Every finding on record at Ascend at Aurora

Based on observation, interview, and record review, the facility failed to provide all residents with functioning call lights system when call lights for four resident rooms affecting three residents (Resident #1, #3, and #4) did not sound at the door nurses' station and when the call light for one resident (Resident #1) did not have a call light cover present. The facility census was 74.Review of the facility policy, Resident Call System and Accessibility, dated 10/15/26, showed the following:-To ensure that all residents are provided with a functioning, operation, and accessible communication system to summon staff assistance, maintain autonomy, and ensure safety from bedsides, toilets, and bathing facilities;-The facility shall maintain an adequately equipped resident call system that relays communication signals directly to an assigned caregiver or a centralized staff work area;-All staff members are responsible for responding to activated call systems immediately;-Facility staff must routinely check bedside and bathroom call buttons to confirm functional visual signals, corridor domes, and electronic tracking logs;-The maintenance department must be notified instantly during call light failure;-The resident must immediately be provided with an approved alternative communication aid;-If a widespread system outage occurs, a dedicated monitoring plan will be activated, deploying staff to physical corridor watches and direct, frequent rounding intervals until the system is restored. 1. Review showed the facility did not provide documentation of checks of call lights system. 2. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following:-admission date of 06/24/26;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), spondylosis with radiculopathy lumbar region (age-related wear and tear in the lower back that causes a pinched or inflamed nerve root), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)). Review of the resident's care plan, dated 06/25/26, showed the following:-Resident had pain and staff should respond immediately to any complaint of pain;-Resident had an activities of daily living (ADL) self care performance deficit;-The resident requires supervision of one staff participation with transfers. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 07/08/26, showed the following:-Cognitively intact;-Use of walker;-Supervision or touching assistance required for showering. During an interview on 07/27/26, at 12:37 P.M., the resident said the following:-His/Her call light had been on for one-half hour.;-Staff do not come into his/her room. They refuse to answer his/her call light; -This has been an issue since his/her admission approximately one month ago; -His/Her call light was often on for over two hours and staff do not respond. Observations on 07/27/26, showed the following:-At 12:37 P.M., the call light outside of the resident's room had two small round light bulbs with no light cover box. The top white light bulb was illuminated. Inside the resident's room, the light was illuminated at call light cord;-At 12:44 P.M., the call light remained illuminated outside the room and no staff responded to the call light;-At 12:45 P.M., a flat panel by the nurses' station showed the resident's call light was illuminated, but no audible sound was noted. No other lights were illuminated at the time. Two nursing staff were seated at the nurses' station;-At 12:48 P.M., maintenance walked by the room and did not stop at the resident's call light;-At 12:51 P.M., the call light for the resident remained on with no response and no audible sound;-At 12:55 P.M., three nursing staff were seated at the nursing station along with the Medical Director. The call light remained illuminated at the room door and on the panel near the nurses' station. There was no audible noise from the call light or the panel. No staff responded to the resident call light;-At 12:58 P.M., the resident exited his/her room with his/her walker and came to the entry of the hall. The resident stated See, I told you no one answers my call light. The resident ambulated to the smoke break area. The call light remained illuminated at the resident room and at the panel with no audible sound;-At 1:05 P.M., the Assistant Director of Nursing (ADON) entered the resident room and checked for the resident. 3. Review of Resident #3's face sheet showed the following:-admission date of 07/03/26;-Diagnoses included pneumonia and chronic pain. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Use of wheelchair;-Substantial to maximal assistance required for eating, oral hygiene, toileting hygiene, showering;-Dependent on staff for dressing and personal hygiene. During an interview on 07/27/26, at 1:15 P.M., a visitor in the building said the following:-On the evening of 07/25/26, he/she noted that the resident's call light was on from 6:30 P.M. to 8:00 P.M. and no staff responded;-The resident was yelling out for water;-The visitor went into the resident's room and assisted the resident with water. During an interview on 07/27/26, at 3:10 P.M., the Director of Nursing (DON) said this morning, the visitor reported his/her concerns regarding the resident's call light not being responded to on 07/25/26. The DON was in the facility during that time and did not recall the light being on. 4. During an interview on 07/27/26, at 2:10 P.M., Resident #4 said the following:-Staff sometimes take a long time, 30 to 45 minutes, to respond to his/her call light;-The resident did not know if the call light makes a noise when pressed. 5. Observation on 07/27/26, at 1:10 P.M., showed the following:-Maintenance, the DON, and Assistant DON (ADON) tested call lights down the 500 hall;-Four out of four rooms did not have an audible sound when tested. 6. During an interview on 07/27/26, at 1:08 P.M., Certified Nursing Assistant (CNA) A said the following:-When a resident pushed their call light, a light turns on above the resident door and at the nursing station panel;-An audible beeping can be heard at the panel at the nurses' station until the light is turned off;-There are some rooms that the call light does not beep, but he/she does not know why. During an interview on 07/27/26, at 1:36 P.M., CNA B said the following:-He/She had not heard any call lights on the 500 hall and was unsure when he/she last heard audible sounds from the call lights on that hall;-He/She looked at the panels when going by the nursing station area and also checked the lights when on the halls;-Some covers are missing from the lights, which makes it harder to tell if a light is on. During an interview on 07/27/26, at 2:15 P.M., Licensed Nurse Practitioner (LPN) C said the following:-He/She was just made aware of the call light system not working on the 500 hall;-Staff should notify the charge nurse and the maintenance department if a call light is not working. During an interview on 07/27/26, at 2:25 P.M., Registered Nurse (RN) D said the following:-If he/she was made aware of call lights not working, he/she would notify the DON and Maintenance;-He/She can hear the call lights when at the nursing station. During an interview on 07/27/26, at 2:50 P.M., the Social Service Director (SSD) said the following:-He was unsure where the sound for the call lights comes from;-If made aware of any call lights not being answered he/she would discuss with the DON and complete and investigation to determine cause of light not being answered timely. During an interview on 07/27/26, at 3:10 P.M., the DON said she believed the call light bells were working. Staff should notify the DON and Maintenance if there are any call light issues. During an interview on 07/27/26, at 3:15 P.M., the Administrator said the following:-Call lights should make an audible sound and illuminate until the call light is turned off by staff;-He was unaware that all the call lights were not making audible sound;-Maintenance staff should be auditing the call lights on a routine basis. Complaint #3117265

Based on interview and record review, the facility staff failed to report all allegations of abuse timely when staff failed to report an allegation of resident-to-resident abuse involving two residents (Resident #1 and Resident #2) immediately to administration and failed to the Department of Health and Senior Services (DHSS) within the required two hours of the facility staff becoming aware of the allegation. The facility census was 77.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 10/2025, showed the following:-Residents have the right to be free of abuse. This includes freedom from verbal, mental, sexual and physical abuse;-Protect the residents from abuse by anyone including facility staff, other residents and any other individual;-The facility develops and implements policies and protocols to prevent and identify abuse or mistreatment of residents;-The facility establishes and maintains a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems;-The facility staff identify all possible incidents of abuse, mistreatment;-The facility staff report any allegations within timeframes required by federal requirements. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/11/26;-Diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings, including emotional highs (mania or hypomania) and lows (depression)), insomnia (a common sleep disorder that involves trouble falling asleep, staying asleep, or waking up too early), anxiety disorder, and major depressive disorder(a serious medical mood disorder). Review of the resident's care plan, reviewed 03/24/26, showed the following:-The resident had behaviors at times related to diagnosis of dementia and intellectual disability;-The resident had a behavior problem, depression, and bipolar disorder;-Administer antipsychotics medications as ordered and monitor/document for side effects and effectiveness;-Give anti-anxiety medications ordered by physician and monitor/ document side effects;-Administer anti-depressant medications as ordered and monitor/document for side effects and effectiveness;-The resident received hypnotics;-Behavioral health consults as needed. Record review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/05/26 showed the following:-Resident cognitively intact;-No behaviors exhibited;-Resident independent with transfers. During an interview on 05/23/26, at 1:26 P.M., the resident said the following:-In May, he/she had a roommate. The roommate would yell and scream and was mean to everyone. The roommate told the resident to get on his/her knees and suck on the roommate's genitals. He/she also tried to get him/her to sit on his/her bed;-He/she reported what his/her roommate had said to Licensed Practical Nurse (LPN) A;-LPN A moved him/her to a different room for the night;-He/she felt safer when he/she was not in the room with the roommate;-He/she went back to his/her old room the next morning;-He/she could not remember exactly what day in May, but the roommate told him/her that he/she needed to tell him something. When he/she got close enough his/her the roommate grabbed him/her by the neck. He/she was able to pull away;-He/she reported that his/her roommate tried to choke him/her to the nurses;-The roommate left the facility soon after that;-He/she felt very triggered by his/her roommate due to being assaulted by his/her father when he/she was a child;-He/she felt like it brought of feelings from when he/she was younger and made him/her feel like he/she was not safe;-He/she felt a lot of anxiety about getting a different roommate due to the experience. 2. Review of Resident #2's face sheet showed the following:-admission date of 05/20/26;-discharge date of 05/26/26;-Diagnoses included displaced bicondylar fracture of left tibia (a severe break of the upper shinbone that affects both the inside and outside parts of the knee joint surface), subsequent encounter for open fracture, hemiplegia and hemiparesis following cerebral infarction (one-sided weakness or inability to move) affecting left dominant side, major depression, anxiety disorder, and primary insomnia. Review of the resident's care plan, dated 05/20/26, showed the following:-The resident has impaired cognitive function and impaired thought processes;-The resident had limited mobility. Review of the resident's nurses' notes showed the following:-On 05/24/26, at 8:52 A.M., LPN A said the resident had behaviors of throwing trays and being verbally and sexual inappropriate towards Resident #1 and staff. He/she contacted the physician and ordered to start Xanax (an anti-anxiety medication) .5 milligrams (mg) every six hours as needed for agitation. (Staff did not document reporting the allegation of possible abuse to the management or DHSS.);-On 05/25/26, at 6:34 A.M., LPN B said the resident was yelling and throwing things. He/she went to the resident's room to administer medications. The resident put his/her hands around LPN B's throat and started choking him/her. He/she got loose from the resident and he/she said he/she would kill LPN B and he/she hated him/her. The resident started yelling at Resident #1, threatening to kill him/her and trying to reach to him/her. Staff notified the physician and a new order for Ativan (sedative/antianxiety medication) was given to the resident. Resident #2 started yelling again and staff found him/her on the floor. The resident tried to kick at the staff and would not allow them to get him up. The staff notified the physician, and the resident was sent to the hospital. (Staff did not document reporting the allegation of possible abuse to the management or DHSS.) 3. Review of DHSS records showed the facility staff notified DHSS of an allegation of abuse involving Resident #1 on 07/13/26 at 6:06 P.M. The Administrator reported the facility informed Resident #1 he/she was getting an new roommate and Resident #1 reported that back around 05/13/26 he/she had a roommate who was sexually inappropriate with him/her and made him nervous. Resident #1 said the roommate grabbed him/her by the throat and said he/she was going to put it in him/her and he/she was going to like what he/she had. 4. Review of the facility's Five-Day Investigation Summary, undated, showed the following:-The report was submitted to DHSS on 07/17/26, at 6:54 P.M.,-On 07/13/26, Resident #1 reported to Social Services, he/she had felt concerned about receiving a new roommate because of prior incident involving Resident #2;-Resident #1 said, during a behavioral episode on 05/13/26, the other resident (Resident #2) was yelling at nursing staff, cursing at the nurse and Resident #1, and attempted to grab Resident #1 in an inappropriate manner-The facility initiated an investigation immediately after Resident #1 reported the allegation on 07/13/26. 5. During an interview on 07/21/26, at 10:54 A.M., Certified Nursing Aide (CNA) C said the following:-He/she would consider a resident telling another resident to suck his/her genitals or a resident choking another resident to be abuse;-He/she would immediately report abuse allegations to the charge nurse. During interviews on 07/21/26, at 10:58 A.M. and 3:50 P.M., LPN D said the following:-He/she was supposed to report allegations of abuse to the Director of Nursing (DON);-In May, Resident #1 was roommates with Resident #2 for a few days. LPN A reported to him/her that Resident #2 had torn up his/her room and Resident #1 said Resident #2 sexually assaulted him/her. Resident #1 also said Resident #2 choked him/her;-He/she assessed Resident #1 and he/she had no red marks on his/her neck;-He/she did not report the allegation to anyone because he/she did not believe Resident #1 was choked. During an interview on 07/21/26 at 2:07 P.M., LPN B said the following:-Resident #2 choked him/her at the end of May. Resident #1 came into the room when Resident #2 was choking her. Resident #2 reached for Resident #1 and he/she was able to get free;-Resident #2 was threatening to harm everyone;-Resident #2 was sent to the hospital. Resident #1 reported to the CNA's that Resident #2 tried to choke Resident #1;-He/she did not ask Resident #1 about it because sometimes he/she makes things up. He/she did not think Resident #1 was choked;-He/she chose not to report the allegation to anyone due to not believing it happened;-He/she was supposed to report allegations of abuse to the DON and Administrator;-Resident #2 was capable of choking someone if they got close enough to them;-He/she thinks a resident being choked would be considered abuse. During an interview on 07/21/26 at 2:48 P.M., LPN A said the following: -Around the end of May, the same day he/she wrote the nurse's note regarding sexual behaviors (05/14/26), Resident #1 reported that Resident #2 told him/her to drop to his/her knees and suck his/her genitals;-He/she worked with the Social Services Director (SSD) to move Resident #1 to a different room for the night;-Resident #1 said he/she did not feel safe in that room and he/she appeared scared;-He/she reported the allegation to the DON and SSD;-He/she assumed the DON reported the allegation to DHSS. During an interview on 07/21/26, at 3:17 P.M., the SSD said the following:-He/she remembered moving Resident #1 to a different room for the night in May 2026 but he/she thought it was because the resident's roommate was disruptive and loud;-He/she did not remember LPN A reporting that Resident #1 had made sexual verbal abuse allegations against Resident #2;-He/she would have reported the allegation to the Administrator. During an interview on 07/21/26, at 3:03 P.M., the DON said the following:-He/she did not remember staff reporting abuse allegations between Resident #1 and Resident #2 in May 2026;-He/she did not see the nurse's note written by LPN A on 05/24/26;-He/she did not report the allegations in May;-If he/she had seen the note written by LPN A until today;-He/she did not know about the allegations until they told Resident #1 he/she was getting a roommate and he/she told them he/she did not want one due to being sexually assaulted by Resident #2 back in May 2026. During an interview on 07/23/26, at 8:45 A.M., the resident's physician said the following:-He/she was contacted by a nurse from the facility on 05/23/26 at around midnight, regarding Resident #2 asking Resident #1 to perform a sexual act;-He/she replied with an order for medication to calm the resident down;-He/she thought the allegation should have been reported due to possibly being abuse;-The staff did not tell him/her about any allegations regarding Resident #1 being choked. During an interview on 07/23/26, at 10:46 A.M., the Administrator said the following:-He/she did not know about the nurse's note from LPN A on 05/24/26, regarding and allegation of sexual behaviors towards Resident #1;-LPN A should have reported the allegation;-The allegation made by Resident #1 regarding sexual allegations and being choked should have been reported to DHSS;-He/she did not know why the staff did not report to the DON or himself. Complaint 3092075

Based on interviews and record reviews, the facility failed to ensure that an allegation of possible abuse was thoroughly and immediately investigated when a staff member received an allegation of abuse regarding two residents (Resident #1 and #2) and staff failed to complete an immediate written investigation. The facility census was 77.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 10/2025, showed the following:-Residents have the right to be free of abuse. This includes freedom from verbal, mental, sexual and physical abuse;-Protect the residents from abuse by anyone including facility staff, other residents and any other individual;-The facility develops and implements policies and protocols to prevent and identify abuse or mistreatment of residents;-The facility establishes and maintains a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems;-The facility staff identify and investigate all possible incidents of abuse, mistreatment;-The facility staff investigate any allegations within timeframes required by federal requirements;-The facility staff protect residents from any further harm during investigations. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/11/26;-Diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings, including emotional highs (mania or hypomania) and lows (depression)), insomnia (a common sleep disorder that involves trouble falling asleep, staying asleep, or waking up too early), anxiety disorder, and major depressive disorder(a serious medical mood disorder). Review of the resident's care plan, reviewed 03/24/26, showed the following:-The resident had behaviors at times related to diagnosis of dementia and intellectual disability;-The resident had a behavior problem, depression, and bipolar disorder;-Administer antipsychotics medications as ordered and monitor/document for side effects and effectiveness;-Give anti-anxiety medications ordered by physician and monitor/ document side effects;-Administer anti-depressant medications as ordered and monitor/document for side effects and effectiveness;-The resident received hypnotics;-Behavioral health consults as needed. Record review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/05/26 showed the following:-Resident cognitively intact;-No behaviors exhibited;-Resident independent with transfers. During an interview on 05/23/26, at 1:26 P.M., the resident said the following:-In May, he/she had a roommate. The roommate would yell and scream and was mean to everyone. The roommate told the resident to get on his/her knees and suck on the roommate's genitals. He/she also tried to get him/her to sit on his/her bed;-He/she reported what his/her roommate had said to Licensed Practical Nurse (LPN) A;-LPN A moved him/her to a different room for the night;-He/she felt safer when he/she was not in the room with the roommate;-He/she went back to his/her old room the next morning;-He/she could not remember exactly what day in May, but the roommate told him/her that he/she needed to tell him something. When he/she got close enough his/her the roommate grabbed him/her by the neck. He/she was able to pull away;-He/she reported that his/her roommate tried to choke him/her to the nurses;-The roommate left the facility soon after that;-He/she felt very triggered by his/her roommate due to being assaulted by his/her father when he/she was a child;-He/she felt like it brought of feelings from when he/she was younger and made him/her feel like he/she was not safe;-He/she felt a lot of anxiety about getting a different roommate due to the experience. 2. Review of Resident #2's face sheet showed the following:-admission date of 05/20/26;-discharge date of 05/26/26;-Diagnoses included displaced bicondylar fracture of left tibia (a severe break of the upper shinbone that affects both the inside and outside parts of the knee joint surface), subsequent encounter for open fracture, hemiplegia and hemiparesis following cerebral infarction (one-sided weakness or inability to move) affecting left dominant side, major depression, anxiety disorder, and primary insomnia. Review of the resident's care plan, dated 05/20/26, showed the following:-The resident has impaired cognitive function and impaired thought processes;-The resident had limited mobility. Review of the resident's nurses' notes showed the following: -On 05/24/26, at 8:52 A.M., LPN A said the resident had behaviors of throwing trays and being verbally and sexual inappropriate towards Resident #1 and staff. He/she contacted the physician and ordered to start Xanax (an anti-anxiety medication) .5 milligrams (mg) every six hours as needed for agitation;-On 05/25/26, at 6:34 A.M., LPN B said the resident was yelling and throwing things. He/she went to the resident's room to administer medications. The resident put his/her hands around LPN B's throat and started choking him/her. He/she got loose from the resident and he/she said he/she would kill LPN B and he/she hated him/her. The resident started yelling at Resident #1, threatening to kill him/her and trying to reach to him/her. Staff notified the physician and a new order for Ativan (sedative/antianxiety medication) was given to the resident. Resident #2 started yelling again and staff found him/her on the floor. The resident tried to kick at the staff and would not allow them to get him up. The staff notified the physician, and the resident was sent to the hospital. 3. Review of the facility's, Five-Day Investigation Summary, undated, showed the following:-The report was submitted to DHSS on 07/17/26, at 6:54 P.M.;-On 07/13/26, Resident #1 reported to Social Services, he/she felt concerned about receiving a new roommate because of prior incident involving Resident #2. -Resident #1 said, during a behavioral episode on 05/13/26, the other resident was yelling at nursing staff, cursing at the nurse and Resident #1 and attempted to grab Resident #1 in an inappropriate manner. Resident #1 also reported he/she was safe at the time of the report, did not feel currently threatened, and had no ongoing safety concerns after follow-up by facility leadership;-The facility initiated an investigation immediately after Resident #1 reported the allegation on 07/13/26;-The investigation team reviewed Resident #1's chart for documentation related to the alleged incident and did not identify evidence through interviews, medical record review, and documentation to substantiate this claim;-The investigation team reviewed Resident #2's record and located documentation dated 05/25/26. The note described a behavioral episode. 4. During an interview on 07/21/26, at 10:54 A.M., Certified Nursing Aide (CNA) C said the following: -He/she would consider a resident telling another resident to suck his/her genitals or a resident choking another resident to be abuse;-He/she expected they would start an investigation. During interviews on 07/21/26, at 10:58 A.M. and 3:50 P.M., LPN D said the following:-He/she was supposed to report allegations of abuse to the Director of Nursing (DON);-In May, Resident #1 was roommates with Resident #2 for a few days. LPN A reported to him/her that Resident #2 had torn up his/her room and Resident #1 said Resident #2 sexually assaulted him/her. Resident #1 also said Resident #2 choked him/her;-He/she assessed Resident #1 and he/she had no red marks on his/her neck;-He/she did not know if the incident was investigated. During an interview on 07/21/26, at 2:07 P.M., LPN B said the following:-Resident #2 choked him/her at the end of May. Resident #1 came into the room when Resident #2 was choking her. Resident #2 reached for Resident #1 and he/she was able to get free;-Resident #2 was threatening to harm everyone;-Resident #2 was sent to the hospital. Resident #1 reported to the CNA's that Resident #2 tried to choke him/her;-He/she did not ask Resident #1 about it because sometimes he/she makes things up. He/she did not think Resident #1 was choked;-Resident #2 was capable of choking someone if they got close enough to them;-He/she thought a resident being choked would be considered abuse;-He/she did not believe the allegation was investigated. During an interview on 07/21/26, at 2:48 P.M., LPN A said the following:-Around the end of May, the same day he/she wrote the nurse's note regarding sexual behaviors, Resident #1 reported that Resident #2 told him/her to drop to his/her knees and suck his/her genitals;-He/she worked with the Social Services Director (SSD) to move Resident #1 to a different room for the night;-Resident #1 said he/she did not feel safe in that room and he/she appeared scared;-He/she reported the allegation to the Director of Nursing (DON);-Abuse allegations were supposed to be investigated by staff. He/she did not know if the allegation was investigated by staff. During an interview on 07/21/26, at 3:17 P.M., the SSD said the following:-He/she remembered moving Resident #1 to a different room for the night in May 2026 but he/she thought it was because the resident's roommate was disruptive and loud;-He/she did not remember LPN A reporting that Resident #1 had made sexual verbal abuse allegations against Resident #2;-He/she would have reported the allegation to the Administrator, and they would have started an investigation. During an interview on 07/21/26, at 3:03 P.M., the DON said the following:-He/she did not see the nurses note written by LPN A on 05/24/26;-He/she did not report or investigate the allegations in May;-If he/she had seen the note written by LPN A, he/she would have investigated;-He/she did not know about the allegations until they told Resident #1 he/she was getting a roommate and he/she told them he/she did not want one due to being sexually assaulted by Resident #2 back in May. During an interview on 07/23/26, at 8:45 A.M., the resident's physician said the following:-He/she was contacted by a nurse from the facility on 05/23/26 at around midnight, regarding Resident #2 asking Resident #1 to perform a sexual act;-He/she replied with an order to calm the resident down;-He/she thought the allegation should have been investigated due to possibly being abuse;-The staff did not tell him/her about any allegations regarding the resident being choked. During an interview on 07/23/26, at 10:46 A.M., the Administrator said the following:-He/she did not know about the note from LPN A on 05/24/26, regarding and allegation of sexual behaviors towards Resident #1;-The allegation made by Resident #1 regarding sexual allegations and being choked should have been investigated. Complaint #3092075

Based on interviews and record reviews, the facility failed to ensure all residents who were trauma survivors receive trauma-informed care when nursing staff was not informed about one resident's (Resident #1) past trauma as it could relate to care and failed to add trauma-informed care interventions to the resident's care plan. The facility census was 77.Review of the facility's policy titled, Trauma-informed Care Policy and Procedure, dated 03/11/26, showed the following:-The facility shall provide culturally competent, trauma-informed care to residents who are trauma survivors. Care and services shall be delivered in accordance with professional standards of practice and will account for each resident's experiences, preferences, cultural background and identified triggers in order to eliminate or mitigate the risk of re-traumatization;-The purpose of the policy is to establish a consistent facility-wide process for identifying trauma history, assessing resident-specific triggers and cultural preferences, incorporating trauma-informed interventions into the comprehensive care plan, and monitoring the effectiveness of those interventions. This policy supports resident dignity, autonomy, choice. psychosocial well-being and regulatory compliance;-The interdisciplinary team shall complete trauma history screening during the initial assessment process and no later than the required comprehensive assessment timeframe;-Social services, nursing and other appropriate disciplines shall review available admission records, behavioral health documentation, resident interviews, collateral information, as appropriate, to identify known or suspected trauma history;-Screening shall be conducted in a respectful, private, and resident-centered manner, using appropriate questions or validated tools as indicated;-Identified trauma history, suspected trauma-related needs, resident preferences and any relevant disclosures shall be documented in the clinical records using objective, respectful and need-to-know language;-The interdisciplinary team will identify environment, physical interpersonal and psychological triggers that may cause distress or re-traumatization. Examples may include, loud noises, specific care approaches, enclosed spaces, gender of care providers loss of privacy and other individualized factors;-Relevant preferences may include gender-related care preferences and other individualized needs identified by the resident or representative;-Trauma history, identified triggers, coping strategies, and cultural preferences will be incorporated into comprehensive person-centered care plan when relevant to the resident's needs and goals;-The care plan will be developed in collaboration with the resident;-The care plan will include specific, practical interventions that direct staff how to avoid known triggers, support preferred coping methods, preserve dignity and privacy, and promote resident choice during care delivery;-Care planning shall support resident choice in daily routines, including waking, bathing, dressing, meals, activities and other aspects of daily life whenever clinically appropriate and consistent with safety needs;-Staff shall monitor residents for verbal and nonverbal signs of distress, behavioral changes, withdrawal, agitation, refusal of care, sleep disturbances, or other indicators, that may be associated with trauma-related responses;-Observed distress, suspected triggers, interventions attempted, resident response, and follow-up actions will be documented in the medical record in a timely and objective manner. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/11/26;-Diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings, including emotional highs (mania or hypomania) and lows (depression)), insomnia(a common sleep disorder that involves trouble falling asleep, staying asleep, or waking up too early), anxiety disorder, and major depressive disorder(a serious medical mood disorder). Review of the resident's care plan, review/updated 05/04/26, showed the following:-The resident had a behavior problem, depression, and bipolar disorder;-Administer antipsychotics medications as ordered and monitor/document for side effects and effectiveness;-Provide a program of activities that is of interest and accommodates residents status;-Monitor/record/report to physician as needed side effects and adverse reactions of psychoactive medications including unsteady gait, tardive dyskinesia (involuntary movements), 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 person;-Give anti-anxiety medications ordered by physicians and monitor/document side effects;-The resident uses antidepressant medication due to depression;-Administer anti-depressant medications as ordered and monitor/document for side effects (dry mouth, dry eyes, constipation, urinary retention and suicidal ideations) and effectiveness;-Monitor/document/report to physician any ongoing sign or symptoms of depression unaltered by depression medications including sadness, anger, never satisfied, crying, shame, agitation, guilt, suicidal ideations, negative mood/comments, slowed movement agitation, disrupted sleep fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/ appetite, fear of being alone or with others, unrealistic fears, attention seeking, concerns with bodily functions, anxiety, and constant reassurance;-The resident received hypnotics.(Staff did not care plan regarding prior identification of trauma-informed care needs or trauma-informed care interventions.) Record review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/05/26 showed the following:-Cognition intact;-No behaviors exhibited. Review of the resident's medical record showed staff did not document a trauma-based care assessment. Review of the resident's psychology note, dated 07/18/26, showed the following:-The resident was evaluated after an allegation of assault by prior roommate. The resident was obsessed and upset about having a roommate and felt he/she should have a room to himself. When asked a few different ways about the assault, the resident could not confirm or get any specific and the evaluation shown that he was at his baseline;-The resident had sexual trauma in the past;-The resident was admitted on [DATE] with chronic diagnosis of bipolar and post-traumatic stress disorder ((PTSD) a mental health condition that develops after experiencing or witnessing a terrifying or life-threatening event).-He/she spoke with the staff and they were not told about the resident's past history and the resident did not bring it up;-The resident had past sexual trauma noted in his past, which made it a chronic condition. At times he/she doesn't want to talk about it, at times he/she will remember some things and the story is distorted at times which may reflect why he/she doesn't want to process or talk about it. It also could be the reason he/she believes it is happening in the present when it was the past, especially manic state with his/her bipolar disorder and major depression. It appears his/her anger was more focused on compulsion because of having a roommate. During an interview on 07/23/26, at 1:26 P.M., the resident said the following:-In May 2026, he/she had a roommate. The roommate would yell and scream and was mean to everyone. The roommate told Resident #1 to get on his/her knees and suck on the roommate's genitals. He/she also tried to get him/her to sit on his/her bed;-He/she reported what his/her roommate had said to LPN A;-LPN A moved him/her to a different room for the night;-He/she felt safer when he/she was not in the room with the roommate;-He/she went back to his/her old room the next morning;-He/she can't remember exactly what day in May but that roommate told him/her that he/she needed to tell him something. When he/she got close enough his/her roommate grabbed him/her by the neck. He/she was able to pull away;-He/she reported that his/her roommate tried to choke him/her to the nurses;-The roommate left the facility soon after that;-He/she felt very triggered by his/her roommate due to being assaulted by his/her father when he/she was a child;-He/she felt like it brought of feelings from when he/she was younger and made him/her feel like he/she was not safe; -He/she feels a lot of anxiety about getting a different roommate due to the experience. The facility recently tried to place another resident in the same room with him/her and he/she is worried about it;-He/she talked to the Director of Nursing (DON) and the Administrator about his/her past trauma with his/her parent at least a month ago. During interviews on 07/21/26, at 10:58 A.M. and 3:50 P.M., Licensed Practical Nurse (LPN) D said the following:-He/she did not know the resident had any history of trauma;-He/she felt it was important for the staff to know if a resident had a history of trauma so they could provide trauma-based care and avoid triggers;-He/she expected trauma based care interventions should be on the care plan. During an interview on 07/21/26, at 2:07 P.M., LPN B said the following:-He/she did not know if the resident had any history of past trauma. He/she thought that would be important to know and would change how he/she provided care depending on possible triggers;-He/she thought there should be interventions for past trauma in the care plan;-Generally, the nurses are told if there was trauma that could affect care. During an interview on 07/21/26, at 2:48 P.M., LPN A said he/she did not know if the resident had a history of trauma. He/she did not know if a history of trauma should be the care plan. During an interview on 07/21/26, at 3:17 P.M., the Social Services Director (SSD) said the following:-He/she did not know the resident had any history of past abuse. He/she did not ask those kind of questions when he/she gathered information about a resident's past history;-He/she did not know if he/she should ask questions related to past trauma. He/she did not know if it should be included in the care plan. During an interview on 07/23/26, at 1:04 P.M., the MDS Coordinator said the following;-He/she did not know the resident had any past trauma;-He/she generally put information regarding past trauma on the care plan, especially if it could affect care;-He/she collaborated with the resident and social services to come up with interventions that may be needed. During an interview on 07/23/26, at 10:46 A.M., the DON said the following:-The resident told him/her that he/she had been abused by his/her parent when he/she was younger. He/she had to move out;-He/she thought it should be included on the care plan with interventions. During interviews on 07/21/26, at 11:58 A.M., and on 07/23/26, at 10:46 A.M., the Administrator said the following:-The resident told him/her that his/her parent physically and sexually assaulted. He/she was not sure exactly when he/she was told;-The resident brought up allegations against his/her prior roommate from May 2026;-He/she thought the staff knew about the resident's past trauma history;-He/she assumed the resident had told staff;-He/she thought the staff should know about any trauma history that is pertinent to care;-He/she believed it was a missed opportunity for trauma-informed care for the resident;-The SSD should be identifying the need for trauma informed care upon admission;-He/she felt staff could do a better job of supporting the resident's mental health needs by making him/her more part of the roommate decision making process;-The resident did not have trauma based care addressed on his/her care plan;-Trauma informed care should be on the care plan with appropriate interventions. Complaint 3092075

