**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a policy and a physician's order that addressed the settings for a low air loss mattress (LAL - a mattress with an air pump designed to distribute the patient's body weight over a broad surface area to prevent and treat pressure wounds) for one sampled resident (Resident #25) with an unstageable (not stageable due to coverage with dead tissue) pressure ulcer, failed to complete weekly wound/skin assessments to include detailed descriptions of the wounds, measurements, and accurate staging of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) and failed to update the resident's care plan to reflect the current stage of the resident's pressure ulcer, out of 17 sampled residents. The facility census was 69 residents. Review of the facility Pressure Ulcer Treatment Policy and Procedure, dated 2007 showed: -Reduce or eliminate causative factors including pressure. -The policy identified treatment recommendations for different stages of wounds but did not discuss or identify recommendations for unstageable wounds. Review of the facility Ulcer Documentation policy dated 2021 showed: -Document the stage of the ulcer. -An ulcer with intact eschar (dead tissue that is hard or soft, usually black, brown, or tan in color, and may appear scab-like, and is usually firmly adherent to the base of the wound) should be noted as unstageable due to eschar formation. A low air loss mattress policy was requested and not received. 1. Review of Resident #25's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 3/18/24 showed: -He/She was severely cognitively impaired. -He/She no pressure ulcers and no other skin conditions. Review of the residents Hospice (end of life care) Visit Note, dated 5/20/24 showed: -He/She had a lateral right upper buttock Stage 2 (partial thickness skin loss presenting as a shallow open sore with a red or pink wound bed, may also present as a fluid filled blister) pressure ulcer. -The documentation did not include a detailed description of the wound, the wound bed, or any measurements. Review of the residents Hospice Visit Note, dated 5/22/24 showed he/she had a lateral right upper buttock Stage 2 pressure ulcer that measured 0.8 centimeters (cm) X 0.75 cm X 0.0 deep. Review of the resident's Licensed Nurse Weekly Skin assessment dated [DATE] showed: -He/She had an open ulcer on his/her right buttock. -The documentation did not include a detailed description of the wound, including type of ulcer and stage of ulcer, the wound bed, or any measurements. Review of the resident's Licensed Nurse Weekly Skin assessment dated [DATE] showed: -He/She had an open ulcer on his/her right buttock. -The documentation did not include a detailed description of the wound, including type of ulcer and stage of ulcer, the wound bed, or any measurements. Review of the residents Hospice Visit Notes, dated 5/26/24, 5/30/24, 6/3/24, 6/5/24, 6/10/24 showed: -He/She had a lateral right upper buttock Stage 2 pressure ulcer. -The documentation did not include a detailed description of the wound, the wound bed, or any measurements. Review of the resident's Physician's Visit, dated 6/11/24 showed no mention of the resident's skin/open ulcers. Review of the facility Weekly Wound Tracking form dated 6/12/24 showed: -The resident had a right hip stage 4 (full thickness issue loss with exposed bone, tendon or muscle) pressure ulcer that measured 1.5 cm X 1.5 cm with no depth (Note: a Stage 4 pressure ulcer would have measurable depth), no drainage and had granulation tissue (granular pink or red moist vascular connective tissue formed on the surface of a healing wound). -The type of wound was incorrectly identified as a stasis ulcer. -The documentation did not include a detailed description of the wound, or the wound bed. -The documentation did not indicate if the right hip wound was a new wound, or when the wound was acquired. -The documentation did not include any information on the resident's previously documented lateral upper buttock stage 2 pressure ulcer. -No documentation a wound/skin assessment was completed between 5/30/24 through 6/12/24. Review of the resident's quarterly MDS, dated [DATE] showed: -He/She was severely cognitively impaired. -He/She had one Stage II pressure ulcer. -His/Her skin and pressure ulcer treatments included a pressure reducing device for his/her bed. -He/She was receiving hospice services. Review of the facility's Weekly Wound Tracking form dated 6/26/24 showed: -The resident had a right hip unstageable wound that measured 1.5 cm X 1.5 cm, no drainage and had granulation tissue (granular pink or red moist vascular connective tissue formed on the surface of a healing wound) -The type of wound was incorrectly identified as a stasis ulcer. -The wound description said only pink surrounding pale center. -The documentation did not include a detailed description of the wound, or the wound bed. -The documentation did not include any information on the resident's previously documented lateral upper buttock stage 2 pressure ulcer. -No documentation a wound/skin assessment was completed between 6/12/24 through 6/26/24. Review of the resident's care plan dated 6/26/24 showed: -The resident had potential for pressure ulcer development. -Goals that he/she would have no skin breakdown and that would have intact skin, free of redness, blisters or discoloration. -No mention of the resident's unstageable pressure ulcer. -No mention of the resident's LAL mattress settings. The LAL mattress was an intervention but there was no instruction regarding the settings or to monitor the settings. Review of the facility's Weekly Wound Tracking form dated 7/10/24 showed: -Measurements of 1.0 cm X 2.1 cm and depth of 0.5 cm and treatment completed by hospice in the notes section of the form. -The documentation did not include a detailed description of the wound, including type of ulcer and stage of ulcer, the wound bed and location of the wound. -No documentation a wound/skin assessment was completed between 6/26/24 through 7/10/24. Review of the resident's weight record showed he/she weighed 182.7 pounds on 7/11/24. Review of the resident's electronic medical record (EMR) showed the following physician's order, dated 7/20/24: -Hospice services dated 2/17/24. -Cleanse right hip with wound cleanser, apply pixie dust (a powdered antibiotic applied directly to a wound), pack with calcium alginate with silver (a highly absorbent wound dressing with antimicrobial properties to prevent and treat wound infection), cover with calcium alginate with silver and adhesive dressing, change daily and as needed. -There was no physician's order for a LAL mattress. -No treatment orders for the resident's right buttock pressure ulcer. Review of the residents Hospice Visit Note, dated 7/22/24 showed: -His/her Stage 2 pressure ulcer on his/her lateral right upper buttock was restaged to Stage 3 (full thickness tissue loss, fat may be visible, slough may be present but does not obscure the depth of tissue loss). -Measurements were 2.0 cm X 2.5 cm and had a depth of 0.9 cm. -The documentation did not include a detailed description of the wound, or the wound bed. -The documentation did not include any information on the resident's previously documented right hip pressure ulcer. -No documentation a wound/skin assessment was completed between 7/10/24 through 7/22/24. Review of the facility's Weekly Wound Tracking form dated 7/24/24 showed: -The resident had a right hip unstageable wound that measured 2.0 cm X 2.0 cm and a depth of 0.5 cm no depth. -The wound had odor, moderate drainage and a dark center. -The type of wound was incorrectly identified as a stasis ulcer. -The documentation did not include any information on the resident's previously documented right buttock pressure ulcer. Review of the facility's Weekly Wound Tracking form, dated 7/31/24 showed: -The resident had a right hip unstageable wound that measured 2.2 cm X 2.0 cm and a depth of 0.6 cm. -The wound had moderate drainage and an open red center. -The type of wound was incorrectly identified as a stasis ulcer. -The documentation did not include any information on the resident's previously documented right buttock pressure ulcer. Review of the Licensed Nurse Weekly Skin Assessment, dated 8/13/24 showed: -A circle on the resident's right hip and pressure sore written with a line connecting to the circled area. -The box to indicate there were open ulcers and a comment section with treatment ordered. -The documentation did not include a detailed description of the wound, the wound bed, the stage of the pressure ulcer or measurements. -The documentation did not include any information on the resident's previously documented right buttock pressure ulcer. -No documentation a wound/skin assessment was completed between 7/31/24 through 8/13/24. Review of the facility's Weekly Wound Tracking form, dated 8/14/24 showed: -The resident had a right buttock wound (no stage identified) that measured 2.0 cm X 2.5 cm and had a depth of 0.5 cm. -There was moderate drainage, no odor, and the wound had granulation tissue (the pink-red moist tissue that fills an open wound, when it starts to heal). Observation on 8/19/24 at 9:49 A.M. showed the resident was up in his/her Broda chair (A specialized medical device comfort cushioned chair that can tilt for positioning and reduces heat and moisture and relieves pressure). Observation on 8/21/24 at 9:38 A.M. showed: -The resident was lying in bed on his/her back. -His/Her LAL mattress was set at 350 pounds. Review of the resident's Physician's Orders Sheet (POS) Active Orders as of 8/21/24 showed: -No order for the resident's LAL mattress or settings for the LAL mattress. -Cleanse right hip with wound cleanser, apply pixie dust (a powdered antibiotic applied directly to a wound), pack with calcium alginate with silver (a highly absorbent wound dressing with antimicrobial properties to prevent and treat wound infection), cover with calcium alginate with silver and adhesive dressing, change daily and as needed. --NOTE: The treatment order had not been updated regarding packing the pressure ulcer after the resident's pressure ulcer became unstageable. Observation and interview on 8/21/24 at 10:02 A.M. showed: -The resident was lying in bed on his/her LAL mattress. -The setting on the LAL mattress was 350 pounds. -He/She had an unstageable pressure ulcer on his/her right buttock that was approximately nickel sized and was greater than 90% covered with with slough. -The wound nurse applied Pixie dust, then calcium alginate to the surface of the resident's unstageable pressure ulcer. --NOTE: The order was for the nurse to apply pixie dust, then pack the wound with calcium alginate with silver, then cover the wound with calcium alginate with silver and adhesive dressing. -While completing the resident's pressure ulcer treatment, the facility Wound Nurse said the resident had a pressure ulcer on his/her right buttock that was unstageable because it was covered with eschar; he/she did not monitor the settings on the resident's LAL mattress. During an interview on 8/22/24 at 9:37 A.M. Licensed Practical Nurse (LPN) A said: -He/She did not look at the settings on the resident's LAL mattress. -He/She did not know what the setting should be; it would be good to know that so that a happy medium could be found between what was comfortable for the resident and the resident's weight. -The resident's LAL mattress should not be set at 350 pounds; the resident did not weigh 350 pounds. -There was nothing in place for the settings on the resident's LAL mattress, nothing that identified what the setting should be and nothing regarding monitoring the setting. -The resident's LAL mattress was not on his/her physician's orders in the resident's electronic medical record (EMR) orders. -He/She did not know why the resident's LAL setting should not be on the resident's physician's orders or at least on the resident's care plan; there was no physician's order for the resident's LAL mattress; he/she did not know if the resident's care plan addressed his/her LAL mattress. -If there had been a LAL mattress physician's order in his/her EMR, it could have included the settings and to monitor the settings; had there been such a physician's order, then monitoring the settings for the resident's LAL mattress settings could have been on the resident's Treatment Administration Record (TAR). Review of the resident's TAR on 8/22/24 showed there was no documentation regarding the resident's LAL mattress settings. During an interview on 8/22/24 at 10:11 A.M. the MDS/Care Plan Coordinator said: -He/She was aware the resident had an unstageable pressure ulcer. -He/She hoped he/she would have updated the resident's care plan to show his/her pressure ulcer was unstageable; he/she could not recall if he/she had updated the resident's care plan to include the current stage of the resident's pressure ulcer. -If the current stage of the resident's pressure ulcer was not in the resident's care plan, then his/her care plan should have been updated to show his/her pressure ulcer was unstageable. During an interview on 8/22/24 at 10:40 A.M. the Director of Nursing (DON) said: -The resident had an unstageable pressure ulcer. -There should have been a physician's order for the resident's LAL mattress -He/she did not recall that LAL mattresses with pressure ulcers were set to a resident's weight. -The resident's care plan should have included the current stage of the resident's pressure ulcer. -Care plans should be individualized and he/she audited care plans quarterly. During an interview on 8/22/24 at 11:42 A.M. the DON said all pressure ulcer documentation should have included the type of wound, the stage and location of the wound and a full description of the wound bed, drainage, odor, and measurements of the wound. Telephone messages were left with the resident's physician on 9/3/24 at 2:10 P.M.:36 A.M. and on 9/4/24 at 8:36 A.M. and at 11:50 A.M. As of 4:00 P.M. no return call had been received.

Based on observation, interview and record review, the facility failed to utilize a tube feeding policy that instructed licensed nursing staff regarding the current professional standard for verifying correct placement of gastrostomy (G-tube - surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube; also known as feeding tube) tubes failed to ensure and document measurement of the resident's feeding tube to ensure correct placement and to ensure the resident's physician's order was correct and that the resident's tube feeding infused in accordance with the physician's order for one sampled resident (Resident #1) out of 17 sampled residents. The facility census was 69 residents. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed: -The placement of an enteral tube is immediately verified after insertion by an X-ray; after X-ray verification, the tube should be marked to indicate the point on the tube where the feeding tube penetrates the abdominal wall; the mark or number on the tube at the entry point should be documented in the resident's medical record. -At the start of every shift, nurses evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislocated. If in doubt, a radiograph should be obtained to determine tube location. -Older methods of checking tube placement included observing aspirated (using a syringe, a tube with a nozzle and piston or bulb for sucking in and ejecting liquid) contents or the administration of air with a syringe while auscultating listening with a stethoscope (a medical instrument for listening to sounds in the body) - however, research has determined these methods are unreliable and should no longer be used to verify placement. Review of the facility Procedure for Tube Care policy, section on Verification of Tube Placement, undated showed: -Check for tube graduation marks if present (Note: there was no instruction to note the mark at the point the tube entered and document that mark in the resident's medical record). -Aspirate and monitor gastric residuals (the volume of fluid remaining in the stomach at a point in time during tube feeding) with a syringe. -Inject air into the tube with a syringe and listening for air bubbles in the stomach with a stethoscope. Review of the facility Continuous Enteral Tube Feeding, undated showed: -No instruction regarding what the physician's orders should include, i.e. the amount of tube feeding to infuse, the time period for the tube feeding infusion/the number of hours for the tube feeding to infuse/run stop times for the tube feeding. -Check placement of feeding tube by injection air into the tube and listening with a stethoscope over the stomach. Review of the facility Tube Feeding Protocol, dated 2022 showed: -Verify the physician's order for tube feedings. -Verification of tube placement shall be done by aspirate of a small amount of gastric contents. -Note: the policy did not instruct staff to verify correct placement by measuring and documenting the length of the feeding tube. 1. Review of Resident #1's electronic medical record (EMR) showed the following order, dated 2/29/24: -Jevity (tube feeding formula) 1.5 calories, 30 milliliters (ml) per hours every night shift for supplement. -The physician's order did not specify an amount of tube feeding to be infused or what time period for the resident's tube feeding to infuse, i.e. how many hours for the resident's tube feeding to infuse or what time to start and end the resident's tube feeding. Review of the resident's care plan, dated 7/10/24 showed the resident's care plan did not include the method and frequency for checking for correct placement of the resident's gastrostomy tube and the rate and duration or daily amount of tube feeding the resident was to receive. Review of the resident's Registered Dietitian's (RD) note, dated 8/14/24 showed: -He/She visited the resident in his/her room and his/her tube feeding was on 30 ml/hr. -The resident's weight was stable and he/she was tolerating his/her tube feeding without problems. -The RD would continue to monitor the resident. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 8/15/24 showed: -He/She was severely cognitively impaired. -He/She had a feeding tube and received greater than 51% of his/her calories via tube feeding and more that 501 cc fluids via his/her feeding tube daily. -He/She had a diagnosis of cerebral palsy (a brain disorder that happens when areas of the brain that control movement and posture do not develop correctly or get damaged; it may cause difficulty eating due to problems with chewing, swallowing, and sucking). Observation on 8/19/24 at 9:37 A.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and running at 30 ml/hour (hr.). Observation on 8/20/24 at 9:46 A.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and not infusing (the pump was not running). Observation and interview on 8/20/24 at 11:08 A.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and not infusing; there was no change in the amount of tube feeding in the tube feeding bag. -Without assessing placement of the resident's feeding tube, the Director of Nursing (DON) disconnected the resident's tube feeding tubing (the tubing that delivers the tube feeding formula from the pump to the G-tube) from his/her G-tube, attached a syringe to the end of the resident's G-tube and poured approximately 30 ml of water into the resident's G-tube, followed by approximately 40 ml of water. -The DON said that when he/she checks G-tube placement he/she used a stethoscope, injected about 30 cubic centimeters (cc) of air into the tube with a syringe and listened over the G-tube insertion area for a bubbly sound; another method that could be used was to attach a syringe with plunger (the piston that expels contents in the syringe/pulls contents into the syringe) to the G-tube, pull back on the plunger and check for check for gastric (stomach/intestine) contents. -The DON said he/she had missed checking the resident's G-tube placement because he/she had left his/her stethoscope in his/her office; checking the placement of the G-tube was the most important part of G-tube care. Observation on 8/21/24 at 1:14 P.M. showed: -The resident was lying in bed. -His/Her tube feeding was connected and running at 30 ml/hour (hr.). During an interview on 8/22/24 at 10:40 A.M. Licensed Practical Nurse (LPN) A said: -The resident's tube feeding was 30 ml continuously around the clock. -When asked, he/she checked the physician's order in the resident's electronic medical record (EMR) and said the order was not correct, the physician's order was supposed to be for his/her tube feeding to be at 30 ml continuously around the clock. -The physician's order for the resident's tube feeding must have been entered incorrectly into the resident's EMR. -He/She would find the hard copy of the resident's tube feeding physician's order and ensure that the resident's tube feeding order matches what the physician had ordered. During an interview on 8/22/24 at 8:02 A.M. the MDS Care Plan Coordinator said: -He/She worked shifts in the facility both nights and days on both floors. -He/She would aspirate to check the residents feeding tube placement. -Aspiration was the only method he/she knew of to check for correct feeding tube placement. -He/She would not have put the method of checking the resident's feeding tube placement in the resident's care plan. During an interview on 8/22/24 at 10:40 A.M. the DON said: -He/She had not known that the professional standard for checking placement of feeding tubes was to look at and document the length of the tube. -He/She had always checked G-tube placement by listening and/or aspirating. -He/She had just been made aware of an issue with the resident's tube feeding order and the order was in the process of being corrected; the physician's order for tube feeding should have previously been noted to be incorrect; licensed nurses check physician's orders monthly and resident physician's review and verify orders monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of resident #53's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included PTSD. Review of the resident ' s Behavioral Care Plan, revised on [DATE] showed the resident: -Had anxiety. -Depression. -PTSD. -Personality Disorder. -The plan did not have interventions specific to the resident's TIC needs. There was no information related to: --Contributing factors to the resident's past trauma. --Triggers associated with his/her past trauma. --Steps staff should take to mitigate triggers. Review if the resident's quarterly MDS, dated [DATE] showed the resident: -Was cognitively intact. -Had psychiatric and mood disorders including PTSD. Review of the resident Electronic Medical Record [DATE] showed there was no documentation of the following: -Brief Trauma Questionnaire. -PTSD Checklist - Civilian Version. -Psychological Well-Being - History of Trauma Care Plan evaluation Based on interview and record review, the facility failed to provide Trauma Informed Care (TIC - an approach to delivering care incorporating knowledge about trauma into care plans, policies, and practices to avoid re-traumatization) assessment and care planning for two sampled residents (Resident #18 and Resident #53) out of 17 sampled residents. Residents #18 and #53 were diagnosed with Post Traumatic Stress Disorder (PTSD - an anxiety disorder that can develop after a person experiences or witnesses a traumatic event. Symptoms of PTSD can include outbursts, disturbed sleep, distressing memories and thoughts about the event, and emotions such as fear, anger, guilt, and shame, which can be severe enough to interfere with one or more aspects of daily life). The facility census was 69 residents. Review of the facility's Trauma Informed Care policy, dated 2022 showed: -Provide self-assessment and trauma questionnaire by Social Services designee or the admitting staff before admitting to the facility. The self-assessment is updated every three years. -Screening for trauma exposure and related symptoms for newly admitted resident using the Brief Trauma Questionnaire for screening. -Address the assessment and findings into the care plan to prevent triggers. -Establish a trauma-informed committee to address the program. -All staff, including direct care staff, is trained/has ongoing training in trauma informed care. Staff trained in trauma informed care should: --Understand trauma and the principles of TIC. --Know the impact of trauma on a resident's life. --Know strategies to mitigate the impact of trauma. --Understand re-traumatization and its impact. -Procedures include: --Incorporate the Brief Trauma Questionnaire into the admission package. --Interview the resident/family about trauma-related events or experiences. --Report to the Care Team for developing a focused individual plan for the resident. --Inform staff of care approaches. --The assessment and Plan of Care for trauma will be in the medical records. -Attached to the TIC policy were the following: --Brief Trauma Questionnaire in which the resident was to be asked 10 questions related to past trauma. --PTSD Checklist - Civilian Version related to signs and symptoms of PTSD. --Evaluation for Psychological Well-Being - History of Trauma Care Plan needs. 1. Review of Resident #18's admission Record showed the resident was admitted to the facility on [DATE] with diagnoses that included PTSD. Review of the resident's Pre-admission Screening and Resident Review (PASRR), Level II (a person-centered evaluation completed for anyone identified by the PASRR Level I screening as having or suspected of having a serious mental illness (SMI), intellectual disability (ID), developmental disability (DD) or related condition (RC). It confirms whether the individual has a SMI or ID/DD/RC; assesses the individual's need for Medicaid certified nursing facility services; and assesses whether the individual requires specialized services.), dated [DATE] showed the resident: -Was diagnosed with PTSD. -Had other psychiatric diagnoses. -Had PTSD as a result of extensive sexual abuse in his/her past. -Had psychiatric symptoms and history including: anxiety; isolating self from others, keeping his/her head down in public; wringing his/her hands and pacing; withdrawn and depressed, suspiciousness and paranoia; had a history of extensive sexual abuse in his/her younger years and substance abuse starting at age [AGE]; long term psychiatric history of alcohol and drug abuse, mental health issues and homelessness. -Felt his/her long struggle with depression and suicidal ideation was a result of extensive past sexual abuse. -Liked plants and flowers, drawing and coloring. -Communicated he/she was abused his/her whole life and was afraid of people. People say they are your friends, but they are not. He/She felt safe in his/her room. -Did not meet the criteria for dementia to the extent he/she would not benefit from specialized services. -Had needs which could be met in a Nursing Facility (NF). -Had needs for a behavioral support plan, medication management, and structured environment providing a schedule. -Needed a crisis intervention plan that provided emotional support, education, safety planning, and case management to handle an immediate crisis that identified clear steps to support the individual during a crisis. The plan should specify who to contact for assistance, how staff should work together with the individual during a crisis, and when the physician or emergency services should be contacted. -The following supports and services were to be provided by the NF: Behavioral Support Plan, structured environment, crisis intervention services, discharge planning, medication therapy, Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) program, and personal support network. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated [DATE] showed the resident: -Was cognitively intact. -Did not have inattention, disorganized thinking, or altered level of consciousness. -Felt down and depressed and bad about himself/herself more than half of days. -Was always socially isolated. -Had psychiatric and mood disorders including PTSD. Review of the resident's Mood Care Plan, initiated [DATE] showed the resident: -Had Major Depression (MD - a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Personality Disorder (a class of mental disorders characterized by maladaptive behavior patterns which are developed early and are associated with significant distress). -PTSD. -The plan did not have interventions specific to the resident's TIC needs. There was no information related to: --Contributing factors to the resident's past trauma. --Triggers associated with his/her past trauma. --Steps staff should take to mitigate triggers. --How the resident typically responded when triggered by past trauma. --How staff could assist the resident if he/she was triggered or had emotional distress related to past trauma. -The plan showed behavioral health consults as needed, but did not specify if the services would include addressing the resident's PTSD needs. Review of the resident's comprehensive Care Plan, updated [DATE], showed there was no PTSD care plan and no interventions in any other individual care plan specifically related to the resident's TIC/PTSD needs. Review of the resident's Psychotherapy Progress Note, dated [DATE] showed: -Therapy was focused on his/her diagnoses of major depressive disorder and anxiety disorder. His/Her PTSD was not mentioned. -The resident wanted to restore his/her relationship with multiple family members and explore his/her use of art to help manage emotions and as a communication tool with his/her family. During an interview on [DATE] at 1:06 P.M. the resident said: -He/She was diagnosed with PTSD related to past sexual abuse during his/her childhood and sexual abused while in jail. -One of his/her family members had overdosed on medications he/she was getting and died as a result. He/She always blamed himself/herself because he/she knew of the addiction problem and couldn't help the family member. -He/She was still emotionally bothered by his/her past trauma, but couldn't identify any particular event that might trigger his/her PTSD. -Nobody at the facility had ever asked him/her about his PTSD or past trauma. -Drawing helped him/her manage his/her anxiety. Review of the resident's medical record on [DATE] showed there was no documentation of the following: -Brief Trauma Questionnaire. -PTSD Checklist - Civilian Version. -Psychological Well-Being - History of Trauma Care Plan evaluation. During an interview on [DATE] at 11:26 A.M. Certified Medication Technician (CMT) A said: -He/She often worked on the resident's floor. -He/She was not aware the resident was diagnosed with PTSD. -He/She didn't know how the resident reacted when triggered and didn't know how staff were supposed to respond when the resident was triggered. -He/She didn't know what the resident's triggers were or what staff were supposed to do to try to prevent the resident from being triggered. -He/She was not educated on trauma informed care. During an interview on [DATE] at 12:06 P.M. the Social Services Director (SSD) said: -The resident received psychiatric treatment and psychological counseling services at the facility. He/She was last seen for counseling on [DATE] and [DATE]. -According to the resident, he/she had a diagnosis of PTSD caused by childhood trauma. He/She didn't know the nature of the resident's trauma and figured the resident would tell him/her about it if he/she wanted to do so. -He/She didn't know what the resident's triggers were. -Since the resident had been at the facility staff hadn't reported the resident being triggered. He/She was not aware of any serious depression or reactions of fearfulness. -The resident once saw a movie with kids in it and said he/she missed his/her family. Family members didn't want to have anything to do with him/her. -It helped the resident's anxiety to sit and talk. The resident watched TV or went to his/her room to calm himself/herself. -The resident had a Level II PASRR, but he/she didn't see any Level II recommendations. During an interview on [DATE] at 9:34 A.M. Licensed Practical Nurse (LPN) A said: -A resident diagnosed with PTSD should have a PTSD care plan which showed the resident's triggers. -He/She hadn't seen any behaviors or reactions indicating the resident had been affected by PTSD. During an interview on [DATE] at 8:08 A.M. the MDS Coordinator said: -He/She was responsible for the MDS and care plans done upon admission and quarterly. -If a resident was diagnosed with PTSD, it was part of their Behavior Care Plan (BCP). Behaviors related to diagnoses were documented in the BCP. -If the resident was actively showing signs of PTSD they would have a PTSD care plan. They wouldn't have one just because they had the diagnosis. The plan should show the resident's triggers and behaviors. -He/She assumed the Social Worker would do a TIC assessment. -He/She wasn't familiar with trauma informed care. During an interview on [DATE] the Director of Nursing (DON) said: -The facility hadn't been doing the TIC assessment. It should be part of the admission packet and done quarterly or as needed. -The MDS Coordinator was responsible for updating care plans which should be individualized. -He/She was responsible for auditing the care plans quarterly. -If a resident was diagnosed with PTSD they had been documenting that in the Behavior Care Plan. The care plan should show the resident's triggers and how staff can help mitigate triggers.

Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendation for gradual dose reduction (GDR) for psychotropic (relating to or denoting drugs that affect a person's mental state) medication in a timely manner for one sampled resident (Resident #22) out of 17 residents. The facility census was 69 residents. Review of the facility Pharmacy Services policy, undated showed: -A consultant pharmacist makes monthly visits. -The consultant pharmacist makes recommendations to the physician and to the facility about GDR. -The Director of Nursing (DON) reviews and implements the monthly consultant pharmacist's recommendations. -The physician is notified for GDR recommendations by the pharmacist. -If there is no reason for the reduction of psychotropic medications, the physician should document the reason on the progress note or the recommendation responded form. -The Nursing Department is responsible to implement the recommendations from the pharmacist or pharmacy consultant. -Review the pharmacist's recommendations. -Assign a licensed nurse to contact the physicians for the input of recommendations. -Physician contact can be via telephone or Fax. -Review the physician's input. -If there is no reason for the recommendation of reduction in dosage for psychotropic medication, re-contact the physician. -Implement the physician's orders. 1. Review of Resident #22's electronic medical record (EMR) showed the following current physician's orders: -Olanzapine (antipsychotic medication) 10 milligrams (mg), one tablet at bedtime for hallucinations, dated 2/17/24. -Trazodone (antianxiety medication that can treat anxiety and insomnia - difficulty sleeping) 150 mg at bedtime for insomnia, dated 2/17/24. -Olanzapine (antipsychotic medication) 5 mg, give one tablet one time a day for hallucinations, dated 2/17/24. -Haloperidol decanoate (a long-acting form of Haloperidol given by infection) 100 mg/milliliter (ml), inject 2 ml intramuscularly (into a large muscle) every 25 days for behaviors and aggression, dated 3/16/24, dated 5/21/24. -Haloperidol - antipsychotic - a medication used to manage hallucinations - sensing things such as visions, sounds, or smells that seem real but are not and delusions - fixed false beliefs based on an inaccurate interpretation of an external reality despite evidence to the contrary) 5 milligrams (mg) tablet, give one tablet three times a day for anger outbursts, agitation, dated 7/13/24. Review of the resident's Consultant Pharmacist Recommendation to Physician, dated 7/16/24 showed: -It was time to assess if there was a potential for gradual dose reduction of any or all of the following psychotropic medications if clinically appropriate: -Escitalopram 20 mg once a day; consider a trial reduction to 10 mg every day: and/or: -Olanzapine 5 mg every morning; consider a trial reduction to 2.5 mg every morning; and/or: -Olanzapine 10 mg every bedtime; consider a trial reduction to 7.5 mg every bedtime; and/or: -Trazodone 150 mg every day; consider a trial reduction to 125 mg every day; and/or: -Haloperidol 5 mg three a day; consider a trial reduction to 5 mg twice every day and 2.5 mg every bedtime. -There was no documented response from the physician on the form's areas for the physician's response. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning), dated 8/15/24 showed: -He/She was severely cognitively impaired. -He/She had symptoms of depression. -He/She experienced hallucinations (had perceptual experiences in the absence of real sensory stimuli). -He/She had no behavioral symptoms. -He/She had diagnoses of anxiety disorder, depression, manic depression (bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels and concentration; formerly known as manic-depressive illness or manic depression) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). -He/She received antipsychotic and antidepressant medications. -A GDR had not been attempted. -A GDR had not been documented by a physician as clinically contraindicated. During an interview on 8/22/24 at 9:37 A.M. Licensed Practical Nurse (LPN) A said he/she had no responsibility for pharmacy recommendations or GDR's. During an interview on 8/22/24 at 10:40 A.M. the Director of Nursing (DON) said: -He/She was responsible for resident's pharmacy review and GDR recommendations. -He/She took over that duty in April or May of 2024 after finding that pharmacy recommendations were not being addressed. -The facility consultant pharmacist came to the facility once monthly. -If a recommendation was made, the pharmacist emailed the recommendation to him/her and he/she then contacted the physician - if the physician said yes to the recommendation, then he/she made changes in the resident's EMR. -If the physician said no to the recommendation there should have been a reason. -If the physician did not give a reason for saying no to the pharmacist's recommendation, then he/she should have contacted the physician to get a reason the physician said no to the recommendation. -He/She entered orders into the resident's EMR if f the physician said yes to pharmacy recommendations. -GDRs were on a schedule determined by the physician and the pharmacist.

