Every finding on record at Heritage Care Center

Based on interview and record review, the facility failed to ensure residents were able to communicate freely with the State Survey Agency (SSA) when the facility's Social Service Director (SSD) and Administrator confronted one resident after the resident voiced concerns about calling the SSA hotline (Resident #15). The sample was 10. The census was 103. Review of the facility's Grievance policy, dated 12/27/24, showed the following:-Purpose: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal;-Resident Right to File a Grievance: Every resident has the right to voice their grievance with the facility or other agency. Grievances could include care and treatment that was not provided, behavior or staff or other residents, or any other concerns regarding their stay. A grievance is a formal complaint, not a question or concern brought to a staff member or a call to the compliance hotline. Review of the facility's Resident Rights policy, dated 9/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Policy: In the case of Resident being adjudged incompetent by a court of competent jurisdiction, the rights of Resident are exercised by the person appointed under State law to act on Resident's behalf;-Resident Rights under Social Security Act: Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside Facility. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/30/26, showed the following:-No cognitive impairment;-No behaviors;-Independent with activities of daily living;-Diagnoses included high blood pressure, diabetes, anxiety disorder, depression, bipolar disorder (a mental health condition that causes extreme shifts in mood) and schizophrenia (a chronic brain disorder that causes people to interpret reality abnormally). Review of the resident's behavior notes, showed the following:-On 5/1/26 at 2:06 P.M., the Social Worker spoke with resident regarding phone calls made to SSA. The resident said that his/her peers asked him/her to call for them and he/she does not want to call for them anymore. The Social Worker and Administrator informed resident that he/she was not obligated to contact SSA for his/her peers, resident stated okay and he/she would not do it again;-On 5/6/26 at 10:09 A.M., the resident contacted SSA this morning with false allegations. The resident said someone did something to him/her. This writer contacted the resident's guardian to inform them of resident's actions. The resident's guardian said that resident contacted him/her and told him/her he/she called State, but resident did not say the reason for his/her call to the SSA. The guardian said he/she will speak with resident as to why he/she made the allegations. The Social Worker will also speak with resident. During an interview on 5/15/26 at 1:05 P.M., the resident said the Administrator and SSD spoke with him/her about calling the SSA hotline. When speaking with them, he/she felt threatened and was told he/she would be kicked out of the facility. During an interview on 5/15/26 at 1:20 P.M., Guardian A said he/she spoke with the resident on 5/6/26 about calling the SSA hotline. If the resident needed to call the SSA hotline, Guardian A would not have a problem with this. The resident had a right to express his/her concerns. During an interview on 5/15/26 at 2:40 P.M., the SSD and Administrator said the resident said he/she called the SSA hotline. The SSD said he/she was trying to find out why the resident called the SSA hotline so he/she could help the resident, not to intimidate the resident. The Administrator said any resident had the right to call the SSA hotline to file a report without intimidation or retaliation. The SSA said by asking why the resident called the hotline, he/she can see how it may have seemed like intimidation.

Based on interview and record review, the facility failed to honor the rights of residents to choose their own physician. The facility discontinued services with Physician A, who provided care to 15 residents. Of those, 4 residents were sampled and 2 reported concerns with being unable to choose their physician (Residents #2 and #7). The sample was 8. The census was 104.Review of the facility's Resident Rights policy, dated 9/21/25, showed the following:-Purpose: To ensure that resident rights are protected;-Resident Rights Under Social Security Act: Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. Facility must protect and promote rights of each resident, including each of the following rights:--Notice of Rights and Services: Facility must inform resident both orally and in writing in a language that resident understands of his or her rights and all rules and regulations governing resident conduct and responsibility during the stay in facility;--Free Choice:---Resident has the right to:----Choose a personal attending physician;----Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect Resident's well-being; and----Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed the following:-No cognitive impairment;-No moods or behaviors;-Diagnoses included stroke, cancer, and diabetes. Review of the resident's progress note, dated 3/18/26 at 9:12 A.M., showed the Social Worker placed a call to the resident's guardian to inform them of the primary doctor change effective on 4/1/26. A voicemail was left for the guardian. Review of the resident's medical record, showed no documentation of a legal guardian appointed to the resident. During an interview on 4/15/26 at 11:00 A.M., the resident said he/she was told by management that Physician A would no longer be at this facility and he/she had go to with another physician. He/She told management he/she did not want another physician. The resident is his/her own guardian and power of attorney. He/She wants to stay with Physician A; this is his/her right. 2. Review of Resident #7's annual MDS, dated [DATE], showed the following:-No cognitive impairment;-No moods or behaviors;-Diagnoses included high blood pressure, stroke, and depression. Review of the resident's progress note, dated 3/16/26 at 11:45 A.M., showed the resident was notified that Physician A will no longer have privileges at the facility and he/she will have a new physician. During an interview on 4/16/26 at 8:09 A.M., the resident said his/her physician was Physician A. The resident was not notified Physician A would not have privileges at the facility and he/she was not asked to change physicians. He/She would like to stay with Physician A and would have appreciated being asked to change his/her physician. 3. During an interview on 4/16/26 at 8:37 A.M., the Director of Nursing (DON) and Administrator said the facility's resident rights policy should be followed as written. The Administrator said she received an email from corporate that Physician A would no longer have privileges at the facility. The Administrator and DON were instructed to notify residents, residents' responsible parties, and resident guardians of the change in physician. The DON said she told the residents about the change and did not ask the residents if they wanted to change their physician. She was following directive from her corporate office. There were no letters sent to anyone about the physician change. The Administrator and DON said they should have asked the residents if they wanted to change physicians. 2797307

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7), who had a history of elopement at prior facilities, was provided adequate supervision, when staff did not confirm the resident's whereabouts for at least 4.5 hours (from 2:30 P.M. to approximately 7:00 P.M.) on 01/12/26. Review of the resident's record showed the resident had a legal guardian and diagnoses which included schizoaffective disorder (a chronic mental health condition of schizophrenia symptoms (such as hallucinations, delusions, or disorganized thinking), bipolar type (involves alternating 'poles' of intense, elevated, or irritable mania/hypomania and profound, low energy depressive episodes that severely disrupt life), lack of coordination and muscle weakness. The resident's care plan showed he/she had a history of elopement at prior facilities and interventions included intensive monitoring. The sample was eight. The facility census was 109. The Administrator was notified on 2/13/26 at 5:12 P.M., of an Immediate Jeopardy (IJ) which began on 1/12/26. The IJ was removed on 2/13/26, as confirmed by surveyor onsite verification. Review of the facility's Elopements and Wandering Residents policy, revised 6/12/24, showed:-Purpose: This facility ensures that residents who exhibit wandering behavior and/are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk;-Definition: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal oriented or aimless;-Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/or any necessary supervision to do so;-Policy:-Preventing Elopements: The facility is equipped with door locks/alarms to help avoid elopements;-Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner;-The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary;-Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering:-Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the Interdisciplinary care plan team (IDT);-The Interdisciplinary Team (IDT) will evaluate the unique factors contributing to risk in order to develop a person-centered care plan;-Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff;-Adequate supervision will be provided to help prevent elopements;-Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly;-The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff;-Procedure for Locating Missing Resident: -Director of Nursing (DON) or designee shall notify the physician, and family member or legal representative;-Appropriate reporting requirements to the State Survey agency shall be conducted;-Procedure Post-Elopement: Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. Review of the facility's Incidents and Accidents policy, revised 5/18/24, showed:-Purpose: It is the policy of this facility for staff to utilize Point Click Care Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident;Definition:-Incident: An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization;-Policy: Purpose of Incident Reporting:-The purpose of incident reporting can include:-Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care;-Conducting root cause analysis to ascertain causative/contributing factors as part of the quality assurance performance improvement (QAPI) to avoid further occurrences;-Meeting regulatory requirements for analysis and reporting of incidents and accidents;-Process of Incident Reporting: The following incidents/accidents require an incident/accident report but are not limited to:-Elopement;-Documentation should include the date, time, nature of the incident, initial findings, immediate interventions, notifications and orders obtained or follow-up information. Review of the facility's Intensive Monitoring policy, revised 4/30/24, showed:-Purpose: To ensure a system is in place for residents who require increased monitoring for crisis, behavioral psychiatric issues;-Procedure: Residents who require more intensive monitoring due to crisis, behavioral/psychiatric symptoms will be monitored by the facility staff;-Definitions: Intensive Monitoring is defined as periodic (e.g. hourly, every two hours, or every shift) check by a facility staff member;-Intensive Monitoring: Intensive monitoring is provided as periodic check by a facility staff member;-Residents may require more intensive monitoring based on their crisis, behavioral, psychiatric issues. The level of intensive monitoring shall be defined by the specific situation or resident assessment;-Residents who are showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, and decompensation mentally or crisis may be placed on intensive monitoring or one-to-one or two-to-one (within eyesight of staff) monitoring at the discretion of the administrative staff or facility supervisor;-Based on the assessment of the resident at the discretion of the administrative staff of the facility supervisor, either intensive monitoring, one-to-one, or two-to-one;-The facility's Interdisciplinary Team will address the residents' behavioral concerns and ensure interventions are in place to address the residents' needs;-The facility staff will document the intensive monitoring in the resident's Electronic [NAME] Record (EMR). Review of the facility's Walking Rounds Shift Report policy, revised 5/7/24, showed:-Purpose: It is the policy of this facility to used walking round shift reporting to promote successful transfer of information between nursing staff at shift change in an effort to prevent adverse events, medication errors and medical mishaps;-Policy: Walking rounds shift report will be used for a 24-hour period to ensure continuity of care;-The walking rounds shift report may only be altered by the Director of Nursing (DON), or designee, if there are changes that need to be made;-All staff will be in-serviced on the use of walking rounds shift report prior to implementation as well as upon hire and as needed. Review of Resident #7's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/14/25, showed the following:-The resident was cognitively intact;-Diagnoses included schizoaffective disorder, bipolar disorder, lack of coordination and muscle weakness;-Sometimes felt lonely or isolated from those around him/her;-No documented mobility devices.Review of the resident's Elopement Assessments, dated 6/2/25 and 9/5/25, showed the resident scored a zero, not at risk for elopement. During an interview on 2/11/26 at 1:42 P.M., the resident's guardian said he/she requested on 1/6/26 the resident be moved to the secured unit of the facility to prevent elopement. He/She said the resident had eloped from previous facilities and had been caught smoking marijuana at this facility and she wanted him in a more secure area. During an interview on 2/12/26 at 9:56 A.M., the social service designee said the resident was not moved after the guardian's request because there were no open beds. The social worker said their interventions were to put in referrals to other facilities but hadn't gotten any information back. They moved him to the secure unit after he was re-admitted to the facility from hospital stay. Observation on 2/11/26 at 2:30 P.M., showed the resident's room on 1/12/26 was located adjacent to an exit door at the end of a hall. Review of the resident's EMR, showed no additional elopement risk assessment completed after the guardian's request to move the resident to a secured unit. Review of the resident's care plan, in use at the time of the investigation, showed:-Problem: Resident at risk of elopement due to a history of elopement from prior secure facility, date initiated: 8/22/24, and revised 8/30/24;-Desired outcome: Resident will be monitored closely and remain safe through next review;-Interventions: Face Checks/Intensive monitoring will be completed per facility protocol, date initiated 8/22/24. Review of the resident's progress notes showed:-1/6/26 at 10:56 A.M., spoke with Guardian today, he/she wants this writer to send referral to a secure unit with all males. Social Worker will search male secure facilities and send referral;-1/12/26 at 9:19 P.M., LPN A said while doing rounds staff noticed resident was not in his/her room. After searching the common areas, code white was called. Staff searched the building extensively including but not limited to all resident rooms, bathrooms, shower rooms, common areas, and outside perimeter. Resident was not located. LPN A had not seen this resident since 1/9/26 at 7:00 A.M. Other residents stated they saw him/her today, 1/12/26 at or around 8:00 A.M. Guardian was called but no answer and a message was left. 911 was called. Police responded and took a statement from LPN A. Administration was notified. DON and Assistant Director of Nursing (ADON) were notified;-1/12/26 at 11:45 P.M., resident noted to be missing from their assigned room at approximately 8:00 P.M. Resident was last seen in room. Upon discovery of the resident's absence, an immediate search was initiated. The elopement protocol was initiated. The resident remains listed as eloped at this time;-1/13/26 at 9:25 A.M., call was placed to local hospitals and jails. Both stated they didn't have the resident in care;-1/13/26 at 10:03 A.M. late entry, resident's doctor was made aware that resident remains out of the facility. Resident left Monday (1/12/26) and did not return;-1/20/26 at 12:42 P.M., received call from physician at psychiatric care hospital, requesting information about the resident's medications, stated resident's mother told him/her to call because the resident was out on the streets for the last six days. The resident had been admitted to [NAME] Jewish Hospital Psychiatric Support Center. Medications and face sheet were faxed to the hospital.-1/26/26 at 2:31 P.M., resident admitted to the facility from hospital. No new orders or comment made. Physician and Guardian aware. Review of the resident's Medication Administration Record (MAR), dated January 2026, showed the following:-Paxil Oral Tablet 20 milligram (MG) (Paroxetine HCL) Give 1 tablet by mouth one time a day for Major Depressive Disorder at 7 A.M., start date 12/27/25, not administered 1/13/26 at 7:00 A.M.;-Potassium Oral Tablet (supplement) Give 20 milliequivalent (mEq) by mouth one time a day for heart at 7 A.M., start date 10/4/25, not administered 1/13/26 at 7:00 A.M.;-Seroquel Oral Tablet (Questiapine Fumarate) Give 200 mg by mouth at bedtime for schizoaffective, start date 10/10/25, not administered 1/12/26 at 8:00 P.M.;-Synthroid Oral Tablet 25 microgram (MCG) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for hypothyroidism, start date 12/27/25, not administered 1/13/26 at 7:00 A.M.;-Divalproex Sodium ER Oral Tablet Extended Release 24 hour 500 MG (Divalproex Sodium) Give 500 mg by mouth three times a day for seizures, start date 10/3/25, not administered 1/12/26 at 8:00 P.M.;-Buspirone HCL Oral Tablet 7.5 MG (buspirone HCL) Give 7.5 mg by mouth two times a day for agitation, start date 10/3/25, not administered 1/12/26 at 4:00 P.M.;-Gemfibrozil Oral Tablet 600 MG (Gemfibrozil) Give 600 mg by mouth two times a day for cholesterol, start date 10/3/25, not administered 1/12/26 at 4:00 P.M.;-Propranolol HCL Oral Tablet 20 MG (Propranolol HCL) Give 1 tablet by mouth two times a day for agitation, start date 10/3/25, not administered 1/12/26 at 4:00 P.M. During an interview on 2/11/26 at 2:06 P.M. LPN C said he/she didn't know what happened with the resident's elopement. Recently, the resident had started making contact with people on social media. The last time he/she saw the resident was the afternoon on 1/12/26. When the resident didn't come for dinner, he/she sent another resident (Resident #8) to get him/her for dinner. Resident #8 said Resident #7 didn't want to be bothered. After he/she gave report to LPN A, he/she left. LPN A called him/her at home and said Resident #7 wasn't at the facility. They started a search. The Administrator was notified. He/She (LPN C) didn't check on the resident before leaving. When staff think they know where the residents are, they just pass that information on to the next shift. LPN C said that he/she should have checked on Resident #7 and not taken the word of another resident regarding his/her whereabouts. LPN C was not aware Resident #7 was not in the building until LPN A called him/her at home.During an interview on 2/11/26 at 1:12 P.M., LPN A said when he/she came to work (shift began at 7:00 P.M.), the resident wasn't at the facility. LPN A was starting his/her rounds when a Certified Nurse's Aide (CNA) came and said they had not seen the resident. A search was started. A code white was called. LPN A didn't know if that CNA had told anyone else the resident hadn't been seen before telling him/her. LPN A didn't know of any elopement history for the resident and wasn't told the resident would leave. He/She didn't know how long the resident had been gone. The resident may have pushed the emergency doors open. After a delay, the doors will open. During the search, he/she noticed the alarm going off. Someone turned the alarm off. The alarm was loud but on the opposite side of the building, it was hard to distinguish from the call light system. During an interview on 2/13/26 at 2:02 P.M., CNA H said rounds are done every two hours. Nurses will do rounds if asked, but mainly CNA and Certified Medication Technicians (CMTs) do rounds. During an interview on 2/13/26 at 2:10 P.M., CNA I said rounds were every two hours and included checking to make sure residents are alive, clean, and where they are. Everyone was supposed to do rounds. Intensive monitoring meant to be able to see the resident constantly. During an interview on 2/13/26 at 2:20 P.M., the Regional Nurse Consultant said the cameras were broken. No video footage was available. Review of the facility's investigation, undated, showed:-At 11:45 A.M., resident did not come out to smoke;-At 1:15 AP.M. -1:30 P.M., door alarm to smoking area sounding - CNA G asked for the key to turn alarm off;-At 4:00 P.M., medications not given and documented as out of building;-At 7:00 P.M. shift change, LPN C did not report to oncoming nurse LPN A that the resident was not in building;-LPN C's written statement, dated 1/12/26, showed the resident left the facility, time unknown. Resident ate breakfast and lunch but did not come for dinner. He/She sent Resident #8 to tell Resident #7 to come to dinner. Resident #8 said Resident #7 refused and said he/she was asleep and did not want to eat or smoke. The last time LPN C laid eyes on the resident was between 2:00 P.M. to 2:30 P.M. During an interview on 2/13/26 at 9:07 A.M., the resident's physician's office said the notification was received on 1/16/26 at 10:11 A.M. from LPN C stating the resident had left on Tuesday (1/13/26) and had not returned. There were no notifications prior to this. Looking at their records, the physician's office said a resident note dated 10/9/25, showed the resident said he/she needed to get out of this place for a while. On 8/26/25, a note written by the physician showed the resident's judgement was impaired. The resident was followed by psychiatry. During an interview on 2/11/26 at 1:42 P.M., the Guardian said while the resident was out of the building, the resident was not dressed appropriately for the weather and did not bring his/her cell phone or wallet. The resident later told the Guardian that he/she didn't plan on being gone a long time. He/She just wanted to get out for a while. The resident was out of touch (did not think clearly). At some point while out of the facility, the resident asked someone to call his/her mom. The resident was taken to the hospital. The resident being without his/her medications was significant. Review of the local temperatures (AccuWeather St. Louis, MO) 1/12/26 - 1/14/26, showed low temperatures ranged from 20 to 32 degrees Fahrenheit (F) and high temperatures ranged from 47 to 66 degrees F. Review of the hospital after visit summary report, dated 1/14/26 to 1/26/26, showed diagnoses of disorganized schizophrenia. During an interview on 2/11/26 at 3:40 P.M., the Administrator said they had not determined how the resident left the building. During an interview on 2/13/26 at 3 P.M., the Administrator said staff told her the door alarm was faint. The door alarm is generally loud when the door is open, but when the door closes, the siren stops yelling and the alarm is faint. On 1/12/26, CNA G said he/she went to the nurse's station, got the key and turned the alarm off. CNA G wasn't working the resident's hall on 1/12/26. The Administrator said she didn't know if anyone checked to see if a resident had gotten out. The alarm wasn't reported. The alarm key was located at the nurse desk. The alarm had to have gone off between 1 P.M. - 3 P.M. on 1/12/26 because that is when the shift change was for CNA G.Unable to contact CNA G for an interview regarding turning off the alarm and if he/she tried to determine if any residents had eloped. During an interview on 2/13/26 at 11:23 A.M., the Administrator said she expected rounds to be completed, and it was not appropriate for LPN C to ask Resident #7 to check on Resident #8 or any other resident. She expected nursing to lay eyes on his/her residents and pass the information to the next shift. She wasn't aware of the physician's notes but said if she had, the resident wouldn't have stayed in the room adjacent to the exit door. She expected staff to follow the resident's care plan and conduct intensive monitoring. During an interview on 2/13/26 at 10:36 A.M., office staff said, per the Physician, the Nurse should have checked on the resident himself/herself, rather than asking another resident to check. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). 2724566

Based on interview and record review, facility failed to follow their policies when staff failed to conduct a thorough investigation of a resident-to-resident altercation between two residents, when one resident (Resident #1) pulled a screwdriver on another resident (Resident #2) and attempted to stab him/her. The sample was eight. The census was 109.Review of the facility's Incidents and Accidents policy, revised 05/18/24, showed:-Purpose: It is the policy of this facility for staff to utilize Point Click Care Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident;-Definition:Incident: An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization;-Policy: Purpose of Incident Reporting:The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management or resident care;Conducting root cause analysis to ascertain causative/contributing factors as part of the quality assurance performance improvement (QAPI) to avoid further occurrences;Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements;-Process of Incident Reporting:Licensed staff will utilize [NAME] Click Care Risk Management to report incidents/accidents and assist with completion of any investigative information to identify root causes;Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy;-The following incidents/accidents require an incident/accident report but ae not limited to:Alleged abuse;Combative behavior;Resident-to-Resident altercations;-If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing (DON) and or Administrator. Review of the facility's Abuse and Neglect policy, revised 06/12/24, included:-Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property ae reported immediately to the Administration of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Definitions:Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff-to-resident abuse and certain resident-to-resident altercations;Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking;-Policy: Guidelines:The facility will develop and operationalize policies and procedures for protection of residents and for the prevention, identification, investigation, and reporting of abuse and mistreatment. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below;Protection: The facility will protect residents from harm during an investigation;Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences;-When suspicion of abuse or reports of abuse occur, the following procedure will be initiated: The Licensed Nurse will:-Respond to the needs of the resident and protect him/her from further incident;-Document actions taken in the medical record;-Complete an incident report, if indicated;-Revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse;-The Administrator or designee will complete an Administrative Investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse;-The Administrative Investigation will consist of any pertinent information describing the situation being investigated, the names of all staff and residents involved, the root cause of the incident, the recommendations from the investigation including facts that prove or disprove the alleged situation occurred, the plan of correction or action by the Administrative staff, all statements attached from residents and staff involved and any training or education that the Administration feels needs to be provided to staff or residents to ensure education has been provided to prevent future similar situations;-The Administrative Investigation will also include a review of the resident's record to ensure that the documentation reveals that the legal guardian and/or responsible party was notified (if applicable), the physician's orders were followed, the resident was re-evaluated, and the plan of care was updated to reflect the change in medical or behavioral status;-The facility DON/Designee will ensure all clinical details and supportive plan of care interventions are completed for the Administrative Investigation;-Confidentiality: After a conclusion based on facts of the investigation is determined, internal reports, interviews and witness states shall be released to those who need to know. Even if the facility investigation is not complete, the Administrator will cooperate with any Department of Health and Senior Services investigation;-Environmental Assessment: Assess the environment for circumstances which may make abuse more likely to occur;-Resident Assessment: As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis;-Pattern Assessment: Facility will further investigate and/or determine whether a change in facility practices is warranted. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/01/26, showed:-Cognitively intact;-Mood interview showed feeling down, depressed, or hopeless seven to eleven days (half or more days) and no behaviors exhibited;-Diagnoses included psychotic disorder (a set of symptoms characterized by a loss of contact with reality, where a person has trouble distinguishing between what is real and what is not) and schizophrenia (a chronic, severe mental brain disorder that distorts how a person thinks, feels, acts, and perceives reality). Review of the Health Status Note dated 02/04/26 at 4:05 P.M. showed, Licensed Practical Nurse (LPN) E said the resident became increasingly violent and aggressive toward staff and another resident. Resident was observed yelling, threatening, and posturing aggressively. Resident then obtained a screwdriver and attempted to stab another resident. No physical contact or injury occurred due to immediate staff intervention. A Code [NAME] (behavior emergency) was initiated immediately. Staff successfully de-escalated the situation and separated resident from others. Resident was directed to return to his/her room, which was completed with staff assistance. Psychiatric Nurse Practitioner (NP) was notified of the incident. New orders received to send resident to the hospital for a psychiatric evaluation. Arrangements initiated per protocol. Power of Attorney (POA) was notified of the resident's behavior and transfer plan. Resident refused vital signs at the time of the incident. No visible injuries noted to resident or others. Resident remained under staff supervision until transfer. On 02/04/26 at 4:08 P.M. the Health Status Note was stricken from the record by LPN E as a mistaken entry. LPN E rewrote the entry and changed screwdriver to an object.Record review of the Health Status Note dated 02/04/26 at 4:08 P.M., showed LPN E said the resident became increasingly violent and aggressive toward staff and another resident. Resident was observed yelling, threatening, and posturing aggressively. Resident then obtained an object and attempted to stab another resident. No physical contact or injury occurred due to immediate staff intervention. A Code [NAME] was initiated immediately. Staff successfully de-escalated the situation and separated resident from others. Resident was directed to return to his/her room, which was completed with staff assistance. Psychiatric Nurse Practitioner was notified of the incident. New orders received to send resident to the hospital for a psychiatric evaluation. Arrangements initiated per protocol. Power of Attorney was notified of the resident's behavior and transfer plan. Resident refused vital signs at the time of the incident. No visible injuries noted to resident or others. Resident remained under staff supervision until transfer. Review of the resident's care plan, in use at the time of the investigation, showed no documentation regarding the most recent (02/04/26) resident-to-resident altercation. There were no interventions added prior to the on-site investigation. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Mood interview showed feeling down, depressed, or hopeless two to six days (several days) and no behaviors exhibited;-Diagnoses included: Diabetes, psychotic disorder and schizophrenia. Review of the resident's nurses' notes showed no documentation related to the resident-to-resident altercation on 02/04/26. Review of the resident's care plan, in use at the time of the investigation, showed no documentation related to the altercation on 02/04/26. There were no interventions added prior to the on-site investigation. Review of the facility's investigation, dated 02/04/26, showed:-On 02/04/26 a Code [NAME] was called for the resident's hall due to erratic behaviors between Resident #1 and #2. Upon her (Administrator's) arrival, it was reported that there was almost a resident-to-resident altercation, but staff were able to intervene and there was no harm and/or physical contact. It was reported that Resident #1 was being sent out for behaviors and that he/she was not at baseline. Resident #2 was off the hall and didn't exhibit any signs or symptoms of distress. Resident #1 returned to the facility on [DATE] and on 02/10/26, she (Administrator) interviewed him/her to find out the source of the incident;-Root Cause: Resident #1 stated that he/she was yelling and talking to himself/herself out loud, and Resident #2 thought he/she was speaking to him/her, but he/she (Resident #1) wasn't. As a result, Resident #1 stated Resident #2 came towards him/her, and he/she (Resident #1) pulled a screwdriver out and waved it around. Resident #1 stated he/she didn't touch, hit, or make any contact with anyone. Resident #1 apologized and stated that he/she and Resident #2 were good friends and enjoy watching TV and movies with one another. Resident #1 was questioned about how he/she retrieved the screwdriver, and he/she stated from the maintenance closet outside of his/her hall;-Investigation did not include written statements from staff who were involved and/or witnessed the incident;-Investigation did not include written statements from Resident #1 or Resident #2;-Investigation did not include written statement from the maintenance employee whose cart the screwdriver was taken from;-No documentation that care plans were updated;-No in-service education prior to on-site investigation. During an interview on 02/10/26 at 10:50 A.M., Resident #2 said Resident #1 got irritated over some money. He/She wasn't hurt by Resident #1, but Resident #1 tried to hurt him/her. Resident #1 pulled a screwdriver out on him/her (Resident #2). He/She didn't know where Resident #1 got the screwdriver from. Resident #1 had the screwdriver in his/her pocket. Resident #1 tried to hit him/her, and Resident #2 moved back. Resident #2 was able to hit Resident #1. They were close up. Resident #1 kept trying to come after him/her. Resident #1 tried to shank (slash or stab) him/her with the screwdriver. Resident #1 tried to take Resident #2's life. Staff separated them and took Resident #2 outside to smoke. Staff just tried to keep Resident #2 calm. Resident #2 didn't know what they did for Resident #1. Resident #2 said his/her feelings were hurt because he/she looked out for Resident #1. It hurt Resident #2's feelings that Resident #1 did that to him/her. The police were called and asked if he/she wanted to press charges. Resident #2 said no because he/she was not a snitch. During an interview on 02/13/26 at 12:34 P.M., Resident #1 said he/she didn't want to talk about what happened. He/She was good. During an interview on 02/10/26 at 1:40 P.M., LPN E said he/she didn't mean to write screwdriver. The object Resident #1 had was a pencil. Staff intervened immediately when observation showed Code [NAME] was initiated. Resident #1 was agitated. LPN E looked and he/she saw Resident #1 grabbing an object. (pencil). LPN E said he/she grabbed the object from Resident #1. All residents were told to go to their rooms. They tried to calm Resident #1, but it wasn't working. Emergency Services were called. The Administrator was made aware. The Administrator was at the facility when the incident occurred and when the Administrator interviewed the resident, the resident told her it was a screwdriver. During an interview on 02/12/26 at 10:28 A.M., Certified Medication Technician (CMT) B said he/she was working on the day of the incident and saw what happened. He/She was passing medication. Resident #2 was outside of his/her room and blocking the room door. CMT B asked if Resident #1 was in his/her room. Resident #2 said he/she would get Resident #1 from the room so he/she could pass the medications. It took Resident #1 a long time to come out of the room. Resident #2 said Resident #1 was mad about not getting his/her money. Resident #1 and Resident #2 started arguing about money and Resident #1 being disturbed. Resident #1 and Resident #2 were in each other's face arguing. CMT B tried to pull Resident #2 away, but he/she broke loose. Resident #1 and Resident #2 started fighting. CMT B was waiting for someone from the back hall to help break them up. Resident #1 and Resident #2 kept arguing. Resident #1 pulled out a screwdriver from his/her back pocket. CMT B ran to the door, put the code in to get Resident #2 off the hall. Afterwards, CMT B went to the Assistant Director of Nursing (ADON) and Administrator to show them the screwdriver. It was left on the Administrator's desk. There was physical contact between Resident #1 and Resident #2. When LPN C came back, he/she said there was no physical contact. CMT B said he/she said there was physical contact, and that's what he/she told the police. CMT B didn't know where Resident #1 got the screwdriver from. During an interview on 02/10/26 at 10:56 A.M., Certified Nurse's Aide (CNA) F said he/she was told Resident #1 got a screwdriver. CNA F didn't know where the screwdriver came from but said Resident #1 went into employee rooms (areas only employees go into, break rooms, linen rooms) sometimes. That was the only way he/she could see Resident #1 got the screwdriver. During an interview on 02/10/26 at 1:20 P.M., the Administrator said Resident #1 was at the hospital. She didn't know what happened on the hall, but it was her understanding, there was a verbal altercation on the hall. Resident #2 was removed from the hall. There was no physical altercation between Resident #1 and #2. Resident #1 was sent out to the hospital for behaviors. This wasn't Resident #1's normal baseline behavior. No one was hurt. She wasn't aware about the object or the attempt to stab anyone. The information wasn't reported to her the way it was documented in Resident #1's progress note. There may have been some statements, but she would have to check. An investigation should had been done. She expected the incident to have been reported, a full investigation completed, and interventions implemented. She didn't know Residents #1 and #2 were roommates. During an interview on 02/11/26 at 10:06 A.M., the Administrator said Resident #1 was back, and he/she went back to his/her same room. Residents pull the light fixtures down on that hall and maintenance staff have to regularly replace the lights. Maintenance staff usually have the cart with them but can't watch the cart all of the time. The maintenance cart was the only thing she could think of how Resident #1 got the screwdriver. During an interview on 02/13/26 at 10:45 A.M., the Administrator said there wasn't an investigation, but she talked to Resident #1 and could get that statement together. During an interview at 12:30 P.M., the Administrator said she just interviewed Resident #1 who was involved in the incident. She didn't know why the DON didn't start the investigation. She didn't get statements from anyone else. Behaviors were usually clinical. Resident #1 was having a behavioral outburst. The Administrator only thought about the clinical part, sending the resident out, doing the risk management part, documentation and notifications.

Based on interview and record review, the facility failed to have a complete and thorough facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies. In addition, the facility failed to have a facility assessment that addressed staffing ratios required per shift to meet the needs of residents, the need for a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, designated an RN to serve as the Director of Nursing (DON), and followed their infection control prevention and control program by ensuring residents received required immunizations. There was no documentation of ratios of direct care staff, restorative therapy staff, Social Services staff, dietary staff, housekeeping and laundry staff necessary on each shift to ensure the needs of residents are met. The facility failed to provide information regarding staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. The census was 105.Review of the facility's Registered Nurse (RN) policy, dated 4/30/24, showed:-Policy: The facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week;-The facility will designate a Registered Nurse to serve as the Director of Nursing on a full time basis. Review of the facility's admission Agreement, received on 9/3/25, showed:-Facility is intended to serve residents in need of skilled nursing care and treatment, which are those services commonly performed by or under the supervision of a Registered Nurse for individuals requiring twenty-four (24) hours a day care. Facility may only accept residents for which it determines, in its sole discretion, it is able to provide appropriate services. No resident will be accepted without a valid physician order for care. In addition, should you become aware that you are no longer able to meet these criteria; you agree to immediately advise Facility. The following criteria outlines the level of cognitive and functional ability required for admission into Facility:-Medical status/symptoms of dementia: The resident has a diagnosis of Alzheimer's disease or related dementia and exhibits symptoms of dementia which necessitates any of the following: guidance and direction, a safe environment, cueing and task simplification, structured programming;-Communication: The resident maintains the ability to respond to other residents, staff, family, and the environment. The resident may exhibit difficulty or awkwardness in communicating and socializing;-Social Behavior: The resident has the ability to participate and relate in a group setting. The resident may exhibit intermittent disruptive or disabling behavior such as wandering, rummaging, uncooperativeness, verbal and/or physical abuse. The resident must not exhibit or suffer from any significant psychiatric or behavioral problems which may escalate anxiety and confusion among other residents and/or present a safety hazard to themselves or others;-Social History: The resident must not have past or current difficulty with substance abuse or addiction, and not have a primary psychiatric diagnosis;-Mobility and Transferring: The resident may be dependent upon a cane, walker or wheelchair. The resident may require minimum to total assistance with mobility and transferring;-Toileting: The resident may require verbal cues, hands on assistance or total assistance with toileting and incontinence care;-Personal Care: The resident requires assistance to perform some or all daily personal care tasks;-Nursing Services: The resident requires on-going supervision, medication administration and assistance. The resident may require intermediate or skilled nursing assistance for preventative, curative or therapy services;-Meals/Eating: The resident may require cues, reminders or hands on assistance during mealtime. The resident may have specialized dietary needs including altered consistencies, approved physician ordered diets, or dietary monitoring;-Facility is an intermediate and skilled care residence. Various services are available to meet a wide range of nursing and rehabilitative needs. Residents shall be assessed for admission to Facility based on the following criteria:-Medical Status: The resident has an acute or longstanding unpredictable medical condition which requires intermittent emergency nursing services;-Social Behavior: The resident does not exhibit or suffer from any significant psychiatric or behavioral problems which may put himself/herself or others at risk of physical or emotional harm;-Personal Care: The resident requires on-going daily assistance with some or all activities of daily living (ADLs): dressing, eating, bathing, transferring, grooming, continence care, etc.;-Nursing Services: The resident requires daily monitoring of a health and/or medical condition by professional staff;-Skilled Services: The resident requires skilled medical services including but not limited to: physical, occupational, speech, and/or intravenous therapy, wound care. Review of the facility's Matrix (form used to track resident conditions and care needs), received on 9/3/25, showed:-Residents with diagnoses of Alzheimer's/Dementia: 20;-Hospice: 3;-Dialysis: 1;-Intravenous therapy: 1;-Indwelling catheter;-Post Traumatic Stress Disorder (PTSD)/Trauma: 7;-Insulin: 13;-Anticoagulant: 4;-Antianxiety: 24;-Antipsychotic: 85;-Antidepressant: 46;-Hypnotic: 5. During the course of the survey process, problems were identified which included:-No full time Director of Nursing (DON);-No full time Social Worker or social service designee. During an interview on 9/9/25 at 12:31 P.M., the Administrator said she is responsible for ensuring the facility assessment is completed. She was supposed to do it but did not have maintenance or nursing information to add to the assessment. The only thing that was documented in the facility assessment was who they were supposed to call or when to use another facility, and contact information. She did not want to give a partial facility assessment. It was not a complete assessment.

Based on interview and record review, the facility failed to implement an effective quality assurance (QA)/quality assurance performance improvement (QAPI) program when they failed to ensure they implemented appropriate interventions to correct on-going, systemic issues. This had the potential to affect all residents. The census was 105.Review of the facility's QAPI Plan, dated 5/14/21, showed:-This QAPI plan provides guidance for the facility overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within the facility. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions;-Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for residents and staff;-On an annual basis, and as needed, a Facility Assessment will be conducted. Any chances in the facility assessment will be reflected, as necessary, in the QAPI Plan;-The QAPI Committee will review data for all areas of the facility to assure systems are being monitored and maintained to achieve the highest level quality. The following reports may be used by the QAPI committee; -Infection control log and infection prevention and control program; -Antibiotic utilization reports; -CMS Quality Measures, CASPER reports and any other data to measure the facility; -Medication administration audits; -Medication room audits;-Additionally, the Committee may use the following information: -Drug regimen review; -Family satisfaction; -Licensed nurse staff hours/resident day; -State survey results. Review of the annual Department of Health and Senior Services (DHSS) statement of deficiencies (SOD) for the past four years, showed the facility was cited for F880, a citation for infection control on July 2018, July 2019, and September 2023. The current SOD, dated 9/9/25, cited F880 for infection control. The facility failed to follow acceptable standards of practice for infection control when the facility failed to ensure an active Legionnaires (Legionella, bacteria in water that causes pneumonia) program was in place. In addition, staff did not pick up or replace oxygen or nebulizer tubing left on the bedroom floor for 3 of 3 residents sampled who received oxygen and breathing treatments. During an interview on 9/9/25 at 1032 A.M., the Maintenance Director said he worked at the facility since March 2025. Since he was employed, he had not conducted water testing. On 9/9/25, the Regional Maintenance Director brought two Legionnaires' test kits. The Maintenance Director said he completed one test. The results take 24 hours. Testing will be completed every 3 months. The facility did not have any water test kits prior to the regional staff delivering the kits on 9/9/25. The Maintenance Director could not locate any prior facility water testing. During an interview on 9/9/25 at 1:40 P.M., the Registered Nurse (RN) Supervisor said he/she expected the oxygen tubing to be picked up by staff, and even housekeeping would be able to pick up tubing to ensure it was not on the floor. He/She expected the oxygen tubing to be changed weekly. Tubing should not be allowed on the floor, the risk of infection increased. Review of the current SOD, dated 9/9/25, showed the facility was cited at F881 for failing to ensure an antibiotic stewardship program was in place and in use by failing to collect data regarding antibiotic treatment, reviewing and documenting the data to the antibiotic surveillance program. Five residents were identified as receiving antibiotics and issues were discovered with all five. During an interview on 9/9/25 at 3:02 P.M., the Administrator said the facility had no procedure in place to provide antibiotic stewardship or tracking of antibiotic use. All antibiotics should include an appropriate diagnosis. The care plan should reflect the antibiotic use. The antibiotic stewardship program is part of the infection control program (ICP). The facility did not have an active ICP staff and antibiotics were not monitored or data collected. During an interview on 9/9/25 at 1:40 P.M., the Administrator said the biggest issue that was found during the QAPI, was re-capping. When residents return from the hospital, pharmacy should be aware. The QAPI meetings have not been consistent. They were doing standup meeting, but it slacked and fell off. Sometimes she would meet with one nurse, at a different time, or during shift change.

Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control when the facility failed to ensure an active Legionnaires' (Legionella, bacteria in water that causes pneumonia) program was in place. In addition, staff did not pick up or replace oxygen or nebulizer tubing left on the bedroom floor for 3 of 3 residents sampled who received oxygen and breathing treatments (Residents #54, #2 and #45). The sample was 43. The census was 105. Review of the infection prevention and control program, revised 5/7/24, showed:-Purpose: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines;-Policy: -The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiologically investigations of exposures of infectious disease;-Isolation protocol (TBP, transmission-based precautions): -A resident with an infection of communicable disease shall be placed on TBP as recommended by current Centers for Disease Control (CDC) guidelines; -Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards; -Residents will be placed on the least restrictive transmission-based precautions for the shortest duration possible under the circumstances; -When a resident on transmission based precautions must leave the resident care unit/area, the charge nurse on the unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport;-Supplies protocol: -Non-sterile supplies are stored and maintained as clean prior to use. Review of the Legionella surveillance policy, revised 6/26/24, showed:-Purpose: to establish primary and secondary strategies for the prevention and control of Legionella infections;-Policy: -Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system; -In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies; -In the case of a definite or possible healthcare associated Legionnaire's disease within a 12-month period, the facility shall implement secondary prevention strategies in addition to primary prevention strategies until such time the water management team determines those strategies are no longer necessary, or as advised by local and/or state health department staff; -Principles of Legionella transmission: -To pose a health risk, Legionella has to grow in number and be aerosolized so people can breath in small, contaminated water droplets; -Legionella grows best in water temperatures of 77-108 degrees Fahrenheit (F), particularly in water that is not moving or that does not have enough disinfectant (pH 6.5-8.5) to kill germs; -Legionella can make people sick when the germs spread in droplets small enough for people to breath in. Medical devices, cooling towers, showers, hot tubs, and water fountains; -Although uncommon, Legionella may be contracted by aspiration of contaminated drinking water. Legionella is not usually spread from person to person; -The incubation period for Legionnaires' disease is generally 2-10 days; -Signs and symptoms of Legionnaires' disease are similar to pneumonia by other pathogens and include cough, fever, positive chest radiograph, sputum production, and new/changed lung examination abnormalities; -Primary prevention strategies: -Diagnostic testing: -The facility shall use the McGeer criteria (an infection surveillance tool) when diagnosing pneumonia; -Residents with healthcare associated pneumonia or who have failed antibiotic therapy for community-acquired pneumonia shall be tested for Legionella using both culture of lower respiratory secretions and the Legionella urinary antigen test; -Investigation for a facility source for Legionella, which may include culturing of facility water for Legionella: -The Infection Preventionist will investigate all cases of definite healthcare-associated Legionnaires' disease for the source of Legionella; -The Infection Preventionist will also investigate for the source of Legionella when two or more possible healthcare associated Legionnaires' diseases are identified; -Physical Controls: -Cooling towers and potable water systems shall be routinely maintained; -At risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations; -Non-potable water systems shall be routinely cleaned and disinfected; -Nebulization devices shall be filed only with sterile fluid (sterile water or aerosol medication); -Temperature controls: -Cold water shall be stored and distributed below 68 degrees F. -Hot water shall be stored above 140 degrees F and circulated at a minimum return temperature of 124 degrees F;-Secondary prevention strategies: -A full scale environmental investigation to identify environmental sources: -All cases of Legionella shall be reported to local/state health officials, followed by an investigation; -Elements of an investigation may include: -Reviewing medical and microbiology records; -Actively identifying all new and recent residents with healthcare-associated pneumonia and testing them for Legionella using both culture of lower respiratory secretions and the Legionella urinary antigen test; -Developing a line list of cases; -Evaluating potential environmental exposures; -Performing an environmental assessment; -Performing environmental sampling, as indicated by the environmental assessment; -Subtyping and comparing clinical and environmental isolates;-Decontamination of identified environmental sources in accordance with current standards;-Heightened surveillance and environmental sampling, including increased suspicion for Legionella cases and increased frequency of testing above the facility's usual testing protocols. 1.During an interview on 9/9/25 at 10:32 A.M., the Maintenance Director said he worked at the facility since March 2025. Since he was employed, he had not conducted water testing. On 9/9/25, the Regional Maintenance Director brought two Legionnaires' test kits. The Maintenance Director said he completed one test. The results take 24 hours. Testing will be completed every 3 months. The facility did not have any water test kits prior to the regional staff delivering the kits on 9/9/25. The Maintenance Director could not locate any prior facility water testing. 2. Review of Resident #54's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/21/25, showed: -Mild cognitive impairment; -Diagnoses include gastroesophageal reflux disease (GERD, acid reflux), hyperlipidemia, aphasia (a language disorder that affects a person's ability to communicate), hemiplegia, seizure disorder, depression, schizophrenia 9a disorder that affects a person's ability to think, feel, and behave clearly), asthma and cataracts; -Oxygen therapy: blank. Review of the Physician Order Sheet (POS), dated 9/2025, showed: -An order, dated 6/6/25 for oxygen at 2 liters continuous for shortness of breath (SOB), while in bed or sleeping; -No physician's orders noted to change the oxygen tubing. Review of the care plan, in use during survey, showed: -Problem: the resident is at risk for shortness of breath related to chronic obstructive pulmonary disease (COPD, lung disease);-Desired Outcome: the resident will have no complications related to shortness of breath; -Interventions: Head of bed elevated to prevent shortness of breath while lying flat; -Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions; -Monitor/document breathing patterns. Report abnormalities to physician; -Position resident with proper body alignment for optimal breathing pattern. Oxygen per orders. Observation on 9/3/25 at 11:36 A.M., 9/4/25 at 9:44 A.M., 9/8/25 at 10:13 A.M., and 9/8/25 at 2:09 P.M., showed the resident's oxygen tubing on the floor. Tape on the tubing showed a handwritten date of 7/15. The oxygen concentrator was turned on and set at 4 liters. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included diabetes and COPD. Review of the care plan, undated and in use at the time of the survey, showed:-Focus: Oxygen therapy for COPD;-Goal: will have no signs and symptoms of poor oxygen absorption;-Interventions: provide extension tubing or portable oxygen apparatus, oxygen setting 02 using nasal cannula per orders. Review of the POS, dated 8/12/24, showed an order for a nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) treatment every six hours as needed (PRN) for COPD. Observation and interview on 9/4/25 at 8:15 A.M., showed the resident resting in bed with a nebulizer machine, the tubing and mask laying on the floor at the head of the bed against the bed and wall. Observation showed dusty and dirty build up and what appeared to be animal scat on the floor along the wall. The resident said the nebulizer machine, tubing and mask lay on the floor because there is not enough room to place the machine anywhere else. The resident said the maintenance staff are aware his/her room has a mice problem, but the mice do not mess with the tubing or machine because the mice are just looking for food. Observation on 9/5/25 at 8:20 AM, and 9/9/25 at 9:30 A.M., showed the resident resting in bed with the nebulizer machine, tubing and mask laying on floor at the head of the bed against the bed and wall. Observation showed dusty and dirty build up and what appeared to be animal scat on the floor along the wall. 4. Review of Resident #45's medical record, showed:-Cognitively intact;-Diagnoses included COPD and acute respiratory failure with hypoxia (low oxygen). Review of the care plan, undated and in use at the time of the survey, showed:-Focus: Oxygen therapy for COPD with acute exacerbation and acute respiratory failure with hypoxia;-Goal: will display optimal breathing patterns daily through review date; -Interventions: monitor for difficulty breathing (dyspnea) on exertion, oxygen setting 02 using nasal cannula at four liters. Review of the POS, dated 7/25/25, showed an order for a nebulizer treatment every four hours PRN for shortness of breath. During observation and interview on 9/3/25 at 11:15 A.M., showed the resident resting in bed with the nebulizer machine placed on a large plastic bin that was on the floor at the head of bed. The plastic bin lid was covered with dust and a dried substance with the nebulizer tubing and mask laying on the floor. The floor had visible dirt build up around the head and foot of the bed. The resident said the nebulizer machine, tubing and the mask lay on floor because that is where the staff kept it. Observation on 9/4/25 at 7:05 AM, and 9/5/25 at 8:30 A.M., showed the resident resting in bed with a nebulizer machine placed on a large plastic bin that was on the floor at the head of bed. The plastic bin lid was covered with dust and a dried substance with the nebulizer tubing and mask laying on the floor. The floor had visible dirt build up around the head and foot of the bed. During an interview on 9/9/25 at 12:25 P.M., Assistant Director of Nursing (ADON) B said he/she expected the oxygen to be put on the resident. He/She never saw the resident without it, but the aides put it back on the resident. ADON B expected staff to ensure the resident was using the oxygen and checking oxygen saturations. The tubing was changed weekly. The night nurse is responsible for checking the oxygen sats and changing the tubing. If the resident took off the oxygen, he/she expected it to be care planned. During an interview on 9/9/25 at 1:40 P.M., the Registered Nurse (RN) Supervisor said he/she expected the oxygen tubing to be picked up by staff, and even housekeeping would be able to pick up the tubing to ensure it was not on the floor. He/She expected the oxygen tubing to be changed weekly. Tubing should not be allowed on the floor, as that would increase the risk of infection.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was in place and in use by failing to collect data regarding antibiotic treatment, reviewing and documenting the data to the antibiotic surveillance program. Five residents were identified as receiving antibiotics and issues were discovered with all five (Residents #9, #34, #2, #72 and #64). The sample was 43. The census was 105.Review of the Infection prevention and control program, revised 5/7/24, showed:-Purpose: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;-Policy:-The designated infection preventionist (IP) is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, room placement, implementing isolation procedures, staff and resident exposures, surveillance and epidemiological investigations of exposures of infectious diseases; -Antibiotic stewardship: -An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program; -Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program; -The IP, with oversight from the Director of Nursing (DON), serves as the leader of the antibiotic stewardship program; -The medical director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program. 1.Review of Resident #9's medical record, showed:-An order, dated 9/3/25: Amoxicillin-Pot clavulanate (used to treat infection) 875/125 (combination medication) milligram (mg). Take one tablet by mouth twice daily for sinusitis for seven days. Review of the care plan, on 9/9/25, showed it did not reflect antibiotic use. 2. Review of Resident #34's medical record, showed an order, dated 9/3/25: Amoxicillin-Pot clavulanate (antibiotic) 875/125 mg. Take one tablet by mouth twice daily for sinusitis for seven days. Review of the care plan, on 9/9/25, showed it did not reflect antibiotic use. 4.Review of Resident #2's medical record, showed an order, dated 8/28/25: Doxycycline (antibiotic) 100 mg, take one tablet daily for seven days. No diagnoses included with the antibiotic order. Review of the care plan, on 9/9/25, showed it did not reflect antibiotic use. 5.Review of Resident #72's medical record, showed an order, dated 9/2/25: Clindamycin (antibiotic) 300 mg, take one capsule three times a day for prophylaxis related to other asthma. Review of the care plan, on 9/9/25, showed it did not reflect antibiotic use. 5. Review of Resident #64's admission MDS, dated [DATE], showed:-Diagnoses included traumatic spinal cord dysfunction, heart disease, high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), neurogenic blader, hyperlipidemia, quadriplegia, malnutrition and depression;-Cognitively intact;-Was administered antibiotics in the last seven days. Review of the care plan, in use during survey, showed:-Problem: Resident has a indwelling suprapubic catheter due to neurogenic bladder. Noncompliance with keeping catheter bag in a privacy cover;-Desired Outcome: Enhanced Barrier Precautions (EBP) in place; -Monitor/document for pain/discomfort due to catheter; -Monitor/record/report to physician for signs and symptoms of urinary tract infection;-No documentation of long-term use of Amoxicillin (antibiotic). Review of the MAR, dated 8/2025, showed:-An order, dated 8/5/25, Amoxicillin oral tablet 500 mg, give one tablet by mouth three times a day for bacteria was administered on the following dates and times: -On 8/6/25 through 8/18/25 and 8/20/25 through 8/31/25 at 7:00 A.M.; -On 8/6/25 through 8/18/25 and 8/20/25 through 8/31/25 at 11:00 P.M.; -On 8/5/25 though 8/31/25 at 8:00 P.M. Review of the POS, dated 9/2025, showed an order, dated 8/5/25, Amoxicillin Oral Tablet 500 mg, give one tablet by mouth three times a day for bacteria. Review of the MAR, dated 9/2025, showed:-An order, dated 8/5/25, Amoxicillin Oral Tablet 500 mg, give one tablet by mouth three times a day for bacteria was administered on the following dates and times:-On 9/1/25 through 9/4/25 at 7:00 A.M.;-On 9/1/25 through 9/4/25 at 11:00 A.M.;-On 9/1/25 through 9/4/25 at 8:00 P.M. Review of the resident's Pharmacy Review note, dated 8/20/25, showed please add a stop date and a more appropriate diagnosis (type of infection) to the amoxicillin order. During an interview on 9/9/25 at 12:41 P.M., the Registered Nurse (RN) Supervisor said the resident's Amoxicillin does not have a stop order per the physician. She expected it to be documented. The RN Supervisor expected all antibiotics to have a diagnosis attached with it. 6. During an interview on 9/9/25 at 3:02 P.M., the Administrator said the facility had no procedure in place to provide antibiotic stewardship or tracking of antibiotic use. All antibiotics should include an appropriate diagnosis. The care plan should reflect the antibiotic use. The antibiotic stewardship program is part of the infection control program. The facility did not have an active ICP staff and antibiotics were not monitored or data collected.

Based on interview and record review, the facility failed to designate one or more individuals with specialized training and certification in infection prevention and control as the Infection Control Preventionist (ICP) for the facility's infection prevention control program. The census was 105. Review of the Infection prevention and control program, revised 5/7/24, showed:-Purpose: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;-Policy:-The designated infection preventionist (IP) is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, room placement, implementing isolation procedures, staff and resident exposures, surveillance and epidemiological investigations of exposures of infectious diseases. During an interview on 9/4/25 at 2:03 P.M., the Administrator said Assistant Director of Nursing (ADON) A is the IP for the facility. She had completed the IP training. During an interview on 9/9/25 at 3:02 P.M., the Administrator said ADON A had not completed the Center for Disease Control (CDC) IP training. The facility did not have a qualified staff member who was a certified ICP. The Administrator said a separate staff person, the transportation driver, had completed the non-medical infection control training, however, the training did not meet the needs of the facility residents, the infection control program or ICP qualifications.

Based on interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. The census was 105.Review of the facility's Registered Nurse (RN) policy, dated 4/30/24, showed:-Purpose: It is the intent of the facility to comply with Registered Nurse staffing requirements;-Full-time is defined as working 40 or more hours a week;-Charge Nurse is a licensed nurse with specific responsibilities designed by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care;-Policy: The facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week;-The facility will designate a Registered Nurse to serve as the Director of Nursing on a full time basis;-The Director of Nursing may serve as charge nurse only when the facility has average daily occupancy of 60 or fewer residents;-The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Jornal (PBJ) system. Review of the facility's census, showed 105 residents. Review of the facility's staffing roster, showed the facility had a DON. Review of the facility's handwritten RN coverage, received on 9/9/25, showed the RN Supervisor provided RN coverage on 9/3/25, 9/4/25, 9/5/25, 9/8/25, and 9/9/25. During an interview on 9/3/25 at 10:52 A.M., the Administrator confirmed the facility had a full time DON. During an interview on 9/9/25 at 12:25 P.M., Assistant Director of Nursing (ADON) B said the DON is on medical leave. He/She was unsure of when the DON would return. The RN Supervisor was the interim DON to his/her knowledge, but he/she was not sure if the RN provided RN coverage or the interim DON. During an interview on 9/9/25 at 12:41 P.M., the Administrator said the current DON was supposed to notify her of when he/she would return. The RN Supervisor is the interim DON and he/she started last week. On 9/8/25 and 9/9/25, he/she provided RN coverage. They did not have an interim DON on 9/8/25 and 9/9/25. RN staff from corporate also provide eight hours of coverage. Some provide coverage every other weekend. It was discussed during their Quality Assurance and Quality Improvement (QAPI) meeting. It was discussed if the DON would be able to complete some tasks from home. During an interview on 9/9/25 at 1:40 P.M., the RN supervisor confirmed he/she was the RN supervisor.

Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment for resident areas throughout the building. The census was 105. 1. 1. Observation on 9/3/2025 at 11:00 A.M., 9/5/2025 at 1:15 P.M., and 9/9/2025 at 9:30 A.M., showed the following:-Room C1, behind the door, showed drywall mudding, measuring 30 inches () by 4 in length, unpainted;-Shared bathroom, located between C1 -C3, with missing cove base along the doorway of C1, exposing a large hole in the wall 8x4;-Shared bathroom, located between C1 -C3, with missing cove base along the doorway of C3 and behind the toilet;-Between room C1 and C3, in the hallway, a section measuring 4x4 of unpainted area, exposing four 1/2 holes;-Shared bathroom, located between C5 -C7, with cove base pulled away from wall along the doorway of C5, exposing crumbling drywall;-Room C7 bed 1, overhead bed light plastic cover laying on top of the fixture, exposing the light bulb;-Room C6 bed 1, approximate 14x4 unpainted section with two 1/2 circle holes;-Room C9 bed 1, 3x3 hole near the door approximately 6 from the floor and two additional circle areas measuring 2x2, exposing drywall;-Room C9, air conditioning unit (AC) with a 2 gap between the AC unit and the wall;-Shared bathroom, located between C10 -C12, with chipped and cracked paint along the length of the bottom of mirror with brown stains. The sink pulled away from wall with cracked paint and caulk;-Room C10, a hole measuring 2x2 behind the door;-Room C10, foot of bed 2, showed a hole in the corner of room measuring 1x1 with black hairy-like substance coming out of the hole with visible mice droppings;-Room C10, side of bed 2, showed a 1 x 1/2 hole in cove base that went through the wall exposing pieces of drywall. In front of the hole was a pest control bug glue trap;-Room C12 bed 1, 4 1/2 holes in wall. 2. Observation on 9/3/25 at 1:24 P.M., and on 9/5/25 at 2:47 P.M., of bedroom and bathroom A-10, showed the floor was dirty and sticky upon walking. In addition, in the bathroom, the baseboard was pulled out from the wall on the bottom left-hand side and the plaster was peeled away from the wall on the top right-side corner above the sink. 3. Observation on 9/3/25 at 1:46 P.M., and on 9/5/25 at 2:50 P.M., of room A-7, showed the floor was dirty and sticky upon walking. In the bathroom, the paint was peeled away from the wall behind the commode. 4. Observations on 9/3/25 at 2:17 P.M., and on 9/5/25 at 2:56 P.M., of room B-4, showed the floor was dirty and sticky upon walking. In in addition, the baseboard was pulled away from the wall behind the bedroom door. 5. Observation on 9/3/25 at 10:41 A.M., showed the floors of room D-3 were sticky upon walking and what appeared to be an opaque, dirty film on the tiles near the doorway. 6. Observation on 9/3/25 at 11:09 A.M., near the D-hall entrance, showed a broken ceiling tile above the doorway to the beautician's office, leaving an approximate 5 inch by 7 inch gap, exposing the electrical wires and space above the ceiling tiles. 7. During an interview on 9/8/25 at 9:30 A.M., the Maintenance Assistance (MA) said the staff fills out the facility's work order sheet when repairs are needed. Once the staff completes the form, the form is placed in the wall mounted box that is located at the entrance of each hall. The MA said every morning he gathers all the completed forms so the issues can be address. The MA said due to budget cuts, the supplies needed to make the repairs are slow.

Based on observation, interview and record review, the facility failed to implement the facility's policy and procedure for the monthly drug regimen review by failing to ensure the physician or designee responded to the pharmacy recommendation timely for nine residents (Residents #2, #7, #11, #72, #64, #13, #67, #35 and #85). The sample was 43. The census was 105.Review of the facility's Medication Regimen Review (MRR) policy, dated 6/26/24, showed: -Purpose: the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the medical chart;-Policy: -MRR or drug regimen review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: -Review of the medical record in order to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities; -Collaboration with other members of the interdisciplinary team, including the resident, the family and/or the resident representative; -The requirements associated with the MR apply to all residents, whether short or long stay; -To facilitate the completion of the MRR, the facility shall provide the licensed pharmacist access to the following: -Residents and their medical records, including Medication Administration Record (MAR); -All portions of the electronic health record; -The pharmacy provider's resident medication profiles; -The facility's records of medication receipt and disposition; -Medication containers and storage areas; -Controlled substance records and supplies; -Answers to the previous month's pharmacy recommendations; -The pharmacist shall document electronically, that each medication regimen review has been completed; -The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities; -The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation; -The pharmacist shall communicate any irregularities to the facility in the following ways: -Verbal communication to the attending physician, Director of Nursing (DON), and/or staff of any urgent needs; -Written communication to the attending physician, the Medical Director and the DON; -Written communications from the pharmacist shall become a permanent part of the medical record; -Timelines and responsibilities for MRR: -The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete to all required activities; -The pharmacist shall communicate any recommendations and identified irregularities via written communications within 10 working days of the review; -If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON or designee is informed verbally; -The pharmacist will complete the MRR, and ensure this is documented into the electronic health record; -The facility shall act upon all recommendations according to procedures for addressing MRR irregularities;-Facility staff shall act upon all recommendations according to procedures for addressing the MRR irregularities. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/7/25, showed:-Cognitively intact;-Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD, ongoing lung condition caused by damage to the lungs). Review of the resident's MRR, dated 6/20/25, 7/21/25 and 8/17/25, showed pharmacy recommendations to discontinue the multiple orders of Amlodipine (used to treat high blood pressure) and Tylenol. Review of the resident's active order summary, showed:-Continued duplicate orders of Amiodipine and Tylenol. Review of the resident's medical record, showed no documentation the physician or provider addressed the pharmacist's recommendation. 2. Review of Resident #7's annual MDS, dated [DATE], showed:-Cognitively intact;-Diagnoses included schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions) delusional disorder and allergies. Review of the Physician Order Sheet (POS), showed an order dated 6/3/25, for hydroxyzine (used to treat anxiety and allergies) oral tablet 50 milligrams (mg) by mouth (for anxiety) as needed (PRN) for 14 days. Review of the MRR, dated 6/26/25, 7/23/25 and 8/21/25, showed pharmacy recommendations to discontinue the order. Review of the medical record, showed discontinue order pending confirmation. 3. Review of Resident #11's medical record, showed his/her diagnoses included bipolar disorder, seizures, depression, liver disease, personality disorder and pain. Review of the pharmacy review note, dated 6/25/25, showed:-Patient has 2 orders for cholecalciferol (Vitamin D) 50000 (one to be given monthly and the other weekly). Duplicate therapy is generally not indicated, unless current clinical standards of practice and documented clinical rationale confirm the benefits of multiple medications from the same class or with similar therapeutic effects. Please discontinue one order to avoid med errors.-Patient has 2 orders for cyclobenzaprine (muscle relaxer) 10 mg daily. Duplicate therapy is generally not indicated, unless current clinical standards of practice and documented clinical rationale confirm the benefits of multiple medications from the same class or with similar therapeutic effects. Please discontinue one order to avoid med errors.-Patient has 2 orders for amlodipine 10 mg daily. Duplicate therapy is generally not indicated, unless current clinical standards of practice and documented clinical rationale confirm the benefits of multiple medications from the same class or with similar therapeutic effects. Please discontinue one order to avoid med errors.-This resident has active orders of Acetaminophen (either alone or in combination with other medications). Please add the following to each acetaminophen-containing order: Not to exceed 3 gm of APAP in 24 hours-Miralax (used to treat constipation) should be dissolved in 4-8oz of fluid before administration to patient. Please include with Miralax instructions for use. Review of the POS, during the survey, showed:-Duplicate orders for cholecalciferol 50,000;-Duplicate orders for cyclobenzaprine;-Duplicate orders for amlodipine 10 mg;-Acetaminophen without the recommended not to exceed 3 gm of APAP in 24 hrs;-Miralax order did not contain the recommended instructions for use. 4. Review of #72's medical record, showed his/her diagnoses included Sshizoaffective (a mental health disorder that combines symptoms of schizophrenia and mood disorder such as depression or bipolar disorder), seizures, asthma and vitamin D disorder. Review of the pharmacy review note, dated 6/25/25, showed:-This resident is currently receiving the following psychotropic (Non Antipsychotic) medication on a PRN basis: hydroxyzine. Per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate. Please evaluate the continued need for this medication. If it is to be extended, please document the rationale for the extended time period in the medical record and indicate a specific duration/end-date. Note, we can no longer have the unspecified duration of 'end of life care;-Please provide a diagnosis for the following medication(s): hydroxyzine. Medication is PRN and has no indication on when to give; -Miralax should be dissolved in 4-8oz of fluid before administration to patient. Please include with Miralax instructions for use;-This resident has active orders of Acetaminophen (either alone or in combination with other medications). Please add the following to each acetaminophen-containing order: Not to exceed 3 grams of APAP in 24 hours; Review of the pharmacy review note, dated 7/22/25, showed: please address pharmacy recommendations from the prior month. Review of the current POS, showed:-Acetaminophen did not contain the recommended not to exceed 3 gm of APAP in 24 hrs;-Miralax did not contain instructions for use;-Hydroxyzine remained as a PRN and no linked diagnoses. 5. Review of Resident #64's admission MDS, dated [DATE], showed:-Diagnoses included traumatic spinal cord dysfunction, coronary artery disease (CAD, heart disease), high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), neurogenic blader, hyperlipidemia (high cholesterol), quadriplegia, malnutrition and depression;-Used an indwelling catheter;-Was administered antibiotics in the last seven days. Review of the resident's Pharmacy Review note, dated 8/20/25, showed:-This resident has active orders of Acetaminophen (either alone or in combination with other medications). Please add the following to each acetaminophen-containing order: Not to exceed 3 grams of APAP in 24 hours;-Please add a stop date and a more appropriate diagnosis (type of infection) to the amoxicillin order;-Miralax should be dissolved in 4-8oz of fluid before administration to patient. Please include with Miralax instructions for use;-Please update the instructions on the Polyvinyl Alcohol Ophthalmic Solution order to say Instill 1 drop in both eyes three times a day;-Please adjust the instructions on the cyclosporine order to Give 1 capsule by mouth twice daily;-Tamsulosin is best taken with food. Please add Take with food Do not crush or chew. Review of the POS, dated 9/2025, in use during the survey, showed:-An order, dated 8/5/25, amoxicillin oral tablet 500 mg, give one tablet by mouth three times a day for bacteria;-An order, dated 8/5/25, acetaminophen tablet 325 mg, give two tablets by mouth every 6 hours as needed for pain;-An order, dated 8/5/25, hydrocodone-acetaminophen Oral Tablet 5-325 mg, give one tablet by mouth, two times a day for pain. Take one tablet by mouth every 12 hours;-An order, dated 8/5/25, polyethylene glycol powder 1450 (MiraLAX), give 17 gram by mouth, one time a day for constipation;-An order, dated 8/5/25, polyvinyl alcohol ophthalmic solution (Artificial tears), instill 1 mg in both eyes, three times a day for eye drops, 1 drop into both eyes, three times daily;-An order, 8/5/25, cyclosporine modified oral capsule (used to treat autoimmune conditions)100 mg, give 1 capsule enterally two times a day for eyes, one drop into both eyes two times a day;-An order, dated 8/5/25, tamsulosin (treats enlarged prostate) HCI oral capsule 0.4 mg, give 1 capsule by mouth at bedtime for enlarged prostate;-An order, dated 8/28/25, hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth two times a day for pain, take one tablet by mouth every 12 hours. 6. Review of Resident #13's medical record, showed his/her diagnoses including chronic kidney disease (CKD, a condition where the kidneys gradually lose their ability to filter waste products from the blood), depression, schizophrenia and unspecified muscle weakness. Review of the POS, in use during the survey, showed:-An order placed on 5/9/23 for Vitamin D (Ergocalciferol) 50,000 unit capsule to be given once daily. The order contained no end date;-An order placed on 10/11/24 for Vitamin D 1.2MG (50,000 units) capsule to be given once daily in the morning. The order contained no end date. Review of the resident's progress notes showed:-A note from 6/21/25 entered by the pharmacist indicating duplicate Vitamin D orders existed and needed clarification to ensure the resident was receiving the appropriate dose of Vitamin D daily;-A note from 7/23/25 entered by the pharmacist indicating pharmacy recommendations from June 2025 had not been responded to and clarification was still needed regarding Vitamin D orders;-No medication regimen review performed by a pharmacist was documented in August of 2025. During the survey period the facility was unable to provide physical copies of the consultant pharmacist's medication recommendations or physician responses to the pharmacist's recommendation. 7. Review of Resident #67's medical record, showed his/her diagnoses included major depressive disorder, schizophrenia, obsessive-compulsive disorder (a mental health condition characterized by intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions that cause significant distress and impairment in daily functioning), post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and bipolar disorder. Review of the POS, in use during the survey, showed:-An order, placed on 7/11/25, for Haldol (Haloperidol, a first-generation or typical antipsychotic medication used to treat psychotic disorders) Injection solution 5 mg/mL (milligrams per milliliter) as needed every 8 hours for agitation/aggression. The order contained no stop date;-An order, placed on 9/7/25, for Haldol 5 mg tablet with instructions to give 2 tablets by mouth every 8 hours as needed for agitation/aggression for a total of 14 days. Review of the progress notes, showed:-7/22/25, the consulting pharmacist noted the resident's Haldol injection order contained, no stop date and antipsychotics should be restricted to 14 days if kept as a PRN order. An additional request to address the previous month's recommendations was made within the consultant review;-8/20/25, the consulting pharmacist noted the resident's Haldol injection still had not received a 14-day stop date and required one. During the survey, the facility was unable to provide physical copies of the consultant pharmacist's medication recommendations or physician responses to the pharmacist's recommendation. 8. Review of Resident #35's medical record, showed his/her diagnoses included localized edema, high blood pressure, weight loss and kidney disease. Review of the pharmacy review note, dated 8/18/25, showed:-This resident is currently receiving the following: Furosemide (Lasix a diuretic treating blood pressure and water retention) without a proper diagnosis. Review of the pharmacy review note, dated 7/21/25, showed: please address pharmacy recommendations from the prior month. Please provide a more appropriate diagnosis for the following medication: Lasix Review of the POS, in use during the survey, showed:-Give Lasix (diuretic) tab 20 mg one tab daily for hyponatremia (low sodium). The facility did not address the pharmacy recommendations. 9. Review of Resident #85's medical record, showed his/her diagnoses included infection of the skin and the subcutaneous tissue, (bacteria in the skins layers), non-pressure ulcer of the left ankle limited breakdown of the skin (not related to pressure wound). Review of the pharmacy review note, dated 6/26/25, showed:-This resident is currently receiving the following provide a more appropriate diagnosis for the following medication(s) Aspirin (i.e. primary/ secondary prevention). Review of the pharmacy review note, dated 7/22/25, showed: please address pharmacy recommendations from the prior month. Review of the POS, in use during the survey, showed:-Aspirin 81 mg chewable one tablet by mouth daily for a supplement active since 2/16/23. -Aspirin 81 mg one tablet by mouth daily for a preventative discontinued since 8/17/21.-The pharmacy recommendations were not addressed. 10. During an interview on 9/9/25 at 1:11 P.M., the Administrator and acting Director of Nurses (DON) said after the consultant pharmacist reviews resident medication regimens, a packet is provided to the facility that contains recommendations for each resident. The DON and Assistant Directors of Nursing (ADONs) should act on those recommendations and notify the physician. The facility Medical Director (MD) usually answers right away. No singular staff member is responsible for ensuring recommendations are followed as any nurse should ensure this is done. Any action taken regarding medication regimen recommendations should be documented in the resident's medical record. Antipsychotic medications given on a PRN basis require a stop date no further than 14 days past the original order date.

Based on interview and record review, the facility failed to offer and vaccinate, as desired, eligible residents with the pneumococcal (pneumonia) and influenza (flu) vaccine for 5 out of 5 residents sampled for immunizations (Residents #85, #72, #67, #54 and #45). The sample was 43. The census was 105. Review of the influenza and pneumococcal immunization policy, revised 5/14/24, showed:-Purpose: to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease;-Procedure: -At admission, the resident and/or the resident's legal representative will be provided education on the benefits and potential side effects of both the influenza and pneumococcal immunizations; -The resident or their legal representative will be informed that the influenza immunization are provided yearly between October 1st and March 31, unless the immunization is medically contraindicated, the facility has evidence that the resident has already been immunized during this time, or the resident or the resident's legal representative has refused the immunization; -The resident or legal representative will be informed that the pneumococcal immunization will be offered upon admission per Centers for Disease Control (CDC) guidelines. The pneumococcal immunization will not be given if the immunization is medically contraindicated, the facility has evidence to support the resident received the immunization, or the resident/legal representative has refused the immunization; -The resident or the legal representative will be required to sign the revolving consent form. The resident or the legal representative will be told the form provides consent for annual influenza immunizations and for the pneumococcal immunization as needed unless those immunizations are medically contraindicated. The resident or legal representative will be told that they can revoke the revolving consent form at any time abut such revocation must be in writing;-Current residents: -Any resident who has not been offered a revolving consent form will have the revolving consent form offered to the resident or their legal representative following the procedure;-Annual consents: -If a resident or legal representative chooses to not sign a revolving consent form, an annual consent may be obtained; -The resident or legal representative will be provided education on the benefits and potential side effects of the immunizations; -On admission and yearly, the resident or their legal representative will sign a form showing the resident or the legal representative has been educated on and is aware of the benefits and potential side effects of receiving the immunizations; -Each resident will be offered the influenza immunization yearly between October 1st- March 31st unless medically contraindicated, the facility has evidence that the resident had already received the vaccine; -The pneumococcal immunization will be offered upon admission and a second pneumococcal immunization may be recommended after five years from the first immunization. The immunization will be given unless the immunization is medically contraindicated, the facility has evidence the resident has already been immunized during this time period, or the resident or their legal representative has refused the immunization;-Consent Process: -The customer service consultant/designee or social services director/designee will provide educational information on the immunization and ensure the consent form is filled out, placed in the resident's chart and updated (if needed) before the immunization is given to the resident; -The consent/refusal form will include documentation to support that the resident or their legal representative is full informed and educated on the benefits and potential side effects of the immunizations; -Physician orders will be obtained for the immunizations unless medically contraindicated or the resident or their legal representative has refused the immunizations; -The resident's clinical record will document: -The resident of their legal representative was provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations; -The resident either received the influenza and pneumococcal immunizations or did not receive them due to medical contraindications or refusals. 1.Review of Resident #85's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/21/25, showed:-admitted : 2/16/23;-Cognitively intact;-Diagnoses included epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), schizoaffective bipolar (irrational thoughts, including emotional highs and lows), anxiety, skin infection and vitamin deficiency;-Did the resident receive the influenza vaccine in this facility for this year's influenza season: No; -If influenza vaccine not received, state reason: offered and declined;-Is the resident's pneumococcal vaccination up to date? No; -If pneumococcal vaccination not received, state reason: not offered. Review of the resident's medical record, showed no documented offering or declination of the flu or pneumococcal vaccinations for the 2024 season. During an interview on 9/9/25 at 10:43 A.M., the resident said he/she had not been offered either vaccination while at the facility. He/She would consider the vaccinations. 2. Review of Resident #72's annual MDS, dated [DATE], showed:-admitted [DATE];-Cognitively intact;-Diagnoses included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), seizure disorder, and vitamin deficiency;-Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state reason: not offered;-Is the resident's pneumococcal vaccination up to date: no; -If pneumococcal vaccination not received, state reason: not offered. Review of the medical record, showed no documented offering or declination of the flu of pneumococcal vaccinations for the 2024 season. During an interview on 9/5/25 at 12:15 P.M., the resident said he/she had not been offered the flu or pneumococcal vaccinations. 3. Review of Resident #67's quarterly MDS, dated [DATE], showed:-admitted : 4/19/24;-Cognitively intact;-Diagnoses included schizoaffective disorder, bipolar disorder, epilepsy and anxiety;-Is the resident's pneumococcal vaccination up to date: no; -If pneumococcal vaccination not received, state reason: not offered. Review of the physician order sheet (POS), showed:-An order, dated 4/19/24: may have to pneumococcal vaccine every 5 years with written or verbal consent. Review of the medical record, showed no documented offer or declination of the pneumococcal vaccination. During an interview on 9/8/25 at 11:22 A.M., the resident said he/she had not been offered the pneumococcal vaccination. 4. Review of Resident #54's annual MDS, dated [DATE], showed:-admitted : 10/26/22;-Moderate cognitive impairment;-Diagnoses included stroke with paralysis, lung disease and Alzheimer's disease;-Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state reason: offered and declined;-Is the resident's pneumococcal vaccination up to date: no; -If pneumococcal vaccination not received, state reason: not offered. Review of the POS, showed:-An order, dated 10/6/22: -May have influenza vaccine yearly and pneumococcal vaccine every 5 years with written or verbal consent. Review of the medical record, showed no documented offer or declination of the influenza or pneumococcal vaccinations. 5. Review of Resident #45's quarterly MDS, dated [DATE], showed:-admitted : 2/4/25;-Moderate cognitive impairment;-Diagnoses included bipolar disorder, personality disorder, hepatitis C (liver infection, causing liver failure), heart failure, lung disease and anxiety;-Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state reason: resident not in the facility;-Is the resident's pneumococcal vaccination up to date: no; -If pneumococcal vaccination not received, state reason: not offered. Review of the POS, showed:-An order, dated 7/25/25: may have flu vaccine yearly and pneumococcal vaccine with written or verbal consent. Review of the medical record, showed no documented offer of declination of the influenza or pneumococcal vaccinations. 6. During an interview on 9/9/25 at 2:12 P.M., the Administrator said residents or the responsible party (RP) should be offered the influenza and pneumococcal vaccines, upon admission or re-admission if not previously offered or administered. The resident or RP should sign either the declination or acceptance form and the form should be placed into the resident record.

Based on observation, interview and record review, the facility failed to ensure a resident who experienced bilateral (both sides) finger amputations, had an accessible device to call for staff assistance (Resident #40). The sample was 43. The census was 105. Review of Resident #40's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/11/25, showed:-Cognitively intact;-Able to make needs and wants known;-Required physical assistance for eating; -Required brace for eating;-Required physical assistance for hygiene, eating, transfers and daily care;-Diagnoses included superficial frostbite of the left and right hand (a mild to moderate form of frostbite where ice crystals form in the top layers of the skin, making the skin appear pale, waxy, and feel stiff or hard), schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), bipolar type (hallucinations with high/low moods), polyneuropathy (peripheral nerve damage), drug induced subacute dyskinesia (involuntary movement disorder). Review of the care plan, in use during the survey, showed: -Problem: -The resident has a movement disorder of the upper extremities. Encourage the resident to use the bell to call for assistance; -The resident has an activities during daily living (ADL) self-care performance deficit related to external device. He/She lost all fingers on both hands to frostbite in March 2020 and needs adaptive devices to perform ADLs effectively. He/She often refuses to wear adaptive equipment, requires supervision for safety oversight;-Desired Outcome: The resident will demonstrate the appropriate use of adaptive devices(s) to increase ability in the ADLs;-Interventions:-The resident requires adaptive equipment of weighted utensils and divided plate, encourage the resident to use bell to call for assistance;-Monitor, document, report any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function; Observation and interview on 9/3/25 at 2:09 P.M., showed the resident sat in bed. No call light was noted next to the bed. The resident said his/her roommate used his/her own cell phone to call for assistance. The resident said the facility call light system was getting repaired. His/Her roommate had been supplied with a whistle. The resident was unable to use a whistle to call for assistance. The facility had not provided a different mechanism of communication. The resident said he/she relied on his/her roommate to call for help. During an interview on 9/10/25 at 1:45 P.M., the Administrator said during the call-light repair, each resident was to receive hourly checks. When the whistles were effective, residents would have 15-minute checks. Most of the residents did not effectively utilize the whistle system. The Administrator also said they tried a bell and did 15-minute checks. All residents should have accessibility to call for staff assistance. It is not appropriate for residents to rely on roommates to obtain staff assistance.

Based on interview and record review, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 98 residents. The census was 105. Review of the facility's Resident Trust policy, dated 6/12/25, showed Resident Trust clerk must reconcile the cash left in the box with the receipts in the box by completing the Resident Trust Petty Cash Reconciliation Form. Attach all receipts in the petty cash box to the Resident Trust Petty Cash Reconciliation form. The administrator signs reconciliation form for approval.Review of the facility-maintained bank statements for the months 4/25 through 7/25, showed no documentation of reconciliations.Review of the facility-maintained attempted reconciliation forms, dated 4/25 through 7/25, showed the attempted reconciliations did not reconcile to the residents' current balance at the time of the attempted reconciliation.Observation and interview on 9/5/25 at 11:40 A.M., showed the Business Office Manager (BOM) counted the resident petty cash that was in the safe. The cash totaled $163.00. The BOM said he/she had been at the facility since July, 2016 and he/she did not know if the petty cash was accounted for on the reconciliation on the bank statement. The corporate office determines the set amount of petty cash that is withdrawn at the beginning of each month which is added to the existing petty cash. The BOM counts the resident petty cash every time he/she replenishes the cash. The BOM said the petty cash comes from the resident trust. There is running total on the petty cash sheet for tracking. The BOM said he/she has never had over $4,000.00 cash on hand and does not know why the bank reconciliation reports showed cash on hand in the amount of $6,626.00 in May 2025, $16,971.00 in June and $16,941.00 in July 2025.During an interview on 9/8/25 at 11:53 A.M., the Activity Director (AD) said every morning, he/she counts the petty cash envelope with the BOM, verifying the cash balances with the receipt book. The AD said each individual withdrawal with the resident signature is recorded in the receipt book. At the end of the day, the petty cash envelope cash is reconciled with the BOM and AD.During an interview on 9/5/25 at 11:45 A.M., the Corporate Business Office Manager (CBOM) said he/she expected the petty cash to be accounted for on the monthly reconciliation sheet and the actual cash itself is counted and documented to ensure accuracy. The petty cash is residents' money.During an interview on 9/9/25 at 9:45 A.M., the Administrator said she expected the facility to ensure the resident trust fund account is reconciled each month.

