from abuse when Resident #1 entered Resident #2's room and started a verbal argument. The verbal argument escalated and CNA F did not intervene. Resident #1 hit Resident #2 in the head and neck repeatedly with a closed fist which resulted in the resident being sent to the hospital where he/she was diagnosed with a neck contusion (bruising). Resident #2 remained fearful and scared of Resident #1 and was moved to another hall for his/her safety. The facility census was 178. Review of the facility Abuse and Neglect policy, dated 6/12/24, showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -Physical abuse is purposefully beating, striking, wounding, or injuring any resident in any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner; -Physical abuse also includes but is not limited to hitting, slapping, punching, biting and kicking; -The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; -The purpose is to assure that the facility is doing all that is within its control to prevent occurrences; -New employees will be educated by the department manager or designee on issues related to abuse prohibition practices during initial orientation and annually; -The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur; -During orientation of new employees, the facility will cover at least the following topics: Sensitivity to resident rights and resident needs and what constitutes physical, sexual, verbal and mental abuse, and how to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his/her safety, as well as the safety of other residents in the facility. 1. Review of the facility Administrative/Registered Nurse Investigation, dated 7/15/24, showed the following: -Date of incident was 7/15/24; -Type of incident; physical aggression involving the head; -Person(s) involved in the incident: Resident #1, #2, #3, and #12; -There was a physical altercation between Resident #1 and #2; -Certified Nurse Aide (CNA) F was one-on-one with Resident #2 when Resident #1 came into Resident #2's room yelling; -CNA F said he/she tried to redirect Residents #1, #3, and #12; -Hall Monitor I heard the commotion and went to Resident #2's room and tried to redirect Resident #1; -Resident #1 pushed past Hall Monitor I and struck Resident #2 with a closed fist; -The facility concluded Resident #1 did strike Resident #2 with a closed fist; -The facility concluded Resident #1 had diagnoses of oppositional defiant disorder and intellectual disabilities with a history per his/her Preadmission Screening and Resident Review (PASARR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) of poor impulse control. When Resident #1 heard that Resident #2 made negative comments about Resident #12, Resident #1 responded by striking Resident #2; -Resident #2 complained of pain in the head and was sent to the hospital for evaluation. Resident #2 returned from the hospital with a diagnosis of a neck contusion (bruising). 2. Review of Resident #1's care plan, dated 9/25/23, showed the following: -Special Instructions: High behavior resident/resident behaviors: physical aggression towards others, assaultive behaviors, biting others and anger management. Effective coping skills included coloring and listening to music; -The resident was at risk for altercation in mood and delusional thought process related to bipolar disorder (a mental illness that causes extreme mood swings that include emotional highs and lows); -Monitor for changes in mood and behaviors, provide a calm environment and redirect as needed; -The resident had a history of behaviors related to his/her mental health including verbal aggression, emotional disturbances, poor impulse control, aggressiveness, combative behaviors, poor judgement, intrusive, anger management, poor social skills, homicidal ideations, assaultive behaviors, auditory and visual hallucinations, poor boundaries with others and was child-like (functions at the level of a [AGE] year old); -The resident had a history of behavioral challenges that required protective oversight in a secure setting that included physically aggressive, threatening behavior, verbally aggressive, and poor impulse control; -The resident had a history of post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances. -Assess the resident for suicidal or homicidal ideations to ensure the safety of the resident and others; -Remain with the resident at all times when levels of anxiety are high. Review of the resident's care plan, dated 5/6/24, showed the resident returned to the facility from jail after assaulting a staff member. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/16/24, showed the following: -The resident was cognitively intact; -The resident had diagnoses that included medically complex conditions, depression, oppositional defiant disorder (ODD, a type of disruptive behavior disorder in which people frequently defy authority with hostility, leading to serious disturbances in their daily life), bipolar disorder, intellectual disabilities (ID, a term used when a person has certain limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills) and mood disorder (mental conditions characterized by persistent disturbance of mood, especially in the form of depression or euphoria or a combination of these). Review of Resident #1's facility acquired written statement, dated 7/15/24, showed the following: -Resident #1 said he/she was told Resident #2 talked bad about Resident #12 who was Resident #1's friend. That upset Resident #1; -Resident #1 went to Resident #2's room and yelled at him/her and told Resident #2 to stop talking about Resident #12; -Resident #1 said he/she hit Resident #2 a few times in the head area and walked out of the room; -A code green (a code called when a behavioral event occurs and trained staff respond to assist to deescalate a situation) was called, and Resident #1 did not remember who was in the room, it all happened fast. During an interview on 7/29/24 at 12:17 P.M., the resident said the following: -Resident #3 told him/her Resident #2 talked bad about Resident #12; -Resident #1 did not like people talking bad about his/her friends and it made him/her mad; -Resident #1 went to Resident #2's room and they argued; -Resident #1 threw Resident #2's blankets at Resident #2 and then Resident #1 hit Resident #2; -Hall Monitor I came in the room and separated the two residents; -Resident #2's one-on-one staff (CNA F) was in the room at the time, but he/she did not do anything or say anything. 2. Review of Resident #2's care plan, dated 9/20/23, showed the resident had a history of behavioral challenges that required protective oversight in a secure setting. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident had diagnoses that included anxiety, depression, borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life. It includes a pattern of unstable, intense relationships, as well as impulsiveness and an unhealthy way of seeing themselves. Impulsiveness involves having extreme emotions and acting or doing things without thinking about them first), and schizophrenia (a chronic mental disorder characterized by delusions, hallucinations, disorganized speech and behavior, and decreased emotional expression and motivation); -The resident did not have any behaviors. Review of the resident's progress notes, dated 7/15/24, showed the following: -At 4:25 P.M. the resident told staff he/she felt suicidal and was immediately placed on one-on-one with staff; -At 8:15 P.M. the resident was one-on-one with staff when a peer entered his/her room and became verbally abusive and punched the resident in the head. Review of the resident's facility acquired written statement, dated 7/15/24, showed the following: -Resident #1 went into Resident #2's room and told him/her to stop talking about Resident #12; -Resident #2 told Resident #1 it was none of his/her business and to leave the room; -Resident #1 did not leave Resident #2's room even after being asked a second time by Resident #2; -A staff member came into Resident #2's room and stood between Resident #1 and #2; -Resident #1 went around the staff member and started hitting Resident #2 in the head. Resident #1 hit Resident #2 six times in the head; -Staff got between the two residents and Resident #1 left the room. During an interview on 7/24/24 at 9:18 A.M. and 7/29/24 at 11:18 A.M., the resident said the following: -Resident #1 came into his/her room and asked why he/she was talking about Resident #12; -He/She and Resident #1 argued and yelled at each other; -He/She asked Resident #1 to leave his/her room, but Resident #1 did not leave; -Resident #1 hit Resident #2 in the head and neck six times; -Resident #12, #3, and another peer blocked the doorway so Resident #2's one-on-one staff could not get out -CNA F did not do anything at all to help the resident when Resident #1 came in his/her room; -He/She had trouble sleeping since the incident with Resident #1 and was supposed to get moved to another room, because he/she just didn't feel safe around Resident #1. Review of the resident's hospital discharge records, dated 7/15/24, showed the following: -The resident was discharged to the facility on 7/15/24; -The resident had a neck contusion. During an interview on 8/1/24 at 9:50 A.M. Resident #2's guardian said the following: -She went to the facility the day of the altercation between Resident #1 and #2; -She filed charges with the police department because this was not the first incident with Resident #1; -Resident #2 was moved to another hall on 7/29/24 because he/she was scared of Resident #1 even though Resident #1 was on one-on-one supervision. During an interview on 7/25/24 at 8:30 A.M., CNA F said the following: -He/She was hired around July 1, 2024; -He/She did not get any training about being one-on-one with residents or how to handle physical aggression by residents; -He/She was one-on-one with Resident #2 on 7/15/24; -He/She did not intervene or get in between Resident #1 and Resident #2; -CNA F said he/she was not going to get in the middle of all that mess; -He/She went to get someone to help and Resident #12 was blocking the doorway; -Another staff was across the hall and came to help. During an interview on 7/30/24 at 2:57 P.M., Hall Monitor I said the following: -Hall Monitor I was across the hall from Resident #2's room with another resident when he/she heard yelling and arguing; -Hall Monitor I went to Resident #2's room and saw Resident #1 and #2 arguing with each other: -CNA F was in the room just standing there watching and doing nothing; -Hall Monitor I tried to calm Resident #1, but the resident went around him/her and started hitting Resident #2 in the head; -Other residents were in the hallway outside Resident #2's room but none of them were blocking the doorway. During an interview on 7/24/24 at 3:33 P.M., 7/29/24 at 5:38 P.M. and 8/1/24 at 1:31 P.M., the Administrator said the following: -He would expect one-on-one staff to intervene in any verbally or physically aggressive situation; -Staff should protect the residents; -CNA F would have had training during orientation that would have covered one-on-one supervision situations, abuse and neglect, intervening when needed and resident to resident altercations. -Resident #2 was moved to another hall to keep him/her away from Resident #1 and to help Resident #2 feel safe. -The facility concluded Resident #1 hit Resident #2 and this was considered abuse by Resident #1. MO239016

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #4) of 13 sampled residents, with mental disorders who lived on a secured locked unit, received individualized treatment and services to meet the resident's needs. The facility failed to ensure the resident received timely and appropriate treatment or services, including administering medications that were prescribed by the physician. The facility census was 178. Review of the facility policy Behavioral Health Services, dated 6/26/24, showed the following: -It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning; -Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders; -Staff will monitor the resident closely for expressions or indication of distress, assess and develop a person-centered care plan for concerns identified in the resident's assessment; -The care plan shall have interventions that are person-centered, evidence based, culturally competent, trauma informed, and in accordance with professional standards of practice, reflect the resident's goals, use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. 1. Review of Resident #4's care plan, dated 9/23/23, showed the following: -The resident was perseverated (to intently focus one's attention on a thought) on medications; -The resident had a behavior problem of becoming verbally and physically aggressive and had a history of suicide attempts related to bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); -Administer medications as ordered. Monitor/document for side effects and effectiveness; -Anticipate and meet the resident's needs; -The resident's coping skills included smoking and listening to music. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 6/23/24, showed the following: -The resident was cognitively intact; -The resident had diagnoses that included medically complex conditions, paranoid (paranoia is a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia, bipolar disorder, and traumatic brain injury (TBI - a brain injury that was caused by an outside force that can cause problems with how a person thinks, understands, moves, communicates and acts). Review of the resident's progress notes, dated 6/8/24, showed the following: -At 8:04 A.M., Wellbutrin XL (used to treat depression) oral tablet extended release 300 mg was not available and the facility was waiting on a preauthorization from insurance; -At 10:03 A.M., staff called a code green (behavioral emergency) because the resident was agitated because his/her morning dose of Wellbutrin was not available. Staff educated to obtain the Wellbutrin from the Omnicell (automated emergency medication system) so the resident would not miss a dose. The pharmacy reported the resident's insurance would not pay for Wellbutrin because they needed a prior authorization form. The Director of Nursing (DON) was notified of the same concerns and reports on 6/7/24. Review of the resident's progress notes, dated 6/8/24 at 10:45 A.M. showed the resident was tearful and apologetic for becoming aggressive over his/her medications. Review of the resident's Medication Administration Record (MAR), dated 6/8/24, showed no documentation staff administered Wellbutrin XL oral tablet extended release 300 mg to the resident. Review of the resident's psychiatrist's notes, dated 6/10/24, showed the following: -The resident was seen for evaluation of sleep, mood, anxiety, delusions and medication; -The resident endorsed auditory hallucination (sensory perceptions of hearing in the absence of an external stimulus) without details; -No recent behaviors or concerns were reported; -Diagnosis of paranoid schizophrenia; review of safety precautions with cognitive decline. Review of medications showed Abilify extended release (a medication used to treat certain mental/mood disorders), maintenance injection 400 mg once every 28 days. Review of the resident's psychiatrist's notes, dated 6/17/24, showed a nurse practitioner's (NP) visit encounter that showed the following: -The resident was seen for a medication follow up; -Medication list was updated on 6/14/24 that included Abilify extended release maintenance injection 400 mg once every 28 days and Wellbutrin XL extended release 24 hour, 300 mg; -The resident was seen for medication reconciliation for re-evaluation of paranoid schizophrenia, depression, and anxiety; -The resident resided in a long term care facility locked unit due to the need for ongoing nursing care and medication monitoring; -No acute changes reported; -Paranoid schizophrenia was stable and continue Abilify maintenance extended release 400 mg maintenance injection, 400 mg once every 28 days; -Severe episodes of recurrent major depressive disorder without psychotic features, no acute signs or symptoms, continue Wellbutrin XL 300 mg daily. Review of the resident's progress notes, dated 6/18/24, showed a plan of care note by the resident's primary care physician that showed the following: -The resident was seen for evaluation of sleep, mood, anxiety, delusions and medication reconciliation; -The resident endorsed auditory hallucination without details; -Paranoid schizophrenia in exacerbation (an acute increase in the severity of a problem, illness, or bad situation); -Review of safety precautions with cognitive decline; -Review of medications: Abilify extended release maintenance injection 400 mg once every 28 days. Review of the resident's MAR, showed Abilify extended release 400 mg intramuscularly (IM) one time a day every 28 days related to schizophrenia scheduled to be administered on 06/19/24. Staff left the date blank which indicated staff did not administer the medication. Review of the resident's progress notes, dated 6/27/24, showed an order administration note: Wellbutrin XL extended release 24 hour, 300 mg by mouth one time day for depression, medication not available, too soon to reorder. Review of the resident's MAR, dated 6/27/24, showed staff did not administer Wellbutrin XL. Review of the resident's progress notes, dated 6/30/24, showed a behavior note the resident pulled the fire alarm. The resident said he/she pulled the alarm because he/she was upset about medication concerns. Review of the resident's MAR, dated June 2024, showed the following: -The resident missed two doses of Wellbutrin XL on 6/8/24 and 6/27/24; -The resident missed his/her monthly injection of Abilify on 6/19/24. Review of the resident's progress notes, dated 7/6/24, showed the following: -At 4:15 P.M., a behavior note showed the resident was observed to be verbally aggressive towards the certified medication technician (CMT). Immediate staff intervention and separation from peers. The resident was not easily redirected and continued to be verbally aggressive to staff and peers; -Staff contacted long term psychological management and got a new order for olanzapine (used to treat schizophrenia) 10 mg injection, one time only. Staff administered the injection and the resident calmed down. Staff will continue to monitor for protective oversight; -At 4:51 P.M., the resident rested in bed and said he/she was sorry for his/her behavior. Review of the resident's progress notes, dated 7/7/24, showed the following: -At 1:06 P.M., the resident told the nurse he/she felt anxious and requested an as needed (PRN) medication; -At 1:11 P.M., staff gave the resident PRN olanzapine 10 mg by mouth. Review of the resident's MAR, dated 7/7/24, showed a new order for olanzapine 10 mg by mouth every eight hours as needed for agitation/anxiety for 14 days. Review of the resident's progress notes dated, 7/9/24, showed the following: -The resident said he/she was extremely anxious and wanted a PRN medication; -Staff walked the resident through coping skills and once done the resident said the coping skills were ineffective. The resident was pacing aimlessly and talking fast; -The staff administered a PRN olanzapine 10 mg by mouth. Review of the resident's progress notes dated, 7/10/24, showed the following: -At 8:21 A.M., the resident said he/she was extremely anxious and wanted an as needed medication; -The resident said he/she had some anxiety; -The resident said he/she had been having dreams where he/she felt stuck; -Staff talked the resident through his/her coping skills and then would check in with the resident in an hour; -At 10:27 A.M., the resident said his/her coping skills were ineffective and he/she wanted a PRN medication because he/she was still anxious and did not want to blowup later. The resident wanted to have a good day; -Staff administered a PRN olanzapine 10 mg by mouth. Review of the resident's progress notes dated, 7/11/24, showed the following: -At 4:01 A.M., the resident requested a PRN medication because he/she had anxiety; -At 4:03 A.M., staff administered PRN olanzapine 10 mg by mouth and encouraged the resident to use coping skills. Review of the resident's progress notes dated, 7/17/24, showed the resident's Wellbutrin XL 300 mg was not available. Review of the resident's MAR, dated 7/17/24, showed the following: -Staff did not administer the resident's Wellbutrin XL 300 mg; -Abilify extended release 400 mg intramuscularly one time a day every 28 days related to schizophrenia was scheduled to be administered. The date was left blank which indicated staff did not administer the medication. During an interview on 7/30/24 at 4:18 P.M., Licensed Practical Nurse (LPN) H said the following: -Resident #4's Abilify probably wasn't available; -LPN H did call the pharmacy and they said it would be delivered the next day and that is why he/she did not chart anything, so that the next nurse would know to administer the medication. Or the pharmacy said it wasn't covered by insurance; -LPN H was not for sure what the pharmacy said; -LPN H would have reported the missed medication to the nurse that came on the next shift and he/she would have reported it in the nurse's meeting; -Resident #4 was loud and agitated and pulled the fire alarm; -If Resident #4 asked for a PRN medication it was usually because he/she was anxious. Review of the resident's progress notes dated, 7/18/24, showed the resident's Wellbutrin XL 300 mg was not available. Review of the resident's MAR, dated 7/18/24, showed staff did not administer the resident's Wellbutrin XL 300 mg. Review of the resident's progress notes dated, 7/19/24, showed the following: -At 8:26 A.M., the resident's Wellbutrin XL 300 mg was not available and staff would follow up with the pharmacy; -At 8:50 A.M., noted that the resident missed a dose of his/her Wellbutrin XL 300 mg. The resident's physician was notified. Wellbutrin was in the building and would be administered per schedule; -At 8:56 A.M., long term psych management notified the resident missed his/her Wellbutrin XL 300 mg; -At 6:00 P.M.,staff removed the Wellbutrin from the Omnicell for the morning dose. Review of the resident's MAR, dated 7/19/24, showed staff did not administer the resident's Wellbutrin XL 300 mg at any time that day. Review of the resident's progress notes dated, 7/25/24, showed the following: -Housekeeping attempted to deep clean the resident's room when the resident began screaming at and threatening the housekeeper; -A code green was called. Review of the resident's progress notes, dated 7/27/24, showed the following: -At 3:40 A.M., the resident reported to the staff he/she did not receive his/her monthly injection; -Staff told the resident they would have to look it up and let the resident know why he/she did not get his/her injection; -Five minutes later the fire alarm went off; -Staff said Resident #4 pulled the fire alarm because staff took too long to give him/her the injection; -The resident yelled and it upset the other residents. Staff separated all the residents but Resident #4 continued to yell; -Resident #4 could not utilize his/her coping skills and could not be redirected; -Staff obtained an order for Thorazine (used to treat schizophrenia and bipolar disorder) 50 mg injection; -At 4:50 A.M., staff administered PRN Thorazine 50 injection to the resident; -At 12:00 