Every finding on record at Estates of St Louis, LLC, The

Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe following a physical altercation between two residents (Residents #3 and #4), in which one resident sustained an eye injury. The sample was four. The census was 73. Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the Department of Health and Senior Services (DHSS) as required within a two-hour timeframe following a physical altercation between two residents (Residents #3 and #4), in which one resident sustained an eye injury. The sample was four. The census was 73. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 4/8/24, showed the following:-Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals;-Policy Explanation and Compliance Guidelines:--Physical Abuse includes, but not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment;-Facility Abuse Prevention Plan:-Response and Reporting of Abuse, Neglect and Exploitation:--Anyone in the facility can report suspected abuse to the abuse agency hotline--When abuse, neglect or exploitation is suspected, the Licensed Nurse should:---Respond to the needs of the resident and protect them from further incident (document);---Notify the Administrator and Director of Nursing (DON) (document).-The policy failed to specify that allegations of abuse must be reported to the State Survey Agency immediately, but not later than two hours after the allegation is made, in accordance with federal regulations. Review of Resident #3's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/25/26, showed the following:-No cognitive impairment;-No mood or behaviors exhibited;-Diagnoses included anxiety disorder and depression. Review of the resident's care plan, dated 2/28/26, showed the following:-Problem: The resident was involved in a physical altercation with another resident related to poor impulse control, hitting a resident, and noncompliance with facility smoking rules;-Interventions: Reeducate the resident on the facility's smoking rules. Reinforce the use of coping strategies such taking deep breathing, verbalizing concerns before escalations. Review of the resident's nurse's note, dated 2/28/26 at 9:50 P.M., showed it was reported to this writer that this resident struck another resident in the eye. This writer did go and asked the resident what happened. The resident said that the other resident was trying to take his/her cigarette when he/she drooled on him/her. This resident was placed on 15-minute checks for behaviors. During an interview on 3/4/26 at 12:35 P.M., the resident said he/she and another resident were smoking a cigarette in the smoking area. Resident #4 came over and drooled on him/her and tried to take his/her cigarette. He/She pulled Resident #4 to the ground and punched him/her in the nose. Review of Resident #4's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-No moods or behaviors exhibited;-Diagnoses included high blood pressure, stroke, seizure disorder, anxiety, and depression. Review of the resident's care plan, dated 3/1/26, showed the following:-Problem: The resident was involved in a resident-to-resident altercation;-Interventions: Monitor the resident for sign of agitation and emotional distress. Provide emotional support as needed. Separate the residents involved when necessary to reduce conflict. Review of the resident's nurse's notes showed the following:-On 2/28/26 at 9:28 P.M., staff documented the resident had walked up on another resident trying to take his/her cigarette. When he/she drooled on the other resident, he/she was hit in the eye by the other resident. The resident's left eye discolored black and purple under the orbit (a bony, pyramid-shaped cavity in the skull);-On 2/28/26 at 10:26 P.M., staff documented a message was left for the resident's psychiatrist, the Assistant Director of Nursing (ADON) and the Director of Nursing(DON) were notified. Observation on 3/4/26 at 11:04 A.M., showed the resident ambulated throughout the facility. The resident had a dark purple area under his/her left eye. An attempt was made to interview the resident without success. The resident was pleasantly confused. Review of the facility's Complaint/Incident Investigation Report, submitted to DHSS on 3/2/26, showed the facility reported a physical altercation between Residents #3 and #4 occurred on 2/28/26. During an interview on 3/4/26 at 1:16 P.M., the ADON said the charge nurse called him/her regarding the altercation between the residents. It was reported that Resident #4 had redness under his/her left eye. The ADON did not read either resident's notes or see the residents until Monday, 3/2/26. During an interview on 3/4/26 at 1:08 P.M., the Administrator said the ADON called her about the incident between Residents #3 and #4 and she read Resident #4's nurse's notes regarding his/her black eye. She wanted to see Resident #4's eye before reporting to DHSS. She should have notified DHSS of the allegation of abuse within the two-hour timeframe, per regulatory requirements. The incident happened on 2/28/26 but was not reported to DHSS until 3/2/26. She was not aware the facility's policy did not include the required reporting timeframes. 2791646

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility did not provide residents with refunds of their personal funds from the operating account in a timely manner for nine residents (Resident #7, #8, #9, #12, #13, #14, #15, #16 and #17). Facility staff failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner, which did not allow the resident/financial guardian the right to manage his/her financial affairs for three residents (Resident #3, #7 and #8) out of a sample of seven. The facility census was 79.1. Record review of the facility-maintained Accounts Receivable Aging Report, dated 12/16/25, showed the following residents with personal funds held in the facility operating account. Resident - Amount Held in Operating Account#7 - $724.75#8 - $1,533.00#9 - $2,096.00#12 - $636.00#13 - $1,327.00#14 - $4,241.67#15 - $1,325.85#16 - $3,310.00#17 - $3,871.10Total - $19,065.37 Record review of the facility-maintained paperwork showed the facility did not credit the resident funds held in the operating account until 12/18/25, two days after the department entered the facility for a complaint investigation. During email correspondence dated 12/18/25 at 2:52 P.M., the Accounts Receivable Manager said the credit balances were created due to:- Resident #9 received a backpay in 08/2024;- Resident #7, #8, #12 and #17 received a backpay in 05/2025;- Resident #13 received a backpay in 08/2025;- Resident #16 received a backpay in 07/2025;-Resident #14's guardian paid his/her bill monthly even though there was a credit on the account;- Resident #15 had a surplus adjustment in 05/2025. During email correspondence dated 12/18/25 at 4:29 P.M., the Accounts Receivable Manager said the credits were not done timely. 2. Record review of the facility-maintained Resident Trust Transaction History for the period 01/01/25 through 12/16/25, showed the following residents did not receive the $50 Social Security/Medicaid monthly allowance timely for the following months: Resident - Amount - Month#3 - $0 - 03/2025 $0 - 04/2025 #7 - $0 - 03/2025 $0 - 04/2025 #8 - $0 - 03/2025 $0 - 04/2025 Record review of the updated facility-maintained Resident Trust Transaction History for the period 01/01/25 through 12/18/25, showed Residents #3, #7 and #8 were not refunded the $50 monthly allowance for 03/2025 and 04/2025 until 12/17/25 and 12/18/25. During email correspondence dated 12/18/25 at 8:38 A.M., the Accounts Receivable Manager said he/she was not sure why there were no deposits and/or Social Security for 03/2025 and 04/2025 for Residents #3, #7 and #8. Complaint MO2689890 *The higher classification merited due to the impact when combined with other deficiencies

Based on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when the facility failed to provide follow-up care and treatment by not completing a clinical referral for a resident with a diagnosis of chronic hepatitis C infection (viral infection that causes liver swelling that can lead to serious liver damage, liver failure and liver cancer). The sample size was 3. The census was 82.Review of the Centers for Disease Control and Prevention (CDC) website, showed hepatitis C treatment plans typically consisted of 8-12 weeks of oral direct-acting antiviral (DAA) medications. This short course of well-tolerated medication could cure more than 95% of cases and was recommended for virtually everyone diagnosed with hepatitis C. Treatment is crucial to reduce the risk of developing chronic liver disease, cirrhosis, and liver cancer. In July 2023 the CDC recommended automatic Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) testing (a test used to detect the presence of the HCV in a person's blood) on all HCV antibody reactive samples to minimize patient visits and increase the number of patients diagnosed and treated. Review of the facility's Physician Orders Policy, updated 8/24/24, showed:-Policy: The purpose of this policy is to ensure our residents receive the care prescribed by their physician;-The Registered Nurse (RN)/Licensed Practical Nurse (LPN) are to follow the orders as written. Review of Resident #1's referral from the previous facility dated 3/25/24, showed: -Diagnosis: Chronic viral hepatitis C;-Advanced Registered Nurse Practitioner (ARNP) Subjective Objective Assessment Plan (SOAP) dated 3/15/24, showed resident to have follow up referral for hepatitis clinic;-Resident noted to have active hepatitis C. Labs for hepatitis C virus Antibody (AB) reactive (blood test used to detect antibodies against the hepatitis C virus), Hepatitis C Virus Ribonucleic Acid (RNA, used to detect the presences of hepatitis C virus in the blood) quantitative blood test level of 531 is elevated and means hepatitis C is an active infection;-Plan: Resident to follow up at clinic regarding hepatitis C results, will coordinate with Medical Doctor (MD) to see about medication regimen to start. Review of the resident's electronic medical record, showed:-admission: [DATE];-Cognitively intact;-Diagnoses included chronic viral hepatitis C;-No referral to the hepatitis clinic or orders to treat acute hepatitis C virus. Review of the resident's care plan, dated 4/4/24, showed:-Problem: Resident has viral hepatitis C;-Goal: Resident will not experience any complications throughout the review period; -Approaches: Administer medications as ordered, assess for signs/symptoms of active disease and notify physician: easy bleeding, easy bruising, fatigue, lack of appetite, itchy skin, ascites (abdominal swelling due to build up of fluid, caused by liver failure), edema, weight loss, confusion, etc. Obtain lab work as ordered by physician. Review of the History and Physical (H&P) dated 5/14/24, completed by Advanced Registered Nurse Practitioner (ARNP) C, showed: -New admission with past medical history including chronic hepatitis C;-Overall Plan: New admission History and Physical completed, hospital records reviewed, Point of Services (POS-documentation) and medications reviewed. Review of the H&P notes, dated 6/3/25, completed by Physician A, showed:-Past Medical History included chronic viral hepatitis C;-No new labs to review;-Plan: Examination completed on rounds in the presence of nursing staff. Lab chart reviewed, treatment plan, medication reconciliation, abnormal labs reviewed, new orders as written follow-up as scheduled. Review of the progress notes, dated 8/26/24, completed by ARNP C, showed: -History: Reviewed this patient with nursing. Current chronic medical conditions are all stable with no acute concerns;-Labs: no new labs to review;-Diagnoses: Chronic viral hepatitis C;-Plan: Chronic hepatitis C, order routine quantitative hepatitis C RNA;-Overall Plan: Order routine labs Completed Blood Count (CBC number of red blood cells, white blood cells, platelets, hemoglobin and hematocrit in blood), Comprehensive Metabolic Panel (CMP measures 14 different substances to provide a picture of the body's chemical balance and metabolism. It includes tests that check the function of the kidneys and liver, as well as blood sugar, protein, and electrolyte levels), Glycated hemoglobin (A1C, blood test that measures average blood sugar levels over the past 2-3 months), Lipoprotein (LP, measures the level of lipoprotein in the blood that can contribute to the buildup of plaque in arteries increasing the risk of heart disease and stroke). Review of the resident's medical record, showed no documentation staff obtained the labs ordered on 8/26/24. Review of the H&P, dated 9/18/24, completed by Physician B, showed:-Active health concerns: No active health concerns recorded;-Inactive health concerns: no inactive health concerns recorded;-Past medical history: did not list chronic or acute hepatitis C. Review of the hospital Discharge summary dated [DATE] showed:-Presenting problem/history of present illness: Patient presents to the Emergency Department (ED) via Emergency Medical Service (EMS) for evaluation of bilateral lower extremity swelling, also complains of shortness of breath and cough. Patient reports the cough has worsened over the past few days but the swelling to his/her lower extremities has been going on for a while now. He/She denies fever, chills or body aches; -Treated for: -Heart failure, cardiology consulted, shortness of breath resolved; -Liver mass in right upper quadrant showed a heterogeneous and micronodular liver (liver damage) with increased echogenicity throughout (lighter than normal in color indicating liver disease), consistent with cirrhosis (scarred tissue) and diffuse steatosis (fatty liver disease); -Cirrhosis secondary to chronic hepatitis C. History of IV (intravenous) drug use. Patient denied heavy alcohol use. Hepatitis C antibody reactive. Hepatitis C RNA detected (indicates active infection). He/She was placed on octreotide (used to treat diarrhea and hormone production in relationship to certain cancers). Review of the hepatology clinic visit notes, dated 1/15/25, in the resident's medical record, showed: -History of present illness: -Biopsy-confirmed hepatocellular carcinoma (liver cancer) in the setting of Hepatis Chronic Infection and alcohol consumption; -Lives in a nursing home, wheelchair-bound, non-ambulatory, and presence of some liver decompensation; -Prognosis is poor. Too advanced for liver transplant evaluation, in addition to his/her frailty;-Recommendations: Not a transplant candidate. No role for hepatitis C treatment in the setting of large, aggressive Hepatocellular carcinoma (HCC); if HCC is treated and demonstrates response, then there would be a role for treating his/her hepatitis C. This cancer is due to cirrhosis that developed over decades from hepatitis C. During an interview on 9/3/25 at 11:53 A.M., LPN E said when the ARNP or Physician round they would let the nurse know or write on a piece of paper for new or changed orders and sometimes would order treatment themselves in the computer. LPN E said he/she sometimes looked at ARNP or Physician notes in the computer after their visit, but most of the time he/she never had a need to review. This could be important if staff did not know their residents. LPN E received his/her information about the resident during report at nurse shift change. LPN E never reviewed a resident's plan of care or assisted in completing it. LPN E was not aware the resident had chronic hepatitis C. He/She only cared for the resident a short time because LPN E mainly worked in a different area of the facility. LPN E was unsure who ordered labs after the ARNP or Physician visited. LPN E only made medication or treatment changes. LPN E would order labs if there was a phone order from the ARNP or physician for acute care issues during his/her shift. Chronic hepatitis C was a condition nursing staff should be aware of. There were several changes in administration over the past year. LPN E thought during that time, the previous Director of Nursing (DON) or Assistant Director of Nursing (ADON) were responsible to review ARNP and Physician orders. During an interview on 9/3/25 at 12:43 P.M., the DON verified the only labs ordered for the resident were the two labs listed in his/her chart. She was unaware the resident did not have labs drawn per ARNP and physician orders or that the referral notes for the resident, showed the facility did not follow up on the previous facility's referral on sending the resident to the hepatitis clinic. She also was not aware staff did not check labs on the resident and failed to follow orders from the ARNP to check blood levels for hepatitis C. He/She said after an ARNP or Physician completed their visit with residents, they should give orders to the nurse they were rounding with. Some ARNPs and Physicians might enter the orders themselves. The facility did not have a standard procedure for this because every ARNP and physician was different. The DON said she was not sure how the previous DON and ADON reviewed ARNP and Physician notes. However, she ran a 24 hour report every morning and it listed all orders and notes that were entered into the electronic medical records. She reviewed this report to follow up and confirm orders were completed. The DON said it was the responsibility of the nursing staff to review ARNP and Physician notes in the system. She was unaware a nurse staff member did not review progress notes, care plans, and was never responsible for ordering labs after an ARNP or Physician rounded. The DON said all nursing staff should review progress notes, care plans and orders daily for the residents they were responsible for and was not sure how the previous administration ordered labs. The DON was also not aware of the new guidance from CDC in July 2023 recommending complete, automatic HCV RNA testing on all HCV antibody reactive samples to minimize patient visits and increase the number of patients diagnosed and treated. 2571771

Based on interview and record review, the facility failed to ensure one resident's right to be informed in advance of treatment and treatment alternatives or treatment options and to choose the alternative or option he/she preferred when staff did not inform the resident's representative prior to the resident having lung surgery (Resident #1). The sample was 4. The census was 80. Review of facility's Change in a Resident's Condition or Status policy, revised 8-24-24, showed: -The facility will assess and identify a change in condition to ensure the resident receives appropriate care; -Procedure: -The nurse supervisor/charge nurse will notify the resident's family or representative when: -There is a significant change in the resident's condition; -It is necessary to transfer the resident to a hospital; -Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status; -The nursing supervisor/charge nurse will document of changes in the resident's medical record, updating of resident and, family of change in status. Review of Resident#1 quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/17/25, showed: -Moderate cognitive impairment; -Diagnoses included Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that makes it hard to breath), malignant neoplasm of right upper lobe of lung (cancer of right upper lung), bipolar disorder (mental health condition characterized by significant mood swing), personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems).in ways that cause problems). Review of resident's care plan, in use during the survey, showed: -Problem: Responsible Party, Resident has a legal guardian, Public Administrator (PA); -Goal: The resident's guardian will continue to assist me in making informed decisions; -Approaches included: -Actively involve the resident's guardian in his/her care by inviting his/her guardian to meetings as needed; -Assist the resident in contacting his/her guardian about concerns that he/she may have. Review of the resident's physician orders, showed no orders for surgery. Review of resident's progress notes, showed: -A progress note dated 2/3/25 at 2:11 P.M., by Social Services The last note that showed requesting the PA to sign the consent forms for bronchoscope biopsy (a small cameral inserted into the airways to view the lungs); -A progress note dated 4/15/25 at 14:22 P.M., by Licensed Practical Nurse (LPN) A, nursing admission summary including message left on phone recording to the PA's Office with resident update and readmit to the facility; -A progress note dated 4/17/25 at 12:00 P.M. by the Administrator, late note on Friday 4/11/25, email came from PA's Office requesting referral pack sent to them. Called the following Monday, 4/14/25, to apologize if there was a problem relating to previous Director of Nursing (DON); -No other progress notes to show communication between the facility and PA in reference to resident's lung surgery to remove right upper lobe for cancer. During an interview, on 4/17/25 at 9:15 A.M., the resident's PA Deputy (PAD) said the PA's Office was unaware the resident was scheduled for lung cancer surgery or was admitted to the hospital for surgery until the resident called the office on 4/8/25, to give the PA an update on his/her surgery that took place on 4/2/25. After speaking with the resident, the PAD said he/she called the nursing facility and spoke with the Assistant Director of Nursing (ADON). The ADON said this had been in the works for a while, and didn't know why the PAD was not notified but would have someone get back with the PAD. The ADON also said the lack of communication was probably due to the change in administration during this time. The PAD did not hear back from the facility until 4/16/25 after the PA's office requested a referral package on 4/11/25 and again on 4/16/25. The PA's office was aware of the mass on 8/23/24 when they received a Magnetic Resonance Imaging (MRI, scan that produces detailed images of the inside of the body) report recommending a follow up Computed Tomography (CT, a diagnostic imaging procedure that produces images of the inside of the body). This scan was cancelled once due to insurance issues. The MRI scan was performed and on 1/8/2. The last contact the PA's Office had with the facility, about resident's lung cancer, was on 2/3/25 for consent to perform a bronchoscope with anesthesia. During an interview, on 4/17/25 at 11:27 A.M., the resident said he/she was upset because he/she is going to have to move because the facility did not tell his/her PA about having lung surgery to remove his/her cancer. He/She denied telling the PA about the surgery and said they were aware of the lung mass. He/She said, I know (LPN A) called them about the surgery because he/she told me he/she did. The resident added, he/she used to talk to a different PAD prior to this one. The resident said he/she told the new PAD that from now on the resident would make sure they know about everything. The resident just didn't want to move because he/she likes it here and has been here for eight years. During an interview on 4/17/25 at 11:44 A.M. LPN A said he/she did not work the day the resident went to surgery and doesn't remember speaking with the PA's Office but if he/she did, it would be in the progress notes. During an interview on 4/17/25 at 2:26 P.M. the ADON said he/she did not work the day the resident went to surgery. When the PA's Office is notified, it will be in the progress notes. He/She received a call from the PAD on 4/8/25 and he/she would check into why they were not notified. He/She was not aware prior to the call that they were not notified. The old DON had been taking care of notifying next of kin, power of attorneys, families, and PAs about changes in conditions but he/she was no longer here on 4/8/25. He/She does not remember if he/she told anyone else, but he/she thinks the Administrator knew about it. There was a lot of things going on that day he/she does remember that. Certified Medication Technician (CMT) B took the resident to the hospital and stayed until after the surgery. During an interview on 4/17/25 at 2:43 P.M. CMT B said, he/she went with the resident to the hospital for the surgery and stayed until the resident was in recovery. They arrived to the hospital at 6:30 A.M. After surgery, he/she returned to the facility around 2:00 P.M. and gave the previous DON the resident's condition update. Resident returned to the facility on [DATE]. He/She did not speak with the PA's Office prior to or after surgery. The DON is responsible for that. During an interview on 4/17/25 at 1:50 P.M., LPN C, said when a resident leaves for medical treatment the facility sends a face sheet, medication list, and bed hold form. They notify the resident's PA whenever they are not aware of something or if the resident has a change in condition. It is the same type of notification for all residents to notify next of kin and/or responsible party. The charge nurse is responsible to notify the PA, next of kin or responsible party. If a resident has an appointment, LPN C calls the PA, next of kin, or responsible party During an interview on 4/17/25 at 1:40 P.M. the Administrator and DON said when a resident has a PA the facility is responsible to notify prior to treatment and the PA is responsible to speak with the resident and help guide them through the treatment plan, approve the treatment, and sign consent forms unless the resident is having an medical crisis and needs treatment. It is the responsibility of the nurse or charge nurse to reach out to the PA as soon as possible. The charge nurse or the nurse who is in charge at the time is responsible to put these forms together and give them to the resident and/or resident guardian. They do not know if this was completed for the resident. Progress notes should be written to show who was notified, what was sent, and who they spoke to. They did not know progress notes were not written, and they are unable to verify if the PA's Office knew about the resident's surgery prior to the resident calling them after the surgery. They should receive approval from the PA's Office prior to sending the resident for treatment unless it is an emergency. They have not been officially told by the PA that he/she was not notified. They suspected something was wrong when the transfer request came in on 4/11/25, They followed up on 4/14/25 but they have not heard back from them. They are assuming the previous DON did not notify the PA. They have not spoken with the PA about this issue but have left several messages for a return call. The Administrator said he/she was unaware the PA had called about not being notified. MO00252492

