Based on observation, interview, and record review, the facility failed to protect one resident (Resident #1) in a review of five sampled residents, from abuse and neglect with care when Certified Medication Technician (CMT) A recorded the resident on his/her personal cellular phone without the resident's consent while the resident cried out and attempted to get out of bed, wearing only a shirt, incontinence brief and pants up to his/her knees. The resident's arm was through the middle of the grab bar of the bed and his/her legs hung off the side of the bed. CMT A did not provide the resident any assistance or care for approximately three minutes and continued to record as the resident cried out and struggled to get up in an unsafe situation. CMT A could be heard speaking to the resident in a demeaning manner. The resident said he/she had overheard staff say to each other they were not going to put up with him/her and were not going to break their backs over him/her. This made the resident feel he/she was not good enough and hurt his/her feelings. The resident said staff threatened him/her with the use of the mechanical lift (a mobile transfer device used to move a resident from one surface to another with the resident placed in a sling, elevated off the surface and lowered onto another surface) to coerce the resident into activities he/she did not want to do. The resident was fearful of the mechanical lift and said it caused him/her pain and emotional anguish. The facility census was 57. The administrator was notified of the Immediate Jeopardy (IJ) on 4/26/23 at 2:00 P.M. which began on 4/17/23. The IJ was removed on 4/26/23 7:00 P.M. as confirmed by surveyor onsite verification. Review of the facility Abuse Prevention Policy, dated February 2018, showed the following in part: -The facility had a zero tolerance of physical, verbal, sexual, and mental abuse, neglect by employees, family members, visitors or other residents; ms--Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. It included verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse was defined as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to a resident or within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse included, but not limited to, threats of harm, saying things to frighten a resident, such as telling a resident they would never see their family again; -Mental abuse included but was not limited to, humiliation, harassment, threats of punishment or deprivation; -Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress; -Verbal or Nonverbal abuse was any conduct that could cause mental abuse, including but not limited to, nursing home staff taking photographs or recordings of resident that were demeaning or humiliating using any type of equipment, (camera, smart phones and other electronic devices) and keeping or distributing them through multimedia messages or on social media networks; -Mistreatment meant inappropriate treatment or exploitation of a resident; -The facility would have a system in place to prevent abuse and would ensure that all resident's responsible parties and staff understood there was zero tolerance of mistreatment, abuse, and neglect by an employee or any other person know to the resident. Review of the facility Cell Phone policy dated 3/17/23 showed the following: -It was the facility's policy to provide a health care environment and customer service that were not disrupted by distractions of personal cell phone or hand held communication devices; -Because of Health Insurance Portability and Accountability Act (HIPPA) (a federal law to protect sensitive patient health information from being disclosed without the resident's consent or knowledge) privacy practices, employees were not allowed to post or communicate any form of personally identifiable information about residents including photographs or any other information about a resident. 1. Review of Resident #1's Care Plan, dated 3/13/23, showed the following: -Diagnoses of dementia with anxiety, anxiety disorder, chronic pain, and history of falling; -The resident had dementia and moderate anxiety. Staff should report to the nurse if the resident was anxious or had changes in mental status; -The resident was known to become very anxious and emotional and at times scream. Staff should redirect as needed; -The resident was cognitively intact. Staff should orient the resident as needed and report any confusion or changes in cognition to the nurse; -The resident had an overall decline in Activities of Daily Living (ADLs). Staff should provide assistance with transfer, the resident transferred better with one staff member due to anxiety. He/She had chronic knee pain, staff should be patient as he/she moved slowly. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 4/13/23, showed the following: -Cognitively intact; -Physical and verbal behavioral symptoms directed toward others was not exhibited; -Other behavioral symptoms not directed toward other (such as hitting or scratching self, verbal/vocal symptoms like screaming, disruptive sounds) occurred in the previous four to six days but less than daily; -Required extensive assistance of two staff members with bed mobility and dressing; -Required total assistance of two staff members with transfers and toileting. Review of the resident's nurses' notes showed the following: -On 4/13/23 at 1:30 P.M. staff documented the resident was very upset and sobbing at 6:00 A.M. that morning, was not able to verbalize what he/she was upset about but said, I'd be better off dead. Spoke with the resident at length but was only able to comfort him/her enough to get him/her to stop crying. The resident eventually laid his/her head on his/her arms on the breakfast bar and continued to cry until about 7:30 A.M. when the resident finally agreed to eat some breakfast. After breakfast the resident gradually returned more to his/her normal self; -On 4/14/23 at 4:58 P.M. staff documented the resident was tearful that morning at 6:00 A.M., crying quietly at his/her table alone. Spoke with the resident who declined to discuss why he/she was crying. The resident agreed to coffee and orange juice. He/She eventually stopped crying and received his/her breakfast; -On 4/17/23 at 6:49 A.M. CMT A documented at 5:00 A.M. he/she went into the resident's room to get the resident's blood sugar (finger stick blood test). The resident became very snarky and mumbled under his/her breath that CMT A did not need to check anything. CMT A asked the resident if he/she could check