Every finding on record at Gainesville Nursing

Based on observation, interview and record review, the facility failed to protect all residents from misappropriation of resident property when staff could not account for 19 missing narcotics tablets for 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). The facility census was 43. Review of the facility policy titled Abuse, Prevention and Prohibition Policy, revised 10/22, showed the following information:-Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy;-The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility.Review of the facility policy titled, Medication Administration-General Guidelines, dated 01/01/18, showed the following information:-If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit (I-STAT - an automated dispensing cabinet used to securely store and track medications);-When medications are administered, the mobile medication cart is taken to the resident's location (room, dining area, etc).Review of the facility policy titled Controlled Substance Policy, revised 10/22, showed the following information:-Controlled substances are subject to special handling, storage, disposal, and record-keeping requirement. The facility will maintain compliance with these special provisions;-The Director of Nursing (DON) is responsible for the control of such drugs;-Controlled drugs are to be stored under double-lock conditions;-The key must remain in the possession of the licensed nurse or certified medication technician (CMT) that completed the count at all times during their shift;-Should it be necessary to give the keys to another licensed practical nurse (LPN) or CMT, a count will be done to verify the inventory;-All controlled substances are to be counted every shift;-Any discrepancy in the inventory of controlled substance is to be reported to the DON immediately. 1. Review of the facility's investigation report, undated, showed the following information:-On 02/26/26, at 7:00 A.M., Registered Nurse (RN) B gave off going shift report to oncoming RN A;-RN B then saw RN A standing in the medication room in front of the I-STAT logging into the machine to dispense medication;-RN B asked CMT C if he/she asked RN A to withdraw any medication from the I-STAT. CMT C said that he/she did not;-RN B then saw RN A walking from the bathroom. RN A said to RN B Well, I feel alive again. RN B said I didn't know you were dead. RN A said, You know, just not ready for the day.;-RN B immediately went to his/her car and notified the DON of the behavior;-The DON immediately notified the Administrator;-The DON and Administrator pulled up the I-STAT records and discovered that on 02/26/27, at 6:57 A.M., RN A had signed out an oxycodone (opiate used to treat moderate to severe pain) IR (immediate release) 10 milligram (mg) tablet under Resident #1's name;-On 02/26/27, at 8:00 A.M., the Administrator interviewed Resident #1. The resident could not remember the last time he/she received a pain pill. He/she thought it had been about three hours prior. The resident did remember that it was a female that gave him/her the medication;-The DON and Administrator interviewed RN A;-RN A said that he/she had not assessed Resident #1. RN A pulled the oxycodone IR 10 mg tablet for Resident #1 because he/she knew the resident would need the medication;-RN A said that he/she went to the bathroom immediately after pulling the medication from the I-STAT because he/she had diarrhea;-The DON told RN A that his/her behavior was very suspicious due to the fact that the medication had not been documented, the CMT covering the hall had not asked RN A to pull the medication, the resident had not been assessed nor asked for the medication, the Medication Administration Record (MAR) had not been checked to confirm when the last pain medication was given, and RN A had not looked for the medication in the medication cart. RN A went straight to the I-STAT and there was no proof that the medication was given;-RN A told the DON and the Administrator that he/she had not taken the medication;-The DON and Administrator told RN A that he/she was suspended pending an investigation;-RN A tossed his/her keys on the DON's desk and left the building;-On 02/26/26, at 9:17 A.M., the Administrator reported the incident to the Department of Health and Senior Services (DHSS);-On 02/26/26, at 9:29 A.M., the Administrator reported the incident to the Sheriff's office;-The Medical Director and Nurse Practitioner were also notified;-The DON printed a report of all the narcotics RN A had pulled from the I-STAT machine for the past six months. The report showed that on sixteen separate occasions, RN A pulled narcotics from the I-STAT without documenting on the MAR;-The DON asked CMT D, CMT E, and CMT F if they had ever asked a nurse to pull medication for them from the I-STAT machine. CMT D, CMT E, and CMT F said that they had never asked a nurse to pull a narcotic from the I-STAT;- Medication cards for the above narcotics were available in the medication carts.2. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following information:-admission date of 03/16/17;-Diagnoses included multiple sclerosis (a chronic autoimmune disease disrupting communication between the brain and body), chronic obstructive pulmonary disease (COPD - lung disease), atrial fibrillation (irregular heart rate and rhythm) and dementia.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 01/06/26, showed the following information:-Moderately impaired cognitive skills;-Reported moderate pain intensity;-Pain frequently was constantly.Review of the resident's current care plan, last updated 01/22/26, showed staff to ensure the resident was assessed for pain.Review of the resident's current Physician Order Sheet (POS) showed an order, dated 12/01/25, for oxycodone IR 10 mg, one tablet every four hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 12/25/25, at 8:18 A.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's electronic medical record (EHR) and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 12/25/25. Review of the I-STAT documentation of medications that were removed by RN A showed on 12/29/25, at 3:59 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 12/29/25.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 3:04 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 7:23 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 01/12/26.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/26/26, at 3:03 P.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 01/26/26.Review of the I-STAT documentation of medications that were removed by RN A showed on 02/26/26, at 6:57 A.M., RN A withdrew oxycodone IR 10 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the oxycodone IR removed from the I-STAT on 02/26/26.3. Review of Resident #2's face sheet showed the following information:-admission date of 08/21/25;-Diagnoses included brain cancer, COPD, and Type 2 Diabetes.Review of the resident's admission MDS, dated [DATE], showed the following information:-Moderately impaired cognition;-Reported moderate pain intensity.Review of the resident's care plan, dated 08/21/25, showed staff to assess the resident for pain.Review of the resident's current POS showed an order, dated 08/21/25 , for tramadol (used to treat moderate to severe and/or chronic pain) 50 mg, one tablet every six hours as needed for pain. Review of the I-STAT documentation of medications that were removed by RN A showed on 09/03/25, at 12:48 A.M., RN A withdrew tramadol 50 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the tramadol removed from the I-STAT on 09/03/25.4. Review of Resident #3's face sheet showed the following information:-admission date of 09/19/25;-Diagnoses included rhabdomyolysis (severe muscle damage), heart attack, hip pain, and history of falls.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Normal cognition;-Reported severe pain intensity. Review of the resident's care plan, last updated 01/03/26, showed staff to ensure the resident is assessed for pain.Review of the resident's current POS showed an order, dated 09/19/25, for hydrocodone- acetaminophen (APAP) (medication used to treat moderate to severe pain) 10-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 09/27/25, at 7:54 A.M., RN A withdrew hydrocodone-acetaminophen (APAP) 10/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 09/27/25.5. Review of Resident #4's face sheet showed the following information:-admission date of 03/22/23;-Diagnoses included Parkinson's disease (neurodegenerative disease primarily of the central nervous system), dementia, Alzheimer's disease, and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Moderately impaired cognition;-Frequently reported pain.Review of the resident's care plan, last updated on 01/06/26, showed staff to assess the resident for pain.Review of the resident's current POS showed an order, dated 12/01/25, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 12/29/25, at 4:00 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 12/29/25.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 3:06 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.6. Review of Resident #5's face sheet showed the following information:-admission date of 12/14/22;-Diagnoses included atrial fibrillation (abnormal heart rate and rhythm), type 2 diabetes, COPD, morbid obesity, and right knee pain.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Normal cognition;-Occasionally reported pain.Review of the resident's care plan, last updated on 01/06/26, showed staff to assess the resident for painReview of the resident's current POS showed an order dated 01/01/26, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/03/26, at 10:01 A.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/03/26.7. Review of Resident #6's face sheet showed the following information:-admission date of 07/11/24;-Diagnoses included dementia, high blood pressure, anxiety, and unspecified pain. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severely impaired cognition;-Reported occasional pain frequency.Review of the resident's care plan, last updated on 11/21/25, showed staff to ensure the resident was assessed for pain.Review of the resident's current POS showed an order, dated 12/20/25, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 3:05 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.8. Review of Resident #7's face sheet showed the following information:-admission date of 09/30/18;-Diagnoses included Alzheimer's disease, dementia, morbid obesity, and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severely impaired cognition;-Reported occasional pain frequency.Review of the resident's care plan, last updated on 06/12/25, showed staff to ensure the resident was assessed for pain.Review of the resident's current POS showed an order, dated 12/20/25, for hydrocodone-APAP 5-325 mg, one tablet every four hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 7:24 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.9. Review of Resident #8's face sheet showed the following information:-admission date of 07/29/24;-Diagnoses included high blood pressure, encopresis (leaking of stool from the rectum), and cachexia (severe weight and muscle loss).Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Normal cognition;-Reported frequently having pain.Review of the resident's care plan, last updated on 08/12/25, showed staff to ensure the resident is assessed for pain.Review of the resident's current POS showed an order, dated 12/23/25, for hydrocodone-APAP 5-325 mg, one tablet every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 01/12/26, at 7:24 P.M., RN A withdrew hydrocodone-APAP 5/325 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.Review of the resident's EHR and MAR showed RN A did not document administration of the hydrocodone-APAP removed from the I-STAT on 01/12/26.10. Review of Resident #9's face sheet showed the following information:-admission date of 07/21/24;-Diagnoses included heart failure, atrial fibrillation (irregular heart rate and rhythm), dementia, anxiety, and stroke.Review of the resident's quarterly MDS, dated [DATE], showed the following information:-Severely impaired cognition;-Reported frequently having pain.Review of the resident's care plan, last updated on 06/12/25, showed staff to ensure the resident is assessed for pain.Review of the resident's current POS showed an order, dated 01/30/26, for tramadol 50 mg, one tablet every six hours for pain.Review of the I-STAT documentation of medications that were removed by RN A on 02/02/26, at 9:57 P.M., RN A withdrew tramadol 50 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the tramadol removed from the I-STAT on 02/02/26.10. Review of Resident #10's face sheet showed the following information:-admission date of 02/07/26;-Diagnoses included congestive heart failure, right lower extremity amputation, high blood sugar and peripheral vascular disease (narrowing blood vessels).Review of the resident's admission MDS, dated [DATE], showed the following information:-Normal cognition;-Reported frequently having pain.Review of the resident's care plan, last updated on 02/09/26, showed staff to ensure the resident was assessed for pain.Review of the resident's current POS showed an order, dated 02/07/26, for tramadol 50 mg, two tablets every six hours as needed for pain.Review of the I-STAT documentation of medications that were removed by RN A showed on 02/15/26, at 12:10 P.M., RN A withdrew tramadol 50 mg tablet for the resident. Review of the resident's EHR and MAR showed RN A did not document administration of the tramadol removed from the I-STAT on 02/15/26.11. During an interview on 03/12/26, at 9:47 A.M., CMT C said the following:-He/she counted the narcotics with the oncoming and off going CMT every shift;-Staff should notify the DON immediately if the narcotic count was off;-He/she signed out the narcotic in the narcotic book log and on the MAR;-He/she would only pull medications from the I-STAT if the medication was not in the medication cart;-He/she has never had to pull a narcotic from the I-STAT;-Misappropriation means stealing resident medications. During an interview on 03/12/26, at 11:06 A.M., RN G said the following:-He/she did a narcotic count with the off going nurse every shift;-Notify the DON of any discrepancy immediately;-Any missing narcotics is considered misappropriation;-All scheduled and PRN narcotics are located in the medication carts under double locks;-Narcotics should be signed out on the narcotic log and the MAR;-I-STAT is available to override any medication that is needed;-Each nurse has a personalized long in and passcode to get into the I-STAT machine;-If pulling medications from the I-STAT, staff must sign off as administering the medication on the MAR.During an interview on 03/12/26, at 11:25 A.M, CMT D said the following:-He/she did a narcotic count with the off going nurse every shift;-He/she signed out all narcotics in the narcotic log and on the MAR;-All narcotics were double locked;-He/she never gives his/her keys to anyone at any time during his/her shift;-He/she would notify the DON immediately with any narcotic discrepancy;-He/she considered missing medications misappropriation.During an interview on 03/12/26, at 11:39 A.M., the Pharmacist Consultant said the following:-Medications are delivered daily from the pharmacy to the facility;-The pharmacy runs a report of controlled medications daily;-The I-STAT does not account for the medication being administered, only how many narcotics are in the I-STAT machine, so if the count is correct, it will not create a discrepancy.During an interview on 03/12/26, at 11:46 A.M., the DON said the following:-He/she knew that RN A had a history of medication diversion in the past;-RN A was told not to administer any narcotics to residents. RN A was told that CMT's administer all medications;-It was discovered that RN A was pulling medication from the I-STAT;-The DON was running a discrepancy report weekly on the I-STAT and was doing a monthly narcotic count with the Pharmacist Consultant, however, what the RN A was doing, did not create a discrepancy;-The DON ran a report by each nurse's name, that showed every medication that the nurse pulled from the I-STAT. That list was then compared against the EHR MAR and the narcotic log;-RN A had been pulling medications and not administering them to the residents;-The DON is now completing a weekly audit of narcotics, comparing the medications pulled from the I-STAT against the medications administered in the EHR MAR;-The DON said he/she should have been completing the weekly audit and comparing the medications against the EHR MAR every week then he/she would had known immediately that RN A was diverting medications.During an interview on 03/12/26, at 4:30 P.M., the Administrator said the following:-On 02/26/26, the DON notified him/her of a potential medication diversion;-The DON and the Administrator immediately started an investigation and discovered that RN A had been removing narcotics from the I-STAT machine and not administering the medications to residents;-The DON and the Administrator have been monitoring and auditing weekly since the diversion;-The Administrator expected staff to administer medication to the residents and document the medication administration appropriately;-The Administrator expected the DON to monitor medication administration and documentation of administration weekly;-The Administrator said that missing narcotics is considered misappropriation of property.Complaint #2789239

