Every finding on record at Current River Rehabilitation & Health Care Center

Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from sexual abuse. Resident #1 had a history of inappropriate sexual contact with Resident #2. On 08/17/26, Resident #1 moved Resident #2's sweater aside, lifted Resident #2's shirt, and touched the resident's breast. The facility subsequently initiated one-to-one supervision of Resident #1. According to staff interviews, on 08/18/26, Resident #1 again approached Resident #2 and touched and rubbed Resident #2's thigh area. After staff intervened, Resident #1 approached Resident #2 again and reached toward Resident #2's thigh while the Administrator was present. The facility's protective interventions did not prevent repeated sexual contact with Resident #2. Resident #2 had severe cognitive impairment and communication limitations and could not provide reliable interview responses regarding the incidents. Resident #2's Significant Other (SO) said the resident was very proper prior to the dementia. He/she said Resident #2 would have been devastated to know another resident had touched him/her like that. The deficient practice impacted one of three sampled residents. The facility census was 46. The Administrator was notified of the immediate jeopardy (IJ) determination on 08/25/26 at 3:25 P.M. The IJ began on 08/17/26. The IJ was removed on 08/25/26 as confirmed by onsite surveyor verification.Review of the facility's Abuse Prevention and Prohibition Policy, dated February 2026, showed residents had the right to be free from abuse, including sexual abuse and abuse by other residents. The policy showed the facility would protect residents from further abuse during an investigation, evaluate and monitor a resident alleged to have abused another resident, and implement interventions to protect residents.Review of the facility's investigation of the 08/17/26 incident showed Certified Nursing Assistant (CNA) A observed Resident #1 open Resident #2's sweater, lift Resident #2's shirt, and grab Resident #2's breast. CNA A redirected Resident #1 into the hallway and then to Resident #1's room. CNA A reported the incident to the nurse at 8:36 A.M. The facility initiated 15-minute checks for Resident #1 at 8:46 A.M. The facility substantiated the allegation of inappropriate physical contact. The facility did not provide any further documentation of an investigation of Resident #1 inappropriately touching Resident #2 past the event which took place on the morning of 08/17/26.Review of Resident #1's medical record showed:admission date of 09/22/25;A diagnosis of dementia (progressive mental deterioration) with behavioral disturbance;Documentation of severe cognitive impairment;The resident lived on the locked behavior unit until 08/18/26. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 06/17/26, showed severe cognitive impairment.Review of Resident #1's care plan showed:A focus initiated on 06/25/26 and revised on 07/01/26 identified allegations of inappropriate behavior. The focus documented the interdisciplinary team (IDT) met on 06/29/26 and discontinued the 15-minute checks effective that date, with a plan to reassess any new behaviors noted by nursing staff;A focus initiated on 08/18/26 identified inappropriate touching of other residents. The goal was for Resident #1 not to inappropriately touch other residents. Interventions initiated on 08/18/26 included temporary placement off the locked behavior unit and a one-to-one sitter until an IDT meeting;Resident #1's sertraline was increased to 50 milligrams (mg) on 08/17/26;The family was informed that, if another incident occurred, Resident #1 would be sent to the hospital for evaluation and placement in an all-male unit would be explored;Other areas of focus included wandering and exit seeking behaviors, dependent on staff for most activities of daily living, and he/she propelled self in a wheelchair for mobility. The care plan did not address a second incident after 08/18/26 or any interventions to continue to protect the safety of other residents once Resident #1 was no longer on 1:1 or 15 minutes monitoring. There were no further interventions regarding monitoring for Resident #1 as he/she no longer had a room on the locked behavior unit. Review of a behavior note dated 08/17/26 at 8:45 A.M. showed CNA A reported assisting Resident #2 to the couch after breakfast on the locked unit. While picking up Resident #2's breakfast tray, CNA A turned and observed Resident #1 groping Resident #2's breasts. The CNA immediately moved Resident #1 away from Resident #2 and checked on Resident #2. Review of a nurse's note dated 08/17/26 at 11:32 A.M. showed the facility initiated one-to-one staff supervision for Resident #1.Review of a progress note dated 08/17/26 at 4:52 P.M. showed a care plan meeting had been scheduled for 08/18/26 at 9:30 A.M.Review of a nurse's note dated 08/17/26 at 12:35 P.M. showed the Director of Nursing (DON) notified the physician that the inappropriate sexual contact with Resident #2 was the second occurrence involving the same resident. The physician had initiated sertraline (antidepressant, also used for sexual behaviors in dementia) 25 mg following the previous occurrence and increased the dose to 50 mg daily.Review of a Social Services note dated 08/18/26 at 9:58 A.M. showed Social Services and the Administrator held a care plan meeting with Resident #1's responsible party and reviewed interventions to promote the safety of Resident #1 and other residents. The facility discussed additional interventions and informed the responsible party that another occurrence could result in Resident #1 being sent to the hospital for evaluation and possible placement in an all-male unit.Review of a behavior note dated 08/19/26 at 5:32 A.M. showed Resident #1 continued to receive one-to-one supervision related to inappropriate touching. Resident #1 asked CNA D, who was providing the supervision, if he/she would perform oral sex or have sex with him/her. When CNA D declined, the resident began touching his/her own body. Resident #1 was unable to provide reliable interview responses due to severe cognitive impairment.2.Review of Resident #2's medical record showed:admission date of 02/01/25;Diagnoses included Alzheimer's disease (progressive mental deterioration) and major depressive disorder (long-term loss of pleasure or interest in life). Review of Resident #2's quarterly MDS, dated [DATE], showed severe cognitive impairment.Review of Resident #2's care plan, revised 08/18/26, showed:Impaired cognitive function/dementia or impaired thought processes;A communication problem due to a hearing deficit and Alzheimer's disease;Risk for a trauma-related emotional and behavioral response related to the recent incident. Interventions included monitoring for signs and symptoms of trauma, documenting findings, and reporting significant changes to the provider. Review of a nurse's note dated 08/17/26 at 12:33 P.M. showed Resident #2's significant other (SO) was notified of an allegation involving another resident inappropriately touching Resident #2's breast. The SO voiced understanding and said this was the second time the incident had occurred. Resident #2 was unable to provide reliable interview responses due to severe cognitive impairment.3. During an interview on 08/25/26 at 10:30 A.M., CNA D said he/she had been told in report on 08/18/26 that Resident #1 made sexual contact with Resident #2 again and had been removed from the unit. CNA D said on 08/14/26 he/she was sitting at the nurse's station with the resident. Resident #1 put his/her hand between CNA D's legs. CNA D pushed the resident's hand away and said no. The resident asked why not, and CNA D told him/her it was inappropriate to touch another person like that. On 08/19/26 CNA D went to wake up Resident #1 and he/she asked if CNA D would have oral sex or sex with him/her. CNA D told Resident #1 no, then the resident began touching his/her own body. CNA D said he/she left the room. During an interview on 08/25/26 at 11:45 A.M., Licensed Practical Nurse (LPN) B said on 08/18/26, the day after the first incident, Resident #2 sat in the hallway while Resident #1 propelled a wheelchair through the hallway. Resident #1 approached Resident #2 and moved his/her hand up Resident #2's thigh. LPN B said Resident #1 touched Resident #2's thigh, and staff intervened before his/her hand reached Resident #2's private area. Staff stood beside Resident #1, and the behavior occurred in approximately one second. The Administrator came to the unit after staff notified the Administrator. LPN B said Resident #1 again attempted to grab Resident #2's leg while the Administrator was present. Staff then removed Resident #1 from the unit. LPN B was unaware of when Resident #1 was removed from 1:1 supervision or of any interventions other than closely monitoring him/her. During an interview on 08/25/26 at 11:50 A.M., CNA A said he/she witnessed the incident on 08/17/26 after assisting Resident #2 to the couch following breakfast. Resident #1 moved a wheelchair toward Resident #2. When CNA A turned to pick up Resident #2's breakfast tray, Resident #1 moved Resident #2's sweater aside, lifted Resident #2's shirt, and touched Resident #2's breast. CNA A said he/she was approximately an arm's length away and immediately redirected Resident #1 into the hallway. CNA A said Resident #1 moved very quickly. CNA A said the next day, 08/18/26, while Resident #1 was receiving one-to-one supervision, Resident #1 went after Resident #2 again. CNA A said CNA C was the staff member who was providing one-to-one supervision was closest to Resident #1 when Resident #1 touched Resident #2's thigh. CNA A described observing Resident #1's hand moving toward Resident #2's private area. CNA A said Resident #1 appeared to target Resident #2 and described the behavior as a pattern. During an interview on 08/25/26 at 12:32 P.M., CNA C, who was assigned to provide Resident #1's one-to-one supervision on 08/18/26, said he/she and LPN B were with Resident #1 in the hallway of the locked behavior unit. Resident #1 propelled a wheelchair through the hallway using the handrails. CNA C looked toward another staff member for approximately one second. When CNA C looked back, Resident #1's hand was between Resident #2's thighs, rubbing Resident #2. CNA C said staff notified the Administrator, who came to the unit and instructed CNA C to remain within five feet of Resident #1. Resident #1 again traveled through the hallway while the Administrator stood behind Resident #1's wheelchair. Resident #1 moved directly toward Resident #2's thigh. Staff then removed Resident #1 from the locked behavior unit. CNA C said he/she was unaware of any other interventions put in place to keep residents safe on the main floor.During an interview on 08/25/26 at 4:15 P.M., the DON said the facility initially placed Resident #1 on 15-minute checks and initiated one-to-one supervision after the Administrator became aware of the occurrence on 08/17/26. Resident #1 had another incident the next day, 08/18/26, while he/she was being monitored, 1:1. The Administrator had the resident removed from the locked behavior unit to a room on the main floor. The DON said Resident #1 was currently receiving 15-minute checks. The DON did not know when the decision was made to take Resident #1 off 1:1 monitoring. The DON was unsure of any plan for Resident #1 to return to the secured unit. The DON was not aware of any other interventions that were put in place to keep the residents of the main floor safe, other than 15 minute checks.During an interview on 08/25/26 at 4:29 P.M., Resident #2's SO said he/she was concerned about the repeated inappropriate sexual contact from Resident #1 to Resident #2. The SO said he/she understands things like this happen when residents are confused, and after the first incident in June he/she felt okay about the facility's response. Now it has happened at least twice, maybe three times. The SO said he/she is scared for Resident #2 and wants the facility to keep the resident safe. He/She does not want another occurrence. He/She had spoken to the Administrator but had not received any information about the actions the facility implemented to keep Resident #2 safe. The SO said Resident #2 had always been very proper and modest before the dementia got bad. He/She said Resident #2 would have been devastated to know another resident had touched him/her like that. During an interview on 08/25/26 at 5:00 P.M., the Administrator said staff were present on 08/17/26 when Resident #1 touched Resident #2's breast and stopped the behavior by separating the residents. The facility placed Resident #1 on one-to-one supervision and changed Resident #1's medication. The Administrator said Resident #1 attempted to touch Resident #2 again while receiving one-to-one supervision. The Administrator did not know the date of the second incident. Staff reported that Resident #1 moved quickly and the behavior occurred while staff were present. Staff then removed Resident #1 from the locked behavior unit. The Administrator said the main floor was not an appropriate placement for Resident #1 because Resident #1 needed a secured, locked unit. He/She said after the first incident in June 2026, they had taken Resident #1 off of 15 minute checks because, after 5 days, he exhibited no other inappropriate behaviors with other residents. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to scope and severity level D. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO3167291

Based on interview and record review, the facility failed to report an allegation of resident to resident sexual abuse to the State Survey Agency in a timely manner for one resident (Resident #2) of three residents sampled. Staff observed Resident #1 fondling Resident #2's thigh area on 08/18/26 and did not report the allegation to the Agency as required. The facility census was 46. Review of the facility's Abuse Prevention and Prohibition Policy, dated February 2026, showed residents had the right to be free from abuse, including sexual abuse and abuse by other residents. The policy showed:-The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation;- The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action including initial reporting to all required agencies;- The facility Administrator, agent or employee, or any other person, will not screen reports or otherwise withhold any reports from the appropriate state agencies and the facility will not establish any rules, criteria, standards, or guidelines to the contrary. Reports shall be made per state agency recommendations for communication. Review of a facility investigation, dated 08/17/26, showed Certified Nursing Assistant (CNA) A observed Resident #1 open Resident #2's sweater, lift Resident #2's shirt, and grab Resident #2's breast. CNA A redirected Resident #1 into the hallway and then to Resident #1's room. CNA A reported the incident to the nurse at 8:36 A.M. The facility initiated 15-minute checks for Resident #1 at 8:46 A.M. The facility substantiated the allegation of inappropriate physical contact. Review of Resident #1's medical record showed:admission date of 09/22/25;A diagnosis of dementia (progressive mental deterioration) with behavioral disturbance;Documentation of severe cognitive impairment;The resident lived on the locked behavior unit until 08/18/26. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 06/17/26, showed severe cognitive impairment. Review of Resident #1's care plan showed:A focus initiated on 06/25/26 and revised on 07/01/26 identified allegations of inappropriate behavior. The focus documented the interdisciplinary team (IDT) met on 06/29/26 and discontinued the 15-minute checks effective that date, with a plan to reassess any new behaviors noted by nursing staff;A focus initiated on 08/18/26 identified inappropriate touching of other residents. The goal was for Resident #1 not to inappropriately touch other residents. Interventions initiated on 08/18/26 included temporary placement off the locked behavior unit and a one-to-one sitter until an IDT meeting;The family was informed that, if another incident occurred, Resident #1 would be sent to the hospital for evaluation and placement in an all-male unit would be explored;Other areas of focus included wandering and exit seeking behaviors, dependent on staff for most activities of daily living, and he/she propelled self in a wheelchair for mobility. Resident #1 was unable to provide reliable interview responses due to severe cognitive impairment. 2.Review of Resident #2's medical record showed:admission date of 02/01/25;Diagnoses included Alzheimer's disease (progressive mental deterioration) and major depressive disorder (long-term loss of pleasure or interest in life). Review of Resident #2's quarterly MDS, dated [DATE], showed severe cognitive impairment. Review of Resident #2's care plan, revised 08/18/26, showed:Impaired cognitive function/dementia or impaired thought processes;A communication problem due to a hearing deficit and Alzheimer's disease;Risk for a trauma-related emotional and behavioral response related to the recent incident. Interventions included monitoring for signs and symptoms of trauma, documenting findings, and reporting significant changes to the provider. Resident #2 was unable to provide reliable interview responses due to severe cognitive impairment. During an interview on 08/25/26 at 11:45 A.M., Licensed Practical Nurse (LPN) B said on 08/18/26, the day after the first incident, Resident #2 sat in the hallway while Resident #1 propelled a wheelchair through the hallway. Resident #1 approached Resident #2 and moved his/her hand up Resident #2's thigh. LPN B said Resident #1 touched Resident #2's thigh, and staff intervened before his/her hand reached Resident #2's private area. Staff stood beside Resident #1, and the behavior occurred in approximately one second. The Administrator came to the unit after staff notified the Administrator. LPN B said Resident #1 again attempted to grab Resident #2's leg while the Administrator was present. Staff then removed Resident #1 from the unit. During an interview on 08/25/26 at 12:32 P.M., Certfied Nurse Aide (CNA) C, who was assigned to provide Resident #1's one-to-one supervision on 08/18/26, said he/she and LPN B were with Resident #1 in the hallway of the locked behavior unit. Resident #1 propelled a wheelchair through the hallway using the handrails. CNA C looked toward another staff member for approximately one second. When CNA C looked back, Resident #1's hand was between Resident #2's thighs, rubbing Resident #2. CNA C said staff notified the Administrator, who came to the unit and instructed CNA C to remain within five feet of Resident #1. Resident #1 again traveled through the hallway while the Administrator stood behind Resident #1's wheelchair. Resident #1 moved directly toward Resident #2's thigh. Staff then removed Resident #1 from the locked behavior unit. During an interview on 08/25/26 at 11:50 A.M., CNA A said on 08/18/26, while Resident #1 was receiving one-to-one supervision, Resident #1 went after Resident #2 again. CNA A said CNA C was the staff member who was providing one-to-one supervision was closest to Resident #1 when Resident #1 touched Resident #2's thigh. CNA A described observing Resident #1's hand moving toward Resident #2's private area. During an interview on 08/25/26 at 4:15 P.M., the Director of Nursing (DON) said he/she was aware Resident #1 had been sexually inappropriate with Resident #2 in June. After the report was made on 08/17/26 the facility initially placed Resident #1 on 15-minute checks and initiated one-to-one supervision after the Administrator became aware of the occurrence on 08/17/26. Resident #1 had another incident the next day, 08/18/26, while he/she was being monitored 1:1. The DON was unaware if anyone from the facility had reported the incident on 08/18/26 to the state agency. During an interview on 08/25/26 at 5:00 P.M., the Administrator said he was aware the resident had a history of inappropriate sexual behaviors with Resident #2 . On 08/17/26, staff was present when Resident #1 touched Resident #2's breast and stopped the behavior by separating the residents. The facility placed Resident #1 on one-to-one supervision and changed Resident #1's medication and he/she reported the incident to the State agency. The Administrator said Resident #1 attempted to touch Resident #2 an additional time while receiving one-to-one supervision. Staff reported to him/her that Resident #1 moved quickly and the behavior occurred while staff were present. Staff then removed Resident #1 from the locked behavior unit. When asked if an investigation had been completed on the contact that happened on 08/18/26, the Administrator said Resident #1 did not make contact with Resident #2 and he/she had a written statement that said that. The Administrator was informed the department had gathered staff interviews contradicting the statement Resident #1 did not touch Resident #2 on 08/18/26. The Administrator said he/she didn't investigate the second incident (08/18/26) or report it because there was nothing to report. The Administrator did not confirm he/she was present during the 08/18/26 incident between Resident #1 and Resident #2. Complaint #MO3167291

Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of resident to resident sexual abuse for one resident (Resident #2) of three residents sampled. Staff observed Resident #1 fondling Resident #2's thigh area on 08/18/26 and did not investigate. The facility census was 46. Review of the facility's Abuse Prevention and Prohibition Policy, dated February 2026, showed residents had the right to be free from abuse, including sexual abuse and abuse by other residents. The policy showed:-The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation;- The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action including initial reporting to all required agencies;- The facility Administrator, agent or employee, or any other person, will not screen reports or otherwise withhold any reports from the appropriate state agencies and the facility will not establish any rules, criteria, standards, or guidelines to the contrary. Reports shall be made per state agency recommendations for communication. Review of the facility's investigation of the 08/17/26 incident showed Certified Nursing Assistant (CNA) A observed Resident #1 open Resident #2's sweater, lift Resident #2's shirt, and grab Resident #2's breast. CNA A redirected Resident #1 into the hallway and then to Resident #1's room. CNA A reported the incident to the nurse at 8:36 A.M. The facility initiated 15-minute checks for Resident #1 at 8:46 A.M. The facility substantiated the allegation of inappropriate physical contact. The facility did not provide any further documentation of an investigation of Resident #1 inappropriately touching Resident #2 past the event which took place on the morning of 08/17/26. Review of Resident #1's medical record showed:admission date of 09/22/25;A diagnosis of dementia (progressive mental deterioration) with behavioral disturbance;Documentation of severe cognitive impairment;The resident lived on the locked behavior unit until 08/18/26. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 06/17/26, showed severe cognitive impairment. Review of Resident #1's care plan showed:A focus initiated on 06/25/26 and revised on 07/01/26 identified allegations of inappropriate behavior. The focus documented the interdisciplinary team (IDT) met on 06/29/26 and discontinued the 15-minute checks effective that date, with a plan to reassess any new behaviors noted by nursing staff;A focus initiated on 08/18/26 identified inappropriate touching of other residents. The goal was for Resident #1 not to inappropriately touch other residents. Interventions initiated on 08/18/26 included temporary placement off the locked behavior unit and a one-to-one sitter until an IDT meeting;The family was informed that, if another incident occurred, Resident #1 would be sent to the hospital for evaluation and placement in an all-male unit would be explored;Other areas of focus included wandering and exit seeking behaviors, dependent on staff for most activities of daily living, and he/she propelled self in a wheelchair for mobility. The care plan did not address a second incident after 08/18/26 or any interventions to continue to protect the safety of other residents once Resident #1 was no longer on 1:1 or 15 minutes monitoring. There were no further interventions regarding monitoring for Resident #1 as he/she no longer had a room on the locked behavior unit. Resident #1 was unable to provide reliable interview responses due to severe cognitive impairment. 2.Review of Resident #2's medical record showed:admission date of 02/01/25;Diagnoses included Alzheimer's disease (progressive mental deterioration) and major depressive disorder (long-term loss of pleasure or interest in life). Review of Resident #2's quarterly MDS, dated [DATE], showed severe cognitive impairment. Review of Resident #2's care plan, revised 08/18/26, showed:Impaired cognitive function/dementia or impaired thought processes;A communication problem due to a hearing deficit and Alzheimer's disease;Risk for a trauma-related emotional and behavioral response related to the recent incident. Interventions included monitoring for signs and symptoms of trauma, documenting findings, and reporting significant changes to the provider. Resident #2 was unable to provide reliable interview responses due to severe cognitive impairment. During an interview on 08/25/26 at 11:45 A.M., Licensed Practical Nurse (LPN) B said on 08/18/26, the day after the first incident, Resident #2 sat in the hallway while Resident #1 propelled a wheelchair through the hallway. Resident #1 approached Resident #2 and moved his/her hand up Resident #2's thigh. LPN B said Resident #1 touched Resident #2's thigh, and staff intervened before his/her hand reached Resident #2's private area. Staff stood beside Resident #1, and the behavior occurred in approximately one second. The Administrator came to the unit after staff notified the Administrator. LPN B said Resident #1 again attempted to grab Resident #2's leg while the Administrator was present. Staff then removed Resident #1 from the unit. LPN B was unaware of when Resident #1 was removed from 1:1 supervision or of any interventions other than closely monitoring him/her. During an interview on 08/25/26 at 12:32 P.M., Certified Nurse Aide (CNA) C, who was assigned to provide Resident #1's one-to-one supervision on 08/18/26, said he/she and LPN B were with Resident #1 in the hallway of the locked behavior unit. Resident #1 propelled a wheelchair through the hallway using the handrails. CNA C looked toward another staff member for approximately one second. When CNA C looked back, Resident #1's hand was between Resident #2's thighs, rubbing Resident #2. CNA C said staff notified the Administrator, who came to the unit and instructed CNA C to remain within five feet of Resident #1. Resident #1 again traveled through the hallway while the Administrator stood behind Resident #1's wheelchair. Resident #1 moved directly toward Resident #2's thigh. Staff then removed Resident #1 from the locked behavior unit. During an interview on 08/25/26 at 11:50 A.M., CNA A said on 08/18/26, while Resident #1 was receiving one-to-one supervision, Resident #1 went after Resident #2 again. CNA A said CNA C was the staff member who was providing one-to-one supervision was closest to Resident #1 when Resident #1 touched Resident #2's thigh. CNA A described observing Resident #1's hand moving toward Resident #2's private area. During an interview on 08/25/26 at 4:15 P.M., the Director of Nursing (DON) said he/she was aware Resident #1 had been sexually inappropriate with Resident #2 in June. After the report was made on 08/17/26 the facility initially placed Resident #1 on 15-minute checks and initiated one-to-one supervision after the Administrator became aware of the occurrence on 08/17/26. Resident #1 had another incident the next day, 08/18/26, while he/she was being monitored 1:1. The Administrator had the resident removed from the locked behavior unit to a room on the main floor. The DON said the Administrator is responsible for investigating allegations. During an interview on 08/25/26 at 5:00 P.M., the Administrator said he was aware the resident had a history of inappropriate sexual behaviors with Resident #2 . On 08/17/26 staff was present when Resident #1 touched Resident #2's breast and stopped the behavior by separating the residents. The facility placed Resident #1 on one-to-one supervision and changed Resident #1's medication and he/she reported the incident to the State agency. The Administrator said Resident #1 attempted to touch Resident #2 an additional time while receiving one-to-one supervision. Staff reported to him/her that Resident #1 moved quickly and the behavior occurred while staff were present. Staff then removed Resident #1 from the locked behavior unit. When asked if an investigation had been completed on the contact that happened on 08/18/26, the Administrator said Resident #1 did not make contact with Resident #2 and he/she had a written statement that said that. The Administrator was informed the department had gathered staff interviews contradicting the statement Resident #1 did not touch Resident #2 on 08/18/26. The Administrator said he/she didn't investigate the second incident (08/18/26) or report it because there was nothing to report. The Administrator did not confirm he/she was present during the 08/18/26 incident between Resident #1 and Resident #2. The facility did not provide documentation of an investigation for the 08/18/26 incident between Resident #1 and Resident #2. Complaint #MO3167291