P.M., the resident pulled the fire alarm two times, he/she was delusional and said everyone was trying to kill him/her. Staff obtained an order to send the resident to the hospital for evaluation. Review of the resident's care plan, dated 7/28/24, showed the following: -Problem: this is my safety plan; -My personal goal is: make healthy decisions; -Interventions: the resident had one PRN (as needed) medication if he/she needed it, his/her warning sign was anxiousness, review the resident's medication with him/her to ensure he/she understood what medications the resident took and why, the following are ways the resident could be distracted or methods that comfort him/her including smoking, TV, games, group, and phone calls, the following worked well for the resident during his/her past crisis moments: sleeping and talking. Review of the resident's physician order sheet (POS), dated 7/29/24, showed the following: -Abilify extended release 400 mg injection once every 28 days start on 4/24/24; -Thorazine 50 mg injection every 12 hours as needed for agitation/anxiety related to paranoid schizophrenia and bipolar disorder start on 7/27/24; -Wellbutrin XL extended release 300 mg by mouth one time a day for depression start on 5/27/24. Review of the resident's MAR, dated July 2024, showed the following: -The resident missed three consecutive doses of Wellbutrin XL on 7/17/24, 7/18/24, and 7/19/24; -The resident missed his/her monthly injection of Abilify on 7/17/24. During an interview on 7/9/24 at 3:08 P.M., Licensed Practical Nurse (LPN) A/Resident Care Coordinator said the following: -The pharmacy said Resident #4's Abilify was not covered by insurance; -If a medication is not available on the medication cart for a resident, staff should call the pharmacy to check on it, call the physician, and notify the DON. During an interview on 7/29/24 at 5:19 P.M. the Assistant Director of Nursing (ADON) said the following: -If a medication was not available she would expect the staff to chart that on the MAR; -She would expect staff to call the pharmacy and find out why the medication wasn't at the facility; -She would expect the nurse to call the physician and get an alternative medication if the one prescribed was not covered by insurance. During an interview on 7/29/24 at 5:19 P.M. the Assistant Director of Nursing (ADON) said the following: -If a medication was not available she would expect the staff to chart that on the MAR; -She would expect staff to call the pharmacy and find out why the medication wasn't at the facility; -She would expect the nurse to call the physician and get an alternative medication if the one prescribed was not covered by insurance. Review of the resident's psychiatric hospital discharge records, dated 8/3/24, showed the following: -Arrival to hospital 7/27/24; -Chief complaint: the resident came from a skilled nursing facility for a mental health evaluation. The resident made suicidal statements and had exhibited increasing paranoia; -admission Impression: the resident was not safe for discharge and was admitted to inpatient with suicidal ideations due to voices that told him/her to kill himself/herself; -Duration of symptoms prior to arrival: days prior to admission; -On 8/3/24 the resident was ready and agreeable to discharge to the skilled nursing facility. During an interview on 8/6/24 at 9:38 A.M., and 8/8/24 at 9:20 A.M. the DON said the following: -There were no medications pulled from the Omnicell for Resident #4 during the months of June and July 2024; -She did not recall LPN H ever reporting in a nursing meeting that the resident's Abilify or Wellbutrin were not available for administration; -She expected nurses to call the pharmacy and the physician when a medication was not available to a resident; -If she was notified a medication was not available, she called the physician to notify them and to get a new order, either to put the medication on hold or get an alternative; -She was made aware that the resident missed his/her Abilify monthly injections for June and July 2024 on the day the resident was sent to the hospital (7/27/24); -She did not know why the resident pulled the fire alarm, the resident just did that when he/she was cycling. During an interview on 8/8/24 at 8:33 A.M., the resident said the following: -He/She pulled the fire alarm at the facility to get attention because he/she didn't get medications; -The resident felt he/she was neglected; -He/She doesn't get to see the psychiatrist, he/she had not seen the psychiatrics in two months. During an interview on 8/8/24 at 9:11 A.M., the Administrator said the following: -He expected staff to contact the resident's physician when his/her medications were not available; -He expected staff to contact the psychiatric physician for an appointment when the resident was having behaviors; -The resident was on a schedule with the psychiatric physician/NP for regular visits. He did not know for sure how often the resident was seen; -If the resident did not get his/her regimen of prescribed medications it could increase his/her behaviors and actions. MO239610

Based on interview and record review, the facility failed to ensure one resident (Resident #5), of 14 sampled residents, received necessary care and services in accordance with professional standards of practice. Resident #5 had a left breast needle biopsy (a diagnostic procedure used to investigate masses or lumps) completed on 6/8/23 after a mass was found. The facility failed to follow up and report the biopsy results to the physician until 2/5/24, approximately eight months after the needle biopsy was completed. The biopsy results indicated infiltering duct adenocarcinoma (the most common form of breast cancer and if caught and treated early the survival rate is high). The facility also failed to ensure the resident attended a scheduled follow up appointment with the resident's oncologist to discuss his/her treatment plan.The facility census was 175. Review of the facility's policy, Transcription of Orders/Following Physician Orders, last revised 9/20/23, showed the following: -The purpose of the procedure is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians orders are followed. That a process is in place to monitor nurses in accurately transcribing and following physician orders; -After laboratory testing, diagnostic testing or other services are ordered, the nurse will document orders in residents electronic medical record and fill out the corresponding requisition for the specific services to be obtained (or follow up protocol set forth by individual lab company). The facility policy did not address who was responsible to report laboratory testing or diagnostic testing to the physician. 1. Review of Resident #5's care plan, last updated 5/8/23, showed the following: -The resident had impaired thought process related to schizophrenia, it was difficult to follow his/ her train of thought at times, he/she does have a guardian to assist him/her in major decision making; -The resident is independent with activities of daily living (ADL) but requires assist with personal hygiene, provide protective oversight and assist where needed. Review of the resident's ultrasound of the left breast, dated 5/18/23, showed the following: -Diagnostic mammogram (x-ray picture) left breast. Ultrasound (a procedure that uses high-energy sound waves to look at tissues and organs inside the body) left breast; -Impression: Suspicious finding for malignancy (cancer). Biopsy should be considered. Review of the resident's Physician's Order Sheet (POS), dated 5/23/23, showed left breast diagnostic, unspecified lump in left breast. Review of the resident's report of consultation (a report that is filled out by the consulting physician following an appointment indicating what was done at the appointment and a copy of the report returns to the facility with the resident), dated 6/8/23, showed the following: -Appointment: breast biopsy; -Diagnosis: breast lump. Review of the resident's physician encounter, progress note, dated 10/2/23 and untimed, showed the following: -The resident had a biopsy of the left breast some time ago and the facility does not have the results; -Mass of the left breast; -Obtain biopsy results. Review of the resident's POS, dated 10/2/23, showed an order to obtain left biopsy results. Review of the resident's left breast pathology report, dated 6/8/23 at 7:29 P.M., reported to the physician on 2/9/24 after the second request, showed the left breast mass, core needle biopsy showed infiltrating duct adenocarcinoma, well differentiated (the tumor cells look more like normal tissue), nuclear grade one out of three (usually means the cancer is slower to grow). Review of the resident's physician encounter progress note, dated 2/9/24, untimed, showed the following: -Type of visit was an add on problem/facility request; -Chief complaint, nature of presenting problem was review of biopsy results; -The resident was seen after requesting left breast biopsy results, I again asked if the facility had results, as no results had been previously noted in the electronic health records. A staff member from the facility in medical records brought the results and it showed infiltrating duct adenocarcinoma of the left breast; -Overall plan, oncology referral regarding left breast adenocarcinoma. Review of the resident's POS, dated 2/9/24, showed oncology referral regarding left breast adenocarcinoma. Review of the resident's surgical oncology clinic note dated, 3/4/24 at 5:16 P.M., showed the following: -This resident, who resides in a long-term care facility, underwent a needle biopsy of a 7-millimeter (mm) lesion in the upper quadrant of his/her left breast on 6/8/23. This biopsy showed a well-differentiated ductal cancer; -Unfortunately, for some reason the final pathology report did not make it back to the resident's primary physician and so the positive results were just discovered recently. This morning the radiologist noted an abnormal left axillary node (lymph node located in the armpit). The resident presents to clinic this morning to determine the next steps in his/her management; -The resident will need an ultrasound guided core needle biopsy of his/her left axillary nodes as well as a recommended breast magnetic resonance imaging (a non-invasive medical imaging technique the produces three dimensional images of body's internal structures, also called an MRI) of both breasts to determine actual extent of the disease; -Will contact the Director of Nursing (DON) and the resident's physician once the final reports are back. Both are scheduled for 3/8/24. During an interview on 3/14/23 at 3:00 P.M., the resident said he/she had a biopsy of the left breast in June of 2023. He/She did not receive the results of the biopsy from last year. He/She didn't think it was cancer or the facility staff would have told him/her. He/She had a biopsy of the left breast again, last Friday (3/8/24) and the biopsy showed cancer. He/She didn't know what was going to be done to treat the cancer. During an interview on 3/18/24 at 9:15 A.M. the resident's guardian said the following: -She was aware in May of 2023 the resident had some type of mass; -The resident was scheduled to have a biopsy; -She did not hear anything about the biopsy results from last year until last month; -It must have got missed by the facility. The outcome could have been much worse. During an interview on 3/14/24 at 4:14 P.M. the Assistant Director of Nursing (ADON) said the following: -The nursing staff are to follow-up on any biopsy results and to assure those results are sent to the physician in a timely manner; -She found out a couple days ago the resident had cancer in his/her left breast. She was not aware there was a biopsy obtained in June of 2023 of the left breast. During an interview on 3/19/24 at 9:15 A.M. and on 4/2/24 at 10:05 A.M. the DON said the following: -The facility did not have a current procedure in place for who was responsible for following up on biopsy results and other pathology reports; -Breast cancer could potentially metastasize if left untreated for almost eight months; -She has been working the floor on night shift because the facility is short-staffed, it was hard for her to follow-up on things like this; -The resident was scheduled for a follow-up appointment with oncology for 3/25/24, she notified the appointment scheduler of the appointment and set up transportation. She found out later that the appointment was missed, she was not sure why the appointment was missed; -The appointment was rescheduled; -She had concerns with the system that was in place for scheduling appointments, as there was no reason for the resident's appointment to have been missed. During an interview on 3/14/24 at 3:20 P.M. the Administrator said the following: -He would expect the nursing staff to follow-up on any resident biopsy results and assure those results were sent to the physician in a timely manner; -There was a potential for disease progression or of cancer spreading if biopsy results are not obtained and reported to the physician in a timely manner. During an interview on 3/28/24 at 2:40 P.M. the resident's oncologist said the following: -The resident had a biopsy of a mass on 6/8/23 but the results did not make it back it to the resident's primary physician; -The resident was seen on 3/8/24 in her office for a biopsy and to look at a abnormal lymph node; -Breast cancer left untreated for over eight months could possibly metastasize; -The resident has stage I breast cancer define (considered early-stage, localized cancer and is highly treatable and survivable) and there was no metastasis; -She recommends all her patients who have been diagnosed with breast cancer be scheduled for treatment/surgery within less than two months after cancer is diagnosed; -The resident was scheduled for a follow-up appointment on 3/25/24 to discuss the lymph node findings and to discuss options for treatment, but the resident did not show up to the appointment scheduled for 3/25/24; -She made multiple phone calls to the facility to inquire why the resident missed the appointment, (there was either no answer or the call went to voicemail) she was finally able to reach facility staff and it was determined the appointment was missed, the appointment was rescheduled; -The plan will be for the resident to have have a lumpectomy; -It was possible that delays in having surgery could affect breast cancer outcomes. MO233076

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (Resident #1 and Resident #2), in a review of nine sampled residents, remained free from abuse. On 8/15/23, Resident #1 and Resident #3 were in a verbal dispute. Resident #1 expressed being fearful of Resident #3. Resident #1 was placed on one on one monitoring with staff for his/her safety. On 8/16/23, Resident #3 continued to make threats (wanting to beat Resident #1 up or kick his/her ass) towards Resident #1. Resident #3 ran into Resident #1's room, shoved and struck the staff member providing the one on one monitoring, and struck Resident #1 multiples times in the head and body. Resident #1 sustained a concussion (a brain injury from a hard, direct hit (trauma) to your head or body, healing from this injury can take time) and hand contusion (deep bruise to the hand, as a result to a blunt injury to tissues and muscle fibers under the skin). On 8/17/23, Resident #2 and Resident #4 got in to a disagreement over beads while in the outside common area. Resident #4 hit Resident #2 in the face. Resident #2 sustained acute fractures (immediate break in the bone) involving the lateral wall and floor of the left orbit (bones around the eyeball, often caused by a hard blow to the face) and acute fractures involving the lateral wall and anterior wall of left maxillary sinus (broken bones around the nasal cavity and below the eyeball). The facility census was 175. Review of the facility's Abuse and Neglect policy, revised on 1/5/23 showed the following: -Physical Abuse - Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Review of the facility's Behavioral Emergency Policy, revised 1/5/23, showed the following: -The purpose is to provide safe treatment and humane care to the residents in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -The licensed nursing staff/Team Leader/Resident Care Coordinator (RCC) will assess the resident who is exhibiting such behaviors, ensuring that safety of the resident and others is the first priority. A one-to-one monitoring of the resident will be initiated at this time under the direction of the licensed nurse; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Documentation of the behavior emergency in the Administrative Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the actual situation to permit underlying cause identification to the extent possible; -Behavior emergency= a code green. A code green can be called to be proactive in ensuring that enough qualified staff are present and to warrant the potential need of utilizing approved CALM hold techniques; -The nurse (unless the administrator, director of nursing (DON) or assistant director of nursing (ADON) are present) is ultimately in charge of the code green and all staff responding will follow the direction of the Team leader. The team leader can be the first one to the scene of the code green, the employee with the most experience or the employee that had the best rapport with the resident; -When a code green is called staff will respond promptly and professionally. A code green does not denote that approved calm hold techniques are automatically utilized. The central purpose of calling a code green is recognizing that the resident has become or has the potential to become a danger to themselves or someone else. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/24/23, showed the following: -Cognition intact; -No behavioral symptoms exhibited; -Independent with walking and locomotion on and off the unit. Review of the resident's progress note dated 8/15/23 at 6:54 P.M., showed a verbal altercation began between the resident and a peer (Resident #3), on the 800 unit dining room, staff intervened. The resident refused to separate himself/herself from his/her peer. A code green was called, peer (Resident #3) attempted to run around the table and the staff member to attack Resident #1. Staff intervened and no contact was made. The resident (Resident #1), was willing and went to the social service office until safe to return to the unit. The resident was currently in his/her room resting. One on one in place. Review of the resident's progress note dated 8/16/23 at 8:00 P.M. showed the following: -A code green was called, with the direction of the Director of Nursing (DON), when Resident #1 was in the smoke room with peer (Resident #3), who was verbally aggressive, said to him/her (Resident #1) he/she still wanted to beat him/her up; -Staff separated both of the residents in the smoke room. Resident #3 went to the common area. Resident #1 smoked, staff escorted him/her back to his/her room, and Resident #1 returned to one on one; -A few minutes later Resident #3 went into Resident #1's room and shoved and punched the staff member. Resident #3 attacked Resident #1, punched his/her body and head, and pulled his/her hair; -Resident #1 said he/she just covered his/her head and face trying to protect himself/herself; -A code green was called again. Staff separated both of the residents. Resident #1 had minor bruises on the right hand and arm and palpable bumps at the back of his/her head. The resident was transferred to the hospital for a medical evaluation. Review of Resident #1's hospital discharge instructions, dated [DATE], showed a concussion without loss of consciousness and contusion to hand. During an interview on 8/23/23 at 1:00 P.M., Resident #1 said he/she had a concussion, and was in a lot of pain. Resident #1 had told staff that he/she was scared of Resident #3 so they put him/her on one on one. Resident #3 had threatened to beat him/her up. Review of Resident #3's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 7/26/22, showed the following: -Diagnoses included schizoaffective (a combination of symptoms of schizophrenia, a serious mental illness that affects how a person thinks, feels, and behaves) , bipolar type ( they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania), Bipolar 1 disorder ( manic episode which can include increased energy, excitement, impulsive behavior and agitation, may or may not experience a depressive episode) and Bipolar 2 disorder ( a chronic mental illness defined by episodes of depression and periods of elevated or irritable mood), major depressive disorder and reactive attachment disorder (a condition where a child doesn't form healthy emotional bonds with their caretakers (parental figures) often because of emotional neglect or abuse at an early age; -The resident had historical symptoms of disorganized thinking, impulsive behaviors, suspicious, paranoid abnormal thought process, verbal and physical aggression both suicidal ideation/homicidal ideation; -The resident displayed consistent unsafe/poor decision making, due to mental functioning; -The resident had poor insight and judgement; -Safety plan to address interventions when the resident poses a risk to himself/herself or others. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility staff, dated 4/21/23 showed the resident was cognitively intact. Review of the resident's annual MDS, dated 7/23, showed the following: -Makes self-understood and understands others; -No physical behavioral symptoms exhibited over the last week; -Verbal behaviors occurred one to three days out of seven; -Required staff supervision/oversight with walking and locomotion on and off the unit. Review of the resident's care plan dated 8/18/23 showed the following: -The resident had a history of behavioral challenges that require protective oversight in a secure setting, needs behavioral support plan, medication therapy, structured environment, crisis intervention, CALM technique if needed, coping skills were drawing and painting, one on one interventions as needed and pharmaceutical interventions as needed; -History of behaviors and current behaviors, impulsive behaviors, psychosis ( a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), suspicious/paranoid, wanders depression/depressed mania; -The resident had a mood problem related to bipolar disorder, educate the resident/family/caregivers to identify strengths, positive coping skills and reinforce these; -The resident had a history of post-traumatic stress disorder (PTSD). PTSD symptoms may flare up without any known trigger. Alterations in reactivity from the traumatic event, including aggressiveness and self-destructive behavior; -Assess anxiety level, determine severity of condition and course of treatment. Coping skills were drawing, painting, listening to music, and talking with staff/peers. Review of the resident's progress note dated 8/16/23 at 10:56 P.M. (late entry) showed the following: -Resident #3 was in the smoke room with peer (Resident #1) when he/she (Resident #3), started becoming verbally inappropriate with peer. Staff separated the residents and implemented different smoke times to prevent further issues. Resident #3 continued to be in the common area and made statements/threats about the peer (Resident #1); -The peer (Resident #1) was placed one on one for protective oversight. Resident #3 was able to be redirected and staff continued to monitor him/her. Resident #3 walked down the hall towards his/her room, but instead he/she ran into the peer's (Resident #1's) room; -The one on one staff attempted to redirect the resident. The resident allegedly shoved/struck staff member. He/She then struck the peer multiple times in the head/body areas. The resident was immediately placed one on one and order was given to send out the resident to be evaluated. During an interview on 8/23/23 at 12:30 P.M. Hall Monitor C said the following: -He/She worked on the hall when the altercation took place between the two residents; -On 8/15/23 Resident #1 was one on one because Resident #3 had charged at Resident #1. On 8/16/23 around 12:00 P.M., Resident #1 was removed from one on one because he/she felt safe; -Hall monitor C thought Resident #3 should have been one on one, because Resident #3 made threats against Resident #1, but he/she didn't know the protocol on that; -On 8/16/23 (later that day) in the smoke room, Resident #3 told Resident #1 he/she was going to beat his/her ass. Resident #1 left the smoke area until Resident #3 was done smoking; -Resident #1 went back to the smoke room and finished smoking. Resident #3 sat outside the smoke area and said he/she was going to beat his/her (Resident #1) ass. A code green was called because of the comments Resident #3 made; -He/She tried to calm Resident #3 down. Staff were instructed to keep Resident #1 in the smoke room until Resident #3 was sent out for evaluation; -Registered Nurse (RN) A responded to the code. Code green staff escorted Resident #1 to his/her room and he/she was placed one on one; -He/She explained to the code green team, that Resident #3 had threatened to beat Resident #1's ass, but the staff that responded to the code green left the hall. He/She knew something was going to happen as he/she worked routinely with the residents; -Resident #3 headed down the hall to his/her room, and suddenly sprinted across the hall to Resident #1's room. When hall monitor C made it to Resident #1's room, Resident #3 was on top of Resident #1 hitting him/her; -He/She should have spoken up when all the staff left the hall, but felt the code green staff that responded were above him/her in their position. During an interview on 8/28/23 at 8:45 A.M. Registered Nurse (RN) B said the following: -He/She worked the evening of the altercation; -Resident #1 was one on one for his/her safety because Resident #3 had threatened Resident #1 on 8/15/23; -On 8/16/23 around 4:00 P.M., Resident #1 felt safe so the resident was removed from one on one; -Later in the shift, hall monitor C called and said Resident #3 started making threatening comments again towards Resident #1. The residents were in the smoke area and hall monitor C had separated the residents; -Resident #3 was typically aggressive and based on his/her history, the instigator. Resident #3 was unpredictable and many of the CNAs were afraid of him/her; -The Director of Nurses (DON) instructed staff (over the phone), to not allow Resident #1 to leave the smoke area until Resident #3 was sent out. Resident #3 (who sat outside of the smoke room), made threatening comments about wanting to beat up or hurt Resident #1 when he/she came out of the smoke room; -A code green was called and RN B left the hall to set up transportation to send Resident #3 out for evaluation due to aggressive behaviors; -Typically, the aggressor was placed one on one. RN B thought staff was sitting with Resident #3 when he/she left the hall to set up transportation. RN B felt the altercation could have been prevented if staff that responded to the code green would not have left the floor. During an interview on 8/28/23 at 9:26 A.M., RN A said the following: -On 8/16/23 he/she arrived to the facility and was only at the facility for just a few seconds before a code green was called; -He/She responded to the code green, but had no knowledge of what occurred between the two residents prior to the code green; -When he/she arrived to the hall, everything was calm. Resident #3 was visiting with his/her peers. An unidentified staff member said we need help getting Resident #1 to his/her room; -RN A did not know Resident #3 had been aggressive. If he/she would have known what had occurred before he/she arrived to the facility, he/she would have done things differently; -Resident #3 should have been placed one on one if he/she was the aggressor and was being sent out for evaluation due to behaviors; -The facility staff should have either called RN A before he/she arrived to the facility to explain what had happened between the two residents, or explained concerns during the code green; -RN A told the staff that responded to the code green he/she didn't see an issue, and the code green staff returned to their halls; -RN A was unaware the DON had instructed Resident #1 to remain in the smoke room until Resident #3 was transferred out. During an interview on 8/23/23 at 1:50 P.M. Staffing Coordinator D said the following: -On 8/16/23 hall monitor C called him/her and said Resident #3 was outside the smoke room and had made threats that he/she was going to fight Resident #1 when he/she came out of the smoke room; -Staffing Coordinator D gave strict orders to staff to not allow Resident #1 to leave the smoke area because once Resident #3 was mad and had something in his/her head, it was going to happen; -Resident #3 was to be sent out for a psychiatric evaluation. He/She had communicated back and forth with the DON about the issue prior to the altercation; -When RN A responded to the code green staff should have spoke up and explained what had been going on before all of the staff that responded to the code green left the hall. During an interview on 8/23/23 at 11:34 A.M. the DON said the following: -On 8/16/23, facility staff called Staffing Coordinator D and said Resident #3 was outside the smoke room waiting to hit Resident #1; -She communicated with Staffing Doordinator C and called RN B and instructed him/her to not allow Resident #1 to leave the smoke room because the smoke room had a lock on the door; -She instructed RN B to call a code green and get Resident #3 sent out for a psychiatric evaluation; -If a code green was called it would be five staff to one resident; -She would never turn his/her back on Resident #3. Resident #3 could be very calm, but was very manipulative. During an interview on 8/22/23 at 9:00 A.M. and 12:06 P.M., and 8/23/23 at 2:25 P.M., and at 4:00 P.M., the administrator said the following: -On 8/15/23, Resident #1 and Resident #3 were arguing over a chair, Resident #1 left the hall and came back and was upset that his/her chair had been taken by another resident. Resident #3 said we don't save seats; -Resident #3 said you want to go, lets go, and staff intervened; -Resident #1 was actually the instigator; -Resident #1 was Resident #3's focus, so staff put Resident #1 one on one monitoring for his/her safety; -Resident #3 was not placed one on one as he/she didn't have any issues with other residents at the facility; -Many of the residents at the facility make aggressive comments towards other residents, that doesn't mean the facility automatically puts the resident who made threatening comments one on one. If they always put residents one on one for aggressive comments made, they would not have any staff to work because staff would be tied up with one on one residents all of the time; -Staff called a code green on Resident #3 after he/she made threatening comments; -On 8/16/23 Resident #1 said he/she felt safe so he/she was removed from one on one. Later in the smoke room there were verbal comments made by Resident #3 towards Resident #1 and staff put Resident #1 back on one on one for his/her safety. One of the residents needed to be secured to assure nothing else happened; -On 8/16/23 RN A responded to the code green when he/she arrived to work. RN A thought everything was calm and didn't find an issue; -Later, Resident #3 walked down the hall and staff took off after him/her at a fast pace. Resident #3 went in his/her room, then took off into Resident #1's room, punched the one on one staff and pulled Resident #1's hair; -Resident #1 said he/she had a headache and was sent out to see if he/she had a concussion; -Resident #3 was fixated with Resident #1. This was not normal for Resident #3, so that was the reason Resident #3 was being sent out for an evaluation. 2. Review of Resident #2's quarterly MDS dated [DATE] showed the following: -Cognition intact; -No behaviors exhibited; -Ambulation and locomotion on and off the unit occurred only once or twice during the last week no setup or physical help from a staff member needed. Review of the resident's progress note, dated 8/17/23 at 9:50 P.M., showed the following: -Resident to resident altercation in which the residents fought over beads that the resident (Resident #4) wanted back. Resident #2 allegedly threw the beads at Resident #4, at which point Resident #4 began hitting Resident #2 in the face; -A code green was called. All available staff went to the Hang Out (common area) to find Resident #2 bleeding from his/her nose, forehead, and above his/her left eye; -A while ago, Resident #4 made Resident #2 a necklace with some of his/her beads. Resident #2 placed some of the beads in his/her hair. Resident #4 asked for six beads back and wanted to pick the beads out. Resident #2 brought the beads to the Hang Out out after he/she took a shower; -Resident #4 said he/she wanted them all, but Resident #2 paid for them. Resident #2 got mad so he/she threw the beads at Resident #4. Resident #4 started hitting Resident #2; -Resident #2 had a large laceration above his/her eye which was swollen, black and blue, and his/her eye was red and irritated. Staff called EMS (emergency medical services) for transportation to the emergency department for evaluation and treatment. Review of Resident #2's hospital radiology report, dated 8/17/23 at 9:14 P.M., showed the following: -Assault, resident punched in the face multiple times; -Acute fractures (immediate break on the bone) involving the lateral wall and floor of the left orbit (bones around the eyeball, often caused by a hard blow to the face). There was also acute fractures involving the lateral wall and anterior wall of left maxillary sinus (broken bones around the nasal cavity and below the eyeball). During interview on 8/22/23 at 11:38 A.M., Resident #2 said the following: -Resident #4 said he/she wanted six beads back from a necklace he/she had given to him/her previously, Resident #2 had put the beads in his/her hair because the necklace turned his/her neck green; -On shower day Resident #2 took the beads out of his/her hair and went to the Hang Out; -Resident #4 said he/she wanted all the beads, so Resident #2 just threw the beads and Resident #4 started hitting him/her in the head; -He/she fell down and didn't remember much about what happened after that. Review of Resident #4's PASRR, dated 8/5/16, showed the following: -Diagnoses included schizo-affective (a mental health problem where you experience psychosis as well as mood symptoms), Bipolar I disorder, rule out intermittent explosive disorder (repeated, sudden episodes of impulsive aggressive, violent behavior or angry outbursts in which you react grossly out of proportion to the situation) verses impulsive control disorder (chronic problems in which people lack the ability to maintain self-control); -Problematic behaviors include impatient/demanding, strikes others provoked; -Specific symptoms included delusional, anxious, labile, restless, pacing, poor concentration. History of angry outbursts, physical aggression, easily agitated, depression, and mood swings. He/She was also guarded; -Functional limitations in interpersonal functioning, concentration, persistence, pace or adoption to change in the last six months included difficulty interacting, appropriately/communicating effectively with others, a history of altercations, evictions, firing, fear of strangers, difficulty concentrating, difficulty in adapting to typical changes associated with work, family or social interaction, and manifests agitation, and exacerbated signs and symptoms associated with the illness. Review of the resident's annual MDS dated [DATE] showed the following: -Cognition intact; -No behavioral symptoms exhibited; -Supervision with walking in room and corridor; -Independent with locomotion on and off the unit; Review of the resident's care plan last revised on 8/19/23 showed the following: -The resident has a history of behavioral challenges that require protective oversight in a secure setting, current behaviors poor judgement, poor decision making, verbally aggressive, physically aggressive, poor insight, impatient and demanding; -Coping skills were crafting (making bracelets), painting, drawing, watching television, coloring, and making bookmarks; -One on one interventions as need and pharmaceutical interventions as needed. Review of Resident #4's progress note dated 8/17/23 at 10:04 P.M., showed the resident and peer (Resident #2) were in a verbal altercation over beads from a necklace. The resident struck the peer in face three times. Immediately placed one on one and resident sent out for psychiatric evaluation. Review of the facility RNI dated 8/18/23 (completion of investigation untimed), showed the following: -Date of incident: 8/17/23; -Type of incident: physical aggression involving head; -Criteria for reporting was abuse; -Code green called to the hang out after Resident #4 allegedly struck Resident # 2 in the face after they had a disagreement over beads. Resident #4 reported he/she made a necklace made of beads for Resident #2 and he/she bought it from him/her some time ago; -Resident #2 agreed to give the beads back, but when it was time to give them back he/she didn't. Resident #4 tried to snatch the beads out of his/her hand; -Resident #4 said Resident #2 shoved his/her shoulder so Resident #4 punched the bitch. Resident #4 claimed it was self-defense for Resident #2 shoving him/her; -Conclusion of the investigation: Facility can confirm that Resident #4 struck Resident #2 when they had a disagreement over beads. There was no build up to the incident and the residents had not had any previous incidents with each other; -Resident #2 noted with redness and swelling to left eye area and a laceration above the left eye. Resident #2 found to have left orbital floor fracture/lateral wall fracture, left maxillary sinus lateral wall and anterior wall fractures. During an interview on 8/23/23 at 11:35 A.M. the DON said the following: -Resident #4 had no recent change in behaviors prior to the altercation with Resident #2; -Resident #4 was sent out for a psychiatric evaluation and later arrested. During an interview on 8/23/23 at 8:50 A.M. the administrator said the following: -Resident #4 sold a necklace to Resident #2 and Resident #4 wanted the beads back. Resident #2 threw the beads and the altercation occurred; -There had been no previous incidents between the two residents; -Resident #4 was arrested and Resident #2's guardian will be pressing charges. MO00223131 MO00223077

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident, (Resident #1) in a review of six sampled residents, was free from abuse when Certified Med Tech (CMT) E cussed and yelled at Resident #1 causing him/her to be afraid of the staff member. The facility census was 178. Review of the facility Abuse and Neglect Policy, dated 1/5/23, showed the following: -Verbal abuse - using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples include harassing a resident, mocking, insulting, ridiculing, yelling at a resident, with the intent to intimidate or threatening residents; -Mental abuse - the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. This includes hovering over a resident with the intent to intimidate or threatening residents; -Mistreatment, neglect or abuse of residents is prohibited by the facility. This includes physical abuse, sexual abuse, verbal abuse, mental abuse and involuntary seclusion; -The facility does not condone resident abuse by anyone, including employees. 1. Review of Resident #1's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 9/2/2015, showed the following: -The resident had diagnoses that included serious mental illness; schizoaffective disorder (a combination of symptoms of schizophrenia, a serious mental illness that affects how a person thinks, feels, and behaves) and mood disorder, such as depression, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Attention Deficit Disorder (trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active), conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others), Post Traumatic Stress Disorder, traumatic brain injury and intermittent explosive disorder (IED - a mental health condition marked by frequent impulsive anger outbursts or aggression); -The resident functioned at a lower social level than his/her age and had poor impulse control and poor judgment; -The resident was not a threat to self or others; -The resident had difficulty interacting appropriately/communicating effectively with others and adapting to typical changes associated with work, family or social interaction. Review of the resident's care plan, dated 4/4/23, showed the following: -The resident had a behavior problem of verbal and physical aggression related to depression and schizophrenia; -Ensure protective oversight is provided; -Anticipate and meet the resident's needs. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/11/23, showed the following: -The resident's cognition was intact; -The resident did not have verbal, physical or other behaviors towards others. Review of the facility's registered nurse investigation (RNI), completed 6/16/23, showed the following: -On 6/7/23 the charge nurse, Licensed Practical Nurse (LPN) D and Psych Aide C reported to the administrator that CMT E took off his/her top shirt and approached Resident #1 aggressively while using profanity; -Staff took Resident #1 to his/her room and CMT E was escorted off the unit and suspended pending the investigation; -Resident #1 reported that he/she and CMT E were joking and talking trash and making fun of one another. CMT E then flinched at Resident #1 as if CMT E were going to hit Resident #1. Resident #1 jumped and accidentally struck CMT E in the face. CMT E took off his/her shirt and said, You better run. I am fucking pissed. Resident #3 stepped between Resident #1 and CMT E and walked Resident #1 to his/her room; -CMT E reported he/she was passing medications when Resident #1 tried to push a soda off the medication cart. When CMT E asked Resident #1 to stop, Resident #1 tried to close the computer on the medication cart. When CMT E asked him/her to stop, Resident #1 balled up his/her fist and hit CMT E in the nose. CMT E got really upset and told Resident #1 to keep his/her fucking hands to himself/herself; -Both LPN D and Psych Aide C, as well as four resident witnesses (Residents #2, #3, #5, and #6) all reported hearing CMT E using profanity; -Conclusion: The facility finds that CMT E used profanity towards Resident #1. CMT was terminated from employment on 6/8/23. Review of a written statement by the resident, provided by the facility, dated 6/7/23, showed the following: -Resident #1 and Certified Medication Technician (CMT) E were joking around and talking trash; -CMT E got mad and flinched at Resident #1 like he/she was going to hit Resident #1 in the face; -CMT E took off his/her shirt and said, You better run, I'm fucking pissed; -CMT E had played with Resident #1 like that before and acted like he/she was going to hit the resident (but never did), but this time CMT E was really close. Review of a written statement by Psych Aide C , provided by the facility, dated 6/7/23, showed the following: -Psych Aide C came onto the hall and saw CMT E screaming at Resident #1; -CMT E told Resident #1, Hit me in the face again mother fucker, I'm mad and you should run; -Psych Aide C got to Resident #1 and took the resident to his/her room, CMT E was escorted off the unit by the Director of Nursing (DON). Review of a written statement by Licensed Practical Nurse (LPN) D, provided by the facility, dated 6/7/23, showed the following: -LPN D was in the nurse's station when he/she heard CMT E yell, Are you going to hit me again, fucking do it; -LPN D saw Psych Aide C come around the corner and take the resident to his/her room; -LPN D contacted administration and the DON came and escorted CMT E off the unit. Review of a written statement by Resident #3, provided by the facility, dated 6/8/23, showed Resident #3 saw CMT E in Resident #1's face. Review of a written statement by Resident #5, provided by the facility, dated 6/8/23, showed the following: -Resident #5 was getting medications from CMT E when Resident #1 knocked the CMT's soda over and closed the computer; -CMT E and Resident #1 started slap boxing and Resident #1 accidentally hit CMT E in the face; -CMT E took off his/her shirt and told Resident #1, Do it again mother fucker, I'll fuck you up; -Resident #3 got inbetween CMT E and Resident #1, then Psych Aide C came and took Resident #1 to his/her room. Review of a written statement by Resident #2, provided by the facility, dated 6/8/23, showed the following: -CMT E got in Resident #1's face aggressively; -Resident #2 heard CMT E say Keep your hands to your fucking self. During an interview on 6/21/23 at 2:56 P.M., Resident #6 said the following: -CMT E popped off and mouthed to Resident #1 then Resident #1 punched CMT E; -CMT E told Resident #1, I'm going to fuck you up; -CMT E cussed at the residents and told them they were pieces of shit. During an interview on 6/20/23 at 10:10 A.M., Resident #1 said the following: -He/She and CMT E were horse playing, they were joking around and making fun of each other and then CMT E got mad; -CMT smacked the resident's hand (the resident held up his/her hand with the palm facing towards CMT E). The resident told CMT E he/she did not mean to make him/her mad. CMT E jumped at the resident; -CMT E took off his/her glasses and shirt and said, You might want to run. The resident asked why and CMT E said Because I'm pissed; -The resident was really, really scared of CMT E at that point. The resident did not know what CMT E would do next; -Psych Aide C came and walked the resident to his/her room. During an interview on 6/20/23 at 10:25 A.M., Psych Aide C said the following: -The psych aide came in the building from outside and heard yelling; -The psych aide got to the end of the 200 hall on [NAME] unit and saw Resident #1 at the opposite end of the hallway in the corner. CMT E was yelling and cussing at the resident; -The psych aide got in between CMT E and the resident and assisted the resident to his/her room. During an interview on 6/20/23 at 4:31 P.M., CMT E said the following: -Resident #1 kept messing with stuff on the medication cart; -CMT E was behind on passing medications and Resident #1 kept messing with stuff on the cart. CMT E asked Resident #1 five or six times to stop; -Resident #1 acted like he/she was going to punch CMT E and then he/she did hit CMT E in the nose with a closed fist; -CMT E told Resident #1 Keep your fucking hands off and then CMT E took off his/her shirt. CMT E was mad, but not that mad. During an interview on 6/20/23 at 5:05 P.M., the administrator said the following: -She expected all staff not to cuss at the residents; -Staff should not be horse playing with the residents. Some residents cannot tell the difference between horse play and someone being upset with a resident; -She would consider CMT E's actions to be abuse. MO219670