Based on interview and record review, the facility failed to protect all resident from misappropriation of property when one facility staff member (Environmental Services Employee A) used one resident's (Resident #1) debit card without consent. The facility census was 46.On 12/26/25, the Social Services Worker became aware of the misappropriation. The facility immediately began their investigation, including multiple interviews of other residents and staff. The facility began education on abuse, neglect, and misappropriation of resident's property. The facility removed Environmental Services Employee A from the facility. The facility reviewed all other resident's accounts with a debit card, as well as educated the residents on the process for debit card transactions. The facility reported the misappropriation to the Department of Health and Senior Services (DHSS) and local law enforcement. The noncompliance was corrected on 12/27/25. Review of the facility policy titled, Abuse, Prevention and Prohibition Policy, revised 10/22, showed, the following:-The facility prohibits misappropriation of resident property;-Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.1. Review of Resident #1's face sheet showed the following:-admission date of 01/30/25;-Diagnoses included chronic obstructive pulmonary disease (COPD - lung condition that blocks airflow, making it hard to breathe), chronic respiratory failure (lungs can't effectively get enough oxygen into the blood or remove the carbon dioxide), myocardial infarction (blood flow to part of the heart muscle is blocked, causing tissue to die), and atrial fibrillation (upper changes of the heart quiver chaotically instead of beating effectively).Review of the resident's quarterly minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 10/08/24, showed the following:-Cognitively intact;-No behavioral symptoms exhibited;-Resident is independent with oral hygiene, toileting hygiene, upper and lower body dressing and personal hygiene;-Resident requested supervision with showers. Review of the resident's care plan, last revised on 10/28/25, showed the following:-Resident had impaired cognitive function or impaired thought process;-Resident had impaired visual function, ensure resident uses glasses and other supports.Review of the resident's bank statement, dated 11/28/25, showed on 11/03/25, a withdrawal, in the amount of $103.25, plus a $2.00 ATM fee. Review of Resident #1's bank statement, dated 12/24/25, showed the following:-On 12/04/25, withdrawals of $123.25 and $306.00, plus $4.00 in ATM fees;-On 12/15/25, Venmo (mobile payment application that lets users send and receive money instantly) payments to Environmental Services Employee A, in the amounts of $10.00, $25.00, $50.00, $60.00, and $100.00;-On 12/17/25, Venmo payments to Environmental Services employee A in the amounts of $5.00, $10.00, $50.00, $50.00, $50.00, $100.00, $100.00, and overdraft fees totaling $125;-On 12/17/25, overdraft fee of $25.00.Review of the facility's investigation summary, dated 12/26/25, showed the following:-On 12/26/25, at 1:50 P.M., the resident reported to the Social Services Director (SSD) eh/she had received an insufficient funds notice from his/her bank, and he/she suspected Environmental Services Employee A of taking money out of his/her account without permission;-The resident and SSD contacted the bank to request a printout of December's bank statement and to report the resident's debit card as stolen and freeze the account;-The resident already had his/her November bank statement, and it showed an ATM withdrawal that he/she stated he/she did not authorize on the same day he/she had given Environmental Services Employee A his/her card to withdraw money for the resident;-Administrator contacted the Environmental Services Employee A, to let him/her know of the allegations and suspension pending investigation;-On 12/26/25, SSD met with the resident. Resident believed that Environmental Services Employee A, stole money from him/her. Resident stated he/she had Environmental Services Employee A, withdraw money from the ATM before and the resident had given Environmental Services Employee A his/her pin number to the debit card. When reviewing the November bank statement, the resident found two ATM withdrawals on the day he/she had requested Environmental Services Employee A, to withdraw money for the resident;-On 12/26/25, the Administrator met with the resident. Resident stated he/she had given his/her card to Environmental Services Employee A on 11/01/25 and 12/01/25 to make withdrawals from his/her account. Resident believed Environmental Services Employee A, took money from his/her account because he/she gave his/her debit card and pin number to Environmental Services Employee A. Resident said Environmental Services Employee A told him/her at one point that if the resident didn't have money, it was okay, the resident could give Environmental Services Employee A his/her debit card and he/she would take care of it. The resident stated that he/she should have never given Environmental Services Employee A his/her card and pin number and that he/she was aware that all purchases should go through the business office;-On 12/26/25, the Administrator spoke to Environmental Services Employee A by phone. Administrator made Environmental Services Employee A aware of allegations and suspension pending investigation. He/she stated I don't know what to tell you, I don't have any money. My dad is dying. I asked people for gas money, and nobody would help me out.-Summary of findings, Resident's November 2025 Bank Statement, ending 11/28/25, showed an ATM withdrawal of $103.25 and an ATM withdrawal of $510 on 11/03/25. Resident stated he/she asked Environmental Services Employee A to withdrawal $500.00 from the account but he/she did not authorize the $103.25. The December 2005 bank statement, dated 12/24/25, showed three ATM withdrawals on 12/03/25. Resident stated he/she asked Environmental Services Employee A, to withdrawal $500.00 on 12/01/25 but did not authorize the ATM withdrawals in the amounts of $123.25 or $306.00 withdrawn the same day. The December2025 bank statement also showed multiple Venmo payments to Environmental Services Employee A between 12/15/25 and 12/17/25. Total Venmo transfer of $610.00;-Resident stated the following transfers were not authorized;-On 11/03/25, ATM transfer of $103.25;-On 12/03/25, ATM transfer of $123.25;-On 12/03/25, ATM transfer of $306.00;-On 12/15/25 through 12/17/25, total of $610.00 of Venmo transfers;-Resident was charged overdraft fees in the amount of $150.00. Review of the county sheriff's department report showed the following:-Report made by the facility to the sheriff's department on 12/26/25;-Sheriff's department interviewed the resident regarding the unauthorized charges. Resident said he/she provided Environmental Services Employee A his/her debit and pin number when the employee asked for it so that the employee could obtain money from the ATM for the resident;-Resident said he never authorized Environmental Services Employee A to take any money from his/her account;-Total unauthorized charges, including overdraft fees were $1012.50;-On 12/27/25, Sheriff's office made contact with Environmental Services Employee A. Environmental Services Employee A acknowledged the authorized $503.00 withdrawal at the Gainesville gas station on 12/03/25. He/she admitted adding the resident's card to his/her Venmo account but claimed he/she did not initially realize it belonged to the resident. Environmental Services Employee A showed the officer several transactions on his/her Venmo account that he/she acknowledged were linked to the resident's card after he/she became aware of the association. Environmental Services Employee A confirmed the card had since been removed from the Venmo account. Officer photographed the credit card used by Environmental Services Employee A without permission and it showed the resident's name on the front and again on the back showing a reasonable person to believe who the owner of the card to be;-Based on the resident's bank statements, bank records, and Environmental Services Employee A's admission, probable cause exits to believe Environmental Services Employee A committed financial exploitation of an elder person, fraud involving unauthorized use of a credit card, and stealing. During an interview on 01/06/26, at 10:30 A.M., the resident said the following:-Environmental Services Employee A came to his/her room one day and asked the resident if he/she needed anything from the store. He/she gave the resident cash that day to pick up a sub sandwich for him/her, another resident, and Environmental Services Employee A. Environmental Services Employee A brought back the receipt and nothing was missing. The resident doesn't remember when this was, but prior to the incidents of missing money;-On 11/03/25, Environmental Services Employee A, asked him/her again if he/she needed anything and the resident said he/she needed money withdrawn from his/her account. The resident said he/she did not have cash and Environmental Services Employee A said he/she could take the resident's debit card and get the cash. He/she gave Environmental Services Employee A his/her debit card and pin number. He/she asked Environmental Services Employee A to withdrawal $500 from his/her account. He/she did not give Environmental Services Employee A permission to get him/herself any money. At that time Environmental Services Employee A also withdrew $103.25;-On 12/04/25, Environmental Services Employee A, asked the resident if he/she needed anything in the community. The resident said he/she needed some money from the ATM, so Environmental Services Employee A, took the resident's debit card. The resident had Environmental Services Employee A, withdraw $503.00 for the resident. The resident did not give Environmental Services Employee A, permission to withdraw other money. Environmental Services employee A, also withdrew $123.25 and $306.00;-The resident received the insufficient funds notice from the bank on 12/26/25. That's when he/she found Environmental Services Employee A, had been taking money from the resident's account; -The resident doesn't know what Venmo was, and he/she wasn't aware Environmental Services Employee A had used his/her card to obtain $610.00 through Venmo as the Resident said he/she never gave permission for this.During an interview on 01/07/26, at 11:55 A.M., Environment Services Employee A said the following:-Only the Activity Director was allowed to shop for the residents, no other staff;-He/she had pulled money out of the ATM for the resident. He/she didn't remember the dates or how much money. He/she took money out of the ATM a couple of times for the resident;-The resident asked him/her to take money out of the ATM. He/she believed the first time it was $500, and he/she wasn't sure about the other time;-The resident had given him/her money before. The resident offered the money. The resident gave him/her $100 to help pay for the electric and just before Christmas the resident gave him/her $100 and said Merry Christmas. It was the week of Christmas;-He/she said the resident's card was mistakenly put on the Venmo account;-It is not acceptable to take money from a resident and that could be misappropriation of funds.During an interview on 01/06/26, at 11:07 A.M., Environmental Services Employee B said the following:-The Activity Director and administration does the shopping for residents; no other staff are allowed to;-Staff aren't allowed to take debit or credit cards and can't accept money from residents;-If staff used a resident's debit card and withdrew money from the resident's account for their personal use it would be misappropriation of a resident's money;-He/she has received in-services on this and would tell his/her supervisor if it happened.During an interview on 01/06/26, at 11:17 A.M., Certified Medication Technician (CMT) C said the following:-SSD or activities does all of the shopping for residents;-Staff are not allowed to take a resident's debit card and get cash for residents;-It would not be appropriate for staff to take money from a resident's debit card for personal use, this would be misappropriation of resident's money;-He/she would report misappropriation to the charge nurse or DON. During an interview on 01/06/26, at 11:20 A.M., Licensed Practical Nurse (LPN) D said the following:-The Business Office Manager goes shopping for the residents;-Staff are not allowed to take a resident's debit card to an ATM to withdraw money;-Staff are not allowed to take money off from a debit card for their personal use, that would be misappropriation of funds, and it's not allowed;-Staff aren't allowed to accept gifts;-If he/she suspects misappropriation, he/she reports to the DON or administration.During an interview on 01/06/26, at 11:27 A.M., Certified Nurse Aide (CNA) E said the following:-People in charge do the resident shopping, aides are not allowed to;-No staff are allowed to take a resident's debit card and withdraw money;-If a staff takes money from a resident's debit card for personal use it would be misappropriation;-Abuse or misappropriation would be reported to the charge nurse, Director of Nursing (DON) or the Administrator.During an interview on 01/06/26, at 11:30 A.M., CNA F said the following: -All shopping is done by the higher ups, he/she is not allowed to shop for the residents;-No staff are allowed to take a resident's debit card to withdraw money from the ATM;-Staff are not allowed to use a resident's debit card for their personal use, that would be misappropriation of resident funds;-If he/she became of aware of misappropriation, he/she would report to the charge nurse and administrator.During an interview on 01/06/26, at 11:33 A.M., SSD said the following:-The resident shopping is done by the front office or the Activity Director;-Staff are not allowed to take a resident's debit card and withdraw money;-All residents are told on admission the process for resident shopping and no staff uses resident's debit cards;-When the appointed staff does the shopping, he/she has receipts and logs that are kept;-If staff withdraw money from a resident's account for their own person use with debit card, it is misappropriation of funds;-Not appropriate to take a resident's debit card and withdraw money for a resident or themselves;-He/she would report to the Administrator if he/she knows of misappropriation of resident property.During an interview on 01/06/26, at 11:36 A.M., the Activity Director said the following:-He/she or upper management are the only staff that does shopping for residents;-The/she gets a list from the resident and the sign the list agreeing to what they want;-He/she gets a facility check and picks up the items for each resident. When he/she goes over the receipt and shows the receipt to the resident, and they sign off saying they received the items and the total cost. This is then taken out of their account. He/she never takes a resident's personal debit cards;-It would be misappropriation to withdraw money from atm for personal use;-He/she would report suspected misappropriation to the Administrator.During an interview on 01/06/26, at 11:40 A.M., the MDS Coordinator said the following:-All shopping was done by the Activities director, the Administrator, and sometimes the BOM;-If a staff takes resident money for their use, it's wrong and would be misappropriation and abuse;-He/she would report suspected abuse or misappropriation to the DON and the Administrator.During an interview on 01/06/26, at 12:10 P.M., the BOM said the following:-Only the BOM, Administrator, and Activity Director goes shopping for residents;-The residents have a shopping list that's a designated from, staff check to see if residents have funds to cover the items, and the facility writes one check for all of the items purchased. Once the employee returns, they go over the items with the resident's and they resident's sign off and those funds are removed from the resident accounts;-Staff are not allowed to take money from a resident or take debit card and withdraw money from ATM. If a staff takes money from a resident's account for their personal use, it's misappropriation of resident funds;-He/she reports misappropriation to the Administrator.During an interview on 01/06/26, at 11:45 A.M., the DON said the following:-The Activity Director and front office does the shopping for residents;-Staff are not allowed to take a resident's debit card;-If staff takes money from a resident or gets money out of an ATM for their personal use, it's abuse and misappropriation and it's not appropriate;-Staff should report any suspected abuse or misappropriation to the Administrator or him/her;-When staff go shopping for the residents the residents make a list and sign the list of items they're requesting. The Activities Director gets the items and once he/she delivers them to the resident's the residents verify and sign off on the items they're receiving and the amount. The money is then taken from the resident's trust account;-What Environmental Services Employee A did is misappropriation of a resident's money.During an interview on 01/06/26, at 11:50 A.M., the Administrator said the following:-The BOM, Activities Director, or the Administrator are the only staff to do shopping for the residents;-The staff that shop for the residents ensure the residents have the money for the items the residents have chosen, and the residents sign their list of things they want. Once the staff returns, they go over the list and items with the resident and the resident's sign off again and the money is taken from the resident's trust account;-Staff are not allowed to take a debit card from a resident; -Environmental Services Employee A took money from the resident and it was misappropriation. Complaint #2701720