Based on interview and record review, the facility failed to ensure staff immediately reported allegations of abuse to facility administration for two residents (Residents #1, #2 and #3) and failed to ensure staff immediately reported an injury of unknown origin for one resident (Resident #4), affecting four of four sampled residents reviewed for abuse. These failures delayed implementation of the facility's abuse prevention and investigation process, including resident assessment, protective interventions, and timely collection of investigative information. The facility census was 46. Review of the facility policy titled, Abuse, Prevention and Prohibition Policy, dated February 2026, showed:- Resident abuse must be reported immediately to the Administrator;- The facility's abuse prohibition program included identification, investigation, protection, and reporting/response;- Allegations of abuse required initiation of an investigation, implementation of protective interventions, assessment of the resident, notification of the physician and responsible party, and reporting to required agencies. 1.Review of the facility's investigation, completed 06/26/26, showed:-On 06/23/26, Resident #3 inappropriately touched Resident #1's breasts while Resident #1 was asleep;-Approximately 30 minutes later, Resident #3 reached underneath Resident #2's blanket, and Resident #2 pushed Resident #3's hands away while telling Resident #3 to stop;-Certified Nurse Aide (CAN) B witnessed both incidents and redirected Resident #3;-CNA B did not immediately notify the charge nurse, Director of Nursing (DON), or Administrator;-The incidents were later identified by the DON on 06/25/26 through documentation entered into the electronic medical record alerts. Review of CNA B's written statement, dated 06/26/26, showed CNA B observed Resident #3 inappropriately touching Resident #1 and later found Resident #3 beside Resident #2's bed with a hand underneath the blanket. CNA B redirected Resident #3 during both incidents but did not notify nursing management or Administration when the incidents occurred.Attempted contact with CNA B for interview on 07/01/26 and again on 07/08/26 was unsuccessful.During an interview on 07/01/26 at 12:20 P.M., the DON said no one notified her or the Administrator when the incidents occurred. The DON said she became aware of the allegations only after discovering the electronic medical record alerts approximately two days later. The DON said CNA B should have immediately reported both incidents to the charge nurse or administration so the facility could have initiated its abuse investigation and implemented protective interventions.During an interview on 07/01/26 at 3:00 P.M., the Administrator said CNA B should have immediately reported both incidents to the charge nurse or administration. The Administrator said if the allegations been reported when they occurred, the facility would have immediately initiated an abuse investigation, implemented protective interventions, and increased supervision of Resident #3. The Administrator acknowledged facility protocol requiring immediate reporting of abuse allegations was not followed.2. Review of the facility's investigation, completed 06/29/26, showed:- On 06/29/26 at approximately 8:00 A.M., CNA C and CNA D identified multiple bruises of unknown origin, including bruises resembling handprints on Resident #4;-The CNAs immediately notified Registered Nurse (RN) E and Licensed Practical Nurse (LPN) A; -Neither RN E or LPN A notified the DON or Administrator regarding the bruising on Resident #4;-The DON was not informed during evening shift report, approximately 11 hours later;-Resident #4 transferred to the hospital before the facility initiated an abuse investigation. Review of CNA C's written statement, undated, showed at approximately 8:00 A.M. on 06/29/26, CNA C observed new bruising on Resident #4's arms, behind the knees, and buttocks while providing care. CNA C immediately notified RN E and LPN A.Review of CNA D's written statement, undated, showed CNA D assisted CNA C with Resident #4's care at approximately 8:00 A.M. on 06/29/26, observed bruising on multiple areas of the resident's body, completed a skin audit identifying the bruising, and notified RN E and LPN A.Review of RN E's incident statement, undated, showed:-On 06/29/26 CNAs C and D reported bruising on Resident #4; Date of incident 06/29/26;-Resident #4 assessed, no signs or symptoms of distress. Observations showed bruising of unknown origin;-Bruising also reported to LPN A by CNA's C and D and LPN A took over; Review of LPN A's written statement, dated 06/29/26, showed:-At approximately 8:00 A.M., LPN A overheard CNAs C and CNA D discussing bruises that resembled handprints on Resident #4 with the charge nurse, RN E that was discovered during care;-The CNAs talked about calling the State, and RN E told them they should not call the State until they talked with the DON;-CNA C said she would follow the chain of command;-LPN A continued to provide care to other residents and did not notify the DON or Administrator at that time. Review of Resident #4's Skin Monitoring CNA Shower Review, dated 06/29/26, showed:-Bruising to right posterior upper forearm, left anterior thigh, left posterior thigh, left posterior calf, right anterior wrist;-Body audit: multiple bruises that resembled handprint. Reported to the nurses;-Signed by CNA D;-Forwarded to DON. During a phone interview on 07/01/26 at 12:23 P.M. the DON said LPN A informed her during evening shift report that CNA C and CNA D had discovered bruising earlier that morning on Resident #4. The DON said no one had notified her prior to the shift report. The DON said the Administrator had been in the building throughout the day, and neither she nor the Administrator had been notified. The DON said that by the time she learned of the allegations, Resident #4 had already been transferred to the hospital and could not be assessed as part of the initial abuse investigation.During an interview on 07/01/26 at 1:59 P.M., RN E said CNA C notified him/her at approximately 8:30 A.M. on 06/29/26 that Resident #4 had bruising that resembled handprints. RN E said he/she assessed Resident #4 and observed bruising on the resident's arms and a partial bruise on one thigh. RN E said he/she did not believe the bruising appeared concerning because the resident had fragile skin and received a blood thinner medication. RN E said she did not notify the DON or Administrator of the allegation.During an interview on 07/01/26 at 2:10 P.M., LPN A said at approximately 8:30 A.M. on 06/29/26 he/she was at the nurse's station when CNA C and CNA D told RN E about the bruises on Resident #4. LPN A said CNA C wanted to call State regarding the allegation. RN E told the CNAs to wait and talk to the DON. LPN A said he/she did not go and assess the resident at that time, or contact the DON or the Administrator since the CNAs were discussing Resident#4 with RN E. LPN A said if reports of abuse or bruising is reported to him/her, he/she would expect to assess the resident, and then contact the person above him/her, which would be the RN, then the DON, and then the Administrator.During an interview on 07/01/26 at 3:00 P.M., the Administrator said since he was in the building throughout the day shift on 06/29/26, one of the staff members (nurse or CNAs) should have immediately reported both incidents to him. The Administrator had the allegations been reported when they occurred, the facility would have immediately initiated an abuse investigation, and Resident #4 could have been assessed and/or reassessed at that time. The Administrator acknowledged facility protocol requiring immediate reporting of abuse allegations was not followed.MO3055423, MO3064675 The Administrator was notified on 07/01/26 of the Past Non-Compliance which occurred on 06/23/26. On 06/25/26, facility staff started an investigation, completed disciplinary action, and began in-servicing all staff on abuse policies and procedures and reporting. No additional allegations of resident-to-resident sexual abuse involving Resident #3 were identified after the corrective actions were implemented. The non-compliance was corrected on 06/25/26 regarding reporting abuse. The Past Non-Compliance regarding reporting an injury of unknown origin, which occurred on 06/29/26 at 8:00 A.M. On 06/29/26 at 7:30 P.M., facility staff started an investigation, in-servicing all staff on abuse policies, injuries of unknown origin, and reporting, and skin audits initiated. The non-compliance was corrected on 06/29/26 at 7:30 P.M., 11 hours later, regarding reporting injury of unknown origin.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #1 and Resident #2) out of three sampled residents remained free from abuse when staff failed to immediately report and respond after observing resident-to-resident sexual abuse/inappropriate sexual contact by one resident (Resident #3). Resident #3 inappropriately touched Resident #1's breasts while Resident #1 was asleep and approximately 30 minutes later reached underneath Resident #2's blanket in an attempt to touch Resident #2 inappropriately. Although both incidents were witnessed by Certified Nursing Assistant (CNA) B, the incidents were not immediately reported to nursing management. As a result, the facility failed to promptly initiate an abuse investigation, implement protective interventions, assess the residents, notify required parties, and monitor Resident #3 to prevent additional incidents. The Director of Nursing did not become aware of the allegations until approximately two days later after discovering documentation in the electronic medical record alerts. The facility census was 46.Review of facility's policy titled, Abuse, Prevention and Prohibition Policy, dated February 2026, showed:-Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers;-The facility's abuse prohibition program includes seven components: screening, training, prevention, identification, investigation, protection, and reporting/response;-Prevention: The resident has the right to be free from sexual abuse. Resident behaviors will be monitored for changes, which trigger abusive behaviors;-Investigation: Resident abuse must be reported immediately to the Administrator. While a facility investigation is under way, steps will be taken to prevent further abuse. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process;-Initiate investigation including initial reporting to all required agencies;-A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party;-When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors, and notify the physician for a determination regarding treatment and/or discharge options. Changes in room assignments and seating arrangements will be recommended as needed. The safety of other residents and employees of the facility is of primary concern;-Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual contact includes intentional touching of intimate body parts, either directly or through clothing. Both resident's capacity to consent to a sexual or intimate relationship must be assessed. 1.Review of the facility's investigation report, completed on 06/26/26, showed:- Allegation of sexual abuse;- Initial intervention: On 06/25/26 Resident #3 put on 15 min checks pending an Interdisciplinary Team (IDT) meeting, medical director (MD), durable power of attorney (DPOA) notified, MD made med change, police made aware with case number 2026-0549;- Investigation: On 06/23/26, Resident #1 was asleep on the couch;Resident #3 intentionally pressed/touched Resident #1's breasts;CNA B redirected Resident #3;Approximately 30 minutes later Resident #3 entered Resident #2's room;Resident #3 reached underneath Resident #2's blanket;Resident #2 stopped Resident #3 by pushing the resident's hands away and telling Resident #3 to stop;CNA B redirected Resident #3;CNA B did not immediately notify the charge nurse, DON, or Administrator.Review of CNA B's written statement dated 06/26/26 showed: Incident around 4:00 P.M., found Resident #3 touching Resident #1 on the leg around perineal area and moving up. I grabbed Resident #3's wheelchair and move him to the other side of the dining room and got coffee. Resident #1 was telling Resident #3 no, and had a mad look. Around 5:00 P.M., CNA B went to get Resident #2 up and found Resident #3 beside his/her bed with hand under the blanket. Resident #2 pushed Resident #3 away and put blanket down and said no, go away. CNA B removed Resident #3 from room to dining room. - Conclusion: Resident #3 did touch both residents. The facility concluded Resident #3 was attempting to awaken Resident #1. Resident #3 was educated on abuse and neglect policy and that if he/she was worried about a resident to inform staff. With Resident #2, Resident #3 had his/her hand under the blanket and Resident #2 kept Resident #3's hand from touching him/her inappropriate areas by pushing his/her hands down. When CNA entered room Resident #3 said, oh come on. Resident #3 was redirected. The CNA didn't report this to the Director of Nursing (DON) or Administrator. Incidents found on the alerts section on Electronic Medical Record (EMR);- Final Interventions: Resident educated (Resident has dementia and a BIMS of 5, Resident placed on 15 minute checks pending IDT meeting, all staff educated on reporting A&N, Resident #1 and #2 had skin assessments with no injuries, facility started a past non-compliance (PNC) correction, CNA suspended pending investigation 07/01/26;- Facility failure CNA aware on 06/23/26 of Resident #3 being physical with two female residents Resident #1 and #2. Allegation was Resident #3 was touching Resident #1 and #2 inappropriately on two separate occasions. Resident #3 inappropriately touched Resident #1's breasts. 30 minutes later Resident #3 placed his/her hands under Resident #2's cover, and Resident #2 told him/her to stop;-Action: -Residents #1 and #2 assessed for injury, sample of other memory care residents interviewed if others abused with none found, responsible parties notified, Primary Care Provider notified, trauma informed care completed and will be done weekly for three weeks or longer if behaviors or changes are noted; 06/25/26; Administrator or designee provided staff education prior to working next shift covered abuse, prevention, and prohibition policy, all new staff will have the same info reviewed with them at time of orientation, police report filed 06/25/26 and Qapi meeting held with MD on 06/25/26;-Systemic changes to ensure compliance: Administrator or designee will ask two staff members a day 5 days a week regarding A&N policy to ensure staff are aware of responsibility. Will continue until compliance achieved. Compliance achieved 06/26/26. 2. Review of Resident #1's medical record showed:- An admission date of 02/01/25;- Diagnosis of Alzheimer's disease (progressive mental deterioration), major depressive disorder (long-term loss of pleasure or interest in life);Review of the resident's Care Plan, revised 06/25/26, showed:- Impaired cognitive function/dementia or impaired thought processes;- Resident has a communication problem due to hearing deficit and Alzheimer's;- At risk for trauma-related emotional and behavioral response related to recent incident. Will monitor for signs/symptoms of trauma, document findings, and report significant changes to provider;- Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff), dated 06/17/26, showed severe cognitive impairment;Nurse's note dated 06/25/26 at 12:20 P.M., showed Resident's spouse notified of allegation involving another resident reportedly inappropriately touching resident's breast. Facility started investigation and implemented interventions to ensure resident safety and reduce risk of further incidents. Spouse voiced understanding;Nurse's note dated 06/25/26 at 2:00 P.M., showed Resident identified as being involved in an alleged incident. Investigation initiated by facility. Resident assessed with no concerns. Resident will continue to be monitored for any changes and appropriate notifications made. Resident #1 was unable to provide reliable interview responses due to severe cognitive impairment.3. Review of Resident #2's medical record showed:- admission date of 11/01/25;- Diagnosis of Alzheimer's, dementia with anxiety (persistent worry and fear about everyday situations), need for assistance with personal care, unspecified psychosis (a mental disorder with a severe loss of contact with reality), unspecified dementia without behavioral disturbance;Review of the resident's Care Plan, revised 06/25/26, showed:- Impaired cognitive function/dementia or impaired thought processes;- Resident moved to secured unit due to increased confusion;- Resident has a communication problem with alteration in neurological status;- At risk for trauma-related emotional and behavioral response related to recent incident. Will monitor for signs/symptoms of trauma, document findings, and report significant changes to provider;- Resident has a mood problem due to dementia with anxiety and psychosis;Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff), dated 06/29/26, showed severe cognitive impairment;Nurse's note dated 06/25/26 at 1:00 P.M., showed Resident's power of attorney notified of allegation involving another resident reportedly being in resident's room and inappropriately touching the resident under covers. Investigation started with interventions implemented to ensure resident safety.Nurse's note dated 06/25/26 at 2:00 P.M., showed Resident identified as being involved in an alleged incident. Investigation initiated by facility. Resident assessed with no concerns. Resident will continue to be monitored for any changes and appropriate notifications made. Resident #2 was unable to provide reliable interview responses due to severe cognitive impairment. 3. Review of Resident #3's medical record showed:- An admission date of 09/22/25;- Diagnoses of dementia with behavioral disturbance;Review of the resident's Care Plan, revised 6/29/26, showed impaired cognitive function/dementia or impaired thought processes.-The resident's BIMS score is a five placing him in the impaired cognitive functioning status;-The Resident has allegations for inappropriate behavior with IDT meeting held 06/29/26 to discontinue 15 minute checks and will reassess any new behaviors. Resident started on Zoloft (an antidepressant used off-label in geriatric care to manage neuropsychiatric symptoms of dementia, such as agitation, low mood, and inappropriate behaviors) 25 milligrams (mg) on 06/25/26;- The resident has behavior problem of screaming out and has been observed attempting to trip staff and will refuse care at times. Respond to resident by being calm and talking in a soothing manner with attempting to re-direct. - Uses an NMDA (N-methyl-D-aspartate) receptor antagonist. It is primarily classified as an antidementia agent or central nervous system agent;- Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by the facility staff), dated 06/17/26, showed severe cognitive impairment. - Prior behavior notes dated 10/30/25 of aggression toward staff.Resident #3 was unable to be interviewed due to severe cognitive impairment.Attempted to contact CNA B for interview twice on 07/01/26 and again on 07/08/26 with no return call.During an interview on 07/01/26 at 10:00 A.M., Licensed Practical Nurse (LPN) A said that evening he/she was giving medications on the unit. He/she was at her cart outside of the dining room and noticed the Certified Nursing Assistant (CNA) B moving Resident #3 to the other side of the dining room table and tell Resident #3, lets get you ready for dinner. LPN A said he/she gave CNA B a look to question what was going on and all CNA B said was Resident #3 was trying to touch Resident #1. LPN A moved on with medication administration since CNA B did not indicate there was any concern with the situation. Resident #3 has no history of being inappropriate sexually and only has a history of being physically aggressive with staff and that was only when Resident #3 first moved into the facility. Nothing further was mentioned throughout the remainder of the shift about Residents #1, #2 or #3.During an interview on 07/01/26 at 12:20 P.M., the Director of Nursing (DON) said no one notified her or the administrator of the incidents until the DON came across them on the alerts in the electronic medical chart. As soon as she saw it she notified the administrator and regional office. They contacted CNA B who said Resident #3 was fondling Resident #1's breasts and verified the alerts. They followed protocol and reported it and started Resident #3 on 15 minute checks until the IDT meeting. The CNA was suspended pending investigation and should have reported it immediately. Resident #3 should have been placed on checks immediately to ensure no other incidents occurred and monitor his/her behaviors. During an interview on 07/01/26 at 1:15 P.M., MDS coordinator said the IDT was completed for Resident #3 on 06/29/26 and 15 minute checks stopped due to no other behaviors. She has worked the unit for a year and been back there in her office for the last two months doing MDS and Resident #3 has never had sexual behaviors before.During interview on 07/01/26 at 3:00 P.M., the Administrator stated CNA B should have immediately reported both incidents to the charge nurse or administration. Had the incidents been reported when they occurred, Resident #3 would have immediately been placed on increased supervision, an abuse investigation would have been initiated, and protective interventions would have been implemented. The Administrator acknowledged the facility was unaware of the incidents for approximately two days because CNA B failed to report them and stated facility protocol was not followed.Complaint #3055423The Administrator was notified on 07/01/26 of the Past Non-Compliance which occurred on 06/23/26. On 06/25/26, facility staff started an investigation, completed disciplinary action, and began in-servicing all staff on abuse policies and procedures. No additional allegations of resident-to-resident sexual abuse involving Resident #3 were identified after the corrective actions were implemented. The non-compliance was corrected on 06/25/26.

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. This had the potential to affect all residents. The facility census was 42.Review of the facility's policy titled, Cleaning Schedule, undated, showed: - Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions: Items cleaned after each use include can opener, small food preparation equipment (e.g. blender, food processor), slicer, kettles, utensils, mixers, cutting boards, worktables, counters, beverage table, coffee urns, pots and pans, dishes, dining room tables and chairs; Items cleaned daily include stove top, grill, kitchen and dining room floors, kitchen towels and cloths, toaster, microwave oven, mop and buckets, steam table, hand washing sink, food carts, pot and pan sink, and exterior of large appliances; Items cleaned weekly include hoods, filters, trash barrels, garbage disposals, coffee machine, storerooms, drawers, cleaning closet, shelves, ovens, and cupboards; Items cleaned monthly include refrigerators, freezers, ingredient bins, ice machines, food containers, and walls; Items cleaned annually include ceilings and windows.Review of the facility's Daily Cleaning Schedule, dated August 2025, showed:- Counter tops, steam table, blender/food processor, toaster, and refrigerator cleaned on 08/25/25;- Counter tops, steam table, blender/food processor, toaster, and refrigerator not cleaned on 08/01/25 - 08/24/25, with 24 missed opportunities out of 25 opportunities.Review of the facility's Weekly Cleaning Schedule, dated August 2025, showed:- Hoods, filters, trash barrels, garbage disposals, coffee machine, storerooms, drawers, cleaning closet, shelves, ovens, and cupboards not cleaned for 08/01/25 - 08/24/25, with three missed opportunities out of three opportunities.1. Observations on 08/26/25 at 9:35 A.M., and 12:15 P.M., 08/27/25 at 2:00 P.M., and 8/28/25 at 12:15 P.M., of the kitchen showed:- The center reach-in refrigerator did not function;- A plate warmer did not function;- A window unit air-conditioner with a brown build up on the ventilation louvers;- The ice machine with a white grime build up on the exterior surfaces and interior plastic surface, the ventilation louvers with a brown substance, three plastic drain lines with black grime build up and no air gap drained into a 4 inch (in.) unglued floor drain with a black grime build up; - The dishwasher with white grime build-up on the exterior surfaces;- An approximate 24 in. x 24 in. ceiling diffuser (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surface and in between the ventilation louvers;- An approximate 12 in. x 12 in. ceiling diffuser with dust buildup and a brown substance in the dry storage area;- Three undated and unlabeled partially full five-gallon clear plastic storage bins with sugar, salt, and oatmeal;- An unidentified dietary aide dipped food from the steam table trays onto plates with a facial hair restraint partially in place; - A refrigeration repairman worked on the reach-in refrigerator during meal preparation without a hair restraint; - A repair mechanic worked on the coffee machine during meal preparation without a hair restraint; - The gas range with an oily grime build up and food debris around each burner; - One undated partially full 15 dozen case box with pasteurized shell eggs with one cracked egg inside the reach-in refrigerator; - An approximate 4 foot (ft.) x 6 in. section of unpainted ceiling and 18 in. of joint cement tape hung near the steam table area;- One rolling hall cart with four trays and uncovered individual pie desserts. During an interview on 08/28/25 at 2:15 P.M., the Dietary Manager (DM) said dated food labels were not on the large bins but should be, the bins shouldn't be used for multiple foods. There was a broken egg in the refrigerated case box, but it should have been thrown out. The plate warmer had sparked the last time it was plugged in and didn't work. It had not been used since, but it would be nice because some residents had complained about cold food in the past. There hadn't been cleaning logs kept for the dietary service staff. The ceiling and air conditioner vents, dishwasher, ice machine, and stove should be cleaned but wasn't. The Maintenance Director should have been told about the ceiling vents but wasn't. The ceiling over the steam table had been an issue and maintenance was aware of the 4 ft. section near the steam table. The repair service workers should not have made repairs during the food service, and they should have had hair restraints on while in the kitchen. During an interview on 08/29/25 at 1:28 P.M., Dietary Aide (DA) D said he/she did dishes mostly and didn't sign off on cleaning logs. Any workers or visitors to the kitchen should have a hair net. The Maintenance Director and DM should be told about kitchen equipment or building damage, the ceiling had been an issue for a while and maintenance was aware. During an interview on 08/29/25 at 1:35 P.M., DA E said he/she did the basics like reporting damage to the DM, the dishwasher and stove top should have already been wiped down, there was a big spill on the stove top yesterday and it needed deep cleaning. There should be cleaning logs. The ice machine was usually cleaned by the DM. Staff and visitors always need to use hair nets. Staff try to warn everyone in the kitchen to wear a hairnet, but it had been an issue this week. During an interview on 08/29/25 at 1:40 P.M., DA F said he/she normally cleaned daily but had not kept up with signing a cleaning log. No one should be allowed in the kitchen without wearing a hair net. During an interview on 08/29/25 at 1:48 P.M., the Administrator said the kitchen should be kept clean. The cleaning logs weren't kept up until recently. There should not be anyone in the kitchen without a hair net including outside repair service workers. There was a sign on the door to the kitchen and staff should remind any visitors to the kitchen to properly restrain their hair. The dishwasher and ice machine should not have a white build up. The dishwasher should be replaced, the ceiling, walls and vents should be kept in good repair throughout the kitchen. There was an issue with the air conditioning causing a leak. During an interview on 08/29/25 at 3:23 P.M., the Maintenance Director said he/she oversaw the repairs in the kitchen and the rest of the building. He/She was aware of the damaged ceiling in the kitchen. There was a leak from the air conditioner, and it had been fixed before and it caused the damage to the ceiling. He/She hadn't been asked to clean the vents in the kitchen.

Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 41.Review of the facility's policy titled, QAPI Policy, dated January 2024, showed:-The QAPI Program consists of monthly/quarterly meetings, daily quality assurance activities, QAPI tasks, and performance improvement plans;- Did not address the required members of the QAA Committee. Review of QAA Committee Minutes, dated 01/16/25, showed:- The Administrator, the Infection Preventionist, Human Resources, a Certified Nurse Assistant (CNA), and Registered Nurse (RN) attended the meeting;- No documentation the DON or the Medical Director attended the meeting. Review of QAA Committee Minutes, dated 08/06/25, showed: - The Administrator, Director of Nursing (DON), Social Services Designee (SSD), and Human Resources attended the meeting;- No documentation the Infection Preventionist and the Medical Director attended the meeting.During an interview on 08/29/25 at 1:16 P.M., the Administrator said they had not been consistent with the quarterly meetings. They had a meeting in June 2025, but she couldn't find the minutes. They didn't do one in July. The only other meeting they had was in January 2025. The QAA/QAPI meetings did not always have the required members but should include the Medical Director, Administrator, DON, Infection Preventionist, and two other staff members at least quarterly.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during peri care for one resident (Resident #14) out of two sampled residents and wound care for one sampled resident (Resident #33) out of one sampled resident. The failed to provide a safe and sanitary environment by failing to disinfect the multi-use glucometer (a device used to measure blood sugar) per the manufacturer's instructions for two residents (Residents #13 and #21) out of two sampled residents and when obtaining FSBS. The facility failed to correctly screen three residents (Residents #5, #31, and #33) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility also failed to establish and maintain an infection prevention and control program (IPCP) that identified a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and other individuals providing services. This had the potential to affect all residents in the facility. The facility's census was 41. Review of the facility procedure titled, Peri Care, undated, showed: - Wash hands, put on gloves, wash and dry upper thighs, wash peri area using a different part of the washcloth for each stroke, rinse area and dry, clean rectal area, rinse and dry area, remove gloves and wash hands. The facility did not provide a policy regarding infection control practices during wound care. Review of the facility's policy titled, Infection Prevention and Control Manual - Standard Precautions – Gloves, dated 2019, showed: - Disposable single-use examination gloves are worn when hand contact with blood, other potentially infectious material, mucous membranes and non-intact skin is anticipated, handling or touching contaminated items or surfaces, caring for a resident with uncontained body fluids or known or suspected drug-resistant organism colonization or infection. Review of the facility's policy titled Infection Prevention and Control Manual – TB Control Plan – Tuberculosis Screening - Residents, dated 2019, showed: - This facility has a comprehensive TB screening program that is administered by the Infection Control Nurse at the direction of the Quality Assurance Committee; - Tuberculin Skin Test (TST) for all new admissions, a TST will be done within 72 hours after admission if there is no documented TST from within three months before admission; - Some states may have different requirements for annual screening. Follow state and local guidelines; - TST results will be documented in the resident's medical record. Skin test results will be documented in millimeters (mm) of induration rather than stating results of positive or negative; - All reports or copies of the TST or Interferon-Gamma Release Assay (IGRA – a blood test to detect TB) and any chest x-rays and medical evaluation conducted should be maintained in the resident's medical record. Review of facility policy titled Infection Prevention and Control Manual, Cleaning and Disinfecting Glucose Meters, dated 2019, showed: - Apply gloves before performing a blood glucose test; - Dispose of used fingerstick devices and lancets in approved sharps container; - Remove gloves and perform hand hygiene; - Apply new gloves; - Thoroughly clean visible soil or organic material from glucometer before disinfection - Perform hand hygiene after removing gloves; - Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters. Review of the Evencare G3 Meter manufacturer guidelines, dated 2017, showed: - The Evencare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach; Medline Micro-Kill+™ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; Clorox Healthcare Bleach Germicidal and Disinfectant Wipes; Medline Micro-Kill™ Bleach Germicidal Bleach Wipes; - Clean the meter with a disinfecting wipe. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then, wipe meter dry or allow to air dry. Review of the directions for Micro-Kill One Germicidal Alcohol Wipes, showed: - To disinfect hard, non-porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface treated; - Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens; - Allow surface to air dry. Review of the facility's Infection Prevention and Control Program policy, revised on 08/2016 and unsigned, showed the policy did not include: - When and whom possible incidents of communicable disease or infection should be reported; - When and how isolation should be used for a resident and address resident room assignments; - The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food; - Environmental cleaning/disinfection of high-touch surfaces in common areas, resident rooms, and resident care equipment; - Maintain a system for recording incidents identified under the facility IPCP and the corrective actions taken by the facility; - Which communicable diseases will be reported to local/state public health authorities; - Education and competency assessment of the staff; - Education of the residents and their representative on the facility IPCP. 1. Review of TB testing for Resident #5 showed: - admission date of 06/26/25; - No documentation of a two-step TST upon admission. 2. Observation of Resident #13's blood glucose monitoring on 08/27/25 at 10:44 A.M., showed: - Certified Medication Technician (CMT) A performed blood glucose monitoring; - CMT A cleaned the glucometer for 15 seconds with a Wipes Plus Disinfecting Wipe; - CMT A placed the glucometer on top of the treatment cart; - CMT A failed to use an approved cleaning and disinfecting wipe per the glucometer's manufacturer guidelines. 3. Observation of Resident #14's peri care on 08/27/25 at 11:58 A.M., showed: - Certified Nurse Assistant (CNA) K put on a gown, performed hand hygiene, put on gloves, and entered the room; - CNA K picked up the trash can with his/her left hand and sat it down beside him/her on the floor; - The resident rolled to the left side and CNA K removed a bed pan filled with urine from under the resident with his/her right hand and sat it down on the floor; - CNA K did not change gloves and did not perform hand hygiene, and provided peri care to the resident with his/her left hand; - CNA K removed the gloves, did not perform hand hygiene, and put on new gloves; - CNA K fastened the brief and covered the resident with a blanket; - CNA K picked up the bed pan filled with urine and emptied it into the resident's bathroom toilet; - CNA K removed gloves and performed hand hygiene. 4. Observation of Resident #21's blood glucose monitoring on 08/27/25 at 11:00 A.M., showed: - CMT A performed blood glucose monitoring; - CMT A cleaned the glucometer for 10 seconds with a Wipes Plus Disinfecting Wipe; - CMT A placed the glucometer on top of the treatment cart; - CMT A failed to use an approved cleaning and disinfecting wipe per the glucometer's manufacturer guidelines. 5. Review of Resident #31's medical record showed: - admission date of 05/12/21; - No documentation of previous TST testing or a sign and symptom assessment for 5/2024 – 5/2025. 6. Review of Resident #33's medical record showed: - admission date of 02/09/25; - A first step TST administered on 02/10/25, with no result or read date; - No second step TST. 7. Observation of Resident #33's wound care on 08/27/2025 at 11:07 A.M., showed: - Registered Nurse (RN) B performed hand hygiene, prepared needed items on the treatment cart, cleaned the scissors with Micro Kill One Germicidal Alcohol wipe, put on gloves and gown, entered the room, opened and placed a barrier drape on the foot of the residents' bed, a sat the supplies on the barrier drape; - RN B assisted the resident to lower his/her pants and brief and rolled to the left side with no dressing in place to the coccyx (small triangular bone at the base of the spine); - RN B removed the gauze saturated with wound cleanser from a plastic cup, cleaned the open area to the coccyx, and removed a brown substance from the wound; - RN B did not change gloves, did not perform hand hygiene, removed dry gauze from a second plastic cup, and dried the wound area; - RN B did not change gloves, did not perform hand hygiene, removed calcium alginate (a highly absorbent wound dressing) from the package, used scissors to cut a small wound size piece, placed it in the wound bed, did not change gloves, did not perform hand hygiene, opened a bordered dressing, removed a marker from his/her pant pocket, wrote on the dressing, returned the marker to his/her pant pocked, and applied the bordered dressing to the coccyx wound; - RN B did not change gloves, did not perform hand hygiene, removed the gauze saturated with wound cleanser from the plastic cup, wiped the right groin area two times with the same the gauze, discarded the gauze, removed another gauze saturated with wound cleanser from the cup, and wiped the left groin two times with the same gauze; - RN B did not change gloves, did not perform hand hygiene, removed a clean dry gauze from a second cup, dried both sides of the groin, picked up a bottle of Nystatin powder (an antifungal medication) and applied to both sides of the groin, and sat the bottle on the bedside table without a barrier; - RN B did not change gloves, did not perform hand hygiene, assisted the resident to pull up the brief and his/her pants into place, changed gloves and performed hand hygiene. 8. Review of the facility's IPCP binder showed: - No documentation of an IPCP program. During an interview on 08/28/25 at 9:20 A.M., the Administrator said the IPCP binder was brought to the daily meetings. The Director of Nursing (DON) brought the binder to the meetings, and they went over who was on antibiotics and why during the meetings. The infection control policies were reviewed monthly. During an interview on 08/28/25 at 9:24 A.M., the DON said there was a binder that had infection control policies and such in it. The policies had been reviewed but not sure when. During an interview on 08/28/25 at 12:20 P.M., the DON said the Administrator reminded her that the previous company took all the binders, including the infection control. The current company had all their policies online and they could pull them when needed. During an interview on 08/29/25 at 10:20 A.M., RN L said staff should perform hand hygiene upon entering a resident's room, put gloves on, remove anything dirty, perform hand hygiene, glove change, clean the resident up, hand hygiene, and glove changes again. A bed pan shouldn't be put on the floor. RN L said when sanitizing the glucometer in between residents, the wipes from the pink top disinfectant wipe container should be used. The glucometer was wiped and then left to air dry. During an interview on 08/29/25 at 10:26 A.M., the DON said with wound care and incontinent care, hand hygiene should be done upon entering the room, gloves put on, anything dirty removed, hand hygiene and glove changed, cleanse wound or clean the resident, and finish with hand hygiene and glove changed. A bed pan shouldn't be put on the floor. Disinfecting wipes should be used on the glucometer between residents and then left to air dry for three minutes. TB orders were entered upon admission with the first step administered on the day of admission, read 48 hours later, seven days later the second step was administered and read again 48 hours later. She administered a TST to all residents in January as part of an annual, not knowing that sign and symptoms could be done. But either a TST or sign and symptoms should be done annually. During an interview on 08/29/25 at 10:40 A.M., CNA I said hand hygiene should be done when entering the room, between dirty and clean care, and at the end of care. Also, glove changes should happen between dirty and clean care. A bed pan shouldn't be put on the floor. During an interview on 08/29/25 at 10:42 A.M., CNA J said hand hygiene should be done at the beginning with gloves on, dirty gloves changed, care performed, gloves removed, hand hygiene performed. A bed pan shouldn't be put on the floor. During an interview on 08/29/25 at 11:30 A.M., the Administrator said she would expect staff to follow the facility's policies and procedures regarding infection control, hand hygiene, and glove changes. Hand hygiene should be completed before going in and out of rooms and gloves changed between dirty and clean care. Residents should get a two-step TB on admission and then sign and symptoms annually. Glucometer cleaning should be done by using the Micro-Kill One Germicidal Alcohol Wipes from the purple top container. Antibiotics should be tracked per the guidelines.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 41.Review of the facility's policy titled, Infection Prevention and Control Manual Antibiotic Stewardship and Multidrug Resistant Organisms (MDROs) - Antibiotic Stewardship, dated 2019, showed:- Stewardship involves identifying the microbe (microorganisms) responsible for disease, utilizing evidence-based definitions when indicated; selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed;- Policy and procedural updates have been completed. Ongoing review and updates will be completed based on standards of practice, collaboration with the Medical Director and Pharmacy Consultant. Staff education will be provided to promote understanding and successful implementation with all policies, procedures and updates to the Antibiotic Stewardship Program;- Tracking and reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to facility policy and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse drug events, antibiotic resistant organisms, C. difficile infections, etc.) will be tracked by the Infection Preventionist (IP) and discussed with the Quality Assurance (QA) Committee for action planning.Review of the facility's policy titled, Infection Prevention and Control Program Manual Surveillance - Infection Surveillance - Overview, dated 2019, showed:- Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause, an outbreak;- The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, analyzing, and interpretation of data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes;- The unit charge nurses will identify residents with symptoms or identified infections and complete the Criteria for Infection Report Forms for the respective type of infection;- The IP will ensure data collection to complete a comprehensive Monthly Infection Control Log for surveillance activities on the infection site, pathogen, signs and symptoms, resident location, summary and analysis of number of residents with infections;- The IP or designee will be alerted to identify any necessary interventions in order to identify trends or clusters for action;- The IP will keep an updated map of infections to identify any clusters or trends;- Data obtained from Process Surveillance Audits will be collected to analyze the compliance of staff with facility policies and procedures. Review of the facility's Antibiotic Stewardship Program Binder showed:- No documentation for August - December 2024 and February - August 2025;- Incomplete documentation related to appropriate indication of antibiotic use for January 2025 Infection/Antibiotic Log;- No documentation of any maps of infection to identify any clusters or trends.- The facility failed to document the prescribed antibiotic, the appropriate dosing, the route, and the duration of the antibiotic therapy, and did not include lab reports/findings.Review of the facility Matrix (a listing of all facility residents), dated 08/26/25, showed:- Seven residents currently received antibiotics.During an interview on 08/28/25 at 8:53 A.M., the Director of nursing (DON) said the previous Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes) Coordinator, who left in May 2025, had been the IP and was responsible for completing the antibiotic stewardship and surveillance logs. The antibiotic stewardship had not been updated since. She was not aware of the antibiotic surveillance log binder and just printed a list of the residents on antibiotics for the weekly meeting to discuss which residents were on antibiotics. She did not have a surveillance log where trending was tracked or mapped, and when labs were completed, they were printed and placed in the lab binder until placed in the resident's chart. The resident's signs and symptoms should be documented in their chart in the nurse's notes. The DON said the IP had always been the MDS Coordinator since she took the DON position in October 2024. Registered Nurse (RN) M took over the MDS Coordinator and IP position May 2025, but he/she was not certified as an IP. During an interview on 08/28/25 at 9:21 A.M., the Administrator said the staff go over the DON's list of which residents were on antibiotics in their morning meeting every day. The antibiotic stewardship and surveillance binder had not been maintained since the previous MDS Coordinator/IP left in May 2025. She did not know it was not completed before or after the previous MDS Coordinator/IP left. She said the DON was responsible for the IP responsibilities after the previous IP left, even though she was not certified as an IP.