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 69 residents. Review of the facility's Antibiotic Stewardship policy dated 2018 showed: -The purpose of the policy included: --To apply the best practice into a system to monitor antibiotic use. --To implement protocols to ensure residents who require an antibiotic are prescribed the appropriate antibiotic. --To monitor the use of antibiotics. --To reduce the risk of adverse events, including development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. -Apply the revised McGreer criteria for assessing for the suspected infections for Upper Respiratory Infections (URI), Urinary Tract Infections (UTI), or other infections. -Document the antibiotic prescribed is for the correct indication, dose, and duration to appropriately treat the resident. -Implement Antibiotic Use Protocol: Antibiotic Prescribing Practices: --Document indication, dose, and duration of the antibiotic. --Review the laboratory results to determine if the antibiotic is indicated or needs to be adjusted. --Monitor antibiotic use. 1. Review of the facility Infection Control tracking log on 8/22/24 at 8:29 A.M. showed: -The tracking log did not include 12 months worth of infection tracking or antibiotic use logs. The only months available were 2/24, 3/24, 4/24, 5/24, 6/24, 7/24, and 8/24. -The monthly logs included a page for each floor titled Infection/Antibiotic Log. Staff were to document the following on the Infection/Antibiotic Log: --The date, room number, resident name, infection type, antibiotic name, order, labs (yes or no), and organism. -The log did not include any lab results or logs indicating signs or symptoms of infections for antibiotic use. No infectious organisms were identified. -An antibiotic stewardship guide that included protocols for three common infections, UTIs, respiratory tract infections, and skin and soft tissue infections. The guide included criteria to be met as an indication to initiate antibiotic use for those infection types. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing said: -He/She had been in charge of the Infection Control tracking log and antibiotic stewardship program since 2/24. -If an antibiotic was prescribed, he/she entered it on the log along with the resident room number, and type of infection such as wound, UTI, or pneumonia. -If there was a lab or an X-ray, the results were added in the tracking book. -He/She could not locate lab results or X-ray results in the tracking book. -The tracking book did not include signs or symptoms of infections being treated with antibiotics.

Based on interview and record review, the facility failed to designate one or more individuals with the required primary professional training as the Infection Preventionist (IP) for the facility's Infection Prevention Control Program. The facility census was 69 residents. The facility did not provide a policy regarding required primary professional training for the IP. 1. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing (DON) said: -He/She was going to be the facility IP. -He/She had not taken any of the certification classes for the IP role at this time. During an interview on 8/22/24 at 9:38 A.M., the Administrator said: -He/She had the IP certificate and dedicated two to three hours per week for Infection Control duties. -His/Her degree was in Social Work. He/She did not have a degree in any of the approved primary professional medical trainings. -The previous IP left the faciity on 3/8/23. The current DON was going to be the primary IP but he/she had not taken the IP classes at this time.

Based on observation, interview, and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week in the fourth quarter of the fiscal year for July 2023, August 2023, September 2023, in the first quarter of the fiscal year for October 2023, November 2023, December 2023 and in the second quarter of fiscal year for January 2024, February 2024, March 2024. The facility further failed to ensure the Director of Nursing (DON) was not serving as the charge nurse when the facility census was greater than 60 residents. This deficiency had the potential to affect all residents. The facility census was 69 residents. A facility RN staffing policy and procedure was requested and not received prior to exit. Review of the facility's Facility Assessment updated 8/2024 showed: -Purpose to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. -The resident population characteristics include: --Bowel and bladder incontinence; bedfast all or most of the time; chair fast all or most of the time; pressure ulcers (localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); hospice ( a comprehensive, holistic program of care and support for terminally ill patients and their families); tube feedings (a medical device used to provide nutrition to patients who cannot obtain nutrition); Injections; dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration on intellectual capacity and function, and impairment of control of memory, judgement and impulse) and psychiatric/mood disorders. 1. Review of the Center for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) staffing data report from the Community Assessment for Public Health Emergency Response (CASPER) report 1705D for fiscal year quarter four 2023 (July 1st thru September 30th), fiscal year quarter one 2023 (October 1st thru December 1st) and fiscal year quarter two 2024 (January 1st thru March 1st) showed: -Four or more days within the quarters with no RN hours for the following dates: --Seven days in July 2023: 7/1/23- Saturday; 7/2/23- Sunday; 7/8/23- Saturday; 7/15/23- Saturday; 7/16/23- Sunday; 7/18/23- Tuesday; 7/23/23- Sunday; 7/29/23- Saturday. --Five days in August 2023: 8/5/23- Saturday; 8/6/23- Sunday; 8/20/23- Sunday; 8/26/23- Saturday; 8/27/23- Sunday. --Seven days in October 2023: 10/4/23- Saturday; 10/8/23- Sunday; 10/16/23- Monday; 10/21/23- Saturday; 10/22/23- Sunday; 10/26/23- Thursday; 10/28/23- Saturday; 10/29/23- Sunday. --Eight days in November 2023: 11/4/23- Saturday; 11/5/23- Sunday; 11/12/23- Sunday; 11/16/23- Thursday; 11/17/23- Friday; 11/18/23- Saturday; 11/19/23- Sunday; 11/26/23- Sunday. --Nine days in December 2023: 12/2/23- Saturday; 12/3/23- Sunday; 12/10/23- Sunday; 12/16/23- Saturday; 12/17/23- Sunday; 12/24/23- Sunday; 12/26/23- Tuesday; 12/30/23- Saturday; 12/31/23- Sunday. --Six days in January 2024: 1/5/24- Friday; 1/6/24- Sunday; 1/7/24- Saturday; 1/20/24- Saturday; 1/27/24- Saturday; 1/28/24- Sunday. --Five days in February 2024: 2/3/24- Saturday; 2/4/24- Sunday; 2/14/24- Wednesday; 2/24/24- Saturday; 2/25/24- Sunday. --Twelve days in March 2024: 3/2/24- Saturday; 3/4/24- Monday; 3/8/24- Wednesday; 3/9/24- Friday; 3/10/24- Saturday; 3/16/24- Sunday; 3/17/24- Saturday; 3/18/24- Sunday; 3/23/24- Saturday; 3/24/24- Sunday; 3/31/24- Saturday; 3/30/24- Sunday. 2. Review of the facility staffing daily staffing schedule showed: -On 8/20/24 the DON was scheduled to work the floor as the charge nurse. The facility census was 69 residents. -On 8/22/24 the DON was scheduled to work the floor as the charge nurse. The facility census was 69 residents. Observations during the survey from 8/18/24 - 8/22/24 showed: -On 8/20/24 between 8:00 A.M. - 2:00 P.M., the DON was the charge nurse. -On 8/22/24 between 8:00 A.M. - 12:00 P.M., the DON was the charge nurse. During an interview on 8/22/24 at 10:09 A.M., the Administrator said: -He/She was aware that not all days were covered with an RN for eight hours. -He/She was still trying to hire more RN's. During an interview on 8/22/24 at 10:25 A.M., the DON said: -He/She was the only RN currently for the facility. -He/She would expect there to be an RN in the facility for eight hours daily. -He/She picks up hours working on the floors as the charge nurse since he/she is the only RN. -The facility as an RN that works as needed (PRN), but he/she does not pick up very many hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionell, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility also failed to have a system for tracking and monitoring infections in the facility for the previous 12 months and to ensure residents were tested upon admission and/or screened annually for tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two sampled residents (Resident #6 and #73) out of 17 sampled residents. The facility census was 69 residents. 1. Observation on 8/20/24 between 10:11 A.M. and 1:34 P.M. during the initial facility Life Safety Code (LSC) basement inspection with the Maintenance Supervisor (MS) showed the following: -The facility was fully sprinklered and had its incoming water supply in the fire sprinkler riser room (A dedicated space for fire protection equipment). -There was a kitchen with a three-sink area, a dish-washing machine, and a hand-washing sink. -There was a laundry area with clothes washers. Observation on 8/21/24 between 9:03 A.M. and 11:04 A.M. during the facility LSC walk-through inspection of the first floor with the MS showed there were gender specific public restrooms located on the west wall along with a Beauty Shop with a sink. Observation on 8/21/24 between 11:04 A.M. and 1:27 P.M. during the facility LSC walk-through inspection of the second floor with the MS showed the following: -There were at least 17 resident rooms with private or shared bathrooms and sinks. -There were two Shower Rooms. -There was a Janitor's Closet with a mop hopper and a Medication Room with a sink. Observation on 8/21/24 between 1:27 P.M. and 2:47 P.M. during the facility LSC walk-through inspection of the third floor with the MS showed the following: -There were at least 17 resident rooms with private or shared bathrooms and sinks. -There were two Shower Rooms. -There was a Janitor's Closet with a mop hopper and a Medication Room with a sink. Review of the facility's maintenance folder entitled Legionella, last reviewed 8/1/23 and provided by the MS, showed the following: -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens, though the first page of their assessment stated to refer to it. -There was no facility-specific infection prevention and control program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was a schematic, diagram, or flowchart of the facility's water system, but no written explanation of the water flow throughout the facility. -There were no indications of possible stagnation locations throughout the facility on the flowchart, with assessments of each location's individual potential risk level. -There were no facility-specific testing protocols and acceptable ranges for control measures with a method of monitoring them at this facility, with interventions or action plans for when control limits were not met. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 8/22/24 at 12:05 P.M. the MS said that he/she learned about the Legionella program requirements from the previous MS. During an interview on 8/22/24 at 12:19 P.M. the Administrator said the following: -The MS was responsible for implementing the Legionella program. -The MS had been educated on it through their corporate office. -He/She was aware of some of the basic requirements. 2. Review of the facility Infection Control Surveillance policy dated 2018 showed: -Separate infection tracking for those that occurred within the facility (facility-acquired) from those that were admitted to the facility with an infection. -A systematic observation on the occurrence and distribution of facility-acquired infections for the purpose of prevention and control. -To help make a judgement on what infection control practices needed to be stressed. -Review data to determine clusters and trends. -Include antibiotic stewardship program. Review on 8/22/24 at 8:20 A.M. of the facility Infection Control book for tracking and trending showed: -The book did not include 12 months of tracking and trending. The first month available for review was February 2024. -The available logs did not include if the infections were facility-acquired or present upon admission to the facility. -The available logs did not include if the infections were resolved and when. -The available logs did not include the type of infectious organisms present. -The available logs did not include the utilization of an antibiotic stewardship program. During an interview on 8/22/24 at 9:22 A.M., the Director of Nursing (DON) said: -He/She took over the Infection Control book in 2/24. -The person previously responsible left in 3/23. He/She was not aware he/she was supposed to be responsible for the program until 2/24. -He/She had not taken the Infection Preventionist course yet. He/She was not aware what information should be included in the tracking/trending logs other than what was on the monthly Infection/Antibiotic log. 3. A policy for resident TB testing and screening was requested but not received at the time of exit. Review of Resident #73's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's electronic medical record showed: -No documentation a two step TB skin test was completed upon admission to the facility. -A TB signs and symptoms assessment was completed on 7/17/24. 4. Review of Resident #6's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's electronic medical record showed his/her last TB assessment for yearly signs and symptoms assessment was completed on 1/17/23. No other assessments were located or provided by the facility. 5. During an interview on 8/22/24 at 10:26 A.M., the DON said: -TB tests for residents should be completed by the admitting charge nurse upon admission to the facility. A second step should be administered two weeks later. -Resident #73 should have had a two step TB skin test completed by now. -Residents should be screened annually for signs and symptoms of TB and documented in their medical record. -He/She did not know why there was not a more recent TB assessment for Resident #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent one sampled resident (Resident #1) from physical abuse when on 6/12/23 Resident #2 struck Resident #1 with a cane which resulted in a contusion to the back of his/her head. There were six residents selected for review. The facility census was 77 residents. On 6/26/23, the Administrator was notified of the past noncompliance which occurred on 6/12/23. The facility administration was notified on the same day of the incident and the investigations was started. Facility staff were educated on abuse and neglect policy, resident intervention and behaviors before the start of the next shift. Residents were separated and care plans were updated. The deficiency was corrected on 6/13/23. Review of the facility Abuse and Neglect Policy dated 2016 showed: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Physical Abuse: the use of physical force that may result in bodily injury, physical pain, or impairment. --Includes hitting, slapping, pinching and kicking. --Any punishing, slapping, hitting, shoving, striking with or without an object, pinching, kicking or burning. -Purpose: -To ensure that the resident's rights are respected and honored. -These rights provide protection from physical and mental abuse, corporal punishment, involuntary seclusion and any physical or chemical restraints imposed for the purpose of discipline or convenience of the staff. -Policy: --Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. --The facility is responsible to prevent not only abuse, but also those practices and omissions, neglect and misappropriation of property that may lad to abuse without thorough investigation. --Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, volunteers, individual contractors, or other staff agencies that provide services to residents or the facility and visitors. -Prevention of Abuse and Neglect: -Purpose: --To prevent potential abuse and negligence from staff to resident and from residents to residents. 1. Review of Resident #1's admission Record showed he/she was admitted on [DATE] with the diagnoses of profound intellectual disabilities and epilepsy (seizures). Review of the Resident #1's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/22/23 showed the resident is cognitively impaired. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with the diagnoses of high blood pressure and alcohol use. Review of the facility Investigation packet dated 6/12/23 showed: -Certified Nursing Aide (CNA) A walked into Resident #1's room as he/she was being struck by Resident #2 and stopped the assault. -The investigation was initiated and completed the same day. -Law enforcement was not contacted due to Resident #2 plan to discharge from the facility. Review of Resident #1's Care Plan dated 6/13/23 showed: -On 6/12/23 the resident was physically attacked by Resident #2. -Resident #2 hit the other resident in the head with his/her cane. -The resident was sent to the emergency room for evaluation. Review of Resident #2's undated Care Plan showed: -He/she had a behavior problem. -On 6/12/23 he/she admitted to drinking whiskey that he/she bought while out in the community. --He/she hit a Resident #1 with his/her cane because he/she thought the resident had been touching/moving his/her personal belongings. -Facility staff were to intervene as necessary with the resident to protect the rights and safety of others, approach/speak in a calm manner, divert his/her attention and remove him/her from situation and tack to alternate location as needed. Review of Resident #1's hospital Medical Record dated 6/13/23 showed: -He/she was seen in the emergency department on 6/12/23 after Resident #2 hit him/her on the right side of his/her head with a cane. -He/she reported some discomfort at the site of the hematoma (a collection of blood. The blood could result from traumatic or non-traumatic causes.) to the right occipital (back) of his/her head. -Diagnosis: Closed Head Injury. Review of Resident #2's Social Services note dated 6/13/23 showed: -He/she was agitated about being asked questions about the altercation with Resident #1. -Stated he/she wanted out of the facility now. -He/she was going to be with his/her friends in the city. -Discharge was completed per his/her request. -He/she was taken to the bus station per his/her request and observed getting on the bus with all personal belongings. During an interview on 6/26/23 at 2:11 P.M., Resident #1 said he/she was in a fight, but had no further memory of the event. During an interview on 6/26/23 at 4:50 P.M., the Director of Nursing (DON) said: -Resident #2 had a king of the hill kind of engagement with his/her peers. -He/she does not know that anything would've prevented the assault. -Resident #2 wanted a private room, but could not afford to pay for a private room. -Resident #2 had several different roommates in an effort to find a good match. -Resident #2 chose to discharge immediately after the assault. -Resident #2 was his/her own person and left the facility with three days of medications and all his/her person effects. MO00219920

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure wound documentation was completed for two sampled residents (Resident #3 and #6). There were six residents selected for review. The facility census was 77 residents. Requested a copy of the facility policy for wound care on 6/26/23 but it was not received and unable to review. 1. Review of Resident #3's admission Record showed he/she was admitted on [DATE] with muscle weakness and pain in his/her left hip. Review of the resident's most recent Skin Concern Report dated 10/25/22 showed he/she: -Had a left plantar foot wound acquired on 9/3/20. -Had a right plantar foot and distal great toe wound acquired on 9/2/20. -On-going tunneling infection. -Was non-compliant and refused dressing changes. Note: The Medical Record showed no current skin concern reports. Review of the Resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/29/23 showed the resident: -Was cognitively intact. -Had unhealed pressure injury (PI). -Had two unstageable PI with infection. Review of the resident's Physician's Orders dated 6/1/23 through 6/31/23 showed: -To cleanse his/her left plantar foot with normal saline, Apply optifoam AG (a foam dressing infused with silver for a moist healing environment for wounds), secure with cloth tape, change daily. -To cleanse his/her right foot with normal saline, apply Alginate (turns into a gel that maintains a moist wound environment and helps in the debridement of sloughing wounds), abdominal pad, wrap with kerlix (woven gauze that is non-adhesive used to wrap wounds and burns) and change every other day. Review of the resident's Treatment Administration Record (TAR) dated 6/1/23 through 6/31/23 showed: -To cleanse his/her left plantar foot with normal saline, apply optifoam AG, secure with cloth tape, change daily. --No documentation to show the treatment was completed 15 out of 26 opportunities -To cleanse his/her right foot with normal saline, apply Alginate, abdominal pad, wrap with kerlix, change every other day. --No documentation as completed five out of 13 opportunities. Review of the resident's Licensed Nurse Weekly Skin Assessments showed the facility provided assessments dated 1/3/23 through 6/26/23. The facility did not assess the resident's skin 22 out of 26 opportunities. (NOTE: no other skin or wound care documents were provided) During an interview on 6/26/23 at 3:50 P.M., the resident said: -The staff was not doing the dressing changes often enough. -The longest he/she had went without a dressing change had been nine days. -He/she was fired from the wound care clinic and was told he/she could not go to the hospital because he/she was fired. -He/she denied refusing any wound care or dressing changes. -On average his/her dressings got changed about every three to four days. 2. Review of Resident #6's admission Record showed he/she was admitted on [DATE] with the diagnoses of high blood pressure and diabetes. Review of the resident's most recent Skin Concern Report dated 10/25/22 showed the resident had a diabetic ulcer to the left great toe acquired 7/1/20. Note: The Medical Record had no recent skin concern reports. Review of the resident's Annual MDS dated [DATE] showed he/she: -Was cognitively intact. -Had diabetic foot ulcers. Review of the resident's Licensed Nurse Weekly Skin Assessments showed the facility provided assessments dated 11/9/22 through 6/26/23 showed the facility did not assess the resident's skin 26 out of 35 opportunities. (NOTE: no other skin or wound care documents provided) Review of the resident's wound clinic documents dated 12/13/22 showed the resident: -Had a wound to his/her left plantar great toe. -Has an order for diabetic shoes. -Doxycylcine 100 milligram (mg) twice daily (antibiotic). -Use moisturizing lotion to lower extremities, or Vaseline, daily for peri-wound (tissue surrounding a wound) care. -Change dressings every other day. -Resident needs to keep a bandage on at all times. -Continue to use medihoney and cover with thick foam. -Secure with elastic bandage to both lower legs from bottom of toes all the way up to crease of his/her knee. Review of the resident's wound clinic documents dated 12/27/22 showed the resident: -Wound debridement (the removal of damaged tissue or foreign objects from a wound) in clinic. -Had a wound to his/her left plantar great toe. -Had an order for diabetic shoes. -Doxycylcine 100 mg twice daily. -Use moisturizing lotion to lower extremities, or Vaseline, daily for peri-wound care. -Change dressings every other day. -Resident needs to keep a bandage on at all times. -Continue to use medihoney and cover with thick foam. -Secure with elastic bandage to both lower legs from bottom of toes all the way up to crease of his/her knee. Review of the resident's Physician's Orders dated 6/1/23 through 6/31/23 showed: - To cleanse his/her right great toe with normal saline every other day, done only at the wound clinic. -Apply Vaseline, optifoam to peri-wound, secure with coban (a self-adherent compression bandage) and medi grip (a medicated pad). Review of the resident's TAR dated 6/1/23 through 6/31/23 showed: -To cleanse his/her right great toe with normal saline every other day, done only at the wound clinic. --Treatment not documented as completed one out of 12 opportunities. --Documented as refused six out of 12 opportunities. --Documented as not done four out of 12 opportunities. - Apply Vaseline, optifoam to peri-wound, secure with coban and medi grip was not documented 26 out of 26 opportunities. During an interview on 6/26/23 at 2:13 P.M., the resident said: -He/she had the wound for about 20 or 30 years. -He/she would not allow the staff to change his/her dressings. -He/she would change his/her own dressings and gets supplies from the nursing staff. Review of the resident's medical record showed no assessment for self wound care and no clear documentation of the resident's refusal. 3. During an interview on 6/26/23 at 2:50 P.M., the Wound Care Nurse said: -The role of the wound care nurse kinda falls in his/her lap. -He/she does not perform wound care on Resident #6. -Resident #3 had wound culture's obtained, however, he/she was unable to provide the physician's order. -He/she confirmed the last wound care consult in the resident's chart was dated 10/26/20. -He/she provided a wound care tracking log with the last entry of 1/4/23. -Any other information was at home on his/her personal computer and not available at the facility. During an interview on 6/26/23 at 4:50 P.M., the Director of Nursing (DON) said: -He/she expected wound care to be done as ordered. -He/she knew there were concerns. -He/she could not locate a wound care policy. -Wound care tracking should have been completed to see progress or decline in wounds. -He/she had not gotten a wound care report for two months or so from the wound clinic. -He/she was not sure where the order for the wound culture for Resident #3 was. -He/she verified there were no wound care tracking logs for the year besides 1/4/23, which was not legible. -There were no other skin or wound care sheets for the residents. MO00220323

Based on observation and interview, the facility failed to keep the kitchen, Dry Storage room floors clean; to maintain food preparation equipment; to safeguard against foreign materials possibly getting into food and/or beverages; to keep trash and garbage receptacles lidded; to follow correct hand hygiene practices; to separate damaged foodstuff; and to ensure the proper labeling, refrigeration, and/or disposal of foodstuffs to prevent the harboring and/or feeding of pests, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 77 residents. 1. Observation on 6/26/23 between 11:21 A.M. and 12:03 P.M. in the kitchen showed: -A bottle of soda, a cell phone, small red zipper pouch, cigarette case, lighter and partially smoked cigarette were observed on the cart next to the condiment stand. -The floor of the kitchen was soiled with a large amount of dirt, trash, food particles and a slick, shinny residue. -Two large round trash barrels without lids. -One medium rectangle trash can without a lid and soiled with food splatter and a grease-like residue. -Serving table soiled with food and dried spills. -Seasoning and spice containers soiled with residue and splatter. -Food, splatter and oil in and around the surfaces of the tilt skillet. -Table with meat slicer soiled with dried food and splatter. -Window unit covered in a brown tinged residue. -Ledge under window unit soiled with dirt, dried food and brown tinged residue. -Drink preparation area for coffee and tea soiled with dried coffee and tea spills. -Cook stove and oven covered in grease-like residue, food splatter and dried food particles. -Handwashing area coated with a grease-like residue and dirt. -In the food storage area just off the kitchen there was a hat and purse hanging from the dry food storage rack. -There was an empty container with white powder on the floor, a black lid covered in white powder set on top of the rice container. -There was an open box with what appeared to be an open bag of drink thickener. -Under prep tables, hot cart, stove, oven and tilt skillet there was a large amount of food, trash, debris and grease-like residue. -The [NAME] dropped a sausage off the plate onto the counter top, picked up the sausage with his/her hand and returned the sausage to the pan from which the entree was being served. -The [NAME] prepared mechanical soft meat after leaving the hot cart, washing the food processor with bare hands and dripping water from ungloved hands. -The [NAME] continued to prepare plates from the hot cart with dripping water from ungloved hands after preparing the mechanical soft meat. During an interview on 6/26/23 at 12:09 P.M. the Dietary Manager said: -He/she expected all dietary staff to clean according to the cleaning charts posted. -He/she expected staff to store personal items such as cigarette cases, partially smoked cigarettes, phones, and drinks in the break room and not in the kitchen. -It was not common practice for personal items to be in the kitchen. -He/she would have to do additional in-services and possible disciplinary action for dietary staff who continue to have personal items in the kitchen area. -He/she identified the lid in the dry storage to be the lid to the empty container on the floor for the drink thickener. -He/she identified the open bag to be drink thickener that had not been dispensed into the container. -He/she and the dietary aides should have sealed the drink thickener in the container with a label indicating the product and date opened and this was not the case the Friday before as he/she had checked it before he/she left for the weekend. -He/she had not yet checked the items since then, it being after noon the following Monday. -He/she was the person responsible for ensuring all the cleaning is being done, all items are marked appropriately and serving of the meals is done within the guidelines. -Areas in the kitchen have not been cleaned since last survey. -He/she was not responsible for cleaning the air conditioner unit and had not completed a work order for maintenance to clean it. MO00220323

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment) was completely filled out and had a physician's signature for one sampled resident (Resident #3); and to complete the PASRR for one sampled resident (Resident #4) although a physician signed it out of six sampled residents. The facility census was 76 residents. Record review of the facility's policy, PASRR POLICY, dated 3/3/08 showed: -The PASRR is a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment. -The screening assures appropriate placement of persons known or suspected of having a mental impairment and also that the individual needs of mentally impaired persons can be and were being met in the appropriate placement environment. -All potential admitting residents would be assessed by the social services director or nursing staff to complete the form. -Initiates the screening process upon or near the point of admission to the nursing facility or skilled nursing facility. -Nursing was to assure the forms were completed and signed by the physician, including the physician's discipline and license number before admitting a resident. 1. Record review of Resident #3's PASRR dated 2/6/02 showed: -He/she had been diagnosed with Paranoid Schizophrenia (a severe mental health condition that can involve delusions and paranoia (the irrational and persistent feeling that people are 'out to get you'). -The form showed you must follow the guide on the back page. -There was no back page. -There was no physician's signature. Record review of the resident's face sheet showed he/she was admitted to the facility on [DATE]. 2. Record review of Resident #3's PASRR dated 2/6/02 showed the following areas were incomplete: -Did the individual show any signs or symptoms of a Major Mental illness. -Did not check yes or no. -Did not list symptoms. -Did the individual have a current, suspected, or history of a Major Mental illness as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). -Did not check yes or no. -Indicate all Major Mental Illness diagnoses. -None were circled. -Did the individual have any area of impairment due to serious mental illness. -Did not check yes or no. -Within the last two years has the individual experienced psychiatric treatment episode that was more intensive than routine follow-up care, was referred to a mental health crisis center, had attended partial care or hospitalization or had received program of Assertive Community Treatment or Integrated Case Management Services or due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement official. -Did not check yes or no. -Did the individual have a substance related disorder. -Did not check yes or no. -Was the need for a skilled nursing facility placement associated with substance abuse. -Did not check yes or no. -When did the most recent substance abuse occur. -Dates were not provided. -Did the individual have a diagnosis of Major Neurocognitive Disorder. -Did not check yes or no. -Was the individual known or suspected to have a diagnosis of intellectual disability that originated prior to age [AGE]. -Did not check yes or no. -Did the individual have a suspected diagnosis or history of an intellectual disability or related condition. -Did not check yes or no. -Indicate all intellectual disability related conditions. -None were circled. -Was the client going to stay past 30 days at the skilled nursing facility. -Did not check yes or no. -Date of first consult completed by a physician or licensed mental health professional. --There was no date. -The physician signed the report on 12/23/21. -The diagnosis list was not attached. -The History and Physical was not attached. -Determine if the applicant required any of the following treatments. -Did not circle any. -Did the client have the ability to make a path to safety. -Did not circle yes or no. -Did the client have a speech impairment. -Did not circle yes or no. -Did the client have a hearing impairment. -Did not circle yes or no. Record review of the resident's face sheet showed he/she was admitted to the facility on [DATE]. 3. During an interview on 1/19/23 at 1:30 P.M. the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) Coordinator/Licensed Practical Nurse (LPN) A said: -All residents should have a completed PASRR done before they come into the facility or immediately upon arrival. -The form should have been completed and signed by a physician. -He/she verified Resident #3's PASRR was not signed by the physician and did not have the second page. -He/she verified Resident #4's PASRR was signed by the physician but was not completed. -He/she was responsible for ensuring the PASRR was completed and was signed by a physician. During an interview on 1/19/23 at 2;40 P.M. LPN C said: -Each resident should have a PASRR done when they admit to the facility. -The PASRR should be filled out and signed by a physician. -The MDS Coordinator was responsible for ensuring it had been done. During an interview on 1/19/23 at 4:15 P.M. the Director of Nursing (DON) said: -The MDS Coordinator was responsible for the PASRR's. -The PASRR should be done before the resident comes to the facility or immediately upon arrival. -The PASRR should be completely filled out and signed by the physician. -The PASRR's have not been audited.