1. Please refer to Event ID B3N912, exit date 11/14/24. MO00243241

Based on observation and interview, the facility failed to ensure food prepared by the facility was palatable when residents complained the food was served cold at times, the food lacked flavor/seasoning, and the meat was tough at times. 1. Observations and interview on 09/11/24, at 1:07 P.M., showed the following: -The Dietary Manager (DM) confirmed testing the food on the last (test) tray on the cart. Prior to leaving the kitchen the temperature of the cheesy rice casserole was 120 degrees Fahrenheit (F); pork chop was 125 degrees F; and the broccoli was 115 degrees F. -When the tray was presented after the last tray was delivered, the casserole was 110 degrees F, the pork chop was 95 degrees F, and the broccoli was 90 degrees F. -The DM said the food was cool and should have been warmer to be palatable for the residents. Interviews during the Resident Council Meeting on 09/11/24, at 9:15 A.M., showed the residents said the food was cold for the residents who eat in their rooms. The pancakes that morning were cold. The prior night (09/10/24) the menu said burrito with beans/rice, but what was served was tortilla chips with meat on top and unmelted cheese on the meat. The orange Jell-O was not set and watery. During an interview on 09/09/24, at 3:42 P.M., Resident #35 said the food was not good and was overcooked. The staff overcook the meat. The breakfast was good, just cold. The oatmeal was served without butter or brown sugar. During an interview on 09/09/24, at 12:02 P.M., Resident #39 said the food did not always taste good. He/she had no teeth so sometimes he/she just threw the food away when he/she could not chew it. During an interview on 09/11/24, at 2:05 P.M., Resident #38 said the pork chop for lunch that day was tough and dry. During an interview on 09/11/24, at 2:05 P.M., Resident #20 said the food lacked seasoning. The pork chops were tough and hard to cut and chew. During an interview on 09/10/24, at 9:37 A.M., Resident #40 said the food had no taste. The pork chops were tough and not easy to chew. During an interview on 09/12/24, at 10:10 A.M., Resident #4 said the pork chop for yesterday's lunch was hard and not easy to chew.

Based on observation, interview, and record review, the facility failed to ensure all food was prepared in a form designed to meet the needs of each resident when the facility failed to cut up meat as ordered for one resident (Resident #17). Review of the facility policy titled Menus and Food Preparation-Nutrition Services, revised January 2018, showed the purpose of the policy was to ensure resident nutritional needs are met in conjunction with resident preferences. 1. Review of Resident #17'sAdmission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE]; -Readmitted [DATE]; -Diagnoses included gastroesophageal reflux disease. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/23/24, showed the resident was cognitively intact. Review of the resident's Orders tab in the EMR showed a physician's order, dated 07/18/24, for regular texture, regular consistency diet with no gravy and meats to be cut small. Review of the resident's Tray Card, printed daily by the kitchen, showed staff did not update the care to show instruction to cut up meat or to not serve gravy. During an observation on 09/11/24, at 12:00 P.M., of lunch tray line (preparing the trays of food for the residents) the menu included pork chops. The resident's tray was served with a whole pork chop (not cut up). During an interview on 09/11/24, at 2:00 P.M., the resident said I could not cut the meat, so I did not eat it. During an interview on 09/11/24, at 11:10 A.M., the Director of Nursing (DON) said when a change to a diet is made by the physician, a copy of the change is given to the Dietary Manager (DM) for implementation. During an interview on 09/12/24, at 2:15 P.M., the DON said the paperwork for the change in diet for the resident was not communicated to the DM.

Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. -Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the State Agency and law enforcement if this is reasonable suspicion of a crime; -Complete a report of alleged resident abuse within the required timelines; -The facility employee or agent, who becomes aware of abuse on neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in his/her absence; -The Administrator will notify the Corporate Nurse; -The facility Administrator shall report to the mandated state agency per reporting criteria; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of the allegation of abuse or neglect of the Administrator will report the allegation of abuse and neglect to the mandated state agency and law enforcement; -The allegation will be reported no later that two hours after the allegation is made if the events involve abuse or result in serious bodily injury; -Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of the Resident #1's face sheet showed the following: -admission date of 07/09/24; -Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following: -Severely cognitively impaired; -Required set up or clean up assistance of staff with eating; -Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers; -Required substantial or maximum assistance of staff for showers. Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following: -A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation. Review of DHSS records showed the facility did not file a self-report regarding the allegation of possible neglect. During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said the following: -He/she would instantly report any allegation of resident abuse or neglect to the nurse, the Director of Nursing (DON), or Administrator; -The facility must notify DHSS within two hours of any allegation of resident abuse or resident neglect; -If someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse. During an interview on 11/14/24, at 4:40 P.M., [NAME] E said the following: -Facility staff members were required to immediately report any allegation of resident abuse or neglect to their supervisors; -The facility was required to notify DHSS within two hours of any allegation of resident abuse or neglect; -If someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse. During interviews on 11/14/24, at 4:35 P.M., and 11/15/24, at 2:30 P.M., the Activity Director (AD) said the following: -Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs; -If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator; -The facility was required to notify DHSS within two hours of any allegation of abuse or neglect; -If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator; -He/she overheard the conversation on 10/14/24 between the Administrator and the visitor in regards to the resident; -The visitor accused the facility of neglecting the resident; -The facility should have called in the allegation of neglect to within two hours to DHSS. During an interview on 11/14/24, at 2:33 P.M., the DON said the following: -He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care; -He/She would be concerned of an allegation of the facility letting a resident lay in bed and die; -He/She could see how an allegation of this nature would be considered an allegation of possible neglect; -Staff should notify DHSS within two hours with any allegation or resident abuse or neglect. During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following: -On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect; -He/She should have notified DHSS of the possible allegation; -The facility was required to notify DHSS of any allegation of abuse or neglect within two hours; -He/she did not notify DHSS of the allegation of neglect. MO00243241

Based on interview and record review, the facility failed to ensure all allegation of possible neglect were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when the facility Administrator received an allegation of possible neglect involving one resident (Resident #1) in a facility and failed to report it to DHSS. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. -Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the State Agency and law enforcement if this is reasonable suspicion of a crime; -Complete a report of alleged resident abuse within the required timelines; -The facility employee or agent, who becomes aware of abuse on neglect, shall immediately report the matter to the facility Administrator or his/her designated representative in his/her absence; -The Administrator will notify the Corporate Nurse; -The facility Administrator shall report to the mandated state agency per reporting criteria; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of the allegation of abuse or neglect of the Administrator will report the allegation of abuse and neglect to the mandated state agency and law enforcement; -The allegation will be reported no later that two hours after the allegation is made if the events involve abuse or result in serious bodily injury; -Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of the Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following: -Severely cognitively impaired; -Required set up or clean up assistance of staff with eating; -Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers; -Required substantial or maximum assistance of staff for showers. Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following: -A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation. Review of DHSS records showed the facility did not file a self-report regarding the allegation of possible neglect. During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said the following: -He/she would instantly report any allegation of resident abuse or neglect to the nurse, the Director of Nursing (DON), or Administrator; -The facility must notify DHSS within two hours of any allegation of resident abuse or resident neglect; -If someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse. During an interview on 11/14/24, at 4:40 P.M., [NAME] E said the following: -Facility staff members were required to immediately report any allegation of resident abuse or neglect to their supervisors; -The facility was required to notify DHSS within two hours of any allegation of resident abuse or neglect; -If someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse. During interviews on 11/14/24, at 4:35 P.M., and 11/15/24, at 2:30 P.M., the Activity Director (AD) said the following: -Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs; -If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator; -The facility was required to notify DHSS within two hours of any allegation of abuse or neglect; -If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator; -He/she overheard the conversation on 10/14/24 between the Administrator and the visitor in regards to the resident; -The visitor accused the facility of neglecting the resident; -The facility should have called in the allegation of neglect to within two hours to DHSS. During an interview on 11/14/24, at 2:33 P.M., the DON said the following: -He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care; -He/She would be concerned of an allegation of the facility letting a resident lay in bed and die; -He/She could see how an allegation of this nature would be considered an allegation of possible neglect; -Staff should notify DHSS within two hours with any allegation or resident abuse or neglect. During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following: -On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect; -He/She should have notified DHSS of the possible allegation; -The facility was required to notify DHSS of any allegation of abuse or neglect within two hours; -He/she did not notify DHSS of the allegation of neglect. MO00243241

Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. Investigation. -The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. -Utilize Resident Abuse Investigation Forms for completing investigation; -A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted; -Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the Abuse Investigation Format; -Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated; -Interview the resident if they are cognitively able to answer questions in private setting free from any intimidating factors; -Complete the investigative summary and statements within five business days; -Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of the Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following: -Severely cognitively impaired; -Required set up or clean up assistance of staff with eating; -Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers; -Required substantial or maximum assistance of staff for showers. Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following: -A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation. Review of facility records showed the facility did not provide documentation of a full investigation completed regarding the allegation of neglect. Review of DHSS records showed an investigation report related to the allegations of neglect was not received. During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said if someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse. During an interview on 11/14/25, at 4:40 P.M., [NAME] E said if someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse. During an interview on 11/14/24, at 4:35 P.M., the Activity Director (AD) said the following: -Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs; -If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator; -If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator. During an interview on 11/14/24, at 2:33 P.M., the Director of Nursing (DON) said the following: -He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care; -He/She would be concerned of an allegation of the facility letting a resident lay in bed and die; -He/She could see how an allegation of this nature would be considered an allegation of possible neglect; -The Administrator is in charge of investigating allegations of resident abuse or neglect. During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following: -He/she was responsible for facility abuse/neglect investigations; -He/she had five days to investigate allegations of resident abuse/neglect and submit the completed investigations; -On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect; -After the visitors left, he/she went to the resident's room to check on the resident; -He/she did not conduct a full investigation of the allegation; -He/she did not interview other residents or staff about the allegations of resident neglect. MO00243241