Based on interview and record review, the facility failed to ensure at least one person with specialized training in infection prevention and control for the Infection Preventionist (IP - a professional who assures healthcare workers and residents are doing everything possible to prevent infection) was responsible for the duties of the position. This had the potential to affect all residents in the facility. The facility census was 41. Review of the facility's policy titled, Infection Prevention and Control Program, dated 2019, showed:-The facility will designate one or more individual(s) as the infection preventionist(s) who is responsible for the facility's Infection Prevention and Control Program (IPCP); -The IP will have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field; Is qualified by education, training, experience or certification; Works at least part-time at the facility; and has completed specialized training in infection prevention and control; Be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis; Be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.Review of the facility's policy titled, Infection Prevention and Control Manual - Antibiotic Stewardship & multi-drug resistant organisms (MDROs) - Antibiotic Stewardship, dated 2019, showed:- IP: The IP will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the Director of Nursing (DON), Medical Director, and Consultant Pharmacist and ongoing system review.The facility did not provide documentation for any staff members who had completed the specialized training for the IP position. During an interview on 08/29/25 at 8:50 A.M., Registered Nurse (RN) M said he/she just started the IP role this week and had not started the required training. During an interview on 08/29/25 at 1:39 P.M., the DON said the facility did not have an IP at this time due to the previous IP left in May 2025. RN M just took over the IP position. RN M and herself would be working on getting his/her certification. She would expect the facility to have an IP with the appropriate qualifications and certifications, and no one followed up to make sure the training was completed. During an interview on 08/29/25 at 1:49 P.M., the Administrator said she would expect the facility to have an IP with the appropriate qualifications and certifications. The previous IP left in May 2025, and hadn't had an IP since. RN M would be completing the training for the IP, and they had another nurse who just started the IP training today. The DON was responsible for the IP duties but was not certified.

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's census was 41.Review of the facility's policy titled, Infection Prevention and Control Manual, dated 2019, showed: - Environmental Services will develop protocols, including schedules for cleaning and decontamination of the work site;- Environmental Services personnel are responsible for routine cleaning of resident rooms, floors, surfaces, emptying and inspecting waste containers, and routine cleaning of resident areas.Review of the facility's 400 Hall deep cleaning schedule, dated August 2025, showed:- room [ROOM NUMBER] scheduled on 08/25/25, 8/27/25, and 8/29/25. Review of the facility's Maintenance Repair Log, dated 04/11/25 - 08/27/25, showed:- No repairs needed to Rooms 106, 107, 301, 516, 500 Hallway shower and 500 dining room baseboards. 1. Observations on 08/26/25 at 10:35 A.M., and 12:15 P.M., and 8/29/25 at 1:15 P.M., of the 500 Hallway showed:- room [ROOM NUMBER] with no vinyl cove baseboard on the four walls;- Dining room missing a 6-foot (ft.) section of vinyl cove baseboard near the refrigerator;- Cracked and peeled shower wall caulk on the chrome shower faucet cover plate and with no shower handle; - Shower ramp missing two 2 inch (in.) x 2 in. ceramic tiles along the edge.2. Observation on 08/26/25 at 10:40 A.M., of the 100 Hallway showed:- room [ROOM NUMBER] with a 3 ft. x 2 ft. hole in the drywall with exposed insulation and multiple 2 in. diameter (dia.) dents in the wall section near the headboard beside the window;- room [ROOM NUMBER] with a 3-ft. section of vinyl baseboard behind the bathroom door with a brown substance. 3. Observations of room [ROOM NUMBER] and the 400 Hallway showed: - On 08/26/25 at 11:17 A.M., a strong urine odor and two emptied plastic urinals hung from the headboard while the resident lay in bed with no blanket. The hallway with a strong urine odor; - On 08/26/25 at 3:20 P.M., a strong urine odor and two urinals hung from the headboard with one emptied and one half filled with urine while the resident lay in bed. The hallway with a strong urine odor; - On 08/28/25 at 8:40 A.M., a strong urine odor, one urinal half filled with urine lay on the nightstand near the headboard, and the bed with an approximate 3 ft. dia. yellow stain on the wadded sheets near the center of the mattress. The hallway with a strong urine odor;- On 08/28/25 at 9:30 A.M., and 12:47 P.M., a strong urine odor, one urinal half filled with urine lay on the nightstand near the headboard, the bed had an approximate 3 ft. dia. yellow stain on the wadded sheets near the center of the mattress, and debris scattered over the majority of the floor space. The hallway with a strong urine odor;- On 08/28/25 at 3:15 P.M., a strong urine odor, one urinal half filled with urine lay on the nightstand near the headboard, the bed with an approximate 3 ft. dia. yellow stain on the wadded sheets near the center of the mattress, and debris scattered over most of the floor space while the resident lay in bed. The hallway with a strong urine odor. During an interview on 08/28/25 at 3:17 P.M., the resident in room [ROOM NUMBER] said he/she had been waiting for his/her urinal to be emptied by staff. He/She accidently spilled the urine on the floor and the bed today and he/she told staff the bed and sheets were damp. During an interview on 08/28/25 at 3:45 P.M., Registered Nurse (RN) M said room [ROOM NUMBER] should not smell like urine, but the resident was known to urinate in the floor which caused the odor. room [ROOM NUMBER] should not have been left in that condition all day, but the bed and sheets were wet from urine. The resident and the room should be checked at least every two hours.During an interview on 08/28/25 at 4:00 P.M., RN B said he/she would expect any resident's room to be kept sanitary and not have an odor. The resident in room [ROOM NUMBER] should not have been left with a wet bed. The resident was known to miss while using his/her urinal which could cause an odor. The room should be checked every two hours. 4. Observation on 08/29/25 at 12:50 P.M., of room [ROOM NUMBER] showed:- Four 2 in. x 6 in. dark wall paint brush marks on the white ceiling above the four dark painted walls; - Four 1/4 in. dia. holes along the left edge of the heating ventilation and air conditioning (HVAC) unit and a light brown build up inside the ventilation louvers;- The bathroom with a non-intact caulk bead with a brown substance near the base of the toilet. During an interview on 08/29/25 at 1:00 P.M., the resident in room [ROOM NUMBER] said he/she was frustrated about the dark paint marks on the ceiling because it should be white. There were holes to the outside around the HVAC unit and the dusty vents need to be cleaned. The toilet had a dark ring around the base and floor that should be clean. He/She was not used to living like this. During an interview on 08/29/25 at 9:41 A.M., Housekeeper N said resident rooms should be checked twice per day throughout the day and at the end of the day he/she went back to check for spills. If there was a urine odor in a room, the floor was sprayed with bleach to clean it. If there was urine on the sheets, he/she told a Certified Nurse Assistant (CNA). If the mattress had a urine spill, he/she was supposed to wipe it down. There was one resident that had a problem with urine and his/her bed was normally sprayed every day on the 200 Hall. On the 400 Hall, there was a resident room issue for when the resident was out of bed, the housekeeping staff were supposed to bleach the mattress down and clean it every day. He/She didn't remember checking on room [ROOM NUMBER] this week. A CNA or nurse was told if he/she saw a urinal that needed to be emptied. If the floor had food or other debris on it, it was supposed to be cleaned up and the meal trays should be removed after a meal. During an interview on 08/29/25 at 10:08 A.M., Housekeeper O said he/she worked on the 400 Hall mostly but sometimes worked the 100 and 200 Halls together. There was often a urine odor from certain rooms but there hadn't been a lot of strong urine odors. Normally rooms were checked daily for the floors or big messes. If there was a urine odor from a bed, a CNA was told, but when a deep clean was needed, the mattress and frames should be cleaned. He/She had two rooms on the 400 Hall that should have been deep cleaned this week. One was room [ROOM NUMBER], and it should be done daily. room [ROOM NUMBER] was deep cleaned last Friday and once today. The housekeeping cart had a schedule for cleaning. The floors should also be checked, housekeeping shouldn't touch the urinals. The Housekeeping Supervisor was notified if there was damage to a room and he/she reported it to maintenance about damage to the rooms. During an interview on 08/29/25 at 1:48 P.M., the Administrator said there should be no urine odors but there were some rooms that were harder to keep up with on cleaning and deep cleaning. She expected extra deep cleaning and extra shower days for some residents. There should be checks at least every two hours for wet mattresses and extreme odors. room [ROOM NUMBER] should have been cleaned when the residents were out of the room. The rooms that had been painted should not have wall paint marks on the ceiling. The toilets should have a clean intact caulk bead, and no brown build up. The shower room faucets should have a handle. The shower floor ramp should not be missing ceramic tiles. The staff should be reporting concerns with the facility in the maintenance log, but she hasn't heard about any of problems with the 500 Hallway shower. During an interview on 08/29/25 at 2:17 P.M., the Maintenance Director said there should be cove base in the dining areas and in resident rooms where they were missing. The handle was missing from the unit shower faucet. All the floor tiles should be in place on the shower ramp. If the resident room walls were painted, the ceiling should remain white. There should not be dark paint marks on the white ceiling. The toilet and shower caulk seals should be clean and intact. He/She was not aware of all the issues, and they were not documented on the maintenance log.

Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #6) out of one sampled resident with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 41. The facility failed to provide a policy regarding PTSD. 1. Review of Resident #6's medical record showed: - admission date of 04/12/24;- Diagnoses of PTSD, anxiety (persistent worry and fear about everyday situations), major depressive disorder (long-term loss of pleasure or interest in life) and dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning);- Severe cognitive impairment;- No trauma informed care assessment. Review of the resident's August 2025 Physician Order Sheet (POS) showed:- An order for prazosin (a blood pressure medication also used to treat nightmares associated with PTSD) 1 milligram (mg) by mouth at bedtime related to PTSD, dated 07/15/25;- An order for donepezil (a medication used to treat the symptoms of dementia) 10 mg by mouth at bedtime related to dementia unspecified severity without behavioral disturbance, psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (a mental health condition characterized by persistent and extreme changes in a person's emotional state), and anxiety, dated 07/15/25;- An order for trazodone (an antidepressant medication) 100 mg by mouth at bedtime related to major depressive disorder (Persistently low or depressed mood), dated 02/10/25;- An order for sertraline (an antidepressant medication) 100 mg 1.5 tablets by mouth one time a day for depression, dated 07/15/25;- An order for alprazolam (an antianxiety medication) 0.5 mg by mouth every morning and at bedtime for anxiety, dated 07/15/25;- An order for memantine (a medication used to slow the progression of dementia) 10 mg one tablet by mouth every morning and at bedtime for dementia, dated 07/15/25. Review of the resident's Care Plan, dated 04/12/25, showed:- Takes a psychotropic (medications that affect mental function, behavior, and experience) medication related to PTSD;- Did not address triggers that could cause resident trauma;- Did not address the resident had past trauma or any triggers that would cause the resident to have behaviors. During an interview on 08/29/25 at 10:26 A.M., the Director of Nursing (DON) said the facility had one resident with PTSD. The care plan should include monitoring, assessments of the medications, behaviors, depression, and safety for PTSD. It really depended on what the cause of the PTSD was. The cause of the PTSD should be part of the care plan. Triggers should also be listed. She didn't know what triggers the resident had. When the resident was admitted , the Social Services Designee (SSD) and nursing did the assessments. SSD dealt with more with the history of the resident. The Minimum Data Set (MDS - a federally mandated assessment to be completed by the facility) Coordinator was responsible for the care plan to ensure it had everything. During an interview on 08/29/25 at 11:30 A.M., the Administrator said PTSD should be care planned and include triggers and interventions. The PTSD assessments should be done. The MDS Coordinator or a nurse could do the assessments. The MDS Coordinator was responsible for ensuring the assessments were completed. During an interview on 08/29/25 at 11:40 A.M., the MDS Coordinator said he/she took the position in the middle of May this year. The PTSD assessments should be done but wasn't sure who was responsible for completing them. It wasn't an assessment on his/her list of responsibilities. He/She was responsible for ensuring the care plan addressed PTSD and it should include triggers, interventions, and preventions. Resident #6's assessment and care plan didn't address his/her PTSD.