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four residents (Resident #1, #2, #3 and #5), in a review of 17 sampled residents, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being when three staff members, (Licensed Practical Nurse (LPN) C, Certified Nurse Aide (CNA) D and Hall Monitory E, had a verbal argument with yelling and cussing that escalated and upset Resident #1 to the point it became a physical altercation between LPN C, CNA D and Resident #1. Residents #2, #3 and #5 became involved when they tried to break up the physical altercation. Resident #1 required an as needed medication for agitation. Resident # 2 was upset got caught in the middle of the physical altercation and got hit in the face which resulted in a swollen black eye with pain. Resident #3 said it triggered his/her Post Traumatic Stress Disorder (PTSD - a mental health condition that's triggered by a terrifying event) and Resident #5 was upset about Resident #1 being in the physical altercation and tried to get him/her back to their room. The facility census was 177. Review of the facility's Behavioral Emergency Policy, revised 1/5/23, showed the following: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure the resident is not being coerced, punished, or disciplined for staff convenience; -It is the policy of the facility to provide a safe environment and provide humane care to all residents; -The licensed nursing staff/Team Leader/Resident Care Coordinator (RCC)/nursing administration will assess the resident who is exhibiting behaviors, ensuring the safety of the resident and others is the first priority. A one to one monitoring of the resident will be initiated immediately; -Documentation of the Behavior Emergency in the Administrative Investigation will include evaluation of the resident's behavior, including consideration for precipitating events or environmental triggers, and other related factors in the medical record with enough specific detail of the situation to permit underlying case identification to the extent possible; -Other supportive methods to control behaviors will be outlined in the plan of care individually for those residents in a behavior emergency crisis; -In the event the resident is unable to be redirected or is requesting an as needed (PRN) medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a PO (by mouth) or IM (intramuscular, injection given in the muscle) PRN for mood stabilizing medication, the licensed nurse must completed the PRN Intervention Form; -The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines; -B= Behavior Emergency - define behavior -I= Intervention - document intervention, note behavior emergency policy and document interventions from the behavioral emergency policy; -R= Reaction/Response - document reaction and response of the resident after the interventions; -P= Plan - continue current plan of care, continue observing and monitoring of the resident; -E= Evaluation; -E= Evaluation; -E= Evaluation; -E= Evaluation; -Behavioral Emergency = Code Green. A Code [NAME] can be called to be proactive in ensuring that enough qualified staff are present. The main purpose of calling the Code [NAME] is recognizing the resident has become or has the potential to become a danger to themselves or someone else. Calling a Code [NAME] also ensures that all staff is readily available to utilize approved Crisis Alleviation Lessons and Methods (CALM, techniques to deescalate and manage behaviors safely) hold techniques if necessary. 1. Review of Resident #1's Preadmission Screening and Record Review (PASRR - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis), dated 02/02/2022, showed the following: -The resident had serious mental illnesses; -The resident was easily frustrated and had limited emotional control. He/She needed clear, concise explanations at his/her level of understanding; -The resident's communication and interaction with others was generally pleasant and cooperative, soft spoken, but easily frustrated. The resident lost his/her temper easily. -The resident had intact immediate, short term and long term memory; -The resident's limitations were his/her impulsiveness, lack of self-control, poor coping skills and quick to anger; -The resident needed support and services that provided a structured environment that included, an environment with low stimulation, instructions at the individual's level of understanding and assess and plan for the level of supervision required to prevent harm to self or others. Review of the resident's care plan, dated 8/19/22, showed the following: -The resident had a history of trauma. Maintain a calm, non-threatening manner while working with the resident; -The resident had a history of behavioral challenges (physical aggression, verbal aggression, suicidal ideation and homicidal ideation) that required protective oversight in a secure setting. One-on-one interventions as needed and pharmaceutical interventions as needed. Review of the resident's care plan, dated 8/22/22, showed the following: -The resident had triggers; being yelled at, not being in control and condescending tones; -No interventions were documented on the care plan for the resident's triggers. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/18/23, showed: -The resident was cognitively intact; -The resident had diagnoses that included serious mental illness, anxiety, depression, autistic disorder (a condition related to brain development that impacts how a person perceives and socializes with others, causing problems in social interaction and communication), Attention Deficit Hyperactivity Disorder (ADHD - trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active). Review of the resident's medication administration record, dated May 2023, showed the following: -The resident was monitored for behaviors every shift; -The resident had no behaviors in May 2023. Review of the resident's progress notes, dated 5/20/23 at 10:04 P.M., charted by LPN C, showed the following: -The resident sat in the dining room with a hall monitor. The resident got mad and started yelling at staff members talking; -The resident yelled at LPN C for waking him/her up and got in the LPN's face and yelled; -Staff got between the resident and LPN C and the resident began to swing; -LPN C called for help and the resident walked off; -The resident got upset again and yelled a racial slur and threats to kill LPN C; -Another nurse stepped in and an as needed medication was administered. Review of a statement by Resident #1, obtained by the facility, dated 5/20/23, showed the following: -The statement was transcribed for Resident #1 by an unknown staff member; -Resident #1 said CNA D came to the 100 hall about 11:30 P.M. on 5/20/23 and yelled at Hall Monitor E; -Resident #1 was not sure why CNA D yelled at the hall monitor but the resident told the CNA he/she was being unprofessional; -CNA D said something (unsure what) smart and Resident #1 did not walk away like he/she should have; -CNA D and LPN C grabbed Resident #1 by the shirt so he/she grabbed their hair just to keep them from doing anything to him/her; -Hall Monitor F held Resident #1 back and CNA D said who is going to hold me back from him/her?; -Resident #1 called LPN C a racial slur; -Resident #1 said he/she blacked out but remembered bits and pieces. Review of the resident's medication administration record, dated May 2023, showed the resident received an as needed psychotropic medication on 5/21/23 at 7:35 A.M., (day following the incident). Review of the resident's progress notes, dated 5/22/23 at 9:19 A.M., charted by the MDS Coordinator, showed the following: -The MDS Coordinator assessed the resident for periods of blacking out; -The resident said Sometimes I feel myself blacking out, it depended on how aggressive the person is with me. The more aggressive they get with me, I feel the anger rise and I black out. I don't remember anything when I black out but over the next few days I remember things. It comes back to me in bits and pieces; -The MDS Coordinator asked the resident if he/she passed out or if staff was still there when the resident blacked out. The resident said, I don't remember anything. I feel like a separate personality inside me. I have no memory of anything. I don't know what happens, it just happens. During an interview on 5/22/23 at 2:26 P.M., the resident said the following: -LPN C came to the resident's room to give his/her roommate medication and it woke Resident #1 up. This made the resident mad and he/she went to the dining room to have a snack; -Everything really started when CNA D came to the 100 hall dining room. CNA D yelled, cussed and threatened Hall Monitor E; -Resident #1 told CNA D he/she needed to take the conversations somewhere else. Resident #1 got up from the table and headed to his/her room; -CNA D said something (unsure what), and Resident #1 turned around and yelled at CNA D; -CNA D kept egging it on and mouthed off again to Resident #1 and they started to scream at one another at the nurse's station; -At that point LPN C came and yelled at Resident #1; -Resident #5, (Resident #1's roommate), came and said, let's go to our room. Resident #1 and #5 were headed to their room and CNA D yelled at Resident #1 again; -Hall Monitor F told LPN C and CNA D to leave the hall because they were upsetting the residents; -Hall Monitor F held Resident #1 back while Resident #1 yelled at LPN C and called him/her a racial slur; -CNA D yelled, Who is going to hold me back from him/her? and lunged at Resident #1 with both fists up; -CNA D grabbed Resident #1's shirt and Resident #1 grabbed LPN C's and CNA D's hair. Finally everyone let go and Hall Monitor F let go of Resident #1; -CNA D went at Resident #1 again and that is when Resident #2 stepped between them. -Resident #1 accidentally hit Resident #2 and CNA D hit Resident #1 on top if his/her head; -Resident #1 said he/she was very tired. He/She had not slept well because all of this was in his/her head. He/She had been very worried about the whole situation. 2. Review of Resident #2's undated face sheet showed the resident had diagnoses that included; major depressive disorder, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder and nightmare disorder (a pattern of repeated frightening and vivid dreams that affects quality of life). Review of the resident's PASRR, dated 9/2/15, showed the following: -The resident had serious mental illnesses; -The resident had diagnoses that included schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression, bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others), paranoid personality disorder (PPD - a mental health condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious) and a traumatic brain injury at age five; -The resident functioned at a lower social level than his/her age, had poor judgment, insight and impulse control. He/She had poor endurance when presented with stressful situations; -The resident was not a threat to self or others. Review of the resident's care plan, dated 4/4/23, showed the following: -The resident had a behavior problem, verbal and physical, related to depression and schizophrenia; -Ensure protective oversight is provided; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -The resident did not have verbal, physical or other behaviors towards others. Review of the resident's progress notes, dated 5/21/23, showed the following: -At 2:43 A.M., the resident reported to Registered Nurse (RN) G he/she was hit in the right eye and complained of pain. The RN administered as needed pain medication to the resident; -At 7:37 A.M., RN G administered as needed pain medication; -At 9:43 A.M., the resident complained of anxiety to nursing staff; -At 11:56 A.M. nursing staff administered as needed anxiety medication. Review of the resident's progress notes, dated 5/21/23 at 2:43 A.M., showed the following: -The resident reported to RN G he/she was hit in the right eye; -The resident complained of pain; -Vital signs were within normal limits; -No skin tear noted; -As needed pain medications; -Will continue to monitor. Review of the resident's progress notes, dated 5/22/23, showed the following: -At 6:00 A.M.,the resident's right eye was extremely swollen and skin around the eye was red. The resident was unable to open his/her right eye. The resident said it was painful; -At 11:52 A.M. the resident was seen by the nurse practitioner (NP) with encouragement to utilize as needed pain medication and ice packs. The NP ordered x-rays of the resident's right eye. During an interview on 5/22/23 at 11:22 A.M. and 5/24/23 at 3:49 P.M., Resident #2 said the following: -On 5/20/23 Resident #2 and #3 were in their room and heard someone yelling. They walked out of their room towards the nurse's station and saw Resident #1. He/She was upset and they tried to calm Resident #1 down; -LPN C mouthed off to Resident #1 and then CNA D jumped in and it escalated super quick; -Residents #2, #3 and #4 and Hall Monitor F got CNA D and LPN C away from Resident #1; -CNA D and LPN C walked towards the 300 hall then turned around and came back around the corner to the nurse's station; -CNA D started running his/her mouth again to Resident #1 and the next thing Resident #2 knew there was a pile up. LPN C and CNA D kept running their mouths and that kept Resident #1 riled up; -CNA D was swinging his/her fists and Resident #1 had a hold of CNA D and LPN C by the hair. CNA D and LPN C hit Resident #1 on top of the head; -CNA D and LPN C walked towards the 300 hall again and came back to the nurse's station. Hall Monitor F grabbed Resident #1 and CNA D went at Resident #1. Resident #2 bumped CNA D out of the way and that is when Resident #2 got hit in the right eye by Resident #1; -Resident #1 went to his/her room and CNA D and LPN C left the hall. Review of the resident's progress notes, dated 5/23/23, showed the following: -The resident went to the nurse and asked about x-ray results. The nurse informed the resident the x-ray came back good and to continue to utilize over the counter pain medications and ice packs; -The resident was not happy about the results and said more was wrong. He/She went and slammed his/her room door and ripped the privacy curtain. A code green was called and the resident was placed in a five man calm hold; -The resident received an as needed psychotropic (medication that affect a person's mental state) intramuscular injection for threatening behavior, combative aggressive imminent danger to self or others; -The resident was placed on 72 hour observation. 3. Review of Resident #3's PASRR, dated 1/16/23, showed the following: -The resident had diagnoses that included borderline intellectual functioning (a categorization of intelligence wherein a person has below average cognitive ability), anxiety disorder, schizoaffective disorder (is combination of symptoms of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and mood disorder, such as depression; mood disorder and Post Traumatic Stress Disorder; -The resident had a history of anxiety and was suspicious and paranoid. He/She had anxiety a lot of the time; -The resident had hallucinations including command delusions, impaired insight and judgment, and abnormal thought process; -The resident needed a structured environment that included individual personal space, environment with a minimum of visual/auditory distractions, consistent routines and instructions at the individual's understanding; -Crisis intervention: Plan should identify clear steps that will be taken to support individual during a crisis situation, specify who to contact for assistance and how staff should work together with the individual during the crisis. Review of the resident's care plan, dated, 2/6/23, showed the resident had impaired coping. Encourage the resident to verbalize feelings regarding fear and/or anxiety. Review of the resident's care plan, dated 4/10/23, showed the resident had a behavior problem with verbal and physical aggression related to schizophrenia, anxiety, mood disorder and PTSD. Ensure protective oversight is provided. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -The resident had mildly impaired cognition; -The resident had no verbal, physical or other behaviors towards others; -The resident had diagnoses that included schizoaffective disorder, medically complex conditions, anxiety disorder and mood disorder (symptoms that are characteristic of a depressive disorder and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning). Review of the resident's care plan, dated 4/20/23, showed the following: -The resident had a history of PTSD and it affects the resident's symptoms and may flare up without any known trigger. Encourage the resident to verbally identify current ineffective coping techniques. Help the resident understand their current behaviors that may be preventing effective healing or treatment; -Administer medications appropriately and monitor for side effects or dependence; -Assess anxiety level, determine severity of condition and course of treatment or therapy needs; -Asses the resident for suicidal or homicidal ideations to ensure safety of the resident and others. During an interview on 5/22/23 at 1:39 P.M., Resident #3 said the following: -On Saturday night (5/20/23), Residents #2 and #4 were in his/her room and we heard loud yelling; -CNA D was following Hall Monitor E down the hallway and cussing him/her out; Hall Monitor E was trying to get out of the situation; -Then a fight started between Resident #1, CNA D and LPN C. Resident #3 saw CNA D with his/her fist up and swinging it towards Resident #1 like he/she was trying to hit Resident #1; -Hall Monitor F separated the two staff and Resident #1 but the two staff just kept egging it on; -Hall Monitor F told the two staff to get off the hall but they wouldn't leave. Hall Monitor F told them again to leave and they left but came back on the hall two to three more times. Resident #3 told the two staff to leave because they were just making things worse; -CNA D and LPN C were cussing at Resident #1 using the F word and every cuss word they could. 4. Review of Resident #5's undated face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident had diagnoses that included borderline personality disorder (a mental illness that severely impacts a person's ability to manage their emotions), adjustment disorder with depressed mood (feeling hopeless and sadder than would be expected after a stressful event), mood disorder, panic disorder (an overreaction of fear and anxiety to daily life stressors), anxiety disorder and PTSD. Review of the resident's PASRR, dated 4/30/14, showed the following: -The resident had serious mental illnesses; -The resident had poor judgement and did not make good decisions; -The resident appropriately responds to others; -The resident appropriately initiates contact with others; -The resident was withdrawn with little to no interaction with others; Review of the resident's care plan, dated 6/13/22, showed the resident had impaired thought process related to mental illness of personality disorder and depression; Review of the resident's care plan, dated 8/19/22, showed the following: -The resident had a history of behavioral challenges that required protective oversight in a secure setting. -The resident had a history of trauma related to family suicides. The resident had triggers that included physical aggression and agitation. Assist the resident when feeling overwhelmed by providing positive support and talk the resident through his/her feelings. Review of the resident's care plan, dated 10/19/22, showed the resident had impaired coping skills. Encourage resident to verbalize feelings regarding fear and/or anxiety and provide one-on-one visits as needed/requested for ventilation of feelings/concerns and attempt to resolve as able. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident's cognition was in tact; -The resident had no verbal, physical or other behaviors towards others. Review of the resident's care plan, dated 5/8/23, showed the resident had a history of PTSD and it affected the resident's symptoms and may flare up without any known trigger. During an interview on 5/22/23 at 2:05 P.M., the resident said the following: -He/She was in his/her room at the end of the hall when he/she heard yelling; -He/She walked up the hall towards the nurse's station and Hall Monitor E and LPN C were arguing; -Resident #5 saw Resident #1 (also his/her roommate), about half way between their room and the nurse's station and tried to get Resident #1 back to their room; -Resident #5 got Resident #1 almost to their room and there was a lot of yelling and chaos going on; -LPN C, Hall Monitor E and Hall Monitor F were at the nurse's station arguing; -Resident #1 walked past the staff at the nurse's station and went to the dining room. Resident #5 got Resident #1 headed back to their room again when someone made a comment and Resident #1 went back towards the staff; -Everyone was yelling and cussing. Hall Monitor F said you are upsetting my residents to CNA D and LPN C; -Resident #5 was trying to protect Resident #1 from getting in trouble; -All the chaos upset a lot of residents. 5. During an interview on 5/23/23 at 11:38 A.M., Registered Nurse (RN) G said the following; -On 5/20/23 at 11:38 P.M. a code green was called and RN G went to the [NAME] unit; -RN G was told staff and residents were cussing each other and Resident #1 was trying to attack LPN C and CNA D; -Resident #1 was upset and required an as needed medication to calm him/her. Resident #2 said he/she had right eye pain from being hit and Resident #3 said it triggered his/her PTSD. During an interview on 5/23/23 at 1:20 P.M., Hall Monitor E said the following: -He/She was working with LPN C on the 100 and 200 halls; -LPN C and Hall Monitor E got into a personal argument where LPN C called Hall Monitor E names and said get off my fucking clock (meaning to leave/clock out); -Hall Monitor E walked away from LPN C and stood at the locked double doors between the 300 hall and 100 hall; -CNA D came to the unit and started screaming, cussing and threatening Hall Monitor E and then CNA D left; -About five minutes later CNA D came back to the unit. Hall Monitor E was sitting in the dining room with Residents #1 and #7 when CNA D came up and started yelling and cussing at him/her again. Hall Monitor E told the residents to just ignore CNA D. CNA D told the residents don't you fucking ignore me, I am a CNA; -Resident #1 jumped up and mouthed off to CNA D. Hall Monitor E stood up, put his/her hands up and walked off; -LPN C said where the fuck are you going, you need to deal with this; -As Hall Monitor E walked to the 300 hall he/she saw CNA D go at Resident #1 and LPN C go toward them; -Hall Monitor E went to the 300 hall and told Hall Monitor F he/she was done and couldn't do this; -Hall Monitor F left the 300 hall and walked down to the end of the 200 hall; -All of the residents were upset. RN G, Hall Monitor E and Hall Monitor F had to get the residents calmed down and back to their rooms. During an interview on 6/1/23 at 2:40 P.M., the administrator said the following: -She would not expect staff to have an argument that involved yelling, cussing and screaming or anything that would have upset the residents; -She would expect the staff to have a discussion behind closed doors if they do not agree on something, not in front of the residents and definitely no yelling or cussing at one another. -She would expect them to act professionally at all times with the residents. During an interview on 6/7/23 at 2:59 P.M., the DON said the following: -Nurses have access to all resident care plans in full. Hall monitors and CNAs have access to care plans that are specific to the scope of practice such as; behaviors, triggers, coping skills, and limitations; -She would expect staff to refer to the care plans and use them to direct their cares for each resident; -She would expect the staff to keep the overall environment to be as calm as possible; -She would expect staff to put aside any differences they may have and deal with them on their own time. If that isn't possible then they should ask for coverage and go somewhere private to have a discussion; -Staff are provided behavioral training upon on hire and annually; -Staff also have access to phone numbers for the Administrator, Assistant Administrators and DON if they had any questions. During an interview on 6/7/23 at 3:05 P.M., Assistant Administrator B said the following: -Crisis Alleviation Lessons and Methods (CALM) classes are provided to all staff upon hire. The class is a six to eight hour class that expands on the Behavioral Emergency Policy; -The staff are given a CALM book on how to handle any type of behavioral emergency; -Upon hire staff have to sign off on the facility abuse and neglect and behavioral emergency policies; -Assistant Administrator B taught the CALM class to both LPN C and CNA D. MO218773 MO218771 MO218757 MO218758