Based on interview and record review, the facility failed to inform the resident representative of a change in condition for one resident (Resident #90) when the resident had a fall that resulted in an injury. The facility census was 73.Review of the facility's policy titled, Change in Resident's Condition or Status, updated December 2025 showed the following: -The facility shall promptly notify the resident, their healthcare provider, and representative of changes in the resident's physical, mental, or psychosocial condition.-Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when:-The resident is involved in any accident or incident that results in an injury including injuries of an unknown source.1. Review of Resident #90's face sheet (brief resident information sheet), showed the following:-admitted to the facility on [DATE];-Diagnoses included heart failure (condition where the heart muscle doesn't pump blood as well as it should) unsteady feet, and overactive bladder (causes sudden, strong urge to urinate).Review of the resident's nurses' progress notes, dated 07/05/26, at 1:45 A.M., showed the following:-Staff reported the resident said he/she had fallen out of the wheelchair;-Resident in sitting position on the bed;-Resident said, I went to stand up and fell down hard. The resident had an approximate 1 inch diameter hematoma (closed wound where blood collects and fills a space inside your body because it cannot flow or drain out) to right forehead, distal (away from the center of the body) to hairline noted. No other obvious injuries noted. -Range of motion and neurological checks (clinical assessment used to monitor a resident's brain function) within normal limits to resident's baseline. -Notified physician and DON of observations/resident's condition.Review of the resident's nurses' progress notes showed staff did not document notification of the resident's representative of the change in condition from the fall.During an interview on 07/10/26, at 12:52 P.M., Registered Nurse (RN) H said the following:-He/she would assess a resident who had a change in condition and notify the physician and family;-If there was no family information available and the resident could not provide the information, he/she would notify the Director of Nursing (DON) and Social Services.During an interview on 07/07/26, at 6:10 P.M., the Director of Nursing (DON) said the following:-The resident's family should have been notified of the fall and any injury:-The resident was a newer admission and the admission information regarding the emergency contact and/or family information had not been entered so the staff had no information to notify the family when the resident had a change in condition. -The staff should have reported this to the DON for directions.-The admission paperwork should have been completed, and all emergency contact information should have been collected at time of admission.During an interview on 7/10/26, at 3:16 P.M., the DON and Regional Director of Operations said the following:-When there is a change of condition, staff should notify the nurse and not move the resident after a fall without a nurse. -Nurse should assess the resident, initiate neuro checks, and provide first aid if needed.-If there is no family information on the factsheet, there are several other areas in the chart to find emergency contact/family contact information. -There may be information in the hospital records;-Staff should have called the DON or administrator;-If the resident was cognitively intact, staff should have just asked the resident. -Staff should notify the physician and family/representative/guardian. -We would expect staff to update emergency contact list. If they can't find it, they could have asked residents, DON, or administrator; -The staff should have notified the resident's family. Complaint 3068972

Based on interview and record review, the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice when the facility failed to administer medications as ordered and failed to notify the physician of missed medications, for one resident (Resident #13). The facility census was 73. Review of facility policy titled Medication Administration, revised August 2025, showed the following: -Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. Nursing policies developed by the facility may supersede the procedures outlined in this policy; -Notify the attending physician and/or prescriber of: persistent refusals, held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results or vital signs resulting in medication being held, or suspected adverse drug reactions. 1. Review of the Resident #13's face sheet showed the following information: -admission date of 01/23/26; -Diagnoses included syncope (fainting) and collapse, fracture of left fibula (lower, outside leg bone), hypotension (low blood pressure), volume depletion (a loss of both water and sodium, which reduces the amount of fluid circulating in the bloodstream), history of strokes, and a pressure ulcer of sacral region (at the base of the spine, above the tailbone), stage 2 (a partial-thickness skin wound where the top layer of skin (epidermis) is broken, exposing the middle layer (dermis)), pain and anorexia. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool filled out by facility staff), dated 05/05/26, showed the following: -Cognitively intact; -Resident receives an antidepressant, an opiate, antiplatelet, and an anticonvulsant. Review of the resident's care plan, dated 06/02/26, showed the following: -The resident has pain; -Administer analgesia (oxycodone) as per orders. Give 1/2 hour before treatments or care; -No diagnosis or interventions related to any other medications. Review of resident physician order sheet (POS), dated June 2026, showed the following: -An order, dated 01/24/26, for phenytoin sodium (to control generalized tonic-clonic (grand mal) and complex partial seizures in epilepsy) extended capsule 100 milligram (mg), give two capsules by mouth two times a day for seizures; -An order, dated 01/24/26, for allopurinol (a prescription medication primarily used to prevent gout attacks and kidney stones by lowering uric acid levels in the blood) oral tablet 100 mg, give one tablet by mouth one time a day for hyperuricemia (a medical condition characterized by an abnormally high level of uric acid in the blood); -An order, dated 01/24/26, for cholecalciferol (a dietary supplement used to treat or prevent vitamin D deficiency) oral tablet, give 3000 unit by mouth one time a day for supplement; -An order, dated 01/24/26, for clopidogrel bisulfate (used to prevent serious blood clots) oral tablet 75 mg, give one tablet by mouth one time a day for antiplatelet; -An order, dated 01/27/26, for midodrine HCI (Indicates that a drug's active ingredient has been converted into a salt by bonding it with hydrochloric acid. This process makes the medication much more stable and easier for your body to absorb) tablet 10mg, give one tablet by mouth three times a day for hypertension (high blood pressure); -An order, dated 02/20/26, for potassium oral tablet (prevent or treat low blood potassium levels), give 10 milliequivalents ((mEq) a unit of measurement used in medicine to express the concentration of electrolytes (like sodium or potassium) in blood and bodily fluids) by mouth one time a day for supplement; -An order, dated 03/17/26, for Reglan (brand name) oral tablet 5 mg, give one tablet by mouth before meals for Gastroesophageal Reflux Disease ((GERD) acid reflux), discontinued 06/12/26; -An order, dated 04/07/26, for folate oral tablet (used to treat and prevent folate deficiency anemia (low red blood cells)), give 1 gram by mouth one time a day for supplement; -An order, dated 05/07/26, for oxycodone, HCl Oral Tablet 10 milligram (MG), give one tablet by mouth three times a day for pain; -An order, dated 05/20/26, for a multivitamin oral tablet, give one capsule by mouth one time a day for supplement; -An order, dated 05/20/26, for polysaccharide iron complex (helps your body produce healthy red blood cells, transports oxygen throughout your body, and combats symptoms like fatigue and weakness capsule) 150 mg, give one capsule by mouth one time a day every other day for deficiency; -An order, dated 05/20/26, for acidophilus (improve digestion, treat diarrhea (including antibiotic-associated) oral capsule, give one capsule by mouth two times a day for probiotic for antibiotic use; -An order, dated 05/21/26, for Pro Source oral liquid (nutritional supplement), give 30 cubic centimeters (cc) by mouth one time a day for pressure ulcer of sacral (at the base of the spine, above the tailbone) region stage 3 (a deep, crater-like wound where there is full-thickness skin loss, meaning it penetrates both the outer (epidermis) and inner (dermis) layers of skin down to the subcutaneous (deepest layer of skin, beneath the dermis) fatty tissue) until 06/03/26; -An order, dated 05/30/26, for zinc (assists with wound healing) oral tablet, give 50 mg by mouth one time a day for supplement; -An order, dated 06/12/26, for Reglan oral tablet five mg, give 1 tablet by mouth before meals for Gastroesophageal Reflux Disease ((GERD) acid reflux). Review of the resident's medication administration record (MAR), dated June 2026, showed the following: -On 06/01/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, ProSource oral liquid, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, polysaccharide iron complex capsule 150 mg, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 06/03/26, at morning administration, staff noted ProSource oral liquid and polysaccharide iron complex capsule 150 mg was not administered with a reason of sleeping; -On 06/03/26 an 06/04/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 06/06/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 06/09/26, at morning administration, staff noted polysaccharide iron complex capsule 150 mg was not administered with a reason of sleeping; -On 06/09/26 and 06/10/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 06/15/26 and 06/17/26, at morning administration, staff noted polysaccharide iron complex capsule 150 mg was not administered with a reason of sleeping; -On 06/15/26, 06/16/26, 06/17/26, and 06/18/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 06/23/26 and 06/25/26, at morning administration, staff noted polysaccharide iron complex capsule 150 mg was not administered with a reason of sleeping; -On 06/22/26, 06/23/26, 06/24/26, and 06/25/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 06/29/26, at morning administration, staff noted polysaccharide iron complex capsule 150 mg was not administered with a reason of sleeping; -On 06/29/26 and 06/30/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet. Review of the resident's progress notes for June 2026, showed no documentation regarding the resident sleeping through medication administration, or physician notification of the held medications. Review of resident's POS, dated July 2026, showed the following: -An order, dated 01/24/26, for phenytoin sodium (to control generalized grand mal and complex partial seizures in epilepsy) extended capsule 100 milligram (mg), give two capsule by mouth two times a day for seizures; -An order, dated 01/24/26, for allopurinol (a prescription medication primarily used to prevent gout attacks and kidney stones by lowering uric acid levels in the blood) oral tablet 100 mg, give one tablet by mouth one time a day for hyperuricemia (a medical condition characterized by an abnormally high level of uric acid in the blood); -An order, dated 01/24/26, for cholecalciferol (a dietary supplement used to treat or prevent vitamin D deficiency) oral tablet, give 3000 unit by mouth one time a day for supplement; -An order, dated 01/24/26, for clopidogrel bisulfate (used to prevent serious blood clots) oral tablet 75 mg, give one tablet by mouth one time a day for antiplatelet; -An order, dated 01/27/26, for midodrine HCI (Indicates that a drug's active ingredient has been converted into a salt by bonding it with hydrochloric acid. This process makes the medication much more stable and easier for your body to absorb) tablet 10mg, give one tablet by mouth three times a day for hypertension (high blood pressure); -An order, dated 02/20/26, for potassium oral tablet (prevent or treat low blood potassium levels), give 10 milliequivalents ((mEq) a unit of measurement used in medicine to express the concentration of electrolytes (like sodium or potassium) in blood and bodily fluids) by mouth one time a day for supplement; -An order, dated 04/07/26, for folate oral tablet (used to treat and prevent folate deficiency anemia (low red blood cells)), give 1 gram by mouth one time a day for supplement; -An order, dated 05/07/26, for oxycodone, HCl Oral Tablet 10 milligram (MG), give one tablet by mouth three times a day for pain; -An order, dated 05/20/26, for a multivitamin oral tablet, give one capsule by mouth one time a day for supplement; -An order, dated 05/20/26, for polysaccharide iron complex (helps your body produce healthy red blood cells, transports oxygen throughout your body, and combats symptoms like fatigue and weakness capsule) 150 mg, give one capsule by mouth one time a day every other day for deficiency; -An order, dated 05/20/26, for acidophilus (improve digestion, treat diarrhea (including antibiotic-associated) oral capsule, give one capsule by mouth two times a day for probiotic for antibiotic use; -An order, dated 05/30/26, for zinc (assists with wound healing) oral tablet, give 50 mg by mouth one time a day for supplement; -An order, dated 06/12/26, for Reglan oral tablet five mg, give one tablet by mouth before meals for Gastroesophageal Reflux Disease ((GERD) acid reflux). Review of the resident's MAR, dated July 2026, showed the following: -On 07/01/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, Reglan oral tablet 5 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, polysaccharide iron complex capsule 150 mg, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet; -On 07/06/26, at morning administration, staff noted oxycodone HCI oral tablet 10 mg was not administered with a reason of sleeping; -On 07/07/26, at morning administration, staff noted Reglan oral tablet 5 mg and polysaccharide iron complex capsule 150 mg was not administered with a reason of sleeping; -On 07/07/26 an 07/08/26, at morning administration, staff noted the following medications were not administered with a reason of sleeping: allopurinol oral tablet 100 mg, cholecalciferol oral tablet, oxycodone HCI oral tablet 10 mg, phenytoin sodium extended capsule 100 mg, midodrine HCI table 10 mg, zinc oral tablet, acidophilus oral capsule, multivitamin oral tablet, potassium oral tablet, clopidogrel bisulfate oral tablet 75 mg, and folate oral tablet. Review of the resident's progress notes for July 2026, showed no documentation regarding the resident sleeping through medication administration, or physician notification of the held medications. During an interview on 07/08/26, at 10:18 A.M., Resident #13 said staff do not wake her for morning medications. He/She would like to at least have his/her pain medication before wound treatments. During an interview on 07/08/26, at 10:27 A.M. and 07/10/26, at 9:40 A.M., Certified Medication Technician (CMT) A said the following: -When passing medication, if a resident is asleep he/she will hold that resident's medication until they are awake;-He/she will not administer scheduled medication if it is too close to the next dose;-Resident #13 has PRN and scheduled pain medication for pain related to his/her wound. -He/She attempts to wake up Resident #13 for his/her medications and he/she will tell CMT A to come back;-When Resident #13 first started sleeping through his/her medications, he/she would tell nurse, but he/she has not told nurse lately. He/She does not know if the nurse notified the physician;-Resident #13 does not refuse medications;-When Resident #13 sleeps through his/her medication, sometimes he/she cannot administer it at a later time because it is too close to the next scheduled dose. During an interview on 07/10/26, at 12:19 P.M., Registered Nurse (RN) H, said the following: -He/She would wake up a resident for medication administration; -If the resident slept through their medications, he/she would put it on report (the document that notifies the next shift of any concerns); -If a resident continuously slept thought their medications, he/she would notify the physician to inquire if the administration times could be adjusted; -He/She is unaware of Resident #13 sleeping through his/her medications; -He/She would expect the CMT to notify him/her if a resident sleeps through their medication administration time. During an interview on 07/10/26, at 1:05 P.M., CMT L said if a resident is asleep during medication administration, he/she will try to wake the resident up. If the resident does not want to wake up, he/she will notify the nurse, and then try to reapproach the resident. During an interview on 07/10/26, at 3:17 P.M., the Director of Nursing (DON) said the following: -Staff should follow the MAR when administering medications; -Staff should attempt to wake up a resident if they are sleeping during medication administration; -If a resident sleeps through their medication administration, staff should notify the nurse and/or DON. The physician and family should also be notified; -If a resident regularly sleeps through medication administration, the nurse should discuss adjusting the administration times with the physician. During an interview on 07/10/26, at 4:00 P.M., the Administrator said nursing staff should follow the physician's orders. Staff should not skip a medication pass and should follow the care plan. During an interview on 07/13/26, at 1:13 P.M., the Physician said the following: -Staff should follow the POS; -He/She expects all residents to receive their prescribed medications as ordered; -If a resident is regularly sleeping through medication administration time, he/she would need to be notified. He/She would consider adjusting the administration time; -Resident #13's wound is painful. He/she would expect pain medication to be administered at least a half hour to an hour prior to wound treatment being performed; -If the resident does not receive their prescribed medication, allopurinol, the resident has an increased risk for a gout flare up; -If the resident does not receive their prescribed medication, clopidogrel bisulfate, the resident has an increased risk for a heart attack or stroke; -It is very important that Resident #13 receives their prescribed medication, phenytoin sodium, as it prevents seizures; -The resident's vitamins are important to promote wound healing.

Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to promote prevention and healing of pressure ulcers (refers to localized damage to the skin and/or underlying tissue usually over a bony prominence) pressure ulcers when the facility failed to timely assess, document, and implement treatment and monitoring of a pressure ulcer for two resident (Resident #3 and #4). The facility census was 53.Review of the facility policy titled Skin Integrity- Pressure and Non-Pressure reviewed 06/30/25, showed the following information:-Pressure and other ulcers will be assessed and measured at least weekly by a licensed nurse and documented;-A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission. The pressure ulcer risk assessment will be updated quarterly and as necessary;-Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure skin conditions are identified;-Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nursing Assistant (CNA). Changes shall be reported to the charge nurse who will perform the detailed assessment. At the earliest sign of a pressure ulcer or other skin problems, the resident, legal representative, and the attending physician will be notified;-The initial observation of the ulcer or breakdown will also be described in the nursing progress notes and/or risk assessment.1. Review of Resident #3's face sheet (brief look at resident information) showed the following information:-admission date of 02/26/26;-Diagnoses include compression fracture of the lumbar vertebra (lower back), high blood pressure, and fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and brain fog).Review of the resident's comprehensive Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 02/26/26, showed the following information:-Intact cognition;-The resident had a stage three (full-thickness loss of skin) pressure ulcer and at risk for developing pressure ulcers;-Required pressure reducing device for chair and bed;-Required pressure ulcer care.Review of the resident's care plan, dated 02/26/26, showed staff did not care plan related to the identified stage III pressure ulcer. Review of the resident's Nursing Admission/readmission Data Collection Assessment, dated 02/27/26, showed the following information:-Moderate risk for impaired skin integrity;-Did not have impaired skin integrity;-No open areas.Review of the resident's Post Acute Care Handoff document from his/her hospital stay, dated 02/22/26, showed the resident had a pressure ulcer to his/her midline sacral spine (the central ridge on the posterior aspect of the inverted triangle shaped sacrum).Review of the resident's medical record showed facility staff did not document completion of a skin assessment had been documented on admission.Review of the resident's progress note dated 03/06/26, at 3:22 P.M., showed the following information:-The resident had excoriation to his/her buttocks;-The progress note did not document any measurements, description, or physician and family notifications.Review of the resident's shower sheet, dated 03/06/26, showed no new skin issues were documented.Review of the resident's progress note dated 03/07/26, at 4:35 P.M., showed the following information:-The resident had excoriation to his/her buttocks;-The progress note did not document any measurements, description, or physician and family notifications.Review of the resident's progress note dated 03/09/26, at 3:21 P.M., showed a wound assessment completed and referred to the assessment for further information.Review of the resident's wound assessment dated [DATE], at 3:01 PM., showed the following:-A facility acquired stage III pressure ulcer had been identified on the resident's coccyx (a small triangular bone located at the very bottom of the spine, also known as the tailbone);-The family and physician were notified;-The wound was 50 percent slough (non-viable yellow, tan, gray, green or brown tissue) and was draining serosanguinous (a thin, watery, pale red or pink fluid) drainage;-The wound measured 1.3 centimeters (cm) by 1.4 cm by 0.8 cm;-Staff noted care plan reviewed and updated.(This was the first document wound assessment after admission.)Review of the resident's care plan showed staff did not update the care plan to reflect the identified stage III pressure ulcer. Review of the resident's March 2026 Physician Order Sheet (POS) showed the following:-An order, dated 03/09/26, for skin assessments to be completed every Monday as part of the admission protocol;-An order, dated 03/09/26, for a low air loss mattress due to stage III wound;-An order, dated 03/12/26, to clean stage III coccyx with wound cleanser, apply calcium alginate (highly absorbent material commonly used for heavily exudating (draining) wounds), cover with super absorbent silicone border foam dressing, and change daily until resolved.Review of the resident's March 2026 Treatment Administration Record (TAR) showed the facility-initiated treatment to the wound on 03/12/26.Review of the resident's progress note dated 03/15/26, at 6:26 P.M., showed the resident's coccyx stage III wound had a moderate amount of purulent (pus filled) drainage noted with an odor. Staff notified the physician. (This was the first documentation regarding the wound after 03/09/26.) Review of the resident's skin assessment, dated 03/17/26, showed the following information:-Stage III pressure ulcer to the resident's coccyx measuring 3.1 cm by 2.5 cm by 0.6 cm with 1.0 cm of redness around the wound. The wound bed consisted of 90 % slough, 10 % of pale pink tissue, and had a scant amount of yellow drainage;-New orders were obtained to apply Santyl (a prescription topical medication used to remove dead tissue (debridement) from chronic skin ulcers) to the wound bed;-Care plan reviewed and updated.Review of the resident's March 2026 POS showed an order, dated to begin on 03/17/26, for Santyl, apply to coccyx topically everyday shift for wound care until resolved.Review of the resident's care plan, dated 03/17/26, showed the following:-The resident had potential/actual impairment to his/her skin integrity related to a coccyx wound;-Administer medications as ordered and monitor and document for side effects;-Administer treatments as ordered and monitor for effectiveness;-Avoid sheering while repositioning in bed;-Low air-loss mattress to bed for pressure reduction relief;-Monitor pressure areas for changes in color, sensation, and temperature. Report changes to the physician;-Monitor/document/report signs and symptoms of infection to the physician.Observation on 03/17/26, at 3:00 P.M., showed a slough covered wound a little larger than quarter sized to the resident's coccyx. The peri-wound (surrounding skin) was pale pink. During an interview on 03/17/26, at 2:06 P.M., CNA A said the following:-He/she noticed the resident's wound around 03/09/26 while providing incontinent care and reported it to the Administrator. The wound was on the resident's coccyx and was slough covered and had some green appearing drainage. The physician happened to be present that day and ordered treatment.During an interview on 03/18/26, at 10:39 P.M., Licensed Practical Nurse (LPN) C said the following:-He/she looked through the resident's medical record and noted that the resident did not have a skin assessment on admission or routine weekly skin assessments completed.;-Whoever had put in the resident's admission orders did not include weekly skin assessments, so that was not triggering for nurses to complete;-He/she believed the wound was present on admission, but since a skin assessment was not completed that cannot be proved.During an interview on 03/18/26, at 1:48 P.M., the Administrator said the following:-She became aware of the wound around the week of 03/09/26;-When she observed the wound, it was slough covered and nurses were expected to implement interventions such as a low air loss mattress and contact the physician for treatment orders.2. Review of Resident #4's face sheet showed the following information:-re-admission date of 02/15/26;-Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD - progressive lung disease that restricts air flow and causes breathing difficulties), and disorder of kidney and ureters (urinary tract).Review of the resident's care plan, dated 12/22/25, showed staff did not care plan related to a risk for skin breakdown and/or if the resident had skin breakdown.Review of the resident's admission (MDS, dated [DATE], showed the following information:-Severe cognitive impairment;-At risk for developing pressure ulcers;-No pressure ulcers or skin concerns-Required pressure reducing device for chair and bed;-Does not require turning and repositioning program.Review of the resident's February 2025 POS showed an order, dated 02/02/26, to apply barrier cream to coccyx (a small triangular bone at the base of the spine)/peri-area every shift for prevention.Review of the resident's Nursing Admission/readmission Data Collection Assessment, dated 02/15/26, showed staff noted no impaired skin integrity.Review of the resident's bath assessment, dated 02/16/26, showed the resident had bumps on his/her bottom. The charge nurse did not sign the form.Review of the resident's medical record showed the resident was sent to the hospital on [DATE] for altered mental status.Review of the resident's progress note dated 02/21/26, at 2:32 P.M., showed he resident's family member had been called for an update regarding the hospitalized resident. The resident's family member stated the hospital staff found two bed sores on the resident's backside that have a current MRSA ( Methicillin-resistant Staphylococcus aureus- an infection caused by a type of staph bacteria that has become resistant to many antibiotics) infection.Review of the resident's progress note dated 02/28/26, at 3:28 P.M., showed the following information:-The resident had returned from the hospital with a diagnoses of pneumonia and Covid;-The resident had shearing to the bilateral (both) buttocks with blanchable erythema (red inflamed area that turns white(blanches) when pressed and then returns to red indicated intact capillaries and temporary inflammation) surrounding.(Staff did not document an assessment of the wounds, new orders for the wounds, or notifications to the resident's physician or family.)Review of the resident's medical record showed staff did not complete a skin assessment completed on 02/28/26 through 03/05/26, when the resident was transferred to the hospital again.Review of the resident's progress notes, dated 02/28/26 through 03/05/26, showed staff did not document regarding the resident's wounds or physician notifications.Review of the resident's physician orders, dated 02/28/26 through 03/05/26, showed staff document new wound care orders or interventions.Review of the resident's care plan, dated 12/22/25, showed staff did not update the resident's care plan related to a risk for skin breakdown and/or if the resident had skin breakdown.During an interview on 03/18/26, at 10:07 A.M., Certified Medication Technician (CMT) B said the resident had wounds on his/her bottom up to maybe two months ago. He/she believed the staff were putting ointment on them.3. During an interview on 03/17/26, at 2:06 P.M., CNA A said the following:-He/she was not aware of nurses completing wound monitoring rounds since the new Director of Nursing (DON) was hired;-He/she did not believe nurses were completing their skin assessments timely;-On occasion nurses would ask him/her to assist with rolling the resident's while they provide wound care, but he/she had not seen a nurse measure wounds.During an interview on 03/18/26, at 10:07 A.M., CMT B said the following:-If he/she were to see a new or worsening open area on the resident's skin, he/she would report it to the charge nurse, who should perform an assessment, document, and make necessary notifications to the physician and family. During an interview on 03/18/26, at 10:39 P.M., LPN C said the following:-If he/she were notified by CNAs a new open area on the skin were present, he/she would go and assess and measure the wound. After assessing the wound, he/she would contact the resident's physician and family. The physician would give treatment orders. The nurses should document the wound findings and the new orders;-Skin assessments should be completed weekly and wounds should be assessed and measured every week;-He/she was not aware of anyone completing weekly wound rounds.During an interview on 03/18/26, at 12:08 P.M., the Director of Nursing (DON) said the following:-Skin assessments were expected to be completed on admission and weekly thereafter;-There used to be an Assistant Director of Nursing (ADON) who was responsible for doing wound and skin assessments, however that is now the charge nurses responsibility;-She was not sure how the nurses know when to complete skin assessments. She was told by the nurses that it just populates on the resident's assessments in the medical record, but she was unsure;-She did not know the current computer system and was getting training on it;-She believed the charge nurses completed skin assessments, but she has not completed audits on that yet, the ADON use to;-After the ADON left, the weekly wound monitoring and measuring became her responsibility and she did not get them done until the end of the week as she was not aware of all the steps that went into that;-Skin and wound assessments should be completed and documented on weekly;-If a new open area were brought to the charge nurse's attention, she expected them to assess, measure, document, notify the physician and family, obtain treatment orders, and document any prevention interventions.During an interview on 03/18/26, at 1:35 P.M., the MDS Coordinator said the following:-Wound treatment and management should be care planned;-Aside from her, nurses and management have the ability to update the care plan.During an interview on 03/18/26, at 1:48 P.M., the Administrator said the following:-She expected nurses to assess newly reported open areas on the skin. The nurse should measure the wound and reach out to the physician to obtain treatment orders. This should be done immediately, not days after finding the new area;-She expected skin and wound assessments to be completed and documented weekly;-Prevention measures should be documented and care planned.#2803841