Based on observation, interview and policy review, the facility failed to ensure floors were clean, baking pans and pots were free of carbon build-up, one of one freezer had debris and food on the floor, one of one refrigerator had food and debris on the floor, and 30 of 30 water bottles were expired and two of 30 gallons of water had mouse droppings on them. This failure had the potential to affect all 75 residents who reside in the facility. Findings include: Review of the policy and procedure titled Receiving and Storage of Food dated [DATE] revealed, .(8) keep storage areas clean and dry (9) all freezer and refrigeration units must be kept clean and free of food debris. Review of the undated policy titled Cleaning Schedule revealed it is the responsibility of the Dietary Manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks. During an observation on [DATE] at 8:46 AM, the following was observed: The kitchen floor was sticky when walked on it and the floor had debris including dust, paper, and food particles on it in the prep area and dry storage area. One box of frozen powdered sugar donuts was in the reach in freezer. The bag was not sealed and some of the donut holes were out of the plastic bag and were inside the cardboard box. The outside of the freezer had a dried sticky substance was on the outside The bottom of the freezer has a plastic spoon on the floor, crumbs, ice cream and frozen cookies. On the floor of the pantry was a soda can, plastic bag, and mouse droppings Crumbs, dust, and mouse droppings were on the plastic storage bin containing flour Dust and debris were on the plastic storage bin located next to the flour bin. Mouse droppings were in the box with the chicken noodle soup. Observation on [DATE] at 10:00 AM of the dietary pantry revealed mice droppings on cans of food and on the floors along the edges of the walls. There was a plastic shelf with six labeled drawers. The drawer labeled Applications contained a baby mouse. During an observation on [DATE] at 11:13 AM, of the dry pantry revealed five one-gallon bottles of water had mouse droppings on them. All the water containers are soiled. During an interview on [DATE] at 11:16 AM, [NAME] (C)2 verified the water bottles had mouse droppings on them. C2 stated the kitchen was cleaned between mealtimes and at the end of the shift. Review of the cleaning schedules provided by the Dietary Manager (DM) for [DATE], [DATE], and [DATE] revealed staff were signing off to indicate they had cleaned the dietary department. During an observation on [DATE] at 8:45 AM, dust and cobwebs were noted above and around a window unit air conditioner located behind the food prep area used to make puree meals in the kitchen. During an observation on [DATE] at 11:01 AM to 11:44AM, nine large baking sheets had a build-up of black carbon on the outer edges and on the inside corners. The pans measure 26 x 18 x 1 inch deep; the large stand mixer has a rusty base and chipped paint; the inside of the microwave had dried food particles inside it; one large deep dish baking pan had a build-up of black carbon on the outer edges. The pan measures 24 x 18 x 4.5 deep. During an interview on [DATE] at 8:56 AM, the DM stated the refrigerator and freezer are cleaned once a week on Monday or Wednesday. He provided a copy of the kitchen cleaning schedules and stated the kitchen should be cleaned and picked up at the end of each meal prep. During an interview on [DATE] at 7:55 PM, Dietary Aide (DA)2 stated she cleans the kitchen during her shift between tasks and at the end of the shift. DA2 stated she helps the cook if she sees he needs something to be cleaned during a meal prep. She stated she was aware of the mice problem and has seen live mice in the mornings when she comes in and opens the kitchen up. DA2 reported seeing mouse droppings in the kitchen and storage area.

Based on interview and record review, the facility failed to follow their tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) policy when staff failed to complete a two step and the annual one step of the employee TB screening tests in a timely manner for a total of 10 employees. The facility also failed to implement their water management plan in order to potentially identify where bacterium Legionella and other waterborne pathogens could grow. The census was 78. Review of the facility's TB Employee Testing Policy, dated 8/25/24, showed the following: -Policy: -In order to minimize the risk of resident acquiring, transmitting, or experiencing complications from tuberculosis, it's the policy of this facility to screen our employees upon hire and annually; -Procedure for Screening: -1. Upon hire, each new employee will have a 2 step TB test administered and read per protocol. -2. Annually, each employee will be screened for TB, and the Director of Nursing and physician will be notified of any questions answered affirmative. If an employee has a previous positive TB, a chest x-ray or Quantum [NAME] test (a simple blood test that aids in the detection of Mycobacterium tuberculosis) will be done. 1. Review of Staff Member A's employee file, showed the following: -Hire date: 6/9/19; -No documentation of an annual one step. 2. Review of Staff Member B's employee file, showed the following: -Hire date: 10/29/21; -No documentation of an annual one step. 3. Review of Staff Member C's employee file, showed the following: -Hire date: 6/29/22; -No documentation of an annual one step. 4. Review of Staff Member D's employee file, showed the following: -Hire date: 10/2/23; -No documentation of an annual one step. 5. Review of Staff Member E's employee file, showed the following: -Hire date: 1/10/24; -No documentation of a two-step. 6. Review of Staff Member F's employee file, showed the following: -Hire date: 1/10/24; -No documentation of a two-step. 7. Review of Staff Member G's employee file, showed the following: -Hire date: 2/8/24; -First step: 2/8/24, Read date: 2/11/24; -No documentation of a second step. 8. Review of Staff Member H's employee file, showed the following: -Hire date: 5/16/24; -No documentation of a two-step. 9. Review of Staff Member I's employee file, showed the following: -Hire date: 9/19/24; -No documentation of a two step. 10. Review of Staff Member J's employee file, showed the following: -Hire date: 11/18/24; -No documentation of a two step. 11. During an interview on 12/23/24 at 12:44 P.M., the Director of Nursing (DON) said she is ultimately responsible for the TB tests to be completed in a timely manner. The DON said she was not aware the TB tests were not being completed and did not know why they were not completed. The DON said they just hired an Assistant Director of Nursing (ADON) who will be taking over the TB tests. 12. During an interview on 12/23/24 at 12:44 P.M., the Administrator said she did not know the TB tests were not being completed. The Administrator said she did not know why they were not completed. 13. Review of the undated facility policy titled; Validation of the Water Management Program revealed .Water management program teams that include infection control staff may also choose to use their facility's routine surveillance for healthcare associated Legionnaires' Disease to validate their program. Procedure 1. Environmental testing for Legionella is useful to validate the effectiveness of control measures. The team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate the program . During an interview on 12/20/24 at 9:16 PM with the Maintenance Director (MD), he stated that the facility did not have text and flow diagrams of water system. He confirmed the facility did not have measures in place to ensure Legionella growth did not occur. During an interview on 12/21/24 at 10:15 PM with the Director of Operations (DO) stated that she had sent the MD an assessment several months ago that needed to be filled out regarding the water management program. She was not sure why he did not complete it but should have. The information that she provided to him included testing of specific organisms, mapping of water system, frequency of flushing pipes, and monitoring of water temperatures. 40824

Based on observation, interview and record review, the facility failed to ensure that dietary and eight of eight sampled resident's (Resident R) 30, R36, R62, R25, R46, R12, R73, and R56) room were free of pest. Specifically, live mice and mouse droppings were observed in dietary and residents reported mice in their room. This failure had the potential for residents to have food prepared in an unsanitary manner and had the potential to expose residents to diseases caused by being exposed to rodents. Findings include: Review of the facility's policy titled, Pest Control Policy dated 08/24/24 revealed, this facility will ensure facility remains clean and free from pests and .(2) monthly contracted pest control company will treat inside and outside of facility. 1. During an observation on 12/16/24 at 8:46 AM, one live mouse and mouse droppings were observed in a plastic container in the dry storage pantry of the facility's kitchen. During an interview on 12/16/24 at 8:56 AM, the Dietary Manager (DM) stated the facility does have a problem with mice. The DM stated he wipes off the canned goods when he sees mouse droppings and tries to place items in a plastic storage bin to keep the mice out. The DM stated pest control comes to the facility twice a month. He had not observed the mouse in the pantry this morning. He confirmed mice droppings were in the dry storage area. 2. Review of the Admission Record located under the Resident tab in the electronic medical record (EMR) indicated R62was admitted with diagnoses of unspecified dementia, bipolar disorder, major depressive disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/24 revealed R62 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. During an interview on 12/16/24 at 12:10 PM, R62 stated there is a rodent problem and that she saw a mouse a week ago. 3. Review of the Admission Record located under the Resident tab in the EMR indicated R46 admitted on [DATE] with diagnoses of paranoid schizophrenia, delusional disorders, unspecified psychosis, and anxiety disorder. Review of the quarterly MDS with an ARD of 11/13/24 indicated R46 has a BIMS score of 15 of 15 indicating she is cognitively intact. During an interview on 12/16/24 at 2:41 PM, R46 stated she saw a mouse in her room last night near the dresser closest to the bathroom door. 4. Review of the Admission Record located under the Resident tab in the EMR indicated R25 admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, bipolar disorder, anorexia nervosa, and personality disorder. Review of the annual MDS located under the Resident tab in the EMR indicated R25 had a BIMS score of 15 out of 15 indicating R25 was cognitively intact. During an interview on 12/16/24 at 2:29 PM, R25 stated she observed mice in her room last night. Review of the [Name of company] pest control documentation revealed, .at the facility on 12/06/24 and rodent traps were placed. No live mice were noted under the observation section of the Orkin report. Review of the Pest Control Logs revealed Orkin comes to the facility twice a month. Review of the Orkin Pest control reports revealed Orkin was at the facility on 10/04/24, 10/18/24, 11/15/24, and 11/27/24. No active mice were seen but rodent traps were placed. Review of the Grievance Form dated 08/13/24 revealed there was a concern with rodents creating by the residents who attend resident council. The grievance was resolved without indicating how the rodent issue would be addressed. During an interview on 12/16/24 at 9:45 AM, the Administrator stated she was aware of a rodent problem several months ago. She was not aware of a current mouse infestation in the kitchen. She stated she had not been notified by the DM of any live mice in the kitchen today. The Administrator stated when she is notified, she can contact Orkin Pest Control to come do additional treatments. The administrator stated the facility puts out their own mouse traps in addition to the ones placed by Orkin. During an interview on 12/16/24 at 10:25 AM, the Director of Nursing (DON) stated the facility does not maintain pest control log documentation of pest sightings or the location of the sightings. During an interview on 12/16/24 at 11:19 AM, the DM confirmed the facility did not currently have any mouse traps out in the kitchen. He stated Orkin Pest Control sprayed for mice the last time they were at the facility and picked up the old traps. During an observation and interview on 12/16/24 3:14 PM, the DM verified a mouse was in the dry pantry in a plastic storage container. During an interview on 12/17/24 at 10:00 AM, the Orkin Representative (OR) 1 stated the number of live mice has significantly decreased since he has been coming to the facility. OR1 stated he sprays and places traps near the doors of the facility to help eliminate the mice. He also stated sometimes the mouse traps are moved prior to him returning to the facility. OR1 confirmed he is at the facility at least twice a month. During an interview on 12/20/24 at 7:55 PM, Dietary Aide (DA)2 stated she was aware of the mice problem and has seen live mice in the mornings when she comes in and opens the kitchen. DA2 stated she has seen mouse droppings in the kitchen and storage area. 4. Review of R12's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R12's admission MDS located in the EMR under the MDS tab with an ARD of 10/17/24 indicated the resident had a BIMS score of 15 out of 15 indicating she was cognitively intact. During an interview on 12/16/24 at 2:03 PM R12 said she had mouse droppings on top of her oatmeal about two weeks ago, she doesn't eat the food the food here and that she orders food to be delivered often. R12 stated that she told the aides that morning about the mice droppings but didn't recall who it was. 5. Review of R36's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R36's annual MDS located in the EMR under the MDS tab with an ARD of 10/23/24 indicated the resident had a BIMS score of nine out of 15, indicating she was moderately cognitively impaired. During an interview on 12/16/24 at 1:54 PM with R36 stated that usually sees mice at night, she had reported it to the nurses. Review of R56's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R56's admission MDS located in the EMR under the MDS tab with an ARD of 11/29/24 indicated that the resident had a BIMS score of nine out of 15, indicating she was moderately cognitively impaired. During an interview on 12/16/24 at 4:27 PM with R56 stated that she frequently saw mice coming from under the bed and that she had reported this to staff, but she could not recall their names. 7. Review of R73's undated Admission Record located in the EMR under the Resident tab indicated the resident was readmitted to the facility on [DATE]. Review of R73's admission MDS located in the EMR under the MDS tab with an ARD of 10/31/24 indicated that the resident had a BIMS score of 15 out of 15, indicating she was cognitively intact. During an interview on 12/16/24 at 4:27 PM with R73 stated that she frequently saw mice in her restroom coming from under the sink cabinet and then running behind the toilet. She had reported this multiple times to the aides and maintenance director, but the mice are still seen especially at night. During an interview on 12/17/24 at 9:27 AM with the Ombudsman stated that residents complained about mice often and that the Administrator told her that they were trying to treat them. During an interview on 12/18/24 at 4:45 PM Licensed Practical Nurse (LPN)1 stated that residents have mentioned to her that they have seen mice, she hasn't seen any herself. R73 reported to her a while back that she saw one in her bathroom; she wrote it down on the maintenance log. Additionally, the pest control company told her that they were all gone. 8.A review of R30's Admission Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, other psychoactive substance dependences, and above-the-knee amputation. A review of R30's Quarterly MDS with ARD of 11/14/24 located in the resident's EMR section tab MDS revealed the resident had a BIMS score of 12 points out of 15 points which indicated the resident was capable of making decisions of his care. Observation on 12/16/24 at 10:15 AM in R30's room revealed mice droppings behind the head of Bed 2. Mice droppings were also observed on the window ledge and floor. An interview with R30 on 12/16/24 at 10:15 AM. during the observation revealed a problem with mice. R30 stated that the mice were running on the nightstands and the over-the-bed lights. R30 stated he saw a mouse last night in the corner next to Bed 2. R30 further stated that sometimes there is an exterminator that comes but it does not seem to be any good. On 12/16/24 at 4:23 PM, an additional observation of R30's room revealed mice droppings on the nightstand for Bed 3. Also, the outside window screen was separated from the window. This sighting was confirmed by the Activities Director. On 12/16/24 at 4:23 PM, an interview with the Activities Director (AD) revealed the facility has experienced a problem with mice for some time. The AD stated they had a contract with pest control that seemed to be working. The AD stated that she would put in a work order to repair the window. The AD agreed that this opening in the screen could afford an opportunity for the mice to enter the facility 9.A review of R23's Admission Record, located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses of schizophrenia, and diabetes. A review of R23's Quarterly MDS with an ARD of 11/14/24 located in the resident EMR under the MDS tab revealed the resident had a BIMS score of nine points out of 15 points which indicated the resident's moderate cognition impairment. A review of the facility's grievance log book for the past year provided by the Administrator revealed a grievance filed by R23 on 08/23/24 regarding the rodent population. A review of the Resident Council Meeting minutes for 09/26/24 provided by the Activities Director revealed the group expressed concerns about the mice population. An observation on 12/16/24 at 10:00 AM in the kitchen pantry revealed mouse droppings on cans of food, on the floors along the edges of the walls, and shredded pieces of paper in the corners. The observation also revealed a plastic shelf with six drawers labeled. The drawer labeled Applications contained shredded paper and a baby mouse. Another drawer labeled Orders also contained shredded paper and mouse droppings. Observation of the resident's main dining room on 12/17/24 at 10:17 AM revealed mice droppings and dried food debris on the windowsill of all the windows in this area. Observation on 12/18/24 at 11:44 AM in R39's room revealed two large colored plastic bags. One of the bags had a hole that looked like it had been chewed; there were mice feces in this area. On 12/18/24 at 1:30 PM a meeting was held with the following members from the Resident Council: R2, R15, R26, R34, R40, R41, R46, R51, and R57. All nine attendees said that there had been a rodent problem for some time at the facility. It seemed to have started earlier this year when the pipes burst and there was flooding a few rooms. The attendees stated that there is a pest control company, but they don't always come around to the rooms. The group agreed that the facility gave residents plastic containers to keep food in their rooms if they needed it. The group stated rodent population was under control when they had cats but now that the cats are no longer allowed it seems the rodent population has gotten out of control. All the attendees stated that they sighted mice in their rooms recently. An interview on 12/18/24 at 7:08 PM with the Administrator revealed that the problems with rodents had been a problem for some time. The facility has contracted three different companies, but it seems to be an ongoing problem. The Administrator stated the pest control companies had looked at covering all the exposed areas in the building that would allow the rodents to enter. The Administrator stated there was turnover in the housekeeping department, leading to a shortage of staff. The shortage of housekeeping staff could contribute to a lack of cleanliness in the environment would could entice the rodent population. MO00243462 30622 40824

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry for two staff members. A sample of 10 employees hired were reviewed. The facility hired at least 45 new employees since the last survey. The census was 78. Review of the facility Abuse and Neglect Policy, undated, showed the following: -Policy: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. -Employee Screening: -Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration/business office managers, in accordance with applicable state and federal regulations. Any person having knowledge that an employee's license or certification is in question should report such information to the Administrator and Leadership Team. 1. Review of Housekeeper (Hsk) A's employee file, showed the following: -Hire date: 10/2/23; -No CNA registry check performed. 2. Review of Hsk B's employee file, showed the following: -Hire date: 9/18/24; -No CNA registry check performed. 3. During an interview on 12/23/24 at 1:35 P.M., the Business Office Manager/Human Resource Manager (BOM/HRM) said he/she is responsible to ensure the CNA registry is checked for all employees. The BOM/HRM said these two employees must have been overlooked. 4. During an interview on 12/23/24 at 1:35 P.M., the Administrator said she expected the facility's policy to be followed. The Administrator did not know the CNA registry was not checked for these two employees.