Based on interview and record review, the facility failed to obtain two Urinalysis (UA- a test for infection, kidney problems or diabetes) tests for one sampled resident (Resident #4) who had a change in behaviors out of six sampled residents. The facility census was 76 residents. Record review of the facility's undated policy, Policy for Physician Order, showed: -The purpose was to ensure the physician's orders were transcribed from the Physician Order Sheet (POS) to the appropriate administration record. -The physician would give the order via phone, fax or written. -Follow the order to provide treatments. -All new orders should be communicated on the 12- hour communication form. -The Director of Nursing (DON) or Assistant Director of Nursing (ADON) would check it daily for appropriate follow-up. 1. Record review of Resident #4's face sheet showed he/she was admitted to the facility with the following diagnoses: -Cirrhosis of Liver (chronic liver damage usually resulting from Hepatitis or alcohol abuse). -Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar). Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility staff for care planning) dated 12/16/22 showed the resident: -Had a Brief Interview for Mental Status (BIMS) score of four, that indicated he/she was severely cognitively impaired. -Was able to make self known to others. -Was able to understand others. Record review of the resident's Care Plan dated 12/21/22 showed: -He/she was admitted to Hospice care (end of life care) on 1/17/23 related to terminal cirrhosis. - he/she had liver disease related to cirrhosis and Hepatitis C. -Staff were to obtain and monitor lab or diagnostic work as ordered by the physician. -Staff were to report results and follow up as indicated. -Staff were to report any changes in level of consciousness and changes in behavior. Record review of the resident's POS dated January 2023 showed the following orders: -Urinalysis next lab day, dated 1/3/23. -Don't see UA results check UA if not done and call results, dated 1/10/23. -NOTE: As of 1/19/23 there were no lab results from the UA ordered on 1/3/23 and re-ordered on 1/10/23. Record review of the resident's Physician's Progress Notes dated 1/10/23 showed: -He/she was seen by the Physician on 1/10/23. - A UA was ordered on 1/3/23 but no results available for review, if UA not done obtain urine for UA on next lab day. -He/she was confused but at baseline. -The Administrator said the resident was not out of bed much any more. During an interview on 1/19/23 at 12:50 P.M. Licensed Practical Nurse (LPN) C said: -There were no results for a UA for the resident. -The lab should have been done the next day. -It was ordered on 1/3/23 and again on 1/10/23. -There were no results so the UA still had not been done as of today, 1/19/23. -They do not have any way to tell if a lab had been done until the results come back. -It was not put in the communication book that a UA had been ordered by the physician. -The Director of Nursing (DON) was ultimately responsible to ensure paperwork was done and orders were completed. During an interview on 1/19/23 at 12:00 P.M. Psychiatric Nurse Practitioner (NP) said: -Staff should always follow the physician's orders. -The UA should have been obtained when ordered on 1/3/23. -The UA should have been obtained when it was re-ordered on 1/10/23. -As of today 1/19/23 the UA had not been obtained. During an interview on 1/19/23 at 2:20 P.M. MDS Coordinator/LPN A said: -The UA for the resident was not done if there were no results. -Still today the UA has not been done. It was missed. -The DON was ultimately responsible for ensuring labs were done. -He/she had not seen anything in the communication book for the resident to have a UA done. During an interview on 1/19/23 at 4:15 P.M. the DON said: -UA's should have been done Monday night for pickup by the lab on Tuesday morning. -Staff obtains the UA, it is picked up by the lab, then the results from the UA were faxed back to the facility. -The MDS Coordinator and he/she go through the lab results. -The UA was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat three sampled residents(Resident #2, #5, and #6) out of 6 sampled residents with dignity by not ensuring the food was of a texture that it could be eaten with a plastic fork; and to provided assistance in cutting up their food so they would not have to pick up the food with their hands to eat it. The facility census was 76 residents. Record review of the facility's policy, Dietary Services, dated May 14, 2009 showed food should be prepared in a form designed to meet individual resident needs, including mechanical alteration of food as required. 1. Observation of the test tray of the breakfast meal on the third floor at 1/19/23 at 9:45 A.M. showed only a plastic fork was provided to eat the meal with. Observation on 1/19/23 at 12:40 P.M. of the lunch meal test tray showed: -A four by six inch pork chop. -A plastic fork and spoon were provided to eat the food with. -The pork chop was too tough to cut with a plastic fork. -The pork chop had to be picked up in order to eat it as there was no knife available on that unit to cut meat with. Observation on 1/19/23 at 12:41P.M., of the lunch meal showed: -A four by six inch pork chop was served. -Only plastic fork and spoon were provided to the residents. -None of the residents had a knife. -No staff provided assistance to the residents to cut the pork chop. -The residents picked the meat up with their hands to eat it. 2. Record review of the Resident #2's face sheet showed he/she had the following diagnoses: -Dementia (a group of thinking and social symptoms that interferes with daily living). -Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). -Bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs). -History of traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head). Record review of the resident's care plan dated 12/17/21 showed: -He/she would reside on a secured unit. -He/she has the potential for choking or aspiration when eating. Record review the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/6/23 showed he/she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he/she was cognitively intact. During an interview on 1/19/23 at 12:49 P.M. the resident said: -Staff treat us like we were less than human. -There was no knife to cut our meat up with. 3. Record review of Resident #6's Annual MDS dated [DATE] showed: -He/she had a BIMS score of 15 which indicated he/she was cognitively intact. -He/she needed set up help to eat. -He/she had Dementia. -He/she had Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During an interview on 1/19/23 at 12:48 P.M. the resident said: -He/she felt like a caveman, they served him/her a pork chop with gravy and no knife to cut it up with. -They don't even provide a plastic knife. -If the staff went to get a knife so they could cut up your food the food would be even colder than it is now. Observation on 1/19/23 at 12:49 P.M. of the resident showed: -He/she had a plastic fork and spoon to eat with. -He/she was not able to cut the pork chop with a fork. -He/she picked up the pork chop with his/her hand and ate it. -There was gravy dripping down the resident's hand. 4. Record review of Resident #5's Quarterly MDS dated [DATE] showed: -His/Her BIMS score was 15 which indicated he/she was cognitively intact. -He/she needed set up help to eat. -He/she had Depression. -He/she had Schizophrenia. During an interview on 1/19/23 at 1:00 P.M. the resident said: -He/she had a pork chop for lunch. -He/she had to pick it up with his/her fingers to eat it. -He/she did not like that. -Staff won't provide a knife to cut food. -It was hard to get staff to cut up food. -Staff had to go downstairs to the kitchen to get a knife. 5. During an interview on 1/19/23 at 8:40 A.M. Certified Medication Technician (CMT) A said: -The residents could only have plastic silverware. -They could not have a plastic knife, they might use it as a weapon. -He/she could go and get a knife if they needed something cut up. -The residents were on a locked unit. During an interview on 1/19/23 at 9:45 A.M. the Dietary Supervisor said: -The residents were on locked units and were not able to get a knife to cut their food. -The residents could not have a plastic knife. -The nursing staff could cut their food if they needed assistance. During an interview on 1/19/23 at 12:15 P.M. Licensed Practical Nurse (LPN) C said: -The residents were on a locked unit. -They could only use plastic silverware for meals. -They could not have any knives not even plastic knives. -If they needed their food cut staff could cut it for them. During an interview on 1/19/23 at 4:15 P.M. the Director of Nursing (DON) said: -The residents only use plastic silverware. -Staff should cut the resident's food up for them. -The residents should not have to pick their food up with their fingers to eat it. -That was a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document identified behaviors on the behavior monitoring sheets which resulted in the continuation of the identified behaviors which included a resident to resident physical altercation with no new interventions being put into place for four sampled residents (Resident #1, #2, #3, and #4) out of six sampled residents who resided on a locked secure unit. The facility census was 76 residents. Record review of the facility's undated policy, Behavior Management Program, showed: -The term behavior symptom is defined as an indication or characteristic of a negative physical or psychosocial outcome, which may indicate negative interactions or negative attitude that result in an unpleasant atmosphere that disturb others. -Change in behavior is any abnormal or unusual pattern of behavior symptoms including increase or decrease in the severity. -Residents who exhibit behavior symptom concerns will be monitored and or treated to prevent incident. -Monitoring should include;check pattern, occurrence. -When a resident is observed with change in behaviors, the observant shall report to the licensed nurse immediately. -The staff should be informed of the monitoring plan and interventions. 1. Record review of Resident #1's face sheet showed he/she was admitted to the facility with the following diagnoses: -Schizophrenia (a serious disorder which affects how a person thinks, feels, and acts). -Schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder -a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Unspecified Psychosis (a condition that affects the way your brain processes information which could cause you to lose tough with reality). Record review of the resident's care plan dated 11/11/22 showed: -He/she had a behavior problem related to Schizoaffective disorder. -Staff were to monitor for signs and symptoms of increasing agitation. -Staff were to report any noted signs or symptoms of increasing agitation. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility staff for care planning) dated 11/18/22 showed: -His/her Brief Interview for Mental Status (BIMS) score was 15 which indicated he/she was cognitively intact. -He/she did not have any behaviors during the look back period. -He/she showed little interest or pleasure in doing things, nearly every day during the look back period. -He/she felt tired or had little energy nearly every day during the look back period. -Record review of the resident's Behavior Intervention Monthly Flow Record dated January 2023 showed: -Staff were to monitor for verbal aggression. --45 out of 54 opportunities were left blank. --Four out of nine were documented but were not signed or initialed. -Staff were to monitor for hitting staff or residents. --45 out of 54 opportunities were left blank. --Four out of nine were documented but were not signed or initialed. -There was no area for staff to sign or initial on the form. 2. Record review of Resident #2's face sheet showed he/she was admitted to the facility with the following diagnoses: -Dementia (a group of thinking and social symptoms that interferes with daily functioning). -Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). -Bipolar (a mental health condition that causes extreme mood swings). -Traumatic Brain injury (TBI a brain dysfunction caused by an outside force, usually a violent blow to the head). -Paranoid Personality disorder (a mental health condition marked by a pattern of distrust and suspicion of others). Record review of the resident's Annual MDS dated [DATE] showed: -He/she had delusions (a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions). -He/she had verbal behaviors directed towards others daily. -He/she significantly disrupted care or the living environment. -He/she rejected evaluation or cares daily. -His/her behaviors were worse than the previous assessment. Record review of the resident's Care Plan dated 12/23/22 showed: -The problem identified: --Cursed at staff. --Refused cares including medications. --Was verbally non compliant with staff. --Threatened staff. --Accused staff of not giving the cares he/she refused. --Accused staff of stealing from him/her. --Threatened Administrative staff about his/her social security. --Refused to allow Housekeeping to enter his/her room. --Blocked the door to keep people from entering. --Slammed his/her room door shut frequently. --Demanded attention from staff when he/she had an audience. --Was verbally aggressive with staff. --He/she threatened another resident and made a gesture like he/she was going to hit the other resident. -Interventions dated 11/14/22 Included: --Staff were to call 911 if he/she becomes violent. --Staff were to monitor for signs and symptoms of increased agitation and report. -Record review of the resident's Behavior Intervention Monthly Flow Record dated January 2023 showed: -Staff were to monitor for yelling or cursing at staff. -33 out of 54 opportunities were left blank. -Eight out of 21 were documented but were not signed or initialed. -Staff were to monitor for yelling or cursing at other residents. --36 out of 50 opportunities were left blank. --Seven out of 18 were documented but were not signed or initialed. -Staff were to monitor for the resident in his/her room alone screaming. --32 out of 50 opportunities were left blank. --10 out of 21 were documented but were not signed or initialed. -Staff were to monitor for the resident barricading his/her door. --32 out of 50 opportunities were left blank. --10 out of 21 were documented but were not signed or initialed. -There was no area for staff to sign or initial on the form. 3. Record review of Resident #3's face sheet showed he/she was admitted to the facility with the following diagnoses: -Psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). -Schizoaffective disorder. Record review of the resident's quarterly MDS dated [DATE] showed: -His/her BIMS score was 13 which indicated he/she was cognitively intact. -He/she had hallucinations (perceptual experiences in the absence of real external sensory stimuli). -He/she had delusions. -He/she had behaviors directed toward self. -He/she had rejected cares. Record review of the resident's care plan dated 1/15/23 showed: -The problem identified: --He/she had the potential for harm to self and others. --He/she had a history of being easily irritated or agitated. --He/she perceived others were threatening him/her. --He/she had been talking and laughing to self. --He/she had accused others of stealing from him/her. --He/she had behaviors of frequently pacing the unit, then stopping and talking to the ceiling and mirrors. --He/she accused others of keeping him/her prisoner. --He/she continued with hallucinations, talking to the ceiling and people who were not there. --He/she had an altercation with another resident by hitting the other resident. --He/she had a history of throwing medications out the window. --He/she tried to start fights with others. -Interventions dated 12/27/22 included: --Staff were to document hallucinations or delusions. --Staff were to make frequent room checks. -Record review of the resident's Behavior Intervention Monthly Flow Record dated January 2023 showed: -Staff were to monitor for pacing. --45 out of 54 opportunities were left blank. --Four out of nine were documented but not signed or initialed. -Staff were to monitor for verbal aggression. --45 out of 54 opportunities were left blank. --Four out of nine were documented but not signed or initialed. -Staff were to monitor for auditory hallucinations. --44 out of 54 opportunities were left blank. --Five out of 10 were documented but not signed or initialed. -Staff were to monitor for isolation. --45 out of 54 opportunities were left blank. --Four out of nine were documented but not signed or initialed. -There was no area for staff to sign or initial on the form. 4. Record review of Resident #4's quarterly MDS dated [DATE] showed: -He/she had a BIMS score of four, which indicated he/she was severely cognitively impaired. -He/she had behaviors directed towards himself/herself during the look back period. -He/she had wandering behaviors during the look back period. -He/she wandered. Record review of the resident's care plan dated 1/17/23 showed: -The resident had the following diagnoses: --Cirrhosis of Liver (chronic liver damage usually resulting from Hepatitis or alcohol abuse). --Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar). --Depression. --Epilepsy (a disorder in which nerve cell activity in the brain was disturbed, causing seizures - a sudden, uncontrolled electrical disturbance in the brain). --Chronic Viral Hepatitis (an infection that causes liver inflammation and damage). --Transient Ischemic Attack (a brief stroke lie attack that may resolve within minutes to hours). --Cerebral Infarction (a disrupted blood flow to the brain). --Hereditary and Idiopathic Neuropathy (a condition which causes numbness, tingling and muscle weakness). --Visual Loss (unable to see normally). -The problem identified: --He/she had a behavior problem related to disease process, major depression and anxiety. --He/she was in an actual physical altercation, where the resident hit his/her roommate and the roommate hit him/her back on 1/15/23. -Interventions dated 9/9/22 included: --Staff were to monitor for signs or symptoms of increasing agitation and report. --He/she was a severe elopement risk and would be on a secured unit. Record review of the resident's Behavior Intervention Monthly Flow Record dated January 2023 showed: -Staff were to monitor for isolating self. --45 out of 54 opportunities were left blank. --Four out of nine were documented but not signed or initialed. -Staff were to monitor for wandering. --45 out of 54 opportunities were left blank. --Four out of nine were documented but not signed or initialed. -There was no area for staff to sign or initial on the form. 5. Observation on 1/19/23 at 8:00 A.M. showed: -Both Resident #3 and Resident #4 were asleep in the same room. -Resident #4's name in large print was on a piece of paper outside of the room. -Licensed Practical Nurse (LPN) C was not aware both residents were in the same room. -LPN C moved Resident #4 down to his/her new room. During an interview on 1/19/23 at 8:10 A.M. LPN C said: -Resident's #4 had been moved to a different room. -Staff had forgotten to move his/her name to the new room and Resident #4 probably forgot which room he/she was in so he/she had went to the room with his/her name on it. -Resident #3 and Resident #4 were not supposed to be in the same room. -Resident #4 needed his/her name on the door so he/she would know which room was his/hers. During an interview on 1/19/23 at 9:15 A.M. the Administrator said: -Resident #4 had Sundowners (a state of confusion occurring late in the afternoon and lasting into the night) and had been aggressive toward staff. -A decline in Resident #4's health may have led to his/her behaviors. During an interview on 1/19/23 at 12:00 P.M. the Psych Nurse Practitioner said: -Resident #3 and Resident #4 had a good relationship. -Both Resident #3 and Resident #4 had behaviors. -The staff could not have done anything different as there were no triggers. -Staff should monitor the residents for behaviors. -He/she expected staff to redirect, separate, and supervise Resident #3 and Resident #4 and any other resident who had behaviors. -There was no need to send them to the hospital unless it is warranted. During an interview on 1/19/23 at 1:30 P.M. MDS Coordinator/LPN A said: -The behavior sheets should have been filled out by the nurse at least twice a day (if a nurse worked a 12 hour shift). -He/she expected the behavior sheets to be completed a minimum of twice a day. -The Director of Nursing (DON) was responsible for auditing the behavior sheets. -He/she had done some audits on the behavior sheets. -If the behavior sheets were blank it was not done. -It should be filled out and initialed. -The staff were not doing the behavior sheets like they should. During an interview on 1/19/23 at 2:40 P.M. LPN C said: -The behavior sheets should have been filled out every shift for all resident's who had behaviors. -If the sheet was blank it was not done. During an interview on 1/19/23 at 4:15 P.M. the DON said: -The behavior sheets should have been filled out every shift by the Nurse for all resident's who had behaviors. -If the Nurse worked a 12 hour shift, behavior sheets should have been filled out twice a day. -He/she was responsible for auditing the behavior sheets to ensure they were done. -He/she has audited some of the behavior sheets. -If the behavior sheet was blank it was not done. -He/she expected Nursing staff to initial or sign there name on the behavior sheet. MO00212695

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide hot appetizing food for meal service; and failed to provide enough of a snack to satisfy the residents until their next meal for four sampled residents (Resident #2, #3, #5, and #6) out of 10 sampled residents. The facility census was 76 residents. Record review of the facility's policy, Dietary Services Policy, dated May 14, 2009 showed: -The Director of Food Services was designated by the Administrator as responsible for the total dietetic service. -Food was stored, prepared, distributed, and served to residents under sanitary conditions. -Hot food was served from the kitchen above 140 degrees Fahrenheit (F). -These temperatures were recommended in the 1993 Food and Drug Administration (FDA) Food Code and were target temperatures. 1. Observation on 1/19/23 at 8:30 A.M. of the breakfast meal service on the second floor showed: -Meal trays were served from a green plastic tray cart. -The tray cart was not plugged in to an electrical outlet to keep the food warm. -The kitchen worker did not test the temperature of the food served on the trays when the cart was delivered to the second floor. -Meal service included; biscuits and gravy, cereal of choice, and two beverages (orange juice and choice of coffee, tea or milk). -Meals served on Styrofoam trays were taken into the isolation rooms. Record review of Resident #5's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 11/18/22 showed his/her Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) score was 15 which indicated he/she was cognitively intact. During an interview on 1/19/23 at 8:35 A.M. the resident said: -He/she had a problem with the texture of the food. -He/she was not able to describe the problem with the texture. -He/she had told staff and they told him/her they couldn't do anything about it, that was the way it was made. -Sometimes the food was cold. -The staff were too busy to heat the food up in the microwave. -Since the last survey everyone got a snack. -Snacks were served at 10:00 A.M., 3:00 P.M., and 7:00 P.M. -They usually had fruit, sandwich, crackers, or potato chips for the snack. -The snacks were a very small portion. -The food had improved but in the last 30 days it was not so good again. During an interview on 1/19/23 at 8:40 A.M. Certified Medication Technician (CMT) A said: -In the last 30 days, the residents had been complaining the food was not hot. -The size of the meals had gotten smaller. -The residents were able to get a second portion if they wanted one. -The residents got small snacks. Observation of food service on 1/19/23 at 8:45 A.M. on the third floor showed: -A test tray of biscuits and gravy was consumed. -There was one square piece of biscuit about four by four inches. -The gravy was not warm and there were three very small pieces of sausage in the gravy. --The sausage pieces were 1/4 of an inch. -There was nothing else on the tray. -The Beast (a heated metal cart used to deliver food from the kitchen) was not plugged in. 2. Observation of the meal service on 1/19/23 at 12:40 P.M. on the second floor showed: -A large plastic tray cart was delivered to the floor by a kitchen staff member. -The kitchen staff member did not check the temperatures of any of the residents' food. -A test tray was obtained and tasted. -The tray included only a plastic fork. -The pork chop's temperature was 106 degrees F. -The scalloped potatoes temperature was 133.8 degrees F. -The peas and carrots temperature was 109 degrees F. -The pork chop was too hard to cut with the plastic fork provided. -No knife was provided. Record review of Resident #6's Annual MDS dated [DATE] showed he/she had a BIMS score of 15 which indicated he/she was cognitively intact. During an interview on 1/19/23 at 12:48 P.M. the resident said: -The food was not good there was no variety. -The food was served cold at least twice a week. -If you asked for a knife then the food would be even colder by the time the staff cut up the food. Record review of Resident #2's quarterly MDS dated [DATE] showed he/she had a BIMS score of 13 which indicated he/she was cognitively intact. During an interview on 1/19/23 at 12:49 P.M. the resident said: -Lunch was cold. -He/she complained to staff but no changes were made. -There was not enough food on his/her tray. -Meal portions were small. -Snack portions were small. Record review of Resident #3's Quarterly MDS dated [DATE] showed he/she had a BIMS score of 13 which indicated he/she was cognitively intact. During an interview on 1/19/23 at 12:50 P.M. the resident said sometimes the food was cold. Observation on 1/19/23 at 3:50 P.M. of snack service on the second floor showed: -Residents were served a cold red drink. -Staff handed out pre portioned bags of potato chips. -Two residents were given a bag with five potato chips in it. -Other residents were given a bag of chips with twice that amount in them. 3. During an interview on 1/19/23 at 9:15 A.M. the Administrator said: -Resident #2 would complain daily about something. -Resident #2 was frequently upset and complained about the food. During an interview on 1/19/23 at 9:45 A.M. the Dietary Supervisor said: -The temperature of the food was checked before it went out. -The Beast was plugged in to an electrical outlet to keep the food warm. -He/she has had some complaints about the food not being warm on the second floor. -Some of the kitchen staff were out ill. -The kitchen staff checked the temperature of the food on the unit before it was served. -It took 30 minutes from the time the food cart was filled to the time the trays were delivered to the last room on the floors. -The kitchen staff was to test two trays for the temperature of the food after it was delivered to the floors. -There was no documentation of testing the temperature of the food in the kitchen before it left the kitchen or when it arrived on the floors to be served to the residents. -The trays had not been tested for temperature since the Thursday after Christmas due to being short staffed related to staff illnesses in the kitchen. -Snacks were delivered to the floors at 10:00 A.M., 3:00 P.M., and 7:00 P.M. -Everyone got a small snack and a drink. -They do not do large or double portions. -Residents could get a second helping of food or there was always soup in addition to the meal. -The Beast was used for the third floor. -The Beast should stay at 160 degrees F. -The other cart was not heated and used on the second floor because they had residents who were on isolation. -If the residents desired to have more food a second helping of food was available. -The nursing staff did not call the kitchen to ask for any second helpings. -He/she had more than enough food and just threw food away. -There had been times when the food had been cold. -Nursing staff could heat the cold food up in the microwave on the floors. -He/she knew of at least two times since January 1st that the food had been cold, because the residents complained about it. -The trays to the third floor go up in the Beast. -The trays to the second floor go up in the plastic cart. -They do not have a second Beast. -He/she had not heard any complaints about the chicken not being cooked. -Resident #2 wrote a note every day complaining about the food being cold or not tasting good. During an interview on 1/19/23 at 12:15 P.M. Licensed Practical Nurse (LPN) C said: -The food here was bad. -The food was not warm. -The quality was bad. -The food did not look good. -In the last two weeks he/she had two or three resident complaints about the food being cold. -The food could be reheated in the microwave. -There was no rapport between the kitchen and nursing staff. -He/she had not seen the kitchen staff check the temperatures of the food when it was delivered to the floors. During an interview on 1/19/23 at 4:15 P.M. the Director of Nursing (DON) said: -He/she had some complaints from the residents about the food being cold in the last two weeks. -They used a heated tray cart that plugged in to keep the food warm on the third floor. -Staff were to plug it in to ensure the food stayed warm. -They used a hot cart for the second floor. -The Kitchen manager was responsible to ensure food was served warm. MO00212336 MO00212460

Based on interview and record review, the facility failed to invite one sampled resident (Resident #41) to their quarterly care plan meetings out of 19 sampled residents. The facility census was 75 residents. 1. Record review of Resident #41's undated face sheet showed the resident admitted with the following diagnoses: -Altered Mental Status (AMS- a group of cognitive and physical symptoms that differ from the baseline mental status). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood). -Personal History of Transient Ischemic Attack (TIA- temporary interference with blood supply to the brain) without deficits. Record review of the resident's Social Service's note dated 8/16/22 showed: -The resident did not speak a lot to anyone. -When he/she did it was often a low tone mumble. -The resident was alert and oriented to self and immediate surroundings. -Social Service visited 1-2 times weekly for added stimulation. Record review of the resident's medical record showed there was no documentation of the resident being invited to his/her care plan meeting. During an interview on 11/14/22 at 2:23 P.M. the resident was able to answer yes/no questions and said: -No when asked if he/she had been invited to any care plan meetings. -Yes when asked if he/she would like to participate in his/her care plan meetings. During an interview on 11/16/22 at 1:10 P.M. Licensed Practical Nurse (LPN) B said the resident usually only answered yes or no questions. During an interview on 11/17/22 at 9:37 A.M. the Social Services Director (SSD) said: -The resident's last care plan meeting was on 11/8/22. -He/she usually tried to inform residents about care plan meetings. -He/she did not have any documentation of any formal invitations provided to the resident inviting him/her to care plan meetings. -The resident could participate in simple conversations. -There was only one resident in the facility that liked to be included in care plan meetings, and it was not Resident #41. During an interview on 11/17/22 at 10:12 A.M. the Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said: -The SSD was responsible for inviting the residents to care plan meetings. -Residents should be invited quarterly to care plan meetings. -He/she did all of the care planning by himself/herself. During an interview on 11/17/22 at 11:25 A.M. the Director of Nursing (DON) said: -He/she would expect all residents to be invited to care plan meetings each quarter. -He/she expected there to be documentation of a formal invitation to residents inviting them to care plan meetings. -He/she expected documentation of resident refusal to go to care plan meetings each quarter. -He/she expected every single resident to be invited to care plan meetings regardless if they are their own person.

