Every finding on record at Abundant Acres Care and Rehab

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD) (a serious type of pneumonia(lung infection) caused by Legionella bacteria, which places all residents at risk of exposure which could lead to illness. This had the potential to affect all residents of the facility. Additionally, the facility failed to ensure staff washed or sanitized their hands between dirty and clean tasks which affected one of 12 sampled residents (Resident #12). The facility census was 44. 1.Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: -The bacterium Legionella can cause a serious type of pneumonia called Legionnaire's Disease in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been liked to poorly maintained water systems in building with large or complex water systems including hospital and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooling towers, hot tubs and decorative fountains. -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:--Develops and implements a water management program that considers the American Society of Heating, Refrigerating and Air-Conditioning Engineers, (ASHRAE)industry standard and the Centers for Disease Control and Prevention, (CDC). Review of the facility's building maintenance inspection and testing records, dated 8/2024 through 8/2025, showed the records did not contain documentation of a complete water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. Record review showed the Legionella policy, undated, guidelines, which instructed the facility staff to complete a risk assessment and develop procedures to monitor for Legionella in accordance with the Centers for Disease Control guidelines had not been completed by the maintenance director. During an interview on 08/20/25 at 3:00 P.M., the Maintenance Director said he checked water temperatures and flushed toilets that are not used on a daily basis. He had no documentation of doing any preventative measures, but did have documentation of water temperatures. During an interview on 08/20/25 at 3:30 P.M., the Administrator said the maintenance department was responsible to conduct water testing for the Legionella Program, monthly. The Administrator had no documentation available. 2. Review of the facility's undated policy for Infection Control for Long Term Care showed: - The purpose is to prevent and control the spread of infectious diseases among residents, staff, and visitors in the facility, ensuring compliance with regulatory standards and promoting a safe environment. - Hand hygiene: perform before and after resident contact, after exposure to bodily fluids, before asepetic tasks, and after removing gloves. Review of Resident #12's care plan, revised 7/11/25, showed: - Toileting: required assistance for toileting, perineal care and managing clothing before and after toileting. - Personal hygiene/oral care: required assistance for all personal hygiene tasks. Review of the resident's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/25, showed: - Cognitive skills severely impaired. - Dependent on the assistance of staff for toilet use. - Required substantial to maximal assistance for dressing. - Required supervision or touch assistance for transfers and oral care. - Always incontinent of bowel and bladder. - Diagnoses included congestive heart failure, high blood pressure, Alzheimer's disease, Parkinson's disease, and COPD. Observation on 8/20/25 at 7:00 A.M., showed: - Certified Nurse Aide (CNA) A and CNA B entered the resident's room, did not wash hands and applied gloves. - CNA A and CNA B unfastened the resident's brief. - CNA A wiped down one side of the resident's groin and CNA B wiped down the other side of the resident's groin. - CNA A wiped once down the middle skin folds. - CNA A and CNA B turned the resident on his/her side. - CNA A wiped once from front to back, removed the wet incontinent brief and placed a clean one under the resident and fastened it. - CNA A and CNA B put clean socks, and pants on the resident. - CNA A and CNA B removed gloves, did not wash his/her hands, and applied new gloves. - CNA A and CNA B transferred the resident to his/her wheelchair and put a clean shirt on the resident. CNA B removed gloves and did not wash his/her hands, applied new gloves and made the resident's bed. - CNA A removed gloves, sanitized his/her hands and left the room. - CNA A entered the resident's room, did not wash his/her hands and applied gloves and combed the resident's hair. CNA A applied perfume to the resident, put the resident's eyeglasses and shoes on the resident. During an interview on 8/20/25 at 12:44 P.M., CNA B said: - He/She should wash his/her hands any time they are soiled. He/she could use hand sanitizer three times then should wash his/her hands. - He/She should have sanitized his/her hands when he/she entered the resident's room, washed his/her hands between glove changes and before he/she left the resident's room. During an interview on 8/20/25 at 3:32 P.M., CNA A said he/she should have washed or sanitized his/her hands after resident cares, between residents, and between glove changes. During an interview on 8/20/25 at 3:12 P.M., Registered Nurse A said staff should wash or sanitize their hands anytime they are soiled, before and after resident cares, and between residents. During an interview on 8/21/25 at 12:33 P.M., the Director of Nursing said staff should wash or sanitize their hands when they enter the room, before they leave the resident's room, between dirty and clean tasks, and between glove changes.

Based on interview and record review the facility failed to provide timely access to resident electronic medical records from 8/18/25 at 10:00 A.M. through 8/19/25 at 1:45 P.M. This resulted in the surveyors being unable to timely review necessary records to conduct the survey and review of care provided to residents. The facility census was 44.Review of the facility's undated electronic medical record policy, showed:- The purpose was to establish standardized guidelines for the use, management, and protection of the facility's electronic medical record (EMR) system to ensure accuracy, confidentiality, and compliance with federal, state, and facility regulations.- Documentation will be done in real time, with use of approved terminology, abbreviations and formatting. - Access Control- Grant access levels determined by specific job role. Staff may view documentation as necessary to perform their role.-The facility will comply with HIPAA, CMS, and state regulations regarding access to medical records.Observation on 8/18/25 at 10:45 A.M., showed the survey team was provided access to the facility's EMR- with no digital/electronic access to any of the residents information: No access to any residents Minimum Data Set (a federally mandated resident assessment completed by facility staff) information, no access to care plans, no access to Advance Directive documents, and no access to any assessments, documents, wound reports, or labs.During an interview 8/18/25 at 1:45 P.M., the Administrator said they had reached out to the EMR provider for assistance to allow access to the survey team, but it would be costly to add all the options to each member of the team.During an interview on 8/18/25 at 4:45 P.M., the Administrator had no update regarding access to EMR records for the survey team, only they were working on the issue.Observation on 8/19/25 at 11:00 A.M., showed the survey team continued with no digital/electronic access to any of the resident's information: No access to any residents MDS information, no access to care plans, no access to Advance Directive documents, and no access to any assessments, documents, wound reports or labs. The surveyor team requested paper records until access could be granted. (Paper records were provided.) During an interview with the Administrator on 8/19/25 at 12:45 P.M., (day two of the survey process) the Administrator was notified that lack of access to the electronic medical records was impeding the survey process and slowing down the team's ability to accurately review documentation and documents timely, that are part of the survey process.During an interview on 8/19/25 at 2:10 P.M., the Administrator said that access was provided to all the surveyors on the team. When asked why this was not done timely, she was unable to say why access was an issue on day one.Observation showed on 8/19/25 at 2:15 P.M., the surveying team had full access to review records to complete the pathways for the survey process.

Based on interview and record review, the facility failed to ensure residents had the right to file grievances in writing, the right to file grievances anonymously, access to the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number within a reasonable expected time frame for completing a review of the grievance, and the right to obtain a written decision regarding his or her grievance. This affected 8 out of the 8 residents who attended group meeting. The facility census was 44. Review of facility policy, Residents' Rights, undated, showed:-Grievances will receive prompt attention to concerns through staff, administration, resident councils, or the ombudsman program;-Residents can file complaints verbally or in writing, all complainants will be investigated and responded to. During a group interview on 8/19/25 at 2:00 P.M., the Resident Council said:- Seven of eight residents did not know who the Grievance Official was at the facility and did not know how to file a grievance or complaint;- Eight of eight residents did not know where the complaint forms were located or how to file an anonymous complaint with the facility;- Eight of eight residents did not know what the resident rights were concerning the grievance process.During an interview on 8/21/25 at 2:30 P.M., the Administrator said:- The Grievance Official was the Social Services Director (SSD);- Grievances can be verbalized and residents would go to the SSD to voice a concern. The SSD would let the resident's caretaker know about the grievance and after discussing with the resident they would either handle the issue informally or write it up as a formal complaint for investigation;- There are no forms for the residents, if they want to file an anonymous grievance they can slide a piece of paper under the Administrator's door;- Families can call on behalf of a resident to voice a grievance and the ombudsman is an additional resource they can pursue as well;- Residents should know who the Grievance Official is and how to file a grievance through resident rights training which is done annually and documented in the resident's medical records.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for three residents (Resident #48, #49, and #50). This affected three of 12 residents sampled. Facility census was 44. Request for a policy covering resident funds upon discharge was not provided by the facility. 1. Review of the facility's accounts receivable aging report, dated 8/20/25, showed the following residents had money in the facility's operating account:- Resident #49 discharged on 2/13/25, with a credit balance of $5,142.00 in the Private Pay account;- Resident #48 discharged on 10/25/24, with a credit balance of $4,932.00 in the Resident Liability account;- Resident #50 discharged on 8/17/24, with a credit balance of $13,852.00 in the Private Pay account.Review of email documentation between the Social Services Director (SSD) and Department of Social Services (DSS) Missouri showed:- Email dated 12/16/24: Resident #48 approved for vendor coverage 9/30/24 through 10/25/24;- Email dated 12/16/24: Resident #49 not approved for vendor coverage and facility was notified on 9/24/24 by phone;- Email follow-up in April, May, and June 2025 did not result in a resolution for Resident #48's account.During an interview on 8/20/25 at 3:30 P.M., the Business Office Manager said:- She was working on a refund check totaling $5,322.00 for Resident #49 and the paperwork would be done today;- The facility still needed a determination on whether Resident #50's stay would be covered by Medicare and this was the cause of the delay for final resolution. The accounting in the accounts receivable aging report should have been changed to show that the resident had a liability to the facility due to funding and not a credit;- Resident #48's account issue had not been resolved or followed up with DSS.During an interview on 8/21/25 at 2:30 P.M., the Administrator said residents should have their accounts closed out and refunds issued within 30-60 days of discharge from the facility.

Based on interview and record review, the facility failed act promptly upon grievances and recommendations made by the resident council when the facility failed to document a response to the council on follow up actions. This affected all the residents serving on the resident counsel and potentially other residents of the facility. The facility census was 44.Review of the undated Resident's Rights policy, showed:- Residents have the right to receive prompt attention to concerns through staff, administration, resident councils, or the ombudsman program;- Grievances: Residents can file complaints verbally or in writing. All complaints will be investigated and responded to;- Residents have the right to receive prompt attention to concerns through staff, administration, resident councils, or the ombudsman program.There was no policy regarding documentation on how to communicate resolutions to residents who had voiced concerns.1.During an interview on 8/19/25 at 2:00 P.M., the Resident Council said:-They would prefer written feedback regarding follow up to their concerns.- Eight out of eight council members had not received copies of the minutes from monthly resident council meetings. All feedback given was verbally and there was no way to see without a written record if the concerns brought up from the last meeting had been addressed to the council during the next meeting;- Eight out of eight council members did not remember staff going over the previous month's concerns at the start of each new meeting. Review of Resident Council Meeting notes showed:- January 2025 seven resident concerns were reported to the staff during the meeting;- February 2025 responses and concerns: No documented list of concerns or facility response provided to the resident council on any of January's concerns. 16 new resident concerns were reported to staff in the February meeting;- March 2025 responses and concerns: No documented list of concerns or facility response provided to the resident council on any of February concerns. 20 new resident concerns were reported in the March meeting notes and three of those concerns were addressed verbally by facility staff directly during the meeting; - April 2025 responses and concerns: Resident council requested a copy of the meeting minutes. No documented list of concerns or facility response provided to the resident council on any of March's meeting notes concerns. 16 new resident concerns were reported in the April meeting and two of those concerns were verbally addressed directly during the meeting; - May 2025 responses and concerns: No documented list of concerns or facility response provided to the resident council on any of April's concerns. One resident reported their concern from last month was resolved. 9 new resident concerns were reported with two of those concerns being addressed verbally by the staff during the meeting; - June 2025 responses and concerns: No documented list of concerns or facility response provided to the resident council on any of May's concerns. Six new resident concerns were reported to staff during the meeting;- July 2025 responses and concerns: No documented list of concerns or facility response provided to the resident council on any of June's concerns. Eight new resident concerns were reported to staff during the meeting. Resident council requested more communication from the administration. None of the previous month's concerns were brought up on the next month's resident council meeting or addressed with the resident council. During an interview on 8/21/25 at 1:45 P.M., the Social Services Designee said:- Minutes of the meeting are not provided to the resident council. Any resident wanting a copy of the minutes would need to ask for it;- The staff goes over all the previous concerns from the last meeting at the start of each resident council meeting;- He/She doesn't normally attend the resident council meetings since the council voted to only have the Activities Director present a few months ago. He/She only attends when the council invites him/her to speak.During an interview on 8/21/25 at 2:30 P.M., the Administrator said:- Residents can verbalize a complaint or grievance to any staff member or go to Social Services directly to file one. This can be done informally or formally on paper. There are no forms, but residents know that they can just slip a note under my door if they want to file an anonymous complaint;- Resident rights training is done so residents know how to file a grievance and know who the grievance official is at the facility;- The training is done annually, in group settings and individually. It's also documented in the medical record;- Issues are discussed as they are brought up in the resident council meeting. Between monthly resident council meetings the resident concerns are discussed during the morning staff meetings;- The facility does not post or print out the resident council meetings for the residents, unless the residents ask for a copy.- Previous concerns addressed at resident council should be followed up during the next resident council meeting. Concerns were being addressed.During an interview o 8/25/25 at 10:45 A.M., the Activities Director said:- He/She takes notes for the resident council meeting and guides the process while working with the resident members;- They go through each section of the minutes form they use to guide the meetings;- He/She does not formally go over each grievance and complaint that was brought up during the last meeting;- He/She relies on the various departments to take care of the complaints and work with the individuals that made the complaints. The facility doesn't make a comprehensive report to the council on the resolution of the complaints and grievances from month to month. The residents are talked to about follow up to their grievance or concerns.

Based on interview and record review, the facility failed to ensure two of 12 sampled residents (Resident #5 and #7) reviewed for unnecessary medications and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 44. Review of the facility's undated Resident's Rights Policy, showed:- Residents have the right to be fully informed in writing of services, costs and changes;- Residents have the right to participate in and know their medical condition and treatment options. Review of the facility's undated Care Plan Policy, showed:- Resident and family/responsible party participation is required and documented;- Residents have the right to participate in care planning and decision-making;- Residents may decline interventions, and refusals must be documented and respected, in accordance with regulations. Review of the facility's Informed Consent for Psychotropic Medication Policy, undated, showed:- Residents will not receive psychotropic medications without obtaining informed consent from the resident or the resident's legally authorized representative (DPOA, POA, guardian). All consents are to be obtained in accordance with federal and state regulations and facility policy;- The resident has the right to be fully informed of the risks, benefits, and alternatives to psychotropic medication;- The resident can refuse or discontinue medications without retaliation or compromised care;- The resident can fully participate in treatment planning if possible; 1. Review of Resident #5's care plan, revised 4/24/25 showed: - The resident used psychotropic medications. - Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. Consult with pharmacy, consider dosage reduction when clinically appropriate, at least quarterly. Monitor/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, and behavior symptoms not usual to the resident. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/25/25 showed: - Cognitive skills intact. - No behaviors noted. - Diagnoses included: progressive neurological conditions, Alzheimer's disease, anxiety, depression, and bipolar. - Seven antipsychotics used in the last seven days. - Antipsychotics were used on a regular basis. - A gradual does reduction was attempted on 7/9/25. Review of the resident's POS (Physician Order Sheet), dated August 2025 showed: - Start date: 7/9/25 - Zyprexa (antipsychotic) 10 milligrams (mg) daily for bipolar disorder. Discontinued on 8/8/25. - Start date: 8/8/25 - Zyprexa 7.5 mg at bedtime for behaviors. Review of the resident's medical record showed no consents or education of risks and benefits for psychotropic medication use was noted from 7/1/25 through 8/19/25. 2. Review of Resident #7's Care Plan, revised 5/16/25, showed: - Resident used psychotropic medications for behavior management;- Resident had a mood problem due to bipolar disorder. Staff administered medications and were to monitor for side effects and effectiveness;- Resident had a psychosocial well-being problem from anxiety, bipolar disorder and major depressive disorder. Review of the resident's Quarterly MDS dated [DATE], showed:- Resident had moderate cognitive impairment;- Resident had no potential indicators of psychosis;- Diagnosis included: heart failure, hypertension, kidney disease, diabetes, depression, dementia, and bi-polar disorder (mental health condition with mood swings);- Medications: antipsychotics. Review of the resident's Behavioral Diagnostic Assessment, dated 8/15/25, showed the resident's currently prescribed psychotropic medication was Cariprazine (antipsychotic) 6 mg once daily. Record review of the resident's Medical Records showed: August 2025 Physician Order for Cariprazine an antipsychotic 6mg 1 tablet by mouth once daily. Review of the resident's clinical record showed no documentation of informed consent for the use of psychotropic medications for the resident. 3.During an interview on 8/202/25 at 3:12 P.M., Registered Nurse (RN) A said the consents were a new thing, but they should be obtained before the resident started on the medication. During an interview on 8/21/25 at 8:14 A.M., Licensed Practical Nurse (LPN) A said: - He/She thought the consent for psychotropic medications should be signed prior to the resident starting on the medication. - He/She did not know who was responsible to obtain the consent. - It should be documented in the resident's progress notes that consent was obtained. During an interview on 8/21/25 at 8:30 A.M., the Director of Nursing (DON) said:- There currently is no process for obtaining informed consent for residents for the use of psychotropic medications;- The facility is developing a program and training so staff can obtain consent and update our system with the proper documentation to show informed consent by our residents. During an interview on 8/21/25 at 12:33 P.M., the DON said: - The nurse should make sure the consent has been signed. - It will be part of the admission packet and Social Services will now have a part in it. - The consents should be obtained prior to the resident starting on the psychotropic medications. - Staff should document it in the resident's progress notes consent has been obtained.

Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to use a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) during a transfer for one of 12 sampled residents (Resident #12). The facility census was 44. Review of the facility's undated policy for gait belt showed:- Nursing staff must use gait belts during assisted ambulation and/or transferring of residents as stated in resident's plan of care.- Note the need for use of gait belt in the resident's plan of care.- Apply the belt around the resident's waist snugly to eliminate the possibility of gait belt movement.- Bring the resident to a standing position by grasping the belt with both hands while remaining upright and staff member to place feet shoulder width apart, one foot more forward than the other and slightly bend knees to assure solid posture with good body mechanics during lift/transfer.- Use the gait belt during ambulation to stabilize the resident by grasping the belt firmly, hands on the underside of belt with fingers upward. 1. Review of Resident #12's care plan, revised 7/11/25 showed:- Toileting: required assistance for toileting, perineal care, and managing clothing before and after toileting.- Personal hygiene/oral care: required assistance for all personal hygiene tasks. - The care plan did not address how to transfer the resident. Review of the resident's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/25 showed:- Cognitive skills severely impaired.- Dependent on the assistance of staff for toilet use.- Required substantial to maximal assistance for dressing. - Required supervision or touch assistance for transfers. - Always incontinent of bowel and bladder.- Diagnoses included congestive heart failure, high blood pressure, Alzheimer's disease, Parkinson's disease, and Chronic Obstructive Pulmonary Disease (COPD). Observation on 8/20/25 at 7:00 A.M., showed:- Certified Nurse Aide (CNA) A and CNA B entered the resident's room and applied gloves.- CNA A and CNA B provided incontinent care for the resident. - CNA A and CNA B put socks and pants on the resident.- CNA B placed the resident's wheelchair beside the bed and locked the brakes. - CNA A and CNA B dressed the resident for the day. - CNA A and CNA B sat the resident on the side of the bed.- CNA A and CNA B placed their arm under the resident's arm pit and stood the resident up. - CNA A and CNA B pulled the resident's pants up with their other hand and held onto the resident's pants as they transferred the resident into his/her wheelchair without the use of a gait belt. During an interview on 8/20/25 at 12:44 P.M., CNA B said:- He/she tried to use a gait belt on all the residents.- If a resident was stand by assist or ambulated on their own, or required assistance to stand and pivot, staff should use a gait belt.- The resident used to ambulate with a walker, but had declined and now used a wheelchair for mobility. - He/She should not have placed his/her arm under the resident's arm pit and should not have grabbed the back of the resident's pants during the transfer.- He/She should have used a gait belt or held onto the resident's hands to get him/her to stand and pivot to the wheelchair, but forgot. During an interview on 8/20/25 at 3:32 P.M., CNA A said:- The resident was walking on his/her own until recently.- He/She should not have placed his/her arm under the resident's arm pit or grabbed the back of the resident's pants during the transfer, but had just forgot. During an interview on 8/20/25 at 3:12 P.M., Registered Nurse A said:- The resident was able to transfer him/herself and was able to get up without assistance.- Staff should not place their arms under the resident's arm pits and should not grab the back of the resident's pants during the transfer.- Staff should have used a gait belt. During an interview on 8/21/25 at 12:33 P.M., the Administrator and the Director of Nursing said:- The resident changed in his/her ability to transfer. Sometimes the resident would transfer him/herself.- Staff should not have placed their arms under the resident's arm pit or grabbed the back of the resident's pants during the transfer, they should have used a gait belt to assist with the transfer.

Based on observation, interview, and record review, the facility failed to ensure staff discarded expired medications stored in the medication room, failed to ensure food was not stored with medications in the medication refrigerator, failed to ensure staff properly labeled opened, multi-dose medications with dates to indicate when they were opened and when they should be discarded, which affected two of12 sampled residents, (Resident #13 and #38) who received Lorazepam Intensol (a liquid anti-anxiety medication). Additionally, staff failed to ensure there were no loose pills in the medication cart. The facility census was 44. Review of the facility's policy for medication storage and handling, revised 5/26/25, showed:- Medications will be monitored by the charge nurse (CN), Certified Medication Technician (CMT) and the Consultant Pharmacist to ensure they are not expired, contaminated or unusable.- Expired, contaminated, and unusable medications will promptly be removed and disposed of. 1. Observation and interview on 8/20/25 at 6:18 A.M., of the 300 and 500 medication carts showed:- One oblong white pill, one oblong orange pill, and one oblong blue pill loose in the drawer of the medication cart.- CMT A said there should not be any loose pills in the medication cart. The pharmacist came in monthly and checked the medication room and the medication carts for expired medications. In between the CMTs checked the medication carts. 2. Observation and interview on 8/20/25 at 6:45 A.M., of the medication room showed:- An opened container of Lay's French Onion Dip in the medication refrigerator. Registered Nurse (RN) A said there should not be any food in the medication refrigerator.- Resident #38 had an opened bottle of Lorazepam 2 mg (milligrams)/ml (milliliter) that did not have a date when it was opened. The box indicated the bottle was to be discarded after 90 days after opening.- Resident #13 had an opened bottle of Lorazepam 2 mg/ml that did not have a date when it was opened. The box indicated the bottle was to be discarded after 90 days after opening.- An opened bottle of Milk of Magnesia, expired 7/25.- RN A said the Lorazepam should be dated when it was opened. He/She thought it was only good for 30 days after it was opened. The expired Milk of Magnesia should not be used, because it was expired, and it should be discarded. During an interview on 8/21/25 at 12:33 P.M., the Director of Nursing (DON) said:- There should not be any loose pills in the medication cart. Staff should properly dispose of them. - There should not be any food in the medication refrigerator.- Expired medications should be disposed of properly.- The Lorazepam should be dated when opened. - The Pharmacist, CN, CMTs and him/herself should check the medication carts and the medication room for expired medications, loose pills and ensure there was no food in the medication refrigerator.

Based on observation, interview and record review, the facility failed to protect resident rights when the facility did not inform residents in writing on how to file a complaint with the State Survey Agency and where to find the Ombudsman's contact information for two sampled residents (Residents #20 and #26) and seven of eight resident council members. The facility census was 44.Review of facility Residents' Rights policy, undated, showed no information on a process for residents to contact and file a grievance with the state of Missouri Department of Health and Senior Services. 1. Review of Resident #20's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 6/30/25, showed:- Resident was cognitively intact;- Diagnosis: epilepsy, traumatic brain injury, anxiety disorder, and schizophrenia.Review of resident's electronic medical record showed there was nothing in writing regarding on how a resident could contact the Missouri Department of Health and Senior Services. During an interview on 8/21/25 at 10:05 A.M., the resident said he/she did not know how to contact the state to make a complaint and did not know where the number was located. The resident also did not know how to contact the ombudsman or where the phone number was located. 2. Review of Resident #26's Quarterly (MDS), dated [DATE], showed:- Resident was cognitively intact;- Diagnosis: neurogenic bladder, diabetes, seizure disorder, depression, and bipolar disorder.Review of resident's electronic medical record showed there was nothing in writing regarding how a resident could contact the Missouri Department of Health and Senior Services.During an interview on 8/21/25 at 10:50 A.M., the resident said he/she did not know how to contact the state to make a complaint or where the number was located. The resident also did not know how to contact the ombudsman or where the phone number was located. 3. During an interview on 8/19/25 at 2:00 P.M., the Resident Council said:- Seven of eight resident council members did not know how to file a complaint with the state agency or how to contact them. - Seven of eight resident council members did not know where the Ombudsman contact information was located and was not provided any information in writing on how to contact the ombudsman or survey agency.During an interview on 8/19/25 at 3:40 P.M., the DON said he/she was not sure if the residents were provided contact information for local ombudsman or survey agency in writing but thought they should be.During an interview on 8/21/25 at 2:30 P.M., the Administrator said:- Resident right training on how to file a grievance and contact the state agency as well as local Ombudsman was done annually either in groups or one on one with residents and was not sure if it was provided in writing to the residents annually; During an interview on 8/25/25 at 12:40 P.M., the Activities Director said residents were last trained on resident rights in resident council in March 2025.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #25) had a toilet that flushed properly. The facility census was 44. Review of the facility's undated policy for Home-Like Environment showed:- The purpose is to promote and maintain a home-like environment within the facility that enhances residents' comfort, dignity, and quality of life, while ensuring safety and regulatory compliance. - The facility will provide an environment that feels comfortable, safe, and familiar to residents. - Housekeeping and maintenance will ensure rooms are clean, safe, well-kept, and within comfortable temperatures. Review of the facility's undated policy Maintenance Repairs showed: - The facility is committed to maintaining a safe, functional, and comfortable environment for residents, staff, and visitors. - All employees are responsible for promptly reporting any maintenance issues to the appropriate personnel. - Maintenance requests may be submitted electronically or in person. - It is essential that repair needs are reported immediately upon discovery to ensure timely prioritization and resolution. - Minor repairs that can be safely and effectively addressed by staff may be completed without delay. - For emergency repairs or issues requiring professional or external support, the Maintenance Director, Administrator, Director of Nursing (DON), or Director of Rehabilitation (DOR) must be contacted for further action. - This policy ensures that all maintenance concerns are handled efficiently to promote safety, comfort, and operational continuity within the facility. 1. Review of Resident #25's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/25 showed: - Cognitive skills intact. - Independent with transfers and toilet use. - Always continent of bowel and bladder. - Diagnoses included atrial fibrillation, congestive heart failure, high blood pressure, arthritis, anxiety, and depression. During an observation and interview on 8/19/25 at 7:52 A.M., the resident said: - For the last two months, there had been problems with the toilet not flushing completely. - The resident had reported the issue to nursing staff, but nothing had been done to fix it. - It made the resident feel embarrassed when the toilet did not flush completely and it made the resident feel like it was his/her fault. - The surveyor flushed the resident's toilet and observed that it did not flush completely. During an interview on 8/20/25 at 11:48 A.M., the Maintenance Director said: - He/She had been in the position for a month. - If something was broken, the staff would either text him/her or call him/her on the walkie. The staff could also put an order in Tels (a computer program used for notification of maintenance repairs). - He/She was not aware of any residents who had issues with their toilet not flushing properly. - The DON had informed him/her this morning of the resident's toilet not flushing properly and he/she augured it out and it seemed to be flushing correctly. During an interview on 8/20/25 at 3:12 P.M., Registered Nurse (RN) A said;- He/She had not had any residents complain about their toilets not flushing correctly. - If a resident reported it, he/she would try to fix the issue, if unable to then would notify maintenance verbally, on the walkie or on the Tels log. During an interview on 8/20/25 at 3:32 P.M., Certified Nurse Aide (CNA) A said: - He/She did not have any residents complain about their toilets not flushing correctly. - He/She would report the issue to maintenance over the walkie. During an interview on 8/21/25 at 8:09 A.M., the Housekeeping Supervisor said: - He/She had been in the position for about a month. - When the residents' toilets were cleaned, the housekeeping staff also flushed them. - There were quite a few toilets that didn't flush all the way and had to be flushed twice. - He/She was aware Resident #25's toilet sometimes had trouble flushing and maintenance had been notified. - He/She called the Maintenance Director on the phone, on the walkie or used the Tels maintenance log to report any issues. During an interview on 8/21/25 at 12:33 P.M., the Administrator said: - She was unaware of resident's toilet not working properly. - She would expect the resident's toilet to flush properly. - If a resident had an issue with the toilet not flushing properly, the resident should inform their aide. - During the day, the staff could use the walkie to notify maintenance or the Tels system.

Based on interview and record review, the facility failed to have documentation of one resident's (Resident #18), with serious mental illness and intellectual disability diagnosis, Level I preadmission screening resident review (PASRR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities (IDD) completed before admission to the nursing facility). The census was 44. Review of the facility PASRR policy showed the facility will complete and comply with all PASRR requirements prior to admitting any resident into the facility and will ensure timely resident reviews in the event of significant changes in condition. The facility will coordinate with the Missouri Department of Health & Senior Services (DHSS) and the Missouri Department of Mental Health (DMH) to ensure proper screenings, evaluations. and placements are carried out. 1.Review of Resident #18's medical records showed: -The resident had diagnoses of major depressive disorder (a mental disease characterized by persistent sadness) and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality and relates to others).-No PASRR level I screen found.-No PASRR level II screen found.Review of the resident's care plan, dated 02/14/2022, revised on 09/28/2022, showed the resident had the potential to be verbally aggressive, related to hallucinations, and delusion associated with schizophrenia diagnosis. During the interview on 08/20/25 at 12:45, The Social Service Director (SSD) said she was unable to produce any PASRR for Resident #18, stating he/she had been in the facility greater than one year and was unable to obtain all paperwork. The SSD said that he/she emailed the COMRU (Central Office Medical Review Unit) to see if he/she could obtain a copy and they could not produce one for him/her. During an interview on 08/21/25 at 09:45 A.M., the Director of Nursing (DON) said he/she was new to the process of PASRRs and was unable to give any direction on what needed to be done, but did say he/she expected this resident to have a PASRR in his/her records.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #1 and #8) that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment as well as services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility census was 44.Review of the facility's undated care plan policy showed the purpose of the care plan policy was to establish a standardized process for the development, implementation, review, and revision of the individualized resident care plans that ensure person-centered care, regulatory compliance, and quality outcomes. The policy applies to all residents, nursing staff, interdisciplinary team members, and contractors providing care and services with the facility. The Director of Nursing (DON) oversees the care plan process and ensures compliance. Care plans must be resident centered, reflecting resident preferences, goals, strengths, and needs. Care plans are to be updated with changes in the resident's condition and during assessments. The care plan should establish measurable goals, interventions and time frames. 1. Review of Resident #8's most recent Quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 7/11/25, showed staff assessed the resident as: - Able to make needs known and understand others. - Cognition intact. - Incontinent of bowel and bladder. - Required nursing assistance for personal care and hygiene needs. - Diagnoses of diabetes, wounds to legs, cardiac disease, and hypertension (high blood pressure). Review of the resident's physician orders for August 2025., showed: - Antibiotic medication of Bactrim DS 800 mg (milligrams) 1 pill twice daily from 8/15/25 through 8/18/25. - Januvia 100 mg for diabetes once daily. - Eliquis 5 mg by mouth twice daily for blood thinning. - Wound care treatment to lower legs: skin cleaner and Triple antibiotic ointment to open sores. Review of the resident's care plan, last dated 5/16/25, showed the care plan did not have interventions care planned for the management of the resident's diabetes, anticoagulant usage, antibiotic medication for recent UTI (urinary tract infection), or staff interventions for wounds on the resident's lower legs. During an interview on 8/19/25 at 12:45 P.M., Registered Nurse (RN) A said Resident #8's care plan should reflect the current care and treatment to wound care as well as the any blood thinners the resident is taking. RN A does not update the resident's care plan, the DON or MDS person does. 2. Review of Resident #1's MDS, dated [DATE], showed staff assessed the resident as:-Cognition not intact.-Dependent of staff for all cares.-Incontinent.-Wounds.-Recent pneumonia. Review of the physician's order sheets for the month of August 2025, showed:- Daily wound care treatment to the right heel by licensed nurse started on 7/16/25.- Daily wound care to left arm by licensed nurse started on 8/14/25. Review of the resident's care plan, dated 7/20/25, showed: - No care plan regarding the resident's risk for skin breakdown.- No care plan regarding interventions for staff on bed mobility and pressure reducing measures with positioning aids. - No care plan regarding the wound to the resident's left wrist where the skin is missing. - No care plan regarding the resident's most recent treatment of pneumonia and risk for infections. During an interview on 8/19/25 at 12:45 P.M., RN A said Resident #1's care plan should reflect the current care and treatment the resident needs regarding medical changes, wound care, and staff interventions. RN A does not update the resident's care plan, the DON or MDS person does. 3. During an interview on 8/20/23 at 2:25 P.M., the MDS Coordinator said he/she had recently taken over the role as MDS coordinator and was concerned the care plans were lacking interventions and were not resident specific. He/She was working to get the care plans updated to reflect the current needs of each resident. During an interview on 8/20/25 at 3:10 P.M., the DON said the MDS coordinator took over the care plans and MDS 30 days ago. He/She would expect that the care plans match the current needs and goals of the resident. This would include needs, strengths, and would be individualized for the residents.

Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care for one of 12 sampled residents (Resident #12). The facility census was 44. Review of the facility's undated policy for Perineal Care showed:- The purpose is to maintain cleanliness, comfort, and dignity while preventing infection and skin breakdown through proper perineal care.- Perineal care will be provided as needed, and at least during daily hygiene routines, after incontinence episodes, and as part of routine bathing.- Wash hands and put on gloves.- Separate the skin folds with one hand.- Wash each side of the skin fold then down the center.- Clean from front to back to prevent infection.- Use a clean portion of the wipe for each stroke.- Turn the resident on his/her side.- Wipe from front to back, clean the rectal area last. - Remove gloves and wash hands. 1. Review of Resident #12's care plan, revised 7/11/25, showed:- Toileting: required assistance for toileting, perineal care, and managing clothing before and after toileting.- Personal hygiene/oral care: required assistance for all personal hygiene tasks. Review of the resident's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/25 showed:- Cognitive skills severely impaired.- Dependent on the assistance of staff for toilet use.- Required substantial to maximal assistance for dressing. - Always incontinent of bowel and bladder.- Diagnoses included congestive heart failure, high blood pressure, Alzheimer's disease, Parkinson's disease, and Chronic Obstructive Pulmonary Disease (COPD). Observation on 8/20/25 at 7:00 A.M., showed:- Certified Nurse Aide (CNA) A and CNA B entered the resident's room.- CNA A and CNA B unfastened the resident's brief. - CNA A wiped down one side of the resident's groin and CNA B wiped down the other side of the resident's groin.- CNA A wiped once down the middle skin folds.- CNA A and CNA B turned the resident on his/her side.- CNA A wiped once from front to back, removed the wet incontinent brief and placed a clean one under the resident and fastened it. - CNA A and CNA B did not separate and clean all areas of the skin where urine had touched.- CNA A and CNA B dressed the resident for the day and transferred him/her to his/her wheelchair. - CNA A removed gloves, sanitized his/her hands and left the room. During an interview on 8/20/25 at 12:44 P.M., CNA B said when he/she provided peri care he/she should make sure to separate the skin folds and clean all areas of the skin where urine had touched. During an interview on 8/20/25 at 3:12 P.M., Registered Nurse (RN) A said when staff provided peri care, they should make sure to separate and clean all the skin and skin folds where urine had touched. During an interview on 8/20/25 at 3:32 P.M., CNA A said when he/she provided incontinent care to the resident, he/she should have made sure to separate all the skin folds and clean all areas of the skin where urine had touched. CNA A was busy with assisting everyone and did not think about it. During an interview on 8/21/25 at 12:33 P.M., the Director of Nursing said staff should separate all the skin folds and clean all areas of the skin where urine had touched.

Based on observation, interview, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent, when staff made two medication errors out of 25 opportunities for error, which resulted in a medication error rate of 8%. This failure affected two of 12 sampled residents, (Resident #25 and #28). The facility census was 44.Review of the facility's policy for Medication Administration, dated 5/26/25, showed:- The facility will provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of each resident to treat their individual medical diagnoses. - Charge Nurse/Certified Medication Technician (CMT) will confirm the medication and order by checking the label on the medication against the order on the resident's medication administration record (MAR) and make sure everything matches: name of the medication; dose; route; and times to be administered. 1. Review of the facility's undated policy for Nasal Spray Administration showed:- The purpose is to provide safe and consistent guidelines for the administration of nasal spray medications to residents, ensuring accuracy, infection prevention, and compliance with physician orders.- Ensure resident is sitting upright. Instruct resident to gently blow their nose, if possible. Shake the bottle if indicated. Insert spray tip into one nostril while occluding the other. Instruct the resident to breathe in gently through the nose while actuating the spray. Repeat as prescribed for the other nostril.- Wipe spray tip with a clean tissue, if needed. Review of the manufacturer's guidelines for Flonase nasal spray (used to treat allergies) showed:- Shake well before use.- Blow your nose to clear your nostrils.- Close one nostril. Tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril.- Start to breath in through your nose, and while breathing in, press firmly and quickly down once on the applicator to release the spray.- Repeat in the other nostril. Review of Resident #28's Physician Order Sheet (POS), dated August 2025, showed a medication start date: 2/20/22 for Fluticasone (Flonase) Propionate Nasal Suspension 50 mcg (micrograms), one spray in each nostril daily related to allergies. Review of the resident's Medication Administration Record (MAR), dated August 2025, showed an order for Fluticasone Propionate Nasal Suspension 50 mcg, one spray in each nostril daily related to allergies. Observation on 8/20/25 at 9:28 A.M., showed:- CMT A entered the resident's room, placed the nasal spray and a Kleenex on a paper towel. Sanitized his/her hands and applied gloves.- CMT A had the resident blow his/her nose.- CMT A did not shake the bottle, removed the cap and gave one spray in the right nostril and then one spray in the left nostril.- CMT A removed gloves and washed his/her hands. - CMT A did not close either side of the nostril during the administration. During an interview on 8/20/25 at 11:56 A.M., CMT A said he/she should have followed the manufacturer's guidelines for administration of the nasal spray. He/She should have shook the bottle and closed each side of the nares. During an interview on 8/21/25 at 12:33 P.M., the Director of Nursing (DON) said staff should follow the manufacturer's guidelines for the administration of Flonase Nasal Spray. Staff should shake the bottle, close one side of the nares, and administer in the opposite nostril and repeat on the other side. 2. Review of the facility's undated policy for eye drop administration showed:The purpose is to ensure safe, effective, and consistent administration of eye drop medications to residents while minimizing the risk of infection, error, or injury.Verify order and resident: check the physician's order for correct medication, dosage, frequency and eye (left, right or both).Position resident sitting or lying with head tilted back. [NAME] (apply) clean gloves if contact with mucous membranes is anticipated. Remove the cap without touching the dropper tip. Instruct the resident to look upward. Gently pull down the lower eyelid to create a small pocket. Hold the dropper close to the eye without touching eyelashes, eyelids or eye surface. Instill the prescribed number of drops into the pocket. Instruct the resident to close their eye gently (do not squeeze shut). Apply gentle pressure to the inner corner of the eye for 30 - 60 seconds to reduce systemic absorption.Review of Resident #25's POS, dated August 2025, showed a order start date: 3/20/25 - Artificial Tears Ophthalmic Solution 1.4 %. Instill one drop in both eyes four times a day for dry eyes. Review of the resident's MAR, dated August 2025 showed Artificial Tears Ophthalmic Solution 1.4 %. Instill one drop in both eyes four times a day for dry eyes. Observation on 8/20/25 at 8:55 A.M., showed:The box and the bottle of Artificial Tears showed 0.2%.CMT A sanitized his/her hands, applied gloves and placed one drop in the resident's right eye. The tip of the eye dropper touched the resident's eyelashes. CMT A placed one drop in the resident's left eye, and the tip of the eye dropper touched the resident's eye lashes. CMT A removed gloves and washed his/her hands. During an interview on 8/20/25 at 11:56 A.M., CMT A said:He/she should have followed the physician's order for the percentage of the eye drops.The tip of the eye dropper should not have touched the resident's eyelashes. During an interview on 8/21/25 at 12:33 P.M., the DON said:Staff should have clarified the percentage of the eye drops and call the pharmacy and get it corrected. The eye drops should not have been administered until the order was clarified.The tip of the eye dropper should not touch the resident's eyelashes.

Based on observation, interview, and record review, the facility failed to ensure availability of staff who can provide cardiopulmonary resuscitation (CPR, any medical intervention used to restore circulatory and/or respiratory function that has ceased) when the facility did not have a full list of CPR certified staff available or copies of CPR cards in employee files. This had the potential to affect all residents who were a full code (residents who want CPR when their heart stops beating). Facility census was 43. The facility did not have a policy in place regarding staff being CPR certified or maintaining a list of staff currently on shift who are CPR certified. Review of employee files on [DATE] a 1:45 P.M., showed: -Employee files of Registered Nurse (RN) A, Minimum Data Set (MDS) Coordinator, Certified Nurses Assistant (CNA) A, Certified Medication Technician (CMT) A, CNA B, and CNA C did not contain evidence of CPR certification. During an interview on [DATE] at 11:20 A.M., CMT B said: -His/Her CPR certification is expired; -The facility did not ask about his/her CPR certification status when hired; -He/She does not know where to find if any of the staff working are CPR certified. He/She assumes the charge nurse is CPR certified. During an interview on [DATE] at 11:22 A.M., LPN A said: -His/Her CPR certification was current; -The facility did not ask about his/her CPR certification status when hired; -He/She does not know where to find if any of the staff working are CPR certified. During an interview on [DATE] at 11:25 A.M., CNA D said: -He/She was not CPR certified; -The facility did not ask about his/her CPR certification status when hired; -He/She does not know where to find if any of the staff working are CPR certified; -He/She assumes the charge nurse on duty is CPR certified. During an interview on [DATE] at 10:58 A.M., the Physician said: -He/She would expect the facility to follow their policy regarding staff being CPR certified; -He/She would expect that all the staff be CPR certified, but at least all the nursing staff at a minimum. During an interview on [DATE] at 4:01 P.M., the Director of Nursing (DON) said: -The facility does not have a policy regarding staff being CPR certified; -There is not a list or record of which staff's CPR certification is current. He/She thought the Business Office kept record of this; -There is not a list that indicates which staff currently working on shift are CPR certified; -He/She does not know how any staff currently on shift would know who is CPR certified; -It is his/her expectation that the charge nurse on duty be CPR certified, at a minimum. During an interview on [DATE] at 12:15 P.M., the Administrator said: -The facility does not have a policy regarding staff being CPR certified. It is his/her expectation that the facility have a policy on this topic; -It is his/her expectation that nursing staff be CPR certified. MO255778

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by Resident #1, when Resident #1 was observed by staff striking Resident #2 in the face resulting in a bruise and two facial skin tears. The facility census was 53. Review of the facility's undated Abuse and Neglect policy showed: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; the infliction of physical, sexual, or emotional injury or harm; -The purpose of this policy is to ensure prevention, protection, prompt reporting and interventions in response of property, or exploitation of any facility resident. Our goal at all times will be the protection of our Residents. -All Residents have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. On 1/4/25, the Administrator was notified of the past noncompliance which began on 1/4/25. The facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 1/7/25. 1. Review of Resident #1's quarterly Minimum Data Set, a federally mandated assessment completed by staff, dated 11/16/24, showed: - Resident was admitted on [DATE]; - Resident scored 7 on the BIMS. This score indicates severe cognitive impairment. - Resident has the diagnosis of dementia, chronic post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, accompanied by intense emotional and physical reactions), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities) , pain, depression, rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), osteoarthritis (a chronic degenerative joint disease that causes cartilage in the joints to break down over time), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). Review of the resident's undated comprehensive care plan showed: - Resident is a wandering/elopement risk due to impaired cognition and impaired safety awareness; - Resident displays behaviors related to dementia and depression; - New behavior resident potentially causing harm to self or others (Episodic), physical towards another; - Staff monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors; - Staff monitor resident for signs/symptoms of agitation; - Resident has behavior problem due to depression and dementia; - Staff are to intervene as necessary to protect the rights and safety of others; 2. Review of Resident #2's annual MDS, dated [DATE], showed: - Resident was admitted on [DATE]; - Resident has a severe cognitive impairment; - Resident has the diagnosis of GERD (acid reflux), neurogenic bladder; diabetes (chronic disease when body can't produce insulin), thyroid disorder (production of an abnormal amount of thyroid hormones), dementia, malnutrition, anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), depression. Review of the resident's comprehensive care plan, dated 11/12/23 showed: - Resident is on Hospice care for senile dementia of the brain; - Resident wanders aimlessly and requires redirection; - Resident has a potential to be physically aggressive towards other residents and has a history of harm to others (Physical events 6/14/24, 8/1/24, 10/12/24, 10/26/24, 1/4/25); - Staff monitor/document/report as needed resident posing danger to self and others; - Resident has impaired cognitive function/dementia or impaired thought processes. Review of the facility investigation showed: - On 1/4/25 at 2:00 A.M. Certified Nursing Assistant (CNA) A witnessed Resident #1 and Resident #2 walking together and then get into a verbal altercation resulting in each resident striking at each other; - CNA A immediately ran down the hallway to intervene and separate the two residents; - Registered Nurse (RN) A was called to assess both residents. - Resident #1 had no injuries noted. - RN A assessed resident #2 and found three red areas and two small skin tears on his/her cheek; - RN A administered first aid to resident #2 and asked the resident about the incident. Resident #2 said he/she was tired and wanted to go back to bed. Staff then escorted resident back to their room and put them back in bad; - RN A questioned resident #1 about the incident and he/she said they hit resident #2 because they called them a bad name. Resident did not want to go to bed so they went to the lounge to watch TV until falling asleep on the couch; - Day shift Licensed Practical Nurse (LPN) A examined resident #2 on 1/4/25, time unknown, and noted a purple bruised and small skin tear on resident's cheek; - LPN A stated there were no other incidents or concerns between the two residents during the day. Review of Resident #2's progress notes, dated 1/4/25, showed, LPN A documented a skin check showed the resident had two small skin tears to the left check and small purple bruising and various stages of bruising to both arms. Review of in-service education provided to staff on 1/6/25 showed: - Training for abuse, intervention tools, re-direction and engagement of residents; - Specific training aimed at providing a safe environment for Alzheimer's dementia, dementia, and cognitively declined residents in the facility; - Special Care Unit (SCU) staffing policy for day and night shifts were covered with requirements required before leaving the floor. RN A was requested to contact the surveyor for interview however no return call was received by the surveyor. During an interview on 1/28/24 at 12:20 P.M., the Administrator and Director of Nursing (DON) said: - Resident #2 sustained minor injuries and first aid was provided and the residents monitored by staff during and after the event; - In service training had been conducted and staff increased to three to four depending on day or night shift conditions; - Immediately after the incident the DON conducted face to face and text message training for staff and provided guidance for self direction and monitoring of residents on the SCU; -There were staffing protocols in place for staff to leave the unit for breaks and other activities, provided there were proper relief and the minimum number of staff. - A quarterly in service for staff was updated to include additional information for interventions and monitoring of staff in the facility and for handling suspected abuse. MO247513