Based on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Residents #5, #34, and #40) out of 12 sampled residents. The facility census was 40. Review of the facility's policy titled, Physician's Orders, undated, showed: - Current lists of orders must be maintained in the clinical record of each resident to avoid conflict and errors; - Orders must be written and maintained in chronological order; - Physician orders must be reviewed and renewed. Review of the facility's policy titled, Skin Assessments, undated, showed residents at risk will have preventative measures implemented to include: weekly documented skin audits by a licensed nurse and treatments as ordered by the physician if skin breakdown occurs. 1. Review of Resident #5's medical record showed: - Diagnoses of schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), cellulitis (a bacterial infection of the skin), high blood pressure, hypokalemia (decreased blood level of potassium), venous insufficiency (a condition in which veins have problems moving blood back to the heart), atrial fibrillation (irregular heart beat), and bipolar disorder (a mental disorder that causes unusual shifts in mood); - An order for consulting wound care clinic to evaluate and treat for cellulitis, dated 11/07/23; - An order for weekly skin assessments completed and documented once a day on Thursdays, dated 12/28/23; - An order to monitor resident's shower/bath, chart, and fill out shower sheet if with any new skin issues once a day on Mondays, Thursdays, Saturdays, dated 02/22/24; - From 04/01/24 - 07/10/24, no documentation of weekly skin assessments completed for 04/04/24, 04/11/24, 04/18/24, 05/02/24, 05/09/24, 05/16/24, 06/06/24, 06/13/24, and 07/04/24, with nine out of 14 opportunities missed. Review of the resident's Treatment Administration Record (TAR), dated April 2024, showed: - An order to cleanse/lightly scrub bilateral (right and left) lower extremities (BLE) with warm water and ketoconazole (an antifungal) 2 percent (% ) shampoo, rinse, pat dry, apply generous amount of triamcinolone (a topical steroid) cream to the BLE twice daily for venous insufficiency, dated 11/14/23, and discontinued on 04/23/24, with 20 out of 60 opportunities missed; - An order to cleanse the BLE with Dakin's wound cleanser (DWC), measure, cut and apply tubigrips (tubular bandages for tissue support) daily for cellulitis, dated 01/30/24, and discontinued on 04/23/24, with 14 out of 22 opportunities missed. Review of the resident's Medication Administration Record (MAR), dated July 2024, showed: - An order for ammonium lactate (used to hydrate the skin) lotion 12%, administer topically at bedtime for cellulitis, dated 07/12/24, with three out of three opportunities missed; - An order to cleanse BLE with soap and water, pat dry, apply ammonium lactate lotion, wrap with an ace wrap daily, undated, with two out of three opportunities missed. Review of the resident's care plan, last reviewed on 06/24/24, showed: - Cellulitis with interventions not addressed; - Venous insufficiency with interventions not addressed. Observations of the resident showed: - On 07/09/24 at 10:07 A.M., 07/10/24 at 8:51 A.M., the resident sat in a recliner in the room with a tan compression sock on halfway up the left lower leg. At the top of the compression sock, the visible skin was red, dry, and swollen with scattered scabs. The right lower extremity (RLE) had a tan compression sock on up to the ankle area, the visible skin at top of the sock was red, dry and swollen with scattered scabs and open areas; - On 07/10/24 at 4:23 P.M., the resident sat in a recliner in the room with a tan compression sock on halfway up the left lower leg. At the top of the compression sock, the visible skin was red, dry, and swollen with scattered scabs. The right lower extremity (RLE) with a tan compression sock on up to the ankle area with the visible skin at top of the sock to the was red, dry and swollen with scattered scabs, open areas, and blisters; - On 07/10/24 at 4:45 P.M. Licensed Practical Nurse (LPN) P entered the resident's room and removed the resident's compression socks. The inside of the resident's RLE had blisters with drainage and multiple open areas noted. LPN P asked the resident where the compression socks came from because they were too small. The resident said he/she didn't know where they came from. LPN P informed the resident he/she would call the physician to see what to do and they should have been assessed by staff before now. The resident agreed with LPN P. LPN P notified the physician and received new orders to send the resident to the hospital; - On 07/15/24 at 8:35 A.M., the resident sat in a recliner in the room with no ace wraps on his/her lower extremities as ordered and yellow non-slip socks on his/her bilateral feet. BLE were red, dry, and swollen with dried skin flakes; - On 07/15/24 at 4:05 P.M., the resident sat in a chair in the common area near the entrance with no ace wraps to his/her BLE as ordered. During an interview on 07/09/24 at 10:07 A.M., Resident #5 said he/she had an infection to his/her right leg that was slow to heal and had been on antibiotics, but not any longer. He/She said the staff used to come in and treat his/her legs but not in a while. During an interview on 07/11/24 at 11:35 A.M., the Assistant Director of Nursing (ADON) said if a resident refused skin assessments and care the staff should give the resident a little bit of time, go back in and try again. She expected nursing staff to document on the resident's skin assessment sheets/shower sheet and in the nurse's notes, what was done, what was tried, what another person tried. If there was a skin concern, the resident should get a shower sheet completed too. If a resident refused a shower or skin assessment, the staff should sign it, a witness should sign it, and the resident should sign it if able, and then it should be turned into her. She was not aware the last skin assessment for Resident #5 was completed in May 2024, and she was not aware it was not getting done. Registered Nurse (RN) E moved to the day shift in June 2024, to make sure the skin assessments were getting done. The charge nurse was responsible for doing the skin assessments, and RN E audited them and made sure they were done. Resident #5 didn't like someone in the shower with him/her so the staff stood outside of the shower curtain and he/she would take a shower. The resident would refuse medications and skin assessments, but she would expect staff to go in and try again later, try another staff member, or a different time for medications, and even another day for assessments and showers. She said they had to get social services involved a lot. The resident's legs should had been found before 07/10/24. There should have been two sets of eyes on the skin assessments, and it should have been caught. During an interview on 07/11/24 at 2:25 P.M., RN E said Resident #5 would complain about pain to his/her legs and would take Tylenol. The resident complained the Tylenol wouldn't do anything, but he/she didn't complain of any pain after it was taken. During an interview on 07/11/24 at 3:19 P.M., Certified Nursing Assistant (CNA) N said every once in awhile the Resident #5's legs were red. The resident was mostly independent with his/her activities of daily living (ADLs) so didn't see his/her legs a lot. He/She can't remember the last time he/she saw the resident's legs. During an interview on 07/11/24 at 3:25 P.M., RN E said the night shift charge nurse was in charge of completing skin assessments. He/She didn't know who was in charge of auditing the skin assessments to ensure they were completed. He/She had not done any skin assessments since moving to the day shift last month. Resident #5 had been aggressive toward him/her when trying to do the skin assessments. He/She hadn't seen Resident #5's legs in over a month and a half. During an interview on 07/11/24 at 3:30 P.M., the Social Services Designee (SSD) said Resident #5 used to listen to him/her but stopped about four - five months ago. He/she was verbally aggressive but not generally physical. He/She had not seen the resident's legs in a very long time and the resident hadn't mentioned them. During an interview on 07/11/24 at 3:35 P.M., the ADON said she had not seen Resident #5's legs since she discontinued the treatment back in April 2024. She discontinued that treatment because the resident only had a penny sized scabbed area. The resident did end up needing oral antibiotics within six days for cellulitis after that. The resident had not complained about pain in the last couple of months. The resident's legs should have been seen prior to them getting to the point of having to go to the hospital. During an interview on 07/11/24 at 4:15 P.M., the Corporate QA RN said the resident could refuse care up until it's started causing harm and then the facility staff would need to step in and figure out some way to provide the care the resident required. The resident couldn't go two months without a shower. The resident shouldn't go more than two weeks since he/she was non-compliant, and no staff saw his/her legs. Physician orders should be followed to include the skin assessments and showers. The resident's legs should have been caught before the point they were at. During an interview on 07/11/24 at 4:15 P.M., the Administrator said they couldn't do skin assessments or showers on Resident #5 because he/she refused everything. The resident even refused care and medications. She had not seen his/her legs. During an interview on 07/11/24 at 10:44 A.M., the Physician said if an order was given, he/she expected it be followed. Resident #5 had a lot of medical conditions. He/She refused to take baths and medications. He/She was not aware of the condition of the resident's skin on his/her legs until last night when the nurse called. That was the first he/she had heard of it. The resident's legs had some chronic conditions, and could have some fungus growing in the wounds. The resident received intravenous (IV) antibiotics while at the hospital. The facility staff should document when the resident refused care. During an interview on 07/11/24 at 4:19 P.M., the Physician said it could have just taken days for Resident #5's legs to get to this point they were before he/she went to the hospital because of him/her living in such a high microbial environment, the resident picked at his/her skin, and refused care. Review of the facility's policy titled, Lab Reporting Guidelines, undated, showed it did not address what to do when lab orders were not completed. 2. Review of Resident #34's medical record showed: - Diagnoses of congestive heart failure (CHF - an inability of the heart to pump sufficient blood flow to meet the body's needs), high blood pressure, hip fracture, and pressure ulcer (damage to the skin and/or underlying tissue as a result of pressure) Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle); - Care plan, last revised on 04/24/24, the resident with a wound to the coccyx (the small triangular bone below the spine). The wound will be followed by the consulting wound clinic and treatment orders followed; - An order to lightly wet plain packing strip with Vashe (wound cleanser), apply collagen (helps promote tissue growth) to strip and pack wound with collagen strip once a day, dated 06/19/24; - An order to soak the wound to the coccyx with Vashe before the treatment, dated 06/19/24; - An order to cut Polymem (a dressing that will constantly cleanse the wound bed, while also managing drainage) to size and place over the wound tissue and cover with bordered gauze daily, dated 06/27/24; - An order for weekly skin assessments completed and documented on Mondays, dated 02/26/24. -Review of the the resident's TAR, dated June 2024, showed an order for weekly skin assessments to be completed and documented on Mondays, with a start date of 02/26/24. Three out of the four Mondays in June 2024 had no skin assessments documented. Review the resident's TAR, dated 07/01/24 through 07/10/24, showed: - An order for weekly skin assessments to be completed and documented on Mondays, with a start date of 02/26/24. No documentation the for the assessment on 07/01/24 (Monday). - An order, dated 06/19/24, to lightly wet plain packing strip with Vashe, apply collagen to strip and pack wound with collagen strip once a day, with two out of 10 opportunities missed; - An order dated 06/19/24, to soak the wound to the coccyx with Vashe before the treatment, with two out of 10 opportunities missed; - An order dated 06/27/24, to cut Polymem to size and place over the wound tissue and cover with bordered gauze daily, with two out of 10 opportunities missed. Observation on 07/10/24 at 1:00 P.M., of the resident's wound care showed: - LPN P soaked the packing strip with Vashe wound cleanser and applied Santyl (a wound debridement) to the packing strip; - LPN P used Santyl instead of collagen as ordered. During an interview on 07/10/24 at 1:30 P.M., LPN P said Santyl and collagen were the same medication. During an interview on 07/11/24 at 10:30 A.M., the ADON said in a resident's medical record, if the TAR has an order for a treatment, and there is no corresponding initial to indicate the treatment was completed, then there is no proof the treatment was completed. Santyl and collagen were not the same treatments and the physician's order for collagen should have been followed. During an interview on 07/11/24 at 1:00 P.M., the consulting wound care clinic nurse said there was a difference between Santyl and collagen powder. Collagen powder was what was ordered for Resident #34's wound. Santyl broke down bad tissue and collagen built up new tissue. The collagen was ordered on 06/18/24. The use of Santyl could cause negative effects like maceration (when a wound experiences excessive moisture, leading to the softening and breaking down of the surrounding skin) of the tissue which would stall the improvement of the wound and create a more wet environment. It wouldn't destroy the healthy tissue but the tissue would be too wet of an environment for tissue growth. During an interview on 07/11/24 at 3:00 P.M., RN E said he/she used collagen powder for Resident #34's wound care. Santyl was an old order and not the same thing as the collagen powder. Santyl shouldn't be used for the resident's wound. During an interview on 07/11/24 at 3:10 P.M., the ADON said physician orders should be followed. During an interview on 07/11/24 at 4:15 P.M., the Corporate QA RN said collagen powder and Santyl were not the same thing. Physician orders should be followed. During an interview on 07/11/24 at 4:17 P.M., the Administrator said physician orders should be followed. 3. Review of Resident #40's medical record showed: - A diagnosis of Alzheimer's disease; - An order for weekly weights for four weeks, dated 06/11/24; - On 06/11/24, the resident weighed 106.9 pounds (lbs); - No documented weight for the week of 06/18/24; - No documented weight for the week of 06/25/24; - On 07/02/24, the resident weighed 101.8 lbs, with a 4.77% weight loss in three weeks; - The facility failed to weigh the resident weekly for four weeks as ordered with two out of four opportunities missed. During an interview on 07/10/24 at 10:42 A.M., the Administrator said the ADON was responsible for making the weekly weight list and monitoring. During an interview on 07/10/24 at 02:53 P.M., the Physician said if weekly weights were ordered, he/she would expect them to be completed as ordered. During an interview on 07/12/24 at 8:09 A.M., CNA L said the resident did not have weekly weights. The resident was not on the weekly weight list. During an interview on 07/12/24 at 8:16 A.M., the ADON said the resident was not on the weekly weight list. She didn't know why the resident wasn't added and didn't get weekly weights. 45693 46521 47445

Based on interview and record review, the facility failed to provide a safe transfer for one resident (Resident #23) in a manner to prevent accidents, when staff did not utilize two staff for transfers as directed on the resident's care plan and the resident sustained a hip fracture. Also, the facility failed to safely transfer one additional resident (Resident #8) outside of the sample. The facility census was 40. Review of the facility's policy titled, Gait Belt (a device used for assistance with transfers and walking) Transfers, undated, showed: - Assist resident to a sitting position; - Apply belt to the resident's waist and tighten to fit snugly with the buckle at the side; - Face the resident; - Bend your knees and place your hands around the gait belt on each side of the resident's waist; - Bring the resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing the turning of the resident. 1. Review of Resident #23's medical record showed diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following a stroke, pneumonia, muscle weakness, COPD, difficulty in walking, fracture of the neck of the left femur (thigh bone), pain to the left hip, bipolar disorder (a mental disorder that causes unusual shifts in mood), and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Substantial/maximal assistance of staff for dressing, personal hygiene, transfers, toilet use, and bathing. Review of the resident's care plan, last revised 05/23/24, showed: - The resident required assist of staff with ADL's, incontinent care and transfers; - Required a minimum of two staff to transfer. Review of the nurse's notes showed: - On 06/19/24 at 3:47 P.M., the resident requested to be transferred from the wheelchair to the recliner. The resident was assisted to stand with a gait belt by Registered Nurse (RN) E. While pivoting, the resident began leaning to the left. RN E attempted to correct the resident's position and the resident leaned further due to his/her left sided weakness. The resident was lowered to the floor by RN E and he/she complained of left hip pain. RN E and a second nurse assisted the resident to a sitting position and transferred the resident into the recliner. The resident had a small skin tear to his/her left hand. The physician was notified and received an order for an x-ray of the left hip; - On 06/19/24 at 7:30 P.M., the left hip x-ray was obtained; - On 06/19/24 at 9:46 P.M., the resident continued to complain of increased pain to the left hip. The resident requested to be sent to emergency department (ED). The physician was notified and received an order to send the resident to the ED. - On 06/20/24, the ED staff notified the facility of the resident being admitted to the hospital for a fractured left hip with possible surgery; - On 06/24/24, the resident returned to the facility from the hospital and the resident's left hip with a small incision with seven sutures in place. Review of RN E's Employee Counseling Notice, dated 06/20/24, showed: - Employee failed to follow the resident's care plan; - Employee transferred a two person assist resident by his/herself resulting in an injury to the resident. During an interview on 07/10/24 at 2:53 P.M., the Physician said staff should transfer residents as indicated. During an interview on 07/11/24 at 11:00 A.M., RN E said the resident started yelling he/she wanted to be transferred. There was no one readily available to assist and he/she thought the resident would be able to assist. The resident was usually a two person assist. The resident did help stand but while pivoting, the resident started leaning over to one side. RN E tried to correct the resident's leaning, but they both started to fall. The resident lifted his/her right leg, which was the strong one, to try to help but when that happened, RN E and the resident fell . He/She tried to control the resident's fall, but it was hard due to falling him/herself. The resident did complain of hip pain immediately. Another nurse came to help assess the resident and they got him/her up out of the floor because of difficulty breathing. They gave the resident pain medication and ordered an x-ray. Later that night, the resident complained of increased pain while the facility still was waiting for results from the x-ray. They sent the resident out to the hospital and he/she did have a fractured femur. During an interview on 07/11/24 at 10:10 A.M., the Administrator was aware of the incident and interviewed RN E. RN E said she transferred the resident as a one person assist but used a gait belt. The staff were in-serviced. She did not complete an official investigation which showed documentation of the incident. She didn't have any monitoring of staff transfers since the incident occurred. 2. Review of Resident #8's medical record showed diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), pneumonia (an infection that inflames the air sacs in one or both lungs), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease that results in too much sugar in the blood), fracture of left clavicle (bone that connects arm to body), anxiety disorder (persistent worry and fear about everyday situations), and chronic heart failure (CHF - a serious condition that occurs when the heart is unable to pump blood efficiently). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by the facility staff), dated 06/05/24, showed: - Cognition severely impaired; - Dependent on staff for activities of daily living (ADL's); - Mechanical lift not indicated; - Impairment to one side of upper and lower extremity; - Sit to standing and all transfers to be substantial/maximal assist where helper does more than half the work. Review of the resident's CNA Care Card, undated, showed the resident required assist of two for mechanical lift transfers. Observation on 07/11/24 at 10:10 A.M., of the resident showed: - CNA D and Nursing Assistant (NA) B transferred the resident from the bed to the wheelchair by a Hoyer Lift (a mechanical lift to move residents); - CNA D and NA B pushed the resident across the hall to the shower room in the wheelchair where Hospice Aide (HA) Q waited to assist the resident with a shower; - CNA D and NA B transferred the resident from the wheelchair to the shower chair by a Hoyer lift; - NA B left the shower room; - While the resident sat in the shower chair, HA Q placed his/her right arm under the resident's left axillary (arm pit area), CNA D placed his/her left arm under the resident's right axillary area, HA Q and CNA D lifted the resident and removed the brief. The resident's feet did not touch the floor to bear weight and no gait belt was used by HA Q and CNA D; - NA B returned to the shower room and the resident sat in the shower room outside of the shower. During an interview on 07/11/24 at 2:45 P.M., CNA D said the resident should be transferred with a Hoyer lift. When the resident was lifted from the shower chair to remove his/her brief a gait belt should've been used, but he/she was just following the lead of HA Q because he/she acted more experienced. CNA D said he/she just started a few weeks ago, was still learning, and hadn't received any training or education on transfers at this facility. During an interview on 07/11/24 at 2:47 P.M., CNA L, said the facility staff verbally tell hospice staff how the residents needed to be transferred. During an interview on 07/11/24 at 2:50 P.M., NA B said lifting the shower chair with the resident in it was the only way to get the resident into the shower when the resident required a Hoyer lift. There was no other way. The facility had a policy that a resident couldn't be taken down the hall in a shower chair, so he/she couldn't be taken to a different hall in the shower chair. He/She hadn't received any recent in-services/education on transfers. Hospice usually did the resident showers for the residents on hospice. During an interview on 07/11/24 at 3:35 P.M., the Assistant Director of Nursing (ADON) said it was not safe transferring a resident without a gait belt or with a gait belt if the resident can't bear weight, a Hoyer lift should be used for a resident that bears no weight. Hospice staff was communicated with verbally and there were CNA care cards for each resident that were available for review. During an interview on 07/11/24 at 4:15 P.M., the Corporate Quality Assurance (QA) Registered Nurse (RN) said staff should not lift residents by placing their arm/hands under the resident's arms at all. If a resident does not bear weight during a transfer, she would expect a Hoyer lift be used for safety. During an interview on 07/11/24 at 4:15 P.M., the Administrator said would expect the resident to be lifted by a gait belt, not under their arms. Complaint #MO237896 45693 46521

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for at least eight consecutive hours per day, seven days a week. The facility also failed to have a Director of Nursing (DON). This deficiency had the potential to affect all residents. The census was 40. The facility did not provide a policy regarding RN and DON coverage. Review of the Facility Assessment, dated 03/07/24, showed: - DON should work five days a week for eight hours; - Licensed Nurses should include a RN eight hours per day when the DON is not available and on weekends. 1. Review of the Facility's Daily Nursing Staffing Sheets, dated 04/06/24 through 07/15/24, showed: - No RN scheduled for 04/11/24 through 04/14/24; - No RN scheduled for 04/18/24, 04/20/24, 04/22/24, 04/25/24, and 04/30/24; - No RN scheduled for 05/03/24, 05/09/24, 05/10/24, 05/12/24, 05/13/24, 05/17/24, 05/19/24, 05/23/24, and 05/30/24; - No RN scheduled for 07/12/24; - No RN scheduled for 19 out of 102 opportunities missed. Review of the facility's staff sheets, dated 07/01/24 through 07/15/24, showed; - RN E worked eight out of 15 days; - Agency RN staff worked five of 15 days; - A total of two out of 15 days with no RN coverage from 07/01/24 to 07/15/24. Review of Staffing Assignment Sheets, dated 07/01/24 through 07/15/24, showed no documentation a RN was assigned for 07/02/24, 07/05/24 - 07/12/24, with nine out of 15 opportunties missed. Review of the facility's current staff list showed one RN E as the only floor nurse and no DON. Review of RN I's employment record showed RN I hired as the DON on 06/29/22, and a termination date of 05/18/23. Review of RN J's employment record showed RN J hired as the DON on 11/08/23, and a termination date of 12/11/23. During an interview on 07/9/24 at 12:02 P.M., the Administrator said the facility didn't currently have a DON, and had not had a DON since November 2023. The Corporate Quality Assurance (QA) RN consults with them. The facility had one RN on day shift as a floor nurse. During an interview on 07/15/24 at 10:30 A.M., RN E said he/she was the only staff floor nurse for the facility. The only other nurses employed by the facility were the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS - a federally required assessment to be completed by facility staff) Coordinator which were Licensed Practical Nurses (LPN). During an interview on 07/15/24 at 4:45 P.M., the Administrator and ADON said there should always be RN coverage for the facility. They used agency staff to try to fill the voids the best they could. They currently did not have a DON.

