Every finding on record at Cotton Point Living Center

Based on observation, interview and record review, the facility failed to maintain sanitary conditions for ice intended for resident consumption. The facility failed to ensure the ice machine drain line maintained a required air gap (empty space that ensures dirty sewer water can never flow backward into the ice machine and contaminate the ice) to prevent potential contamination, failed to maintain sanitary conditions surrounding the ice machine, and failed to prevent contamination of communal ice during resident use. These deficient practices had the potential to affect all residents who consumed ice from the facility ice machine. The facility census was 47.Review of the facility's policy titled, Sanitization, revised November 2022, showed:- Ice machines and ice storage containers are drained, cleaned, and sanitized per manufacturer's instructions;- Ice chest and coolers used to store and transport ice are cleaned regularly, especially prior to use or when contaminated or visibly soiled;- Did not address the air gap required for the ice machine. 1. Observations on 05/11/26 at 10:32 A.M., and 3:21 P.M., and 05/13/26 at 10:09 A.M., of the ice machine room on Birch Boulevard showed:- Two plastic containers with a buildup of dust were located on top of the ice machine;- Dirt, debris and a blue ice scoop were observed on the floor beneath the ice machine;- A round white plastic pipe connected from the back of the ice machine extended through the wall into the furnace room and rested directly on a floor drain located next to the furnace;- Water dripped from the pipe onto the floor drain;- Dirt and debris were observed on the floor in the furnace room; and- The ice machine drain line lacked an air gap to prevent direct contact between the pipe and the floor drain. 2. Observations on 05/13/26 at 8:20 P.M., showed:- A cart labeled dirty cups only containing several dirty cups was located next to a cart labeled clean cups only containing clean cups in the dining room;- Resident #26 removed a dirty cup from the dirty cup cart;- Resident #26 walked to the ice chest located near the nurse's station and opened the lid;- Resident #26 poured liquid from the dirty cup into the communal ice chest;- Resident #26 handled the communal ice scoop with bare hands and scooped ice into the dirty cup two times;- Licensed Practical Nurse (LPN) A remained at the nurse's station and did not intervene or redirect Resident #26; and- No staff assisted Resident #26 with obtaining ice.3. Observations on 05/14/26 at 8:02 A.M., and 11:03 A.M., showed a cart labeled dirty cups only containing dirty cups was located next to a cart labeled clean cups only containing clean cups in the dining room.During an interview on 05/13/26 at 8:25 P.M., LPN A said residents were instructed not to obtain their own ice and were expected to ask staff for assistance due to infection control concerns. Resident #26 should have requested staff assistance before accessing the communal ice chest.During interviews on 05/13/26 at 9:27 P.M., and on 05/14/26 at 8:24 A.M., the Administrator said the ice machine drain line should have maintained an air gap to prevent backflow contamination and should not have been in direct contact with the floor drain. Residents should not obtain their own ice and staff should intervene, redirect, and assist residents with ice handling.During an interview on 05/14/26 at 7:55 A.M., the Housekeeping Supervisor said the floors in the ice machine room and furnace room should have remained clean and free of dirt and debris. Ice scoops should not be stored on the floor beneath the ice machine.During an interview on 05/14/26 at 8:22 A.M., the Maintenance Supervisor said the ice machine drain line should have maintained an air gap to prevent contamination from the floor drain.During an interview on 05/14/26 at 10:49 A.M., the Director of Nursing (DON) said residents should not independently obtain ice from the communal ice chest and staff should intervene, redirect, or assist residents with obtaining ice.

Based on interview and record review, the facility failed to provide restorative services for one resident (Resident #9) out of two sampled residents and one resident (Resident #17) outside the sample. The facility census was 47.Review of the facility's policy titled, Restorative Nursing, revised July 2017, showed:- Residents will receive restorative nursing care as needed to help promote optimal safety and independence;- Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care;- Restorative goals may include, but are not limited to supporting and assisting the residents in:a) Adjusting or adapting to changing abilities;b) Developing, maintaining or strengthening his/her physiological and psychological resources;c) Maintaining his/her dignity, independence and self-esteem; andd) Participating in the development and implementation of his/her plan of care. 1. Review of Resident #9's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by staff), dated 04/06/26, showed:- Independent for bed mobility, transfers, toileting and mobility;- Required minimal assistance/supervision for dressing, personal hygiene, and showers. Review of the resident's May 2026 physicians order sheet (POS) showed:- An order to receive restorative therapy (RT) three times per week for bilateral (left and right) upper extremity therapy, passive range of motion (the movement of a joint or body part entirely by an external force) and active range of motion (the movement of a joint or body part entirely on your own) and stretching, dated 04/17/26. Review of the resident's medical record showed:- No documentation the resident received RT three times per week from 04/17/26 - 05/14/26;- 12 missed out of 12 opportunities. During an interview on 05/13/26 at 9:38 A.M., Resident #9 said he/she did things on his/her own and did not need therapy other than help with showering on occasion. He/She was unsure what RT was and if he/she received it. 2. Review of Resident #17's quarterly MDS, dated [DATE], showed:- Independent for bed mobility, bathing, and transfers;- Required minimal assistance/supervision for dressing and toileting;- Required partial or moderate assistance with personal hygiene;- Wheelchair for mobility;- Impairment of both sides to the lower extremities. Review of the resident's May 2026 POS showed:- An order to receive RT three times per week. Seated bilateral lower extremity therapy exercises with green band and 2-pound (lb.) ankle weights, two sets x 15 repetitions, sit to stand and stand to sit, ambulation in parallel bars, and NuStep (seated exercise machine) on level five for 10 minutes, dated 02/03/26. Review of the resident's medical record showed:- No documentation the resident received RT three times per week 02/03/26 - 05/14/26;- 45 missed out of 45 opportunities. During an interview on 05/13/2026 at 10:30 A.M., the Restorative Nursing Aide (RNA) F said if there were no notes under the restorative progress notes in the resident's electronic medical record (EMR), then there were no notes. He/She tried to do RT as ordered but got pulled to the floor often and it did not always get done. When a resident refused restorative, the RNA told a nurse and was unsure if they charted the refusal or not. He/She knew there should be more documentation related to RT. During an interview on 05/14/26 at 1:38 P.M., the Assistant Director of Nursing (ADON) said residents should receive RT services as ordered. She would expect the RNA to document when RT was being done and if a resident refused. During an interview on 05/14/26 at 2:00 P.M., the Administrator said he would expect the RNA to be doing RT on residents as ordered and letting him, the Director of Nursing (DON), or the therapy department know if a resident was not getting the ordered therapy.

Based on observation, interview, and record review, the facility failed to monitor and consistently implement interventions, including adequate supervision consistent with resident needs, goals, and current professional standards of practice, in order to eliminate or reduce the risk of falls and accidents, failed to document an assessment after a fall, to notify the provider and the on-call nurse after a fall, and to update the care plan with new interventions to prevent additional falls for one resident (Resident #49) out of two sampled residents. The facility census was 47.Review of the facility policy titled, Falls and Fall Risk, Managing, dated March 2018, showed:- Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling;- A fall is unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming force (a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred;- The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling;- The nurse shall assess and document/report the following: a. Vital signs; b. Recent injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; j. All active diagnoses. 1. Review of Resident #49's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/24/26, showed:- Cognition intact;- Partial to moderate assistance of staff for toileting and sitting to standing position;- Substantial to maximal assistance of staff for sitting to lying and lying to sitting positions;- Resident used a wheelchair. Review of the resident's medical record showed:- No documentation of a fall on 05/08/26;- No documentation of an assessment of the fall on 05/08/26;- No documentation the resident's provider and the on-call nurse were notified of the fall on 05/08/26. Review of the resident's care plan, last updated on 04/24/26, showed:- At risk for falls;- History of falls;- Works with the restorative program for strengthening and balancing;- Monitor, document, and report as needed to the physician for signs and symptoms of pain, change in condition, or new onset of confusion;- Physical therapy (PT) consult for strength and mobility as needed;- Did not address the fall on 05/08/26 with new interventions. Observation on 05/11/26 at 12:43 P.M., of the resident showed:- Resident sat at a table in the dining room with a plate of food in front of him/her;- Resident did not touch his/her food;- Medical Records (MR) staff asked the resident why he/she was not eating;- The resident told the MR staff he/she did not feel well, had a fall over the weekend, and didn't feel like eating. During an interview on 05/11/26 at 12:45 P.M., the resident said he/she was not eating because of soreness from a fall he/she had over the weekend. He/She fell on Friday and reported the incident to staff. During an interview on 05/11/26 at 12:17 P.M., Certified Nurse Assistant (CNA) I said if a resident fell, he/she immediately would assist the resident and call for help. The charge nurse was always informed so the resident could be assessed immediately. During an interview on 05/11/26 at 12:21 P.M., Certified Medication Technician (CMT) J said if a resident fell, he/she stayed with the resident and called for help. The charge nurse was always informed so the resident could be assessed immediately. During an interview on 05/12/26 at 8:37 A.M., Restorative Nurse Aide (RNA) F said if a resident fell, he/she would call for help. The charge nurse was always informed so the resident could be assessed immediately. During an interview on 05/12/26 at 9:15 A.M., the MDS Coordinator was unaware of the resident's fall. During an interview on 05/13/26 at 10:20 A.M., CNA K said the resident had mentioned he/she was sore but did not mention anything about a fall. During an interview on 05/13/26 at 2:20 P.M., the Assistant Director of Nursing (ADON) said the resident had left the facility by ambulance. During an interview on 05/14/26 at 2:12 P.M., the Director of Nursing (DON) said she would expect staff to call the on-call nurse, notify the resident's family, and notify the physician of a fall. If there was an injury, the resident should be sent out by the physician's order to be evaluated. She expected staff to document any resident's fall and then follow-up, whether it be vitals, neurological checks, etc. During an interview on 05/14/26 at 2:17 P.M. the Administrator said he would expect staff to assess the resident after a fall, to follow-up, to notify the provider and the guardian if the resident had one, and to try to send the resident out to be evaluated. The facility always had an on-call physician and an on-call nurse. He expected staff to document resident falls and follow-up after a fall. During an interview on 05/19/26 at 11:40 A.M., Licensed Practical Nurse (LPN) L said when he/she arrived on the day shift on 05/08/26, the resident was on the floor. LPN L had other staff in there with him/her assisting with the resident, but he/she could not remember who it was. The resident was assessed, assisted to the wheelchair, and then assisted to the resident's bed. He/She did check the resident out to make sure the resident was not hurt, but failed to document anything about the fall, to notify the provider, or the on-call nurse.Complaint #3000359