Based on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by Resident #1, when Resident #1 was observed by staff sitting on Resident #2's bed with his/her pants and underwear pulled down to his/her mid thigh and Resident #1's hand inside the front of Resident #2's brief. The facility's census was 56. On 1/3/25, the Administrator was notified of the past noncompliance which began on 12/25/24. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 12/28/24. Review of the facility's undated Abuse and Neglect policy showed: -It is responsibility of employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspect incident of neglect or resident abuse, including injuries of unknown source, exploitation, theft or misappropriation of resident property to the facility management. -The purpose of this policy is to ensure prevention, protection, prompt reporting and interventions in response of property, or exploitation of any facility resident. Our goal at all times will be the protection of our Residents. -All Residents have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; the infliction of physical, sexual, or emotional injury or harm; -Sexual abuse is defined as including, but not limited to, sexual harassment, sexual coercion, or sexual assault; Non-consensual sexual contact of any type with a resident. 1. Review of Resident #1's quarterly Minimum Data Set, a federally mandated assessment completed by staff, dated 12/8/24, showed: -He/she was admitted to the facility on [DATE]. -He/she has the diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), acidosis (a condition were bodily fluids become too acidic), diverticulosis (a condition in which small, bulging pouches develop in the digestive tract), weakness, unsteadiness on feet, pain, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning). -He/she scored 11 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognitive skills. Review of the resident's undated comprehensive care plan showed: -The resident displays inappropriate sexual behaviors and was started on estrogen/estrodiol (a hormone/medication used to increased the level of the hormone, estrogen, in a person's body). - The resident is an elopement risk/wanderer related to wandering into other resident's rooms, exit seeking, stating he/she is leaving facility. -He/she has impaired cognitive function and impaired thought processes related to dementia. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -He/she was admitted to the facility on [DATE]. -She has the diagnoses of dementia, chronic post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, accompanied by intense emotional and physical reactions), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities) , pain, depression, rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), osteoarthritis (a chronic degenerative joint disease that causes cartilage in the joints to break down over time), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). -He/she scored 7 on the BIMS. This score indicates severe cognitive impairment. Review of the resident's undated comprehensive care plan showed: -He/she is a wandering/elopement risk due to impaired cognition and impaired safety awareness. -He/she displays behaviors related to dementia and depression. 3. Review of Resident #1's progress notes, dated 12/25/24 at 1:27 A.M., showed: -Resident #1 was observed by Certified Nurses Assistant (CNA) A in Resident #2's room, sitting on Resident #2's bed. Resident #1's pants and underwear were around his/her mid-thighs. Resident #2's gown and brief were in place. CNA A observed Resident #1 with his/her hand down the front of Resident #2's brief. CNA A then told Resident #1 to stop and remove his/her hand from Resident #2. CNA A then called for the charge nurse to come to the memory care unit. When Licensed Practical Nurse (LPN) A arrived to Resident #2's room, Resident #1 was still sitting on Resident #2's bed with his/her hand on Resident #2's leg. Resident #2 was asleep. LPN A and CNA A began to redirect Resident #1 from Resident #2's room. Resident #1 became verbally agitated, stating it is his/her room and threatened to throw the staff out of the room. Staff were able redirect Resident #1 to the common area. He/she was placed on one to one supervision. The physician was notified and gave an order to increase the resident's estrodiol medication to decrease the sexual behaviors. Review of the facility investigation showed: - Resident #1 has a history of inappropriate sexual behavior towards residents. - Resident #1 has been off his baseline this shift (12/25/24) with hallucinations and delusions. - Statement by CNA A: On 12/25/24 at 12:30 A.M., he/she was doing rounds when he/she walked into Residnet #2's room. Resident #1 was sitting on the he bed, touching Resident #2 in the private area. CNA A told resident #1 he/she was not allowed to do this and got him/her to stop. CNA A then reached out for the nurse for assistance. And the Resident #1 came and sat down at the tables. -Statement by LPN A: On 12/25/24 at 1:27 A.M., LPN A was called back to the secure care unit by CNA A. Upon walking into the unit, RNA A went to Resident #2's room. Resident #1 was sitting on Resident #2's bed, with pants and underwear down to mid thigh. Resident #1's hands were still on Resident #2's legs. Resident #2 was wearing a facility provided night gown and a brief and were laying on his/her bed, on top of the covers. Resident #1 was wearing pajama pants, non-skid socks and no shirt. LPN A separated the residents and Resident #1 became verbally aggressive, stating It's not your room and I'll throw right out of here, I'm not going to leave. LPN A and CNA A were able to get Resident #1 from the room and into the living area. Resident #1 was placed on one to one supervision with the CNA on duty. Both resident's were assessed. Resident #2 did not appear to be in distress, but was confused and asked if he/she could go to bed. Resident #1 has a previous history of inappropriate sexual behavior towards residents. -Resident #1 was started on estrodiol 1.5 milligrams daily on 10/20/24 for sexual behaviors. -The Director of Nursing (DON) spoke with the physician on 12/25/24 at 4:06 P.M. The physician increased Resident #1's lexapro (a medication used to treat depression and generalized anxiety disorder) from 5 milligrams to 10 milligrams daily. The physician also gave orders to continue to the estrodiol at 1.5 milligrams daily. - Resident #1's POA had discussed with management members that Resident #1 likes the ladies. - The DON explained to Resident #2s spouse that Resident#1s physician is working to adjust Resident #1s medications and staff are monitoring the two residents to ensure they are safe. During an interview on 1/3/24 at 2:17 P.M., the Administrator said: -The physician was notified of the incident between Residents #1 and #2. The Administrator asked the physician about sending Resident #1 out for in-patient psychiatric evaluation. The physician responded that he/she felt the resident's medications can be adjusted in the facility and did not need to be sent out. -The Director of Nursing (DON) immediately began educating all staff on increased observation for Resident #1, increased staffing on the memory care unit, and education on caring for residents with dementia and behaviors. This education was completed on 12/28/24. -Staffing on the memory care unit was increased starting 12/25/24. There are now three staff members during the day shift and two staff members during the night shift. If the aides are assisting residents, the medication technician or nurse will come to the common area to monitor the hall until the aides are available again. If a staff member needs to leave the unit, they will notify the charge nurse who will then come to assist in monitoring the unit until the staff member returns to the unit. -It is his/her expectation that residents are free of abuse. Review of Secure Care Unit Employee In-service sign in sheet showed staff received education on monitoring of individuals on the secure care unit, completed on 12/28/24. During an interview on 1/3/25 at 2:02 P.M., Certified Medication Technician (CMT) A, said: -He/she has received education from the facility about increased monitoring of residents on the secure care unit. There must be at least two staff members at all times on the unit. If the aides are assisting residents, the CMT must bring the cart to the common area so he/she can monitor the hall and common area while the aides are busy. - He/she has observed the resident go into other resident's rooms. During an interview on 1/3/25 at 2:05 P.M., CNA B said; - He/she has observed Resident #1 go into other resident's rooms. - After the incident he/she received education from facility leadership about monitoring residents on the secure unit. - There now is to be at least two staff people on the unit at all times. - If a staff person needs to leave the unit, they need to call the charge nurse and make sure another staff person comes to the unit to monitor before the staff person leaves. During an interview on 1/3/25 at 2:08 P.M., CNA C said; -He/she has observed Resident #1 go into other resident's rooms. - After the incident he/she has received education from facility leadership about the need to increase monitoring of residents. - There now is to be two staff members on the secure unit at all times and staff are to watch the hall and the common areas. - If a staff member needs to leave, another staff member is to cover the unit. During an interview on 1/3/25 at 2:47 P.M. CNA A said: -He/she was doing bed checks/rounds on 12/25/24 at 12:30 A.M., and saw Resident #1 sitting on Resident #2's bed. -When CNA A entered the room, he/she saw that Resident #1's pants were around his/her thighs and Resident #1's hand was inside the front of Resident #2's brief. Resident #2 was asleep. -CNA A told Resident #1 to stop and he/she removed his/her hand from Resident #2's brief but would not leave the room. -CNA A called for the charge nurse to come to the room. -The charge nurse, Registered Nurse A came to the room and assisted in redirecting Resident #1 from the room. Resident #1 became verbally aggressive and Resident #2 woke up. -RN A and CNA A were able to redirect Resident #1 from the room. During an interview on 1/10/25 at 9:10 A.M., the Physician said: -He/she was notified of the incident involving Residents #1 and #2. -He/she declined to send Resident #1 out for in-patient geriatric psychiatric evaluation. -He/she adjusted Resident #1's medication to assist in decreasing inappropriate sexual behaviors. MO247062

Based on interview and record review, the facility failed to honor the resident's right to be informed regarding care and treatment decisions when the facility failed to involve and notify one resident's (Resident #1) responsible party in the decision to change resident's medications. Medication changes included administering a medication the resident was known to have an allergy to. This affected one out of six sampled residents. The facility census was 54. Review of the facility's in-service training for staff regarding Medication Procedures and Orders, dated [DATE], showed the nurse receiving the orders, new or changes, must call the reisdent's responsible party and document the order and phone call including the name of the family member the nurse spoke with in the progress note. Review of the facility's undated Rights and Protections as a Nursing Home Resident handout, showed: - The resident has the right to be fully informed about their medical condition, prescription and over the counter drugs, vitamins and supplements. - The resident has the right to participate in the decisions that affect your care; - The residents family members can also help with the residents' care plan with resident's permission; - The reisdent's legal guardian has the right to look at all of the resident's medical records and make important decisions on the resident's behalf. - The nursing home staff must notify the reisdent's legal representative or an interested family member when: the resident's physical, mental, or psychosocial status starts to get worse and/or the resident's treatment needs to be changed significantly. 1. Review of Resident's Admission Minimum Data Set (MDS), a federally a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - admitted [DATE]; - Adequate hearing and vision; - Clear speech - distinct intelligible words; - Brief Interview for Mental Status score of 6, resident has severely impaired cognition; - No behavioral symptoms; - Diagnoses included: Heart disease, hypertension, dementia, asthma, psychotic disorder and depression; Review of Hospice Medication Admission packet for Resident dated [DATE] showed: Medications: - Seroquel 25 mg tablet at bedtime ([DATE]); - Norco 5 mg-325 mg tablet, 1 tablet PRN BID, Q4H ([DATE]); - Zoloft 25 mg tablet, 1 tablet daily ([DATE]); - Carbidopa ER 50 mg-Levodopa 200 mg tablet, 1 tablet 3x daily Parkinson's; - Lorazepam 0.5 mg tablet, 1 tablet every 6 hours as needed for anxiety; Allergies: - Albuterol, Haldol; Primary Diagnosis: - Parkinsonism, Dementia, Depression, History of Falling, Hypertension, Heart Disease, Cerebrovascular Disease, Restless legs syndrome, Hypercholesterolemia, GERD; Review of the Resident's Care Plan, dated [DATE], directed staff to provide the following: - ,d+[DATE] Evaluate medication schedule and possible pharmacological causes of repetitive behavior. - Staff are to utilize diversion techniques; - The reisdent requires substantial assistance by one staff for bathing/showering; - The resident requires substantial assistance by two staff for dressing, toileting, and transfers; - ,d+[DATE] Hospice added Trazodone at bedtime for insomnia due to Seroquel being discontinued ,d+[DATE]; - ,d+[DATE] Depakote added due to the reisdent resisting care and grabbing staff; - ,d+[DATE] Zoloft discontinued due to falls; - ,d+[DATE] Increased Depakote dose to 250 mg due to behaviors; - ,d+[DATE] Lowered Sinemet dose to ,d+[DATE] due to behaviors and adverse effects of hallucinations; - Staff are to communicate with the resident/family/caregivers regarding the resident's capabilities and needs. Review of Medication Administration Record, dated [DATE] - [DATE], showed: - Seroquel 25 mg Start Date [DATE], discontinued [DATE]; - Carbidopa-Levodopa ER ,d+[DATE] mg 3x daily start date ,d+[DATE], discontinued [DATE]; - Norco ,d+[DATE] mg hydrocodone start date [DATE], 2x daily through ,d+[DATE]; - Zoloft 25 mg start date [DATE], discontinued date [DATE]; - Trazodone HCL 50 mg start date [DATE], D/C date [DATE]; 1x at bedtime for insomnia; - Depakote 125 mg for dementia, start date [DATE], discontinued date [DATE]; - Rivastigmine Tartrate 1.5 mg for dementia, start date ,d+[DATE], discontinued date [DATE], 2x daily; - Trazodone HCL 50 mg start date [DATE], discontinued date [DATE], 3x a day for depression; - Haldol Injection 5 mg/ml every 1 hour as needed for behaviors, start date ,d+[DATE], discontinued ,d+[DATE]; - Depakote 125 mg for dementia, start date ,d+[DATE], no end date; - Nuplazid 34 mg (Parkinson's Disease) started [DATE], discontinued date [DATE]; - Haldol Injection 10 mg/ml every 1 hour as needed for behaviors start date [DATE], discontinued date [DATE] - Trazodone HCL 50 mg start date [DATE], no end date; - Carbidopa-Levodopa ER ,d+[DATE] mg 3x daily start date ,d+[DATE], no end date; - Seroquel 100 mg Start Date ,d+[DATE], no end date; Review of Resident Progress notes showed: - [DATE] 17:44 P.M. Resident admitted to facility, resident is very pleasant, mildly confused, seems to be adjusting well to his/her environment and has been conversing with other residents; - [DATE] 1:45 A.M. Able to make needs known, ambulates with walker; [DATE] 5:03 A.M. Resident found on the floor by nursing staff and resident stated he/she had fallen. Resident had a small cut on the inner aspect of their left ear. No documented notification to responsible party - [DATE] 3:53 P.M. Received physician orders to discontinue prochlorperazine and Seroquel, hospice notified. No documentation that responsible party was notified of medication change; - [DATE] 3:45 A.M. Resident mood is pleasant and is not currently experiencing unwanted behaviors(s); - [DATE] 1:39 P.M. Physician Order for Depakote 125 mg placed for resident to treat dementia. No documentation that responsible party was notified. -[DATE] 2:39 P.M. Order placed for Zofran 4 mg, no documentation that responsible party was notified. -[DATE] 5:28 P.M. Resident order placed for Pramiprexole 9.125 mg for restless leg syndrome, no documentation that responsible party was notified; -[DATE] 11:00 P.M. Resident seen by attending physician. Care plan updated to start Mirapex taper for restless leg, care coordinated with patient and facility staff, no documentation that responsible party was informed; -[DATE] 11:20 A.M. Resident is very agitated, fighting with staff, throwing cups of water. 4 staff members required to disarm resident when he/she attempted to use walker as a weapon picking it up from the bottom and brandishing (A threatening or aggressive manor to scare someone) it at staff. Resident repeatedly grabbing staff tight enough to leave reddened areas. Hospice contacted, no documentation that responsible party was notified was notified. -[DATE] 1:01 P.M. Rivastigmine Tartrate 1.5 mg for dementia, Lorazepam 0.5 mg for anxiety, Trazodone HCL 50 mg for depression, ordered for resident, no documentation that responsible party was notified. -[DATE] 3:07 P.M. Haldol injection 5 mg/ml ordered for dementia for resident. System alert for possible drug allergy, no documentation that responsible party was notified about prescribed drug that was on the resident's allergy list; -[DATE] 1:25 P.M. Order for Depakote 250 mg for treatment of dementia received for resident, no documentation that DPOA (responsible party) was notified; -[DATE] 3:47 P.M. DPOA contacted about the medication changes made for the resident. DPOA was informed about Depakote and Nuplazid only. DPOA requested that staff call him/her. DPOA stated that the resident is very sensitive to medications that affect his/her brain and DPOA wants to be a part of the conversation. It was not documented that the DPOA was informed of the medication orders for Haldol, Rivastigmine, Trazodone, or Lorazepam for the resident.; -[DATE] 1:05 P.M. Haldol order increased to 10 mg/ml every hour as needed for resident, no documentation that DPOA was informed; -[DATE] 2:22 P.M. DPOA informed of medication change to patch from tablets for Transdermal 24 hour 4.6 mg Rivastigmine, DPOA stated they were unaware that resident was taking Rivastigmine tablets since resident had issues in the past taking them but agreed to switch to the patch; -[DATE] 2:07 P.M. Carbidopa Levodopa ,d+[DATE] reduced to ,d+[DATE] for resident, no documentation that DPOA was informed. During an interview on [DATE] at 9:25 A.M. the Staffing Coordinator, said the resident showed signs of declined after one week at the facility and has been difficult to work with since he/she could not get his medication. He/She was unsure what that medication was. Staff are unable to communicate with resident and the resident's actions are often passive aggressive when they are providing care. The resident has episodes of hitting the staff and yelling at them. This morning, staff reported the resident tore up his/her room and was yelling. After the resident had a shower and ate some cookies he/she returned to an unresponsive state. During an interview on [DATE] at 10:45 A.M. Hospice RN A, said he/she was assigned to the resident for Hospice care. There has been no verbal coordination between Hospice and the facility staff about doctor's orders or the changes made to the resident's drug regimen. Hospice followed the drugs regimen that the resident was on upon transfer. The behaviors the resident is demonstrating at the facility did not occur at his prior assisted living residence. The change in behaviors coincide with the changes facility staff made with the reisdent's drug regime. During an interview on [DATE] at 12:30 P.M., Family Member A said: - He/she was not informed of or approved of the following medication changes for the resident: - He/she was not informed on ,d+[DATE] about Ketoprofen 50mg/ml order; - He/she was not informed on ,d+[DATE] about Sennosides 8.6 mg order; - He/she was not informed on ,d+[DATE] about Midodrine HCL 2.5 mg order; - He/she was not informed on ,d+[DATE] about Depakote 250 mg order; - He/she was not informed on ,d+[DATE] about Zofran 4 mg order; - He/she was not informed on ,d+[DATE] about Trazodone HCL 50 mg order; - He/she was not informed on ,d+[DATE] about Carbidopa-Levodopa ,d+[DATE] mg order; - He/she was not informed on ,d+[DATE] about Lorazepam 2 mg/ml order; - He/she was informed on ,d+[DATE] about Seroquel being added but not of the amount that had been ordered. - He/she had not been notified of Haldol administration and would not have given approval for that medication because the resident was allergic to it and had negative side effects from it in the past. - After he/she found out that Haldol was being given, he/she requested that staff stop administering it immediately. It it took the staff a few days before the Haldol was discontinued. -The resident is upset and feels helpless in helping the resident because the facility staff do not notify him/her of when they should. The resident's ability to communicate has completely changed since they arrived seven weeks ago and he/she is unable to communicate with the resident and feels the decline is due to all the medication changes. During an interview on [DATE] at 1:15 P.M., The DON (Director of Nursing) said: - A referral for Hospice services should be sent by the facility staff to the hospice provider with a list of the reisdent's current medications and care needs. - Social services is involved in the process of the transition to hospice. - Hospice staff provides facility staff with their plan of care and the attending physician can follow it, if they want. - Care plan meetings with the residents responsible party are held within the first seven days so the case plan can be developed. - The Resident had a couple of falls after admission to the facility as well as displaying some behaviors. - The resident is very stubborn and his/her behaviors have gotten worse since the reisdent has been admitted . - These last two to three weeks the resident has been very combative and the reisdent has refused to take his/her medications. - He/she was not informed the resident was sensitive to the medications or allergic to Haldol. - The resident became very violent recently. On ,d+[DATE] the resident flailed his/her arms and struck and bloodied a CNA's face. Seroquel was administered at a high does due to the acute problems providing the resident's care. - The resident has increased behaviors since being admitted and the DON is not sure why. - Geriatric psychiatry was suggested for the resident but the resident would have to come off of hospice and hospice does not support that position. - He/she expects staff to notify the resident's responsible party right away for falls, medication changes and significant changes in the resident condition. - The reisdent's responsible party may refuse a change in the medication dosage or the administration of a medication to the resident. MO245201

Based on observation and interview, the facility staff failed to ensure all shower hoses had a backflow preventer. This affected all five shower hoses and had the potential to affect all residents. A backflow preventer keeps toxins from backing up into the facility's potable water supply. The facility census was 47. 1. Observation on 6/26/24 starting at 11:15 A.M., showed: - Two shower hoses without backflow preventer in the 400 hall shower room; - Two shower hoses without backflow preventer in the 500 hall shower room; - One shower hose without a backflow preventer in the only shower in a resident's room. During an interview on 6/26/24 at 4:30 P.M., the Maintenance Supervisor said he did not realize all shower hoses needed a backflow preventer and that none of the shower hoses had them.