Based on interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when one resident was placed in a head lock by Floor Tech N (Resident #39). The sample was 43. The census was 105. Review of the facility's Abuse and Neglect Policy, dated 6/12/24, showed the following:-Purpose: -It is the policy of this facility ensure all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Physical Abuse: -Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior;-Protection of Residents:-The Facility will take steps to prevent mistreatment while the investigation is underway; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. Review of the facility's restraint free environment policy, dated 4/30/24, showed:-Purpose: -It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints-Definitions: -Physical Restraints: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: -Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove; -Holding down a resident in response to a behavioral symptom, or during the provision of care if the resident is resistive or refusing the care; -Discipline: Discipline means any action taken by the facility for the purpose of punishing or penalizing residents.-Policy: -The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms. -Behavioral interventions should be used and exhausted prior to the application of a physical restraint; -How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. Review of the facility's Crisis Prevention Institute (CPI) pamphlet/brochure overview, showed:-CPI Training Solutions for Human Services: De-escalation training solutions that improve staff safety and retention while lowering costs related to injuries, time off the floor, and workers' compensation claims.-Evidence-Based Training for Human Services Professionals: CPI teaches human services professionals the skills and techniques to identify, prevent, and de-escalate the complex situations they encounter in the workplace. With tiered levels of training, we offer customizable solutions that fit every role and risk level to foster facility-wide safety and well-being:-Experience the Benefits of a Tailored Training Solution -At CPI, we know that everyone plays a critical role in creating a safer workplace. So, we offer tailored training solutions for all staff, to help you create an organization-wide culture of safety. Our training provides your staff with relevant skills based on their role and the risks they encounter every day; -CPI training has helped human services facilities improve staff safety and retention, as well as lower costs related to staff injuries, time off the floor, and workers' compensation claims. Our partners have also successfully reduced the need for restraints through our training's focus on prevention and proactive verbal intervention skills.-CPI NCITM with Advanced Physical Skills: -Learn Advanced Disengagement and Physical Intervention Techniques for Situations Involving Dangerous Behaviors CPI NCITM With Advanced Physical Skills; -High Risk Associated Behaviors: Destructive behavior. Causing harm to self or others. Physically aggressive; -Select Staff.-CPI Nonviolent Crisis Intervention: -Learn Intervention Skills and Techniques to Safely De-escalate Crisis Situations; -Mid-To-High Risk Associated Behaviors: Challenging behavior. Trauma-induced behavior. Using abusive language; -All staff.-CPI Verbal Intervention: -Learn Verbal De-escalation Skills to Avoid Restrictive Interventions; -Low Risk Associated Behaviors: Anxious behavior. Disruptive behavior. Verbally defensive; -All staff. Review of Resident #39's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/10/24, showed the following:-Intact cognition;-No behaviors;-Diagnoses of high blood pressure, high cholesterol, depression and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). Review of the resident's nurse's note, dated 8/10/25 at 2:57 P.M., showed a code green was called. The resident was physically fighting the staff. The resident was sent out to the area's local hospital for physical aggression and attacking staff. Staff called psych Nurse Practitioner (NP) for a PRN order for aggression. The Physician, NP, and Director of Nurses (DON) notified. Review of the resident's care plan, dated 9/1/24, showed the following:-Problem: On 8/10/25: Physical aggression against staff: The resident was coming in from his/her 1:1 smoke break with staff. While walking back into the building from the patio, he/she hit Certified Nurse Aide (CNA) O in the head and the face and pulled CNA O's hair. The resident also hit the Administrator in the right shoulder, neck area and in several regions of the head: top, back, left/right side of the head with a closed fist.-Desired Outcome: 8/10/25: The resident will not display physical aggression to staff through next review period; -Interventions: 8/10/25: A physical hold used to restrain resident from hitting others. Emergency Medical Services (EMS) was called and accompanied by police to assist. Administered as needed (PRN) intramuscular (IM), ordered 25 milliliter (ml) Thorazine (antipsychotic). The resident was sent to the hospital for evaluation and treatment with a medication evaluation. The resident was admitted . Review of the Statement for incident: Resident to Staff, dated 8/11/25, provided by the Administrator showed: On 8/10/25, the resident had a resident-to-resident altercation in the early afternoon about 1:00 P.M., He/She hit another resident while he/she was on the patio smoking. The resident said that the other resident was counting the number of flicks he/she made while smoking his/her cigarette. The residents were immediately separated. The resident was placed on 1:1. After the next smoke break, the resident was taken out when all the other residents were finished smoking. The resident's 1:1 was present. When the resident was walking with his/her 1:1, Floor Tech N, behind him/her, the resident ran up to CNA O and hit him/her and pulled his/her hair. Floor Tech N stopped the resident from hitting and pulling CNA O's hair. As Floor Tech N was walking the resident away from CNA O, he/she did not de-escalate the situation. Floor Tech N was asked by the Administrator to allow the resident to walk about the hall. At that time, the other residents were directed to go to their rooms for safety. The resident ran up on the Administrator and hit her in the head several times, the right shoulder, chest and thigh area. The resident walked to the dining area to await the EMS and the police. Review of the Floor Tech N's CPI Blue Card, showed:-Completion date: 6/2/25;-Expiration date: 6/3/26;-Completed seven Modules; -Thirteen hours completed. During an interview on 9/3/25 at 4:30 P.M., the resident said he/she has been at the facility for 10 years. There was an altercation. Floor Tech N choked him/her when Floor Tech N was trying to restrain him/her. Floor Tech N wouldn't let him/her go. Floor Tech N told the resident he/she was going to F- - k him/her up. The resident hit CNA O, Floor Tech N's family member, and then Floor Tech N hit the resident. No one else tried to restrain him/her. No one else hit the resident or had been rough with him/her that he/she knew of. The resident had not seen Floor Tech N since. During an interview on 9/9/25 at 10:40 A.M., Staffing Coordinator (SC) M said he/she worked at the facility for twenty-five years. He/She was familiar with the resident. He/she was aware of the incident involving the resident. He/she never slammed the resident against the wall. SC M may not have done the proper technique, but he/she never slammed the resident against the wall. The Administrator was down on the hall with him/her. Floor Tech N had the resident and was holding him/her. Staff told Floor Tech N to let the resident go. He/She let the resident go. He/she attacked the Administrator. Everyone was scared and running. The resident was just going through the hall just hitting people. Before the resident attacked the Administrator, he/she had punched Floor Tech N's family member, CNA O. SC M and the Administrator were not on the hall during that time. They had called code green. The resident had done this before. He/She would just snap out to where he/she would have to be sent out. He/She would not yell out; the resident would just start punching people. SC M did not know if Floor Tech N had the resident in a choke hold or head lock, but Floor Tech N wasn't doing the CPI technique right. The resident was punching the Administrator. SC M told the Administrator to run. SC M grabbed the resident's hand. She didn't know which hand. She was just trying to stop the resident from beating the Administrator to death. The other staff were supposed to help, but they didn't. They used to do a five man take down. He/She was just trying to get the resident off the Administrator. The resident had beat the Administrator within two seconds. The resident started punching the Administrator the first time. Floor Tech N then grabbed the resident. SC M didn't know how Floor Tech N grabbed the resident but just knew he/she grabbed the resident to get him/her off the Administrator. The resident was just punching, and everyone was too scared to do the CPI hold. The second time the resident punched the Administrator, he/she was punching her in her head. The resident even told SC M he/she didn't want to hurt her. The other staff left her. They were all scared and running. During an interview on 9/9/25 at 11:11 A.M., Floor Tech N said he/she had worked at the facility for about one and a half years, but he/she was no longer employed at the facility. He/she was familiar with the resident. Floor Tech N said it was true. He/She had placed the resident in a head lock. He/She said it was because at the time, it was just him/her right there. He/She had to restrain the resident. The resident had an altercation with another resident prior. After the altercation, the resident was placed on a 1 to 1 in which he/she was appointed the resident's 1 to 1. The resident couldn't smoke with the other residents on his/her hall so once everyone was done smoking, he/she smoked the resident. As they were walking back in, Floor Tech N's family member was working B Hall as the CNA. CNA O started to say something to Floor Tech N and before CNA O could get it out, the resident started punching CNA O in his/her face and head. Floor Tech N intervened as quickly as he/she could. He/She grabbed the resident from behind and that is when he/she proceeded to take the resident against the wall and that was when the headlock came in. At that point, the resident turned so it was a side-by-side head lock. Floor Tech N is trained in CPI. He/She just had his/her re-certification about two months prior to that incident. Floor Tech N was familiar with SC M. He/She did not see SC M slam the resident into the wall. He/She honestly did not see SC M lay a hand on the Resident. SC M arrived after he/she had got word of what was happening on the hall. After the situation with his/her family member, everyone told him/her to let the resident go. So, he/she let the resident go. It was at that time, the Administrator was walking up the hall and Floor Tech N and the resident were walking down the hall. As soon as he/she let the resident go, he/she attacked the Administrator. That's when Floor Tech N stepped in the middle of them. He/She didn't touch the resident. Floor Tech N just stepped between the resident and the Administrator and moved him/her away from the Administrator. They actually terminated him/her. Floor Tech N was originally sent home after the incident on that Sunday. On Monday, he/she called off work. He/She returned to work on that Tuesday, and they let him/her work his/her entire shift, 8:00 A.M. to 4:00 P.M. Later that night, around 11:00 P.M, he/she received a voice message from the Administrator saying he/she was suspended pending investigation, then he/she was officially terminated about one week later. Floor Tech N completed abuse and neglect in-services. They were passed around very often. He/She signed one probably a couple of weeks prior to the incident. During interviews on 9/5/25 at 3:25 P.M., 9/9/25 at 9:52 A.M., and 9/10/25 at 12:50 P.M., the Administrator said the resident had a resident to resident earlier that day. He/She was placed on a1:1 as a result. The resident had been hearing voices and had gotten delusional, so had gone up and hit another resident. With his/her 1:1 status, it was already determined he/she wouldn't smoke with the other residents. His/her 1:1 staff, Floor Tech N, was behind him/her. The resident went up to CNA O, which happened to be Floor Tech N's family member, and had begun to hit him/her in his/her head and pulling his/her hair. Floor Tech N pulled the resident off CNA O. By that time, she heard some noise, maybe a code green call, so she went to the hall and staff were there. Floor Tech N was walking down the hall. She told staff to get residents into their rooms. Normally, they would have had a de-escalator. Floor Tech N was supposed to have deescalated the situation, which was include making sure everyone was safe, de-escalate, making sure the resident was safe, and making sure nothing was in the way. Floor Tech N was more focused on the resident getting off the unit and wasn't following her directive (to de-escalate). She told Floor Tech N to get his/her family member off the hall but deescalate and make sure all the residents were in their rooms. Floor Tech N finally followed the directive. By that time, she had told the staff to let the resident have the hall. She told one of the nurses to call the Physician to get an IM for the resident. At that point, Floor Tech N said he/she would do what was asked and that what was to escalate. The Administrator was the closet one to the resident. The resident started hitting her in the head. Mostly, the right side of her head and then when she leaned over to try to protect her face, he/she started hitting her on both sides of her head and other parts of her body. The Administrator was yelling out to get the residents to their rooms. Floor Tech N made sure his/her family member was off the unit and out the door. Then he/she grabbed the resident's arms (wrist area) to stop the resident from hitting her. After that, Floor Tech N tried to deescalate the resident, so he/she had the resident in a CPI hold by his/her wrists and walked him/her off the unit to the dining room area. Floor Tech N never had the resident in a head lock. She didn't think Floor Tech N did the CPI hold correctly. The hold was correct although it would have normally been two people to do the hold. Floor Tech N was terminated because he/she did not follow her directives regarding the de-escalation. It was her expectation for all the residents to be free from abuse and neglect. It is everyone's responsibility to ensure residents are free from abuse and neglect. This would include leaders, managers, supervisors, directors as well as front line staff.2606143

Based on interview and record review, facility staff failed to prevent the misappropriation of one resident's patient trust funds, which was used without authorization of the resident. The funds were withdrawn from resident's patient trust account between the dates of 4/10 and 4/17/25, with total withdrawals of $7,877.01 (Resident #20). The census was 105. Review of the facility's policy titled, Abuse and Neglect, dated 6/12/24, showed:-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent;-Theft of money from bank accounts;-Unauthorized or coerced purchases from resident's funds;-The Administrator will conduct all investigations. A formal investigation shall begin immediately and include interviews with all staff, interview facility residents and document that interviews were completed. Review of Resident #20's Mental Status Exam, dated 8/18/25, showed:-No cognitive impairment;-Diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder, depression and dementia. Review of the resident's Trust Statement, dated 6/30/25, showed: -On 4/10/25, a $500.00 cash withdrawal with description, money for shopping with family;-On 4/17/25, a $5,756.16 (invoice #81466) and $1,620.85 (invoice #82089) withdrawal with description, Resident Essentials Clothing. Review of the Resident Essentials Clothing invoice #81466, dated 4/17/25, showed:-Various sweatpants, shirts and other clothing items;-[NAME] two drawer nightstand for $550.00;-[NAME] five drawer chest for $1,260.00;-Home music system for $135.00;-Two twin bed sets for a total of $270.00;-Pep talk recliner for $945.00. Review of the Resident Essentials Clothing invoice #82089, dated 4/30/25, showed:-Various t-shirts, socks and other clothing items;-Two comforters for a total of $170.00. Observation on 9/8/25 at 3:30 P.M showed the resident sat on the edge of his/her bed with a large unopened box (24x18x24) marked Resident Essentials on the floor, in front of the closet and a blue roller walker. There were black tote boxes filled with various t-shirts, sweatpants and tops. There were numerous baseball hats laying around the room. The style and color of the resident's bedding, dresser and nightstand were seen throughout the facility. The Pep talk recliner, [NAME] nightstand, [NAME] dresser, twin bed sets, and comforters were not present. Observation on 9/9/25 at 9:04 A.M., showed the home music system in the unopened box in the resident's room and the Pep talk recliner were located in room A15. During an interview on 9/8/25 at 2:30 P.M., the resident said he/she did not give the facility permission to use his/her funds to make any purchases on his/her behalf. The resident said he/she received some clothes and a recliner but requested those items be returned because he/she only wears Adidas clothing and the recliner was a waste of money. The resident said he/she never received a new dresser, nightstand, twin bed sets and comforters. During an interview on 9/8/25 at 3:30 P.M., the Business Office Manager (BOM) said when the corporate office reports a resident is over resources (Medicaid eligibility maximum resource is $5,909.25), he/she will ask the Certified Nurse Aides (CNA) what the resident needs, then will make those purchases on the resident's behalf. The BOM said he/she remembers giving the resident $500 to go shopping with his/her family but forgot to have the resident sign the ledger receipt book. The BOM said she did not speak to the resident prior to making purchases and was unaware the resident did not want the items or requested for the items to be returned. During an interview on 9/9/25 at 9:30 A.M., the Administrator said she expected staff to follow the facility's patient withdrawal policy. The resident must sign the receipt for all withdrawals. The facility should not make purchases for a resident without first obtaining their permission and signature.

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 and the facility's bed hold policy at the time of transfer for three residents who were discharged to the hospital (Residents #119, #69 and #114) out of three residents sampled for bed hold notification. The census was 105.Review of the facility's undated admission agreement, showed facility offers a bed hold policy which assures you of re-occupation to your bed during a temporary absence from facility due to therapeutic leave or hospital admission. If you choose not to hold the bed during an absence from the facility, that bed shall be considered vacant and facility may place another resident in it for occupancy. If your personal belongings have not been removed and it becomes necessary to occupy that room with another resident, facility will package all personal items and place them in storage for a period not to exceed two (2) weeks. Upon your re-admission to facility, you will be placed in the first available appropriate bed. Paying to hold a bed is strictly voluntary. However, Facility cannot guarantee re-admission to the same specific bed from which you previously occupied, prior to the absence, unless the daily bed hold rate is paid. In the event you choose to hold the bed and pay the daily bed hold rate, but facility cannot re-admit you due to the determination that your resident level of care cannot be adequately provided, a refund will be issued for the bed hold days. However, if we can adequately provide care and you choose not to return to our facility for any reason, no refund will be made.1. Review of Resident #119's hospital discharge record, showed:-admitted on [DATE];-discharged on 12/9/24;-Diagnosis of suicidal thoughts.Resident #119's face sheet, showed the resident was admitted on [DATE]. Review of the resident's progress notes, dated 12/9/24, showed during rounds this nurse spoke with resident, who expressed that he/she was suicidal. I ask resident did he/she have a plan which he/she responded, yes. Resident stated he/she would not tell me his/her plan. Upon assessment resident has red marks on his/her left arm. I asked resident were those from today. Resident said no. I asked resident did he/she plan to cut him/herself today, which he/she responded yes. When asked did resident have any objects in the room that he/she could use to harm him/herself, he/she stated yes and he/she would not tell me where they were. Administrator and Director of Nursing (DON) notified. Social worker notified. One to one left with resident while this nurse reported and printed paperwork. This nurse waited with resident until Emergency Medical Services (EMS) and police arrived. Resident sent out to hospital via stretcher. Guardian contacted, message left. Resident's mother contacted, message left. Psych physician notified. Review of the resident's medical record, showed no bed hold notice. During an interview on 2/11/25 at 2:17 P.M., hospital Registered Nurse (RN) said the resident had been hospitalized since early December. In mid-January, the hospital received communication from the facility that the resident was being discharged for being out of the facility for an extended period of time. An appeal was made for the discharge. Department of Health and Senior Services (DHSS) upheld the appeal and the resident's discharge was waived and bed was held. 2. Review of Resident #69's face sheet, showed he/she was admitted on [DATE].Review of the resident's progress notes, dated 8/30/25, showed resident had mental status change. Family came to take him/her out for lunch but resident said he/she did not feel good and he/she did not want to go. Certified Nurse Aide (CNA) who works with this resident also said he/she was not his/her normal self. Vital signs were taken his/her blood pressure was 162/86 and his/her pulse was 78. At that time I did notice that he/she was acting a little sleepy and he/she was very weak. I called the doctor and reported what I saw. The doctor said send him/her out, he/she may be in a-fib or having a stroke because I did report left-sided weakness. Family made aware. I notified our corporate nurse, the Administrator and the DON. Family came and wanted resident taken to hospital. Niece said she had already called 911 before she got here. Ambulance came, report was called to hospital. Niece was with the transport. Family said they would call back and talk about their concerns. Review of the resident's medical record, showed no bed hold notice. 3. Review of the Resident #114's medical record showed:-admitted to the facility on [DATE];-discharged to the hospital on 7/27/25. Review of the resident's progress notes showed:-On 5/24/25 at 12:16 A.M., the resident attacked staff. The resident became upset that his/her supervision was late and that he/she had to sit at the front with the nurse. The resident attempted to leave nurse supervision. The nurse attempted to stop him/her. The resident attacked the nurse. He/she scratched and swung at the nurse. The resident threw a pitcher of water at the nurse. He/she reached for a pill crusher and fell from a chair. 911 called. Two police officers and fire department EMS arrived. The resident was given her cell phone and was taken to the area's local hospital. Guardian notified. Management notified. Physician notified and psych notified.-On 6/3/25 at 12:15 A.M., the resident was refusing medication. The resident had been on 1:1. Staff bought it to writer attention that the resident was saying it would all be over soon while he/she held a shoestring. The nurse asked resident if he/she felt like he/she wanted to harm him/herself or others. The resident was unresponsive. The nurse asked if he/she could search the resident's person. The resident said no. The nurse called the Director DON and he spoke with the nurse practitioner (NP) psych who recommended that the resident be seen at the hospital. Before he/she left, the resident's bags were searched with the resident's consent, and the nurse found a screw in the pouch. The guardian and ADON were made aware. EMS transported the resident to the area's local hospital. The resident was alive and breathing when left the facility. Further review of the resident's medical record, showed no documentation of a transfer notice(s) was give 4. During an interview on 9/8/25 at 12:20 P.M., the Administrator said they will send the bed holds with the resident; however, a copy is sent to the hospital. She expected the resident to have a bed hold if they were transferred to the hospital. She was not in the facility at the time, so she was not aware of Resident #119's transfer. 1731660

Based on interview and record review, the facility failed to ensure two residents received an accurate assessment, reflective of the residents' status at the time of assessment, by failing to identify the residents' hospice admission (Residents #10 and #36). The facility identified three residents receiving hospice services, two were sampled. The census was 105. 1. Review of Resident #10's face sheet, showed his/her diagnoses included malignant neoplasm (cancerous tumors) of cecum (pouch that forms the first part of the large intestine), secondary malignant neoplasm of liver and intrahepatic bile duct, and secondary malignant neoplasm of left lung.Review of the resident's Physician's Orders Sheet (POS), showed an order, dated 5/20/25, okay for hospice to evaluate and treat. Review of the resident's care plan, in use during survey, showed:-Problem: Resident receiving chemotherapy related to cancer that has metastasized (mets, spread to other parts of the body) to several areas of his/her body;-Desired Outcome: The resident will remain free of complications related to chemotherapy side effects;-Interventions: Give medications and treatments as ordered. Monitor/document for side effects and effectiveness;-Problem: The resident has a terminal prognosis related to cancer that has mets to multiple sites. June 3rd, resident was admitted under the care of hospice services due to cancer diagnosis;-Desired Outcome: The resident will be free of depression and anxiety;-Interventions: Adjust provision of activities of daily living (ADLs) to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate; -Assess resident coping strategies and respect resident wishes; -Consult with physician and Social Services to have Hospice care for resident in the facility; -Encourage resident to express feelings, listen with non-judgmental acceptance, compassion; -Encourage support system of family and friends; -Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain; -Refer for Psychiatric/Psychogeriatric consult if indicated; -Review resident's living will and ensure it is followed. Involve family in discussion; -Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met; -Work with nursing staff to provide maximum comfort for the resident. Review of the resident's hospice agreement, showed it was signed on 6/2/25. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/16/25, showed:-Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: No. 2. Review of Resident #36's face sheet, showed his/her diagnoses included heart failure, pulmonary hypertension (high blood pressure) and chronic kidney disease.Review of the resident's quarterly MDS, dated [DATE], showed:-Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: No. Review of the resident's POS, dated 9/25/25, showed an order, dated 12/3/24, admit to hospice. Review of the resident's hospice agreement, showed:-Signed on 11/20/24;-Diagnosis of left middle cerebral artery (MCA) stroke. Review of the resident's care plan, in use during survey, showed:-Problem: Resident is on hospice;-Desired Outcome: The resident's comfort will be maintained;-Interventions: Adjust provision of ADLs to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate; -Assess resident coping strategies and respect resident wishes; -Encourage resident to express feelings, listen with non-judgmental acceptance, compassion; -Encourage support system of family and friends; -Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near; -Refer for Psychiatric/Psychogeriatric consult if indicated; -Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met; -Work with nursing staff to provide maximum comfort for the resident. 3. During an interview on 9/9/25 at 12:25 P.M., the Administrator said corporate completes the MDS. The calendar is sent, and they work on it together as a group with the care plans. She expected the MDS to be accurate and completed timely.

Based on interview and record review, the facility failed to ensure a resident who re-admitted to the facility on [DATE] with a recommended hospice evaluation received the ordered hospice evaluation. The resident's physician assessed the resident on 7/18/25 and documented the resident received hospice services. On 7/30/25, the resident experienced a change in condition. Staff discovered the resident had not been enrolled into hospice services and did not notify the physician of the discovery. The resident expired at the facility approximately three hours after the change in condition (Resident #118). The census was 105. Review of the notifying clinician's policy, revised 6/26/24, showed:-Purpose: to ensure clinicians are properly notified of a resident's change in condition and overall, health and mental status;-Policy: -Process for notification: -Before calling the physician, the nurse must ensure they have all pertinent/situational information on the resident readily available; -The clinician shall be notified of changes in condition, emergent situations and concerns of the resident's overall health status; -Examples include falls, out of range vital signs, altered mental status, poor intake, changes in behaviors, and anything regarding a change in the resident's baseline or condition; -The nurse will implement 911 (emergency services) for immediate transfer for physician evaluation when a significant change or deterioration in the resident's physical, mental or psychosocial status (life threatening condition or clinical complication); -The nurse will initiate verbal communication with the clinician when a condition or incident arises with a resident which would warrant and immediate implementation of a change in plan of care to include physician advisement or initiation of physician orders to avoid a delay in treatment that may cause worsening in condition. Review of Resident #118's medical record, showed:-re-admitted : 7/13/25;-Diagnoses included chronic obstructive pulmonary disease (COPD, scarring to lung tissues), kidney disease, depression, heart failure, lung cancer, protein malnutrition and dementia. Review of the post hospital after visit summary, dated 7/13/25, showed:-discharged : 7/13/25;-Discharge diagnosis: hospice care;-Start taking the following medications:-Lorazepam (Ativan, for anxiety); -Morphine (used to treat severe pain);-Stop taking the following medication: -Atorvastatin (used to lower cholesterol); -Vitamin B-12; -Colace (stool softener); -Aricept (used for dementia); -Lexapro (used for depression); -Iron tablet; -Norco (narcotic used for moderate pain); -Midodrine (used for high blood pressure); -Remeron (used as an appetite stimulant and treat depression); -Prednisone (used for inflammation);-Outpatient referrals: referral to hospice. Review of the care plan, dated 7/15/25, showed:-Problem: the resident has a terminal diagnoses related to lung mass and has elected hospice services;-Outcome: comfort will be maintained;-Interventions: observe the resident closely for pain and work cooperatively with hospice to ensure needs are met. Review of the facility re-admission Physician Order Sheet (POS), showed:-An order, dated 7/13/25: Hyoscyamine sulfate (used for spasms) 0.125 milligram (mg) tablet. Give one tablet as needed (PRN) every four hours. Noted as not given 7/13/25 through 7/30/25;-An order, dated 7/13/25: Lorazepam concentrate. Give 0.25 milliliter (ml) every four hours, PRN. Noted as not administered from 7/13/25 through 7/30/25;-An order, dated 7/13/25: Morphine solution. Give 0.25 ml every four hours, PRN. Noted as not administered from 7/13/25 through 7/30/25. -No hospice orders were documented in the re-admission orders. Review of the progress notes, showed:-On 7/13/25 at 4:28 P.M., a nursing admission note: resident readmitted from hospital, oxygen in place. Skin is fair condition and multiple pinpoint bruising to both arms. The resident physician was notified and verified orders and hospice team contacted regarding admission to hospice services;-On 7/14/25 at 2:49 P.M., a plan of care note: a do not resuscitate order, signed by the resident;-On 7/15/25 at 11:22 A.M., a dietary note: the resident readmitted to the facility on hospice services, provide food preferences. Review of the care plan, initiated 7/15/25, showed:-Problem: the resident has a terminal prognosis related to a lung mass and elected hospice services;-Desired outcome: the resident's comfort will be maintained;-Interventions: observed the resident for signs of pain or discomfort. Work cooperatively with the hospice providers to ensure needs are met. Review of the physician visit note, dated 7/18/25, showed:-History of present illness: COPD with exacerbation, dementia and now on hospice care;-Assessment and plan: COPD end state, on hospice. Review of the significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/25, showed:-Rarely understood;-Memory problem;-Moderate cognitive impairment;-Used wheelchair for mobility;-Staff assistance for hygiene, eating and transfers:-Diagnoses included lung cancer, dementia, heart disease and severe protein malnutrition;-Does the resident have a life expectancy of 6 months or less: No Review of the progress notes, showed:-On 7/24/25 at 8:07 A.M., a social service note: the hospice team was contacted regarding the hospice referral. The hospice team said the referral had been closed, and a new referral would be sent to a different hospice provider;-On 7/25/25 at 7:05 A.M.,: a nurse note: the resident found lying next to the bed and he/she said he/she rolled out of the bed. No injuries noted and bed in lowest position. Message left with physician;-On 7/25/25 at 1:41 P.M., a nurse note: fall mat ordered for the resident due to decline in mental and physical status. Physician aware;-On 7/30/25 at 3:04 P.M., a nurse note: attempted to contact next of kin to notify of the resident's declining status. Unable to reach next of kin. The physician was notified;-On 7/30/25 at 5:32 P.M., a nurse note: vital signs ceased at 4:39 P.M. The family was called and unable to be reached. The physician was at the facility, and cause of death as COPD. Funeral home notified;-No further progress notes were noted to ensure the resident was admitted into hospice services. During an interview on 9/4/25 at 12:43 P.M., Licensed Practical Nurse (LPN) G said on 7/30/25 he/she started work at 7:00 A.M., and he/she received report from the night shift nurse. The night shift nurse said the resident was not doing well, was on hospice and he/she attempted to reach the next of kin. LPN G said he/she assessed the resident, and he/she appeared very ill. The resident had low blood pressure, irregular breathing and a low oxygen saturation. LPN G attempted to call the next of kin and was unable to speak to family. He/She contacted the physician regarding the change in condition, and did not recall what the physician said, except to keep the resident comfortable. LPN G reviewed the record for the hospice provider and when researched, LPN G discovered the resident had not been enrolled in hospice care. LPN G made the discovery around noon and he/she expired several hours later. LPN G did not call the physician back and notify him the resident was not on hospice services. LPN G wrote down the assessment and vital signs on a piece of paper and forgot to document the findings in the medical record. During an interview on 9/4/25 at 12:23 P.M., the resident's physician said he assessed the resident on 7/18/25 and assumed the resident had been admitted into hospice services per review of the hospital discharge orders on 7/14/25. He did not recall if he had been contacted regarding the resident's change in condition on 7/30/25 and expected the nursing assessment and vital signs to be documented in the medical record. If the staff discovered the resident had not received hospice services, he should have been notified. He would have sent the resident to the hospital for evaluation and treatment. The resident had a history of refusal of care, if he/she refused hospice services, it should have been documented in the medical record. During an interview on 9/4/25 at 1:23 P.M., the Administrator and Assistant Director of Nursing (ADON) B said the resident's hospital discharge orders included hospice assessment orders. The resident had not been admitted to hospice services related to obtaining signatures from the next of kin. The resident was not enrolled in hospice services at the time of his/her death. When staff became aware the resident was not enrolled in hospice, the nurse should have notified the physician. The physician may have elected to send the resident to the hospital. All assessments and vital signs should be in the medical records. 2591480

Please see deficiency cited at F689 in Event ID 533H12. This citation is uncorrected. See the narrative at Event ID 533H11. This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 3/14/25.

Based on interview and record review, the facility failed to ensure one resident (Resident #1), with a known history of suicidal ideation, high risk of suicide and frequent self-harming behavior received adequate supervision. The facility determined the resident required close supervision, defined as supervision from three to five feet, to ensure the resident's safety and well-being. Per the resident's care plan, the resident was to receive 1:1 monitoring. On 3/3/25, staff assigned to provide 1:1 supervision for the resident were reassigned to other duties and left the resident unsupervised in his/her room with the door closed. The resident broke the window in his/her room and used the glass to cut himself/herself resulting in multiple deep cuts requiring medical intervention. The sample size was eleven. The census was 106. The Administrator was notified on 3/13/25 at 2:20 P.M., of an Immediate Jeopardy (IJ) which began on 3/3/25. The IJ was removed on 3/13/25, as confirmed by surveyor onsite verification. Review of the facility's Supervision Types, no date, showed: Close Supervision: Supervise resident from a distance of three to five feet. Review of the facility's Accidents and Supervision Policy, revised 5/18/24, showed: -Purpose: Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: -Implementing interventions to reduce hazard(s) and risk(s); -Monitoring for effectiveness and modifying interventions when necessary; -Definitions: -Hazards: Elements of the resident environment that have the potential to cause injury or illness; -Risk: Any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident; -Supervision/Adequate Supervision: Intervention and means of mitigating risk of an accident; -Implementation of Interventions: Using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: -Communicating the interventions to all relevant staff; -Assigning responsibility; -Providing training as needed; -Ensuring that the interventions are put into action; -Interventions are based on the results of the evaluation and analysis of information about hazards and risks; -Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully; -Monitoring and Modification: Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: Ensuring that interventions are implemented correctly and consistently; -Supervision: Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: -Defined by type and frequency; -Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the facility's Suicide Prevention policy, revised 5/14/24, showed: -Purpose: It is the policy of this facility to assess residents for suicidality. Additionally, it is the policy of this facility to act quickly and appropriately if a resident expresses thoughts of suicide; -Definitions: -Protective Factors: Personal and environmental characteristics that help protect people from suicide. It's important to note that protective factors may not counteract significant suicidal risk; -Suicidal Ideation: Self-Reported thoughts about engaging in suicide-related behaviors; -Suicidality: The tendency of a person to commit suicide; -Suicide Prevention: The resident will not be left alone. One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/24, showed the following: -Cognitively intact; -Used wheelchair; -No impairment to upper extremities; -Diagnoses included: major depressive disorder (Serious mental health condition characterized by persistent sadness, hopelessness, and loss of interest or pleasure in activities), anxiety disorder (mental heal disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances). Review of the resident's care plan, initiated on 1/29/25 and revised on 2/05/25, showed: -Problem: The resident's Columbia Suicide Severity Rating Scale (C-SSRS, suicide risk assessment tool) assessment deems the resident is at high risk for suicide; -Desired outcomes included: To keep the resident in a safe protective environment. To provide proper tools and coping skills to reduce suicidal ideation. To reduce the amount of times resident experiences suicidal ideation; -Interventions included: Begin behavior monitoring. Begin 1:1 monitoring. Remove items from room that could be used in his/her plan. Safety Planning Interventions: -Safety Planning Intervention: -Warning Signs for impending crisis: left blank; -Internal coping strategies or Activities that distract from suicidal ideations (specify); -Person or place that helps distract them from suicidal thoughts: left blank; -Identify person that they can talk to (specify); -Unique hopes for the future and reason for living: left blank; -Seek professional help from counselor or psychologist. Review of the resident's physician order sheet in use at the time of the investigation, showed an order, dated 12/23/24, for: Behaviors, Monitor for the behaviors of binging and purging, every shift related to personal history of suicidal behavior. Review of the resident's medical record, showed: -On 1/12/25 at 11:01 P.M., staff documented they were made aware of the resident trying to self-harm. The resident had two sharpened pieces of a can lid. The resident said he/she was trying to cut himself/herself; -Mental Status Exam, Date of service: 1/16/25. History from nursing/family. On 1/12/25, resident attempted to self-harm with two sharpened pieces of a can lid, attempting to cut himself/herself. Resident stated if he/she didn't get a cigarette he/she would find something else to do it with it; -On 1/20/25 at 9:22 P.M., staff documented the resident said he/she cut himself/herself because his/her anxiety pushed him/her to it. The resident had blood on his/her pants and sleeves, but refused to let staff assess the wound. The resident claimed to have stopped the bleeding. The resident clutched an object in his/her hand. Emergency Medical Services (EMS) was called. EMS arrived with the police. After speaking with the resident, the officer was able to get the piece of glass the resident used to self-harm. Review of the resident's C-SSRS assessment, dated 1/29/25, showed: -Scoring is as follows: low risk 0-4, moderate risk 5-10, high risk 11-50; -Category: High Risk; -Score: 43.0; -In the past month, have you wished you were dead or wished you could go to sleep and not wake up, Yes; -In the past month, have you had any thoughts about killing yourself, Yes; -Have you been thinking about how you might kill yourself, Yes; -Have you had these thoughts and had some intention of acting on them, Yes; -Have you started to work out or worked out the details of how to kill yourself, Yes; -Do you intend to carry out this plan, No; -Have you ever done anything, started to do anything, or prepared to do anything to end your life, Yes. Review of the resident's progress notes, showed on 2/4/25 at 8:33 A.M., staff documented they found the resident with a laceration to his/her left arm. The resident said he/she was in his/her room and up all night having emotional issues. The resident wanted to cut himself/herself to release emotional pain. The resident said this helped him/her cope. The resident used glass from a bottle of make-up Review of the resident's Psychosocial Post-Incident Impact Questionnaire, dated 2/4/25, showed: -Description: Incident; -Why were you trying to hurt yourself or others: Patient stated he/she was angry with himself/herself. He/She stated cutting helps him/her cope with emotional and physical pain; -What do you feel the facility can do or change to allow your coping skill to be more effective: Patient stated he/she needs himself/herself back. He/She does not do good with sitting alone. He/She feels like he/she is a burden. Review of the resident's C-SSRS assessment, dated 2/10/25, showed: -Category: High Risk; -Score: 46.0; -In the past month, have you wished you were dead or wished you could go to sleep and not wake up, Yes; -In the past month, have you had any thoughts about killing yourself, Yes; -Have you been thinking about how you might kill yourself, Yes; -Have you had these thoughts and had some intention of acting on them, Yes; -Have you started to work out or worked out the details of how to kill yourself, Yes; -Do you intend to carry out this plan, Yes; -Have you ever done anything, started to do anything, or prepared to do anything to end your life, Yes. Review of the resident's mental status exam, showed: -Date of service, 2/13/25; -An order was placed for Abilify (medication used to treat schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors)) 400 milligrams intramuscular (IM, administration directly into the muscle tissue) every 28 days for the management of schizophrenia, and the patient agreed to the treatment plan. Additionally, an order was given for 15-minute safety checks to closely monitor him/her well-being and intervene promptly if needed. They patient will continue to be observed for any changes in symptoms, mood, or behavior; Review of the resident's progress notes, showed: -On 3/1/25 at 9 P.M., staff documented it was reported to this LPN (Licensed Practical Nurse) C that resident stated he/she was very upset, and he/she had been self-harming himself/herself. Body inspection done. The resident has what appeared to be cuts on his/her arms and legs. His/her roommate said that the resident had been doing this for a couple of days. Resident called his/her family. Resident stated to other staff members that he/she was going to keep cutting himself/herself. Ambulance called; -On 3/3/25 at 12:48 A.M., the resident broke the window in his/her room and cut his/her left arm with a piece of glass. The door to the resident's room was closed at that time. Staff discovered the resident cut himself/herself while doing rounds. The resident told staff the act of cutting takes the pain away. During an interview on 3/3/25 at 9:04 A.M., the Director of Nursing (DON) said on 3/3/25 at 12:48 A.M., the resident broke the window in his/her room and cut his/her left arm with a piece of glass. The door to the resident's room was closed at that time. Staff discovered the resident cut himself/herself while doing rounds. The resident told staff the act of cutting takes the pain away. During an interview on 3/10/25 at 2:35 P.M. and on 3/11/25 at 4:50 P.M., the resident said he/she was on 1:1 supervision on 3/3/25. The resident said they took the 1:1 staff away because the facility was short staffed. He/She took advantage of the opportunity and broke the window. The resident said he/she was without his/her 1:1 staff for maybe 15 to 20 minutes. He/She was able to bust the window out within the 15-20 minutes the 1:1 staff was gone. He/She tried to use his/her hairbrush, but that didn't work. Then he/she wrapped a towel over his/her hand and hit the window in the corner. Most of the window broke when he/she hit the glass. The glass fell out in different size pieces. The glass fell inside the room. He/She used a medium size piece. He/She held up both index fingers, pulled them apart to approximately 5 inches to represent the medium size piece of glass used to cut his/her right arm. He/She got steri-strips on his/her right arm. During a telephone interview on 3/11/25 at 2:28 P.M., Activity Aide (AA) F said he/she was assigned to a different resident for 1:1 on 3/3/25. He/She saw the resident's door was shut. AA F opened the door to the resident's room and saw the resident was shaking. AA F told LPN G the resident had cut himself/herself. He/She saw the resident's arm bleeding. LPN G wrapped the resident's arm up. The resident was taken to the nurse's desk to wait for the ambulance. During an interview on 3/11/25 at 10:41 A.M., and 5:59 P.M., LPN G said he/she reassigned the 1:1 staff that was with the resident to help clean other residents due to short staffing. He/She didn't remember the name of the 1:1 staff. LPN G was going to be the 1:1 staff for the resident. LPN G and AA F went back to the resident's room. LPN G said he/she was only gone 5 minutes or less from the resident. He/She said the resident was on his/her phone playing games when he/she first went into his/her room. The resident had on long sleeves, so he/she didn't see the blood at first. After LPN G raised the resident's sleeve, he/she saw blood on the resident's right arm. He/She said the resident's arm looked like [NAME] or [NAME] Scissor Hands cut the resident's arm up. LPN G said it was horrible. LPN G said a couple of the cuts were so deep, he/she thought the resident would need stitches. During an interview on 3/12/25 at 3:13 P.M., Certified Medication Technician (CMT) B said staff were never supposed to leave a 1:1 resident unattended. If staff needed to go to the bathroom, lunch, break, or anything else, they had to pass the 1:1 supervision to another staff member. During an interview on 3/12/25 at 3:20 P.M., LPN N said staff should never leave a 1:1 resident. The resident should be within arm's reach. If the assigned staff had to leave, they must get a relief staff member. During an interview on 3/12/24 at 3:32 P.M., LPN C said staff should never leave an assigned 1:1. If he/she had to do something, he/she would take the assigned 1:1 resident with him/her. It has happened before but it was easy to get a replacement. During an interview on 3/11/25 at 5:13 P.M., the Social Service Director said she thought the 1:1s gave the resident personal attention. She knew the resident was 1:1s when he/she broke the glass, but she wasn't aware of the particulars. During an interview on 3/12/25 at 11:01 A.M. and 11:17 A.M., the Administrator said she expected the resident to have more opportunities to participate in activities and for family to be more involved. She expects staff to listen, pay attention, ask questions, provide help, and be 1:1 companion for the resident when he/she was having thoughts of self-harm. The Administrator expected staff to be within arm's length of resident's who needed 1:1s. She expected staff to stand outside of the bathroom door during toileting. She expected staff to be with their assigned 1:1 resident at all times. The Administrator said she didn't think the resident was on 1:1s when he/she broke the window. Both the Administrator and Assistant Director of Nursing (ADON) said they didn't know the resident had a 1:1 staff assigned to him/her or that the 1:1 staff had been removed due to short staff. Both said having a 1:1 staff member assigned to the resident would reduce opportunities for self-harm. The Administrator expected staff to find coverage for the resident if they have some other task to do. During a telephone interview on 3/12/25 at 11:43 A.M., the Medical Doctor (MD) said he had planned to stop by to see the resident today. He read from the resident's psych note, dated 2/15/25, which said the resident was experiencing depression and anxiety. Due to being a high risk of suicide, other precautions were necessary. The resident had a conscious desire to inflict harm. The resident scored 46.0 on the suicide evaluation assessment and was considered high risk. The MD said 1:1 staff should never leave the resident alone; especially based on the psych note showing high risk of self-harm. He said the resident was 1:1 until he/she could be reassessed this month. The MD said 1:1 removal left the resident unattended, and if the resident committed self-harm, it would not be noticed right away, and more damage can be done. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00250594 MO00250414