Based on observation, interview, and record review the facility failed to ensure residents received and the facility provided food to accommodate resident allergies when the facility failed to ensure residents were not served foods they were allergic to, failed to care plan resident allergies, and failed to enter resident allergies into the physician orders for one resident (Resident #1) out of 6 sampled residents. The facility census was 53.Review of the facility policy titled Food Allergies and Intolerances, reviewed on 10/01/25, showed the following information:-Residents are assessed for history of food allergies upon admission as part of the comprehensive assessment;-All resident reported allergies are documented in the medical record;-Severe food allergies are noted on the resident's profile and communicated in writing directly to the dietitian and the director of food and nutrition services;-Meals for residents with severe food allergies are prepared so that cross-contamination with allergens does not occur;-Residents with allergies are offered appropriate substitutions for foods that they cannot eat;-Nursing staff and food service employees are trained in the signs and symptoms of allergic reactions to foods and basic first aid measures in the event of a food allergy emergency.Review of the facility policy titled Interdepartmental Notification of Diet reviewed on 11/01/25, showed the following information:-When a new resident admitted , or a diet changed, the nurse supervisor ensured the food and nutrition services department received a written notice of the diet order;-The food and nutrition services department were notified verbally if the diet change or report occurred one hour or less before a scheduled meal, or if circumstances indicated that only the written procedures would not be adequate to ensure service at the next meal;-Each nursing station shall maintain a supply of diet order/change in diet forms. 1. Review of Resident #1's face sheet (brief look at resident information) showed the following information:-admission date of 03/03/26;-Allergies included beef, beef derived product, grapes, peanuts, wheat, and mountain dew;-Diagnoses include Alzheimer's disease, high blood pressure, and cerebral infarction (a type of ischemic stroke caused by a blockage in an artery supplying blood to the brain, resulting in tissue death(necrosis).Review of the resident's comprehensive Minimum Data Set (MDS-a federally mandated assessment tool filled out by facility staff), dated 03/03/26, showed the following information:-Cognitively impaired;-Required supervision from staff for eating.Review of the resident's care plan, dated 03/03/26, showed staff did not care plan related to the resident's diet or known food allergies.Review of the resident's Nursing Admission/readmission Data Collection assessment, dated 03/03/26, showed the following information:-Allergies included beef derived product, peanuts, and wheat;-No special nutritional needs indicated.Review of the resident's Physician Order Sheet (POS), dated 03/01/26 through 03/31/26, showed an order, dated 03/03/26, for regular diet, regular texture, and regular consistency. The order did not address resident allergies.Review of the resident's progress note dated 03/11/26, at 3:00 P.M., showed the following information:-The resident was sent to the emergency department via ambulance;-The resident was found vomiting and having diarrhea. The resident's vital signs were assessed and the resident became unresponsive on the toilet;-The Director of Nursing (DON) was called into the room and assisted with the transfer of the resident to bed. The resident's feet were elevated in bed;-The resident continued vomiting and was given a basin. Staff attempted to do sublingual (under the tongue) medication and the resident could not absorb the medication;-The resident's family was called and notified of change of condition and of the sending to the emergency department;-The physician was notified.Review of the resident's progress note dated 03/11/26, at 9:24 P.M., showed hospital indicated to nursing staff that the resident was being admitted .Review of the resident's transfer to hospital form. dated 03/11/26, showed the following information:-The resident was not alert at the time of transfer;-Allergies included beef, beef derived product, grapes, peanuts, wheat, and mountain dew.Review of the resident's care plan, created on 03/11/26, showed the following information:-The resident had an allergy to beef, beef derived product, grape, peanut, wheat, and mountain dew;-Document allergies in the chart;-Ensure the resident, family, and staff to communicate information regarding history of allergy or possible allergic reactions.Review of the resident's History and Physical from the hospital stay and resident's facility physician, dated 03/12/26, showed the following information:-The resident admitted to the hospital for an allergy to beef with delayed reaction;-The resident had a beef taco at his/her facility and had an episode of emesis (vomiting) and syncope (collapse);-The resident was sent to the hospital for further eval. There was a concern for aspiration and the resident received Benadryl (over the counter anti-histamine used for allergies), Solu Medrol (a potent, fast acting injectable corticosteroid used to treat severe allergic reactions), and Pepcid (an antagonist that treats heartburn by reducing stomach acid production).Review of the resident's progress note dated 03/13/26, at 11:20 A.M., showed the resident returned to the facility form the hospital with new orders that included an antibiotic.During an interview on 03/17/26, at 1:29 P.M., the Kitchen Manager said the following:-He was aware that the resident had food allergies;-He was in the process of completing all of the resident's dietary card which would show if any resident had an allergy;-He served lunch on 03/11/26, and though he was aware the resident had allergies, the diet order did not indicate that. An order change came through showing the resident allergies after the resident had been served the beef product;-He believed two menu cards were accidently made for the resident, one showing the residents allergies and one that did not show the residents allergies. When making the resident's tray that day, he was given the wrong dietary card;-The incident was investigated and reported to the Administrator and Dietitian;-The expectation was that when a new resident admitted to the facility, the nurse admitting the resident should fill out a diet slip and give it to him and he would fill out the menu name card himself. During an interview on 03/17/26, at 2:06 P.M., Certified Nursing Assistant (CNA) A said the following:-If a resident had food allergies it should be shown on their dietary card;-The typical serving process was he/she would obtain all of the resident's dietary cards and sort them by hall and/or if they eat in the dining room. After he/she sorted the cards, he/she would hand the cards to the Kitchen Manager/server to begin dishing the plates;-Allergies should be shown on the resident's care plan, but aides do not have access to view the care plans;-The resident was sent to the hospital because he/she was served beef;-He/she later saw two dietary cards for the resident. One of the cards had the right room number but did not list allergies, and the other card had the wrong room number but listed the allergies;-The DON filled out the resident's diet on admission, that he/she personally delivered to the Kitchen Manager;-It was later found out that the resident was served beef tacos for lunch which had caused an allergic reaction.During an interview on 03/18/26, at 10:07 A.M., Certified Medication Technician (CMT) B said the following:-The residents face sheet showed any allergies a resident had;-Allergies should be care planned, though CMT's cannot view the care plans;-Dietary cards show allergies;-He/she was working the day of the incident and observed the resident eating a beef taco. At the time, he/she was not aware that the resident had any allergies. He/she was in the dining room passing medications and even asked the resident if he/she enjoyed his/her lunch. He/she indicated that he/she didn't have complaints, it was his/her body that disagreed with beef;-Shortly after, the resident went back to his/her room and when nursing assistants assisted him/her to the bathroom, one of them came out of the room and was saying that the resident was having excessive amounts of diarrhea and vomiting;-The nurse on duty went to the resident's room and begin assessing the resident, his/her oxygen was lower than normal and he/she was awake but not responding to stimuli;-One of the nurses discovered that he/she had an allergic reaction;-Allergies should be documented immediately upon admission and diet orders and allergies should be communicated with dietary.During an interview on 03/18/26, at 10:39 P.M., Licensed Practical Nurse (LPN) C said the following:-Staff was aware of a resident's allergies by the admission orders that the nurse puts into place. Additionally, staff should be able to see resident allergies to food on the resident's dietary card;-There used to be slips that the admitting nurse would fill out and give to the Kitchen Manager, but now the expectation is just to communicate with the Kitchen Manager and he will fill out the dietary card himself;-He/she was aware the DON made the resident's menu name card and gave it to the Kitchen Manager, but somehow the resident ended up with an additional dietary card that did not list his/her allergies;-Allergies should be care planned;-If a resident were served food they were allergic to, there is potential to aspirate with excessive vomiting, additionally a resident could present with respiratory distress.During an interview on 03/18/26, at 12:08 P.M., the DON said the following:-Staff were aware of resident's allergies by looking at the resident's dietary cards. Additionally, the face sheet would show any allergies, as well as the care plan;-When a new resident admitted to the facility, the nurse was expected to enter the allergies into the residents POS and print that out and give it to the Kitchen Manager;-She was aware of the incident with the resident. A nurse came and got her and told her that the resident was having excessive vomiting and diarrhea. No one realized at the time that the resident had been served beef. Eventually she checked the resident's allergies and asked the kitchen staff what the resident had to eat for lunch. This showed he/she had consumed beef;-She went through the dietary cards and noticed that the resident had two cards. One card was accurate with the resident's allergies and the other card did not list the resident's allergies; -She had entered the allergies into the allergies tab in the resident's electronic medical record, she did not add the allergies to his/her diet order but wrote them down and verbally told the Kitchen Manager the resident's allergies on admission.During an interview on 03/18/26 at 1:35 P.M., the MDS Coordinator said the following:-She was responsible for the care plans, though nursing staff is able to also enter information;-Care plans should include a resident's diet and any food allergies.During an interview on 03/19/26, at 1:14 P.M., the dietitian said the following:-She was aware of the incident with the resident;-Nursing staff should notify dietary of a resident's diet and any allergies upon admission and the Kitchen Manager should document that on the dietary cards.During an interview on 03/18/26, at 1:48 P.M., the Administrator said the following:-She expected staff to know resident allergies by observing the resident's admission documentation, communicating with the resident and family, and the resident's history and physical;-Allergies were expected to be care planned and a diet order should show any allergies;-The diet order should be completed on admission and a copy should be given to the Kitchen Manager. The Kitchen Manager should document the resident's diet and any food allergies on the resident's dietary card immediately;-There was a possibility for aspiration with the resident vomiting to the extent noted;-She completed an investigation regarding the incident with the resident and found that there were two dietary cards made for the resident. One of the cards was accurate and the other card did not list the resident's allergies, evidently that is the card that was used on the day of the incident.Complaint #2803841

Based on interview and record review, the facility failed to protect residents from misappropriation of property when staff could not account for two residents' (Resident #1 and #2) cards of controlled medications (narcotics) that had been in the possession of the facility. The facility census was 60.The Administrator and former Director of Nursing (DON) were notified on 11/23/25 of the missing medications. The facility completed an audit of resident medications, completed in-servicing of licensed staff who were involved in medication pass and medication storage, and notified families and physicians of the missing medications. The noncompliance was corrected 11/26/25. Review of the facility's policy Identifying Exploitation, Theft and Misappropriation of Resident Property, dated October 2025 showed the following:-As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property;-Exploitation, theft and misappropriation of resident property are strictly prohibited;-Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent;-Examples of misappropriation of resident property include drug diversion (taking the resident's medication;-Staff and providers are expected to report suspected exploitation, theft or misappropriation of resident property. Review of the facility's policy Controlled Substances, reviewed October 2025, showed the following:-The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances;-Only authorized nursing staff and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises;-The Director of Nursing Services (DNS) will identify staff members who are authorized to handle controlled substances;-Controlled substances must be counted upon delivery. The nurse receiving the medication, will count the controlled substances to ensure the right quantities are there. Authorized personnel will sign for delivery. Any discrepancies will be reported to pharmacy and Director of Nursing (DON);-Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services;-Reconciliation of controlled medications shall include number of cards and pills in each card;-The DNS shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify and responsibility parties, and shall give the Administrator a written report of such findings. Review of the facility's policy titled Discarding and Destroying Medications, reviewed October 2025, showed the following:-Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances;-All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of;-Schedule II, III and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. 1. Review of the facility's investigation summary, dated 12/01/25, showed the following:-On Sunday, 11/23/25 at 12:42 A.M., the DON was notified by an agency Licensed Practical Nurse (LPN) that there was potentially missing/misplaced narcotics;-The DON alerted the Administrator on Sunday morning around 7:00 A.M. indicating that the facility had a potential medication error issue. The Administrator told the DON to meet her at the facility to investigate the allegation;-The DON and Administrator met at the facility around 9:00 A.M. This is when the DON mentioned to Administrator that the facility may be missing some controlled medications;-The DON told the Administrator that the regional team was notified and that she self-reported the potential allegation to the state;-The Administrator instructed the DON to investigate the allegation gather facts by auditing each chart, order, and medication cart, interview and gather staff statements and to report back to her if indeed medications were missing and where and who may be responsible for it;-On Tuesday morning, the regional team came in for a weekly visit and was made aware that there was an ongoing investigation into potentially missing narcotics;-The regional team brought in an external registered nurse (RN) to assist with the investigation as well;-Investigational findings showed all residents received their pain medications as ordered, every day, and every shift. The medication oxycodone/acetaminophen (APAP) (opioid pain medication) tablet 10-325 (30 tablet) cards that belonged to Resident #1 and Resident #2 that were reported missing, were not located. The narcotic count sheet matching the missing cards was provided by the DON and marked and co-signed as destroyed. 2. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 12/18/23;-Diagnoses include morbid obesity, high blood pressure, and schizophrenia (a mental health condition that affects how people think, feel and behave). Review of the resident's care plan, dated 12/18/23, showed the following:-The resident had arthritis pain;-Staff should monitor, record, and report to the nurse of the resident complaints of pain or requests for pain treatment.Review of the resident's current Physician Order Sheet (POS) showed an order, dated 05/27/25, for oxycodone-acetaminophen (opioid pain medication) oral tablet 10-325 milligrams (mg); staff to give one tablet by mouth (PO) every four hours for pain related to secondary osteoarthritis (arthritis of the joints). Review of the resident's November 2025 Medication Administration Record (MAR) showed an order, dated 05/27/25, for oxycodone-acetaminophen oral tablet 10-325 milligrams (mg); staff to give one tablet by mouth (PO) every four hours for pain related to secondary osteoarthritis.Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff), dated 11/22/25, showed the following:-Moderately impaired skills;-He/she received scheduled pain medications;-He/she had pain almost constantly;-He/she received opioid medication. Review of the resident's individual controlled substances record showed the following:-An order for the resident's oxycodone-acetaminophen tablet 10-325 mg for one tablet PO every four hours;-Date received of 11/19/25 by a staff member with a count of 30;-Disposition of unused drug showed as destroyed, dated 11/23/25 for a quantity of 30;-Authorized signature of the former Director of Nursing (DON) and Certified Medication Technician (CMT) A. Review of the facility's destruction log binder did not show a destruction sheet for the resident's oxycodone. During an interview on 12/09/25, at 11:30 A.M. the Administrator said the resident's missing card of oxycodone was not found. During an interview on 12/09/25, at 1:06 P.M., CMT A said the following:-The facility did not have the 30-count card of the oxycodone for the resident;-He/she did not destroy the oxycodone for the resident;-The former DON asked him/her to sign the bottom of the narcotic sheet for the resident's oxycodone and said it was taken care of. The narcotic sheets did not have destroy, a date, or other information written on the it. During a phone interview on 12/09/25, at 1:40 P.M., the former DON said the following:-On 11/23/25, after midnight, the night agency nurse texted her that he/she noticed a bundle of narcotic cards bundled together with another resident's card in the middle of the oxycodone cards and a card of oxycodone was missing for the resident; -She came to the facility on [DATE] and informed the Administrator that staff could not find the narcotic cards for the resident;-She did not destroy the resident's oxycodone. The resident's oxycodone was missing;-She thought if she wrote missing or stolen on the paper, it would be wrong, and should not had written destroyed on the paper;-She had not been trained as a DON, and it was her mistake writing destroyed on the bottom of the narcotic sheets.During an interview on 12/10/25 at 2:33 P.M., Licensed Practical Nurse (LPN) E said around 4:30 A.M., on 11/24/25, he/she called the Administrator and said there were cards of missing narcotics. The Administrator said she would notify the former DON. 3. Review of Resident #2's face sheet showed the following:-admission date of 10/20/25;-Diagnoses included anxiety disorder, low back pain, major depressive disorder, and high blood pressure. Review of the resident's care plan, dated 10/26/25, showed the following:-The resident had pain;-Staff to monitor, record and report to the nurse of the resident's complaints of pain or requests for pain treatment. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitive skills intact;-The resident received scheduled pain medication;-The resident had pain frequency almost constantly;-The resident received an opioid medication. Review of the resident's current POS showed an order, dated 11/03/25, for Percocet oral tablet 10-325 (oxycodone with acetaminophen); for staff to give one tablet PO every four hours for pain. Review of the resident's November 2025 MAR showed an order, dated 11/03/25, for Percocet oral tablet 10-325; for staff to give one tablet PO every four hours for pain. Review of the resident's individual controlled substances record showed the following:-An order for oxycodone/APAP tablet 10-325 mg;-Date received 11/07/25, no staff signature for received by;-Amount received of 30;-Disposition of unused drug: destroyed-Date: 11/23/25;-Quantity 30;-Authorized signature of the former DON and CMT A. Review of the facility's destruction log binder did not show a destruction sheet for the resident's medication. During an interview on 12/09/25, at 11:30 A.M., the Administrator said the resident's missing card of oxycodone was not found. During an interview on 12/09/25, at 1:06 P.M., CMT A said the following:-The facility did not have the 30-count card of the oxycodone for the resident;-He/she did not destroy the oxycodone for the resident;-The former DON asked him/her to sign the bottom of the narcotic sheet for the resident's oxycodone and said it was taken care of. The narcotic sheets did not have destroy, a date, or other information written on the it. During a phone interview on 12/09/25, at 1:40 P.M. the former DON said the following:-On 11/23/25 after midnight, the night agency nurse texted her that he/she noticed a bundle of narcotic cards bundled together with another resident's card in the middle of the oxycodone cards and a card of oxycodone was missing for the resident; -She came to the facility on [DATE] and informed the administrator that staff could not find the narcotic card for the resident;-She did not destroy the resident's oxycodone. The resident's oxycodone was missing;-She thought if she wrote missing or stolen on the paper, it would be wrong, and she should not had written destroyed on the paper;-She had not been trained as a DON, and it was her mistake writing destroyed on the bottom of the narcotic sheets. During an interview on 12/10/25, at 2:33 P.M, LPN E said around 4:30 A.M., on 11/24/25, he/she called the administrator and said there were two cards of missing narcotics. The Administrator said she would notify the former DON. 4. During an interview on 12/09/25, at 10:20 A.M., RN B said the following:-Nurses administer the narcotic liquids and the CMTs administer the narcotic tablets;-Narcotic counts are counted before and after shift;-Staff should notify the DON if a medication count is not correct;-Two nurses destroy medications. During interviews on 12/09/25, at 10:29 A.M. and 11:15 A.M., CMT C said the following:-CMTs administer the narcotic tablets;-Staff count the narcotic medications each shift change;-Staff should notify the DON if a medication narcotic count is not correct;-Staff wrap the narcotic sheet with the medication card and now place it in the black box for the nurses to destroy. CMTs did not destroy medications;-He/she would not sign a medication document if he/she did not observe the medication destroyed. During an interview on 12/09/25, at 1:06 P.M., CMT A said the following:-Staff count narcotic cards and narcotics each shift change;-Staff should report to the DON if a narcotic count is not correct and not leave until investigated;-Two staff should destroy medications at the same time;-Staff destroy medications if a resident passed away or the medication was discontinued. Staff should subtract the card from the number of total cards and take to the charge nurse;-Staff should sign the bottom of the narcotic sheet after observation of a destroyed medication;-He/she considered a missing medication to be misappropriation of property.During an interview on 12/10/25, at 2:33 P.M., LPN E said the following-Nursing staff count should count narcotics each shift change;-Staff should count and check to make sure the narcotics match the card and sheet each shift;-On Saturday 11/23/25, night into Sunday morning 11/24/25, he/she was with an agency nurse who notified him/her at midnight that he/she went through the narcotic cards to verify he/she signed everything and saw two bundles of narcotics bundled together with a rubber band;-He/she witnessed each of the resident's one card of oxycodone missing;-Around 4:30 A.M., on 11/24/25, he/she called the Administrator and said there were two cards of missing narcotics. The aAdministrator said she would notify the former DON;-Staff should not write destroy on the bottom of a narcotic sheet if they are missing or stolen. During an interview on 12/09/25, at 10:57 A.M., RN D said the following:-Nurses administer the medications for residents on hospice and narcotic liquids;-CMTs administer the narcotic tablets;-Staff count the narcotics on shift change to ensure the cards and sheets match;-Staff should notify the DON if a narcotic count is incorrect;-He/she considers misappropriation of property if a medication count is incorrect. During an interview on 12/09/25, at 11:30 A.M., the interim DON said the following:-She would consider missing medications misappropriation of property;-Staff should do narcotic counts before and after each shift;-Staff should notify the DON if a medication count is not accurate;-Nursing staff should sign the document of the medication destroyed, staff should observe the destroyed medication and sign as witnesses;-Nursing staff should document on the resident's sheet in the destruction log binder when a medication is destroyed;-She expected staff to witness destruction of a medication before signing the paper;-Staff should not write destroy on a paper if a medication is not destroyed. During an interview on 12/09/25, at 1:26 P.M., the corporate Regional Director of Operations (DOP) said the following:-CMT A said he/she did not witness destruction of the resident's oxycodone;-CMT A said he/she thought he/she was signing the bottom of the narcotic sheets for a medication correction;-The former DON said she did not know how else to correct it. During an interview on 12/09/25, at 11:30 A.M., the Administrator said the following:-She considered medications not found as misappropriation;-She did not know the narcotic sheets had destroyed written on it;-The former DON called her that the two cards of oxycodone were missing;-The missing narcotics were never found;-She expects staff to witness destruction of a medication before signing the paper. Complaint 2679395

Based on interviews and record review, the facility failed to ensure all allegations of misappropriation of property were reported within 24 hours to the State Survey Agency (Department of Health and Senior Services-DHSS) when staff failed to report timely when they discovered two missing cards of narcotics for two residents (Resident #1 and Resident #2). The facility census was 60. The Administrator and former Director of Nursing (DON) were notified on 11/23/25 of the missing medications. It was discovered on 11/26/25 are report to DHSS had not been made. The facility completed in-servicing of staff and audits of records. The noncompliance was corrected on 11/26/25. Review of the facility's policy Identifying Exploitation, Theft and Misappropriation of Resident Property, dated October 2025 showed the following:-As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property;-Exploitation, theft, and misappropriation of resident property are strictly prohibited;-Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent;-Examples of misappropriation of resident property include drug diversion (taking the resident's medication);-Staff and providers are expected to report suspected exploitation, theft or misappropriation of resident property. 1. Review of the facility's investigation summary, dated 12/01/25 showed the following:-On Sunday, 11/23/25 at 12:42 A.M., the Director of Nursing (DON) was notified by an agency Licensed Practical Nurse (LPN) that there was potentially missing/misplaced narcotics;-The DON alerted the Administrator on Sunday morning around 7:00 A.M. indicating that the facility had a potential medication error issue;-The Administrator told the DON to meet her at the facility to investigate the allegation;-The DON and Administrator met at the facility around 9:00 A.M. This is when the DON mentioned to the Administrator that the facility may be missing some controlled medications;-The DON told the Administrator that the regional team was notified and that she self-reported the potential allegation to the state;-On Tuesday (11/25/25) morning, the regional team came in for a weekly visit and was made aware that there was an ongoing investigation into potentially missing narcotics. When the regional team discussed the allegation and investigation with the Administrator and DON, the Administrator realized that the DON did not report the allegation to the regional team;-The DON then admitted that she did not self-report this allegation to the state;-Investigational findings showed all residents received their pain medications as ordered, every day, and every shift. The medication oxycodone/APAP (opioid pain killer) tablet 10-325 (30 tablets) that belonged to Resident #1 and Resident #2 that were reported missing, were not located. Review of DHSS records showed the allegation of misappropriation was reported on 11/26/25. During an interview on 12/09/25, at 10:20 A.M., Registered Nurse (RN) B said the following:-Staff should notify the DON if a medication count is not correct;-Staff should report to DHSS in four hours if narcotics are missing or unaccounted for. During an interview on 12/09/25, at 10:29 A.M. and 11:15 A.M., Certified Medication Tech (CMT) C said staff should notify the DON if a medication narcotic count is not correct. Staff should report to DHSS of a misappropriation of property.During an interview on 12/09/25, at 1:06 P.M., CMT A said the following:-Staff should report to the DON if a narcotic count was not correct and not leave until investigated;-He/she considers a missing medication to be misappropriation of property;-Staff should report to the DON of any missing medications and to DHSS within two hours. During an interview on 12/09/25, at 10:57 A.M., RN D said the following:-Staff should notify the DON if a narcotic count is incorrect;-Staff should report to DHSS within two hours of misappropriation of property;-He/she considers misappropriation of property if a medication count is incorrect. During an interview on 12/09/25, at 1:40 P.M., the former DON said the following:-She and the Administrator decided it was not a two-hour reportable report due to it was not abuse;-She considered missing medications a misappropriation of property. During an interview on 12/9/25 at 11:30 A.M. the interim DON said the following:-She would consider missing medications misappropriation of property;-Staff should report to DHSS within two hours of misappropriation of property.During an interview on 12/09/25, at 1:26 P.M., the corporate Regional Director of Operations said the allegation of the missing narcotics should had been reported within 24 hours. During an interview on 12/09/25, at 11:30 A.M., the Administrator said the following:-She considered medications not found as misappropriation;-Staff should report to DHSS within 24 hours of a misappropriation of property;-She believed the former DON sent the allegation of misappropriation of property to DHSS on Sunday 11/23/25. Complaint 2679395