Based on observation, interview, and record review, the facility failed to ensure a choice in scheduled meal times; to honor a resident's request for additional food after communicating he/she was still hungry; to provide snacks when requested; to assist the resident to move to a facility closer to his/her family for one sampled resident (Resident #38); and to provide an alternate food of similar nutritive value for one sampled resident (Resident #71) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's undated Dietary Services Policy showed if a resident refused food, an alternate of a similar nutritive value, consistent with the usual and ordinary food items provided to residents, should have been offered. 1a. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party. Record review of the resident's nurse's notes dated 5/24/22 showed: -The resident requested an order for snacks which was written by the Nurse Practitioner (NP). --NOTE: No order for snacks found on the Physician's Order Sheet (POS). Record review of the resident's care plan dated 8/20/22 showed: -Staff were to orient the resident to the nursing home schedule and explain the reason for the schedule. -Staff were to offer the resident snacks/fluids when he/she exhibited behavioral issues. During an interview on 11/15/22 at 10:37 A.M., the resident said: -Staff would not provide a snack when requested. -Staff would not provide a second portion of a meal when requested. Observation on 11/15/22 at 12:31 P.M. showed: -Staff called the kitchen to get a second roll, per the resident's request. --The resident did not receive another roll. Observation on 11/16/22 at 8:53 A.M. showed the resident was resting in bed and did not eat breakfast. During an interview on 11/16/22 at 10:37 A.M., the resident said: -He/she became very angry when he/she couldn't get a snack or alternate meal. -He/she requested an alternate meal the night before but was refused. -He/she was still hungry after dinner. -He/she was not given a meal or snack if he/she slept through the scheduled meal time. 1b. Record review of the resident's nurse's note dated 5/4/22 showed: -The resident had agreed to stay at the facility until a case worker could find a skilled nursing facility with all geriatric residents as he/she did not want to be with mental health residents. Record review of the resident's care plan dated 8/20/22 showed: -Staff were to orient the resident to the facility's schedule. -There were no discharge plans at that time. Record review of the resident's Social Services note dated 11/3/22 showed the resident had requested to move to another facility out of state. During an interview on 11/16/22 at 1:48 P.M., the Social Services Director (SSD) said the 11/3/22 Social Service note was the only Social Services note since the resident's admission. During an interview on 11/17/22 at 9:05 A.M., the SSD said: -He/she was first made aware the resident had asked to move to a facility out of state in November 2022. -He/she never began searching for alternate placement for the resident. -There was no formal process for a transfer request, residents just needed to tell him/her and he/she would begin looking for placement. During an interview on 11/17/22 at 9:20 A.M., Certified Medical Technician (CMT) A said: -The resident had made several requests to move to a facility out of state. -The facility hadn't sent the request to his/her knowledge. During an interview on 11/17/22 at 9:33 A.M., Certified Nurse's Aide (CNA) B said the resident had made several requests to move to a facility out of state. During an interview on 11/17/22 at 9:36 A.M., Licensed Practical Nurse (LPN) C said: -He/she was aware the resident wanted to move to a facility out of state. -He/she believed the Director of Nursing (DON) was working on it. During an interview on 11/17/22 at 10:12 A.M., the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -The facility either did not have any discharge planning meetings or he/she had never been notified. -He/she believed the resident wanted to stay at the facility long term. During an interview on 11/17/22 at 11:01, LPN B said: -He/she had been told many times by the resident that he/she wanted to move to a facility in another state. -It was the SSD job to initiate and complete the transfer process. -He/she had told the SSD many times the resident wanted to move. During an interview on 11/17/22 at 12:11 P.M., the DON said: -He/she let the SSD know if he/she was made aware of a resident wanting to transfer facilities. -Staff were responsible for all aspects of a facility transfer, the resident only needed to verbally notify any staff member. -He/she expected the SSD to meet with any resident requesting a transfer and keep them informed of where he/she was at in the process. -He/she expected the SSD to check periodically with a resident if the resident had requested a transfer and later refused it, to ensure the resident wished to remain or restart the transfer process. -He/she was first notified by the resident that he/she wanted to transfer to a facility out of state in August 2022. -He/she was frequently told by the resident that he/she wanted to move to another facility and would immediately notify the SSD. -The SSD would say he/she met with the resident and the resident is not moving but he/she was unclear if that was the resident's or the facility's choice. -He/she was told the SSD sent paperwork to the out of state facility long before he/she started working at the facility. -He/she would expect the SSD to document any and all conversations about a transfer request. During an interview on 11/17/22 at 1:35 P.M., the resident said: -He/she wanted to move out of state to be nearer his/her family. -He/she was very upset that he/she couldn't be near family. 2. Record review of Resident #71's face sheet showed he/she was admitted to the facility as his/her own responsible party. Record review of the resident's care plan dated 10/26/22 showed staff were to encourage good nutrition and hydration to promote wound healing. Record review of the resident's POS dated 11/1/22, showed staff were to give the resident large protein portions and double portions at lunch and dinner. During an interview on 11/15/22 at 10:36 A.M., the resident said staff refused to provide an alternative meal when he/she didn't like the food. Observation on 11/15/22 at 12:29 P.M. showed the resident did not eat any protein for lunch; staff removed his/her plate without offering an alternative. During an interview on 11/16/22 at 8:42 A.M., the resident said: -The staff had a meeting with the residents the night before and stated all residents were to go to the dining room for meals. -CMT A had told the resident the facility would no longer provide alternate meals. During an interview on 11/16/22 at 10:40 A.M., the resident said: -He/she had been saving the snack sandwiches provided because if he/she didn't like dinner then he/she had nothing to eat. -He/she was furious when his/her dislikes were not taken into consideration. -He/she had not eaten any meat the day before and staff did not offer any alternate protein source. 3. During an interview on 11/16/22 at 8:24 A.M. Nursing Assistant (NA) B said: -Staff cannot offer residents alternate foods. -If a resident did not eat the staff were instructed to mark the resident had refused their meal. -Staff could only offer a make-up meal if the meal was missed due to a medical appointment. -Staff were not allowed to give alternate meals for residents that simply didn't like the food that was given to them. During an interview on 11/16/22 at 9:29 A.M., Dietary [NAME] (DC) E said: -Staff would only allow second helpings if enough food was prepared. -Staff would only give daytime snacks to residents that had a physician's order. -He/she was not allowed to give a snack off schedule unless there was a physician's order. During an interview on 11/16/22 at 9:48 A.M., CNA C said: -Daytime snacks were only given to residents with a physician's order. -Residents were allowed to purchase items from the vending machine with their own money if they wanted a snack. -Alternate meals were only provided to residents that could not eat the meal offered as the other residents would hear and would want something else too. -The facility used to have a primary and alternate menu but due to food waste they now only provided one menu and an alternate of a sandwich. During an interview on 11/16/22 at 10:08 A.M., LPN B said: -He/she was told the previous week that staff could not give alternate meals. -Kitchen staff did not announce meals ahead of time so residents were not given an opportunity to make their likes/dislikes known. -Many residents had complained about the food the previous evening but when he/she called the kitchen to request alternate meals the kitchen staff told him/her the residents get what they get. During an interview on 11/16/22 at 12:32 P.M., CMT B said: -He/she had difficulty getting alternate food for a resident that did not eat. -If a resident did not eat, he/she would try to get a pudding cup for the resident. -He/she was told by the Dietary Manager that staff were not allowed to give alternate foods, if the residents didn't like what was served that was their problem. -He/she frequently requested second portions for residents but the residents rarely received any additional food. -The facility had been trying to force residents to eat only in the dining room and had threatened to not feed any resident not in the dining room or revoke the resident's smoking privileges. -The facility did not allow residents to decide when they eat, residents must follow the facility's meal schedule. -If a resident didn't eat a meal or missed a meal, the resident had to wait until snack time for food. -If a resident requested meal times different than the facility's schedule it would not be honored. During an interview on 11/16/22 at 1:10 P.M., CNA B said: -The kitchen won't always give residents an alternate meal. -Daytime snacks were only for residents with a physician's order. -Snacks were given three times a day for residents with an order, and once at bedtime for all residents. -Some residents ordered take-out food if they were hungry because the kitchen wouldn't give them more food. During an interview on 11/16/22 at 1:21 P.M., the Dietary Manager said: -Alternate meals were only provided for residents that had dietary restrictions. -If a resident's tray returned to the kitchen without a large portion of food eaten, the kitchen staff should provide a substitute. -Kitchen staff offered a peanut butter and jelly or turkey and cheese sandwich if a resident did not eat their protein. During an interview on 11/17/22 at 12:11 P.M., the DON said: -He/she expected an equivalent substitute of equal nutritional value to be offered to any resident who didn't like the food they were served. -A peanut butter and jelly sandwich or a turkey with cheese sandwich were not appropriate substitutes for a resident that required double protein portions. -He/she expected residents to be provided a snack whenever they voiced being hungry. -He/she was aware the Dietary Manager had told the care staff that no alternate meals would be offered. -He/she believed all residents were entitled to a snack at each snack time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse/neglect or mistreatment while under supervision of the facility staff, resulting in a resident to resident altercation for two sampled residents (Resident #73 and #66), who both had potential reactive behaviors that were known by the facility, out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's Abuse and Neglect policy dated reviewed in 2016 showed: -To ensure that resident's rights are respected and honored. -To ensure each resident is treated with dignity and care, free from abuse or neglect, to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. -An resident to resident alteration or mistreatment was defined as a negative, often aggressive, interaction between residents in long term care communities. These incidents include but not limited to: physical, verbal and sexual abuse and are likely to cause emotional and or physical harm. Other examples of a resident to resident mistreatment include: roommate conflicts, invasion of privacy and personal space; and verbal threats and harassment. 1. Record review of Resident #73's admission Face-Sheet showed he/she had the following diagnoses: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Was his/her own responsible person. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/7/22 showed he/she: -Was cognitively intact and able to make his/her needs known. -Had disorganized thinking and would switch subjects or have rambling speech. -Was on antianxiety (a drug used to treat symptoms of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) and antidepressant (a drug used to reduce feelings of sadness and worry) medication. Record review of the resident's nurse's notes dated 11/8/22 at 1:40 A.M. showed: -He/she had reported to the nurse he/she had been hit in the back by his/her roommate (Resident #66). -He/she had around a five centimeter (cm) red mark on the left side of his/her back. -He/she was moved to another room closer to the nurse's station. -Nursing staff had notified the Director of Nursing (DON) and the Administrator of the resident to resident altercation/incident. Record review of the resident's individualized behavioral care plan initiated on 9/29/22 showed: -The resident was hyperactive and intrusive of others personal space, he/she did not understand boundaries. -The care plan did not show any updated or new interventions documented following the 11/8/22 resident to resident altercation. Observation on 11/15/22 at 8:55 P.M. showed: -The resident was in the living area. -The resident would come to the nursing station and ask questions of the staff. During interview on 11/16/22 at 8:47 A.M., the resident said: -His/her old roommate (Resident #66) was upset and he/she had hit him/her with a cup on his/her back. -He/she was moved to a different room. -The resident said he/she felt safe at the facility and had no further concerns. -He/she had no other incidents with his/her old roommate (Resident #66). -NOTE: He/she did not go into details and had flight of ideas and changed subjects. Record review of the resident's medical record showed there was not any ongoing behavioral monitoring. 2. Record review of Resident #66's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Stroke. -Traumatic amputation (severing/removal of limb) of the right lower leg at knee level. -He/she was his/her own responsible person. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was cognitively intact and able to make his/her needs known. -Had no documentation of behaviors noted. -Was able to provide own care and transfer himself/herself. -Required use of a wheelchair for mobility. Record review of the resident's nurse's notes dated 11/8/22 at 1:40 A.M. showed: -He/she had hit his/her roommate (Resident #73) in the back with his/her thermos cup because he/she was mad. -His/her roommate (Resident #73) had farted and was laughing and disrespected him/her. -Nursing staff informed the resident that his/her behavior was not acceptable behavior. -The DON and Administrator were notified. Record review of the resident's individualized Care plan showed: -The resident had no behavioral care plan prior 11/8/22. -He/she did not have any new intervention documented in his/her care plan immediately after his/her resident to resident altercation on 11/8/22. Observation on 11/15/22 at 8:55 P.M., of the resident showed: -He/she was in the living area and had no interaction with Resident #73. -The resident had no outburst, behaviors or conflicts with peers noted. -He/she was having an appropriate conversation with peers and staff. Record review of the resident's medical record showed no additional documentation related to his/her behaviors. During an interview on 11/16/22 at 6:55 A.M., the resident said: -His/her old roommate (Resident #73) was farting and laughed about it and that was being disrespectful to the resident. -He/she asked the roommate (Resident #73) to go out of room since he/she was trying to eat. --His/her old roommate (Resident #73) continued to fart and laugh. -He/she had become upset and threw the cup at the roommate (Resident #73) to get him/her to stop the farting and laughing. -He/she had learned in prison you do not do that behavior, it was disrespectful. The roommate would not listen when asked to stop. -He/she was sorry that it happen but would do it again, if he/she had to. -He/she did not plan to harm the roommate (Resident #73), he/she was reacting to the roommates (Resident #73) behavior that did not stop after being asked several times. -Had no other issues with any other peers or with former roommate since 11/8/22. -They try to stay away from each other. Record review of the resident's medical record showed there was no ongoing behavioral monitoring. 3. Record review of the facility hand written nurse's documentation related to the resident to resident altercation on 11/8/22 showed:. -On 11/8/22 at 1:40 A.M., Resident #73 came to Registered Nurse (RN) A and said the his/her roommate (Resident #66) hit him/her in back with a cup. He/she had a five cm red mark on left side on his/her back. -RN A went to Resident #73's roommate (Resident #66) and asked why he/she hit Resident #73. -Resident #66 said Resident #73 was farting and laughing while he/she was eating. -He/she said Resident #73, was disrespectful to him/her. -Resident #66 said he/she had learned in prison, you do not do that. -He/she said Resident #73 was a punk and he/she was not going to try to teach him/her about respect no more. -Resident #66, said he/she would hit Resident #73 again if he/she disrespected him/her again. -Resident #66 said the facility staff can throw him/her out on the street and he/she would not care. -Nursing staff informed Resident #66 that he/she could not be hitting people. -Resident #66 had apologized to the facility nurse, but would not apologize to Resident #73. -Resident #73 was moved to a different room for the night and the nurse had notified the DON and Administrator. Record review of the hand written statement report dated 11/9/22 showed: -The charge nurse had messaged the Administrator about the incident on 11/8/22. -Resident #73 had been moved to a different room and had no further incident. -He/she had spoken to Resident #73 and he/she was fine with the room move and was ok being separated from the previous roommates. -Resident #73 said he/she was not hurt, he/she would be fine and felt safe at the facility. -The Administrative staff would monitor behaviors of each of the residents for further episodes to ensure safety of the residents. -Signed by the Administrator and dated 11/9/22. During an interview on 11/15/22 at 11:50 A.M., Certified Nursing Assistant (CNA) A said he/she was not aware of the resident incident with any roommates or any special behavioral monitoring. During an interview on 11/16/22 at 12:46 P.M. Licensed Practical Nurse (LPN) B said: -He/she was not aware of any incident. -He/she would have to ask the evening charge nurse. -Was not aware of any special behavioral monitoring for Resident #66 and Resident #73. During an interview on 11/16/22 at 2:01 P.M., the Administrator said: -He/she did not report the resident to resident altercation to other authorities including state abuse and neglect hotline. -The facility felt the altercation did not have an intent to harm and was not a willful action to harm the resident. -The facility felt this was reactive behavior by Resident #66 and was an attempt to stop another resident's behavior. -Neither resident had a guardian. They were their own responsible person. -The residents were separated immediately and a room change was made. -Staff had educated the residents on acceptable behaviors and interaction with peers by facility nursing staff. During an interview on 11/16/22 at 2:44 P.M., Administrator said: -The nurse's written report and Administrator's written note were the facility final investigation. -The facility staff did not interview any other resident due to it happened in the resident's room. -The next morning everything was calm and there were no further issues on the unit. -Had no other occurrences after the incident with the residents on 11/8/22. During an interview on 11/16/22 at 2:50 P.M. LPN A said: -He/she was not working the night of the incident. -He/she was given information during shift change report on 11/8/22. -Resident #73 had been moved to another room and both resident's were placed on 15 minute monitoring/checks. -He/she was not sure where the documentation of the monitoring was or had been documented. -The facility had in place behavioral monitoring each shift with medication pass. -The residents involved have not had any additional conflict since 11/8/22. -He/she would separate the residents, assess each resident for any injury and then place both resident's on 15 minutes checks. -He/she would notify the DON, administrator, physician and guardian if the resident had one. -He/she would document the incident in a behavioral nursing note and/or complete a facility incident report. During an interview on 11/17/22 at 6:28 A.M., RN A said: -Resident #73 had come up to him/her and said the the Mexican had hit him/her in the back with a cup. -He/she assessed Resident #73 and found a red mark on left side of his/her back. -Resident #66 said that Resident #73 was farting and laughing, he/she would not stop. Resident #66 had asked several times for Resident #73 to stop farting and laughing. Resident #66 then threw the cup toward Resident #73 and hit him/her in back. -He/she asked why Resident #66 threw the cup and he/she said that's what he/she would have done in prison. You don't disrespect peers like that. (Farting and laughing, and when he/she did not stop) -Resident #66 would not apologize to Resident #73 but did apologize to the nurse for his/her behavior. -He/she had Resident #73 take blankets and items from his/her room and was moved closer to the nurse's station. -He/she did frequent checks on Resident #73. -After the incident the nurse monitored Resident #66 during medication pass. -Both resident's had no further incident during the night or during other night/evening shifts. -He/she had reported the incident to the DON and Administrator. -He/she had documented the resident's incident on a paper nurse's note with the details of what happened. The information was then given to the Administrator for further investigation. -He/she felt this was an isolated incident. -Resident #66's behavior was a reaction to stop a behavior of Resident #73. -He/she had not seen any other behaviors of not interacting well with peers and staff. -Nursing staff would complete any behavioral monitoring documented on the resident's MAR when the resident had mental illness medications. -He/she had annual abuse and neglect training. -He/she was not aware of any updated training related to changes in regulation related to abuse and neglect reporting and behavioral health. During an interview on 11/17/22 11:25 A.M., the Social Services Designee (SSD) said: -He/she was not aware of any new intervention for the residents altercation, that would be the responsibility of the MDS coordinator. -The facility administration talked about resident behaviors or incidents during morning meetings. During an interview on 11/17/22 at 11:46 A.M. DON said: -Related to any resident to resident incidents or residents with behaviors, those residents involved would be placed on 15 minute checks. -He/she would expect staff to document on 15 minute check/monitoring form, which would include where the resident was and what time observed. Staff would initial observation. -He/she would expect one staff member assigned to this task. -He/she would expect to have a detailed nurse's note with all behaviors, statements of what happened prior to incident and after the incident or behavior and what interventions were put into place and outcome from them. -Would expect nursing to notify the resident's physician, emergency contact or guardian -The charge nurse had moved Resident #73 to a different room. -He/she would expect the facility to ensure the safety of the resident by completing and documenting 15 minute checks for each resident involved. -He/she would expect the facility to have called in the resident to resident altercation within two hours of the alleged altercation. -Would expect nursing staff or charge nurse to have completed a comprehensive detailed nursing note, completed an incident report, then provided the detailed incident report to administrator or DON. -Administration would be responsible for completing the facility's investigation of the incidents and final outcome and any follow-up needed. -He/she was unsure of the investigation process for this facility at that time. During an interview on 11/17/22 at 12:57 P.M. Administrator said: -The facility also looked at their incidents during the Quality Assurance (QA) meeting and the safety committee also looked at the incidents (safety committee meets quarterly). He/She said of the concerns, they would prioritize which concerns they would develop a Performance Improvement Plan (PIP) for. -They looked at behaviors in the QA meeting all of the time because of their population. -They talked about the residents who had more behaviors than others and what those behaviors were. -They had a protocol for how staff were to respond to behaviors-especially resident to resident and they also tried to keep the residents separated or moved if necessary in order to better manage behaviors. -The facility administration staff reviewed the resident medications to ensure they were receiving/taking them appropriately, reviewed the medications with the psychiatrist to see if there were any changes needed, they tried to be more observant of indicators for possible behaviors they may be able to prevent from occurring and implementing interventions that may prevent behaviors. -The QA community would review the results/feedback in their QA meeting. they looked at whether the issue has gotten better. -The facility staff have not had in-services recently on dealing with difficult behaviors or psychiatric behaviors, but the DON had a psychiatric background and they were going to try to implement behavioral training/psychiatric training with their nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an alleged resident to resident altercation to the state agency within the required time frame for two sampled residents (Resident #73 and #66), who had an alleged non-injury altercation, out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's Abuse and Neglect policy dated reviewed in 2016 showed: -An resident to resident alteration or mistreatment was defined as a negative, often aggressive, interaction between residents in long term care communities. These incidents include but not limited to: physical, verbal and sexual abuse and are likely to cause emotional and or physical harm. Other examples of a resident to resident mistreatment include: roommate conflicts, invasion of privacy and personal space; and verbal threats and harassment. -The suspected incident will be investigated immediately. The State Agency will be contacted if investigation was found valid. the facility will follow the investigation report policy for timely reporting. -The facility must report all allegation of mistreatment, neglect or abuse as well as injuries of unknown source, are reported immediately to administrator or to other officials in accordance with state law through established procedures. 1. Record review of Resident #73 admission Face-Sheet showed he/she had the following diagnoses: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -He/she was his/her own responsible person. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/7/22 showed he/she: -Was cognitively intact and able to make his/her needs known. -Had disorganized thinking and would switch subjects or rambling. -Was on an antianxiety (a drug used to treat symptoms of anxiety (a feeling of fear, dread, and uneasiness) and an antidepressant (used to treat depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) medication. 2. Record review of Resident #66's Face Sheet showed he/she had the following diagnoses: -Stroke. -Traumatic amputation (severing/removal of limb) of the right lower leg at knee level. -He/she was his/her own responsible person. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was cognitively intact and able to make his/her needs known. -Had no documentation of behaviors noted. -Was able to provide own care and transfer himself/herself. -Required use of a wheelchair for mobility. 3. Record review of the nurse's note related to the resident to resident altercation on 11/8/22 showed: -On 11/8/22 at 1:40 A.M., Resident #73 reported to Registered Nurse (RN) A the Mexican hit him/her in back with a cup. He/she had a five centimeter (cm) red mark on left side on his/her back. -RN A went to Resident #73 roommate (Resident #66) and asked why he/she hit Resident #73. -Resident #66 said Resident #73 was farting and laughing while he/she was eating. He/she said Resident #73, was disrespectful to him/her. -Resident #66 said he/she had learned in prison, you do not do that. He/she said Resident #73 was a punk and he/she was not going to try to teach him/her about respect no more. -Resident #66, said he/she would hit him/her again if disrespected him/her again. -Resident #66 said the facility staff can throw him/her out on the street and he/she would not care. -Nursing staff informed Resident #66 that, he/she could not be hitting people. -Resident #66 had apologized to the facility nurse, but would not apologize to Resident #73. -Resident #73 was moved to a different room for the night and the nurse notified the Director of Nursing (DON) and Administrator. Record review of the administration report showed no documentation of notifying other officials such as the state agency and law enforcement in accordance with state and federal law . During an interview on 11/16/22 at 2:01 P.M., Administrator said: -He/she did not report the resident to resident altercation to other authorities including state agency abuse and neglect hotline. -The facility did not feel the altercation was an intent to harm and was not a willful action to harm the resident. -The facility felt this was a reactive behavior by Resident #66 and was an attempt to stop another resident's behavior. -Neither resident had a guardian. They both were their own responsible person. -The residents were separated immediately and a room change was made. -Staff had educated the resident's on acceptable behaviors and interaction with peers by facility nursing staff. During an interview on 11/17/22 at 11:46 A.M. DON said: -Would expect nursing to notify the resident's physician, and emergency contact or guardian. -He/she would expect the facility to have reported the resident to resident altercation within two hours of the alleged altercation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough investigation of a resident to resident altercation that showed the circumstances of the incident, what occurred, what the facility's response was, witness statements (including residents) and the facility's plan of action to prevent the recurrence for two sampled residents (Resident #73 and #66) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's Abuse and Neglect policy dated reviewed in 2016 showed: -To ensure each resident is treated with dignity and care, free from abuse or neglect, to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. -An resident to resident alteration or mistreatment was defined as a negative, often aggressive, interaction between residents in long term care communities. These incidents include but not limited to: physical, verbal and sexual abuse and are likely to cause emotional and or physical harm. Other examples of a resident to resident mistreatment include: roommate conflicts, invasion of privacy and personal space; and verbal threats and harassment. -The suspected incident will be investigated immediately. The State Agency will be contacted if investigation was found valid. the facility will follow the investigation report policy for timely reporting. -The facility also assures a timely, thorough, and objective investigation of all allegations of abuse, neglect or mistreatment. -Investigation including collecting evidences such witness interview all involved, roommate interviews, confirm and determine what happen or if did happen., assessing the resident for any bruising, laceration or signs of distress and document findings, psychical and mental assessment on both suspect and victim. -Include a summary/conclusion of the findings to determine an abuse or negligence had occurred. Intervention put in place and plan to prevent further behavior or occurrence. 1. Record review of Resident #73's admission Face-Sheet showed he/she had the following diagnoses: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -He/she was his/her own responsible person. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/7/22 showed he/she: -Was cognitively intact and able to make his/her needs known. -Had disorganized thinking and would switch subjects or rambling. -Was on antianxiety and antidepressants medication During interview on 11/16/22 at 8:47 A.M., the resident said: -His/her old roommate (Resident #66) was upset and he/she had hit him/her with cup on his/her back. -He/she was moved to a different room. -He/she felt safe at the facility and had no further concern. -He/she had no other incidents with his/her old roommate. Record review of the resident's medical record showed there was no documentation of ongoing behavioral monitoring. 2. Record review of Resident #66's Face Sheet showed he/she had the following diagnoses: -Stroke. -Traumatic amputation (severing/removal of limb) of the right lower leg at knee level. -He/she was his/her own responsible person. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was cognitively intact and able to make his/her needs known. -Had no documentation of behaviors noted. -Was able to provide own care and transfer himself/herself. -Required use of a wheelchair for mobility. Record review of the resident's medical record showed there was no documentation of ongoing behavioral monitoring. 3. Record review of the nurse's note dated 11/8/22 related to the resident to resident altercation showed: -On 11/8/22 at 1:40 A.M., Resident #73 reported to Registered Nurse (RN) A the Mexican hit him/her in back with a cup. He/she had a five centimeter (cm) red mark on left side on his/her back. -RN A went to Resident #73's roommate (Resident #66) and asked why he/she hit Resident #73. -Resident #66 said Resident #73 was farting and laughing while he/she was eating. He/she said Resident #73, was disrespectful to him/her. -Resident #66 said he/she had learned in prison, you do not do that. He/she said Resident #73 was a punk and he/she was not going to try to teach him/her about respect no more. -Resident #66, said he/she would hit him/her again if he/she disrespected him/her again. -Resident #66 said the facility staff can throw him/her out on the street and he/she would not care. -Nursing staff informed Resident #66 he/she could not be hitting people. -Resident #66 had apologized to the facility nurse, but would not apologize to Resident #73. -Resident #73 was moved to a different room for the night and the nurse had notified the DON and Administrator. Record review of the Administrators statement dated 11/9/22 showed: -RN A had messaged him/her about the incident on 11/8/22. -Resident #73 had been moved to a different room and had no further incidents. -He/she had spoken to Resident #73 and he/she was fine with the room move and was ok being separated from the Resident #66. -Resident #73 said he/she was not hurt, he/she will be fine and felt safe at the facility. -The Administrative staff would monitor behaviors of both of the residents for further episode to ensure safety of the residents. -It was signed by the Administrator and dated 11/9/22. -The facility did not complete a thorough investigation of the resident to resident alteration. During an interview on 11/16/22 at 2:50 P.M. LPN A said: -He/she would notify the Director of Nursing (DON), Administrator, resident's Physician and guardian if the resident had one. -He/she would document the incident in a behavioral nursing note and/or complete a facility incident report. -The Administrator or the DON would complete the facility investigation. During an interview on 11/16/22 at 2:44 P.M., Administrator said: -The nurse's written report of the incident his/her written note were the facility's final investigation. -The facility staff did not interview any other resident due to it happen in the residents room. -The next morning everything was calm and had no further issue on the unit. -Had no other occurrence after incident with residents on 11/8/22. During an interview on 11/17/22 at 6:28 A.M., RN A said: -He/she had annual abuse and neglect training. -He/she was not aware any update training related to changes in regulation related to abuse and neglect reporting and behavioral health. During an interview on 11/17/22 11:25 A.M., Social Services Designee (SSD) said: -He/she was not aware of any new interventions for the residents after the altercation, that would be the responsibility of the MDS coordinator. -The facility administration talked about resident behaviors or incidents during morning meetings. During an interview on 11/17/22 at 12:57 P.M. Administrator said: -The facility also looked at incidents during the Quality Assurance (QA) meeting and the safety committee also looked at the incidents (safety committee met quarterly). -They would prioritize which concerns they will develop a Performance Improvement Plan (PIP) for. -They looked at behaviors in their QA meeting all the time because of their population and they talked about the residents who had more behaviors than others and what those behaviors were. -They had a protocol for how staff were to respond to behaviors-especially resident to resident and they also tried to keep the residents separated or moved if necessary in order to better manage behaviors. -The administrative staff reviewed the resident medications to ensure they were receiving/taking them appropriately, and reviewed the medications with the Psychiatrist to see if there were any changes needed. -They tried to be more observant of indicators for possible behaviors they may be able to prevent from occurring and implementing interventions that may prevent behaviors. -The QA community would review the results/feedback in their QA meeting. they looked at whether the issue had gotten better. -The staff had not had in-services recently on dealing with difficult behaviors or psychiatric behaviors. During an interview on 11/17/22 at 11:46 A.M. the DON said: -Any resident to resident incidents or residents with behaviors, the residents involved would be placed on 15 minute checks. -He/she would expect staff to document on 15 minute check/monitoring form, which would include where the resident was and what time observed. Staff would initial the observation. -He/she would expect one staff member to be assigned to this task. -He/she would expect a nurse's note with details of all incidents/behaviors, statements of what happened prior to the incident/behavior and after the incident/behavior and what interventions were put into place and the outcome from them. -He/she would expect nursing to notify the resident's physician, emergency contact or guardian. -He/she would expect staff to ensure the safety of the residents by completing and documenting 15 minute checks for each resident involved. -He/she would expect staff to report resident to resident altercation within 2 hours of the alleged altercation. -He/she would expect the charge nurse to document a thorough nurse's note, complete an incident report, then provide the detailed incident report to Administrator or DON. -Administration would be responsible for completing the facility's investigation of the incidents and final outcome, including any follow-up needed.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan that met the medical, nursing, mental, and psychosocial needs by addressing major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's policy titled Policy for Care Plan dated 2014 showed: -The care plan shall be comprehensively communicated to all care staff that addresses short-term problem/services and long-term problem/services. -The Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator communicates with a care staff, licensed and non-licensed personnel and reviews medical records in order to obtain the information for developing the care plan. -The MDS coordinator communicates with other care providers to ensure the care plan reflects interventions such as hospice services, rehab, and psychological therapies. - Care plans will be reviewed and updated every three months during care plan meetings with input from all care plan team members. 1. Record review of Resident #41's undated face sheet showed he/she admitted with a diagnosis of Major Depressive Disorder. Record review of the resident's most recent Social Service's note dated 8/16/22 showed: -The resident did not speak a lot to anyone. -When he/she did speak it was often in a low mumble. Record review of the resident's care plan dated 11/9/22 showed there was no focus or intervention in place for his/her diagnosis of depression. During an interview on 11/14/22 at 2:23 P.M. the resident was able to answer yes/no questions and said: -No when asked if he/she was aware of what a care plan was. -No when asked if he/she had been asked any questions regarding his/her care. -No when asked if he/she had been asked about attending a care plan meeting. During an interview on 11/16/22 at 1:10 P.M. Licensed Practical Nurse (LPN) B said: -He/she did not normally mess with the care plans. -Whoever completed care plans used the nurse's notes to determine care areas that needed to be updated. During an interview on 11/17/22 at 9:30 A.M. LPN C said: -He/she thought that care plans were updated by the Director of Nursing (DON) and medical records. -Care plans should reflect the resident's current condition and be updated with acute changes as needed. During an interview on 11/17/22 at 9:37 A.M. the Social Services Director (SSD) said: -The resident was not always able to comprehend things and that it was best to have a simple conversations with him/her. -Care plans should reflect the current condition of the resident. -Residents with a diagnosis of depression should have a care plan that addresses depression. During an interview on 11/17/22 at 10:12 A.M. the MDS Coordinator said: -Care plans should reflect the resident's current condition. -Residents with a diagnosis of depression should have that addressed in the care plan. -He/she has to go to the resident charts to find the information needed to develop care plans. During an interview on 11/17/22 at 11:25 A.M. the DON said: -Care plans should reflect the current condition of the resident. -He/she would expect that care plans include a focus and interventions in place for the residents diagnosed with depression.

Based on interview and record review, the facility failed to include any direct care staff, the resident, and/or the resident's representative when developing a comprehensive care plan for one sampled resident (Resident #38) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's policy titled Policy for Care Plan dated 2014 showed: -Care plans were to be developed with input from an interdisciplinary team (IDT) as well as the resident/family. -Care plans will be reviewed and updated every three months during care plan meetings with input from all care plan team members. 1. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party with diagnoses of: -Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). -Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). During an interview on 11/16/22 at 1:48 P.M., the Social Services Designee (SSD) said: -Care plans were done by the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator. -He/she did not involve the residents in their care planning because they became agitated. During an interview on 11/17/22 at 10:05 A.M., the SSD said: -He/she was responsible for inviting residents and their family to care plan meetings. -He/she had no documentation of inviting residents or their families. During an interview on 11/17/22 at 10:12 A.M., the MDS Coordinator said: -The SSD was responsible for inviting residents and family to the care plan meetings. -He/she believed the residents should be involved with their care planning. -He/she did not include resident preferences for food choices, meal times, or waking schedule in the care plans as the residents changed their minds frequently so it didn't matter. -He/she expected residents that were their own guardian to be asked what their preferences were for care planning reasons. -He/she did the care plans alone with only information gathered from the resident's chart. -No residents or other staff were involved in the care planning process. During an interview on 11/17/22 at 12:11 P.M., the Director of Nursing (DON) said: -He/she expected residents to be involved in their own care planning and their preferences to be honored. -He/she expected the care plan to be accurate. During an interview on 11/17/22 at 1:35 P.M., the resident said: -He/she wanted to go to his/her own care plan meeting. -He/she believed he/she should be allowed to make his/her own choices known.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide one sampled resident (Resident #41) with proper Activities of Daily Living (ADL) care necessary to maintain grooming and care plan the procedures necessary to carry out grooming care out of 19 sampled residents. The facility census was 75 residents. 1. Record review of Resident #41's undated face sheet showed the resident admitted on [DATE] with the following diagnoses: -Personal History of Transient Ischemic Attack (TIA- temporary interference with blood supply to the brain) without deficits. -Essential (Primary) Hypertension (HTN-high blood pressure). Record review of the resident's care plan dated 11/9/22 showed: -The resident was fully dependent on care staff for personal hygiene and oral care. -No interventions for behaviors during ADL care and what the care staff could do to aide in completion of the grooming ADL's. Observation on 11/14/22 at 2:30 P.M. showed the resident had food crumbs and red liquid dried on his/her lower lip and on his/her chin. Observation on 11/15/22 at 11:22 A.M. showed the resident had red liquid dried on his/her lower lip and on his/her chin. During an interview on 11/16/22 at 8:15 A.M. Nursing Assistant (NA) B said: -The resident needed assistance with most of his/her ADL's. -The resident got assistance with grooming every day and evening shift. -The resident had refused his/her last two showers. During an interview on 11/16/22 at 12:57 P.M. Certified Nursing Assistant (CNA) B said: -The resident needed assistance with all grooming ADL's. -If the resident looked disheveled or unkempt he/she would provide whatever assistance would be needed to make the resident appear as he/she would want. -The resident did not like when care staff tried to clean his/her face and had behaviors that made it difficult to meet his/her needs. During an interview on 11/16/22 at 1:10 P.M. Licensed Practical Nurse (LPN) B said: -The resident had always needed help with ADL's since he/she had been working at the facility. -The resident had behaviors that made it difficult to complete grooming ADL's. -If the resident looked disheveled or unkempt he/she would perform the assistance that would be needed to make the resident appear as he/she would want or delegate the task. -The resident did not like when his/her face got cleaned and the care staff tried to use a cloth instead of wet wipes because he/she seemed to tolerate that better. Observation on 11/17/22 at 9:25 A.M. showed the resident had food crumbs on the right side of his/her lower lip and a red line of dried red liquid underneath his/her lower lip with it going into the resident's chin. During an interview on 11/17/22 at 9:46 A.M. the Social Services Director (SSD) said: -Care plans should reflect the resident's current condition. -The resident's care plan should include any care updates that may assist the care staff in completing ADL's. -The resident's care plan should have specific interventions in place when the resident was exhibiting behaviors during ADL care that were needed to keep the resident and care staff safe. During an interview on 11/17/22 at 11:25 A.M. the Director of Nursing (DON) said: -He/she would expect all care staff to assist any resident who needed assistance with ADL's to make them look how each individual would want to look. -He/she would expect the care staff to have assisted the resident in cleaning his/her face and chin when it was notably dirty. -He/she would expect the care plans to reflect the resident's current condition. -He/she would expect care plans to have specific interventions in place for the care staff to be able to complete ADL care when a resident was exhibiting behaviors or refusing care. -He/she would expect the staff to complete the behavior sheet if the resident was refusing care or exhibiting behaviors such as hitting.