Based on record review, interview, and policy review, the facility failed to ensure six of six residents (Resident (R) 9, R13, R17, R28, R78, and R129) and their representatives reviewed for facility initiated emergent hospital transfer from a total sample of 24 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Additionally, the Ombudsman was not notified of hospital transfers for three of six residents (R9, R13, R17). Findings include: Review of the facility policy titled, Admission, Transfer and Discharge Policy revised 08/24/24 indicated .The facility may transfer or discharge the resident in compliance with facility standards, and are as follows, but not limited to: 1. The resident's welfare and needs cannot be met in the facility . There was no information in the policy to include that the resident, RR, or the Ombudsman needed to be notified in writing of the transfer. 1.Review of R9's Admission Record located in the Electronic Medical Record (EMR) under the Profile tab stated the resident was originally admitted to the facility on [DATE]. She was discharged to the hospital on 03/28/24, readmitted on [DATE], discharged to the hospital on 07/13/24, and readmitted on [DATE]. Review of R9's Transfer and Discharge document provided by the facility and dated 03/28/24 did not include the reason for the transfer or the location of the transfer. A copy of the form was not provided to the resident or their RR. Review of R9's Transfer and Discharge document provided by the facility and dated 07/13/24 did not include the reason for the transfer or the location of the transfer. A copy of the form was not provided to the resident or their RR. 2.Review of R13's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. He was discharged to the hospital on 08/23/24, readmitted on [DATE], and readmitted on [DATE]. Review of R13's Transfer and Discharge document provided by the facility and dated 08/23/24 did not include the reason for the transfer or the location of the transfer. A copy of the form was not provided to the resident or their RR. 3.Review of R28's Admission Record located in the EMR under the Profile tab stated the resident was originally admitted to the facility on [DATE]. He was discharged to the hospital on 10/11/24, readmitted on [DATE], discharged to the hospital on 10/22/24, readmitted on [DATE], discharged to the hospital on 11/15/24, and readmitted on [DATE]. Review of R28's Transfer and Discharge document provided by the facility and dated 10/11/24 did not include the reason for the transfer or the location of the transfer. A copy of the form was not provided to the resident or their RR. Review of R28's Transfer and Discharge document provided by the facility and dated 10/22/24 did not include the reason for the transfer or the location of the transfer. A copy of the form was not provided to the resident or their RR. Review of R28's Transfer and Discharge document provided by the facility and dated 11/15/24 did not include the reason for the transfer or the location of the transfer. A copy of the form was not provided to the resident or their RR. During an interview on 12/18/24 at 4:45 PM with Licensed Practical Nurse (LPN)1 stated that for emergent transfers to the hospital, the floor nurses notify the RR's by telephone of the transfer and do not send any transfer/discharge documents that she was aware of. During an interview on 12/20/24 at 5:26 PM with the Social Services Designee (SSD) stated that she and the floor nurses provide the transfer/discharge notifications. The nursing department was responsible for having the resident or their RR sign the form, then the nurse notifies the RR by phone. The SSD stated that she had not read the form, had not mailed copies of any of the forms, and was not aware that the RR was required to receive a copy. She further revealed from July-September 2024 she had been giving the Ombudsman a verbal report of how many residents were admitted /discharged /hospitalized . Beginning October 2024, she started emailing the Ombudsman a summary of all admissions/transfers/discharges. During an interview on 12/20/24 at 6:20 PM with the Director of Nursing (DON) stated that when a resident was sent out to the hospital, the original form was sent with the resident to the hospital. No one signs the document to acknowledge receival. The guardian should be mailed a copy of the transfer/discharge form. Once the nurse sends the resident out to the hospital, a copy of the transfer/discharge form should be placed in the SSD's mailbox. When the resident returned from the hospital, the original comes back to the facility and it goes in their permanent record. In November 2024, the SSD was in-serviced regarding the need for the Ombudsman to be notified monthly of all transfers/discharges. The DON was not aware that the forms were not being completed, but the expectation was that the forms be completed and a copy to be provided to the resident/RR. 4. A review of R129 Admission Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility with an initial admitted [DATE] and readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic viral hepatitis C, and major depressive disorder. A review of R129's Nurses Notes located in the resident's EMR section tab Profile revealed on 11/28/24 the resident with coffee-colored emesis MD notified was sent to the hospital with admission returned to the facility on [DATE]. A review of the R129's Admission Transfer Discharge form for 11/28/24 revealed two copies, one copy did not identify the destination of the resident or the effective date of transfer and why the resident is being transferred. 5. A review of R17's Admission Record located in the resident EMR section tab Profile revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, schizoaffective disease, and Alzheimer's disease. A review of the resident's Nurses' Notes located in the resident's EMR section tab Progress Notes revealed the resident was sent to the emergency department for evaluation of complaints of chest pain and behaviors. Most recently the resident was sent and admitted to the hospital on 12/09/24 for behaviors. A review of the Admission, Transfer, and Discharge Forms for R19 provided by the Director of Operations for the dates of 03/14/24, 09/14/24, 11/04/24, and 12/09/24 revealed the following: On 03/14/24, the form lacked documentation as to why the resident was being sent out, the destination, and notification of the responsible party On 09/14/24, the form lacked documentation of a copy of the form being sent with the resident and a copy of the form being sent to the legal representation. On 11/104/24, the form lacked documentation of the form being sent to the legal representative. On 12/09/24, the form lacked documentation on where and why the resident was being transferred, and the responsible representative was notified and a copy of the form was sent with the representative and mailed to the responsible representative. An interview with the Social Services Director on 12/20/24 at 7:30 PM she was not aware that she was responsible for mailing a copy of the form to the legal representative and had not sent the form until a couple of months ago. The Social Services Director also revealed that the previous Director of Nursing handled that process An interview on 12/20/24 at 6:36 PM with the Director of Nursing revealed the forms were incorrectly filled out it should reflect the date, destination, and the reason why the resident is being sent out. It should also reflect the notification of the responsible representative, that a copy of the form was sent with the resident and a copy of the form the was mailed to the responsible representative. 6. Review of R78'sAdmission Record located under the Resident tab in the EMR revealed R78 was admitted on [DATE].Review of the admission MDS with an ARD of 10/01/24 located under the Resident tab of the EMR revealed R78 had a BIMS score of six out of 15 indicating severe cognitive impairment. Review of the Progress Note dated 10/01/24 located under the Resident tab of the EMR indicated, staff were called to the resident's room at 6:20 PM by the roommate. The roommate reported the resident began shaking and fell face first onto the floor. R78 was observed on the floor with food in her mouth (peanut butter sandwich) Patient was placed on her side and the food was removed from her mouth as it had not been swallowed. Patient was noted to be blue and apneic, and unresponsive . 911 was called. Patient transferred to the hospital. Review of the document titled, discharge/transfer notice provided by the facility indicated, copy will be provided to the resident's legal representative if applicable at the time of transfer/discharge from the facility .copy will be mailed to the legal representative by Social Services. During an interview on 12/20/24 at 5:34 PM, the SSD stated she has not been sending family members or resident's guardians the transfer/discharge notices via mail. During an interview on 12/20/24 at 6:36 PM, the DON verified the transfer/discharge notice was not signed by the resident or resident's representative. She confirmed that the form indicated that SSD would mail a copy to the legal representative. 30622 40824

Based on record review, interview, and policy review, the facility failed to ensure six of six residents (Resident (R) 9, R13, R17, R28, R78, and R129) out of a sample of 24 residents who were reviewed for hospitalization were provided with a bed hold notice within 24 hours of emergent transfer to the hospital to include bed reserve payment. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility. Findings include: Review of the undated facility policy titled, Bed Hold Policy indicated, .This notification shall be given on admission to the facility, at the time of transfer to the hospital .Medicare does not pay for any type of bed hold. If the resident is discharged to the hospital, or goes out of the facility for over-night leave of absence, the bed may be held by paying the current room rate for the bed being served . 1.Review of R9's Admission Record located in the Electronic Medical Record (EMR) under the Profile tab stated the resident was originally admitted to the facility on [DATE]. She was discharged to the hospital on 03/28/24, readmitted on [DATE], discharged to the hospital on 07/13/24, and readmitted on [DATE]. Review of R9's Bed Hold Policy notifications provided by the facility for hospitalization s on 03/28/24 and 07/13/24 revealed they were blank, unsigned by the resident/RR, and were not provided to the resident/RR. 2.Review of R13's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. He was discharged to the hospital on 08/23/24 and readmitted on [DATE]. Review of R9's Bed Hold Policy notification provided by the facility for a hospitalization on [DATE] was blank, unsigned by the resident/RR, and was not provided to the resident/RR. 3.Review of R28's Admission Record located in the EMR under the Profile tab stated the resident was originally admitted to the facility on [DATE]. He was discharged to the hospital on 10/11/24, readmitted on [DATE], discharged to the hospital on 10/22/24, readmitted on [DATE], discharged to the hospital on 11/15/24, and readmitted on [DATE]. Review of R28's Bed Hold Policy notifications provided by the facility for hospitalization s on 10/11/24, 10/22/24, and 11/15/24 were blank, unsigned by the resident/RR, and were not provided to the resident/RR. 4. Review of R129 Admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R129's Nurses Notes located in the EMR under the Profile tab revealed on 11/28/24 the resident was sent to the hospital. Review of R129's Bed Hold Form, dated 11/28/24 and provided by the facility, revealed it was not completed. 5. Review of R17's Admission Record located in the EMR under the Profile tab revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Nurses' Notes located in the EMR under the Progress Notes tab revealed the resident was sent to the emergency department for evaluation of complaints of chest pain and behaviors on 03/14/24, 09/14/24, 11/04/24, and 12/09/24. A review of the resident's bed-hold forms, provided by the facility, for these dates revealed the form was not completed. During an interview on 12/20/24 at 5:26 PM with the Social Services Designee (SSD) stated that the Bed Hold Policy on the back of the Transfer and Discharge form was to filled out by the nurse sending the resident to the hospital and then a copy provided to the resident/RR. The SSD stated that she had not sent out copies of any Bed Hold Policy upon transfer to the hospital and was not aware that the resident/RR were to sign the document and be provided a copy. During an interview on 12/20/24 at 5:26 PM with the Director of Nursing (DON) stated that she was not aware that the SSD had not been providing the resident/RR with a copy of the Bed Hold Notification and was not aware that it did not include the reserve payment information. Her expectation was that the nurse discharging the resident to the hospital was to obtain signatures on the Bed Hold Policy notification, they provide a copy to the SSD, and the SSD should be sending a copy to the resident/RR. 6. Review of R78's Admission Record located under the Resident tab in the EMR revealed R78 was admitted on [DATE]. Review of the admission MDS with an ARD of 10/01/24 located under the Resident tab of the EMR revealed R78 had a BIMS score of six out of 15 indicating severe cognitive impairment. Review of the Progress Note dated 10/01/24 located under the Resident tab of the EMR indicated, staff were called to the resident's room at 6:20 PM by the roommate. The roommate reported the resident began shaking and fell face first onto the floor. R78 was observed on the floor with food in her mouth (peanut butter sandwich) Patient was placed on her side and the food was removed from her mouth as it had not been swallowed. Patient was noted to be blue and apneic, and unresponsive . 911 was called. Review of the document titled, discharge/transfer notice provided by the facility indicated, copy will be provided to the resident's legal representative if applicable at the time of transfer/discharge from the facility .copy will be mailed to the legal representative by Social Services. During an interview on 12/20/24 at 5:34 PM, the SSD stated she has not been sending family members or resident's guardians the transfer/discharge notices via mail. 30622 40824

30622 40824 Based on interviews, record reviews, and facility policy reviews the facility failed to ensure that all Interdisciplinary Team Members (IDT) were participated in quarterly care conferences for 12 of 24 sampled residents (Resident (R) 9, R12, R13, R17, R25, R29, R32, R34, R36, R40, R57, and R73). This failure had the potential for the residents to have unmet care needs. Findings include: Review of the facility policy revised 08/24/24 stated, A care plan shall be used in developing the resident's daily care routine .Every quarter, an attempt will be made to schedule a care plan conference with the resident, family and/or responsible party to allow the staff to provide the best person-centered care .Care plan meetings will be held quarterly with the interdisciplinary team, resident and responsible party or guardian .A care plan conference will include the interdisciplinary team as applicable. Attendees will sign the care plan conference sign in sheet . 1.Review of R9's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab indicated she was readmitted to the facility on [DATE] with a primary diagnosis of heart failure. Review of R9's Care Plan meeting notes provided by the facility dated 04/08/24, 07/08/24, and 10/10/24 indicated that only the Social Services Designee (SSD) and R9 attended the care conference. 2.Review of R12's undated Admission Record located in the EMR under the Profile tab indicated she was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following a stroke. Review of R12's Care Plan meeting notes provided by the facility dated 10/15/24 indicated that only the SSD and R12 attended the care conference. 3.Review of R13's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of dementia. Review of R13's Care Plan meeting notes provided by the facility and dated 01/17/24, 04/15/24, 07/22/24, and 10/17/24 indicated that only the SSD and R13 attended the care conferences. 4.Review of R29's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (COPD). Review of R29's Care Plan meeting notes provided by the facility dated 05/23/24 indicated that only the SSD, family, and R29 attended the care conference and on 09/23/24 the SSD, family, and R13 attended the care conference. 5.Review of R36's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. Review of R36's Care Plan meeting notes provided by the facility dated 02/06/24, 05/07/24, 08/04/24, and 11/03/24 indicated that only the SSD and R13 attended the care conferences. Review of R36's Care Plan located in the EMR under the Care Plan tab did not include allergic dermatitis treatment. 6.Review of R73's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R73's Care Plan meeting notes provided by the facility and dated 10/15/24 indicated that only the SSD and R73 attended the care conference. During an interview on 12/18/24 at 4:45 PM with Licensed Practical Nurse (LPN)1 stated that she had never been invited to attend care conferences. During an interview on 12/20/24 at 7:45 AM with the Director of Nursing (DON) stated that she wasn't sure which IDT members should attend the care conferences but if the resident had issues with weight for instance, then someone from dietary should attend. If the resident was on therapy services or restorative, then someone from the therapy department should attend. Any staff that would have attended would have signed the care plan meeting form. During an interview on 12/20/24 at 7:08 PM with the DON, confirmed that all disciplines should attend the care conferences. The day before the care conference the staff were notified of the care conferences, and the morning of the care conferences was mentioned again during the all staff meetings. She didn't know why, but the staff just don't show up. During an interview 12/20/24 at 5:58 PM with the Social Services Designee (SSD) stated that it was her responsibility to hold admission, quarterly, and change of condition care conferences that included the responsible party if applicable, the resident, and IDT members to include dietary, activities, nursing, social services, and therapy services. 7. A review of R15's Admission Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, major depressive disorder, and bipolar disorders. A review of R15's Care Plan Meetings notes dated provided by the facility for dates of12/6/23, 03/14/24, and 07/30/24 revealed the care plan meetings were attended only by the Social Services Director with the resident's responsible party on the phone.No other member from the Interdisciplinary attended the care conference. 8. A review of R17's Admissions Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, Alzheimer's Disease, and chronic obstructive pulmonary disease. A review of R17's Care Plan Meeting notes provided by the facility for the dates of 03/13/24, 6/13/24, and 09/03/24 revealed only the Social Services Director and the resident's responsible party (by phone) attended the care conference. No other member from the Interdisciplinary attended the care conference. 9. A review of R40's Admission Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] revealed the resident was admitted to the facility with diagnoses that included end-stage renal disease, diabetes mellitus type II with neuropathy, major depressive disorder. A review of R40's Care Plan Meeting notes provided by the facility revealed the care plan meetings held on 02/02/24 and 06/12/24 were attended by the SSD and Assistant Director of Nursing. Care plan meetings were held on 09/18/24 and 11/30/23 were attended by the SSD. No other member from the Interdisciplinary attended the care conference. 10. A review of R57's Admission Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia, psychotic disorders with delusions, and neuroleptic-induced Parkinsonism. A review of R57's Care Plan Meeting notes provided by the facility revealed the care plan notes dated 03/13/24, 06/06/24, and 10/07/24 showed the SSD attended the meetings. No other member from the Interdisciplinary attended the care conference. Interviews on 12/20/24 at 2:35 pm with the following staff regarding if invited to a resident care plan conference: Certified Medication Technician (CMT)2 stated she/he has never been invited to participate in care plan conferences and has been told the meeting is only for the department heads. Licensed Practical Nurse (LPN)3 stated he/she has never been invited to a care conference and would like to attend since he/she has direct contact with the resident. CMT has been told it's only for the department heads to feel that staff working directly with the residents would have beneficial information. An interview on 12/20/24 at 7:45 AM with the Director of Nursing revealed that she attends the care conferences when possible and sometimes other disciplines will attend. The contract Registered Dietician visits the facility monthly but does not attend the care planning meetings. 11.Review of R25'sAdmission Record located under the Resident tab in the EMR indicated R25 admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, bipolar disorder, anorexia nervosa, and personality disorder. Review of the annual MDS with an ARD of 10/16/24, located under the Resident tab in the EMR indicated R25 had a BIMS score of 15 out of 15 indicating R25 was cognitively intact. During an interview on 12/16/24 at 2:28 PM, R25 stated she had only been invited to two care plan meetings in eight years. Record review of the paper Care Plan note provided by the facility, revealed R25 last had a care plan meeting on 02/15/24. The following attended the meeting: R25, and SSD1 attended via phone call. No other member from the Interdisciplinary attended the care conference. 12.Review of R32's Admission Record located under the Resident Tab in the EMR indicated R32 was admitted on [DATE]. Review of the significant change MDS with an ARD of 10/02/24 located under the Resident Tab of the EMR indicated R32 had a BIMS score of eight out of 15 indicating moderate cognitive impairment. Review of the paper care plan sheets, dated 12/07/23, provided by the SSD1 revealed R32, the SSD and R32's responsible party and the DON were in attendance. Review of the paper care plan sheet, dated 04/04/24, provided by the SSD1 revealed R32 and the SSD were the only one in attendance. Review of the paper care plan sheet, dated 08/21/24, provided by the SSD1 revealed R32 and the SSD were the only ones in attendance. Review of the paper care plan sheet, dated 11/06/24, provided by the SSD1 revealed R32 and the SSD1 were the only ones in attendance. No other member of the Interdisciplinary attended the care conferences. During an interview on 12/18/24 at 9:37 AM, SSD1 stated the nursing staff, therapy and dietary staff are invited to the care plan meetings. They often do not show up and tell her they are short-staffed or don't have time to attend the meetings. She stated she has offered multiple time frames, and the staff still do not show up to them. She stated the administrative staff are notified about any scheduled care plan meetings during the morning stand up meetings.

Based on interview, record review, and facility policy review, the facility failed to correctly issue Medicare Part A beneficiaries CMS-10055 (Skilled Nursing Advanced Beneficiary Notice (SNFABN) when resident completed therapy or skilled nursing services for two of three residents (Resident (R) 9 and R68) reviewed for beneficiary notices. This failure had the potential of a resident or responsible party to not make an informed decision related to continuing to receive Medicare A services, by having the facility continue services and bill Medicare A, continue the services, and bill the resident, or not receive the services. Findings include: Review of the undated facility policy titled ABN / NOMNC Policy provided by the facility stated, Skilled nursing facilities must deliver a completed copy of the Advance Beneficiary Notice of Non-Coverage (ABN) and Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing services. The ABN/NOMNC must be delivered at least 2 calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Procedure - Social Services is responsible to deliver notice 2 calendar days prior to the resident or their Responsible Party for review and signature. The resident or Responsible Party receives a signed copy and Social Services keeps a copy for facility records. 1.Review of R9's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab indicated she was readmitted to the facility on [DATE] with a primary diagnosis of heart failure. Review of R9's Skilled Nursing Facility Advance Beneficiary Notice SNFABN document dated 05/03/24 and provided by the facility indicated that R9 reached her highest potential for speech therapy services and that Medicare probably would not pay. The estimated cost to continue speech therapy was blank and the address and phone number to contact the Medicare contractor was blank. An option to please choose one option. Check one box, date & sign this notice .option 1. Yes, I want to receive these items or services .Option 2. No, I will not receive these items or services . No choice was made and R9 signed the document on 05/03/24. Revie of R9's Notice of Medicare Non-Coverage document indicating services would end on 05/07/24 stated, Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current insert type services after the effective date indicated above. The type of care was blank, and no information was filled provided to contact the Quality Improvement Organization (QIO) in the event R9 chose to appeal the decision or had questions. R9 signed the document on 05/03/24. Review of R9's Skilled Nursing Facility Advance Beneficiary Notice SNFABN document dated 09/13/24 and provided by the facility indicated that R9 reached her highest potential for occupational therapy services and that Medicare probably would not pay. The estimated cost to continue speech therapy was blank and the address and phone number to contact the Medicare contractor was blank. An option to please choose one option. Check one box, date & sign this notice .option 1. Yes, I want to receive these items or services .Option 2. No, I will not receive these items or services . No choice was made and R9 signed the document on 09/13/24. Review of R9's Notice of Medicare Non-Coverage document indicating services would end on 09/18/24 stated, Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current insert type services after the effective date indicated above. The type of care was blank, and no information was provided to contact the Quality Improvement Organization (QIO) in the event R9 chose to appeal the decision or had questions. R9 signed the document on 09/13/24. 2.Review of R68's undated Admission Record located in the EMR under the Profile tab indicated he was admitted to the facility on [DATE] with a primary diagnosis of muscle wasting with atrophy. Review of R68's Skilled Nursing Facility Advance Beneficiary Notice SNFABN document dated 10/01/24 and provided by the facility indicated that R68 reached his highest potential for occupational therapy services and that Medicare probably would not pay. The estimated cost to continue speech therapy was blank and the address and phone number to contact the Medicare contractor was blank. An option to please choose one option. Check one box, date & sign this notice .option 1. Yes, I want to receive these items or services .Option 2. No, I will not receive these items or services . No choice was made and R68's Responsible Party (RP) signed the document on 10/01/24. Review of R68's Notice of Medicare Non-Coverage document dated 10/04/24 stated, Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current insert type services after the effective date indicated above. The type of care was blank, and no information was provided to contact the QIO in the event R9 and or RP chose to appeal the decision or had questions. The RP signed the document on 10/01/24. During an interview on 12/20/24 at 8:01 PM with the Social Services Designee (SSD)1 stated that the business office issued the NONMC/SNFABN forms. During an interview on 12/21/24 at 12:35 AM with the Director of Operations (DO) stated that the SSD had been filling out the NOMNC/SNFABN forms. The expectation was for the letter to be provided to the resident or their RP 48 hours prior to discharge from Medicare A services. The forms should be filled out in their entirety.