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure additional resident (Resident #48), was free from abuse, including mental anguish, when staff refused to allow the resident to smoke if he/she did not feed him/herself meals. The resident had tremors in his/her hands and arms and required assistance to eat. The smoking restriction had no basis and caused the resident to feel awful and to go hungry. Additionally, the facility failed to ensure sampled resident, Resident #141, was free from abuse when Resident #2 hit him/her on the head with a porcelain toilet tank lid. The resident sustained two lacerations and three facial fractures as a result. In addition, the facility failed to keep residents free from abuse when one resident (Residents #43) of 65 sampled residents and an additional resident (Resident #379), who resided on locked behavioral units, obtained alcohol and marijuana from staff. Resident #379 tested positive for marijuana on 12/8/20 and resident #43 tested positive for alcohol. Floor technician PP admitted to the administrator he/she brought marijuana into the facility for Resident #379. The facility failed to protect the residents from staff verbal and mental abuse when Licensed Practical Nurse (LPN) LLL yelled, cussed and accused additional Resident #304 of being at fault when another resident self harmed. The facility census was 170. Review of the facility's policy, Abuse, Neglect, Grievance Procedures, dated 11/28/16, showed the following: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. It is also the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; -Mistreatment, neglect, or abuse of residents is prohibited by this facility; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -The facility abuse prohibition program included screening, training, prevention, identification, reporting/investigating, and protection of the resident. 1. Review of Resident #48's significant change Minimum Data Set (MDS), a federally required assessment, dated 1/9/20, showed the following -Severe cognitive impairment; -Required extensive physical assistance from one staff member with eating; -Required limited physical assistance from one staff member for bed mobility, transfers, dressing, toilet use, and hygiene. Review of the resident's smoking care plan, last revised 1/12/20, showed the resident at times had increased tremors. Review of the resident's Physician's Orders, dated 3/21/20, showed the following: -Regular diet; -Mechanical soft; -Two handled cups to increase fluid intake during meals; -Two health shakes three times a day with meals; -No order to restrict smoking if the resident did not eat. Review of the resident's care plan, revised 8/27/20, showed the following: -Mechanical soft, regular diet, two health shakes three times a day with meals and a divided plate; -Edentulous (no natural teeth) and has dentures but refuses to wear them; -Requires supervision and assist of one staff member at times for meals and eats in assist to dine dining room; -Uses two handled cups to increase fluid intake with a straw; -History of significant weight change and recent significant weight change; -Attempts to feed him/herself but will ask for staff assistance when he/she has increased tremors, assist the resident as needed; -Will let food run out of his/her mouth at times and will usually consume 100% of meals; -Allow extra time to eat as needed; -Aspiration risk-follow aspiration protocol; -Refuses meals at times, he/she will eat if rewarded with a candy bar at times; -No direction to prohibit resident from smoking if the resident did not feed him/herself. Review of the resident's annual MDS, dated [DATE], showed the following -Moderate cognitive impairment; -Primary diagnosis of dementia; -Weighs 112, significant weight gain not on a physician prescribe weight-gain regimen (resident had lost weight, not gained); -Supervision and set up with eating. Review of the resident's Weight Record, dated 1/19/21, showed the resident weighed 106 lbs. Review of the resident's care plan, revised 1/26/21, showed staff revised the resident's goal to have no significant decline in nutritional status. Review of the resident's Weight Record, dated 2/22/21, showed the resident weighed 102 lbs. Review of the Dietitian's Recommendations to Nursing Services, dated March 2021, showed the following recommendations regarding the resident: -Concern/Recommendation: Recommend Med Pass 2.0-90 cc (nutritional supplement), TID (three times daily) with med pass due to continued weight loss (significant in three and six months) and due to underweight weight status per BMI. Review of the resident's Weight Record, showed on 03/16/21, the resident weighed 98 pounds, a 22.10% loss in six months. Observation on 3/30/21, at 12:23 P.M.-1:30 P.M., showed the following: -Staff served the resident spaghetti, green beans, roll with butter on a divided plate and two glasses of tea in two handled cups with straws; -The resident appeared emaciated and his/her eyes were sunken; -The resident had spastic involuntary movements of both arms and hands at the elbow, wrist and fingers; -The resident asked the MDS Coordinator (MDSC) for help to eat; -The MDSC responded to the resident, You have to choose, I can help you eat, but then you can't smoke; -The resident responded, I want to smoke; -The MDSC walked away from the resident; -The resident picked up his/her fork and his/her spastic movements worsened; -After several attempts the resident had loaded his/her fork with spaghetti; -When the resident attempted to bring the spaghetti to his/her mouth the food flew off his/her fork onto the table, the resident's clothing, and the floor; -The resident sat his/her fork down; -The resident attempted to eat his/her spaghetti with his/her hands. When the resident picked up the spaghetti it flew out of his/her hands, and the resident put his/her hands in his/her lap; -At 12:44 P.M. the resident said, Will you please, please help me, I am hungry to the MDSC; -The MDSC responded, You know the rules, it is a restriction in your care plan and the physician ordered it, if I help you eat you cannot smoke, the MDSC walked away from the resident; -The resident picked up a handled cup of tea, his/her spastic movements worsened; -The resident's straw hit his/her forehead, cheeks and nose several times when the resident attempted to drink; -The resident sat in front of his/her food and did not attempt to eat; -At 1:05 P.M. the resident said, I want to eat and I want to smoke, will you help me? to the MDSC; -The MDSC responded, You can do it, get your belly full, and the MDSC walked away from the resident; -The resident attempted to load his/her fork with green beans, his/her spastic movements worsened, the green beans flew off the resident's fork and onto the table and the floor; -The resident attempted to load his/her fork with spaghetti, the spastic movements worsened, -When the resident attempted to bring the spaghetti to his/her mouth the food flew of his/her fork onto the table, the resident's clothing and the floor. During an interview on 3/30/21, at 2:52 P.M., CNA RR said the following: -The resident always needed help to eat; -Some of the staff make him/her choose to have assistance to eat or smoke; -He/She does not know why he/she has to feed himself/herself to smoke, they say it is a limitation; -The resident was not able to physically feed himself/herself; -The resident has had that limitation for several months; -The resident will choose smoking over eating. During an interview on 3/30/21, at 2:55 P.M., CNA II said the following: -A nurse on Homestead told staff if the resident did not feed himself/herself the resident could not smoke; -Today he/she could not let the resident smoke because the MDSC saw him/her feed the resident. During an interview on 3/31/21, at 7:45 P.M., Licensed Practical Nurse (LPN) BBB said the following: -Previous staff trained current staff that the resident has a limitation that if he/she does not feed himself/herself he/she cannot smoke, he/she does not know where the limitation came from; -He/She did not know what was on the resident's care plan. During an interview on 4/6/21, at 11:23 A.M., the resident said the following: -Staff never ask him/her what he/she wanted for lunch; -For a long time, like months, the staff would not let him/her smoke unless he/she fed him/herself. This made him/her feel awful; he/she wants to eat and wants to smoke. -Sometimes he/she couldn't feed himself/herself so he/she, Would just be hungry, he/she could not help that his/her arms shake. During an interview on 3/30/21, at 3:15 P.M., the Director of Nursing (DON) said the resident does not have limitations on when he/she can smoke. Staff are expected to help the resident if he/she needs assistance, sometimes his/her tremors are worse than other times. 2. Review of Resident #2's face sheet showed the following: -admission date 7/19/19; -Diagnoses included dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), delusional disorders (disorder where a person has trouble recognizing reality) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/27/20, showed the following: -Staff did not assess the resident's memory; -Resident is understood by others and understands others; -Had no behaviors. Review of the resident's PASRR (Preadmission Screening and Resident Review), dated 7/11/19, showed he/she had been physically aggressive with a female staff member while living at his/her previous placement. Further review showed no history of physical aggression towards peers. Review of the resident's care plan, dated 10/22/19 and last reviewed on 8/3/20, showed the resident had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. He/She was at risk for alteration in mood/behavior related to diagnoses of schizophrenia and delusional disorder. He/She has a history of physical aggression. Review of the resident's nurses' notes, dated 12/26/20, showed at 12:30 A.M., a Code Blue was called due to the resident getting into a physical altercation with another resident. The resident was sitting by the nurses' station appearing calm and quiet. The other resident was injured with several lacerations to the face. When asked what happened, the resident said he/she felt as if the other resident was out to get him/her. The two residents had previously been arguing about the temperature of their room. Staff had went in and talked with the residents, redirected them and came up with a compromise. Resident #2 came out of his/her room to ask staff if he/she could shut his/her door, and the resident returned to his/her room with the door shut. Moments later Resident #2 came out of the room and told staff to call 911, I attacked him/her. Staff found Resident #141 sitting on the side of his/her bed injured and distraught. Other staff attended to Resident #141. Resident #2 was sent for a psychiatric evaluation. Review of the facility's investigation, dated 12/29/20, showed the following: -On 12/26/20, the resident came out of his/her room holding the back of the toilet (porcelain lid that covers the tank), and reported to staff he/she attacked his/her roommate (Resident #141) and staff should call 911. When staff entered the room, Resident #141 was sitting on the side of his/her bed with a laceration (cut) over his/her right eye, a laceration on his/her scalp and a scratch on his/her nose. Code Blue was immediately called and staff ensured the residents remained separated. Staff called 911 and provided first aid to Resident #141, then sent the resident to the hospital for treatment; -Upon interview with Resident #2, he/she refused to talk about the incident and claimed he/she did not know what happened to Resident #141; -Resident #141 reported he/she and Resident #2 could not agree over the room temperature, and then Resident #2 came over and knocked him/her in the head; -Staff reported Resident #141 had told staff he/she was unhappy with the temperature in the room and felt it was cold. The temperature in the room was set to 80 degrees. Resident #141 was observed wearing a coat, scarf and hoodie. Resident #2 was observed wearing a t-shirt and jeans and voiced he/she was hot. Staff were able to get the roommates to agree to a compromise of 75 degrees. Approximately ten minutes later, Resident #2 came out of his/her room with the lid to the toilet tank and told staff to call 911 because Resident #141 needed to be sent to the hospital; -Summary of findings: After reviewing statements, it was understood that after agreeing to compromise about the room temperature, Resident #2 went to get the lid from the toilet tank and hit Resident #141 on his/her head and face. Resident #2 does not have any history of physical aggression towards peers and it is not listed in his/her PASRR. During his/her stay at the facility, Resident #2 had not had any physical altercations or even verbal altercations. When leaving the room, staff reported that Resident #2 was calm and did not show any signs of agitation or anger. Resident #2's care plan showed he had a history of physical aggression. Review of Resident #141's face sheet showed he/she was admitted to the facility on [DATE] with diagnoses including schizophrenia, impulse disorder and dementia without behavioral disturbances. Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Did not have any behaviors or psychosis. Review of the resident's hospital discharge notes, dated 12/26/20, showed the resident had two lacerations (cuts) which required sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision) and a left orbital lateral wall fracture (a break in the bone around the eye), inferior wall blowout fracture (a break in one or more bones around the eye) and nasal (nose) bone fractures. Review of the resident's care plan, dated 11/18/19 and last revised on 3/2/21, showed no documentation of a resident to resident altercation with Resident #2 resulting in lacerations to Resident #141's head and fractured orbital bone (bone around the eye). During interview on 3/29/21 at 10:49 A.M., Resident #141 said Resident #2 hit him/her in the head with the toilet lid because they were fighting over the temperature in the room. During interview on 4/7/21 at 8:13 P.M., Certified Nurse Aide (CNA) TT said the following: -He/She was working when Resident #2 hit Resident #141 with the toilet tank lid; -The residents had their call light on and staff said they were arguing about the temperature in the room. Staff set the room temperature at 72 degrees; -Resident #2 came walking up the hall with the toilet tank lid and told staff to call 911; -Resident #141 had blood on his/her head and the nurse assessed him/her. During interview on 3/31/21 at 8:30 P.M., Licensed Practical Nurse (LPN) DD said the following: -Resident #2 came out of his/her room and told staff he/she hit Resident #141 with the toilet tank lid and to call 911; -Staff called a Code Blue and found Resident #141 sitting on his/her bed with blood on his/her head; -Resident #141 was sent to the hospital and came back to the facility with stitches and a fractured orbital bone; -Resident #2 told him/her he/she didn't know why he/she hit Resident #141; he/she was just tired of Resident #141 making comments, but was non-specific as to what the comments were. 3. Review of Resident #379's admission MDS, dated [DATE], showed the following: -admission date 9/16/20; -Diagnosis of schizophrenia; -Cognition was intact; -Received antipsychotic and anti-anxiety medication daily. Review of the resident's care plan, dated 9/23/20, showed the following: -At risk for alteration in mood related to schizophrenia, history of minimal confusion, being withdrawn, and causing management problems; -Intensive monitoring per unit and facility protocol to ensure protective oversight; -One on one visits as needed for venting of concerns/feelings; -Re-direct as able to encourage positive behavior choices. Review of the resident's nurse's notes showed the following: -On 12/8/20 at 4:40 P.M., the administrator interviewed the resident about being in possession of and smoking marijuana the day before. The resident admitted to having smoked marijuana the day before and said there was nothing the facility could do about it. The resident refused to say who provided the marijuana. The resident tested positive for marijuana on urinalysis. The medical director, police and guardian were notified. -On 12/11/20 at 9:15 A.M., the physician was made aware of the resident's continued physical and verbal behaviors. An order was received for the resident to be transported to the acute psychiatric hospital for evaluation and treatment. The guardian was notified. Review of the facility's Investigative Narrative Note, undated, showed the following: -It was reported by another resident that Staff PP brought drugs into Resident #379; -Floor technician PP was suspended pending the investigation; -Floor technician PP came into the facility the following day for an interview and was asked if he/she had brought any drugs or contraband into the facility. Floor technician PP admitted to the administrator he/she had brought in roaches for Resident #379. When asked what are roaches, Floor technician PP responded marijuana; -The administrator asked Floor technician PP if he/she understood it was against the rules of the facility and the law to bring marijuana in to residents, Floor technician responded, My bad; -Floor technician PP was terminated and asked to leave the facility; -A police report was filed; -Staff questioned Resident #379. The resident admitted to smoking marijuana, but would not tell administration who brought it in to him/her. The resident became agitated when questioned; -Resident #379 tested positive for marijuana on a drug test; -Summary: It was found Floor technician PP brought illegal drugs into the facility and he/she was terminated. Residents were educated on the danger of mixing illegal drugs with their medication regimens. During an interview on 3/30/21 at 2:50 P.M., the administrator said Floor technician PP admitted to her that he/she brought marijuana into the facility for Resident #379. During an interview on 4/6/21 at 5:50 P.M., the resident's guardian said the facility made him/her aware the resident tested positive for marijuana and they suspected a staff member brought it into the facility. The resident had a history of drug abuse. 