Based on observation, interview and record review, the facility failed to accurately document medication administration and any refusal of medication; to notify the resident's physician of ongoing refusal of medication and document notification with outcome for one sampled resident (Resident #57) out 19 sampled residents. The facility census of 75 residents. 1. Record review of Resident #57's admission Face-sheet showed he/she had the following diagnosis: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behaviors. -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Non-compliance with medication. -Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Traumatic brain injury (TBI damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile) -Paranoid personality disorder (PPD is one of a group of conditions called eccentric personality disorders. People with PPD suffer from paranoia, an unrelenting mistrust and suspicion of others, even when there is no reason to be suspicious). -He/she was own responsible person. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 9/26/22 showed he/she: -Was cognitively intact and able to make his/her needs known. -Had disorganized thinking and would switch subjects or have rambling speech. -Had delusions (fixed false beliefs). -No documentation of psychotropic medications given during seven day look back. Record review of the resident's Physician Order Sheet (POS) dated 10/1/22 to 10/31/22 showed: -Trulicity (an injectable diabetes medicine that is used together with diet and exercise to improve blood sugar control) 0.75 milligrams (mg)/0.5 milliliter (ml) was to be administered by injection of 0.75 mg subcutaneously (SQ) every week on Wednesday. -Glipizide Extended release (ER) 10 mg one tab by mouth every morning for diabetes. -Januvia 50 mg was to be given one tab by mouth in morning diabetes. -Meloxicam 15 mg was to be given one tab by mouth in morning for joint pain. -Prilosec 20 mg was to be given one cap by mouth in morning for Acid reflux. -Tegretol 100 mg was to be given one tab by mouth twice a day for bipolar disorder. -Neurontin 300 mg was to be given one capsule by mouth three times a day for nerve pain. -Elavil 25 mg was to be given one tab by mouth at bedtime for depression and nerve pain. -Banophen 25 mg was to be given four capsules by mouth at bedtime for insomnia. -Losartin-HCTZ 50-12.5 mg was to be given one tab by mouth at bedtime for high blood pressure. Record review of the resident's Medication Administration Record (MAR) dated 10/1/22 to 10/31/22 showed: -Glipizide ER the initials were circled indicating the mediation was not given three out of 31 opportunities. --There was no documentation as to why the medication was not given. -Glipizide ER was blank 10 out of 31 opportunities. --There was no documentation as to why the medication was not given. -Januvia the initials were circled indicating the mediation was not given one out of 31 opportunities. --There was no documentation as to why the medication was not given. -Januvia was blank 10 out of 31 opportunities. --There was no documentation as to why the medication was not given. -Meloxicam was blank 13 out of 31 opportunities. --There was no documentation as to why the medication was not given. -Prilosec was blank 11 out of 31 opportunities. --There was no documentation as to why the medication was not given. -Tegretal the initials were circled indicating the mediation was not given 14 out of 62 opportunities. --There was no documentation as to why the medication was not given seven out of 14 times. -Tegretal was blank 19 out of 62 opportunities. -Neurontin the initials were circled indicating the mediation was not given four out of 93 opportunities. --There was no documentation as to why the medication was not given four out of four times. -Neurontin was blank 51 out of 93 opportunities. --There was no documentation as to why the medication was not given. -Elavil the initials were circled indicating the mediation was not given 12 out of 31 opportunities. --There was no documentation as to why the medication was not given six out of 12 times. -Elavil was blank eight out of 31 opportunities. --There was no documentation as to why the medication was not given. -Banophen the initials were circled indicating the mediation was not given 12 out of 31 opportunities. --There was no documentation as to why the medication was not given six out of 12 times. -Banophen was blank eight out of 31 opportunities. --There was no documentation as to why the medication was not given. -Losartan-HCTZ the initials were circled indicating the mediation was not given 13 out of 31 opportunities. --There was no documentation as to why the medication was not given seven out of 13 times. Record review of the resident's MAR dated 11/1/22 to 11/30/22 showed from 11/1/22 to 11/13/22: -Trulicity the initials were circled indicating the mediation was not given on 11/9/22. --Documentation on the back of the MAR indicated the resident would let nursing know when he/she would take it. -Tegretal was blank seven out of 26 opportunities. --There was no documentation as to why the medication was not given. -Neurontin was blank 13 our of 39 opportunities. --There was no documentation as to why the medication was not given. -Elavil was blank seven out of 13 opportunities. --There was no documentation as to why the medication was not given. -Banophen was blank seven out of 13 opportunities. --There was no documentation as to why the medication was not given. -Losartan-HCTZ was blank seven out of 13 opportunities. --There was no documentation as to why the medication was not given. Record review of the resident's Behavioral Care plan revised on 11/14/22 showed: -The resident had behaviors of refusal of cares to include medication. -Interventions included: --Staff were to ensure scheduled medications were administered following the physician's orders. --He/she had a history of accusing staff of not giving cares or medications when he/she had actually refused them. --Housekeeping and care staff were to go into the resident room in pairs. --Resident was to have a mental health evaluation on next rounds mental health rounds. During an interview on 11/15/22 at 10:00 A.M., Licensed Practical Nurse (LPN) A said: -The refusal of medication should have been documented on the back of the resident's MAR. -The refusal of medication should have been documented in the resident's nurse's notes. -If the resident refused a medication more than two times in a row, his/her physician should have been notified of the refusals. -Notification of the resident's physician regarding refusal of medications should have been documented in the resident's nurse's notes. Observation on 11/16/22 at 10:25 A.M. of the resident's Medication Administration by Certified Medication Technician (CMT) A showed: -The resident received six medications that morning. -The resident become agitated and verbally aggressive towards CMT A and the surveyor. -The resident would not allow observation of medications being given to the resident. -CMT A exited the resident room with an empty medication cup. During an interview on 11/16/22 at 10:25 A.M. CMT A said: -The resident had taken his/her medication without difficulty. -The resident normally would take medication from him/her. -If the resident would refuse his/her medications, he/she would document the refusal on the back of the resident's MAR and would notify the charge nurse. During an interview on 11/17/22 at 6:28 A.M., Registered Nurse (RN) A said: -On the night shift of 11/16/22, the resident had barricaded himself/herself in his/her room with a suitcase and refused all medication that night. -The resident responded through the door when asked if he/she wanted his/her medication. -The resident was verbally aggressive towards staff and told nursing staff to get out. -The resident's physician had been notified in the past related to his/her refusal of medication and his/her outburst behaviors. -He/she was not aware of any new interventions or any medication changes made. -He/she would expect nursing staff and the CMT's to document on MAR with their initials and then circle when resident had refused a medication. -He/she would then document on back MAR what medication was refused, time and any follow-up completed. -He/she also would document any behavior or refusal of medication or care in the resident's nurse's notes. -If the MAR was blank, either the nurse or CMT had forgotten to document due to not having the time to document medication given or medication was not given. During an interview on 11/17/22 at 11:46 A.M., the Director of Nursing (DON) said: -He/she would expect nursing staff to notify the resident's physician of refusal of medication. -The resident's physician was aware of the resident's non-compliance with medication and no plan was in place to intervene. -He/she would expect nursing staff and CMT's to document all refusal of medication, by initialing the MAR and then circling their initials. -On the back of the MAR should be documentation as to why the medication was not given. Complaint #MO 00208653

Based on observation, interview and record review, the facility failed to follow-up with recommendations from a hearing exam, to include a return appointment for hearing aids for one sampled resident (Resident #40) out of 19 sampled residents. The facility census was 75 residents. A policy related to follow-up of outside appointments was requested and not provided at the time of exit. 1. Record review of Resident #40's admission Face Sheet showed he/she was his/her own responsible person. Record review the resident's Audiology Visit Summary Report dated 2/24/22 at 10:20 A.M. showed: -The resident was referred to the hearing clinic by the facility due to decreased hearing. -The resident had a hearing exam on 2/24/22. -The resident had profound hearing loss in the right ear and moderate/severe hearing loss in left ear. -The resident staid he/she would be getting a hearing aid elsewhere. -Plan was for a follow-up hearing aid evaluation in three to six months. -The Audiologist clinic was to be notified immediately if the resident's primary care physician did not agree with the plan of treatment. -The resident had no other documentation related to having hearing aids ordered. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/21/22 showed he/she: -Was moderately cognitively impaired. -Was able to understand others and make his/her needs known. -Had moderate difficulty in hearing. -He/she did not have hearing aids. Record review of the resident's medical record dated 2/1/22 to 11/17/22 showed: -The resident had no physician orders or other documentation for a follow-up hearing aid evaluation in three to six months. -No documentation indicating hearing aids had been ordered for the resident. Observation on 11/14/22 at 10:00 A.M. showed the resident: -Was able to make his/her needs known. -Had difficulty understanding others at times as a result of his/her decreased hearing. -Staff had to be closer to the resident and had to raise their voice so the resident could hear them. During an interview on 11/14/22 at 10:00 A.M., the resident said: -He/she had a concern about to his/her hearing screening. -He/she didn't know when he/she was going to get his/her hearing aids. -He/she thought the facility had ordered his/her hearing aids. -He/she was wondering why the hearing aids were taking so long. During an interview on 11/16/22 at 9:25 A.M., the MDS Coordinator said: -He/she could not locate any notes related to the resident's hearing aids or if hearing aids had been ordered. -He/she had reached out to the hearing clinic to find out if they still recommended the hearing aids or if they had a plan or next step for the resident obtaining hearing aids. During an interview 11/16/22 at 1:50 P.M. Licensed Practical Nurse (LPN) A said: -He/she was not aware of the resident's hearing aid appointment for fitting hearing aids or ordering hearing aids. -The nursing staff were responsible for making the resident's medical appointments. During an interview on 11/17/22 at 10:00 A.M., the Social Services Director (SSD) said; -He/she was not aware of the resident requiring hearing aids or any pending appointments. -He/she would make appointments for residents be seen by the Audiologist at the facility. -Nursing staff would be responsible for any medical appointment outside the facility. During an interview on 11/17/22 at 11:46 A.M., the Director of Nursing (DON) said: -The resident's physician orders were to be transcribed by the nurse who took the order. -He/she would expect Social Services staff to be responsible for follow-up to appointments and to ensure the physician's order for evaluation for hearing aids had been completed and if hearing aids had been ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a physician's order for oxygen was transcribed to the resident's physician's order sheet and to ensure oxygen nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) and tubing was stored to prevent contamination when not in use for one sampled resident (Resident #42) out of 19 sampled residents. The facility census was 75 residents. 1. Record review of Resident #42's Face Sheet showed he/she was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), seasonal allergies, high cholesterol and arthritis. Record review of the resident's Care Plan updated 7/25/22 showed the resident received oxygen at 2 liters per minute. Staff were to: -Change the oxygen tubing on Sunday. -Check oxygen settings every shift and as needed. -Notify the nurse of respiratory difficulty. -Check oxygen saturation levels as needed. -Place oxygen and tubing in a bag when not in use. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/7/22, showed the resident: -Was alert and oriented without memory losses. -Was independent with bathing, dressing, eating, toileting, grooming and walking. -Received oxygen therapy. Record review of the resident's Physician's Order Sheet (POS) dated 10/22 showed a physician's order for: -Oxygen at 2 liters per minute at bedtime for COPD (order dated 10/13/22). -Change oxygen tubing every Sunday (order dated 10/13/22). Record review of the resident's POS dated 11/22 showed there were no physician's orders for oxygen on the resident's POS Record review of the resident's Treatment Administration Record (TAR) dated 11/22 showed there were no orders for oxygen or for changing the oxygen tubing. The TAR did not show that the resident's oxygen and tubing were changed. Observation on 11/14/22 at 11:56 P.M., showed the resident was not in his/her room. His/her oxygen concentrator (a medical device that concentrates environmental air and delivers it to a patient in the form of supplemental oxygen) was beside his/her bed and was turned off. The oxygen tubing and nasal cannula was coiled around the rail of the resident's bed, uncovered. Observation on 11/14/22 at 12:15 P.M., showed the resident was not in his/her room. The nasal cannula and oxygen tubing were coiled around the bed rail and was uncovered. The oxygen concentrator was beside his/her bed and was turned off. Observation on 11/16/22 at 6:54 A.M., showed the resident was laying down in his/her bed with the nasal cannula in his/her nose. The oxygen concentrator was beside his/her bed and was on at 2 liters per minute. The resident's eyes were closed and he/she seemed to be resting comfortably. During an interview on 11/16/22 at 7:05 A.M., Certified Nursing Assistant (CNA) A said: -The resident did not use oxygen during the day. He/she only used oxygen as needed and usually only wore oxygen at night. -The oxygen tubing and nasal cannula should be covered when not in use. -The resident has a physician's order for oxygen. During an interview on 11/16/22 at 8:55 A.M., Certified Medication Technician (CMT) A said: -The resident only wore oxygen as needed during the day and he/she wore oxygen primarily at night due to difficulty breathing. -There should be an order for oxygen for the resident. During an interview on 11/17/22 at 10:54 A.M., Licensed Practical Nurse (LPN) C said (regarding physician's orders on the POS): -The nurse that completed the changeover month to month was usually the night nurse because they had more time to go over the POS's and ensure the orders were carried over to the following month. -If they see a physician's order was not transcribed onto the POS, any of the nurses could write the order on the POS. -Physician's orders for oxygen should be carried over to the resident's POS every month unless it was discontinued. -Typically staff use a plastic bag to put the nasal cannula and tubing in and then date it and tape it onto the concentrator to ensure it is covered and not on the floor. -All nasal cannulas and tubing should be in a bag when not in use. During an interview on 11/17/22 at 11:46 A.M., the Director of Nursing (DON) said: -Oxygen face masks nasal cannulas and tubing should be placed in a bag when not in use. -The CNA/CMT was responsible for ensuring there were bags available for the resident. -There should be orders for oxygen. -Whichever nurse takes the physicians orders would be responsible for ensuring it was on the resident's POS. -The new monthly POS come from the pharmacy during the last week of the month. -Month to month, all of the nurses review the POS's to ensure the physician's orders were transcribed to the next month's POS correctly and were transcribed onto the Medication Administration Record (MAR) and Treatment Administration Record (TAR) correctly. -They did not have anyone specifically assigned to review the POS's month to month. -They probably did not review the resident's POS to ensure the orders were transcribed to the following month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified of an acute behavior, to document the facility intervention for one to one behavioral monitoring, to ensure timely follow up to behavioral health services was provided and to develop care plan interventions, to include a detailed suicide intervention plan, for one sampled resident (Resident #21) who had a history of verbalizing suicidal ideations and had expressed a suicidal ideation, out of 19 sampled residents. The facility census was 75 residents. Record review of the facility policies and procedures showed there was no policy and procedure for behaviors related to suicidal Ideation. The facility provided an undated Suicidal Ideation Screening form that showed screening questions to indicate whether a further more detailed assessment was indicated. Any yes answers to the initial questions indicated further assessment was necessary. The questions were: Are you seriously thinking about killing yourself? Do you have a plan for killing yourself? If you have been considering suicide, do you have the means to take your life? There were additional questions in the screening that were indicators of suicide. The screening required the assessor to determine if the resident was at risk and show the immediate interventions and notifications (responsible party and physician). 1. Record review of Resident #21's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Major depression that was recurrent and severe (a serious mood disorder. It touches every part of your life and is caused by a chemical imbalance in your brain) without psychotic features. -Substance dependence and abuse (abuse of drugs or alcohol that continues even when significant problems related to their use have developed) with withdrawal (discontinuation of the use of an addictive substance). Record review of the resident's hospital discharge records dated 9/14/22, showed: -The resident had the following diagnoses: --Stroke. --Paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia). --Depression. --Substance abuse. --Suicidal ideation. -Discharge instructions included: --Stroke education. --Patient safety plan. --Suicide risk prevention information. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/30/22, showed the resident: -Was alert and oriented without memory loss, delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly), inattention or disorganized thoughts. -Was independent with ambulating, bathing, dressing, toileting and was continent of bowel and bladder. -Had feelings of being down, depressed or hopeless. -Did not have hallucinations ( the apparent perception of something not present) or delusions (a belief that is clearly false), but had verbal behaviors that did not impact the resident's social interactions, interfere with his/her care or put the resident at risk for physical illness or injury. -Received anti-anxiety (medications used to treat anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) and anti-depressant (medication used to treat depression) medications. -The document did not show the resident was suicidal or had a history of suicidal ideations. Record review of the resident's Physician's Order Sheet (POS) dated 11/2022, showed an additional diagnosis of anxiety and medication orders for: -Hydroxyzine 50 milligrams (mg) every 12 hours as needed for anxiety (ordered on 9/27/22). -Bupropion 300 mg daily for depression (ordered on 9/27/22). -Hydroxyzine 50 mg at bedtime for anxiety (ordered on 10/26/22). -Hydroxyzine 50 mg every morning as needed for anxiety (ordered on 10/25/22). Record review of the resident's Care Plan dated 9/28/22 showed the resident would adjust to the facility. Interventions showed facility staff would: -Allow for quality time to communicate and be sensitive to non-verbal communication. -Assist with written communication if necessary. -Encourage family and friends to visit, encourage program participation. -Counsel the resident regarding responsibilities and resident rights. -Encourage the resident to participate in activities and escort to activities per request. -Explain procedures for addressing concerns, requests and complaints. -Explain resident counsel and encourage to attend and express concerns, problems, needs. -Offer choices whenever possible to promote a feeling of self worth and control over his/her environment. -Orient the resident to the nursing home schedule, explain reasons for schedules, orient to surroundings and provide daily visits. -The care plan did not show the resident had a history of depression, substance abuse and suicidal ideations and there were no interventions to specifically address how the facility would respond to the resident when exhibiting these behaviors. Record review of the resident's undated Behavior Monitoring charting showed: -Behaviors of drug seeking and suicidal ideation. -Documentation showed staff documented daily the resident had no suicidal ideations except on day 25. Record review of the resident's Nurse's Notes showed: -From 9/26/22 to 9/30/22 there was no documentation showing the resident had any behaviors. -There were no notes from 10/1/22 to 10/3/22. -On 10/3/22 the nurse documented the resident was exit seeking, had packed his/her bags, wanted to leave and be on the street. The nursing staff convinced the resident to stay in the facility. -On 10/4/22 the nurse administered Hydroxzaline to the resident. His/her mood improved and he/she was no longer exit seeking. -On 10/7/22 the resident was eating and had no complaints about leaving the facility. Hydroxazine was administered at bedtime and it seemed to be effective. The resident attended activities. -There were no further notes related to the resident wanting to leave the facility or being exit seeking. -There were no notes that showed the resident's mood or behavior. -There was no documentation showing the resident had any depression symptoms or suicidal ideations. -There was no documentation showing the facility sought any counseling services or supportive services for the resident based on the hospital documentation in the resident's medical record. Record review of the resident's Pre admission Screening and Resident Review (PASSAR-an assessment, conducted to determine if there are any indications of mental illness or intellectual or developmental disabilities) Level II Evaluation dated 10/24/22, showed the resident: -Was diagnosed with paranoid schizophrenia, attention deficit disorder, major depression that was recurrent and severe with psychotic features, anti-social personality disorder, and substance abuse. The resident had a history of childhood sexual abuse. -The resident had inpatient psychiatric treatment as recent as 9/14/22 to 9/21/22, but had several prior hospitalizations for severe depression with psychotic features and suicidal/homicidal ideations as far back as 2015. -The resident received services from the Department of Mental Health for adult community psychiatric rehabilitation, community services and supported community living. -Current supportive services included outpatient psychiatric follow up services and residing on a secured behavioral unit. -Had suicidal ideations recently and per previous records in 2016. Records dated 9/20/22 showed the resident had an overall low level of suicide risk. -Had historically felt his/her long struggle with depression and suicidal ideation was a result of his/her extensive past sexual abuse. Notes during a recent hospitalization (dated 9/2022) showed there was improvement in the resident's depression. -Had limited attention, poor concentration, impaired intellect and poor knowledge and judgement. -Was fully independent with daily living but liked to self-isolate and do independent activities, no group activities. -Received anti-depressant and anti-anxiety medications that were given by facility staff. Record review of the resident's Medical Record showed the Suicidal Screening Form was not in the resident's medical record. Record review of the resident's Nurse's Notes showed: -On 10/25/22 the Physician was on rounds and there was a new order for scheduled anxiety medication. --The nurse documented the resident was attending activities, got up and went to his/her room began to cry, stating he/she had not seen his/her children in several years and they would not talk to him/her. --The nurse documented the resident said he/she wished he/she were dead. One to one monitoring was provided. --The nurse documented the resident had no plan for suicide, but he/she requested to speak with a counselor. -The nurse's notes did not show that the facility staff notified the resident's physician, Director of Nursing (DON), Administrator or Social Service Director (SSD) of the resident's suicidal ideation. --There was no documentation showing how long the facility staff provided the resident with one to one monitoring (duration) and there was no documentation showing the facility assisted the resident to access acute suicide prevention services at any time after the incident occurred. -There were no follow up notes from 10/25/22 to 11/7/22. -On 11/7/22 the note showed the resident's physician was in the building and ordered an x-ray for the resident. -There was no documentation showing the physician was ever notified of the incident on 10/25/22 or any follow up services provided that were related to his/her verbalizing suicidal ideation. Record review of the resident's undated Behavior Monitoring Charting showed: -On day 25 the resident had one suicidal ideation on the evening shift. -The facility staff provided one to one monitoring, that was documented as successful. Record review of the resident's Medical Record showed there was no record of the one to one monitoring that was provided to the resident on 10/25/22 as was documented in the resident's nursing note on 10/25/22. Record review of the resident's SSD Notes showed there were no notes showing the SSD was notified of the resident's suicidal ideation or that there were any interventions that the SSD provided on that date to assist the resident emotionally. Record review of the resident's Medical Record showed there were no psychological, psychiatric or counseling services initiated for the resident. During an interview on 11/16/22 at 9:31 A.M., the resident was sitting on his/her bed in his/her room. He/she was alert and oriented and said: -He/she was usually in a depressed state, but he/she did not always feel bad. -He/she received medication for depression and had been on an anti-depressant for a long time, prior to entering the facility. -He/she had a history of suicidal ideation and had been hospitalized prior to entering the facility for suicidal ideations. -Currently he/she did not have any feelings of wanting to harm himself/herself, but last month he/she told nursing staff that he/she wanted to die and was feeling very depressed about his/her life, generally (he/she said he/she did not remember the exact date). -Staff came to his/her room and talked to him/her. He/She said he/she did not have any actual plan to harm himself/herself. -He/she asked to see a counselor but he/she never saw anyone to talk to about his depression or suicidal ideations. -The Social Service Worker at the facility did not talk to him/her about the incident or about his/her feelings of suicide and depression. -The facility staff told him/her that they would take him/her to the counseling center tomorrow (11/17/22), but he/she has not seen a counselor to date. During an interview on 11/16/22 at 7:30 A.M., Certified Nursing Assistant (CNA) A said: -When the resident first came to the facility, he/she was very thin, sad, depressed and he/she would cry in his/her room and not socialize. -He/she would go into the resident's room and try to encourage him/her to come to eat and socialize with peers. -He/she would also just talk to him/her to try to find out why he/she was upset and to try to comfort him/her. -He/she was not aware of the resident wanting to harm himself/herself or the incident on 10/25/22 when he/she made a suicidal ideation. During an interview on 11/16/22 at 8:52 A.M., Certified Medication Technician (CMT) A said: -The resident reportedly had a suicidal ideation last month, but he/she was not aware of the resident ever saying that he/she didn't want to live anymore. -The staff scheduled an appointment with psychiatric services last week for the resident, but he/she was not sure what actually occurred. -The resident did receive medication for depression and anxiety. -The resident was very quiet and pleasant and he/she had not heard the resident say anything that would alert him/her to the resident having suicidal ideations. During an interview on 11/16/22 at 9:34 A.M., the MDS Coordinator said: -He/she was not aware of the resident's verbalization of suicidal ideations on 10/25/22. -On 10/25/22, he/she was aware that the night nurse said the resident was crying and had depression and the nurse stayed with the resident for a while. -He/she was aware that the resident requested to go to outside counseling vendor at that time and the nurse wrote a note for the SSD to follow up. -He/she did not know what had been done since then, but he/she thought someone had taken the resident to the outside counseling vendor. -The resident had just had the PASSAR completed and he/she was responsible for ensuring this assessment was obtained. -He/she was responsible for completing the resident's care plan. -If the resident had suicidal thoughts or ideations, the nursing staff was supposed to find out if the resident had a plan and they should have sent the resident out to the hospital for a psychiatric evaluation and treatment. -He/she did not know if the physician was notified at the time of the incident, but the resident was his/her own responsible party. -When providing one to one monitoring, they do not document the one to one monitoring on a form, but documentation of the incident and nursing response should be in the nursing notes. -The resident had not seen long term psychiatric management services regarding his psychiatric medications since admitting to the facility and did not know if his/her medications had been reviewed. During an interview on 11/16/22 at 2:01 P.M., the SSD said: -He/she was not made aware of an incident on 10/25/22 when the resident verbalized a suicidal ideation and was placed on one to one monitoring. -He/she received a note that the resident requested to see a counselor so he/she scheduled an appointment with the mental health vendor. -He/she took the resident to the outside mental health vendor on 10/27/22 for intake, but he/she did not have a copy of the intake records or anything that occurred while the resident was there because the vendor would not provide it. -While the resident was there he/she assisted the resident to complete the intake document. At that time, the resident did not state that he/she had had any suicidal ideations. -On the form, there was a section on suicidal history and the resident did not document having any suicidal ideations. -On 10/28/22 he/she took the resident back to the mental health vendor and the resident met with them for two hours, but the vendor did not provide any information regarding what was discussed. -If a resident made a statement of not wanting to live the nursing staff would notify the charge nurse and DON, Admin, physician and place the resident on one to one monitoring and they would send the resident out for an evaluation he/she said this should also be in his care plan. -He/She should also be notified so that he/she could also interview the resident and initiate interventions that may assist the resident. During an interview on 11/16/22 at 3:01 P.M., the SSD said he/she had found the documents requested and she/she: -Provided a printout from the mental health vendor. -Provided the SSD notes regarding what the resident said, and what the vendor would provide. Record review of the resident's SSD Notes showed: -There were no notes on 10/25/22 showing the SSD was informed of the resident's suicidal ideation or participated in any acute treatment or interventions for the resident. -A Social Service Note dated 10/28/22, showed the SSD took the resident to the mental health vendor for an intake appointment and the resident said he/she wanted to speak to a counselor about his/her past physical, mental and sexual abuse, poor relationship with his/her child, his/her sexual orientation and identification that had been problematic for him/her. --The note did not address anything related to the incident on 10/25/22 or suicidal ideation. Record review of the resident's mental health vendor documentation dated 10/31/22, showed: -The resident was referred to the mental health vendor for outpatient therapy for symptom management (unidentified), independent living skills, communication/relationship skills, management of chronic health condition (unidentified), budgeting and housing. The document did not show the vendor had a counseling session or discussed the recent suicidal ideation with him/her. During an interview on 11/16/22 at 3:01 P.M., the SSD said: -The mental health vendor completed an initial screening and assessment of the resident, but he/she did not know for sure if there was a counseling session because he/she was not in the room with the resident at the time and the resident did not discuss what they discussed. -If the resident had voiced suicidal ideations or thoughts of harming himself/herself at the time of his/her visit to the mental health vendor on 10/28/22, they would not have allowed him/her to leave the mental health facility and would have recommended hospitalization for the resident. During an interview on 11/17/22 10:54 AM Licensed Practical Nurse (LPN) C said: -He/She spoke with the resident frequently and he/she had expressed depression about being in a facility and regrets with his/her children, but he/she had never expressed any statements of wanting to harm himself/herself. -If a resident made an expression of wanting to harm themselves, they were to immediately put the resident on 15 minute checks, then notify the physician, next of kin or guardian, the DON, Administrator and follow up with any orders given. -The nurse's should try to identify the root cause and make any changes as needed to their interventions. -If the resident had a suicide plan, then they would send the resident to the hospital for evaluation and treatment. -Initially when the resident was admitted , he/she was upset about not having access to his/her money but the resident was able to resolve that issue and seemed to be adjusting to the facility. During an interview on 11/17/22 at 11:46 A.M., the DON said: -The protocol for any resident who made suicidal ideations was to place the resident on one to one monitoring immediately if the resident had a suicide plan, or on 15 minute checks if the resident did not have a plan for self-harm. -One to one monitoring should be documented on the form they used for documenting where the resident was located and what they were doing and who was assigned to the resident. -He/She expected staff to notify the resident's responsible party and physician immediately and also notify him/her, the Administrator and follow the recommendation of the physician. -Staff should document all the information and write a detailed nurse's note regarding what occurred leading up to the behavior, what behaviors occurred and what interventions were implemented to assist the resident. -Due to him/her being newly hired, he/she did not know if the facility protocol was to immediately send the resident to the hospital for evaluation and treatment or if the nursing staff were supposed to document an incident report. -They should have attempted follow up support services right away to assist the resident with his/her behavior. -If they had prior knowledge of the resident's suicidal ideation history, they should have had interventions that were specific to the resident's behaviors and interventions showing psychiatric and counseling services were being initiated in order to try to prevent acute behaviors and support the resident. -Care planning interventions should show what behaviors the resident had so the interventions could be tailored to the resident such as keeping the resident away from sharp objects and things the resident could use to hurt himself/herself. -The incident on 10/25/22 occurred on his/her second day in the facility, but staff did not make him/her aware of the incident until this week.

Based on observation, interview and record review the facility failed to adequately assess, monitor, reevaluate and document ongoing verbally aggressive behaviors; and failed to implement and document a behavioral safety plan in response to increased aggressive behavioral reactions for one sampled resident (Resident #57) who had a history of inappropriate behavioral actions (barricade bedroom door), being verbally aggressive, and making threats of harm toward facility staff, out 19 sampled residents. The facility census of 75 residents. A behavior policy was requested and was not provided by the time of exit. 1. Record review of Resident #57's admission Face-sheet showed he/she had the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with behaviors. -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Non-compliance with medication. -Bipolar (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Traumatic brain injury (TBI damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile). - Paranoid personality disorder (PPD is one of a group of conditions called eccentric personality disorders. People with PPD suffer from paranoia, an unrelenting mistrust and suspicion of others, even when there is no reason to be suspicious). -He/she was own responsible person. Record review of the resident's Level One screening (Department of Health and Senior Services, (DHSS) pre-admission screening for mental health illness and Intellectual disability, or related conditions) that was submitted on 12/17/22 and completed the mental exam on 12/23/21 showed: -The resident had sign and symptoms of a mental illness that included flight of thoughts, anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), agitation, being suspicious and paranoia (a mental disorder characterized by delusions and feelings of extreme distrust, suspicion, and being targeted by others). -Had diagnoses including Depression, Paranoid personality disorder, Traumatic brain injury, non-compliance, Bipolar disorder and Dementia with behaviors. -The physician had signed the resident was not currently a danger to himself/herself and others. -Referred for Level II screening. Record review of the resident's Level II Evaluation/Screening for admission into long term care facility dated 1/26/22 showed: -The resident had substantial Dementia. -The resident had been determined that he/she had meet skilled nursing facility admission requirements. -Did not require needs for specialized psychiatric services. -The facility must continuously assess the resident for any significant changes in status. -The facility needed to promptly notify the Department of Mental Health Services (DMH) regarding any changes of condition. Record review of the resident's Physician Progress note dated 9/15/22 showed: -The resident was a bit confused, but at baseline, he/she was anxious and fairly agitated. -Was on medication for agitation. -The resident had refused lab work. -He/she had encouraged the resident to complete his/her blood work follow-up. -No other plan for follow-up related to behaviors. Record review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 9/26/22 showed he/she: -Was cognitively intact and able to make his/her needs known. -Had disorganized thinking and had delusions (fixed false beliefs). Record review of the resident's Social Service Director (SSD) note dated 11/3/22 showed: -Numerous times the Social Services staff had gone to the resident's room and knocked on the door, tried to open the resident's bedroom door and found the resident had blocked the bedroom door with the closest door. -The resident was preventing others from entering his/her room. -The resident said he/she was looking for clothing when he/she was actually sitting on the bed. -Social Services had spoken to the resident in great detail related to the fire safety concern. -The resident said he/she did not care. He/she would call emergency number (911) himself/herself. -Social Service reminded the resident he/she did not have a phone in his/her room and would not be able to call 911 for fire or other medical needs. -The resident was argumentative and cursing at Social Services. -The administrative team discussed the situation and the decision was made to remove the resident's closet door for his/her safety. -The resident had been educated several times related to his/her safety and on-going behavior of blocking the bedroom door. Record review of the resident's Nurse's Note date 11/3/22 at 4:00 P.M. showed: -The Maintenance supervisor reported that he/she had removed the resident's closet door due to the resident using the closet door to barricade himself/herself in his/her room. -The resident was preventing anyone else from entering his/her room. This behavior was causing a fire hazard and could be potential concern in a medical emergency. -When the resident was receiving his/her evening medications, he/she told staff that damn door better get put back on right now. -The nurse explained to the resident the closet door was removed due to a fire hazard. -The door was removed in direction of the Administrator. -The resident's began yelling at the nurse and said you best get that person up here, I will smack him/her in the face. -The resident continued to yell obscenities. -The resident came out to the living area after slamming his/her bedroom door. Record review of the resident's Non-Compliance and Behavioral Care plan revised on 11/14/22 showed the resident: -Would refuse cares, refusing medications, refusing lab draws, refusing physician visits. -Had a history of accusing staff of not providing cares or medications when he/she had actually refused them. -Could be verbally aggressive with staff and making verbal threats -Would curse at staff. -Refused to let housekeeping enter his/her room. -Threatened administrative staff related to social security. -Accused staff of stealing from him/her. -Had a history of barricading himself/herself in his/her bedroom by blocking the door to keep people/staff from entering room. -Would slam his/her doors frequently. -Staff were to utilize the following interventions: --Approach him/her in a nonjudgmental manner. --Identify influencing factors associated with noncompliant behaviors. --Listen to his/her reason for noncompliance. --Re-direct or remove him/her from situation. --Let the resident express his/her feelings. --Staff were to provide cares and services in pairs. --Resident was to have a mental health evaluation on next rounds. --Staff were to monitor and report signs and symptoms of increased agitation. Record review of the resident's medical record showed: -There was no documentation related to the resident having a mental health re-evaluation since admission. During an interview on 11/14/22 at 12:10 P.M. the resident said: -He/she was a person and staff should only focus on his/her needs. -He/she wanted his/her concerns and issues addressed and didn't care about others. -He/she felt he/she was being neglected by staff. --When asked he/she did not give any specific details. --He/she had a list of issues and concerns in his/her room. -He/she wanted to know what the staff were going to do about his/her concerns. --He/she asked who sent the surveyor to the facility. ---The surveyor started to explain the investigation process. -He/she was showing signs of increased agitation, made a sound of disgust and rolled his/her eyes. Observation on 11/14/22 at 12:10 P.M. showed the resident: -Was sitting in dining activity area for the noon meal. -Was short tempered and demanding of staff. -Was able to feed himself/herself and provide his/her own personal cares throughout the meal. -Had no odors and was well groomed. -Had become more agitated and verbally assertive towards staff by the end of the meal. -Finished his/her meal and walked out of the dining area, went to his/her room, and slammed the door shut. Observation on 11/14/22 at 1:30 P.M., of the resident showed: -There was a sign on his/her door to knock before entering his/her room. -He/she was in a private room. -Staff were trying to provide services timely and answer his/her questions. Observation on 11/16/22 at 6:43 A.M., of the resident showed: -He/she was in the dining/smoke area. -He/she walked to his/her room and slammed the bedroom door shut. During an interview on 11/16/22 at 6:43 A.M. Certified Medication Technician (CMT) A said: -Any time the resident starts slamming doors in the morning, it was not going to be a good day for the resident. -If he/she asked a questions and the answer was not what he/she wanted to hear, he/she would get upset and storm off back to his/her room and then slam his/her bedroom door. Observation on 11/16/22 at 10:25 A.M. of the resident's Medication Administration by CMT A showed the resident: -Received six medication that morning. -Become agitated and verbally aggressive. During an interview on 11/17/22 at 6:28 A.M., Registered Nurse (RN) A said -On night shift of 11/16/22, the resident had barricaded himself/herself in his/her room with a suitcase and had refused all medication. -The resident responded through the door when asked if he/she wanted his/her medications. -The resident was verbally aggressive and told staff to get out. -The resident's physician had been notified in the past related to his/her refusal of medication and his/her outburst behaviors. --The resident's physician was not notified every time medications or cares were refused. -He/she was not aware of any new interventions or medication changes made. -He/she would expect nursing staff and the CMT's to document on MAR with their initial and then circle when the resident refused medications. -He/she would document on the back of the MAR the medication that was refused, the time of the refusal and any follow-up that was completed. -He/she would document any behaviors or refusal of medication or cares in the resident's nurse's notes. -If the MAR was blank, either the nurse or CMT had forgotten to document or the medication was not given. During an interview on 11/17/22 at 11:12 A.M. Certified Nursing Assistant (CNA) A said: -He/she had no specific training on how to handle residents who were aggravated, upset, or had increased behaviors. -CNA's did not have access to the resident's plan of care. -The facility care staff had Assistant Daily Living (ADL) sheets for each resident, that showed the cares needed and the type of assistance needed. During an interview on 11/17/22 at 11:25 A.M., Social Services Designee (SSD) said: -The resident did not like or get along with him/her. -He/she would scream at him/her and other staff members. -He/she recently took some disability paperwork to the resident. -He/she offered assistance to the resident and the resident became verbally aggressive toward him/her. -The resident told him/her to get out of his/her room, he/she didn't need any assistance filling out paperwork. -The resident barricaded himself/herself in his/her room using the closet door for a week. -After speaking with the resident and him/her continuing to barricade himself/herself in his/her room, the closet door was removed for his/her safety. -The resident had a history of non-compliance with cares and medications. -The resident's admission assessment noted the resident was nice person, was hard to talk to, but very agreeable. -When he/she first came to the facility the resident had refused to be in room with another resident and he/she had been non-complaint and verbally aggressive. -Administrative staff would discuss issues, concerns and resident behaviors during the morning meeting. -The MDS Coordinator was responsible for making any mental heath appointments for the resident. -He/she didn't know if the resident had been referred or actually had any mental health evaluations after his/her admission to the facility. -The resident refused to sign the consent to see the mental health physician upon admission. During an interview on 11/17/22 at 12:57 P.M. Administrator said: -The facility looked at incidents during the Quality Assurance (QA) meeting and the safety committee looked at the incidents quarterly when they met. -Concerns were prioritized which then Performance Improvement Plans (PIP) were developed. -They looked at behaviors in the QA meeting all the time because of their population. -They talk about the residents who have behaviors and what those behaviors are. -They have a protocol for how staff were to respond to behaviors-especially resident to resident altercations, and they tried to keep the residents separated or moved if necessary in order to better manage behaviors. -The facility administrative staff reviewed the resident medications to ensure they were receiving/taking them appropriately, they reviewed the medications with the Psychiatrist to see if there were any changes needed. -They tried to be more observant of indicators for possible behaviors they may be able to prevent by implementing interventions that may prevent behaviors. -The QA community would review the results/feedback in their QA meeting. -The staff have not had in-services recently on dealing with difficult behaviors or psychiatric behaviors, During an interview on 11/17/22 at 11:46 A.M. Director of Nursing (DON) said: -He/she would expect nursing staff to notify the resident's physician of refusal of medication or cares. -The resident's physician was aware of the resident's non-compliance with medication and cares. -There was no plan in place to intervene at this time. -Resident's involved in altercations would be placed on 15 minute checks. -He/she would expect staff to document on 15 minute check/monitoring form, which would include where the resident was, behaviors and what time the resident was observed. Staff would initial the observation. -He/she would expect one staff member to be assigned to this task. -He/she would expect a nurse's note with all behaviors with statements of what happened prior to the incident and after the incident and what interventions were put into place and the outcome from them. -He/she would expect nursing to notify the resident's physician, emergency contact or guardian. -He/she would expect the staff to complete and document 15 minute checks for each resident involved. -He/she would expect the nurse to have a thorough nurse's note and a completed incident report, given to him/her or the Administrator. -Administration was responsible for completing the investigation including any follow-up. -He/she would expect the nursing staff to monitor the residents for safety, whether through one to one monitoring or otherwise. -He/she would expect the resident's care plan interventions to be implemented to help manage the resident's behaviors. -He/she would expect the behavioral safety plan to be completed and followed. Complaint #MO 00208653