Based on interview and record review, the facility failed to ensure written transfer agreements with hospitals were in effect to assure residents of a timely hospital admission when medically appropriate and the necessary information would be exchanged between the providers. This failure had the potential to affect all residents. The facility census was 40. The facility did not provide a policy on transfer agreements. The facility did not provide transfer agreements with any hospitals. During an interview on 07/15/24 at 5:00 P.M., the Administrator and the Assistant Director of Nursing (ADON) said the corporate Quality Assurance Registered Nurse could not find transfer agreements for any hospitals. The Administrator said she had no knowledge of transfer agreements with any hospitals.

Based on interview and record review, the facility failed to provide written notice to the State agency responsible for licensing the facility when their Director of Nursing (DON) was no longer employed. This had the potential to affect all resident. The facility census was 40. Review of the Facility Assessment, dated 03/07/24, showed: - DON should work five days a week for eight hours; - Licensed Nurses should include a Registered Nurse (RN) eight hours per day when the Director of Nursing (DON) is not available and on weekends. Review of RN I's employee record showed: - RN I hired as the DON on 06/29/22, and a termination date of 05/18/23. Review of RN J's employee record showed: - RN J hired as the DON on 11/08/23, and a termination date of 12/11/23. Review of the last state agency Change of DON Form, dated 07/07/22, showed RN I started employment as the DON on 06/29/22. Review of the nursing schedules, dated 04/06/24 - 07/15/24, showed: - No documentation of a DON scheduled for 04/06/24 - 07/15/24; - No documentation a DON worked 04/06/24 - 07/15/24, with 107 out of 107 days missed. During an interview on 07/15/24 at 5:00 P.M., the Administrator said the facility did not have a DON. The last DON that worked was back in November 2023.

Based on interview and record review, the facility failed to consistently document a code status for one resident (Resident #12) out of 12 sampled residents. The facility census was 40. The facility did not provide a policy regarding a resident's code status. 1. Review of Resident #12's medical record showed: - An admitted [DATE]; - The revised care plan, dated [DATE], showed a Do Not Resuscitate (A DNR instructs providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating). - The face sheet, undated, showed a DNR status; - The Physician's Order Sheet (POS), dated [DATE], showed a full code (if a person's heart stopped beating and/or they stopped breathing, CPR procedures would be provided) status; - A DNR form signed by the resident on [DATE], and signed by the physician on [DATE]; - The resident's Medication Administration Record (MAR) showed a red DNR code sheet. During an interview on [DATE] at 9:34 A.M., Resident #12 said he/she had discussed a code status change with his/her family a few months ago and they had decided together on the DNR status. During an interview on [DATE] at 9:30 A.M., Certified Medication Technician (CMT) F said he/she would look at the orders to check a resident's code status. The MAR had red or green paperwork that indicated a code status for a quick reference and a nurse could be asked. During an interview on [DATE] at 10:05 A.M., the Assistant Director of Nursing said there was a red or green sheet that indicated the code status in the charts, red meant DNR and green was full code. There were also purple sheets that showed a code status either way, and there were usually several kept in the chart, so it was easy to grab if a resident transferred out of the facility. The staff could also look at the code status in the physician's order sheet. The orders should match the color-coded sheets in the MAR and show the correct code status.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, homelike environment, and failed to clean and/or repair/replace wheelchairs for one sampled resident (Resident #22) and three residents (Resident #6, #9, and #20) outside the sample. The facility's census was 40. Review of the facility's policy titled, Orientation Manual Guidelines, dated May 2006, showed the maintenance manager responsibilities will be: - Supervise the day-to-day activities of the maintenance department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and as may be directed by the environmental manager or the Administrator; - Assure the facility will be maintained in a safe and comfortable manner; - To repair and install drywall including mudding, taping and sanding; - Paint walls; - Assist in setting maintenance standards as well as establishing a preventative maintenance program; - Perform general rough and finish carpentry as well as rough and finish concrete work; - Sweep, mop, and buff floors; - Clean, disinfect and sanitize bathrooms, kitchens and bedrooms; - The maintenance manager will perform preventive and routine maintenance of the facility. Observation on 07/11/24 at 10:15 A.M., of the 500 Hall shower room showed: - The tiled shower base foundation was elevated three and one half inches above the floor, creating a step up into the shower; - The caulking bead with a brown substance in the corner where the wall and floor met on each of the three walls of the shower stall floor. Observations on 07/15/24 at 12:49 P.M., of the 300 Hall shower room showed: - The left side shower end wall section without three 6 in. ceramic tile baseboard pieces and a 16 in. unpainted section above the floor surface; - The fiberglass shower unit with the left end panel unattached and separated 8 in. from the shower unit near the top; - Corner wall base section below the shelf and towel rack missing one 4 in. section of ceramic tile base. During an interview on 07/15/24 at 1:05 P.M., Housekeeper F said damage in the shower rooms should be reported to maintenance staff. There was a maintenance log and some of the current issues like wall damage, missing paint and tiles had been reported a long time ago. Housekeeping staff were supposed to enter issues in the log but sometimes they were reported verbally to maintenance. The fiberglass shower unit on the 300 Hall had not worked since he/she was hired and the left side panel had always been separated but he/she had not reported it to maintenance. He/she hadn't noticed the caulk bead being discolored in the 500 Hall shower but it should be cleaned or replaced. During an interview on 07/15/24 at 1:20 P.M., the Maintenance Director said he/she was not aware of plans to repair the damage in the shower rooms and he/she inspected the showers at least once a week. The fiberglass shower unit on the 300 Hall had not worked in the two years he/she had been here and removing and/or repairing it had not been discussed. The side panel was separated from the fiberglass shower but since that shower unit didn't work there were no plans to make a repair. He/She was aware of the damaged shower wall section and missing paint and ceramic tiles in the 300 Hall shower room stall, but was not planning to replace the tiles or paint currently but it might be done eventually. The shower stall was currently used by the residents. The discolored caulk should be cleaned or replaced in the 500 Hall shower but it wasn't reported. Observations of Resident #22's wheelchair showed: - On 07/09/24 at 9:42 A.M., the resident sat in his/her wheelchair in the room with the wheelchair arms wrapped with Coban (a self-adherent wrap) stained, dirty, pilled up, and the seat cushion hung over the front edge by four inches (in.), and the wheelchair dirty with food and debris; - On 07/09/24 at 12:18 P.M., wheelchair in the hall with the wheelchair arms wrapped with Coban stained, dirty, pilled up, and the seat cushion hung over the front edge by four inches (in.), and the wheelchair dirty with food and debris; - On 07/10/24 at 2:36 P.M., the resident lay in bed with his/her wheelchair in the room with the wheelchair arms wrapped with Coban stained, dirty, pilled up, and the seat cushion hung over the front edge by four inches (in.), and the wheelchair dirty with food and debris. Observations of Resident #20's wheelchair showed: - On 07/09/24 at 9:43 A.M., the resident lay in bed with his/her wheelchair at the bedside, the back of wheelchair cover with cracks all across the back, both corners split 1.5 in. down toward the seat with filler showing, both arm rests with cracks all down the outside edge and around the back edge, the seat cushion dirty with food and debris; - On 07/10/24 at 12:55 P.M., the resident sat in his/her wheelchair with the back of wheelchair cover with cracks all across the back, both corners split 1.5 in. down toward the seat with filler showing, both arm rests with cracks all down the outside edge and around the back edge, the seat cushion dirty with food and debris. Observations of Resident #9's wheelchair showed: - On 07/09/24 at 9:45 A.M., the resident sat in his/her wheelchair without an arm rest on the right arm and propelled him/herself down the hall; - On 07/10/24 at 12:58 P.M., the resident sat in the dining room in his/her wheelchair without an arm rest on the right arm. Observations of Resident #6's wheelchair showed: - On 07/11/24 at 5:42 P.M., the resident sat in his/her wheelchair the covering missing and foam fill exposed on both arm rests and propelled him/herself down the hall; - On 07/12/24 3:22 P.M., the resident sat in his/her wheelchair the covering missing and foam fill exposed on both arm rests. During an interview on 07/10/24 at 5:42 P.M., Resident #6 said his/her wheelchair had been like that for a very long time and the wheel made a noise but no one had fixed it. He/She needed a new one. Review of the Maintenance Director repair logs dated 11/21/23 through 7/15/24, showed: - No documentation of the 300 and 500 Hall shower room repair concerns; - No documentation of residents' wheelchairs repair concerns; During an interview on 07/11/24 at 7:53 A.M., Nurse Aide (NA) B said he/she hadn't been at the facility long and was unsure about when the wheelchairs should be cleaned or what to do about equipment that needed repaired or replaced. During an interview on 07/11/24 at 7:55 A.M., CNA D said he/she did not know about the wheelchair cleaning/maintenance. During an interview on 07/11/24 at 7:57 A.M., Licensed Practical Nurse (LPN) M said as far as he/she knew, the wheelchairs should be cleaned by the night shift CNAs and should be done nightly. During an interview on 07/11/24 at 5:29 P.M., CNA G, said the wheelchairs that need cleaned, should be cleaned by night shift, and if he/she wasn't busy. During an interview on 07/12/24 at 11:22 A.M., the Maintenance Director said needed wheelchair repair was usually just verbally reported. No wheelchair repairs had been reported to him/her recently. Wheelchairs that were all cracked up should be taken out of use and replaced, but didn't remember any new wheelchairs ever being bought. During an interview on 07/10/24 at 3:46 P.M., the Administrator said she wished there were funds to get new wheelchairs. They should be cleaned, repaired or replaced. The wheelchairs should be cleaned weekly and night shift CNAs were responsible. There is no documentation to show when they are cleaned. During an interview on 07/11/24 at 4:40 P.M., the Corporate Quality Assurance (QA) Registered Nurse (RN) said the facility had available funds for resident wheelchairs and an order just had to be submitted. 45693

Based on observation, interview and record review, the facility failed to assess the use of a bed and chair alarm (devices that contain sensors that trigger an alarm when they detect a change in pressure) to determine if utilized as restraints and to complete on-going evaluations for the continued need for one resident (Residents #24) out of three sampled residents. The facility census was 40. Review of the facility's policy titled, Nursing Guidelines Manual, undated, showed bed and chair alarm documentation should include: Date and time bed and chair alarm ordered and name and title of person ordering the restraint; Type of restraint; Reason or reasons for the use of the bed and chair alarm and the resident's response; All pertinent observations; Signature and title of person recording the data. 1. Review of Resident #24's medical record showed: - Diagnoses of Alzheimer's Disease (progressive mental deterioration), altered mental status, and osteoporosis (a condition causing loss of bone mass, predisposing a person to fractures); - Required assistance of one staff for toileting; - No documentation of a physician's order for the bed and chair alarms; - No documentation of a bed and chair alarm assessment. Review of the facility's fall records showed: - On 06/11/24 at 3:00 P.M., the resident had an unwitnessed fall with no injuries; - On 06/25/24 at 6:58 P.M., the resident was found sitting on the fall mat in front of his/her bed with no injuries; - On 06/28/24 at 8:09 A.M., the resident had a witnessed fall on the fall mat; - On 07/05/24 at 1:58 P.M., the resident had an unwitnessed fall; - On 07/09/24 at 9:50 P.M., the resident had an unwitnessed fall. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 04/15/24, showed: - Cognition severely impaired; - Dependent for most activities of daily living (ADL's); - Wheelchair used for mobility; - Bed and chair alarms not used. Review of the resident's care plan, revised 05/23/24, showed: - The resident requires supervision with ADL's and one person assist with bathing; - The resident at risk for falls; - Bed and chair alarms used as a fall intervention; - Resident fell out of bed on 6/11/24; - Multiple interventions to prevent falls attempted. Observations of the resident on 07/09/24 at 10:49 A.M. and 3:14 P. M., and 07/15/12/24 at 8:37 A.M., showed: -The resident lay in bed with a bed alarm attached to a pressure pad under his/her back; -The resident was unable to remove the bed alarm. Observations of the resident on 07/09/24 at 12:37 P.M., 07/12/24 at 12:35 P.M. and 2:42 P.M., and 07/15/12/24 at 1:08 P.M., showed: - The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and a pressure pad under the resident's thighs and buttocks; - The resident was unable to remove the chair alarm. During an interview on 07/12/24 at 1:30 P.M., the MDS Coordinator said chair and bed alarms were not assessed in the facility, but should have been. The bed and chair alarm monitoring were not documented but should be to ensure they were working properly. They were used as a fall intervention. During an interview on 07/15/24 at 4:00 P.M., the Administrator and Assistant Director of Nursing (ADON) said they expect monitoring and assessments for bed and chair alarms to be completed. Assessments should be done every three months. During a phone interview on 07/26/24 at 1:24 P.M., the Administrator she is not sure why there was not a physician's order in place for the bed and chair alarms but there should have been orders.