the resident's blood sugar and the resident started screaming, crying and smacked everything out of CMT A's hands. CMT A asked the resident what was wrong and why he/she was being hateful that morning. The resident responded he/she liked to be hateful. The resident started screaming at CMT A. CMT A told the resident that was uncalled for and inappropriate, the resident screamed he/she did not care. CMT A then called the charge nurse Licensed Practical Nurse (LPN) D over to observe the resident's behavior. LPN D tried to obtain the resident's blood sugar. The resident still refused and was very vulgar and hateful, while he/she laid there kicking his/her legs out of the bed and continued to scream at the top of his/her lungs and cried out. CMT A then again asked the resident what was wrong, the resident said he/she was playing. CMT A asked the resident what he/she was playing, the resident said playing house. CMT A repeated to the resident you are playing house? The resident replied yes then continued to scream and cry. During interview on 4/21/23 at 9:00 A.M. the administrator said on 4/17/23 at about 5:00 A.M., CMT A took a video recording of Resident #1 with his/her personal cellular phone in order to show the Director of Nursing (DON) the resident's behaviors. CMT A videoed Resident #1 and sent the video from his/her personal cellular phone to the facility's cellular phone on the other side of the building. CMT A wanted the charge nurse to see the resident's behavior. The administrator felt the recording was nothing. He had not watched the video but the DON saw the video on 4/17/23 and decided the video was not abuse. The resident was upset, yelling and throwing himself/herself out of bed. The resident had increased anxiety and behaviors at night. CMT A agitated the resident. The day shift charge nurse, LPN B, saw the video and wrote up CMT A. Review of the warning notice dated 4/17/23 showed LPN B wrote the following: -Type of violation was unsatisfactory performance and violation of facility policy and procedures; -Date of incident was 4/17/23 at 5:00 A.M.; -Description of violation was CMT A woke the resident at 4:00 A.M. to check fasting blood sugar (FBS). When the resident became angry about being awakened so early the resident began yelling out. CMT A did not check the resident's FBS, gave as needed Tylenol at 4:03 A.M., and videoed the resident on his/her personal cellular phone; -DON follow up action taken was a warning, no malicious intent. Spoke with CMT A by telephone and informed not to use personal phone. During interview on 4/21/23 at 9:15 A.M. the DON said she saw the video, the resident was upset, yelling and trying to throw his/herself out of the bed. The resident had increased anxiety and behaviors at night. Night shift was responsible to get the resident up before the end of the shift (6:00 A.M.). During the night the resident refused to get up, he/she was difficult to get up. On day shift the resident did better. Staff used the mechanical lift in the night to transfer the resident. Review of the facility's cellular phone saved video on 4/21/23 at 10:00 A.M. showed the following: -CMT A videoed from the resident's doorway as the resident lay in bed next to the window, cried out and attempted to get out of bed, wearing only a shirt, incontinence brief and pants up to his/her knees. The resident's arm was through the middle of the grab bar of the bed and his/her legs hung off the side of the bed. CMT A did not provide the resident any assistance or care for approximately three minutes and continued to record as the resident cried out and struggled to get up in an unsafe situation. Staff could be heard speaking to the resident in a demeaning manner; - CMT A called the resident's name three times and said what are you doing? what are we playing, playing house?. The resident continued to struggle, pulling at the grab bar and his/her pants while crying out and screaming; -CMT A walked over to the edge of the resident's bed and said you don't care laying here screaming and carrying on keeping every one awake? that's not very nice. The resident said I'm not very nice. CMT A said so what's going on this morning? the resident said nothing and continued to cry out struggle, pulling at the grab bar and his/her pants while crying out and screaming; -CMT A said you are going to end up in the floor, the resident moaned and cried out. CMT A called the resident's name and asked the resident to put his/her legs up you are gonna be on the floor, the resident said I don't care; -CMT A said why are you being hateful? the resident said I like being hateful and continued to cry out; -CMT A said you aren't hateful, why are you being like this? During interview on 4/21/23 at 10:50 A.M. LPN C said the following: -He/She was the care plan coordinator and charge nurse; -The resident was cognitively intact and very much alert and oriented, he/she had dementia with anxiety and lived on the locked special care unit (SCU); -The resident hollered out frequently and had fear with transfers and fear of falling. He/She required one staff member assistance with transfers. The resident hollered out and was anxious during when transfers; -LPN C saw the video taken by CMT A. The video was abusive to the resident. Staff should approach the resident calmly and help the resident rest and remain calm. CMT A's behavior would make the resident's anxiety worse. Night shift staff woke the resident early in the morning and got the resident up for the day before the end of the night shift (6:00 A.M.) During interview on 4/21/23 at 11:00 A.M. the resident said the following: -He/She worried at night, about going home and what will happen. Staff get him/her up by 6:00 A.M. every day and use the mechanical lift to get out of bed. He/She hated the thing (mechanical lift). Staff say to each other they are not going to put up with him/her. He/She heard what staff said. He/She did not like it. Staff would not let him/her sleep any longer, they have to dress him/her. Staff put his/her pants on about to the knee, put the sling underneath him/her and then transfer him/her to the wheelchair. The mechanical lift was painful and stressful, made him/her feel like he/she was not good enough and staff did not want to work with him/her; -He/She had fallen a lot at home; -The staff were pretty awful and say they were not going to break their backs over him/her. Staff woke him/her between 3:00 A.M. and 4:00 A.M. for a blood sugar, he/she hollered out after that and said, I'm not ready for this. Staff