Based on observation, interview and record review, the facility failed to allow one resident (Resident #4) to participate in his/her own plan of care, when the resident was placed in a secured/locked unit based solely on his/her history of justice involvement. This failure did not support the resident's goals, choices, and preferences. This practice affected one resident who was admitted into the facility and immediately placed on the secured unit due to his/her status as a sex offender (Resident #4). The resident was described as being visibly upset when he/she got to the facility. The resident stated he/she did not want to come to this facility, and no one asked or provided him/her any paperwork. The resident stated he/she didn't do anything and didn't know why he/she was locked up in this place. The sample was 5. The census was 111. Review of the facility's Sex Offender (Resident) Policy, revised 12/1/22, showed: -Purpose: Establish policy and protocol to develop good risk management practices regarding the decision to admit registered sex offenders; Establish procedure for assessing where residents will reside in facility; Protecting all residents from abuse while abiding by anti-discrimination laws to protect prospective and current residents from unfair treatment or discrimination; -Procedure: -The facility that maintains housing of a sex offender must provide appropriate supervision commensurate with the risk posed by the resident. This entails an obligation to analyze the risk posed by the resident's placement on the registry, in determining the level of supervision and assistive devices required to monitor the resident; -The facility will check all resident referrals evenly to abide by Medicare and Medicaid anti-discrimination laws to protect prospective and current residents from unfair treatment or discrimination, because of race, color, national origin, disability, age, sex (gender), or religion; -The Interdisciplinary Team (IDT) admission team will determine if they can meet the residents' needs taking into consideration the following: -Analyze and assess the residents for abusing other residents; -Ensure the following criteria for sex offenders is also met for admission to the facility: -The resident must not have displayed sexually aggressive and/or sexually abusive behaviors towards another resident residing in any other nursing facility within the past twelve months; -The resident must agree to register the facility address as their own in the sexual offender registry; -A sexually violent predator refers to a person who has been adjudicated guilty of a sex offense or acquitted on the grounds of mental disease or defect of a sex offense that makes the person likely to engage in predatory sex offenses; -Notify admitting physician and Medical Director that the resident is a sex offender; -The treating physician must be informed of a resident's status on the registry and input solicited as to the physician's assessment of the resident's risk for committing abuse; -Immediately address any sexually inappropriate behaviors with all offending residents; -Discharge Restrictions: -A resident's status on the sex offender registry, by itself, does not give a facility the right to seek involuntary discharge of the resident; -Federal and state laws relating to discharge require showing that a resident's behaviors have negatively impacted other residents; -For example, Federal certification regulations applicable to nursing facilities allow a discharge if the safety of individuals in the facility is endangered. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/14/25, showed: -admission date: 3/26/25; -Cognitively intact; -Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited; -Upper/Lower extremities: Impairment on one side; -Cane/Crutch; -Diagnoses included diabetes, seizure disorder or epilepsy, cerebrovascular accident (CVA, stroke), and hypertension. Review of the resident's Discharge Planning Review Social Services, dated 3/29/25 at 1:43 P.M., showed: -Description: Quarterly; -Select one for resident's overall goal established during assessment process: Expects to be discharged to another facility; -What determination was made by the resident and the care planning team regarding discharge to the community? Determination not made; -Treatment care/needs: Left blank. No response; -Overall summary of potential for discharge: Resident is a sex offender. -Resident is his/her own responsible party. Review of the resident's care plan, in use at the time of the investigation, showed no documentation regarding placement on the secured unit. The care plan and physician orders in the resident's medical records were sent with him/her from the previous facility and were dated 2024. Nothing was documented for 2025. The medical record did not contain documentation related to communication with the resident regarding the transfer to the facility or assessments completed to ensure the facility could provide necessary care and treatment. Review of the resident's medical record notes, showed: -3/27/25 at 6:14 P.M., adjusting well. No behaviors noted; -3/26/25 at 6:41 P.M., Clinical admission, mood and behavior, mood is pleasant, no unwanted behaviors witnessed; -3/26/25 at 6:33 P.M., Skilled evaluation, mood and behavior, no unwanted behaviors witnessed; -No documentation related to previous or current sexual abuse behavior towards other residents; -No documentation related to medical risk assessments of sexual abuse towards other residents determined and/or completed. Observation and interview on 4/23/25 at 11:36 A.M., showed the resident on the secured unit. He/She sat on the edge of his/her bed with the door open. The resident said he/she was at the sister facility (another skilled nursing facility owned by the same corporation). He/She didn't want to come here. His/Her voice raised a little louder and said again that he/she didn't want to be here. The resident was shaking his/her head no, while he/she spoke about not wanting to be at the facility. He/She didn't know how he/she had gotten over here. He/She just ended up here. No one asked him/her if he/she wanted to come here and nobody gave him/her any papers about coming here. The resident told the facility that he/she didn't want to be here. He/She wanted to go back to his/her previous facility. He/She didn't know why he/she was in the locked unit. No one told him/her. He/She didn't do anything and doesn't know why he/she was locked up in this place. He/She didn't like being locked in here. He/She felt bad because he/she couldn't come and go in the facility. He/She didn't do anything. He/She wanted to go back where he/she came from. During an interview on 4/22/25 at 11:54 A.M., the Social Service Director (SSD) said the resident had been sent over from their sister facility. The resident was a sex offender, and she guessed that facility couldn't host him/her. The resident was pretty upset when he/she got to the facility. Sex offenders can only go to certain facilities, this is one of them. She thought there was a miscommunication about the types of residents the sister facility could have. She called corporate and told them the resident didn't want to be here. By the look on the resident's face, he/she didn't know he/she was coming to this facility. The resident didn't know why he/she came here. The SSD expected the sister facility and the admission Coordinator to have asked the resident where he/she wanted to go. The resident should have options. The admission Coordinator facilitated the resident's transfer. The transfer was not done correctly. The resident was on a locked unit because that's the policy for sex offenders at the facility. The SSD didn't want to put him/her on the locked unit. She didn't know the resident didn't know he/she was coming. The resident wasn't given transfer/discharge paperwork. He/She didn't have any of his/her belongings. She expected the resident to be asked where he/she wanted to live and for referrals to have been placed to give him/her options. During an interview on 4/23/25 at 12:10 P.M., the Regional Nurse Director of Operations (RNDO) said the resident was transferred/discharged improperly. She said the sister facility did an improper discharge, and this facility had an improper admission. The resident wasn't given any paperwork related to the transfer. He/She was just swapped from the sister facility. She thought the resident was going back to the sister facility within a day or so. The resident would be given the 30-day notice, asked where he/she may want to live, and they would complete referrals based on what the resident said. The RNDO said the resident was on the locked unit because he/she was a sex offender and sex offenders went to the locked unit, per the facility policy. The RNDO said she was not aware the resident could not be put on a locked unit based on sex offender status. Per their policy, the resident had to go on a locked unit because he was a sex offender. MO00252881

Based on observation, interview, and record review, the facility placed one resident (Resident #4) on a secured/locked unit within the facility, without clinical justification and an assessment of whether the individual met the criteria for admission on to a secured unit. The facility placed the resident, who was cognitively intact and their own responsible person, on the secured unit- based solely on his/her status as a registered sex offender. The resident stated he/she did not want to come to this facility, and no one asked or provided him any paperwork. The resident stated he/she didn't do anything and didn't know why he/she was locked up in this place. The sample was 5. The census was 111. Review of the facility's Sex Offender (Resident) Policy, revised 12/1/22, showed: -Purpose: Establish policy and protocol to develop good risk management practices regarding the decision to admit registered sex offenders; Establish procedure for assessing where residents will reside in facility; Protecting all residents from abuse while abiding by anti-discrimination laws to protect prospective and current residents from unfair treatment or discrimination; -Procedure: -The facility that maintains housing of a sex offender must provide appropriate supervision commensurate with the risk posed by the resident. This entails an obligation to analyze the risk posed by the resident's placement on the registry, in determining the level of supervision and assistive devices required to monitor the resident; -The facility will check all resident referrals evenly to abide by Medicare and Medicaid anti-discrimination laws to protect prospective and current residents from unfair treatment or discrimination, because of race, color, national origin, disability, age, sex (gender), or religion; -The Interdisciplinary Team (IDT) admission team will determine if they can meet the residents' needs taking into consideration the following: -Analyze and assess the residents for abusing other residents; -Ensure the following criteria for sex offenders is also met for admission to the facility: -The resident must not have displayed sexually aggressive and/or sexually abusive behaviors towards another resident residing in any other nursing facility within the past twelve months; -The resident must agree to register the facility address as their own in the sexual offender registry; -A sexually violent predator refers to a person who has been adjudicated guilty of a sex offense or acquitted on the grounds of mental disease or defect of a sex offense that makes the person likely to engage in predatory sex offenses; -Notify admitting physician and Medical Director that the resident is a sex offender; -The treating physician must be informed of a resident's status on the registry and input solicited as to the physician's assessment of the resident's risk for committing abuse; -Immediately address any sexually inappropriate behaviors with all offending residents; -Discharge Restrictions: -A resident's status on the sex offender registry, by itself, does not give a facility the right to seek involuntary discharge of the resident; -Federal and state laws relating to discharge require showing that a resident's behaviors have negatively impacted other residents; -For example, Federal certification regulations applicable to nursing facilities allow a discharge if the safety of individuals in the facility is endangered. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/14/25, showed: -admission date: 3/26/25; -Cognitively intact; -Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited; -Upper/Lower extremities: Impairment on one side; -Cane/Crutch; -Diagnoses included diabetes, seizure disorder or epilepsy, cerebrovascular accident (CVA, stroke), and hypertension. Review of the resident's Discharge Planning Review Social Services, dated 3/29/25 at 1:43 P.M., showed: -Description: Quarterly; -Select one for resident's overall goal established during assessment process: Expects to be discharged to another facility; -What determination was made by the resident and the care planning team regarding discharge to the community? Determination not made; -Treatment care/needs: Left blank. No response; -Overall summary of potential for discharge: Resident is a sex offender. -Resident is his/her own responsible party. Review of the resident's care plan, in use at the time of the investigation, showed no documentation regarding placement on the secured unit. Review of the resident's medical record notes, showed: -3/27/25 at 6:14 P.M., adjusting well. No behaviors noted; -3/26/25 at 6:41 P.M., Clinical admission, mood and behavior, mood is pleasant, no unwanted behaviors witnessed; -3/26/25 at 6:33 P.M., Skilled evaluation, mood and behavior, no unwanted behaviors witnessed; -No documentation related to previous or current sexual abuse behavior towards other residents; -No documentation related to medical risk assessments of sexual abuse towards other residents determined and/or completed. Observation and interview on 4/23/25 at 11:36 A.M., showed the resident on the secured unit. He/She sat on the edge of his/her bed with the door open. The resident said he/she had been at a sister facility (another skilled nursing facility owned by the same corporation). He/She didn't want to come to this facility. His/Her voice raised a little louder and said again that he/she didn't want to be here. The resident was shaking his/her head no, while he/she spoke about not wanting to be at the facility. He/She didn't know how he/she had gotten over here. He/She just ended up here. No one asked him/her if he/she wanted to come here and nobody gave him/her any papers about coming here. The resident told the facility that he/she didn't want to be here. He/She wanted to go back to his/her previous facility. He/She didn't know why he/she was in the locked unit. No one told him/her. He/She didn't do anything and doesn't know why he/she was locked up in this place. He/She didn't like being locked in here. He/She felt bad because he/she couldn't come and go in the facility. He/She didn't do anything. He/She wanted to go back where he/she came from. During an interview on 4/22/25 at 11:54 A.M., the Social Service Director (SSD) said the resident had been sent over from their sister facility. The resident was a sex offender, and she guessed that facility couldn't host him/her. The resident was pretty upset when he/she got to the facility. Sex offenders can only go to certain facilities, this is one of them. She thought there was a miscommunication about the types of residents the sister facility could have. She called corporate and told them the resident didn't want to be here. By the look on the resident's face, he/she didn't know he/she was coming to this facility. The resident didn't know why he/she came here. The SSD expected the sister facility and the admission Coordinator to have asked the resident where he/she wanted to go. The resident should have options. The admission Coordinator facilitated the resident's transfer. The resident was on a secured unit because that's the facility policy for sex offenders. The SSD didn't want to put him/her on the locked unit. She didn't know the resident didn't know he/she was coming. The resident wasn't given transfer/discharge paperwork. He/She didn't have any of his/her belongings. She expected the resident to be asked where he/she wanted to live and for the resident to be given options. During an interview on 4/23/25 at 12:10 P.M., the Regional Nurse Director of Operations (RNDO) said the resident was transferred/discharged improperly. She said the sister facility did an improper discharge, and this facility had an improper admission. The resident wasn't given any paperwork related to the transfer. He/She was just swapped from the sister facility. She thought the resident was going back to the sister facility within a day or so. The resident would be given the 30-day notice, asked where he/she may want to live, and they would complete referrals based on what the resident said. The RNDO said the resident was on the locked unit because he/she was a sex offender and sex offenders went to the locked unit, per the facility policy. The RNDO said she was not aware the resident could not be put on a locked unit based on sex offender status. Per their policy, the resident had to go on a locked unit because he was a sex offender. MO00252881

See the narrative at event ID WGJ612 Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated [DATE], for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on [DATE], staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on [DATE]. The sample was 10. The census was 110.

Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated [DATE], for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on [DATE], staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on [DATE]. The sample was 10. The census was 110. The Administrator was notified on [DATE] at 12:23 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Explanation of Diets dated, 2024 showed: -Mechanical Soft: This consistency modified diet is for individuals with limited or difficulty in chewing regular textured food; -The diet consists of food of nearly regular textures but eliminated very hard, sticky, crunchy or hard to chew foods; -Foods should be moist and fork tender; -Meat is ground or chopped into bite-sized pieces (,d+[DATE] inch or smaller). Review of the facility's Diets Policy dated [DATE], showed: -The facility will provide each resident with a regular or therapeutic diet as ordered by the physician; the consistency of the diet shall also be ordered; -A therapeutic diet is defined as any deviation from the regular diet; -Diets available in the facility included regular mechanical soft diet. -Regular mechanical soft diet consists of soft fruits, vegetables and ground meat. Review of Resident #7's physician's progress note dated [DATE], showed: Noted: Provincial dyskinesia (ODK, a movement disorder that causes involuntary, repetitive, and sometimes painful movements of the face, mouth, and can directly cause swallowing problems (dysphagia) because the involuntary movements affecting the face and mouth muscles can interfere with the coordinated movements needed for chewing and swallowing food, leading to difficulties transferring food to the throat and potential choking hazards). Review of the mechanical soft lunch menu for [DATE], showed: -Ground chicken with onions; -Stuffing with gravy; -Soft vegetable medley; -Apple streusel cake. Review of the facility's dietary spread sheet, dated 2024, showed a ham and cheese sandwich for mechanical soft diet should be made with ground ham and cheese. It was on the menu as an alternate food selection. Review of Resident #7's care plan dated [DATE], and updated on [DATE] (the resident expired on [DATE]) showed: -Problem: At risk for aspiration related to mechanically altered diet and resident swallows chewing tobacco; -Desired outcome: Resident will have no choking episodes when eating; -Interventions included: -All staff to be informed of the resident's special dietary and safety needs; -Alternate small bites and sips. Use a teaspoon for eating, do not use a straw; -Diet to be followed (No documentation on type of diet); -Instruct the resident to eat in an upright position, to eat slowly and to chew each bite thoroughly. Review of the resident's progress note dated, [DATE], showed: -Resident in dining room eating lunch; -Certified Nursing Assistant (CNA) Q and Director of Nursing (DON) observed resident choking, staff intervened and provided Heimlich maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe (throat) in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) and mouth sweeps; -The resident was without a pulse; -Cardiopulmonary resuscitation (CPR, an emergency treatment that's done when someone's breathing or heartbeat has stopped.); -Police and Emergency Medical Services (EMS) arrived and took over; -At 12:40 P.M., resident transported to hospital. Review of the EMS trip sheet, dated [DATE], showed: -Responded to facility for a cardiac arrest; -Took over CPR; -The resident was connected to a monitor and it displayed asystole (no heartbeat); -EMS removed an obstruction in the resident's airway; -Resident transported to hospital. Review of the resident's hospital record dated [DATE], showed: -Patient Active Problem List: -Acute respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues); -Aspiration pneumonia of both lower lobes; -Anoxic brain injury (caused by a complete lack of oxygen to the brain); -[DATE], resident presents with pulseless electrical activity (PEA, a condition where a person is unresponsive and has no pulse, but there is some electrical activity in the heart) arrest; -Acute respiratory failure, and aspiration pneumonia with shock; -Onset of symptoms was abrupt. The resident has dysphagia. He/She was eating a sandwich at his/her nursing home when he/she began choking, aspirated, and went into PEA arrest and was in asystole when EMS arrived; -The resident received CPR, intubated (tube put down throat for artificial breathing), and central line placed (a catheter placed into a vein for medication administration); -[DATE], remains comatose. Resident extubated (breathing tube removed) at 3:17 P.M. and died at 3:33 P.M. During an interview on [DATE], at 7:20 A.M., Dietary Staff (DS) A said on [DATE], the resident was served a mechanical soft lunch. The resident refused the meal. A short time later Certified Medication Technician (CMT) B came to the kitchen window and asked for two sandwiches. CMT B did not say he/she needed mechanical soft sandwiches. Dietary staff gave CMT B two ham and cheese sandwiches with some cheese puffs. The sandwiches were not mechanical soft. During an interview on [DATE] at 7:18 A.M., CMT B said on [DATE], the resident refused his/her meal tray and asked for sandwiches. CMT B got the sandwiches from dietary. The sandwiches were mechanical soft. During an interview on [DATE] at 7:27 A.M., the DON said he/she was walking past the resident in the dining room and noticed the resident was choking. He/She called a Code Blue (medical emergency) and attempted the Heimlich Maneuver. At that time the resident became unresponsive. Staff lowered the resident to the floor and CPR was initiated. He/She swept the resident's mouth, but only got chewed up cheese puffs. He/She said the resident's dietary card showed he/she was on a mechanical soft diet. EMS arrived and took over CPR. The resident was transported to the hospital. The resident expired on [DATE]. During interviews on [DATE] at 9:50 A.M. and 11:21 A.M., the Dietary Manager (DM) said he/she was not in the facility when the incident occurred. He/She knew the resident refused his/her meal tray. Staff came and asked for two sandwiches, but did not say who the sandwiches were for and/or if they needed mechanical soft sandwiches. DS A called the DM and said the resident was given two regular diet sandwiches, choked and had to have CPR. When the DM returned to the facility and interviewed the dietary staff, they confirmed the resident was provided two regular textured ham and cheese sandwiches. He/She told the Administrator what the dietary staff said. During an interview on [DATE] at 9:54 A.M., Licensed Practical Nurse (LPN) C said he/she worked the day the resident choked on a sandwich and he/she saw what looked like bread when the DON performed the mouth sweep. During an interview on [DATE] at 10:07 A.M., DS D said he/she worked the day the resident choked. Nursing staff asked for two sandwiches. They did not say who the sandwiches were for or what diet consistency was needed. Dietary staff gave the nursing staff two regular ham and cheese sandwiches. The ham had not been ground up. During an interview on [DATE] at 10:10 A.M., DS A said DS E made sandwiches in advance of the meal as substitutes if residents did not want the chicken. All the sandwiches were regular consistency. No mechanical soft sandwiches were made. CMT B asked for two sandwiches. He/She did not say who the sandwiches were for and/or what consistency the sandwiches should be. Dietary staff did not ask who the sandwiches were for and/or if they should be mechanical soft. During an interview on [DATE], at 11:32 A.M., DS E said he/she made the sandwiches, but did not give the sandwiches to CMT B. He/She did not know who gave the sandwiches to the CMT, but he/she had not prepared any mechanical soft sandwiches. If the nursing staff gave the resident sandwiches that DS E made, the sandwiches were regular consistency. During an interview on [DATE] at 11:39 A.M., the Registered Dietitian said if a resident was on a mechanical soft diet, all lunch meat should be ground up. Staff should never serve sliced meat to a resident with orders for a mechanical soft diet. He/She was aware the resident choked on a sandwich. He/She was told the resident was provided a regular sandwich with sliced ham. Nursing staff should have identified who they wanted the sandwich for and dietary staff should have asked what consistency sandwich was needed. During an interview on [DATE], at 11:07 A.M., the Speech Therapist said he/she worked with the resident for intelligibility of speech (articulation) and communication cognitive skills. He/She did not work on swallowing problems with the resident. The resident had an order for a mechanical soft diet. He/She was admitted with the order for a mechanical soft diet. Speech Therapy screened the resident, but did not request Skilled Speech therapy for swallowing. The resident was at risk for aspiration. If a resident had an order for a mechanical soft diet, the deli meat on the sandwich should be ground up. The dietary staff did not always grind up the deli meat. He/She worked the day the resident choked, but was in the assisted dining area and had his/her back to the resident. During an interview on [DATE] at 11:53 A.M., the Medical Director's Nurse Practitioner said he/she was notified by facility staff the resident aspirated on food while in the dining room and was sent to the hospital. Facility staff did not provide any details about what the resident aspirated on. The resident had dysphagia. Staff did not report the resident might have been provided the wrong diet consistency. The resident was on a mechanical soft diet. He/She should have been served a mechanical soft meal and should have been supervised at each meal. The facility should always follow physician's order when it came to the consistency of a resident's diet. During an interview on [DATE] at 12:19 P.M., the Chief Medical Officer from EMS said he/she responded to the facility for a chief complaint of resident in cardiac arrest. He/She suctioned the resident's mouth and pulled out multiple large pieces of thinly sliced deli meat. During an interview on [DATE] at 12:52 P.M., CNA F said he/she saw EMS pull sliced ham out of the resident's mouth. During an interview on [DATE], at 9:08 A.M., the DON and Administrator both said they were not aware the resident was served two regular consistency sandwiches. If a resident requested an alternate food, they expected nursing staff to tell dietary staff who the resident was and what their diet order was. The DON said after EMS left, she noticed the resident's dietary card showed he/she was on a mechanical soft diet. She did not see a meal tray or left over food. Staff had already removed the resident's plate, so she didn't know the resident had been served regular consistency sandwiches. She assumed the resident had been provided a mechanical soft diet. During an interview on [DATE] at 1:21 P.M., the Speech Therapist said each resident should be assessed for the amount of supervision required when they were eating and drinking. The level of supervision should be on the resident's care plan. Each resident was different and needed to be assessed individually for the amount of supervision required. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00248025 MO00248163

Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated 9/13/24, for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on 1/13/25, staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on 1/17/25. The sample was 10. The census was 110. The Administrator was notified on 1/30/25 at 12:23 P.M. of an Immediate Jeopardy (IJ) which began on 1/13/25. The IJ was removed on 1/30/25, as confirmed by surveyor onsite verification. Review of the facility's Explanation of Diets dated, 2024 showed: -Mechanical Soft: This consistency modified diet is for individuals with limited or difficulty in chewing regular textured food; -The diet consists of food of nearly regular textures but eliminated very hard, sticky, crunchy or hard to chew foods; -Foods should be moist and fork tender; -Meat is ground or chopped into bite-sized pieces (1/2 inch or smaller). Review of the facility's Diets Policy dated 1/29/25, showed: -The facility will provide each resident with a regular or therapeutic diet as ordered by the physician; the consistency of the diet shall also be ordered; -A therapeutic diet is defined as any deviation from the regular diet; -Diets available in the facility included regular mechanical soft diet. -Regular mechanical soft diet consists of soft fruits, vegetables and ground meat. Review of Resident #7's physician's progress note dated 12/12/24, showed: Noted: Provincial dyskinesia (ODK, a movement disorder that causes involuntary, repetitive, and sometimes painful movements of the face, mouth, and can directly cause swallowing problems (dysphagia) because the involuntary movements affecting the face and mouth muscles can interfere with the coordinated movements needed for chewing and swallowing food, leading to difficulties transferring food to the throat and potential choking hazards). Review of the mechanical soft lunch menu for 1/13/25, showed: -Ground chicken with onions; -Stuffing with gravy; -Soft vegetable medley; -Apple streusel cake. Review of the facility's dietary spread sheet, dated 2024, showed a ham and cheese sandwich for mechanical soft diet should be made with ground ham and cheese. It was on the menu as an alternate food selection. Review of Resident #7's care plan dated 10/9/24, and updated on 1/24/25 (the resident expired on 1/17/25) showed: -Problem: At risk for aspiration related to mechanically altered diet and resident swallows chewing tobacco; -Desired outcome: Resident will have no choking episodes when eating; -Interventions included: -All staff to be informed of the resident's special dietary and safety needs; -Alternate small bites and sips. Use a teaspoon for eating, do not use a straw; -Diet to be followed (No documentation on type of diet); -Instruct the resident to eat in an upright position, to eat slowly and to chew each bite thoroughly. Review of the resident's progress note dated, 1/13/25, showed: -Resident in dining room eating lunch; -Certified Nursing Assistant (CNA) Q and Director of Nursing (DON) observed resident choking, staff intervened and provided Heimlich maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe (throat) in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) and mouth sweeps; -The resident was without a pulse; -Cardiopulmonary resuscitation (CPR, an emergency treatment that's done when someone's breathing or heartbeat has stopped.); -Police and Emergency Medical Services (EMS) arrived and took over; -At 12:40 P.M., resident transported to hospital. Review of the EMS trip sheet, dated 1/13/25, showed: -Responded to facility for a cardiac arrest; -Took over CPR; -The resident was connected to a monitor and it displayed asystole (no heartbeat); -EMS removed an obstruction in the resident's airway; -Resident transported to hospital. Review of the resident's hospital record dated 1/17/25, showed: -Patient Active Problem List: -Acute respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues); -Aspiration pneumonia of both lower lobes; -Anoxic brain injury (caused by a complete lack of oxygen to the brain); -1/13/25, resident presents with pulseless electrical activity (PEA, a condition where a person is unresponsive and has no pulse, but there is some electrical activity in the heart) arrest; -Acute respiratory failure, and aspiration pneumonia with shock; -Onset of symptoms was abrupt. The resident has dysphagia. He/She was eating a sandwich at his/her nursing home when he/she began choking, aspirated, and went into PEA arrest and was in asystole when EMS arrived; -The resident received CPR, intubated (tube put down throat for artificial breathing), and central line placed (a catheter placed into a vein for medication administration); -1/17/25, remains comatose. Resident extubated (breathing tube removed) at 3:17 P.M. and died at 3:33 P.M. During an interview on 1/29/25, at 7:20 A.M., Dietary Staff (DS) A said on 1/13/25, the resident was served a mechanical soft lunch. The resident refused the meal. A short time later Certified Medication Technician (CMT) B came to the kitchen window and asked for two sandwiches. CMT B did not say he/she needed mechanical soft sandwiches. Dietary staff gave CMT B two ham and cheese sandwiches with some cheese puffs. The sandwiches were not mechanical soft. During an interview on 1/29/25 at 7:18 A.M., CMT B said on 1/13/25, the resident refused his/her meal tray and asked for sandwiches. CMT B got the sandwiches from dietary. The sandwiches were mechanical soft. During an interview on 1/29/25 at 7:27 A.M., the DON said he/she was walking past the resident in the dining room and noticed the resident was choking. He/She called a Code Blue (medical emergency) and attempted the Heimlich Maneuver. At that time the resident became unresponsive. Staff lowered the resident to the floor and CPR was initiated. He/She swept the resident's mouth, but only got chewed up cheese puffs. He/She said the resident's dietary card showed he/she was on a mechanical soft diet. EMS arrived and took over CPR. The resident was transported to the hospital. The resident expired on 1/17/25. During interviews on 1/29/25 at 9:50 A.M. and 11:21 A.M., the Dietary Manager (DM) said he/she was not in the facility when the incident occurred. He/She knew the resident refused his/her meal tray. Staff came and asked for two sandwiches, but did not say who the sandwiches were for and/or if they needed mechanical soft sandwiches. DS A called the DM and said the resident was given two regular diet sandwiches, choked and had to have CPR. When the DM returned to the facility and interviewed the dietary staff, they confirmed the resident was provided two regular textured ham and cheese sandwiches. He/She told the Administrator what the dietary staff said. During an interview on 1/29/25 at 9:54 A.M., Licensed Practical Nurse (LPN) C said he/she worked the day the resident choked on a sandwich and he/she saw what looked like bread when the DON performed the mouth sweep. During an interview on 1/29/25 at 10:07 A.M., DS D said he/she worked the day the resident choked. Nursing staff asked for two sandwiches. They did not say who the sandwiches were for or what diet consistency was needed. Dietary staff gave the nursing staff two regular ham and cheese sandwiches. The ham had not been ground up. During an interview on 1/29/25 at 10:10 A.M., DS A said DS E made sandwiches in advance of the meal as substitutes if residents did not want the chicken. All the sandwiches were regular consistency. No mechanical soft sandwiches were made. CMT B asked for two sandwiches. He/She did not say who the sandwiches were for and/or what consistency the sandwiches should be. Dietary staff did not ask who the sandwiches were for and/or if they should be mechanical soft. During an interview on 1/29/25, at 11:32 A.M., DS E said he/she made the sandwiches, but did not give the sandwiches to CMT B. He/She did not know who gave the sandwiches to the CMT, but he/she had not prepared any mechanical soft sandwiches. If the nursing staff gave the resident sandwiches that DS E made, the sandwiches were regular consistency. During an interview on 1/29/25 at 11:39 A.M., the Registered Dietitian said if a resident was on a mechanical soft diet, all lunch meat should be ground up. Staff should never serve sliced meat to a resident with orders for a mechanical soft diet. He/She was aware the resident choked on a sandwich. He/She was told the resident was provided a regular sandwich with sliced ham. Nursing staff should have identified who they wanted the sandwich for and dietary staff should have asked what consistency sandwich was needed. During an interview on 1/29/25, at 11:07 A.M., the Speech Therapist said he/she worked with the resident for intelligibility of speech (articulation) and communication cognitive skills. He/She did not work on swallowing problems with the resident. The resident had an order for a mechanical soft diet. He/She was admitted with the order for a mechanical soft diet. Speech Therapy screened the resident, but did not request Skilled Speech therapy for swallowing. The resident was at risk for aspiration. If a resident had an order for a mechanical soft diet, the deli meat on the sandwich should be ground up. The dietary staff did not always grind up the deli meat. He/She worked the day the resident choked, but was in the assisted dining area and had his/her back to the resident. During an interview on 1/29/25 at 11:53 A.M., the Medical Director's Nurse Practitioner said he/she was notified by facility staff the resident aspirated on food while in the dining room and was sent to the hospital. Facility staff did not provide any details about what the resident aspirated on. The resident had dysphagia. Staff did not report the resident might have been provided the wrong diet consistency. The resident was on a mechanical soft diet. He/She should have been served a mechanical soft meal and should have been supervised at each meal. The facility should always follow physician's order when it came to the consistency of a resident's diet. During an interview on 1/29/25 at 12:19 P.M., the Chief Medical Officer from EMS said he/she responded to the facility for a chief complaint of resident in cardiac arrest. He/She suctioned the resident's mouth and pulled out multiple large pieces of thinly sliced deli meat. During an interview on 1/29/25 at 12:52 P.M., CNA F said he/she saw EMS pull sliced ham out of the resident's mouth. During an interview on 1/30/24, at 9:08 A.M., the DON and Administrator both said they were not aware the resident was served two regular consistency sandwiches. If a resident requested an alternate food, they expected nursing staff to tell dietary staff who the resident was and what their diet order was. The DON said after EMS left, she noticed the resident's dietary card showed he/she was on a mechanical soft diet. She did not see a meal tray or left over food. Staff had already removed the resident's plate, so she didn't know the resident had been served regular consistency sandwiches. She assumed the resident had been provided a mechanical soft diet. During an interview on 1/30/25 at 1:21 P.M., the Speech Therapist said each resident should be assessed for the amount of supervision required when they were eating and drinking. The level of supervision should be on the resident's care plan. Each resident was different and needed to be assessed individually for the amount of supervision required. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00248025 MO00248163