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party. Record review of the resident's nurse's note dated 5/4/22 showed the resident had agreed to stay at the facility until a case worker could find a skilled nursing facility with all geriatric residents as he/she did not want to be with mental health residents. Record review of the resident's care plan dated 8/20/22 showed there were no discharge plans at that time. Record review of the resident's Social Services note dated 11/3/22 showed: -The resident had requested to move to another facility out of state. --Note: This was the only Social Services note since the resident's admission in the resident's medical record. During an interview on 11/16/22 at 1:48 P.M., the SSD said: -Care plans were done by the MDS Coordinator. -He/she did not involve the residents in their care planning because they become agitated. During an interview on 11/17/22 at 9:05 A.M., the SSD said: -He/she was aware the resident had asked to move to a facility out of state. -He/she never began searching for alternate placement for the resident. -There was no formal process for a transfer request, residents just needed to tell him/her and he/she would begin looking for placement. During an interview on 11/17/22 at 9:36 A.M., Licensed Practical Nurse (LPN) C said: -He/she was aware the resident wanted to move to a facility out of state. -He/she believed the DON was working on it. During an interview on 11/17/22 at 10:05 A.M., the SSD said: -He/she was responsible for inviting residents and their family to care plan meetings. -He/she had no documentation of inviting residents or their families. During an interview on 11/17/22 at 10:12 A.M., the MDS Coordinator said: -The SSD was responsible for inviting resident and family to the care plan meetings. -The facility either did not have any discharge planning meetings or he/she had never been notified. -He/she believed the residents should be involved with their care planning. -He/she believed the resident wanted to stay at the facility long term. -He/she expected residents that were their own guardian to be asked what their preferences were for care planning reasons. -He/she did the care plans alone with only information gathered from the resident's chart. -No residents or other staff were involved in the care planning process. During an interview on 11/17/22 at 11:01, LPN B said: -He/she had been told many times by the resident that he/she wanted to move to a facility in another state. -It was the SSD job to complete that process. -He/she had told the SSD many times the resident wanted to move. During an interview on 11/17/22 at 12:11 P.M., the DON said: -He/she let the SSD know if he/she was made aware of a resident wanting to transfer facilities. -Staff were responsible for all aspects of a facility transfer, the resident only needed to verbally notify any staff member. -He/she expected the SSD to meet with any resident requesting a transfer and keep them informed of where he/she was at in the process. -He/she expected the SSD to check periodically with a resident if the resident had requested a transfer and later refused it, to ensure the resident wished to remain or restart the transfer process. -He/she was first notified by the resident that he/she wanted to transfer to a facility out of state in August 2022. -He/she was frequently told by the resident that he/she wanted to move to another facility and would immediately notify the SSD. -The SSD would say he/she met with the resident and the resident was not moving but he/she was unclear if that was the resident's choice or the facility's. -He/she was told the SSD sent paperwork to the out of state facility long before he/she started working at the facility. -He/she would expect the SSD to document any and all conversations about a transfer request. -He/she expected residents to be involved in their own care planning and their preferences to be honored. -He/she expected the care plan to be accurate. During an interview on 11/17/22 at 1:35 P.M., the resident said: -He/she wanted to go to his/her own care plan meeting. -He/she believed he/she should be allowed to make his/her own choices known. -He/she wanted to move out of state to be nearer to his/her family and had notified staff multiple times. -He/she was very upset that he/she couldn't be near family. Based on interview and record review, the facility failed to ensure adequate social services were implemented upon admission when a history of depression and suicidal ideation was known; to provide acute interventions after an acute behavior and requested counseling services for one sampled resident (Resident #21); and to provide assistance with or make arrangements for a transfer to another facility for one sampled resident (Resident #38) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's undated policy titled Discharge and Transfer Resident showed: -Residents were to be assessed for discharge potentials at admission, quarterly, and when a verbal request was made by a resident. -Residents were to be interviewed quarterly, at a minimum, to assess discharge wishes. -The Social Services Director (SSD) was to offer the option of discharge to each resident during each care plan meeting. 1. Record review of Resident #21's Face Sheet showed he/she was admitted on [DATE] with diagnoses including: -Major depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) that was recurrent and severe, without psychotic (conditions that affect the mind, where there has been some loss of contact with reality) features. -Substance dependence and abuse (abuse of drugs or alcohol that continues even when significant problems related to their use have developed) with withdrawal (the syndrome of often painful physical and psychological symptoms that follows discontinuance of an addicting drug). Record review of the resident's hospital discharge records dated 9/14/22, showed he/she had diagnoses including stroke, paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia), depression, substance abuse and suicidal ideation. Documentation showed discharge instructions included stroke education, patient safety plan and suicide risk prevention information. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/30/22, showed the resident: -Was alert and oriented without memory loss, delirium, inattention or disorganized thoughts. -Was independent with ambulating, bathing, dressing, toileting and was continent of bowel and bladder. -Had feelings of being down, depressed or hopeless. -Did not have hallucinations or delusions, but had verbal behaviors that did not impact the resident's social interactions, interfere with his/her care or put the resident at risk for physical illness or injury. -Received anxiety and anti-depressant medications. -The document did not show the resident was suicidal or had a history of suicidal ideations. Record review of the resident's Physician's Order Sheet (POS) dated 11/22, showed an additional diagnosis of anxiety and medication orders for: -Hydroxyzine 50 milligrams (mg) every 12 hours as needed for anxiety (ordered on 9/27/22). -Bupropion HCL XL 300 mg daily for depression (ordered on 9/27/22). -Hydroxyzine 50 mg at bedtime for anxiety (ordered on 10/26/22). -Hydroxyzine 50 mg every morning as needed for anxiety (ordered on 10/25/22). Record review of the resident's Care Plan dated 9/28/22 showed the resident would adjust to the facility. Interventions showed facility staff would: -Allow for quality time to communicate and be sensitive to non-verbal communication. -Assist with written communication if necessary. -Encourage family and friends to visit, encourage program participation. -Counsel the resident regarding responsibilities and resident rights. -Encourage the resident to participate in activities and escort to activities per request. Explain procedures for addressing concerns, requests and complaints. -Explain resident counsel and encourage to attend and express concerns, problems, needs. -Offer choices whenever possible to promote a feeling of self worth and control over his/her environment. -Orient the resident to the nursing home schedule, explain reasons for schedules, orient to surroundings and provide daily visits. -The care plan did not show the resident had a history of depression, substance abuse and suicidal ideations and there were no interventions to specifically address how the facility would respond to the resident when exhibiting these behaviors. Record review of the resident's Medical Record showed there was no Social Service Assessment in the resident's medical record. Record review of the resident's undated Behavior Monitoring charting showed: -The resident had behaviors of drug seeking and suicidal ideation. -Staff documented daily the resident had no suicidal ideations except on day 25. Record review of the resident's Nurse's Notes showed: -From 9/26/22 to 9/30/22 there was no documentation showing the resident had any behaviors. -There were no notes from 10/1/22 to 10/3/22. -On 10/3/22 the nurse documented the resident was exit seeking, had packed his/her bags, wanted to leave and be on the street. The nursing staff convinced the resident to stay in the facility. -On 10/4/22 the nurse administered Hydroxzaline to the resident. His/her mood improved and he/she was no longer exit seeking. -On 10/7/22 the resident was eating and had no complaints about leaving the facility. Hydroxazine was administered at bedtime and it seemed to be effective. The resident attended activities. -There were no further notes related to the resident wanting to leave the facility or being exit seeking. There were no notes that showed the resident's mood or behavior. There was no documentation showing the resident had any depression symptoms or suicidal ideations. There was no documentation showing the facility sought any counseling services or supportive services for the resident based on the hospital documentation in the resident's medical record. Record review of the resident's Pre-admission Screening and Resident Review (PASSAR-an assessment, conducted to determine if there are any indications of mental illness or intellectual or developmental disabilities) Level II Evaluation dated 10/24/22, showed the resident: -Was diagnosed with paranoid schizophrenia, attention deficit disorder, major depression that was recurrent and severe with psychotic features, anti-social personality disorder, and substance abuse. The resident had a history of childhood sexual abuse. -The resident had inpatient psychiatric treatment as recent as 9/14/22 to 9/21/22, but had several prior hospitalizations for severe depression with psychotic features and suicidal/homicidal ideations as far back as 2015. -The resident received services from the Department of Mental Health for adult community psychiatric rehabilitation, community services and supported community living. -Current supportive services included outpatient psychiatric follow up services and residing on a secured behavioral unit. -Had suicidal ideations recently and per previous records in 2016. Records dated 9/20/22 showed the resident had an overall low level of suicide risk. -Had historically felt his/her long struggle with depression and suicidal ideation was a result of his/her extensive past sexual abuse. Notes during a recent hospitalization (dated 9/2022) showed there was improvement in the resident's depression. -Had limited attention, poor concentration, impaired intellect and poor knowledge and judgement. -Was fully independent with daily living but liked to self-isolate and do independent activities, no group activities. -Received anti-depressant and anti-anxiety medications that were given by facility staff. Record review of the resident's Nurse's Notes showed: -On 10/25/22 showed the Physician was on rounds and there was a new order for scheduled anxiety medication. --The nurse documented the resident was attending activities, got up and went to his/her room began to cry, stating he/she had not seen his/her children in several years and they would not talk to him/her. --The nurse documented the resident said he/she wished he/she were dead. One to one monitoring was provided. --The nurse documented the resident had no plan for suicide, but he/she requested to speak with a counselor. -The nurse's notes did not show that the facility staff notified the resident's physician, Director of Nursing (DON), Administrator or Social Service Director of the resident's suicidal ideation. -There was no documentation showing the facility assisted the resident to access acute suicide prevention services at any time after the incident occurred. Record review of the resident's Medical Record showed there were no psychological, psychiatric or counseling services initiated for the resident or that the Social Service Designee followed up after the incident occurred to address the resident's suicidal ideation. During an interview on 11/16/22 at 9:31 A.M., the resident was sitting on his/her bed in his/her room. He/she was alert and oriented and said: -He/she was usually in a depressed state, but he/she did not always feel bad. -He/she received medication for depression and had been on an anti-depressant for a long time, prior to entering the facility. -He/she had a history of suicidal ideation and had been hospitalized prior to entering the facility for suicidal ideations. -Currently he/she did not have any feelings of wanting to harm himself/herself, but last month he/she told nursing staff that he/she wanted to die and was feeling very depressed about his/her life, generally (he/she said he/she did not remember the exact date). -Nursing staff came to his/her room and talked to him/her. He/She said he/she did not have any actual plan to harm himself/herself. -He/she asked to see a counselor but he/she never saw anyone to talk to about his depression or suicidal ideations. -The Social Service Worker at the facility did not talk to him/her about the incident or about his/her feelings of suicide and depression. -The facility staff told him/her that they would take him/her to the counseling center tomorrow (11/17/22), but he/she had not seen a counselor to date. During an interview on 11/16/22 at 7:30 A.M., Certified Nursing Assistant (CNA) A said: -When the resident first came to the facility, he/she was very thin, sad, depressed and he/she would cry in his/her room and not socialize. -He/she would go into the resident's room and try to encourage him/her to come to eat and socialize with peers. -He/she would also just talk to him/her to try to find out why he/she was upset and to try to comfort him/her. -He/she was not aware of the resident wanting to harm himself/herself or the incident on 10/25/22 when he/she made a suicidal ideation. During an interview on 11/16/22 at 2:01 P.M., the Social Service Designee said: -The resident had been homeless and living in a shelter prior to admitting to the facility. -He/she was aware that the resident had childhood trauma related to sexual abuse and physical abuse, and his/her family had made fun of him/her due to his/her sexual orientation. -When the resident was admitted , he/she was worried because he/she had a court appearance for outstanding warrants and at the time of the resident's scheduled court hearing, he/she was in the facility so he/she had to notify the judge so that the resident would not go to jail. -The resident used to cry and he/she spoke with the resident who said that he/she did not have access to his/her money (in the bank) and he/she wanted to purchase items to make him/her feel normal so he/she assisted the resident to resolve the issue with his/her funds and he/she went to purchase items the resident wanted and the resident was thankful. -The resident did not mention anything about having any suicidal ideations during his/her interactions with him/her. -He/she had seen the resident's medical record and noted the resident had substance abuse and depression, but he/she was not aware that the resident had a history of suicidal ideation or that his/her hospitalization prior to admitting to the facility (dated 9/20/22) showed the resident also had been treated for suicidal ideation. -He/she was not aware that the resident had a documented history of mental health hospitalizations or previous suicidal ideations that he/she was treated for and had been receiving mental health services through the Department of Mental Health. -He/she said he/she had not reviewed the resident's PASSAR because it had recently been completed. -He/she was not made aware of an incident on 10/25/22 when the resident verbalized a suicidal ideation and was placed on one to one monitoring. -He/she was notified that the resident wanted to see a counselor so he/she set up an appointment and took him/her to the mental health vendor on 10/27/22 and assisted the resident with completing the intake paperwork. -The mental health vendor did not provide any of the intake records nor did they report any information at that time. -On 10/28/22 he/she took the resident back to the mental health vendor and the resident met with them for two hours, but the vendor did not provide any information regarding what was discussed. -The resident had provided consent for the vendor to provide information to them regarding their services and the counseling session summaries but they did not provide anything. During an interview on 11/16/22 at 3:01 P.M., the Social Service Designee: -Provided a printout from the mental health vendor. -Provided social service notes regarding what the resident said and what the vendor would provide. Record review of the resident's Social Service Notes showed: -The note dated 9/26/22, showed the resident was newly admitted and was alert and oriented and said he/she did not have any family that wanted to have a relationship with him/her. The note showed the Social Service Designee would visit the resident once to twice weekly for added socialization. -There was no documentation regarding follow up mental health serves or reinstating mental health services for the resident. -The note dated 9/29/22 showed the resident was upset in the lobby and said he/she had a debit card and the funds should have been available, but he/she had forgotten the pin number and could not access his/her funds. The resident said he/she wanted to purchase items to make him/her feel normal. --The Social Service Designee documented he/she purchased the items the resident requested and also tried to resolve the issue with his/her debit card. The resident was thankful. -The note dated 10/28/22 showed the Social Service Designee took the resident to the appointment at the mental health vendor and the resident said he/she wanted to speak with a counselor about his/her past physical, mental and sexual abuse, poor relationship with his child, his/her sexual orientation and identification that has been problematic for him/her. --The note did not address anything related to the incident on 10/25/22 or suicidal ideation. During an interview on 11/16/22 at 3:01 P.M., the Social Service Designee said: -The mental health vendor completed an initial screening and assessment of the resident, but he/she did not know for sure if there was a counseling session because he/she was not in the room with the resident at the time and the resident did not discuss what they discussed. -If the resident had voiced suicidal ideations or thoughts of harming himself/herself at the time of his/her visit to the mental health vendor on 10/28/22, they would not have allowed him/her to leave the mental health facility and would have recommended hospitalization for the resident. -The mental health vendor would complete counseling services and psychiatric medication management for the resident. -If he/she was aware of the resident's psychiatric history, they could have sought out services upon admission, but he/she did not know the resident had any suicidal ideations because the nursing staff did not inform him/her of it when the incident occurred. During an interview on 11/17/22 at 11:46 A.M., the DON said: -They should have attempted follow up support services right away to assist the resident with his/her behavior. -If they had prior knowledge of the resident's suicidal ideation history, they should have had interventions that were specific to the resident's behaviors and interventions showing psychiatric and counseling services were being initiated in order to try to prevent acute behaviors and support the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician's diet orders were followed for one sampled resident (Resident #52) with a diagnosis of dysphagia (difficulty swallowing) and orders for a mechanical soft diet (a diet designed for people who have trouble chewing and swallowing; chopped, ground foods are included in this diet, as well as foods that break apart without a knife) out of 19 sampled residents; and failed to follow the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) Salisbury steak and pureed cabbage and carrots to ensure those items had the consistency of creamy paste or liquid. This practice potentially affected at least six residents with pureed diets. The facility census was 75 residents. 1. Record review of Resident #52's Face Sheet showed he/she was admitted on [DATE], with diagnoses including: -Delusional disorder ( mental health condition in which a person can't tell what's real from what's imagined). -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). -Tremors (an involuntary quivering movement). Record review of the resident's Video Swallow Evaluation dated 12/1/21, showed: -The resident had aspiration (the accidental breathing in of food or fluid into the lungs) events at the facility. -His/her speech therapy treatment problem was dysphagia with possible aspiration pneumonia. -Recommendation for diet consistency was soft, ground foods with thin liquids, remain up right after meals 60 minutes, single cup sips, small bites of food, small sips of liquid. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/15/22, showed the resident: -Had significant cognitive impairment and memory loss. -Was independent with ambulation, bathing, dressing, toileting and needed supervision with eating/meal set up. -Did not have a chewing or swallowing problem. -Had no teeth and/or broken teeth. Record review of the resident's Dietary History and Initial Screening dated 7/22/22, showed the resident: -Had physician's orders for a mechanical soft diet. -Needed a mechanical soft diet for chewing difficulty. -Had good intake and was independent with eating. Record review of the resident's Care Plan updated 7/25/22, showed the resident had the potential for aspiration and choking. Staff interventions included: -Monitor for choking during food consumption. -Monitor for signs and symptoms of swallowing difficulty and report. -Monitor for texture intolerance and report. -Provide and serve diet as ordered. Monitor intake and record each meal. -The Registered Dietician (RD) will evaluate and make diet recommendations as needed. Record review of the resident's monthly Physician's Order Sheet (POS) dated from 8/2022 to 11/2022, showed physician's dietary orders for a mechanical soft diet. Record review of the resident's Nutritional Evaluation dated 10/10/22, showed he/she received a mechanical soft diet and had adequate intake that met the resident's needs. It showed the resident's current plan of care was continued. There were no recommendations for any changes to his/her diet. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Had significant cognitive incapacity and memory issues. -Needed supervision with eating/meal set up. -Had no chewing or swallowing problem. Record review of the resident's diet card showed a regular diet. Observation on 11/14/22 at 1:04 P.M., showed the resident was sitting in the main dining room eating a regular diet of beef (that was not ground), with cabbage and vegetables with choice of beverages. He/she was eating without an assistive devices or assistance. The resident did not seem to have any choking or coughing while eating. Observation on 11/15/22 at 12:49 P.M., showed the resident was served a regular diet of pork fritter (that was not ground meat) with gravy, green beans and stuffing. He/She was eating without choking or coughing. Observation and interview on 11/15/22 at 12:55 P.M., showed in the kitchen on the steam table there was a container of pork fritters and another container of ground meat. [NAME] A said the ground meat was pork fritters for residents who received mechanical soft diets and the residents on a regular diet received the pork fritter that was not ground. During an interview on 11/16/22 at 8:57 A.M., Certified Medication Technician (CMT) A said: -The resident usually had a good appetite and he/she ate a regular diet. -(After looking in the resident's medical record) the resident's diet order showed he/she was to receive a mechanical soft diet. Observation on 11/16/22 at 12:30 P.M., showed the resident was in the dining room eating a regular diet of a smothered pork chop (that was not ground) with buttered noodles, squash and a dinner roll with a choice of beverages. The resident was trying to cut the pork cutlet with a spoon. The resident was able to cut pieces of meat and eat it without choking or coughing. During an interview on 11/16/22 at 12:33 P.M., [NAME] A said: -The mechanical diet meat was ground pork with a gravy added. -The dietary staff knew the diet orders for the residents by following the diet order on the resident's diet card. During an interview on 11/16/22 at 12:35 P.M., the Dietary Manager (DM) said: -He/she received a dietary communication that was sent from the nursing staff that had the resident's diet orders on it or any dietary changes. -He/she put the order on the resident's diet card and that was what the dietary staff used when they served the resident meals. -He/she normally received a copy of the resident's diet orders on the resident's POS. -He/she said he/she did not have any diet communication orders or the resident's POS. -Sometimes he/she had to track down the resident's diet order when nursing staff did not provide it to him/her. -He/she did not receive a copy of resident diet orders monthly. -For newly admitted residents, he/she received a copy of the diet communication which let him/her know the resident's diet order, resident preferences and any special needs. During an interview on 11/17/22 at 10:54 A.M., Licensed Practical Nurse (LPN) C said: -The nurse that took the dietary order from the physician was supposed to communicate it to the dietary staff verbally initially, then they also put the order on the diet communication sheet and send it to the DM. -The DM should also verify the dietary order. -The DM should also receive a POS with the resident's dietary order on it (to verify the physician's diet order). -If the resident's diet order changes, the nurse was supposed to send a dietary communication form to the DM showing the change in the diet order. -The dietary staff should follow the resident's diet orders. During an interview on 11/17/22 at 11:46 A.M., the Director of Nursing (DON) said: -They did not have good communication between the dietary department and nursing department regarding the resident dietary orders. -Currently, if there is a diet order change, the nurse will call the kitchen staff and inform them verbally. -They also have a dietary communication form that they fill out to give to the dietary staff if there was a change in the resident's diet order. -He/She did not know whether the DM received a copy of the resident's POS showing the resident's diet order. -The POS should have the diet order on it and the diet order should be followed. -He/she was trying to develop a protocol for improving the communication between nursing and the dietary staff regarding the resident diet orders. 2. Record review of the recipe for pureed Salisbury steak dated 2022, showed: -Ingredients which included Salisbury, water and beef base (a highly concentrated stock with liquids from beef) -Directions: --Dissolve beef base and water to make broth. --Place prepared meat in a sanitized food processor. --Gradually add broth as needed and blend until smooth. Observation on 11/14/22, showed: -At 11:06 A.M., the DM pureed Salisbury steak without looking at the recipe. --The DM added milk instead of beef base. -At 11:25 A.M., the DM pureed the Salisbury steak without opening the book to the recipe and he/she did not taste the finished product. -At 11:56 A.M., the pureed Salisbury steak had a mechanical soft texture. During an interview on 11/14/22 at 11:58 A.M., the Social Service Designee (SSD) said the pureed Salisbury steak had a texture like the mechanical soft Salisbury steak. During an interview on 11/14/22 at 12:02 P.M., the DM said: -He/she had one day of training in making the pureed recipes. -He/she was told by the previous dietary supervisor to use milk. -The Registered Dietitian (RD) did not tell him/her a certain length of time to puree the items for. -The RD had not said anything about them using milk. During an interview on 11/14/22 at 1:15 P.M. Dietary [NAME] (DC) C said the RD said they should use milk. During a phone interview on 11/23/22 at 9:36 A.M., the RD said: -He/she goes to the facility once per month. -He/she watched the process of pureed food once. -He/she spoke with the staff about making the pureed food. -He/she spoke with the staff about making sure there were no lumps in the pureed food and the dietary staff needed to reheat the food to 165 ºF (degrees Fahrenheit). -He/she told them to follow the recipe. -He/she did not say to use milk with the pureed recipes because milk should be used for desserts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed accommodate residents' food preferences; and to offer appealing options of similar nutritive value to residents who chose not to eat the food that was initially served or requested a different meal choice for two sampled residents (Resident #38 and #17) out of 19 sampled residents. The facility census was 75 residents. Record review of the facility's undated Dietary Services Policy showed if a resident refused food, an alternate of a similar nutritive value, consistent with the usual and ordinary food items provided to residents, should have been offered. 1. Record review of Resident #38's face sheet showed he/she was admitted to the facility as his/her own responsible party. Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by the facility staff for care planning) dated 11/11/22 showed: -He/she was cognitively intact, with a Brief Interview for Mental Status (BIMS- an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 15. -He/she did not have any signs or symptoms of swallowing difficulties. -He/she did not have an altered diet. During an interview on 11/16/22 at 10:37 A.M., the resident said: -He/she became very angry when he/she couldn't get an alternate meal. -He/she requested an alternate meal the night before but was refused. -He/she was still hungry after dinner. 2. Record review of Resident #17's face sheet showed he/she was admitted to the facility: -As his/her own responsible party. Record review of the resident's quarterly MDS dated [DATE] showed: -He/she was cognitively intact, with a BIMS of 15. -He/she did not have any signs or symptoms or swallowing difficulties. -He/she did not have an an altered diet. During an interview on 11/15/22 at 10:36 A.M., the resident said staff refused to provide an alternative meal when he/she didn't like the food. Observation on 11/15/22 at 12:29 P.M. showed the resident did not eat any protein for lunch; staff removed his/her plate without offering an alternative. During an interview on 11/16/22 at 8:42 A.M., the resident said Certified Medical Technician (CMT) A had told him/her the facility would no longer provide alternate meals. During an interview on 11/16/22 at 10:40 A.M., the resident said: -He/she had been saving the snack sandwiches provided because if he/she didn't like dinner then he/she had nothing to eat. -He/she was furious when his/her dislikes were not taken into consideration. -He/she had not eaten any meat the day before and staff did not offer any alternate protein source. 3. During an interview on 11/16/22 at 8:24 A.M., Nursing Assistant (NA) B said: -Staff cannot offer residents alternate foods; if a resident did not eat, the staff were instructed to mark the resident refused their meal. -Staff could only offer a make-up meal if the meal was missed due to a medical appointment. -Staff were not allowed to give alternate meals for residents that simply didn't like the food that was given to them. During an interview on 11/16/22 at 9:48 A.M., Certified Nursing Assistant (CNA) C said: -Alternative meals were only provided to residents that could not eat the meal offered as the other residents would hear and want something else, too. -The facility used to have a primary and alternate menu but due to food waste they now only provided one menu and an alternate of a sandwich. During an interview on 11/16/22 at 10:08 A.M., Licensed Practical Nurse (LPN) B said: -He/she was told staff could not give alternative meals. -Kitchen staff did not announce meals ahead of time so residents were not given an opportunity to make their likes/dislikes known. -The night before, many residents had complained about the food but when he/she called the kitchen to request alternate meals the kitchen staff told him/her the residents get what they get. During an interview on 11/16/22 at 12:32 P.M., CMT B said: -He/she had difficulty getting alternate food for a resident that did not eat. -If a resident did not eat, he/she would try to get a pudding cup for the resident. -He/she was told by the Dietary Manager that staff were not allowed to give alternate foods, if the residents didn't like what was served that was their problem. During an interview on 11/16/22 at 1:10 P.M., CNA B said: -The kitchen won't always give residents an alternative meal. -Some residents ordered take-out food if they were hungry because the kitchen wouldn't give them more food. During an interview on 11/16/22 at 1:21 P.M., the Dietary Manager said: -Alternate meals were only provided for residents that had dietary restrictions. -If a resident's tray returned to the kitchen without a large portion of food eaten, the kitchen staff should provide an alternate meal. -Kitchen staff offered a peanut butter and jelly or turkey and cheese sandwich if a resident did not eat their protein. During an interview on 11/17/22 at 12:11 P.M., the Director of Nursing (DON) said: -He/she expected an equivalent substitute of equal nutritional value to be offered to any resident who didn't like the food they were served. -A single sandwich was not an appropriate substitutes for a resident that required double protein portions. -He/she was aware the Dietary Manager had told the care staff that no alternate meals would be offered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure privacy curtains were clean for one sampled resident (Resident #25); failed to maintain the mattress in Resident #13's room in an easily cleanable condition and without cracks; failed to maintain the ceiling of the 3rd floor dining room free of a dust buildup; failed to maintain the fan in resident room [ROOM NUMBER] free of a dust buildup; failed to maintain the bed in resident room [ROOM NUMBER] in an easily cleanable condition; and failed to maintain a ceiling fan in the basement dining room free of a heavy dust buildup. The facility census was 75 residents. Record review of the facility's policies showed no reference to cleaning, laundering, or disinfecting residents' privacy curtains. 1. Record review of Resident #25's face sheet showed he/she was admitted to the facility with the following diagnoses: -Intellectual disability (when there are limits to a person's ability to learn at an expected level and function in daily life). -Post-Traumatic Stress Disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by the facility staff for care planning) dated 9/16/22 showed: -The resident was cognitively intact. Observation on 11/14/22 at 1:53 P.M., 11/15/22 at 11:57 A.M., and 11/16/22 at 8:22 A.M. showed: -The resident's privacy curtain #1 had a one inch diameter yellow substance adhered to the curtain and two finger sized brown streaks, each approximately one inch long. -The resident's privacy curtain #2 had a brown substance smeared, approximately half an inch wide, at eye level. During an interview on 11/14/22 at 1:53 P.M. the resident said: -He/she noticed the curtains were dirty and told unknown staff. -He/she wanted clean curtains. During an interview on 11/15/22 at 11:57 A.M. the resident said: -The curtains were still dirty. -He/she wanted clean curtains. During an interview on 11/16/22 at 8:24 A.M., Nursing Assistant (NA) B said he/she did not know who was responsible for maintaining the privacy curtains. During an interview on 11/16/22 at 8:37 A.M., Housekeeper A said he/she did not know who was responsible for the privacy curtains. During an interview on 11/16/22 at 8:50 A.M., Housekeeper B said laundry was responsible for the privacy curtains. During an interview on 11/16/22 at 9:22 A.M., Laundry Aide A said: -Laundry staff were responsible for washing curtains when they were brought to the laundry room. -He/she would never go in a resident's room and remove a curtain. -Maintaining/removing curtains was the job of maintenance and/or housekeepers. During an interview on 11/16/22 at 10:07 A.M., the Maintenance Supervisor said: -The housekeeping department was responsible for maintaining curtain cleanliness. -Curtains were to be checked weekly. -Curtains were to be removed and replaced weekly during each room's deep clean. During an interview on 11/16/22 at 10:08 A.M., Licensed Practical Nurse (LPN) B said Housekeeping was responsible for spot cleaning the curtains but only maintenance had the tool to remove the curtains so they could be laundered. During an interview on 11/16/22 at 9:48 A.M., Certified Nursing Aide (CNA) C said: -Maintenance was responsible for ensuring the privacy curtains were clean. -Maintenance was the only department that had the special tool to remove the curtains. On 11/16/22 at 12:21 P.M., Maintenance Supervisor was shown the stains/substances on the resident's curtains. Observation on 11/17/22 at 9:52 A.M. showed: -The resident's privacy curtains had not been cleaned or changed. -The right edge of privacy curtain #2 was also noted to have 2 large brown/tan spot approximately 1.5 inches in circumference and black oil/grime covered one foot of the edge of the curtain. During [NAME] interview on 11/17/22 at 9:52 A.M. the resident said: -The curtains were still dirty. -He/she wanted clean curtains in the room. During an interview on 11/17/22 at 10:59 A.M., NA C said: -He/she would not be comfortable in a room with those curtains. -The privacy curtains needed to be changed. During an interview on 11/17/22 at 12:11 P.M., the Director of Nursing (DON) said: -All staff were responsible for ensuring cleanliness. -Any staff member that saw the resident's curtains should have called housekeeping to have new curtains placed. 2. Record review of Resident #13's quarterly MDS dated [DATE] showed he/she was cognitively intact and interviewable. Observations on 11/14/22 at 8:45 A.M., and on 11/16/22 at 9:42 A.M., showed the resident's mattress had numerous cracks which made the mattress not easily cleanable. During an interview on 11/16/22 at 9:44 A.M., NA C said he/she did not notice the mattress before because the resident made his/her own bed. During an interview on 11/17/22 at 8:21 A.M., the resident said: -He/she made up her bed daily. -He/she did notice cracks in his/her mattress before, but he/she did not tell anyone that his/her mattress was cracked. Observation on 11/16/22 at 10:29 A.M. with the Maintenance Director showed a damaged mattress in resident room [ROOM NUMBER]. There was no resident in the room at the time. 3. Observation on 11/16/22 at 8:25 A.M. with the Maintenance Director showed a heavy buildup of dust on the ceiling of the third floor dining room which was also the smoking room when meals were not being served. During an interview on 11/16/22 at 8:26 A.M., the Maintenance Director said he/she tried to get the housekeepers to clean the ceiling and the fan blades one to two times every few months. Observations on 11/16/22 at 8:49 A.M. with the Maintenance Director showed a heavy buildup of dust on the fans in resident room [ROOM NUMBER]. Observation on 11/16/22 at 12:42 P.M. with the Maintenance Director showed a heavy buildup of dust on the ceiling fan in the basement dining room. During an interview on 11/17/22 at 8:22 A.M., the Maintenance Director said: -The ceiling fans were supposed to be cleaned once per month. -Many times when they try to clean the fans in the dining rooms/day rooms, the cleaning could interfere with the resident's smoking times or eating times. -In the smoke room, the dust builds up faster. -In the dining rooms, it looked like it went longer than a month for cleaning the ceiling fans.