tell him/her to be quiet, you don't have to be like this; -What staff say hurts his/her feelings and his/her thoughts. He/She did not want to hear staff talking about him/her; -Two night shift staff treat him/her this way and it usually happened every night. During interview on 4/21/23 at 11:20 A.M. CMT G said the following: -On 4/17/23 at 1:30 A.M. he/she came to work. Resident #1 was sleeping at that time; -Sometime after 3:30 A.M. CMT A said the resident was hollering and yelling. CMT G entered the resident's room and found the resident in bed, turned on his/her side yelling with legs out of the bed towards the window. The resident wore a night shirt and an incontinence brief and was exposed. The resident denied pain; -CMT A said she videoed Resident #1 with his/her cellular phone while the resident laid in bed screaming and yelling; -CMT G saw the video. The video showed the resident struggled in the bed, exposed while he/she screamed and cried out. CMT A did nothing to help the resident while he/she videoed. The video was mental and emotional abuse; -There was no reason staff had to wake the resident and staff should not force the resident to get out of bed. Staff now used a mechanical lift transfer in the early mornings, the rest of the day one or two staff could assist the resident with a pivot transfer. The resident did not usually holler unless staff was getting her up. The resident was visibly upset. During interview on 4/21/23 at 2:25 P.M. the DON said the following: -LPN B informed her on 4/17/23 CMT A took a video of Resident #1; -He/She viewed the video and expected staff to have more concern for the resident, and contact the charge nurse for help if unable to calm the resident. Staff should not video residents in distress and should not say the things CMT A said to the resident; -Staff should not obtain a FBS at 3:00 A.M. to 4:00 A.M., this was way too early. Staff should let the resident rest and if asleep do not wake the resident; -Staff were concerned about the resident's transfer status. The resident could transfer with one or two staff member assisting during the day. Night shift requested the mechanical left for early morning because of the resident's behaviors and problems with transfers; -After talking with LPN B, she informed the Administrator CMT A should be terminated for abuse. During interview on 4/21/23 at 3:40 P.M. LPN B said the following: -He/She was the SCU day shift charge nurse on 4/17/23; -On 4/17/23 at change of shift (6:00 A.M.) CMT A pulled out his/her personal cellular phone and showed LPN B a video CMT A took of Resident #1 in the night. LPN B told CMT A he/she was not supposed to video residents, he/she should have called the charge nurse and gotten some help; -CMT A taunted and provoked the resident on the video making the situation worse; -The resident usually had behaviors in the early mornings. He/She did not like the mechanical lift or getting up early. There was no reason for night shift to wake the resident; -He/She informed the DON around lunch time about the video and abuse. On 4/21/23 at 4:20 P.M. CMT A said the following: -He/She worked the night shift usually on the SCU; -The usual routine was bed checks every two hours for incontinence and turn or reposition those who require assistance. Staff usually get Resident #1 and the feeders (residents who require assistance with eating) up out of bed by 5:00 A.M.; -Resident #1 had behaviors of screaming and crying especially at night. The resident liked to cry or be hateful and try to throw his/herself on the floor. During bed checks staff woke Resident #1 every two hours, say the resident's name, turn the lights on and check the resident for incontinence. If the resident was soiled staff provided incontinence care and then turned the lights off. At about 5:00 A.M. staff transferred the resident to the wheelchair with a mechanical lift. The resident hated the mechanical lift; -On 4/17/23 at about 4:00 A.M. or 5:00 A.M. (unsure of exact time) he/she woke the resident and attempted to check the resident's blood sugar. The resident slapped things out of CMT A's hands. The resident was in bed, screaming, yelling, and tried to throw his/herself out of the bed. CMT A grabbed his/her personal cellular phone and recorded the resident's behavior for approximately three minutes while the resident continued to scream and yell, legs hanging off the side of the bed. CMT A texted the video to the facility cellular phone to show the charge nurse how the resident behaved. During interview on 4/25/23 at 5:03 P.M. CNA F said the following: Resident #1 was hard to deal with, he/she screamed, yelled, and cried when staff woke him/her in the night. The resident was alert and oriented, aware of his/her surroundings and got anxious and agitated in the early morning. When staff asked if the resident was ready to get up, he/she usually said no; -At 3:30 A.M. staff routinely woke the resident for bed check and put the resident's pants partially on, up to the knees. When staff woke the resident in the night, the resident screamed and said no he/she did not want to get up; -Staff did say to the resident if you cannot stand up to transfer we will have to get the lift (mechanical lift). Staff tell the resident he/she is going to hurt their backs; -At 5:00 A.M. to 6:00 A.M. staff got the resident dressed and up out of bed. CNA F did not know what the resident's deal was; -CNA F worked on 4/17/23 from 2:00 A.M. to 2:00 P.M.; -He/She was not present when the video was taken but saw part of the video while watching over another staff members shoulder. CMT A should not have taken the video. The video was not appropriate and CNA F did not approve of the video. During interview on 4/25/23 at 3:15 P.M. the resident's family member said the following: -The resident cried out when he/she was afraid and had anxiety with transfers. Staff should be calm with the resident and not rush him/her. The resident was modest and would not want videos or pictures taken, he/she would not approve of that. The resident's family member was unaware staff videoed the resident for approximately three minutes in distress, screaming and crying, while exposed in an incontinence brief and trying to get out of bed. The resident would not like being videoed and being videoed would upset the resident; -The resident hated the mechanical lift, the lift made the resident anxious, he/she cried and was afraid; Staff needed to be calm with the resident, not demanding and not rush him/her; -A couple of staff told the