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were four errors out of 27 opportunities for errors, resulting in an error rate of 14.81%. This affected three residents (Residents #9, #30, and #36) out of five sampled residents. The facility census was 47.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in a safe and timely manner and as prescribed;- Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed:- Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 1. Review of Resident #9's medical record showed:- admitted on [DATE];- Diagnoses of hyperlipidemia (high cholesterol), occlusion and stenosis of unspecified carotid artery (narrowing of an artery increasing risk of stroke), essential hypertension (high blood pressure), other specified disorders of the veins (complications with veins or blood flow), Alzheimer's disease and cerebrovascular disease (a group of conditions than can affect blood flow to the brain and cause potential neurological problems). Review of the resident's physician order sheet (POS), dated May 2026, showed:- An order for rosuvastatin (a cholesterol medication) calcium 40 milligrams (mg) by mouth every day for hyperlipidemia, dated 07/04/25. Observation on 05/13/26 at 8:50 A.M., of the resident's medication administration showed:- Licensed Practical Nurse (LPN) C prepared the resident's medications for administration;- LPN C did not administer the resident's rosuvastatin calcium medication dose. Review of the resident's May 2026 medication administration record (MAR) showed:- The last administration date for rosuvastatin calcium was 05/06/26;- Dates 05/07/26 - 05/14/26 documented as unavailable in-house;- Eight missed out of eight opportunities. 2. Review of Resident #30's medical record showed:- admitted on [DATE];- Diagnoses of hyperlipidemia, unspecified atrial flutter (abnormal beating pattern of the heart), essential hypertension, and nonrheumatic mitral valve prolapse (condition where the mitral valve in the heart does not close properly and could cause complications). Review of the resident's POS, dated May 2025, showed:- An order for Eliquis (a blood thinner) 5 mg by mouth twice a day for deep vein thrombosis (a blood clot) prevention, dated 05/21/25. Observation on 05/13/26 at 8:41 A.M., of the resident's medication administration showed:- LPN C prepared the resident's medications for administration;- LPN C did not administer the resident's Eliquis medication dose. Review of the resident's May 2026 MAR showed:- The last administration date for Eliquis was the morning dose on 05/05/26;- The evening dose on 05/05/26 and the morning and evening doses 05/06/26 - 05/14/26 documented as unavailable in-house;- 19 missed out of 19 opportunities. During an interview on 05/13/26 at 8:43 A.M., LPN C said Resident #30 was out of Eliquis and the electronic medical record (EMR) showed the medication had been ordered on 05/05/26. LPN C said he/she was unsure why it had not come in yet. During an interview on 05/14/26 at 9:23 A.M., the Assistant Director of Nursing (ADON) said staff should be ordering medications at least seven days prior to the resident running out. Anyone who re-orders medications should follow up within a day or two and/or let the ADON know if it had not been received. If a resident was missing a dose of medication due to the medicine not being in the facility, he/she would expect staff to contact the pharmacy immediately. During an interview on 05/14/26 at 1:45 P.M., the Administrator said he would expect nursing to ensure residents do not run out of medications or miss doses. If a resident was out of medication, he would expect staff to check the overflow medications and then contact the pharmacy immediately and let the Director of nursing (DON) or ADON know. During an interview on 05/19/26 at 11:49 A.M., Pharmacy Staff M said Resident #9's rosuvastatin calcium was last ordered on 03/31/26, and Resident #30's Eliquis was last ordered on 04/07/26. During an interview on 05/19/26 at 1:40 P.M., the Physician said the facility did not notify him/her that Resident #9 had missed several doses of rosuvastatin calcium and Resident #30 had missed multiple doses of Eliquis. He/She would expect the facility to be aware of when residents needed medication refills, to make sure the residents did not miss any doses, and someone to contact him/her when this issue occurred. He/She said missing medication doses could potentially have ill effects on the residents.3. Review of Resident #36's medical record showed:- admitted on [DATE];- Diagnosis of type two diabetes mellitus (a metabolic disease). Review of the resident's POS, dated May 2026, showed:- An order for Humalog (a fast-acting insulin used to treat diabetes) KwikPen inject as per sliding scale: if blood sugar 140 - 169 = 33 units subcutaneously (beneath the skin) with meals related to type 2 DM, dated 05/07/26. Observation on 05/13/26 at 11:02 A.M., of Resident #32's blood sugar showed:- LPN B checked the resident blood sugar with a blood sugar reading of 159;- LPN B told the resident his/her blood sugar reading was 159;- LPN B entered the resident's blood sugar reading as 139 on the MAR; - LPN B told the resident he/she would get zero units of insulin;- LPN B did not administer the resident's Humalog 33 units as ordered for a blood sugar of 159. During an interview on 05/14/2025 at 1:18 P.M., LPN B said he/she must have gotten nervous while checking the blood sugar and entered the wrong blood sugar reading. He/She normally double checked the reading before entering it into the resident's electronic medical record (EMR). During an interview on 05/14/26 at 9:23 A.M., the ADON said he/she would expect staff checking insulin to double check the reading versus what was being administered to eliminate the room for error. During an interview on 05/14/26 at 1:45 P.M., the Administrator said he would expect nursing to review blood sugar readings before it was entered into the resident's EMR to eliminate the room for error.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #30 and #36) were free from significant medication errors when staff did not administer medications as ordered by the physician and did not document the correct blood sugar reading. The facility census was 47.Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in a safe and timely manner and as prescribed;- Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed:- Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. 1. Review of Resident #30's medical record showed:- admitted on [DATE];- Diagnoses of hyperlipidemia (high cholesterol), unspecified atrial flutter (abnormal beating pattern of the heart), essential hypertension (high blood pressure), and nonrheumatic mitral valve prolapse (condition where the mitral valve in the heart does not close properly and could cause complications). Review of the resident's physician order sheet (POS), dated May 2026, showed:- An order for Eliquis (a blood thinner) 5 milligrams (mg) by mouth twice a day for deep vein thrombosis (a blood clot) prevention, dated 05/21/25. Observation on 05/13/26 at 8:41 A.M., of the resident's medication administration showed:- Licensed Practical Nurse (LPN) C prepared the resident's medications for administration;- LPN C did not administer the resident's Eliquis medication dose. Review of the resident's May 2026 medication administration record (MAR) showed:- The last administration date for Eliquis was the morning dose on 05/05/26;- The evening dose on 05/05/26 and the morning and evening doses 05/06/26 - 05/14/26 documented as unavailable in-house;- 19 missed out of 19 opportunities. During an interview on 05/13/26 at 8:43 A.M., LPN C said Resident #30 was out of Eliquis and the electronic medical record (EMR) showed the medication had been ordered on 05/05/26. LPN C said he/she was unsure why it had not come in yet. During an interview on 05/14/26 at 9:23 A.M., the Assistant Director of Nursing (ADON) said staff should be ordering medications at least seven days prior to the resident running out. Anyone who re-orders medications should follow up within a day or two and/or let the ADON know if it had not been received. If a resident was missing a dose of medication due to the medicine not being in the facility, he/she would expect staff to contact the pharmacy immediately. During an interview on 05/14/26 at 1:45 P.M., the Administrator said he would expect nursing to ensure residents do not run out of medications or miss doses. If a resident was out of medication, he would expect staff to check the overflow medications and then contact the pharmacy immediately and let the Director of nursing (DON) or ADON know. During an interview on 05/19/26 at 11:49 A.M., Pharmacy Staff M said Resident #30's Eliquis was last ordered on 04/07/26. During an interview on 05/19/26 at 1:40 P.M., the Physician said the facility did not notify him/her that Resident #30 had missed multiple doses of Eliquis. He/She would expect the facility to be aware of when residents needed medication refills, to make sure the residents did not miss any doses, and someone to contact him/her when this issue occurred. He/She said missing medication doses could potentially have ill effects on the residents.2. Review of Resident #36's medical record showed:- admitted on [DATE];- Diagnosis of type two diabetes mellitus (a metabolic disease). Review of the resident's POS, dated May 2026, showed:- An order for Humalog (a fast-acting insulin used to treat diabetes) KwikPen inject as per sliding scale: if blood sugar 140 - 169 = 33 units subcutaneously (beneath the skin) with meals related to type 2 DM, dated 05/07/26. Observation on 05/13/26 at 11:02 A.M., of the resident's blood sugar showed:- LPN B checked the resident blood sugar with a blood sugar reading of 159;- LPN B told the resident his/her blood sugar reading was 159;- LPN B entered the resident's blood sugar reading as 139 on the MAR; - LPN B told the resident he/she would get zero units of insulin;- LPN B did not administer the resident's Humalog 33 units as ordered for a blood sugar of 159. During an interview on 05/14/2025 at 1:18 P.M., LPN B said he/she must have gotten nervous while checking the blood sugar and entered the wrong blood sugar reading. He/She normally double checked the reading before entering it into the resident's electronic medical record (EMR). During an interview on 05/14/26 at 9:23 A.M., the ADON said he/she would expect staff checking insulin to double check the reading versus what was being administered to eliminate the room for error. During an interview on 05/14/26 at 1:45 P.M., the Administrator said he would expect nursing to review blood sugar readings before it was entered into the resident's EMR to eliminate the room for error.