Based on record review and interview, the facility failed to issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (form Centers for Medicare and Medicaid (CMS)-10055 to each resident. The SNF ABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid by Medicare and assume financial responsibility. This affected three of the 12 sampled residents (#11,#24 and #32). The facility census was 47. The facility did not provide a policy for Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (form Centers for Medicare and Medicaid (CMS)-10055. 1. Review of Resident #11's medical record showed: - The resident had a Notice of Medicare Non-Coverage (NOMNC) issued that showed Medicare Part A benefits were ending on 5/7/24 The resident did not have a SNF ABN in their records. Records showed the resident remained in the facility after being discharged from Part A services with benefit days remaining. 2. Review of Resident #24's medical record showed: - The resident had a NOMNC issued that showed Medicare Part A benefits were ending on 3/12/24. The resident did not have a SNF ABN in their records. Records showed the resident remained in the facility after being discharged from Part A services with benefit days remaining. 3. Review of Resident #32's medical record showed: -The resident had a NOMNC issued that showed Medicare Part A benefits were ending on 2/28/24. The resident' did not have a SNF ABN in their records. Records showed the resident remained in the facility after being discharged for Part A services with benefit days remaining. During an interview 6/27/24 at 11:44 A.M. the Business Office Manager said she was responsible for providing the beneficiary notices and was not aware of the SNF ABN form needed to be provided as well. During an interview on 6/28/24 at 1:10 P.M., the Administrator said she was unaware of the SNF ABN form needed to be provided as well.

Based on interview and record review, the facility failed to ensure four out of nine sampled residents (Resident #1, #2, #3, and #5) were free from neglect when a staff member transported them in a reckless and unsafe manner. On 5/12/23, Driver A was arrested on scene while conducting a transport to a medical appointment for one resident (Resident #1) in the facility transportation van. Driver A did not fully secure residents' wheelchairs (Resident #1, #2, and #3), did not lock wheelchair brakes (Resident #1 and #5), and made residents feel unsafe (Resident #1, #2, #3, and #5). The facility census was 54. The administrator was notified on 5/25/23 at 3:44 P.M., of an Immediate Jeopardy (IJ) which began on 5/12/23. The IJ was removed on 5/31/23 as confirmed by surveyor onsite verification. Review of the facility vehicle policy, undated, showed: -Drivers were expected to do the following: -Have a valid driver's license. -Maintain a safe and reliable vehicle. -Always wear a seat belt. -Not be under the influence of alcohol, drugs, or other substances that in any way impair driving ability. -Follow all driving laws and safety rules, such as adherence to posted speed limits and directional signs, use of turn signals, and avoidance of confrontation or offensive behavior while driving. -Not engage in other distracted activities such as eating, shaving, putting on makeup, even in stopped or in slow-moving traffic -Only drive the company vehicle for business purposes and never for personal reasons. -Report to their supervisor any change in their license status. -Decline to drive if they lose their driving privileges. -Promptly report any moving or parking violations received while driving on company business or in company vehicles. -Anew Healthcare reserves the right to run a motor vehicle report on employees driving for business purposes. Review of facility Abuse, Neglect, and Misappropriation prohibition policy, undated, showed: -Training will be provided during general orientation, twice annually, and ongoing as needed. -Neglect and Misappropriation during General orientation and information on how to report. -Training twice annually. -Identification Guidelines included: -All staff will be educated on abuse, neglect, and misappropriation and how to prevent. Review of policy, background investigations, dated 1/23, showed: -Job reference checks, drug screenings, licensure verifications, and criminal conviction record checks are conducted on all personnel making application for employment with this company. Driving record checks are conducted when the job in question requires the employee to drive for the company. -The Human Resource department will conduct all applicable background investigations on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position which the individual has applied. For example, if an employee applied for job position that required driving, an investigation of the employee's driving record will be conducted. Review of employee handbook, drug and alcohol policy, undated, showed: -The unlawful manufacture, distribution, dispensation, possession, sale, or use of any drug or controlled substance in the workplace, or while performing any services for Anew Healthcare on Company premises, is strictly prohibited. -Employees are further prohibited from having any drug or controlled substance illegally present in their body at any detectable level at any time while on Anew Healthcare premises, or while performing services for the company. -Consumption of alcohol in the workplace, or while performing any services for Anew Healthcare is strictly prohibited. Review of Driver A's time card showed he/she worked for 5.55 hrs on 5/12/23. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 3/21/23 showed: -Brief Interview Mental Status (BIMS) of 15, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, showed the resident was cognitively intact. -He/She used a wheelchair. -Diagnoses included: pain, neuropathy (weakness, numbness, and pain from nerve damage, usually in hands and feet), obesity, abnormalities of gait and mobility, Guillain-Barre syndrome (a rare disorder in which body's immune system attacks the nerves), and uterine cancer. During an interview on 5/24/23 at 12:46 P.M., Resident #1 said: -Driver A was a terrible driver with a lot of road rage. When he/she saw thirty cars ahead of him/her with brake lights on such as a construction zone where the lanes merge, he/she would speed up so cars could not merge. -Driver A gave him/her anxiety when Driver A drove. -He/she learned to look down at his/her phone and not pay attention while Driver A drove as it helped him/her feel less anxiety and stress. -On another transport, Driver A did not have him/her secured in back, which took the rubber off brake of the manual wheelchair and he/she was moving about in the back of the van. Driver A pulled over to secure him/her, but because the rubber had come off his/her wheelchair brake it did not hold properly. -Driver A would hit the bumper strip on the side of the road and swerve. It occurred every time Driver A drove. -When Driver A got pulled over on 5/12/23, Driver A hit the brakes hard and this scared the resident as he/she did not know what was happening as had been trying to look at phone to relieve anxiety from Driver A's driving. -Driver A had to brake hard to stop on 5/12/23 to avoid hitting the metal barrier on the side of road. -The state trooper advised Driver A he/she had followed him/her for several miles and Driver A displayed wild and erratic driving -On 5/12/23, Driver A drove the facility van and blared the van horn for several seconds after other drivers who blared [NAME]. -He/she observed the state trooper handcuffing Driver A, which made her feel helpless and worried. He/she tried calling the facility and contacted the doctor's office to advise he/she would not be getting to his/her appointment due to the arrest of the driver. -The state troopers came to the van after the arrest and advised Driver A was intoxicated. -He/she missed his/her appointment on 5/12/23 to have a port (a device that makes it easier for healthcare providers to access a vein) placed for radiation to begin. During interview on 5/25/23 at 2:05 P.M., Resident #1 said: -His/her port was surgically implanted under his/her collarbone on 5/17/23. -He/she had to push back starting chemotherapy due to the missed appointment on 5/12/23. During an interview on 5/25/23 at 5:37 P.M., Resident #1 said: -He/she sat on the side of the road for an hour waiting and was hot and uncomfortable. -He/she had no food or water and had been fasting after midnight for the surgical placement of his/her port. -He/she called the facility to notify them of the situation with Driver A and spoke with the Assistant Director of Nursing (ADON). Record review of facility investigation, dated 5/12/23, showed: -On 5/12/23, Driver A arrived to the facility at 9:30 A.M. to transport Resident #1 to St. Luke's Northland for a scheduled surgical implantation of a port at 11:00 A.M. -On 5/12/23,at 10:30 A.M., facility received call from the Missouri Highway Patrol advising they arrested Driver A for a Driving Under the Influence (DUI), a second state trooper stayed with Resident #1 in the van on Interstate 29 -Separation action form, dated 5/12/23, showed safety violation for gross misconduct. Driver A was charged with driving under the influence of alcohol while transporting a resident to an appointment. During an interview on 5/24/23 at 3:00 P.M., the Administrator said: -He/she considered Driver A's actions as neglectful. During an interview on 5/25/23 at 2:18 P.M., Licensed Practical Nurse (LPN) A said: -He/she worked on 5/12/23. -He/she received calls from several commuters regarding the facility van driver's erratic driving. -A female called and stated Driver A cut him/her off and he/she wanted to make a complaint. LPN A advised the female caller to notify 911 immediately. -He/she received two more phone calls from other commuters regarding Driver A. -He/she spoke to the ADON regarding what had happened and then the ADON left the facility to pick up Resident #1 with the Maintenance Director. During an interview on 6/5/23 at 4:05 P.M., Trooper A said: -He/she received a call for careless and imprudent driving of the facility van driver coming from south bound Interstate 29. -He/she positioned so he/she could locate Driver A in the facility van. When located he/she positioned him/herself behind Driver A. -He/she witnessed Driver A fail to signal and change lanes to lanes that could not be occupied safely. -He/she completed a preliminary breath test which showed 0.082 blood alcohol content, which was above the legal limit. -Driver A was charged with driving while intoxicated. -Driver A's record showed he/she had one prior offense. -Driver A was arrested on scene and transported to jail where a breathalyzer test was again completed with results of 0.074, slightly under the legal limit. -He/she stated on average a person's blood alcohol concentration will decrease concentration levels every hour, based on totality of Driver A's driving time it was determined Driver A had been driving for over an hour when pulled over. He/she felt due to the nature of the size of the vehicle operated by Driver A and the fact a facility resident, Resident #1, was a passenger in the vehicle was placed in jeopardy. -Trooper B stayed with Resident #1 in the facility van until the facility staff arrived. -Resident #1 stated to Trooper B on scene he/she and other residents did not like the way Driver A drives. Resident #1 said he/she chose not to watch while Driver A transported and focused on his/her phone. Resident #1 also told Trooper B that Driver A drove erratically frequently. -He/she referred charges to the prosecutor and Driver A had a court date. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -BIMS of 15, cognitively intact. -Required extensive assistance with one person for transfers. -He/She had impairment to both upper and lower extremities. -He/She was wheelchair dependent -Diagnoses included: amputation between knee and ankle of both legs, septicemia (infection in the blood stream), and amputation of left index finger. During an interview on 5/17/23 at 2:25 P.M., Resident #2 said: -He/She did not feel safe riding in the van with Driver A. -He/She slid around the back of the van when Driver A drove. Driver A only used two of the four tie downs to secure his/her wheelchair a couple of weeks ago. -Driver A drove fast. -He/she slipped out of his/her wheelchair onto the ground one time during transport. He/she did not get hurt. Driver A pulled over and got him/her back in the wheelchair. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed: -BIMS of 9, severely impaired cognitive status. -Required extensive assistance with two person physical assist with bed mobility and transfers. -He/she was wheelchair dependent -Diagnoses included: paraplegia (paralysis when you can't deliberately control or move your muscles in your legs), neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), abdominal pain. During an interview on 5/25/23 at 2:30 P.M., Resident #3 said: -Driver A passed people on the shoulder while he/she rode with him/her. -Driver A did not secure him/her in the van with tie downs. He/she would move around in the van due to not being fully secured. -He/she did not feel safe riding with Driver A. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed: -BIMS of 15, cognitively intact. -He/she required extensive assistance with one person physical assistance for transfers. -He/she used a walker. -He/she required substantial/maximal assistance from sitting to stand with one person physical assist. -Diagnoses included: unspecified dementia (a progressive loss of intellectual functioning with impairment to memory and abstract thinking), restlessness and agitation. During an interview on 5/25/23 at 2:38 P.M., Resident #5 said: -Driver A wanted him/her to lock his/her wheelchair wheel during transport. -Driver A would not secure all four points on the wheelchair to tie downs in the van. -Driver A would speed up instead of slow down when he/she would see holes in the road. He/she did not feel safe when holes or speed bumps were in the road. 5. Record review of Driver A's employee file showed: -Date of hire 2/6/23 for part time employment in transportation department. -Facility did not have any record of abuse and neglect training provided to Driver A. -No driver's record check was completed by the facility. 6. During an interview on 5/24/23 at 3:00 P.M., the Administrator said: -All Human Resource (HR) business was handled off site, he/she had limited employee records in the facility. -The insurance company would have completed the driver record checks of hired facility drivers. -He/she received no complaints from residents regarding Driver A and their safety. During an interview on 5/25/23 at 10:10 A.M., Driver A said: -He/she was not intoxicated. -He/she had no charges of erratic driving in the past. -He/she was issued a ticket for switching lanes without a signal. -He/she did transport Resident #1 on 5/12/23. -He/she did get pulled over by a Missouri State Trooper. -The state trooper advised he/she had cut someone off in traffic, had switched lanes without use of turn signal. -He/she had his/her Class E license for two years. -He/she received training from the facility on how to use seat belts and van tie downs. -Resident #1 was strapped down during transport. -He/she did pull over with Resident #1 one time to secure the resident in the vehicle due to a brake on the wheelchair being messed up. -He/she did not take any medications that would interfere with his/her ability to drive safely. -His/her job was strictly driving residents as a part time driver. During an interview on 5/25/23 at 1:40 P.M., Administrator said: -Driver A did not participate in any of the all staff training's held by facility. -The facility did not get a copy of Driver A's driver history from the insurance company. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility (briefly state what the facility did to remove the immediacy/imminent danger and what the facility still has to do before it can be corrected.) A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO218489