Based on observation and interview, the facility failed to protect each resident's right of self-determination when the facility staff failed to provide routine showers per reasonable preferences of each resident and as care planned for three sampled residents (Residents #1, #2, and #3). The facility census was 54. Review of the facility policy, Your Rights and Protections as a Nursing Home Resident, undated, showed the following:-The resident has the right to be treated with dignity and respect, as well as make to make hi/s/her own schedule and participate in the activities he/she chooses;-The resident has the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment. The nursing home must address the issue promptly. Review of the facility policy, Resident Rights State and Federal, dated May 2017, showed the following:-The resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and the facility must protect and promote the rights of each resident;-The resident had a right to voice grievances without discrimination or reprisal including those with respect to treatment which had been furnished as well as that which had not been furnished and prompt efforts by the facility to resolve grievances the resident may have;-The resident had the right to choose activities, schedules, and health care consistent with his/her interests, assessments, and plan of care. 1.Review of Resident #1's face sheet (admission information at a glance) showed the following:-admission date of 11/16/23;-Diagnoses included syringomyelia and syringobulbia (involve the formation of fluid-filled cavities within the spinal cord that include symptoms of pain, weakness, numbness, and changes in sensation that can cause swallowing difficulties, speech problems, and balance issues) and spinal stenosis (narrowing of the spinal cord that causes pain, tingling or weakness in hand, arm, foot or leg and can cause problems with the bowel or bladder). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/25/24, showed the following:-Cognition was intact and resident could make choices;-The resident's daily preferences included it was somewhat important for him/her to choose between a tub bath, shower, bed bath, or sponge bath. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact and resident was able to make choices;-Resident had limited range of motion with impairment on both sides of lower extremities;-Resident dependent on staff for showers shower and bathing self-including washing, rinsing, and drying self .-Occasionally incontinent of urine and bowel. Review of the resident's care plan, revised 11/28/23, showed the following:-Resident had an activities of daily living (ADL) self-care performance deficit;-For bathing, the resident required one staff participation with bathing two times a week. Review of the resident's June 2025 shower documentation sheets showed the following:-Resident received a shower on 06/05/25; -Resident received a shower on 06/11/25 (six days after the prior shower);-Resident received a shower on 06/17/25 (six days after the prior shower);-Resident refused a shower on 06/20/25. Review of the resident's progress note, dated 06/20/25, showed the resident refused his/her shower. Staff did not document a reason. Review of the resident's medical record showed staff did not document offers of a follow up with a shower at another date or time after 06/20/25. Review of the resident's July 2025 shower documentation sheets showed the following:-Resident received a shower on 07/01/25 (11 days after the prior offered shower);-Resident received a shower on 07/09/25 (eight days after the prior shower);-Resident received a shower on 07/16/25 (seven days after the prior shower). During interviews on 07/16/25, at 1:30 P.M., and on 07/18/25, at 11:25 A.M., the resident said the following: -Getting his/her showers was a problem;-He/she only gets one shower per week and sometimes it has been two weeks between showers;-Shower days were scheduled Tuesdays and Fridays, and he/she would get a shower in the morning usually, but sometimes in the afternoon, like 2:00 P.M. to 3:00 P.M. He/she had no preferences except twice a week. He/she didn't care what day it was, just have it twice a week. 2. Review of Resident #2's face sheet showed the following:-admission date of 11/23/24;-Diagnoses included type 2 diabetes mellitus (high blood glucose) with diabetic nephropathy(kidney damage and can't filter waste, fluids, and toxins from the kidneys), acute and chronic respiratory failure with hypoxia (low oxygen), congestive heart failure (CHF), atrial fibrillation (irregular heart rate), and high blood pressure. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognition was intact and the resident could make decisions;-The resident's daily preferences showed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact and the resident could make decisions;-Partial/moderate assistance needed to shower/bathe. Review of the resident's care plan, revised 05/20/25, showed the following:-ADL self-care performance deficit;-The resident required one staff participation with bathing twice a week. Resident sometimes refuses showers. Review of the resident's June 2025 shower documentation sheets showed the following:-Resident resident's shower on 06/05/25 was rescheduled due to family present. It was noted a shower would be provided on 06/06/25.-Resident received a shower on 06/11/25 (at least 11 days since the last shower);-Resident received a shower on 06/18/25 (seven days after the prior shower);-Resident received a shower on 06/20/25;-Resident received a shower on 06/26/25 (six days after the prior shower). Review of the resident's July 2025 shower documentation sheets showed the following:-Resident received a shower on 07/03/25 (seven days after the prior shower);-Resident received a shower on 07/09/25 (six days after the prior shower);-Resident received a shower on 07/15/25 (six days after the prior shower). During interviews on 07/16/25, at 1:35 P.M. and 11:28 A.M., the resident said the following: -He/she would like at least two showers a week;-Staff gave him/her a shower Monday and Thursday when he/she first came there. Then staff changed the shower to Tuesday and Friday;-It did not matter what day he/she took a shower except to take a shower twice a week and not take one back-to-back or the next day;-He/she wanted at least couple of days between showers;-They used to have a makeup day;-When they have a shower aide, they have a call in, and they take the shower aide to work on the floor and then no one gets a shower;-They don't always give a shower the next day because they have that day's list of showers to do. 3. Review of Resident #3's admission MDS, dated [DATE], showed the following:-Cognition was intact and the resident could make decisions;-The resident's daily preferences showed it was somewhat important to choose between a tub bath, shower, bed bath or a sponge bath; Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognition was intact and the resident could make decisions;-Substantial/maximal assistance of staff for shower/bathing. Review of the resident's care plan, revised 09/03/24, showed the following:-ADL Self Care Performance Deficit due to impaired balance and weakness;-The resident required one staff participation with bathing two times a week. Review of the resident's June 2025 shower documentation sheets showed the following:-Resident received a shower on 06/03/25;-Resident received a shower on 06/10/25 (seven days after the prior shower);-Resident received a shower on 06/17/25 (seven days after the prior shower);-Resident received a shower on 06/20/25;-Resident received a shower on 06/26/25 (six days after the prior shower). Review of the resident's July 2025 shower documentation sheets showed the following:-Resident received a shower on 07/01/25;-Resident received a shower on 07/13/24 (12 days after the prior shower);-Resident received a shower on 07/16/25. During an interview on 07/18/25, at 11:22 A.M., the resident said the following-There were times he/she would get one shower a week;-He/she had only had one shower this week;-This had happened two or three times this past month;-There was no one in the showers to give him/her one;-His/her preference would be what everyone else would have, at least two showers a week, but his/her preference would be to have one every other night;-Here, he/she gets early morning or afternoon showers, but at home he/she would have them in the evening before bed;-He/she was supposed to get two showers a week but hasn't;-His/her shower days used to be on Tuesdays and Fridays but now they had a substitute shower aide, and he/she would get a shower on Wednesday. During an interview on 07/18/25, at 12:00 P.M., Certified Nurse Aide (CAN) E said the resident gets upset because his/her hair gets oily, and he/she doesn't want to come out of his/her room some days because his/her hair is oily. 4. During an interview on 07/16/25, at 3:00 P.M., CNA C said he/she did medical records and was the restorative aide. He/she assisted with showering residents about three weeks ago in June for one week. He/she did at least 20 showers per day for one week. The shower issue has been going on since at least the middle of June. The residents were supposed to get at least two showers minimum a week. During an interview on 07/18/25, at 12:00 P.M., CNA E said he/she worked all the halls. He/she had to do 27 to 28 showers every other day but does get pulled to work as a nurse's aide and then showers do not get done. Evening staff do not do showers. Residents need showers right now because they get sweaty and need them. The Dietary Supervisor and Activity Director who are CNAs were constantly pulled to the floor to work. During an interview on 07/16/25, at 2:55 P.M., Licensed Practical Nurse (LPN) A said the shower aide quit about 2 to 3 weeks ago. CNAs and staff were helping with showers for residents. They document showers by filling out a shower sheet and place this in the medical record box and Medical Records/CNA C scans the shower sheets into the electronic medical record under documents tab. The residents average one shower a week. They all complain about this. During an interview on 07/16/25, at 3:12 P.M., LPN D said they do showers and fill out shower sheets on residents. The charge nurse signs off on the shower sheets and this was to go to medical records to scan or file them. Once the resident received a shower, he/she would check off the shower sheet schedule. The residents were to receive at least one shower a week and they try to do at least two showers. They do try to give residents a shower if they get sweaty or go out to an appointment. During interview on 07/18/25, at 12:53 P.M., LPN F was in the memory care unit and work every Friday, Saturday, and Sunday from 6:00 A.M. to 6:00 P.M. There was no shower aide for a while. They were having staff on floor do five showers each. Two weekends ago, he/she had two nurse aides but did have one aide giving showers. Bed baths on given on some residents maybe or at least once a week. They try to give two showers but mostly it was one shower for a good month. When there was a shower aide, they give two showers a week to each resident. He/she doesn't feel that two showers a week was enough since some residents need more than two showers. They should have option to how many showers and when they will receive them. During interview on 07/18/25, at 11:44 A.M., Registered Nurse (RN) B he/she goes through the shower list for Monday, Tues, Thursday, and Friday. He/she picks and assigns residents for these aides to give a shower to. The aides cannot handle more than five showers since they assist with other personal cares, do vital signs, pass ice water, and answer call lights. The residents do get one shower a week and were supposed to have two showers. Several residents have expressed wanting to have more than one shower a week. During interviews on 07/16/25, at 3:20 P.M., and on 07/18/25, at 1:40 P.M., the Director of Nursing (DON) said they had been without a shower aide for a month. They have the nurse aides split up the showers and give five showers or so each to do. They do have staff come in on their days off to do showers. They have other staff to do as needed showers. Upon admission, they try to give a shower within 24 hours if they want one and do a full body assessment on them. If admitted on Tuesday, then Tuesday and Friday would be their shower schedule. If admitted on Monday, it would be Monday and Thursday. They try to do showers twice weekly. They always make sure the residents were clean and odor free and try to do twice weekly showers. The resident had a right to have a shower when they wanted one. They do try to accommodate this. Some of the residents complained and said they haven't had a shower in over a week.

Based on observation, interview, and record review, the facility failed to maintain a complete infection prevention and control program when the facility failed to ensure staff posted appropriate signage and failed to ensure staff wore person protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines for residents subject to enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO-microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for one resident (Resident #3), of three sampled residents, who had a indwelling medical device. Staff also failed to perform hand hygiene per standard of practice when staff did not perform appropriate hand hygiene during perineal care for three residents (Residents #4, #1, and #2) in a sample of four residents reviewed in a facility with a census of 50. 1. Review of the CDC's Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms, dated 07/12/22, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care; -EPB use of PPE refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -Examples of high-contact resident care activities requiring gown and glove use for EBP includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central line, urinary catheter (flexible tubing that is used to drain urine from the bladder), feeding tube, and tracheostomy/ventilator, and wound care on any skin opening requiring a dressing; -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE. For EBP signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility's policy, Enhanced Barrier Precautions, revised 12/12/23, showed the following: -EBP refers to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices); -All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions; -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of gown and gloves; -Make gowns and gloves available. Face protection may also be needed if performing activity with risk of splash or spray; -Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room; -High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, wound care (any skin opening requiring a dressing). Review of Resident #3's face sheet (admission information) showed the following: -admitted [DATE]; -Diagnoses included transient cerebral ischemic attack (TIAs- mini strokes), dementia (progressive impairment in memory), edema (excess fluid in the tissues), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), Type 2 diabetes mellitus (high blood sugar), neuromuscular bladder dysfunction (lack of bladder control due to brain, spinal cord, or nerve problems), and urine retention (difficulty in urinating and emptying the bladder). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/17/24, showed the following: -Severely impaired cognition; -Dependent with helper does all of the effort and resident does none of the effort to roll left and right; -Has the ability to transfer to and from a bed to a chair/wheelchair; -Had an indwelling catheter (flexible tubing that is used to drain urine from the bladder); -Had a urinary tract infection in the last 30 days. Review of the resident's physician orders, dated 07/12/24, showed an order for EBP. Review of the resident's care plan, dated 7/12/24, showed the following: -The resident had a catheter for neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve condition); -Catheter care every shift and as needed (PRN) with EBP. Observation on 10/22/24, at 8:55 A.M., showed the following: -Certified Nurse Aide (CNA) A and CNA B entered the resident's room. There was no EBP signage at the entrance of the resident's room or on the door. The resident was lying on a mechanical lift vest in the bed. A Foley urinary catheter bag with urine hung on the side of the bed. -Without washing and/or sanitizing hands, both CNAs put on gloves and rolled the resident to his/her side to remove the mechanical lift vest. -CNA B picked up the catheter bag with urine, laid it on top of the bed as they turned the resident side to side to pull the mechanical lift vest from underneath the resident. -Both CNA A and CNA B removed gloves and washed hands at resident's sink before leaving the room. -No PPE, such as gowns, were present in the room; Observation on 10/22/24, at 11:10 A.M., in the resident's room showed underneath the sink there was a clear container with personal protection gowns for staff to use. During an interview on 10/22/24, at 11:40 A.M., CNA A said they did have training on EBP at the beginning of the year. If a resident had a wound and catheter, they were to put on a gown and gloves. If the resident did not have a wound, they didn't have to put on a gown. If gowns were in the room, he/she would put a gown on. The resident had just transferred from another room to this room and he/she did not see any gowns to use. During an interview on 10/22/24, at 2:00 P.M., Licensed Practical Nurse (LPN) B said he/she had worked at the facility for a couple of months and was not aware of EBP. During an interview on 10/22/24, at 2:40 P.M., the Director of Nursing (DON) said for the EBP she expected staff to put on a gown and gloves to provide cares to any residents like the resident who had a urinary catheter who was on these precautions. The gowns should be in the resident's closet and staff were to get a gown out of the closet. During interview on 10/22/24 at 3:00 P.M., the Administrator said for the EBP staff were supposed to wear gowns, gloves, and a face shield if any body fluids would splash them like for a urinary catheter. They had a policy for EBP and they had several in-services with staff. Some of the PPE, such as gowns, were in the closet or in a container under the resident's sink for staff to use. 2. Review of the facility's policy Standard Precautions Hand Hygiene, dated 2019, showed the following: -Appropriate hand hygiene is essential in preventing transmission of infectious agents; -Purpose was to cleanse hands to prevent the spread of potentially deadly infections, to provide a clean and healthy environment for residents, staff, and visitors, and to reduce the risk to the healthcare provider of colonization or infections acquired from a resident; -Hand hygiene continued to be the primary means of preventing the transmission of infection; -Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin or potentially contaminated intact skin (e.g. of a patient incontinent of stool or urine) could occur; -Remove gloves after contact with a patient, bodily fluids/excretions, and the surrounding environment (including medical devices) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient; -Change gloves during patient care if the hands will move from a contaminated body site (e.g. perineal area) to a clean body site (e.g. face, clothing, etc.). -Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood body fluids, secretions, or excretions is anticipated; -Remove gown and perform hand hygiene before leaving the patient's environment. 3. Review of Resident #4's face sheet showed the following: -admitted [DATE]; -Diagnoses included degeneration of nervous system due to alcohol, anemia (lack of red blood cells that leads to reduced oxygen flow to the body's organs), and high blood pressure. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Toileting hygiene - dependent on helper who does all of the effort; -Always incontinent of bowel and bladder. Review of the resident's care plan, dated 10/17/24, showed the following: -Incontinent of bowels. Staff to check every two hours for incontinence and as needed; -Bladder incontinence. Staff to check the resident every two hours and as required for incontinence; -Staff to wash, rinse, and dry perineum (space between the anus and the genitals); -Used disposable briefs. Observation on 10/22/24, at 9:00 A.M., showed the following: -CNA A and CNA B took a mechanical lift into the resident's room. The CNAs put on gloves without performing hand hygiene and transferred the resident in the mechanical lift from the wheelchair and then to the bed. -CNA B unfastened the resident's incontinence brief, used perineal wash with wipes to the front perineal area, then rolled the resident over to his/her side. The resident had a small bowel movement. The CNA cleansed the area with the perineal wash and wipes, picked up the tube of barrier cream, without washing hands and changing gloves, applied the cream to the buttocks. -Without removing gloves and washing hands, CNA B put a new incontinence brief on the resident. -CNA B removed gloves, did not perform hand hygiene, and put on another pair of gloves to pull up the resident's pants. -CNA A removed his/her gloves, did not perform hand hygiene, and moved the mechanical lift to the side of the bed. -The CNAs transferred the resident back to the wheelchair. -CNA A moved the lift to the hall and then came back to the room and washed his/her hands. -CNA B, removed his/her gloves, did not perform hand hygiene, picked up the trash bag with the soiled linens, walked down the hall to the soiled utility room, and then walked halfway back down the hall. The CNA then performed hand hygiene with hand sanitizer. 4. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), high blood pressure, metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognition intact; -Toileting hygiene - dependent on helper who does all of the effort; -Always incontinent of bowel and bladder. Review of the resident's care plan, dated 09/03/24, showed the following: -Self care performance deficit related to weakness and memory loss; -Required one staff for personal hygiene; -Staff to check for incontinence every two hours and as needed. Observation on 10/22/24, at 10:22 A.M., showed the following: -CNA A and CNA B entered the resident's room, did not wash and/or sanitize their hands, and put on gloves. -CNA A removed the resident's brief soiled with urine and bowel movement, wiped the front perineal area, turned the resident to his/her side, and cleansed the rectum and buttocks soiled with bowel movement. The CNA then changed his/her gloves without washing or sanitizing hands and applied barrier cream to the resident's buttocks. The CNA then removed his/her gloves, washed hands, and left the room. -CNA B pulled up the resident's sheets and cover and placed a pillow beneath the resident's right hip. CNA B then went over to the Resident #1's roommate, without washing hands and changing gloves, and picked up the wet wipes to perform perineal care on Resident #2. 5. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included congestive heart failure (CHF = chronic condition in which the heart, doesn't pump blood as well as it should), high blood pressure, and osteoarthritis (degeneration of joint cartilage and underlying bone which causes pain and stiffness especially in hip, knee, and thumb joints). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition was intact; -Toileting hygiene - dependent on helper who does all of the effort; -Always incontinent of bowel and bladder. Review of the resident' care plan, dated 8/14/24, showed the following: -Bladder incontinence related to impaired mobility; -Staff to change every two hours and as needed. Staff to wash, rinse, and dry perineum. -The resident used disposable briefs. Observation on 10/22/24, at 10:30 A.M., showed the following: -CNA B put on gloves without washing and/or sanitizing hands, picked up the package of cleansing wipes, and completed front perineal cleansing on the resident. The resident turned to his/her side and showed he/she had a bowel movement. -CNA B cleansed the resident's buttocks and rectum with perineal cleanser and wipes. -CNA B removed his/her gloves, did not wash or sanitize hands, put on another pair of gloves, and went to the resident's closet and got a pair of pants for the resident to wear. -CNA B then removed the mechanical lift vest wearing the same pair of gloves. 6. During an interview on 10/22/24, at 10:38 A.M., CNA B said they were to wash hands normally after they change the resident. They don't have to wash hands after doing perineal care, like if the resident had a bowel movement, they can take the soiled briefs in the trash bag to the soiled utility room and then remove gloves and wash hands. He/she used to carry hand sanitizer a long time ago, but it fell out of his/her pocket so he/she stopped carrying it. During an interview on 10/22/24, at 11:40 A.M., CNA A said he/she does not remove his/her gloves until done with the resident's care. He/she will wash hands before and after performing perineal care, but does use hand sanitizer in between. He/she does not carry hand sanitizer. Hand sanitizer is in the resident's room, on the halls, and on the medication carts. If a resident had a bowel movement and he/she did perineal care, he/she should remove gloves and wash hands, but usually just put on new gloves and don't wash his/her hands. During an interview on 10/22/24, at 2:26 P.M., LPN D said staff were to go into a resident's room, wash hands and put on gloves to do perineal care, dressings, and applying creams. They were to remove gloves, wash hands, and apply gloves after doing perineal care and before touching other items in the room. They were to always wash or sanitize hands after removing gloves and before applying gloves. During an interview on 10/22/24, at 2:40 P.M., the DON said she would expect staff to enter a resident's room, wash their hands, and put on gloves. Staff were to remove gloves and wash or sanitize hands when going from touching or performing cares and touching resident's bodily fluids and excretions to other items in the room and moving to a clean body site, clothing, or other items in the room. Staff were to remove gloves, and wash hands before leaving the resident's room and removing the trash to the soiled utility room. During interview on 10/22/24, at 3:00 P.M., the Administrator said she would expect staff to wash and or sanitize hands, and put on gloves when they enter a resident's room. They were to wash hands, change gloves when visibly soiled, prior to and after giving care. They were not to wear gloves outside the resident's room or walk down the hall with the same pair of gloves after performing cares on a resident. MO00242521

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #48), who is non-verbal and dependent on staff for all personal needs and mobility, was free from mental abuse by staff when one staff member, Certified Nurse Aide (CNA) S, purposely made comments to the resident to upset him/her. The resident was visually upset when discussing the CNA and the comments made to him/her, including becoming red faced, teary eyed, reaching out his/her arm and grunting. A sample of 26 residents was reviewed in a facility with a census of 60. On 2/8/24, SLCR completed a complaint investigation at the facility regarding an allegation of the resident not being treated with dignity and was unable to verify deficient practice occurred. A reinvestigation began during the recertification survey. As a result of the findings of the investigation, the Administrator was notified on 04/10/24, at 6:26 P.M., of an Immediate Jeopardy (IJ). The IJ was removed on 04/11/2024, as confirmed by surveyor onsite verification. Review of the facility's Abuse Prevention Policy, dated 2021, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain or mental anguish. It includes verbal abuse, and mental abuse. Willful, as used in this definition of abuse, means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within the hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are limited to threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. 1. Review of Resident #48's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included stroke, aphasia (a language disorder that affects how one speaks and understands language), reduced mobility, and weakness. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff), dated 02/01/24, showed the following: -Unclear speech-slurred or mumbled words; -Sometimes makes self understood-responds adequately to simple, direct communication only; -Sometimes able to understand others - responds adequately to simple, direct communication only; -Severely impaired cognitive skills; -Felt or appeared down, depressed or hopeless nearly every day; -Upper extremity (shoulder, elbow, wrist, hand) functional limitation in range of motion, impaired on one side; -Used a wheelchair for mobility; -Dependent on staff for personal, oral and toileting hygiene, lower extremity dressing, bathing, and all modes of mobility. Review of the resident's current care plan, revised on 02/02/24, showed the following information: -The resident had a communication problem; -Staff to monitor for and record confounding problems decline in cognitive status, mood, and decline in activities of daily living (ADLs); -Staff to monitor and document frustration level. Staff should wait 30 seconds before providing resident with word; -Use communication techniques which enhance interaction; allow adequate time to respond, repeat as necessary, do not rush, request feedback and clarification from the resident to ensure understanding, face when speaking and make eye contact, reduce environmental noise, and ask yes/no questions if appropriate. Use simple, brief, consistent words/cues, use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs and pictures; -Validate the resident's message by repeating aloud; -The resident has impaired cognitive function and dementia or impaired thought processes; -Communicate with the resident, family, caregivers regarding resident's capabilities and needs; -Use preferred name and identify yourself with each interaction. The resident understands consistent, simple directive sentences. Provide the resident with necessary cues-stop and return if the resident becomes agitated. Review of CNA Q's handwritten statement, dated 01/07/24 and provided to the State Agency on 04/10/24 by CNA Q, showed the following: -On more than one occasion he/she heard and witnessed comments being made to the resident, saying I hope you dream of [descriptor] people, because they (CNA S and CNA V) heard the resident was a racist. They did not want to help the resident at any time. During interviews conducted on 04/09/24, at 12:08 P.M., and on 04/10/24, at 10:02 A.M., CNA Q said the following: -He/she worked the night shift in December 2023 with CNA S; -CNA S made statements in the past about how he/she did not want to assist the resident and how he/she could not stand the resident because he/she heard stories the resident was racist; -The resident was nonverbal, but could make noises and sounds, shake his/her head yes or no, and scream; -The resident's roommate did not get along with CNA S so when CNA Q worked, he/she often assisted the resident's roommate; -On 12/30/23, CNA Q worked the night shift with CNA S and CNA V. That night, when CNA Q assisted the resident's roommate. He/she heard CNA S tell the resident, he/she hoped he/she (the resident) dreamed of [descriptor] people. CNA Q heard CNA S say this to the resident two times on 12/30/23 and one time on 12/31/23. CNA Q did not tell the night nurse because she did not trust him/her. He/she did not tell the day shift nurses because at the time, he/she did not know them; -On 01/07/24, CNA Q worked the day shift and assisted the resident up the hall towards the nurses' station. When the resident saw CNA S, he/she planted his/her feet onto the ground and grunted, screamed, and pointed at CNA S. After the incident, CNA Q tried to console the resident and wheeled him/her to his/her room. The resident was upset and had tears in his/her eyes; -Licensed Practical Nurse (LPN) D and Registered Nurse (RN) F saw the resident's response to CNA S and wondered what happened. CNA Q told LPN D and RN F about the incidents that occurred the weekend before; -RN F interviewed the resident about the incident and he/she became tearful; -The facility hired a new Administrator who started last Friday (04/05/24). CNA Q told the new Administrator about the incident regarding the resident because he/she did not want her blindsided. Review of a CNA CC's handwritten statement, dated 01/07/24 and provided to the State Agency on 04/10/24 by LPN D (the nurse who collected the statement and sent to the ADON), showed CNA CC documented there was a day when CNA S was giving him/her report and he/she made a comment about how the resident was completely racist and he/she sometimes told him/her Good night, hope you dream of [descriptor] people. During an interview on 04/10/24, at 3:25 P.M., CNA CC said the following: -The resident was not a fan of CNA S. Since the resident was mostly nonverbal, CNA CC said he/she knew the resident was not a fan by how he/she acted around CNA S. CNA CC could tell that something was not right. Anytime the resident saw CNA S, he/she grimaced or just acted off in his/her actions. It was hard to explain if you did not know the resident's usual actions; -CNA S told him/her (CNA CC) and others that he/she did not like the resident. CNA CC did not really know the reason CNA S did not like the resident, but thought it may stem from rumors that the resident was racist and that he/she may hold that against him/her (the resident); -Because the resident did not care for CNA S, he/she and CNA Q tried to limit the time that CNA S would need to care for the resident. They did that by making sure the resident was either in bed or ready for bed, before CNA S came on shift; -Sometime at the end of December 2023/beginning of January 2024, while completing shift rounds with CNA S, CNA S told him/her that when he/she (CNA S) tucked the resident into bed at night, he/she told the resident that he/she hoped he/she (the resident) had bad dreams of [descriptor] people. CNA S basically bragged and boasted about it to CNA CC; -One morning, around the end of December 2023/beginning of January 2024 (01/07/24), he/she and CNA Q assisted the resident out of his/her room. When CNA S walked past the resident, the resident immediately placed his/her feet on the ground and pointed at CNA S, grunting and yelling. The nurses heard and wanted to know what had happened. Certified Medication Technician (CMT) DD was in another room near the nurses' station, and heard the commotion and wanted to know the reason the resident was mad. CNA S said he/she guessed the resident was mad at him/her, then clocked out; -CNA Q and CNA CC told the nurses what they knew about CNA S's interactions with the resident; -He/she thought LPN D called one of their bosses to report it. During interviews conducted on 04/09/24, at 1:17 P.M., and on 04/10/24, at 11:55 A.M., RN F said the following: -On 01/07/24, the resident either sat in his/her wheelchair, in the hallway, or in his/her room and became upset when he/she saw CNA S. RN F talked to the resident about CNA S. When RN F mentioned CNA S's name, the resident turned red, breathed heavily and his/her eyes became teary. The resident was mostly nonverbal. He/she communicated by grunts and gestures and sometimes he/she could acknowledge yes or no; -CNA Q told RN F that when he/she (CNA Q) started working at the facility, he/she worked the night shift with CNA S. CNA S told CNA Q that when he/she (CNA S) assisted the resident to bed at night, he/she told the resident I hope you dream about [descriptor] people. then laughed about it. The RN considered CNA S's statements to the resident verbal and emotional abuse, at the very least; -The nurse did not document the incident that occurred on 01/07/24 in the resident's progress notes, but he/she should have. He/she did not know why he/she did not document, he/she usually did; -The nurse said he/she felt bad that nothing was done. During interviews conducted on 04/09/24, at 12:30 P.M., and on 04/10/24, at 12:17 P.M., LPN D said the following: -He/she did not remember the date, but one morning, during shift report, he/she heard a noise and looked up to find the source. The resident sat in his/her wheelchair, near the nurses' station, with his/her feet planted firmly on the floor seemingly to prevent CNA Q from pushing him/her further down the hall. The resident pointed his/her finger at CNA S's face, yelling angrily. CNA Q saw the resident's reaction to CNA S and asked the resident if he/she was okay and if he/she was hurt. The resident grunted and indicated he/she was not hurt; -CMT DD asked CNA S why the resident responded that way and CNA S said I guess he/she's mad at me; -LPN D said he/she could tell the resident was frustrated and scared all at the same time; -CNA Q and CNA W then told LPN D and RN F that CNA S and CNA V whispered to the resident at night, I hope you dream about [descriptor] people. That was significant because there were rumors the resident was racist. LPN D considered what the CNAs said to be verbal abuse. The nurse did not document this incident because RN F took responsibility for the hall; -Anytime CNA S was on shift, the resident's demeanor changed. It was difficult to describe how it changed but LPN D noticed a change. During an interview on 04/11/24, at 1:15 P.M., CMT DD said the following: -A few months ago in the early morning, the resident sat in his/her wheelchair in the hall. The resident saw CNA S and pointed, shook and grunted at CNA S. The resident tried to back up in his/her wheelchair like he/she was trying to get away from CNA S. The look on the resident's face was fear. The resident never acted like that before; -CNA CC told CMT DD said that CNA S told him/her that he/she tells the resident he/she hoped the resident dreamed of [descriptor] people tonight. CMT DD thought this was a significant statement because he/she did not think the resident cared for [descriptor] people. During an interview on 04/10/24, at 9:18 A.M., CNA R said the following: -The resident did not talk and communicated with actions such as putting his/her feet down if he/she did not want to go somewhere; -He/she wrote a statement about the incident that occurred on 01/07/24 between the resident and CNA S, and slid it under the former DON's office door. Review of the resident's January 2024, February 2024, and March 2024 progress notes showed staff did not document the incident that occurred on 01/07/24 or of the information obtained regarding CNA S's statements. During an interview on 04/10/24, at 12:39 P.M., the ADON said the following: -If staff told her or she heard an allegation of abuse, she obtained statements from staff and completed an assessment of the resident. She then reported the allegation to the DON, who contacted the Administrator. The Administrator then contacted the Regional Clinical Director (RCD). The DON or Administrator investigated the allegation. The DON or Administrator consulted with the RCD, and if she agreed, the Administrator would call in a self-report to the state agency; -The nurses should document the allegation in a progress note. The nurses also complete an incident report and the DON or Administrator would review it; -She did not know the entire story regarding the resident, but thought it occurred a couple months ago. A staff member told her that another staff member told the resident he/she hoped the resident dreamed of [descriptor] people. The ADON did not know who told her or who said this to the resident. The ADON was on call around that time, but nobody sent her any pictures of statements related to CNA S or the resident; -The former DON and former Administrator already knew about the incident when she reported it to them. -She considered the statement about dreaming about [descriptor] people as verbal abuse. During an interview on 4/10/24, at 4:02 P.M., the former DON said the following: -On 01/07/24, the ADON sent the former DON, via phone, employee statements that alleged when CNA S and CNA V assisted the resident to bed, they would say they hoped he/she dreamed about [descriptor] people. The former DON did not know why the staff would say this to the resident. She did not know anything about the resident's past; -The former Administrator told the former DON, that even though the CNA's comments were not considered abusive statements, corporate staff told her (the former Administrator) they needed to investigate or talk to other residents to ensure there was not something else going on with CNA S. The former DON talked with other residents regarding staff treatment of them with no identified problems. During an interview conducted on 04/11/24, at 12:17 P.M., the former Administrator said the following: -On 01/07/24, CNA S assisted the resident and the resident became upset with him/her in the hallway on his/her way to breakfast. That behavior was not abnormal for the resident because sometimes he/she did not want to go to breakfast; -On Monday morning (01/08/24) the former DON brought her paper statements from CNA Q and CMT DD. which accused CNA S of telling the resident that he/she hoped he/she (the resident) dreamed of [descriptor] people; -The former Administrator thought the statement about dreaming of [descriptor] people was borderline abuse. Observation and interview on 4/10/24, at 5:05 P.M., showed the following: -The resident laid in bed with his/her eyes closed. RN F entered the resident's room and lightly touched his/her shoulder. The resident opened his/her eyes. The RN asked the resident if he/she remembered talking about CNA S? The resident grunted in reply. The RN asked the resident if CNA S was ever mean to him/her and he/she grunted. RN F asked the resident if she ever whispered in his/her ear I hope you dream of [descriptor] people. The resident grimaced then loudly grunted. He/she tried to sit up and raised his/her left arm. The resident was clearly upset and tried to communicate by angrily grunting/yelling, and firmly shutting his/her eyes. RN F placed his/her right hand in the resident's hand and the resident calmed. After speaking with the resident briefly ensuring he/she was calm, the RN left the room. -RN F said the resident was having an off day. He/she usually communicated more verbally with the RN. He/she said the resident expressed anger by attempting to sit up and by raising his/her arm in the air. In a statement written by RN F, dated 5/10/24, she wrote that during the interview with the surveyor she asked the resident if he/she remembered when she asked him questions awhile back about CNA S and he/she grunted his reply as in yes. When asked if CNA S was ever mean to him/her, the resident grunted yes. When asked if when she put him/her to bed at night if she ever whispered in his/her ear I hope you dream of [descriptor] people, the resident got red faced, teary eyed, and started reaching his/her left arm out and grunting, trying to speak with his/her stroke, he/she is unable to verbally communicate. RN F wrote she is able to tell he/she is upset and really wants to speak when he/she grunts more than usual, reaching his/her left arm out trying to talk and when his/her face turns red and becomes teary eyed. RN F wrote the resident usually only turns red faced and grimaces when in pain. During an interview conducted on 04/11/24, at 1:35 P.M., the resident's physician said the following: -She did not know about CNA S telling the resident who he/she hoped he/she dreamed of [descriptor] people. She would consider the comment an allegation of psychological abuse; -The resident's actions on 01/07/24 were not typical for him/her and neither was his/her response to RN F's questions about CNA S. She had only seen the resident become slightly frustrated with her if she asked him/her too many questions. During an interview on 04/10/24, at 3:04 P.M., the RCD said the following: -If administration wrote up a staff member, they placed the write up in the employee's personnel file; -She expected staff to suspend an employee if named in an allegation of abuse and for staff to complete an abuse investigation; -The RCD did not know anything about comments made to the resident by CNA S. During an interview on 04/10/24, at 3:04 P.M., the Administrator said the following: -CNA Q told her about something that happened in the past, no date, regarding a night shift aide, CNA S who said something about [descriptor] people to the resident; -CNA Q said he/she told the former Administrator of the allegation; -At first, she did not know the context or reason for the comment; -She should investigate the possible allegation to find out the context; -The Administrator did not find an investigation into the comment I hope you dream about [descriptor] people conducted by the previous Administration. NOTE: At the time of the annual survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G 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(s). 34871 49585