Based on observation and interview, the facility failed to ensure the foods on the test tray after the residents on the third floor were served, maintained at or close to 120 ºF (degrees Fahrenheit) at the time of service. This practice potentially affected at least five residents who ate in the third floor dining room. The facility census was 75 residents. 1. Record review of Resident #57's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 10/14/22 showed he/she was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10 out of 15. During an interview on 11/14/22 at 1:24 P.M., the resident said all three meals he/she received were cold. Observations on 11/14/22 showed: - At 1:29 P.M., three residents on the third floor received their meals Salisbury steak at 108 ºF. - At 1:35 P.M., the temperatures of the test tray foods were taken with Certified Medication Technician (CMT) C observing and the temperatures of the cabbage/carrots was 109.6 ºF and the temperature of the Salisbury steak was 108 ºF. During an interview on 11/14/22 at 1:37 P.M., CMT C said: -Most residents from the third floor go downstairs to the large dining room to eat. -There were a few residents who want to eat on the third floor. -There were some trays that were not on the first cart so the new trays were the additional trays that were not on the first cart. During a phone interview on 11/14/22 at 9:46 A.M., the Registered Dietitian (RD) said the issue he/she had with dietary staff and cold food was that some dietary staff did not reheat the pureed food before placing on the steam table. Complaint #MO 00208653

Based on observation and interview, the facility failed to prevent the existence of live roaches in the kitchen area. This practice affected the kitchen area. The facility census was 75 residents. 1. Observations on 11/14/22, showed the following: - At 9:30 A.M., one roach crawled around and under the table at the dishwasher area. - At 9:43 A.M. one dead roach was on the ground in the dry storage room next to the kitchen - At 9:52 A.M. one dead roach was observed behind table with seasoning bottles. - At 11:23 AM., one roach was seen on the phone table next to the Dietary Manager's (DM) office. During an interview on 11/14/22 at 1:47 P.M., the DM said roaches were an ongoing problem and the pest control company came every two weeks. During an interview on 11/17/22 at 7:29 A.M., the Administrator said the dietary staff were doing cleaning in addition to having the pest control company come in to address the presence of roaches in the kitchen.

Based on observation, interview and record review, the facility failed to maintain the nozzles of the dishwasher spray wand free of debris; to maintain the vent outlets of the climate control units in the kitchen free from a heavy dust buildup; to discard molded food from the walk-in refrigerator; to ensure two thermometers were calibrated (correlate the readings of (an instrument) with those of a standard in order to check the instrument's accuracy), to ensure the food warmer was cleaned prior to use for breakfast on 11/14/22; to have test strips to test the concentration of the sanitizing agent in the sanitizing sink; and to maintain the ice machines on the 2nd floor and in the dining room free of biofilm (the result of microorganisms attaching to a surface). The facility census was 75 residents. Record review of the cleaning list for dishwashers to implement during the morning and the afternoon shifts included the following duties: - Sweep and mop the floor. - Clean the food carts inside and out. Record review of the cleaning list for dietary aides to implement during the morning and afternoon shifts, included pulling food that was three days old or older from the walk-in fridge, 1. Observation on 11/14/22 from 9:23 A.M. through 1:50 P.M., showed: - A buildup of dust was present on the vent of two air conditioners in the kitchen. - Four molded large bell peppers in the walk-in fridge. -The presence of debris inside the food cart warmer. - The presence of debris inside one utensil drawer at the seasoning storage table. - The dietary staff used a three compartment sink with separate washing, rinsing and sanitizing compartments without any test strips for the sanitizing solution concentration. - Dietary [NAME] (DC) A used a thermometer which measured the temperature of the cabbage and carrots 20 ºF (degrees Fahrenheit) more than the surveyor's thermometer. - About five minutes later, DC A used a different thermometer and it measured the temperature of the cabbage and carrots 46 ºF (degrees Fahrenheit) more than the surveyor's thermometer. During an interview on 11/14/22 at 10:19 A.M., the Social Service Designee (SSD) said that food warmer had not been used for a while , and a while in his/her estimation was a couple months. During an interview on 11/14/22 at 10:37 A.M., the Dietary Manager (DM) said he/she had been employed since August 2022 and they have not been using that food delivery cart until that day on 11/14/22. During an interview on 11/14/22 at 11:39 A.M., the DM said there were not any test strips for the sanitizing water on 11/14/22 because the test strips they had, did not correspond to what they used at the time, which was chlorine. During an interview on 11/14/22 at 12:21 P.M., DC A said he/she had not calibrated the thermometers. During an interview on 11/14/22 at 1:47 P.M., the DM said neither he/she nor the dietary staff knew how to remove the spray wand from the dishwasher to clean it. During an interview on 11/14/22 at 1:50 P.M., the DM said the air conditioning vents have not been cleaned in several months and the dietary department had not notified maintenance to clean the vents of the climate control units. 2. Observations on 11/16/22 at 10:47 A.M. showed a layer of pink colored biofilm on the upper part of the ice machine in the second floor clean utility room. Observation on 11/17/22 at 8:01 A.M., showed a layer of pink colored biofilm on the upper part of the ice machine located in the dining room. During an interview on 11/17/22 at 8:06 A.M., DA B said he/she has not cleaned the ice machine in a while and he/she did not know the answer to how often they were supposed to clean the machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the facility's undated policy Hand Washing Technique showed: -Hand washing should be done upon entering a resident room before putting on gloves, when completing incontinence care before performing other cares, and when exiting resident rooms. -Gloves are to be worn at any time there may be contamination of body fluids and unsanitary conditions outside of a resident room. -Hand sanitizer can be used between resident cares including medication pass. Record review of Resident #41's undated face sheet showed the resident was admitted on [DATE] with the following diagnoses: -Personal History of Transient Ischemic Attack (TIA- temporary interference with blood supply to the brain) without deficits. -Essential (Primary) Hypertension (HTN-high blood pressure). Observation on 11/14/22 at 9:32 A.M., of a wheelchair to bed transfer with a Hoyer lift showed: -Certified Nursing Assistant (CNA) B and Nursing Assistant (NA) B brought the Hoyer lift and resident into the room. --No hand washing or hand sanitizing was completed. -CNA B and NA B placed the resident onto the Hoyer lift sling. --No hand washing or hand sanitizing was completed. -CNA B and NA B performed the transfer without the use of gloves and did not perform hand hygiene of washing hands or using hand sanitizer. -NA B checked the resident's brief to see if it was soiled without wearing gloves and did not wash his/her hands or use hand sanitizer. -After completing resident care hand hygiene was not performed before exiting the room. During an interview on 11/14/22 at 9:53 A.M., NA B said he/she would not have done anything different during the transfer or performing the resident care. During an interview on 11/16/22 at 9:41 A.M., NA B said hand hygiene should be performed: -Before entering a resident room. -When exiting a resident room. -In between different resident's cares. -When going from task to task during resident cares. -When the hands were visibly soiled. During an interview on 11/16/22 at 9:59 A.M. CNA B said: -Hand hygiene should be performed before and after handling a resident. -He/She knew that hand hygiene had not been done. -He/She should have performed hand hygiene in between the resident transfer and doing resident care. -He/She should have worn gloves when performing the transfer. 3. A medication pass policy was requested and not received at the time of exit. Record review of Resident #25's undated face sheet showed the resident admitted on [DATE] with the following diagnoses: -Type II Diabetes Mellitus (DMII-a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) -HTN. Observation on 11/16/22 at 6:48 A.M., of a medication pass with Certified Medication Technician (CMT) B showed: -He/she did not perform hand hygiene before starting the medication pass. -He/she did not put on gloves before getting the medication out of the packets and bottles. -He/she dropped a pill on the medication cart and used his/her bare hands to pick it up and place into the medication cup. --All medications in the medication cup were given to the resident to take, and the resident took all the medications. -He/she did not perform hand hygiene once the medication pass was complete. During an interview on 11/16/22 at 10:12 A.M., CMT B said: -Hand hygiene should be performed before and after each resident during medication pass. -Gloves should be worn when handling medication especially when a medication needed to be picked up after dropping it. 4. Record review of Resident #33's undated face sheet showed he/she admitted on [DATE] with the following diagnoses: -HTN. -Hypothyroidism (below normal function of the thyroid gland which regulates metabolism). -Other seizures (a hyper excitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles). Observation on 11/16/22 at 7:10 A.M., of a medication pass showed CMT B: -Did not perform hand hygiene before the medication pass. -Did not put on gloves before getting the medication out of the packets and bottles. -Gave the resident his/her medications. -Did not perform hand hygiene after the medication pass. During an interview on 11/16/22 at 7:18 A.M., CMT B said he/she would not have done anything different during the two different medication passes. During an interview on 11/16/22 at 10:12 A.M. CMT B said hand hygiene should be performed before and after each resident during medication pass. 5. Record review of the facility's policy Policy for Laundry Practices, dated 2020, showed staff must wear disposable gloves when handling dirty laundry. Observation on 11/16/22 at 9:54 A.M., showed CNA B: -Had soiled clothes in his/her hands at the nurse's station without gloves on. -Did not have the clothing stored inside of a bag. -Asked NA B for a trash bag, placed them into the bag. During an interview on 11/16/22 at 9:59 A.M., CNA B said: -Linens should be carried with gloves on. -Linens should be put into a bag before leaving a resident room. 6. During an interview on 11/17/22 at 11:25 A.M., the Director of Nursing (DON) said: -He/she would expect hand hygiene be performed before and after resident care, when entering and exiting a resident room, when in contact with bodily fluids, and when going from a dirty to clean task. -He/she would expect staff to wear gloves throughout all resident care. -He/she would expect hand hygiene to be performed in between each resident during medication pass. -He/she would expect gloves to be worn during medication pass and when handling dropped medication. -He/she would expect staff to place linens in a bag before exiting a resident room. -He/she would expect staff to wear gloves when handling soiled linens/clothing. Based on observation, interview, and record review, the facility failed to include the following in its Water Management Plan: a diagram which showed which hot water heaters the water originated from and the destinations of water from those hot water heaters; plans for implementing testing protocols to ensure what corrective actions that the facility would implement as a result of changes in municipal or facility water quality; an assessment of where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility's water system; and failed to maintain infection control regarding improper hand hygiene during a transfer of one sampled resident (Resident #41) from his/her wheelchair to bed with a Hoyer lift, failed to ensure proper hand hygiene was completed during medication pass for two supplemental residents (Resident #25 and #33) out of 19 sampled residents and five supplemental residents, and failed to maintain infection control practices while handling soiled clothing/linens. The facility census was 75 residents. Record review of page 3 of Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated 6/15, showed: -Obtain a written copy of the program policy. -Page 1 of the assessment noted that requirements for any occupant rooms taken out of service during specific parts of the year. -Note: It is important to gain an understanding of where and how water flows, starting where it enters the facility and including its distribution to and through buildings to the points of use. Obtain copies of these and/or draw a diagram and include with the completed assessment. -Page 3 Obtain a written copy of the program policy. -Page 5 Does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)? -Page 14 Is there a standard operating procedure (SOP) for shutting down, isolating, and refilling/flushing for water service areas that have been subjected to repair and/or construction interruptions. Record review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. 1. Record review of the facility's assessment of water systems, dated 5/20/22, showed the absence of a diagram, which showed where water came into the facility and to which hot water heaters that water went to and where the water went within the facility from those hot water heaters. During an interview on 11/17/22 at 11:31 A.M., the Maintenance Director said he/she thought there was a diagram of where the hot water went, but he/she did not see a diagram. Record review of the facility's assessment of water systems, dated 5/20/22, showed the absence of plans for implementing testing protocols for the water if there were changes in the municipal water quality. During an interview on 11/17/22 at 11:44 A.M., the Maintenance Director said: -He/she would run all faucets for a period of time and flush all toilets. -He/she would test the facility water for acceptable chlorine levels because they have a chlorine test kit in the facility, but he/she would have to find out what the acceptable level of chlorine that should be in the water from the municipal water company. Record review of the facility's assessment of water systems, dated 5/20/22, showed the absence of an assessment of all areas where opportunistic waterborne pathogens could grow and spread within the facility's water system. During an interview on 11/17/22 at 11:47 A.M., the Administrator said: -Shower rooms and other areas where water was not used very much, were areas that should be assessed for potential growth. -He/she spoke about the water used in oxygen concentrators as another area that could also be assessed. -Those areas should be written in the facility's assessment.

Based on interview and record review, the facility failed to ensure the Certified Nursing Assistants (CNA's) had a minimum of 12 hours of in-service education (which was required to include abuse/neglect and dementia cares) per year. This had the potential to affect all residents. The facility census was 75 residents. The policy regarding CNA training was requested and not received from the facility at the time of exit. 1. Record review of the facility's in-service records showed: -There were six in-services performed this year. -Dementia and abuse/neglect were not included. During an interview on 11/15/22 at 11:24 A.M., the Director of Nursing (DON) said the facility had not had any CNA in-services in a long time. During an interview on 11/15/22 at 11:25 A.M., the Administrator said: -The facility stopped doing in-services during the pandemic. -He/she had sent staff videos from a social media site for them to view but had no record of the videos being watched. -He/she was aware the facility was not providing appropriate in-services. During an interview on 11/16/22 at 12:32 P.M., Certified Medication Technician (CMT) B said: -He/she had three in-services in 2022. -He/she had not received any in-services regarding abuse/neglect or dementia cares. During an interview on 11/16/22 at 1:10 P.M., CNA B said: -He/she could not remember the last time the facility had a CNA in-service. -He/she had not received any dementia training this year. During an interview on 11/17/22 at 12:11 P.M., the DON said: -He/she expected CNA's to have the required 12 hours of annual in-services. -He/she expected CNA's to receive the required yearly abuse/neglect and dementia in-services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a Care Plan for weight loss/nutrition for two sampled residents (Resident #14 and #53) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility's policy for care plan dated 2014 showed: -The charge nurses and the Director of Nursing (DON) shall communicate to each other the care delivery and the progress of care and other provider's plan of care. -Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) coordinator follows the Resident Assessment Instrument (RAI - helps facility staff to gather definitive information on a resident which must be addressed in an individualized care plan) to develop the care plan and coordinates the RAI process. -The MDS coordinator communicates with the care staff, licensed and non-licensed personnel and reviews the medical records in order to obtain the information for developing the care plan. -The care plans shall be developed with all interdisciplinary team input and the resident/family members. -The care plan can be reviewed and revised at any time to ensure it reflects the resident's current conditions. -The care plan will be reviewed and updated every three months during care plan meetings with input from all care plan team members. -The charge nurses will update the care plan immediately when there are falls, behaviors, change in functional ability. -The charge nurse will then notify the MDS coordinator who will put changes in the care plan system and reprint the care plan on the next working day. 1. Record review of Resident #14's admission record showed he/she was admitted on [DATE] with the following diagnoses: - Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Chronic (persisting for a long time or constantly recurring) viral (relating to a virus) Hepatitis C (a type of virus causing liver inflammation and long-term or chronic infections). -Viral Hepatitis B (a type of virus causing liver inflammation and long-term or chronic infections). Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Required set up only from staff for eating. -Had no weight loss. -Weighed 146 pounds. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Required set up only from staff for eating. -Had no weight loss. -Weighed 148 pounds. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Required set up only from staff for eating. -Had a 6.5% weight loss in three months. -Was not on a physician's prescribed weight loss regimen. -Weighed 139 pounds. Record review of the resident's food intake record dated December 2019 showed: -Breakfast, lunch, and dinner meals were only charted for ten out of 31 days. -None of the uncharted days showed that the resident refused the meals. -The 10 days charted showed an average meal consumption of 75%-100%. -The resident did drink Ensure (brand of nutrition shake that provides complete balanced nutrition to help gain or maintain weight) nutritional shakes and was documented with the meal fluid intake. Record review of the resident's food intake record dated January 2020 showed: -Breakfast, lunch, and dinner meals were charted as refused or not charted 20 out of 31 days. -The eleven days charted showed an average meal consumption of 25%-80%. -The resident did drink Ensure nutritional shakes and was documented with the meal fluid intake. Record review of the resident's food intake record dated February 2020 showed: -Breakfast, lunch, and dinner meals were charted as refused or not charted 15 out of 29 days. -The 14 days charted showed an average meal consumption of 80%-100%. -The resident did drink Ensure nutritional shakes and was documented with the meal fluid intake. Record review of the resident's food intake record dated March 2020 showed: -Breakfast, lunch, and dinner meals was not charted on the first day out of 5 days. -The 5 days charted showed an average meal consumption of 80%-100%. -The resident did drink Ensure nutritional shakes and was documented with the meal fluid intake Record review of the resident's care plans showed there was no care plan that addressed his/her nutritional status or weight loss. During an interview on 3/2/20 at 2:18 P.M., the resident said he/she: -Had lost some weight. -Did skip/refuse meals. -Sometimes was too tired to go eat or just didn't feel like eating, even when the staff try to get him/her to eat. -Poured the Ensure drink into his/her coffee. It made the coffee taste better. -Liked peanut butter and jelly sandwiches and liked to dip them into his/her coffee. -Sometimes would just request a peanut butter and jelly sandwich. -Ate all of his/her lunch today. During an interview on 3/4/20 Certified Medication Technician (CMT) B said: -When the resident skipped a meal he/she would offer the resident a snack when he/she was up. -The resident usually ate the snack and would drink the Ensure shake. Record review of the Registered Dietician's (RD) nutritional progress record dated 3/5/20 showed: -The resident said he/she often slept through breakfast, lunch, and dinner. -He/she drank strawberry Ensure/health shakes with meals. -He/she agreed to increasing the strawberry supplements to five times a day. -Would recommend to increase the strawberry supplements to TID with snacks and with lunch and dinner. -The resident received Thera tabs and multi vitamins daily. 2. Record review of resident #53's admission record showed he/she was admitted on [DATE] with the following diagnoses: -Hepatic failure (loss of liver function caused by liver damage). -Protein malnutrition (insufficient intake of protein) -Diabetes Mellitus II [condition that affects the way the body processes blood sugar (glucose)]. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Required set up and supervision from one staff member for eating. -Had a diagnosis of malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). -Had no weight loss. -Weighed 153 pounds. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Required set up and supervision from one staff member for eating. -Had a diagnosis of malnutrition. -Had no weight loss. -Weighed 154 pounds. Record review of the resident's annual MDS dated [DATE] showed he/she: -Required set up and supervision from one staff member from eating. -Had a diagnosis of malnutrition. -Had a 4% weight loss in three months. -Weighed 148 pounds. Record review of the resident's care plans showed there was no care plan that addressed his/her nutritional status or potential for weight loss due to his/her diagnosis of malnutrition. 3. During an interview on 3/6/20 at 8:55 A.M., the MDS Coordinator said: -Resident's who have had weight loss should have a care plan that addresses weight loss. -Resident's who have a potential for weight loss, who refuse to eat all meals, or have nutritional diagnoses, including malnutrition, should have a care plan that addresses potential for weight loss and/or his/her nutritional status. During an interview on 3/6/20 at 2:33 P.M., the Director of Nursing (DON) said: -There should be a care plan for weight loss and/or nutrition when a resident is not eating well, has weight loss, or diagnosis of malnutrition. -The RD should be contacted to assist in making a care plan for the resident. -The resident's physician should be notified if there were recommendations from the RD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide or obtain physician ordered medical services to meet the residents' needs by not ensuring tests that were ordered by a physician were done for three sampled residents (Resident #36, Resident #46, and Resident #57) out of 16 sampled residents. The facility census was 64 residents. 1. Record review of Resident #36's face sheet showed he/she was re-admitted on [DATE] with the following diagnoses: -Acute respiratory failure (when your lungs can not get enough oxygen into your blood). -Chronic obstructive pulmonary disease (COPD - an inflammatory lung disease that causes obstructed airflow from the lungs). -Dyspnea (a shortness of breath related to heart or lung disease). -Obstructive sleep apnea (a disorder in which breathing starts and stops repeatedly during sleep). -High blood pressure. -Metabolic encephalopathy (when your immune systems attacks your brain and changes the way it works). -Hypothyroidism (when the thyroid gland does not produce enough hormone). -Heart failure (when the heart muscle does not pump blood as it should). -Pulmonary fibrosis (when lung tissue becomes damaged or scarred). -Anemia (a condition in which you lack enough healthy red blood cells to carry oxygen to the body's tissues). -Atrial fibrillation (an irregular heart rhythm). -Diabetes (a group of diseases that affect how your body uses blood sugar). -The resident was not his/her own person. Record review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 1/10/20 showed he/she: - Was mildly cognitively impaired with a BIMS (brief interview for mental status) of 11 out of 15. -Was independent with activities of daily living. -Had Anemia. -Had Atrial Fibrillation. -Had Diabetes. -Had a Thyroid disorder. -Had COPD. -Had Respiratory failure. Record review of the resident's care plan dated 1/10/20 showed: -The staff was to follow the physician's orders. -The staff was to monitor lab work as ordered related to the resident's heart failure. -The staff was to ensure labs were done as ordered by the physician related to the resident's high blood pressure. -The staff was to ensure Fasting Serum Blood Sugars were done as ordered by the physician related to the resident's Diabetes. Record review of the resident's January 2020 Physician's Order Sheet (POS) showed the resident had an order for a Pulmonary Consult (a Physician that specializes in lung diseases such as COPD) dated 1/21/20. Record review of the resident's February 2020 POS showed the resident had an order for an annual Electrocardiogram (EKG - a test that detects the electrical activity in the heart used to screen for heart disease) to be done in February. Record review of the resident's medical record showed: -No documentation the resident's physician's ordered Pulmonary Consult from 1/21/20 was completed or scheduled. -No documentation the resident's EKG ordered to be completed in February 2020 was completed as ordered. 2. Record review of Resident #46's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes (a group of diseases that result in too much blood sugar in the blood). -Hyperlipidemia (elevated levels of lipids in the bloodstream). -COPD. -Hypokalemia (a low level of potassium in the blood which can an abnormal heart rhythm). -The resident had a guardian. Record review of the resident's Annual MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Had Diabetes. -Had COPD. -Had Hyperlipidemia. -Had behaviors. -Would reject bloodwork. Record review of the resident's care plan dated 1/29/20 showed: -The resident had nutritional problems related to diabetes. -The staff was to obtain laboratory work as ordered. -The staff was to obtain diagnostic work as ordered. -The staff was to report the results to the physician. Record review of the resident's February 2020 POS showed: -The resident had an order to have an annual EKG done in February. -The order was signed by the physician on 2/4/20. Record review of the resident's March 2020 POS showed: -The resident had an order to have an annual EKG done in February. -The order was signed by the physician on 3/3/20. Record review of the resident's medical record showed no documentation the resident's EKG ordered to be completed in February 2020 was completed as ordered. 3. Record review of Resident #57's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Huntington's disease (a condition in which the nerve cells in the brain break down). -Vitamin D deficiency. -Hyperlipidemia. -The resident had a guardian. Record review of the resident's Annual MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 12 out of 15. -Had Hyperlipidemia. -Had Huntington's disease. Record review of the resident's care plan dated 1/10/20 showed: -The staff was to follow the physician's orders (11/12/19). -The resident had the potential for altered cardiac output. -The staff was to obtain diagnostic work as ordered. -The staff was to report results to the physician. Record review of the February 2020 POS showed: -The resident had an or for an annual EKG to be done in February. -The order was signed on 2/4/20. Record review of the March 2020 POS showed: -The resident had an or for an annual EKG to be done in February. -The order was signed on 3/8/20. Record review of the resident's medical record showed no documentation the resident's EKG ordered to be completed in February 2020 was completed as ordered. 4. During an interview on 3/5/20 at 6:00 A.M. Certified Medication Technician (CMT) A said: -The nurses were responsible for verifying that the orders were correct. -The nurses were responsible to ensure Physician's orders were done. During an interview on 3/5/20 at 6:24 A.M. Licensed Practical Nurse (LPN) A said: -The Director of Nursing (DON) would check the orders on the POS to make sure they were correct. -The DON would check the orders on the POS to make sure they were done. During an interview on 3/6/20 at 2:32 P.M. the DON said: -The charge nurse double checks the orders. -The MDS Coordinator double checks the orders. -He/she would expect the staff to ensure tests have been done. -The charge nurse was responsible to ensure orders were transcribed and completed as ordered. -They have not been consistently done. -They were trying to get them caught up on incomplete orders.