resident if he/she did not stand during the transfer or do what staff wanted him/her to do, staff would get the lift. Staff threaten the resident with the use of the mechanical lift and used the mechanical lift to get the resident to do something. The resident hated the lift. During interview on 4/25/23 at 3:30 P.M. the DON said he/she saw the video on 4/17/23 taken by CMT A that morning. The video was abuse. She informed the administrator CMT A should be terminated at that time. She expected staff to follow the facility abuse policy and should not abuse residents. Videoing residents on personal phones and taking pictures of residents without consent was abuse. During interview 4/26/23 at 2:00 P.M. the Administrator said the following: -He was not aware other staff had seen the video other than CMT A and charge nurse LPN D. Other staff should not have access to the video; -CMT A should have provided the resident assistance and not let the resident remain in distress; -Staff should not use their personal cellular phones for any purpose regarding residents; -He did not think the video was abusive or malicious. MO 00217324 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of five residents, a resident with diagnosis of dementia and anxiety ,received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. Staff failed to investigate underlying causes of the resident's agitation and anxiety. Staff failed to develop and implement individualized interventions for the resident which caused the resident emotional distress when staff routinely woke him/her prior to 6:00 A.M. against the resident's wishes and for the purpose of staff convenience. Staff administered an antipsychotic medication on two occasions due to the resident's increased anxiety and subsequent behaviors following an incident when staff woke the resident against his/her wishes. The facility also failed to obtain the resident's history and prior level of functioning on admission to identify appropriate goals and interventions and create a plan of care for the resident and failed to identify his/her response to stressors, including waking the resident from sleep early in the morning and the resident's fear of transferring with the mechanical lift (a device used to move a resident from one surface to another). This caused the resident continued anxiety and emotional stress. The resident worried during the night, was fearful of the mechanical lift and staff documented he/she cried and was tearful in the mornings and required time to calm down after getting out of bed. On two occasions staff documented administration of an antipsychotic injectable medication not appropriate for residents with dementia for increased anxiety and agitation as a result of staff transferring the resident with the mechanical lift. The facility census was 57. The administrator was notified of the Immediate Jeopardy (IJ) on 4/26/23 at 2:00 P.M. which began 3/2/23. The IJ was removed on 4/26/23 7:00 P.M. as confirmed by surveyor onsite verification. During interview on 4/25/23 at 5:40 P.M. the administrator said the facility did not have a policy regarding dementia care and treatment or behavioral health care treatment and services. 1. Review of Resident #1's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 1/19/23 showed the following: -Moderately impaired cognition; -No hallucinations or delusions; -Physical and verbal behavioral symptoms directed toward others was not exhibited; -Other behavioral symptoms not directed toward others (such as hitting or scratching self, verbal/vocal symptoms like screaming, disruptive sounds) occurred in the previous four to six days; -Required extensive assistance of two staff members with bed mobility and dressing; -Required total assistance of two staff members with transfers and toileting; -Required a wheelchair for mobility; -Very important for the resident to choose what clothes to wear and chose his/her own bedtime. Review of the resident's Physician Order Sheet (POS) dated February 2023 showed the following: -Diagnosis of dementia with anxiety, anxiety disorder, chronic pain. and history of falling; -On 2/1/23 check blood sugar before meals three times daily at 6:00 A.M., 11:30 A.M. and 4:30 P.M.; -On 2/3/23 Buspar (medication used to treat anxiety) 15 milligrams (mg) three times daily for anxiety; -On 2/27/23 Remeron (medication used to treat depression) 15 mg daily at bed time for depression. Review of the resident's Care Plan dated 3/1/23 showed the following: -The resident had dementia and moderate anxiety. Staff should report to the nurse if the resident was anxious or had changes in mental status; -The resident was known to become very anxious and emotional and at times scream when working with staff. Staff should redirect as needed; -The resident was cognitively intact. Staff should orient the resident as needed and report any confusion or changes in cognition to the nurse; -The resident had an overall decline in Activities of Daily Living (ADLs). Staff should provide assistance with transfer, the resident transferred better with one staff member due to anxiety. He/She had chronic knee pain, staff should be patient as he/she moved slowly; -The resident was a high risk for falls. Staff should keep the resident's call light in reach. - The care plan did not include the use of Haldol as a intervention or the parameters for its use. Review of the resident's nurses' note dated 3/2/23 at 6:54 A.M., showed staff documented the resident threw things, ripped up a magazine, screamed and attempted to throw himself/herself on the floor from the wheelchair. The resident was currently on the mechanical lift sling (a mobile transfer device used to move a resident from one surface to another with the resident placed in a sling, elevated off the surface and lowered onto another surface) due to refusing to stand on the previous shift. Two staff attempted to lift the resident back in the chair to prevent a fall, the resident screamed, kicked, hit and pinched the staff. Additional staff assistance was called, required five staff members to transfer the resident to the recliner. The physician was notified and order received for Haldol (antipsychotic medication) 5 milligrams (mg) injection now. Haldol was administered, the resident remained combative, called staff names and screamed for everyone to go to hell. The resident required one on one care and told staff she did not care if he/she got hurt or hurt anyone else. Review of the resident's Physician Order Sheets dated 3/2/23 showed Haldol 5 