Based on observation, interview, and record review, the facility failed to provide adequate supervision to one of five sampled residents with a history of elopement, hallucinations/delusions, behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management, and limited insight and judgement. Facility staff failed to make visual observations of the resident hourly, staff failed to follow up after not seeing the resident to administer ordered medications, and failed to ensure exit doors were working properly. Resident #1 left the building without staff's knowledge on [DATE] at 6:37 AM. Facility staff responsible for conducting visual checks- failed to do so, although they were documented as completed. The resident remained gone from the facility for over 24 hours before staff realized the resident was missing on [DATE] at 8:00 AM. The resident was not located until [DATE] at approximately 2:00 P.M. by another area police department at a gas station. The census was 107. The Administrator was notified on [DATE] at 5:36 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on [DATE]. The facility conducted an investigation and immediately in-serviced staff prior to the start of their shift regarding the following: Code white (facility's elopement code), secured doors, shift reports and rounds, falsifying documentation; completed elopement assessments on all residents to make sure appropriate placement, monitored exit doors one on one until they verified all working properly, charge nurses do two hour checks and document, management audits face check documentation, and the Administrator created a department head rotation schedule for completing random rounds in the facility at various times, other than regular daily rounds, to include evening and night shift. The IJ was corrected on [DATE]. Review of the facility's Elopement and Wandering Residents policy, updated [DATE], showed: -Purpose: This facility ensures that residents who exhibit behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or eloping risk; -Definitions: - Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e, an order for discharge or leave of absence) and/or any necessary supervision to do so; -Policy: -Preventing Elopements: -The facility is equipped with door locks/alarms to help avoid elopements; -Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner; -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risks, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. -Monitoring and managing residents at risk for elopement or unsafe wandering; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; -Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff; -Adequate supervision will be provided to help prevent accidents or elopements; -Charge nurses and unit managers will monitor the implementation of interventions, responses to interventions, and document accordingly. Review of the facility's Intensive Monitoring Policy, revised on [DATE], showed: -Procedure: -Residents who require more intensive monitoring due to crisis, behavior/psychiatric symptoms will be monitored by the facility staff. -Intensive monitoring: -Intensive monitoring is provided as periodic (e.g. hourly, every two hours, or every shift) check by a facility staff member; -Residents may require more intensive monitoring based on their crisis, behavior, psychiatric issues. The level of intensive monitoring shall be identified by the specific situation or resident assessment; -Residents who are showing poor impulse control including crisis, behavior, psychiatric issues, such as, verbal/ physical aggression/elopement ideations, suicidal/homicidal ideations, and decompensation mental or crisis may be placed on intensive monitoring or one to one or two to one (within eyesight of staff) monitoring at the discretion of the facility staff or the facility supervisor; -The facility staff will document the intensive monitoring in the resident's electronic medical record; -Documentation: -All documentation of intensive monitoring will be done in the electronic medical record under the task. During an interview on [DATE] at 5:36 P.M., the Administrator said she expected for face checks to be done hourly on all residents on all shifts Review of Resident #1's preadmission screening and resident review (PASRR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in medicaid certified beds in a nursing facility regardless of payment source), dated [DATE], showed the resident had a history of elopement, hallucinations/delusions, medical treatment and/or monitoring for chronic conditions, behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management, and limited insight and judgement. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted to the facility: [DATE]; -Cognitively intact; -Independent for eating, hygiene, dressing, walking in room and corridor, locomotion on unit; -No physical impairments of either upper and/or lower extremities; -Wandering not exhibited; -Diagnoses of anxiety disorder, depression (other than bipolar), and schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly). Review of the resident's elopement assessments showed the following: -On [DATE], elopement evaluation: The resident was an elopement risk; --On [DATE] elopement evaluation: The resident was an elopement risk; -On [DATE], elopement evaluation: The resident was an elopement risk; -On [DATE], elopement evaluation: The resident was an elopement risk. Review of the resident's care plan, dated [DATE], showed: -Focus: The resident is at risk of elopement due to he/she has a history of elopement from prior facility; -Goal: The resident will be monitored closely and remain safe through next review; -Interventions: Complete elopement assessments on admission, readmission, and quarterly. Face checks/intensive monitoring will be completed per facility protocol. Resident's photo and information will be kept in elopement book; -Focus: The resident is at risk of elopement related to history of leaving previous facility; -Goal: The resident's safety will be maintained through the review date; -Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television book. Monitor location frequently. Document wandering behavior and attempted diversional interventions in behavior log. Provide structured activities: Toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of the facility's [DATE] documentation of exit door maintenance checks showed: -Dates of [DATE], [DATE], and [DATE] missing from sheet; -Date of [DATE] showed a line drawn through all the exit doors; -Patio exit door documented as checked [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. Review of the facility's [DATE] documentation of exit door checks showed the patio exit door checked [DATE] to [DATE]. Review of the facility's video footage, dated [DATE] at 6:37 A.M., showed Resident #1 standing in the open, fully dressed with a hoodie on. He/She looked around, walked to the patio (exit door), pushed it open then walked out the door. The back side of the resident's body could be observed climbing over the fence. Review of Resident #1's hourly face check documentation completed on [DATE] showed: -Hourly face check completed; resident in the building at the following times: 6:58 A.M. (logged two times), 6:59 A.M. (logged six times), 12:59 P.M., 1:00 P.M., 1:02 P.M., 1:04 P.M., 2:30 P.M., 6:02 P.M., 6:03 P.M., 6:05 P.M., 9:15 P.M., 9:17 P.M., 9:43 P.M.; -No hourly face checks logged from: 7:00 A.M. to 12:00 P.M., 3:30 P.M. to 5:30 P.M., 7:00 P.M. to 8:00 P.M.; -No hourly face checks logged over the evening and overnight shifts from: 9:45 P.M. ([DATE]) to 10:00 A.M. ([DATE]). Review of the resident's progress notes, dated [DATE], showed: -At 11:10 A.M., (Late entry); the resident was noticed missing upon rounds by Certified Nurse Aide (CNA) D on A hall. Staff alerted the DON the resident was not in his/her room. Staff began searching and the night shift nurses were contacted to see if the resident was sent out without knowledge. At 8:30 A.M., a code white was called. All staff, department heads, Administrator and DON continued to search every room, closets, and bathrooms. The department heads and staff searched room to room for resident, as well as a ground search. All emergency exits and doors were checked ensuring they were closed completely. After facility search yielded no results, all department heads began searching local areas, local bars, liquor stores, convenient stores, and placed calls to local hospital and shelters. Some department heads stayed behind to review footage for resident. Local authorities contacted at 9:06 AM. A police officer (PO) from the local police department showed up on scene and a missing person's report was filed. DHSS, Physician and psychiatric Nurse Practitioner (NP) were notified. Guardian was notified with no answer, and no available voice mail. The resident's other family member was then called and said he/she was updating the guardian at 9:15 AM. The other family member said he/she had worried the resident was feeling cooped up on B unit (closed unit) and stopped taking him/her out for a while, because he/she would become aggressive with him/her and not want to return to the facility. He/She knew the resident wanted to leave and had said so previously. The family member recently spoke with Social Services Director (SSD) about room moves with Guardian approval, requesting the resident be taken off the locked unit and given a chance in the main area of the facility. The family member did not communicate the resident's anxiety or the resident's statements about wanting to leave the facility until yesterday while speaking to the DON and SSD. Family was aware of the resident's past elopement history at other facilities and his/her assessment scores, but no recent elopement attempts. The family member was educated to report any and all concerns regarding the resident's safety to the facility. The family member said he/she didn't think to tell anyone, because he/she didn't think the resident could get out, but the resident had tried at other facilities before. The resident enjoyed walking in and around the facility as a coping mechanism. DHSS was notified at 10:27 A.M. The Physician was contacted at 9:18 A.M., with no answer (message left). Psychiatric NP was contacted and the Administrator, DON, Regional Director and the local police departments were notified, and another local police department with police report for missing persons filed; -On [DATE] at 11:10 A.M., (Late Entry): Social Services spoke with the resident's family member in regard to their conversation on [DATE] about the resident coming off the locked unit on [DATE]. The family member left Social Worker (SW) a voice message asking for the resident to be moved to the main area of the building. SW had resident moved off the secured/locked unit on [DATE] back to the main area of the building. Also, the family member said the resident told him/her on several occasions that he/she was going to leave the facility, but the family member didn't notify the facility what the resident was saying. Review of the resident's [DATE] Medication Administration Record (MAR), showed from [DATE] to [DATE], the resident did not receive any of his/her medications which included olanzapine (taken for schizophrenia), scheduled daily for 7:00 A.M. and 4:00 P.M., and divalproex Sodium ER tablet (taken for bipolar disorder), scheduled daily for 7:00 A.M., 11:00 A.M., and 4:00 P.M. Review of the resident's hourly face checks documentation completed on [DATE] showed face checks documented as resident not available beginning at 11:22 A.M. until 1:30 P.M. During interviews on [DATE] at 11:00 A.M. and 11:45 A.M., with the Administrator and the DON, the DON said Resident #1 had eloped and had not returned to the facility. His/Her whereabouts were still unknown. They were still investigating. Yesterday morning, CNA D realized the resident was missing, and he/she informed the DON. Police reports were made to two local police departments. The family had just requested that the resident be taken off the locked unit to give him/her an opportunity to be in the main area of the building. It was unbeknownst to the facility the family had known the resident had been feeling antsy and wanted to leave while he/she was at the facility. The resident's family member didn't want to take the resident home on passes because it was a fight taking him/her back to the facility. Another family member is the resident's Guardian. They tried contacting the Guardian yesterday. The DON called the other family member multiple times yesterday and he/she had updated the Guardian. Review of the resident's progress notes, dated [DATE] at 6:35 P.M., showed around 2:10 P.M., a local area police department contacted the Administrator and said the resident had been found and was being taken to a area local hospital to be assessed. The PO told the DON he/she received a call 1:44 P.M., about an older person at a local gas station telling bystanders he/she wanted to go home but seemed very disoriented and confused. No injuries were noted. The PO said that a call came in around 6:50 A.M., in the morning from a local community member about a man/woman walking with no shoes. SSD and the other department heads went to the hospital to verify the resident's identification and once verified, the Guardian was contacted. DHSS made aware resident was found. Resident was still currently at the hospital. Review of the summary of the facility investigation, dated [DATE], showed: -On [DATE], Resident #1 was last seen by CNA B at 6:00 A.M. and at 6:33 A.M., by nursing staff in the dining room getting coffee per his/her usual routine. The camera footage showed CNA B completing his/her rounds throughout his/her shift and with the DON during the night of [DATE] beginning at 11 PM leading to [DATE]. After 6:00 A.M., CNAs began rounds on residents and began getting their residents up on their halls. Residents visited the dining area by the nurses station where both Nurse K and DON were sitting and charting on residents' assessments. At 6:29 A.M., the resident walked in the dining area to get water and then returned to get coffee. At 6:35 A.M., CNA C saw the resident in the common area. There were no signs of restlessness or agitation in the residents. At 6:36 A.M., Resident #1 walked and drank his/her morning coffee, and as soon as aides went to their halls, the resident approached the door leading to the patio smoking area, and pushed the door open, where no alarm sounded. The camera footage showed the resident climbed over the chain link fence. On [DATE], CNA D noticed the resident was missing. Staff notified the DON the resident was not in his/her room. Staff began searching and the night shift nurses were contacted to see if the resident was sent out without knowledge. At 8:30 A.M., a code white was called. All staff, department heads, Administrator and DON continued to search every room, closet and bathroom. The department heads and staff searched room to room for resident, as well as an exterior ground search. All emergency exits and doors were checked to ensure they were closed completely. After facility search yielded no results, all department heads began searching local areas, local bars, liquor stores, convenient stores and placed calls to local hospitals and shelters. Some department heads stayed behind to review footage for the resident. Residents and staff were interviewed about any knowledge of the resident's whereabouts, as well as residents' feelings of safety, staff monitoring and if residents felt if they are being treated with dignity and respect. Doors leading to exits with alarms were immediately checked for proper functioning. A one to one monitor was placed on smoking hall patio door and other exits until they were checked to be in good working condition. Alarm boxes were checked for any and all alerts. -On [DATE] around 2:10 P.M., the Administrator was contacted by a local police department stating the resident had been found and was being taken to a local area hospital to be assessed. At 9:18 P.M., the resident returned to the facility via stretcher. Physical and neurological assessments were performed and assessment reported to psychiatric NP. Resident, upon return to facility, was placed back on a locked unit, with Guardian approval of the room move. During an interview on [DATE] at 3:30 P.M., Resident #7 said he/she lived at the facility for five or six years. A code white was called yesterday at the beginning of the first shift. The aides on A Hall were asleep and not on the hall on Sunday [DATE]. The staff don't check on the residents at night. Observation and interview on [DATE] at 4:05 P.M., showed Hall Monitor (HM) G sat at the patio exit door. The patio door was shut. A crack, approximately 2 ,d+[DATE] inches, could be observed at the top and the bottom of the door. When the door was opened the alarm did not sound. HM G said he/she has worked at the facility for about one year and four months. He/She was familiar with Resident #1. Today was HM G's first day back at work since last Thursday [DATE]. When the resident lived on B hall, he/she had never verbalized wanting to leave the facility or showed signs that he/she wanted to leave. He/She only wanted to smoke and drink coffee all day. HM G was watching the door until maintenance fixed the door because they can't leave the door unattended. The door is not always secured (closed) when it is shut. He/she wasn't sure of how long the door had been like that. During an interview on [DATE] at 4:18 P.M., the Administrator said the video footage showed Resident #1 left out of the patio exit door at 6:37 A.M. on [DATE]. The patio door does alarm and lock, but if it is not pulled closed, it may stay propped opened. During an interview on [DATE] at 1:25 P.M., CNA C said he/she worked the 11:00 P.M. to the 7:00 A.M. shift. He/She was new to the facility. Saturday night, [DATE] to [DATE] was his/her first shift and Sunday night, [DATE] to [DATE] was his/her second shift (the morning the resident eloped). He/She was with another staff on [DATE] to [DATE] at which time he/she orientated. When he/she went in to work on [DATE] to [DATE], he /she was with another person, but he/she did not orientate. On [DATE]/to [DATE] shift, CNA C last saw the resident at about 6:30 A.M., that morning. The resident was walking with a walker and had a Styrofoam cup saying he/she was wanted some coffee. The resident was walking away from his/her room and toward the dining room area, where the residents watch television. There was nothing out of the ordinary with the resident. CNA C said he/she got off work at 7:00 A.M. on [DATE]. Staff conduct rounds on the residents and document in the computer, but the system wouldn't let him/her in. He/She had tried to get in contact with someone regarding the matter. CNA C did his/her checks like he/she was supposed to. On that Monday night (,d+[DATE]-[DATE]) CNA C said he/she went to work, but did not know where he/she worked at. During an interview on [DATE] at 1:58 P.M., CNA B said he/she had worked at the facility for about three years and was familiar with Resident #1. CNA B worked on the the A hall on the 11:00 P.M.- 7:00 A.M. shift on [DATE] to [DATE]. CNA B said the resident had left on [DATE] at about 6:30 A.M. He/She last saw the resident at 6:00 A.M. on [DATE]. The resident had come from out of his/her room and was walking down the hallway as CNA B was doing his/her rounds. He/She does his/her rounds every hour, but they could be done every two hours. Rounds are documented in the electronic medical record. CNA B documented the rounds in real (actual) time. Staff have to actually put eyes on the resident during rounds. The resident was asleep when CNA B reported to work at 11:00 P.M. The resident slept the entire time. It was a normal night. The resident was in his/her room during every round, with the exception of the 6:00 A.M. round, when the resident left his/her room. The resident woke up to get his/her coffee. The resident used a walker, so CNA B didn't have any indications the resident wanted to leave. The resident is alert and oriented. During an interview on [DATE] at 2:37 P.M., CNA A said he/she had worked at the facility for about one year and a couple of months. He/She was familiar with Resident #1 and was one of the resident's regular CNAs. Resident #1 just moved from the B Hall to his/her assignment on the A hall. During the short time on A hall, the resident never gave any indication that he/she would leave. He/She was naturally a wanderer and walked the halls a lot. He/She would also go to the dining room and sit outside of the dining room and drink coffee. Prior to this, CNA A last worked with the resident on Friday [DATE] on the ,d+[DATE] shift. The resident gave CNA A no indication on Friday ([DATE]) that he/she was going to leave. The CNAs do rounds every hour and the nurses do rounds every 30 minutes, so technically rounds are done every 30 minutes. When rounds are done, staff document them in the computer. CNA A takes a laptop around with him/her and walks and charts at the same time. The resident left Monday [DATE] at early morning. On Monday [DATE], CNA A didn't see the resident at all. CNA A did document in the electronic medical record that he/she saw the resident, but he/she realized he/she made a mistake. He/She really saw another resident on B hall. He/She tried to document as much as possible as he/she goes, because it does get hectic when you trying to document at the end. The resident did the same thing every day and was never in his/her room. The resident would get up to get his/her coffee and then roamed the halls. Since the resident was never in his/her room, when CNA A got in on [DATE], he/she thought the resident was already walking around getting his/her coffee. CNA A saw another resident, Resident #8, sitting in the dining area and thought he/she was Resident #1. CNA A worked a double on [DATE]. He/she worked the ,d+[DATE] shift and ,d+[DATE] shift. CNA A documented the entire day and evening that he/she had seen Resident #1. CNA A knew that he/she messed up. Prior to this, CNA A was not aware of anything wrong with the smoking patio door. During an interview on [DATE] at approximately 3:15 P.M., CNA D said he/she started at the facility in February of 2024. He/She worked the 7:00 A.M. to 3:00 P.M. shift. He/She was not too familiar with the resident because he/she was new to the A Hall. The resident was not on CNA D's assignment. The last time he/she saw the resident was Sunday ([DATE]) right before lunch, about 11:15 A.M. The resident is alert and totally independent. He walked on his/her own. CNA D worked Monday ([DATE]), but the resident was not on his/her assignment. He/She discovered the resident was gone on Tuesday [DATE] at about 8:05 A.M., right before the 8:15 A.M. smoke break. CNA D and Certified Medication Technician (CMT) H were walking down the hallway and noticed the resident's bed was untouched. That wasn't normal, so CNA D went to check the dining room to see if the resident was in there. CNA D didn't see the resident in there, so he/she checked the resident's bathroom and didn't see him/her. CNA D asked the DON if the resident was in the hospital. That's when they all started looking for him/her. The DON called a code white. The resident had eloped. The staff searched everywhere. They went to the metro station, the gas station, and he/she thinks someone went to the apartments too (adjacent to the facility). CNA D would normally just see the resident when he/she would leave out of his/her room to go and get his/her coffee. The staff do rounds every hour. CNA D does face checks every hour, but he/she couldn't speak for anyone else. He/she documents in the electronic medical record in real time. It is possible to go back and document later. With the face checks you have to document if in the building, or if you didn't see them, there are other options like resident out for appointments, resident outside privileges/Leave of absence (LOA) or resident at the hospital. CNA D was not aware of anything wrong with the patio door. It doesn't shut all the way and you have to push it hard for it to open. On the outside, it is kind of hard to open, but you won't be able to get out without putting a code in. The resident didn't put a code in to get out so CNA D's only speculation was that the door wasn't closed all the way. During an interview on [DATE] at 2:56 P.M., CMT H said he/she has worked for the facility for about twelve and half years, normally on the 7:00 A.M. to 3:00 P.M. shift. He/She was familiar with Resident #1. The resident had not received any medication on [DATE]. He/She looked for the resident thinking he/she hadn't taken his/her medications. The resident's roommate told him/her the resident was in the bathroom. This had happened at about 10:00 A.M. on [DATE]. He/She then had gotten called to another hall. He/She had gotten tied up on another hall and had forgotten about it. CMT H left at 3:00 P.M. It hadn't dawned on him/her that he/she still had not seen the resident. CMT H left a memo for the oncoming CMT, advising that he/she had not seen the resident. CMT H said he/she left on the memo that he/she thought the resident was on LOA with his/her family member because one of his/her family members goes and gets the resident. He/She didn't see the resident at all on [DATE]. CMT H said typically when he/she arrived to work, he/she tried to get a report. He/She would ask about people deceased , hospitalization s, LOAs, or so forth. CMT H asked the nurse and he/she wasn't aware of anything. During an interview on [DATE] at 3:10 P.M., Resident #6, said he/she was roommates with Resident #1. Resident #6 really didn't know that much about Resident #1. Resident #1 left a couple of days ago. Resident #6 was unsure of the last time he/she saw Resident #1 prior to him/her leaving. They had been roommates for maybe a day or two. Resident #1 hadn't mentioned anything about wanting to leave the facility. During an interview on [DATE] at 2:27 P.M., the DON said Resident #1 had been found. The police were taking him/her to a local area hospital. Once the resident was checked over, he/she would return to the facility. During observation and interview on [DATE] at 11:18 A.M., Resident #1 said he/she did not feel like talking and declined speaking with the surveyor. During an interview on [DATE] at 11:35 A.M., with Maintenance Assistants (MA) I and MA J, MA I said on Monday [DATE], he/she noticed the patio door was hard to catch. He/She called the Maintenance Director (MD) and he contacted an area lock company on Monday [DATE]. The lock company came out to the facility on [DATE] and [DATE]. They looked at the door and said they had to come back. A little metal box was needed which would make the lock catch when the door was shut. Right now, the door is locked, but if the door was not slammed, it would not lock like it was supposed to. With the elopement incident, the last person who went out the door didn't make sure the door was secure. You have to make it connect with the box so that it connects with the magnet. During an interview on [DATE] at 4:24 P.M., the MD said MA I called him on Monday, [DATE] a little after 7:00 A.M., and told him he/she had to slam the smoking patio door to get it to shut. MD went in to work about 9 AM. He called a local lock company. That is when the MD became aware of the problem with the door. They routinely checked the patio smoking door. There had not been any problems with the smoking patio door prior to this. They checked all the exit doors daily. The lock company was called on [DATE] but they couldn't come out to the facility until today ([DATE]). That is why they have a staff person by the door around the clock. All the exit doors have alarms on them, so if residents try to bust through them, the alarms will sound. If the door was opened without a code, it would alarm. The resident didn't put a code in. When MA I arrived at work, he/she discovered the door was messed up. The issue with the door was that the door had to be pulled really hard to shut it completely. Door alarm drills were done monthly. During an interview on [DATE] at 2:13 P.M., the resident's Guardian said the resident had eloped from the facility on [DATE]. The resident was tired of being at the facility. The resident had told a family member this before. There were no indication given to the Guardian the resident was going to leave. The resident had gone to the hospital and was released yesterday. The resident is not able to take care of him/herself. The resident needs around the clock care. It was not safe for the resident to be out by him/herself. The resident had been at other facilities in the past. He/She had left four or five times prior from other facilities. The Guardian did not know if the facility was aware of this or not. The Guardian was not aware the resident had been recently moved off the locked unit. The facility had placed him/her on the locked unit for supposedly 90 days. The resident's 90 days were up, so the resident was upset he/she had to stay on locked unit. The Guardian thought his/her other family member had said something to the facility about the resident moving off the locked unit. During an interview on [DATE] at 4:44 P.M., the DON said they were aware on admission that Resident #1 did have elopement attempts at other facilities, but the resident had been doing well at this facility. The DON got to the facility in February 2024, so she is still getting to know the residents. The resident has an elopement history and had been on the behavioral unit. It was very normal for him/her to walk up and down the halls with his/her coffee. The resident's family member asked the Social Worker for the resident to come off the locked unit because he/she felt the resident was getting a little more antsy and needed more freedom, and being on the behavioral unit was causing him/her anxiety. The DON worked overnight from [DATE] to [DATE]. No alarms sounded. The resident was doing his/her usual morning walks in the dining room. The resident had gotten coffee and water. She wasn't working the resident's hall but was rounding the entire building with CNA B. There was nothing outside the resident's normal that morning. The resident was normally quiet. Re [TRUNCATED]

See the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, revised 1/5/23, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by Administrator. Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations, the following steps will occur; the licensed nursing staff, team leader, Resident Care Coordinator (RCC), nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The Director of Nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. Review of the Crisis, Alleviation, Lessons and Methods (CALM, staff assisted therapeutic hold) Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively intact; -Diagnoses included major depressive disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed, implement plans to change inappropriate behavior, and pharmaceutical interventions as needed. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. Registered Nurse (RN) J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (emergency room ) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of Resident #1's readmission skin assessment following hospitalization , dated 1/1/24, showed the resident did not have any skin injuries on the face or body. Review of the facility's investigation, dated 1/3/24, showed: -Initial Investigation: On 12/31/23 at approximately 8:00 P.M., the Director of Nursing (DON) and Administrator were notified an altercation had occurred between Resident #1 and Resident #2; -Investigative Narrative: Resident#2 propelled his/her wheelchair and attempted to strike Resident #1, but Hall Monitor A was able to intervene and stated no contact was made. Resident #1 believed he/she was hit in his/her face during the commotion but was unsure what happened; -Initial Intervention: The residents were separated by Hall Monitor A. Both Hall Monitor A and Resident #1 were interviewed. Resident #1 was sent out to the ER for a psychiatric evaluation. Resident #1 was placed on one-on-one supervision after coming back from the hospital. Resident #2 was moved to a different hallway; -Hall Monitor A's written statement, dated 12/31/23, showed Resident #2 was in his/her wheelchair propelling past Resident #1 when Resident #2 attempted to hit Resident #1, but Hall Monitor A intervened in time to stop an injury from occurring; -Resident #1's written statement, dated 1/2/24, showed he/she had just come back from the hospital after being sent out for a psychiatric evaluation on 12/31/23 and was in the hallway. He/She said Resident #2 came at him/her and Hall Monitor A broke up the altercation, and he/she did not know what happened. During interviews on 1/24/24 at 9:19 A.M., 9:30 A.M. and 9:49 A.M., Resident #1 said on 12/31/23, he/she returned from the hospital. Resident #1's bed was in the hallway because staff were in the process of moving him/her to a private room. Hall Monitor A stood close by, but Resident #1 did not want Hall Monitor A near him/her and was upset from the first altercation earlier in the day on 12/31/23. Resident #2 and Resident #1 started to get into an altercation and Hall Monitor A stepped in between them both before it could get physical. In the process of Hall Monitor A breaking up the altercation, he/she grabbed Resident #1 around the neck in a head lock, which knocked his/her glasses off his/her face. The resident said Hall Monitor A hit him/her in the jaw while putting him/her in the head lock. Resident #1 swung at Hall Monitor A in anger, attempting to hit him/her. Hall Monitor A then grabbed Resident #1 by the front of his/her shirt and slammed him/her on the bed. Hall Monitor A held him/her down and the resident was positioned on his/her back with his/her hands behind his/her back. The resident said it hurt him/her physically and made his/her heart hurt. It made him/her feel humiliated to be held down in the hallway. The resident said a female nurse came and called an ambulance to send him/her to the hospital. The resident said he/she told the DON everything. Hall Monitor A was still working at the facility, even after the resident reported being hit. Hall Monitor A still worked on Resident #1's hallway, but he/she tried not to talk to him/her. The resident did not want Hall Monitor A around him/her anymore since the incident, due to not feeling safe. During an interview on 1/25/24, at 8:55 P.M., Hall Monitor A said the following: -On 12/31/23, he/she was working on Resident #1 hall; -Resident #1 had returned from the hospital and staff were in the process of moving Resident #1's belongings into another room. Resident #1's bed was located in the hallway; -Resident #1 sat on his/her bed in the hall and Hall Monitor A stood in the hall a few feet away, on the left side of Resident #1, near the entry of the hall; -Resident #2 was in his/her wheelchair, a few feet away from where Resident #1 sat. Resident #2 was on the right side of Resident #1, at the opposite side of the hall; -Resident #2 called out to Hall Monitor A that Resident #1 was staring at him/her, and he/she thought Resident #1 was going to attack him/her; -Hall Monitor A told Resident #2 that it was okay, to just go to his/her room; -Resident #2 rolled his/her wheelchair past Resident #1 while Hall Monitor A walked towards Resident #1 and Resident #2; -Resident #1 stood up and Hall Monitor A said it looked like he/she was going to hit Resident #2, so Hall Monitor A got in between Resident #1 and Resident #2 and intervened; -Hall Monitor A pushed Resident #1 back onto the bed, using both hands on the resident's chest and then held the resident down, by placing both of his/her hands on the resident's upper chest; -Resident #2 was not struck by Resident #1 and continued to advance down the hall while Hall Monitor A held Resident #1 on the bed; -Resident #1 was swinging and kicking at Hall Monitor A, while Hall Monitor A held the resident down on the bed; -Hall Monitor A thought about swinging on (hitting) Resident #1, but didn't because Resident #1 was little; -Hall Monitor A grabbed Resident #1's right arm below the elbow to try to prevent the resident from hitting him/her; -Resident #1 did hit the back of Hall Monitor A's head with his/her hand. Hall Monitor A balled up his/her fist and was going to strike Resident #1 but then thought better of it; -Hall Monitor A restrained Resident #1 by holding the resident's right arm with one hand and holding the resident down with the left hand that was placed on the resident's chest until another unknown staff member came to the scene; -Hall Monitor A knew it was the facility's policy to not hit a resident, even if they hit staff or other residents. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included schizophrenia and Post Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). During an interview on 1/25/24 at 9:36 A.M., Resident #9 said on 12/31/23, a Code [NAME] (behavior emergency) was called, and the incident happened pretty fast. He/She said he/she saw Resident #1 start swinging, trying to punch Hall Monitor A after Hall Monitor A got close to Resident #1's bed in the hallway. Hall Monitor A grabbed Resident #1 by the front of the shirt and flung Resident #1 on the bed outside of Resident #1's room. Resident #9 said he/she did not see Hall Monitor A hit or punch Resident #1. Hall Monitor A held Resident #1 down for approximately two minutes until other staff came to assist. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/25/24 at 9:37 A.M. Resident #10 said the incident was on 12/31/23. The altercation happened after Resident #1 had returned from the hospital on 12/31/23. Resident #10 said Resident #1 stood at his/her bed located in the hallway and Hall Monitor A was standing 4-5 inches away from Resident #1. Resident #1 was mumbling under his/her breath and all of a sudden, swung his/her arm out at Hall Monitor A to strike him/her. Hall Monitor A grabbed Resident #1 by the shirt and flung him/her to the bed and held the resident down until other staff arrived. Review of the time cards for Hall Monitor A, showed he/she continued working after the incident on 12/31/23, every day until 1/24/24. During an interview on 1/25/24 at 11:32 A.M., Resident #1 told the DON that he/she did not initially report to her that Hall Monitor A hit him/her and he/she was slammed to the bed, because he/she did not want the DON or other staff to be mad at him/her. During an interview on 1/25/24 at 11:11 A.M. and at 11:42 A.M., the DON said after the 12/31/23 incident, Resident #1 told her nothing had happened. Then on 1/1/24 the resident changed his/her story and said that in the process of Hall Monitor A breaking up the altercation, he/she hit Resident #1 in the jaw. Hall Monitor A should not have held the resident down by the shoulders and should have followed the CALM technique protocols. She said other staff are to be present and involved when the CALM technique is being used. Review of the facility's employee discipline notice, dated 1/29/24, showed: -Reason for disciplinary action: Hall Monitor A was on a suspension pending investigation for a resident abuse allegation. It was found that Hall Monitor A had held the resident on the bed, and didn't follow proper protocol for behavior de-escalation procedure. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included bipolar disorder (disorder associated with mood swings from depressive lows to manic highs) and dementia. Review of Resident #13's care plan, dated 7/20/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Behaviors include verbally abusive, hallucinations, delusions, insomnia, suspicion, and agitation with a history of aggressiveness with staff and peers; -Desired outcomes: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed, CALM technique if needed, non pharmaceutical interventions: one-on-one supervision interventions as needed. Review of Resident #13's progress notes, showed: -On 12/21/23 at 7:53 P.M., Licensed Practical Nurse (LPN) H, arrived to work and Code [NAME] was in process. He/She responded to C hall and the resident had been involved in a resident-to-resident altercation. Resident #13 was the aggressor in the altercation. LPN H asked the resident what happened. He/She said, Resident #14 went in his/her drawer taking his/her stuff and got two cigarettes. Resident #13 asked Resident #14 to give them back, and (he/she) said [expletive] me, so Resident #13 started punching Resident #14. LPN H asked the resident how many times he/she hit the other resident and where. The resident said he/she hit the resident four to five times in the face and (his/her) helmet fell off. LPN H educated the resident that he/she should always inform a staff member when he/she has a problem with a staff member or a resident. LPN H informed the resident that he/she can always ask to speak to a nurse as well. (Emergency Medical Service) EMS was called so that resident could go out for evaluation. -On 12/22/23 at 12:56 P.M., a Social Worker note, showed Administrator alerted social worker that Resident #13 was in an altercation with Resident #14 last night. Resident #13 is currently on 1:1 pending the investigation. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and diabetes. Review of the resident's care plan, dated 1/16/24, showed -Behavior care plan for pulling the fire alarm (not for resident to resident aggression); -Interventions included: one-on-one supervision, CALM technique if needed, and pharmaceutical interventions as needed. Review of Resident #14's progress notes showed: -On 1/27/24 at 6:56 A.M., LPN I, was called to C hall by staff because this resident was in an altercation with Resident #13 in the hallway. The residents were separated. A skin assessment was done and no injury noted at this time. An ambulance was called for transportation to the hospital. Awaiting arrival. DON notified; -On 1/27/24 at 3:23 P.M., the resident returned to the facility at approximately 10:34 A.M., no new orders, at this time. Voicemail was left on the guardian's phone to make him/her aware of the incident; -On 1/29/24 at 6:45 A.M., the DON documented, upon reading statements, it is unclear who initiated the altercation. Both employees were in rooms getting residents up when commotion was heard in the hall. A Code [NAME] was called. An altercation between Resident #13 and Resident #14 was in progress. The residents were separated verbally after asking several times. Resident #14 appears to have punched the other resident in the face. No injuries were noted upon initial assessment. EMS was called. The resident was sent to the hospital for evaluation and treatment. Returned quickly with no new orders. Resident is nonverbal and unable to make needs known. During an interview on 1/31/24 at 3:08 P.M. Certified Nurse's Assistant (CNA) E said he/she was in a room assisting a resident when he/she heard a lot of commotion coming from the hallway. He/She went out to the hallway and witnessed Resident #13 and Resident #14 fighting. He/She, along with another staff member, broke up the fight. He/She did not see who the aggressor was but they know that Resident #13 has a history of behaviors. He/She said he/she is not aware of any interventions used for Resident #13 to prevent behaviors and altercations. During an interview on 1/31/24 at 3:18 P.M., Licensed Practical Nurse (LPN) F said he/she was on a different hallway when he/she was asked by another staff member to assist on the C hallway. While LPN F was in the resident's room, he/she heard a commotion in the hallway. He/She went into the hallway to find Resident #13 and Resident #14 fighting. He/She got in the middle of the residents to stop the fight. He/She said both residents were sent out to the hospital and once they got back, both were placed on one to one with staff. During an interview on 1/27/24 at 9:41 A.M. the DON said Resident #13 was walking down the hallway using his/her walker when he/she suddenly came at Resident #14 and attempted to strike the resident with his/her walker. Resident #14 started to fight back when staff intervened and separated the residents. Resident #13 was injured with a black eye under his/her left eye. Resident #13 had been having altercations in January, which they believe to be due to his/her dementia progression. She said the only interventions that had been put in place before the altercation had been redirection when ever the resident had an altercation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00229569 MO00229571 MO00230921 MO00230160 MO00229886

Based on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, revised 1/5/23, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by Administrator. Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations, the following steps will occur; the licensed nursing staff, team leader, Resident Care Coordinator (RCC), nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The Director of Nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. Review of the Crisis, Alleviation, Lessons and Methods (CALM, staff assisted therapeutic hold) Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively intact; -Diagnoses included major depressive disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed, implement plans to change inappropriate behavior, and pharmaceutical interventions as needed. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. Registered Nurse (RN) J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (emergency room ) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of Resident #1's readmission skin assessment following hospitalization , dated 1/1/24, showed the resident did not have any skin injuries on the face or body. Review of the facility's investigation, dated 1/3/24, showed: -Initial Investigation: On 12/31/23 at approximately 8:00 P.M., the Director of Nursing (DON) and Administrator were notified an altercation had occurred between Resident #1 and Resident #2; -Investigative Narrative: Resident#2 propelled his/her wheelchair and attempted to strike Resident #1, but Hall Monitor A was able to intervene and stated no contact was made. Resident #1 believed he/she was hit in his/her face during the commotion but was unsure what happened; -Initial Intervention: The residents were separated by Hall Monitor A. Both Hall Monitor A and Resident #1 were interviewed. Resident #1 was sent out to the ER for a psychiatric evaluation. Resident #1 was placed on one-on-one supervision after coming back from the hospital. Resident #2 was moved to a different hallway; -Hall Monitor A's written statement, dated 12/31/23, showed Resident #2 was in his/her wheelchair propelling past Resident #1 when Resident #2 attempted to hit Resident #1, but Hall Monitor A intervened in time to stop an injury from occurring; -Resident #1's written statement, dated 1/2/24, showed he/she had just come back from the hospital after being sent out for a psychiatric evaluation on 12/31/23 and was in the hallway. He/She said Resident #2 came at him/her and Hall Monitor A broke up the altercation, and he/she did not know what happened. During interviews on 1/24/24 at 9:19 A.M., 9:30 A.M. and 9:49 A.M., Resident #1 said on 12/31/23, he/she returned from the hospital. Resident #1's bed was in the hallway because staff were in the process of moving him/her to a private room. Hall Monitor A stood close by, but Resident #1 did not want Hall Monitor A near him/her and was upset from the first altercation earlier in the day on 12/31/23. Resident #2 and Resident #1 started to get into an altercation and Hall Monitor A stepped in between them both before it could get physical. In the process of Hall Monitor A breaking up the altercation, he/she grabbed Resident #1 around the neck in a head lock, which knocked his/her glasses off his/her face. The resident said Hall Monitor A hit him/her in the jaw while putting him/her in the head lock. Resident #1 swung at Hall Monitor A in anger, attempting to hit him/her. Hall Monitor A then grabbed Resident #1 by the front of his/her shirt and slammed him/her on the bed. Hall Monitor A held him/her down and the resident was positioned on his/her back with his/her hands behind his/her back. The resident said it hurt him/her physically and made his/her heart hurt. It made him/her feel humiliated to be held down in the hallway. The resident said a female nurse came and called an ambulance to send him/her to the hospital. The resident said he/she told the DON everything. Hall Monitor A was still working at the facility, even after the resident reported being hit. Hall Monitor A still worked on Resident #1's hallway, but he/she tried not to talk to him/her. The resident did not want Hall Monitor A around him/her anymore since the incident, due to not feeling safe. During an interview on 1/25/24, at 8:55 P.M., Hall Monitor A said the following: -On 12/31/23, he/she was working on Resident #1 hall; -Resident #1 had returned from the hospital and staff were in the process of moving Resident #1's belongings into another room. Resident #1's bed was located in the hallway; -Resident #1 sat on his/her bed in the hall and Hall Monitor A stood in the hall a few feet away, on the left side of Resident #1, near the entry of the hall; -Resident #2 was in his/her wheelchair, a few feet away from where Resident #1 sat. Resident #2 was on the right side of Resident #1, at the opposite side of the hall; -Resident #2 called out to Hall Monitor A that Resident #1 was staring at him/her, and he/she thought Resident #1 was going to attack him/her; -Hall Monitor A told Resident #2 that it was okay, to just go to his/her room; -Resident #2 rolled his/her wheelchair past Resident #1 while Hall Monitor A walked towards Resident #1 and Resident #2; -Resident #1 stood up and Hall Monitor A said it looked like he/she was going to hit Resident #2, so Hall Monitor A got in between Resident #1 and Resident #2 and intervened; -Hall Monitor A pushed Resident #1 back onto the bed, using both hands on the resident's chest and then held the resident down, by placing both of his/her hands on the resident's upper chest; -Resident #2 was not struck by Resident #1 and continued to advance down the hall while Hall Monitor A held Resident #1 on the bed; -Resident #1 was swinging and kicking at Hall Monitor A, while Hall Monitor A held the resident down on the bed; -Hall Monitor A thought about swinging on (hitting) Resident #1, but didn't because Resident #1 was little; -Hall Monitor A grabbed Resident #1's right arm below the elbow to try to prevent the resident from hitting him/her; -Resident #1 did hit the back of Hall Monitor A's head with his/her hand. Hall Monitor A balled up his/her fist and was going to strike Resident #1 but then thought better of it; -Hall Monitor A restrained Resident #1 by holding the resident's right arm with one hand and holding the resident down with the left hand that was placed on the resident's chest until another unknown staff member came to the scene; -Hall Monitor A knew it was the facility's policy to not hit a resident, even if they hit staff or other residents. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included schizophrenia and Post Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). During an interview on 1/25/24 at 9:36 A.M., Resident #9 said on 12/31/23, a Code Green (behavior emergency) was called, and the incident happened pretty fast. He/She said he/she saw Resident #1 start swinging, trying to punch Hall Monitor A after Hall Monitor A got close to Resident #1's bed in the hallway. Hall Monitor A grabbed Resident #1 by the front of the shirt and flung Resident #1 on the bed outside of Resident #1's room. Resident #9 said he/she did not see Hall Monitor A hit or punch Resident #1. Hall Monitor A held Resident #1 down for approximately two minutes until other staff came to assist. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/25/24 at 9:37 A.M. Resident #10 said the incident was on 12/31/23. The altercation happened after Resident #1 had returned from the hospital on 12/31/23. Resident #10 said Resident #1 stood at his/her bed located in the hallway and Hall Monitor A was standing 4-5 inches away from Resident #1. Resident #1 was mumbling under his/her breath and all of a sudden, swung his/her arm out at Hall Monitor A to strike him/her. Hall Monitor A grabbed Resident #1 by the shirt and flung him/her to the bed and held the resident down until other staff arrived. Review of the time cards for Hall Monitor A, showed he/she continued working after the incident on 12/31/23, every day until 1/24/24. During an interview on 1/25/24 at 11:32 A.M., Resident #1 told the DON that he/she did not initially report to her that Hall Monitor A hit him/her and he/she was slammed to the bed, because he/she did not want the DON or other staff to be mad at him/her. During an interview on 1/25/24 at 11:11 A.M. and at 11:42 A.M., the DON said after the 12/31/23 incident, Resident #1 told her nothing had happened. Then on 1/1/24 the resident changed his/her story and said that in the process of Hall Monitor A breaking up the altercation, he/she hit Resident #1 in the jaw. Hall Monitor A should not have held the resident down by the shoulders and should have followed the CALM technique protocols. She said other staff are to be present and involved when the CALM technique is being used. Review of the facility's employee discipline notice, dated 1/29/24, showed: -Reason for disciplinary action: Hall Monitor A was on a suspension pending investigation for a resident abuse allegation. It was found that Hall Monitor A had held the resident on the bed, and didn't follow proper protocol for behavior de-escalation procedure. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included bipolar disorder (disorder associated with mood swings from depressive lows to manic highs) and dementia. Review of Resident #13's care plan, dated 7/20/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Behaviors include verbally abusive, hallucinations, delusions, insomnia, suspicion, and agitation with a history of aggressiveness with staff and peers; -Desired outcomes: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed, CALM technique if needed, non pharmaceutical interventions: one-on-one supervision interventions as needed. Review of Resident #13's progress notes, showed: -On 12/21/23 at 7:53 P.M., Licensed Practical Nurse (LPN) H, arrived to work and Code Green was in process. He/She responded to C hall and the resident had been involved in a resident-to-resident altercation. Resident #13 was the aggressor in the altercation. LPN H asked the resident what happened. He/She said, Resident #14 went in his/her drawer taking his/her stuff and got two cigarettes. Resident #13 asked Resident #14 to give them back, and (he/she) said [expletive] me, so Resident #13 started punching Resident #14. LPN H asked the resident how many times he/she hit the other resident and where. The resident said he/she hit the resident four to five times in the face and (his/her) helmet fell off. LPN H educated the resident that he/she should always inform a staff member when he/she has a problem with a staff member or a resident. LPN H informed the resident that he/she can always ask to speak to a nurse as well. (Emergency Medical Service) EMS was called so that resident could go out for evaluation. -On 12/22/23 at 12:56 P.M., a Social Worker note, showed Administrator alerted social worker that Resident #13 was in an altercation with Resident #14 last night. Resident #13 is currently on 1:1 pending the investigation. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and diabetes. Review of the resident's care plan, dated 1/16/24, showed -Behavior care plan for pulling the fire alarm (not for resident to resident aggression); -Interventions included: one-on-one supervision, CALM technique if needed, and pharmaceutical interventions as needed. Review of Resident #14's progress notes showed: -On 1/27/24 at 6:56 A.M., LPN I, was called to C hall by staff because this resident was in an altercation with Resident #13 in the hallway. The residents were separated. A skin assessment was done and no injury noted at this time. An ambulance was called for transportation to the hospital. Awaiting arrival. DON notified; -On 1/27/24 at 3:23 P.M., the resident returned to the facility at approximately 10:34 A.M., no new orders, at this time. Voicemail was left on the guardian's phone to make him/her aware of the incident; -On 1/29/24 at 6:45 A.M., the DON documented, upon reading statements, it is unclear who initiated the altercation. Both employees were in rooms getting residents up when commotion was heard in the hall. A Code Green was called. An altercation between Resident #13 and Resident #14 was in progress. The residents were separated verbally after asking several times. Resident #14 appears to have punched the other resident in the face. No injuries were noted upon initial assessment. EMS was called. The resident was sent to the hospital for evaluation and treatment. Returned quickly with no new orders. Resident is nonverbal and unable to make needs known. During an interview on 1/31/24 at 3:08 P.M. Certified Nurse's Assistant (CNA) E said he/she was in a room assisting a resident when he/she heard a lot of commotion coming from the hallway. He/She went out to the hallway and witnessed Resident #13 and Resident #14 fighting. He/She, along with another staff member, broke up the fight. He/She did not see who the aggressor was but they know that Resident #13 has a history of behaviors. He/She said he/she is not aware of any interventions used for Resident #13 to prevent behaviors and altercations. During an interview on 1/31/24 at 3:18 P.M., Licensed Practical Nurse (LPN) F said he/she was on a different hallway when he/she was asked by another staff member to assist on the C hallway. While LPN F was in the resident's room, he/she heard a commotion in the hallway. He/She went into the hallway to find Resident #13 and Resident #14 fighting. He/She got in the middle of the residents to stop the fight. He/She said both residents were sent out to the hospital and once they got back, both were placed on one to one with staff. During an interview on 1/27/24 at 9:41 A.M. the DON said Resident #13 was walking down the hallway using his/her walker when he/she suddenly came at Resident #14 and attempted to strike the resident with his/her walker. Resident #14 started to fight back when staff intervened and separated the residents. Resident #13 was injured with a black eye under his/her left eye. Resident #13 had been having altercations in January, which they believe to be due to his/her dementia progression. She said the only interventions that had been put in place before the altercation had been redirection when ever the resident had an altercation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00229569 MO00229571 MO00230921 MO00230160 MO00229886