Based on interview and record review, the facility failed to ensure three residents (Residents #9, #13, and #15) out of five sampled residents received the influenza (a highly contagious respiratory illness) immunization. The facility census was 47.Review of the facility's policy titled, Influenza, Prevention and Control of Seasonal, dated August 2014, showed:- The Infection Preventionist (IP) will promote and administer the seasonal influenza vaccine;- Unless contraindicated, all residents and staff will be offered the vaccine. 1. Review of Resident #9's medical record showed:- admitted on [DATE];- Diagnoses of chronic obstructive pulmonary disease (COPD - a lung disease) and Alzheimer's disease (a progressive and irreversible brain disorder);- No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine;- No documentation of the consent or refusal for the influenza vaccine;- No documentation the resident received the influenza vaccine. 2. Review of Resident #13's medical record showed:- admitted on [DATE];- Diagnoses of major depressive disorder (a mental health disorder) and hypertension;- No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine;- No documentation of the consent or refusal for the influenza vaccine;- No documentation the resident received the influenza vaccine. 3. Review of Resident #15's medical record showed:- admitted on [DATE];- Diagnoses of COPD and generalized anxiety disorder (a mental health condition);- No documentation of the education provided to the resident or representative regarding the benefits and potential side effects of the influenza vaccine;- No documentation of the consent or refusal for the influenza vaccine;- No documentation the resident received the influenza vaccine. During an interview on 05/14/26 at 2:05 P.M., the Assistant Director of Nursing (ADON) said she and another staff member share the duties of the Infection Preventionist. She was responsible for staff prevention and the Infection Preventionist was responsible for resident prevention. She and the IP were new to the facility, but she would expect the immunization forms to either be signed for consent or refusal and documented. During an interview on 05/14/26 at 2:10 P.M., the Director of Nursing (DON) said she was new to the facility and would expect the facility to have the immunization forms documented on the residents of the facility. During an interview on 05/14/26 at 2:14 P.M., the Administrator said it was the DON's responsibility to monitor the infection program, however this task had been delegated to the ADON at this time. The IP was responsible for obtaining the residents' consents or refusals for immunizations. He would expect the immunizations forms to be documented.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse on 07/23/25 when, as staff escorted the residents outside to smoke, Resident #2 made physical contact pushing Resident #1 down to the floor. Resident #1 was sent to the emergency room and diagnosed with a fractured hip that required surgical repair. The facility census was 60.The Administrator was notified on 07/31/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 07/23/25. Upon notification, the facility administration immediately started an investigation, notified the police department and Department of Health and Senior Services of the incident, and in-serviced all staff on the facility's policy and procedures for abuse and neglect. The IJ was corrected on 07/24/25. Review of the facility's policy titled, Abuse Prevention Program, undated, showed:The facility will not tolerate verbal, sexual, physical, or mental abuse, corporal punishment, and voluntary seclusion, neglect, or misappropriation of resident property;All allegations will be investigated and any findings that indicate abuse, willful neglect, mistreatment, or misappropriation of property will be taken very seriously and will be dealt with harshly;Every employee must report witnessed abuse, any remarks made, which might indicate abuse has occurred, and any signs of injury, like bruising or skin, tears to the supervisor, or charge nurse immediately;The Administrator and the Director of Nursing (DON) Services have an open-door policy for reports of abuse, neglect, mistreatment, or misappropriation of resident property and confidential reports can be made at any time. Review of Resident #2's medical record showed:admitted on [DATE];Diagnoses of major depressive disorder, anxiety disorder (persistent worry and fear about everyday situations), paranoid personality disorder (a persistent pattern of extreme distrust and suspicion of others), schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), and post-traumatic stress disorder (PTSD - psychological distress following a traumatic event);Had an appointed guardian/public administrator. Review of the resident's Care Plan, revised 03/25/25, showed:Needs assistance from staff to make appropriate decisions;Has poor judgment and a guardian (public administrator) to help in making decisions;Difficulty getting along with other people and required staff oversight;Confrontational and usually easy to redirect;Can make his/her wants and needs known;Intervene as necessary to protect the rights and safety of others;Remove from the situation and take to alternate locations as needed; Review of the resident's Physicians Orders Sheet (POS), dated July 2025, showed:An order for olanzapine (an antipsychotic- primarily used to treat psychosis, a mental state characterized by a disconnect from reality, often involving hallucinations, delusions, and disorganized thinking) medication 10 mg by mouth at bedtime for schizophrenia, dated 07/18/25;An order for Invega (and antipsychotic medication) 234 mg/1.5 milliliter (ml) inject intramuscularly (injection into the muscle) every day shift every 28 days for schizophrenia affective disorder, depressive type, dated 05/23/25;An order to monitor for the following behaviors: agitation, stealing, delusions, hallucinations, psychosis, aggression, refusal of care, smoking in his/her room, related to paranoid schizophrenia and major depressive disorder, dated 06/13/25. Review of the resident's Behavioral Progress Notes, dated 07/23/25 - 07/24/25, showed:On 07/23/25, the resident made physical contact with Resident #1 on the unit. The resident punched Resident #1 in the face and back of the head and then proceeded to push him/her down;On 07/24/25, the resident was sent to the hospital. The guardian was notified of the emergency discharge. Review of Resident #1's medical record showed:admitted on [DATE];Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), major depressive disorder (long-term loss of pleasure or interest in life), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs);Had an appointed guardian/public administrator. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/20/25, showed:Moderate cognitive impairment;Required supervision with all aspects of daily activities of daily living. Review of the resident's Progress Notes, dated 07/23/25 - 07/28/25, showed:On 07/23/25, Resident #2 made physical contact with Resident #1 with bruising to left side of his/her face and complaints of right hip and leg pain. The Administrator was at facility when the incident occurred. The police and the ambulance were notified;On 07/24/25, Resident #1 admitted to the hospital on [DATE] for a right hip fracture and surgery;On 07/28/25, Resident #1 readmitted to the facility. During an interview on 07/31/25 at 10:15 A.M., Resident #1 said he/she didn't have surgery and wasn't sent to the hospital. Everything was fine. Another resident hit him/her in the back and up his/her body. He/She just remembered hurting. Review of the facility's investigation, dated 07/23/25, showed:Resident-to-resident altercation on the unit between Resident #1 and Resident #2;Resident #1 and Resident #2 separated immediately;Responsible parties and physician notified;Resident #1 assessed and transferred to hospital for further evaluation;Resident #2 transferred to the hospital for further evaluation;Witness statements gathered;Staff education and in-service initiated;Local authorities notified with police report filed;Emergency discharge issued with guardian in agreement for Resident #2. During an interview on 08/06/25 at 2:10 P.M., Licensed Practical Nurse (LPN) N A said on the day of the incident, it was reported to him/her that a resident to resident altercation occurred on the unit between Resident #1 and Resident #2. He/She did not witness the incident. Resident #1 and Resident #2 were separated, assessed, and sent to the Emergency Department for further evaluation. Resident #1 had bruising to the left side of his/her face and complaints of right hip and leg pain that LPN A documented in Resident #1's 07/23/25 Progress Note. During an interview on 07/31/25 at 9:05 A.M., the Administrator said the night nurse called her and she was still in the facility. LPN A reported there had been a resident-to-resident altercation on the unit. Resident #1 and Resident #2 were on their way to smoke at the patio at the end of the unit hall and had not made it to the patio area, when Resident #2 hit Resident #1 and pushed him/her down. Both residents were immediately separated by staff. Resident #2 was sent out and given an emergency discharge. Emergency Medical Services (EMS) took both Resident #1 and Resident #2 out of the facility to different hospitals to be further evaluated. Police were notified. An investigation was started immediately with staff witness statements collected regarding the incident on the unit. Resident #2 was transported to a local hospital, and the facility was notified the resident had been transferred to a psychiatric facility. Resident #1 was transported to a local hospital upon assessment and the resident's complaints of pain in the right leg and hip. The facility was notified Resident #1 would have surgery due to a fractured hip. Resident #1 returned to the facility. A police report was filed. Both residents have a Public Administrator and were notified of the incident.

Based on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 54. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. Observations on 03/04/25 at 10:21 A.M., and 03/05/25 at 8:15 A.M., of room [ROOM NUMBER] showed: - A buildup of dust and dirt on the air filter inside the air conditioner unit; - Several long dark markings on the wall near the light switch by the door; - Two areas of exposed sheetrock and peeled paint on the wall near the recliner; - Several long dark markings along the wall next to the bed near the window. Observations on 03/04/25 at 10:24 A.M., and 03/05/25 at 8:21 A.M., of room [ROOM NUMBER] showed: - Several long dark markings with areas of exposed sheetrock and peeled paint on the wall near the door. Observations on 03/04/25 at 10:29 A.M., and 03/05/25 at 8:25 A.M., of room [ROOM NUMBER] showed: - A large area of exposed sheetrock and peeled paint next to the nightstand. Observations on 03/04/25 at 10:51 A.M., and 03/04/25 at 8:32 P.M., of room [ROOM NUMBER] showed: - A buildup of dried food and dirt on the resident's wheelchair cushion, seat, foot pedals, and the sides; - A buildup of dirt and grime on the Hoyer lift next to the bed near the window. Observations on 03/04/25 at 10:59 P.M., and 03/05/25 at 8:42 A.M., of room [ROOM NUMBER] showed: - Long dark markings on the bottom part of the wall next to the bed near the window. Observations on 03/04/25 at 11:09 A.M., and 03/05/25 at 8:53 A.M., of the resident private phone room showed a missing square vent cover on the ceiling near the sprinkler head. Review of February 2025 Resident Council Meeting Minutes showed: - A concern with resident wheelchairs not being cleaned or washed by staff. During an interview on 03/07/25 at 10:03 A.M., the Maintenance Supervisor (MS) said he/she was aware there were a lot of things that needed to be repaired and painted. It was hard at times to keep up with maintenance duties when he/she was verbally told when something needed to be addressed by staff in passing. It would be nice if staff would write down the environmental concerns on the maintenance log to be addressed in a timely manner. During an interview on 03/07/25 10:21 A.M., the Administrator said she was aware the facility had a lot of environmental concerns that needed to be addressed. Staff should be writing down any environmental issues on the maintenance log instead of verbally telling the MS in passing so he/she didin't forget throughout the day.