Based on observation, interview and record review, the facility failed to ensure grievances were resolved in a timely manner for one of 24 sampled residents (Resident (R) 23). This failure has the potential to affect the current residents and/or their family members by not having grievances resolved in a timely manner. Findings include: Review of the policy titled Grievance Policy and Procedure dated 06/15/24 indicated our facility investigates all grievances and complaints filed within the facility in a timely manner .(3) if a grievance is pertaining to an alleged violation of resident rights, as necessary, the Administrator must be notified, by the Social Service Worker, so that immediate action can be taken to prevent further potential violations of any resident right. Review of the Admission Packet provided by the facility indicated our facility investigates all grievances and complaints filed within the facility in a timely manner. The Administrator has assigned the responsibility of investigating grievances and complaints to the Social Service Department. For investigations and follow-up that take longer than 5 working days, the Administrator will notify the resident and social service document on Grievance form daily the progress until the concern is resolved. Review of the Social Service Director and or Designee job description provided by the facility indicated .19. review complaints/grievances from residents and families and from employees on behalf of the residents and families and submit written reports to the Administrator and include actions taken by the facility. A review of R23's Admission Record located in the resident's electronica medical record (EMR) section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses of schizophrenia, and diabetes. A review of R23's Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/14/24 located in the resident EMR section tab MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 points which indicated the resident's moderate cognition impairment. A review of the facility's Grievance Log revealed on 08/23/24 R23 filed a grievance with two concerns. The first concern dealt with the number of people visiting his roommate. The second concern dealt with the rodent population in the facility. A continued review of the form revealed the Administrator addressed the resident's concerns about the number of visitors in his room. However, the form did not address or provide a resolution to the resident's concerns about the rodent population. The form was not signed by the resident indicating that he was satisfied with the resolution. The form was instead signed by the Administrator. On 12/18/24 at 7:08 PM, an interview with the Administrator revealed the Social Services Director (SSD) was responsible for handling the grievances. However, the Administrator stated the SSD was overwhelmed and she took over the process of handling the residents' grievances. The Administrator was unable to show where she resolved the resident's concerns. The Administrator acknowledged that she signed the form that the resident should sign. The Administrator had to read the grievance policy and acknowledge that she had not followed the policy. An interview on 12/19/24 at 9:30 AM with R23 revealed that he remembered filing the grievance in August and felt the issue with the rodent population still had not been resolved. MO00235802

Based on interview, record review, and review of facility's policy, the facility failed to timely report a resident to resident alleged physical altercation to the State Agency (SA) involving two residents (Resident (R)13 and R17) of 16 residents reviewed for reporting alleged allegations of abuse. This had the potential for continued resident to resident altercations for the two residents. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Policy revised 04/08/24 revealed, .1. The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegation or suspected abuse, neglect or exploitation immediately to the Administrator, Other officials in accordance with State Law (this includes law enforcement officials), and State Survey and Certification agency through established procedures. 1.Review of R13's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R13's quarterly Minimum Data Set (MDS) under the MDS tab in the EMR had an Assessment Reference Date (ARD) of 10/16/24 indicated the resident had a Brief Interview of Mental Status (BIMS) score of three out of 15 which revealed the resident had severe cognitive impairment. Review of R17's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R17's quarterly MDS under the MDS tab in the EMR had an ARD of 12/05/24 indicated the resident had a BIMS score of five out of 15 which revealed the resident had severe cognitive impairment. Review of R17's Progress Note located in the EMR under the Progress Notes tab dated 11/30/24 at 7:28 AM indicated R17 allegedly punched R13 in the eye. There were no visible injuries. During an interview with R13 on 12/18/24 at 2:30 PM R13 stated that he did not recall anyone hitting him and stated that he was not afraid of any staff or other residents. During an interview on 12/18/24 at 1:20 PM the Administrator confirmed the alleged incident between R13 and R17 was not reported to the SA.

Based on interview, record review, and policy review, the facility failed to complete a thorough investigation for and resident to resident alleged altercation for two residents (Resident (R) R13 and R17) out of 16 sampled residents reviewed for abuse. This failure had the potential to place the residents to future potential altercations. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy provided by the facility and revised on 04/08/24 stated, .When suspicion of abuse .occur, it must be communicated to the facility's Administrator, Department Head, or Supervisor and the Administrator and/or designee must initiate an investigation Components of the investigation may include: .Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and any noted visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically .The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies . Findings include: Review of R13's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R13's quarterly Minimum Data Set (MDS) under the MDS tab in the EMR had an Assessment Reference Date (ARD) of 10/16/24 indicated the resident had a Brief Interview of Mental Status (BIMS) score of three out of 15 which revealed the resident had severe cognitive impairment. Review of R17's undated Admission Record located in the EMR under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R17's quarterly MDS under the MDS tab in the EMR had an ARD of 12/05/24 indicated the resident had a BIMS score of five out of 15 which revealed the resident had severe cognitive impairment. Review of R17's Progress Note located in the EMR under the Progress Notes tab dated 11/30/24 at 7:28 AM indicated R17 allegedly punched R13 in the eye. There were no visible injuries. During an interview with R13 on 12/18/24 at 2:30 PM R13 stated that he did not recall anyone hitting him and stated that he was not afraid of any staff or other residents. During an interview on 12/20/24 at 3:15PM the Administrator confirmed that the alleged incident between R13 and R17 was not investigated and should have been.

30622 40824 Based on interview, record review, and policy review, the facility failed to ensure that four (Residents (R)9, R19, R32, and R37) out of 24 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review of the undated policy titled MDS (Minimum Data Set) provided by the facility stated .The RAI (Resident Assessment Instrument) Manual serves as the policy by which the facility follows the process of completing MDS assessments. 1.Review of R9's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab indicated she was readmitted to the facility on [DATE] with a primary diagnosis of heart failure. Review of R9's MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/13/24 with a Brief Interview for Mental Status (BIMS) score of not assessed. R9 was coded as not having any falls since admission or prior assessment. Review of R9's Health Status Note located in the EMR under the Progress Notes and dated 07/08/24 at 4:09 PM indicated that she sustained a fall and was hospitalized . 2.Review of R37's undated Admission Record located in the EMR under the Profile tab indicated the was readmitted to the facility on [DATE] with a primary diagnosis of pulmonary fibrosis. Review of R37's annual MDS assessment with an ARD of 12/04/24 and a BIMS of zero indicated that he had severe cognitive impairment. R37's MDS was coded for smoking. Review of R37's Smoking Safety Evaluation located in the EMR under the Assessments tab dated 12/03/24 indicated that he was not a smoker. Review of the facility's undated document titled Residents Who Smoke . provided by the facility did not include R37. During an interview on 12/20/24 at 3:34 PM Regional Corporate Nurse (RCN) confirmed R9 had sustained a fall on 07/13/24 and the MDS was incorrectly coded for fall status and R37 was not a smoker and that the MDS assessment was coded in error. 3. Review of R32'sAdmission Record located under the Resident Tab in the EMR indicated R32 was admitted on [DATE] with diagnosis of Schizophrenia. Review of the significant change MDS with an ARD of 10/02/24 located under the Resident tab of the EMR indicated R32 had a BIMS of eight out of 15 indicating moderate cognitive impairment. The MDS indicated R32 had a diagnosis of Schizophrenia. During an interview on 12/18/24 at 7:32 PM, the RCN stated she reviewed the hospital records and documentation that R32 had a Schizophrenia diagnosis. During an interview on 12/19/24 at 11:13 AM, the RCN and DOR stated R32 did not have a Schizophrenia diagnosis. The mental health providers were able to provide documentation that R32 has not been diagnosed or treated for Schizophrenia. 4. A review of R19's Admission Record located in the resident's EMR section tab Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities, dementia, schizoaffective disorder, and diabetes mellitus type II. A review of R19's Fall Risk Evaluation dated 01/08/24 located in the resident's EMR section tab Assessment revealed the resident sustained one to two during the assessment; the resident had a fall score 14. A review of the resident's Quarterly Fall Risk assessment dated [DATE] located in the resident's EMR section tab Assessments revealed the resident sustained one to two falls during the assessment. A review of the facility's Incidents and Accidents for the year provided by the Administrator revealed that R19 sustained a fall in her room without injury on 01/16/24. A review of R19's Annual MDS with an ARD of 02/16/24 located in the resident's EMR section tab MDS, revealed the resident had not sustained any falls during the assessment period. In an interview on 12/20/24 at 11:10 PM the Corporate Director of Operations revealed the RCN was responsible for completing the MDS. The RCN was unavailable for interview.

Based on observation, interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision when staff failed to reschedule transportation arrangements for one sampled resident (Resident #500) out of 13 sampled residents, who had an eye appointment and was recommended to have retina surgery then cataract surgery. The resident missed the appointment when transportation did not show up and staff failed to reschedule the appointment after it was missed. The facility also failed to follow-up with the resident's routine eye appointment. The census was 77. During an interview on 2/7/25 at 12:50 P.M., the transportation policy was requested. The Administrator said there is no policy. There is just a protocol that staff follow. Review of Resident #500's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed: -Severe cognitive impairment; -Vision: Adequate-Sees fine detail, including regular print in newspaper/books; -Diagnoses included diabetes, dementia, schizophrenia, and anxiety. Observation and interview on 2/7/25 at 8:56 A.M., showed the resident in his/her room and sat on his/her bed. He/She appeared to have a hard time focusing on one item and his/her pupils looked gray/cloudy. The resident said he/she does not have any complaints except he/she just wants his/her glasses. During an interview on 2/7/25 at 10:08 A.M., the social worker said the medical record shows the resident was seen on 5/29/24 by the eye doctor, but she is not seeing any progress note. The provider sends the notes of who they plan to see and then sends the progress note of the visit to nursing after the visit is complete. The resident should have some glasses on the way. The social worker states he/she will call the provider now to get the last visit notes. Review of the resident's provided eye examination, dated 6/25/24, showed: -Problem List: Diabetes with mild non-proliferative diabetic retinopathy (condition that damages the retina, light sensitive layer of tissue at the back of the eye) without macular edema (early stage of diabetic retinopathy that occurs when small blood vessels in the retina swell) bilateral; -Posterior subcapsular polar age-related cataract (type of cataract, clouding of the lens of the eye that occurs due to aging and is characterized by a gradual thickening of the lens) bilateral; -Age related nuclear cataract (type of cataract that develops in the central part of the eye's lens, known as the nucleus) bilateral; -high cholesterol, altered mental status, schizophrenia, dementia with behavioral disturbance, and diabetes; -Diagnosis/Treatment: Resident seeing retina specialist for hole in retina (small tear or break in the retina) before cataract surgery. Resident has cataract appointment on 8/13/24. Review of the resident's medical record, showed: -A progress note, dated 9/13/24 at 1:30 P.M., that included: Care plan meeting held with resident's case monitors. Resident did not attend. Case monitors asked about dentures and glasses and was informed the resident had been seen by dental and eye team recently; -A progress note, dated 1/16/25 at 4:51 P.M., that included: Care plan meeting held with case managers. Resident did attend. Case monitor and resident asked about dentures and glasses. Resident has been seen by eye and dental team and staff will follow up about dentures and glasses; -No progress note related to the resident's retina eye appointment, cataract appointment, or retina surgery or related to the appointments being canceled. Review of the upcoming eye visit appointment list, for 2/14/25 at 9:00 A.M., did not show the resident on the list for an appointment. The resident was on the back of the list as one of the residents with incomplete information. The resident was missing a consent form and needed the facility to provide one so the eye care partner could see the resident at the next scheduled visit. During an interview on 2/7/25 at 12:22 P.M., the Administrator said she is not sure of the resident's eye provider. The resident had an appointment in August 2024 which got rescheduled to this July 2025. She is on the phone with the provider to determine why the resident was rescheduled. At 12:36 P.M., the Administrator said the reason the appointment in August was canceled is the former transportation provider did not show up. The facility use our own transportation company now. During an interview on 2/7/25 at 12:45 P.M., the Administrator said she should have been made aware of the eye appointment issue prior to today and recommended treatments should have been looked into prior to today as well. The eye appointment should have been rescheduled when transportation did not show up in August. The Administrator does not remember the resident having an eye surgery, so she does not think that was done. The Interdisciplinary Team (IDT) team and transportation person are responsible for scheduling appointments. The transportation staff person and nursing/Director of Nursing (DON) are responsible for following up when an appointment is cancelled and that the appointments are also rescheduled. She would also expect any changes such as cancellations or rescheduled appointments to be documented in the medical record so nursing staff are aware of the situation and can follow up. During an interview on 2/7/25, the Administrator said the resident did not have a vision appointment. The appointment was scheduled today for July 2025. MO00247917

Based on observation, interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision when staff failed to reschedule transportation arrangements for one sampled resident (Resident #500) out of 13 sampled residents, who had an eye appointment and was recommended to have retina surgery then cataract surgery. The resident missed the appointment when transportation did not show up and staff failed to reschedule the appointment after it was missed. The facility also failed to follow-up with the resident's routine eye appointment. The census was 77. During an interview on 2/7/25 at 12:50 P.M., the transportation policy was requested. The Administrator said there is no policy. There is just a protocol that staff follow. Review of Resident #500's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/25, showed: -Severe cognitive impairment; -Vision: Adequate-Sees fine detail, including regular print in newspaper/books; -Diagnoses included diabetes, dementia, schizophrenia, and anxiety. Observation and interview on 2/7/25 at 8:56 A.M., showed the resident in his/her room and sat on his/her bed. He/She appeared to have a hard time focusing on one item and his/her pupils looked gray/cloudy. The resident said he/she does not have any complaints except he/she just wants his/her glasses. During an interview on 2/7/25 at 10:08 A.M., the social worker said the medical record shows the resident was seen on 5/29/24 by the eye doctor, but she is not seeing any progress note. The provider sends the notes of who they plan to see and then sends the progress note of the visit to nursing after the visit is complete. The resident should have some glasses on the way. The social worker states he/she will call the provider now to get the last visit notes. Review of the resident's provided eye examination, dated 6/25/24, showed: -Problem List: Diabetes with mild non-proliferative diabetic retinopathy (condition that damages the retina, light sensitive layer of tissue at the back of the eye) without macular edema (early stage of diabetic retinopathy that occurs when small blood vessels in the retina swell) bilateral; -Posterior subcapsular polar age-related cataract (type of cataract, clouding of the lens of the eye that occurs due to aging and is characterized by a gradual thickening of the lens) bilateral; -Age related nuclear cataract (type of cataract that develops in the central part of the eye's lens, known as the nucleus) bilateral; -high cholesterol, altered mental status, schizophrenia, dementia with behavioral disturbance, and diabetes; -Diagnosis/Treatment: Resident seeing retina specialist for hole in retina (small tear or break in the retina) before cataract surgery. Resident has cataract appointment on 8/13/24. Review of the resident's medical record, showed: -A progress note, dated 9/13/24 at 1:30 P.M., that included: Care plan meeting held with resident's case monitors. Resident did not attend. Case monitors asked about dentures and glasses and was informed the resident had been seen by dental and eye team recently; -A progress note, dated 1/16/25 at 4:51 P.M., that included: Care plan meeting held with case managers. Resident did attend. Case monitor and resident asked about dentures and glasses. Resident has been seen by eye and dental team and staff will follow up about dentures and glasses; -No progress note related to the resident's retina eye appointment, cataract appointment, or retina surgery or related to the appointments being canceled. Review of the upcoming eye visit appointment list, for 2/14/25 at 9:00 A.M., did not show the resident on the list for an appointment. The resident was on the back of the list as one of the residents with incomplete information. The resident was missing a consent form and needed the facility to provide one so the eye care partner could see the resident at the next scheduled visit. During an interview on 2/7/25 at 12:22 P.M., the Administrator said she is not sure of the resident's eye provider. The resident had an appointment in August 2024 which got rescheduled to this July 2025. She is on the phone with the provider to determine why the resident was rescheduled. At 12:36 P.M., the Administrator said the reason the appointment in August was canceled is the former transportation provider did not show up. The facility use our own transportation company now. During an interview on 2/7/25 at 12:45 P.M., the Administrator said she should have been made aware of the eye appointment issue prior to today and recommended treatments should have been looked into prior to today as well. The eye appointment should have been rescheduled when transportation did not show up in August. The Administrator does not remember the resident having an eye surgery, so she does not think that was done. The Interdisciplinary Team (IDT) team and transportation person are responsible for scheduling appointments. The transportation staff person and nursing/Director of Nursing (DON) are responsible for following up when an appointment is cancelled and that the appointments are also rescheduled. She would also expect any changes such as cancellations or rescheduled appointments to be documented in the medical record so nursing staff are aware of the situation and can follow up. During an interview on 2/7/25, the Administrator said the resident did not have a vision appointment. The appointment was scheduled today for July 2025. MO00247917

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one of 39 residents (Resident (R)13) reviewed for smoking wore a smoking apron while smoking. This failure placed R13 at risk for injury. Findings include: Review of the facility policy titled Smoking Policy last reviewed on 10/12/24 revealed .Residents who are identified as 'supervised smokers' will be monitored by facility staff. If a resident identifies as a supervised smoker who requires smoking assistance (i.e., smoking aprons .) will be addressed and care planned for preventative measures to ensure residents safety . Review of R13's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of dementia. Review of R13's quarterly Minimum Data Set (MDS) under the MDS tab in the EMR had an Assessment Reference Date (ARD) of 10/16/24 indicated the resident had a Brief Interview of Mental Status (BIMS) score of three out of 15 which revealed the resident had severe cognitive impairment. Additionally, R13 was a smoker. Review of R13's Care Plan located in the EMR under the Care Plan tab and revised 01/04/23 included supervised smoking status requiring a smoking apron. Review of R13's Smoking Evaluation located in the EMR under the Assessments tab and dated 10/17/24 indicated that R13 required smoking supervision. The assessment did not include the option to indicate apron usage/requirements. Review of the facility's undated document titled Residents who smoke on 300 hall included R13 and the need for an apron. During an observation on 12/18/24 at 2:13 PM R13 was outside smoking with Certified Nurses Aid (CNA)7 and was not wearing a smoking apron. During an interview on 12/18/24 at 2:13 PM with CNA7 confirmed that R13 was smoking without an apron and was not sure where the aprons were located or which residents required them. During an interview on 12/20/24 at 6:08 PM with the Social Services Designee (SSD) stated that all residents are supervised during smoking times per facility policy. There was a list at all nurses stations which included the names of all smokers and their apron requirements. The SSD confirmed that R13 was a smoker and should wear an apron during smoking. During an interview on 12/20/24 at 6:41 PM with the Director of Nursing (DON) stated that she wasn't sure how staff were to know which residents required a smoking apron. The DON confirmed that R13 was a smoker and that he required an apron during smoking.

Based on observation, interview, record review, and facility policy review, the facility failed to provide oxygen services that included cleaning of the oxygen concentrator for one of one residents (Resident (R)13) reviewed for oxygen therapy. This failure had the potential for the concentrator to not remove all contaminated air and provide adequate oxygenation to the resident. Findings include: Review of the facility's policy titled Oxygen Supply Policy revised 07/15/24 stated This facility will maintain oxygen device supplies in a clean status, ensuring proper labeling and replacement of supplies as needed/per physician's orders . Review of R13's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of dementia. Review of R13's quarterly Minimum Data Set (MDS) under the MDS tab in the EMR had an Assessment Reference Date (ARD) of 10/16/24 indicated the resident had a Brief Interview of Mental Status (BIMS) score of three out of 15 which revealed the resident had severe cognitive impairment. Additionally, R13 received oxygen therapy. Review of R13's Care Plan located in the EMR under the Care Plan tab and revised 09/23/24 included oxygen therapy related to ineffective gas exchange. Review of R13's Order Summary located in the EMR under the Orders tab included Administer oxygen at 2L (two liters) per nasal cannula as needed for SOB (shortness of breath). During an observation on 12/16/24 at 2:29 PM included an oxygen concentrator next to R13's bed with external filter on the back of the machine with light gray substance covering the filter. During an interview on 12/18/24 at 11:32 AM with Registered Nurse (RN1) stated that hospice staff did not maintain oxygen concentrators but if the facility staff notified them that the machines were not working properly, then hospice would replace or repair the machine. RN1 was not aware of the dirty oxygen filter and did not know when it was last cleaned. During an observation and interview on 12/20/24 at 7:30 PM with the Director of Nursing (DON) confirmed that R13's oxygen concentrator filter had a light gray substance covering the filter. The DON stated that R13 uses the oxygen often and that the hospice agency provided the oxygen concentrator delivered the machine and was responsible for maintenance of the machine. During an interview on 12/20/24 at 8:40 PM with Regional Corporate Nurse (RCN) stated that the facility did not have a policy regarding maintenance/cleaning of oxygen concentrators. RCN stated that when the nurses change out the tubing, they should also be checking the filter to make sure it doesn't need to be cleaned.