Based on observation, interviews and record reviews, the facility failed to provide the necessary care, treatment, services and equipment in accordance with professional standards to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of 13 sampled residents (Resident #42). The facility failed to ensure the resident maintained and/or improved his/her highest level of range of motion (ROM) and mobility. When he/she admitted to the facility on [DATE], he/she had active ROM (the performance of an exercise to move a joint without any assistance or effort of another person to the muscles surrounding the joint) in both ankles. Resident #42 now has muscle atrophy (the wasting or loss of muscle tissue) around ankles and feet resulting in his/her feet pointing downward, toes curling and beginning to turn in at the sides. The facility's census was 50. Review of the undated facility policy Accommodation of Needs showed: - The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered; - Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity and well-being to the extent possible. The facility did not provide a policy directing staff on facility procedures for a change in a resident's status or condition or for providing quality care based on the resident's comprehensive assessment to ensure they receive treatment and care using professional standards of practice. Instead the facility provided a copy of the regulatory guidance listed in Centers for Medicare and Medicaid (CMS) State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Federal Regulation 0684 (F684). Review of Resident #42's hospital records, dated 7/23/22-8/4/22, showed: - admitted to hospital from home living independently. - diagnosed with Guillain-Barre Syndrome (GBS, a disorder in which the body's immune system attacks the nerves) and was treated for eight days with intravenous immunoglobulin (IVIG, medicine given into veins to normalize the immune system). - Physical Therapy completed an assessment on 7/27/22 and rated the resident's strength at a 3 for dorsiflexion (pointing foot upward towards head) and plantarflexion (pointing foot downward away from head) on both ankles. The 3 rating is 3 out of 5 with 5 being maximum strength and 0 being unable to perform movement. A 3 score indicates moderate weakness. - On 8/4/22, he/she participated in physical therapy 41 minutes with Physical Therapy Assistant (PTA) B before being discharged to the facility. - PTA B documented the resident had limited bilateral (both legs) ankle dorsiflexion. Completed passive stretching of ankle dorsiflexion, three reps x 20 second hold. Active plantarflexion. Fair progress. Increased use of lower extremities (legs, ankles, and feet) during therapeutic exercise. Quads (large muscle group in thigh) were the weakest muscle group today. Decisions consistent/reasonable. - Follow up visit scheduled with neurologist (a medical specialist in treatment of disorders of the nervous system) for 9/13/22 at 11:00 AM. During an interview on 1/23/23 at 1:46 P.M., PTA B said: - When he/she completed the assessment of the resident's ankle strength on 7/27/22 he/she required the resident to move his/her ankles independently without assistance. The 3 rating is 3 out of 5 with 5 being maximum strength and 0 being unable to perform movement. 3 indicates moderate weakness. -During therapy on 8/4/22 he/she worked with the resident on ankle stretching due to slight tightness. The session focused more on the large muscle group in thigh. If he/she had seen any indication of foot drop beginning on that date he/she would have made that the focus area. - Foot drop can be prevented with use of assistive devices by maintaining foot in neutral position. - He/she would have recommended assistive devices if foot drop was present during physical therapy sessions. - Assistive devices can cause harm if foot drop is already present by rubbing or improperly placing pressure. Review of the resident's admission paperwork 8/4/22 showed: -Hospital discharge diagnosis was generalized weakness. -Continue physical therapy for 5 sessions per week for 2 weeks for bed mobility, transfer training and therapeutic balance exercises. -Follow-up appointment to Neurologist Tuesday September 13, 2022 11:00 AM. -Facility admission diagnosis: hereditary and ideopathic (condition that arises with cause unknown) neuropothy (disease effecting nerves), morbid obesity (overweight that can effect health). weakness, other abnormalities of gait (a person's manner of walking) and mobility, Guillain-Barre Syndrome (GBS, a disorder in which the body's immune system attacks the nerves),pain, depression. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: - A Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment; - Required extensive assistance from staff for bed mobility, transferring from one surface to another, moving on and off the nursing unit, dressing, toilet use and personal hygiene; - Did not move from a seated to standing position; and had range of motion (ROM) impairment on both lower extremities; - The resident and staff believe he/she is capable of increased independence in at least some activities of daily living (ADLs) functioning; - The resident had an active discharge plan for the resident to return to the community but no referral had been made to assist with the discharge planning; - Received 190 minutes of physical therapy (PT) in five days, beginning on 8/5/22; - Diagnoses did not include foot drop. Review of nurse's admission note dated 8/4/22 showed: - The resident has weak bilateral lower extremities push and pulls (test of both ankles for strength in pushing feet downward against pressure and pulling feet upward against pressure, able to perform weakly). Review of the resident's physician orders dated 8/4/22 showed an order for the resident to go to an appointment with his/her neurologist on 9/13/22 at 11:00 A.M. Review of the physical therapy (PT) encounter notes showed: - 8/8/22 instructed the resident on bilateral lower extremities (BLE) nerve glides times 10 repetitions (reps) for two sets each; resident able to complete active range of motion ankle plantar/dorsiflexion times five reps for five sets, following treatment; - 89/22 instructed the resident on BLE nerve glides times 10 repetitions (reps) for two sets each; resident able to complete active range of motion ankle plantar/dorsiflexion times five reps for five sets, following treatment; resident reports that pain has diminished for nearly three hours from end of treatment on 8/8/22; reports being able to complete plantar/dorsiflexion at full available range up until bedtime; minimal movements at A.M.; - 8/10/22 instructed the resident on BLE nerve glides times five repetitions (reps) on each side; resident able to complete active range of motion ankle plantar/dorsiflexion times 20 reps and knee flexion times 20 reps each on BLE in supine. Review of interdisciplinary team (IDT) care plan note dated 8/10/22 showed: - The IDT met with the resident for admission care plan meeting. - Discussed current medications/orders, diet/weights, current plan of care. - Would like to discharge to home where he/she lives alone. - Has not been up on his/her feet since 7/22/22. - He/she developed GBS and a UTI from fasting and was unable to use his/her legs. - His/her pain is more in control over the past three to four days with scheduled medications and as needed medications. - Able to make needs known, requires extensive-maximum assist with most ADLs. - Working with PT for strengthening and mobility. Review of the resident's care plan dated 8/15/22 showed: - Required assist with ADLs, had recent hospitalization related to GBS, weakness to all extremities with a goal to participate in daily care and activities to the best of his/her abilities and improve or maintain current abilities. - Needs one person assist with locomotion when up in a wheelchair. - Needs one person assist with showering/bathing. - Needs two people assist with dressing and undressing. - Needs two people assist with transfer using a mechanical lift. - Wears briefs and needs two people assist for incontinence care. At times will use a bed pan. - No mention of the resident's ankles or feet in the care plan. Review of the nurses' notes for August 2022 showed only one skin assessment on 8/15/22 and no mention of the resident's foot drop. During an interview on 1/20/23 at 11:03 A.M., the resident's neurologist said: - A follow-up appointment was scheduled for 9/13/22 at 11:00 A.M.; - The resident did not keep the scheduled appointment. - No one from the facility contacted the office to cancel or change the date of the appointment. - Follow-up visits are important and more visits would possibly have been scheduled depending on the resident's progress. During an interview on 1/16/23 at 11:09 AM the resident said: - He/she was admitted to facility on 8/4/22. - He/she stayed in bed all the time because the wheelchair was uncomfortable, caused pain and he/she could not stay in it long enough to make it worth the effort of transfer with mechanical lift. - He/she received physical therapy for a short time after he/she admitted but not now; the facility said it was not longer covered. - Since being admitted to the facility, he/she has developed foot drop. His/her feet look like an eagle's talons and he/she is not able to stand because of this. - The facility provided boots that are designed to prevent foot drop and they do not fit like they are supposed to because both of his/her feet are already so deformed. Staff roll wash clothes and place them in the space where heal should be which puts pressure on his/her toes and the ball of his/her foot which hurts or burns and tingles. - The facility did not get the boots for him/her until after his/her feet were pointing down and it was not possible to get them to normal position. - The facility nurse practitioner (NP) A told him/her he/she put in orders to see a mobility specialist (FNP B) for a power wheelchair and a podiatrist appointment in early December, but just last Friday (1/13/23), the social worker said that no one had told her and they had not been followed through on. The appointment about the wheelchair got made that day, but the appointment was not until sometime in March. That is two more months of staying in this bed. - He/she began making phone calls for appointments. He/she had just completed a virtual appointment with FNP B and was approved for a motorized wheelchair; he/she scheduled his/her own appointment for an evaluation of his/her feet and other barriers to mobility for 2/6/23. - He/she called the neurologist' office that treated him/her at the hospital and found that he/she had missed a scheduled appointment in September 2022 and had never been told about the appointment. The hospital gave the facility paperwork; he/she had not been given the paperwork or any information from it. - He/she had planned on regaining strength and returning to living at home but now does not know if his/her feet can be corrected or if it would be possible for him/her to ever stand. Review of the resident's PT encounter notes showed no physical therapy encounter notes between 8/14/22 and 9/7/22. Review of the resident's physician's order dated 9/7/22 showed: - PT to evaluate and treat for possible left foot drop. Signed by NP A and entered by Registered Nurse (RN) B at 2:33 P.M. - Discharge PT services as no additional visits authorized by facility beyond PT certification period. Signed by NP A and entered by the Physical Therapist at 10:38 P.M. Review of the resident's physician progress note dated 9/8/22 showed a new diagnosis of foot drop to the left foot. An order was also written for PT to evaluate his/her left foot for foot drop. Review of the physician's progress note, dated 9/9/22, showed: - Has still not yet talked to PT regarding drop foot in the left foot; - Will make sure that this order has been placed; - PT evaluated for left foot drop and recommend orthotic. Review of physical therapy encounter notes showed: - 9/7/22 through 9/26/22 No documentation addressing evaluation ordered 9/7/22; no documentation of left foot drop. - 9/27/22 ankles in plantar flexion and may need a brace to prevent contracture. Instructed nursing staff regarding plantar flexion; signed by PTA C. Review of the resident's physician's progress note dated 9/28/22 showed: - Physical therapy was able to come in and evaluate bilateral (both) lower extremities for foot drop; - Also did a consult for a orthotics; - Diagnosis remains foot drop of the left foot; - PT evaluation for orthotics to BLE. Review of the nurses' progress notes for September 2022 showed: - No documentation surrounding the resident's neurology appointment on 9/13/22; - The resident regularly requested as needed (PRN) medications for leg and nerve pain; - No assessments of any kind other than the effectiveness of the pain medication; - No documentation to indicate they notified the physician of the resident's pain. Review of physical therapy encounter note showed: - 10/4/22 plantarflexion and dorsiflexion with yellow TheraBand two sets of 10 reps. - 10/17/22 Fit the resident into ortho boot and made adjustments in order to stretch his/her feet into dorsiflexion; passive ROM (moving with assistance of another person) to both feet and stretched into dorsiflexion. Discussed getting up into wheelchair for next treatment session so we can work in the therapy room; explained omincycle will move legs for him/her; - 10/19/22 facilitated heel slides and assisted straight leg raise (SLR) times ten; Passive range of motion; stretched ankles into dorsiflexion and applied plantar fasciitis boots. - 10/21/22 facilitated heel slides, assisted SLR and ankle circles; Passive ROM to both feet and applied plantar fasciitis boots. Review of physician's progress note dated 10/22/22 showed: - Musculosketal: noted foot drop bilateral feet; - The resident does have bilateral dropfoot, but they are getting him/her 90 degree inserts to help with that. - Diagnosis remains foot drop, left foot. Review of the physical therapy encounter notes showed: - 10/24/22 Passive ROM to both feet and applied plantar fasciitis boots; - 10/26/22 Passive ROM to both feet and applied plantar fasciitis boots; - 10/28/22 Passive ROM to both feet and applied plantar fasciitis boots; - 10/31/22 Passive ROM to both feet and applied plantar fasciitis boots. Review of the nurses' progress notes for October 2022 showed: - The resident regularly requested as needed (PRN) medications for leg and nerve pain; - No assessments of any kind other than the effectiveness of the pain medication; - No documentation to indicate they notified the physician of the resident's pain. Review of the physical therapy encounter notes showed: - 11/2/22 PTA A gave the resident education on the use of plantar fasciitis stretching splint for application and function to stretch the ankle joint into dorsiflexion in order to stand eventually; The resident complained of nerve pain and achillis (cord connecting muscle to the bone of ankle); pain with stretching and touching of the sensitive area of the foot and legs. - 11/7/22 PTA A gave the resident education on wearing plantar fasciitis stretching splint as much as possible to gain range of motion and not lose range of motion over the course of this week. Gave information on the process for stretching and tightening down the straps as his/her range of motion increases. Put on plantar fasciitis stretching braces and adjusted tightness per resident tolerance and encouraged him/her to wear as tolerated to increase dorsiflexion range of motion. Review of physician progress note dated 11/9/22 showed noted foot drop to bilateral feet; Review of the PT encounter notes showed: - 11/11/22: facilitated passive ROM to BLE to increase functional mobility, facilitated strengthening with supine SLR, heel slides; has shown improvement in ability to perform SLR without assistance - 11/16/22 passive ROM to both feet and applied plantar fasciitis boots; - 11/16/22 PT assessment of functional mobility skills to determine progress with PT plan of care and progression towards goals with cuers and facilitation for improved performance; - 11/17/22, 11/18/22, 11/21/22 and 11/22/22 passive ROM to both feet and applied plantar fasciitis boots. Review of Physical Therapy Discharge Summary dated 11/22/22 showed: -Discharge recommendations: continue with therapeutic exercise program. Review of the nurses' progress notes for November 2022 showed: - The resident regularly requested as needed (PRN) medications for leg and nerve pain; - No assessments of any kind other than the effectiveness of the pain medication; - No documentation to indicate they notified the physician of the resident's pain; - No documentation surrounding the resident's discontinuation of PT or the need to continue with a therapeutic exercise program. Review of physician progress note dated 12/9/22 showed NP A wrote: - Noted foot drop to bilateral feet; - Has been working with PT but does not seem to be helping; - Has bilateral foot drop; would like to be referred to podiatry; - Refer to Podiatry. Review of the resident's medical record showed no documentation of a restorative nursing program to continue the resident's therapeutic exercises after being discharged from PT on 11/22/22. Review of the physician's progress notes dated 12/20/22 showed: - Noted food drop to bilateral feet; - Being seen as the nursing staff report he/she was wanting as needed ibuprofen scheduled; scheduled Tylenol 1000 milligrams (mg) twice daily for pain; - Wanting in house podiatry referral; will write order; - Wanting evaluation for electric wheelchair; will write order for him/her to be sent to provider; - Unspecified abnormalities of gait and mobility. Review of the nurses' progress notes for December 2022 showed: - The resident regularly requested as needed (PRN) medications for leg and nerve pain; - No assessments of any kind other than the effectiveness of the pain medication; - No documentation to indicate they notified the physician of the resident's pain; - No documentation to show NP A's request for a referral to podiatry; and no appointment scheduled; - No documentation regarding referring the resident for a specialized electric wheelchair. Review of the resident's medication review report (MRR) printed on 1/19/23 for the date range of 8/1/22 through 1/31/23 showed: - Order date 12/21/22 Consult for in house podiatry; - Order date 12/21/22 Consult for motorized wheelchair; - No order for restorative nursing to continue exercise program; During an interview on 1/19/23 at 11:11 A.M., physical therapy department supervisor said: - He/She started working at the facility in November of 2022. - The resident already had the plantar fasciitis boots at that time. He/She did not know who ordered them and could find no record of when they had been ordered. - He/She would not be qualified to make a decision on what assistive footwear to get and would have sent the resident to a local specialized provider of assistive devices. - Currently the resident is not receiving physical therapy and has not since 11/22/22. - The therapy department does not do any monitoring or evaluation of the resident's foot drop. He/She does not know if the resident currently has any contractures. -The therapy department is instructing nursing staff about putting on the plantar fasciitis boots and placing wash cloths rolled in the space that is between the residents heel and the bottom of the boot. Review of Grievance form dated 1/12/23 showed the resident filed a grievance regarding his/her appointment for FNP B as ordered had not been scheduled. Review of the nurses progress notes showed: - 1/13/23 Assistant Director of Nursing (ADON) wrote, spoke with resident regarding the boots for his/her foot drop. He/she refused to wear them stating that his/her toes had nerve damage and the boot did not fit appropriately. He/she is wanting a boot that will gradually bring his/her foot to an upright position. - 1/13/23 Social Services called FNP B's office regarding resident's evaluation; no open dates as of today. Review of a staff education form, dated 1/13/23 showed staff received education on the correct way to apply the resident's boot. Review of the MMR showed: - An order dated 1/14/23 for an ortho referral; - An order dated 1/14/23 for x-rays for bilateral knees however many views they can do. Review of the nurses' progress notes showed: -1/15/23 ADON wrote, resident wore his/her braces for his/her feet today from 1:50 P.M. until 6:00 P.M. Observation 1/16/23 at 11:30 A.M. showed: - The resident sat in the upright position in bed with both feet pointing toward the foot of the bed; his/her toes had spaces between each of them and his/her ankle was turned in at the side. - One toe moved slightly when he/she attempted to move his/her feet from pointing downward to more neutral position however, the position of his/her feet are pointing downward did not change. - Hard plastic boots with straps sat on a chair next to the bed. Review of care plan entry dated 1/16/23 showed: -Intervention added to care plan on 1/16/23 reads, resident wears Plantar Fasciitis stretch splints to his/her bilateral feet. He/She is dependent on nursing staff for putting on/taking off. He/she is not always compliant with wearing these. Observation 1/18/23 at 1:40 P.M. showed: - The resident wore the hard plastic boots; his/her toes pointed downward and touched the bottom of the boot just slightly in front of area designed for the heel and his/her heel was 2 to 3 inches above the area designed for the heel; rolled wash clothes were in the space between his/her heel and the heel of the boot. - The back of his/her heel touched on the area designed for lower calf. - His/Her right ankle was turned in and his/her great toe, second toe and inside portion of the ball of his/her foot rubbed against the inner/upper section of the boot. - The amount the ankles turned in at the side was greater with the boots on then without the boots. During an interview on 1/19/23 at 11:17 A.M., Physical Therapy Assistant (PTA) A said: - He/she started at the facility in October of 2022. The resident had the plantar fasciitis boots at that time. He/she did not know who ordered them and could find no record of when they had been ordered. - He/she would not be qualified to make a decision on what assistive footwear to get and would have sent the resident to a local specialized provider of assistive devices. - Due to the degree of foot drop, the boots can not be applied with the heel at the heel position of the boot and rolled washcloths are used to fill the space. -The therapy department is instructing nursing staff about putting on the plantar fasciitis boots and placing wash cloths rolled in the space that is between the residents heel and the bottom of the boot. During an interview on 1/19/23 at 10:18 A.M. Family Nurse Practitioner/Mobility Specialist (FNP B) said: - Foot drop is totally preventable. - He/she had a virtual visit with the resident on 1/16/23 for assessment of qualification for a specialized wheelchair. Someone will come to the facility to obtain measurements and do strength testing; FNP B will see the resident during an office visit 2/6/23 at 9:40 A.M. to assess mobility concerns as a result of the foot drop. - A plan for treatment for the resident's feet requires the ability to see him/her in person and to touch and assess the presence or absence of contractures. - The resident described the boots he/she currently has. These could be doing more harm than good by putting pressure on wrong areas. During an interview on 1/18/23 at 4:21 P.M. Social Services Director (SSD) said: - The nurse takes orders from the physician and enters what needs to be entered in their electronic medical records (EMR) system then makes a copy for him/her; then he/she makes appointments or arranges transportation. - They currently do not have any processes in place to verify if orders have been transcribed correctly or if things have been missed. -He/She started at the facility in August and does not know who was completing the SSD duties prior to his/her completion of training. -He/She was not aware of resident's Neurologist appointment September 13, 2022 or that it had been missed. - The first time he/she had any knowledge of an order for the resident to have an appointment with FNP B scheduled was 1/12/23 in grievance process. During an interview on 1/18/23 at 4:48 P.M., the Assistant Director of Nursing (ADON) said: - The nurse enters an order into the EMR and gives a copy to SSD so she can make appointments. - She did not know of any way to verify this has happened. During an interview 1/19/23 at 2:31 P.M.,the resident's physician said: - He expected orders regarding care to be followed, otherwise they would just be suggestions. - He expected any orders given by NP A to be followed. During an interview 1/19/23 at 6:20 P.M. the DON said: -Physician orders are put into EMR by a nurse; appointments are put on the calendar in the EMR and SSD is notified to schedule and arrange transportation. -Night shift completes chart checks to ensure accuracy. -He/She has no knowledge of what is to be done if this process is not completed properly and an appointment is missed. During an interview on 1/19/23 at 6:25 P.M., the Administrator said: - She expects physician orders to be followed. - She expects resident's be taken to scheduled appointments. - She was not aware of missed appointments. 31102