Based on interview and record review, the facility failed to follow their policy and procedure to complete Criminal Background Checks (CBC) for one employee (Employee I) prior to hire and to check the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected, misappropriated funds or property from a resident) periodically for six employees (Employees G, I, J, K, L, and M) out of ten sampled employees. The facility census was 54. Review of the facility's policy titled, Employee Disqualification List (EDL), dated February 2022, showed: - At the time of consideration of employment, the designated employee shall access the EDL website and check the EDL; - The designated employee will review the EDL list on the EDL website to make certain the name of the employee has not been placed on the the EDL since the initial checking requirement; - The annual and quarterly information is found on the same website as the individual information; - The annual list is updated each January. - Each quarter, names are added and deleted; - The designated employee should check and print the list each quarter and annually, check it against the current employee list, and file in a folder called EDL quarterly checklist. Review of the facility's policy titled, Criminal Background Checks Policy and Procedure, dated February 2022, showed: - The facility shall perform criminal background checks on all employees hired after August 28, 1997; - After an employment application has been received by Administration and it is determined the applicant will be offered employment, the designated facility employee will complete an online Criminal Background Request; - Print the request for the employee record. In addition, a copy of the disclosure of the applicant's rights under the Fair Credit Reporting Act shall be given to the applicant. Both requirements shall be completed the same day as the decision to hire, and prior to allowing any person contact with a resident. The responsibility for completing this requirement shall remain with the Administrator even if the task shall be delegated to a designee; - The reply for Criminal Background Request will be emailed with a notice that there is no match or that a follow-up is being mailed, which will indicate a criminal history and this applicant shall not be started to work until such time as the Administrator, or designee, shall receive the response and determine whether or not the applicant is to be disqualified; - There will be no exceptions to this policy. 1. Review of Employee G's personnel file showed: - A hire date of 04/09/24; - The last EDL list check was 04/09/24; - The facility did not check a quarterly EDL list check. 2. Review of Employee I's personnel file showed: - A hire date of 12/24/21; - No documentation the CBC was completed before the employee's hire date; - The most recent EDL list check was 09/16/22; - The facility did not check a quarterly or annual EDL list check. 3. Review of Employee J's personnel file showed: - A hire date of 10/02/24; - The last EDL list check was 09/30/24; - The facility did not check a quarterly EDL list check. 4. Review of Employee K's personnel file showed: - A hire date of 08/23/24; -The last EDL list check was 08/19/24; -The facility did not check a quarterly EDL list check. 5. Review of Employee L's personnel file showed: - A hire date of 11/20/24; - The last EDL list check was 11/06/24; - The facility did not check a quarterly EDL list check. 6. Review of Employee M's personnel file showed: - A hire date of 03/07/24; - The last EDL list check was 02/15/24; - The facility did not check a quarterly or annual EDL list check. During an interview on 03/07/25 at 4:00 P.M., the Human Resources (HR) staff said he/she was not aware it was required for the facility to check the EDL list except at the time of hire. During an interview on 03/07/25 at 4:38 P.M. the Administrator said the CBC and EDL checks should be completed prior to employment and she thought at least quarterly after employment.

Based on interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS) assessments, a federally mandated assessment instrument completed by the facility, in a timely manner and in accordance with the guidelines for two residents (Residents #37 and #40) out of 14 sampled residents and two residents (Residents #38 and #42) outside the sample. The facility's census was 54. Review of the facility's policy titled, Resident Assessments, dated October 2023 showed: - A comprehensive assessment of each resident is completed at intervals designated by Omnibus Budget Reconciliation Act (OBRA) regulations and Protective Payment System (PPS) requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. - OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and Medicaid certified nursing homes. OBRA assessments include: a. Admission assessment; b. Quarterly assessment; c. Annual assessment; d. Significant change in status assessment; e. Significant correction to prior comprehensive assessment; f. Significant correction to prior quarterly assessment; g. Discharge assessment. - PPS Assessments are conducted (in addition to the OBRA required assessments) for residents for whom the facility receives Medicare Part A Skilled Nursing Facility benefits; - Comprehensive MDS assessments include both the completion of the MDS as well as completion of the Care Area Assessments (CAA) process and care planning. Comprehensive MDS, include admission, annual, and significant changes. - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated October 2023, showed: - Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual; - Submission of MDS records to the iQIES is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of 15 months from the date submitted. 1. Review of Resident #37's MDS assessments showed: - admitted on [DATE]; - An admission assessment, dated 08/24/24; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 2. Review of Resident #38's MDS assessments showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 3. Review of Resident #40's MDS assessments showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. 4. Review of Resident #42's MDS assessments showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE]; - The facility did not complete a quarterly MDS for the resident within 92 days of the last MDS. During an interview on 03/06/25 at 10:10 A.M., the MDS Coordinator said he/she just started in the position but was aware there were some MDS assessments that were behind and/or late. During an interview on 03/07/25 at 4:31 P.M., the Administrator said she would expect the MDS's to be completed on time. During an interview on 03/07/25 at 4:35 P.M., the Regional Nurse Consultant said she was told all of the MDS's were up to date.

Based on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for two residents (Residents #17 and #41) out of 14 sampled residents. The facility's census was 54. Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated October 2023, showed: - Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes; - Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual; - Submission of MDS records to the to the Internet Quality Improvement Evaluation System (iQIES) is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of 15 months from the date submitted. 1. Review of Resident #17's MDS record showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE], completed but not transmitted; - The facility did not transmit the MDS within 14 days of the completion date. 2. Review of Resident #41's MDS assessment showed: - admitted on [DATE]; - A quarterly MDS, dated [DATE], completed but not transmitted; - The facility did not transmit the MDS within 14 days of the completion date. During an interview on 03/06/25 at 10:10 A.M., the MDS Coordinator said he/she just started in this position, but was aware there were some MDS assessments that were behind and/or late. During an interview on 03/07/25 at 4:31 P.M., the Administrator said she would expect the MDS's to be submitted on time. During an interview on 03/07/25 at 4:35 P.M., the Regional Nurse Consultant said she was told all of the MDS's were up to date.

Based on interview and record review, the facility failed to include an admitting diagnosis of post traumatic stress disorder (PTSD - psychological distress following a traumatic event) with specific interventions on the baseline care plan upon admission for one resident (Resident #158) out of two sampled residents. The facility census was 54. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident; - The baseline care plan is used until the staff can conduct the comprehensive assessment and develop interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission); - The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. 1. Review of Resident #158's medical record showed: - An admitted of 02/17/25; - Diagnoses of PTSD, paranoid schizophrenia (a long term mental disorder that causes distrust, affects a person's ability to think, feel, and behave clearly, and sometimes including delusions or hallucinations, schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), major depression disorder (long-term loss of pleasure or interest in life), irritability, and anger. Review of the resident's Baseline Care Plan, dated 02/18/25, showed: - PTSD with specific interventions not addressed. During an interview on 03/05/25 at 2:19 P.M., the resident said he/she was in the military and witnessed people that were killed. Loud noises triggered the PTSD. During an interview on 03/05/25 at 2:56 P.M., the Social Service Director (SSD) said the resident was asked about his/her PTSD a few days after being admitted to the facility and he/she avoided the question. During an interview on 03/07/25 at 3:42 P.M., the Director of Nursing said if a new resident was admitted to the facility with a PTSD diagnosis, it should be included on the baseline care plan with specific interventions. During an interview on 03/07/25 at 4:42 P.M., the Administrator said if a new resident was admitted to the facility with a diagnosis of PTSD, the resident's baseline care plan should include specific interventions along with other admission diagnoses documented on the admission paperwork.