Based on interview and record review, the facility failed to ensure residents were free from physical abuse and failed to follow its policies to prevent resident-to-resident abuse when staff failed to consistently monitor Resident #1 during 15-minute face checks as an intervention for wandering. This contributed to three known resident-to-resident altercations, and had the potential to effect the safety and privacy of all other residents on the secured unit. (Residents #2, #3 and #4). The census was 78. Review of the facility's Abuse, Neglect and Exploitation Policy, revised 4/8/24, showed: -Policy: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. Resident must not be subject to abuse by anyone, including but not limited to: facility staff, other residents, consultants or volunteers, staff of other agencies servicing the resident, family members, legal guardians, friends or other individuals; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain, physical, mental and psychosocial well-being; -Physical abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness; -The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: -Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents; -Observe resident behavior and their reaction to other residents, roommates, and/or tablemates; -Provide instructions to staff on care needs of residents; -Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect. Utilize facility's abuse/neglect risk assessment and develop care needs according to the findings; -Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses; -Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and any noted visitors in the area. Obtain witness statements, according to appropriate policy. All statements should be signed and dated by the person making the statement; -The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation. Review of the facility's Supervision and Management of Residents with Behaviors policy, reviewed 1/24/24, showed: -Policy: To provide support to team members to maintain safety and security when providing care to our residents who may exhibit behaviors, while treating our residents with dignity, respect, and compassion; -Protocol: -De-escalation education will be provided to team members; -Be aware and be on the lookout for a change in the resident's behaviors; -When a resident is exhibiting anxiety, paranoia, defensive or risky behaviors, staff will respond by using de-escalation techniques: -Maintain a safe distance, 5-6 feet; -Use a clear voice tone; -Use a quiet voice to speak to the resident; -Use relaxed, well-balanced, non-threatening posture, while maintaining tactical awareness; -Be active in helping; -Build hope-resolution if possible; -Focus on their strengths; -Present yourself as a calming influence; -Use limit setting to provide safe and respectful choices; -Be consistent; -Effective verbal intervention must be: -Specific - precise, explicit and clear; -Concise - short, to the point, simple; -Directive - instructive, communicating clearly what you want to other person to do; -Follow the protocol for a resident-to-resident altercation; -Call a Code Grey immediately on your walkie talkie and/or overhead page; -Staff members on scene will attempt to separate the residents and ensure the safe of all residents, without causing further harem; -The staff member will remain in the area of disruption until further assistance arrives; -If the situation escalates, allow the Charge Nurse of Emergency Medical Service (EMS) personnel to relieve you upon arrival. Review of the Resident-to-Resident Altercation Protocol, revised 01/2022, showed: -Policy: To minimize potential harm to our residents, all staff members of the facility will follow this protocol; -Protocol: -The staff member on the scene of the resident-to-resident altercation will immediately call a Code Grey on the walkie/talkie and/or overhead intercom; -Staff members, on scene, will attempt to separated residents and ensure the safety of all residents; -The staff member will remain in the area of disruption until further assistance arrives; -The responding Charge Nurse will notify the Administrator for further instruction, as well as the Director of Nursing (DON) or designee; -The responding Charge Nurse will notify the Primary Care Physician (PCP) and responsible parties of the residents involved; -The Charge Nurse will obtain statements of all staff who witnessed the event and involved residents; -Documentation of the resident-to-resident altercation, notification of administrator, DON/designee, and physician and outcome to the event will be done in the eMedical Record (EMR). Review of the facility's Coverage on Secure Units policy, revised 01/2022, showed: -Policy: The facility will ensure appropriate staffing and safety for all residents and staff; -Protocol: -The staffing coordinator/designee and Nurse Leadership will work together to provide consistent coverage of the building and the secure units; -No staff will leave their assignment during their shift without proper coverage in place; -Any facility staff member may cover your assigned unit while you leave for your assigned break, to obtain supplies needed for the unit, etc; -No staff will leave their assignment at the end of their shift, until relief is in place. Review of Resident #1's Face Sheet, showed he/she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of the resident's Aggression Assessment, dated 3/20/24 at 8:50 A.M., showed: -Have you ever had episodes of violence - Yes; -If yes, specify how many - 1 or 2; -What specifically happened - He/She had to defend himself/herself; -Who are the targets of the violent behavior - the person that was after me. Review of the resident's physician order sheet, sheet, showed: -Active order dated 4/12/24: Did the resident demonstrate any behaviors such as wandering, elopement, aggression, agitation, anxiety, suicidal ideations, refusal of care, assessments, and any other behaviors. Please document specific behaviors every shift related to Alzheimer's disease. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/26/24, showed: -Severe cognitive impairment; -Physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) - behavior of this type occurred 4 to 6 days; -Wandering - Presence and Frequency: Has the resident wandered - Behavior of this type occurred daily; -Supervision or touching assistance with bed mobility, eating, and locomotion on the unit; -Diagnoses of Alzheimer's disease, depression, and anxiety. Review of the resident's progress notes, showed: -On 4/1/24 at 10:24 A.M. the resident wandered into another resident room and was in a physical altercation. Resident has multiple bloody scratches on his/her face and neck. Scratches cleaned with normal saline per this reporter. Call placed to Psychiatrist office and Psychiatrist made aware that the resident will be transferred to the hospital. Director of Nursing (DON) made aware; -On 4/1/24 at 11:03 A.M. the resident will no longer be transferred to the hospital. Call placed to the physician, new order received to obtain x-ray of the left pointer finger and hand, all views, which are anatomically not in alignment and swollen; -On 4/3/24 at 4:07 P.M., it was reported to the Social Service Department (SSD) the resident was involved in a physical altercation with another resident after wandering into their room. The resident's Power of Attorney (a legal document that allows someone else to act on your behalf) was informed. He/She thinks resident may need medication adjustment. Nursing staff reached out to psychiatric doctor for possible medication adjustment. POA (Power of attorney) was informed the resident would not be sent out to the hospital and the psychiatric doctor had been contacted and POA said ok. POA was informed the resident had been placed on 15-minute face checks. Staff will continue to monitor the resident's mood and behavior; -On 4/3/24 at 5:20 P.M., the resident remains on 15-minute checks related to wandering. Resident had to be redirected this morning from another resident's room. The resident was laying in another resident's bed; -On 4/5/24 at 3:38 P.M., Resident wanders in others room and up and down the halls without purpose. Resident is consistently redirected; -On 4/5/24 at 9:57 P.M., the resident remains on 15-minute checks related to wandering. Resident wanders into other resident's rooms. Resident wanders aimlessly through the unit and has to be consistently redirected this shift. Review of the facility's self-report, dated 4/1/24 at 10:30 A.M., showed a staff member heard noises coming from a room. As he/she arrived, he/she saw a resident trying to leave the side of the room that Resident #3 was located on. It appeared that an altercation had happened between Resident #1 and Resident #3. Resident #1 stated that he/she went into the room that wasn't his/hers by mistake. He/She said Resident #3 started hitting Resident #1 when he/she was on his/her bed. Resident #1 started to hit Resident #3 back. The staff member separated the two residents. Resident #3 appeared to have discoloration on the left side of his/her face, with scratches and it appeared to be swollen. There was blood noted as well. Nursing assessed the area and cleansed it. Ice was applied to the left side of his/her face. Resident #3 remained seated at the edge of his/her bed. Resident #1 was taken to his/her room. He/She was assessed. His/Her left hand appeared swollen. New orders were received from the physician to obtain x-rays of Resident #3's face and Resident #1's hand. All pertinent parties were contacted. Both residents were placed on 15-minute checks. Investigation is ongoing. Review of the resident's progress note, dated 5/22/24 at 5:59 P.M., showed at approximately 5:40 P.M., the resident was seen walking out of another resident's room. He/She was alert and responsive. Upon further assessment, the resident's right hand and knuckles were red and slightly swollen. The resident whose room he/she was coming out of stated that the resident hit him/her in the face. Ice applied to the resident's right hand. EMS called, and resident transported to the hospital. All parties notified; -On 5/24/24 at 11 P.M., the resident wandered into the same resident's room three times. He/She was re-directed gently. Review of the facility's final investigation of a resident-to-resident altercation, dated 5/22/24, showed: -On 5/23/24, Resident #1 and Resident #4 returned from the hospital. Resident #1 returned at 1:10 A.M. and Resident #4 at 1:45 A.M. Resident #4 returned with 2 steri-strips (a thin sticky adhesive bandage that can be used to close small cuts and wounds, or to cover surgical incisions) to the right upper cheek area. Resident #1 returned with ace bandage wrapped to his/her right hand. New orders and interventions include the following: -New orders for Depakote Sprinkles (capsule can be opened and sprinkle the medication on soft food) 2 capsules by mouth 3 times a day for mood affective disorder (a mental health condition that causes significant disruptions in a person's emotions); -Trazodone (used to treat depression and sedative) 25 mg by mouth 3 times a day for depression; -Zyprexa 5 mg by mouth every 6 hours as needed for agitation for 14 days with end date of 6/6/24; -Resident #1's room sign was enlarged and made more colorful; -He/She will be utilizing an iPad to engage in music and certain activities for persons living with dementia. He/She will be utilizing the iPad with staff throughout the day. If he/she was able to use the iPad independently, he/she will have the opportunity to use as needed. All parties are aware of the additional new orders and use of the iPad; -On 6/18/24 at 3:29 P.M., the resident remains on 15-minute checks related to wandering. Resident continues to wander in others' room and had to be consistently redirected. Review of the resident's 24 hour, 15-minute check sheet, showed: -No 15-minute face check documentation for the month of April 2024; -No 15-minute face check documentation for the month of May 2024; -No 15-minute face check documentation for 6/1/24 through 6/5/24 and 6/8/24 through 6/11/24. Review of the resident's progress notes, showed: -On 7/4/24 at 12:15 P.M., the resident was found in a resident's room on top of him/her. Resident currently on every 15-minute face checks. He/She had last been seen at 11:45 A.M. The resident was immediately removed from the room and taken to 300 hall dining area with no injuries present. He/She was easily redirected and was calm. All parties notified. Psychiatric Department will review his/her current medications and make any changes, if needed. Family made aware of the situation. Resident awaiting lunch meal and 15-minute face checks continued; -On 7/4/24 at 9:01 P.M., The resident was placed on 1:1 supervision, per DON; -On 7/9/24 at 3 P.M., the resident wandering the halls, requires frequent redirecting from other resident's private area. Review of the facility's final investigation of a resident-to-resident altercation, dated 7/11/24, showed on 7/4/24, Resident #1 went into Resident #2's room and got in the bed and laid down. Resident #2 was laying in his/her bed resting. Resident #1 startled Resident #2 as he/she laid down on the bed. An altercation occurred. Staff heard the noises and went to the room. They found the residents in an altercation. Residents #1 and #2 were separated and Resident #1 was led out of the room without incident. Both residents were assessed. Resident #1 had no injuries. Resident #2 had a small scratch above his/her right eye. Neurological checks were initiated per protocol. All pertinent parties were notified, including physicians, responsible parties, and the Administrator. New orders received for Resident #1: Ativan (Lorazepam Oral Tablet, works on the brain to relieve symptoms of anxiety) and Trazodone HCL (used to treat depression) was increased. He/She was placed on a 1:1 observation status indefinitely until he/she can be transferred to another facility that can meet his/her needs. Responsible party is aware and will tour places once the referrals accept him/her for admission. Referrals have been sent out to other facilities at this time. Review of LPN (Licensed Practical Nurse) F's facility investigation statement, dated and signed 7/4/24, showed at approximately 12:00 P.M., he/she was just finishing up with a resident and his/her family. When LPN F came out of the room, staff told him/her there was an altercation between Residents #1 and #2. Upon further assessment, it was noted that Resident #2 had a small scratch above his/her right eye with a scant amount of bleeding. Neurological checks were initiated. Review of CMT (Certified Medication Technician) G's facility investigation statement, dated and signed 7/4/24, showed he/she was standing at his/her medication cart. A Certified Nurse Assistant (CNA) yelled down the hall for help. When CMT G entered the room, there was a resident-on-resident altercation. Review of CNA A's facility investigation statement dated and signed 7/12/24, showed CNA A said he/she yelled for help due to Resident #1 and #2 fighting. He/She walked to Resident #1 and #2, so he/she separated them both. He/She took Resident #1 out of the room and told the nurse. During an interview on 7/12/24 at 10:32 A.M., the resident's POA said the facility told him/her the resident wandered into another resident's room and ended up hitting that resident in the face. The facility had been doing the same things over and over again. The resident was moved from the front to the back of the hall, was placed on 1:1 but he/she wasn't told about the 1:1. He/She was visiting the resident and noticed a staff person with him/her and asked why. That's when he/she found out about the 1:1 assignment. He/She purchased the resident a TV so he/she could spend more time in his/her room. He/She said there was a care plan meeting scheduled for next week to talk about the 1:1 assignment and the facility told him/her the 1:1 was expensive, so they weren't sure how long the resident would be 1:1. The POA said he/she didn't usually see a lot of activities for the residents but the facility said they had activities. He/She didn't know if that was true. He/She said the staff had to be conscious of the resident's movement because he/she was always moving about. He/She was active before going to the facility. He/She wanted to know where the staff were prior to the resident wandering into Resident #2's room. Resident # 1 was not always the aggressor, but the POA didn't know if he/she was in this incident or not. The only change the facility had made was the 1:1's and moved the resident to the back of the hall. He/She bought the resident an iPad and the facility kept it in the office. He/She didn't know if the resident could even use the iPad and wasn't given an update to know if the iPad was working as a distraction or not. The facility told him/her the resident only used the iPad for music, but wasn't told the resident only liked it for a couple of days and was not longer using it. When asked if the resident could read, the POA said he/she didn't know. The POA said he/she didn't want Resident #1 or any other resident to be hurt. The 1:1's would be the most helpful if there was a way to pay for it. He/She was told the facility had a memory care section and it was small so they could manage the resident's needs more. The POA said he/she couldn't control the resident and the facility knew that, that's why the resident was there. He/She thought the resident's dementia had gotten worse, which could be another issue. The 1:1's made him/her feel better because he/she thought the resident was safer. During an interview on 7/11/24 at 1:39 P.M., the Administrator said the resident's POA had the idea of the iPad as an intervention and got the resident one. He/She liked it for a couple of days but not now. The Administrator said the facility could not meet the resident's needs and can't keep him/her from wandering into other resident's rooms, so they are helping the POA find more suitable places. Review of the resident's care plan, dated 6/23/24, showed: -Problem: resident wanders and gets into other resident's beds related to Alzheimer's disease. On 4/1/24, the resident got into another resident's bed and there was a physical altercation. On 5/22/24, the resident went into another resident's room and there was a physical altercation; -Goal: The resident will demonstrate happiness with daily routine through the review date; -Approaches/Tasks included: -4/1/24: Separate for safety. 15-minute checks times 72 hours for safety, notify psychiatrist and PCP (Primary Care Physician), orders for x-ray of left hand; -5/22/24: Send to hospital for evaluation of right hand, 15-minute checks for safety, notify psychiatrist for medication evaluation, place a larger name sign on colored paper outside the resident's room, redirect as needed; -Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; -Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise, and intervene as appropriate; -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; -Staff did not document any patterns of wandering; -Staff did not include direction for staff to use the paper with a house and the resident's name printed on it as an intervention for wandering; -Problem: Behaviors - Aggression: the resident has a potential for being a danger to self and others related to a history of behavior, major depressive disorder, anxiety, insomnia, Alzheimer's disease. The resident doesn't like to be touched; -Goal: The resident will have no indications of psychosocial well-being problem by/through review date; -Approaches/Tasks: Consult with Pastoral Care, Social Services, and Psychiatric Services; -Encourage participation from the resident who depends on others to make own decisions; -Provide opportunities for the resident and family to participate in care; -Staff did not document trigger(s) specific to the resident; -Staff did not document it was very important to the resident to go outside whenever the weather permitted; -Staff did not document de-escalation techniques specific to the resident; -Staff did not document staff were to use the iPad as an intervention. -Staff did not document when to use the resident-to-resident altercation protocol; -Staff did not update the resident's care plan to reflection the physical altercation related to wandering into another resident's room on 7/4/24; -Staff did not document 1:1's as an intervention. Review of the resident's 24 hour, 15-minute check sheet, showed: -No 15-minute face check documentation for the month of April 2024; -No 15-minute face check documentation for the month of May 2024; -No 15-minute face check documentation for 6/1/24 through 6/5/24 and 6/8/24 through 6/11/24. Observation and interview on 7/12/24 at 9:42 A.M., showed Resident #1 was in bed, lying on his/her stomach, but turned to his/her right side while the questions were asked. He/She nodded his/her head when asked if he/she was ok. The resident said he/she was doing the best he/she could. The resident said it wasn't his/her room. Observation and interview on 7/12/24 at 9:41 A.M., showed Resident #2 lay in bed. He/She said he/she had more than a couple scuffles with other residents. He/She didn't remember exactly what happened but just wanted other residents to not come in his/her room, especially if they were thieves. He/She didn't see Resident #1 take anything this last time. He/She didn't have much stuff anyway. During a telephone interview on 7/11/14 at 1:51 P.M., CNA A said he/she knew Resident #1 and #2. He/She went to get them for lunch. When, he/she walked into the room, Resident #1 was on top of Resident #2. Resident #1 hit Resident #2. He/She didn't know what caused Resident #1 to hit Resident #2. He/She wasn't sure if Resident #2 did anything, but Resident #1 wandered into Resident #2 room. Maybe Resident #2 tried to redirect Resident #1 out of his/her room and that's why they had the altercation. Resident #1 walked around a lot. He/She went into the same rooms a lot and needs to be redirected. The staff take turns watching him/her, but they have other residents to watch too. As soon the resident was sat down, he/she was up again. He/She must be redirected a lot. CNA A said he/she had behavioral training at another facility. He/She didn't document any of the resident's wandering behavior but said he/she told the nurse. CNA A was to monitor him/her every 15-minutes, but he/she didn't document on any of the times he/she checked on the resident. That was impossible for two staff to do. During a telephone interview on 7/11/24 at 10:55 A.M., CMT G said he/she didn't see the altercation and was passing medications. He/She heard a CNA yell for help. He/She didn't know the CNA's name but knew the CNA was a new. When he/she got to the room, Resident #1 was on top of Resident #2. Resident #1 just walked around into other resident's rooms. The resident was nice but confused. He/She was not aggressive. You could tell by the resident's voice that he/she was nice. The resident didn't hit people unless they did something to him/her. CMT G said maybe Resident #1 touched Resident #2's snacks, but was not sure. He/She left the room after the residents were separated. There was enough staff in the room by then. During an interview on 7/11/24 at 12:11 P.M., CNA H said he/she didn't know where the 15-minute documentation was but heard the nurse was supposed to do the checks. He/She wasn't sure about that. CNA H said Resident #2 told him/her Resident #1 came into his/her room to steal, so he/she punched Resident #1 and then Resident #1 hit back. CNA A walked into the room to separate the residents. CNA A was scared and didn't do anything. CNA A went to grab Resident #1's arm, but CMT G said don't touch him/her. CNA H said he/she told Resident #1 to leave the room. CNA H said he/she and LPN F asked Resident #2 what happened, and he/she told them Resident #1 walked into his/her room and picked up his/her things, so he/she punched Resident #1. The Assistant Director of Nursing (ADON) was looking for CNA A and asked where he/she was. CNA H said he/she didn't think the 15-minute checks were being done and there were no activities until the last week or so. During a telephone interview on 7/11/24 at 11:03 A.M., LPN F said he/she was in another resident's room and didn't see what happened but overhead there was an altercation. He/She went to assess Resident #2. He/She had an area above his/her right eye that was bleeding, but not really bad. He/She didn't know who saw the altercation, but the DON, ADON, and nurse supervisor took care of the rest. He/She was not aware of any injuries for Resident #1. LPN F said the residents were not roommates, Resident #1 had a history of wandering behavior, and had a previous altercation with another resident about a month ago. The resident was on 15-minute checks before the altercation and was now 1:1 observation since the altercation. Staff are with him all the time now. Neither resident went to the hospital. During an interview on 7/11/24 at 11:56 A.M., the ADON said she was at the desk and could hear someone hollering. She didn't know the name of the CNA because he/she was new. By the time she got to the room, the CNAs had already gotten Resident #1 off of Resident #2. They were bringing the residents from the room. She looked at Resident #2 and his/her head had a little blood. It was just a scratch. No steri strips or other treatment was provided. She didn't know who the aggressor was but Resident #1 had a history of aggression towards other residents. Resident #1 wandered and the aggression was usually from other residents trying to get Resident #1 out of their rooms. If Resident #1 became aggressive, it was because he/she would defend himself/herself. He/She was on 15-minute checks but since the altercation, had been 1:1 observation. The ADON said the 15-minute checks not/did not work and the resident actually needed someone with him/her all the time to say, this is your room and redirect him/her. The resident would be a 1:1 on every shift until he/she was discharged . She didn't think the resident knew his/her room and didn't think the colored sign with his/her name was working. The facility was just trying things to lessen the wandering. The ADON said the resident didn't use an iPad and she was not sure if there was an iPad in the facility for him/her. She said the resident's care plan had been updated. During an interview on 7/11/24 at 10:14 A.M., CNA C said he/she knew Resident #1 but wasn't at the facility on the day of the altercation. The resident was a wanderer and quite often went into other residents' rooms. He/She would put on the other residents' shoes and clothes. Because of the resident's physical appearance, he/she was more intimidating. Of the residents who wandered on the unit, he/she wandered the most. Recently, the staff were given a list of activities to keep the resident engaged. At first, they were to keep an eye on him/her, but the resident was getting lost because staff weren't really able to do that. The resident would not be the aggressor. He/She said the resident would protect himself/herself if he/she went into another resident's room and the other resident pushed or hit him/her for being in there, but he/she was not the aggressor. CNA C said the resident was on 1:1 supervision but he/she didn't know how long they would be able to keep 1:1 supervision for the resident. He/She said 1:1 supervision would be effective, but they had a staffing shortage and was using agency staff. CNA C said the resident was on 15-minute checks prior to the altercation with Resident #2 because of his/her wandering. The resident had been on 15-minute checks since he/she came to the facility. The other residents didn't like seeing Resident #1 or any other residents in their rooms. CNA C said the resident had been a boxer. The resident was not the aggressor, but he/she would finish it. Resident # 2 was quiet, stayed mostly in his/her room, and was not sociable. Resident #2 had seen Resident #1 in the empty bed in his/her room before and had not gotten upset or had an altercation before. Maybe Resident #2 had a bad day, he/she wasn't sure what happened because he/she wasn't there that day. During an interview on 7/11/24 at 2:31 P.M., CNA B said he/she knew Resident #1 and he/she wandered a lot. The resident went into all the other residents' rooms and a few of them would get upset but some didn't. The resident would get into the other residents' beds. He/She moved fast, that's why he/she was put on 1:1 supervision. The nurse, CNAs, and CMTs did the 15-minute checks but CNAs and CMTs reported the checks to the nurse who then signed and documented in a book at the nurse desk. They were told to pay attention to and keep an eye on the resident. The resident had dementia. He/She didn't bother anyone unless they bothered him/her. If the resident said no, he/she meant that. He/She was easily redirected but didn't want to be forced to do anything. The other residents were aware that Resident #1 would fight. It didn't end well for the other residents. Some residents would call for staff and not touch the resident. Those residents had dementia but wouldn't touch Resident #1. Resident #2 was in his/her right mind. CNA B said he/she did not have any behavioral or dementia training from the facility but had training from a psychiatric facility he/she worked at before. CNA B thought the 15-minute checks worked a little but said the resident was fast. He/She thought it was impossible to keep the resident out of other resident rooms but thought the 1:1 supervision and activities was the best thing. During an observation on 7/11/24 at 2:45 P.M., CNA C was 1:1 with the resident. He/She was seated in a chair outside of the resident's door. There was an approximately 8 x 10 turquoise paper, with an image of a house with the resident's name in black lettering underneath. The picture was affixed to the left side of the wall behind the brown railing with only half of the image of the house visible above the railing. The resident's name was not visible and was hidden below the railing. During an interview, CNA C said he/she never used an iPad with the resident and didn't know he/she ever had one. It was hard to keep watch on the resident because most of the time, there was only one or two staff. He/