Based on observation, interview, and record review, the facility failed to ensure an environment as free from accident hazards as possible for all residents when staff failed to evaluate effective of interventions, care plan new interventions, and failed to complete root cause analysis after multiple elopement attempts and combativeness for one of two residents (Resident #22) reviewed for wandering. Review of the facility's policy titled Elopement Policy, undated, showed it was the intent of the facility to maintain and enhance a resident's dignity by promoting free access in and around the facility, while safeguarding the well-being of the resident, and to monitor behavior or residents to identify potential elopers, such as excessive wandering, especially to doors. 1. Review of Resident #22's Admission Record, undated, found under the Profile tab of the electronic medical record (EMR), showed the following: -admitted [DATE]; -Diagnoses included dementia. Review of the resident's annual Minimum Data Set (MDS - federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 06/28/24, showed the following: -The resident had severe cognitive impairment; -The resident experienced delusions, did not exhibit wandering, and used a wheelchair for mobility. Review of the resident's Care Plan showed the following: -Elopement risk and wanderer; -Interventions, initiated on 06/15/23, included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books; -Identify a pattern of wandering; -An elopement wandering risk due to dementia and was independently ambulatory and able to propel wheelchair. Review of the resident's Progress Notes, found in the EMR under the Progress Notes tab, showed the following: -On 06/02/24, the resident exited out the hall side door two times alone. Interventions were that staff redirected and assisted resident back into the facility and offered the resident a snack and drink. -On 07/29/24, the resident exited out 200 hall side door. The aide immediately went out to bring the resident back in. Interventions were therapeutic communication, and redirection, both were ineffective. -On 07/30/24, the resident was repeatedly exiting the facility out 200 hall side door unsupervised. Staff assisted the resident back into the facility. -On 08/03/24, the resident exited out 200 hall side door several times. The Certified Nursing Aide (CNA) immediately went out to bring the resident back in. The resident was hitting at staff and yelling to leave him/her alone. Staff attempts to redirect were unsuccessful. -On 08/07/24, the resident continued to exit seek out of the 200-hall side door. The resident was monitored while he/she was outside in the fenced in area. -On 08/21/24, the resident was exiting 200 side door during a non-smoking time. -On 08/25/24, the resident exited out the front door while another resident was coming back into the building with family. The nurse was immediately alerted and got the resident. Resident saw nurse coming and began wheeling his/her wheelchair faster while ignoring the nurse. The nurse brought the resident back into the facility. -On 08/27/24, the resident was exiting out 200 side door alone. Staff followed the resident out and attempted to redirect and the resident became agitated and tried to evade them. The resident hit a CNA four times. Buspirone (used to treat anxiety) was increased on 08/07/24 and has not seemed to help with behaviors. -On 08/27/24, the resident exited out 200 hall side door, again. Resident agitated and combative. Staff redirected resident back into facility. -On 08/29/24, the resident attempted to exit 200 hall side door unsuccessfully once this evening, but the staff caught and redirected. -On 09/10/24, the resident was found several times trying to enter the nursing staff's break room and has now figured out how to unlock the break room door with the nearby key. The resident went around the dining room during supper touching and moving around several other resident's plates and food. The resident found throwing away several plastic cups in the dining room that are used for hot beverages. The resident was redirected several times and therapeutic communication was tried unsuccessfully. The physician was notified and the resident was transferred to a behavioral unit for evaluation and treatment. Review of the resident's Elopement Assessment, dated 09/10/24, showed the resident was at risk for elopement, did not have a history of elopement, did have a desire to leave the facility, exit seeking with a purpose, and wandering activity. Observation on 09/10/24, at 11:20 A.M., showed hall 200 had two exit doors, one at the end of the hall and one exit door on the right side of the hall exiting to a patio, flower/vegetable garden, and smoking area. The area was fenced from the end of hall 200 exit door to the corner of hall 300. The area had closed gates that were unlocked. Review of the resident's medical record showed staff did not update the care plan with new interventions after the multiple elopement attempts and did not complete a root cause analysis to determine the cause of elopements and steps to be take to deter the elopement behaviors. During an interview on 09/10/24, at 11:20 A.M., the Director of Nursing (DON) said the gates were not locked for emergency purposes. The DON confirmed the resident had not had an elopement assessment completed since June of 2024 until 09/10/24. During an interview on 09/10/24, at 2:57 P.M., Registered Nurse (RN) 1 said that the staff keep an eye on the resident. RN 1 said that when the staff hear the alarm, they can check the monitor and know which door to go to. During an interview on 09/10/24, at 3:06 P.M., RN 2 said all staff monitor the resident and that when the alarm sounds, they check the appropriate door. During an interview on 09/11/24, at 10:13 A.M., the DON said a root cause analysis for the resident's exit seeking and successfully getting out hall 200 side door had not been done. When asked if the concern regarding the resident's increased wandering had been discussed in Quality Assurance, the DON stated no. During an interview on 09/12/24,.at 2:30 P.M., with the DON and the Administrator, the DON said his/her expectations for successful supervision in the future would mean that the resident's behaviors would have to be under control. The DON said that her hope was that the cause of the resident's exacerbation of exit seeking, wandering, aggression and combativeness could be determined and treated.

Based on interviews and record review, the facility failed to ensure all allegations of possible neglect were investigated by the facility and the investigation submitted to the State Survey Agency (Department of Health and Senior Services - DHSS) within five days when a staff member received an allegation of possible neglect of one resident (Resident #1) and the facility failed to complaint a full investigation. The facility census was 43. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, dated October 2022, showed the following: -The facility prohibits mistreatment, neglect, or abuse of residents. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychological wellbeing. -The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. Investigation. -The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. -Utilize Resident Abuse Investigation Forms for completing investigation; -A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted; -Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist with completing a questionnaire and statements if indicated that will be attached to the Abuse Investigation Format; -Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated; -Interview the resident if they are cognitively able to answer questions in private setting free from any intimidating factors; -Complete the investigative summary and statements within five business days; -Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of the Resident #1's face sheet showed the following: -admission date of 07/09/24; -Diagnoses included acute kidney failure (AKF), severe dementia with agitation, repeated falls, need for assistance with personal cares, and weakness. Review of the resident's admission Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 07/22/24, showed the following: -Severely cognitively impaired; -Required set up or clean up assistance of staff with eating; -Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers; -Required substantial or maximum assistance of staff for showers. Review of the resident's progress note dated 10/14/24, at 9:45 A.M., showed the facility Administrator documented the following: -A visitor said the Administrator was letting the resident die. The resident had lost 25% of his/her body weight and the Administrator was fine with the resident lying in bed, dying. The Administrator asked the visitor how he/she knew the resident's weight. The visitor said he/she saw the resident when entering the facility to pick up other residents. The Administrator informed the visitor per the request of the resident's durable power of attorney (DPOA), the visitor should not seek out the resident while in the facility. The visitor said he/she saw the resident while he/she was in the facility conducting business. The visitor stated that on the previous day, 11/13/24, the resident had food on his/her clothes and was dirty. The visitor again told the Administrator that he/she (the Administrator) was just going to let the resident lay in bed and die. The Administrator told the visitor that their conversation was over and he/she did not appreciate what the visitor was accusing the Administrator of and that any further information needed, he/she would need to get the information from the DPOA, from Adult Protective Services (APS), or he/she could hire a lawyer and file for guardianship. After the visitor left, he/she went to the resident's room. The resident was resting in bed. The Administrator had assisted the resident back to his/her room after breakfast and he/she was doing fine. The resident had fresh ice water and snacks available on his/her overbed table. The Activity Director was present during the conversation. Review of facility records showed the facility did not provide documentation of a full investigation completed regarding the allegation of neglect. Review of DHSS records showed an investigation report related to the allegations of neglect was not received. During an interview on 11/14/24, at 4:30 P.M., Certified Nurse Aide (CNA) D said if someone alleged the facility staff were letting a resident lay there and die, he/she would consider that to be an allegation of neglect and would immediately report the allegation to his/her charge nurse. During an interview on 11/14/25, at 4:40 P.M., [NAME] E said if someone accused a facility staff member of letting a resident lay in bed and die, he/she would consider that to be an allegation of neglect and would immediately report that information to his/her supervisor or charge nurse. During an interview on 11/14/24, at 4:35 P.M., the Activity Director (AD) said the following: -Examples of resident neglect would be staff leaving a resident alone or not tending to a resident's needs; -If anyone made an allegation or resident abuse or neglect, he/she would immediately notify the Administrator; -If someone accused the staff of allowing a resident to lay there and die, the AD would consider that to be an allegation of neglect and would immediately report to the Administrator. During an interview on 11/14/24, at 2:33 P.M., the Director of Nursing (DON) said the following: -He/She was unaware of the specifics of the situation with the resident and a visitor who had become involved in his/her care; -He/She would be concerned of an allegation of the facility letting a resident lay in bed and die; -He/She could see how an allegation of this nature would be considered an allegation of possible neglect; -The Administrator is in charge of investigating allegations of resident abuse or neglect. During an interview on 11/14/24, at 3:13 P.M., the Administrator said the following: -He/she was responsible for facility abuse/neglect investigations; -He/she had five days to investigate allegations of resident abuse/neglect and submit the completed investigations; -On 10/14/24, at that time he/she did not consider what the visitor said about the resident to be an allegation of abuse or neglect; -After the visitors left, he/she went to the resident's room to check on the resident; -He/she did not conduct a full investigation of the allegation; -He/she did not interview other residents or staff about the allegations of resident neglect. MO00243241

Based on observation, interview, and record review, the facility failed to develop complete a person centered care plan for each resident when staff failed to care plan related to side rails use for one resident (Resident #13) and wandering/elopement risks for one resident (Resident #36) of 21 sampled residents. Review of the facility's Care Planning - Interdisciplinary Team policy, dated January 2017 showed the following: -Upon completion of comprehensive assessments care areas of concern will be triggered to be addressed in the plan of care for that resident. -Each triggered care area will be reviewed by designated staff to determine if a triggered condition affects the resident's function and quality of life. -Staff will document whether or not a care plan is needed to address the triggered area. 1. Review of the facility policy titled Proper Use of Side Rails, reviewed 02/2021, showed the use of side rails will be addressed in the resident's care plan. Review of Resident #13's Admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admitted [DATE]; -Diagnoses that included history of frequent repeated falls and unsteadiness on feet. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 06/16/24, showed the resident was cognitively intact. Review of the resident's EMR under the Misc tab, showed the following: -Consent for Side Rail Usage, dated 05/24/24, for bilateral (both sides) half side rails to assist with bed mobility and repositioning. Review of the resident's EMR, under the Progress Notes tab, a Progress Note,, dated 06/19/24 showed bilateral half side rails continued for mobility assist and repositioning assist while in bed. Observation and interview on 09/09/24, at 11:13 A.M., showed the resident in bed with half side rails on both sides of the bed. The resident said the rails were on the bed at his/her request to assist in positioning and support when he/she gets out of bed. Review of the resident's EMR, under the Care Plan tab, showed staff did not care plan the use of side rails. During an interview on 09/12/24, at 11:32 P.M., the MDS Coordinator confirmed staff did not care plan the resident's use of side rails that were installed on 04/21/23. The use of side rails should have been care planned. During an interview on 09/12/24, at 12:14 P.M., the Director of Nursing (DON) confirmed residents with side rails should have a care plan for side rails and confirmed the staff did not care plan the resident's use of side rails. 42440 2. Review of Resident #36's Admission Record, located in the Profile tab of the EMR, showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease. Review of the resident's Elopement Assessment - V3, dated on 08/12/24 and located under the Assmnts tab of the EMR, showed the following: -At risk for elopement; -Interventions included frequent visual monitoring and provided with distracting activity. Review of the resident's Behavior Note, dated 08/19/24 and located in the Prog Note tab of the EMR, showed the resident was exit seeking at the end door of 600 hall and required redirection. Review of the resident's admission MDS assessment, with an ARD of 08/25/24, located in the resident's EMR under the MDS tab, showed the following: -The resident had severely impaired cognition. -The resident walked with supervision or touching assistance. -The resident had daily wandering behavior and did not utilize a wander/elopement device. -The resident had dementia and would get up and wander if not busy. Staff should give resident tasks to do, games to play, magazines to peruse, etc. Family visits also helps keep the resident busy. -The behavior CAA stated wandering would be on the Care Plan. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab of the EMR, showed staff did not care plan regarding the resident's identified wandering and elopement risk. Review of the resident's Behavior Note, dated 08/27/24 and located in the Prog Note tab of the EMR, showed the resident exited out the door at the end of 300 hall and required redirection. During an interview on 09/09/24, at 2:21 P.M., the resident's representative said a couple of weeks ago, facility staff told him/her the resident ,had tried to get out the front door twice in one day. During an interview on 09/11/24 at 10:56 A.M., Certified Nurse Aide (CNA) 3 said the resident was confused and had a recent room change so he/she gets turned around needed redirection. During an interview on 09/11/24, at 2:01 P.M., the Infection Preventionist (IP) said the resident walked by himself and was confused. On 08/27/24, the resident walked by himself and pushed on the 300-hall door, which alarmed. Staff responded and redirected the resident as he reached the threshold. During an interview on 09/12/24, at 11:14 A.M., the MDS Coordinator (MDSC) said the Social Services Director (SSD) completed the Behavior section of the MDS. The MDSC confirmed the resident wandered daily. The MDSC stated the wandering should be care planned. During an interview on 09/12/24,at 3:00 P.M., the Director of Nursing (DON) said she expected wandering to be addressed on the Care Plan.