Based on observation, interview, and record review, the facility failed to obtain and/or follow physician's orders for three residents (Residents #15, #37 and #158) out of five sampled residents and one resident (Resident #2) outside the sample. The facility census was 54. Review of the facility's policy titled, Medication and Treatment Orders, dated July 2016, showed: - Orders for medication and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record; - Drugs and biological orders shall be recorded on the physician's order sheet (POS) in the resident's chart; - Such orders are reviewed by the pharmacy consultant on a monthly basis. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood) and major depressive disorder (long-term loss of pleasure or interest in life). Review of the resident's February 2025 Physician Order Sheet (POS) showed: - An order for Invega Trinza (an antipsychotic medication) intramuscularly (IM -injection administered into the muscle) 819 milligram (mg)/2.63 millimeter (ml) every three months, starting on the 6th February/May/August/November related to schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), dated 07/06/24. Review of the resident's November 2024 MAR showed: - Invega scheduled for administration on 11/06/24; - The facility failed to administer the medication. Review of the resident's February 2025 MAR showed: - Invega scheduled for administration on 02/06/25; - The facility failed to administer the medication. 2. Review of Resident #15's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (a serious medical illness that negatively affects how you feel, the way you think and how you act), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and emphysema (a lung disease where the tiny air sacs in the lungs make it hard to breathe). Review of the resident's March 2025 POS showed: - No order for oxygen. Review of the resident's progress note, dated 03/04/25, showed: - Difficulty breathing; - Breathing treatment administered; - Oxygen level at 99% via oxygen concentrator in use at 2 liters (L) per nasal cannula (tubing inserted into the nostrils for supplemental oxygen). Observation on 03/04/25 at 10:21 A.M., showed the resident lay in his/her bed with an oxygen concentrator in use at 2 L per nasal cannula. Observations on 03/04/25 11:01 A.M., and 03/07/25 at 10:11 A.M., showed the resident sat upright in his/her chair with an oxygen concentrator in use at 2 L per nasal cannula. During an interview on 03/04/25 at 11:06 A.M., the resident said he/she had difficulty breathing at times and needed oxygen. During an interview on 03/04/25 at 11:26 A.M., the Director of Nursing (DON) said Resident #15 did not have an oxygen order on his/her current POS. There should be a physician's order for oxygen. During an interview on 03/04/25 at 11:47 A.M., the Administrator said she would expect a resident who required oxygen to have a physician's order on his/her current POS. 3. Review of Resident #37's medical record showed: - admitted on [DATE]; - Diagnoses of hypertension (HTN-high blood pressure), congestive heart failure (CHF- heart muscle weak and cannot pump properly), and atrial fibrillation (a-fib - an irregular, often rapid heart rate causes poor blood flow); - No order for hospice care. Review of the resident's hospice binder showed: - Resident admitted to hospice on 07/22/24; - Diagnosis of CHF. During an interview on 03/07/25 at 4:22 P.M., Licensed Practical Nurse (LPN) F said the resident did not have an order for hospice until 03/05/25. During an interview on 03/07/25 at 4:35 P.M., the Administrator said any resident on hospice needed an order for the hospice care. 4. Review of Resident #158's medical record showed: - admitted on [DATE]; - Diagnoses of post traumatic stress disorder (PTSD - psychological distress following a traumatic event), paranoid schizophrenia (a long term mental disorder that causes distrust, affects a person's ability to think, feel, and behave clearly, and sometimes including delusions or hallucinations), schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions), major depression disorder, irritability, and anger. Review of the resident's February 2025 POS showed: - An order for Invega Sustenna IM 234 MG/1.5 ml one time a day starting on the 23rd and ending on the 23rd every month for schizoaffective disorder, depressive type dated 02/17/25. Review of the resident's February 2023 MAR showed: - Invega scheduled for administration on 02/23/25; - The facility failed to administer the medication. Review of the resident's progress note, dated 02/27/25, showed: - The resident involved in a resident-to-resident altercation; - No injuries noted for either resident; - Administrator notified of the incident. During an interview on 03/05/25 at 2:30 P.M., the Regional Nurse Consultant said she would expect nursing staff to document when medications were given and to follow the physician's orders. During an interview on 03/07/25 at 4:45 P.M., the Administrator said she would expect nursing staff to follow physician's orders. 45872 48532

Based on observation, interview, and record review, the facility failed to implement, monitor and modify interventions to maintain acceptable parameters of nutritional status for two residents (Residents #19 and #40) out of four sampled residents. The facility census was 54. Review of the facility's policy titled, Weight Assessment and Intervention, dated March 2022 showed: - Resident weights are monitored for undesirable or unintended weight loss or gain; - Residents are weighed upon admission and at intervals established by the interdisciplinary team; - Any weight change of 5% or more since the last weigh assessment is retaken the next day for confirmation; - Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time; - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. one month - 5% weight loss is significant; greater than 5% is severe; b. three months - 7.5% weight loss is significant; greater than 7.5% is severe; c. six months - 10% weight loss is significant; greater than 10% is severe; - If the weight is desirable, this is documented; - An undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met; - The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia (reduction in appetite and food intake), weight loss or increasing the risk of weight loss. 1. Review of Resident #19's medical record showed: - admitted on [DATE]; - Diagnoses of anemia (low red blood cells), heart failure (when the heart muscle is weakened and cannot pump blood effectively), hypertension (high blood pressure), anxiety, and depression; - An order for a regular diet, mechanical soft texture, thin liquids, dated 01/09/25; - No order for a health shake. Review of the resident's weights showed: - On 11/14/24, 148.0 pounds (lbs.); - On 12/05/24, 145.4 lbs. - On 01/09/25, 140.0 lbs. - On 02/07/25, 136.0 lbs. - On 03/06/25, 138.0 lbs. - From 11/14/24-02/07/25, the resident had a severe weight loss of 8.11% in three months. Review of the resident's RD Nutritional Assessment, dated 12/04/24, showed: - A recommendation to add ice cream two times daily. Review of the resident's RD Assessment and Recommendations, dated 01/09/25, showed: - A health shake/house supplement two times daily. Review of the resident's RD Assessment and Recommendations, dated 02/17/25, showed: - Add a health shake/house supplement two times daily and provide encouragement to improve intake. The facility failed to address the RD recommendations. Observations on 03/05/25 at 12:24 P.M., 03/06/25 at 12:08 P.M., and 03/07/25 at 12:19 P.M., showed the resident with a divided plate and ate 50% of the meal with no assistance. Staff did not encourage the resident to eat his/her meals. Ice cream nor health shakes were provided to the resident. 2. Review of Resident #40 medical record showed: - admitted on [DATE]; - Diagnoses of hypertension, gastrointestinal esophageal reflux disease (GERD-a stomach acid being forced back into the throat region), diabetes mellitus (DM- a condition that affects the way the body processes blood sugar), and congestive heart failure (CHF); - An order for a regular diet, regular texture, no concentrated sweet (NCS) for diabetes mellitus, dated 06/05/24; - No order for a health shake. Review of the resident's weights showed: - On 10/07/24, 186.6 lbs.; - On 11/04/24, 184.6 lbs.; - On 12/05/24, 183.4 lbs.; - On 01/09/25, 175.4 lbs.; - On 02/07/25, 163.2 lbs.; - On 03/06/25, 166.0 lbs. - From 01/09/25 - 02/07/25, the resident had a severe weight loss of 6.9% in one month; - From 10/07/24 - 03/06/24, the resident had a severe weight loss of 11.3% in six months. Review of the resident's RD Assessment and Recommendations, dated 01/15/25, showed: - Increase the health shake from two times daily to three times daily and to discontinue the low concentrated sweet diet to allow more food choices. Review of the resident's RD Assessment and Recommendations, dated 02/10/25, showed: - Liberalize the diet to a regular diet due to weight loss, increase the health shake to three times daily, and provide encouragement at meals. The facility failed to address the RD recommendations. Observations on 03/06/25 at 12:10 P.M., and on 03/07/25 at 12:16 P.M., showed the resident ate 100% of his/her meal and the ice cream provided with the meal. During an interview on 03/07/25 at 11:00 A.M., the Regional Nurse Consultant said staff weigh the residents. If there was a discrepancy, then the resident was weighed the next day to validate the weight. Nursing was notified and the nursing department would notify the provider of the weight loss. After the RD visited the facility, he/she sent a report to the facility, and the nursing department followed up with the provider with any recommendations. During an interview on 03/07/25 at 3:07 P.M., the Dietary Manager (DM) said he/she received a weight variance report from the RD after his/her facility visit. The DM could look at the residents' medical records after nursing had put the orders in for diet changes and/or supplements. 48532