mg injection now for one dose. Review of the resident's Medication Administration Record dated 3/2/23 showed staff documented Haldol 5 mg injection administered. Review of Drugs.com showed the following regarding Haldol: -An antipsychotic medication used to treat schizophrenia (a mental illness causing hallucinations and delusions); -Not approved for use in older adults with dementia-related psychosis; -Might increase the risk of death in older adults with dementia-related psychosis; -Common side effects might include drowsiness, headache, dizziness, feeling restless or anxious, and sleep problems. Review of the resident's nurses' showed staff documented the following: -On 3/2/23 at 1:56 P.M., the resident rested with eyes close in recliner most of the day after 8:00 A.M. and then he/she ate lunch. Staff transferred the resident to the wheelchair with the mechanical lift and assisted him/her to the table. The resident remained sharp and short with staff but sat at the table in the wheelchair with no current negative behaviors; -On 3/3/23 at 4:59 A.M. the resident would not stand on 3/1/23 or 3/2/23. Staff had to use the mechanical lift. He/She would not stand up with the walker, yelled and screamed and carried on. The resident would not put his/her legs in a position where it was safe to transfer with the walker and gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair). Review of the resident's POS dated 3/7/23 showed and order to decrease Buspar to 15 mg twice daily at breakfast and bedtime. Review of the resident's nurses' notes showed staff documented the following: -On 3/14/23 at 5:50 P.M. at the start of the shift, another resident picked up a plant that Resident #1 believed was his/hers. The plant was returned. This started aggression and irritation. At supper he/she refused the meal and refused drinks, the resident would not eat. He/She began to say there were more cars coming and going and something bad was happening. He/She said it's something deadly, began to yell, and had extreme agitation and delusional thoughts with visual hallucinations. Refused all care and was suspicious of all staff. The physician was notified and orders received for Haldol 5 mg injection for one dose. Review of the resident's Physician Order Sheets dated 3/14/23 showed Haldol 5 mg injection now for one dose. Review of the resident's Medication Administration Record dated 3/14/23 showed staff documented Haldol 5 mg injection administered. Review of the resident's nurses' notes showed staff documented the following: -On 3/24/23 at 5:27 A.M., staff transferred the resident to get out of bed and he/she would not stand up, pulling buttocks in. The staff had to turn the resident without the resident's help. This was happening most every morning to get the resident out of bed. It was a hard transfer. Used the mechanical lift to get resident up to wheelchair that morning; -On 4/3/23 at 5:57 A.M., the resident laid in bed crying around 5:30 A.M. staff asked the resident what was wrong. The resident said he/she just wanted to get up so staff tried to dress the resident and he/she still cried and screamed. Staff asked what was wrong and why the resident still cried. The resident said he/she liked to cry. As three staff members tried to get the resident to stand, the resident cried and screamed and would not stand with three staff trying to help. Instead the resident pushed himself/herself backwards, bent over while holding onto the walker and about hit his/her face on the walker. The resident propelled himself/herself down the hall to the dining area and continued to scream and cry, then yelled at other residents to shut up; -On 4/6/23 at 11:14 A.M., night shift staff reported that morning the resident refused to allow staff to get him/her up that morning and requested to remain in bed. Staff also reported they attempted to stand the resident and the resident became agitated and refused to get up. The resident required maximum staff assistance of three staff members and a gait belt to get up and into the wheelchair. The resident refused medications and breakfast initially but eventually took the medications and ate breakfast; -On 4/10/23 at 2:21 P.M., the resident was pleasant with staff all day. Pivot transferred multiple times in the bathroom with stand by assistance to minimal assistance of one staff member. He/She continued to be a difficult transfer from bed to wheelchair in the mornings when night shift attempted to get the resident up for breakfast. The resident verbalized that he/she was afraid he/she would be forced to use the mechanical lift for transfers. The charge nurse assured the resident they would continue to work on his/her confidence as well as strength and endurance with transfers and would not use a mechanical lift unless the resident's safety or staff safety was an issue; -On 4/11/23 at 5:46 A.M., staff requested the charge nurse witness the resident's transfer. The resident screamed no I can't do it, dropped his/her buttocks below the level of his/her knees and refused to stand for the transfer. The charge nurse educated the resident this method of transfer was unsafe for the resident and the staff; -On 4/11/23 at 3:54 P.M., the resident continued to be a very difficult bed to wheelchair transfer in the mornings putting both resident and staff safety at risk. The physician witnessed the resident transfer from wheelchair to the toilet. The resident stood, held the grab bars in the bathroom with verbal cues from the staff to look up. The resident stood and supported his/her own weight with no needed physical assistance and sat on the toilet without difficulty. The resident did not have grab bars near the bed. The physician ordered nursing to collaborate with therapy to transition from mechanical sling lift to mechanical sit to stand lift (a mechanical transfer device with a strap secured around the resident's chest and fastened to a movable bar with legs and feet strapped to the base. The resident is lifted to a standing position as the bar is raised turned and lowered to another surface) if appropriate. Review of the resident's POS dated 4/11/23 showed mechanical sit to stand lift for bed to wheelchair transfers in the mornings. Review of the resident's care plan showed no updated interventions or staff direction regarding the resident's transfer status and behavior management. Review of the resident's nurses' notes showed staff documented the following: -On 4/12/23 at 5:27 A.M., staff attempted to use the mechanical sit to stand lift for transfer