Based on observation, interviews, and record review the facility failed to implement measures to prevent an accident for one resident (Resident #1). This resulted in the resident suffering a [MEDICAL CONDITION] when he/she fell from the bed while one staff provided care. The facility census was 40. 1. During an interview on 4/9/18 at 2:45 P.M., the Director of Nursing (DON) said the facility did not use any type of side rails (bed rails) on residents' beds. Review of the facility's current skill sheet for making an occupied bed showed: - Loosen top bedding at the foot of the bed. - Raise the side rail; - Assist the resident to turn on his/her side away from you toward the far side of the bed. - Place the fresh sheet in the center of the mattress. - Lift the mattress up several inches, and with the other hand tuck the sheet firmly under the mattress. - Push all bottom linens to the center of the bed along the resident's back. This will create a hump of linen next to the resident in the center of the bed. - Assist the resident to roll toward you over the hump of linen and immediately raise the side rail for support. - Go to the opposite side of the bed and lower the side rail. - Remove soiled linen, pull fresh linen toward the edge of the bed, and tuck the sheet in pulling it taut and removing wrinkles as you go. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/7/18, showed: - admitted [DATE]; - No cognitive impairment; - No behaviors; - Required assistance of two or more staff for bed mobility and transfers; - Incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. During an interview on 4/9/18, at 12:40 P.M., and 3:35 P.M., the Assistant Director of Nursing (ADON) said: - He was the MDS/care plan coordinator for the last year. - He did not develop residents' baseline care plans. - Restorative Aide (RA) A, who was a certified nurse aide (CNA), completed a nurse aide's information sheet (NAIS, the facility's baseline care plan) and the staff used that to provide care. - The resident's right hand was contracted and his/her right arm was flaccid (weak, hanging limp). - No residents had side rails. During an interview on 4/5/18, at 2:10 P.M., CNA B said: - Residents had a NAIS on the inside of their closet door. - RA A highlighted the areas on the NAIS that pertained to the resident's care needs, and the CNAs provided care according to the NAIS. - If residents' transfer ability or needs changed the CNA reported the change to RA A and he/she updated the NAIS. Observation of the resident's room on 4/5/18, at 2:15 P.M., showed: - No NAIS on the inside of the resident's closet door. During an interview on 4/10/18, at 3:30 P.M., RA A said: - Sometimes he/she completed the NAIS when a resident was admitted . - He/she did not complete a NAIS when Resident #1 was admitted on [DATE]. - He/she still had not completed a NAIS for the resident, because he/she did not have time. During an interview on 4/9/18, at 12:40 P.M., the ADON said: - During (MONTH) (YEAR), he worked as the charge nurse, so he did not have time to develop the required care plan from the MDS information. During an interview on 4/9/18 at 2:45 P.M., the DON said: - She normally had a total five CNAs to cover all of the 12-hours night shifts for the month. She staffed three CNAs and a nurse each night, except for every other weekend when that left only two CNAs and a nurse on the night shift. - One CNA was assigned to the locked Alzheimer's unit, two CNAs covered the main halls, and the nurse covered both the unit and main halls. - In early (MONTH) (YEAR), a night shift CNA quit, so on numerous nights she only had two CNAs to cover the night shift, which left one CNA on the unit and the other CNA on the main halls. - The facility did not use any agency staff. - She expected the nurse to assist the CNAs with bed checks when able. - She said it was optimal to have two staff for bed checks, but at times one staff had to do the residents' bed checks alone. - She knew staff did bed checks without assistance of a second staff. Observation and interview on 4/5/18, at 9:15 A.M., showed: - The resident sat in a recliner, in his/her room, watching television. - The resident said he/she had lived at home and his/her spouse provided the needed care. - His/her spouse was admitted to the hospital so he/she came to the facility for care. - Two weeks ago one of the staff rolled him/her out of bed onto the floor while changing his/her bed. - He/she said it was an accident but he/she had to have surgery to repair his/her broken hip. During an interview on 4/10/18, at 11:00 A.M., CNA A said: - CNA A named ten incontinent residents who needed regular bed checks. - When there were two CNAs on the main hall they did the bed checks as a team, but when he/she was the only CNA on those halls he/she often did the bed checks alone. - On 3/22/18, he/she was the only CNA on the main halls. - Around 10:30 P.M., on 3/22/18, the resident turned on his/her call light and said he/she was wet. - CNA A said RN A assisted with bed checks when he/she had time but was busy passing medications. - CNA A went to get clean linens to change the bed. - CNA A said he/she stood on the side of the bed closest to the door and turned the resident on his/her side toward the window. - CNA A then moved the wet linens to the center of the bed and wiped the mattress. He/she tucked the sheet under the bottom of the mattress, reached for the resident, and the resident just flipped out of the bed onto the floor. - The resident said, I hurt, I hurt and CNA A let out a loud scream. - RN A heard the scream and came into the room, assessed the resident, sent CNA A for a bath blanket, and they lifted the resident into bed. During an interview on 4/5/18, at 3:05 P.M., Registered Nurse (RN) A said: - He/she worked about two shifts a month. - On the night shift they were supposed to have two CNAs on the main hall and one on the unit. - On 3/22/18, they only had two CNAs. - CNA A and he/she were on the main halls and one CNA was on the unit. - When they had only one CNA on the main halls, he/she assisted with bed checks as time allowed. His/her regular tasks consisted of finger sticks, insulin, medication pass and almost all the residents wanted pain medication, 24-hour chart checks, checking the crash cart, skin assessments, charting, treatments, dressing changes, answering call lights, and handling anything out of the ordinary that happened. He/she said it took longer to pass medications to the residents on the unit. RN A said one resident on the main halls turned on his/her call light almost every 30 minutes, which took time. - Numerous times, the one CNA did bed checks alone. - On 3/22/18, the resident was on antibiotics so RN A needed to do vital signs. He/she was across the hall getting supplies from the cart and heard a loud thud and CNA A scream. When he/she entered the room, the resident was on the floor on his/her left side. CNA A had tried to change the bed linen, rolled the resident to the opposite side of the bed, and he/she rolled out of bed. The resident complained of left side pain. RN A assessed the resident and his/her left leg was shortened and rotated (signs of a [MEDICAL CONDITION]). He/she had CNA A get a sheet, and they lifted the resident into bed. He/she asked the ADON, who was still in the facility to look at the resident's leg as he/she did not know the resident well. RN A called the Nurse Practitioner (NP) A who gave orders to send the resident to the emergency room (ER). He/she sent the resident to the ER by ambulance. Review of RN A's nurse's notes, dated 3/22/18, at 10:20 P.M., showed: - RN A was in the hall outside of resident's room getting ready to go into the room when he/she heard a loud thud and the CNA scream. The resident was lying on his/her left side next to the wall. CNA A stated he/she was changing the linens, had rolled the resident to put clean linens under the resident and was going around to the other side of the bed when the resident kept rolling and rolled out of the bed. The resident complained of pain in the left hip and shoulder, and his/her left leg was shortened and rotated. He/she called the ADON to the room as RN A had no frame of reference as to if the leg was shortened before or not. The ADON stated he believed the leg was shortened before. Resident is alert, oriented, and stated the events that happened. Vital signs 110/60, regular heart rate, temperature 98.1 and respirations regular and unlabored. Review of the ADON's nurse's note, dated 3/22/18, at 10:42 P.M., showed: - Notified NP A of resident falling out of bed and complaints of left side pain. Received order to send the resident to the ER for evaluation and treatment and notified family. During an interview on 4/9/18, at 3:35 P.M., the ADON said: - He did not put an intervention on the resident's care plan related to the fall from the bed, because the resident did not fall on his/her own. He/she fell from the bed while staff provided care. During an interview on 4/10/18, at 2:47 P.M., Licensed Practical Nurse (LPN) A said: - He/she worked as the charge nurse on the 12-hour night shifts. - He/she was responsible for checking finger sticks, giving insulin and medications, charting, treatments, dressings, skin assessments, checking the crash cart and refrigerator, 24-hour chart checks, ordering medications, and checking medications for the pharmacy evening delivery, answering call lights and one resident was on the call light almost every 30 minutes. - When they only had one CNA on the main hall he/she helped the CNA with bed checks as much as possible, which was about 50% of the bed checks. The rest of the time the CNA did the bed checks alone. During an interview on 4/9/18 at 9:25 A.M., and 2:45 P.M., and 4:10 P.M., the DON said: - Even after the facility hired a CNA to replace the CNA who quit in (MONTH) she still had only two CNAs on the night shift every other weekend. - She expected the nurse to assist the CNAs with bed checks when he/she had time. - She said it was optimal to have two staff for bed checks, but at times one staff had to do the residents' bed checks alone. - She knew staff did bed checks without assistance of a second staff member. Review of the hospital history and physical, dated 3/23/18, at 2:16 A.M., showed: - The resident suffered a fall out of bed at the nursing home. - Complains of sharp and stabbing left hip pain. - He/she had a left [MEDICAL CONDITION]. MO 498 MO 500

Based on interview and record review, facility staff failed to provide protective oversight and adequate supervision for one cognitively impaired resident (Resident #1), who the facility assessed as high risk for elopement, which resulted in the resident eloping from the facility. A deputy with the sheriff's office found the resident on 5/15/16 at 1:15 A.M. laying in the middle of a county highway by the local sheriff. Facility census was 45. Review of the undated facility policy for elopement showed: -Purpose: Identify residents at risk for elopement, protect residents that are not capable of protecting themselves and provide techniques and equipment to minimize safety risks; -Definition: Elopement is defined as the situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs and therefore at risk for injury outside the confines of the facility and its grounds, has left the facility without knowledge of staff; -Staff education: All new employees will be in-serviced on elopement policy during orientation then annually; -Those residents who have been identified to be an elopement risk through assessment and/or statements or attempts will be identified in the CODE BEAR binder located at the nurses' station and also in the individual care plan. Review of the the facility's undated Potential Wanderer Assessment Form showed: -If the resident is assessed as being at risk for wandering, initiate the policy for wandering residents. 1. Review of Resident #1's Potential Wanderer Assessment Form, dated 10/30/15, showed staff assessed the resident as: -At risk to wander/elope. Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/4/15, showed staff assessed the resident as: -Severely impaired cognitive skills for daily decision-making; -Did not exhibit behaviors or wandering; -Dependent upon staff for Activities of Daily Living (ADL's); -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 11/5/15, showed staff did not develop interventions to address the resident's risk to wander or elope. Review of the resident's social services progress notes, dated 3/8/16, showed: -The resident's family member addressed concerns and history of the resident's elopement attempts at a previous facility; -Informed the Director of Nursing (DON); -Psychiatric consultation scheduled for 5/3/16. Review of the resident's nurses' notes, dated 3/20/16, showed staff documented: -The resident was trying to buy a truck from the ads in the newspaper, told the staff that he/she would get a truck, and when the staff took the other residents out to smoke he/she would leave. Review of the resident's nurses' notes, dated 3/21/16, showed staff documented the resident threatened to leave the facility at 2:00 A.M. Measures have been taken to prevent this. Review of social services progress notes, dated 3/21/16, showed staff documented: -The resident had increased behaviors; -Stated he/she wanted to buy a truck out of the paper and became very upset with the staff; -Reported by housekeeping staff that the resident climbed out of the window during the night; -Maintenance secured the window and they placed the resident on 15 minute face checks. Review of the facility's 15 minute checks form, dated 3/21/16 through 3/22/16, showed staff documented visual checks every 15 minutes from 3/21/16 at 1:00 P.M. until 3/22/16 at 11:45 P.M. Review of the resident's nurses' notes, dated 3/25/16, showed the MDS Coordinator documented: -It was reported that the resident told a staff member he/she was going out the window of his/her room and that his/her roommate would then replace the window access. The window was checked by maintenance and screws were in very tight. The DON and Administrator were notified. Review of the resident's physician progress notes [REDACTED]. -The resident had an increase in recent behaviors; -The resident talked about wanting to get out of here and he/she has a couple of people working for him/her to get out;-Nursing reports that the resident has tried to get out of the window; -The window is secured now. Review of the resident's physician progress notes [REDACTED]. -The resident had increased agitation; -Made recent threats against staff and residents; -Hid medications; -The resident stated he/she is ready to go back to active duty, also states he/she can run and crawl a mile and fire weapons. Review of the resident's physician progress notes [REDACTED]. -The resident fell on [DATE] with no injuries, per nursing the resident put self on the floor; -According to the resident his/her new plan of escape was to be admitted to the hospital and leave from there; -Cognitive status worse at night, plotting to escape from nursing home. Review of the quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making; -Had delusions; -Exhibited verbal behavior one to three days; -Rejected care one to three days; -Wandered one to three days; -Independent with ADL's; -Ambulated with a walker. Review of the resident's care plan showed staff did not develop interventions to address the resident's wandering or statements of wanting to elope from the facility and did not update the Potential Wanderer Assessment Form. Review of the resident's nurses' notes, dated 4/13/16, showed: -The resident was admitted to the hospital due to elopement behavior at the doctor's office. Review of the resident's history and physical from a local hospital, dated 4/15/16, showed: -The resident was admitted to a behavioral heath unit for bipolar exacerbation and verbal and physical aggression. He/she threatened staff and peers and refused his/her medications. He/she made attempts to elope from the facility. He/she was seen on an outpatient basis by the psychiatric clinic and even attempted to elope from the outpatient clinic while he/she was there. A local police department transported him/her to the hospital emergency room and from there he/she was brought to the behavioral unit for inpatient psychiatric evaluation and treatment. Review of of the resident's nurses' notes, dated 4/26/16, showed staff documented the resident was readmitted to the facility. Review of the resident's Potential Wanderer Assessment Form, dated 4/26/16, showed staff assessed the resident as high risk for elopement/wandering. Review of the resident's care plan showed staff did not develop/update the care plan with interventions to address the resident's high risk for wandering and elopement. Review of the resident's Behavior Intervention Monthly Flow Record (a flow sheet used by nursing to document behaviors and what interventions are to be used for the behavior), dated May 2016, showed staff documented: -The resident's behavior was anger; -Had depression; -No interventions were indicated for the staff to use for these behaviors; -No interventions were noted for threats to elope from the facility. Review of the initial interview from contracted psychological services, dated 5/6/16, showed the resident was referred due to inappropriate behaviors, increased anxiety and elopement attempts. Review of the care plan for cognitive loss/dementia, dated 5/11/16, showed: -The resident was at risk for elopement related to exit seeking behaviors; -Goal: The resident will not elope; -Approaches: Monitor for exit seeking behavior, place resident profile in the Code Bear binder at the nurses station, redirect the resident when he/she exhibits exit seeking behavior. Review of the resident's social services progress notes, dated 5/12/16, showed: - Public Administrator (PA) notified of the residents repetitive calls to the county sheriffs office and the Marine recruitment office. Review of the resident's physician progress notes [REDACTED]. The resident made threats about climbing out the window. The physician documented there was genuine concern for the resident's safety due to his/her delusions of being held hostage as a prisoner. Review of the resident's nurses' notes, dated 5/14/16, showed staff documented the resident told everyone he/she was leaving tonight. The screen in the resident's window was bent and torn. The nurse notified the Administrator of the threats. Staff will do checks on the resident. Review of the resident's nurses' notes, dated 5/15/16 at 4:30 A.M., showed staff documented: -At approximately 1:12 A.M., the facility staff received a call from the county sheriffs dispatch wanting to confirm that the resident lived at the nursing home. The sheriff's office received a call from a passerby that an elderly person was on the side of the county road at 1:02 A.M. A deputy sheriff was dispatched and the resident was found on the side of the county road. The resident refused to return to the facility. The deputy sheriff took the resident to a local hospital. During an interview on 5/16/16 at 12:10 P.M., the Administrator said: -On 5/14/16 around 12:00 P.M., the resident was threatening to leave the facility; -The Administrator directed staff to start 15 minute face checks; -There is no documentation for the face checks; -The resident opened the left side of the window and the screen had a hole in the lower left side and had been replaced after the resident climbed out of the window; -In March 2016 the maintenance staff placed a screw in the right side of the resident's window after the resident made attempts to elope; -He was unaware the left side of the window opened; -The resident placed bedding under the bedspread to give the appearance of a body in the bed; -The resident placed a gray tote under the left side of the window; -Facility staff notified the Administrator that a sheriff's deputy found the resident on the county highway. During an interview on 5/16/16 at 4:30 P.M., the director of nursing (DON) said: -The resident was talking about leaving the facility in March; -In April the resident eloped from the outpatient psychiatric clinic; -The local police department had to take him/her to the emergency room ; -The resident was admitted to a psychiatric hospital after eloping from the clinic. During an interview on 5/16/16 at 3:00 P.M., the Public Administrator said: -He/she was aware that the resident was an elopement risk, and the resident tried to elope from previous facilities; -The resident eloped from the outpatient psychiatric clinic in April and was admitted to a local psychiatric hospital; -Staff notified him/her on 5/15/16 that the resident eloped from the facility. During an interview on 5/16/16 at 3:20 P.M., Registered Nurse (RN) A said: -He/she worked 6:30 A.M. to 6:30 P.M. on 5/14/16; -The resident was pleasant and telling the staff that he/she was leaving; -The resident frequently said he/she was leaving; -The resident told the housekeepers that he/she was going to leave the facility out of the window in his/her room; -He/she had the housekeepers check the resident's window; -The housekeepers found a small hole in the left lower part of the screen; -The right side of the window had a screw to prevent the window from opening but the left side of the window could open; -He/she left a message for the Administrator; -The resident had his/her belongings packed and was giving other resident's his/her personal items; -The resident told other resident's that he/she was leaving and he/she was going to miss them; -He/she did not trust the resident when he threatened to leave the facility; -He/she told the staff to check on the resident every 30 minutes; -He/she last saw the resident at 7:00 P.M. in another resident's room wearing sweat pants, a ball cap, blue jacket and tennis shoes. During an interview on 5/17/16 at 10:45 A.M., Housekeeper B said: -He/she worked 7:00 A.M. to 3:00 P.M. on 5/14/16; -The resident told him/her he/she was going to leave the facility that day; -He/she heard the resident tell another resident that he/she was leaving today and they could have his/her newspaper; -As he/she was cleaning the resident's room, he/she saw the screen had been pushed out and a hole was on the left side of the screen; -He/she reported the hole in the screen to the nurse; -He/she was not told to do face checks; -The resident told him/her that the left side of the window would open. During an interview on 5/17/16 at 11:20 A.M., Certified Medication Technician (CMT) A said: -He/she worked the day shift on 5/14/16; -The resident made comments about leaving the facility; -The resident told him/her in March that both sides of the window would open; -He/she was not instructed to complete 15 minute face checks on the resident; During an interview on 5/17/16 at 1:10 P.M., Certified Nurse Aide (CNA) B said: -He/she worked 6:30 A.M. to 6:30 P.M. on 5/14/16; -The resident was agitated and asking the employees how to get to town; -The resident had all of his personal possessions packed; -He/she was aware of the hole in the screen; -He/she was not instructed to complete 15 minute face checks on the resident; -He/she is not aware of the Code Bear Book. During an interview on 5/17/16 at 2:05 P.M., CNA C said: -He/she worked 6:30 A.M. to 6:30 P.M. on 5/14/16; -He/she was not instructed to complete 15 minute face checks; -He/she is not aware of the Code Bear book; -He/she is not aware of any other resident who is at risk for elopement. During an interview on 5/17/16 at 2:30 P.M., CMT B said: -He/she worked 2:30 P.M. to 10:30 P.M. on 5/14/16; -There was one aide on the locked Alzheimer's Unit and one aide on the unlocked side of the facility; -He/she passed medications to the residents on the locked Alzheimer's Unit and the unlocked hall; -The resident was anxious, pacing back and forth; -He/she was not instructed to complete the 15 minute face checks; -He/she is not aware of the Code Bear Book. During an interview on 5/17/16 at 2:45 P.M., the MDS Coordinator said: -He/she worked 6:30 P.M. to 12:00 A.M. on 5/14/16; -There was one CNA on the locked Alzheimer's unit, one CNA on the unlocked unit and a CMT passing medication on both units; -The day shift charge nurse told him/her the resident wanted to leave the facility and 15 minute face checks were being done; -He/she was told about the hole in the screen; -He/she did not observe the resident every 15 minutes; -He/she did not document 15 minute face checks; -He/she saw the resident in the dining room from 9:00 P.M. to 11:00 P.M.; -At 11:00 P.M., the resident came to the nurse's station, got a snack and went to his/her room; -He/she saw the resident at 11:15 P.M. in the resident's room, the resident was wearing dark colored pants and tennis shoes; -There was no care plan to address the resident's behaviors, delusions, past elopement or that the resident was at high risk for elopement until 5/11/16. During an interview on 5/16/16 at 3:15 P.M., CNA A said: -He/she worked 5/14/16 from 6:30 P.M. to 7:00 A.M.; -He/she did not receive any report from the day shift about any behaviors or the resident saying he/she was leaving; -At 7:15 P.M., the nurse told him/her to keep an eye on the resident and that there was a small hole in the left lower corner of the screen in the window in the resident's room; -He/she was the only aide on the hall; -He/she saw the resident at 8:00 P.M. walking down the hall by the dining room; -At 11:00 P.M., the resident was at the nurses' station getting a snack and told the nurse he/she was going to bed; -The resident had on a red tee shirt with pajama pants at 11:00 P.M.; -At 12:15 P.M., he/she observed the resident sitting on the side of the bed facing the window with a dark colored sweatshirt and dark colored pants; -At 1:00 A.M., CNA A was at the nurses' station charting and answered the phone while the nurse was on the locked Alzheimer's Unit; -The county sheriff dispatch asked if the resident lived at the facility; -He/she paged for the nurse to answer the phone call; -He/she went to the resident's room and found bed linens placed under the bedspread, a gray tote was under the left side of the window, the window was closed and the screen was placed back into the window; -The resident was not in the room; -All of the resident's belongings were packed in suitcases and boxes. During an interview on 5/16/16 at 4:05 P.M., Licensed Practical Nurse (LPN) A said: -He/she worked 5/15/16 from 12:00 A.M. until 7:00 A.M.; -He/she was the nurse for the entire facility; -There was one aide on the locked Alzheimer Unit and one aide on the other hall; -RN A told him/her that the resident was at the nurses' station at 11:00 P.M., looking in a phone book, got a snack and went to his/her room; -He/she did not see the resident; -He/she knew there was a small hole in the screen in the resident's room; -He/she was not told that the resident made comments about leaving the facility; -He/she was not told to do face checks on the resident; -At 1:10 A.M., CNA A told him/her the county sheriff's dispatch was on the phone and the resident was found on the side of the county road; -He/she checked the resident's room, the resident's bed had something under the bedspread to give the appearance of a body, a gray tote was under the left side of the window, the window was closed and the screen had a hole in the lower left side; -At approximately 1:20 A.M., the deputy sheriff brought the resident back to the facility; -The resident was wearing dark colored clothing and a ball cap; -The resident refused to get out of the police car; -The deputy sheriff took the resident to a local hospital. -He/she knew to do face checks for residents who wandered or verbalized the intent to elope; -He/she knew both sides of the window could open. During an interview on 5/16/16 at 4:30 P.M., the Administrator said: -The facility did not have a policy for face checks; -Placing a resident on face checks is an individual judgement call; -Face checks should be completed every 15 minutes and documented on the Face Check Form. During an interview on 5/16/16 at 10:00 A.M., the Nurse Practitioner (NP) said: -He/she saw the resident on 5/3/16; -The resident was delusional; -The resident talked about leaving the facility; -The resident would not be safe alone outside of the facility. During an interview on 5/17/16 at 10:30 A.M., the Maintenance Director said: -The resident talked about leaving the facility; -He secured the right side of the window with a screw so the window would only open about 4 inches; -He was not aware that the left side of the window would open; -He was not aware that the resident put a hole in the screen. During an interview on 5/17/16 at 3:00 P.M., the DON said: -The Behavior Monitoring Sheets are used to direct staff on interventions to be used when residents had behaviors; -There were no interventions on the Behavior Monitoring Sheets for wandering; -Staff use the care plans to direct them how to provide care for each resident; -The care plan should address the resident's behaviors and elopement risk; -15 minute face checks should have been started and documented on 5/14/16. During a telephone interview on 5/19/16 at 7:00 P.M., the Deputy Sheriff said: -Dispatch received a call from a passerby at 12:50 A.M. on 5/15/16 of an elderly person walking on a county highway; -He/she left the sheriff's department at 1:03 A.M.; -He/she was driving north along the county road, topped a hill and saw the person lying on the white line in the center of the road; -The resident got up on his/her own and sat in the deputy's car; -The resident told the deputy that his/her truck broke down and he/she needed a ride to his/her daughter's house. The resident said he/she had been visiting a friend at the nursing home; -The deputy took the resident back to the nursing home, where he/she refused to get out of the car; -The deputy took the resident to a local hospital for evaluation. MO 3 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observations, record review, and interviews completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility had secured both sides of the windows of residents who were identified at risk for elopement and revised the facility's policy for elopement to include 15 minute face checks for a minimum duration of 36 hours and immediate reporting to the Charge Nurse, Director of Nursing, and Administrator for any statements, threats or actions of elopement by any resident. The facility implemented the teddy bear symbol identifiers placed on the resident room door nameplates to alert staff of those resident's who were at high risk for elopement. All residents were reassessed by the Elopement/Wander Assessment tool to identify others who may be at risk for elopement. The facility began in-servicing all staff on the Code Bear binder for identification of residents at high risk for elopement, revised elopement policy, the teddy bear identifiers, and 15 minute face checks for residents who made statements, threats or actions of elopement. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity level was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation.