Based on observation, interview, and record review, the facility failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for five residents (Residents #8, #12, #27, #31, and #199); failed to obtain informed consent prior to the use side rails for one resident (Resident #31); failed to address the use bed rails in residents' care plans for four residents (Residents #8, #12, #31, and #199); and failed to obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 48. Record review of a facility policy entitled Proper Use of Side Rails, reviewed 2/2021, showed the following: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails and will be reviewed quarterly; -The use of side rails will be addressed in the resident care plan; -The risks and benefits of side rails will be considered for each resident; -Consent for side rail, when used as a restraint, will be obtained from the resident or representative, after presenting potential benefits and risks. 1. Record review of Resident #31's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/14/2022, showed the following information: -admitted [DATE]; -Severely impaired cognition; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Independent for bed mobility, transfers, ambulation with walker or cane, locomotion using wheelchair, and toileting; -Required set up only for eating, dressing, and personal hygiene; -Bed rails not used as a restraint. Observation on 11/15/2022, at 1:40 P.M., showed the resident's bed had a u-shaped side rail attached to his/her right side of the bed in a fixed upright position. During the observation, the resident was unable to understand or respond appropriately to the surveyor's questions regarding the side rail. Record review of the resident's electronic medical record (EMR) conducted on 11/17/2022, at 8:48 A.M., showed the following: -Staff documented completion of a Device/Restraint Evaluation on 5/13/2022. The evaluation did not reference the use of a bed side rail; -Staff did not document a pre-use risk evaluation/assessment or informed consent for the use of side rails. Record review of the resident's care plan, last updated 8/17/2022, showed the following: -Resident was able to turn him/herself in bed; -Staff did not document information pertaining to the use of a side rail. During an interview on 11/17/2022, at 11:40 A.M., the Director of Nursing (DON) said he/she was unable to locate a signed consent for the resident's use of a side rail. 2. Record review of Resident #8's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -Moderately impaired cognition; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Total dependence on staff for bed mobility, transfers, toileting, and bathing; -Required extensive assistance from staff for dressing, personal hygiene, and bathing; -Bed rails not used as a restraint. Observation on 11/14/2022, at 1:42 P.M., showed the resident's bed had a half rail on his/her right side, in the upright position and padded with foam tubing. Observation on 11/16/2022, at 10:06 A.M., showed the resident's bed had a padded half rail on his/her right side toward window. The resident grasped the rail during personal care and turning by staff. Record review of the resident's EMR, showed the following: -Staff documented informed consent for the use of side rails for bed mobility on 9/30/2022; -Staff documented completion of the Nursing Admission Data Collection, dated 10/1/2022. Staff documented the resident did use or request to use side rails; -Staff did not document a pre-use risk evaluation/assessment for the use of side rails. Record review of the resident's care plan, last updated 11/17/2022, showed the following information: -Resident totally dependent on staff for positioning and turning in bed; -Staff did not document information pertaining to the use of bed rails. 3. Record review of Resident #27's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Totally dependent on staff for bed mobility, transfers, and bathing; -Required extensive assistance for dressing and personal hygiene; -Bed rails not used as a restraint. Record review of the resident's care plan, last updated 9/12/2022, showed the resident required the use of bed rails and the assistance of two staff to reposition and turn in bed. Observation on 11/15/2022, at 2:28 P.M., showed the resident's bed had square side rails, approximately 10 inches by 10 inches, in an upright, fixed position on both sides. Record review of the resident's EMR showed the following: -Staff documented informed consent for the use of side rails for bed mobility on 8/15/2022; -Staff documented completion of the Nursing Admission Data Collection, dated 8/15/2022. Staff documented the resident did use or request to use side rails to promote independence with bed mobility and positioning; -Staff did not document a pre-use risk evaluation/assessment for the use of side rails. 4. Record review of Resident #12's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive assistance required for transfers, mobility, dressing, and toilet use; -Limited assistance required for bed mobility, personal hygiene, and eating; -Indwelling catheter (sterile tube used to drain urine). Observation and interview on 11/14/2022, at 2:00 P.M., showed one-half side rails on the both sides of the resident's bed in the up position. The resident was seated in his/her recliner and said that he/she used the side rail to assist with repositioning in bed. He/she did not remember any assessment or forms required to be signed for the side rail. Observation on 11/16/2022, at 11:00 A.M., showed the resident seated in his/her recliner. The bed had side rails in the up position. Record review of the resident's care plan, dated 9/22/2022, showed the following information: -The resident had an activities of daily living self-care deficit; -The resident will demonstrate the appropriate use of adaptive devices to increase ability in bed mobility, transfers, eating, dressing, toilet use and personal Hygiene; -Required one staff assistance to reposition and turn in bed; -The care plan showed no other information related to the side rails. Record review of the resident's November 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's EMR, showed the following: -Staff documented informed consent for the use of side rails for bed mobility on 9/14/2022; -Staff did not document a pre-use risk evaluation/assessment for the use of side rails. 5. Record review of Resident #199's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive assistance required for transfers, mobility, dressing, personal hygiene, and toilet use; -Set up assistance for eating. During observation and interview on 11/15/22, at 11:25 A.M., resident's bed had bilateral one-half size side rails in the up position. The resident was seated in the bedside chair. He/she said that he/she used the side rails to assist with repositioning in bed. Observation on 11/16/2022, at 8:30 A.M., the resident rested in bed with his/her eyes closed and the side rails in the up position. Record review of the resident's November 2022 POS showed staff did not document any physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's EMR, showed the following: -Staff documented informed consent for the use of side rails for bed mobility on 11/10/2022; -Staff did not document a pre-use risk evaluation/assessment for the use of side rails. Record review of the resident's care plan, dated 11/12/2022, showed the following information: -The resident had an activities of daily living self-care deficit; -Required two staff assistance to reposition and turn in bed; -The care plan showed no information related to the side rail use. 6. During an interview on 11/17/2022, at 10:20 A.M., the Social Services Director (SSD) said the nurse assesses a resident for the need or request for side rails or requests that therapy do an evaluation and recommend a side rail. The nurse obtains signed consent for the use of side rails and requests Maintenance to install the rails. 7. During an interview on 11/17/2022, at 10:30 A.M., Maintenance said he was responsible for installing bed rails when requested by nursing staff. He installs rails according to manufacturer's guidelines for the type of bed and completes the initial safety gap measurements. He did not do further periodic bed rail safety checks, unless someone asked him to do so. 8. During an interview on 11/17/2022, at 10:50 A.M., the Administrator said staff should obtain informed consent for the use of side rails on a resident's bed. Maintenance installs the bed rails and completes the safety gap measurements. 9. During an interview on 11/17/2022, at 3:45 P.M., the Administrator said staff should complete a Device Evaluation for each resident on admission and quarterly. A pre-use evaluation should also be done if a resident or responsible party requests side rails after admission. Maintenance should complete periodic safety checks on all bed rails.

Based on observation, interview, and record review, the facility failed ensure proper care for all residents with catheters (a sterile tube inserted into the bladder to drain urine) when staff failed to obtain updated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 48. 1. Record review of Resident #12's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/26/22, showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Cognitively intact; -Total dependence on staff assistance for transfers, dressing, toileting, and bathing; -Limited assistance required with bed mobility and personal hygiene; -Always continent of bowel and bladder; -Indwelling catheter present. Record review of the resident's care plan, dated 9/14/22, showed the following: -Resident has catheter and is incontinent of bowel at times; -Monitor for signs/symptoms of urinary tract infection; -Perform catheter care every shift and as needed. Record review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Catheter 20 French indwelling catheter with 30 milliliter(mL) in balloon on admission 9/14/22; -Discontinue catheter on 9/27/22; -Change catheter drainage bag as needed for leaking until 09/27/2022; -Remove catheter per original orders for on day, if resident still needs catheter, call the doctor for a new order; -No new orders documented for catheter after 9/27/22. Record review of the resident's nurse progress notes showed the following: -On 9/27/22, at 2:38 P.M., staff removed the 20 French Foley per doctor's order. The resident stated that he/she had a catheter for over [AGE] years and that we will have to put one back. Educated on increased risk of infection associated with catheter use. He/she expressed understanding, but stated that every time it gets discontinued they have to put another one in because he/she cannot control his/her voiding. The resident stated, Be ready to be changing me and my bed all the time because I am just going to wet all the time. Educated resident to notify staff by turning on call light whenever he/she voids; -On 9/27/22, at 9:40 P.M., staff replaced the catheter with size 18 French, resident tolerated well, urine flowing light yellow, will continue to monitor. Observation and interview on 11/15/22, at 11:42 A.M., showed the resident seated in a recliner with the Foley catheter collection bag tucked into the recliner side pocket. The resident said that his/her bladder does not work and he/she has had a catheter for several years. Observation on 11/16/22, at 1:00 P.M., showed the resident in his/her recliner and the Foley catheter bag was tucked into the recliner pocket. During an interview on 11/17/22, at 2:40 P.M., Licensed Practical Nurse (LPN) F said that the order for the catheter was to be discontinued, but that was a hospice order and that when the doctor found out he did not want the catheter to be discontinued. The catheter was re-inserted due to [CONDITION(S)] bladder diagnosis. During an interview on 11/17/22, at 2:55 P.M., the Director of Nursing (DON) said that the order to discontinue the catheter on 9/27/22 should have been completed off the order sheet. She said that the facility prefers not to have catheters in the facility if possible. She said that she did not know if the catheter was removed or if the resident refused to have it removed. She said that if the staff did remove the catheter there should have been a new order to re-insert catheter. The order should be up to date. During an interview on 11/17/22, at 4:00 P.M., the Administrator said that staff should follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #6) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 48. Record review showed the facility did not provide a policy regarding PASARR requirements. 1. Record review of Resident #6's Level 1 Nursing Facility Pre-Admission Screening for Mental Illness/Mental [CONDITION(S)] or related condition, dated 5/23/19, showed the following information: -Does not show any signs of symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had never had serious problems in levels of functioning in the last six months; -Not known or suspected to have mental [CONDITION(S)] that originated prior to age 18; -Not known or suspected to have a related condition; -Did not qualify for a special admission category. Record review of resident's face sheet showed the following information: -admitted on [DATE]; -Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Diagnosis, dated 12/18/19, included paranoid [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally - may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning) and generalized anxiety disorder; -Diagnosis, dated 10/1/22, included dementia with agitation (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of the resident's medical record showed no new Level II PASARR screening had been completed. During an interview on 11/17/22, at 11:00 A.M., Licensed Practical Nurse (LPN) E said that after a PASARR screening is submitted, if there is a change in Medicaid status a new form may need to be completed. He/she was unsure if a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/17/22, at 2:46 P.M., the Administrator said that at the time of the resident's admission in 2019 and submission of the PASARR screening the facility was not aware of the paranoid [CONDITION(S)] diagnosis. She said that the PASARR screening should have been re-submitted with the new diagnosis.

Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for two residents (Residents #6 and #37) who were transferred out to the hospital. The facility census was 48. Record review of the facility's policy entitled Bed Hold Policy & Agreement Form, revised February 2014, showed the following: -Purpose to establish policy and procedure for facility to notify the resident/responsible party of the Bed Hold Policy and Agreement To Pay Charges For Bed Hold. The facility is to execute an acknowledgement stating whether or not such resident desires to exercise his or her right to a bed hold. The policy should meet applicable regulatory, federal and state program guidelines; -The Bed Hold Agreement is to be obtained for each occurrence - hospital or therapeutic home leave; -When hospital or therapeutic home leave is reported on the Midnight Census, the Social Service Director (SSD)/Business Office will notify the resident/responsible party to sign the Bed Hold Agreement. The SSD/Business Office will address weekend or holiday transfers to the hospital on the next business day; -When the resident goes to the hospital the bed may be held by paying the rate as identified in the Bed Hold Agreement; -A telephone call may be documented as notification on the Bed Hold Agreement. 1. Record review of Resident #37's face sheet (gives brief information about the resident) showed the following information: -admitted [DATE]. Record review of the resident's progress notes showed staff documented the following: -On 9/30/2022, at 8:29 A.M., staff rechecked blood glucose after night shift received 536 milligrams/deciliter (mg/dl) blood sugar and physician gave order for this nurse to give 10 units regular insulin. It has been about one hour since insulin was given. Staff gave resident eggs and water at breakfast. AccuCheck (used to check blood sugar levels) machine only gave high reading, no number given. Staff rechecked twice with the same reading. Staff notified physician and he/she stated to recheck in two hours, as it can take four hours for the insulin to peak. Resident left up for monitoring and encouraging water; -On 9/30/2022, at 8:53 A.M., staff noted the resident's hand shaking. Staff rechecked glucose level and received a reading of 524 mg/dl; -On 9/30/2022, at 10:36 A.M., staff noted blood sugar still 396 mg/dl. Staff notified physician of level and that resident's brief was also dry. The resident had not voided since 6:15 A.M. Physician ordered another 7 units of insulin and to recheck in four hours. Staff made the family aware and would like updated on rechecks and physician calls; -On 9/30/2022, at 2:45 P.M., staff noted the resident's blood sugar down to 226 mg/dl and notified the physician; -On 9/30/2022, at 3:34 P.M.: staff notified family notified of IV (intravenous - administered into the blood vein) fluids to be run; -On 10/1/2022, at 11:29 P.M., staff noted resident in the hospital. Record review of the resident's record showed staff did not document the resident was informed in writing of the facility's bed hold policy at the time of transfer. 2. Record review of Resident #6's face sheet showed the following: -admitted on [DATE]. Record review of the resident's quarterly minimum data set (MDS - an federally mandated assessment tool completed by facility staff), dated 10/28/22, showed the following: -Resident discharged to the hospital with anticipation to return on 7/29/22; -Resident returned from the hospital on 7/31/22. Record review of the resident nurses' notes showed the following information: -On 7/29/22, at 12:45 A.M., staff documented the resident had a change in condition and had coffee brown emesis. The resident appeared restless and complained of tummy pain. The doctor was contacted and gave new orders to include [MEDICATION(S)] (an antianxiety medication), Maalox (used to treat stomach upset), and proton pump inhibitor (used to treat the amount of stomach acid). The resident was only agreeable to take the [MEDICATION(S)]. The resident's responsible party requested resident be sent to the hospital. Record review of the resident's record showed staff did not document the resident was informed in writing of the facility's bed hold policy at the time of transfer. 3. During an interview on 11/17/2022, at 10:20 A.M., the SSD said he/she did not send a written notification of hospital transfers; only for permanent transfers or discharges. The SSD said he/she had the resident or responsible party sign agreement with the Bed Hold policy upon transfer or on the next business day. 4. During an interview on 11/17/2022, at 11:10 A.M., the Administrator said the facility's policy was to verbally notify a resident's responsible party of a transfer to the hospital. A copy of the written transfer notice, which includes the Bed Hold Policy on the reverse side, should be mailed to the responsible party or given to the resident if they were self-responsible and alert and oriented.

Based on interview and record review, the facility failed to ensure one nursing assistant (NA B) completed a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. This deficient practice had the potential to affect all residents who received care from the NA. The facility's census was 48. Record review showed the facility did not provide a written policy pertaining to Certified Nurse Aide (CNA) training and certification testing. 1. Record review of NA B's personnel file showed the following: -Date of hire: 6/28/2022; -Staff did not have documentation NA B had completed the nurse aide training program and passed the required certification testing. Record review of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification. Observation on 11/14/2022, at 1:02 P.M., showed NA B was passing meal trays wearing a name tag with his/her name and title of NA. During the observation, he/she told the surveyor that he/she had been employed at the facility since June 2022. Observations on 11/15/2022, at 1:32 P.M., and 11/16/2022, at 9:15 A.M., showed NA B providing direct care to residents in the facility. NA B wore an identification badge bearing his/her name and the title NA. During an interview on 11/17/2022, at 3:25 P.M., with the Administrator and the Assistant Director of Nursing (ADON), the Administrator confirmed that NA B was hired on 6/28/2022. The ADON said NA B had finished the classroom and clinical training, but had not completed the testing for CNA certification and was not yet scheduled for the testing. The Administrator and the ADON said NA's should complete their training and pass the certification testing within four months.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for one resident (Resident #37) and failed to notify the ombudsman of transfers to the hospital for two residents (Residents #6 and #37). The facility census was 48. Record review showed the facility did not provide a a written policy pertaining to transferring a resident to the hospital. Record review of a facility form entitled Notice of Resident Transfer or Discharge, revised 11/2016, showed the following spaces to fill: -Date of notice; -Name, address, city, state, and zip (did not specify for whom); -Salutation to addressee; -Name of resident; -Name and location of institution where resident to be transferred/discharged ; -Date of transfer; -Rationale for transfer; -Facility contact information for appeal; -Information regarding State Long-Term Care Appeal Agency, State Ombudsman, State Agency for the Developmentally Disabled, and State Agency for the Mentally Ill; -Signature/Title/Date by facility; -Signature of resident or responsible party acknowledging receipt of the notice. 1. Record review of Resident #37's face sheet (gives brief information about the resident) showed the following information: -admitted [DATE]. Record review of the resident's progress notes showed staff documented the following: -On 9/30/2022, at 8:29 A.M., staff rechecked blood glucose after night shift received 536 milligrams/deciliter (mg/dl) blood sugar and physician gave order for this nurse to give 10 units regular insulin. It has been about one hour since insulin was given. Staff gave resident eggs and water at breakfast. AccuCheck (used to check blood sugar levels) machine only gave high reading, no number given. Staff rechecked twice with the same reading. Staff notified physician and he/she stated to recheck in two hours, as it can take four hours for the insulin to peak. Resident left up for monitoring and encouraging water; -On 9/30/2022, at 8:53 A.M., staff noted the resident's hand shaking. Staff rechecked glucose level and received a reading of 524 mg/dl; -On 9/30/2022, at 10:36 A.M., staff noted blood sugar still 396 mg/dl. Staff notified physician of level and that resident's brief was also dry. The resident had not voided since 6:15 A.M. Physician ordered another 7 units of insulin and to recheck in four hours. Staff made the family aware and would like updated on rechecks and physician calls; -On 9/30/2022, at 2:45 P.M., staff noted the resident's blood sugar down to 226 mg/dl and notified the physician; -On 9/30/2022, at 3:34 P.M.: staff notified family notified of IV (intravenous - administered into the blood vein) fluids to be run; -On 10/1/2022, at 11:29 P.M., staff noted resident in the hospital. Record review of the resident's medical record showed staff did not document written notification to the resident or resident's responsible party of the resident's transfer to the hospital on 9/30/2022 or 10/1/2022. Record review of the facility provided information showed staff did not documentation notifying the Ombudsman of the resident's transfer to the hospital. 2. Record review of Resident #6's face sheet showed the following: -admitted on [DATE]. Record review of the resident's quarterly minimum data set (MDS - an federally mandated assessment tool completed by facility staff), dated 10/28/22, showed the following: -Resident discharged to the hospital with anticipation to return on 7/29/22; -Resident returned from the hospital on 7/31/22. Record review of the resident nurses' notes showed the following information: -On 7/29/22, at 12:45 A.M., staff documented the resident had a change in condition and had coffee brown emesis. The resident appeared restless and complained of tummy pain. The doctor was contacted and gave new orders to include [MEDICATION(S)] (an antianxiety medication), Maalox (used to treat stomach upset), and proton pump inhibitor (used to treat the amount of stomach acid). The resident was only agreeable to take the [MEDICATION(S)]. The resident's responsible party requested resident be sent to the hospital. Record review of the facility provided information showed staff did not document notifying the Ombudsman of the resident's transfer to the hospital. 3. During an interview on 11/17/2022, at 10:20 A.M., the Social Services Director (SSD) said he/she did not send a written notification for hospital transfers; only for permanent transfers or discharges. The SSD said he/she sends a monthly log to the ombudsman showing admissions, discharges, and transfers. 4. During an interview on 11/17/2022, at 11:10 A.M., the Administrator said the facility's policy was to verbally notify a resident's responsible party of a transfer to the hospital. A copy of the written transfer notice should be mailed to the responsible party or given to the resident if they were self-responsible and alert and oriented. The monthly log sent to the Ombudsman should include hospital transfers.

Based on interview and record review, the facility staff failed to report an allegation of abuse involving one resident (Resident #1) to facility management immediately and to the Department of Health and Senior Services (DHSS) within two hours as required. The facility census was 45. Record review of the facility's Abuse and Neglect Policy and Procedures, updated 6/06/19, showed the following: -The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or his/her designated representative in the administrators absence; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately to the administrator; -The person made aware of allegations of abuse or neglect or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement; -The allegation will be reported no later than two hours after the allegation is made if the event that cause the allegation involve abuse or result in serious bodily injury. 1. Record review of Resident #1's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/22/21, showed the following information: -Adequate hearing; -Makes self understood; -Ability to understands others; -Ability to recall; -No disorganized thinking; -No evidence in acute change of mental status. During an interview on 12/8/21, at 9:55 A.M., Certified Nurse Aide (CNA) A said the following: -On 12/5/21, at approximately 2:00 P.M., he/she heard CNA B yelling at the resident; -He/she rushed to the resident's room; -CNA B was in the resident's room alone; -He/she saw the resident resisting the dressing change and the resident did not want to lay down; -CNA B yelled at the resident, if you don't stop, I will [OBSCENITY] slap you; -CNA B's yelling was upsetting and confusing the resident; -He/she should have reported immediately; -The incident occurred when management staff were gone; -On 12/7/21, at approximately 9:30 A.M., he/she reported the allegation of abuse to the Director of Nursing (DON). Record review of DHSS records show the facility reported the allegation of abuse the morning of 12/7/21. Record review of the facility's investigation related to the resident's allegation showed on 12/5/21, Certified Nurse Aide (CNA) A failed to report suspected abuse in a timely manner. During an interview on 12/8/21, at 11:20 A.M., CNA C said staff should report all allegations of abuse immediately to the charge nurse and within two hours to DHSS. During an interview on 12/8/21, at 12:20 P.M., the Activity Director (AD) D she said the following: -CNA B has temperament issues towards residents; -He/she over reacts and gets aggressive and angry with residents; -Staff have been trained on abuse and neglect reporting requirements. During an interview on 12/8/21, at 2:35 P.M., CNA B said the following: -On 12/5/2021, at approximately 2:00 P.M., he/she wheeled the resident from the nurses' station to his/her room; -The resident needed a dressing change; -The resident is a two staff assist and is a Hoyer (a mechanical device designed to assist staff in lifting and moving residents) lift; -He/she did not request assistance from other staff; -Hooked the resident on the Hoyer and changed the resident's under pants; -The resident was yelling, leave me alone; -Did not verbally abuse the resident and did not use offensive language while taking care of the resident. During interview on 12/8/21, at 4:05 P.M., the Director of Nursing (DON) said all staff were educated and trained on abuse and neglect reporting requirements. During interview on 12/8/21, at 4:15 P.M., the Administrator said the following: -Staff did not follow facility abuse policy; -She expects all allegations regarding abuse to be reported immediately to DHSS within two hours, as per facility policy; -Use of offensive language is not an appropriate way of communicating with residents; -She would expect all staff to report abuse immediately to the charge nurse; -Staff did not follow facility policy. MO 288