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when one resident was abused by other resident resulting in a head laceration (Resident #4 and #5). The facility census was 81. The Administrator was notified on 2/26/24 of the past non-compliance. The facility immediately began an investigation into the incident, separated and assessed the residents, as well as contacted all responsible parties and physicians, and sent the residents out for evaluations following the altercation. Upon the residents' return to the facility, the facility had interventions in place to ensure no further altercations would take place, which included: Medication adjustments (while at the hospital), room changes, and care plan meeting scheduled. In addition, monthly abuse and neglect in-servicing had been completed with staff, which included resident to resident abuse. The noncompliance was corrected on 2/10/24. Review of the facility's Abuse, Neglect, and Exploitation policy, revised 4/15/19, showed: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain, physical, mental and psychosocial well-being; -Physical Abuse includes, but not limited to hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment; -Identification of Abuse, Neglect, and Exploitation: The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following factors: -Resident, staff or family report of abuse; -Physical marks such as bruises or patterned appearances such as a handprint, fingerprints, or distinguishable mark on the resident's body; -Physical injury of a resident, of unknown origin; -Resident reports of theft of property, or missing property; -Verbal abuse of a resident overheard; -Physical abuse of a resident witnessed; -Psychological abuse of a resident observed; -Failure to provide care needs such as eating, bathing, dressing, turning and positioning. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/28/23, showed: -Severe cognitive impairment; -Has delusions and hallucinations; -Has behaviors; -Diagnoses included psychotic disorder, schizophrenia (disorder that affects ability to think, feel, and behave clearly), high blood pressure, and kidney failure. Review of the resident's progress notes, showed: -On 2/10/24 at 5:56 A.M., this nurse was at the nursing station, heard a loud crash and loud scream coming from the resident's room. When this nurse entered the room, observed this resident sitting on his/her bed with fist clenched. Resident states, he/she hit the other resident. Resident roommate has sustained injuries from this resident. This resident alert and oriented, answers questions inappropriately. Resident removed from room immediately placed at nursing station with staff present. 911 called, resident transported to hospital emergency room , physician made aware of occurrence. Resident representative Guardian was called with message left. Resident assisted onto stretcher assisted by two paramedics to hospital, emergency room , nurse given report; -At 7:14 P.M., resident returned from hospital with diagnoses of alleged assault and aggressive behavior. No new orders. Resident returned on a stretcher accompanied by two emergency medical technicians (EMTs). Resident able to walk from stretcher to bed in room without difficulties. No signs of aggressive behaviors noted at this time. Resident placed on 15 minute checks at this time. Physician, Assistant Director of Nursing (ADON) and resident guardian made aware of resident's return; -On 2/13/22 at 10:00 P.M., regarding the prior incident on 2/10/24, resident stated that he/she had a fight with his/her roommate because his/her roommate was trying to kill him/her with a [NAME] and long blade. His/Her other roommate was interviewed. He/She stated he was awaken to hearing his/her roommate being attacked in his/her bed. He stated that all he/she could remember was seeing Resident #4 punching his/her roommate. He/She also stated that his/her roommate got up from lying down and transferred to his/her wheelchair. He stated that Resident #4 continued to punch him/her in the wheelchair. The roommate said that staff came in and stopped Resident #4. They pulled the privacy curtain. Review of the resident's care plan, dated 1/20/22, showed: -Problem: Resident has potential to be physically aggressive related to a history of physical assault; -Goal: Will demonstrate effective coping skills through the review date; -Approaches: --Administer medications as ordered. Monitor/document for side effects and effectiveness; --Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; --Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; --Modify environment: Adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed etc.; --Psychiatric/Psychogeriatric consult as indicated. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Severely impaired cognition; -Has delusions and verbal behaviors; -Diagnoses included high blood pressure, hyperlipidemia (high level of fat lipids in the blood), and manic depression. Review of the resident's progress notes, dated 2/10/24 at 3:33 A.M., showed this nurse was at nursing station, heard a loud crash and loud scream coming from the resident's room, when this nurse entered room, observed this resident sitting on buttocks next to his/her bed, moderate amount of bright red blood covering his/her face and head. Laceration observed to top of resident head, area measures 6.0 x 2.0 centimeters (cm). First aide provided to area with pressure dressing. Resident alert and oriented, answers questions appropriately. Resident complaints of pain to head and right rib area. No other injuries noted at this time. 911 called, resident transported to hospital, physician made aware of occurrence. Resident representative notified of occurrence and transport. Paramedics at facility, resident assisted onto stretcher, x 2 medics heading to hospital, emergency nurse given report. Review of the resident's care plan, dated 1/5/22, showed: -Problem: Resident has a history of bipolar disorder and obsessive compulsive disorder; -Goal: Will have improved mood state: happier, calmer appearance, no signs or symptoms of depression, anxiety or sadness; -Approaches: --Administer medications as ordered. Monitor/document for side effects and effectiveness; --Assist the resident in developing/provide the resident with a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity; --Behavioral health consults as needed (psycho-geriatric team, psychiatrist); --Monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Review of the facility's investigation, dated 2/16/24, showed: -Resident #4's and #5's other roommate said that he/she heard Resident #5 (victim) yelling. He/She said that Resident #4 was punching him/her. He/She stated that it was dark and he/she could not see a lot. He/She did see Resident #5 in his/her wheelchair getting hit by Resident #4. He/She stated that staff came in and separated the two. The privacy curtain was pulled. He/She could not see anything else; -Perpetrator: Resident #4 was interviewed by nursing and by the administrator. When asked why he/she did what he/she did he stated the following, he/she said Resident #5 was assaulting him/her; -Per administrator note: He/She was trying to kill me with a [NAME]/large blade. Resident #4 said he/she had to fight him/her to stop him/her from trying to kill him/her. Resident #4 was returned to the facility in less than 24 hours. He/She was moved to another room before his/her return. He/She was placed on 1:1 observation and remained on that level of observation; -Victim: Resident #5 not available for interview. He/She was quickly attended to by nursing and emergency medical services (EMS) came quickly to transfer him/her to the hospital for evaluation and treatment. Resident #5 did not return to the facility. He/She was discharged from the hospital to another undisclosed facility; -Resident #4 had been refusing medication for an extended period of time. Guardian, forensic case worker and physician had been made aware. Resident #4 had been placed on 1:1 observation pending arrangements for treatment at another facility. Care plan meeting scheduled on 2/16/24 with guardian and case worker for treatment options. Review of Certified Nursing Assistant (CNA) D's written statement, dated 2/12/24, showed Saturday, around 3:00 or 4:00 in the morning, he/she was sitting outside a resident's room doing a 1:1 when suddenly he/she heard yelling and loud bangs, ran down the hall, opened the resident's door and seen a wheelchair getting thrown on the floor by Resident #4 and Resident #5 on the floor next to his/her bed with blood all over his/her face, shirt and on the top of his/her head. The next aide came in behind me. He/She made Resident #4 exit the room while going to get the nurse and the other aide sat with Resident #5. Review of Certified Medication Technician (CMT) C's written statement, dated 2/12/24, showed he/she was by the break room, then he/she head a resident yelling help. He/She got in the room, Resident #5's face was full of blood. He/She asked what happened. Resident #5 said he/she was asleep and Resident #4 just started hitting him/her with the wheelchair. Resident #4 just laying like nothing happened. CMT C and other staff told Resident #5 to get dressed and come out of the room. He/She put his/her things on and left. Resident #5 just kept yelling I was asleep, he/she just started hitting him/her. Staff got the nurse. Review of the ADON's statement, dated 2/14/24, showed on 2/14/24 around 3:30 A.M., this nurse heard a loud noise of a resident yelling out. As this nurse approached the resident's room, CNAs made it to the room first and this nurse entered the room, noted Resident #5 sitting on the floor next to his/her bed. Resident #5 was yelling out, stating Resident #4 attacked him/her in his/her sleep with his/her face covered in blood. Resident #4 was sitting on his/her bed and stated to this that Resident #5 assaulted him/her and that was why he/she hit him/her. Resident #4 was immediately removed from the room and a CNA was assigned 1:1 until EMS arrived. First aide was given to Resident #5 due to laceration at the top of his/her head. Resident #5 stated his/her left side was hurting as well. Resident #5 was sent to the hospital and Resident #4 was sent to a different hospital. During an interview on 2/14/24 at 9:55 A.M., Resident #4 and #5's other roommate said he/she was the roommate of Resident #4 and #5. It was the first time he/she witnessed Resident #4 hit another resident. Sometimes Resident #4 acted like he/she wanted to fight, but never did. He/she heard the fight and it woke him/her out of his/her sleep. Resident #4 hit Resident #5 while he/she was still in the bed. Resident #5 got out of the bed and into the wheelchair. Resident #5 never hit Resident #4. Staff entered the room and pulled the privacy curtain. During an interview on 2/14/24 at 11:12 A.M., Resident #4 said he/she was in the hospital until last night or this morning. He/She did not remember what happened or why he/she went to the hospital. He/She pointed out that he/she had a new room. He/She said something happened in the other room. During an interview on 2/14/24 at 9:30 A.M. and 1:30 P.M., the administrator said Resident #5 went to another facility. He/she sustained injuries from the resident-to-resident altercation. It was reported Resident #5 had a fractured rib. During an interview, Resident #4 said Resident #5 tried to kill him/her with a long [NAME]. The administrator said Resident #5 could not physically get to another resident's bed. He/She is older and frail. Their roommate also witnessed the altercation and said he/she witnessed Resident #4 hitting Resident #5 while Resident #5 was still in the bed. Resident #4 continue to hit Resident #5. At that time, staff came into the room and pulled the curtain. Resident #4 returned to the facility this morning and had been on 15 minutes checks. Resident #4 and #5 did not have a history of physical behaviors. During an interview on 2/14/24 at 10:00 A.M., CMT E said he/she never observed behaviors from Resident #4; however, he/she refused medications. During an interview on 2/26/24 at 11:45 A.M., Licensed Practical Nurse (LPN) B said he/she never witnessed physical behaviors from Resident #4. LPN B had never known Resident #4 to be aggressive. During an interview on 2/26/24 at 10:15 A.M., the administrator said Resident #5 went to another facility. Resident #5 returned to the facility on [DATE] and after a couple of days, he/she displayed some verbal behaviors. They were not physical behaviors. The facility referred the resident to a psychiatric facility that would be more appropriate for him/her and was accepted. The facility staff were in-serviced on the abuse and neglect policies. Staff will continue to document all resident behaviors and provide 1:1 monitoring and 15 minute checks when needed. MO00231686 MO00231676