Based on observation, interview and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received therapeutic restorative treatments for residents with contractures (an abnormal shortening and hardening of muscles, tendons, or tissue, often leading to deformity and rigidity of joints) which affected two of eleven sampled residents (Resident #1 and #5). The facility census was 47. Review of the facility's Range of Motion (active, active assistance, and passive) policy, Nursing Guidelines Manual, dated March, 2012, showed: - Purpose: To move the resident's joints through as full a range of motion as possible, to improve or maintain joint mobility and muscle strength; - Guideline: Assess the resident for disability, pain, and weakness; - Determine which joints need range of motion exercise and need for passive or active assistance; - Consult the physician or physical therapist for limitations or precautions for specific exercises. 1. Review of Resident #1's certified nurse aide (CNA) care card, dated 2/4/2013, and posted inside the resident's closet door showed staff did not complete the restorative care (active range of motion (AROM) or passive range of motion (PROM) portion of the care card. Staff wrote the resident was on a restorative aide (RA) program and was to wear a splint on his/her left hand. The CNA care card had not been updated since February, 2013. Review of the last RA daily documentation note, dated 5/19/14, showed staff wrote the resident received ROM for both elbows three times per week and hot compresses to both elbows. The RA discharged the resident from the RA program on 5/22/14, and documented the resident now received skilled care and physical therapy would take over care. Review of the physical therapy (PT) evaluation/plan of care, dated 8/12/14, showed the therapist wrote the resident received therapy five times per week for four weeks. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 8/27/14, showed: - The resident received five days of physical therapy (PT) from 8/5/14 to 8/9/14; - No restorative nurse program documented to start after PT completed. Review of the physical therapy resident screening form, dated 10/13/14, showed: - Hospice declined therapy services at this time; - Continue with splinting and ROM from the RA/nursing program; - Nursing staff notified of suggested changes; - Signed by the PT supervisor. Review of the resident's quarterly MDS, dated [DATE], showed: - [DIAGNOSES REDACTED]. - A Brief Interview for Mental Status (BIMS), with a score of one (0-7 indicates severe cognitive impairment); - Resident required total dependence of staff for bed mobility, transfers, dressing, toileting, and hygiene; - Hospice care; - Did not receive restorative nurse programs (includes passive range of motion); - CAA (care area assessment, an indepth assessment to identify resident specific problems, needs, and strengths): Restorative nursing programs including passive ROM: left blank. Review of the resident's care plan conference summary, dated 2/26/15, showed the areas addressed: dietary, activities, and social services. No mention of RA or the resident's contractures on the care plan and the last nursing note on the care plan was on 10/14/14 for [MEDICATION NAME] twice a day. Review of the resident's physician order [REDACTED]. Observation on 3/9/15, at 3:00 P.M. and 4:35 P.M., showed the resident sat in a Broda chair (a tilt and recline wheelchair) in his/her room. The resident did not have any rolled towels in either hand. Both hands show fingers contractured (fisted). No hand splints visible in the resident's room. Observation on 3/10/15, at 12:30 P.M., Registered Nurse (RN) C entered the resident's room to provide a treatment to the resident's peg tube (a special tube placed into the abdominal wall for supplemental feedings, medications, or fluids) site. RN C attempted to pull the resident's left arm away from the peg tube site several times with difficulty due to contractures of both shoulders. Observation on 3/11/15, at 1:00 P.M., showed CNA F entered the resident's room to assist a hospice CNA with care. The resident did not have any rolled towels in his/her hands. Skin check of both of the resident's shoulders show slight inward rotation due to contractures. Observation on 3/11/15, at 2:20 P.M., showed the following: - CNA B and CNA F entered the resident's room to provide perineal care, and washed their hands; - CNA B pulled the resident's legs apart, due to contractures, as CNA F performed perineal care; - CNA F said staff kept a blanket between the resident's knees to prevent skin breakdown from contractures. Observation on 3/12/15, at 8:10 A.M., showed the resident seated in a Broda chair, in their room, with no rolled towels in either hand or blanket between the knees. During an interview on 3/12/15, at 8:20 A.M., the RA said: - The resident had not had an order for [REDACTED]. - He/she could only keep them so long; - If staff felt the resident needed RA, he/she called therapy in to evaluate the resident; - The PT supervisor did an evaluation to decide if the resident needed RA; - The resident's old hand splints disappeared; - He/she asked for new hands splints about two weeks ago and had not heard back; - He/she preferred the resident had something in his/her hands and something between the knees to prevent contractures. During an interview on 3/12/15, at 5:30 P.M., the PT supervisor said: - One and one-half to two years ago, the resident had mild contractures, nothing severe. - They treated him/her off and on with PT and occupational therapy (OT). - Since the resident had been admitted to hospice in August, 2014, the contractures have worsened; - The resident should have hand splints on or rolled towels in his/her hands. - For the shoulder contractures, they needed to look at what best for the resident. If they tried to be too aggressive, they would cause the resident discomfort. - He/she did not know of any reason why nursing did not do any PROM or RA with the resident; - Nursing or the RA let them know when there was a problem. - PT screened residents quarterly for any changes in a resident's condition; - They did not screen this resident quarterly. - A bed-bound resident would be someone they should watch; - He/she would want something in the resident's palms and could write an in-service for CNA staff to instruct about this. - He/she did not know staff had difficulty spreading the resident's legs apart for perineal care. - PT last screened the resident for a change in condition in the fall. - Quarterly screenings can be given to the Director of Nurses (DON) to follow through with care. During an interview on 3/12/15, at 7:20 P.M., RN B said he/she should contact the DON about starting an RA program. Staff should keep a rolled towel in the resident's hands, and a pillow or blanket between the legs. During an interview on 3/12/15, at 8:45 P.M., the DON said: - She and the PT department supervised the RA program; - Anyone who advanced beyond PT or OT should be on an RA program. - The nursing staff needed to notify the PT department of resident changes; - For hand contractures, nursing staff could put rolled wash clothes in resident's hands and needed to document this in the resident's medical record. - She could not answer why the RA program stopped last May for the resident; - PT should do screenings quarterly on the residents. 2. Review of Resident #5's care plan, dated 10/30/13, showed: - Physical and occupational therapy to evaluate and treat for wheelchair position and padding. Review of the resident's Care Area Assessment (CAA) Summary annual report, dated 3/6/14, showed: - Activities of daily living (ADL's) functional status/Rehabilitation Potential: Analysis of findings: dependent on staff in all areas of cares due to [MEDICAL CONDITION] (MS, a progressive deteriorating nervous system disease that results in a gradual loss of muscle function), and [MEDICAL CONDITION] (paralysis of all four limbs); - Falls: analysis of findings: unable to assist with transfers or locomotion. Review of the resident's care plan conference summary, dated 9/11/14, showed: - Plan of care for nursing: continue plan of care; - Rehab: staff did not note any comments. Review of the resident's undated care plan conference summary, showed: - Diagnosis: [REDACTED]. - Plan of care for nursing: did not address any ROM or RA program; - Rehab: staff did not note any comments. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills for daily decision making moderately impaired; - Dependent on one staff assistance for bed mobility, dressing, toilet use and personal hygiene; - Dependent on assistance of two staff for transfers; - Had a Foley catheter (a sterile tube inserted into the bladder to drain urine); - Upper and lower extremities impaired on both sides; - [DIAGNOSES REDACTED]. Review of the resident's physical therapy progress report, dated 2/19/15-3/3/15, showed: - Saw the resident for ten days during 2/19/15-3/3/15, progress period; - Assessment summary: resident and caregiver training: instructed the resident and primary caregivers in positioning/pressure relieving techniques and splinting/orthotic schedule in order to increase safety and reduce the risk of further medical complications [REDACTED]. - Rehab potential for achieving goals: the resident demonstrates excellent rehab potential as evidenced by high cognitive functioning, attentive to tasks and supportive staff; - Reason for skilled services: continued physical therapy services are necessary in order to increase lower extremity ROM and strength and facilitate motor control in order to enhance resident's quality of life by improving ability to relieve pressure for decreased risk of skin breakdown; - Did not show documentation related for ROM to hands. Review of the physical therapy treatment encounter notes, dated 3/4/15-3/12/15, showed, in part: - Therapeutic exercises included cervical (neck) ROM; stretching to shoulders, neck for increased upright posture; elbows, hips, knees, and ankles for orthotic placement; - Did not show documentation for ROM to hands. Review of the resident's POS, dated March, 2015, showed: - Physical therapy: evaluate and treat five times a week for therapeutic exercises, therapeutic activities, neuromuscular education, wheelchair management, estim (electrical current used to cause a single muscle or group of muscles to contract) and manual therapy; - [DIAGNOSES REDACTED]. Observation at various times during the facility's annual survey from 3/9/15 through 3/12/15, showed: - The resident in activities, in the dining room, and in his/her room; - Did not have any rolled washcloths in his/her hands which appeared contractured. During an interview on 3/12/15, at 8:10 A.M., the RA said: - The resident received services from physical therapy, not on the RA program. - Nursing staff sometimes placed rolled washcloths in the resident's hands but did not know how often. During an interview on 3/12/15, at 11:52 A.M., CNA B said: - Sometimes the staff would place a rolled washcloth in the resident's hands; - The resident used to have a blue foam roll (used to help with hand flexibility and rehabilitation), but one got torn up and the other one was lost. During an interview on 3/12/15, at 5:30 P.M., the PT supervisor said: - The resident received physical therapy five times a week; - They did ROM and stretching with his/her hands; - Was not aware the resident did not have any carrots for his/her hands; - Nursing should attempt to place rolled washcloths in his/her hands.