Based on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, revised 1/5/23, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by Administrator. Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations, the following steps will occur; the licensed nursing staff, team leader, Resident Care Coordinator (RCC), nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The Director of Nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. Review of the Crisis, Alleviation, Lessons and Methods (CALM, staff assisted therapeutic hold) Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively intact; -Diagnoses included major depressive disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed, implement plans to change inappropriate behavior, and pharmaceutical interventions as needed. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. Registered Nurse (RN) J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (Emergency Room) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of Resident #1's readmission skin assessment following hospitalization, dated 1/1/24, showed the resident did not have any skin injuries on the face or body. Review of the facility's investigation, dated 1/3/24, showed: -Initial Investigation: On 12/31/23 at approximately 8:00 P.M., the Director of Nursing (DON) and Administrator were notified an altercation had occurred between Resident #1 and Resident #2; -Investigative Narrative: Resident#2 propelled his/her wheelchair and attempted to strike Resident #1, but Hall Monitor A was able to intervene and stated no contact was made. Resident #1 believed he/she was hit in his/her face during the commotion but was unsure what happened; -Initial Intervention: The residents were separated by Hall Monitor A. Both Hall Monitor A and Resident #1 were interviewed. Resident #1 was sent out to the ER for a psychiatric evaluation. Resident #1 was placed on one-on-one supervision after coming back from the hospital. Resident #2 was moved to a different hallway; -Hall Monitor A's written statement, dated 12/31/23, showed Resident #2 was in his/her wheelchair propelling past Resident #1 when Resident #2 attempted to hit Resident #1, but Hall Monitor A intervened in time to stop an injury from occurring; -Resident #1's written statement, dated 1/2/24, showed he/she had just come back from the hospital after being sent out for a psychiatric evaluation on 12/31/23 and was in the hallway. He/She said Resident #2 came at him/her and Hall Monitor A broke up the altercation, and he/she did not know what happened. During interviews on 1/24/24 at 9:19 A.M., 9:30 A.M. and 9:49 A.M., Resident #1 said on 12/31/23, he/she returned from the hospital. Resident #1's bed was in the hallway because staff were in the process of moving him/her to a private room. Hall Monitor A stood close by, but Resident #1 did not want Hall Monitor A near him/her and was upset from the first altercation earlier in the day on 12/31/23. Resident #2 and Resident #1 started to get into an altercation and Hall Monitor A stepped in between them both before it could get physical. In the process of Hall Monitor A breaking up the altercation, he/she grabbed Resident #1 around the neck in a head lock, which knocked his/her glasses off his/her face. The resident said Hall Monitor A hit him/her in the jaw while putting him/her in the head lock. Resident #1 swung at Hall Monitor A in anger, attempting to hit him/her. Hall Monitor A then grabbed Resident #1 by the front of his/her shirt and slammed him/her on the bed. Hall Monitor A held him/her down and the resident was positioned on his/her back with his/her hands behind his/her back. The resident said it hurt him/her physically and made his/her heart hurt. It made him/her feel humiliated to be held down in the hallway. The resident said a female nurse came and called an ambulance to send him/her to the hospital. The resident said he/she told the DON everything. Hall Monitor A was still working at the facility, even after the resident reported being hit. Hall Monitor A still worked on Resident #1's hallway, but he/she tried not to talk to him/her. The resident did not want Hall Monitor A around him/her anymore since the incident, due to not feeling safe. During an interview on 1/25/24, at 8:55 P.M., Hall Monitor A said the following: -On 12/31/23, he/she was working on Resident #1 hall; -Resident #1 had returned from the hospital and staff were in the process of moving Resident #1's belongings into another room. Resident #1's bed was located in the hallway; -Resident #1 sat on his/her bed in the hall and Hall Monitor A stood in the hall a few feet away, on the left side of Resident #1, near the entry of the hall; -Resident #2 was in his/her wheelchair, a few feet away from where Resident #1 sat. Resident #2 was on the right side of Resident #1, at the opposite side of the hall; -Resident #2 called out to Hall Monitor A that Resident #1 was staring at him/her, and he/she thought Resident #1 was going to attack him/her; -Hall Monitor A told Resident #2 that it was okay, to just go to his/her room; -Resident #2 rolled his/her wheelchair past Resident #1 while Hall Monitor A walked towards Resident #1 and Resident #2; -Resident #1 stood up and Hall Monitor A said it looked like he/she was going to hit Resident #2, so Hall Monitor A got in between Resident #1 and Resident #2 and intervened; -Hall Monitor A pushed Resident #1 back onto the bed, using both hands on the resident's chest and then held the resident down, by placing both of his/her hands on the resident's upper chest; -Resident #2 was not struck by Resident #1 and continued to advance down the hall while Hall Monitor A held Resident #1 on the bed; -Resident #1 was swinging and kicking at Hall Monitor A, while Hall Monitor A held the resident down on the bed; -Hall Monitor A thought about swinging on (hitting) Resident #1, but didn't because Resident #1 was little; -Hall Monitor A grabbed Resident #1's right arm below the elbow to try to prevent the resident from hitting him/her; -Resident #1 did hit the back of Hall Monitor A's head with his/her hand. Hall Monitor A balled up his/her fist and was going to strike Resident #1 but then thought better of it; -Hall Monitor A restrained Resident #1 by holding the resident's right arm with one hand and holding the resident down with the left hand that was placed on the resident's chest until another unknown staff member came to the scene; -Hall Monitor A knew it was the facility's policy to not hit a resident, even if they hit staff or other residents. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included schizophrenia and Post Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). During an interview on 1/25/24 at 9:36 A.M., Resident #9 said on 12/31/23, a Code [NAME] (behavior emergency) was called, and the incident happened pretty fast. He/She said he/she saw Resident #1 start swinging, trying to punch Hall Monitor A after Hall Monitor A got close to Resident #1's bed in the hallway. Hall Monitor A grabbed Resident #1 by the front of the shirt and flung Resident #1 on the bed outside of Resident #1's room. Resident #9 said he/she did not see Hall Monitor A hit or punch Resident #1. Hall Monitor A held Resident #1 down for approximately two minutes until other staff came to assist. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/25/24 at 9:37 A.M. Resident #10 said the incident was on 12/31/23. The altercation happened after Resident #1 had returned from the hospital on [DATE]. Resident #10 said Resident #1 stood at his/her bed located in the hallway and Hall Monitor A was standing 4-5 inches away from Resident #1. Resident #1 was mumbling under his/her breath and all of a sudden, swung his/her arm out at Hall Monitor A to strike him/her. Hall Monitor A grabbed Resident #1 by the shirt and flung him/her to the bed and held the resident down until other staff arrived. Review of the time cards for Hall Monitor A, showed he/she continued working after the incident on 12/31/23, every day until 1/24/24. During an interview on 1/25/24 at 11:32 A.M., Resident #1 told the DON that he/she did not initially report to her that Hall Monitor A hit him/her and he/she was slammed to the bed, because he/she did not want the DON or other staff to be mad at him/her. During an interview on 1/25/24 at 11:11 A.M. and at 11:42 A.M., the DON said after the 12/31/23 incident, Resident #1 told her nothing had happened. Then on 1/1/24 the resident changed his/her story and said that in the process of Hall Monitor A breaking up the altercation, he/she hit Resident #1 in the jaw. Hall Monitor A should not have held the resident down by the shoulders and should have followed the CALM technique protocols. She said other staff are to be present and involved when the CALM technique is being used. Review of the facility's employee discipline notice, dated 1/29/24, showed: -Reason for disciplinary action: Hall Monitor A was on a suspension pending investigation for a resident abuse allegation. It was found that Hall Monitor A had held the resident on the bed, and didn't follow proper protocol for behavior de-escalation procedure. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included bipolar disorder (disorder associated with mood swings from depressive lows to manic highs) and dementia. Review of Resident #13's care plan, dated 7/20/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Behaviors include verbally abusive, hallucinations, delusions, insomnia, suspicion, and agitation with a history of aggressiveness with staff and peers; -Desired outcomes: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed, CALM technique if needed, non pharmaceutical interventions: one-on-one supervision interventions as needed. Review of Resident #13's progress notes, showed: -On 12/21/23 at 7:53 P.M., Licensed Practical Nurse (LPN) H, arrived to work and Code [NAME] was in process. He/She responded to C hall and the resident had been involved in a resident-to-resident altercation. Resident #13 was the aggressor in the altercation. LPN H asked the resident what happened. He/She said, Resident #14 went in his/her drawer taking his/her stuff and got two cigarettes. Resident #13 asked Resident #14 to give them back, and (he/she) said [expletive] me, so Resident #13 started punching Resident #14. LPN H asked the resident how many times he/she hit the other resident and where. The resident said he/she hit the resident four to five times in the face and (his/her) helmet fell off. LPN H educated the resident that he/she should always inform a staff member when he/she has a problem with a staff member or a resident. LPN H informed the resident that he/she can always ask to speak to a nurse as well. (Emergency Medical Service) EMS was called so that resident could go out for evaluation. -On 12/22/23 at 12:56 P.M., a Social Worker note, showed Administrator alerted social worker that Resident #13 was in an altercation with Resident #14 last night. Resident #13 is currently on 1:1 pending the investigation. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and diabetes. Review of the resident's care plan, dated 1/16/24, showed -Behavior care plan for pulling the fire alarm (not for resident to resident aggression); -Interventions included: one-on-one supervision, CALM technique if needed, and pharmaceutical interventions as needed. Review of Resident #14's progress notes showed: -On 1/27/24 at 6:56 A.M., LPN I, was called to C hall by staff because this resident was in an altercation with Resident #13 in the hallway. The residents were separated. A skin assessment was done and no injury noted at this time. An ambulance was called for transportation to the hospital. Awaiting arrival. DON notified; -On 1/27/24 at 3:23 P.M., the resident returned to the facility at approximately 10:34 A.M., no new orders, at this time. Voicemail was left on the guardian's phone to make him/her aware of the incident; -On 1/29/24 at 6:45 A.M., the DON documented, upon reading statements, it is unclear who initiated the altercation. Both employees were in rooms getting residents up when commotion was heard in the hall. A Code [NAME] was called. An altercation between Resident #13 and Resident #14 was in progress. The residents were separated verbally after asking several times. Resident #14 appears to have punched the other resident in the face. No injuries were noted upon initial assessment. EMS was called. The resident was sent to the hospital for evaluation and treatment. Returned quickly with no new orders. Resident is nonverbal and unable to make needs known. During an interview on 1/31/24 at 3:08 P.M. Certified Nurse's Assistant (CNA) E said he/she was in a room assisting a resident when he/she heard a lot of commotion coming from the hallway. He/She went out to the hallway and witnessed Resident #13 and Resident #14 fighting. He/She, along with another staff member, broke up the fight. He/She did not see who the aggressor was but they know that Resident #13 has a history of behaviors. He/She said he/she is not aware of any interventions used for Resident #13 to prevent behaviors and altercations. During an interview on 1/31/24 at 3:18 P.M., Licensed Practical Nurse (LPN) F said he/she was on a different hallway when he/she was asked by another staff member to assist on the C hallway. While LPN F was in the resident's room, he/she heard a commotion in the hallway. He/She went into the hallway to find Resident #13 and Resident #14 fighting. He/She got in the middle of the residents to stop the fight. He/She said both residents were sent out to the hospital and once they got back, both were placed on one to one with staff. During an interview on 1/27/24 at 9:41 A.M. the DON said Resident #13 was walking down the hallway using his/her walker when he/she suddenly came at Resident #14 and attempted to strike the resident with his/her walker. Resident #14 started to fight back when staff intervened and separated the residents. Resident #13 was injured with a black eye under his/her left eye. Resident #13 had been having altercations in January, which they believe to be due to his/her dementia progression. She said the only interventions that had been put in place before the altercation had been redirection when ever the resident had an altercation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00229569 MO00229571 MO00230921 MO00230160 MO00229886

Based on interview and record review, the facility failed to ensure the provision of treatment and services for one resident (Resident #1), diagnosed with a mental health disorder and post-traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety) to attain the highest practicable mental and psychosocial well-being. The facility failed to provide or arrange for mental health services, and failed to notify psychiatric services of suicide attempts and of the contents of the suicide note authored by the resident. Facility staff also did not follow the facility's program for a proper therapeutic hold while the resident had a behavior emergency. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M., of an Immediate Jeopardy (IJ) which began on 12/27/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations the following steps will occur; the licensed nursing staff, team leader, and nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The director of nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility; -The licensed nurse and team leader will follow direction from the management team member on call, Resident Care Coordinator and the Administrator or designee. The guardian will be notified at this time and imposed limitations may be placed on the resident, including hospitalization or other specific directives. The physician will be notified of the licensed nurse, team leader, assessment and orders will be followed. The licensed nurse and team leader will will follow all physician orders and will notify the management team member on call regarding the new orders from the physician. If the management team member on call and Administrator or designee decide that resident's needs cannot continue to be safely met, or that the resident is not appropriate for placement at the facility, the physician (primary psychiatrist, house psychiatrist, or medical director) will be notified by the licensed nurse requesting for a psychiatric evaluation, at this time an immediate discharge notice may be sent with the resident. The legal guardian will be notified of the immediate discharge and reason for the notice; -The Administrator, Director of Nursing (DON), designee will complete an administrative investigation within 24 hours of the behavioral emergency. This may include a (as needed) PRN Intervention Form and notification of state agencies in the event that criteria are met. In the event that the resident is unable to be redirected or is requesting a PRN medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a (by mouth) PO or (Intramuscular) IM PRN mood stabilizing medication, the licensed nurse must complete the PRN Intervention Form in the electronic medical record. The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines (which means define behaviors, interventions for behaviors, reaction/response, plan continued plan of care, evaluate, evaluate, evaluate, evaluate.) -After every Code Green (behavior emergency) that required the utilization of approved Crisis, Alleviations Lessons and Methods program (CALM, staff assisted therapeutic hold) hold techniques, the administrator, DON, or designated employee will complete an administrative investigation of the occurrences regarding the resident's behavior and the staff responses. Remember that any Resident who requires approved CALM hold techniques must meet the criteria, which must be documented and that physical or chemical interventions are never used to as a punishment for discipline or staff convenience. Review of the CALM Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively Intact; -Diagnoses included major depressive disorder, PTSD, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed. Implement plans to change inappropriate behavior, pharmaceutical interventions as needed; -Problem: Resident has a history of PTSD. PTSD affects resident symptoms and may flare up without any known trigger. Altercations in reactivity from the traumatic event including aggressiveness and self destructive behavior; -Desired outcome: Resident will be able to identify triggers. Resident will learn and utilize positive coping strategies. Resident will demonstrate control of emotions and relaxation techniques. Resident will be free from injury; -Interventions: Administer medication appropriately and monitor for side affects, encourage resident to express emotions in a safe environment, encourage resident to verbally identify current ineffective coping techniques, and help resident understand that their current behaviors that may be preventing effective healing or treatment, provide counseling services when needed. Review of the resident's progress note, dated 12/27/23, showed Certified Medication Technician (CMT) alerted (Licensed Practical Nurse) LPN K, that the resident refused his/her medications. LPN K went to speak with the resident regarding why he/she was refusing his/her meds. Upon entry to his/her room, observation showed the resident with a sheet wrapped around his/her neck. The resident was instructed to remove it immediately and he/she complied. The resident was allowed to vent his/her frustrations. He/She stated that he/she felt suicidal. He/She was asked why he/she felt that way and he/she said he/she didn't know. The resident stated he/she wanted their medication shot and to go to the hospital. The resident was educated on the importance of taking his/her medication and the psychiatric doctor would be alerted. He/She agreed to take his/her medication if he/she could get it. Physician was notified, new order was obtained for Zyprexa (antipsychotic) 10 milligrams (MG) IM every eight hours PRN (as needed). IM medication was administered to left deltoid (shoulder muscle) without difficulty. Shortly after the resident went to his/her room and started moving his/her items around the room. He/She was placed on a one on one supervision for safety. The resident was placed in the hallway for a while to help him/her de-escalate his/her behaviors. He/She eventually calmed down and went into his/her room to sleep. Guardian was called and a message was left. Administrator, DON, Social Worker were made aware. Will continue to monitor for protective oversight. During an interview on 1/26/24 at 12:30 P.M., Resident #1 said on the morning of 12/31/23 he/she was hearing voices. He/She was also aggravated because his/her roommate was using the room light and he/she wanted the light off. He/She placed the sheet around his/her neck in attempt to kill himself/herself. The resident said his/her roommate noticed the resident had a sheet around his/her neck and told him/her to take it off. The resident's roommate called staff into the room to tell them what Resident #1 was doing with the sheet. Resident #1 said he/she was asked by nursing staff if he/she wanted to go to the hospital and he/she said yes. The resident said he/she was feeling like he/she wanted to kill himself/herself due to the voices. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. (Registered Nurse) RN J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (emergency room ) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of the resident's progress note, dated 1/7/24 showed RN J called to resident room. Resident was trying to remove room air conditioner. Tried to redirect resident and resident started swinging at staff. Resident was lying on bed and he/she got up and was lying on the floor. Resident up on own and the police came and the officer and RN J asked the resident why. Emergency Medical Services (EMS) came and the resident was taken to the hospital. During an interview on 1/26/24 at 11:35 A.M., the resident said he/she wanted to use parts of the air conditioner unit to cut and hurt himself/herself. He/She was sent to the emergency room following this incident. Review of the resident's progress note, dated 1/9/24, showed Code Green called to resident's room via overhead announcement. LPN I, and several other staff members responded to the code. Upon arrival, patient was being restrained by two staff members, one restraining each hand/wrist and patient biting onto pillow lying face down on bed. A verbal explanation was given that patient tied the bed sheet around his/her neck and attempting to strangle himself/herself, along with a clothes hanger. The resident refused to talk to nursing staff about the incident. LPN I initiated a 911 call for assistance with a suicide attempt. The second nurse stayed at the bedside to assist. At that time, a hand written suicide note was given to the second nurse at the scene by a staff member who was at beside for one-on-one monitoring. EMS arrived to facility and transferred resident to the hospital. Police department responded and filed police report. DON notified. Physician answering service left call, waiting return call. Guardian left voicemail, awaiting return call. During an interview on 1/25/24 at 3:53 P.M., Resident #1 said prior to the incident on 1/9/24, he/she was feeling very anxious. When the staff held him/her down on the bed, he/she knew that the staff were trying to help him/her. His/Her anxiety took over and he/she started to feel like the staff were attacking him/her. The resident was held down on his/her stomach with his/her hands behind his/her back. His/Her head was in a pillow and to the side. He/She continued trying to hit and kick the staff members and it was hard to breathe with all of the staff holding him/her down. Review of the resident's Electronic Medical Records (EMR) showed: -On 1/19/24 Resident #1 was readmitted to the facility after being at the hospital and was placed on one on one supervision; -A depression scale assessment, completed by the Social Worker on 1/20/24 at 1:11 P.M., showed Resident #1 reported feeling down, depressed, or hopeless two to six days per week, had thoughts of wanting to harm himself/herself or that that he/she would be better off dead two to six days a week. -On 1/22/24 Resident #1 was taken off of one on one supervision after being deemed safe. During an interview on 1/26/24 at 9:24 A.M., the Social Worker said she has been completing depression assessments on Resident #1 in attempt to help him/her. She said the facility does not currently have a contract with a counseling service. She said after each documented suicide attempt Resident #1 was placed on one-on-one supervision until he/she was determined to be safe. She had been in communication with the resident's guardian due to how many suicide attempts the resident was having. During an interview on 1/26/24 at 12:41 P.M., Hall Monitor B said Resident #1 gets agitated sometimes. His/Her interventions include going to the charge nurse to see if the resident has an as needed medication they can take. He/She said the hall monitors will buy the resident sodas sometimes to help the resident. He/She said if the behavior is something they can manage without nursing staff they will, but that if they need nursing staff, the charge nurse is the first place they go. He/She said the hall monitors don't always know what interventions to use or what the residents' care plans say. He/She was unaware of what Resident #1's care plan said. During an interview on 1/26/24 at 12:59 P.M., Licensed Practical Nurse (LPN) C said whatever interventions staff come up with for residents should be documented in a nurse's note and on the care plan. He/She said he/she is not sure if hall monitors are able to access a resident's care plan. He/She said nursing staff walk around every shift and relay information about the residents to the oncoming shift. He/She believed the care plan was the plan, but there was no written down intervention plan for Resident #1. Restraining Resident #1 is not the first step hall monitors should take, and they should at first, attempt to talk with the resident. During an interview on 1/25/24 at 1:06 P.M., the resident said he/she does not like loud noises or crowds. These are triggers for his/her emotions and he/she gets mad quickly. He/She would like a staff member he/she could trust, to talk with him/her weekly about his/her triggers and give him/her coping skills to use. Review of the resident's care plan, dated 12/7/23, showed the care plan had not been updated to include specific personalized interventions to address the resident's PTSD and suicide attempts on 12/27/23 and 1/9/24. During an interview on 1/26/24, at 1:06 P.M. the Psychiatrist said the following: -She expected the facility to notify her or her office of any suicide attempts, as their protocol was to send residents to the hospital for evaluation and then to see them after the incident; -She could not remember if the facility had notified her of any suicide attempts; She would have made a note in the resident's file and was not able to access the resident's medical record at the time of interview; -She expected the facility to provide counseling to residents with PTSD and/or suicide ideation on a weekly or biweekly basis, as well as care plan for both with meaningful interventions; -She expected the facility to follow up with her after a resident had a suicide attempt as it may alter plan of care; -She was new to the resident's care team, she had started approximately three weeks ago. During an interview on 1/26/24, at 2:23 P.M., the resident's Guardian said the following: -The facility did not inform her of any suicide attempts made by the resident; -She was not told the resident was sent to the hospital for suicide attempts. She and her office were only asked by the hospital for consent to admit and to discharge; -She expected the facility to notify her or her office of any suicide attempt; -She expected the facility to provide counseling to the resident for PTSD and suicide ideation; -She asked the facility social worker in the beginning of January, if they provided psychiatric counseling and she was told the facility did not provide the service and to move the resident to a different facility; -She expected the facility to develop a care plan for PTSD and suicide ideation with appropriate interventions to address the resident's psychiatric needs. During an interview on 1/26/24 at 3:04 P.M., the Psychiatrist Nurse Practitioner, said the following: -He only saw the resident on 12/28/23; -The Psychiatrist saw the resident on 1/3/24 and 1/24/24, via TeleHealth (virtual visit), which are meetings that generally take 15 to 20 minutes; -He was not aware the resident had any suicide attempts while the resident was in the facility; -His protocol was to send a resident out to the hospital immediately following a suicide attempt and would have followed up with the resident once the resident returned from the hospital to reevaluate the plan of care; -He reviewed the medical records on the resident and found there was no record that he or his office was notified by the facility on 12/27/23, 12/31/23 or 1/9/24 of the resident's suicide attempts. During an interview on 1/25/24 at 1:51 P.M., the DON said she was never made aware of the resident's suicide attempt on 1/9/24 or that the resident was restrained with his/her face in a pillow. She said this event was not investigated. She said the facility should have investigated the suicide note and kept the note. She said the resident should not have been held down with his/her face in a pillow and that it is unsafe. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to ensure the provision of treatment and services for one resident (Resident #1), diagnosed with a mental health disorder and post-traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety) to attain the highest practicable mental and psychosocial well-being. The facility failed to provide or arrange for mental health services, and failed to notify psychiatric services of suicide attempts and of the contents of the suicide note authored by the resident. Facility staff also did not follow the facility's program for a proper therapeutic hold while the resident had a behavior emergency. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M., of an Immediate Jeopardy (IJ) which began on 12/27/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations the following steps will occur; the licensed nursing staff, team leader, and nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The director of nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility; -The licensed nurse and team leader will follow direction from the management team member on call, Resident Care Coordinator and the Administrator or designee. The guardian will be notified at this time and imposed limitations may be placed on the resident, including hospitalization or other specific directives. The physician will be notified of the licensed nurse, team leader, assessment and orders will be followed. The licensed nurse and team leader will will follow all physician orders and will notify the management team member on call regarding the new orders from the physician. If the management team member on call and Administrator or designee decide that resident's needs cannot continue to be safely met, or that the resident is not appropriate for placement at the facility, the physician (primary psychiatrist, house psychiatrist, or medical director) will be notified by the licensed nurse requesting for a psychiatric evaluation, at this time an immediate discharge notice may be sent with the resident. The legal guardian will be notified of the immediate discharge and reason for the notice; -The Administrator, Director of Nursing (DON), designee will complete an administrative investigation within 24 hours of the behavioral emergency. This may include a (as needed) PRN Intervention Form and notification of state agencies in the event that criteria are met. In the event that the resident is unable to be redirected or is requesting a PRN medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a (by mouth) PO or (Intramuscular) IM PRN mood stabilizing medication, the licensed nurse must complete the PRN Intervention Form in the electronic medical record. The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines (which means define behaviors, interventions for behaviors, reaction/response, plan continued plan of care, evaluate, evaluate, evaluate, evaluate.) -After every Code [NAME] (behavior emergency) that required the utilization of approved Crisis, Alleviations Lessons and Methods program (CALM, staff assisted therapeutic hold) hold techniques, the administrator, DON, or designated employee will complete an administrative investigation of the occurrences regarding the resident's behavior and the staff responses. Remember that any Resident who requires approved CALM hold techniques must meet the criteria, which must be documented and that physical or chemical interventions are never used to as a punishment for discipline or staff convenience. Review of the CALM Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively Intact; -Diagnoses included major depressive disorder, PTSD, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed. Implement plans to change inappropriate behavior, pharmaceutical interventions as needed; -Problem: Resident has a history of PTSD. PTSD affects resident symptoms and may flare up without any known trigger. Altercations in reactivity from the traumatic event including aggressiveness and self destructive behavior; -Desired outcome: Resident will be able to identify triggers. Resident will learn and utilize positive coping strategies. Resident will demonstrate control of emotions and relaxation techniques. Resident will be free from injury; -Interventions: Administer medication appropriately and monitor for side affects, encourage resident to express emotions in a safe environment, encourage resident to verbally identify current ineffective coping techniques, and help resident understand that their current behaviors that may be preventing effective healing or treatment, provide counseling services when needed. Review of the resident's progress note, dated 12/27/23, showed Certified Medication Technician (CMT) alerted (Licensed Practical Nurse) LPN K, that the resident refused his/her medications. LPN K went to speak with the resident regarding why he/she was refusing his/her meds. Upon entry to his/her room, observation showed the resident with a sheet wrapped around his/her neck. The resident was instructed to remove it immediately and he/she complied. The resident was allowed to vent his/her frustrations. He/She stated that he/she felt suicidal. He/She was asked why he/she felt that way and he/she said he/she didn't know. The resident stated he/she wanted their medication shot and to go to the hospital. The resident was educated on the importance of taking his/her medication and the psychiatric doctor would be alerted. He/She agreed to take his/her medication if he/she could get it. Physician was notified, new order was obtained for Zyprexa (antipsychotic) 10 milligrams (MG) IM every eight hours PRN (as needed). IM medication was administered to left deltoid (shoulder muscle) without difficulty. Shortly after the resident went to his/her room and started moving his/her items around the room. He/She was placed on a one on one supervision for safety. The resident was placed in the hallway for a while to help him/her de-escalate his/her behaviors. He/She eventually calmed down and went into his/her room to sleep. Guardian was called and a message was left. Administrator, DON, Social Worker were made aware. Will continue to monitor for protective oversight. During an interview on 1/26/24 at 12:30 P.M., Resident #1 said on the morning of 12/31/23 he/she was hearing voices. He/She was also aggravated because his/her roommate was using the room light and he/she wanted the light off. He/She placed the sheet around his/her neck in attempt to kill himself/herself. The resident said his/her roommate noticed the resident had a sheet around his/her neck and told him/her to take it off. The resident's roommate called staff into the room to tell them what Resident #1 was doing with the sheet. Resident #1 said he/she was asked by nursing staff if he/she wanted to go to the hospital and he/she said yes. The resident said he/she was feeling like he/she wanted to kill himself/herself due to the voices. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. (Registered Nurse) RN J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (Emergency Room) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of the resident's progress note, dated 1/7/24 showed RN J called to resident room. Resident was trying to remove room air conditioner. Tried to redirect resident and resident started swinging at staff. Resident was lying on bed and he/she got up and was lying on the floor. Resident up on own and the police came and the officer and RN J asked the resident why. Emergency Medical Services (EMS) came and the resident was taken to the hospital. During an interview on 1/26/24 at 11:35 A.M., the resident said he/she wanted to use parts of the air conditioner unit to cut and hurt himself/herself. He/She was sent to the emergency room following this incident. Review of the resident's progress note, dated 1/9/24, showed Code [NAME] called to resident's room via overhead announcement. LPN I, and several other staff members responded to the code. Upon arrival, patient was being restrained by two staff members, one restraining each hand/wrist and patient biting onto pillow lying face down on bed. A verbal explanation was given that patient tied the bed sheet around his/her neck and attempting to strangle himself/herself, along with a clothes hanger. The resident refused to talk to nursing staff about the incident. LPN I initiated a 911 call for assistance with a suicide attempt. The second nurse stayed at the bedside to assist. At that time, a hand written suicide note was given to the second nurse at the scene by a staff member who was at beside for one-on-one monitoring. EMS arrived to facility and transferred resident to the hospital. Police department responded and filed police report. DON notified. Physician answering service left call, waiting return call. Guardian left voicemail, awaiting return call. During an interview on 1/25/24 at 3:53 P.M., Resident #1 said prior to the incident on 1/9/24, he/she was feeling very anxious. When the staff held him/her down on the bed, he/she knew that the staff were trying to help him/her. His/Her anxiety took over and he/she started to feel like the staff were attacking him/her. The resident was held down on his/her stomach with his/her hands behind his/her back. His/Her head was in a pillow and to the side. He/She continued trying to hit and kick the staff members and it was hard to breathe with all of the staff holding him/her down. Review of the resident's Electronic Medical Records (EMR) showed: -On 1/19/24 Resident #1 was readmitted to the facility after being at the hospital and was placed on one on one supervision; -A depression scale assessment, completed by the Social Worker on 1/20/24 at 1:11 P.M., showed Resident #1 reported feeling down, depressed, or hopeless two to six days per week, had thoughts of wanting to harm himself/herself or that that he/she would be better off dead two to six days a week. -On 1/22/24 Resident #1 was taken off of one on one supervision after being deemed safe. During an interview on 1/26/24 at 9:24 A.M., the Social Worker said she has been completing depression assessments on Resident #1 in attempt to help him/her. She said the facility does not currently have a contract with a counseling service. She said after each documented suicide attempt Resident #1 was placed on one-on-one supervision until he/she was determined to be safe. She had been in communication with the resident's guardian due to how many suicide attempts the resident was having. During an interview on 1/26/24 at 12:41 P.M., Hall Monitor B said Resident #1 gets agitated sometimes. His/Her interventions include going to the charge nurse to see if the resident has an as needed medication they can take. He/She said the hall monitors will buy the resident sodas sometimes to help the resident. He/She said if the behavior is something they can manage without nursing staff they will, but that if they need nursing staff, the charge nurse is the first place they go. He/She said the hall monitors don't always know what interventions to use or what the residents' care plans say. He/She was unaware of what Resident #1's care plan said. During an interview on 1/26/24 at 12:59 P.M., Licensed Practical Nurse (LPN) C said whatever interventions staff come up with for residents should be documented in a nurse's note and on the care plan. He/She said he/she is not sure if hall monitors are able to access a resident's care plan. He/She said nursing staff walk around every shift and relay information about the residents to the oncoming shift. He/She believed the care plan was the plan, but there was no written down intervention plan for Resident #1. Restraining Resident #1 is not the first step hall monitors should take, and they should at first, attempt to talk with the resident. During an interview on 1/25/24 at 1:06 P.M., the resident said he/she does not like loud noises or crowds. These are triggers for his/her emotions and he/she gets mad quickly. He/She would like a staff member he/she could trust, to talk with him/her weekly about his/her triggers and give him/her coping skills to use. Review of the resident's care plan, dated 12/7/23, showed the care plan had not been updated to include specific personalized interventions to address the resident's PTSD and suicide attempts on 12/27/23 and 1/9/24. During an interview on 1/26/24, at 1:06 P.M. the Psychiatrist said the following: -She expected the facility to notify her or her office of any suicide attempts, as their protocol was to send residents to the hospital for evaluation and then to see them after the incident; -She could not remember if the facility had notified her of any suicide attempts; She would have made a note in the resident's file and was not able to access the resident's medical record at the time of interview; -She expected the facility to provide counseling to residents with PTSD and/or suicide ideation on a weekly or biweekly basis, as well as care plan for both with meaningful interventions; -She expected the facility to follow up with her after a resident had a suicide attempt as it may alter plan of care; -She was new to the resident's care team, she had started approximately three weeks ago. During an interview on 1/26/24, at 2:23 P.M., the resident's Guardian said the following: -The facility did not inform her of any suicide attempts made by the resident; -She was not told the resident was sent to the hospital for suicide attempts. She and her office were only asked by the hospital for consent to admit and to discharge; -She expected the facility to notify her or her office of any suicide attempt; -She expected the facility to provide counseling to the resident for PTSD and suicide ideation; -She asked the facility social worker in the beginning of January, if they provided psychiatric counseling and she was told the facility did not provide the service and to move the resident to a different facility; -She expected the facility to develop a care plan for PTSD and suicide ideation with appropriate interventions to address the resident's psychiatric needs. During an interview on 1/26/24 at 3:04 P.M., the Psychiatrist Nurse Practitioner, said the following: -He only saw the resident on 12/28/23; -The Psychiatrist saw the resident on 1/3/24 and 1/24/24, via TeleHealth (virtual visit), which are meetings that generally take 15 to 20 minutes; -He was not aware the resident had any suicide attempts while the resident was in the facility; -His protocol was to send a resident out to the hospital immediately following a suicide attempt and would have followed up with the resident once the resident returned from the hospital to reevaluate the plan of care; -He reviewed the medical records on the resident and found there was no record that he or his office was notified by the facility on 12/27/23, 12/31/23 or 1/9/24 of the resident's suicide attempts. During an interview on 1/25/24 at 1:51 P.M., the DON said she was never made aware of the resident's suicide attempt on 1/9/24 or that the resident was restrained with his/her face in a pillow. She said this event was not investigated. She said the facility should have investigated the suicide note and kept the note. She said the resident should not have been held down with his/her face in a pillow and that it is unsafe. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to provide protective oversight for one resident (Resident #1) who had a history of elopement and a diagnosis of schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) when staff failed to provide supervision during a smoke break, failed to conduct a head count after the smoke break, failed to conduct hourly face checks, and did not discover the resident was missing until nine hours after the resident left the building. The resident sample was 4. The census was 114. The Administrator was notified on 12/10/23 at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on 12/8/23. The IJ was removed on 12/11/23, as confirmed by surveyor onsite verification. Review of the facility's Intensive Monitoring/Visual Checks policy, revised on 6/30/23, showed: -Purpose: To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues; -Procedure: Residents who require more intensive monitoring due to medical behavioral/psychiatric symptoms will be monitored on visual face checks by the Licensed Nurse and/or designee, and Certified Nurse's Aide (CNA) and/or designee. The Licensed Nurse monitoring shall include a visual assessment of clinical symptom changes or abnormalities; -Definition of Intensive Monitoring: Periodic (e.g. hourly, every two hours or shiftly) check by a Licensed Nurse or one to one monitoring by the designated employee assigned by the Licensed Nurse. A face check is defined by the employee visually seeing the face of the resident; -Residents may require more intensive monitoring based on their medical and behavioral/psychiatric needs; -One to one monitoring: Residents who are showing poor impulse control including verbal/physical aggression, elopement ideations or suicidal/homicidal ideations may also be placed on one to one or two to one (within eyesight of staff at all times) monitoring at the discretion of the administrative staff; -Face checks: *All residents on each unit will be monitored by visual checks at least every two hours or may be provided more intensive monitoring every hour; *Special units will not be left unattended at any time; -Documentation: All documentation of face checks, one on one, or other intensive monitoring will be done in electronic monitoring. Review of the facility's Elopement Protocol, revised on 1/19/22, showed: -Purpose: An elopement will be defined as anytime a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown; -Procedure: The first person aware of an elopement will call a Code [NAME] (this is the alert that a resident is missing and staff need to start a search for that resident) to the area of the believed elopement, if known; -If the resident is believed to possibly still be inside the facility, the first person to be aware of the missing resident is to page for all units to search room to room for the resident. All rooms, closets, bathrooms and work areas are to be searched; -If the resident has in fact left the facility, notify the resident's family or guardian. The person to notify the family or guardian will be designated by the Administrator; -The facility will notify the local police; -The Charge Nurse on duty will initiate facility grounds search; -Notification of state agencies will be at the discretion of the Administrator/designee. Review of the facility's Smoking Safety Regulation policy, revised on 6/29/23, showed: -The facility will follow all smoking regulations; -The facility will provide direct supervision for smoking by patients classified as not responsible. Review of the B Hall Smoke Break Checklist, in use at time of the elopement, showed: -Only seven residents at a time can smoke; -Must be two staff members present in order to conduct smoke break, one on the hall and one in the smoke area during smoke break; -A column with smoke break times, showed 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M. listed; -A column with 100% head count completed and Yes/No listed adjacent to each smoke time; -A column with a line for staff initials adjacent to each smoke time. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/19/23, showed: -admitted [DATE]; -Cognitively intact; -Wandering: Not exhibited; -Independent in self-care tasks; -Diagnosis of schizophrenia. Review of the elopement assessment, dated 10/31/23, showed: -History of elopement at home: Yes; -History of attempted leave of the facility without notifying staff: Yes; -Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes; -Wanders: Yes; -Wandering behavior a pattern or goal directed: Yes; -Wanders aimlessly or non-goal directed: No; -Wandering behavior likely to affect the safety or well-being of self/others: Yes; -Wandering behavior likely to affect the privacy of others: No; -Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No; -Problem: Risk for Wandering/Elopement Identified; -Clinical Suggestions: Review current medication regimen. Monitor location frequently. Review of the resident's care plan, dated 11/5/23, showed: -Problem: Resident had a long history of mental illness and frequent psychiatric hospital admissions related to Schizophrenia; --Interventions: Pharmaceutical (medications) interventions as needed; -Problem: Risk for harm. Self directed or other directed; --Interventions: Administer medications as prescribed; -Problem: Resident had a history of aggressive behavior towards others; --Interventions: Administer medications as ordered. Monitor/Document/Report; -Problem: Resident was not allowed to come off unit and dine in dining room for lunch except on days when the Administrator is present in the building/Resident was not allowed to go out with activities for any reason related to high risk for elopement per guardian's request; --Interventions: Follow guardian's restrictions as indicated and continue to monitor whereabouts frequently. Notify guardian of any changes along with physician; -Problem: Resident is high risk of elopement due to elopement from the facility on 8/27/22. Resident resides on special care unit; --Desired Outcome: Resident will be monitored closely and remain safe. Resident will not elope from facility; ---Interventions: Monitor resident whereabouts every hour and document that you are aware he/she is safe. Inform charge nurse immediately of any attempts to exit the unit or facility unsupervised. Resident resides on a locked unit to provide protective oversight. Staff to complete hourly face checks; -Problem: Resident had an episode of elopement from facility and returned on 4/30/23; --Desired Outcome: Resident will be located by staff/Police department safely; --Interventions: One on one for four days, new orders per psych, staff to continue face checks per protocol. Review of the resident's hourly face checks, showed: -On 12/8/23, a face check documented at 3:30 P.M. Observation of camera footage and interview with the Administrator on 12/11/23 at 2:15 P.M. showed: -On 12/8/23 at 9:47 P.M., three staff members gathered at the back of B hall. Several residents stood in the area in front of the back door waiting to go outside to smoke; -One of the staff members opened the door and began to light the cigarettes for the residents as they went outside; -The Administrator pointed out Resident #1 and said he/she was dressed in a coat and boots. The administrator said this was different from the earlier times the resident went out to smoke when he/she wore flip flops and a sweater; -All of the staff members stayed inside at the table while the residents went outside. There were more than 10 residents outside at this time. The residents continued to come to the back door and staff would light their cigarettes and allow them to go outside unsupervised. The three staff members eventually got up one by one and went out the back door, leaving the hall unsupervised; -The smoke break lasted approximately 20 minutes. During this time, residents wandered back one by one into the facility. Other residents wandered from the hall to the back door area; -Approximately 20 minutes after the smoke break began, the last staff member came back in. The unidentified staff member shut the door. The resident was not observed returning into the building; -There were no obvious face checks completed after residents came back into the facility after the smoke break. Review of the resident's hourly face checks, showed: -On 12/9/23, face checks documented at 1:31 A.M., 1:34 A.M., 3:08 A.M., 4:21 A.M., 5:14 A.M., 5:42 A.M., and 9:50 A.M. Review of the resident's progress notes, showed on 12/9/23: -At 8:10 A.M.: Staff received hand over report from the night shift nurse that the resident was not seen in his/her room. Staff checked all the rooms and a search was done throughout the building. Staff called the resident's guardians and left a voicemail; -At 2:05 P.M.: The resident was noted to be missing at 7:10 A.M. to 7:15 A.M. The day shift nurse and Director of Nursing (DON) were made aware during shift change. A code white was called. An investigation was started. Facility staff searched for the resident. They were unable to locate him/her at this time. The nurse was unable to locate the guardian after multiple attempts. The police filed a missing persons report. Review of the facility's self-report investigation, dated 12/9/23, showed: -Summary of incident: The resident was noted to be missing by 7:00 A.M. to 3:00 P.M. staff on 12/9/23. Review of camera footage showed the resident last seen on 12/8/23 at 9:45 P.M., going out the door of the smoke patio for a designated smoke break on B hall. The resident did not come back into the facility from the smoke break. At approximately 7:15 A.M., the DON was notified of the missing resident. The DON immediately notified the Administrator. The facility initiated a code white and started a search for the resident immediately. The police were notified. The resident was still missing. The police have a missing person report initiated and they are looking for the resident. Staff failed to follow the following policy and procedures: Failed to follow residents during smoke break times, failed to ensure the residents were all accounted for before and after smoke break times, and failed to complete face checks per policy and procedure; -Written statement by Hall Monitor (HM) K dated 12/9/23, showed the last time he/she saw the resident was when he/she went on break at 8:10 P.M.; -Written statement by HM M dated 12/9/23, showed he/she worked from 11:00 P.M. to 7:00 A.M. on B Hall and he/she did not do his/her face checks and did not see the resident; -Written statement by HM J, undated, showed he/she was on B Hall from 3:00 P.M. to 7:00 A.M. and last saw the resident around 8:00 P.M. He/She was no longer on the hall starting at 10:00 P.M., because he/she was called off the hall. During an interview on 12/10/23 at 3:00 P.M., HM M said he/she worked 11:00 P.M. to 7:00 A.M. that night. When he/she got to work, he/she completed rounds with the other staff. When he/she did not see the resident, HM M thought the resident was in the restroom. HM M got busy mopping and cleaning the halls and did not make any more checks. HM M documented he/she made the checks, because he/she thought the resident went back to bed. HM M knew he/she was supposed to do physical face checks and document these checks. No one on the earlier shift said anything about the resident missing. HM H helped search for the resident when he/she heard the resident was missing. He/She was shocked when the Administrator said the resident had been gone since the night before. During an interview on 12/17/23 at 12:30 P.M., HM J said he/she worked 3:00 P.M. to 7:00 A.M. the night the resident eloped. He/She had only been a HM for about two months. He/She knew staff were supposed to go out with the residents when they smoked, but did not know the person who lit their cigarettes was supposed to supervise. The Administrator did not tell him/her that until after the incident. It was not in the policy. The other two staff he/she was working with said they would supervise the residents outside if he/she lit the cigarettes. So, he/she lit all the cigarettes and then they let the residents go outside by themselves. HM J finally got up and went outside with the residents and then the other staff went outside too. They left the residents inside unsupervised. He/She knows they should not have let more than seven residents out at one time. It was the end of the night. As one resident came back in, another resident could go out. They were not paying good enough attention that night and more than seven residents were outside. They were supposed to count them when everyone came back in. The DON called HM J off the floor right at the end of the smoke break so he/she did not make a count of all the residents when they came back in. HM J did not know the resident did not come back into the building. HM J agreed to work the double shift and his/her co-workers agreed to do the checks. He/She did not have a working code for the app to document the face checks. There was some kind of technical issue and they were still trying to work it out. The staff told him/her to use someone else's code, but he/she won't do it because that would be fraudulent documenting. HM J thought his/her co-workers were making the checks, because he/she was getting up and walking down the hall. HM J should have made face to face checks himself/herself. Observation on 12/10/23 at 12:15 P.M., of the B Hall outside smoke break area, showed a large patio area bordered by a large wooden fence. To the left of the door, the patio led to a pathway that ran along the side of the building. The pathway ended at a gate that was locked. The fence from the door to the gate was approximately 12 feet in height. To the right of the door, the pathway ran around the building into a large open area that was bordered by the fence and ended at a gate with a lock. The height of the fence varied in different areas from approximately 9 feet to 12 feet. Some of the boards of the fence, including the area around the gate, were broken or missing. There was a table and several chairs on the patio. There were several chairs throughout the area on both sides of the patio, in the yard. Neither area beside the building could be seen from the B hall door. During an interview on 12/11/23 at 1:45 P.M., the DON said he/she came in to work that night because a nurse had gone home. He/She called HM J off the hall around 10:10 P.M., but sent him/her right back and told him/her to make his/her hourly face checks. He/She did not make checks on that hall because he/she was working on an investigation and managing the halls for the nurse that left. She did not find out about the missing resident until about 7:10 A.M., when a staff member told her they might have a code white. She told staff to do a head count, at which time they realized the resident was missing. They searched the perimeter of the building and some of the staff got in their cars and searched the immediate area. When they could not find the resident, she notified the Administrator and the police. She interviewed the night staff who admitted to not making checks on the resident throughout the night. She viewed the camera footage and saw the resident go out for the 10:00 P.M. smoke break and did not see him/her return. The staff did not make their face checks even though she reminded them to do so several times during the night. The night staff have to lay eyes on the residents and make sure they are breathing. This may mean they have to talk to the resident or turn on the lights. She told the oncoming nurse to notify the resident's physician and guardian. During an interview on 12/15/23 at 10:00 A.M., the resident's guardian said no one at the facility contacted her regarding the resident's elopement. She called and spoke to the administrator on 12/14/23 and was not told about the elopement. This was concerning as the resident had eloped from the facility before and this was why he/she was on the locked unit. The facility had contacted him/her recently about the resident refusing his/her medication, but there was no note about the elopement. The resident could be a danger to himself/herself if not on his/her medication and unsupervised. The resident was hyperreligious and could be aggressive toward others if provoked. The staff should have been making hourly face checks on the resident and should not have allowed the resident to go outside to smoke unsupervised. During an interview on 12/10/23 at 12:20 P.M., HM N said when there are two staff on the unit, one is supposed to stay inside with the residents who do not smoke and one is supposed to stay outside and supervise the residents who do smoke. They are only supposed to let seven residents out to smoke at a time. When one comes back in then another one can go out. They are supposed to do a head check when everyone is done smoking. This is documented on the smoke break checklist. They are supposed to fill this out on every smoke break and turn it in at the end of the day. B Hall is a special care unit and they are supposed to do hourly checks on all of the residents. They have an app on their phones and they enter the checks into their phones as they make them. This goes into the resident's electronic chart. The residents do not have smoke breaks on the night shift. The staff usually just make beds, fill ice buckets, make face checks and help those residents who might need a little extra help. Staff are supposed to go in the resident's room and look at the resident. There is usually enough light from the hallway to see the resident or staff can call their name. Staff check to see if they are breathing and document the check in the app. During an interview on 12/11/23 at 3:00 P.M., the Administrator said staff did not follow policy and protocol prior to and after the resident's elopement. They allowed more than seven residents to go out during the smoke break. Staff allowed the residents to go outside unsupervised and left the hall unsupervised when they all went outside. Staff did not make a head count when the residents returned from the smoke break and did not fill out a smoke break check list for the entire shift. They did not make hourly face checks or document they made hourly face checks for the rest of the 3:00 P.M. to 11:00 P.M. shift and they did not make face checks on the 11:00 P.M. to 7:00 A.M. shift. During an interview on 12/11/23 at 10:00 A.M., the resident's physician said he had not been notified the resident was missing from the facility. The resident could be a danger to himself/herself if he/she was out on the street. If the resident did not get his/her medication he/she could start having hallucinations. If the resident was on a secured unit the staff should have been making regular checks on him/her. MO00228538 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observations, interviews, record reviews, facility policy reviews, and review of a manufacturer's user's guide, the facility failed to ensure a multi-use blood glucose meter was cleaned and disinfected after each use for three (Residents #4, #28, and #35) of six sampled residents reviewed for medication administration. The facility also failed to ensure staff did not touch medication with their bare hands for one (Resident #24) of six sampled residents reviewed for medication administration. Further, the facility failed to ensure staff washed their hands before and after gloves were removed during wound care for one (Resident #211) of twenty seven sampled residents. In addition, the facility failed to follow their infection control policy when staff failed to complete the second step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests for five employees. The census was 108. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 Infection Control at a scope and severity of J. The IJ began on 09/20/2023 when Licensed Practical Nurse (LPN) #1 failed to clean and disinfect the blood glucose meter between use for Residents #4, #28, and #35. The previous Administrator (Administrator #2), the current Administrator (Administrator #3), and the Facility Nurse Advisor (FNA) were notified of the IJ on 09/20/2023 at 6:25 P.M. The IJ was removed on 09/21/2023. Noncompliance remained at the lower scope and severity of D, isolated harm that was not immediate jeopardy. Findings included: 1. Review of the EvenCare G2 Blood Glucose Monitoring System Users Guide, with a copyright date of 2015, indicated, Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Further review of the user's guide specified, Cleaning and Disinfecting Your Meter and Lancing Device 1. Wash hands with soap and water and dry thoroughly. 2. Inspect for blood, debris, dust, or lint anywhere on the meter or lancing device. 3. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. 4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Per the user's guide, one of the validated disinfecting wipes listed was Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes. The user's guide further specified, Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. 5. Wipe meter dry or allow to air dry. 6. Wash hands with soap and water and dry thoroughly. Review of a facility policy titled, Cross Contamination of Equipment, with a revision date of 06/29/2023, indicated, The purpose of this policy is to define procedures to prevent the spread of infection/diseases when utilizing multiple use equipment. Procedure: 1. Examples of multiple use equipment include: a. Pulse-Oximetry b. Accucheck [blood glucose meter] machine c. Thermometer d. Scissors 2. Multiple use equipment will be cleaned after each use and allowed to dry before being placed back into its place of storage. 3. All multiple use equipment will be cleaned with a disinfectant wipe, bleach wipe and/or as recommended by the Manufacturer. Review of a facility policy titled, Handwashing, with a revision date of 06/29/2023, indicated, To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infection. The policy specified, 2. The use of gloves does not replace handwashing. 3. Hands are to be washed before and after gloving. 4. A waterless antiseptic solution may be used as an adjunct to routine handwashing. 5. Appropriate ten (10) to fifteen (15) second handwashing must be performed under the following conditions: a. Whenever hands are obviously soiled; b. Before performing invasive procedures; c. Before preparing or handling medications; d. After having prolonged contact with a resident; e. After handling used dressings, specimen containers, contaminated tissues, linens, etc.; f. After contact with blood, body fluids, secretions, excretions, mucous membranes, or broken skin; g. After handling items potentially contaminated with a resident's blood, body fluids, exertions and secretions; h. After removing gloves. A review of Resident #28's Admission Record indicated the facility admitted the resident on 08/18/2022 with a diagnosis to include type 2 diabetes mellitus. Further review of the Admission Record revealed the resident received a diagnosis of acute hepatitis C on 04/06/2023. A review of Resident #28's Order Summary Report revealed a physician's order, dated 09/20/2023, that directed staff to conduct finger stick blood glucose checks twice a day related to diabetes mellitus. A review of Resident #35's Admission Record indicated the facility admitted the resident on 12/29/2022 with a diagnosis to include type 2 diabetes mellitus. A review of Resident #35's Order Summary Report revealed a physician's order,, dated 09/20/2023 that directed staff to conduct fingerstick blood glucose checks four times a day related to diabetes mellitus. A review of Resident #4's Admission Record indicated the facility admitted the resident on 09/28/2012 with a diagnosis to include type 2 diabetes mellitus. A review of Resident #4's Order Summary Report revealed a physician's order, dated 09/20/2023, that directed staff to conduct fingerstick blood glucose checks with meals related to diabetes mellitus. Observation on 09/20/2023 at 8:05 A.M., showed Licensed Practical Nurse (LPN) #1 obtained a blood glucose level for Resident #28. LPN #1 placed the blood glucose meter on top of the medication cart and did not clean or disinfect the machine. At 8:18 A.M., LPN #1 was observed to wipe the top of the blood glucose meter with an alcohol wipe. LPN #1 then obtained a blood glucose level for Resident #35 using the same blood glucose meter. At 8:24 A.M., LPN #1 wiped the blood glucose meter with a disinfectant wipe; LPN #1 did not allow the blood glucose meter to dry before she checked the blood glucose level of Resident #4. During an interview on 09/20/2023 at 9:31 A.M., LPN #1 stated the blood glucose meter should be cleaned with bleach wipes after every use. LPN #1 stated she thought the dwell time (time spent in the same position) was 10 or 20 seconds, but she was not sure. During an interview on 09/20/2023 at 9:28 A.M., Registered Nurse (RN) #19 stated when a resident's blood glucose level was obtained, she would put on gloves, clean the resident's finger with an alcohol pad, stick the resident's finger with a lancet to retrieve the blood sample. Per RN #19, she would change her gloves if she needed to give insulin. RN #19 stated she would clean the blood glucose meter with an antiseptic wipe after every use and allow the blood glucose meter to air dry. During an interview on 09/20/2023 at 9:40 A.M., Resident Care Coordinator (RCC) #15 stated the blood glucose meters were to be cleansed and/or disinfected with a disinfectant between each resident. She stated gloves should be worn and hand sanitizer or hand washing should occur between glove changes. During an interview on 09/20/2023 at 10:13 A.M., RN #19 confirmed the blood glucose meters used by the facility were Even Care G2 and the wipes used for cleaning the machines were Micro-Kill One germicidal wipes. During an interview on 09/23/2023 at 8:53 A.M., Director of Nursing (DON) #51, the current DON stated that when a nurse performed a blood glucose check, the nurse should perform hand hygiene, gather the needed supplies, and set up clean and dirty fields. She stated the blood glucose meter should be cleaned and then the nurse should remove their gloves, conduct hand hygiene, and then re-glove. DON #51 stated the nurse should clean the resident's finger with alcohol and let the resident's finger dry and then obtain the sample. She stated the nurse should remove their gloves and put on new gloves, clean the blood glucose meter with a disinfectant wipe and place the meter on the clean field to air dry. She stated that once it was dry, then it would be put in the bag that was used for storage. During an interview on 09/23/2023 at 11:51 A.M., Administrator #3, the current Administrator, stated cleaning and disinfecting blood glucose meters and obtaining blood glucose levels should be performed according to the facility policy. 2. During medication administration observation on 9/20/2023 at 8:08 A.M., Certified Medication Technician (CMT) #17 removed one capsule of Vitamin D3 from a bottle with her bare hand, CMT #17 then placed the capsule in a medication cup to administer to Resident #24. During an interview on 09/22/2023 at 12:13 P.M., Resident Care Coordinator (RCC) #15 stated nurses and CMTs should not touch medications with their bare hands. During an interview on 09/23/2023 at 8:53 A.M., Director of Nursing (DON) #51, the current DON, stated medications should not be touched with bare hands and if they were, the medication should be discarded. DON #51 stated if CMT #17 touched the medication, the medication should have been discarded. 3. Review of a facility policy titled, Handwashing, with a revision date of 06/29/2023, indicated, To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infection. The policy specified, 3. Hands are to be washed before and after gloving. During wound care observation on 09/21/2023 beginning at 6:42 P.M., Registered Nurse (RN) #19 did not wash her hands before she put gloves on to provide wound care for Resident #211. During wound care, RN #19 removed her gloves three times, and each time she did not wash her hands before she put on new gloves. During an interview on 09/22/2023 at 12:13 P.M., Resident Care Coordinator (RCC) #15 stated hand hygiene should occur before gloves are put in and in between glove changes. During an interview on 09/23/2023 at 8:53 A.M., Director of Nursing (DON) #51, the current DON, stated hand hygiene should be performed before putting on gloves and in between every glove change. 4. Review of the facility's Tuberculosis Testing policy, revised dated 6/29/23, showed the following: -Purpose: To ensure each resident and employee of the facility is tested for TB after entering the facility to prevent the spread of the infection; -Procedure: 1. Upon hire, a new employee will receive a two-step purified protein derivative skin test (PPD, used in a skin test to help diagnose TB). Each employee will also have an annual one step TB test to ensure that any possible infections can be triggered proactively to prevent further spread; 2. If the new hire has had a positive reaction history to a previous TB test, a chest x-ray will be done. If the resident has a history of positive TB test, the physician will be notified and a chest x-ray will be done; 3. All TB test and chest x-ray records will be kept on file in the employee files. 5. Review of Staff Member A's employee file showed the following: -Hire date: 3/29/23; -First step: 3/29/23, Read date: 3/31/23; -No documentation of a second step. 6. Review of Staff Member B's employee file showed the following: -Hire date: 5/10/23; -First step: 5/10/23, Read date: 5/12/23; -No documentation of a second step. 7. Review of Staff Member C's employee file showed the following: -Hire date: 6/7/23; -First step: 6/7/23, Read date: 6/9/23; -No documentation of a second step. 8. Review of Staff Member D's employee file showed the following: -Hire date: 8/16/23; -First step: 8/16/23, Read date: 8/18/23; -No documentation of a second step. 8. Review of Staff Member E's employee file showed the following: -Hire date: 8/24/23; -First step: 8/24/23, Read date: 8/26/23; -No documentation of a second step. During an interview on 9/26/23 at 11:22 A.M., the Administrator said she expected the TB policy to be followed as written. The Administrator said the DON should monitor the employee TB tests. The Administrator said the DON were new and just started in September 2023. The Administrator did not know there was an issue with the second step TB test.