Based on interview and record review, the facility failed to ensure residents remained free of significant medication errors when staff administered a fentanyl patch (a narcotic patch placed on the skin to treat moderate to severe pain) and hydrocodone-APAP (narcotic that is used for relief of severe pain) to one resident (Resident #162) without orders, resulting in significant side effects and hospitalization . A sample of 26 residents was reviewed in a facility with a census of 60. The Administrator was notified on [DATE], at 2:28 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The resident went to the hospital and did not readmit to the facility. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's policy titled Medication Administration, dated [DATE], showed the following: -Administer medications to residents in a safe and timely fashion; -Observe for drug reactions; -Chart on medication record dose, time given, and any pertinent observations. Review of the facility's policy titled Medication Monitoring Medication Errors and Drug Reactions, dated [DATE], showed the following: -Medication errors and drug reactions must be reported to the physician immediately; -A Medication Error Report must be completed by the person discovering the error; -An Incident Report must be completed and a 72-hour observation initiated; -Follow physicians order to monitor resident and report any significant abnormalities or adverse reactions to the physician. Review of the Food and Drug Administration's (FDA) Medication Guide for Norco (hydrocodone-APAP), dated 2019, showed the following: -Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids; -While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of Norco, the risk is greatest during the initiation of therapy or following a dosage increase. Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy with and following dosage increases of Norco; -Life-threatening respiratory depression is more likely to occur in elderly patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients; -Elderly patients may have increased sensitivity to Norco. Use caution when selecting a dosage for an elderly patient, usually starting at the low end of the dosing range; -Respiratory depression is the chief risk for elderly patients treated with opioids, and has occurred after large initial doses were administered to patients who were not opioid-tolerant or when opioids were co-administered with other agents that depress respiration; -Acute overdosage with Norco can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and hypoxia (low blood oxygen levels). Review of the FDA's Medication Guide for Fentanyl patch, dated ,d+[DATE], showed the following: -Indicated for the management of pain in opioid-tolerant patients; -Is not indicated as an as-needed analgesic; -Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals; -Accidental exposure to even one dose can result in a fatal overdose of fentanyl; -Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids; -Life-threatening respiratory depression is more likely to occur in elderly patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients; -Adverse reactions have been identified to include convulsions, depressed level of consciousness, loss of consciousness, respiratory distress, high blood pressure. 1. Review of the Resident #162's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included mini stroke, unspecified dementia, and high blood pressure. Review of the resident's hospital to facility discharge information dated [DATE], at 7:13 A.M., showed the following: -An order for olanzapine (an antipsychotic medication used to treat mental disorders and agitation) 10 milligrams (mg), take one tablet twice daily. The next dose due on [DATE] at 9:00 P.M. (The resident did not have orders for medications for pain.) Review of a physician progress note, dated [DATE], showed the following: -The note had the name of three residents listed on it including orders for each residents; -Resident #162's name was at the top of the list. Under his/her name, the physician wrote orders for buspirone HCL (an anti-anxiety medication) and Xanax (medication used to treat anxiety disorders). The physician did not write orders for pain medication for Resident #162; -Under the orders for Resident #162, a different resident's name was listed with orders that included a fentanyl 50 microgram (mcgs) patch; -A third's resident's name was listed with several orders listed under his/her name. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed the following: -An order, dated [DATE], for buspirone HCL oral tablet 10 mg, give one tablet twice a day for anxiety; -An order, dated [DATE] for olanzapine 10 mg, give one tablet twice a day for unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; -An order, dated [DATE], for Xanax 0.5 mg tablet, give one tablet every four hours for anxiety for 14 days. (The physician did not order for medications for pain.) Review of the facility's Emergency Medication Kit (E-kit - medication the facility keeps on hand to use in emergency or while waiting on pharmacy delivery) Administration Record, dated [DATE], showed the following: -On [DATE], at 10:29 A.M., RN X signed out one patch of fentanyl 50 mcg/hour (hr) for the resident; -On [DATE], at 10:33 A.M., RN X signed out one tablet for hydrocodone-APAP ,d+[DATE] mg tablet for the resident. Review of the resident's [DATE] Medication Administration Record (MAR) showed RN X did not document administration of fentanyl or hydrocodone-APAP to the resident in the resident's medical record. Review of the resident's progress note, dated [DATE],showed RN X documented the following: -At 6:40 P.M., a certified nurse aide (CNA) reported the resident having a possible seizure; -Three RNs ran back to the area and found the resident actively having a seizure; -The resident's blood pressure measured ,d+[DATE] millimeters of mercury (mmHG) (a reading greater than ,d+[DATE] mmHg is considered high); -A nurse called 911 for transport; -The resident continued to have seizures; -Resident's pupils at 2 and non reactive (an indication of possible trauma or neurological issues);. -At 6:45 P.M., staff administered two mg lorazepam (a narcotic sedative) intramuscularly (into the muscle) in the right thigh; -At 7:08 P.M., staff rechecked the resident's blood pressure and noted it at ,d+[DATE] mmHG. Staff noted resident sweating; -At 7:20 P.M., staff measured resident's blood pressure at ,d+[DATE] mmHG with blood oxygen level (SPO2) of 74% (normal is greater than 90%); -Staff moved the resident to the floor and gave oxygen flow of 15 liters, SP02 increased to 90%; -Resident mumbled throughout most of this time, but unable to understand. Review of the resident's medication error note dated [DATE], at 10:36 A.M., showed the following: -The former Director of Nursing (DON) documented on [DATE] Norco (hydrocodone-APAP) ,d+[DATE] and fentanyl 50 mcg patch were administered to the resident; -The physician in the facility wrote new orders for the resident. Orders for multiple residents were written on the same paper with Resident #162's name at the top of the page; -A new nurse saw the physician orders for the first time. The nurse and former Administrator misread the orders for the resident, as it was thought to be the orders on the page were only for Resident #162; -Staff sent the resident to the hospital. -The physician orders were placed in the correct charts for the residents. Review of RN X's written statement, dated [DATE], showed the following: -The resident was new admit at 9:05 A.M. ([DATE]) and the physician was present in the facility to complete the initial assessment and medication orders for the resident. The physician hand wrote medication orders under the resident's name. The physician wrote orders for multiple residents on the same page; -The RN did not see where the resident's orders ended and a different resident's orders began. The RN read the order for 50 mcg fentanyl patch and Norco as being for Resident #162. Around 10:00 A.M., the RN administered the patch and the Norco with the resident's other medications due to the resident fighting staff, tried to escape the unit, and was one-on-one status; -At 6:40 P.M., a CNA came out of the resident's room and said he/she thought the resident was having a seizure. The nurse assessed the resident and measured the resident's blood pressure as ,d+[DATE]ish mmHg; -The RN administered Ativan 2 mg IM and sent the resident to the hospital; -The resident's oxygen level decreased to 76%. Staff placed the resident on the floor in case further intervention was needed. Oxygen at 15 liters given and SPO2 was at 90% plus before EMS transport. The resident mumbled and said his/her spouse's name. Review of the former Administrator's statement, dated [DATE], showed on [DATE] she personally looked at the paper that the physician had written for new orders. She did not notice the fentanyl order was listed for another resident when the RN was going to pull medications for Resident #162. During an interview on [DATE], at 12:31 P.M., the former Administrator said the following: -She was at the nurses' station and an aide sat with the resident; -The physician had just left the facility; -The physician wrote his/her orders on a piece of paper; -RN X said he/she needed to get the resident some medications; -RN X grabbed the sheet with all the orders; -She remembered seeing the resident's name and a fentanyl order; -On [DATE], she met with RN X and the former DON. The Administrator told the DON the resident had an order for a fentanyl patch and the DON said that was not the resident's order; -They looked at the paper in the shred box and the order was not for Resident #162; -The physician listed all the residents on one page and there was no line drawn on the paper between the residents; -The former Administrator said the physician writes on a piece of copy paper with names on the left and physician orders on the right, and not divided out; -If staff did not see the resident name on the left, staff could miss the order for who the order was for. It was an opportunity for a medication error; -RN X said he/she picked up the paper of the physician and gave the resident some medications; -RN X did not look at the MAR and/or POS for the resident's orders; -RN X just looked at the paper on the desk; -RN X should have entered the orders. Review of recent physician's orders, dated [DATE], [DATE], [DATE], and [DATE], showed the physician continued to write multiple residents' orders on the same piece of paper. During an interview on [DATE], at 2:53 P.M., LPN EE said the following: -On [DATE], he/she sat at the nurses' station receiving end of shift report from one of the day shift nurses, when a CNA came out of the unit and said he/she thought the resident was having a seizure. He/she, RN FF, and another night shift nurse went to the unit to assess the resident's condition. RN X, the unit's day shift nurse, had stepped away, but he/she returned shortly. The resident's color was normal, but he/she was diaphoretic (sweating profusely) and had tremors like a seizure. His/her blood pressure was very high. The nurses worried the resident would have a stroke with his/her blood pressure so high. The nurses transferred the resident to the floor in case he/she needed cardiopulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped). The other night shift nurse called EMS and the nurses continued to monitor the resident's condition. -RN X left the unit and returned with lorazepam. RN X said since the resident's blood pressure was so high that maybe something to sedate him/her would help; -LPN EE did not think the resident had a seizure, but did not know exactly what was going on with the resident; -The resident calmed after RN X administered the lorazepam. EMS arrived and transported the resident to the hospital; -Sometime after midnight, the other night shift nurse received a call from the hospital. The hospital nurse said they found a fentanyl patch on the resident, but they did not find an order for it; -The next day ([DATE]), LPN EE told RN FF the hospital called and said they found a fentanyl patch on the resident. RN FF told LPN EE that RN X applied the fentanyl patch and administered a pain pill to the resident, at the same time, and did not have orders; -The physician usually wrote orders on a progress note and had a running list with different residents' names with their orders on the same page; -The nurse did not understand how the error occurred, if the nurse did not enter the order into the computer, he/she should not have administered the medication; -Usually the day shift nurse who admitted the resident entered the orders into the computer. The nurse did not know if anyone checked those orders after the admitting nurse entered them. During an interview on [DATE], 3:53 P.M., RN FF said the following: -When a resident admitted to the facility, sometimes the MDS Coordinator entered the orders, other times the nurse who admitted the resident entered the orders; -The physician writes orders on a progress note. He/she writes several residents' orders on the same note; -The physician used to write residents' orders in each of their paper charts. When the system changed to electronic orders, he/she would electronically sign the order, but would not enter them; -On [DATE], during shift change, an aide came out to the desk (from the unit) and said it looked like the resident was having a seizure or he/she was unresponsive; -RN FF told the CNA to grab the code cart and to transfer the resident onto the floor. One of the night shift nurses called EMS; -On [DATE], during report, LPN EE said that the hospital called and told him/her that the resident received too much medication. A nurse applied a fentanyl patch on the resident. During an interview on [DATE], at 12:28 P.M., CNA Y said the following: -The resident was in a recliner in the dining room sleeping (on [DATE]); -Staff woke up the resident to do vital signs and he/she started shaking; -Nurses assessed the resident and sent him/her to the hospital; -He/she asked the resident when he/she woke up if he/she was ok and the resident said no. During an interview on [DATE], at 1:20 P.M., Certified Medication Technician (CMT) B said the following: -The resident paced back and forth and was almost manic; -Staff tried to walk the resident who appeared like he/she could not rest; -The resident appeared sleepy, but would not stay in bed. He/she mentioned to RN X that maybe the resident needed a Xanax. RN X said do not worry he/she had orders for a fentanyl patch for the resident. During an interview on [DATE], at 10:11 A.M., RN E said the following: -The resident did not have orders for a fentanyl patch or Norco; -Staff should not have administered a fentanyl patch or Norco to the resident due to the resident did not have orders for these medications; -The hospital sends orders with new admissions. Nurses review the physician orders and enter them in the computer and notify the physician with a new admission; -The Medical Director/physician writes down the resident's name and order on a sheet of paper; -The physician gives the paper to the nurse when he/she completed his/her visits; -The nurses enter the orders in the computer; -The physician writes all the orders for different residents on the same paper; -The physician writes the resident name and order underneath the name and starts new order. The physician does not write a line, just puts the resident name and orders on the same page; -The physician continued with the same process of writing different residents with different orders on the same paper; -The nurse gives the paper to medical records staff after entering the physician orders in the computer. During an interview on [DATE], at 10:38 A.M., Medical Record Staff said the following: -The nurses give him/her the papers with the physician's orders once per week; -All the residents are on the same page. During an interview on [DATE], at 10:28 A.M., the Assistant Director of Nursing (ADON) said the following: -Staff should not have administered the fentanyl patch or Norco if the resident did not have a physician order; -A fentanyl patch or Norco could cause adverse reaction such as serious allergy or death, rash, or hallucinations; -The MDS/Care Plan Coordinator gets the orders and enters them in the computer; -The SSD receives a fax from the hospital of the referral and physician orders; -The physician assesses the residents and writes the orders on a piece of paper with lines on it; -The physician writes the resident name and order on the paper and signs after each order; -All the residents are on the same paper; -He/she goes down the list and checks the orders off after he/she enters them in the computer for each resident; -He/she gives the paper to medical record staff after he/she enters the orders; -The physician continues to write the residents and orders all on the same page. During interviews on [DATE], at 10:50 A.M., and on [DATE], at 10:33 A.M., MDS/Care Plan Coordinator said the following: -The resident did not have physician orders for a fentanyl patch or Norco on his/her POS; -Staff should not have given the resident a fentanyl patch and Norco; -Adverse reactions caused from fentanyl patch and Norco could include drowsiness and lethargic; -He/she did not see documentation on the resident's MAR of administration of the fentanyl patch and Norco or any of the orders in between the resident's name and the bottom of the page; -Nurses enter the physician orders in the computer; -He/she she enters the diagnosis codes and orders in the computer for a new admission; -He/she gives the physician orders to the nurse who sends to the to pharmacy; -The Medical Director/Physician writes every resident and their orders on a progress note; -The nurse enters the physician orders into the computer when the physician has completed his/her weekly visit; -He/she did not know of staff looking at the paper and entering an order for another resident; -Different residents on the same page with orders could be a cause for a medication error; -Adverse reactions caused from fentanyl patch and Norco could include drowsiness and lethargic. During an interview on [DATE], at 12:15 P.M., the Social Service Director (SSD) said she just got off the phone with the resident's family member who said the facility medication error is believed to have caused the resident's seizure. During interviews on [DATE], at 11:55 A.M., and on [DATE], at 2:15 P.M., the Corporate Regional Director said the following: -Nurses should have entered and documented the fentanyl patch and Norco on the MAR; -Nurses should enter the physician orders in the computer at the end of the physician visit; -The nurse saw the resident's name on the paper and did not see the other residents' name on the paper who had the fentanyl patch and Norco order; -Possible effects from the fentanyl patch and Norco is just what happened, seizures. -She expected nurses to review a resident's MAR before administration of a medication instead of off a piece of paper. During an interview on [DATE], at approximately 12:20 P.M., the Administrator said the following: -Nurses should enter the physician orders in the computer before they go to the E-kit; -Staff should document on the MAR of what they took from the E-kit; -She expected education with staff and the physician for the medication error. During an interview on [DATE], at 1:19 P.M., the Medical Director said the following: -She writes orders on a sheet of paper on her rounds; -She gives the paper to the nurses who enter them into the computer; -All the residents names are on the same paper with all the physician orders on front and back for several residents; -This was a medication error. The nurse thought he/she had the right resident and he/she did not see the other residents' names listed; -She expects staff to look at the physician orders, enter the orders in the computer, and administer the medications; -She expects the nursing staff to document administration of medications; -She was notified of the staff giving the resident a fentanyl patch and Norco. NOTE: At the time of the survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00231592

Based on record review and interview, the facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full time basis. The facility census was 60. Review of the facility's document titled, Director of Nursing Services job description showed the following: -The primary purpose of the job position is to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times; -The Director of Nursing Services (DON) is delegated the administrative authority, responsibility, and accountability necessary for carrying out the assigned duties. In the absence of the Medical Director, the DON is charged with carrying out the resident care policies established by the facility; -Duties and responsibilities include administrative functions, committee functions, personnel functions, nursing care functions, staff development, safety and sanitation, equipment and supply functions, care plan and assessment functions, budget and planning functions, and resident rights. Review of the facility's assessment, dated 2020, showed the following: -Nursing management includes a DON for 40 plus hours a week and on call; -The DON is responsible for continuity of care, bathing scheduling, wound and skin risk management, resident weights, and various human resources duties regarding job performance of all nursing staff. 1. During an interview on on 04/07/24, at 4:02 P.M., the Administrator said the facility did not have a DON or interim DON. During an interview on 04/09/24, at 1:17 P.M., Registered Nurse (RN) F said the following: -The DON left in February 2024; -The facility had not had a DON since February 2024. During an interview on 04/11/24, at 10:11 A.M., RN E said the following: -Staff report to the Assistant Director of Nursing (ADON) or Regional Corporate Clinical; -The facility did not have an acting DON. During an interview on 04/11/24, at 10:50 A.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff)/Care Plan Coordinator said the following: -The facility has not had a DON since the middle of February 2024; -The facility did not have applicants for a DON. During an interview on 04/07/24, at 4:02 P.M., the Regional Director of Clinical said the following: -The facility had not had a DON or interim DON since the middle of February 2024; -The former DON quit without notice on 02/17/24; -She had set up three interviews and no one showed up; -The DON position provides oversight on the nursing staff, assists the Administrator with guidance and questions and oversees medications.

Based on observation, interview, and record review, the facility failed to store food in a manner to protect it from potential contamination when staff failed to date and label stored food in refrigerators; failed to keep non-food contact surfaces clean and free of debris; and failed to sanitize dishes in the three vat sink at the minimum manufacturer's requirements. The facility's census was 60. 1. Review of the facility's policy titled, Food Storage - Refrigeration, undated, showed all leftovers shall be labeled and dated with expiration dates. Observation on 04/07/24, at 2:42 P.M., of the reach in refrigerator showed the following: -One individual serving dish of peach pie not covered, labeled, or dated; -One cheese sandwich on a plate, covered and not dated. Observation on 04/07/24, at 2:51 P.M., of the walk-in refrigerator showed the following: -An open container on the top shelf containing four apples and three lemons that were wilted, brown, and not dated; -A serving tray on the top shelf containing 12 individual condiment containers, containing a clear liquid, not labeled; -A serving tray on the top shelf containing 21 individual condiment containers, containing a yellow substance, not labeled. Observation on 04/08/24, at 9:53 A.M., of the reach in refrigerator showed the following: -Two individual serving dishes of cottage cheese not dated. Observation on 04/08/24, at 9:59 A.M., of the walk-in refrigerator showed the following: -An open container on the top shelf containing four apples and three lemons that were wilted, brown, and not dated; -A serving tray on the top shelf containing 12 individual condiment containers, containing a clear liquid, not labeled; -A serving tray on the top shelf containing 21 individual condiment containers, containing a yellow substance, not labeled. Observation on 04/09/24, at 10:01 A.M., of the reach in refrigerator showed the following: -Three plates of lettuce salad not dated; -Three plates of sandwiches not dated. Observation on 04/09/24, at 10:16 A.M., of the walk-in refrigerator showed the following: -An open container on the top shelf containing four apples and three lemons that were wilted, brown, and not dated; -A serving tray on the top shelf containing 12 individual condiment containers, containing a clear liquid, not labeled; -A serving tray on the top shelf containing 21 individual condiment containers, containing a yellow substance, not labeled. During an interview on 04/10/24, at 1:18 P.M., Dietary Aide (DA) J said kitchen staff are responsible for covering, labeling, and dating food prior to it being put in the refrigerator. During an interview on 04/10/24, at 1:36 P.M., DA K said cooks or cooks' helpers are responsible for dating and labeling food prior to being put in the refrigerator. During an interview on 04/10/24, at 2:02 P.M., Cook L said the following: -Cooks are responsible for dating and labeling leftover food prior to it being put in the refrigerator; -DAs are responsible for dating and labeling food items prepared by him/her prior to being put in the refrigerator. During an interview on 04/10/24, at 2:27 P.M., the Dietary Manager (DM) said the following: -The cooks and DAs are responsible for putting food in the refrigerator; -All food should be covered, labeled, and dated prior to being put in the refrigerator. During an interview on 04/12/24, at 7:47 A.M., the Administrator said staff should label and date food prior to it being put in the refrigerator. 2. Review showed the facility did not provide a policy regarding wall and floor maintenance. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following: -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Observations on 04/07/24, at 3:00 P.M., on 04/08/24, at 10:05 A.M., and on 04/09/24, at 10:21 A.M., showed the following: -A four foot line of peeling paint on the ceiling above the three vat sink and a food prep table. (The peeling paint could fall and contaminate food or food contact surfaces.); -The floor under the food preparation table to the left of the steam table had an area approximately 4 feet wide by 5 feet deep area that was a rough, porous surface that appeared to be concrete where food and dirt could become trapped. The surface was not tiled like the rest of the floor; -Seven tiles were missing in random spots throughout the kitchen where food and dirt could become trapped. During an interview on 04/10/24, at 1:18 P.M., DA J said the following: -The kitchen floor was not cleanable with a mop; -Food and debris could get in spots where tile were missing; -He/she did not think there was any peeling paint in the kitchen; -All staff were responsible for cleaning and maintaining the floor and walls in the kitchen. During an interview on 04/10/24, at 1:36 P.M., DA K said pieces of the floor could be fixed. He/she was not aware of any peeling paint in the kitchen. Maintenance staff were responsible for the upkeep of the walls and floors. During an interview on 04/10/24, at 2:02 P.M., Cook L said he/she would report any floor or peeling paint issues to the DM. During an interview on 04/10/24, at 2:27 P.M., the DM said the following: -The floor in the kitchen is not a cleanable surface; -The DM reports issues with the floor, walls, and ceiling to the maintenance supervisor. During an interview on 04/12/24, at 7:47 A.M., the Administrator said staff should report maintenance issues to the maintenance supervisor either by word of mouth or through the maintenance log kept at the nursing desk. The DM is responsible for the condition of the kitchen. 3. Review of the facility's policy titled, Sanitation - Ware washing, dated November 2007, showed the following: -Dinnerware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines; -All dinnerware, utensils, and preparation and service supplies shall be washed and sanitized in the pot sink; -The pot sink shall be a three sink unit with detergent in the first sink, clear rinse water in the second, and a sanitizer in the third and final sink. Review of the FDA 2022 Food Code showed utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning. Observation on 04/09/24, at 11:21 A.M., showed Cook L used a metal pot and two flat metal pans to prepare lunch. Cook L used the three vat sink and submerged the pot and pans in the wash sink and washed them, rinsed the pot and pans, and skipped the sanitizer sink. Cook L placed the pot and pans on a clean surface to dry. During an interview on 04/10/24, at 2:02 P.M., Cook L said the following: -The three vat sink was used to wash, rinse, and sanitize pots and pans; -Staff were not using the sanitize sink for large items because the sink does not have a plug; -A dish pan sits inside the third sink to sanitize cooking utensils; -The DM was responsible for making sure plugs are available for the sink. During an interview on 04/10/24, at 1:36 P.M., DA K said staff use the three vat sink to wash, rinse, and sanitize items used to prepare food. The DM was responsible for making sure plugs are available for the sink. During an interview on 04/10/24, at 2:27 P.M., the DM said the following: -Cooks use the three vat sink to wash, rinse, and sanitize items used during food preparation; -Cooks were expected to use all three steps when washing dishes; -All pots and pans had to be sanitized; -Staff are sanitizing all pots and pans when using the three vat sink. -The DM did not know that a plug was needed for the three vat sink. During an interview on 04/12/24, at 7:47 A.M., the Administrator said that staff should be using the three vat sink to wash, rinse, and sanitize pots and pans used to prepare food.

Based on interview and record review, the facility failed to review and update the comprehensive facility assessment annually, in accordance with all applicable Federal requirements. Failure to review and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 60. Review showed the facility did not provide a policy regarding the facility assessment. 1. Review of the facility's assessment, showed the following: -Staff completed the facility assessment in 2020; -Staff did not document review of the facility assessment since 2020. During an interview on 04/12/24, at 2:15 P.M., the Administrator said the following: -She began the position on 04/05/24; -She is responsible for reviewing and completing the facility assessment; -The facility staff should review the facility assessment yearly; -The facility assessment determines resident acuity needs; -The facility assessment determines staffing required for resident care; -Departments heads and the physician should be involved and discuss the facility assessment; -The facility staff should review the facility assessment annually due to changes with the population, staffing, and acuity needs; -She expected the facility assessment to have been reviewed since 2020. During an interview on 04/12/24, at 2:15 P.M., the Regional Corporate Clinical Staff said she expected the facility assessment to be reviewed yearly and since 2020.