Based on observation, interview and record review, the facility failed to implement interventions and provide adequate supervision and monitoring to ensure one (Resident #1) of five sampled residents identified at risk for elopement did not leave the facility without supervision. Resident #1 exited the facility without staff knowledge and was found in the parking lot of a business across the street from the facility by a passerby. The passerby transported the resident to the local hospital. The facility census was 54. 1. Record review of the facility's Elopement Risk Procedure policy, dated April 2006, showed: - The purpose of the facility is to provide 24 hour protective oversight to residents. - The admission screening process should thoroughly evaluate a resident's potential for wandering. - If a resident verbalizes or attempts to leave the facility and does not have any previous elopement potential, staff should evaluate the resident for placement on the locked unit; the Director of Nursing (DON) should notify the physician; the Social Service Director (SSD) should notify the family; a care plan should be developed; the resident should be placed into a room in the line of sight from the nurses' station; and a Certified Nurse Aide (CNA) should be assigned to observe the resident at all times. 2. Review of the facility's Code White Protocol, dated April 2006, showed: - The purpose of the policy is to ensure resident safety and security with identification of risk of wandering or elopement being imperative. - Nursing staff should complete the wander and/or elopement assessment form upon admission. - Once identified as being at risk for wandering and/or elopement, the MDS/Care plan Coordinator should develop a care plan to address the risk. - If determined to be at high risk for wandering/elopement, the resident should be added to the code white program and placed on the special care unit (SCU) (a locked unit). 3. Review of the facility's door alarm protocol, dated April 2006, showed: - A specific system had been developed to notify staff when an external door had been opened in areas accessible to residents. - Staff should test doors at least monthly and document test results. - The appropriateness of staff's response to the alarms should be monitored at the time of testing. - Only the Administrator should authorize the disabling of the alarm system. 4. Record review of Resident #1's face sheet showed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's medical record, showed the record did not contain any information to show staff completed a wander and/or elopement risk assessment upon admission as directed by the Code White Protocol. Review of nurses' notes showed: - On 9/29/13, the resident wandered into another resident's room. - On 9/30/13, the resident wandered into another resident's room and in the hall. - On 10/1/13, the resident wandered. - On 10/2/13, the resident wandered into another resident's room and said he/she wanted to leave to find his/her spouse. Staff applied a personal (fall) alarm to the resident but the resident carried the alarm (which prevented it from sounding when he/she rose from the chair). Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/3/13, showed staff identified the resident had moderately impaired cognitive skills for daily decision making. Additionally, review showed staff did not assess the resident's wandering behaviors. Review of a nurse's note, dated 10/4/13, showed staff documented the resident's spouse (who stayed in the facility with the resident overnight) said the resident attempted to leave the room several times during the night but the spouse redirected the resident. Review of a wander and/or elopement assessment, dated 10/4/13, showed staff completed the assessment eight days after admission. Staff assessed the resident at risk for elopement and/or wandering due to being a new admission, he/she is ambulatory and able to walk with assistance, has a history of wandering, and has dementia. Review of the resident's care plan for psychosocial well-being problems, dated 10/4/13, showed staff documented the resident "goes to the dining room and sits in the lobby and TV room and visits with family, staff and others." Staff documented the resident had been going through the bathroom door into another resident's room and across the hall into other rooms at night. Review showed facility staff did not plan interventions to address the resident's wandering and the resident's assessed risk of wandering/elopement. Review of the resident's nurses' notes, dated 10/6/13, showed: - At 2:00 A.M., staff noted the resident wandered and said he/she was getting his/her truck and leaving. Staff redirected the resident. - At 7:40 A.M., staff saw the resident in the dining room self-propelling his/her wheelchair. - At 8:30 A.M., staff received a call from the local hospital that the resident had been found down the hill from the facility by a passerby and taken to the hospital. -At 8:40 A.M., staff documented they had approached the resident's family several times over the previous week about the resident's increased wandering and the need to place the resident on the locked unit, but the family declined. Review of the hospital report, dated 10/6/13, showed at 8:42 A.M., the resident was triaged by the emergency room (ER) staff. Hospital staff documented the resident was found seated on the ground in the parking lot of a car wash (located next to the facility) and taken to the ER by a passerby who was concerned about the resident's confusion/whereabouts. The ER contacted the facility at 8:45 A.M. and facility staff reported they were unaware of the resident's elopement. The resident had no injuries. Observation on 10/8/13 at 9:00 A.M. showed: - The front exit door had no alarm system. - The alarm system on the exit door on the 100 hall did not sound when the door opened. - The exit door on the 400 hall had a delayed response, in which the door alarm did not sound until a person was already out the door. During an interview on 10/8/13 at 8:00 A.M., the Administrator said the resident left from an undetermined exit door on the morning of 10/6/13. The Administrator said no alarms sounded and staff did not know the resident eloped from the facility until the hospital called and reported the resident was at the hospital. During an interview on 10/8/13 at 8:40 A.M., the MDS/Care Plan Coordinator said she completed the wandering and/or elopement risk assessment for the resident and assessed the resident at risk. The MDS/Care Plan Coordinator said she documented on the care plan that the resident wandered into other rooms, but she did not develop interventions to address the wandering. The MDS/Care Plan Coordinator said she did not code the resident's MDS to show the resident wandered because she was unaware of the resident's wandering at the time she completed the MDS. She said she spoke with the resident's spouse about placing the resident on the locked unit on either 10/3/13 or 10/4/13, but the spouse declined. During an interview on 10/8/13 at 9:05 A.M., the Maintenance Supervisor said staff turned off the alarm system on the 100 hall exit door because it accessed the smoking area. Additionally, the 400 hall exit door had a delayed response but the alarm eventually sounded. The Maintenance Supervisor said the facility did not have a formal monitoring system of the doors/alarms. During an interview on 10/8/13 at 9:10 A.M., Licensed Practical Nurse (LPN) B said the resident wandered on the hall with increased frequency at night. LPN B talked to the resident's spouse on 10/2/13 about placement on the locked unit due to the resident's wandering, but the resident's spouse declined. LPN B said staff, "always" left the 100 hall exit door alarm disengaged, the front exit door did not have an alarm system, he/she was unaware of the alarm delay on the 400 hall exit door, and staff turned off the alarm system on the therapy exit door and propped the door open to allow patients from the community access to outpatient services, and so staff could take out the trash. During an interview on 10/8/13 at 9:25 A.M., the Director of Nursing (DON) said the resident wandered in and out of other rooms on his/her hall. On 10/6/13 the resident eloped with two wheelchairs which staff later found near the garbage dumpsters. The DON did not know from which door the resident eloped. Staff "always" left the 100 hall exit door alarm disengaged for access to the smoking area. Staff had a history of [REDACTED]. During an interview on 10/8/13 at 9:35 A.M., Certified Nurse Aide (CNA) E said on the day the resident eloped from the facility, he/she did not hear an alarm to indicate anyone opened an alarmed door. CNA E said staff "always" left the 100 hall exit door alarm disengaged and staff propped open the therapy exit door when taking out the trash. During an interview on 10/8/13 at 9:55 A.M., CNA F said he/she did not hear an alarm on the day the resident eloped from the facility to indicate anyone opened an alarmed door. CNA F said staff left the 100 hall exit door alarm disengaged and the front exit door did not have an alarm. Staff should have kept all exit doors closed and left alarms turned on. During an interview on 10/8/13 at 10:13 A.M., CNA G said staff "never" engaged the alarm on the 100 hall exit door. During an interview on 10/8/13 at 11:10 A.M., the Administrator and Maintenance Supervisor said staff did not keep the 100 hall exit door alarm system turned on prior to 10/8/13 when surveyors assessed the door. During an interview on 10/8/13 at 12:40 P.M., the MDS/Care Plan Coordinator said she had not previously been aware of the facility's elopement risk protocol (Code White Protocol) and it had not been implemented for the resident. During an interview on 10/8/13, the SSD said she was unaware staff assessed the resident at risk for elopement,and therefore she had not yet completed a follow-up assessment on the resident. The SSD was unaware of the facility's elopement risk protocol. During an interview on 10/8/13 at 1:10 P.M., LPN B said he/she was unaware of the facility's elopement risk protocol. During an interview on 10/8/13 at 1:10 P.M., Certified Medication Technician (CMT) said he/she was unaware of the facility's elopement risk protocol. During an interview on 10/8/13 at 1:15 P.M., the Administrator and DON said: - The resident eloped with two wheelchairs and left them in a ravine/ditch by the trash dumpsters next to the street. - They did not know from which door the resident exited. - The facility had a wanderguard system on the front exit door but no longer used it due to the alarm went off all the time. During an interview on 10/8/13 at 3:22 P.M., Resident #1's family member said the resident begged to go home and roamed about at night. The resident indicated to the family member that he/she left through the exit door by the therapy department on 10/6/13. During an interview on 10/9/13 at 5:30 A.M., Registered Nurse (RN) A said: - The resident was always confused and wandered about the facility. RN A had been very concerned about his/her elopement risk and discussed concerns with the Administrator who said the family did not want the resident locked up. - RN A did not notify the resident's physician of the resident's wandering, nor did staff implement further interventions to reduce the risk of elopement. - On the night prior to the elopement, staff had reported the resident had been up all night looking for his/her truck. - RN A last recalled seeing the resident during breakfast at around 7:40 A.M. on 10/6/13. - At 8:30 A.M., the ER called and said the resident had been found by a passerby outside between the facility and car wash. The resident told staff he/she pushed two wheelchairs out of the facility. - No one heard the door alarms sound and no one was aware the resident was missing. - Staff found two wheelchairs in the large ditch/ravine by the dumpsters along the street in front of the facility. -Staff never engaged the 100 hall exit door alarm, the front door did not have an alarm, and staff often disengaged the alarm on the therapy exit door and propped the door open. During an interview on 10/9/13 at 9:58 A.M., the resident's physician said staff had reported the resident was agitated and experienced sleeping problems but had not notified him/her that the resident wandered. The physician said he/she expected the facility to have alarms and/or guard systems in place and said he/she was unaware the facility did not keep all door alarms turned on, nor was he/she aware that facility staff propped open exit doors. During an interview on 10/11/13 at 6:30 A.M., the passerby who found the resident on 10/6/13 said: - He/she was driving by the detail shop across the street from the facility sometime between 8:00 A.M. and 9:00 A.M. and saw the resident motion for him/her to stop. The resident had picked up a 2 X 4 board and was leaning against it to support him/herself. - The resident wore street clothes but was not wearing a jacket. It was chilly and the resident was cold and appeared to be "shook up". He/she helped the resident into his/her truck to warm up. - The resident said he/she lost two wheelchairs in the ditch. The passerby looked in the three ditches around the nursing home, car wash and detail shop but did not see the resident's wheelchairs. - The resident told the passerby his/her name and who his/her family was but did not indicate he/she lived at the nursing home. - The passerby called an ambulance. After being made aware it may take a while, the passerby took the resident to the ER. 5. Review of the facility's most recent preventative maintenance checklist and monthly inspection, dated September 2013, showed: - The checklist directed staff to check egress (exit) locks daily. Staff noted they checked the locks on 9/17/13. Staff did not document daily checks of the egress locks. - The checklist also directed staff to check doors for repairs and exit doors egress locks weekly. Staff noted they checked the locks on 9/3/13, 9/12/13, 9/16/13, and 9/25/13. - The checklist did not address monitoring alarm systems or clearly identify frequency of monitoring, nor did staff identify the delayed response of the 400 hall exit door alarm, 100 hall exit door alarm being disengaged, or staff response to alarms. Complaint #MO 780 *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 address and lower the violation at the time. During the onsite visit, facility staff adjusted the alarms of all exit doors to "always on" status. Facility staff corrected the delay on the 400 hall exit door to immediately alarm when opened. Maintenance staff installed key pad entries at the front door and therapy entrance and installed alarm devices at all exit doors. Maintenance staff began conducting daily rounds to include checking all doors for alarms to be on and in working order, and that doors are not propped open. All staff were inserviced on keeping all door alarms turned on at all times and not propping doors open. The SSD and MDS/Care Plan Coordinator were inserviced on proper coding of the MDS regarding wandering. Nursing staff began to reassess all residents' risk for wandering/elopement by utilizing a new wander/elopement risk tool to be done immediately, quarterly, and with a change in condition and will continue to work on this until completed. Nursing staff began to implement temporary care plans based on the results of the wander/elopement risk assessments and continue to work on this until completed. Nursing staff will complete wander/elopement risk assessments at the time of admission and will complete a temporary plan of care within 24 hours if a resident is assessed at risk. Facility staff are continuing to complete wander/elopement risk assessments on new admissions and complete plans of care if the resident is assessed at risk. Facility staff are continuing to monitor door alarms and that doors are not being propped open. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review one (Resident #1) of three reviewed residents, who had an acute medical condition, did not receive prompt or appropriate treatment. The facility census was 50. Record review the physician's orders [REDACTED]. Observation on 5/14/13 at 9:30 A.M., showed Resident #1 had a red and excoriated peri-area with white macerated skin along the labia and toward the inside of the vagina. The redness and excoriation extended toward the anus and areas of white maceration presented along the buttock cheeks. During incontinent care, Resident #1 cried out each time the nurse aides wiped her peri-area. During an interview on 5/14/13 at 9:35 A.M., Resident #1 said she itches,[MEDICAL CONDITION] hurts. Resident #1 asked if anything could be done to help, she would sure appreciate it. Record review of all weekly skin assessments done in 2012 showed Resident #1 had redness, scratching and itching in the perineal area 26 out of 52 weeks. Record review of weekly skin assessment sheets for 2013 showed Resident #1 had redness, excoriation and itching 21 of 21 weeks. Record review of a physician's orders [REDACTED]. Record Review of the POS [REDACTED]. Record review of weekly skin assessment sheets for 2012 showed the resident's skin was clear for three weeks and the [MEDICATION NAME] cream was discontinued. Record Review of the POS [REDACTED]'s buttock, labia and vagina. Staff documented the application of the cream every shift the entire month. The manufacturer's instructions for this cream showed the physician should be notified if symptoms do not improve within one week when treating the groin area. Record review of the Treatment Administration Record (TAR), dated 11/27/12 directed the staff to apply [MEDICATION NAME] (an [MEDICATION NAME], antiseptic) ointment to the resident's buttocks/peri-area every shift and as needed. Staff documented the application of the cream every shift the entire month. The manufacturer's instructions for this cream showed if symptoms do not get better within seven days, the physician should be notified. Record Review of the POS [REDACTED]. The staff documented the application of the cream every night at 8:00 P.M. for the rest of December and all of January 2013. Instructions on the back of the tube showed, if symptoms persist more than seven days or clear up, then recur within a few days, to discontinue use and contact the physician. Record review of the TAR for January 2013 showed: - [MEDICATION NAME]/[MEDICATION NAME] cream three times a day (TID). Staff documented the administration of the cream TID the entire month. - [MEDICATION NAME] to buttocks and peri-area every shift and as needed. Staff documented the application of the cream every shift the entire month. - Vagisil creme as directed at 8:00 P.M. Staff documented the application of the cream all of January, 2013. Record review of the TAR for February and March 2013 showed: - [MEDICATION NAME]/[MEDICATION NAME] cream TID. Staff documented application of the cream TID the entire month. - [MEDICATION NAME] to buttocks and peri-area every shift and as needed. Staff documented application of the cream every shift. Record review of the TAR for April and May 2013 showed: - [MEDICATION NAME]/[MEDICATION NAME] cream TID to buttocks, peri-area and labia. Staff documented application of the cream TID the entire month. During an interview on 5/14/13 at 9:40 A.M., Certified Nurse Aide (CNA) A said he/she takes care of Resident #1 most days that he/she works and the resident is always red and excoriated in the peri-area. CNA-A said Resident #1 had been like this for at least six months. CNA-A said the resident cries when they have to clean her peri-area. During an interview on 5/14/13 at 9:00 A.M., the Director of Nursing (DON) said Resident #1 has chronic hemorrhoids, chronic vaginitis, yeast infection and itching. The DON said the nurses have been following the physician's orders [REDACTED]. The DON said if there is no documentation in the nurse's notes, none of the nurses ever asked the physician to refer the resident again to a OB/GYN, told the physician about the resident's continued skin problems/infection or asked the physician for a different type of treatment. On 5/14/13 at 2:00 P.M. LPN A said he/she had done the treatments for Resident #1 many times. LPN A said he/she had not called the physician and did not know if any of the other nursing staff had either. LPN A said he/she just did the treatments as the physician ordered. During a telephone interview on 5/16/13 at 8:15 A.M., the resident's physician said he had not been informed by the nursing home staff that the resident's infection was that bad. He said none of the staff ever asked him to examine the resident. The physician said if he had known he would have referred the resident to an OB/GYN a long time ago. The physician said it is definitely a problem that needed to be attended to and should not have been left to go on for so long. The physician said prolonged antibiotic use for treatment of [REDACTED]. The physician said he expects facility staff to tell him if a patient of his had any kind of infection that does not get better. Complaint # MO 218