into the wheelchair from bed. The resident yelled and screamed out during the entire transfer and hung by his/her arms and could not hold himself/herself up onto the lift. Staff asked the resident if it hurt to use this lift and the resident said no, he/she yelled out because he/she could; -On 4/13/23 at 1:30 P.M., staff documented the resident was very upset and sobbing at 6:00 A.M. that morning, was not able to verbalize what he/she was upset about but said, I'd be better off dead. Spoke with the resident at length but was only able to comfort him/her enough to get him/her to stop crying. The resident eventually laid his/her head on his/her arms on the breakfast bar and continued to cry until about 7:30 A.M. when the resident finally agreed to eat some breakfast. After breakfast the resident gradually returned more to his/her normal self. Review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Other behavioral symptoms not directed toward others (such as hitting or scratching self, verbal/vocal symptoms like screaming, disruptive sounds) occurred in the previous four to six days but less than daily. Review of the resident's nurses' notes showed staff documented the following: -On 4/14/23 at 4:58 P.M., staff documented the resident was tearful that morning at 6:00 A.M., crying quietly at his/her table alone. Spoke with the resident who declined to discuss why he/she was crying. The resident agreed to coffee and orange juice. He/She eventually stopped crying and received his/her breakfast; -On 4/17/23 at 6:49 A.M., Certified Medication Technician (CMT) A documented at 5:00 A.M. he/she went into the resident's room to get the resident's blood sugar (finger stick blood test). The resident became very snarky and mumbled under his/her breath that CMT A did not need to check anything. CMT A asked the resident if he/she could check the resident's blood sugar and the resident started screaming, crying and smacked everything out of CMT A's hands. CMT A asked the resident what was wrong and why he/she was being hateful that morning. The resident responded he/she liked to be hateful. The resident started screaming at CMT A. CMT A told the resident that was uncalled for and inappropriate, the resident screamed he/she did not care. CMT A then called the charge nurse Licensed Practical Nurse (LPN) D over to observe the resident's behavior. LPN D tried to obtain the resident's blood sugar, the resident still refused and was very vulgar and hateful, while he/she laid there kicking his/her legs out of the bed and continued to scream at the top of his/her lungs and cried out. CMT A then again asked the resident what was wrong, the resident said he/she was playing. CMT A asked the resident what he/she was playing, the resident said playing house. CMT A repeated to the resident you are playing house? The resident replied yes then continued to scream and cry; -On 4/18/23 at 4:58 A.M., staff bed checked the resident and told the resident he/she was wet and staff needed to change the resident's soiled brief. Staff began to roll the resident and he/she yelled out and said I can't. Staff continued to change the resident as he/she continued to yell out the entire time; -On 4/18/23 at 8:14 A.M., the resident was in his/her wheelchair after a mechanical stand up lift transfer. The resident continued to yell out. When asked what was the matter the resident said nothing. Staff continued to get the resident ready for the day and he/she continued to yell out; -On 4/18/23 at 8:55 A.M., the Director of Nurses (DON) documented the night shift reported the resident was agitated and yelled out since Buspar was decreased in March. The resident refused to use the mechanical stand up lift. The physician was notified and orders received to increase Buspar back to three times daily and therapy evaluate and treat for transfers. Review of the resident's POS dated 4/18/23 showed Buspar 15 mg three times daily for anxiety. Review of the resident's care plan showed no updated interventions or staff direction regarding the resident's transfer status and behavior management. Review of the resident's nurses' notes showed staff documented the following: -On 4/18/23 at 2:22 P.M., the resident was quiet and tearful at 6:00 A.M. that morning. He/She did not offer a reason and would not answer when asked what was wrong. Staff gave the resident time to have coffee alone and sob. At 7:00 A.M. the resident ate breakfast. Pleasant throughout the rest of the day, bathroom transfers with stand by staff assistance; -On 4/20/23 at 10:42 A.M., the resident was very upset and angry early that morning, would not talk with staff or make needs known. Gradually became more pleasant and interactive with staff. During interview on 4/21/23 at 9:15 A.M. the DON said the resident had increased anxiety and behaviors at night. Night shift was responsible to get the resident up before the end of the shift (6:00 A.M.) During the night the resident refused to get up, he/she was difficult to get up. On day shift the resident did better. Staff used the mechanical lift in the night to transfer the resident. During interview on 4/21/23 at 10:50 A.M. LPN C said the following: -He/She was the care plan coordinator and charge nurse; -The resident was cognitively intact and very much alert and oriented, he/she had dementia with anxiety and lived on the locked special care unit (SCU); -The resident hollered out frequently and had fear with transfers and fear of falling. He/She required one staff member assistance with transfers. The resident hollered out and was anxious during transfers; -Staff should approach the resident calmly and help the resident rest and remain calm. Night shift staff woke the resident early in the morning and got the resident up for the day before the end of the night shift (6:00 A.M.). The resident had increased anxiety during the night, but night shift staff woke the resident and got him/her up early. Breakfast was at 7:00 A.M.; -He/She did not know how night shift approached the resident. There was no specific care plan interventions for night shift regarding the resident's anxiety and fear with transfers; -The resident's Buspar was increased for the anxiety; -No new interventions were added to the resident's care plan following the increase in Buspar and therapy evaluation and no new interventions for staff to allow the resident to remain in bed if he/she was resting. Observation on 4/21/23 at 10:55 A.M. showed the resident sat in a wheelchair in the common dining area of the SCU near the front windows. During