4. Review of Resident #43's PASRR, dated 12/15/12, showed the following: -He/She had a lengthy/significant history of polysubstance use/abuse; -He/She denied any significant history of alcohol problems, but did report using from age [AGE] until 18; -He/She sought treatments for abuse multiple times; -He/She was coherent, alert and oriented to person, place and time; -He/She had poor judgement and did not make good decisions; -His/Her diagnoses included bipolar disorder (mental condition marked by alternating periods of elation and depression), schizoaffective disorder ( a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder), post-traumatic stress disorder (PTSD, condition where a person has difficulty recovering after experiencing or witnessing a terrifying event), borderline personality disorder (severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), anxiety disorder, chronic pain, and questionable seizure disorder. Review of resident's care plan, initiated on 11/6/19, showed the following: -He/She had mood swings, ups and downs, mania, racing thoughts, difficulty completing activities of daily living (ADLs); -He/She began hallucinating at age [AGE]- tactile/auditory/visual and required multiple psychiatric inpatient admissions and medication adjustments; -He/She was impulsive, impatient, disorganized, nervous and anxious; -He/She had a lengthy drug history with use of cannabis (marijuana), meth, and pills, but meth was drug of choice; -He/She was at risk for alteration in mood related to bipolar disorder, anxiety, schizoaffective disorder, and insomnia; -He/She had a history of verbal and physical aggression, self-harm, suicide attempts, being raped/abused, and recent surgery had increased those moods/anger outbursts; -Staff were to offer one-on-one time to allow him/her to voice his/her feelings/concerns, offer support/encouragement as needed/requested; -Staff were to assist him/her to use coping skills and provide examples as needed; -Staff were to redirect as able/needed to encourage positive behavior choices; -Social service was to consult as needed/requested. Review of the resident's progress note, dated 3/21/21 at 5:24 P.M., showed earlier that morning, LPN W was called over to the unit for another resident issue, and the resident's roommate said the resident had alcohol and was drunk. Upon investigation, the nurse found alcohol and pills in the resident's room. The resident's physician was notified and an order for a drug and alcohol screen was obtained. The resident was negative for any drugs, but tested positive for alcohol. Review of the facility's RN (Registered Nurse) Investigation report showed the following: -Date of incident: 3/21/21; -Resident #139 reported to staff that Resident #43 had alcohol that Hall Monitor W had provided him/her; -Upon environmental rounds, alcohol was recovered along with several empty containers of alcohol; -Drug and alcohol screenings were conducted which were negative for drugs, but the resident's alcohol level was noted to be 0.08% (legal limit for drivers over age [AGE]); -Resident #43 admitted to paying a staff member to get him/her alcohol and cigarettes, but denied receiving them from Hall Monitor W; -Review of camera footage showed Hall Monitor W never entered the resident's unit and stayed on his/her assigned unit; -After further questioning, the resident continued to deny that it was Hall Monitor W; -During investigation, several staff members were mentioned, however upon review of camera footage, Hall Monitor EE was noted to have been the only staff member on the hall out of all the accused staff members; -Hall Monitor EE was suspended due to the allegations. Review of Resident #139's written statement, provided by the facility, dated 3/21/21, showed Resident #43 told him/her he/she had been receiving alcohol from a person (and provided the person's first name), and he/she had been going to the end of the hall to meet him/her. During an interview on 3/29/21 at 10:51 A.M., the resident said staff personally brought him/her alcohol. He/She was given a small bottle of Crown Royal and Honey Turkey. He/She refused to disclose the staff's name, but mentioned the staff had been terminated. He/She said the employee approached him/her about bringing him/her the alcohol. He/She did not ask for the alcohol. During interview on 3/30/21 at 11:55 A.M., the administrator said the resident mentioned another staff's name who he/she said provided the contraband, but that particular staff member was never on the resident's unit. Empty bottles were found in resident's room and his/her blood alcohol (BAC) level was 0.08% (legal intoxication limit). During interview on 3/31/21 at 4:35 P.M., the resident said Hall Monitor EE had provided him/her with the alcohol. During an interview on 3/31/21 at 5:08 P.M., LPN FF said the resident had pseudo seizures (triggered by anxiety). He/She contacted the resident's physician, but the physician did not feel comfortable with ordering any medications for increased anxiety because the resident was getting medications and alcohol from other people and he/she did not know what else he/she could have access to. During an interview on 3/31/21 at 6:20 P.M., Certified Medication Technician (CMT) V said Hall Monitor EE had been known to bring drugs, alcohol, and cigarettes in for other residents, but residents would not tell on him/her. CMT V did not say how he/she knew this was occurring. During an interview on 4/8/21 at 4:00 P.M., CMT GG said the following: -He/She worked with Hall Monitor EE the night he/she allegedly brought alcohol to the resident (3/21/21); -He/She was the staff member who reported Hall Monitor EE's suspicious activity that night; -Hall Monitor EE kept going in and out of the facility and had a big bulge in his/her jacket pocket when he/she went into the resident's room, but was not bulging when he/she came out of resident's room; -Before that, Hall Monitor EE said he/she was going to go to the gas station; -Residents (no names provided) said Hall Monitor EE provided alcohol for residents and he/she told the charge nurse. During an interview on 5/3/21 at 12:00 P.M., LPN I said he/she worked the morning after resident allegedly consumed alcohol. It was brought to his/her attention that resident was not acting right. He/She assessed the resident who showed him/her the empty alcohol bottles, but would not tell him/her who supplied him/her with alcohol. Daily environmental rounds had been done the day prior with nothing found. The resident's roommate (#139) told staff the resident had alcoholic beverages and he/she was concerned. During interview on 3/31/21 at 4:30 P.M., the Assistant Director of Nurses (ADON) A said he/she reviewed six hours of camera footage from 3/20/21-3/21/21 and tracked each individual working. Video footage showed Hall Monitor EE took off his/her shoes and left them on the floor under a table in the common area and went to the shower room. He/She had a towel wrapped up, holding it like a baby and just had weird behavior. First thing the next morning (3/22/21), Hall Monitor EE alerted staff he/she had spent a lot of time with the resident because he/she had a bad night. The resident's roommate, Resident #139, reported to the environmental service director (EVS) Director and LPN I to check the resident's room. The resident had hidden something under his/her undergarments because there was an obvious disfigurement. He/She pulled down the undergarment and several small sized bottles of various alcoholic beverages (12 total), two packages of cigarettes, a lighter, CBD (cannabidiol - found in marijuana) oil, and three pills that appeared to look like Ativan (anti anxiety prescription medication), fell out. Resident #139 informed staff that resident received pills and CBD oil in the mail. The resident's alcohol level was 0.08 several hours after ingestion. Hall Monitor EE was suspended. The resident told him/her Hall Monitor EE provided him/her with the alcohol. He/She saw a Snap Chat (social media application), conversation on the resident's phone. The resident asked Hall Monitor EE, How are you doing? I didn't tell anyone anything. During an interview on 4/7/21 at 8:30 A.M., the resident's guardian said he/she received a call from the facility who reported the resident was receiving alcohol. The resident should not be provided alcohol. During interview on 4/30/21 at 12:50 P.M., the resident's physician said the resident would not decline any type of drug or alcohol. The resident would seek it out. Staff informed her of the situation and she would expect that staff not provide residents street drugs or alcohol. Staff should protect residents from harm. 5. Review of Resident #304's undated Physician Order Summary Report showed the following: -admission dated 12/23/19; -Diagnosis of bipolar disease, paranoid schizophrenia, depressive disorder, anxiety, seizure disorder, mild intellectual disability and antisocial personality disorder. Review of the resident's significant change MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's nurses' notes, dated 3/31/20, showed the following: -Up in the hall socializing appropriately with staff and peers. Dressed appropriately and denied complaints or concerns; -No feelings of agitation or negative thoughts. -No staff documentation of altercations or behaviors occurred on 3/31/20. Review of the facility undated RN Investigation Report, Investigative Narrative Note, showed the following: -CMT MMM reported to facility administration on the night of 3/31/20 that LPN LLL yelled at Resident #304. Another resident self-harmed and LPN LLL said it was Resident #304's fault. Certified Nurse Aide (CNA) MMM reported the incident to the Director of Nursing (DON) at the end of his/her shift. CMT MMM provided four written statements from staff who witnessed the incident; -Staff documented during interview Resident #304 said a resident (unknown name) told him/her a resident (friend) cut his/her wrists. He/She was very upset and requested a cigarette from the charge nurse. The charge nurse, LPN LLL, yelled at him/her and said, It's all your fault the resident did what he/she did. Resident #304 became very upset and yelled back, It was not! LPN LLL came out of the nurses' station and yelled back, Yes it was! Resident #304 said he/she walked to his/her room and LPN LLL followed. He/She yelled at LPN LLL to get out of his/her room. LPN LLL told the resident no that he/she did not have to listen to the resident, but the resident had to listen to him/her because he/she was the nurse. LPN LLL then left the room; -Staff documented during interview Resident #82 recalled the incident the same as Resident #304. Resident #82 was in the hallway when he/she heard LPN LLL yell at Resident #304 that it was all Resident #304's fault that a resident had self-harmed. Resident #82 approached Resident #304's room. LPN LLL was in the resident's room, but he/she could not hear what was said. Staff documented during interview, CNA GGG said he/she observed Resident #304 yelling and cussing at LPN LLL that it was not his/her fault. LPN LLL came out of the nurses' station and loudly said he/she did not care and he/she was not going to sugar coat anything. They needed to stop and think about their actions and how it affected others. CNA GGG attempted to take Resident #304 to his/her room, LPN LLL followed the resident into the room and was still talking to him/her about the situation. Resident #304 left his/her room and entered Resident #82's room. Resident #82 told staff to stay out and LPN LLL replied, Don't tell me what to do. LPN LLL left and said, I'll remember that; -Staff documented during interview, CNA NNN said he/she was present when the incident occurred. Resident #304 was upset due to another resident self-harming and asked CNA NNN for a cigarette. CNA NNN directed the resident to ask the charge nurse. Resident #304 asked LPN LLL and LPN LLL said it was not his/her problem. Resident #304 became more upset and LPN LLL replied, I don't care. Then LPN LLL told the resident it [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the facility's weight loss policy for weekly weights, re-evaluation of the care plan and interventions with continued weight loss, notification of the physician for continued weight loss, and failed to provide assistance with eating for one sampled resident (Resident #32) of 65 sampled residents, who had a 10% weight loss in one month and one additional resident (Resident #48) who had a 22% weight loss in six months. The facility staff also failed to re-evaluate the resident's care plan for weight loss, provide adaptive equipment, provide assistance, and provide desserts and all items on the menu for a diabetic resident (Resident #62), who had significant weight loss in the previous six months. The facility also failed to ensure two sampled residents (Residents #172 and #136) and four additional residents (Residents #122, #126, #8 and #25) received supplements as indicated on their meal tickets. The facility census was 170. Review of the facility policy, Unintentional Weight Loss, dated 2017, showed the following: -Discussion: Unintentional weight loss can have serious implications for older adults. Studies indicate unintentional weight loss can lead to malnutrition, poor wound healing, risk of pressure ulcers, decline in function and inability to fight infection. Unintentional weight loss can be rapid or sometimes slow and insidious. It is important that systems are in place to detect, assess and develop an individualized plan of care for persons with unintentional weight loss; -Causes/Risk Factor of Unintentional Weight Loss: Frequent causes of unintentional weight loss include inadequate oral food and beverage intake to match activity, inadequate absorption and metabolism of foods consumed, a wasting disease that increases metabolic rate such as in cancer, AIDs, hyperthyroidism, or excess energy during psychological or emotional stress; -Consideration of Environmental Factors Affecting Intake: It is important to consider the environmental factors contributing to decreased appetite. Factors to evaluate include food and meal time preference, the need for assisted devices for self-feeding, the temperature of the food served, the appearance of the meal, the atmosphere of the dining room and the need for coaching or cueing at the meal and proper body positioning; -Screening to Identify Individuals with Unintentional Weight Loss: Weight can be a useful indicator of nutritional status, when evaluated in context with the individual's personal history and overall condition. Recent changes in weight or insidious weight loss may indicate a nutritional problem. Therefore, it is important that a health care community maintain a screening program to identify individuals at risk for unintentional weight loss. In a health care community the Center for Medicare and Medicaid Services (CMS) roster/matrix report generated from the Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) identifies individuals that have experienced weight loss. Weight tracking tools, often available in meal card programs of care plan software, can all be helpful tools to identify and monitor for unintentional weight loss. Observation of individuals at mealtime is often the best way to identify people that have a change in normal eating patterns or are eating poorly and at risk for weight loss. Current standards for weighing individuals in health care communities recommend weighing the individual for the first four weeks after admission at least monthly thereafter to help identify and document trends such as insidious weight loss. More frequent weighing is often suggested for individuals at risk or with unintentional weight loss. In some cases, weight monitoring is not indicated such as the terminally ill that requests comfort care. When evaluating weight it is important to take into consideration current medical conditions such as the following: Fluid loss and retention, Altered nutrient intake, absorption and utilization, Chewing abnormalities, Swallowing abnormalities, Functional Ability, Medications, Goals and prognosis, Lab analysis/diagnostic evaluation; -Individual Preferences Honored and Choices Provided at Meals: Offering choices of food at meals and giving people foods they enjoy eating has been shown to decrease the need for fortified food or supplements. The New Dining Practice Standards of the Pioneer Network report that individuals offered a choice among a variety of foods and fluids twice a day may be a more effective intervention than oral supplementation. Therefore it is recommended to attempt food favorites before initiating a nutritional supplement or nutritional supplementation between versus with meals to encourage food intake at meals; -Consideration of Environmental Factors Affecting Intake: It is important to consider the environmental factors contributing to decreased appetite. Factors to evaluate include food and meal time preference, the need for assisted devices for self-feeding, the temperature of the food served, the appearance of the meal, the atmosphere of the dining room and the need for coaching or cueing at the meal and proper body positioning. Breakfast is often the meal consumed the best in the day and offers excellent opportunities to increase caloric and protein intake; -Registered Dietitian/Dining Services Manager Role: If it is determined that the individual requires additional calories and /or protein, the Registered Dietitian or Dining Services Manager assesses the individual with unintentional weight loss to determine the goal for calories and/or protein. Improving intake via wholesome foods is generally preferable to adding nutritional supplements. The Registered Dietitian or Dining Services Manager will work with the individual to determine the food or foods that the person might enjoy and be willing to consume. It is very important that an individualized plan of care be developed, based on the individual's physical condition and preferences. The plan should be documented in the individual's medical record and care plan. Breakfast is often the meal consumed best in the day and offers excellent opportunities in increase caloric and protein intake; -Ongoing Monitoring and Adjusting: For individuals with unintentional weight loss, monitoring is vital after plan of care implementation to assess progress on nutritional related goals. Goals may need to be modified and new interventions implemented based on the individuals's responses to current interventions, their weight and other factors related to their medical condition. Review of the undated facility policy, Nourishments, showed the following: -Nourishments will be provided to offer therapeutic nutritional support. A physician's order will be required; -Procedure: Residents receiving nourishments may include those who are underweight, who are on therapeutic diets, and those with poor intake, weight loss, skin problems, low albumin and other problems addressed on care plans; -A Nourishment and Supplement List is maintained for residents receiving physician-ordered supplements, renal diets and calorie-controlled diets; -This list is posted in Dietary Department; -These nourishments are delivered by Dietary in individual portions that are labeled with the resident's name, date and time; -Percentage of consumption of these nourishments is recorded on the consumption log sheets by the nursing department. Review of the undated policy, House Supplements, showed the following: -When an order for a house supplement is received the product may vary depending on availability and resident preference. At least 6 grams of protein and 180 calories will be provided in all products used as house supplements; -Procedure: House supplements will be dated when taken out of the freezer; -Cartons will not be sent out of the kitchen without being individually dated; -A physician's order must be received for a house supplement to be given; -Frequency and amounts must be specific in the physician's order; -House supplements will be delivered at routine meal times in this facility unless otherwise specified in the physician's order; -The preferred house supplement is a shake supplement. 1. Review of Resident #48's significant change Minimum Data Set (MDS), a federally required assessment, dated 1/9/20, showed the following -Severe cognitive impairment; -Required extensive physical assistance from one staff member with eating; -Required limited physical assistance from one staff member for bed mobility, transfers, dressing, toilet use, and hygiene. Review of the resident's smoking care plan, last revised 1/12/20, showed the resident at times had increased tremors. Review of the resident's Physician's Orders, dated 3/21/20, showed the following: -Regular diet; -Mechanical soft; -Two handled cups to increase fluid intake during meals; -Two health shakes three times a day with meals. Review of the resident's care plan, revised 8/27/20, showed the following: -Mechanical soft, regular diet, two health shakes three times a day with meals and a divided plate; -Edentulous (no natural teeth) and has dentures but refuses to wear them; -Requires supervision and assist of one staff member at times for meals and eats in assist to dine dining room; -Uses two handled cups to increase fluid intake with a straw; -History of significant weight change and recent significant weight change; -Attempts to feed him/herself but will ask for staff assistance when he/she has increased tremors, assist the resident as needed; -Will let food run out of his/her mouth at times and will usually consume 100% of meals; -Allow extra time to eat as needed; -Aspiration risk-follow aspiration protocol; -Assess for any change in nutritional intake as needed; -Dietary consult as needed/ordered; -Refuses meals at times, he/she will eat if rewarded with a candy bar at times; -Obtain labs as ordered-report results to physician when available; -Obtain weights as ordered/needed-report significant gain/loss to physician promptly; -Offer diet as ordered; -Therapy to evaluate and treat as ordered/needed; -No direction to prohibit resident from smoking if the resident did not feed him/herself. Review of the resident's Weight Record, dated 9/8/20, showed the resident weighed 125.8 pounds (lbs.). Review of the resident's quarterly MDS, dated [DATE], showed the following -Moderate cognitive impairment; -Supervision and set up with eating; -Weight 126 lbs Review of the resident's Weight Record, showed the following: -10/15/2020 121. lbs.; -11/1/2020 113.0 lbs.; -12/14/2020 112.0 lbs. Review of the resident's annual MDS, dated [DATE], showed the following -Moderate cognitive impairment; -Primary diagnosis of dementia; -Weighs 112, significant weight gain not on a physician prescribe weight-gain regimen (resident had lost weight, not gained); -Supervision and set up with eating. Review of the resident's Weight Record, dated 1/19/21, showed the resident weighed 106 lbs. Review of the resident's care plan, revised 1/26/21, showed staff revised the resident's goal to have no significant decline in nutritional status. There was no evidence any new interventions were added or current interventions were revised. Review of the resident's Dietitian Note, dated 1/26/21, showed the following: -Resident remains on a mechanical soft diet with two health shakes three times a day and two handled cups; -Resident having variable intake by mouth recently, often refusing meals; -Height is 63 (inches); -January 21 weight: 106 lbs., -Down 6 lbs. in one month (5.4% loss), -Down 15 lbs. in three months (12.4% loss), down 10 lbs. in six months. -BMI (Body Max Index) = 18.8 - low-end of normal weight range; -No further recommendations at this time; -Will continue to follow and be available as needed. Review of the resident's Weight Record, dated 2/22/21, showed the resident weighed 102 lbs. Review of the resident's Dietitian Note, dated 2/27/21, showed the following: -Resident remains on a mechanical soft diet with two health shakes three times a day and two handled cups; -Continues to eat fairly well, with 76-100% of most meals consumed; -Does occasionally skip meals; -Height is 63; -February 21 weight: 102 lbs; -Down 4 lbs. in one month; -Down 11 lbs. in 3 and 6 months (9.7% loss); -BMI = 18.8 - low-end of normal weight range; -No further recommendations at this time; -Will continue to follow and be available as needed. Review of the Dietitian's Recommendations to Nursing Services, dated March 2021, showed the following recommendations regarding the resident: -Concern/Recommendation: Recommend Med Pass 2.0-90 cc (nutritional supplement), TID (three times daily) with med pass due to continued weight loss (significant in three and six months) and due to underweight weight status per BMI. Review of the resident's Weight Record, showed on 03/16/2021, the resident weighed 98 pounds, a 22.10% loss in six months. Review of the spreadsheet menu for lunch on 3/30/21, showed residents were to receive spaghetti with meat sauce, Italian tossed salad (green beans were substituted for all residents), fruit cobbler (item not prepared by staff and residents received cake instead) and garlic bread (residents received a dinner roll). Observation on 3/30/21, at 12:23 P.M.