Based on interview, record review, and facility document and policy review, the facility failed to ensure one (Resident #363) of ten residents were properly supervised to prevent an accident. The facility failed to ensure Resident #363, who had a diagnoses of suicidal ideation and schizophrenia, was supervised with a razor, which resulted in Resident #363 cutting him/her self with the razor, causing injuries to the neck and wrists. The facility census was 108. Findings included: A facility policy titled, Behavioral Emergency Policy, revised on 01/05/2023, indicated, It is the Policy of [the facility] to provide a safe environment and provide humane care to all Residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or Resident to Resident altercations the following steps will occur: 4. The Physician will be notified of the licensed nurse/Team Leader/RCC [Resident Care Coordinator] assessment and orders will be followed. 5. The licensed nurse/Team Leader/RCC will follow all physician orders and will notify the Management Team Member on call regarding the new orders from the physician. 7. The ADMIN [Administrator]/DON [Director of Nursing]/Designee will complete an Administrative Investigation within 24 hours of the behavioral emergency. A review of Resident #363's Admission Record showed the facility admitted Resident #363 on 05/21/2018 with diagnoses that included suicidal ideations, mild intellectual disabilities, unspecified psychosis, major depressive disorder, anxiety disorder, and paranoid personality disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2021, showed Resident #363 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of Resident #363's Care Plan, initiated on 05/28/2021, showed Resident #363 admitted with a diagnosis of suicidal ideations. The care plan instructed staff to administer medications as ordered; provide behavioral health consultations; and monitor, document, and report any risk for harm to the resident, a suicidal plan, risky actions, or any intentional harm or attempt to harm self. Review of the Care Plan showed the resident had a history of behavioral challenges that required protective oversight in a secure setting due to a diagnosis of suicidal ideations, schizophrenia, depression, psychosis, anti-social personality disorder, and a history of polysubstance abuse. A review of an Administrator/RN [Registered Nurse] Investigation, dated 11/29/2021, showed on 11/29/2021, Resident #363 requested a razor to shave. Certified Nurse Aide (CNA) #38 was instructed the resident needed to be supervised while using the razor. CNA #38 stated she was stopped by another resident as she and Resident #363 walked to Resident #363's room. When CNA #38 arrived at Resident #363's room, the resident was in the bathroom with the door closed. CNA #38 pushed the bathroom door open and found Resident #363 with blood on their face and on other surfaces in the bathroom. Resident #363 then became physically violent toward CNA #38. Resident #363 then ran toward an exit door, which Resident #363 kicked open to leave the facility. The police were called, and resident was recovered at an apartment building next door. The resident had injuries to the neck and wrists. Resident #363 was transferred to the hospital for treatment. A review of CNA #38's Employee/Witness Statement, dated 11/29/2021, revealed CNA #38 had requested a razor from the nurse, who instructed CNA #38 that she needed to supervise Resident #363 with the razor. CNA #38's statement indicated she was stopped by another resident while following Resident #363 to their room. CNA #38's statement indicated she turned off another resident's light and a resident asked for a cover. When she arrived at Resident #363's room, the resident was in the bathroom with the door closed and the resident held the door closed. CNA #38 stated she finally pushed the door open, and when the CNA started to go in the bathroom, Resident #363 became violent and tried to pull her in the bathroom. CNA #38 was able to pull away, ran down the hallway, and yelled for help. Resident #363 chased after the CNA and jumped on the CNA in the hallway, pulling the CNA's hair and ripping her shirt. The CNA got up and ran into another room. The CNA's statement showed Resident #363 bled and yelled words like kill and other unintelligible words. Attempts to reach CNA #38 on 09/20/2023 at 12:57 P.M. and 09/21/2023 at 10:35 A.M., were unsuccessful. CNA #38 no longer worked at the facility. A review of Licensed Practical Nurse (LPN) #40's witness statement, dated 11/29/2021, showed CNA #38 had asked her if Resident #363 could shave themselves. LPN #40's statement showed she had advised and educated CNA #38 not to leave the resident alone while shaving. LPN #40's statement showed 15 minutes later, she observed CNA #38 and Resident #363 in the hallway and separated them. LPN #40 then called the police. In an interview on 09/19/2023 at 4:27 P.M., LPN #4 stated Resident #363 had never displayed any behaviors prior to the incident. LPN #4 stated she was not there when the incident occurred, but was completely surprised when she was notified of the incident. LPN #4 stated Resident #363 had always been very stable, independent, and had never exhibited any verbal or physical aggression. In an interview on 09/20/2023 at 2:28 P.M., Certified Medication Technician (CMT) #17 stated residents could not have razors in their rooms. CMT #17 stated if a resident requested a razor to shave, the CNA or CMT had to stay with the resident and observe them shaving. In an interview on 09/20/2023 at 3:31 P.M., CNA #18 stated residents were not allowed to have razors. If a resident wanted to shave, the CNA was to get the disposable razor from the nurse and supervise the resident while the resident was shaving, then return the razor to the nurse's station for disposal. In an interview on 09/21/2023 at 11:30 A.M., Registered Nurse (RN) #19 stated residents were not allowed to have razors. If a resident wanted to shave, the CNA had to come to the nurse to get a razor out of the medication room and sign out the razor. The nurse reminded the CNA to monitor the resident at all times while shaving. The CNA would return the razor to dispose of it in the sharp's container. In an interview on 09/21/2023 at 9:43 A.M., the previous Administrator, Administrator #2, stated he could not locate any additional information for the investigation of the incident that involved Resident #363. Administrator #2 stated the DON that was at the facility during that time was no longer there. In a telephone interview on 09/20/2023 at 5:31 P.M., DON #34, a previous DON, stated she was the DON at the facility for three to four months and was out sick during some of that time. DON #34 stated she could not recall the incident with Resident #363 cut themselves. In an interview on 09/21/2023 at 4:21 P.M., DON #51, the current DON, stated residents should never be left alone with a razor. DON #51 stated staff were instructed to always supervise the resident when a resident was shaving. Staff were to obtain a razor from the nurse and return it to the nurse to be discarded in the sharps container when the resident was done shaving. In an interview on 09/21/2023 at 4:36 P.M., Administrator #3, the current Administrator, stated residents should never have razors while unsupervised. The Administrator stated staff should always stay with the resident and assist the resident. Staff should put the razor in the sharps container when the resident was finished shaving. The Administrator stated all staff should be aware of the requirement, because of the population the facility served, and they must take supervision with razors very seriously.

Based on observation, interview and record review, the facility failed to prevent abuse between staff and a resident against one resident (Resident #1). The facility failed to follow their policies for behavioral emergencies and abuse. Facility staff failed to provide safe and humane care and endangered the resident's mental and physical well-being. Facility staff also failed to prevent another resident (Resident #2) from kicking Resident #1 in the head while staff held the resident on the floor. The facility also failed to ensure staff did not employ chemical restraints in an effort to punish the resident when Nurse A injected an antipsychotic medication without approval from the resident's physician, as a means of discipline. The resident sustained multiple bruises, scratches and a hematoma (a pool of mostly clotted blood which collects due to a broken blood vessel damaged by injury or surgery) to the left forehead as a result. Staff involved in the incident did not report the abuse to the administrator, in accordance with the facility policy. The resident was hospitalized and diagnosed with strangulation/suffocation, trauma and anemia. The census was 111. The administrator was notified on 8/10/22, of the immediate jeopardy (IJ) past non-compliance, which occurred on 7/6/22. The facility provided training and in-services for all staff regarding the facility's abuse and neglect policy as well as approved CALM techniques for de-escalation and performing a five-man takedown and updated care plans. Two staff were terminated. The IJ was removed and corrected on 7/6/22. Review of the facility's policy titled, Abuse and Neglect Policy, revised 9/17/21, defined physical abuse as purposefully beating, striking, wounding or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior. The facility is committed to protecting its residents from abuse by anyone including, but, not limited, to facility staff, other residents, consultants, volunteers and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices such as dealing with aggressive residents, reporting allegations without fear of reprisal, recognizing signs of burnout, frustrations or stress that may lead to abuse and the definition that constitutes abuse, neglect and misappropriation of property. During orientation of new employees, the facility covers topics including: sensitivity to resident rights and resident needs and what constitutes physical, sexual, verbal and mental abuse, staff obligations to prevent and report abuse, neglect and theft, how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that protects both residents and staff, how to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents. Employees and vendors are required immediately to report any occurrences of potential mistreatment including alleged violations, mistreatment, neglect, abuse, sexual assault and injuries of unknown source and misappropriation of resident property they observe, hear about or suspect to a supervisor or the administrator. Review of the facility's policy titled, Behavioral Emergency Policy, revised 2/26/21, showed the purpose of the policy was to provide safe treatment and humane care to the resident in a behavioral crisis to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure the resident is not being coerced, punished or disciplined for staff convenience. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement or resident-to-resident altercations, staff was to take the following steps: The licensed nursing staff will assess the resident who is exhibiting such behaviors. Ensuring the safety of the resident and others is the first priority. A one-to-one monitoring of the resident was to be initiated at this time, under the direction of the licensed nurse. Behavior emergency guidelines: There are only two reasons that staff will utilize approved CALM hold techniques and release of any resident who poses imminent danger to self or others: when a resident is in imminent danger of harming themselves or when a resident is in imminent danger of harming others. A Code Green can be proactive in ensuring that enough qualified staff are present and to warrant the potential need of utilizing approved CALM hold techniques. Approved CALM hold techniques are never utilized for punitive reasons, discipline or for staff convenience. Residents are never threatened by the use of CALM as a scare tactic or a threat by staff. The central purpose of calling a Code Green is recognizing that the resident has become or has the potential to become a danger to themselves or someone else. Calling a Code Green also ensures that all staff is readily available to utilize approved CALM hold techniques if necessary. 1. Review of Resident #1's preadmission screening and resident review (PASRR, a federally mandated assessment to help ensure individuals are not inappropriately placed in nursing homes for long term care), dated 8/11/17, showed the following: -Diagnoses of schizophrenia catatonic type (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior due to catatonia, they may move their body erratically or not at all for minutes, hours or even days and may experience brief periods of unexplained excitability or defiance), mild mental retardation (mild cognitive and neuromuscular deficits that cause some interference with learning, physical coordination or social skills), high blood pressure and obesity; -The resident is not delusional when speaking with others, but has a baseline of delusional themes; -The resident frequently misperceives others' statements and behaviors; -Inappropriate responses/interactions: bizarre statements, oppositional, wandering and isolation; -Persistent problems with oppositional/distracted thoughts, poor concentration, agitation, poor impulse control, verbal aggression and exposing him/herself to others. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/22, showed the following: -Cognitive summary score -; It was not completed. Staff left the cognitive assessment questions blank. -No behaviors; -Diagnoses included seizure disorder, anxiety disorder, depression, catatonic schizophrenia, schizophrenia (is a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), mild intellectual disabilities, unsteadiness on feet and generalized muscle weakness. Review of the resident's care plan, did not identify any behavioral problems or interventions including the use of antipsychotic medication injections to address behaviors. Review of the resident's July 2022 physician's orders, showed the following: -4/12/22, Lorazepam 0.5 milligrams (mg), give 1 tablet one time a day related to anxiety disorder unspecified; -4/12/22, Ziprasidone HCL 80 mg, give 1 tablet two times a day related to anxiety disorder unspecified, catatonic schizophrenia; -4/13/22, may send to hospital for evaluation and treatment for behaviors. Review of the resident's progress notes, dated 5/22/22 at 3:28 P.M., showed the resident showed an indicator of delirium through inattention (easily distracted, difficulty following what was said). Review of the resident's progress notes, dated 7/6/22 at 7:36 A.M., showed the charge nurse was doing rounds at the time the resident was standing in the hallway outside of his/her room and he/she demanded the charge nurse get out of his/her room. The nurse exited the room and the resident proceeded to request that the nurse be his/her girlfriend. The nurse tried to educate the resident, who became verbally aggressive and tried to approach staff. Code Green was called, during which the resident hit the nurse in the chest. Staff administered the resident's as needed (PRN) Olanzapine (antipsychotic) 10 mg intramuscular (IM). The resident calmed down and apologized to staff. He/she refused medical treatment for the hematoma on his/her forehead. The physician, administrator and director of nursing (DON) were all aware. Further review of the resident's July 2022 physician's orders, showed an order, dated 7/6/22, for Olanzapine Solution Reconstituted 10 mg, inject 10 mg intramuscularly (IM) every 6 hours PRN for anxiety related to anxiety disorder. Review of the resident's care plan, updated 7/6/22, showed the following: -The resident has impaired cognitive function/dementia/impaired thought processes related to mild intellectual disabilities; -The resident has a behavior problem. He/she has a history of impulsive behaviors related to anxiety. The resident becomes upset, when his/her family does not visit, unless he/she gets a soda when he/she demands or when he/she is not allowed to smoke beyond designated smoke times. The resident threatens staff with physical harm. Staff will call code greens and evaluate the need for CALM techniques; -The resident is at risk for injury to self and others related to behaviors of verbal aggression. -The care plan did not include the use of antipsychotic medication injections to address behaviors. Review of Nurse B's written statement, dated 7/7/22, showed Nurse B was doing morning rounds on 7/6/22 at around 6:00 A.M., when he/she entered the resident's room. He/she screamed at Nurse B to get out of his/her room and told Nurse B not to touch the door. Then the resident asked for coffee. Nurse B explained that coffee would be served shortly with breakfast. The resident cursed at Nurse B, because he/she asked if Nurse B could be his/her girlfriend and Nurse B said no. The resident said he/she was going to punch Nurse B in the face for being stupid. Staff heard the outburst and came to calm down the situation. The resident told staff that he/she did not hit men, but did hit women. The resident then swung on the staff member and Code Green was called as the resident was being taken down. The resident punched Nurse B in the chest and grabbed Nurse B's shirt. While on the ground, the resident began spitting on staff, was still agitated and fighting to get up. Nurse B had another person hold the resident, while Nurse B got the PRN injection. The resident was still very angry. Other residents started to gather around the resident, who was then taken into his/her room and held until he/she calmed down. Review of Certified Nurse Aide (CNA) A's written statement, dated 7/8/22, showed CNA A was performing face checks (briefly observing a resident in order to ensure he/she is breathing, comfortable and safe), on 7/6/22 at around 6:00 A.M., when the resident got mad at Nurse B because the resident had been up all night and wanted to smoke. So, the resident got loud with the nurse. That was when CNA A got up. The resident said he/she was going to hit Nurse B and tried to go around CNA A to do so. So, we took the resident down. The resident got mad and spit on CNA A. Resident #2 came and kicked the resident in the head. Review of CNA C's undated written statement, showed around 6:00 A.M. on 7/6/22, he/she heard a loud commotion, stepped out of a room on the unit and saw the resident in Nurse B's face screaming and cursing at him/her. The Hall Monitor (CNA A) come up and got in the resident's face screaming, That's a female. You don't hit no woman. The resident started walking down the hall. The hall monitor started walking behind the resident, telling the resident to go to his/her room. CNA C looked away for a moment, thinking it was over. When CNA C looked back, he/she saw the resident and hall monitor somewhat tussling. The hall monitor took the resident down by the back of the resident's shirt. When the resident landed on the floor, CNA C, Nurse B and CNA D helped the hall monitor hold the resident down. The resident continued to be aggressive. Another resident came and stomped the resident (Resident #1) in the face. Staff got the other resident away. Nurse B went to get the injection, once Nurse E entered the unit to assist. After the resident was injected with the shot, they proceeded to pick the resident up by his/her arms and legs, took him/her to his/her room and held the resident down, until the resident said he/she would not do it again. CNA C stood by the door, in order to make sure other residents did not enter. CNA C stepped out of the room, to make sure the medication cart was locked. Review of the CNA D's written statement, dated 7/8/22, showed Nurse B and CNA C entered B Hall at about 6:00 A.M. on 7/6/22 with the medication cart. Nurse B and CNA C were talking. The resident was at the door talking and yelling at Nurse B about a woman and saying that he/she was going to hit a woman. Nurse B said, no you're not. CNA A (the other CNA on the unit with CNA D) came down to see what the yelling was about. CNA A approached the resident and asked, why you want hit me? Nurse B yelled to the resident, go to your room. The resident hit Nurse B in the chest. CNA A pushed the resident and twirled the resident to the ground by the right arm. When CNA A got the resident to the floor, CNA A started choking the resident. CNA D and CNA C went to grab the resident's legs. Nurse E came, grabbed the other arm and told CNA A to stop choking the resident. Nurse B got a shot ready, gave it to the resident in the butt and was kicking the resident in the side with his/her foot. CNA C could not control the other leg, due to the resident's excessive movement. The resident almost kicked them in the face, so CNA D helped CNA C with the other leg, by putting CNA D's body weight on both legs. Out of nowhere, a resident came over, spit in Resident #1's face and stomped on Resident #1's head with a foot and ran off. When Resident #1 was almost settled down, Nurse B told the staff members to bring the resident to his/her room. So, they tried to pick the resident up by the arms and legs, and placed him/her face down on the floor in his/her room. Nurse B talked to the resident, while he/she was still in the CALM position arm-arm-leg-leg same spots as before in the hallway. Nurse B asked if he/she was calm and said if he/she calmed down, then they would let him/her go. The resident said he/she was calm. Nurse B instructed them to let him/her up. They released the resident, who went straight to bed. About ten minutes later, the resident quietly came out of his/her room, returned about five minutes later and remained until the CNA's shift was over. Review of Nurse E's written statement, dated 7/7/22, showed when Nurse E arrived on B Hall on 7/6/22 at around 6:00 A.M., after a Code Green was called, the resident was on the floor being held down by staff. Nurse E asked the other residents in the hall to go to their rooms. The resident was jerking, spitting and yelling at staff. Nurse E took Nurse B's place, by holding the resident's right arm. The resident said to let him/her go, so he/she could beat the nurse. The resident was turned onto his/her side and Nurse B administered the IM injection. They held the resident in that position for several minutes on his/her back. The resident continued to yell and threaten Nurse B. Nurse B told staff to take the resident to his/her room. They picked the resident up by the extremities which they were holding and carried the resident to his/her room. The resident yelled to the nurse to stop kicking him/her. Once in his/her room, the resident was held for several minutes in position. The resident yelled that staff was hurting him/her. Nurse E asked if the resident was calm and told him/her to unclench his/her fist. The resident complied and was released. Nurse E left the room. Review of the resident's transcribed statement, collected by the DON and signed by Nurse F, dated 7/6/22, showed the resident said that at around 5:30 A.M. or 6:00 A.M. on 7/6/22, he/she said something to Nurse B. The resident said he/she started a problem for no reason. Nurse B opened the door and came into the hallway and was like in my room or something. The resident said he/she got mad for no reason and yelled for Nurse B to get out of his/her room. Then CNA A came and asked why the resident was yelling at Nurse B. Then, the resident was struggling with CNA A, but did not hit CNA A. The resident was trying to go around CNA A. He/she said, I was thinking like why I did that. I think like something happened. The resident grabbed Nurse B's shirt. He/she was not sure if he/she pushed Nurse B. They took the resident to the floor and then the resident spit in CNA A's face. They were holding him/her down on the floor. Nurse B was holding the resident's throat with one hand and CNA B was holding the resident's throat for about seven to ten seconds. They held his/her neck from the front with him/her facing upward. The resident did not know how he/she got the lump on his/her head and did not feel anyone scratch him/her on the back. The resident said, they were like dragging me. I kicked one in the stomach when I was down. The resident denied hitting Nurse B, saying he/she pulled Nurse B's shirt. The resident kicked one of the staff members (CNA D), who was kind of big and wearing a hat. The resident did not feel abused. He/she said, they did it because of what I did. They had me in my room, twisting and pulling my leg. I said please, please it hurts. Have a little mercy. I promised I would never do it again to a woman. Further review of the resident's progress notes, dated 7/6/22 at 12:00 P.M., showed the administrator went into the resident's room on 7/6/22 at 12:00 P.M. to speak with him/her concerning the incident reported by the nurse at 6:28 A.M. During the conversation, the administrator observed reddened areas to the resident's neck area. He asked the residential care coordinator and the DON to assess the resident's skin. The resident had reddened areas around the front of the neck, a hematoma to the left forehead, a reddened area to the right temple and what appeared to be scratches to the bilateral upper back. The resident denied pain or discomfort. The DON placed a call to the physician and sent the resident to the hospital for treatment and evaluation. At 2:20 P.M., staff documented the arrival of the ambulance and police. At 2:31 P.M., staff documented an assessment of the resident at 12:00 P.M., during which scratches around the neck and back were observed, bruising to the left lower arm, above the right elbow, a lump to the left side of the head and bruising to the right temple. Observation on 7/15/22 at 9:00 A.M., of the silent surveillance footage of Unit B, recorded on 7/6/22 at 7:04 A.M., showed Nurse B and CNA A standing in front of Resident #1's room. CNA A grabbed the resident with his/her right arm across the resident's chest, gripping the left shoulder with CNA A's left hand holding the resident's right arm and pushing the resident backwards, until the resident lost his/her balance and fell down onto his/her buttocks. Resident #2 ambulated towards them. CNA C and CNA D began ambulating towards them as CNA A stood over Resident #1 who was seated on the floor. Nurse B approached Resident #1. CNA A attempted to stop Resident #1 from getting up, via a hand pushing downward on Resident #1's chest. Struggling to stand, Resident #1 grabbed the front of Nurse B's shirt and rose to his/her feet into a crouched position, as CNA A continued to push Resident #1 downward. Nurse B pried Resident #1's hands off of his/her shirt as CNA A pulled the resident backwards onto the floor with Nurse B holding Resident #1's wrists. The resident landed on his/her back with Nurse B and CNA A falling on top of him/her and then moving to restrain him/her. CNA C and CNA D came forward and bent over the resident, reaching down to assist with restraining the resident. The resident's head was sideways on the floor, when Resident #2 rushed forward, lifted his/her right foot high in the air and brought it down forcefully onto Resident #1's head. The staff did not look up at Resident #2 or visibly react to his/her abusing the resident. Resident #2 continued to stand over them with Resident #1's head at his/her feet. Resident #1 continued to struggle, moving his/her arms and legs until CNA C and CNA D moved down to restrain the resident's legs. Resident #2 moved to the opposite wall for a few moments, before turning away and ambulating down the hallway (in the opposite direction of his/her room). Nurse B and CNA A knelt over the resident, each with a hand up at the resident's neck. CNA D knelt on the resident's left arm and leg. Nurse E entered the unit and Nurse B rose up onto his/her haunches, holding the resident's right arm folded across his/her chest. CNA A rose into a crouch, replacing the right hand at the resident's throat with his/her left hand and the right hand moving to hold the resident's right arm. As Nurse E entered the unit, approaching the group on the floor, he/she turned away from the group on the floor to move the medication cart away from a resident. Nurse E turned back to the group on the floor, walked towards and around them and stood up near Resident #1's head for a few moments, as Resident #1 lay motionless on the floor. CNA A moved his/her right hand to the resident's chest. Nurse E walked back around to the resident's right side and as he/she took Nurse B's place holding the resident's right arm, the resident attempted to get up. Nurse B knelt back down and assisted staff in pushing the resident back down onto the floor and restraining him/her. The resident's pants slid down, exposing his/her bare genitals. CNA D placed a hand on the resident's bare left thigh, while attempting to assist CNA C in restraining the resident's right leg. CNA A moved from behind the resident's head to the resident's left side and knelt on the left arm with CNA A's left leg, extending CNA A's right leg out and back while reaching out to grasp the railing along the wall with his/her right hand for balance and then kneeling on the resident's arm with both legs. The resident attempted to free his/her legs, succeeding in lifting the right leg with CNA C holding onto it and nearly losing his/her balance. CNA D stretched out and lay across both of the resident's legs. Nurse B stood, walked to the medication cart and retrieved medication. Resident #1 attempted to move his/her left leg, which was bent and laying off to the side, with CNA D sitting on the inside of the thigh. CNA D forced the leg back down to the floor by pressing his/her bodyweight down on it. Resident #1 lifted the leg and CNA D sat on his/her knee, forcing the leg back down onto the floor, moving to lay on the leg with his/her upper torso along the resident's bare thigh, while CNA C restrained the right leg by leaning forward with both hands on it. The resident moved his/her legs again and CNA D forced the left leg down, then laid back across the resident's torso. Staff pulled the resident onto his/her left side and held him/her there, allowing Nurse B to administer an injection into his/her buttock. Nurse B gestured for staff to take the resident into his/her room. They stood and the resident resisted staff's efforts to lift him/her by his/her arms and legs. Nurse B kicked the resident in his/her bare buttocks and side five times, drawing back a croc (rubber/foam) style shoe clad foot and thrusting it forward, as staff lifted and partially dragged the struggling resident facing downward, with his/her bare genitals exposed and making contact with the floor at times, into his/her room and closed the door. Review of the facility's undated administrative/registered nurse investigation, showed the following: -Per camera footage: It clearly shows that CNA A approached the resident, who did not appear to be physically aggressive, and using an improper CALM technique grabbed the resident around the shoulder area and took him/her to the floor without assistance of any additional staff. It also showed that the resident was struck several times by the feet of Nurse B and another resident. Nurse B allowed staff to use unapproved CALM techniques to transport the resident to his/her room afterwards. A skin assessment showed multiple bruised areas, a hematoma on the head, reddened areas to the throat, a reddened area to the temple, and shoe prints to the resident's bilateral back area. On 7/6/22 at 1:50 P.M., the facility reported the incident to the police department and sent the resident to the hospital for further evaluation and treatment; -Nurse B administered a Zyprexa (brand name for Olanzapine) injection without the directive of the DON or any nursing management; -All evidence pointed to abuse by staff members. It appeared that the resident was deliberately abused. All involved staff members were suspended pending further investigation. CNA A and Nurse B were subsequently terminated. CNA C, CNA D and CNA E received a final written warning, underwent abuse and neglect policy in-service and were re-educated on CALM techniques prior to returning to caring for residents on the floor; -This incident was a result of abuse. Abuse is defined as the purposeful infliction of physical, sexual or emotional injury or harm; -This was a result of neglect. Neglect is defined as failure to provide by those responsible for the care, custody and control of a resident in a facility, the services which are reasonable and necessary to maintain the physical and mental health of the resident, when such failure presents either imminent danger to the health, safety or welfare of the resident or substantial probability that death or severe physical harm would result; -The altercation was not accidental and was preventable. Review of the resident's hospital emergency record and discharge summary, dated 7/6/22, showed following: -The resident presented with bruising to the right side of the throat and right clavicle (collarbone, one of a pair of bones at the base of the front of the neck); -Diffuse bruising noted to the anterior neck as well as to the right side of the face, abrasions/scratch marks around his/her neck; -Mild left frontal scalp hematoma. Acute calvarial (the portion of the skull including the braincase and excluding the lower jaw and facial portion) fracture is seen; -Diagnoses of strangulation or suffocation initial encounter, trauma and anemia. Review of the police investigative report, dated 7/6/22, showed on 7/6/22, the police officer received a radio assignment to the facility. Upon arrival, the officer made contact with the administrator who reported that when he came in to work, CNA A and Nurse B reported the resident had become irate with them in the hallway of the building, attempted to attack them and they had to take the resident down to the floor. The administrator then spoke with the resident and noticed numerous abrasions to the resident's neck area. Once he had a skin assessment done on the resident, red abrasions were discovered to most of the resident's body including the chest, neck and face. The administrator looked at surveillance footage of the incident and observed a confrontation between the resident, CNA A and Nurse B. The situation became physical when CNA took the resident to the floor in a very aggressive and violent way which he deemed as inappropriate and against the organization's policy. The administrator further stated Nurse B began kicking the resident repeatedly in a violent manner. The administrator escorted the police officer to the resident's room. The resident said he/she had an altercation with CNA A and Nurse B who were trying to instruct him/her on where to go and he/she did not want to listen. The resident said CNA A slammed the resident to the floor and Nurse B kicked him/her several times. The officer attempted multiple times to contact CNA A and Nurse B. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Signs and symptoms of delirium: continuous inattention and disorganized thinking. During an interview on 7/14/22 at 11:25 A.M., the resident said on 7/6/22 at 5:00 A.M. or 6:00 A.M., Nurse B entered his/her unit. When Nurse B opened the resident's door, in order to give his/her roommate an injection, the resident said, don't go in my room. I don't want nobody in my room. Nurse B entered the resident's room and he/she very loudly said, get out of my room. I don't want nobody in my room. CNA A confronted the resident, asking why the resident was yelling at Nurse B and telling the resident not to bother Nurse B. CNA A took the resident to the floor and held him/her down. Nurse B and CNA A were holding the resident down and squeezing the resident's neck, which hurt. In reaching up and grabbing Nurse B's shirt, the resident might have pushed or struck Nurse B. CNA A and Nurse B were squeezing the resident's neck hard. The resident said, I'm gonna die. Nurse B said, promise never to hit a woman again. The resident did not recall being kicked in the head. Four staff held the resident down, until he/she finally gave up. They told the resident to stay in his/her room for 30 minutes. At the time of the interview, the resident's left foot was still hurting from being turned and held sideways against the floor. The resident believed staff would not do anything to him/her, as long as he/she did what they told him/her to do. During an interview on 8/10/22 at 1:30 P.M., Resident #8 said on the morning of 7/6/22, Resident #1 was shouting and staff told him/her to calm down. CNA A took the resident down and was holding the resident by the neck. Nurse B, CNA C and CNA D helped CNA A hold the resident down, until the medication could kick in. Nurse B told them to go to their rooms. During an interview on 8/10/22 at 1:45 P.M., Resident #10 said on the morning of 7/6/22, Resident #1 got mad and called Nurse B a bitch. Nurse B said, I ain't no bitch. Resident #1 started yelling things and repeating him/herself, saying what's up? Wanna fight? Nurse B said, What's up? I'll fight. Resident #1 pushed past Nurse B with his/her arm and Nurse B pushed Resident #1 back and yelled Code Green to the others on the unit, saying Resident #1 had hit him/her. CNA A took the resident to the floor and the staff on the unit held the resident down. CNA A put a hand on Resident #1's throat, to hold him/her down. The resident was struggling. CNA A said, start acting your age. Resident #1 said, I can't breathe. I can't breathe. CNA A said, calm down, before we have to send you to the hospital. CNA A sounded frustrated. During an interview on 8/10/22 at 1:30 P.M., Resident #9 said on 7/6/22, Resident #1 was yelling at Nurse B, don't go in my room. At that point, Resident #9 expected staff to call a Code Green and get more help, because Resident #1 tended to be rough on female staff. CNA A came from the opposite end of the hall, telling Resident #1 to stop yelling and calm down. However, CNA A was kind of yelling too. Resident #9 was coming out of his/her room when Nurse B told CNA A not to grab Resident #1 too hard. Nurse B said to CNA A, don't be rough. Resident #1 fought back and then lost his/her balance because CNA A had both hands on the resident. Resident #1 grabbed the front of Nurse B's shirt, as Resident #1 fell . At that point, Resident #9 went down to the opposite end of the hall, looking for the phone so that he/she could call off the unit and get someone