interview on 4/21/23 at 11:00 A.M. the resident said the following: -He/She worried at night, about going home and what will happen. Staff get him/her up by 6:00 A.M. every day and used the mechanical lift to get out of bed, he/she hated the thing (mechanical lift). Staff say they can use the lift even if he/she does not like the lift. Staff say to each other they are not going to put up with him/her. He/She heard what staff said. He/She did not like it. Staff would not let him/her sleep any longer, they have to dress him/her. Staff put his/her pants on about to the knee during the night, until they get the lift. Then they put the sling underneath him/her and transfer him/her to the wheelchair. They pull his/her pants up after getting in the wheelchair. Staff stand him/her up and pull up his/her pants. The mechanical lift was painful and stressful, it made him/her feel like he/she was not good enough and staff did not want to work with him/her; -He/She had fallen a lot at home; -The staff were pretty awful, they said they were not going to break their backs over him/her. Staff woke him/her between 3:00 A.M. and 4:00 A.M. for blood sugar checks, he/she hollered out after that and said I'm not ready for this. Staff tell him/her to Be quiet, you don't have to be like this; -He/She preferred not to use the mechanical lift, it usually happened every night. During interview on 4/21/23 at 11:20 A.M. CMT G said staff woke the resident between 4:45 A.M. and 5:00 A.M. and checked the resident's blood sugar. There was no reason staff had to wake the resident and staff should not force the resident to get out of bed. Staff now use a mechanical lift transfer in the early mornings, the rest of the day one or two staff could assist the resident with a pivot transfer. The resident did not usually holler unless staff was getting her up. During interview on 4/21/23 at 11:45 A.M. LPN I said the resident was tearful through breakfast that morning and tearful most mornings. The resident wanted to sleep in and night shift staff did not let her sleep in. After breakfast the resident laid his/her head on the table. It took a while after the resident got up in the morning for him/her to calm down. During interview on 4/21/23 at 3:40 P.M. LPN B said the following: -He/She was the SCU day shift charge nurse; -The resident usually had behaviors in the early mornings. The resident did not like the mechanical lift or getting up early. There was no reason for night shift to wake the resident. Observation on 4/25/23 at 10:05 A.M. showed the resident asked to use the toilet. The resident sat on a mechanical lift sling pad in the wheelchair. The resident grabbed the bathroom grab bar and stood with one staff member assistance and pivoted to the toilet. The resident remained on the toilet and yelled out when finished. The resident stood with one staff member assistance and pivoted back to the wheelchair. The resident hollered I can't during the transfers. During interview on 4/25/23 at 10:45 A.M. LPN H said early mornings were rough for the resident. Staff started getting residents up between 5:00 A.M. and 6:00 A.M. every morning. Resident #1 struggled in the mornings. It mattered how staff approached the resident; some went in and told the resident what they wanted or planned to do,. If the resident hollered staff should wait, switch staff and let the resident settle down. The resident got anxious. Staff started getting residents up early to work for the nurses' schedules. If staff check the resident's blood sugars early it was because of the need to get everything done by the end of the shift. The resident's behavior depended on how the staff approached the resident. During interview on 4/25/23 at 11:15 A.M. the Physical Therapist said the resident could transfer with a walker when secured by staff for stability. He/She was not sure why night shift staff could not transfer the resident or why the resident had to get up so early. The resident hollered, but hollering did not mean the resident could not do the transfer. Staff should be consistent. The resident hated the mechanical lift, it hurt the resident and the resident did not like being made to do something. During interview on 4/25/23 at 3:00 P.M. the resident said it was a bad morning, he/she had a hard time in the mornings. Staff woke him/her at 4:00 A.M. or so to check his/her blood sugar, he/she preferred not to wake up that early. He/She liked his/her bed and wanted to get up around 6:00 A.M. or so. He/She did not want staff to use the mechanical lift, he/she hated the lift. Staff used the mechanical lift this morning because he/she was upset after they woke him/her. Finally he/she told the staff go ahead just get the mechanical lift and they got him/her up with the lift. Staff talk about him/her and he/she could hear them. Staff don't do what he/she asks and today he/she finally just said fine, get the lift. During interview on 4/25/23 at 5:03 P.M. CNA F said the following: -Resident #1 was hard to deal with, he/she screamed, yelled, and cried when staff woke him/her in the night. The resident was alert and oriented, aware of his/her surroundings and got anxious and agitated in the early morning. When staff asked if the resident was ready to get up, he/she usually said no; -Night shift bed checks were between 10:30 P.M. to 11:30 P.M. and 1:30 A.M. to 3:30 A.M. During bed checks staff woke the resident, turned the lights on, changed the resident if soiled and turn the lights off; -At 3:30 A.M., staff routinely woke the resident for bed check and put the resident's pants partially on, up to the knees or thighs. Partially dressing the resident helped the staff with the 5:00 A.M. routine of getting residents up for the day. There were three residents night shift got up every day before 6:00 A.M. on the SCU; -When staff woke the resident in the night, the resident screamed and said no he/she did not want to get up. When the resident cried or yelled, he/she went in frequently and checked on the resident asking what the resident needed. It was hard to figure out why the resident was crying and upset; -If the resident was upset he/she would not do anything for the staff or try to help his/herself. Early in the morning the resident screamed and cried saying I can't with his/her buttocks stuck out and bent at the waist when night shift staff attempted a pivot transfer. The resident was grouchy. It was a morning thing, morning was not a good time for the resident; -Staff did say to the resident if you cannot stand up to transfer