-1:30 P.M., showed the following: -Staff served the resident spaghetti, green beans, roll with butter on a divided plate and two glasses of tea in two handled cups with straws; -The resident appeared emaciated and his/her eyes were sunken; -The resident had spastic involuntary movements of both arms and hands at the elbow, wrist and fingers; -The resident asked the MDS Coordinator (MDSC) for help to eat; -The MDSC responded to the resident, You have to choose, I can help you eat, but then you can't smoke; -The resident responded, I want to smoke; -The MDSC walked away from the resident; -The resident picked up his/her fork and his/her spastic movements worsened; -After several attempts the resident had loaded his/her fork with spaghetti; -When the resident attempted to bring the spaghetti to his/her mouth the food flew off his/her fork onto the table, the resident's clothing, and the floor; -The resident sat his/her fork down; -The resident attempted to eat his/her spaghetti with his/her hands. When the resident picked up the spaghetti it flew out of his/her hands, and the resident put his/her hands in his/her lap; -At 12:44 P.M. the resident said, Will you please, please help me, I am hungry to the MDSC; -The MDSC responded, You know the rules, it is a restriction in your care plan and the physician ordered it, if I help you eat you cannot smoke, the MDSC walked away from the resident; -The resident picked up a handled cup of tea, his/her spastic movements worsened; -The resident's straw hit his/her forehead, cheeks and nose several times when the resident attempted to drink; -The resident sat in front of his/her food and did not attempt to eat; -At 1:05 P.M. the resident said, I want to eat and I want to smoke, will you help me? to the MDSC; -The MDSC responded, You can do it, get your belly full, and the MDSC walked away from the resident; -The resident attempted to load his/her fork with green beans, his/her spastic movements worsened, the green beans flew off the resident's fork and onto the table and the floor; -The resident attempted to load his/her fork with spaghetti, the spastic movements worsened, -When the resident attempted to bring the spaghetti to his/her mouth the food flew of his/her fork onto the table, the resident's clothing and the floor; -At 1:16 P.M., the resident asked certified nurse assistant (CNA) II for assistance; -CNA II did not offer to reheat the resident's food; -CNA II fed the resident and he/she consumed 75% of his/her meal; -The resident was not served cake or his/her nutritional shakes. Review of the resident's meal ticket showed the following: -Regular diet; -Mechanical Soft; -Divided plate; -Two handled cups with a straw; -Ground meats with gravy. -The meal ticket did not include the resident's two health shakes. During an interview on 3/30/21, at 2:52 P.M., CNA RR said the following: -The resident always needs help to eat; -Some of the staff make him/her choose to have assistance to eat or smoke; -He/She does not know why he/she has to feed himself/herself to smoke, they say it is a limitation; -The resident was not able to physically feed himself/herself; -The resident has had that limitation for several months; -The resident will choose smoking over eating. During an interview on 3/30/21, at 2:55 P.M., CNA II said the following: -A nurse on Homestead told staff if the resident did not feed himself/herself the resident could not smoke; -Today he/she could not let the resident smoke because the MDSC saw him/her feed the resident. During an interview on 3/30/21, at 3:15 P.M., the Director of Nursing (DON) said the resident does not have limitations on when he/she can smoke. Staff are expected to help the resident if he/she needs assistance, sometimes his/her tremors are worse than other times. Review of the resident's Dietitian Note, dated 3/31/21, showed the following: -Resident remains on a mechanical soft diet with two health shakes three times a day and two handled cups; -Continues to eat fairly well, with 76-100% of most meals consumed; -Does occasionally skip meals; -Height is 63; -March 21 weight: 102 lbs. -Down 4 lbs. in one month; -Down 14 lbs. in three months, a 12.5% wt. loss; down 28 lbs. in six months, a 22.2% wt. loss. BMI = 17.4 - underweight weight range; -Recommend adding Med Pass (nutrition supplement) 2.0 - 90 cubic centimeter (cc) three times at this time due to weight loss (significant in three and six months), and due to underweight weight status per BMI; -Will continue to follow and be available as needed. During an interview on 3/31/21, at 7:45 P.M., Licensed Practical Nurse (LPN) BBB said the following: -Previous staff trained current staff that the resident has a limitation that if he/she does not feed himself/herself he/she cannot smoke, he/she does not know where the limitation came from; -He/She did not know what was on the resident's care plan. Observation on 4/6/21, at 10:58 A.M., showed the following: -CNA RR assisted the resident from bed to a standing position; -When the resident stood, his/her pants slid down and fell to the floor. During an interview on 4/6/21 at 10:58 A.M., CNA RR said a lot of the resident's pants were too big now. During an interview on 4/6/21, at 11:23 A.M., the resident said the following: -Staff never ask him/her what he/she wanted for lunch; -For a long time, like months, the staff will not let him/her smoke unless he/she feeds him/herself. This made him/her feel awful; he/she wants to eat and wants to smoke. -Sometimes he/she couldn't feed himself/herself so he/she, Would just be hungry, he/she could not help that his/her arms shake.; -He/She liked shakes, and gets them once in a while; -He/She does not get two shakes every meal. Observation on 4/6/21, at 12:25 P.M., showed the following: -Staff served the resident his/her meal; -The resident had two handled glasses one with tea and one with milk; -The staff did not serve the resident his/her two health shakes. Review of the Physician's Orders on 4/12/21, showed no documentation of an order for Med Pass 2.0 90 cc three times a day. Review of the resident's Medication Administration Record, on 4/12/21, did not show Med Pass 2.0 90 cc three times a day. Review of the resident's Care Plan, on 4/12/21, did not show Med Pass 2.0 90 cc three times a day. Review of the resident's medical record did not show documentation of weekly weights. During an interview on 4/12/21, at 4:42 P.M., the DON said the resident's health shakes should be on the resident's dietary ticket. 2. Review of Resident #32's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Physician's Orders, dated 11/13/19, showed the following: -No Added Salt diet; -Regular texture; -Thin/Regular consistency; -Large portions at all meals. Review of the resident's Physician's Orders, dated 12/10/19, showed the physician ordered Arginaid Packet (nutritional supplement) give 1 packet by mouth two times a day. Review of the resident's Physician's Orders, dated 1/3/20, showed the physician ordered health shakes three times a day with meals. Review of the resident's weight record, dated 9/16/20, showed the resident weighed 124 lbs. Review of the resident's Care Plan, revised on 9/22/20, showed the following: -Regular no added salt diet with large portions; -History of dysphagia (difficulty swallowing); -Wears dentures; -Eats in the assisted dining room on Meadowbrook related to aspiration risk with the assistance of restorative nursing staff; -Health shakes three times a day with meals; -Risk factors include mouth pain, difficulty chewing, aspiration, weight instability and abnormal lab values; -Needs encouragement to finish his/her meals; -Has had significant weight loss; -Goal will not have decline in current nutritional status through next review; -Dietician consult as needed; -Provide supervision during meals; -Tray set up as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnosis of dementia, depression and hemiplegia (paralysis on one side) from stroke; -Supervision and set up with eating; -Range of motion limited to one upper extremity; -Weight 126 lbs.; -Mechanically altered diet. Review of the resident's weight record showed the following: -On 10/14/20 126 lbs.; -On 11/1/20 126 lbs. Review of the resident's Progress Notes, dated 12/9/20, showed the Nurse Practitioner documented no reported concerns with the resident's appetite. Review of the resident's weight record, dated 12/14/20, showed the resident weighed 112 lbs. (11% weight loss in one month). Review of the resident's medical record showed no evidence facility staff notified the resident's physician of his/her weight loss. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Supervision and set up with eating; -Loss of liquids/solids from mouth when eating or drinking, pocketing and choking; -Weight 112 lbs. (10% wt loss in one months); -Significant weight loss, not on a physician prescribed plan; -Mechanically altered and therapeutic diet. Review of the resident's medical record did not show re-evaluation of the resident's current interventions for weight loss. Review of the resident's Progress Notes, dated 1/13/21, showed the Nurse Practitioner documented no concerns with appetite reported. Review of the resident's Progress Notes, dated 2/10/21, showed the Nurse Practitioner documented all diagnoses are treated. Appetite, sleep and constipation controlled. Review of the resident's weight record showed the following -On 2/22/21 112 lbs.; -On 3/16/21 111 lbs. (a 10.48% weight loss in six months.) Review of the resident's medical record showed no evidence facility staff notified the physician regarding the resident's initial significant weight loss in December, or continued weight loss in February or March. Review of the Dietitian's Recommendations to Nursing Services, dated March 2021, showed the following: -Concerns/Recommendations: Recommend Med Pass 2.0-90 cc TID (three times daily) due to continued weight loss (significant in six months) and due to decreased PO (by mouth) intake; -Can discontinue the Arginaid BID (twice daily) if desired, he/she no longer has any skin issues; -The med pass will provide more calories and protein than the Arginaid. Review of the facility's Diet Roster-By Diet, dated 3/29/21, showed the following for the resident: -Diet: Regular; -Diet Other: NAS (no added salt), Health Shakes TID (three times daily), large portions; -Texture: Regular; -Dislikes: Spinach. Review of the Dietitian Note, dated 3/31/21, showed the following: -Resident remains on a regular, no added salt diet with large portions; -Arginaid two times a day; -Health shakes three times a day with meals; -Resident has not been eating as well, having a variable intake; -Eating 0-100% of meals per documentation; -Height: 64; -March 2021 weight: 111 lbs., down 1 lb. in one and three months, down 13 lbs. in six months, a 10.5% weight loss; -BMI = 19.1 - lower end of normal weight range; -Recommend adding Med Pass 2.0 (nutritional supplement) - 90 cc three times a day at this time due to continued weight loss (significant in six months) and decreased intake of meals; -Will continue to follow and be available as needed. Review of the resident's medical record on 4/13/21, showed no evidence the Med Pass 2.0 was implemented as recommended on 3/31/21, or weekly weights since the resident's initial significant weight loss on 12/14/20. Observation on 3/30/21, at 12:43 P.M., showed the following: -Resident sat in his/her wheel chair at the dining room table in the assist to dine dining room on Meadowbrook; -Staff served the resident spaghetti, green beans, a roll (no butter) on a regular plate, and cake in a Styrofoam bowl; -The resident with paralysis of his/her left arm, attempted to eat with his/her right arm; -Each time the resident tried to load his/her fork with spaghetti, the plate slid away from him/her or the food fell off the edge of the resident's plate; -The resident pushed his/her plate away; -Staff did not assist or cue the resident; -He/She consumed 10% of his/her spaghetti, ¾ of his/her cake, and his/her mighty shake (supplement). Review of the resident's Progress Note, dated 4/8/21, showed the Nurse Practitioner documented the following: -Weight: 111 pounds; -Height: 64 inches; -BMI: 19.1; -Chief Complaint / Nature of Presenting Problem: Interval medical round and medication reconciliation; -Nursing reports a poor appetite and mostly just drinks his/her health shakes; -His/Her weight in October 2020 was 126 lb.; -Weight for March 2021 is 111 lb. -Diagnosis and Assessment: Poor appetite, ongoing weight loss unstable. During an interview on 4/12/21, at 2:24 P.M., CNA LL said the following: -He/She does not know which residents have weight loss; -The resident does not always want to get up for breakfast. During an interview on 4/12/21, at 3:40 P.M., LPN BBB said the following: -He/She did not know if the resident had a weight loss; -The resident does not always get up for breakfast; -He/She eats in the assisted dining room and staff should help the resident if he/she needs it; -He/She was not sure if the resident has supplements or interventions for weight loss. 3. Review of Resident #62's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis Alzheimer's disease, diabetes\mellitus, arthritis, Parkinson's disease (disease which may affect movement), anxiety, dysphagia (difficulty swallowing); -Requires supervision and set up with and eating; -Weight 228 lbs.; -Therapeutic diet. Review of the resident's Weight Record, showed the following: -On 8/14/20 206 lbs.;(9.6% weight loss in one month) -On 9/16/20 210 lbs. Review of the resident's annual MDS, dated [DATE], showed the following: -Weight 217 lbs.; -Weight gain, not on physician prescribed program; -Therapeutic diet. Review of the resident's Weight Record, showed the resident's weight on 11/1/20, at 208 lbs. Review of the resident's Care Plan, last revised on 11/19/20, showed the following: -Regular low concentrated sweets diet; -Diagnosis of diabetes mellitus II and dysphagia; -Wears dentures; -Eats all meals in the assisted dining room (on Meadowbrook); -Aspiration risk; -Goal will maintain current nutritional intake; -Administer insulin and medication as ordered; -Dietitian consult as needed; -Weighted mug, weighted utensils, and divided plate for meals to increase food and drink intake and decrease spillage; -Report significant weight changes to the physician; -Offer substitutes if the resident refuses what is being offered; -Provide supervision during meals and tray set up assistance. Review of the resident's Weight Record, dated 12/6/20, showed the resident weighed 186 lbs. (a 9.45% weight loss in one month). Review of the resident's care plan showed no evidence staff re-evaluated goals and interventions after the resident lost more weight. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Weight gain, not on physician prescribed program; -Mechanically altered and therapeutic diet. Review of the resident's Weight Record, dated 1/19/21, showed the resident's weight at 188 lbs. Observation on 3/29/21, at 12:35 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table on Homestead; -CNA LL served the resident ground meat, shredded cheese, black beans on a flat Styrofoam plate, tomatoes in a Styrofoam bowl, plastic utensils, and a glass of tea; -The resident said, My food is cold; -The resident said he/she did not know why his/her food was on a Styrofoam plate; -The resident attempted to load his/her utensils and the plate moved across the table; -The resident had tremors in his/her hands; -The resident dropped his/her fork; -The resident attempted to load beans on his/her spoon; -The beans fell off the edge of the resident's plate; -The resident pushed his/her plate away and left the table; -The resident consumed less than 25% of his/her meal; -Staff did not give the resident a weighted mug, a divided plate or weighted utensils. Review of the resident's meal ticket showed the following: -CCHO (consistent carbohydrate diet) low concentrated sweets; -Mechanical soft; -Divided plate; -Adaptive equipment per therapy. Observation on 3/30/21, at 12:52 P.M., showed the following: -The resident sat in his/her wheel chair at the dining room table in the assist dining room on Meadowbrook; -Staff served the resident spaghetti, green beans and a roll on a divided plate, cake, a glass of tea, regular utensils, and two chocolate milk cartons; -The resident fed himself/herself; -The resident's plate moved across the table as he/she ate; -The resident dropped his/her fork two times during the meal; -Staff did not give the resident a weighted mug or weighted utensils; -A licensed nurse did not supervise the meal. Observation on 3/31/21, at 12:31 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table in the assist dining room on Meadowbrook; -Staff served the resident ground turkey, mashed potatoes and gravy, spinach on a divided plate and a glass of tea; -Staff did not serve the resident dessert (other residents were served cake); -The resident did not have a weighted cup or weighted utensils. Observation on 3/31/21, at 5:50 P.M., showed the following: -The resident sat in his/her wheelchair at the dining room table in the assist dining room on Meadowbrook; -Staff served the resident a chicken salad sandwich and cheese curls on a divided plate, regular silverware and a glass of tea; -Staff did not serve the resident pasta salad (that was on the menu), or dessert

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of email communication from the administrator, dated 4/14/21 at 11:11 P.M., showed there was no facility policy for block medication times. 2. Review of www.accessdata.fda.gov/drugs, showed the following: -Morphine sulfate tablets are an opioid agonist indicated for the management of acute and chronic pain severe enough to require an opioid analgesic and for which alternative treatments are inadequate; -Recommended dose for morphine sulfate tablets: 15 to 30 mg every 4 hours as needed; -Risks of addiction, abuse, and misuse with opioids, even at recommended doses; -Do not abruptly discontinue morphine sulfate tablets in a physically dependent patient because rapid discontinuation of opioid analgesics has resulted in serious withdrawal symptoms, uncontrolled pain, and suicide; -When discontinuing morphine sulfate tablets in a physically dependent patient, gradually taper the dosage; -Rapid tapering of morphine in a patient physically dependent on opioids may lead to a withdrawal syndrome and return of pain; -Physical dependence is a physiological state in which the body adapts to the drug after a period of regular exposure, resulting in withdrawal symptoms after abrupt discontinuation or a significant dosage reduction of a drug; -For patients on morphine sulfate tablets who are physically opioid-dependent, initiate the taper by a small enough increment (e.g., no greater than 10% to 25% of the total daily dose) to avoid withdrawal symptoms; -Common withdrawal symptoms include restlessness, lacrimation (tearing), rhinorrhea (nasal discharge), yawning, perspiration, chills, myalgia (aches), and mydriasis (dilated pupils). Other signs and symptoms also may develop, including irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. 3. Review of Resident #157's Face Sheet showed the resident admitted on [DATE] with a diagnosis of pain. Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care, Level II (screening refers to clients with the diagnosis of Mental Illness or Mental Retardation), dated 8/18/19, showed the following: -Diagnosis of chronic back pain; -Takes morphine (pain medication) every 4 hours as well as Lyrica (medication for pain); -Back pain and right hand pain chronic in nature; -Followed by the pain clinic. Review of the resident's care plan, updated 11/18/19, showed the following: -Chronic pain in his/her right hand due to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the 4th and 5th fingers; -Takes routine pain medications; -Goal: Resident will be able to verbalize adequate relief of pain or the ability to cope with incompletely relieved pain, resident will report new onset of pain to staff promptly; -Administer analgesia (pain medications) medications as ordered; -Give pain medications 30 minutes before treatments or care; -Monitor for worsening pain status; -Physical therapy evaluation and treatment as needed; -Pain management consult. Review of the resident's Physician's Orders, dated 11/2019, showed the following: -Morphine (opioid pain medication) sulfate IR (immediate release) 15 milligrams four times a day; -Lyrica (medication used for nerve pain) 150 mg two times a day. Review of the resident's care plan, dated 1/28/20, showed the following: -Pain management consult for low back pain, leg pain, joint pain; -Refer to physical therapy as instructed; -No medication adjustments. Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment completed by facility staff, dated 12/6/20, showed the following: -Cognitively intact; -Diagnosis of pain; -Routine pain medication; -Pain interview not conducted; -No staff pain interview conducted; -Opioids received everyday. Review of the resident's MAR, dated 2/15/21, showed the resident received his/her 6:00 P.M. dose of morphine sulfate at 9:00 P.M. Review of the resident's Nurses Notes, dated 2/16/21, at 6:22 A.M., showed the following: -Morphine sulfate immediate release 15 mg tablet; -None available for resident; -Director of Nursing (DON) notified. Review of the resident's Nurses Notes, dated 2/16/21 at 6:37 A.M., showed the following: -Last dose of morphine given at bedtime on 2/15/21; -Charge nurse notified, nurse looked in Omnicell (machine that dispenses medications in the facility for new orders, or needed doses), and there was none in stock; -Medication is ordered; -Will let next shift follow up with pharmacy. Review of the resident's Nurses Notes, dated 2/16/21, at 12:20 P.M., showed the following: -Morphine sulfate immediate release 15 mg tablet; -None available for resident; -None in the Omnicell either; -Pharmacy has it back ordered. Review of the resident's Nurses Notes, dated 2/16/21, at 5:59 P.M., showed the resident's morphine arrived from another pharmacy. Review of the MAR, dated 2/16/21, showed the following: -Morphine sulfate not given for the 7:00 A.M. or 11:00 A.M. doses; -Morphine sulfate 3:00 P.M. dose administered at 6:00 P.M. -The resident did not have morphine sulfate from 9:00 P.M., on 2/15/21, until 6:00 P.M. on 2/16/21 for a total of 21 hours. Review the resident's Nurses Notes, dated 3/1/21, showed the resident returned from the hospital at 4:00 P.M. Review of the resident's MAR, dated 3/1/21, showed the resident did not receive his/her 6:00 P.M. medications after return from the hospital. 3/1/21. No medications documented as administered. Review of the resident's Medication Administration Audit Report, dated 3/1/21-3/6/21, showed the following: -On 3/2/21 7:00 A.M. morphine sulfate administered at 6:09 A.M. (prior to scheduled time), the 11:00 A.M. and 3:00 P.M. morphine doses administered at 2:51 P.M. (two scheduled doses administered at the same time), and the 6:00 P.M. morphine administered at 9:23 P.M.; -On 3/3/21 7:00 A.M. morphine sulfate administered at 9:44 A.M. (12 hours and 21 minutes from the last dose), 11:00 A.M. morphine at 12:25 P.M. (2 hours and 41 minutes from the last dose), 3:00 P.M. morphine administered at 3:15 P.M.(2 hours and 50 minutes from the last dose), and the 6:00 P.M. morphine administered at 7:25 P.M.; -On 3/6/21 7:00 A.M. morphine sulfate administered at 10:06 A.M. (13 hours and 9 minutes from the last dose), 11:00 A.M. morphine at 12:05 P.M. (2 hours and 1 minute from the last dose), 3:00 P.M. morphine administered at 4:25 P.M., and the 6:00 P.M. morphine administered at 6:50 P.M.