Based on interview and record review, the facility failed to provide protective oversight for one cognitively impaired resident discharged from the facility against medical advice (AMA), without the resident's physician's consent, written orders, medications and without contacting the resident's legal guardian. Facility staff placed the resident in a cab and sent him/her to the train station. The resident sample was eight. (Resident #20) The census was 62. Review of Resident #20's hospital discharge summary sheet provided by the facility, dated 2/27/15, showed the following: -Reason for hospital stay: danger to others; -Discharge to long term care facility; -Guardian notified of transfer by social worker. Review of the facility's resident's face sheet, showed the following: -Date of admission, 2/27/15; -Is responsible for self: No; -Contact section: -Relationship - Friend - (name). Responsibilities - Emergency Contact. -Relationship - Resident - (Resident #20). Responsibilities - Responsible to receive own accounts receivable (A/R) statement. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. Review of the resident's elopement risk assessment dated [DATE], showed, staff identified him/her as at risk for elopement related to dementia. Review of the resident's history and physical dated 3/8/15, showed the following: -Non-English speaking, communicated through hand signals and one word phrases; -[DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/15, showed the following: -Sometimes was understood-responded adequately to simple, direct communication only; -Sometimes understands-responds adequately to simple, direct communication only; -Score for the brief interview for mental status (BIMS): 6 (scale of 0-15, with 0-7 indicating severe impairment); -Signs and symptoms of delirium included inattention and disorganized thinking; -Area for mood indicators left blank; -No behaviors present; -Wandering: No; -Independent with no set up help with activities of daily living; -Active [DIAGNOSES REDACTED]. -Antipsychotic and antidepressant medications provided for seven of seven days; -No guardian or legally authorized representative participated in assessment. Review of the resident's care plan, dated 3/12/15, showed the following: -A handwritten entry: update 3/31/15, noncompliant with nursing home stay. Own responsible party. Staff to monitor location. -Communication: Did not speak in the dominant language of the facility, English. Provide education on using hand gestures and communication board. Review of the resident's social service notes, dated 3/19/15, showed the following: -admitted on [DATE]; -The only contact number provided by the hospital was a number in Chicago; -Prior to admission to the hospital, he/she resided at another long term care facility in St. Louis; -Social worker from previous facility said the resident was an elopement risk and resided on a locked unit; -The resident indicated through an interpreter he/she wanted to go to Iran; -The resident's legal guardian contacted the facility and informed the staff the resident had a legal guardian. Review of the resident's nurse's notes, showed the following: -3/19/15 at 8:00 P.M., the resident was agitated and stated he/she wanted to go; -3/23/15 at 9:00 A.M., the resident packed all his/her personal belongings and attempted to exit the facility. He/She became agitated and could not be redirected. Orders were received to send him/her to the hospital for evaluation. (No information documented to show the guardian was notified of the transfer). Review of the resident's hospital "patient profile report", provided by the facility, dated 3/23/15, showed the following; -The resident was a ward of the court and had a legal guardian; -[DIAGNOSES REDACTED]. Review of the resident's hospital history and physical provided by the facility, dated 3/23/15, showed the following: -admitted to the hospital for increased agitation; -Angry, frustrated, agitated and hostile towards nursing staff; -Difficult to communicate with, due to language barrier. Review of the resident's hospital psychiatric evaluation provided by the facility, dated 3/23/15, showed the following: -Not a reliable historian; -admitted to hospital because of agitation and aggression; -[DIAGNOSES REDACTED]. -Disorganized, could not make meaningful conversation and could not state time and place. Poor insight, poor judgment and poor impulse control; -Once stable, he/she will be discharged back to the nursing facility. Review of the resident's discharge summary sheet, dated 3/31/15, provided by the facility, showed the following: -To be discharged back to nursing facility; -Emergency contact was a legal guardian; -discharged from the hospital at 2:25 P.M. Review of the resident's facility nurse's notes, showed on 3/31/15 at 3:00 P.M., he/she was readmitted to the facility and continued to say, "I want to go home". No further documentation for 3/31/15. Review of the resident's social service note, dated 3/31/15, showed he/she readmitted to facility from the hospital, was able to communicate and express his/her needs to staff and required redirection for elopement attempts. Review of the resident's social service note, dated 4/1/15, showed the resident continued to express a desire to leave the facility, get on a bus and return to his/her native country. The resident said he/she had money and a passport. He/She became agitated and orders were received to transport him/her to the hospital. Review of the resident's facility nurse's notes, dated 4/1/15, showed the following: -7 to 3 P.M. shift, resident went to his/her room, packed personal belongings and walked down the hall saying, "I want to go". Staff unable to redirect; resident became aggressive with staff, stating he/she would sleep on the street, but he/she wanted to leave "NOW". Staff contacted the resident's primary care physician and received orders to send the resident to the hospital. Resident transported to hospital; -9:00 P.M., resident returned to the facility, smoked a cigarette and went to bed. No documentation staff notified the primary care physician of the resident's return to the facility to obtain new orders or to follow previous orders. Review of the resident's social service note, dated 4/2/15, showed he/she continued to be persistent in wanting to leave the facility. The resident said he/she would take a bus to California because he/she had family there, but was unable to provide contact information. The social service director attempted to contact the person listed on the face sheet, but it was a medical office in Chicago. Resident is own responsible party and wanted to leave the facility. Staff contacted a local taxi company and had the resident sign AMA papers prior to discharge from the facility. Review of the resident's facility nurse's notes, dated 4/2/15 at 2:15 P.M., showed the following: -discharged from the facility at about 11:00 A.M. A local cab company came to escort resident to the train station. Resident was walked out to cab. -No further documentation noted. Review of the facility's "Against Medical Advice" (AMA) form, dated 4/2/15, showed the resident signed the form along with the facility's charge nurse and medical director. Review of the resident's POS, dated 4/1 through 30/15, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. an order for [REDACTED]. -No order, dated 4/2/15, to discharge the resident from the facility. Review of a police report, dated 4/3/15, showed the following: -The resident was found at 1:35 P.M., by a local police department, 30 miles away from the facility; -The resident was dressed in pajama like clothing, pulling a large green suitcase and appeared to be unstable on his/her feet. -Able to identify the resident by a Missouri driver's license; -Unable to ascertain additional information from the resident because police could not understand what he/she said. The resident wore a hospital bracelet on his/her right wrist which showed he/she had been at a hospital on [DATE]. The hospital was only able to confirm the resident had been at the hospital on [DATE]; -A records search showed the resident had been entered in the system as a missing/endangered person through the police department on 4/1/15 (incident happened on 4/2/15); -Taken to the police station and made contact with the Director of Nursing (DON) at the nursing home; -The DON told the police the resident had resided at the nursing home because he/she was a ward of the state due to his/her medical and mental state. The DON told the police the resident had been causing a disruption at the facility on 3/31/15, so the facility discharged him/her to a local hospital for evaluation. The DON then said, for unknown reasons, the hospital released the resident on 4/1/15, and allowed the resident to leave on his/her own accord. The DON then said she told the hospital she would respond to pick the resident up; -The missing person report was canceled; -At 6:00 P.M., the DON arrived at the police station and took custody of the resident; -Police again questioned the DON regarding the circumstances of the resident leaving the facility. The DON then told the police a state auditor of the nursing home told another employee that the facility was holding the resident against his/her will and that was illegal. The other employee (unknown name) supposedly observed the alleged paperwork from the auditor stating this, so the facility released the resident and allowed him/her to leave the facility on his/her own accord. The DON stated she was unaware the resident had been a ward of the state. During an interview while surveyors were in the building, on 4/3/15 at 7:20 A.M., the DON and MDS coordinator said they had a problem. On 4/2/15, the facility discharged the resident AMA to the community. The resident was alert and oriented to person, place and time, did not speak English, but could understand English. He/She demanded to leave and the facility face sheet, showed he/she was his/her own responsible party. The facility had the resident sign AMA papers, called a cab and discharged him/her to the community. The facility staff did not send any medications, a copy of the POS, a transfer sheet or the resident's communication board because the resident refused to take them. They could not remember what train station the resident said he/she wanted to go to. A couple of hours after the resident was discharged someone from the public administrator's office called and said the resident had a legal guardian. The facility was unaware of this. No one ever contacted the facility and told them the resident had a legal guardian. On 4/2/15, a box was found in the medical records office, with paperwork that showed the resident did have a legal guardian. The DON said the box belonged to the former social service director. No one could say how the paperwork got into the medial records office or why no one at the facility went through the box after the former social worker's employment was terminated. Facility staff contacted the police and filed a missing person's report. During an interview on 4/3/15 at 8:30 A.M., the social service director said he/she started work at the facility on 3/23/15. He/She thought the resident was his/her own responsible party. When he/she went through the resident's medical record, he/she did not find any paperwork showing the resident had a legal guardian. On 4/2/15, the resident expressed a desire to go to Iran and the social service director tried to explain it was not possible to take a bus/train to Iran. The resident became very agitated and kept demanding to leave the facility. The social service director attempted to contact the number listed on the face sheet as the responsible party, but it was a dentist's office. The resident continued to have increased agitation and demanded to leave. The administrator told the social service director to discharge the resident AMA. The resident said he/she was going to take a train to California where he/she had relatives. Due to the resident's limited ability to communicate and not taking his/her communication board, the social service director did not think the resident was safe to be discharged to the community. During an interview on 4/3/15 at 9:00 A.M., the administrator said on 4/2/15, the resident kept saying he/she wanted to go. The resident was hard to communicate with, but he/she understood English. He/She was admitted from a hospital on [DATE]. On 3/23/15, the resident was sent to a different hospital for increased agitation and disruptive behaviors and returned on 3/31/15. He/She continued to express a desire to leave and was agitated, disruptive and displaying aggressive behavior, so on 4/1/15, the resident was sent to a third hospital in the St. Louis area for evaluation and returned to the facility on the same day. On 4/2/15, the resident kept saying he/she wanted to leave. The facility had no documentation the resident had a guardian. At around 11:00 A.M., the facility had the resident sign AMA papers, called a local cab company and discharged the resident to the community with his/her personal belongings and a debit card. At around 5:15 P.M., the facility received a call from the public administrator's office saying the resident had a legal guardian. The public administrator's office had received a phone call from a local hospital saying the resident was at the hospital, before the hospital could treat the resident he/she left the hospital grounds. The resident had been a patient at the hospital in the past and the hospital had the legal guardian contact information. The guardian instructed the facility to call the police and make a missing person's report. Facility staff called the police and filed the report. During an interview on 4/3/15 at 9:39 A.M., the DON said she walked the resident to the taxi cab on 4/2/15 and told the cab driver to take the resident to the nearest train station. The resident had a debit card, a trash bag full of clothes and a duffle bag. The resident did not have any medications, a transfer sheet, a copy of his/her POS or his/her communication board. The DON said, the owner of the facility was also the clinical liaison and he makes the decision of who to admit to the facility. He went to the hospital and interviewed the resident prior to admission to the facility. The DON did not know if the owner asked anyone at the hospital if the resident had a legal guardian. Prior to the resident's admission from the hospital, the hospital sent over a referral form. The referral form did not contain any information about the resident having a legal guardian. On 2/27/15, the hospital sent a transfer sheet with the resident. The transfer sheet did show the hospital contacted the legal guardian about the transfer. The DON said this paperwork was not in the resident's clinical record, it somehow got put in a box in the medical records department and was not found until 4/2/15, after the guardian called the facility. The resident was discharged to a different hospital on [DATE], and returned to the facility on [DATE]. The hospital face sheet clearly showed the resident had a legal guardian, but that information was not noted by facility staff until after the resident was discharged AMA. She said the facility did not know at any time the resident had a legal guardian. During a telephone interview on 4/3/15 at 9:52 A.M., the owner said he did the initial assessment of the resident prior to admission to the facility. The resident did have a language barrier, but said he/she wanted to come to the facility. The resident was alert and somewhat oriented and appropriate for their facility. The owner did not ask anyone if the resident had a legal guardian. He did not have an explanation as to why he did not inquire about guardianship, but it was a question he routinely asked. He did not go see the resident during the other hospital stay. During an interview on 4/3/15 at 10:35 A.M., the DON said the nurse that was assigned to the resident, on 4/2/15, did not call the resident's primary care physician and get orders to discharge the resident AMA, but did talk to the physician's office the next day (4/3/15). The nurse not working on Resident #20's hall had the resident sign the AMA papers. The administrator made the decision to discharge the resident AMA. Once the former social worker was terminated, all of her files were moved to the medical records office. After the boxes were moved, no one went though the files to see what they contained. During an interview on 4/3/15 at 10:20 A.M., Licensed Practical Nurse (LPN) A said he/she worked as the charge nurse on the resident's unit on 4/2/15. He/She knew the resident was saying he/she wanted to leave. The resident packed his/her belongings and was dragging them around the facility. At around noon, the admissions coordinator came to the desk and said the resident had been discharged AMA. At no time, did any one ask him/her to call the resident's primary care physician and get an order to discharge the resident, fill out a transfer sheet or pack up the resident's medications for discharge. He/She did not document in the resident's medical record about the discharge because he/she was not told the resident was being discharged and did not participate in the discharge process. He/She did not know the resident had a legal guardian. The only way he/she would know if a resident had a legal guardian was to read the face sheet. If it was not on the face sheet there was no way to tell. When a resident returned from the hospital all hospital records were kept in the resident's current medical record. During an interview on 4/3/15 at 10:28 A.M., the admissions coordinator said he/she was responsible for all admissions, but not discharges. He/She remembered the resident's referral from his/her first hospital stay. The referral did not contain any information about a legal guardian. He/She did not see the resident's hospital discharge papers on 2/27/15. The social worker was responsible for filling out the paperwork, including the face sheets. If a resident had a legal guardian, it should be listed on the face sheet. He/She did not know who made the decision to discharge the resident AMA. He/She was told by the DON to tell LPN A that the resident had been discharged from the facility. He/She did not know who called the taxi or who escorted the resident out of the facility. During a telephone interview on 4/6/15 at 11:00 A.M., the former social service director said he/she was aware the resident had a legal guardian. The legal guardian had contacted the facility and let them know this, on 3/17/15. The former social worker said he/she told the administrator and DON the resident had a legal guardian in the stand up meeting and documented the information in the social service notes in the resident's medical record. He/She asked the legal guardian to fax the paper work to the facility, but did not know if that was done because he/she left employment very soon after the phone call. All of the resident's information was in his/her medical record. She did not keep any portion of a resident's medical record in her personal files. During an interview on 4/3/15 at 11:10 A.M., LPN B said he/she was working on 4/2/15, when the resident was discharged AMA, but was not his/her charge nurse. The resident was just standing by the nurse's station with his/her personal belongings saying he/she wanted to leave. The DON instructed him/her to have the resident sign the paper work, so he/she had the resident sign the AMA paper and then the facility medical director sign the paper. The medical director was not the resident's primary care physician. The LPN did not know if anyone contacted the resident's primary care physician and received orders to discharge the resident. He/She did not know who called the taxi or escorted the resident to the taxi. During a telephone interview on 4/6/15 at 10:00 A.M., the deputy public administrator said the facility was made aware the resident had a legal guardian. The facility sent an admission packet to the public administrator's office after the resident was admitted to the facility. The first contact their office had with the nursing facility was on 3/12/15, when their office called the facility to confirm the resident was there. On 3/19/15, the facility's social worker (former) was contacted and said he/she would send paperwork to the public administrator's office. The paper work was faxed to the office on that date. On 3/23/15, a local hospital contacted the public administrator's office for consent to treat the resident who was sent to the hospital by the facility. On 3/31/15, the hospital contacted the public administrator's office for permission to send the resident back to the facility. On 4/1/15, another hospital called the public administrator's office stating the resident was at their hospital, but they did not have the ability to treat him/her and were waiting for a bed to open up at another local hospital. On 4/2/15 at 4:37 P.M., a local government office called their office and said the resident was in their office dressed in a hospital gown asking for money. The guardian did not know the resident had been released from the hospital. On 4/3/15, the guardian contacted the nursing facility and was told by the facility's MDS coordinator the facility was unaware the resident had a legal guardian. The resident had requested to go to the hospital, so the facility put him/her in a cab and sent him/her to the hospital. The guardian was never told the resident was sent to the nearest train station. The resident was appointed a legal guardian by the probate courts because of dementia secondary to age, psychosis, HIV status and hepatitis C (liver disease). He/She was not able to make sound decisions and the facility put him/her in danger when they sent him/her out into the community in a cab. During a telephone interview on 4/6/15 at 12:17 P.M., the resident's primary care physician said this was the first time he was the resident's physician in a long term care facility. On 4/2/15, no one from the facility called him and asked for discharge orders for the resident. His nurse called the facility the next day after hearing about the incident on a local news report. When he asked who gave the order to discharge the resident, the staff said no one. If the facility had called him, he would have never said it was OK to discharge the resident. The primary care physician had not seen the resident since his/her admission to the facility, he/she was seen by his associate physician. No one from the facility contacted the associate physician either. The first thing the facility should have done was call someone, either the physician, the family or the guardian. No one in his office was aware the resident was discharged AMA until the next day. The physician was very upset with the facility staff and everyone should have known better. Even though, he did not see the resident at the facility, he did follow him/her while he/she was inpatient at the hospital. The resident had multiple medical and mental issues that made him/her a danger to himself/herself and others. The resident was not capable of making cognitive decisions and often became violent. He/She had been in and out of psychiatric hospitals and nursing homes for dangerous behaviors. The facility put him/her and others in a great deal of danger when they sent him/her out by himself/herself. They should have at a very minimum sent his/her POS sheets, a transfer sheet and his/her medications and called the primary care physician for directions and orders. During a telephone interview on 4/6/15 at 12:45 P.M., Physician C said he was the resident's primary care physician's associate physician. He saw the resident at the facility on 3/6/15. He heard the resident wandered away from the facility, but had been found safe. On 4/2/15, no one from the facility called him to report the resident's behavior or ask for discharge orders. The resident was in no way capable of making decisions. He/She needed protective oversight. The resident was not safe in the community related to his/her medical diagnoses, violent tendencies and English not being his/her primary language. The facility absolutely put the resident in danger when they sent him/her out in the community in a cab by himself/herself with no orders, no medication and no supervision. On 4/6/15 and 4/9/15, Department of Health and Senior Services (DHSS) called the facility's medical director about signing out the resident AMA. He did not return any of the phone calls. 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 on-site visit, the facility developed a plan of correction that included the following: reviewed and updated the eighteen resident records they identified as having a guardian to make sure the information was readily available to staff; provided inservice training to the licensed nurses on duty to make sure they called physicians and guardians for discharge instructions; planned to audit all current residents' records for guardianship paperwork. The resident no longer lived in the facility. At the time of the exit, the facility still needed to review the rest of the resident's records, complete in-services to the remaining nursing staff and determine how they would implement their plan of correction on a long-term basis and keep their systems in place. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 2424