Based on record review and interview, the facility failed to ensure one resident (Resident #1) was free from abuse when (Certified Nurse Aide (CNA) B) spoke to the resident in an aggressive manner, used force to physically restrain the resident's arms/hands, and provided positioning in a rough manner. The facility census was 46. Record review of the facility's Abuse, Prevention and Prohibition Policy (revised 11/2018), showed the following information: - Statement of Intent: Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone; -Policy: This facility prohibits mistreatment, neglect or abuse of residents; -Abuse Prohibition Program: The facility's abuse prohibition includes Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response; -Abuse definition: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/25/2020, showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Severely impaired cognition; unable to make decisions; -Sometimes short-tempered; no other behaviors exhibited during the seven day lookback period; -Frequently incontinent of bowel and bladder; -Required extensive assistance of two staff for dressing and toileting; one staff for bathing and other personal grooming; limited assistance for eating. Record review of the facility's investigation summary, signed by the Administrator, the Director of Nursing (DON), and the Social Services Director (SSD), showed the following information: -On 9/4/2020, shortly after 7:00 A.M., CNA A reported to the ADON that during care around 7:00 A.M., CNA C was rough and spoke aggressively to a resident (Resident #1); -The ADON immediately reported this to the Administrator, and the facility started an investigation; -The facility suspended the alleged perpetrator (CNA C) prior to having any other resident interaction before leaving the building; -The charge nurse and the DON assessed the resident and found no injuries or new bruising. They notified the Missouri Department of Health and Senior Services, the local sheriff's department, the physician, and Resident #1's family member. During a telephone interview on 9/4/2020, at 4:58 P.M., CNA A said the following: -That morning around 7:00 A.M., CNA A and CNA C went in to get Resident #1 up for breakfast. CNA A uncovered the resident and said Good morning. CNA C started undressing the resident to change his/her brief. The resident became anxious and combative toward both staff; -CNA C used her hand to forcefully hold the resident's arms crossed against the resident's chest, and used a raging, then very aggressive voice to tell the resident, Quit! You need to quit; we are changing you!; -CNA A's arm was in a sling and he/she could not turn or lift the resident; CNA B came in to assist with turning the resident for completing the brief change; -After changing the resident's brief, CNA C yanked the resident to a sitting position by pulling on her wrists, still loudly telling the resident to Quit! CNA C insisted the resident get out of bed; -The resident was upset and screamed throughout the procedure, quieting once staff positioned the resident in his/her wheelchair and nobody touched him/her; -The CNA immediately went and reported the incident to the Assistant Director of Nursing (ADON); -CNA A said staff should not insist a resident get out of bed against his/her wishes and should be left alone if combative. During a telephone interview on 9/4/2020, at 11:15 P.M., CNA B said the following: -When CNA B arrived at Resident #1's room to assist, the resident yelled out and was combative, resistive to getting up and resistive to care by CNA A and CNA C; -CNA C held both of Resident #1's hands/wrists, forcing them toward the resident's chest. CNA B could see the resident tense up and try to push CNA C away; -CNA C was yelling, in a definitely raised voice, Stop it! Stop hitting me!; -CNA B said he/she stepped in and held the resident's hands while talking to him/her to calm him/her down; -CNA C yanked the resident by the shoulder and hip to turn him/her toward CNA C and CNA B, causing the resident's head to almost hit CNA B's hip; -CNA C then forced the resident to sit up, against his/her wishes; the resident seemed to want to stay in bed. During a telephone interview on 9/8/2020, at 8:51 A.M., CNA C verified his/her written statement and said the following: -CNA A and CNA C changed Resident #1 for breakfast. The resident was combative, hitting and pinching the staff. CNA C crossed the resident's arms on his/her chest and held them with one hand, telling the resident they were not hurting him/her; only changing and getting him/her up for breakfast; -CNA C did not use too much force or endanger the resident; just acted to protect the resident from hurting him/herself or the staff. The CNA said he/she did nothing to harm the resident and didn't squeeze him/her; just held onto him/her to protect against his/her flailing arms; -CNA C did not yell at the resident, but got louder when saying the resident's name to get his/her attention; -CNA C did not use force to turn or lift the resident during care. During an interview on 9/8/2020, at 2:35 P.M., the DON said it was inappropriate for any employee to use force to restrain a resident or yell at a resident. Staff should not force a resident to get up if they don't want to. If a resident is combative, staff should walk away and retry the care later or with different staff. #MO 003

Based on observation, interview, and record review, the facility failed to protect food from possible contamination when staff failed to follow proper hand hygiene when handling food items and food contact surfaces; when staff failed to properly wear facial hair nets and hair nets; when staff failed to ensure that the warewasher was working properly; and when staff failed to keep open drinks out of the kitchen. The facility had a census of 49 residents. 1. Record review of the 2013 Food and Drug Administration (FDA) Food Code showed the following information: -Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; -After touching bare human body parts other than clean hands and clean, exposed portions of arms; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; -Before donning gloves to initiate a task that involves working with food; -After engaging in other activities that contaminate hands. Record review of the facility's (undated) policy titled, Handwashing, showed staff to wash hands whenever they are soiled and before food preparation. Record review of facility records showed the facility did not provide a policy for glove usage for the kitchen or food preparation area. Observation of the kitchen on 10/23/19, beginning at 9:58 [NAME]M., showed the following information: -Cook G exited the kitchen into the main dining room and re-entered the kitchen; -Cook G touched a trash can liner inside of the dishwashing area with his/her right hand; -Cook G entered the dry goods room, picked up a paper cover, and placed the paper cover over the open, upright water pitchers; -Cook G exited the dry goods room, entered the kitchen, picked up a clear plastic pitcher, went to the ice machine, and used the scoop to fill the pitcher with ice; -Cook G exited the kitchen with the pitcher filled with ice; -During this timeframe, Cook G did not wash his/her hands or utilize gloves. Observation of the kitchen on 10/23/19, beginning at 9:58 [NAME]M., showed the following information: -Dietary Aide (DA) F washed hands and put on gloves; -DA F began to fill 8 ounce plastic cups with milk and put plastic, disposable lids on the cups to cover them; -DA F ran out of milk, exited the kitchen prep area, opened the door to the milk cooler and obtained a gallon of milk, opened the gallon of milk, and proceeded to fill the remaining plastic cups and place plastic, disposable lids on the cups; -DA F opened the reach-in cooler in the kitchen preparation area, retrieved individual dietary shake cartons from the cooler, opened them, poured them into 8 ounce plastic cups, and placed plastic, disposable lids on them; -During this timeframe, DA F did not change gloves or wash hands after touching other non-food contact surfaces with the gloves. Observation of the kitchen on 10/24/19, beginning at 11:23 [NAME]M., showed the following information: -Cook G entered the kitchen from the dining room and sanitized his/her hands with sanitizer on the way in; -Cook G exited the kitchen preparation area and put away his/her personal belongings in the lockers; -Cook G did not wash his/her hands; -Cook G entered the preparation area, retrieved salad items from the reach-in cooler, placed them on a prep area by the sink, and put on gloves that were in a box on the shelf above the sink area (potentially contaminating the gloves); -Cook G reached into the bag of lettuce and removed lettuce from the bag with his/her gloved hand and placed it into two plastic salad bowls; -Cook G opened the bag of cheese and removed cheese with gloved hands and placed it on top of the lettuce in the two plastic salad bowls; -Cook G opened the bag of diced meat and removed the diced meat with gloved hands and placed it on top of the cheese in the two plastic salad bowls; -Cook G diced one tomato and placed it on top of the salad in the two plastic salad bowls; -Cook G did not change gloves or wash hands during this timeframe. During an interview on 10/24/19, at 2:01 P.M., Cook C said the following: -Wash hands upon entering the kitchen after putting away your personal belongings; -Wash hands between glove changes and gloves should be changed when you go from clean to dirty or dirty to clean, touch anything outside of the food prep like door handles or the dishwasher; -Staff should wash hands all the time. During an interview on 10/24/19, at 2:18 P.M., the Certified Dietary Manager (CDM) said the following: -Hand hygiene should be performed all the time; -When staff enter the kitchen, if staff open a cooler or freezer door to get something, after going to the dry goods room to do or get something, going from dirty to clean, and with every glove change; -Kitchen staff have been trained and in-services have been completed on hand hygiene; -They should not use only sanitizer upon entering the kitchen, they must still wash hands; -They should wash their hands after touching a trash can liner, cooler or freezer doors, or taking dirty dishes to the dish area; -They should wash hands after exiting the dry goods room; -They should wash hands after changing gloves and gloves should be changed after they have touched any other surface besides the food they are preparing. During an interview on 10/24/19, at 7:30 P.M., the administrator said the following: -Staff should wash hands upon entering the kitchen, going from dirty to clean, and after touching non-food areas; -They cannot touch everything with their gloves and if they do touch something gloves should be changed, hands washed, and new gloves put on; -He/she expects kitchen staff to follow the facility hand washing and glove usage policies. 2. Record review of the 2013 FDA Food Code showed the following information: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed to be worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Record review of facility records showed the facility did not provide a policy for for hair restraints or beard restraints. Record review of the facility's employee in-service, dated 9/16/19, showed the following information: -Employees received an in-service that hair nets and beard nets must be worn at all times when in the kitchen; -Cook C signed the attendance form. Observation of the kitchen on 10/21/19, beginning at 10:05 [NAME]M., showed Cook C had a full beard and did not wear a beard restraint. Observation of the kitchen on 10/23/19, beginning at 9:58 [NAME]M., showed the following information: -Cook C had a hair net on his/her head; -Cook C had a pony tail that was exposed and hung below the hair net down his/her back about six inches; -Cook C continued to prepare food with the pony tail exposed outside of the hair net. During an interview on 10/24/19, at 2:01 P.M., Cook C said the following: -Hair nets and beard nets are required at all times in the kitchen; -Beard nets are to be worn with any facial hair; -He/she should have had a beard net on his/her face on 10/21/19; -His/her pony tail should have been covered by the hair net on 10/23/19. During an interview on 10/24/19, at 2:18 P.M., the CDM said the following: -If a facility employee has facial hair, they must wear a beard net while working in any area of the kitchen; -Hair nets should cover all of the hair and are required for any employee working in any area of the kitchen; -Cook C should have worn a beard net and his/her pony tail should have been covered by the hair net. During an interview on 10/24/19, at 7:30 P.M., the administrator said she expects facility employees to follow the facility policy and wear hair and beard nets at all times while working in the kitchen. 3. Record review of the 2013 FDA Food Code showed the following information: -Warewashing machines require the presence of a temperature measuring device in each tank of the warewashing machine and is based on the importance of temperature in the sanitization step; -In hot water machines, it is critical that minimum temperatures be met at various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the minimum temperature for sanitization; -When chemical sanitizers are used, specific minimum temperatures must be met because of the effectiveness of chemical sanitization is directly affected by the temperature of the solution. Record review of the facility's Hobart Warewashing Machine Wash and Rinse Cycle tag showed the following information: -Wash cycles must be at a minimum of 150 degrees Fahrenheit (F) or higher; -Rinse cycles must be at a minimum of 180 degrees F or higher. Observation of the kitchen on 10/22/19, beginning at 9:15 [NAME]M., showed the following information: -DA F started the warewasher with a tray of miscellaneous kitchen utensils; -The rinse cycle registered at 174 degrees F. Observation of the kitchen on 10/23/19, beginning at 9:58 [NAME]M., showed the the warewasher rinse cycle registered at 176 degrees F. Observation of the kitchen on 10/23/19, beginning at 11:48 [NAME]M., showed the following information: -DA [NAME] placed the puree bowl into a tray and began the warewasher; -The warewasher rinse cycle registered at 174 degrees F. Observation of the kitchen on 10/23/19, beginning at 5:54 P.M., showed the warewasher rinse cycle temperature ranged from 159 degrees F to 161 degrees F. Observation of the kitchen on 10/24/19, beginning at 12:01 P.M., showed the warewasher rinse cycle temperature registered at 166 degrees F. During an interview on 10/22/19, at 9:15 [NAME]M., DA F said the following: -The warewasher wash cycle has to be at 150 degrees F or higher and the rinse cycle has to be at 180 degrees F or higher; -If it does not reach those temperatures, then you have to wash the items again. During an interview on 10/24/19, at 2:01 P.M., Cook C said the following: -The warewasher wash cycle must be at 150 degrees F or higher; -The rinse cycle can range from [RM #]80 degrees F or higher; -They record the temperatures daily for each shift on the clipboard; -He/she did not know the rinse cycle must be at 180 degrees F or higher; -He/she has not told the CDM the warewasher is not rinsing at the correct temperature. During an interview on 10/24/19, at 2:18 P.M., the CDM said the following: -The warewasher wash cycle should be at 150 degrees F or higher; -The rinse cycle should be at 180 degrees F or higher; -They test the warewasher daily and record the temperatures on the clipboard; -He/she did not know the temperature for the rinse cycle registered below 180 degrees F. During an interview on 10/24/19, at 7:30 P.M., the administrator said the following: -The warewasher should be utilized per the manufacturer's recommendations; -The wash and rinse cycles should be completed at the recommended temperatures or higher; -If the warewasher did not work correctly, she would expect facility staff to tell the CDM or herself of the problem. 4. Record review of the 2013 (FDA) Food Code showed the following information: -An employee shall not eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment, utensils, and lines; unwrapped single-service and single-use articles; or other items needing protection cannot result. Observation of the kitchen on 10/21/19, beginning at 10:05 [NAME]M., showed the following information: -An open water pitcher filled with a dark liquid sat on the prep table while staff prepared lunch; -Cook C took the pitcher with him/her on break. Observation of the kitchen on 10/22/19, beginning at 9:15 [NAME]M., showed the following information: -An open water pitcher filled with a dark liquid sat on the prep table where staff prepared lunch; -Cook C picked up the water pitcher, took a drink, and moved it to the sink area. Observation of the kitchen on 10/23/19, beginning at 9:58 [NAME]M., showed the following information: -An open water pitcher filled with a dark liquid sat on the prep table by the puree machine and sink; -Cook C picked up the water pitcher, took a drink, and sat it back down by the sink. Observation of the kitchen on 10/24/19, beginning at 11:23 [NAME]M., showed the following information: -An open water pitcher filled with a dark liquid sat on the prep table where staff prepared lunch; -Cook C left the area to go on break and took the open water pitcher with him/her. During an interview on 10/24/19, at 2:01 P.M., Cook C said the following: -There should be no open food or drinks kept in the kitchen prep area; -They should be kept in the lockers and employees should go back there for a drink or snack. During an interview on 10/24/19, at 2:18 P.M., the CDM said the following: -There are to be no open food or drinks in the kitchen area; -All food and drinks for staff are to be kept in their lockers or in the employee break room.