we will have to get the lift (mechanical lift). Staff tell the resident he/she is going to hurt their backs; -At 5:00 A.M. to 6:00 A.M. staff got the resident dressed and up out of bed. The resident usually laid flat in bed and cried while staff got him/her up. CNA F said he/she did not know what the resident's deal was. If the resident liked the staff member, he/she tried harder to please the staff member; -CNA F did not know the resident was afraid of the mechanical lift and afraid of falling; -There was no direction on how to care for the resident, no one had shown staff how to transfer the resident with a gait belt and the walker; -No one had directed CNA F on interventions for the resident, the resident just needed to be up by 6:00 A.M. During interview on 4/25/23 at 3:15 P.M. the resident's family member said the following: -The resident cried out when he/she was afraid and had anxiety with transfers. Staff should be calm with the resident; -He/She was anxious in the mornings and was that way before the resident came to the facility. If staff let the resident sit and settle down, he/she did better; -Staff had not asked him/her about the resident and how to care for him/her. He/she cared for the resident at home prior to facility admission; -The resident hated the mechanical lift, the lift made the resident anxious, he/she cried and was afraid. Using the lift caused the resident increased anxiety and fear; -At home, the resident sat on the side of the bed for awhile before he/she tried transferring the resident to the chair. Sometimes for fifteen to thirty minutes. The resident would be calmer and the transfer was easier and caused less anxiety; -The resident was a 6:00 A.M. to 7:00 A.M. riser most of his/her life. It was not necessary to check the resident's blood sugar at 4:00 A.M. Staff should not wake the resident for a blood sugar unless they were concerned the blood sugar might be low. Staff needed to be calm with the resident, not demanding and not rush him/her; -A couple of staff told the resident if he/she did not stand during the transfer or do what staff wanted him/her to do, staff would get the lift. Staff threaten the resident with the use of the mechanical lift and used the mechanical lift to get the resident to do something. The resident hated the lift. During interview on 4/21/23 at 2:25 P.M. and 4/25/23 at 3:30 P.M. the DON said the following: -Staff should not obtain a fasting blood sugar at 3:00 A.M. to 4:00 A.M., this was way too early. Staff should let the resident rest and if asleep do not wake the resident; -Staff was concerned about the resident's transfer status. The resident could transfer with one or two staff member assistance during the day. Night shift staff requested the mechanical lift for early morning because of the resident's behaviors and problems with transfers; -Staff had some dementia care training, but were not appropriately trained and were not aware of dementia care and how to approach residents with dementia. Staff needed dementia care and behavior management education; -Staff should implement individualized care plans for all residents and educate staff regarding the resident's care plans, treatments and interventions. Each resident's care plan should reflect the resident's condition and current needs; -Staff should not put the resident's pants on half way during the night, this was restrictive to the resident's movements; -Pre-dressing the resident and checking the resident's blood sugar at 4:00 A.M. was task oriented to staff needs instead of resident oriented. Getting residents up early was for the convenience of staff; -Staff should allow residents to sleep as late as they wanted; -The resident had anxiety before facility admission. Staff did not know specifically the resident's normal morning wake time and what the family did for the resident at home; -On admission the resident yelled a lot early in the morning. It was decided to move the resident to the SCU because the resident yelled and woke other residents. During interviews on 4/21/23 at 1:30 P.M. and 4/26/23 at 2:00 P.M. the administrator said the following: -All residents should have individualized care plans; -He expected staff to evaluate residents on admission for needs and implement resident centered care to meet the resident's needs. The care plan interventions should be individualized and direct the resident's care; -Staff should not pre-dress residents during the night and should not check blood sugars in the night, this was not appropriate. Staff should not provide care based on staff convenience; -All staff should be aware of the resident's needs, anxiety and how to respond to calm the resident and not make the anxiety worse; -He was concerned about the resident's anxiety with transfers, the staff wanted to use the mechanical lift for safety; -Staff should have direction on how to care for each resident and how to respond to changes in care needs; -The resident's transfer status should be included on the resident's care plan. No residents should be required to get up before the end of night shift. It should be the individual's choice when to get up for the day; -Staff were educated yearly on dementia care; -The facility had a SCU for residents with dementia, but the facility did not have a specific program and treatment plan for residents with dementia or behavior issues. The facility should provide increased staff education and a treatment program for residents with dementia and behavior issues. During interview on 5/11/23 at 1:30 P.M. the resident's physician said waking the resident every two hours for incontinence care and pre-dressing the resident caused the resident increased anxiety and confusion. There was no reason to wake the resident for early morning blood sugars before 6:00 A.M. Staff should allow the resident to rest to keep the resident's sleep cycle consistent. He preferred the resident saw the sun in the morning and avoid a night time of confusion. The resident had dementia with behaviors and became very anxious easily. Staff should provide consistent care and a consistent routine. He saw the resident stand and pivot transfer a couple of weeks ago and was aware the resident did not like the mechanical lift. The charge nurse informed him the resident hated the mechanical lift. Staff should not transfer the resident with the mechanical lift. He directed staff about two weeks ago to no longer utilize the mechanical lift as it caused the resident increased anxiety. Night shift needed direction on how to [TRUNCATED]