2 Based on interview and record review, the facility failed to provide protective oversight for one cognitively impaired resident discharged from the facility against medical advice (AMA), without the resident's physician's consent, written orders, medications and without contacting the resident's legal guardian. Facility staff placed the resident in a cab and sent him/her to the train station. The resident sample was eight. (Resident #20) The census was 62. Review of Resident #20's hospital discharge summary sheet provided by the facility, dated 2/27/15, showed the following: -Reason for hospital stay: danger to others; -Discharge to long term care facility; -Guardian notified of transfer by social worker. Review of the facility's resident's face sheet, showed the following: -Date of admission, 2/27/15; -Is responsible for self: No; -Contact section: -Relationship - Friend - (name). Responsibilities - Emergency Contact. -Relationship - Resident - (Resident #20). Responsibilities - Responsible to receive own accounts receivable (A/R) statement. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. Review of the resident's elopement risk assessment dated [DATE], showed, staff identified him/her as at risk for elopement related to dementia. Review of the resident's history and physical dated 3/8/15, showed the following: -Non-English speaking, communicated through hand signals and one word phrases; -[DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/12/15, showed the following: -Sometimes was understood-responded adequately to simple, direct communication only; -Sometimes understands-responds adequately to simple, direct communication only; -Score for the brief interview for mental status (BIMS): 6 (scale of 0-15, with 0-7 indicating severe impairment); -Signs and symptoms of delirium included inattention and disorganized thinking; -Area for mood indicators left blank; -No behaviors present; -Wandering: No; -Independent with no set up help with activities of daily living; -Active [DIAGNOSES REDACTED].>-Antipsychotic and antidepressant medications provided for seven of seven days; -No guardian or legally authorized representative participated in assessment. Review of the resident's care plan, dated 3/12/15, showed the following: -A handwritten entry: update 3/31/15, noncompliant with nursing home stay. Own responsible party. Staff to monitor location. -Communication: Did not speak in the dominant language of the facility, English. Provide education on using hand gestures and communication board. Review of the resident's social service notes, dated 3/19/15, showed the following: -admitted on [DATE]; -The only contact number provided by the hospital was a number in Chicago; -Prior to admission to the hospital, he/she resided at another long term care facility in St. Louis; -Social worker from previous facility said the resident was an elopement risk and resided on a locked unit; -The resident indicated through an interpreter he/she wanted to go to Iran; -The resident's legal guardian contacted the facility and informed the staff the resident had a legal guardian. Review of the resident's nurse's notes, showed the following: -3/19/15 at 8:00 P.M., the resident was agitated and stated he/she wanted to go; -3/23/15 at 9:00 A.M., the resident packed all his/her personal belongings and attempted to exit the facility. He/She became agitated and could not be redirected. Orders were received to send him/her to the hospital for evaluation. (No information documented to show the guardian was notified of the transfer). Review of the resident's hospital patient profile report, provided by the facility, dated 3/23/15, showed the following; -The resident was a ward of the court and had a legal guardian; -[DIAGNOSES REDACTED]. Review of the resident's hospital history and physical provided by the facility, dated 3/23/15, showed the following: -admitted to the hospital for increased agitation; -Angry, frustrated, agitated and hostile towards nursing staff; -Difficult to communicate with, due to language barrier. Review of the resident's hospital psychiatric evaluation provided by the facility, dated 3/23/15, showed the following: -Not a reliable historian; -admitted to hospital because of agitation and aggression; -[DIAGNOSES REDACTED]. -Disorganized, could not make meaningful conversation and could not state time and place. Poor insight, poor judgment and poor impulse control; -Once stable, he/she will be discharged back to the nursing facility. Review of the resident's discharge summary sheet, dated 3/31/15, provided by the facility, showed the following: -To be discharged back to nursing facility; -Emergency contact was a legal guardian; -discharged from the hospital at 2:25 P.M. Review of the resident's facility nurse's notes, showed on 3/31/15 at 3:00 P.M., he/she was readmitted to the facility and continued to say, I want to go home. No further documentation for 3/31/15. Review of the resident's social service note, dated 3/31/15, showed he/she readmitted to facility from the hospital, was able to communicate and express his/her needs to staff and required redirection for elopement attempts. Review of the resident's social service note, dated 4/1/15, showed the resident continued to express a desire to leave the facility, get on a bus and return to his/her native country. The resident said he/she had money and a passport. He/She became agitated and orders were received to transport him/her to the hospital. Review of the resident's facility nurse's notes, dated 4/1/15, showed the following: -7 to 3 P.M. shift, resident went to his/her room, packed personal belongings and walked down the hall saying, I want to go. Staff unable to redirect; resident became aggressive with staff, stating he/she would sleep on the street, but he/she wanted to leave NOW. Staff contacted the resident's primary care physician and received orders to send the resident to the hospital. Resident transported to hospital; -9:00 P.M., resident returned to the facility, smoked a cigarette and went to bed. No documentation staff notified the primary care physician of the resident's return to the facility to obtain new orders or to follow previous orders. Review of the resident's social service note, dated 4/2/15, showed he/she continued to be persistent in wanting to leave the facility. The resident said he/she would take a bus to California because he/she had family there, but was unable to provide contact information. The social service director attempted to contact the person listed on the face sheet, but it was a medical office in Chicago. Resident is own responsible party and wanted to leave the facility. Staff contacted a local taxi company and had the resident sign AMA papers prior to discharge from the facility. Review of the resident's facility nurse's notes, dated 4/2/15 at 2:15 P.M., showed the following: -discharged from the facility at about 11:00 A.M. A local cab company came to escort resident to the train station. Resident was walked out to cab. -No further documentation noted. Review of the facility's Against Medical Advice (AMA) form, dated 4/2/15, showed the resident signed the form along with the facility's charge nurse and medical director. Review of the resident's POS, dated 4/1 through 30/15, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. an order for [REDACTED]. -No order, dated 4/2/15, to discharge the resident from the facility. Review of a police report, dated 4/3/15, showed the following: -The resident was found at 1:35 P.M., by a local police department, 30 miles away from the facility; -The resident was dressed in pajama like clothing, pulling a large green suitcase and appeared to be unstable on his/her feet. -Able to identify the resident by a Missouri driver's license; -Unable to ascertain additional information from the resident because police could not understand what he/she said. The resident wore a hospital bracelet on his/her right wrist which showed he/she had been at a hospital on [DATE]. The hospital was only able to confirm the resident had been at the hospital on [DATE]; -A records search showed the resident had been entered in the system as a missing/endangered person through the police department on 4/1/15 (incident happened on 4/2/15); -Taken to the police station and made contact with the Director of Nursing (DON) at the nursing home; -The DON told the police the resident had resided at the nursing home because he/she was a ward of the state due to his/her medical and mental state. The DON told the police the resident had been causing a disruption at the facility on 3/31/15, so the facility discharged him/her to a local hospital for evaluation. The DON then said, for unknown reasons, the hospital released the resident on 4/1/15, and allowed the resident to leave on his/her own accord. The DON then said she told the hospital she would respond to pick the resident up; -The missing person report was canceled; -At 6:00 P.M., the DON arrived at the police station and took custody of the resident; -Police again questioned the DON regarding the circumstances of the resident leaving the facility. The DON then told the police a state auditor of the nursing home told another employee that the facility was holding the resident against his/her will and that was illegal. The other employee (unknown name) supposedly observed the alleged paperwork from the auditor stating this, so the facility released the resident and allowed him/her to leave the facility on his/her own accord. The DON stated she was unaware the resident had been a ward of the state. During an interview while surveyors were in the building, on 4/3/15 at 7:20 A.M., the DON and MDS coordinator said they had a problem. On 4/2/15, the facility discharged the resident AMA to the community. The resident was alert and oriented to person, place and time, did not speak English, but could understand English. He/She demanded to leave and the facility face sheet, showed he/she was his/her own responsible party. The facility had the resident sign AMA papers, called a cab and discharged him/her to the community. The facility staff did not send any medications, a copy of the POS, a transfer sheet or the resident's communication board because the resident refused to take them. They could not remember what train station the resident said he/she wanted to go to. A couple of hours after the resident was discharged someone from the public administrator's office called and said the resident had a legal guardian. The facility was unaware of this. No one ever contacted the facility and told them the resident had a legal guardian. On 4/2/15, a box was found in the medical records office, with paperwork that showed the resident did have a legal guardian. The DON said the box belonged to the former social service director. No one could say how the paperwork got into the medial records office or why no one at the facility went through the box after the former social worker's employment was terminated. Facility staff contacted the police and filed a missing person's report. During an interview on 4/3/15 at 8:30 A.M., the social service director said he/she started work at the facility on 3/23/15. He/She thought the resident was his/her own responsible party. When he/she went through the resident's medical record, he/she did not find any paperwork showing the resident had a legal guardian. On 4/2/15, the resident expressed a desire to go to Iran and the social service director tried to explain it was not possible to take a bus/train to Iran. The resident became very agitated and kept demanding to leave the facility. The social service director attempted to contact the number listed on the face sheet as the responsible party, but it was a dentist's office. The resident continued to have increased agitation and demanded to leave. The administrator told the social service director to discharge the resident AMA. The resident said he/she was going to take a train to California where he/she had relatives. Due to the resident's limited ability to communicate and not taking his/her communication board, the social service director did not think the resident was safe to be discharged to the community. During an interview on 4/3/15 at 9:00 A.M., the administrator said on 4/2/15, the resident kept saying he/she wanted to go. The resident was hard to communicate with, but he/she understood English. He/She was admitted from a hospital on [DATE]. On 3/23/15, the resident was sent to a different hospital for increased agitation and disruptive behaviors and returned on 3/31/15. He/She continued to express a desire to leave and was agitated, disruptive and displaying aggressive behavior, so on 4/1/15, the resident was sent to a third hospital in the St. Louis area for evaluation and returned to the facility on the same day. On 4/2/15, the resident kept saying he/she wanted to leave. The facility had no documentation the resident had a guardian. At around 11:00 A.M., the facility had the resident sign AMA papers, called a local cab company and discharged the resident to the community with his/her personal belongings and a debit card. At around 5:15 P.M., the facility received a call from the public administrator's office saying the resident had a legal guardian. The public administrator's office had received a phone call from a local hospital saying the resident was at the hospital, before the hospital could treat the resident he/she left the hospital grounds. The resident had been a patient at the hospital in the past and the hospital had the legal guardian contact information. The guardian instructed the facility to call the police and make a missing person's report. Facility staff called the police and filed the report. During an interview on 4/3/15 at 9:39 A.M., the DON said she walked the resident to the taxi cab on 4/2/15 and told the cab driver to take the resident to the nearest train station. The resident had a debit card, a trash bag full of clothes and a duffle bag. The resident did not have any medications, a transfer sheet, a copy of his/her POS or his/her communication board. The DON said, the owner of the facility was also the clinical liaison and he makes the decision of who to admit to the facility. He went to the hospital and interviewed the resident prior to admission to the facility. The DON did not know if the owner asked anyone at the hospital if the resident had a legal guardian. Prior to the resident's admission from the hospital, the hospital sent over a referral form. The referral form did not contain any information about the resident having a legal guardian. On 2/27/15, the hospital sent a transfer sheet with the resident. The transfer sheet did show the hospital contacted the legal guardian about the transfer. The DON said this paperwork was not in the resident's clinical record, it somehow got put in a box in the medical records department and was not found until 4/2/15, after the guardian called the facility. The resident was discharged to a different hospital on [DATE], and returned to the facility on [DATE]. The hospital face sheet clearly showed the resident had a legal guardian, but that information was not noted by facility staff until after the resident was discharged AMA. She said the facility did not know at any time the resident had a legal guardian. During a telephone interview on 4/3/15 at 9:52 A.M., the owner said he did the initial assessment of the resident prior to admission to the facility. The resident did have a language barrier, but said he/she wanted to come to the facility. The resident was alert and somewhat oriented and appropriate for their facility. The owner did not ask anyone if the resident had a legal guardian. He did not have an explanation as to why he did not inquire about guardianship, but it was a question he routinely asked. He did not go see the resident during the other hospital stay. During an interview on 4/3/15 at 10:35 A.M., the DON said the nurse that was assigned to the resident, on 4/2/15, did not call the resident's primary care physician and get orders to discharge the resident AMA, but did talk to the physician's office the next day (4/3/15). The nurse not working on Resident #20's hall had the resident sign the AMA papers. The administrator made the decision to discharge the resident AMA. Once the former social worker was terminated, all of her files were moved to the medical records office. After the boxes were moved, no one went though the files to see what they contained. During an interview on 4/3/15 at 10:20 A.M., Licensed Practical Nurse (LPN) A said he/she worked as the charge nurse on the resident's unit on 4/2/15. He/She knew the resident was saying he/she wanted to leave. The resident packed his/her belongings and was dragging them around the facility. At around noon, the admissions coordinator came to the desk and said the resident had been discharged AMA. At no time, did any one ask him/her to call the resident's primary care physician and get an order to discharge the resident, fill out a transfer sheet or pack up the resident's medications for discharge. He/She did not document in the resident's medical record about the discharge because he/she was not told the resident was being discharged and did not participate in the discharge process. He/She did not know the resident had a legal guardian. The only way he/she would know if a resident had a legal guardian was to read the face sheet. If it was not on the face sheet there was no way to tell. When a resident returned from the hospital all hospital records were kept in the resident's current medical record. During an interview on 4/3/15 at 10:28 A.M., the admissions coordinator said he/she was responsible for all admissions, but not discharges. He/She remembered the resident's referral from his/her first hospital stay. The referral did not contain any information about a legal guardian. He/She did not see the resident's hospital discharge papers on 2/27/15. The social worker was responsible for filling out the paperwork, including the face sheets. If a resident had a legal guardian, it should be listed on the face sheet. He/She did not know who made the decision to discharge the resident AMA. He/She was told by the DON to tell LPN A that the resident had been discharged from the facility. He/She did not know who called the taxi or who escorted the resident out of the facility. During a telephone interview on 4/6/15 at 11:00 A.M., the former social service director said he/she was aware the resident had a legal guardian. The legal guardian had contacted the facility and let them know this, on 3/17/15. The former social worker said he/she told the administrator and DON the resident had a legal guardian in the stand up meeting and documented the information in the social service notes in the resident's medical record. He/She asked the legal guardian to fax the paper work to the facility, but did not know if that was done because he/she left employment very soon after the phone call. All of the resident's information was in his/her medical record. She did not keep any portion of a resident's medical record in her personal files. During an interview on 4/3/15 at 11:10 A.M., LPN B said he/she was working on 4/2/15, when the resident was discharged AMA, but was not his/her charge nurse. The resident was just standing by the nurse's station with his/her personal belongings saying he/she wanted to leave. The DON instructed him/her to have the resident sign the paper work, so he/she had the resident sign the AMA paper and then the facility medical director sign the paper. The medical director was not the resident's primary care physician. The LPN did not know if anyone contacted the resident's primary care physician and received orders to discharge the resident. He/She did not know who called the taxi or escorted the resident to the taxi. During a telephone interview on 4/6/15 at 10:00 A.M., the deputy public administrator said the facility was made aware the resident had a legal guardian. The facility sent an admission packet to the public administrator's office after the resident was admitted to the facility. The first contact their office had with the nursing facility was on 3/12/15, when their office called the facility to confirm the resident was there. On 3/19/15, the facility's social worker (former) was contacted and said he/she would send paperwork to the public administrator's office. The paper work was faxed to the office on that date. On 3/23/15, a local hospital contacted the public administrator's office for consent to treat the resident who was sent to the hospital by the facility. On 3/31/15, the hospital contacted the public administrator's office for permission to send the resident back to the facility. On 4/1/15, another hospital called the public administrator's office stating the resident was at their hospital, but they did not have the ability to treat him/her and were waiting for a bed to open up at another local hospital. On 4/2/15 at 4:37 P.M., a local government office called their office and said the resident was in their office dressed in a hospital gown asking for money. The guardian did not know the resident had been released from the hospital. On 4/3/15, the guardian contacted the nursing facility and was told by the facility's MDS coordinator the facility was unaware the resident had a legal guardian. The resident had requested to go to the hospital, so the facility put him/her in a cab and sent him/her to the hospital. The guardian was never told the resident was sent to the nearest train station. The resident was appointed a legal guardian by the probate courts because of dementia secondary to age, psychosis, HIV status and hepatitis C (liver disease). He/She was not able to make sound decisions and the facility put him/her in danger when they sent him/her out into the community in a cab. During a telephone interview on 4/6/15 at 12:17 P.M., the resident's primary care physician said this was the first time he was the resident's physician in a long term care facility. On 4/2/15, no one from the facility called him and asked for discharge orders for the resident. His nurse called the facility the next day after hearing about the incident on a local news report. When he asked who gave the order to discharge the resident, the staff said no one. If the facility had called him, he would have never said it was OK to discharge the resident. The primary care physician had not seen the resident since his/her admission to the facility, he/she was seen by his associate physician. No one from the facility contacted the associate physician either. The first thing the facility should have done was call someone, either the physician, the family or the guardian. No one in his office was aware the resident was discharged AMA until the next day. The physician was very upset with the facility staff and everyone should have known better. Even though, he did not see the resident at the facility, he did follow him/her while he/she was inpatient at the hospital. The resident had multiple medical and mental issues that made him/her a danger to himself/herself and others. The resident was not capable of making cognitive decisions and often became violent. He/She had been in and out of psychiatric hospitals and nursing homes for dangerous behaviors. The facility put him/her and others in a great deal of danger when they sent him/her out by himself/herself. They should have at a very minimum sent his/her POS sheets, a transfer sheet and his/her medications and called the primary care physician for directions and orders. During a telephone interview on 4/6/15 at 12:45 P.M., Physician C said he was the resident's primary care physician's associate physician. He saw the resident at the facility on 3/6/15. He heard the resident wandered away from the facility, but had been found safe. On 4/2/15, no one from the facility called him to report the resident's behavior or ask for discharge orders. The resident was in no way capable of making decisions. He/She needed protective oversight. The resident was not safe in the community related to his/her medical diagnoses, violent tendencies and English not being his/her primary language. The facility absolutely put the resident in danger when they sent him/her out in the community in a cab by himself/herself with no orders, no medication and no supervision. On 4/6/15 and 4/9/15, Department of Health and Senior Services (DHSS) called the facility's medical director about signing out the resident AMA. He did not return any of the phone calls. 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 on-site visit, the facility developed a plan of correction that included the following: reviewed and updated the eighteen resident records they identified as having a guardian to make sure the information was readily available to staff; provided inservice training to the licensed nurses on duty to make sure they called physicians and guardians for discharge instructions; planned to audit all current residents' records for guardianship paperwork. The resident no longer lived in the facility. At the time of the exit, the facility still needed to review the rest of the resident's records, complete in-services to the remaining nursing staff and determine how they would implement their plan of correction on a long-term basis and keep their systems in place. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO 2424

Based on interview and record review, the facility failed to provide adequate supervision and follow procedures for obtaining guardian consent for one of three sampled residents with legal guardians (Resident #20) who was allowed to sign out of the facility on leave of absence (LOA). The resident was admitted to the facility with a legal guardian and had a history as an elopement risk and impulsive behaviors. On 3/1/11, the facility allowed the resident to sign out with an acquaintance without guardian consent. The resident left the facility, participated in sexual activities and the resident was placed in danger. The census was 63. Review of the resident's medical record, showed a Judicial Circuit Court Letter of Guardianship of an Incapacitated/Disabled Person dated 9/19/06, in which family member A was appointed as Resident #20's legal guardian. Review of the facility's resident LOA policy and procedure dated 7/1/10 and revised 12/29/10, showed the following: -The charge nurse will review the resident's chart prior to allowing the resident to sign out on LOA to determine if the resident is his/her own responsible party and able to sign him/herself out; -If the resident is not their own responsible party or guardian, the charge nurse will call the responsible party or guardian to request permission for the LOA. Review of a Preadmission screening and resident review (PASRR) Level II Screening (is completed on those persons identified at Level I who are known or suspected to have a serious mental illness (schizophrenia, major depression, panic disorder, etc.), mental retardation (MR) or related MR condition to determine the need for specialized service. To assure appropriate placement of persons known or suspected of having a mental impairment and to assure that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment.) notification of completion for long term care placement dated 2/23/11, showed approval for nursing facility placement with the conditional stipulation that the resident must reside in an all female unit. Review of the admission physician order [REDACTED]. Review of the face sheet dated 3/2/11, showed a note in the comment section: Resident has a guardian and may only exit facility with guardian's permission. Review of the initial social history assessment completed by the social worker dated 2/25/11, showed the following: -Legal guardian involved in placement; -Decision of placement in this facility: guardian, Level II screening and hospital; -Initial communications and interactions level: poor judgement, depressed and quick tempered; -Initial problem area: Poor insight and judgement; -Initial comments: Resident is a readmit after being discharged home from this facility three months ago. He/she ran away from home and was sent to the hospital. Review of the facility potential elopement assessment form dated 2/25/11, showed staff identified the resident at risk of elopement. Review of the admission care plan dated 2/25/11, showed the following interventions: -Oriented to person, place and time; -Ask simple yes/no questions and allow adequate time to respond; -Approach in a calm manner; -Encourage diversional activities; -No interventions for elopement risk. Review of the Release of Responsibility for LOA log dated 3/1/11, showed an unknown male acquaintance signed the resident out at 5:50 P.M. and left a phone number. Staff failed to mark 'yes' or 'no' in the section on the log asking if the guardian gave permission, expected date/time of return and address of destination. Review of a full page memo on the front of the log, showed procedures for filling out the log included the following: -Document if the guardian gave permission prior to exiting the facility; -If you are not sure the guardian has given permission, you must call them and document it in the nurse's notes; -No resident leaves unless you know they are allowed to. Review of the nurse's notes on 3/1/11 at 5:50 P.M., showed the resident went on LOA with her father at 5:00 P.M. Staff notified the resident's responsible party (guardian) at 6:00 P.M. Review of the nurse's notes on 3/1/11 (first noted at 6:00 P.M., then crossed out and noted at 8:00 P.M., then crossed out and noted at 9:00 P.M.), showed the following: -Staff notified guardian of resident on LOA; -Guardian stated resident did not have permission to go on LOA; -Staff called the phone number left in the sign out book and spoke with the resident; -Resident and the male acquaintance both stated they would return to the facility within 45 minutes; -Director of Nursing (DON) and facility social worker (SW) aware. Review of the nurse's notes on 3/1/11 at 11:50 P.M., showed the following: -Resident returned to the facility with staff; -Staff picked her up at a grocery store; -DON and SW made aware of her return; -Resident said she had been planning to go LOA with the man that portrayed to be her father. Medications were packed earlier in the day shift to last until 9:00 A.M. on 3/2/11. Resident then informed nurse that she would be returning on 3/5/11, additional medication then packed; -SW stated she would call the guardian to see if the guardian wanted the resident taken to the hospital for evaluation; -Guardian approved of resident going to the hospital; -Resident taken to the hospital at 1:45 A.M. Review of the social service notes dated 3/1/11 at 12:00 P.M. (marked late entry), showed the following: -Received call from charge nurse concerning resident going on LOA with a [AGE] year old man claiming to be resident's father; -No documentation in the medical record showing staff notified or obtained approval for LOA from the guardian; -Charge nurse called the guardian who then called the resident's father; -The resident's father said he did not have the resident; -The father called the number left on the LOA log and told the unknown male to bring the resident back to the facility; -Charge nurse also called the number on the LOA log and spoke with the resident, telling her to return to the facility; -Unknown male did not have money for a cab, so the charge nurse picked the resident up at a grocery store; -Resident told SW on the phone she had sex with the unknown male; -SW called guardian and obtained permission to take the resident to the hospital for psychiatric and medical evaluation; -SW picked the resident up from the facility and took her to the emergency room (ER); -Resident told ER doctor and nurse sexual encounter was consensual; -Pregnancy test and other lab work obtained. Review of the social service notes dated 3/3/11, showed the resident told the SW she ran away from her guardian's home prior to current placement at the facility. During an interview on 3/11/11 at 11:35 A.M., the SW said while at the ER, the resident was given the "morning after" pill, a pregnancy test and other lab work. The resident does not understand the consequences of her actions. She does have insight about sex and sexually transmitted diseases (STD's), but she acts impulsively. The SW thinks Nurse K let the resident leave the facility because on a previous admission, she did have permission to go out with her father. During an interview on 3/15/11 at 2:05 P.M., Certified Medication Technician (CMT) L said he/she worked day shift on 3/1/11. At approximately 9:00 A.M., the resident said her father was taking her out overnight. CMT L asked the day shift nurse, Nurse M, if the resident was going on LOA overnight with her father and Nurse M said the resident had told him/her the same thing. CMT L then packed the residents 5:00 P.M. medications for the evening and her 9:00 A.M. medications for the next morning. At the end of his/her shift the resident had not left, so he/she told the evening shift CMT that the resident told him/her about going on an overnight LOA. Prior to that day, CMT L had not heard anything about the resident going on LOA with her father. It is the nurse's responsibility to contact the guardian to obtain permission for LOA prior to a resident leaving the building. During an interview on 3/15/11 at 2:15 P.M., Nurse M said he/she worked the day shift on 3/1/11. The resident started talking about going on LOA with her father at approximately 7:00 A.M. Prior to that, he/she had not heard anything about the LOA. When the resident does go out of the building, his/her guardian always notifies the facility. At change of shift, Nurse M did not report anything about the LOA to the evening nurse because she had not seen anything in writing or heard from the guardian. During an interview on 3/11/11 at 12:30 P.M., Nurse B said the facility policy for residents with guardians going on LOA is for the nurse to verify permission with the guardian prior to the resident leaving the facility. If the LOA is approved, the nurse packs the resident's medications and then lets them leave the facility. On 3/1/11, Nurse B was working with CMT K on the evening shift. The day shift had about two days of medications packed for Resident #20. CMT K packed more because the resident said she would be on LOA for four nights. Nurse B did not check the resident's chart to make sure the guardian had been notified because the resident had been talking about the LOA for a few days and everyone was aware of it. He/she also thought it was okay because day shift had already packed some of the medications. He/she was not told anything about the resident going on LOA during change of shift. After the resident had been gone for about 45 minutes to an hour, Nurse B decided to check the chart and could not find any documentation that the guardian had been notified. He/she called the guardian and found out the resident did not have permission to go on LOA. The guardian called back and said the resident was not with her father. He/she called the DON, SW and the number of the unknown male left in the log book. The unknown male said he would bring the resident right back. After 45 minutes, he/she called the number again and the unknown male said he was trying to get gas money and would bring the resident back to the facility within another 45 minutes to one hour. A little after 10:00 P.M., he/she called the number again. The unknown male said he was just going to drop the resident off at a grocery store parking lot. The nurse left the facility to pick the resident up around 10:20 or 10:30 P.M. Nurse B found the resident in the grocery store parking lot with a blank stare on her face. Nurse B asked the resident if she had sex with the man. The resident denied having sexual contact with him. When back at the facility, Nurse B let the resident talk to the SW on the phone. The resident told the SW she did have sex with the unknown male. During an interview on 3/11/11 at 3:51 P.M., CMT K said he/she worked the evening shift on 3/1/11 with Nurse B. The day shift CMT told CMT K that Resident #20 was going on LOA with her father for the night. Some of the resident's medications had been packed already and CMT K finished packing enough for the next day. CMT K saw the resident leave the facility with a man, but assumed it was her father. During an interview on 3/11/11 at 11:03 A.M., the administrator said prior to allowing resident's who have legal guardians to go on LOA, staff have to get permission from the guardian and document it. Nurse B allowed Resident #20 to sign out and leave without his/her guardian's permission. The administrator said he did not think of it as an elopement because the resident came back to the facility. During a telephone interview on 3/14/11 at 9:50 A.M., the resident's primary care physician's assistant said she had seen the resident for her last few appointments. She last saw the resident on 2/9/11. She said the resident was "absolutely not able to make sound decisions or use good judgement." She spoke to the resident and her guardian about this at the appointment on 2/9/11, because the resident was living with the guardian and had run away. She talked to the resident and the guardian about the need for a controlled environment due to dangerous behaviors and poor judgement. During a telephone interview on 3/14/11 at 10:28 A.M., the resident's psychiatrist said he last saw the resident some time in February. In the past, the resident would make strange arrangements for sexual encounters over the Internet. The resident displays hypersexual behaviors and puts herself in dangerous situations. She puts herself at risk of obtaining STD's. For these reasons, she requires a guardian and a controlled, secure environment. During a telephone interview on 3/14/11 at 10:34 A.M., the resident's guardian said he/she did not give permission for the resident to leave the facility on 3/1/11 and would not consent to the resident having any sexual activity. He/she obtained guardianship due to the resident's severe promiscuity, history of rape, behaviors and mental retardation/developmental difficulties. The facility is aware the resident has an STD, so not only did they endanger the resident, they endangered the unknown male. When the facility first called him/her and it was determined the resident was not with his/her father, the guardian asked Nurse B to call the police. Nurse B called the "head nurse" to inquire about calling the police. The "head nurse" told Nurse B not to call the police. The guardian called the police him/herself when he/she arrived at the facility that evening, but was told there was nothing they could do because it was a civil matter and no crime was committed. *At the time of the abbreviated survey/revisit, on 3/17/11, the violation's grid placement was "J" immediate and serious jeopardy level. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at this time. Per the facility's plan of correction, staff were inserviced regarding obtaining guardian consent for LOA and documenting it. The facility's policy was updated to include notifying the DON or Administrator when a resident with a guardian is leaving the building. The policy now also instructs staff to notify the police immediately if a resident with a guardian leaves the facility without permission. Staff interviewed on 03/15/11, were aware of the policy and procedures as described in the inservice information. The residents' guardian status is now listed on a master list in the LOA log. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations. MO 826