Based on observation, interview, and record review, the facility failed to maintain an effective and complete infection control program when staff failed to follow the facility's policy to monitor and prevent the development Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella. It can become a health concern when it grows and spreads in human-made water systems) in the facility's water system. The facility also failed to update policies, educate staff, and implement policies related to Enhanced Barrier Precautions for six residents (Resident #110, #47, #160, #20, #161, and #24) out of a sample of 26 residents. The facility census was 60. 1. Review of the Centers for Disease Control (CDC) Toolkit for Legionella bacteria (officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assessing how much risk the hazardous conditions in those water systems pose; -Applying control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective. Review of the facility's policy titled, Water Safety Policy and Procedure, undated, showed the following: -All water outlets that are, or may remain unused, will be on a schedule of periodic flushing; -The water management team will meet quarterly forming a quarterly assessment. This assessment will be discussed at the monthly safety team meeting; -A water flow textual explanation, or flow diagram, will be maintained, reviewed, and updated when necessary on a quarterly basis; -All corrective actions will be logged in water safety team meeting notes. Review of such corrective action will be scheduled on a timeline established when corrective action is implemented. Observations on 04/10/24, starting at 9:30 A.M., showed the following: -Numerous empty resident rooms around the facility with no residents currently assigned to the rooms; -One full hall (500 hall) did not have residents assigned to the 12 rooms. Staff used some of the rooms as storage. During an interview on 04/10/24, at 4:45 P.M., the head of Environmental Services said the following: -Housekeeping staff weekly flush all showers in the facility; -Housekeeping staff will also try to flush toilets and sinks in empty rooms. There was no schedule for how often staff should flush anything; -There was no documentation of any flushing of the sinks, showers, or toilets; -Housekeeping does not flush or check utility rooms or places other than resident rooms, since utility rooms and others are always being used; -He/she did not know of any water diagram or other assessment for areas in the building that might be prone to water stagnation; -She was not part of a water management team that met monthly or quarterly. During an interview on 04/10/24, at 4:45 P.M., the Maintenance Director said the following: -He was not aware of any procedures or policies related to reducing Legionella growth and spread in the building; -He was not checking any part of the facility, in any manner, for risk and conditions related to Legionella prevention or growth; -He was not part of a water management team that met monthly or quarterly. During an interview on 04/10/24, at 4:45 P.M., the Administrator said she was new to the facility and was not familiar with any facility policy or practice for water management or Legionella prevention. 41787 2. Review of the facility's policy, titled Infection Prevention and Control Program, dated 2019, showed the following: -Purpose was to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections; -It is the policy that the facility's IPCP be based upon information from the facility assessment and follows national standards and guidelines; -The facility's policy did not address the requirement of enhanced barrier precautions (EBP - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targets gown and glove use during high contact resident care activities). Review of the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 07/12/22, showed the following: -EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices; -High-contact resident care activities requiring gown and glove use for EBP included providing hygiene, changing briefs or assisting with toileting, device care (central line (intravenous (IV) line that goes all the way up to a vein near the heart or just inside the heart), urinary catheter (a sterile tube inserted into the bladder to drain urine), and wound care; -PPE, including gowns and gloves, should be available immediately outside of the resident rooms. Review of the facility's policy titled Infection Control - Catheter Care, dated 10/19/18, showed the policy did not address the use of gowns when providing catheter care. Review of the facility's policy titled, Central Venous (intravenous (IV) line that goes all the way up to a vein near the heart or just inside the heart) and Midline (long, thin, flexible tube that is inserted into a large vein in the upper arm) Catheter Flushing, dated April 2016, showed the policy did not address the use of gowns when providing care of central venous and midline catheter flushing. Review of the facility's policy titled Pressure Ulcer/Pressure Injury Prevention, dated April 2018, showed the policy did not address precaution to be taken with wound care. 3. Review of facility provided list received on 04/12/24, at 12:54 P.M., showed the following: -Resident #110 had a peripherally inserted central catheter line (PICC - form of intravenous access that can be used for a prolonged period of time or for administration of substances) for antibiotics; -Resident #47 had a PICC line for antibiotics; -Resident #160 had an indwelling Foley catheter; -Resident #20 had an indwelling Foley catheter; -Resident #161 with pressure ulcers on coccyx; -Resident #25 with wounds on right arm. 4. Review of Resident #110's face sheet (admission data) showed the following: -admitted [DATE] with readmitted [DATE]; -Diagnoses included osteomyelitis (inflammation of the bone cause by an infection) and diabetes. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/09/24, showed the following: -Cognitive skills intact; -Received antibiotic. Review of the resident's current care plan, undated, showed the following: -The resident had intravenous (IV - fluids and medicine in the vein) access to the right side for seven days; -Monitor, document, and report to the Medical Director as needed for signs and symptoms of infiltration (fluid leaks out into the tissues under the skin where the tube has been put into the vein) at the site; -Check dressing at site daily; -Check IV site daily for redness, swelling, or drainage and report any findings to the nurse. (Staff did not care plan regarding EBP.) Review of the resident's current POS showed an order, dated 04/07/24, for ertapenem (medication used to treat infections) sodium solution reconstituted one gram (gm) IV. Review of the resident's April 2024 Treatment Administration Record (TAR) showed an order, dated 04/07/24, for ertapenem sodium solution reconstituted one gm use one gm IV every 24 hours for infection (urinary tract infection) for seven days. Staff documented administration of the medication as ordered. Observation on 04/08/24, at 9:24 A.M., showed the resident requested assistance from CNA Q to the bathroom. The resident stood up and transferred himself/herself to his/her wheelchair. CNA Q applied gloves and did not put on a gown. CNA Q assisted the resident up out of the wheelchair to the toilet. Resident sat on the toilet in his/her bathroom. CNA Q assisted the resident out of the bathroom. CNA removed his/her gloves and washed his/her hands after the resident was out of the bathroom. The facility did not have gowns inside the resident's bathroom and room. Observation on 04/08/24, at 1:12 P.M., showed the resident sat on his/her bed in his/her room. The resident had his/her call light on and told CNA O that he/she needed to use the bathroom. CNA O applied gloves and did not put on a gown. CNA O placed a gait belt around the resident. CNA O reached around the resident to place the gait belt on. CNA O wheeled the resident to his/her bathroom and assisted the resident up and onto the toilet. The resident sat on the toilet while the CNA waited outside the bathroom door to allow privacy for the resident. The resident said he/she was done and the CNA entered the resident's bathroom and assisted the resident with continence care. CNA O then assisted the resident off of the toilet to the wheelchair and wheeled the resident out of the bathroom. The CNA washed his/her hands after removed gloves. 5. Review of Resident #160's face sheet showed the following: -admitted [DATE]; -Diagnoses included multiple sclerosis (MS - a long-lasting (chronic) disease of the central nervous system, that impacts the brain and spinal cord, which make up the central nervous system and controls everything we do), muscle wasting and atrophy (decrease in size) right and left lower leg, neuromuscular dysfunction of the bladder (the nerves and muscles don't work together very well, the bladder may not fill or empty correctly), depression, anxiety, pain, and muscle spasm. Review of the resident's care plan, dated 03/27/24, showed the following: -The resident had multiple sclerosis; -The resident had a catheter due to neurogenic bladder; -Staff should complete catheter care every shift and as needed; -Staff should position the catheter bag and tubing below the level of the bladder and away from the entrance of the room door; -Check tubing for kinks each shift; -Monitor and document intake and output as per facility policy; -Staff should monitor, record, report to physician for signs and symptoms of urinary tract infection (UTI). (Staff did not care plan related to EBP.) Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Resident had an indwelling catheter; -Required set up or clean up assistance for eating, oral hygiene, toileting hygiene, personal hygiene, upper body dressing, lower body dressing. Review of the resident's physician's order sheet, current as of 04/12/24, showed the following: -Indwelling catheter 20 French (catheter size), 10 milliliter (ml) balloon; -Flush Foley with 60 cubic centimeters (cc) of sterile water as needed; -Change drainage bag and catheter anchor every Sunday -Indwelling catheter care. Check catheter for anchor placement every shift and as needed. During interview and observation 04/07/24, at 4:50 P.M., the resident said he/she had a leg bag currently attached to the catheter tubing. He/she used the larger catheter bag at bedtime. He/she said that staff wear gloves when working with the catheter, but they did not wear a protective gown. Observation on 04/10/24, at 9:10 A.M., showed staff did not wear a gown when working with the resident's catheter. 6. Review of Resident #161's face sheet, showed the following: -admitted on [DATE]; -Diagnoses included displaced fracture of first cervical vertebra with routine healing (broken bone in the neck), cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), and chronic pain. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Use of wheelchair for locomotion. Review of the resident's physician orders, current as of 04/12/24, showed the following: -Cleanse open areas to buttocks with wound cleanser, pat dry, apply aquacel (wound dressing with medication) dressing every 72 hours until resolved; -Follow up appointment on 05/22/24 to have peg tube (tube inserted through the wall of the abdomen directly into the stomach) removed. Review of resident's care plan, dated 04/03/24, showed the following: -Resident had potential/actual impairment to skin integrity related to redness to coccyx (tailbone), peg tube in place; -Staff will monitor pressure areas for changes, report any changes to nurse; -Administer treatments as ordered and monitor for effectiveness; -Staff should assist resident to turn/reposition every two hours and more often as needed. (Staff did not care plan related to EBP/) Observation on 04/08/24, at 10:45 A.M., showed the Assistant Director of Nursing (ADON) entered the resident's room with supplies to complete wound care on the resident's coccyx. The ADON did not put on a gown. 7. During an interview on 04/10/24, at 9:30 A.M., Certified Nurse Aide (CNA) G said he/she was notified in report if a resident had wound, catheter, or any other special needs. He/she could ask the charge nurse if he/she had questions. He/she would wear gloves and wash hands when working with residents for infection prevention. He/she had heard of EBP. Staff do use barrier creams on residents and that hand hygiene was an effective method to prevent contamination. During an interview on 04/10/24, at 9:40 A.M., Registered Nurse (RN) E said when working with residents with wounds, IVs, catheters, or any other special needs, staff ensure to change tubing as ordered and catheters were changed every 30 days or as needed. He/she had not heard about EBP. They had infection control in-services related to hand hygiene. If a resident was on isolation or contact precautions staff would wear gown, gloves, masks, as needed. During an interview on 04/10/24, at 9:45 A.M., RN F said nurses were notified during report or on resident physician order sheets if a resident had wounds, catheter, or IVs. Staff should complete hand washing and wear gloves when working with the residents. He/she had not heard of EBP. The facility had transmission barrier precaution training and in-services. Staff should use gown, mask, gloves with residents in contact or isolation precaution due to infection. During an interview on 04/12/24, at 12:00 P.M., the ADON said he/she was the current facility Infection Preventionist and that he/she had not received any training or information related to EBP. He/she said that initially he/she thought about barrier creams when heard this question. During an interview on 04/11/24, at 9:40 A.M., the MDS/Care Plan Coordinator said he/she had not heard of EBP. He/she was aware of transmission based precautions when there was PPE outside a resident room door and a sign on the door for staff or visitor to see the nurse before entry. When using PPE the staff would dispose of dirty gown, gloves, and mask in a dedicated trash can in the resident room. During an interview on 04/12/24, at 9:48 A.M., the Therapy Director said the following: -She did not have training about EBP; -Staff are suppose to have education about enhanced barrier precautions; -Staff should wear gowns and gloves when assisting residents who have catheters or wounds; -She did not have residents on caseload who have catheters or wounds at this time; -Facility staff did not instruct her to wear a gown with residents with catheters or wounds. During an interview on 04/12/24, at 1:53 P.M., with the Administrator and Corporate Nurse, the Administrator said that the ADON/Infection Preventionist should be updated in clinical meetings of new infection control information. The Administrator said the plan was to implement and train on EBP this week. EBP included wearing gown and gloves when working with residents wound, protruding peg tubes, mid lines, catheters, and ostomies (a surgical procedure that creates an opening in your abdominal wall, a new way for waste to leave the body). There would be signs and education for staff to notify the nurse. There would be PPE stocked in supply rooms. The need for EBP would also be in the resident's care plan. 48534 34871

Based on interview and record review, the facility failed to implement an effective and complete antibiotic stewardship program when staff failed to track residents on antibiotics for various infections in the facility by not completing a current and ongoing antibiotic log of residents with active infections. This failure could potentially place all residents at risk of infection. The facility census was 60. Review of the facility's policy, titled 'Infection Prevention and Control Program', dated 2019, showed the following: -The primary mission is to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections; -It is the policy that this facility's IPCP is based upon information from the facility assessment and follows national standards and guidelines to prevent, recognize, and control the onset and spread of infection whenever possible; -The IPCP includes a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards; -The IPCP includes an antibiotic stewardship program that includes antibiotic use protocols and system to monitor antibiotic use; -The intent of this regulation is to ensure that the facility develops and implements an ongoing IPCP to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually, based upon the facility assessment and as necessary. This would include revision of the IPCP as national standards change; -Elements of the program include the facility will designate one or more individuals as the Infection Preventionist (IP) who is responsible for the facility's IPCP; -Surveillance, including process and outcome surveillance, will include monitoring, data analysis, documentation, and communicable diseases reporting (as required by State and Federal law and regulation). Surveillance activities will be conducted to identify practice, infection trends, and early identification of new infections and potential outbreak situations; -Antibiotic stewardship and review includes reviewing data to monitor the appropriate use of antibiotics in the resident population. Review of the facility's 'Infection Prevention and Control Program - Infection Preventionist: Responsibility, Qualifications and Functions, dated 2019, showed the following: -The IP is responsible for the IPCP; -Review microbiology culture and sensitivity report on a regular basis to identify types of organisms causing infections, antibiotic-resistant organisms, and transmission of organisms between residents; -The IP will oversee the facility antibiotic stewardship program; -Review of the use of antibiotics (including comparing prescribed antibiotics with available susceptibility reports) is a vital aspect of the infection prevention and control program; -Involve the consultant pharmacist with the oversight by identifying antibiotics prescribed for resistant organisms; -Track antibiotic use monthly and complete an antibiogram yearly or as directed by the Medical Director and the quality assurance committee. Review of facility's titled, Antibiotic Stewardship Policy, dated 03/26/18, showed the following: -Aurora Nursing Center will follow a policy of antibiotic stewardship by instituting the following procedures: -The facility will provide resident, family, and community education regarding appropriate use of antibiotics by offering Center for Disease Control (CDC) information and updates by; -Insertion of CDC published information regarding antibiotic stewardship program into the admission packet; -Mailing of CDC published information regarding antibiotic stewardship to all family members; -Offered with the resident newsletter a copy of CDC published information regarding antibiotic stewardship; -Review of CDC published information regarding antibiotic stewardship in resident council annually; -The Care Plan Coordinator is the leader of the antibiotic stewardship program. The facility Care Plan Coordinator will log and monitor antibiotic usage, trends, and that all documentation procedures are compliant with this policy; -The Care Plan Coordinator will meet with the Director of Nursing (DON) on a frequent basis to share information regarding antibiotic trends and policy and procedure. Antibiotic stewardship will be reported at each monthly quality assurance meetings at least quarterly; -The DON will maintain a form for all direct care nursing to use when communicating with the Medical Director. This form will include: -Symptoms of infectious concern regarding a resident; -Recent history of infection; -Recent use of antibiotics for current, or other infection; -Other interventions to reduce infectious symptoms; -Alternative medications or remedies previously effective; -Any culture, or lab results with specific type growth. 1. Review showed the facility did not provide an antibiotic log. Review of facility provided list of residents currently on antibiotics, as of 04/07/24, showed the following: -Resident #110 on ertapenem sodium solution (brand name Ivanz - used to treat certain serious infections) intravenous (IV - administers fluids, medications and nutrients directly into a person's vein) every 24 hours for 7 days due to urinary tract infection (UTI - bladder infection); -Resident #47 on ertapenem sodium IV every 24 hours for 7 days due to UTI; -Resident #55 on sulfamethoxazole-trimethoprim (brand name Bactrim - combination of two antibiotics, used to treat a wide variety of bacterial infections) tablet 800-160 milligram (mg), 1 tablet on Tuesday, Thursday, and Saturday for 84 days, no reason provided; -Resident #54 on cefdinir 300 mg (brand name Ceftin - treats bacterial infections) every 12 hours for 5 days, due to UTI. Review of facility provided certificate titled Infection Preventionist Training Program, completed on 01/09/24, showed the Assistant Director of Nursing (ADON) completed the training. During an interview on 04/10/24, at 4:00 P.M., the ADON/IP said the following: -He/she started in the position in December 2023; -He/she completed a map of the facility with colored markings for each resident that had an infection during the month; -He/she just started writing the type of treatment provided on the map as well; -He/she was unsure what happens with the information, other than keeping in a 3-ring binder at his/her desk; -He/she thinks the previous DON was reviewing the type of infection for monitoring; -He/she said that he/she had been working the floor mostly since starting the job in December; -The previous DON and/or Administrator had been monitoring antibiotic stewardship; -Once a resident is started on an antibiotic, they also are started on a probiotic (foods or supplements that contain live microorganisms intended to maintain or improve the good bacteria (normal microflora) in the body) per physician standing orders; -The nurse will place the resident on daily vital signs and daily monitoring; -The DON was the person that tracked antibiotic use; -He/she was unsure if any staff audit charts. Observation on 04/10/24, at 4:15 P.M., of the Infection Surveillance 3-ring binder showed maps colored with types of infections by room and medications resident taken for when and how long, for the months of January 2024, February 2024, and March 2024. There was not a resident specific log or an evaluation of information. During an interview on 04/12/24, at 1:53 P.M., with the Administrator and the Corporate Nurse said the IP should be updated in clinical meetings of new information. Antibiotic stewardship should be done by the IP. The IP should be keeping a log of all antibiotics prescribed to residents, so infection trends can be monitored in the facility. 34871

Based on observation and interview, the facility failed to maintain a facility temperature range of 71 to 81 degrees Fahrenheit (F) and at a comfortable level of the residents in resident rooms and common areas accessible to residents affecting ten residents (Residents #160, #14, #52, #25, #50, #32, #31, #41 ,#35, and #45) out of a sample of 26 residents. The facility census was 60. Review showed the facility did not provide a policy regarding facility heating and cooling system or monitoring of facility temperature for resident comfort. 1. Review of the National Weather Service (website weather.gov) showed on 04/07/24 the high temperature measured 71.6 degrees F. 2. Review of Resident #160's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by the facility), dated 04/08/24, showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included multiple sclerosis (MS - a long-lasting (chronic) disease of the central nervous system, that impacts the brain and spinal cord, which make up the central nervous system and controls everything one does). Observation and interview on 04/07/24, at 5:21 P.M., showed the following: -The temperature of the dining area measured 81.6 degrees F; -The resident said the building was often hot which caused his/her MS symptoms to be worse. 3. Observation on 04/07/24, at 5:35 P.M., showed the following: -The thermostat on the wall at the beginning of the 500 hall showed a temperature of 78 degrees F with a thermostat setting at 70 degrees F; -The temperature on the hall in the common area by the nurses' desk measured 84 degrees F; -The temperature on the 200 hall measured 82 degrees F. 4. Observation on 04/7/24, at 6:12 P.M., of the thermostat on the 400 hall (unit) showed the temperature measured 79 degrees F with two windows open in the dining room. 5. Review of the National Weather Service (website weather.gov) showed on 04/08/24, the high outside temperature measured 78 degrees F. 6. Review of Resident #14's face sheet showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease the causes obstructed airflow from the lungs) and congestive heart failure (CHF - a long-term condition in which the heart can't pump blood well enough to meet the body's needs). Review of the resident's admission MDS, dated [DATE], showed moderate cognitive impairment. During an observation and interview on 04/08/24, at 12:15 P.M., the resident called the surveyor into his/her room and said it was warm and requested the fan turned on. The resident sat in his/her recliner with a short-sleeved shirt and shorts on. Registered Nurse (RN) F entered the room and reported the air conditioner comes on in May due to the building being old. He/she said the building had only heat or air at one time possibly due to a boiler system. During an observation on 04/08/24, at 3:51 P.M., the resident sat in his/her room in a recliner with the curtains closed and a fan on. The temperature of the room measured as 82.2 degrees F based on thermometer reading. 7. Review of Resident #52's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included pneumonia and respiratory failure (condition in which the blood doesn't have enough oxygen or has too much carbon dioxide) Review of Resident #25's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included COPD with acute exacerbation (episode of symptom worsening). Observation and interview on 04/08/24, at 3:37 P.M., of Resident #52's and Resident #25's room showed the room had a fan on and the room temperature measured 82.8 degrees F. The residents said their room was always hot and the only time it was cool was in the winter. Resident #52 said that when he/she laid down, his/her back sweat and caused the sheets to be wet due to being too warm in the room. 8. Review of Resident #50's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included end-stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). Observation and interview on 04/08/24, at 3:46 P.M., showed the resident's room temperature measured 82.4 degrees F. The resident said it was too hot most of the time in his/her room. There was no fan in the resident's room. 9. Review of Resident #32's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included diabetes. Observation and interview on 04/08/24, at 3:52 P.M., showed the room temperature measured 81.6 degrees F with the window open. The resident said that his/her room was too warm and caused him/her to sweat. 10. Review of Resident #31's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included respiratory failure and heart failure. Review of Resident #41's quarterly MDS, 03/20/24, showed the following: -admitted [DATE]; -Severe cognitive impairment; -Diagnoses included dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Observation on 04/08/24, at 4:00 P.M., showed the residents' room temperature measured 81.9 degrees F with the window open and fan on. The residents said it was warm in the room. 11. Review of Resident #35's annual MDS, dated [DATE], showed the following: -admitted [DATE]; -Severe cognitive impairment; -Diagnoses included hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side and dementia. Review of Resident #45 quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -Diagnoses included hip fracture and dementia. Observation on 04/08/24, at 4:10 P.M., showed the residents' room temperature measured 81.2 degrees F. 12. During an interview on 04/7/24, at 6:12 P.M., Certified Nurse Aide (CNA) GG said the following: -It was constantly hot on the unit since the weather started getting nice outside; --He/she tells the charge nurse when the unit is uncomfortable because of the temperature; -One resident complained yesterday that it was hot on the unit; -He/she opened the windows in the dining room, because it was very warm. During an interview on 04/7/24, at 6:15 P.M., CNA HH said the following: -The temperature on the unit is pretty warm; -The unit stays hot even when the air conditioning is on; -The residents have complained in the past about the unit being too warm; -He/she was told the heat to the facility could not be turned off until a certain date; -The windows in the dining room were open because it was too hot; -One resident's family member opened the resident's window and brought in a fan for the resident, because his/her room is too warm. During an interview on 04/08/24, at 4:32 P.M., the Maintenance Director said the facility heating and cooling system was either hot or cold. It is a boiler and chiller system and it is either off or on. Usually, the facility changes from heat to air conditioner on April 15th of each year. This was the first day he was made aware that residents complained of being hot. He would be contacting the contractor for the system to schedule the switch to cool for the following Friday. He had not been monitoring the facility or resident room temperatures unless someone complained. If it was too hot, the facility would provide fans and open windows. The facility also had a portable AC cooler/heater that could be taken to rooms if a resident was too uncomfortable. During an interview on 04/11/24, at 12:03 P.M., the Assistant Director of Nursing (ADON) said if any residents complained of being too hot or too cold, staff could adjust the thermostat on the wall or on the unit in the resident room. Staff could open a window or provide a fan. If that did not resolve the issue staff could notify the Director of Nursing (DON), Administrator, and/or maintenance staff. During an interview on 04/12/24, at 1:53 P.M., with the Administrator and the Corporate Director of Clinical Operations, the Administrator said staff should monitor building temperatures. Staff should be going around with temperature gauge. The facility does not have an actual policy on that, but it should be done any time it is perceived that someone is uncomfortable. The Maintenance Director would be responsible, but it ultimately falls on the administrator. 48534 49585 34871

Based on observation, interview, and record review, the facility staff failed to ensure all residents received adequate supervision to prevent accidents, when staff failed to follow one resident's (Resident #2), with a history of falls, care plan and left the resident alone in the shower resulting in the resident suffering laceration (a deep cut or tear in skin or flesh) to the back of the resident's head due to falling. The facility census was 57. Record review of the facility's policy titled Fall Policy, revised 9/17/29, showed the following: -Residents found to be at high risk for falls are placed on the Fall Program and interventions are implemented to meet individual needs. 1. Record review of Resident #2's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), high blood pressure, anxiety, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and dementia. Record review of the resident's Fall Incident Report showed the following: -On 5/23/22, at 8:29 A.M., the nurse was down the hall when he/she heard a crash. The nurse went to find out what it was and observed the resident on the floor in the dining room by the refrigerator. The resident stated they were going to get some coffee when they tripped over their wheelchair trying to get around it. The resident stated they hit the back of their head and butt. The nurse completed an assessment and noted redness to the back of the resident's head with no open skin noted. There was no bruising noted to the resident's buttocks or back. Staff assisted the resident to their wheelchair and educated them about trying to get coffee on their own. Staff asked the resident to please ask for help with getting their coffee. Staff noted predisposing situation factors were ambulating without assistance. Record review of the resident's quarterly Fall Risk Data Collection, dated 6/2/22, showed the following: -The resident was a low fall risk; -The resident had no history of falls; -The resident used an assistive device such as a cane or walker for gait. Gait issues fall interventions included the resident had limited physical mobility, the resident was able to propel their wheelchair independently, and the resident used a wheelchair for mobility. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 6/3/22, showed the following: -Moderate cognitive impairment; -The resident used a walker and wheelchair for locomotion; -The resident's balance during transitions and walking was not steady, but was able to stabilize without human assistance. Record review of the resident's care plan, revised 6/27/22, showed the following: -The resident was at risk for falls related to a history of falls and poor safety awareness; -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; -Encourage the resident to ask for assistance; -The resident had an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self-care performance deficit; -The resident required one staff participation in bathing; -The resident required one staff participation with transfers; -The resident required one staff participation to dress. Record review of the resident's nurses' progress notes showed the following: -On 6/26/22, at 6:30 A.M., the nurse was called to the resident's room by the certified nurse aide (CNA). The nurse observed the resident sitting on the side of his/her bed with a skin tear to his/her left elbow. The resident reported he/she fell in the bathroom and got a skin tear on his/her elbow. He/she was able to get up after a few attempts and made it back to bed. The nurse complete physical, skin, and neuro assessments. His/her neuro assessment was within normal limits. Nurse noted a skin tear to the left elbow, cleaned with wound cleaner, skin prep to the peri wound, and triple antibiotic ointment (TAO - a safe and effective topical agent for preventing infections in minor skin trauma) applied. The nurse covered with a telfa pad (an ultra-absorbent pad to provide maximum protection and not disrupt healing) and wrapped with gauze. Staff made the primary care provider and Director of Nursing (DON) aware. Record review of the resident's Fall Incident Report showed the following: -On 6/26/22, at 3:30 P.M., the nurse was called to the resident's room by the CNA. The nurse observed the resident sitting on the side of their bed with a skin tear to the left elbow. The resident reported they fell in the bathroom and got a skin tear to their elbow. The resident stated they were able to get up after a few attempts and made it back to bed. Immediate action taken included physical, skin and neuro assessments completed. The resident's neuros were within normal limits. The nurse noted a skin tear to the resident's left elbow, cleaned the skin tear with wound cleaner, applied skin prep to the peri wound, applied a TAO, covered with a telfa pad and wrapped it with gauze. The resident's vital signs were stable. Staff made the physician and DON aware of the fall. No injuries observed at the time of the incident. The resident's level of consciousness was alert and their mobility was ambulatory without assistance. The resident oriented to person, place and situation. No predisposing environmental factors. Predisposing physiological factors included gait imbalance and impaired memory and predisposing situation factors included ambulating without assistance. No witnesses found; Record review of the resident's nurses' progress notes showed the following: -On 7/15/22, at 5:12 P.M., the resident fell while attempting to throw a brief away after showering. He/she hit his/her head on the floor and had a gash. The nurse sent the resident out to the emergency room (ER) for evaluation. Staff made the resident's family member aware and will attempt to contact another family member. Record review of the resident's Fall Incident Report showed the following: -On 7/15/22, at 5:12 P.M., the resident fell while throwing away a brief after showering. They hit their head and the nurse sent them to the hospital. The resident stated they threw away a brief, lost their balance, and fell . The incident location was the shower. Injuries observed at the time of the incident included a laceration to the top of the scalp on the back of the head. Staff noted predisposing environmental factors included a wet floor. Staff noted predisposing physiological factors included weakness and fainted. The resident was up unassisted throwing a brief away. Record review of the resident's nurses' progress notes showed the following: -On 7/16/22, at 3:00 A.M., the resident arrived via family transport from theER on [DATE], at 12:30 A.M. New orders to hold Plavix (a blood thinner) and aspirin for twenty-four hours received. Staff to keep dressing to the head in place for forty-eight hours, then clean with soap and water. Resident to have sutures removed in seven to ten days. Resident diagnosed with laceration to scalp from a fall. The resident to have a follow up appointment as soon as possible with physician for wound recheck; -On 7/20/22, at 5:08 P.M., the resident continued to have a headache from the fall. Pain medications provided upon request. The resident did have a lot of dried blood to the laceration to the back of head and the nurse could not tell if any stitches were missing. The area had a lot of edema (swelling). Nurse observed scattered bruising throughout the entire body and reminded the resident to ask for assistance when getting up; -On 7/29/22, at 10:36 A.M., the suture area on the back of the resident's head was very moist and matted with blood. Staff received new order to leave sutures in place for an additional five days. During interviews and observation on 7/27/22, at 2:37 P.M., and on 8/1/22, at 8:20 A.M., the resident said the following: -He/she fell in the shower and received seven sutures; -No staff were present in the shower with him/her when he/she fell ; -The CNA was in the shower room to begin with, but left to get some towels and that was when he/she fell ; -He/she fell outside the shower and could not access the call light; -The staff allowed him/her to shower alone all the time. They did not stay in the shower room with him/her; -The resident sat in his/her wheelchair in his/her room and had blood in his/her hair on the back of his/her head. During an interview on 8/1/22, at 1:27 P.M., CNA G said the following: -He/she did not know how much assistance the care plan book said the resident required for bathing, but it probably said supervision because the resident completed all tasks in the shower; -The resident was a fall risk; -He/she should not leave the resident in the shower alone because the floor was wet and the resident could fall; -He/she and CNA H did not stay in the shower room with the resident while he/she showered. He/she and CNA H were in the dining room assisting residents to their tables; -He/she heard the resident fall in the shower room and ran into the shower room. The resident hit their head and the nurse sent the resident to the ER; -He/she should have stayed in the shower room with the resident; -The care plan book showed how much assistance a resident required for bathing. During an interview on 8/2/22, at 3:23 P.M., CNA H said the following: -The resident required assistance of one staff for bathing; -He/she worked in the Special Care Unit (SCU - a secure locked unit for residents with dementia) for a while and always allowed the resident to shower alone. It was his/her practice to let the resident shower alone; -He/she did not believe the resident was a fall risk and was unsure if the resident had previous falls; -He/she and CNA G took turns checking on the resident in the shower while they pushed the other residents to their tables for dinner. They went in the shower room, made sure the resident was fine and then stepped back out of the shower room; -He/she heard the resident fall in the shower and ran in to assist them. The resident hit their head, was bleeding and sent to the ER; -If he/she stayed in the shower room with the resident, he/she could have prevented the resident's injury; -He/she knew how much assistance a resident required for bathing by looking at their care plan; -He/she should never leave a resident in the shower alone. During an interview on 7/27/22, at 2:52 P.M., CNA B said the following: -CNA G and CNA H staffed the Special Care Unit (SCU - a secure locked unit for residents with dementia) when the resident fell ; -Staff should not leave the resident in the shower alone. One staff member should be with the resident in the shower at all times. During an interview on 7/27/22, at 3:13 P.M. Certified Medication Technician (CMT) C said staff should assist the resident in the shower and should not leave the resident in the shower alone. During an interview on 7/28/22, at 8:42 A.M., CNA D said the following: -The resident required assistance of one staff in the shower; -The resident was a fall risk; -The resident fell in the shower and no staff were present in the shower room with him/her. During an interview on 7/28/22, at 12:16 P.M., CNA I said the following: -The resident required assistance with bathing and staff should not leave the resident in the shower alone; -The resident becomes unsteady and could fall at any time; -Staff had access to care plans that told how much assistance a resident required for bathing. During an interview on 7/28/22, at 1:16 P.M., Registered Nurse (RN) E said the following: -The resident required assistance for showers and staff should not leave the resident in the shower alone; -The resident was a high fall risk. During an interview on 7/28/22, at 2:26 P.M., CNA F said the following: -The resident required supervision from staff in the shower and staff should not leave the resident alone in the shower; -The resident was a fall risk. During an interview on 7/28/22, at 3:04 P.M., the Assistant Director of Nursing (ADON) said the following: -The care plan said the resident required one staff assistance with bathing and staff should never leave the resident alone in the shower; -He/she spoke with CNA G and CNA H and they told him/her the resident preferred privacy when showering and they stepped in and out of the shower room to check on the resident. They said they allowed the resident to shower alone. He/she educated the CNAs to pull the shower curtain if the resident requested privacy, but to not leave the resident in the shower room alone; -The nurse sent the resident out to the ER for a laceration to the back of the head that required sutures. During an interview on 8/1/22, at 9:56 A.M., the MDS Coordinator said the following: -The resident's care plan said he/she required one staff assistance for bathing; -The resident showered him/herself, but staff should remain in the shower room because he/she was a fall risk; -Staff knew how much assistance a resident required for bathing from the resident's care plan. Staff should not leave any resident in the shower alone. During an interview on 8/1/22, at 11:17 A.M., the Director of Nursing (DON) said the following: -The resident required assistance from one staff with bathing and was a high fall risk; -Staff left the resident in the shower alone and the resident fell and received a laceration to the back of the head that required a trip to the ER and sutures; -Staff knew how much assistance residents needed by looking at the residents care plans and ADL sheets. During an interview on 8/1/22, at 2:07 P.M., the Interim Administrator said the following: -The resident required one staff assistance for supervision while showering; -The staff should have stayed in the shower room with the resident even if the resident wanted privacy; -Staff should stay in the shower room with residents at all times. During an interview on 8/4/22, at 1:04 P.M., the medical director said the following: -The resident was a fall risk; -He/she did not know staff did not stay in the shower room with the resident, but believed staff should stay with the resident; -Staff may have prevented the resident's injuries if they stayed in the shower room with the resident. MO00204205 and MO00204598