(2 hours and 25 minutes from the last dose); Review of the resident's MAR, dated 3/7/21-3/8/21, showed the following: -On 3/7/21 the resident did not receive his/her 7:00 A.M., 11:00 A.M., 3:00 P.M., or 6:00 P.M. doses of morphine; -On 3/8/21 the resident did not receive his/her 7:00 A.M. dose of morphine. Review of the resident's Nurses Notes, dated 3/8/21, showed the following: -Morphine sulfate immediate release 15 mg tablet; -None available for the resident; -Waiting on the medication from the pharmacy. Review of the resident's Medication Administration Audit Report, date 3/8/21-3/31/21, showed all the following: -On 3/8/21 administered 11:00 A.M. morphine at 1:37 P.M. (42 hours and 27 minutes from last dose on 3/6/21); 3:00 P.M. morphine at 3:23 P.M. (1 hour 46 minutes from last dose), 6:00 P.M. morphine at 6:47 P.M. (3 hours and 24 minutes from last dose); -On 3/9/21 administered 7:00 A.M. morphine at 9:51 A.M. (15 hours and 3 minutes from last dose, 11:00 A.M. morphine at 11:48 A.M. (1 hour and 57 minutes from the last dose), 3:00 P.M. and 6:00 P.M. dose at 7:47 P.M.; -On 3/10/21 administered 7:00 A.M. morphine at 9:08 A.M. (13 hours and 21 minutes since the last dose), 11:00 A.M. morphine at 10:50 A.M. (1 hour and 42 minutes from last dose), and 6:00 P.M. dose at 8:05 P.M.; -On 3/11/21 administered 7:00 A.M. morphine at 7:53 A.M. (11 hours and 48 minutes from the last dose), 11:00 A.M. morphine at 11:17 A.M. (3 hours and 20 minutes from last dose), 3:00 P.M. morphine at 4:52 P.M., and the 6:00 P.M. morphine at 7:10 P.M. (2 hours and 18 minutes from the last dose); -On 3/12/21 administered 7:00 A.M. morphine at 6:09 A.M. (11 hours and 59 minutes from last dose on 3/6/21); 11:00 A.M. and 3:00 P.M. morphine at 3:17 P.M. (two doses at the same time), 6:00 P.M. morphine at 7:23 P.M.; -On 3/13/21 administered 7:00 A.M. morphine at 8:38 A.M. (13 hours and 16 minutes from the last dose), 11:00 A.M. morphine at 11:58 A.M. (3 hours and 20 minutes from last dose), 3:00 P.M. morphine at 3:10 P.M. (3 hours and 12 minutes from the last dose), and the 6:00 P.M. morphine at 7:10 P.M.; -On 3/14/21 administered 7:00 A.M. morphine at 9:16 A.M. (14 hours and 6 minutes from the last dose), 11:00 A.M. morphine at 2:42 P.M., 3:00 P.M. morphine at 4:15 P.M. (1 hour and 33 minutes from the last dose), and the 6:00 P.M. morphine at 6:26 P.M. (2 hours and 11 minutes from the last dose); -On 3/15/21 administered 7:00 A.M. morphine at 8:07 A.M. (13 hours and 41 minutes from the last dose), 11:00 A.M. morphine at 11:19 A.M. (3 hours and 12 minutes from last dose), 3:00 P.M. morphine at 3:20 P.M., and the 6:00 P.M. morphine at 6:40 P.M. (3 hours and 20 minutes from the last dose); -On 3/16/21 administered 7:00 A.M. morphine at 8:28 A.M. (13 hours and 48 minutes from the last dose), 11:00 A.M. morphine at 10:59 A.M. (2 hours and 31 minutes from last dose), 3:00 P.M. morphine at 2:54 P.M., and the 6:00 P.M. morphine at 6:31 P.M. (3 hours and 37 minutes from the last dose); -On 3/17/21 administered 7:00 A.M. morphine at 7:02 A.M. (12 hours and 31 minutes from the last dose), 11:00 A.M. morphine at 1:37 P.M., 3:00 P.M. morphine at 5:09 P.M., and the 6:00 P.M. morphine at 7:21 P.M. (2 hours and 12 minutes from the last dose); -On 3/18/21 administered 7:00 A.M. morphine at 9:32 A.M. (14 hours and 11 minutes from the last dose), 11:00 A.M. morphine at 12:23 A.M. (2 hours and 51 minutes from last dose), 3:00 P.M. morphine at 3:11 P.M.(2 hours and 48 minutes from the last dose), and the 6:00 P.M. morphine at 7:10 P.M.; -On 3/19/21 administered 7:00 A.M. morphine at 10:02 A.M. (14 hours and 52 minutes from the last dose), 11:00 A.M. morphine at 11:55 A.M. (1 hour and 53 minutes from last dose), 3:00 P.M. morphine at 3:31 P.M.(3 hours and 36 minutes), and the 6:00 P.M. morphine at 8:58 P.M.; -On 3/20/21 administered 7:00 A.M. morphine at 9:27 A.M. (12 hours and 29 minutes from the last dose), 11:00 A.M. morphine at 1:33 P.M., 3:00 P.M. morphine at 6:19 P.M., and the 6:00 P.M. morphine at 6:19 P.M. (2 dose administered at the same time); -On 3/21/21 administered 7:00 A.M. morphine at 9:02 A.M. (14 hours and 41 minutes from the last dose), 11:00 A.M. morphine at 10:33 A.M. (1 hour and 31 minutes from last dose), 3:00 P.M. morphine at 14:28 P.M. (3 hours and 55 minutes), and the 6:00 P.M. morphine at 5:58 P.M. (3 hours and 30 minutes from the last dose); -On 3/22/21 administered 7:00 A.M. morphine at 8:39 A.M. (14 hours and 41 minutes from the last dose), 11:00 A.M. morphine at 1:46 P.M., 3:00 P.M. morphine at 4:59 P.M. (3 hours 13 minutes from the last dose), and the 6:00 P.M. morphine at 6:24 P.M. (1 hours and 24 minutes from the last dose); -On 3/23/21 administered 7:00 A.M. morphine at 8:18 A.M. (13 hours and 54 minutes from the last dose), 11:00 A.M. morphine at 12:15 A.M., 3:00 P.M. morphine at 3:21 P.M. (3 hours and 6 minutes from last dose), and the 6:00 P.M. morphine at 6:12 P.M. (2 hours and 51 minutes from the last dose); -On 3/24/21 administered 7:00 A.M. morphine at 9:56 A.M. (15 hours and 44 minutes from the last dose), 11:00 A.M. morphine at 10:38 A.M. (42 minutes from last dose), 3:00 P.M. morphine at 3:40 P.M., and the 6:00 P.M. morphine at 6:14 P.M. (2 hours and 34 minutes from the last dose); -On 3/25/21 administered 7:00 A.M. morphine at 1:23 P.M. (19 hours and 9 minutes from the last dose), 11:00 A.M. morphine at 1:23 P.M. (two doses at the same time), 3:00 P.M. morphine at 5:23 P.M., and the 6:00 P.M. morphine at 5:23 P.M. (2 doses at the same time); -On 3/26/21 administered 7:00 A.M. morphine at 9:00 A.M. (15 hours and 37 minutes from the last dose), 11:00 A.M. morphine at 11:31 A.M. (2 hours and 31 minutes from last dose), 3:00 P.M. morphine at 4:13 P.M., and the 6:00 P.M. morphine at 7:06 P.M. (2 hours and 53 minutes from the last dose); -On 3/27/21 administered 7:00 A.M. morphine at 8:09 A.M. (13 hours and 3 minutes from the last dose), 11:00 A.M. morphine at 12:01 A.M., 3:00 P.M. morphine at 4:56 P.M., and the 6:00 P.M. morphine at 6:06 P.M. (1 hour and 10 minutes from the last dose); -On 3/28/21 administered 7:00 A.M. morphine at 8:22 A.M. (14 hours and 16 minutes from the last dose), 11:00 A.M. morphine at 12:27 A.M., 3:00 P.M. morphine at 4:52 P.M., and the 6:00 P.M. morphine at 7:10 P.M. (2 hours and 18 minutes from the last dose); -On 3/29/21 administered 7:00 A.M. morphine at 9:46 A.M. (14 hours and 36 minutes from the last dose), 11:00 A.M. morphine at 11:01 A.M. (1 hour and 17 minutes from last dose), 3:00 P.M. morphine at 7:11 P.M., and the 6:00 P.M. morphine at 7:11 P.M. (two doses administered at the same time); -On 3/30/21 administered 7:00 A.M. morphine at 8:01 A.M. (11 hours and 50 minutes from the last dose), 11:00 A.M. morphine at 12:03 P.M., 3:00 P.M. morphine at 3:27 P.M.(3 hours and 24 minutes from the last dose), and the 6:00 P.M. morphine at 7:59 P.M.; -On 3/31/21 administered 7:00 A.M. morphine at 9:44 A.M. (12 hours and 45 minutes from the last dose), 11:00 A.M. morphine at 12:25 P.M. (2 hours and 41 minutes from last dose), 3:00 P.M. morphine at 4:18 P.M., and the 6:00 P.M. morphine at 7:13 P.M. During an interview on 3/31/21, at 7:25 P.M., the resident said the following: -He/She has chronic back pain; -The staff do not give his/her morphine like they are supposed to; -Before he/she came to this facility, the previous facility spaced out the doses; -The previous facility gave him/her one morphine in the morning, one before bed and spaced out the other doses to give him/her pain relief for the entire day; -Yesterday he/she got his/her 7:00 A.M. dose at 9:45 A.M., then a dose at 12:30 P.M., the third dose at 3:00 P.M., and then his/her last does at 6:30 P.M.; -This puts all his/her morphine doses within eight or nine hours of each other and he/she does not have any pain medications for the other 15 to 16 hours of the day; -Sometimes the staff give him/her two doses at the same time like the 7:00 A.M. dose and the 11:00 A.M. doses both at 11:00 A.M.; what was the point of having it scheduled four times a day?; -If his/her pain medications were closer to every six hours he/she would have better pain relief; -His/Her pain medications wear off in the middle of the night and he/she can not sleep. In the morning he/she has an 8 or a 9 pain level and feels awful; -When his/her pain is over a 5, which is daily, he/she spends his/her time trying to be comfortable. I can't sit too long, lay too long, or walk too long, and am constantly repositioning. Because of this he/she cannot watch a movie when his/her pain is elevated, or do anything that requires being in one position for any length of time. During an interview on 3/31/21, at 7:50 P.M., certified medication technician (CMT) YY said the following: -The resident had run out of morphine several times; -Usually the pharmacy was waiting on a prescription from the physician; -Earlier this month the facility had to get an emergency prescription filled from a pharmacy in town; -The DON has to handle the prescriptions so sometimes the residents just have to wait until their medication gets here; -The facility does block time medication pass so he/she can give the resident's morphine that is four times a day, anytime within the block time; -The medication pass times are 7:00 A.M.-11:00 A.M., 11:00 A.M.-3:00 P.M., 3:00 P.M.-6:00 P.M. and 6:00 P.M.-10:00 P.M.; -He/She tried to space the medications that are several times a day out, but as long as they are within the time frame it was not a problem; -The facility cut the budget about a month ago and now there was no one to pass medications after 7:00 P.M. on the resident's side of the building (referring to the 500, 600, and 700 halls); -All the 500 hall medications are done by 7:00 P.M., 7:30 P.M. at the latest. Review of the resident's Nurses Notes, dated 4/5/21 at 9:30 P.M., showed the following: -Morphine sulfate immediate release 15 mg tablet; -None available for resident; -The morphine was reordered, but pharmacy awaiting a new signed prescription from the physician's office; -Pharmacy said they would be sending a partial card of eight pills tonight until the prescription was refilled; -ADON and DON notified; -Attempted to reach the physician's office via Emergency Line to receive a supplement order but it went to voicemail; -Nurse left a voicemail; -Nurse attempted to call three more times and left messages, no response yet. Review of the resident's Nurses Notes dated 4/5/21 at 9:54 P.M., showed staff received an order for hydrocodone-acetaminophen tablet 7.5-325 mg, one tablet every six hours as needed until the morphine sulfate arrived in the building from pharmacy. Review of the resident's MAR, dated 4/5/21, showed the resident missed his/her morphine dose at 3:00 P.M. and 7:00 P.M. because the medication was not available. Review of the resident's Nurses Notes, dated 4/6/21 at 2:33 A.M., showed the following: -Resident upset about pain medicine not being available earlier in this shift and wanted to wait until pain medication was available to take night medications; -When pain medication became available, administered with night medications per orders; -Resident cooperative; -States he/she has lower back pain and nothing else seems to help. During an interview on 4/6/21, at 3:45 P.M., CMT YY said the following: -Staff order the resident's medication when the resident gets down to four pills for the daily medications, and ten pills for medications that are administered more often; -The resident ran out of morphine on 4/5/21; -He/She does not know why the resident ran out this time; -He/She does not routinely ask for resident's pain score, the resident will tell him/her if he/she is in pain. During an interview on 4/6/21, at 3:50 P.M., the resident said the following: -He/She missed his/her 3:00 P.M. dose of morphine yesterday because staff said they ran out; -The night nurse gave him/her one at 12:30 A.M. when they came in from the pharmacy because the nurse knew he/she was pain; -His/Her pain was an 8 or 9 by then; -He/She was hurting so bad and felt so bad he/she could not go to sleep; -Staff said the pharmacy only sent four pills; -He/She asked for Tylenol (pain medication) and CMT YY said he/she was out of Tylenol, he/she was not able to get Tylenol today; -He/She requested Tylenol for breakthrough pain, especially if he/she was having more pain. During an interview on 4/6/21, at 4:07 P.M., CMT YY said the following: -He/She was out of the stock Tylenol; -He/She was waiting on the stock medications to be delivered; -If he/she had the Tylenol he/she would give it, otherwise the resident would have to wait; -He/She didn't call the other units to see if they had Tylenol. During an interview on 4/6/21, at 4:10 P.M., the resident said the following: -He/She requested Tylenol at 2:00 P.M.; -His/Her back was aggravated more than normal; -His/Her pain was a 6 on a scale of 1-10; -He/She thinks he/she twisted wrong in therapy and his/her back was already a little fired up from running out of morphine yesterday; -His/Her lower spine has one vertebra that presses against his/her spine, and a disc that is not in the right place; -His/Her pain goes from his/her lower back, then down the left side of his/her body from his/her lower back, through the buttock, down the back of his/her left leg to his/her heel; -Surgery was not an option for him/her because the physician said it could paralyze him/her; -Before his/her admission to this facility he/she went to the pain clinic every month; -At the pain clinic he/she received steroid injections in his/her back; -His/Her pain at the lowest is a 3, which is tolerable, his/her normal, the pain is always there; -When his/her pain is at a 5, it interferes with what he/she wants to do because he/she will have to change positions frequently, he/she can't sit too long, lay too long, or walk too long because of the pain; -Four hours after he/she takes his/her morphine his/her pain gets up to a 5 and he/she is uncomfortable, after 6 hours his/her pain gets up to the 6 or 7 pain level which is when he/she can't sleep, can't get comfortable, he/she feels himself/herself get grumpy and anxious; -After several hours he/she starts to have withdrawal symptoms; -He/She will feel anxious, sweaty, his/her eyes water, and he/she has body aches like he/she has the flu, and the longer it goes the worse his/her withdrawal symptoms get; -He/She feels that way every morning now that the staff are giving him/her his/her last dose by 7:00 P.M.; -By 9:00 A.M. or 10:00 A.M. the next day he/she already feels terrible. During an interview on 4/7/21, at 5:30 P.M. CMT AAA said the following: -The facility uses a 1-10 pain scale, one the least pain and ten is the worst pain, or the faces for the residents that can't tell staff their pain level; -The resident was sometimes over a 5 on his/her pain scale, it depended on how his/her back was that day; -He/She used the resident's last dose of morphine at 3:00 P.M.; -The resident had a lot of anxiety when he/she was out of morphine. The resident worries about when it will come; -He/She let nursing administration know the pharmacy did not send the resident's morphine; -There was no night CMT, the position was cut on 3/1/21, and now the CMT on days works a 12 hour shift; -The day shift CMT tries to give all the bedtime medications before they leave at 7:00 P.M. or 7:30 P.M. During an interview on 4/7/21, at 5:30 P.M., ADON B said the following: -He/She called the pharmacy on 4/5/21 about the resident's morphine; -He/She thought it was a prescription issue and between the physician and the pharmacy; -The resident would have to take hydrocodone if his/her morphine does not come; -Hydrocodone was not as strong as morphine and would not stop withdrawal symptoms. During an interview on 4/7/21, 9:17 A.M., pharmacy control technician ZZZ, said the following: -Pharmacy received a refill request for the resident's morphine on 2/10/21, and eight tablets were sent on 2/11/21; -Pharmacy received a refill request for the resident's morphine on 2/13/21, and the request had a message that a new script was needed; -Pharmacy received a refill request for the resident's morphine on 2/15/21, at 9:00 P.M., the request for the refill prescription was sent to the physician on 2/16/21, and it takes 24-48 hours to get a response; -Pharmacy received the prescription on 2/17/21 and sent 56 tablets on the 8:05 P.M. delivery; -Record showed the resident went to the hospital on 2/26/21; -Pharmacy received the refill request for the resident's morphine on 3/7/21 at 6:45 A.M. and sent out 56 tablets on 3/8/21 night delivery; -Pharmacy received a refill request for the resident's morphine on 3/30/21, and the system had a message ordered too soon, there was an error on the pharmacy side and it did not order the medication to be sent in the pharmacy system when it was able to refill; -On 4/5/21 the pharmacy sent eight tablets and requested a new prescription and had not received it at this time; -To get an emergency delivery the DON has to request a medication to be sent STAT (immediately), there was no STAT request on any of the resident's morphine refills. During an interview on 4/8/21, at 2:45 P.M., the resident's physician said the following: -The resident has morphine sulfate IR ordered four times a day routinely for chronic pain; -The facility is expected to order the resident's morphine and all medications that could require a new prescription at least 72 hours in advance to allow time for the required prescription to be obtained; -The resident should not run out of his/her morphine; -The medication should be administered every 4-6 hours to be effective at relieving the resident's pain; -Pain that is uncontrolled should be reported to the physician; -The facility should notify the physician on call anytime there is a problem obtaining a resident's prescription medication. 4. Review of Resident #175's Face Sheet showed the resident admitted to the facility on [DATE]. Review of the resident's Physician's Order Sheet, dated 3/8/21, showed the following: -Acetaminophen 325 mg every six hours for pain or fever; -Ibuprofen 600 mg every eight hours as needed for pain for 10 days, discontinued on 3/18/21. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of an intracranial (head) injury, schizophrenia, bipolar disorder, panic disorder, personality disorder, mild intellectual disability; -Did not receive scheduled or as needed pain medication; -Resident has pain almost constantly; -Pain makes it hard to sleep, interferes with daily activities; -Resident rates his/her pain a 9 on a 1-10 pain scale (1 being no pain, 10 being worst pain). Review of the resident's care plan, revised on 3/20/21, showed the following: -History of generalized pain at times; -Complains of occasional pain; -Diagnosis of mild osteoarthritis in his/her right knee; -Goals: Resident will not have an interruption in normal activities due to pain, will verbalize adequate relief of pain or ability to cope with incompletely relieved pain; -Administer analgesia (pain medication) as per orders; -Respond immediately to any complaint of pain; -Evaluate the effectiveness of pain interventions as ordered/requested; -Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; -Monitor and document for probable cause of each pain episode, remove/limit issues where possible; -Monitor/record/report to the nurse resident complaints of pain or request for pain treatment; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from the resident's past experience of pain. Review of the resident's Nurses Notes, dated 3/31/2021, at 4:21 P.M., showed the following: -Resident complaining of right knee pain; -The resident said he/she has arthritis in his/her knee; -Notified the physician and received orders for Tylenol and Biofreeze (topical pain medication); -Will be put on the list to see the physician on next rounds. During an interview on 3/31/21, at 5:30 P.M., the resident said the following: -He/She is in pain; -His/Her right knee hurts, his/her pain was an eight; -He/She told the staff and staff said there wasn't anything they could do; -He/She felt like his/her knee was going out when he/she walks; -He/She was afraid he/she was going to fall. Observation on 3/31/21, at 5:30 P.M., showed the following: -The resident ambulated down the hall with a limp; -He/She held his/her right knee with his/her right hand; -He/She held the hand rail with his/her left hand to ambulate; -He/She grimaced in pain. During an interview on 3/31/21, at 6:20 P.M., CMT XX said the following: -The resident complained of pain in his/her right knee yesterday; -He/She did not know if staff did anything about the resident's knee. During an interview on 3/31/21, at 7:10 P.M., Licensed Practical Nurse (LPN) FF said the following: -Staff reported the resident's knee pain earlier today; -The resident was added to the list of residents for the physician to see; -He/She obtained an order for Tylenol and Biofreeze; -He/She Instructed CMT YY to administer Tylenol around 2 P.M. During an interview on 3/31/21, at 7:45 P.M., the resident said the following: -The pain in his/her right knee was a 9 out of 10; -Tylenol does not help, staff have not offered Tylenol, Ibuprofen or Biofreeze. Review of the resident's Medication Administration Record (MAR), dated March 2021, showed the following: -Staff administered three acetaminophen (Tylenol) 325 milligrams (mg) on 3/31/21, at 8:02 P.M. for pain; -Pain level of 5; -Effectiveness documented as unknown; -The documentation did not show evidence staff administered ibuprofen or Biofreeze. Review of the resident's Medication Administration Note, dated 4/1/2021, at 8:42 A.M., showed the following: -Staff administered three acetaminophen (Tylenol) 325 milligrams (mg) on 3/31/21, at 8:02 P.M. for pain; -The resident walked out of his/her room limping; -The resident complained of knee pain, said it felt like it was on fire. Review of the resident's Nurses Notes, dated 4/1/21, at 2:32 P.M., showed the resident said his/her right knee gave out and he/she fell. Review of the resident's Nurses Notes, dated 4/2/2021, showed X ray of the right knee showed degenerative changes. 5. Review of Resident's #176's face sheet showed diagnoses included chronic pancreatitis (inflammation of the pancreas that does not heal and can cause constant or recurrent abdominal pain) and chronic cholecystitis (inflammation of the gall bladder caused by gall stones, characterized by attacks of pain when gall stones periodically block the cystic duct. Review of the resident's Physician Order Sheet (POS) for March 2021 showed an order for hydrocodone/acetaminophen (narcotic pain medication) 10/325 milligrams (mg) by mouth every four hours scheduled for pain (start date of 10/28/20). Review of the resident's Medication Administration Record (MAR) for April 2021 showed the following: -Medications timed for 8:00 A.M., 12:P.M., 4:00 P.M. and 8:00 P.M.; -On 3/1/21 at 12:00 A.M. the resident's pain was zero out of ten. LPN X documented 9 (other, see nurse's notes), indicating the medication was not administered; -On 3/1/21 at 4:00 A.M. the resident's pain was zero out of ten. LPN X documented 9 (other, see nurse's notes), indicating the medication was not administered; -On 3/1/21 at 8:00 P.M. the resident's pain was not assessed. LPN X documented 7 (resident sleeping), indicating the medication was not administered; -On 3/2/21 at 12:00 A.M. the resident's pain was zero out of ten. LPN X documented 9 (other, see nurse's notes), indicating the medication was not administered; -On 3/2/21 at 4:00 A.M. the resident's pain was zero out of ten. LPN X documented 9 (other, see nurse's notes), indicating the medication was not administered; -On 3/2/21 at 8:00 P.M. the resident's pain was four out of ten. LPN DD documented 9 (other, see nurse's notes), indicating the medication was not administered; -On 3/3/21 at 12:00 A.M. the resident's pain was four out of ten. LPN DD documented 9 (other, see progress note), indicating the medication was not administered; -On 3/3/21 at 4:00 A.M. the resident's pain was five out of ten. LPN DD documented 9 (other, see progress note), indicating the medication was not administered; -On 3/4/21 at 12:00 A.M. the resident's pain was four out of ten. LPN DD documented 9 (other, see progress note), indicating the medication was not administered; -On 3/4/21 at 4:00 A.M. the resident's pain was one out of ten. LPN DD documented 9 (other, see progress note), indicating the medication was not administered; -On 3/5/21 at 12:00 A.M.