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three medication carts. This practice had the potential to affect all residents. The facility census was 54. The facility did not provide a policy on narcotic reconciliation documentation. 1. Review of the 100 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 A.M.-6 P.M. shift on 02/03/25-02/24/25, the staff missed 13 out of 44 opportunities to reconcile the narcotic medications; - For 6 A.M.-6 P.M. shift on 02/25/25-03/07/25, the staff missed 6 out of 21 opportunities to reconcile the narcotic medications. 2. Review of the 200 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 P.M.-6 A.M. shift on 02/10/25-03/07/25, the staff missed 22 out of 47 opportunities to reconcile the narcotics medications. 3. Review of the 300 Hall Medication Cart Narcotic Count Log for Controlled Substances showed: - For 6 A.M.-6 P.M. shift on 02/15/25-03/07/25, the staff missed 20 out of 42 opportunities to reconcile the narcotic medications. 4. Review of the Medication Room Narcotic Count Log for Controlled Substances showed: - For 6 A.M.-6 P.M. shift on 01/23/25-02/10/25, the staff missed 10 out of 35 opportunities to reconcile the narcotic medications; - For 6 P.M.-6 A.M. shift on 02/10/25-02/27/25, the staff missed 13 out of 35 opportunities to reconcile the narcotic medication; - For 6 A.M.-6 P.M. shift on 02/28/25-03/07/25, the staff missed 4 out of 13 opportunities to reconcile the narcotic medications. During an interview on 03/07/25 at 3:47 P.M., Licensed Practical Nurse (LPN) D said two staff members, the on-coming and off-going staff, count the narcotic medications in the cart or the medication room and signed the narcotic log book. During an interview on 03/07/25 at 4:30 P.M., the Regional Nurse Consultant said the on-coming and off-going staff should count the narcotic medications together and sign the narcotic count log. During an interview on 03/07/25 at 4:35 P.M., the Administrator said the on-coming staff and off-going staff should do a narcotic medications reconciliation and sign the narcotic log book.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of a psychotropic (medications that affect a person's mental status) medication for three residents (Residents #1, #15, and #20) out of five sampled residents. The facility census was 54. Review of the facility's policy titled, Antipsychotic (a medication that affects the brain activities associated with mental processes and behavior) Medication Use, revised July 2022, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations); b. Schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions); c. Schizophreniform disorder (a mental illness similar to schizophrenia but symptoms last for a shorter period); d. Delusional disorder (a mental disorder marked by false beliefs); e. Mood Disorders (any mental disorder with a disturbance of mood) (e.g. bipolar disorder (a mental disorder that causes unusual shifts in mood), depression with psychotic features (combination of a loss of interest with hallucinations and delusions), and treatment refractory major depression (depression does not respond to standard treatments); f. Psychosis in the absence of dementia (a state where an individual experiences a loss of touch with reality, marked by symptoms like delusions and hallucinations, without dementia); g. Medical illness with psychotic symptoms and/or treatment related psychosis or mania (state of extreme highs such as intense energy and excitement); h. Tourette's Disorder (a neurological disorder that causes people to make sudden, involuntary movements or sounds); i. Huntington's Disease (a genetic progressive brain disorder that causes nerve cells to break down, leading to uncontrolled movements); j. Hiccups (not induced by other medications); or; k. Nausea and vomiting associated with cancer or chemotherapy; - Diagnoses alone do not warrant the use of antipsychotic medication. In addition, to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; and: 1. the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or; 2. behavioral interventions have been attempted and included in the plan of care, except in an emergency; - Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying alone that is not related to depression or other psychiatric disorders, fidgeting, nervousness, uncooperativeness. 1. Review of Resident #1's March 2025 Physician's Order Sheet (POS) showed: - admission date of 03/13/23; - Diagnoses of Alzheimer's disease (a disease that destroys memory and other important mental functions), anxiety disorder, major depressive disorder (long-term loss of pleasure or interest in life), and unspecified dementia without psychosis (memory loss where the specific underlying cause cannot be identified); - An order for Seroquel (an antipsychotic medication) 25 milligram (mg) by mouth at bedtime for unspecified dementia, dated, 08/08/24; - The facility did not provide an appropriate diagnosis for the Seroquel. 2. Review of Resident #15's March 2025 POS showed: - admission date of 03/14/24; - Diagnoses of atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and dementia; - An order for Seroquel 37.5 mg by mouth two times a day for behaviors, dated 06/28/24; - The facility did not provide an appropriate diagnosis for the Seroquel. 3. Review of Resident #20's March 2025 POS showed: - admission date of 06/14/24; - Diagnoses of major depressive disorder and dementia; - An order for Seroquel 25 mg by mouth two times a day for psychosis, dated 01/03/25; - The facility did not provide an appropriate diagnosis for the Seroquel. During an interview on 03/07/25 at 4:50 P.M., the Regional Nurse Consultant said dementia was not an appropriate diagnosis for Seroquel. During an interview on 03/07/25 at 4:50 P.M., the Administrator said dementia was not an appropriate diagnosis for Seroquel.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 54. Review of the facility's policy titled, Refrigerators and Freezers, dated November 2022, showed: - The facility will ensure safe refrigerator and freezer temperatures, and sanitation, and will observe food expiration guidelines; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Food service supervisors or designated employees check and record refrigerator and freezer temperatures with first opening and at closing in the evening; - Use by dates are completed with expiration dates on all prepared food in refrigerators; - Expiration dated on unopened food and observed and use by dates are indicated once food is opened. Review of the facility's policy titled, Food Preparation and Service, dated November 2022, showed: - Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices; - When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy; - Proper hot and cold temperatures are maintained during food distribution and service; - The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition service staff; - The policy did not address food temperature tracking sheets for meals served. Review of the facility's policy titled, Sanitation, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All kitchens, kitchen areas, and dining areas are kept clean, free of garbage and debris, and protected from rodents and insects; - All equipment, food contact services, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Observation on 03/04/25 at 9:22 A.M., of the meal time food temperature logs showed: - No food temperature logs for 02/22/25 - 03/04/25, with 42 missed opportunities out of 42 opportunities. Observation on 03/04/25 at 9:22 A.M., of the refrigerator temperature logs showed: - No refrigerator temperature logs for 03/01/25 - 03/04/25, with eight missed opportunities out of eight opportunities. Observation on 03/04/25 at 9:28 A.M., of refrigerator 1 showed: - A bag of opened biscuits undated and not labeled; - Four bags of frozen pancakes undated and not labeled; - A large opened bag of French fries undated. Observations on 03/04/25 at 9:39 A.M., and 03/05/25 at 9:51 A.M., of the dishwasher machine showed a build up of debris, crumbs, and a hard white substance on the top surface. Observation on 03/05/25 at 9:34 A.M., of the refrigerator near the Dietary Manager's (DM) door showed: - A clear container of red jello undated and not labeled; - An opened bag of boiled eggs undated and not sealed; - A bag of shredded cheese opened and undated; - A half-used stick of butter opened, unwrapped, undated, and not sealed. During an interview on 03/05/25 at 10:31 A.M., the DM said the food temperature logs should be checked with each meal. The refrigerator temperature logs should be checked daily. The kitchen equipment should be cleaned daily and as needed. All foods should be labeled, dated, and secured to prevent any type of contamination. During an interview on 03/05/25 at 10:37 A.M., the Registered Dietician (RD) said food temperatures should be checked before each meal. The refrigerator temperatures should be checked and logged daily per policy. The kitchen equipment should be cleaned on a daily basis for sanitary purposes. All foods should be labeled, dated, and secured to prevent any type of contamination. During an interview on 03/05/25 at 10:52 A.M., the Administrator said she would expect kitchen staff to check food temperature logs before serving the food to the residents. Refrigerator temperature logs should be checked every day by the kitchen staff. The kitchen equipment should be clean at all times. All foods should be labeled, dated, and secured to prevent any type of contamination.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) out of four sampled residents was free of misappropriation of his/her property when Housekeeper A utilized the resident's bank card for his/her own personal use. The facility census was 57. The administration was notified on 01/26/25 of the Past Non-Compliance which occurred between 01/25/25 through 01/26/25. On 01/26/25, upon notification, the facility administration started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. The non-compliance was corrected on 01/26/25, as the facility completed disciplinary action for Housekeeper A, in-serviced all staff on the facility's policy and procedures on misappropriation and refunded Resident #1 for the amount misappropriated. Review of the facility's policy titled, Abuse Prevention Program, revised September 2021, showed: -Misappropriation of resident property defined as deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent; -Employees are educated on the Abuse Prevention Program upon hire and annually. 1. Review of Resident #1's face sheet showed: - admitted on [DATE]; - Diagnoses of type 2 diabetes mellitus (high blood sugar), emphysema (enlargement of the air sacs in the lungs making breathing difficult), urinary retention, and ventricular tachycardia (irregular electrical signals to the heart causing the heart to beat too fast in the lower chambers). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 12/20/24, showed no cognitive impairment. Review of the facility's investigation dated, 01/26/25, showed: -On 01/26/25, Resident #1's family member notified the facility Director of Nursing (DON) he/she was made aware by residents bank multiple transactions were made over two days, on 01/25/25 and 01/26/25. DON reported the incident to the Administrator and assisted family with notifying the police. Resident #1's family filed a complaint with the police department and while in the facility, resident's family spoke with the bank and provided dates, times, and location where the card had been used. Police were able to obtain video footage from the gas station ATM (automatic teller machine) where the card had been used and it correlated with the times provided by the bank showing Housekeeper A utilizing the card at the ATM. Resident #1 was assessed and at baseline and felt safe in the facility and wished to stay. Alleged perpetrator was suspended, by contract company and termination pending the company receiving the police report. Staff were immediately in-serviced regarding abuse, neglect, and exploitation. Restitution to be made to Resident #1's account. Facility obtained interviews from residents and staff regarding the alleged incident. Facility was unable to interview the alleged perpetrator as he/she exited the facility when the police officer showed up. Review of the police report dated 01/26/25 showed: -Resident #1 and family member noticed money missing from resident's bank account and contacted the facility and the police department; -Resident #1's family contacted the bank to inquire about the money and were given the times and dates the card was used at a gas station ATM on 01/25/25 and 01/26/25; -Police received permission from gas station to review video footage on the dates and times provided by the bank and Housekeeper A was identified on the video footage by facility Administrator; -Administrator reviewed facility camera footage and Housekeeper A identified going into Resident #1's room, exiting the room and proceeding down the hall then leaving the facility. Approximately 9 minutes later, Housekeeper A observed on the gas station video at the ATM; -The transactions were estimated to be $2544.55 with ATM fees; -Administrator told police department Housekeeper A left the facility upon her arrival for the investigation and had not returned. During an interview on 02/04/25 at 12:46 P.M., Police Officer said the department will be pursing charges against Housekeeper A for stealing. Review of Housekeeper A's personnel file showed: - Abuse Prevention Program Policy signed on 12/19/24. During an interview on 02/04/25 at 9:30 A.M., Dietary Aide C said Housekeeper A asked him/her on 01/25/25 after he/she finished prepping lunch to take her to the gas station so he/she could take money off his/her work card to bail his/her brother out of jail. Dietary Aide C said Housekeeper A took out a red card and proceeded to take money out of the ATM. Dietary Aide said in the car, Housekeeper A counted approximately $1200 he/she had taken out of the ATM and again said he/she had to bail his/her brother out of jail. Dietary Aide C said he/she had no knowledge Housekeeper A was utilizing a resident's card. During an interview on 02/04/25 at 9:45 A.M., Housekeeper B said on 01/25/25 at approximately 11:29 A.M., Housekeeper A sent a texted asking to take him/her to the gas station to meet his/her child's father. Housekeeper B said he/she took Housekeeper A to the gas station and saw him/her use the ATM. Housekeeper B observed Housekeeper A count out approximately $1200. Housekeeper B said he/she had no knowledge the card being used by Housekeeper A did not belong to him/her. During an interview on 02/04/05 at 12:00 P.M., Resident #1 said he/she never gave any staff access or permission to use his/her card. Resident #1 said his/her family received a notification regarding a large money withdrawal, which is how he/she realized the card was stolen. Resident said his/her card was red and he/she only uses the card at the facility to make purchases mainly out of the vending machine. Resident said the card must've been taken out of his/her wallet while he/she was sleeping or out of his/her room. During a phone interview on 02/04/05 at 12:27 P.M., Housekeeper A said he/she is being accused of stealing because he/she goes to the gas station almost every day for lunch. Housekeeper A said he/she will be getting a lawyer. Housekeeper A denied taking Resident #1's card and using it at the gas station ATM. Housekeeper A said he/she did not count money in the car in front of Housekeeper B or Dietary Aide C. During a phone interview on 02/04/05 at 12:46 P.M., Police Officer said the police department will be pursuing charges against Housekeeper A for stealing. During an interview on 02/04/25 at 1:30 P.M., the Administrator said he/she would expect facility staff to follow the Abuse Prevention Program policy. Administrator said facility staff should not use a resident bank card to make personal purchases. Complaint #MO00248600