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse when one resident (Resident #2) touched another resident (Resident #1), who did not have the capacity to consent, by fondling his/her breasts on multiple occasions. The facility census was 41. The administrator was notified on 08/16/2021 at 5:05 P.M., of an Immediate Jeopardy (IJ) which began on 08/14/2021. The IJ was removed on 08/17/2021, as confirmed by surveyor onsite verification. Record review of the facility's policy titled Abuse, Prevention, and Prohibition Policy, revised 11/2018, showed the following: -Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion; -Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals; -Resident behaviors will be monitored for changes, which trigger abusive behaviors; -The facility will reassess care plan interventions on a regular basis. (The policy did not address how to determine if a resident was able to consent to sexual contact with another resident.) 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 5/25/2021, showed the following: -Severely cognitively impaired; -No mood interview was completed because the resident was rarely or never understood; -The resident had disorganized thinking continuously and the behavior did not fluctuate. Record review on 8/16/2021 of the resident's current care plan showed the following: -The resident enjoyed spending time and visiting with Resident #2; -The resident would continue to have pleasurable activities with other residents of his/her choice through the review date; -The resident was to choose who he/she visits with; -The resident was to determine his/her pleasurable activities. Record review of the resident's Progress Notes showed the following: -On 8/2/2021 at 12:39 P.M., a nurse witnessed Resident #1 and Resident #2 holding hands and visiting near the nurses' station. Resident #1 and Resident #2 planned to eat meals together. The nurse made the Director of Nursing (DON) and Social Services Director (SSD) aware. Per instructions from the DON, the nurse notified family members. The durable power of attorney (DPOA - a person appointed to act as an individual's agent) reported to the nurse that as long as it was just holding hands or visiting, he/she was ok with it. However, he/she asked to be notified of any further developments; -On 8/8/2021 at 2:16 P.M., a nurse spoke with Resident #1's DPOA, who was concerned about Resident #1's safety regarding a new friend. The DPOA reported he/she was okay with Resident #1 having friendly conversation, dining, or holding hands with Resident #2, but nothing else. Resident #1's family did not want Resident #1 left alone with Resident #2 or Resident #2 to be in Resident #1's room. The nurse advised the Administrator and DON. The nurse instructed staff to monitor and help Resident #1 maintain his/her personal space. Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/2/21 and 8/8/21 notes. Record review of the resident's Progress Notes showed the following: -On 8/14/2021 at 8:40 A.M., Resident #1 was in the main dining room with Resident #2 during breakfast. Resident #2 was groping Resident #1's breast. Resident #1 was laughing and smiling. Resident #1 was redirected and the resident said okay. (Staff did not document notifying family, physician, or management of the incident.) Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/14/21 incident. Record review of the resident's Progress Notes showed the following: -On 8/15/2021 at 8:21 P.M., Resident #1 was observed in his/her room by two certified nursing assistants (CNAs) with Resident #2. Resident #1 had both breasts exposed with Resident #2 groping him/her. Resident #2 was immediately escorted from the room by the nurse. Resident #1 denied being upset or feeling violated. Staff notified the DON immediately after the incident. Staff notified the DPOA of the situation. (Staff did not document notifying the physician of the incident.) Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/15/21 incident. Record review of the resident's Progress Notes showed the following: -On 8/16/2021 at 4:48 A.M., night shift CNAs reported to the nurse at 9:30 P.M., that at 8:00 P.M., when they were taking Resident #1 to the toilet, Resident #2 was in Resident #1's room with the door closed. Resident #2 had his/her hand on Resident #1's right breast and his/her hand between Resident #1's legs. Resident #2 was asked to leave the room, and personal care was provided for Resident #1. The night shift CNA also reported to the nurse at 9:30 P.M., that when he/she came on duty at 6:00 P.M., he/she witnessed Resident #1 and Resident #2 kissing in the main dining room and he/she notified the day shift nurse on duty at the time. The nurse notified the DON immediately and asked the day shift nurse to notify the DPOA. (Staff did not document notifying the physician of the incident.) Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/16/21 incident. During an interview on 8/16/2021 at 9:57 A.M., the resident said he/she did not have a boyfriend/girlfriend in the facility. Resident #1 said he/she did not want Resident #2 or anyone to touch him/her in the breast or private area. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the resident as cognitively intact. Record review on 8/16/2021 of the resident's current care plan showed the following: -The resident enjoyed spending time and visiting with Resident #1; -The resident would continue to choose his/her own pleasurable activities and with whom he/she does so through the next review date; -Interventions included the resident would choose his/her own pleasurable activities. Record review of the resident's Progress Notes showed the following: -On 8/2/2021 at 12:49 P.M., the nurse witnessed Resident #2 and Resident #1 holding hands and planning to eat meals together. Resident #2's next of kin was notified, and he/she reported he/she thought it would be a good idea if Resident #2 had a connection with someone and thought Resident #2's health would benefit. Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/2/21 incident. Record review of the resident's Progress Notes showed the following: -On 8/14/2021 at 8:40 A.M., Resident #2 was in the main dining room with Resident #1. Resident #2 was seen groping Resident #1's breasts and putting his/her hand under Resident #1's shirt. The residents were redirected by staff. Resident #1 was laughing, and showing no signs of being uncomfortable. (Staff did not document notifying family, physician, or management.) Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/14/21 incident. Record review of the resident's Progress Notes showed the following: -On 8/15/2021 at 8:03 P.M., Resident #2 was witnessed in Resident #1's room by two CNAs. The CNAs went to the nurse to report inappropriate conduct between Resident #2 and Resident #1. Resident #2 was noted in the room groping Resident #1's breasts. Resident #2 was immediately directed out of the room and began to curse at the nurse. He/she returned to his/her own room. Staff notified the DON of the incident. (Staff did not document notifying the physician or family.) Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/15/21 incident. Record review of the resident's Progress Notes showed the following: -On 8/16/2021 at 5:14 A.M., night shift CNAs reported to the nurse at 9:30 P.M., that at 8:00 P.M., when the night shift CNAs were taking Resident #1 to the toilet, Resident #2 was in Resident #1's room with the door closed. Resident #2 had his/her hand on Resident #1's right breast and his/her had between Resident #1's legs. Resident #2 was asked to leave the room, and personal care was provided for Resident #1. The night shift CNA also reported to the nurse at 9:30 P.M., that when he/she came on duty at 6:00 P.M., he/she witnessed Resident #1 and Resident #2 kissing in the main dining room and he/she notified the day shift nurse on duty at the time. The night shift nurse notified the DON immediately and asked the day shift nurse to notify the DPOA. Record review on 8/16/2021 of the resident's current care plan showed staff did not update the care plan with related interventions after the 8/1/21 incident. During an interview on 8/16/2021 at 11:49 A.M., the resident's said he/she sits with another resident in the facility during mealtimes. He/She and the other resident had held hands and shared a quick kiss. They had not had sex. Resident #2 said he/she had gone to Resident #1's room a couple times and he/she did touch Resident #1's breast one time. The Administrator came to him/her this morning and told him/her to back off because Resident #1's family did not accept the relationship. Resident #2 said he did not realize the other resident had Alzheimer's. 3. During an interview on 8/16/2021 at 2:55 P.M., Resident #4 said in the last two weeks he/she had noticed Resident #1 and Resident #2 in Resident #1's room by themselves a lot. He/she witnessed Resident #2 with his/her hands up Resident #1's shirt and said he/she reported it to the night nurse approximately a week and a half ago. He/she said Resident #1 had Alzheimer's. He/she had seen staff separate Resident #1 and Resident #2, although it did not seem effective. The residents would go back to each other. During an interview on 8/16/2021 at 2:25 P.M., Resident #3 said on 8/15/2021 he/she saw Resident #2 rubbing his/her hand up and down Resident #1's arms and legs and had his/her hand on Resident #1's thigh. Staff did stop Resident #2. On the night of 8/15/2021 Resident #3 reported that Resident #2 was in Resident #1's room with the door shut and it was not the first time. Resident #3 said Resident #1 does not have the mental capabilities to decide to be in a relationship. He/she had heard Resident #1 say No to Resident #2 in the dining room when Resident #2 was attempting to hold his/her hand. When staff redirects Resident #2 he/she is right back with Resident #1 in five minutes. During an interview on 8/16/2021 at 1:27 P.M., CNA B said he/she received abuse and neglect training upon hire and in-services at least twice yearly. The in-services included how to recognize abuse, when to report, and types of abuse. CNA B said if he/she encountered two residents who were being sexually active, who were not married, and had not given consent, he/she would report them immediately. If he/she is unsure if the residents were able to consent, he/she would separate them immediately. Consent should be on the residents' care plans. The residents' care plans should show if a resident is confused. On the weekend of 8/7/2021, CNA B witnessed Resident #2 in Resident #1's room. Resident #2 had his/her hand up Resident #1's shirt and his/her hand on his/her genital area over his/her pants. CNA B said he/she reported it to the nurse, who reported to the DON. If the resident was not able to consent, it would be considered abuse. Resident #1 is confused and not able to consent. CNA B did hear about Resident #2 kissing and touching Resident #1's breasts in the dining room on 8/14/2021. When CNA B did cares with Resident #1 the evening of 8/15/2021, he/she said his/her private area hurt, and when trying to dress Resident #1 on 8/16/2021, he/she kept covering his/her private area and was very frustrated with staff. This was not Resident #1's usual demeanor. CNA B was not sure if the nurse had assessed the resident or if the physician had been notified. During an interview on 8/16/2021 at 5:18 P.M., CNA C said he/she has received abuse and neglect training and in-services. The training included types of abuse, how to report abuse, and when to report abuse. During report on Monday (8/16/2021), staff told him/her Resident #1 was screaming for staff not to touch him/her down there. CNA C said on Friday, 8/13/2021, he/she went into Resident #1's room around 4:00 P.M. and saw Resident #1 with his/her head on Resident #2's shoulder. Resident #2 had his/her hand in Resident 1's brief and the residents were kissing. CNA C separated the residents immediately and said he/she told Resident #2 that he/she could not be in Resident #1's room. Incidents have been reported to nurses, the DON, and Administrator and staff were told the residents do not have powers of attorney. CNA C said Resident #1 is not cognitively intact. He/she would not be able to consent. CNA C said if a resident could not consent he/she would consider inappropriate contact abuse. During an interview on 8/16/2021 at 5:41 P.M., Certified Medication Technician (CMT) H said he/she had abuse and neglect training at orientation. The training covered types of abuse and when to report abuse. CMT H said he/she should first report abuse to the charge nurse and the report would go up the chain of command. On 8/15/2021, CMT H said he/she saw an aide come to the nurses' station and tell the charge nurse to come with him/her to Resident #1's room. He/she saw the aide and nurse remove Resident #2 from Resident #1's room and heard the nurse say Resident #2's hand was up Resident #1's shirt and he/she cannot fondle Resident #1. He/she does not think Resident #1 had the ability to consent and Administration had been notified. He/she believed the DON was told, but was unsure. During an interview on 8/16/2021 at 11:55 A.M., Housekeeping Staff F said he/she had abuse and neglect training upon hire and regularly. The in-services covered resident to resident abuse, staff to resident abuse, types of abuse, and how to identify and prevent abuse. If he/she sees resident to resident abuse, he/she would separate the residents, and report to the charge nurse, Administrator, DON, or someone in charge. If a resident had dementia, he/she would not be able to consent to a sexual relationship. During an interview on 8/16/2021 at 12:40 P.M., CNA A said he/she had abuse and neglect training upon hire and at least annually. The training covered types of abuse, when to report abuse, and to whom to report If he/she witnessed two residents being sexually inappropriate, he/she would separate them and report to the charge nurse. He/she was not aware of any residents being in a consensual relationship. Consent would be determined if the resident was able to be mentally able to consent, and the guardian or POA approved the relationship. If two residents had sexual relations and one resident was not able to consent, CNA A would consider that abuse. He/she was told on the morning of 8/16/2021 to keep Resident #1 and Resident #2 separate, because Resident #1's family did not want them together. During an interview on 8/16/2021 at 12:48 P.M., CMT I said he/she received abuse training upon hire and periodically throughout the year. The training included who to report to, when to report, and types of abuse He/she had seen Resident #1 and Resident #2 holding hands and was told it was okay, they were consenting adults. Resident #1 had told him/her, he/she wished Resident #2 would leave him/her alone when staff would separate them. CMT I had reported that conversation to the Administrator and was told Resident #1 and Resident #2 were their own people, and nothing could be done. Their families said they can sit and talk, but not touch each other. Resident #1's DPOA then said they do not want the residents to interact. Resident #1's dementia was bad, but Resident #2's is alert most of the time. CMT I had seen Resident #2 going to Resident #1's room. Staff had tried to explain to Resident #2 that Resident #1 had dementia, but Resident #2 goes back to Resident #1 when staff walks away. During an interview on 8/16/2021 at 1:50 P.M., Registered Nurse (RN) K said he/she was provided abuse and neglect training upon hire and had received in-services regarding types of abuse, and when to report. The training's covered resident to resident abuse. To determine consent, staff would look at a resident's Brief Interview for Mental Status (BIMS-a test used to get a quick snapshot of how well you are functioning cognitively) and look at the resident's guardian or DPOA's consent to see if the resident was able to make consent known. RN K said there were no residents in the facility in relationships. He/she would consider a resident being touched inappropriately and without consent, abuse. Resident #1 is confused and unable to have given consent. Neither resident was on 15 minute checks or any kind of monitoring. He/she was told in morning report on 8/16/2021, that Resident #2 had touched Resident #1 inappropriately and they were to be kept separated. 12. During an interview on 8/16/2021 at 2:02 P.M., the care plan/MDS coordinator said changes to residents' care plans are discussed during stand up meetings and interdisciplinary team (IDT) meetings. The care plans are resident care directed. If a resident had behaviors, they should be on the care plan. If a resident was sexually inappropriate, that should be on their care plan. If residents are in a relationship, that should be on their care plan. The care plan/MDS coordinator said she was aware of Resident #1 and Resident #2 being allowed to spend time together and being allowed to eat together and hold hands. She said the physician would determine consent if the residents were unable to make the choice. If the residents showed sexual behavior the families should be notified. If one resident was unable to consent, it would not be appropriate for the resident to have a relationship. It would be considered abuse. Based on Resident #1's BIMS score taken on 8/16/2021, Resident #1 would not have the ability to consent. She would consider Resident #2 touching Resident #1 abuse. During an interview on 8/16/2021 at 3:45 P.M., the DON said if there was an allegation of abuse between residents, the allegation should be reported immediately. The Administrator was the Abuse Coordinator and typically all allegations of abuse are reported to him. If an allegation of sexual abuse between residents occurs, the DON said she expected staff to separate and protect the residents. If staff was not sure if a resident could consent, she expected staff to separate the residents and report the incident. Consent would be determined by the resident's guardian and the resident's BIMS score. The DON said no staff reported allegations of sexual abuse to her on Saturday (8/14/2021) or Sunday (8/15/2021). If a resident was touched inappropriately and unable to consent she would consider it abuse. She does not think Resident #1 had the capacity to consent and would consider Resident #2 touching his/her breast abuse. During an interview on 8/16/2021 at 4:12 P.M., the Administrator said if residents were involved in a resident to resident altercation or allegation of abuse, he expected staff to separate them, and ensure their safety. Staff is to notify their charge nurse immediately and the charge nurse is to notify him. He was not aware of Resident #2 being in Resident #1's room before yesterday. Resident #1's family member is his/her DPOA for healthcare and finances. He/she was okay with the two residents holding hands and sitting together in the dining room. The Administrator said he would expect staff to let him know if a resident touched another resident on the breast, if that was unusual behavior for the resident. In the moment, the resident could determine if it felt good, and staff would need an Interdisciplinary Team (IDT) meeting to determine consent. Consent could be determined by IDT meetings, care plan, physician consults if needed, and consulting anyone appropriate to the situation. During an interview on 8/16/2021 at 4:13 P.M., the Medical Director said she was made aware of the situation (relationship and sitting/holding hands) between Resident #1 and Resident #2 by the facility on 8/11/2021. Resident #1 had dementia as well as Resident #2, even though Resident #2 appears to be more cognitively intact. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 538 MO 553

Based on record review and interview, the facility failed to complete timely and thorough investigations of allegations of abuse involving two residents (Resident #1 and Resident #2) and failed to take immediate steps to protect all residents after becoming aware of the allegation of abuse. The facility census was 41. The administrator was notified on 08/16/2021 at 5:05 P.M., of an Immediate Jeopardy (IJ) which began on 08/14/2021. The IJ was removed on 08/17/2021, as confirmed by surveyor onsite verification Record review of the facility's policy titled Abuse, Prevention, and Prohibition Policy, dated 11/2018, showed the following: -Resident abuse must be reported immediately to the Administrator; -The facility Administrator would ensure a thorough investigation of alleged violations of individual rights and document appropriate action; -While a facility investigation was under way, steps would be taken to prevent further abuse; -A licensed professional nurse would assess the resident for signs of injuries and notify the resident's physician and responsible party of any injuries noted; -If sexual assault had been alleged, the physician would be contacted for an order to transfer to the emergency room for examination; -Two management level staff would conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation; -Staff members who worked on the affected resident's hall would be interviewed; -Interview the resident if they are cognitively able to answer questions; -When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors, and notify the physician for a determination regarding treatment and/or discharge options. Residents will be referred for behavior management when indicated. Changes in room assignments and seating arrangements will be recommended as needed. The safety of other residents is of primary concern. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 5/25/2021, showed the following: -Severely cognitively impaired; -No mood interview was completed because the resident was rarely or never understood; -The resident had disorganized thinking continuously, and the behavior did not fluctuate. Record review on 8/16/2021 of the resident's current care plan showed the following: -The resident enjoyed spending time and visiting with Resident #2; -The resident would continue to have pleasurable activities with other residents of his/her choice through the review date; -The resident was to choose who he/she visits with; -The resident was to determine his/her pleasurable activities. Record review of the resident's Progress Notes showed the following: -On 8/14/2021, at 8:40 A.M., Resident #1 was in the main dining room with Resident #2 during breakfast. Resident #2 was groping Resident #1's breast. Resident #1 was laughing and smiling. Resident #1 was redirected and the resident said okay. Further review of the resident's medical record showed staff did not document notifying family, physician, or management of the incident. Staff also did not document beginning an investigation into the incident or how they ensured resident safety. Record review of the resident's Progress Notes showed the following: -On 8/15/2021, at 8:21 P.M., Resident #1 was observed in his/her room by two certified nursing assistants (CNAs) with Resident #2. Resident #1 had both breasts exposed with Resident #2 groping him/her. Resident #2 was immediately escorted from the room by the nurse. Resident #1 denied being upset or feeling violated. Staff notified the DON immediately after the incident. Staff notified the DPOA of the situation. Further review of the resident's medical record showed staff did not document notifying the physician of the incident. Staff also did not document beginning an investigation into the incident or how they ensured resident safety. Record review of the resident's Progress Notes showed the following: -On 8/16/2021, at 4:48 A.M., night shift CNAs reported to the nurse at 9:30 P.M., that at 8:00 P.M., when they were taking Resident #1 to the toilet, Resident #2 was in Resident #1's room with the door closed. Resident #2 had his/her hand on Resident #1's right breast and his/her had between Resident #1's legs. Resident #2 was asked to leave the room, and personal care was provided for Resident #1. The night shift CNA also reported to the nurse at 9:30 P.M., that when he/she came on duty at 6:00 P.M., he/she witnessed Resident #1 and Resident #2 kissing in the main dining room and he/she notified the day shift nurse on duty at the time. The nurse notified the DON immediately and asked the day shift nurse to notify the DPOA. Further review of the resident's medical record showed staff did not document notifying the physician of the incident. Staff did not document beginning an investigation into the incident or how they ensured resident safety. During an interview on 8/16/2021 at 9:57 A.M., the resident's said he/she does not have a boyfriend/girlfriend in the facility. Resident #1 said he/she did not want Resident #2 or anyone to touch him/her in the breast or private area. 2. Record review of Resident #2's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the resident as cognitively intact. Record review on 8/16/2021 of the resident's current care plan showed the following: -The resident enjoyed spending time and visiting with Resident #1; -The resident would continue to choose his/her own pleasurable activities and with whom he/she does so through the next review date; -Interventions included the resident would choose his/her own pleasurable activities. Record review of the resident's Progress Notes showed the following: -On 8/14/2021 at 8:40 A.M., Resident #2 was in the main dining room with Resident #1. Resident #2 was seen groping Resident #1's breasts and putting his/her hand under Resident #1's shirt. The residents were redirected by staff. Resident #1 was laughing, and showing no signs of being uncomfortable. Further review of the resident's medical record showed staff did not document notifying family, physician, or management. Staff did not document beginning an investigation into the incident or how they ensured resident safety. Record review of the resident's Progress Notes showed the following: -On 8/15/2021 at 8:03 P.M., Resident #2 was witnessed in Resident #1's room by two CNAs. The CNAs went to the nurse to report inappropriate conduct between Resident #2 and Resident #1. Resident #2 was noted in the room groping Resident #1's breasts. Resident #2 was immediately directed out of the room and began to curse at the nurse. He/she returned to his/her own room. Staff notified the DON of the incident. Further review of the resident's medical record showed staff did not document notifying the physician or family. Staff did not document beginning an investigation into the incident or how they ensured resident safety. Record review of the resident's Progress Notes showed the following: -On 8/16/2021, at 5:14 A.M., night shift CNAs reported to the nurse at 9:30 P.M., that at 8:00 P.M., when the night shift CNAs were taking Resident #1 to the toilet, Resident #2 was in Resident #1's room with the door closed. Resident #2 had his/her hand on Resident #1's right breast and his/her had between Resident #1's legs. Resident #2 was asked to leave the room, and personal care was provided for Resident #1. The night shift CNA also reported to the nurse at 9:30 P.M., that when he/she came on duty at 6:00 P.M., he/she witnessed Resident #1 and Resident #2 kissing in the main dining room and he/she notified the day shift nurse on duty at the time. The night shift nurse notified the DON immediately and asked the day shift nurse to notify the DPOA. Further review of the resident's medical record showed staff did not document beginning an investigation into the incident or how they ensured resident safety. During an interview on 8/16/2021, at 11:49 A.M., the resident's said he/she sits with another resident in the facility during mealtimes. He and the other resident had held hands, and shared a quick kiss. They had not had sex. Resident #2 said he/she had gone to Resident #1's room a couple times and he/she did touch Resident #1's breast one time. The Administrator came to him/her this morning and told him/her to back off because Resident #1's family did not accept the relationship. Resident #2 said he/she did not realize the other resident had Alzheimer's. 3. Record review of the facility's investigation showed staff began an investigation on 8/16/2021 of possible abuse involving Resident #1 and Resident #2 on 08/15/2021. Further review of the facility's investigation showed no documentation on how the facility ensured resident safety during the investigation. During an interview on 8/16/2021 at 1:27 P.M., CNA B on the weekend of 08/07/2021 CNA B witnessed Resident #2 in Resident #1's room. Resident #2 had his/her hand up Resident #1's shirt and his/her hand on his/her genital area over his/her pants. He/she reported it to the nurse, who reported to the DON. If the resident was not able to consent, it would be considered abuse and he/she would expect the facility to do an investigation. During an interview on 8/16/2021 at 5:18 P.M., CNA C said during report on Monday 8/16/2021, staff told him/her Resident #1 was screaming for staff not to touch him/her down there. CNA C said on Friday, 08/13/2021, he/she went into Resident #1's room around 4:00 P.M., and saw Resident #1 with his/her head on Resident #2's shoulder. Resident #2 had his/her hand in Resident 1's brief and the residents were kissing. CNA C separated the residents immediately and said he/she told Resident #2 that he/she could not be in Resident #1's room. Incidents have been reported to nurses, the DON, and Administrator and staff were told the residents do not have powers of attorney. CNA C said Resident #1 is not cognitively intact. He/she would not be able to consent. CNA C said if a resident could not consent he/she would consider inappropriate contact abuse. Any allegations of abuse should be reported and investigated by the facility and he/she would expect all residents to be protected during the investigation. During an interview on 8/16/2021 at 5:41 P.M., CMT H said he/she should first report abuse to the charge nurse, and the report would go up the chain of command. On 8/15/2021, CMT H said he/she saw an aide come to the nurses' station and tell the charge nurse to come with him/her to Resident #1's room. CMT H said he/she saw the aide and nurse remove Resident #2 from Resident #1's room and said he/she heard the nurse say Resident #2's hand was up Resident #1's shirt and he/she cannot fondle Resident #1. CMT H said he/she does not think Resident #1 had the ability to consent and Administration had been notified. He/she would expect an investigation to be done for allegations of abuse and residents should be protected. During an interview on 8/16/2021 at 12:40 P.M., CNA A said staff should complete an investigation of an allegation of abuse. He/she was told on the morning of 8/16/2021 to keep Resident #1 and Resident #2 separate because Resident #1's family did not want them together. During an interview on 8/16/2021 at 1:50 P.M., Registered Nurse (RN) K said neither Resident #1 nor Resident #2 were on any kind of monitoring. He/she was told in morning report on 8/16/2021 that Resident #2 had touched Resident #1 inappropriately and they were to be kept separated. During an interview on 8/16/2021 at 2:02 P.M., the care plan/MDS coordinator said the care plan/MDS coordinator said she was aware of Resident #1 and Resident #2 being allowed to spend time together, and being allowed to eat together and hold hands. If one resident was unable to consent, it would not be appropriate for the resident to have a relationship. It would be considered abuse. Based on Resident #1's BIMS score taken on 8/16/2021, Resident #1 would not have the ability to consent. She would consider Resident #2 touching Resident #1 abuse. An investigation should be done and the residents should be protected. During an interview on 8/16/2021 at 3:45 P.M., the DON said if there was an abuse allegation between residents, the allegation should be reported immediately. The Administrator is the Abuse Coordinator and typically all allegations of abuse are reported to him. If an allegation of sexual abuse between residents occurs, the DON said she expects staff to separate the residents, and protect the residents. An investigation should be started immediately. Residents and staff should be interviewed. During an interview on 8/16/2021 at 4:12 P.M., the Administrator said if residents were involved in a resident to resident altercation or allegation of abuse, he expected staff to separate them and ensure their safety. Staff is to notify their charge nurse immediately and the charge nurse is to notify him. An investigation should be started immediately, and all residents would be made safe during the investigation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate 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 remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 538 MO 553