Based on observation, interview, and record review, the facility failed to complete an investigation to determine the cause of a second-degree burns (damage the outer layer and the layer underneath) one resident (Resident #2), with severe cognitive impairment, sustained from hot coffee and failed to develop and implement interventions to protect the resident from any further burns in a selected sample of 11 residents. The facility census was 48. According to the National Institute of Health, U.S. National Library Department of Health and Human Services, updated 11/30/15: -A burn is damage to body tissues caused by heat, chemicals, electricity, sunlight or radiation. -Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns. -There are three types of burns: First-degree burns (damage only the outer layer of skin), second-degree burns, and third-degree burns (damage or destroy the deepest layer of skin and tissues underneath). -Burns can cause swelling, blistering, scarring and, in serious cases, shock and even death. They also can lead to infections because they damage your skin's protective barrier. -treatment for [REDACTED]. Record review of information from the Consumer Product Safety Commission (cpsc.gov) showed most adults would suffer third degree burns if exposed to 150-degree hot water for two seconds. 1. Record review of the facility's policy titled Accidents and Incidents-Investigating and Reporting showed the following: -All accidents or incidents involving residents occurring on the premises shall be investigated and reported to the administrator; -The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident; -The following shall be included on the Report of Incident/Accident form: Date and time the accident and incident took place, nature of the injury, circumstances surrounding the accident or incident, where the accident or incident took place, names of witnesses and their accounts of the accident or incident, the injured person's account, the time the attending physician was notified, as well as physician's response and instructions, the date/time the injured person's family was notified and by whom, the disposition of the injured (hospital, put to bed, sent home, etc), any corrective action taken, follow-up information, other pertinent data as necessary or required and the signature of person completing the report; -This shall be completed and submitted to the Director of Nursing within 24 hours of the accident or incident; -The Director of Nursing (DON) shall ensure the administrator receives a copy of the form. Record review of Resident #2's face sheet (admission information) showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/14/15, showed: -Severe cognitive impairment; -Assistance of two staff for transfers, dressing, hygiene, and bathing; -Limited assistance of one staff for eating; -Used a wheelchair for mobility. Record review of the resident's care plan, dated 11/16/15, showed: -The resident needed two staff to assist him/her with transfers, toileting, dressing, and hygiene; -He/she fed himself/herself, but needed supervision and set up at times; -Staff should check on the resident frequently for safety and comfort and try to anticipate his/her needs as much as possible. Record review of a nurse's note dated 11/26/15, at 8:00 A.M., showed a nurse documented staff found the resident in the TV room. He/she had assisted himself/herself to coffee and dropped it on his/her left thigh. The nurse assessed the resident and found the resident had red, peeling skin on his/her thigh and groin, extending down to his/her knee. The nurse obtained an order for [REDACTED]. The nurse did not document measurement of the burns. Record review of a physician's orders [REDACTED]. Record review of the resident's care plan showed on 11/26/15 staff added the following information: -The resident spilled hot coffee and had a burn to his/her left thigh; -Perform the treatment as ordered; -Medicate the resident for pain due to the burn; -Notify the physician if the area worsened or did not improve with current measures; -Precautions with hot liquids; -Supervision and assistance to prevent spilling. During an interview on 12/04/15, at 9:10 A.M., the MDS coordinator said on 12/02/15 she added precautions with hot liquids and supervision and assistance to prevent spilling to the resident's care plan, but she did not really know what she meant when she wrote it. During an interview on 12/4/15, at 1:15 P.M., the DON said staff added precautions with hot liquids and supervision and assistance to prevent spilling to the resident's care plan on 12/02/15. Record review of the resident's nurses' notes showed the following: -On 11/30/15 (no time documented), a nurse documented the resident's left thigh was red with blisters along the upper left thigh and groin. The nurse would continue to monitor; -On 12/02/15, at 2:30 P.M., a nurse documented the resident's left leg was red and had popped blisters and scabs covering the reddened area. The nurse would continue the treatment as ordered; -On 12/03/15, at 3:00 A.M., a nurse documented the resident had blisters to his/her left upper thigh. His/her left hip and upper thigh looked beefy red and angry. The resident denied pain, but guarded the area; -On 12/03/15, at 9:00 A.M., a nurse documented the resident had three large dried scabs on his/her outer thigh that measured 3 centimeters (cm) x 3 cm and a large red raw area on his/her groin with scabs that measured 2 cm x 2 cm; the nurse did not observe any drainage and continued the treatment as ordered. Observation on 12/03/15, at 3:25 P.M., showed the resident lay in bed while Licensed Practical Nurse (LPN) M prepared the treatment to the resident's burn. The LPN said the resident was medicated for pain approximately one hour ago. With the assistance of a Certified Nurse Aide (CNA), LPN M pulled back the bedding from the resident's left thigh and showed a thin, shiny, red and pink area of new skin, approximately 8 inches (long) x 1 inch (wide), at the top of the left thigh, near the crease of the groin, extending downward toward the knee; a second thin, shiny, red and pink area of new skin, approximately 4 inches (long) x 1 inch (wide), branched off from the top of the left thigh burn and extended down (perpendicular) to the resident's inner thigh at the groin area near the crotch. Three to four brown, crusty, scabbed areas, approximately 1/4 to 1/2 inch in diameter, were located in various portions of the shiny, red and pink areas of new skin; the nurse observed no drainage. LPN M cleaned and applied Silvadene to the areas. During an interview on 12/02/15, at 2:25 P.M., the resident's family member said: -He/she visited the resident every day; -Staff told him/her the resident tried to get himself/herself coffee and spilled it causing a burn; -Staff had not talked with him/her about ways to avoid future burns; -He/she was concerned about this happening to the resident again. During an interview on 12/02/15, at 2:35 P.M., CNA L said: -The resident propelled himself/herself around the facility in a wheelchair, ate his/her meals in the main dining room, liked coffee with meals and sometimes wanted coffee in the afternoon or evening; -He/she had never seen the resident attempt to get coffee from the thermal coffee servers in the day room; -He/she had just taken the resident a cup of coffee. He/she always puts one or two ice cubes in the coffee before giving it to the resident. No one told him/her to do this, he/she does this for most of the residents that drink coffee; -He/she did not know exactly how the resident's burns occurred. He/she thought it happened in the dining room; -He/she did not know of any new precautions implemented for the resident since the burns occurred. During an interview on 12/02/15, at 2:50 P.M., CNA F said: -He/she was not working the day the resident got burned; -Another staff told him/her that someone gave the resident a cup of coffee and the resident spilled it in her lap; -He/she was not aware of the resident attempting to get coffee on his/her own before; -He/she did not know of any new interventions put in place for the resident. During an interview on 12/02/15, at 3:05 P.M., Registered Nurse (RN) J said: -He/she was not working on the day the resident received the burns; -He/she was told that the resident was getting coffee unassisted and spilled it on himself/herself; -The resident's burns are healing; -He/she did not know of any new interventions put in place for the resident since this accident. During an interview on 12/03/15, at 8:30 A.M., RN G said: -He/she worked the day the resident received the burns; -No one witnessed the accident. The aides who worked that day said they did not give the resident a cup of coffee. The RN did not know if someone gave the resident a cup of coffee or if the resident attempted to get coffee without help. An aide found the resident in the TV room with coffee spilled on him/her; -Typically, in the mornings, an aide will take the resident to the dining room for coffee; -He/she was not aware of any times the resident had attempted to get coffee without help; -The resident's burns are healing; -No new interventions were put in place for the resident since this accident. During an interview on 12/03/15, at 9:45 A.M., the Dietary Manager said: -Around 5:45 A.M., dietary staff makes coffee, pours it in thermal coffee servers and places the coffee servers in the dayroom for the residents; -Dietary staff refills the thermal coffee servers as needed throughout the day. The residents let dietary staff know when the coffee is empty; -Staff can access to the kitchen during the night and make coffee if residents wanted it. Observation on 12/03/15, at 11:10 A.M., showed the temperature of the coffee, brewed into the thermal coffee server, measured 170 degrees Fahrenheit (F). During an interview on 12/04/15, at 9:00 A.M., CNA D said: -He/she brought the resident to his/her room after finding the resident in the TV room with coffee spilled; -He/she notified the nurse that the resident had burns; -He/she did not witness what happened and did not know if someone gave the resident coffee or if the resident attempted to get coffee without help; -He/she did not give the resident coffee in the dayroom that morning; -He/she takes the resident to the dining room if the resident wants coffee. He/she always cools the coffee before giving it to the resident; -No new interventions put in place for the resident since the accident. During an interview on 12/04/15, at 9:10 A.M., the MDS coordinator said: -She did not know how the resident got the burns. Nursing staff told her the resident attempted to get coffee from a thermal coffee server in the TV room and spilled it; -The interdisciplinary team did not discuss how to prevent burns from happening again; -We should put our heads together and find out why this happened and how to prevent it; -She does not complete any type of assessments to determine if residents are safe to handle hot liquids. Observation on 12/4/15, at 9:30 A.M., one hour after staff filled a thermal coffee server, showed the temperature of the coffee measured 160 degrees F. During an interview on 12/04/15, at 1:15 P.M., the DON said: -She did not think the resident attempted to get coffee on his/her own, someone must have handed it to him/her; it could have been another resident; -After the accident, she talked to one aide who said he/she did not know how the resident got the coffee and she also talked to a charge nurse; -After talking with the aide and charge nurse, she completed an incident report; -She did not interview any residents; -Staff did not implement any new interventions for the resident; -Staff did not evaluate residents to determine if they were safe with hot liquids. Observations made during the survey from 12/01/15 to 12/04/15 showed the following information: -Staff placed two thermal coffee servers and several coffee cups on a table, easily accessible by all residents, in the day room. Throughout the day, residents entered the day room and poured themselves a cup of coffee. -Resident #2 propelled his/her wheelchair using his/her feet. He/she ate meals in the main dining room and needed encouragement from staff to eat. He/she fed himself/herself and drank coffee, independently, from a cup or glass. He/she answered yes/no questions, but did not hold a conversation. During an interview on 12/10/15, at 12:00 P.M., the Nurse Practitioner (NP) said: -On 12/03/15, when she filled in for the resident's primary physician, was the first time she saw the resident's burn; -It was a second degree burn and was healing well; -When she observed the resident in the dining room, the resident held his/her cup steady and did not have any shakiness; -The NP ordered Tramadol for pain, with instructions for staff to administer the medication, to the resident, before performing the treatment to his/her burn; -As far as she knew, the resident was doing well. Staff had not placed the resident on the list, for the physician to see, since receiving the burn.