U4413 Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for 12 residents (Resident #9, #17, #18, #26, #27, #28, #29, #30, #31, #32, #33 and #34). The facility staff failed to obtain written authorization from the resident and/or financial guardian for money withdrawn for five residents (Resident #1, #2, #3, #6 and #7) out of a sample of seven. Facility staff also failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner, which did not allow the resident/financial guardian the right to manage all of his/her financial affairs for five residents (Resident #2, #3, #4, #6 and #9) out of a sample of five. The facility census was 53. 1. Record review of the facility maintained Accounts Receivable Aging Report, dated 12/05/24, showed the following residents with personal funds held in the facility operating account. Resident Amount Held in Operating Account #9 $0.04 #17 $186.00 #18 $4,104.00 #26 $1,882.00 #27 $2,496.00 #28 $992.00 #29 $480.00 #30 $100.00 #31 $2,670.00 #32 $1,368.00 #33 $600.00 #34 $392.00 Total $15,270.04 During an interview on 12/05/24 at 3:30 P.M., the Interim Administrator said Resident #27's refund was requested in September 2024, Resident #29's refund was requested on 08/28/24, and Resident #33's refund had been requested twice and did not know why it has taken so long for the credits to be refunded. Resident #9, #17, #18, #26, #28, #30, #31, #32 and #34's credit should be refunded and did not know why they had not been refunded. 2. Record review of the facility maintained Resident Trust Transaction History for the period 06/01/24 through 12/05/24, showed the following withdrawal for 10/2024 room & board from Resident #1's account listed twice: Date Amount Description 10/04/24 $1,125.00 10/2024 Room & Board 10/10/24 $1,125.00 10/2024 Room & Board Record review on 12/05/24 of the facility maintained paperwork for Resident #1's Resident Trust Transaction History, showed no written authorization by Resident #1 and/or financial guardian for the duplicate withdrawal. During an interview on 12/05/24 at 4:42 P.M., the Business Office Manager said there was no written authorization for Resident #1's duplicate withdrawal and the October 2024 room and board should only be withdrawn one time. 3. Record review of the facility maintained Resident Trust Transaction History for the period 06/01/24 through 12/05/24, showed the following withdrawal from Resident #2's account: Date Amount Description 10/17/24 $31.48 Room & Board Given Record review on 12/05/24 of the facility maintained paperwork for Resident #2's Resident Trust Transaction History, showed no written authorization by Resident #2 and/or financial guardian for the withdrawal. During an interview on 12/05/24 at 4:42 P.M., the Business Office Manager said there was no written authorization for Resident #2's listed withdrawal. 4. Record review of the facility maintained Resident Trust Transaction History for the period 06/01/24 through 12/05/24, showed the following withdrawals from Resident #3's account: Date Amount Description 07/31/24 $848.00 July Room & Board 07/31/24 $34.94 Cigarettes 10/29/24 $36.03 Cigarettes 10/31/24 $50.00 Walmart Shopping 10/31/24 $50.00 Walmart Shopping Record review on 12/05/24 of the Cost Summary Settlement Report provided by Missouri Medicaid showed no room and board due for 07/2024 for Resident #3 due to a hospitalization stay. Record review on 12/05/24 of the facility maintained paperwork for Admission/Discharges Report dated 12/05/24 shows Resident #3 discharged to Missouri Delta Medical Center on 06/22/24. Record review on 12/05/24 of the facility maintained paperwork for Resident #3's Resident Trust Transaction History, showed no written authorizations by Resident #3 and/or financial guardian for the withdrawals. During an interview on 12/05/24 at 8:33 A.M., the Interim Administrator said he/she and the Business Office Manager had been working on the financials and were still working on them. During an interview on 12/05/24 at 5:10 P.M., the Interim Administrator said there was no written authorization for Resident #3's listed withdrawals. 5. Record review of the facility maintained Resident Trust Transaction History for the period 06/01/24 through 12/05/24, showed the following withdrawal from Resident #6's account: Date Amount Description 07/31/24 $1,600.00 July Room & Board Record review on 12/05/24 of the facility maintained paperwork for Resident #6's Resident Trust Transaction History, showed no written authorization by Resident #6 and/or financial guardian for the withdrawal. During an interview on 12/05/24 at 5:06 P.M., the Interim Administrator said the $1,600.00 should be credited back to Resident #6's account. 6. Record review of the facility maintained Resident Trust Transaction History for the period 06/01/24 through 12/05/24, showed the following withdrawal from Resident #7's account: Date Amount Description 10/31/24 $300.00 Fall/Winter Clothing Record review on 12/05/24 of the facility maintained paperwork for Resident #7's Resident Trust Transaction History, showed no written authorization by Resident #7 and/or financial guardian for the withdrawal. During an interview on 12/05/24 at 4:19 P.M., the Business Office Manager said the $300.00 was not a valid withdrawal and needs to be credited back to Resident #7's account. 7. Record review of the facility maintained Resident Trust Transaction History for the period 06/01/24 through 12/05/24, showed the following residents did not receive the $50 Social Security/Medicaid monthly allowance timely for 10/2024 or 11/2024: Resident # Amount Received Month #2 $0 11/2024 #3 $0 11/2024 #4 $0 10/2024 & 11/2024 #6 $0 11/2024 #9 $0 11/2024 During an interview on 12/05/24 at 4:20 P.M., the Regional Accountant and Business Office Manager said the books had not been closed for 11/2024 and allowances were not given.