Based on observation, interview, and record review, the facility failed to implement timely and effective measures to prevent residents from smoking in their rooms when one resident (Resident #1), with a history of smoking in his/her room, smoked in his/her room while wearing oxygen causing combustion. The facility census was 52. The Administrator was notified on 9/29/2020, at 3:20 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 9/6/2020. The facility implemented measures including storing of all smoking materials in a locked location, in-servicing all staff, and meeting with all smoking residents. The IJ was removed and corrected on 9/7/2020. Record review of the undated facility policy titled, Smoking Regulations, showed the following information: -No smoking is permitted inside the facility; -All residents are to be supervised by facility staff while smoking; -Any resident using oxygen will have their oxygen tank removed from their person prior to going outside to smoke; -Oxygen will be stored in a holder inside the facility while the resident smokes; -Residents are not allowed to keep smoking materials including matches, lighters, lighter fluid, or smoking tobacco products in their rooms; -Resident smoking materials will be stored by the facility at the nurses' station; -Any resident found violating the smoking policy will be given a 30-day notice of discharge due to the inability to provide protective oversight. 1. Record review of Resident #1's medical record showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment took completed by facility staff), dated 6/29//20, showed the following: -Cognitively intact; -Limited range of motion of both lower extremities; -Used walker or wheelchair; -Did not require assistance for locomotion. Record review of the resident's medical record showed staff did not document completing a smoking assessment for the resident upon admission. Record review of the resident's care plan for smoking showed the following interventions created on 6/18/2020: -The resident is to be supervised by staff while smoking; -The resident's smoking materials are to be kept by facility staff; -The resident is to adhere to the facility smoking policy. Record review of the resident's nurses' notes showed the following: -On 7/1/2020 at 4:21 A.M., a certified nurse aide (CNA) observed the resident smoking in his/her room. The CNA reported observing the resident with a lit cigarette in his/her hand with his/her hand outside of the window. The resident was educated on the smoking policy. The resident's room was searched with no lighter or cigarette found. Record review of the resident's care plan showed staff did not update the care plan regarding the incident or any new intervention. Record review of the resident's nurses' notes showed the following: -On 8/7/2020 at 4:25 P.M., the Social Services Director (SSD) documented speaking with the resident regarding cigarette butts being found in the resident's trash can. The resident stated he/she had completed the evening smoke break and placed the used cigarette butts in his/her pocket instead of disposing of them properly. The Director of Nursing (DON) and SSD informed the resident of the facility policy regarding smoking and if he/she was caught smoking in his/her room, the resident would be issued a 30-day notice due to resident safety concerns. Record review of the resident's care plan showed staff did not update the care plan regarding the incident or any new intervention. Record review of the resident's nurses' notes showed the following: -On 8/19/2020 at 11:34 A.M., a CNA observed the resident smoking in his room. The room smelled like smoke and the nurse observed the resident spraying cologne to cover up the smell. The resident had a smoking break at 10:30 A.M., and the resident reported to the nurse, I had it so I was smoking it. The nurse asked the resident where he/she received the smoking materials and the resident stated, I got it at smoke break last night. The resident was educated regarding the smoking policy for the facility and concerns. The nurse documented reporting the incident to the Assistant Director of Nursing (ADON) and the DON. Record review of the resident's care plan showed staff did not update the care plan regarding the incident or any new intervention. Record review of a facility document titled, Physician's Standing Orders, not dated, showed a standing physician's orders [REDACTED]. The document stated a telephone order must be written for standing orders and put on the resident's physicians order sheet. Record review of the resident's active physician's orders [REDACTED].>Record review of the resident's nurses' notes showed the following -On 9/7/2020 at 1:21 A.M., a nurse documented on 9/6/2020 at 10:15 P.M., nursing staff was alerted to assist the resident. The resident reported to staff he/she had burned himself/herself. The nurse went to the resident's room and unplugged the resident's oxygen concentrator. The resident had two open areas on the abdomen area appearing to be blisters. The resident's face had marks where the oxygen tubing had been. The resident had missing skin on his/her nose and his/her nostrils were internally black. The resident did not appear to have redness or blackness to the throat. The resident's facial hair was burned with black soot on his/her skin. The resident's nasal cannula was black and melted to the point of being unrecognizable as tubing with burn marks on the floor significant enough to have depth to the burn area. The resident's window was open approximately five inches with the screen partially removed. Observations of the window in the past showed the window screen to be intact. The resident reported the screen was partially removed since admission to the facility. Emergency Medical Services (EMS) transported the resident to the hospital; -On 9/7/2020 (time not indicated), the Administrator documented the Minimum Data Set (MDS) Coordinator and Administrator conducted a search of the resident's room and found no tobacco/smoking materials in the resident's room. The administrator documented they believed the resident got smoking materials from another resident. Record review of the resident's smoking assessment, dated 9/7/2020, showed the following: -The resident is to be supervised while smoking; -The resident can smoke without assistance. Record review of the resident's care plan for smoking showed the following interventions created on 9/7/2020: -The resident received education regarding the risks of not adhering to the facility smoking policy; -The resident is not compliant with the smoking policy; -The staff are to ensure the resident does not have any smoking materials on his/her person when re-entering the facility; -Ensure the resident has his/her oxygen off and in his/her room when smoking; -Staff are to ensure all smoking materials are locked in a secure area; -Staff are to ensure the resident places all cigarette butts in the correct receptacle. During an interview on 9/8/2020 at 3:35 P.M., the administrator said on 9/7/2020, around 10:00-10:15 P.M., the resident was taken out for a supervised smoke around 10:00-10:15 P.M., after being found in another resident's room. The Administrator said there was suspicion of the residents attempting to smoke in a resident room. The Administrator said during the process of implementing 15-minute checks on the residents, at approximately 10:22 P.M., Resident #1 reported to staff he/she had burned himself/herself before staff could complete the first check. Resident #1's room was searched and no smoking materials were found in his/her room. The Administrator believes Resident #1 received smoking materials from another resident. Resident #1 was unable to be interviewed following the incident and Resident #2 denies giving Resident #1 any smoking materials. The facility policy is all smoking materials are to be kept and monitored by the facility and residents are not allowed to keep their own smoking supplies. The Administrator did not know how the resident got smoking materials, but suspected he/she got the smoking materials from another resident. Observation of Resident #1's room on 9/8/2020 at 3:49 P.M., showed three burn marks on the floor. Each burn mark was golf ball sized with charred lines connecting the burn marks. The three burn marks were approximately golf ball sized with a depth of [MEDICAL CONDITION] approximately one eighth of an inch. During an interview on 9/8/2020 at 4:08 P.M., Resident #2 said residents are not allowed to keep their own smoking supplies. The resident said on 9/7/2020 he/she and Resident #1 were in his/her room. Staff came in and found cigarettes in his/her room. Resident #2 said he/she got the cigarettes and lighter approximately a week prior. Resident #2 said he/she has ways of getting items he/she wants in the facility, but would not elaborate how he/she got smoking materials in the facility. The resident denied giving any smoking materials to any other resident. During an interview on 9/8/2020 at 4:24 P.M., Licensed Practical Nurse (LPN) A said residents are to have smoking assessments completed quarterly. All smoking materials are to be kept by facility staff. Residents are not allowed to keep their own smoking supplies. Resident #1 was being sent to the hospital when he/she arrived to the facility on [DATE]. The resident attempted to smoke in his/her room while wearing oxygen. He/she believed the resident has been suspected of smoking in his/her room before. During an interview on 9/16/2020 at 2:25 P.M., Registered Nurse (RN) B said all residents are to be supervised while smoking. The facility is to keep all smoking materials and residents are not allowed to keep smoking materials. If smoking materials are found in a resident room it is to be removed and reported to administration. During an interview on 9/24/2020 at 5:49 P.M., LPN D said he/she arrived to the facility on [DATE] around 10:00 P.M When he/she arrived to the facility Resident #1 reported he/she had been burned. He/she went to the resident's room immediately and turned off the oxygen concentrator. He/she assessed the resident and observed the resident to have two dime sized blistered burn areas on his/her abdomen, a red nose with peeling skin and black nostrils, singed facial hair with black soot, and blackened marks on his/her face where the oxygen tubing had been. The resident'[MEDICAL CONDITION]ly second to third degree burns. The resident had no reddened swelling noted to the throat or mouth. Staff instructed the resident to breathe only through his/her mouth to prevent any materials from being inhaled through the nostrils. Staff gently cleaned the resident's nasal cavity with solution with soot and other materials coming out of the resident's nose. The resident's pulse oxygen level was at 92-93 percent. Emergency Medical Services (EMS) arrived and took over the care for the resident. The resident was holding an orange lighter that did not belong to the facility. The resident did not say how he/she got the lighter. Residents are not allowed to maintain their own smoking supplies and did not know how the resident got any smoking materials. EMS transported the resident to the hospital. During an interview on 9/29/2020 at 12:50 P.M., Certified Nursing Assistant (CNA) E said smoking materials for residents are kept in a box in the medication room. The CNA said he/she knew Resident #1 had attempted to smoke in his/her room in the past. During an interview on 9/29/2020 at 1:00 P.M., RN B said resident smoking materials are kept in a box in the medication room. The facility keeps only one lighter. The smoking policy has been in place since the beginning of the year. Staff were in-serviced and residents were educated regarding the smoking policy following the incident with Resident #1 smoking with his/her oxygen on. Resident #1 had a history of [REDACTED]. During an interview on 9/29/2020, at 1:15 P.M., the Administrator said a smoking assessment is completed upon admission. Residents are to be given a 30 day discharge notice per facility policy for violating the smoking policy. Resident #1 did not receive a 30-day discharge notice following attempts to smoke in his/her room. The resident did not receive a discharge notice, because the resident was only suspected of smoking in his/her room and was not identified as being caught smoking in his/her room. MO 089

Based on interview and record review, the facility staff failed to protect residents from physical and sexual abuse from one resident (Resident #22) when staff failed to provide sufficient monitoring of the resident who had a history of [REDACTED]. In addition,staff failed to implement new interventions when the resident continued to display the abusive actions. A sample of 14 residents were selected for review. The facility census was 56. Record review of the facility's policy titled Abuse Prohibition Policy (undated) showed the following: -It is the policy of this facility that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident property or exploitation; -Residents must not be subjected to abuse by anyone, including, but not limited to staff, other residents, consultants, volunteers, agency staff, family or legal guardians, friends, or other individuals; -Abuse means the willful inflicting of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; -Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault; -Physical abuse includes hitting, slapping, pinching, and kicking. It may also include controlling behavior through corporal punishment. 1. Record review of Resident #22's admission record showed the following:-admitted on [DATE]; -[DIAGNOSES REDACTED]. (a progressive disease that destroys memory and other important mental functions). Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 7/25/18, showed the following:-Severely impaired cognition; -Requires extensive assistance for personal hygiene; -Requires one person physical assist with dressing and bathing; -Requires two person assist with transfers. Record review of the resident's care plan, dated 7/27/18, showed the following: -Impaired cognitive function related to Alzheimer's; -Argues with another resident at times; -Will ask visitors and staff Are you mad at me? or will say Hi(NAME)to people that are passing by; -Administer medications as ordered; -Engage in simple, structured activities that avoid overly demanding tasks; -Flag is on wheelchair, so it is easier for staff to know whereabouts; -Assistance is needed with all decision making; -Keep routine consistent and provide consistent care givers as much as possible; -Monitor/document/report to physician any changes in cognitive function; -Separate from other resident if arguing. -Potential to demonstrate verbally inappropriate behaviors toward opposite gender, staff, and other residents related to dementia, poor impulse control; -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation; -Consult with physician as needed; -Document observed behavior and attempted interventions in behavior log; -Provide resident with reminders of need to use appropriate language and why observed behavior is inappropriate; -Provide positive feedback for good behavior. Emphasize the positive aspects of compliance; -When resident exhibits inappropriate behavior, intervene before agitation escalates, guide away from source of distress. Engage calmly in conversation. If response is aggressive, walk away calmly and approach later. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 4/10/18, showed the following: -Three events of sexually inappropriate behavior on day shift; -Interventions were to engage the resident in an enjoyable physical activity/or interest (group setting); -The outcome was ineffective or behavior worsened. Record review of the resident's nurses' notes, dated 4/10/18, showed staff did not document regarding the resident's sexually inappropriate behaviors. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the sexually inappropriate behaviors, or add new interventions to address the sexually inappropriate behaviors. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 4/16/18, showed the following: -Two events of sexually inappropriate behavior on day shift; -Interventions were to plan ahead, slow down or speak in simple soothing terms and tones, familiar routines; -The outcome was effective or behavior improved. Record review of resident's nurses' notes, dated 4/16/18, showed staff did not document regarding the sexually inappropriate behaviors. Record review of the resident's care plan dated 7/27/18 showed staff did not update the care plan with the sexually inappropriate behaviors, or add new interventions to address the sexually inappropriate behaviors. Record review of resident's form titled Disruptive Behavior/Intervention/Outcome, dated 4/23/18, showed: -Resident had one event of sexually inappropriate behavior on evening shift; -The intervention was to remove from the situation; -The outcome is marked as U which is not listed as a possible outcome. (The possible outcome choices included: N for not observed or unchanged, E for effective or improved, or I for ineffective or worsened.) Record review of resident's nurse's note, dated 4/23/18, at 9:00 P.M., showed the resident was seen/witnessed putting hands under another resident's shirt. Staff redirected the resident, removed both residents and did not document anything further. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 4/24/18, showed the following:-Two events of sexually inappropriate behaviors on day shift; -Interventions listed on the form included staff to: Plan ahead, slow down, speak in simple soothing terms and tones, and maintain a familiar routine; -Encourage resident to live their moment, validate their feelings, and use familiar terms; -The outcome was marked N for not observed or unchanged. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care with the sexually inappropriate behaviors, or add interventions regarding the sexually inappropriate behaviors. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 5/5/18, showed the following: -One event of sexually inappropriate behavior on day shift; -Intervention was to plan ahead, slow down, speak in simple terms and tones, and maintain a familiar routine; -The intervention was ineffective or the behavior worsened. Record review of the resident's nurses' notes, dated 5/5/18, showed staff did not document the sexually inappropriate behavior. Record review of the resident's care plan, dated 7/27/2018, showed staff did not update the care plan with the sexually inappropriate behaviors or add interventions regarding the sexually inappropriate behaviors. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 5/7/18, showed the following: -One event of sexually inappropriate behavior on day shift; -Intervention was to plan ahead, slow down, speak in simple terms and tones, and maintain a familiar routine; -Intervention was ineffective. Record review of the resident's nurses' notes, dated 5/7/18, showed staff did not document regarding the sexually inappropriate behavior. Record review of the resident's care plan, dated 7/27/2018, showed staff did not update the care plan with the sexually inappropriate behaviors or add interventions regarding the sexually inappropriate behaviors Record review of the resident's physician's orders [REDACTED]. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan to reflect the medication change or add interventions regarding the sexually inappropriate behaviors. Record review of the resident's nurse's note, dated 5/14/18, at 4:00 P.M., showed the resident inappropriately touching another resident's breasts multiple times. Staff redirected the resident verbally and moved the resident away from the other resident. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incident, or add interventions regarding the sexually inappropriate behaviors. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 5/16/18, showed: -Two events of sexually inappropriate behavior on day shift. -Intervention was to adjust the environment, light, sound, scent, familiar themes, and to plan ahead, slow down, speak in simple soothing terms and tones and maintain a familiar routine. -The outcome was marked as U. (The possible outcome choices included: N for not observed or unchanged, E for effective or improved, or I for ineffective or worsened.) Record review of the resident's nurses' notes showed staff did not update the nurses' notes with sexually inappropriate behaviors for 5/16/18. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incident, or develop and implement new interventions. Record review of the resident's nurse's note dated 5/18/18 at 5:00 P.M., showed it was reported to the nurse by activity staff that the resident had spoken to a young guest of the opposite gender inappropriately. He/she also fondled another resident's family member's buttocks. The nurse reported this to the on-call nurse. Record review of resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incidents from 5/18/18, or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 5/19/18, showed: -Two events of sexually inappropriate behaviors on day shift. -Interventions were to adjust the environment, light, sound, scent, and familiar themes. Plan ahead, slow down, speak in simple soothing terms and tones and maintain a familiar routine. -The outcome of the interventions was marked as U. (The possible outcome choices included: N for not observed or unchanged, E for effective or improved, or I for ineffective or worsened.) Record review of the resident's nurses' notes, dated 5/19/18, showed staff did not document regarding the sexually inappropriate behavior. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incident, or develop and implement new interventions. Record review of resident's form titled Disruptive Behavior/Intervention/Outcome, dated 5/25/18, showed: -Three events of sexually inappropriate behavior on day shift; -Interventions were to adjust the environment, light, sound, scent, familiar themes. Plan ahead, slow down, speak in simple soothing terms and tones and maintain a familiar routine; -The outcome of the interventions was marked as U. (The possible outcome choices included: N for not observed or unchanged, E for effective or improved, or I for ineffective or worsened.) Record review of the resident's nurses' notes, dated 5/25/18, showed staff did not document regarding the sexually inappropriate behavior. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incident, or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 6/2/18, showed: -Two episodes of sexually inappropriate behaviors on day shift; -Interventions listed were to redirect resident and provide one on one care (resident had someone with him/her at all times until behavior ceased); -The intervention outcomes were marked as E for effective (no outbursts). Record review of the resident's nurses' notes, dated 6/2/18, showed staff did not document regarding the sexually inappropriate behavior. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incident, or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 6/3/18, showed the following: -Three episodes of sexually inappropriate behaviors on day shift and one episode on night shift; -Interventions listed were to provide one-on-one care and refer to the nurses' notes for day shift and redirect for night shift episode; -The intervention outcomes were marked as U for unchanged for day shift episode and I for improved for night shift episode. Record review of the resident's nurse's note dated 6/3/18 at 11:00 A.M., showed resident continues to be sexually aggressive towards other residents. Noted trying to pinch another resident's breasts. Resident told that this behavior was inappropriate. Resident said I don't know what you are talking about. Staff notified the resident's primary physician. Record review of the resident's Monthly Behavior Monitoring Flowsheet dated 6/3/18 showed the following: -Two episodes of sexually inappropriate behaviors on day shift. -Interventions listed were to redirect and provide one on one care. -Outcomes listed for both episodes were listed as U for Unchanged. Record review of the resident's care plan showed staff did no update the care plan with the incident, or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 6/6/2018, showed the following: -Three episodes of sexually inappropriate behaviors on night shift; -Interventions listed were to redirect and provide one on one care; -The intervention outcomes were marked as U for Unchanged. Record review of the resident's nurses' notes, dated 6/6/18, showed staff did not document regarding the sexually inappropriate behavior. Record review of the resident's care plan 7/27/18 showed staff did not update the care with the sexually inappropriate behaviors, or develop and implement new interventions Record review of resident's nurses' notes dated 6/9/18 at 3:40 P.M., showed a certified nursing assistant (CNA) brought the resident to nurses' station, because he/she was pinching the breasts of another resident. This was observed by a dietary worker. The dietary worker told him/her to stop pinching the resident's breasts. He/she wouldn't stop. He/she was brought in his/her wheelchair to the nurses station where he/she decided to go to his/her room. During an interview on 9/20/18 at 2:50 P.M., Dietary Aide O said he/she witnessed the resident pinching the nipple of Resident #34 approximately two to three months ago. He/she kept trying to pinch Resident #34's nipple and he/she was telling him/her no. The resident said, come on, you know you like it. The dietary aide said he/she went to the nurses' station to ask for assistance and nursing staff came to get the resident. He/she would consider the incident abuse. Record review of the resident's care plan 7/27/18 showed staff did not update the care with the sexually inappropriate behaviors, or develop and implement new interventions. Record review of the resident's nurse's note dated 6/11/18 at 9:40 A.M., showed resident continued to be sexually and physically aggressive towards other residents, grabbing and pinching the breasts of residents of the opposite gender. Staff notified the resident's primary physician. Record review of a fax to resident's primary physician, dated 6/11/18, showed resident continued on [MEDICATION NAME] 5 mg. Resident continues to be physically and sexually aggressive towards other residents. Requested a urinalysis (a test of urine by physical, chemical, and microscopical means to test for the presence of disease, drugs, etc.) with a culture and sensitivity (a culture is a test to find germs that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection.) to rule out a urinary tract infection and for a referral to a psychiatrist. The physician reply on the fax was ok to all, and increase [MEDICATION NAME] to 10 mg one by mouth daily. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care with the medication change, sexually inappropriate behaviors and did not develop or implement any new interventions Record review the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 6/15/18, showed: -Four episodes of sexually inappropriate behavior on day shift; -Interventions were to redirect and provide one-on-one care; -The intervention outcomes were marked U for Unchanged. Record review of the resident's nurses' notes, dated 6/15/18, showed staff did not document the sexually inappropriate behavior. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care with the sexually inappropriate behaviors, or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 6/17/18, showed: -Three episodes of sexually inappropriate behaviors on day shift and three episodes on evening shift; -Interventions were to redirect resident and provide one-on-one care for all episodes; -The intervention outcomes were marked U for Unchanged for all episodes. Record review of the resident's nurse's note dated 6/17/18 at 4:45 A.M., showed the resident was sexually inappropriate with a certified nursing assistant (CNA). He/she put his/her face in a CNA's chest and stated you have nice boobs. Resident then told CNA his/her leg hurt, but indicated his/her genitalia. Staff notified the Director of Nursing (DON). Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the incident from 6/17/18, or develop and implement interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 7/2/18, showed: -One episode of sexually inappropriate behavior on day shift; -Interventions were to redirect resident and provide one-on-one care; -The intervention outcomes were marked E for effective (no outbursts). Record review of the resident's nurses' notes, dated 7/2/18, showed the staff did not document the inappropriate sexual behaviors. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care with the sexually inappropriate behaviors,or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 7/11/18, showed: -Two episodes of sexually inappropriate behavior on day shift; -Interventions were to redirect the resident and provide one-on-one care; -The intervention outcomes were marked U for Unchanged. Record review of resident's nurses' notes, dated 7/11/18, showed the staff did not document inappropriate sexual behaviors. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care with the sexually inappropriate behaviors, or develop and implement new interventions. Record review of the resident's form titled Disruptive Behavior/Intervention/Outcome, dated 8/25/18, showed the following: -Two episodes of sexually inappropriate behaviors on day shift; -Interventions were to redirect and provide one on one care; -The intervention outcomes were marked I for Improved. Record review of the resident's nurses' notes, dated 8/25/18, showed staff did not document inappropriate sexual behaviors. Record review of the resident's care plan, dated 7/27/18, showed staff did not update the care plan with the sexually inappropriate behaviors, or develop and implement new interventions. Record review of resident's nurse's note dated 9/6/18, 2-10 shift, showed obtained UA (urinalysis) this afternoon due to increased sexual behaviors. Staff called for lab to pick up and awaiting initial results. Record Review of the resident's nurses' notes dated 9/19/18 2-10 shift show: Received final culture and sensitivity report of greater than 100,000 of streptoccus viridans (a frequent bacterial infection that causes urinary tract infections). Notified primary physician. New order for Keflex (an oral antibiotic) 500 mg three times daily for ten days with acidophilus. Spouse notified. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's care plan, dated 7/27/18, showed staff did not add the medication change to the care plan or develop and implement new interventions During the resident council meeting held on 9/18/18 at 3:06 P.M., the question was asked of the group Are there any concerns with any residents bothering you, being mean to you, or being inappropriate to you? Resident #42 pointed to Resident #22 and said You! During an interview on 9/19/18, at 4:17 P.M., Resident #42 said everyone in the facility was very nice and he/she liked everyone except Resident #22. Resident #22 grabbed him/her when he/she first came to the facility. Resident #42 reported it to the nurses and said he/she just stays away from Resident #22. During an interview on 9/19/18, at 9:17 A.M., Nursing Assistant (NA) K said he/she had abuse and neglect training when he/she was hired and had no residents with behaviors. He/she was told Resident #22 likes pretty girls. If he/she saw the resident grabbing someone, he/she would get a nurse and tell them what was going on. He/she is unsure if that would be abuse if the resident didn't know what he/she was doing. He/she would want to keep the resident separated from the other residents if there was an altercation. During an interview on 9/19/18 at 10:20 A.M., CNA R said he/she had abuse and neglect training when hired and periodically. Types of abuse are sexual, verbal, physical and financial. He/she does have a few residents with behaviors. Resident #22 has sexual behaviors. Resident #22 has grabbed residents' breasts and said inappropriate things to other residents and staff. He/she grabbed Resident #34's breasts. They were separated and it was reported to the charge nurse. The incident happened a couple months ago. There were no 15-minute checks completed or any special monitoring. The aide said it would probably be considered abuse. During an interview on 9/19/18, at 3:44 P.M., Resident #207 said that around two to three months ago, he/she could see Resident #22 touching Resident #34 on the breast. He/she told the aide passing water to move Resident #22 away from Resident #34 or he/she would kill him/her. The aide intervened and moved Resident #22 away from Resident #34. Resident #207 thinks a nurse was told. During an interview on 9/20/18, at 2:27 P.M., CNA B said he/she received abuse and neglect training upon hire and has received some in-services since. He/she has witnessed Resident #22 with his/her hands up Resident #34's shirt fondling his/her breasts. He/she told him/her to stop and took Resident #22 to the TV room, and took Resident #34 to lie down. Everyone is aware to keep their eyes on Resident #22. It would be seen as a behavior if it the contact was consensual, but abuse if not. During an interview on 9/20/18 at 6:39 P.M., Resident #22's guardian said he/she was notified of sexual behaviors towards staff and residents. The resident does say some inappropriate things to the staff. This is not normal behavior for the resident. During an interview on 9/21/18 at 9:38 A.M., CNA Z said Resident #22 has sexual behaviors and he/she has told the nurse. Resident #22 talks sexually to the aides and staff tell him/her that is inappropriate. He/she has seen Resident #22 touch Resident #34 on the breast two to three times. The aide did report the incidents to the nurse. The aide is unsure if the nurse reported it on to anyone. Staff is to remove whomever is touching and take them to the nurses' station and let the nurses take over. During an interview on 9/19/18 at 2:00 P.M., LPN (Licensed Practical Nurse) P said Resident #22 is sexually inappropriate. Staff have to watch him/her. Staff can tell when the resident is starting to get worse, because he/she starts to flirt. Staff has to redirect the resident. LPN P said Resident #22 knows what he/she is doing more than what he/she lets on. He/she tried to grab Resident #34 and that is what prompted the [MEDICATION NAME]. Staff have told the young aides to be mindful. They were instructed to just say hello and go on, because he/she gets inappropriate with staff if the aides spend too much time with him/her. The resident's spouse is aware of his/her behavior. No one considered the resident's behavior abuse. If abuse, he/she would have been sent to geriatric-psych facility or given a 30 day notice. During an interview on 9/20/18 at 4:39 P.M., the DON said the orientation staff receives focuses on abuse. Examples of abuse are resident to resident, hitting, shoving, bumping, yelling, anything unwanted, and anything sexual. The same would apply for employees to residents. If someone reports abuse employees are taken away from resident contact areas. If it is a resident-to-resident situation the residents are separated and the state is notified. Resident #22 has sexual behaviors. The resident's primary physician started him/her on [MEDICATION NAME] to tone down his/her sexual urges. It had been reported that he/she was saying sexual things to the staff and to other residents. He/she has had physical contact with Resident #34. He/she lifted Resident #34's shirt and attempted to touch his/her breast. He/she is only aware of the one time that occurred and that was a couple months prior. The [MEDICATION NAME] was increased because it wasn't working. Some improvement had been seen, but not enough. He/she was unsure why it had been increased in September. When Resident #22 is having sexual behaviors staff should redirect. The DON says he/she is easily redirected, and the term sexually aggressive hits him/her wrong. Resident does not have orders for 15 minute checks or one-on-one monitoring. He/she usually sits at the nurses' station. He/she thinks resident-to-resident abuse is situational. If Resident #22 is grabbing a breast or sticking hands down pants, it's situational. Sometimes he/she is coherent, sometimes he/she is not. No changes in interventions or documentation have been made. If an intervention is implemented, it is put in a communication book to make everyone aware of the change. It is not part of the resident record. If the new intervention is tried, it is added in the nurses' notes. The care plan coordinator is notified to make the actual change on the care plan. We have a form some of them use. It is filled out and given to the care plan coordinator. The nurses write any changes for the CNAs on the purple care plan sheets. As far as the full care plan, he/she is unsure how the care plan coordinator updates it. During an interview on 9/20/18 at 8:54 A.M., the facility administrator was told of the different incidents in Resident #22's nurses notes and asked for investigations of the incidents. The administrator said the incidents were not called in to the State. The nurses were addressing it by calling the doctor, treating it medically. The administrator said social services talked to family members about inappropriateness. Residents did not remember any incidents or have any adverse effects that were noticed. No residents were in isolated situations with the resident during that time and the incidents occurred at the nurses' station. Monitoring was done and he/she would see what it was. During an interview on 9/20/18 at 11:42 A.M., the facility administrator said Resident #34 will lift his/her shirt at the nurses' station. Resident #22 is handsy. He/she tries to pinch, but not aggressively, his/her hands just land wherever. He/she does this all the time. Staff redirects him/her to keep his/her hands to him/herself. The administrator said he/she was a little alarmed by the term the nurses used of sexual aggression. He/she thinks it is more touching and getting in personal space. The more intimate conversation he/she has with someone can sometimes lead to inappropriate conversation. Resident #22 has told asked Resident #3 to give him/her a kiss. Staff looks at it as behaviors. If it was aggressive, it would be abusive, and it would be reported. Resident #22 has an escalation of behaviors when he/she has an infection. The events have been situational. The only episodes the administrator was aware of were between Resident #22 and Resident #34 at the nurses' station and Resident #22 possibly kissing Resident #3 in the dining room. During an interview on 9/20/18 at 2:04 P.M., the Social Services Director said when Resident #22 has behaviors the facility contacted his/her primary physician and the physician did a medication change. Resident #34 touched Resident #22 on the abdomen and Resident #22 touched Resident #34's breasts. Resident #34 has large breasts and sometimes they just come out from under his/her shirt. Staff keeps an eye on him/her and readjusts his/her shirt. The facility does abuse and neglect training on hire and in services throughout the year. It would be considered abuse if one resident grabbed another resident's breasts. It has been a few weeks since any inappropriate behaviors have been reported to social services. During an interview on 9/20/18 at 3:38 P.M., Resident #22's primary physician, who is also the facility's medical director, said that Resident #22 has a lot of behaviors and is very sexually aggressive. The physician has had the resident on [MEDICATION NAME] to try to curb those behaviors. He/she is aware of the resident grabbing people, but not necessarily residents. Most of what is known is from direct observation. Facility staff fax information to the physician as needed. Resident #22 was inappropriate with the physician's staff on the last visit, so [MEDICATION NAME] was increased. The facility staff should be redirecting the resident. Incidents are not considered abuse, because they are related to his/her diagnosis. Resident #22 has no impulse control. The use of 15 minute checks and one-on-one care is for abusive residents. The physician doesn't think the resident harms anyone. He/she is annoying, not abusive. He/she has more sexual thoughts and has no ability to stop what comes out of his/her mouth or stop what he/she does. During an interview on 9/20/18 at 3:51 P.M., Resident #22's psychologist said he/she started seeing Resident #22, because of anxiety and depression. He/she was unaware of any behaviors regarding the resident grabbing other residents. He/she had not offered guidance to staff related to other residents. He/she said Resident #22 might be able to make decisions at times. If a resident grabbed another resident's breast, it would be a target behavior and potentially abuse to other residents. Staff had not made him/her aware of any incidents besides being verbally inappropriate with staff. NOTE: At the time (TRUNCATED)