Based on observation, interview and record review, the facility failed to ensure full, metal bar side rails were protected to reduce the risk of injury for one sampled resident (Resident #30) who had a seizure disorder out of 16 sampled residents. The facility census was 64 residents. 1. Record review of Resident #30's care plan revised 11/2/19 showed: -The resident was witnessed falling and/or was found on the floor. -The resident used bed rail restraints due to a seizure disorder. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/3/20 showed the following assessment of the resident: -Had short-term and long-term memory impairment. -Was dependent upon staff for bed mobility. -Had a diagnosis of a seizure disorder. -Used bed rail restraints daily. Record review of the resident's March 2020 Physician's Order Sheet (POS) showed a physician's order for side rail restraints up in bed due to seizures, epilepsy (a brain disorder that causes seizures), multiple flexion contractures (bent joints that cannot be straightened) and spasticity (a muscle control disorder that is characterized by tight or stiff muscles with an inability to control those muscles) to aid in positioning and safety. Observations showed: -During initial tour beginning on 3/2/20 at 9:30 A.M., the resident was in bed asleep with full metal bar bed rails with no padding, up on both sides of the bed. -On 3/5/20 at 6:06 A.M., the resident was in bed asleep with full metal bar bed rails with no padding, up on both sides of the bed. -On 3/5/20 at 10:15 A.M., the resident was in bed asleep with full metal bar bed rails with no padding, up on both sides of the bed. During an interview on 3/6/20 at 2:33 P.M., the Director of Nursing (DON) said: -The resident hasn't had any seizures recently. -He/she didn't think about the metal bed rails being a safety risk with the resident's seizure disorder diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure diagnoses/purposes were indicated for psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications on the resident's Physician Order Sheets (POS) and Medication Administration Records (MAR) for one sampled resident (Resident #40) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility's medication management and monitoring policy dated 2019 showed: -The responsibility of the Director of Nursing (DON) was to review the medication plan on a monthly basis for residents who were on psychotropic (includes antipsychotic) medications. Record review of the facility's physician's orders policy dated 10/20/19 showed for medication orders, the prescribers will include the purpose of the drug to ensure that the order makes sense in the context of the resident's condition. 1. Record review of Resident #40's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 12/27/19 showed: -The resident had diagnoses including Dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -The resident was receiving antianxiety medications (inhibits anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) seven out of seven days in the lookback period. -The resident was receiving antidepressant medications (inhibits depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) seven out of seven days in the lookback period. -The resident was receiving hypnotic medications (drug that induces sleep) seven out of seven days in the lookback period. Record review of the resident's Significant Change MDS dated [DATE] showed he/she: -Had diagnoses including Dementia and Anxiety. -The resident was receiving antianxiety medications seven out of seven days in the lookback period. -The resident was receiving antidepressant medications seven out of seven days in the lookback period. -The resident was receiving hypnotic medications seven out of seven days in the lookback period. Record review of the resident's POS dated February 2020 and March 2020 showed the following medications: -Haldol (an antipsychotic medication used to treat mental and mood disorders) 1 milligram (mg) tablet by mouth (PO). --There was no diagnosis/purpose for use. -Temazepam (an antipsychotic medication used for sleep and anxiety) 7.5 mg PO. --There was no diagnosis/purpose for use. During an interview on 3/6/20 at 11:30 A.M., Certified Medication Technician (CMT) B said: -He/she had not noticed there were missing diagnoses on the MAR. -There should be a diagnosis for each medication on a MAR. During an interview on 3/6/20 at 2:33 P.M., the DON said: -There should be a diagnosis for each medication that is on a POS and a MAR. -It was the charge nurse's responsibility to see that a diagnosis was on the POS and the MAR. -The charge nurse should call the physician to receive a diagnosis for the medication when there was no diagnosis listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain laboratory services, to meet the residents' needs by not ensuring laboratory tests that were ordered by a physician were completed and/or the resident's physician was notified of the resident's refusal for laboratory tests for two sampled residents (Resident #36 and Resident #46) out of 16 sampled residents. The facility census was 64 residents. 1. Record review of Resident #36's face sheet showed he/she was re-admitted on [DATE] with the following diagnoses: -Acute respiratory failure (when your lungs can not get enough oxygen into your blood). -Chronic obstructive pulmonary disease (COPD - an inflammatory lung disease that causes obstructed airflow from the lungs). -Dyspnea (a shortness of breath related to heart or lung disease). -Obstructive sleep apnea (a disorder in which breathing starts and stops repeatedly during sleep). -High blood pressure. -Metabolic encephalopathy (when your immune systems attacks your brain and changes the way it works). -Heart failure (when the heart muscle does not pump blood as it should). -Pulmonary fibrosis (when lung tissue becomes damaged or scarred). -Anemia (a condition in which you lack enough healthy red blood cells to carry oxygen to the body's tissues). -Atrial fibrillation (an irregular heart rhythm). -Diabetes (a group of diseases that affect how your body uses blood sugar). -The resident was not his/her own person. Record review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 1/10/20 showed he/she: - Was mildly cognitively impaired with a BIMS (brief interview for mental status) of 11 out of 15. -Was independent with activities of daily living. -Had Anemia. -Had Atrial Fibrillation. -Had Diabetes. -Had COPD. -Had Respiratory failure. Record review of the resident's care plan dated 1/10/20 showed: -The staff was to follow the physician's orders. -The staff was to monitor lab work as ordered related to the resident's heart failure. -The staff was to ensure labs were done as ordered by the physician related to the resident's high blood pressure. -The staff was to ensure Fasting Serum Blood Sugars were done as ordered by the physician related to the resident's Diabetes. Record review of the resident's January 2020 Physician's Order Sheet (POS) showed: -The resident had an order for a Comprehensive Metabolic Panel (CMP a blood test that gives physicians information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working) dated 1/14/20. -The resident had an order for an Hemaglobin A1C test (a test that measures the amount of hemoglobin with attached glucose that reflects the average level over the last three months) dated 1/14/20. Record review of the resident's February 2020 POS showed: -An undated, handwritten order for a Vitamin D level and a CBC (Complete Blood Count - a test that gives information about blood cells). -The resident's physician signed the POS on 2/4/20. Record review of the resident's March 2020 POS showed: -No documentation lab orders from January and February 2020. -No documentation lab orders were discontinued by the resident's physician. -The physician signed the POS on 3/3/20. Record review of the resident's medical record showed: -No documentation a CMP was obtained or of a CMP result from the resident's physician order dated 1/14/20. -No documentation a Hemaglobin A1C was obtained or of a Hemaglobin result from the resident's physician order dated 1/14/20. -No documentation a Vitamin D level was obtained or of a Vitamin D result from the undated resident's physician order on his/her February 2020 POS. -No documentation a CBC was obtained or of a CBC result from the undated resident's physician order on his/her February 2020 POS. 2. Record review of Resident #46's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes (a group of diseases that result in too much blood sugar in the blood). -Paranoid Schizophrenia. -High cholesterol. -COPD. -Vitamin D deficiency (a vitamin needed for strong bones). -Hypokalemia (a low level of potassium in the blood which can an abnormal heart rhythm). The resident had a guardian. Record review of the resident's Annual MDS dated [DATE] showed he/she: -Had Diabetes. -Had COPD. -Had high cholesterol. -Had behaviors. -Would reject bloodwork. Record review of the resident's care plan dated 1/29/20 showed: -The resident had nutritional problems related to diabetes. -The staff was to obtain laboratory work as ordered. -The staff was to obtain diagnostic work as ordered. -The staff was to report the results to the physician. Record review of the resident's February 2020 POS showed: -The resident had an order for Lipids (test to check for high cholesterol) to be drawn in February. -There were no results for that test. -The order was signed by the physician on 2/4/20. Record review of the resident's March 2020 POS showed: -The resident had an order for Lipids to be drawn in February. -There were no results for that test. -The order was signed by the physician on 3/3/20. Record review showed the resident had refused to have labs drawn at 12:00 A.M. (midnight) on the following dates: -CMP on 10/12/19. -CMP on 11/20/19. -Valporic acid (used to treat mental illness), CBC, TSH (a test to check thyroid level) on 1/20/19. -CMP, TSH, Valporic acid, A1C on 3/3/20. 3. During an interview on 3/5/20 at 6:00 A.M. Certified Medication Technician (CMT) A said the nurses were responsible for verifying that the orders were done. During an interview on 3/5/20 at 6:24 A.M. Licensed Practical Nurse (LPN) A said the Director of Nursing (DON) would check the orders on the POS to make sure they were completed. During an interview on 3/6/20 at 2:32 P.M. the DON said: -The charge nurse double checks the orders. -The MDS Coordinator double checks the orders. -He/she would expect the staff to ensure labs have been done. -The charge nurse was responsible. -They have not been consistently done. -They were trying to get them caught up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer influenza and/or pneumococcal immunizations; to provide documentation the resident or the resident's representative refused the immunizations or provide a medical reason the immunizations could not be administered, and to document the history of these vaccines having been offered or administered before being admitted to the facility for three sampled residents (Residents #36, #46, and #57) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy, Influenza and Pneumococcal Immunizations, dated 2006 showed: -The residents or his/her family/legal representatives will be provided educational instructions regarding the benefits of immunization as well as the potential for side effects prior to consenting to receive the immunizations. -Refusal of immunization will be honored by the facility upon consent agreement. -The resident and/or his/her legal representatives have the right to refuse or accept the offer of immunizations. -The staff would explain to the residents and family the benefits of the immunization. -The staff was to document the reason the resident did not receive the immunization. 1. Record review of Resident #36's face sheet showed he/she was re-admitted on [DATE] with the following diagnoses: -Acute respiratory failure (when your lungs can not get enough oxygen into your blood). -Chronic obstructive pulmonary disease (COPD - an inflammatory lung disease that causes obstructed airflow from the lungs). -Dyspnea (a shortness of breath related to heart or lung disease). -Obstructive sleep apnea (a disorder in which breathing starts and stops repeatedly during sleep). -Pulmonary fibrosis (when lung tissue becomes damaged or scarred). -Anemia (a condition in which you lack enough healthy red blood cells to carry oxygen to the body's tissues). -The resident was not his/her own person. Record review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 1/10/20 showed he/she: - Was mildly cognitively impaired with a BIMS (brief interview for mental status) of 11 out of 15. -Was offered and declined the influenza vaccine. -Was not current with his/her pneumococcal vaccine. -Was offered and declined the pneumococcal vaccine. -Had COPD. -Had Respiratory Failure. Record review of the resident's care plan dated 1/10/20 showed the staff was to follow the physician's orders. Record review of the Physician's Order Sheet (POS) dated March 2020 showed: -The resident had an order to receive the Influenza immunization (Flu vaccine) annually unless contraindicated. -Last date Flu vaccine was given was blank. -Last date Pneumovax vaccine (pneumococcal vaccine) was given was blank. -The Pneumovax vaccine should be given every five years. Record review of the resident's Immunization Report dated 3/1/20 - 3/31/20 showed: -The resident had refused the Influenza immunization. -The resident had refused the Pneumovax immunization. -No documentation the facility staff provided the resident or the resident's representative written education, or the risks and benefits of the influenza and pneumococcal vaccines. Record review of the resident's medical record showed: -No documentation the resident had a previous history if the resident had received the influenza or pneumococcal vaccines. -No documentation if the resident had a medical reason for not receiving the influenza and pneumococcal vaccines. -No documentation the resident or the resident's representation had refused the influenza and pneumococcal vaccines. 2. Record review of Resident #46's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes (a group of diseases that result in too much blood sugar in the blood). -COPD. -The resident had a guardian. Record review of the resident's Annual MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Had Diabetes. -had COPD. -Was offered and declined the influenza vaccine. -Was not current with his/her pneumococcal vaccine. -Was offered and declined the pneumococcal vaccine. Record review of the resident's care plan dated 1/29/20 showed the staff was to the follow the physician's orders. Record review of the POS dated March 2020 showed: -The resident had an order to have the Flu vaccine annually unless contraindicated. -The last date the Flu vaccine was refused was 10/19/19. -The last date the Pneumovax was given was 1/16/14. --The Pneumovax vaccine should be given every five years. Record review of the resident's Immunization Report dated 3/1/20 - 3/31/20 showed: -The resident had refused the Influenza immunization. -No documentation the facility staff offered the resident or the resident's guardian to provide the resident a pneumococcal vaccine. -No documentation the facility staff provided the resident or the resident's guardian written education, or the risks and benefits of the influenza and pneumococcal vaccines. Record review of the resident's medical record showed: -No documentation if the resident had a medical reason for not receiving the influenza and pneumococcal vaccines. -No documentation the resident or the resident's guardian had refused the influenza and pneumococcal vaccines. 3. Record review of Resident #57's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Huntington's disease (a condition in which the nerve cells in the brain break down). -The resident had a guardian. Record review of the resident's Annual MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 12 out of 15. -Was not current with his/her pneumococcal vaccine. -Was offered and declined the pneumococcal vaccine. -Had Huntington's disease. Record review of the resident's care plan dated 1/10/20 showed: -The staff was to follow the physician's orders (11/12/19). -The resident was difficult to understand. -If the resident was resistive to care, do not continue, notify charge nurse. Record review of the Physician's Order Sheet (POS) dated March 2020 showed: -Last date Pneumovax vaccine was given was blank. -The resident had an order to receive the Pneumovax every five years. Record review of the resident's Immunization Report dated 3/1/20 - 3/31/20 showed: -The resident had refused the Pneumovax. -No documentation the facility staff provided the resident or the resident's guardian written education, or the risks and benefits of the pneumococcal vaccines. Record review of the resident's medical record showed: -No documentation if the resident had a medical reason for not receiving the pneumococcal vaccine. -No documentation the resident or the resident's guardian had refused the pneumococcal vaccine. 4. During an interview on 3/5/20 at 10:21 A.M. the Director of Nursing (DON) said: -A local pharmacy came in to give the influenza immunizations. -The Pneumovax was given by the MDS Coordinator/LPN. -The MDS Coordinator was responsible for keeping track of the immunizations. -The nurses could give the immunizations. -It should have been charted if a resident had refused. During an interview on 3/6/20 at 10:32 A.M. the Administrator said: -The physician orders the Influenza immunizations. -The Influenza immunizations were done annually. -The physician orders the Pneumovax immunizations. -The Pneumovax immunizations were given every five years. -Information about the immunization was provided before the shot was given. -If the resident refused, they were educated on the benefits of having it. -The nurse would try again to get the resident to receive the immunization. -The MDS coordinator was responsible to keep track of the immunizations. -The Influenza immunizations were given by a local pharmacy. -The Administrator did chart audits to ensure the immunizations were given. -The charts were also audited every three months when the MDS has been done. During an interview on 3/6/20 11:10 A.M. Licensed Practical Nurse (LPN) A said: -The Director of Nursing (DON) keeps track of the immunizations. -The MDS coordinator gives the immunizations. -A local pharmacy gave the Influenza immunizations this last year. During an interview on 03/06/20 at 12:28 P.M. the MDS Coordinator said: -There was no documentation of education provided to resident or guardian if they had refused the immunizations. -It was his/her responsibility to keep track of this. -He/she did not do it. -He/she also did not provide education if the guardian agreed and the resident then refused. -He/she did not have the resident sign the form when they refused. -(Education about the benefits were on the form).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Record review of Resident #46's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Diabetes (a group of diseases that result in too much blood sugar in the blood). Record review of the resident's care plan dated 1/29/20 showed: -The resident had nutritional problems related to Diabetes. -The staff was to obtain laboratory work as ordered. -The staff was to obtain diagnostic work as ordered. -The staff was to report the results to the physician. Record review of the resident's January 2020 POS showed: -The resident did not have a physician's order to check his/her blood sugar. -The January POS was signed by the physician on 1/7/20. Record review of the resident's February 2020 POS showed: -The resident did not have a physician's order to check his/her blood sugar. -The February POS was signed by the physician on 2/4/20. Record review of the resident's March 2020 POS showed: -The resident did not have a physician's order to check his/her blood sugar. -The March POS was signed by the physician on 3/3/20. Record review of the resident's MAR dated January 2020, February 2020 and March 2020 showed: -The facility had checked the resident's blood sugars four times a day. -There was no order to check blood sugars. During an interview on 3/5/20 at 6:00 A.M. Certified Medication Technician (CMT) A said: -The nurses get the resident's blood sugars. -The nurses were responsible for verifying that the orders are correct. During an interview on 3/5/20 at 6:24 A.M. LPN A said: -The DON would check the orders on the POS to make sure they were correct. -There should have been an order for blood sugars to have been checked if the resident was Diabetic. -Staff were checking the resident's blood sugars. -There was no order from the Physician to check the resident's blood sugars. During an interview on 3/6/20 at 2:32 P.M. the DON said: -There should have been an order for a resident's blood sugars to be checked if a resident was Diabetic. -There should have been an order for a resident's blood sugars to be checked if a resident was on insulin. -The charge nurse double checks the orders. -The MDS coordinator double checks the orders. Based on interview and record review, the facility failed to ensure one sampled resident (Resident #39) received his/her medication as ordered; to document the reasons medications were not administered as ordered for one sampled resident (Resident #39); to indicate the diagnoses or symptoms for medications for four sampled residents (Residents #39, #64, #26 and #25); and to ensure the physician had ordered blood sugar samples for one sampled resident (Resident #46) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility's Physician's Orders policy dated 10/20/19 showed the purpose of the medication should be included in the physician's order. Record review of the facility's Medication Management and Monitoring policy dated 2019 showed the nursing staff should: -Coordinate the communication between the pharmacy and the physician when the physician is not responding to pharmacy requests. -Inform the pharmacy if the physician is not responding to pharmacy requests and ask the pharmacy to contact the physician. -Continue to call the physician for the pharmacy inquiry. -Circle initials on the Medication Administration Record (MAR) if medication is not administered as ordered and record the reason. 1. Record review of Resident #39's care plan dated 10/24/19 showed he/she experienced pain, received antidepressant medication and received antianxiety medication. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/17/20 showed the following staff assessment of the resident: -Was cognitively intact. -Had diagnoses of anxiety disorder (a psychiatric disorder characterized by extreme fear, worry and nervousness) and depression (a mental disorder in which the individual has intense sadness or despair that affects their daily life). -Received scheduled pain medication. -Reported he/she had frequent pain with an eight out of ten on a pain scale with ten being the worst pain. -Received antianxiety medication and antidepressant medication seven out of the past seven days. Record review of the resident's Nurse Practitioner's (NP) note dated 2/19/20 showed: -The resident reported he/she was trying to keep his/her anxiety under control. -The resident reported being anxious. -The resident's Klonopin (anticonvulsant medication that is also used to treat anxiety by calming the brain and nerves) would be increased to 0.5 milligrams (mg) three times daily to manage anxiety. Record review of the resident's February 2020 Medication Administration Record (MAR) showed: -A physician's order for Klonopin 0.5 mg three times daily for anxiety. -Initials were circled three times daily on 2/28/20 and 2/29/20 as Klonopin 0.5 mg not being administered. -It was documented on the back of the MAR that Klonopin 0.5 mg was not administered on 2/28/20 in the P.M. because it was unavailable. -There was no reason documented as to why the resident did not receive his/her Klonopin 0.5 mg the other five times in February 2020. -A physician's order for Gabapentin 600 mg four times daily for fibromyalgia (characterized by widespread musculoskeletal pain, fatigue, sleep disturbance, memory and mood issues). -Initials were circled as not being administered 22 times from 2/22/20-2/29/20. -It was documented on the back of the MAR that Gabapentin 600 mg was not administered in the morning or at noon on 2/24/20 because it was unavailable. -There were no reasons documented as to why the resident did not receive his/her Gabapentin 600 mg the other 20 times in February 2020. During an interview on 3/2/20 at 9:45 A.M., the resident said: -The facility was out of some of his/her medication for multiple days. -He/she thought the medications he/she was not receiving were Klonopin and an antidepressant. -His/her anxiety is going through the roof because of not receiving his/her Klonopin. Record review of the resident's March 2020 MAR on 3/3/20 at 11:08 A.M. showed: -A physician's order for Klonopin 0.5 mg three times daily for anxiety. -The resident did not receive his/her Klonopin 0.5 mg eight out of eight opportunities 3/1/20-3/3/20 at noon. -It was documented on the back of the MAR that Klonopin 0.5 mg was not administered because it was unavailable on two out of eight opportunities. -There were no reasons documented as to why the resident did not receive his/her Klonopin 0.5 mg the other six times in March 2020. Record review of the resident's nurses' notes for February 2020 and March 2020 showed no documentation regarding the resident's Klonopin or Gabapentin. During an interview on 3/3/20 at 11:08 A.M., Licensed Practical Nurse (LPN) C said: -They were out of the resident's Klonopin. -The pharmacy contacted the physician and they are waiting for a written prescription from the doctor. -There's nothing they could do about the resident not having his/her medication. -They were waiting on the doctor. During an interview on 3/6/20 at 9:40 A.M., LPN B said: -If a medication was not administered, the reason should be documented on the back of the MAR. -They were supposed to order medications before they run out. -If a medication was not available, they should call the pharmacy again, call the doctor's office again and/or try to contact the nurse practitioner. -Sometimes they ask the pharmacy to call the doctor again to request the written prescription. During an interview on 3/6/20 at 2:33 P.M., the Director of Nursing (DON) said: -Two to seven days before a resident's medication will run out, the nurse should pull the sticker off the card and send it to the pharmacy for a refill. -The pharmacy calls the doctor, the doctor has to write a prescription and send it to the pharmacy. -They should keep calling the pharmacy every day if a resident's medication has not been received. -They should call the doctor if a resident's medication has not been received. -He/she doesn't know if anyone called the resident's doctor. -The resident's doctor is the facility's medical director. -They should document why a medication was not administered on the back of the MAR. Record review of the resident's March 2020 Physician's Order Sheet (POS) showed: -A physician's orders for Zanaflex (a muscle relaxer) and Trazodone (an antidepressant) without a diagnosis, symptom or purpose. -Some of the resident's diagnoses included anxiety, depression, insomnia, arthritis and fibromyalgia. 2. Record review of Resident #64's March 2020 POS showed: -A physician's order for Norvasc (used to treat high blood pressure and chest pain) without a diagnosis, symptom or purpose. -The resident had a diagnosis of high blood pressure. 3. Record review of Resident' #26's March 2020 POS showed: -A physician's order for Lisinopril (used to treat high blood pressure) without a diagnosis, symptom or purpose. -The resident had a diagnosis of high blood pressure. 4. Record review of Resident #25's March 2020 POS showed: -A physician's order for Carvedilol (used for high blood pressure, heart failure and irregular heart beat) 3.125 mg without a diagnosis, symptom or purpose. -The resident has a diagnosis of high blood pressure. 5. During an interview on 3/6/20 at 2:33 P.M., the DON said: -There should be diagnosis for each medication prescribed. -The charge nurse was responsible for ensuring there was a diagnosis for the medication.

Based on observation, interview and record review, the facility failed to post the daily census and the total hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's), Certified Medication Technicians (CMT's) Certified Nurse Assistants (CNA's), and Nurse Assistants (NA's). The facility census was 64 residents. The facility did not have a policy regarding posting census or nursing staff hours worked per shift. 1. Observation on 3/2/20 to 3/6/20 showed: -The total hours worked per discipline was not posted daily. -The staff schedule was posted but it did not contain the total hours per discipline worked or the daily resident census. Record review of the daily staffing sheets dated 2/23/20 to 3/7/20 showed: -The names of the licensed and unlicensed nursing staff directly responsible for resident care per shift. -Did not include the total number of hours worked by each position listed per shift. -No daily resident census for the facility on the staffing sheets. 2. During an interview on 3/6/20 at 2:33 P.M., the Director of Nursing (DON) said: -The secretary was responsible for posting the staffing sheet in the main lobby. -The charge nurse from the previous shift on the second floor was responsible for posting the staffing sheets on the second and third floors. -The actual total hours of each position directly responsible for resident care per shift should be noted on each daily staffing sheet. -The facility daily census should be on each daily staffing sheet. -He/She will start putting the daily census and the actual total hours of each position directly responsible for resident care on the daily staffing sheets.

Based on interview and record review, the facility failed to ensure the controlled medications (narcotics - medications with a potential for abusive use and dependence upon the medication) were counted and documented at the beginning and the end of the 10:00 P.M. to 6:00 A.M., shift on the second floor to ensure the accuracy of the distribution and use of the controlled medications. This had the potential to affect all residents who used controlled medications on the second floor. The facility census was 64 residents. Record review of the facility's undated controlled drug policy and procedure the narcotic count and inventory showed: -Controlled drugs are counted every eight hour tour by the nurse reporting on duty with the nurse reporting off duty. -The inventory of the controlled drugs must be recorded on the narcotic records and signed for correctness of count. -The controlled drug check list must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct. -If a discrepancy is found: --Check the resident's order sheets and chart to see if a narcotic has been administered and not recorded. --Check previous recordings on the control sheets for mistakes in arithmetic. --If the cause of the discrepancy cannot be located and/or the count does not balance, report the matter to the supervisor. Record review of the facility's medication management and monitoring policy dated 2019 showed: -It was the responsibility of the charge nurses and the Certified Medication Technician (CMT) to ensure the correct counting of medications on the changeover (changing out the old month records for the new month's records) shift. -It was the responsibility of the nursing professional (Registered Nurse (RN), Licensed Practical Nurse (LPN) to count together each shift for the schedule II (drugs with a high potential for abuse with use potentially leading to severe psychological or physical dependence) medications to ensure the correct number of delivery and document and sign off the book. -Notify the Director of Nursing (DON) immediately for any discrepancy for investigation. 1. Record review of the narcotic count record for the 3/4/20 10:00 P.M. to 3/5/20 6:00 A.M. shift showed: -The oncoming nurse signed on 3/4/20 at 10:00 P.M. -The off going nurse did not sign on 3/5/20 at 6:00 A.M. after completing the narcotic count. -The oncoming nurse signed on 3/5/20 at 6:00 A.M. after completing the narcotic count. Record review of the narcotic count sheet dated March 2020 showed: -The 10:00 P.M. to 6:00 A.M., shifts did not have two licensed nurse's signatures. -The oncoming and off going nurse's did not sign the narcotic count sheet on 3/1/20, 3/2/20, and 3/3/20. During an interview on 3/5/20 at 6:05 A.M., CMT B said the nurses should sign the narcotic count record when they count coming on shift and off shift. During an interview on 3/6/20 at 2:33 P.M., the DON said: -Each nurse counting the narcotic count record signs after counting when they come on and go off shift. -He/She was responsible for checking if the narcotic count record was signed.

Based on observation, interview, and record review, the facility failed to follow menus prepared in advance; to have menu changes approved by the dietician or other clinically qualified nutrition professional for nutritional adequacy; to have a pre-set menu of approved alternate choices; and to ensure that the amount of prepared food was sufficient. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 64 residents with a licensed capacity for 87 residents. Record review of the undated Week at a Glance menus for weeks 1 through 4, provided by the Dietary Supervisor, showed the following: -Week 1 had 18 food items for various meals on various days that were crossed out completely or changed. -Week 2 had 22 food items for various meals on various days that were crossed out completely or changed. -Week 3 had 28 food items for various meals on various days that were crossed out completely or changed. -Week 4 had 29 food items for various meals on various days that were crossed out completely or changed. 1. Observations on 3/2/20 at 12:11 P.M. showed that [NAME] B had run out of the meatloaf for lunch and began substituting shredded turkey in its place. During an interview on 3/2/20 at 12:11 P.M., [NAME] B said the following: -They do not run out of food very often. -A new cook made the meatloaf today so that may be the reason they ran out. During an interview on 3/2/20 at 12:23 P.M., the Dietary Supervisor said when he/she saw how much the meatloaf had shrunk in the oven they prepared some shredded turkey as a back-up. During an interview on 3/2/20 at 1:14 P.M., the Dietary Supervisor said the following: -There was no standing alternate food menu. -If a resident wanted something besides the main meal on the menu they would offer leftovers, some kind of sandwich, or whatever was on hand. During an interview on 3/4/20 at 9:49 A.M., the Dietary Supervisor said the following: -The kitchen did not run out of food very often. -When he/she pulled the meatloaf out of the oven two days ago he/she knew it was not enough. -That incident was a fluke. -The previous Dietary Supervisor had made all the hand-written changes to the menus, but he/she was not sure why.

Based on observation and interview, the facility failed to keep the dry storage and walk-in freezer and refrigerator floors swept to avoid foodborne illness; to separate dented cans of food; to maintain sanitary food preparation equipment and utensils; to ensure plastic plate warmers and cutting boards were in good condition to avoid food safety hazards; and to adequately clean food preparation appliances. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 64 residents with a licensed capacity for 87. 1. Observations during the initial kitchen inspection on 3/2/20 between 9:08 A.M. and 12:11 P.M. showed the following: -A 108 ounce (oz.) can of pork and beans dented on the bottom, a 101 oz. can of collard greens heavily dented on the side and bottom, a 104 oz. can of sliced apples dented on the side and bottom, and a 108 oz. can of applesauce dented at the top, were all on a can dispenser rack with other undented cans in the Dry Storage room. -In the next room was a three-shelf unit with 12 dented cans of various sizes on it. -Bits of plastic, paper, and cardboard were on the floor under the racks in the dry storage. -Paper, food debris, foil, and a milk carton were on the floor in the walk-in refrigerator. -Plastic and small trash were on the floor under the racks in the walk-in freezer. -A red, a brown, and a white cutting board were all heavily scored with minute bits of plastic hanging on, and the white cutting board also had brown streaks stained on it. -The green plate warmer lids and bottoms were discolored and/or chipping. -There was a large chunk of food and paper residue on the manual can opener. -A metal ladle hanging by the herbs and spices had white food residue on the rim. -The toaster had excessive crumbs in the bottom and underneath. -The resident microwave in the dining room adjoining the kitchen had food splatters on the inside top, bottom, door, and sides. 2. Observations during the follow-up kitchen inspection on 3/3/20 at 9:11 A.M. showed the following: -A 108 ounce (oz.) can of pork and beans dented on the bottom, a 101 oz. can of collard greens heavily dented on the side and bottom, a 104 oz. can of sliced apples dented on the side and bottom, and a 108 oz. can of applesauce dented at the top, were all on a can dispenser rack with other undented cans in the Dry Storage room. -Bits of plastic, paper, and cardboard were on the floor under the racks in the dry storage. -A red, a brown, and a white cutting board were all heavily scored with minute bits of plastic hanging on, and the white cutting board also had brown streaks stained on it. -The green plate warmer lids and bottoms were discolored and/or chipping. -There was a large chunk of food and paper residue on the manual can opener. -The toaster had excessive crumbs in the bottom and underneath. -The resident microwave in the dining room adjoining the kitchen had food splatters on the inside top, bottom, door, and sides. During an interview on 3/4/20 at 9:49 A.M., the Dietary Supervisor said the following: -Whoever puts the food stock away should check for damaged food stuffs and take a picture of it for credit from the vendor. -Food preparation equipment and utensils should be cleaned after each use by whoever used them. -Floors are to be swept by the dietary staff at the end of shift. -If any plastic items are damaged, cracked, or chipped they should be thrown away when found and replaced.

2. Observation on 3/2/20 at 12:15 P.M. of the assisted dining room (lunch meal) showed: -Certified Nursing Assistant (CNA) A was assisting Resident #62 with eating. -CNA A scratched his/her stomach under his/her shirt. -Without cleansing his/her hands, CNA A picked up Resident #62's cup, and with contaminated hands, gave Resident #62 a drink. -With contaminated hands, CNA A tucked his/her hair out of his/her face. -CNA A did not cleanse his/her hands. -With contaminated hands, CNA A fed the Resident #62 his/her carrots. -With contaminated hands, CNA A turned Resident #41's plate around. -CNA A did not cleanse his/her hands. -With contaminated hands, CNA A gave Resident #62 a drink. -CNA A scratched his/her neck. -CNA A did not cleanse his/her hands. -With contaminated hands, CNA B was feeding Resident #64. -CNA B scratched his/her head. -CNA B put his/her hands on his/her face. -CNA B did not cleanse his/her hands. -With contaminated hands, CNA B fed Resident #64 his/her mashed potatoes. -CNA B cleansed his/her hands with hand sanitizer. -CNA B wiped his/her eye. -CNA B did not cleanse his/her hands. -With contaminated hands, CNA B continued to feed Resident #64. -CNA B rubbed his/her lip with his/her left hand. -CNA B did not cleanse his/her hands. -CNA B played with his/her hair. -CNA B did not cleanse his/her hands. -With contaminated hands, CNA B continued to feed Resident #64. -CNA B used hand sanitizer to cleanse his/her hands. During an interview on 3/2/20 at 1:00 P.M. with Licensed Practical Nurse (LPN) B said: -You are supposed to wash your hands between feeding residents. -You should not touch hair or pants without washing your hands. 3. Observation of the breakfast meal on 3/5/20 at 07:30 A.M. from 7:52 A.M. of the assisted dining room showed: -CNA C opened a carton of milk to pour it on Resident #64's cereal. -CNA C pulled up his/her pants. -CNA C did not cleanse his/her hands. -CNA C scratched his/her hair. -CNA C did not cleanse his/her hands. -With contaminated hands, CNA C continued to feed Resident #64 without cleansing hands. During an interview on 3/5/20 at 2:00 P.M. CNA C said: -The facility does training on handwashing. -You should not touch hair, pants, or face without washing your hands while feeding the residents. During an interview on 3/6/20 at 2:32 P.M. the Director of Nursing (DON) said: -He/she would not expect the staff to touch any part of their body and not wash their hands while assisting the residents to eat. -The staff has had education on handwashing. Based on observation, interview and record review, the facility failed to ensure the staff was practicing hand hygiene at mealtime by not cleansing their hands between assisting different residents to eat for one sampled resident (Resident #64) and two supplemental residents (Resident #41 and Resident #62) out of 16 sampled residents; the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 64 with a licensed capacity for 87 residents. Record review of the facility's Policy for Handwashing, dated 2019 showed: -Nursing staff must comply to the hand washing policy. -Hand washing is not limited to handling food or snack. -Hand washing is not limited to washing hands after touching ear, nose, or mouth. -Alcohol based hand rubs cannot be used in place of proper hand washing techniques in a food service setting. -Hands are to be washed before and after handling food. -Hands are to be washed before and after assisting a resident with meals (with soap and water). 1. Record review of the facility's EP manual entitled Disaster Manual reviewed by the Administrator on 2/17/20 and obtained from the second floor nurse station showed an absence of any waterborne pathogen prevention program including, but not limited to, the following: -A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard. -A completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -A program and flowchart that identifies and indicates specific potential risk areas of growth within the building. -Assessments of each individual potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. During an interview on 3/4/20 at 2:05 P.M., the Maintenance Supervisor said that he/she did not believe the facility had a waterborne pathogen prevention program. During an interview on 3/5/20 at 10:49 A.M., the Administrator said the facility did not have a waterborne pathogen prevention program.