U4413 Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 34 residents. The census was 53. 1. Record review of the facility maintained bank statements for the account ending in 2107 for the months 12/2023 through 11/2024 showed no documentation of reconciliations for the following months. Month 12/2023 06/2024 07/2024 09/2024 10/2024 11/2024 Record review of the facility maintained attempted reconciliation forms for account ending in 2107, dated 12/2023 through 09/2024, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of the attempted reconciliation and showed no attempted reconciliation for 10/2024 through 11/2024. During an interview on 12/05/24 at 11:46 A.M., the Regional Accountant and Business Office Manager said 10/2024 and 11/2024 books had not been closed out and 10/2024 books are still being worked on. During an interview on 12/05/24 at 12:10 P.M., the Regional Accountant said the 10/2024 and 11/2024 reconciliations were not done due to the amount of financial work.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to decrease the risk of a resident, with impaired judgement and decision making skills, from leaving the premises unsupervised when one resident (Resident #1) out of three sampled residents exited the facility without staff awareness. The facility failed to recognize the resident as missing for over eight hours. The resident was found eleven hours after exiting the facility, across from the facility, on the other side of a busy railroad track lying on the muddy ground. The facility census was 59. The Administrator was notified on 04/15/2021 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 04/14/2021. The IJ was removed on 04/15/2021, as confirmed by surveyor onsite verification. 1. The facility's Elopement Precautions/Missing Resident Policy, dated 2007 showed: - An objective of prevention of resident leaving facility without supervision when assessed to be an elopement risk and measures to take when a resident is found missing; - A resident will be considered an elopement risk when unsafe to leave the facility without supervision and: - Have a history of elopement; - Attempted elopement; - Give verbal indicators that they have intent to leave; - Demonstrate elopement behavior or there is an elopement incident. - Residents who are considered an elopement risk are to have their whereabouts confirmed at least every 30 minutes. Residents who are demonstrating agitation and elopement attempts are to remain under constant surveillance until the period of agitation resolves. Increased where about checks shall be maintained until staff is assured the resident is thoroughly redirected and it is safe to return to 30 minute checks; - Residents who continually demonstrate periods of agitation and elopement and do not suffer from dementia, who are able to manipulate the alarms and the exits, and who are unsafe to leave without assistance, shall be considered for discharge to a more secure environment pending consultation with physician, family legal authority, case manager if appropriate, and the interdisciplinary team of the facility. The facility's Missing Persons Policy dated 3/2019, showed the following: - If identified at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety; - If a resident is missing, initiate the elopement/missing resident emergency procedure: - Determine if the resident is out on an authorized leave or pass; - If the resident was not authorized to leave, initiate a search of the building and premises; - If the resident is not located, notify the Administrator, the Director of Nurses (DON), the resident's legal representative, the Attending Physician, law enforcement officials, and as necessary volunteer agencies; - If a resident is found to be missing, the charge nurse is to be immediately notified and an immediate search of the facility is to occur followed by a search of facility grounds. At the same time, the status of each alarmed and secured door shall be verified. If the resident is not located within 15 minutes, the Administrator and/or the Director of Nurses is to be notified and all available staff will begin a fanned out search. Any hazards that are close to the facility are to be assigned for monitoring by a searching person and would include highways, lakes or [NAME], drop-off s, etc., where practicable; - If the resident is not located within 30 - 45 minutes, the local authorities are to be notified for assistance. The family is to be notified and may wish to provide assistance or may have knowledge of the resident's whereabouts. The charge nurse/s will remain available in the facility and shall provide the authorities with a picture and other pertinent information. Any information about where the resident might try to go should be conveyed, i.e. location of prior living arrangements, family location, past habits such as spending long periods of time in a local establishment, church, etc. Charge nurse should verify the status of the resident's condition and medication requirements depending on the time that is lapsing. Issues such as an insulin dependent diabetic who is approaching mealtime and other significant medication requirements should be understood by the charge nurse and conveyed; - As soon as is reasonable and practical, family, legal authority, case manager, state required agencies and Health Facility Management Corporation representative are to be notified. The facility shall use the ABUSE PREVENTION PROGRAM for investigation and follow-up; - When it is necessary to call in law enforcement authorities to search for a missing resident, further resources to be used for the search will be under their direction. The use of dogs with special training for discovery, aerial support services, etc. will be at their request and direction. The facility will maintain contact with the authorities until the resident is found; - Any time a resident has an elopement incident that is not managed by existing facility resources and care plan interventions, additional assessment and additional care planning is required. 2. Record review of Resident #1's medical record showed an admitted [DATE] and a legal guardian appointed on 7/6/20. Record review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 1/17/21, showed: - Supervision with setup help only for ambulation; - Balance not steady but able to stabilize him/herself; - Impairment on one side of upper and lower extremities; - Brief Interview for Mental Status (BIMS) of 15 (a score of 13-15 indicates cognitively intact); - No behaviors; - Does not wander. Record review of Resident #1's Physician Order Sheet (POS) dated April, 2021 showed the following: - Diagnoses included [CONDITION(S)], seizures, major depressive disorder, dementia, diabetes, history of alcohol abuse, [CONDITION(S)], vitamin deficiencies, general idiopathic epileptic syndrome (([NAME]) is a group of epileptic disorders that are believed to have a strong underlying genetic basis. Patients with an [NAME] subtype are typically otherwise normal and have no structural brain abnormalities). - The following medications to be given at 8:00 A.M.: -1 multivitamin -Vitamin B 100 milligrams (mg) -Vitamin D 2,000 mg -[MEDICATION(S)] 10 mg (allergy medication) -[MEDICATION(S)] 1 mg (vitamin) -[MEDICATION(S)] 100 mg (antidepressant) -[MEDICATION(S)] 250 mg (epilepsy medication) -[MEDICATION(S)] 150 mg (antiseizure medication) -[MEDICATION(S)] 10 mg (antiseizure medication) The facility Elopement Risk Sheet dated 1/31/19 and 5/4/19 showed the following: - Resident #1 has dementia; - Never eloped while at home; - Never left the facility without need of supervision; - Never left the facility without informing staff; - Resident #1 not at risk of elopement/wandering at this time. - No additional elopement risk assessments available. Record review of the nurse's notes for Resident #1 showed: - On 2/8/20 resident left the facility without informing staff. After a search of the building and premises, staff observed the resident walking down the road. Staff intervened and educated on safety concerns; - On 4/14/21, at approximately 3:00 A.M., Licensed Practical Nurse (LPN) A went out to the smoking area and Resident #1 was sitting outside smoking. LPN A told the resident he/she wasn't supposed to be outside smoking when it is not a designated smoke break. Resident said he/she knew, took about three more puffs on the cigarette and went inside; - On 4/14/21, at approximately 8:30 A.M., LPN A passed meds on 100 Hall. Resident #1 was not in his/her room. The resident is normally up and about the facility. Bathroom door shut with the light on. LPN A will attempt later; - On 4/14/21 at 11:55 A.M., LPN A got the resident's medications to administer. A staff member asked if he/she had seen the resident. He/she said no, but believed the resident was in the bathroom earlier and was taking medications to the resident now. Resident was not in the room. The Administrator was notified immediately that the resident had not been seen since the early morning. Review of Resident #1's Care Plan dated 2/27/20, showed: - A concern area regarding decision making added 2/20/19 noted the resident was alert and oriented with a history of impaired judgement and decision making. Resident #1 needs to be monitored for safe and adequate decisions and provided assistance to make decisions as needed; - A concern area regarding safety from falls dated 2/20/19, noted his/her history included the resident had been struck by a car and had a stroke. Has [CONDITION(S)], walks with a limp and swings his/her leg out. He/she cannot use his/her left arm; - There were no new interventions implemented following the 2/8/20 incident. - An entry dated 4/14/21 showing the resident left the facility without telling staff. Record review of the facility's investigation completed by the Administrator showed the following time line on 4/14/21: - At 12:15 P.M., code pink (missing person) called and a facility wide and premise search began; - At 12:30 P.M., Social Services Director (SSD) instructed to contact guardian; - At 12:40 P.M., SSD to contact and notify all police agencies of missing person. Staff continued to search; - At 12:50 P.M., Highway Patrol filed missing person report; - At 1:30 P.M., camera footage reviewed. Resident #1 seen leaving the building around 4:04 A.M. exiting the service hall door (laundry room); - At 3:30 P.M., notified the resident found across from the facility on the ground with wet and muddy clothes. He/she was able to get up with assistance. Resident #1 transported to the hospital. Record review on 4/26/21 of a police report dated 4/16/21 showed the following: -Notified of resident's disappearance on 4/14/21 at 1:37 PM; -On the morning of disappearance, the staff that normally administers the medication went to resident's room and assumed the resident was in the bathroom and did not attempt any further contact in the room at that time; -Observation of facility video showed the resident exited the facility through a door on the northeast side of the building. The resident wandered around the parking lot for a short period, then walked behind a residence on the north side of the facility's driveway. The resident continued to walk north in the residence's yard until no longer able to view resident on the video; -Officers from several agencies, along with other First Responders and civilians searched the area, beginning at the facility and widening out as the search continued. After approximately two hours of searching, the resident was found at the edge of a field, across the railroad tracks, approximately 150 yards south east of the facility. He/she was laying on the ground and had a significant amount of mud on his/her clothing. The resident was alert and oriented and did not complain of any possible injuries. An ambulance was dispatched to transport the resident to the hospital for medical evaluation due to his/her exposure to the overnight rain in the area. Observation on 4/15/21 of the facility security camera footage on 4/14/21 at 4:02 A.M., showed Resident #1 walked out of the laundry room exit door toward the north parking lot. During an interview on 4/15/21 at 9:45 A.M., LPN A said he/she worked 2:00 A.M. to 2:00 P.M. on 4/13/21-4/14/21. There was nothing unusual reported on Resident #1 from the previous shift. LPN A said at 2:45 A.M. he/she went outside to smoke and found Resident #1 outside smoking unsupervised. LPN A told Resident #1 he/she could not be outside smoking without a staff member. LPN A did not know how Resident #1 got a lighter, cigarettes or outside to the smoke area. LPN A did not investigate or follow up on the incident. Resident #1 took a few more puffs on his/her cigarette and went back inside. LPN A said the resident did not appear upset or angry. LPN A said after the smoke break he/she performed normal work duties and saw nothing out of the ordinary. At 5:00 A.M., he/she started taking blood sugars and passing 6:00 A.M. medications. Resident #1 had no 6:00 A.M. medications, but his/her roommate did. Resident #1 was not in his/her room, but that was not unusual as the resident is often up early walking around and talking to people. At 8:30 A.M., LPN A entered Resident #1's room to administer his/her 8:00 A.M. medications. Resident #1 was not in his/her room, but the bathroom light was on and door closed. LPN A thought Resident #1 was in the bathroom, so he/she made a note to return later to administer medications. LPN A did not speak through the door or knock to see if Resident #1 would answer. LPN A returned to his/her other duties. At 11:50 A.M., LPN A remembered Resident #1 needed medication. Once LPN A discovered Resident #1 was still not in his/her room and no one had seen him/her, all on duty staff performed a quick preliminary search, LPN A contacted the Administrator and a Code Pink was called. During an interview on 4/15/21 at 11:45 A.M., the Maintenance Supervisor said he/she was asked by another staff member if he/she had seen Resident #1. The Maintenance Supervisor realized he/she had not seen the resident and began to check everywhere. After Resident #1 returned to the facility, the resident said he/she fell and dragged himself/herself to where the resident was found. During an interview on 4/15/21 at 2:35 P.M., CNA D said he/she worked 11:00 P.M. to 9:30 A.M. (4/13-4/14). CNA D saw Resident #1 at 3:30 A.M. in his/her room. Resident #1 had been up all night and is often up all night. At 5:00 A.M. CNA D went back into Resident #1's room to assist the resident's roommate. Resident #1 was not in the room which did not concern CNA D because of him going back and forth to the lobby. During an interview on 4/15/21 at 2:40 P.M., CNA E said he/she worked 11:00 P.M. to 9:30 A.M. (4/13-4/14). Resident #1 was in the lobby when CNA E arrived for work. The resident was walking back and forth past the nurses station. CNA E last saw the resident at 3:30 A.M. The resident was in a good mood and never mentioned leaving. CNA E did not see the resident after that time but remembered LPN A saying something about the resident being outside smoking and told him/her to go in. During a telephone interview on 4/20/21 at 9:00 A.M., Police Officer (PO) A said the resident was found on 4/14/2021 at 3:30 P.M., on his/her back on the east (farthest) side of the railroad tracks. The resident was wet and muddy but had no visible wounds or bruises. The resident said he/she went for a walk and fell . During a telephone interview on 4/27/21 at 8:52 A.M., Certified Nurse Aide (CNA) J said Resident #1 was alert and oriented and would visit with the other residents. The resident was fairly independent but would ask for help with his/her belt sometimes. The resident used to stay in bed all night but does not do that any longer. The staff should do bed checks every two hours or how ordered. During a telephone interview on 4/27/21 at 8:56 A.M., LPN K said Resident #1's activities varied from day to day. The resident did not always eat breakfast and/or lunch and was ambulatory, alert and oriented. The resident was a smoker and did not participate in activities. Staff should do bed checks every two hours unless they are ordered more often. During a telephone interview on 4/27/21 at 8:45 A.M., the Director of Nursing (DON) said staff should make rounds during their shift every two hours and everyone should keep an eye out for ambulatory residents. During a telephone interview on 4/27/21 at 8:38 A.M., the Administrator said she expected staff to make rounds every two hours with eyes on each resident. Staff should monitor residents that are up and about. The Administrator said the two staff that worked the day shift on Resident #1's hall are no longer employed at the facility. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to 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). Complaint #MO 6