Based on interview and record review, the facility failed to ensure one resident (Resident #502) was free from resident to resident sexual abuse, when Resident #501 entered Resident #502's room while he/she was sleeping and touched his/her genital area without consent. This incident caused Resident #502 to become scared and irate. The sample size was 15. The census was 100. Review of the facility's Abuse and Neglect Policy, last revised on 7/9/21, showed the following: -Definitions: Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes unwanted intimate touching of any kind especially of breasts or perineal (region between the thighs) area; -Prevention and Identification: The facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the administrator and the proper authorities. Review of Resident #501's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/21, showed: -admitted : 5/14/19; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe cognitive impairment; -Independent with bed mobility, transfers, walking and dressing; -Required supervision with eating and bathing; -Required limited assistance with personal hygiene. Review of the resident's current care plan, in use at time of the on-site visit, showed: Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has a history of delusions, sexual molestation of others and was sexually abused as a child. Date initiated: 5/27/21, Revision on: 7/19/21; -Goal: Protective oversight; -Interventions: Non-pharmaceutical interventions: one-on-one interventions as needed (PRN), date initiated 5/27/21; pharmaceutical interventions as needed, date initiated 5/27/21; psychiatric (psych) medical doctor (MD)/nurse practitioner (NP) visits per policy, date initiated 7/7/21; Special focus interview PRN, date initiated 7/7/21; Problem: Very social, likes to go into peers' rooms with or without permission, 5-28-21. 7-19-21, Potential unwanted sexual advances the resident made towards peer about two weeks ago. Date initiated: 7/7/21, Revision on 7/19/21; Goal: Protective oversight; Interventions: 5/28/21, involving incident on this date, guardian made aware, on this incident, educated on the difference between wanted and sexual advances. Resident stated they understood; 7/19/21 one to one at this time until further notice, medroxyprogestrone ([MEDICATION(S)], medication used for hormonal imbalance) increased by psych MD, RNI (type of facility investigation) started, all parties made aware per policy, education on not going into peers' rooms unless invited. During an interview on 8/12/21 at 1:25 P.M., Resident #501 said he/she fooled around with one resident who did not want to. The resident said the other resident was asleep and he/she went into his/her room and touched the other resident's genitalia. The other resident started yelling staff, staff. The resident said he/she went back into his/her room. The resident said this got him/her pulled off the hall and placed on 1:1. The resident said he/she had to sit at the nurses' station. Review of Resident #502's annual MDS, dated [DATE], showed: -admitted : 10/30/17; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe cognitive impairment; -No behaviors; -Independent in bed mobility and eating; -Required limited assistance for transfers, dressing and hygiene; -Impaired vision and impaired lower extremity on one side; -Required extensive assistance for toilet use and bathing; -Used a wheelchair. During an interview on 8/12/21 at 8:45 A.M., Resident #502 said another resident who used to live on his/her hall touched him/her in the genital area. The resident was asleep and woke up to the other resident groping his/her genitals over his/her clothes. He/she told the other resident to Get the hell out of his/her room. The resident has visual impairment and his/her roommate is completely blind. They do not allow visitors in their room due to their impairments, so they feel safe. The resident felt scared and didn't know what was happening. The resident only has one leg and felt like he/she could not get up and get away. Review of the facility's administrative investigation report, dated 7/21/21, showed the following: -Persons involved in incident: Resident #501 and Resident #502; -Statements received from the affected person: a filled in circle next to the word Yes; -On 7/19/21 at 12:15 P.M., Resident #502 alerted a staff member that Resident #501 allegedly touched his/her genitals approximately two weeks ago without his/her consent. During an interview on 8/13/21 at 1:12 P.M., the environmental service director (ESD) said he is usually the first supervisor to arrive at the facility in the morning. That morning (7/19/21), Resident #502 came to him when he first arrived. The resident said Resident #501 came into his/her room during the night and fondled him/her. The resident was irate. The ESD reported it to the Director of Nursing (DON) when she got to the facility that morning. Resident #501 never denied doing it, and he/she was placed on 1:1. Resident #501 was moved off that hall, the same day. During an interview on 8/16/21 at 9:30 A.M., the administrator said the timeline of events for 7/19/21 included the following: Resident #502 reported the incident to the ESD, who reported the incident to the DON when she arrived at the facility. The DON asked the social service designee (SSD) to go interview the two residents involved in the allegation. The SSD reported back to the DON that the allegation happened about two weeks ago. The DON reported the allegation to the administrator. Resident #501 was placed on one-on-one monitoring and moved off the hall, so the residents would be separated. MO 472

Based on observation, interview and record review, the facility failed to ensure resident rights to be free from sexual abuse were not violated when the facility housed residents with dementia on the same locked unit as residents with hyper-sexuality and/or had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #10 and #11). In addition, the facility failed to implement steps to prevent further abuse after sexual abuse was observed when the staff person who observed an incident of sexual abuse, left the unit and residents unattended when he/she went to report the abuse. The sample was 11. The census was 103. The administrator was notified on 4/30/21 at 12:18 P.M. of an Immediate Jeopardy (IJ) which began on 4/16/21. The IJ was removed on 4/30/21, as confirmed by surveyor onsite verification. Review of the facility Abuse and Neglect Policy, dated 11/28/16 and revised on 7/8/20, showed: -Purpose: To outline procedure for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -It is the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment and involuntary seclusion; -It is the policy of this facility that each resident has a right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations and personal care; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -Definitions: Sexual abuse, any touching, directly or through clothing, of a consumer for sexual purpose, or in a sexual manner, this includes, but not limited to the following: kissing, touching of genitals, buttocks, or breasts. Causing a consumer to touch employee for sexual purposes, promoting or observing for sexual purpose any activity or performance involving consumers including play, motion picture, photography, dance or other visual or written representation. This also includes failure to intervene or attempt to stop or prevent inappropriate sexual activity or performance between consumers; -Facility/Interventions could include: nursing staff separating alleged perpetrator and alleged victim including moving the residents to separate halls, physician involvement, intensive monitoring of 15 minute face checks of the alleged perpetrator and alleged victim; this may include more intensive monitoring of 5 minute face checks based on the behavioral, psychiatric or medical needs of the resident, legal guardian notification, possible hospitalization or immediate discharge; -Protection of residents: residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his/her safety, as well as the safety of other residents and employees in the facility. Review of the Facility Secured/Locked Area Assessment Tool, showed: -The facility has identified the clinical criteria for placing a resident in the secured/locked area; -Placement on the secured/locked area is not: -Used for staff convenience or discipline; -Based on resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Based on request from the resident's representative or family member without clinical justification; -A resident has met one or more of the below criteria, and has been determined appropriate for the secure unit: -Dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -History of manic behaviors; -Impulsive Control; -Sexual Offender; -Hypersexual; -Unit identified on Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care); -Guardian request; -Resident request; -Resident wanders; -Resident requires intense monitoring. 1. Review of Resident #1's annual Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/15/21, showed the following: -Brief Interview for Mental Status (BIMS, a brief screening that aids in detecting cognitive impairment), score of 11 out of a possible 15 (indicating moderately impaired cognition); -No behaviors. Review of Resident #1's medical record, showed: -A face sheet, showed admitted [DATE]; -The transfer/admission records, sent from the prior facility upon admission to the current facility, showed: -Goals: Will not display sexual behaviors toward staff/other residents, dated 12/21/19; -Progress note, dated 9/19/20, resident is on 15 minute checks due to previous inappropriate behavior with other residents; -physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -An order, dated 11/10/20, for [MEDICATION(S)] ([MEDICATION(S)], a form of the hormone [MEDICATION(S)], used to lower sexual drive), 5 milligrams (mg), take one tablet by mouth twice daily, for high risk sexual behavior; -The care plan, undated and in use at the time of the investigation, showed: -Problem: Per papers he/she came with a history of sexual inappropriate behaviors with staff and peers. Not noted on sex offender register; -Approaches: Educate on inappropriate behaviors. Discourage behaviors. Notify primary physician. Order received for [MEDICATION(S)]. Review of Resident #2's quarterly MDS, dated [DATE], showed: -BIMS score of 0 out of a possible score of 15 (indicating severe cognitive impairment); -Memory recall ability, none; -Cognitive skills for decision making poor, cues/supervision required; -No behaviors; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record, showed: -A care plan, undated and in use at the time of the investigation, showed: -Problem: Dementia with behaviors, [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels and behaves). Has mild cognitive impairment, attention deficit [CONDITION(S)] disorder (ADHD), visual hallucinations, can get verbally aggressive, but easily redirected; -Approach: Needs best met on secure unit, visual checks by staff per policy; -A nurse's progress note, dated 4/16/21 at 11:53 A.M., showed the resident assessed in response to allegation of sexual contact by a peer. No redness, swelling or bruising noted at genitalia. Resident's mood remains at baseline and does not appear to be emotionally upset. Physician, Director of Nursing (DON), administrator and police notified. Review of the facility abuse investigation, dated 4/16/21, showed: -Date and time of occurrence: 4/16/21 at 9:30 A.M.; -Summary of alleged incident, staff alleges that Resident #1 made sexual contact with Resident #2. Both residents were immediately separated. Resident #1 was placed on 1:1 for protective oversight. Assessment negative for any findings of any injury. Resident #2 mood is at baseline. Police notified; -The Registered Nurse Investigation report, showed: -Statements received from the witnesses, yes; -Guardian notified of incident by Charge Nurse, Yes; -Documentation of incident completed by Charge Nurse, Yes; -Did the documentation include notification of guardian, physician, DON and administrator, Yes; -Signed and dated 4/16/21 by the DON and administrator; -Investigative Narrative Note: It was reported by Physical Therapy Assistant (PTA) A that he/she witnessed Resident #1 grope Resident #2 at his/her groin. Resident #1 was placed on 1:1 for protective oversight. Both residents were assessed, residents were immediately separated, assessed for physical signs of injury and evaluated mood for evidence of decline/decompensation emotionally, no injury and no decline noted; -Summary of Findings: Resident #1 inappropriately touched Resident #2 by groping his/her crotch. Resident #1 was placed on 1:1 and educated to avoid inappropriate sexual contacts with his/her peers. Although he/she denied the allegation, he/she verbalizes understanding not to touch his/her peers inappropriately in any sexual way; -Care Plan Changes: Resident #1's care plan includes interventions due to a history of sex offenses with previous peers and staff. Not on sexual registry, but no history of inappropriate touching. Keep residents separated. Currently on 1:1 for protective oversight; -Plan of Action Educational Needs: Continue to educate resident to avoid sexual contact with others/peers. Review of PTA A's Facility Employee/Witness Statement, signed and dated 4/16/21, showed PTA A documented as he/she walked onto C Hall, he/she saw Resident #1 have Resident #2 come to him/her as he/she sat in his/her room doorway. He/she then put his/her hand down the front of Resident #2's pants. Then Resident #2 walked away. During an interview 4/29/21 at 10:30 A.M., PTA A said he/she walked onto C Hall and saw Resident #2 walking back and forth. Resident #1 called Resident #2 over and with one hand, reached down the front part of his/her pants. Resident #2's room is the 2nd to the last room on the hall. Resident #2 was pulling back. He/she redirected Resident #2 down the hall and told Resident #1 to go back into his/her room. PTA A then left the unit and went to tell his/her supervisor. PTA A said one certified nursing assistant (CNA) held the door for him/her when he/she arrived to the hall, that CNA was holding the door open for the residents to go smoke. The CNA was gone with the smokers, off the unit at the time of the incident. The only other CNA was in a different resident room and did not observe the incident. PTA A said he/she went to tell his/her supervisor who is the physical therapy supervisor. His/her supervisor said to report to the resident's charge nurse, Nurse B. Nurse B was not at the nurse's station, so he/she went down A Hall looking for him/her. He/she saw Nurse B with the medication cart. He/she went down the hall to Nurse B, informed him/her of the incident, and Nurse B told him/her that he/she would have to write a statement. PTA A went back to therapy department. Nurse B brought him/her the paperwork for a statement. PTA A said he/she thought Resident #1 was very alert, they had him/her in therapy, and the resident could tell him/her how long it has been since he/she walked. He/she would engage in conversations enough that PTA A thought he/she was alert. Review of Nurse B's Facility Employee/Witness statement, signed and dated 4/16/21, showed Nurse B documented he/she was not a witness, he/she was informed by staff that resident (Resident #2) was sexually contacted by a peer. On assessment, there was no bruising or swelling to genitals. Resident denied that there was contact. This writer informed resident that behavior is not allowed. Resident claimed to understand. During an interview on 4/29/21 at 11:34 P.M., Nurse B said he/she was on A Hall and was told Resident #1 fondled Resident #2 on C Hall. PTA A told him/her that it happened and that Resident #1 had touched Resident #2. He/she then went to the nurse's station, and the DON called him/her to the office because it had just happened. Nurse B and the DON talked about it, and the DON told him/her when something like that happens, to bring it to the administrator first, and of all the charting required. Then Nurse B did the incident report, attempted to call family, but there was no answer, and did the charting. After that, he/she went to the hallway and separated the two residents. Resident #2 walks up and down the halls, so once he/she arrived to the hall, he/she told staff to watch Resident #2 because he/she wanders in and out of rooms. Then he/she assessed Resident #2, and there was no sign of injury. During an interview on 4/28/21 at 12:01 P.M., Resident #9, said Resident #1 is his/her roommate. When asked if Resident #1 ever attempted any type of sexual advances towards him/her, he/she laughed and said Resident #1 never tried anything with him/her. Review of CNA F's Facility Employee Witness Statement form, unsigned and dated 4/16/21, showed CNA F documented, I don't know. During an interview on 4/29/21 at 12:14 P.M., CNA F said he/she was not assigned to the hall, and he/she did not recall any incident between Resident #1 and Resident #2. He/she did not know anything regarding Resident #1 having sexually inappropriate behaviors. The facility had everyone fill out a statement. During an interview on 4/29/21 at 12:30 P.M., the administrator verified that CNA F was assigned to the hall and did work the day of the incident. Review of CNA E's Facility Employee Witness Statement form, unsigned and dated 4/16/21, showed CNA E documented, I don't know what happened. During an interview on 4/29/21 at 12:34 P.M., CNA E said Resident #1 lays down all day. After he/she has breakfast, he/she gets up to smoke. CNA E said he/she left the hall and took the smokers outside, on the patio next door. The facility asked him/her to write a statement, stating if he/she saw something between Resident #1 and Resident #2. He/she filled it out that evening, because he/she worked a double that day. Resident #2 wanders, he/she doesn't really go in other rooms, but wanders the hall, and Resident #2 follows CNA E around the hall. Resident #2 continued to walk around the halls the rest of the day. It was after lunchtime when he/she went back on the hall and saw Resident #1 was on 1:1 observation, no one told him/her about the incident. Observation and interview on 4/29/21 at 2:37 P.M., showed CNA H on C Hall, no other staff were observed. CNA H said the other person assigned to the hall was out taking the residents to smoke. He/she said it is difficult to keep an eye on the residents when busy and he/she is the only staff person on the hall. He/she was not aware of an incident between Resident #1 and Resident #2. He/she was not aware Resident #1 had sexual behaviors. The CNA care plans for the residents are located in the small dining room, right next to the entrance to the Hall. Review of Resident #1's CNA Care Plan, showed: -Behavioral, low; -The care plan did not define low behaviors and did not provide interventions regarding sexual behaviors; -A box Behavioral, Sexually Inappropriate, not checked as a problem. During an interview on 4/29/21 at 3:52 P.M., the administrator said PTA A told his/her supervisor what he/she saw. Another restorative aide, PTA G, overheard PTA A telling his/her supervisor and PTA G came to her office to tell her. The DON was in the administrator's office when PTA G told her what he/she overheard. The administrator said the DON took the lead in the investigation, because she was busy with something else. The DON got up and took over. She did not see where she went. She called the police to make a report. The DON was responsible to ensure everything was getting done, and make sure the resident was assessed and anything else that was needed was done. The administrator said she didn't speak with lead CNA C, the two CNAs on the floor or Nurse B following the incident. During an interview on 4/30/21 at 2:55 P.M., the nurse practitioner for Resident #2 said, he/she is alert and oriented only to him/herself and would be at risk for abuse because he/she wouldn't be able to report an incident. He/she needed to be on a dementia unit without residents with a history and ability to sexually abuse. 2. During an interview on 4/30/21 at 11:30 A.M., the administrator said they had another incident on C Hall. A resident had alleged another resident kissed him/her and they were in the process of investigating the allegation. Review of Resident #10's medical record, showed: -The resident's transfer documentation, dated 3/30/21, showed: -Struggles with severe memory deficits and delusional thoughts; -Registered sex offender; -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -A nurse's progress note, showed on 4/21/21 at 4:11 P.M., admitted from state department of mental health. Resident unable to recall the name of the facility where he/she lived. -Further review of the nurse's progress notes, showed: -On 4/30/21 at 12:42 P.M., resident assessed after allegation that resident had inappropriate sexual contact with another peer. Resident denies the allegation and states he/she is just friends with the resident; -On 4/30/21 at 1:17 P.M., police here on service call and to interview resident. Resident stated in interview, he/she liked to talk to the resident across from him/her. He/she is friends and talked about puppies and not picking them up by their tails. He/she liked to make him/her smile and denied any inappropriate contact. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's medical record, showed: -A care plan, undated and in use at the time of the investigation, showed: -Problem: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Uses [CONDITION(S)] to manipulate staff and try and get away with inappropriate behaviors, also has a history of making up false stories for attention; -Approach: Wears cervical collar for positioning, but can remove as needed. Legally blind, but can see minimal, sees shadows. Moves around common area in facility well. Educate on inappropriate behaviors, that they will not be tolerated and to keep his/her hands to his/herself. Review of the Facility Investigation, dated 4/30/21, no time noted, showed: -Resident #11 alleged that Resident #10 made sexual contact with him/her without consent. Resident #10 was placed on 1:1 for protective oversight. Assessment negative for any findings of any injury. Resident #11's mood is at baseline. Police notified.; -Summary of findings: Resident #10 denies inappropriate sexual activity with Resident #11. Resident #11 reports that Resident #10 kissed him/her on the mouth without his/her consent. Resident #10 was moved off the unit and housed on Unit A, does not have a roommate, and shares a bathroom with 2 residents who are alert and able to make their needs known and report any instances of unwelcomed sexual advances. Resident #10 remains on 1:1 intensive monitoring at this time. Resident and staff interviews reveal there is no knowledge of any other inappropriate sexual behaviors or report made by this resident or any other peer. The facility then reviewed residents who have a history of sexually inappropriate behavior or sex offender charges to determine if their location in the facility needed to be addressed to ensure that no other residents residing in the facility with cognitive deficits shared a room or bathroom with the residents who have a history of sexually inappropriate behaviors or history of sex offense charges. During an interview on 4/30/21 at 1:09 P.M., CNA I said Resident #10 was behaving strangely, he/she normally stays in his/her room, but kept coming out of his/her room talking to Resident #11. When he/she noticed Resident #10 go into Resident #11's room, he/she went down the hall to make sure they stayed in view. He/she separated them and they went back to their rooms. Then, around 12:30 P.M., he/she noticed Resident #11 in Resident #10's room. Resident #11 might have gone through the bathrooms, both resident's lived on the same side of the hall, with an adjoining restroom. Someone from therapy was down by their rooms so he/she sat down on the opposite end of the hall, by the entrance. Another resident propelled Resident #11 in his/her wheelchair up to CNA I and told him/her Resident #11 needed to tell him/her something. Resident #11 told CNA I Resident #10 asked him/her for oral pleasure. Resident #11 said he/she did not do it. CNA I said he/she propelled the resident into the adjacent dining area and asked CNA J to watch him/her and he/she went to tell the Resident Care Coordinator (RCC) what happened. During an interview on 4/30/21 at 1:15 P.M., CNA J said CNA I came to him/her and told him/her to watch Resident #11, he/she told him/her what Resident #11 had told him/her. CNA J said he/she always thought Resident #10 behaved oddly towards Resident #11. Resident #10 always wanted to be with him/her, he/she was infatuated with him/her. Resident #10 told CNA J he/she wanted to take Resident #11 home. Resident #11 is very child minded and playful, acts like a child. During an interview on 4/30/21 at 1:54 P.M., the RCC said CNA I came and told him/her what happened. He/she then went and talked to Resident #11. Resident #11 said Resident #10 asked him/her to provide oral sex. He/she didn't do it, but Resident #10 did kiss him/her on his/her mouth. Resident #11 said he/she did not want him/her to do it. He/she told another resident, and that resident propelled him/her down the hall to CNA I. Resident #11 said Resident #10 had tried to kiss him/her before and he/she didn't report it, he/she didn't know why. Resident #10 is fairly new, the RCC said he/she was not familiar with him/her, they had only been at the facility about a week. Resident #11 is legally blind, and alert and oriented X3-4. During a resident's first 72 hours in the facility, they are intensely monitored, especially if care planned for elopement or sexual behaviors. During an interview on 4/30/21 at 2:46 P.M., Resident #11 said Resident #10 had kissed him/her from day one. He/she didn't tell anyone because Resident #10 is a nice person. He/she would come into his/her room and touch him/her, on his/her face and private areas. It scared him/her. Resident #10 told him/her not to tell anyone. He/she asked him/her to pull his/her pants down and he/she tried to stop him/her from going into the hall. Resident #10 would cut through the bathroom to get to his/her room. Resident #10 tried to have sex with him/her and he/she punched him/her in the face and knocked him/her off the bed. Every day and every night he/she came to my room he/she wanted him/her to come to his/her house and play with puppies. During an interview on 4/30/21 at 2:50 P.M., Resident #10 said Resident #11 is his/her friend and he/she wanted him/her to come to his/her house to show him/her a puppy. When asked where his/her house was, he/she replied, this is his/her house. 3. During an interview on 4/29/21 at 5:07 P.M., the administrator said the risk of placement of people with known inappropriate sexual behaviors depends on who the person might have been sexually inappropriate with in the past. Placement on the unit with people with known sexual inappropriateness possibly puts the residents with impaired cognitive function at risk, due to their inability to recall or report. She was not aware the staff person left the hall without alerting other staff to watch the resident after observing the incident between Resident #1 and #2. Her expectation of staff was they should have separated the resident who was harmed, and someone should have stayed with them while someone else went get assistance. The residents should not have been left on the hall alone. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 172

Based on observation, interview and record review, the facility failed to appropriately assess, monitor and intervene after multiple verbalized [MEDICAL CONDITION] made and failed to notify the physicians and the guardian when one resident caused a self-inflicted injury. The resident had expressed concerns with his/her life's circumstances, was depressed and the facility did not provide the appropriate treatment and services. This affected one of 20 sampled residents (Resident #1). The census was 112. Review of the facility's behavioral emergency policy and procedure, showed the following: -The purpose was to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis and to ensure that the resident is not being coerced, punished or disciplined for staff convenience; -If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement or resident to resident altercations, the following steps will occur: -Licensed nursing staff will assess the resident, ensuring that safety of the resident and others is the first priority; -One on one monitoring of the resident will be initiated under the direction of the licensed nurse; -Each resident who has an increased potential for aggressive behavior toward self or others will have an assessment completed upon admission or prior to the use of approved supportive C.A.L.M. take down techniques. Residents assessed as inappropriate to use the approved C.A.L.M. will be placed on the behavior management/care list. Supportive methods to control behaviors will be outlined in the plan of care individually for those residents in behavior emergency crisis; -The director of nurses and the administrator will be notified regarding assessment findings and decide, given assessment findings, as to whether the resident's needs can be met safely and if the resident continues to be appropriate for placement at the facility; -The guardian will be notified and imposed limitations may be placed on the resident, including hospitalization or other specific directives; -The physician will be notified of the licensed nurse assessment and orders will be followed; -The licensed nurse will follow all physician orders [REDACTED]. -If the on-call management team member and administrator decide the resident's needs cannot continue to be safely met, the physician (primary psychiatrist, house psychiatrist, or medical director) will be notified by the licensed nurse requesting for a psychiatric evaluation; -The director of nursing will complete a nurse investigation within 24 hours of the behavior emergency; -In the event that the resident is unable to be redirected or is requesting an as needed (PRN) medication for mood stabilization, medication should be given per physician orders. If the resident receives an oral PRN mood stabilizing medication, the licensed nurse must complete the PRN intervention form. Review of the facility's intensive monitoring/visual checks policy, showed the following: -The purpose is to ensure a system is in place for residents who require increased monitoring for behaviors/psychiatric and medical issues; -The definition of intensive monitoring is defined as hourly checks by a licensed nurse or one to one monitoring by the designated employee assigned by the licensed nurse. A face to face check is defined by the employee visually seeking the face of the resident; -One on one monitoring can only be removed by the administrative staff; -Residents who are showing poor impulse control, including verbal/physical aggression, elopement ideations and suicidal/homicidal ideations may also be placed on one to one or two to one (within eyesight of staff at all times) monitoring at the discretion of the administrative staff; -A one to one or two to one will be determined at the severity of the behavior at the discretion of the administrator, director of nursing, management team and physician; -Residents who require intensive monitoring of one to one will have a dedicated staff member at all times within eye sight; -All residents on each unit will be monitored by visual checks at least every two hours by the licensed nurse or may be provided more intensive monitoring by the licensed nurse every hour; -Certified nursing assistants (CNA's) will continue to monitor residents at the discretion of administration. CNA's can be provided direction on how to monitor the resident in a timely manner at the discretion of administration for a medical or behavior decomposition; -The facility recognizes that the licensed nurse is the only truly dedicated employee to provide face checks every two hours. The facility will not depend on the CNA's to guarantee intensive timely monitoring checks; -As of 8/14/12, all licensed nurses will be required to sign intensive monitoring checks of at least every two hours and leave a voice mail report. 1. Review of Resident #1's face sheet, showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of the resident's social services notes, dated 1/1/16 through 7/11/16, showed the following: -On 1/7/16 at 10:43 A.M., the resident had no change in status since last quarterly assessment. The resident enjoys participating in activities of his/her choice. The resident did not have any behaviors noted. The resident had no concerns at this time. Social services will continue to follow up and support; -On 5/12/16 at 6:19 P.M., the resident had no change in status, remains on B-hall. The resident is able to make needs known. The resident has a spouse and he/she stayed in contact with him/her often. The resident had no concerns at this time. Social services will continue to follow and support; -On 6/27/16 at 4:12 P.M., the resident has not had a change in status. The resident remains on the B hall. The resident is able to make his/her needs known. The resident has a spouse and he/she stays in contact with them very often. The resident had no concerns at this time. Social services will continue to follow up and support for any concerns; -On 7/11/16 at 10:11 A.M., the resident was admitted into the facility from a hospital stay. The resident returned on 6/26/16. The resident's guardian was notified of the resident returning back to the facility. The resident had no further concerns at this time. Social services will continue to follow and support any further concerns; -No further documentation or assessment of the resident's concerns with depression or [MEDICAL CONDITION]. Review of the resident's nurses notes, dated 1/1/16 through 7/11/16, showed the following: -On 1/19/16 at 3:34 P.M., the resident is on the secure unit. Claimed to be upset over family issues, had negative behaviors. Called police, cell phone taken and locked in the lock box. The resident showed no more negative behaviors or [MEDICAL CONDITION]; -On 1/24/16 at 10:04 A.M. at approximately 8:30 A.M., the nurse assssed the resident for [MEDICAL CONDITION], the resident verbally denied. When the nurse asked why he/she verbalized before that he/she wanted to kill him/herself. The resident responded, I wanted attention. The resident is apologetic for his/her behavior. The nurse educated the resident on appropriate coping and venting mechanisms. The nurse feels the facility can meet the resident's safety needs. The administrator discontinued one to one due to the resident being placed on intense increased monitoring. The guardian made aware; -On 2/25/16 at 7:34 A.M., the resident up in his/her wheelchair at 12:00 A.M. and requested to smoke. The resident was informed that smoke time was over. The resident became agitated calling the nurse a [***] , went to his/her room, agitation continued with attention seeking behaviors. The resident stated I want one on one, I will hurt myself. The resident was monitored by staff with the door open to the room. The resident continued to act out, [MEDICATION NAME] (medication used to treat anxiety) given, television removed from room to defuse behaviors. States he/she will stop acting out and comply with facility policy. Seen by the physician, notified of behaviors; -On 6/20/16 at 5:34 P.M., a call was received from the guardian office to send the resident to the hospital immediately. Caller made aware that the social worker and division nurse talked to the resident to see what was going on with the resident and why he/she stated to the caller he/she felt like hurting him/herself. The resident was having negative feelings and wanted to go to the hospital. The guardian was called and made aware of the investigation of the resident. Social services and the director of nursing (DON) made aware. Call placed to the administrator and the corporate nurse. The resident stated his/her partner stopped calling and his/her brother called and said his/her partner started a relationship with the resident's best friend and it hurt. The resident placed on one on one observation. Call placed to the resident's psychiatrist, new orders received to send the resident to the hospital for treatment and evaluation. Called placed to resident's primary doctor, made aware of psychiatrist orders, all the above mentioned, made aware of new orders; -On 6/28/16 at 3:55 P.M., the resident placed a call to the guardian stated he/she was having feelings of hurting him/herself. Charge nurse talked with the resident earlier and the resident seemed to have no distress. Went back to talk with the resident and social worker. The resident stated did my social worker call you about me going to the hospital? Call placed to the psychiatrist, made aware of resident's guardian demanding to send the resident to the hospital and not to place the resident on one on one monitoring. Call placed to the primary physician exchange, awaiting return call; -No further documentation or assessment of the resident's depression, [MEDICAL CONDITION] or one on one monitoring. Review of the resident's hospital record, dated 6/20/16 through 6/26/16, showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. -The resident stated he/she was suicidal over a breakup with his/her partner; -The resident had plans to cut his/her wrists; -The resident had previous attempts in the past by cutting his/her wrists. Review of the resident's physician assessment, dated 6/27/16, showed the following: -Chief complaint was depression; -The resident was recently admitted for [MEDICAL CONDITION]; -The resident felt depression and suicidal, but does not have a plan; -The resident reported nothing made him/her feel better; -The resident reported going home would make him/her feel better. Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/16, showed the following: -[DIAGNOSES REDACTED]. -Brief interview of mental status (BIMS) score of 13 out of a possible score of 15; -A BIMS score of 8-15 shows the resident is cognitively intact; -No staff assessment of the resident's mood; -Safety notification: Was responsible staff or provider informed that there is a potential for resident self harm? Left blank; -The resident has delusions; -Anti-psychotic medications received in the last seven days. Review of the resident's care plan, dated 7/7/15, showed no documentation of the resident's [DIAGNOSES REDACTED]. There was no documentation on supportive methods used to control behaviors during a behavior emergency crisis. Review of the facility's target list for resident's with special needs or requests, dated 7/13/16, showed to monitor the resident for attempting to harm his/her self or other residents. Review of the resident's psychiatrist note, dated 7/19/16, showed the following: -The resident had multiple suicide attempts by over-dosing and by cutting. The resident has multiple scars on his/her arm; -The resident said he/she did those suicide attempts because he/she was angry and his/her partner left him/her; -The resident said he/she went to the hospital a few weeks ago, he/she still feels down some days; -The resident does not want to be at the facility and wants to go to the hospital again, he/she misses his/her family. Further review of the resident's care plan, dated 7/7/15 and updated 7/23/16, showed the following: -The resident had a history of [REDACTED]. -Safety checks per facility policy; -Consult with psychiatrist PRN; -Social services to visit PRN; -One on one as needed for [MEDICAL CONDITION]. During an interview on 7/28/16 at 1:35 P.M., the MDS coordinator said the resident's care plan was updated on 7/23/16. The information that was updated was the resident's history of depression and suicide attempts. Further review of the resident's nurses notes, dated 7/23/16, showed the following: -At 10:30 P.M., the resident cut his/her left wrist with an ink pen. He/she acquired an abrasion that measured 3 centimeter with a small amount of drainage. Cleansed left wrist and applied dry dressing. He/she continued to threaten him/herself. Went into room and removed all sharp items. The resident put on suicide watch until lifted by the DON. Continue to monitor; -At 1:00 A.M., called placed to the DON to inform her that the resident cut his/her wrist. [MEDICATION NAME] 0.5 milligram (mg) PRN was given earlier at 11:00 P.M.; -At 1:05 A.M., call placed to the resident's primary doctor, reached voicemail; -At 1:15 A.M., call placed to the responsible party, reached voicemail; -No further documentation or assessment of the resident's depression, suicidal ideation or attempts to harm him/herself. No further documentation of contact with the resident's physician or guardian. Review of the nurse report sheet for B-Hall, dated 7/23/16 through 7/24/16, showed the following: -On 7/23/16 on the 3:00 P.M. to 11:00 P.M. shift: The resident is on suicide watch, one on one until DON lifted. The resident cut his/her left wrist with an ink pen, [MEDICATION NAME] 0.5 mg; -On 7/23/16 on the 11:00 P.M. to 7:00 A.M. shift: The resident is in bed, one on one, suicide watch; -On 7/24/16 on the 7:00 A.M. to 3:00 P.M. shift: The resident is on one on one, [MEDICAL CONDITION]; -On 7/24/16 on the 3:00 P.M. to 11:00 P.M. shift: (Left blank); -On 7/24/16 on the 11:00 P.M. to 7:00 A.M. shift: The resident slept all night, no problems. Review of the B-Hall's suicidal, homicidal and elopement check list, dated 7/23/16 and 7/24/16, showed the following: -On 7/23/16, no documentation for all three shifts; -On 7/24/16, staff circled yes for suicidal behavior and elopement behavior during the 7:00 A.M. to 3:00 P.M. shift; -On 7/24/16, staff circled yes for homicidal behavior during the 3:00 P.M. to 11:00 P.M. shift. Review of the B-Hall's one hour licensed nurse intensive monitoring checks, dated 7/23/16 and 7/24/16, showed no documentation to show one hour monitoring checks were completed. Review of the resident's one on one monitoring check form for CNA's, showed staff provided one on one from 7/23/16 at 10:30 P.M. to until 7/24/16 at 6:55 A.M. Observation and interview on 7/25/16 at 11:45 A.M., showed the resident sat in his/her wheelchair in the dining room of the B-hall (a behavior secured unit). The resident said he/she was depressed. He/she cut his/her left wrist with a piece of plastic a couple of days ago. The resident said he/she will finish the job. The resident said no one from nursing or social services spoke to him/her about his/her depression or the cuts on his/her wrists. The resident had several scratches on his/her left wrist. At 1:20 P.M., the resident showed scrapes his/her left posterior forearm. The scrapes measured 2.0 centimeters (cm) by 2.0 cm. with no open areas. The resident said he/she tried to cut his/her wrists with eyeglasses. The staff removed his/her eyeglasses. The resident said he/she was going to the hospital. On 7/25/16 at 2:45 P.M., the resident was transported to the hospital by ambulance. During an interview on 7/26/16 at 6:15 A.M. and 9:15 A.M., Hall Monitor K said he/she worked on 7/23/16 from 7:00 A.M. to 11:00 P.M. The resident said he/she was depressed about his/her parent. The resident said he/she wanted to harm him/herself at approximately 8:00 P.M. Hall Monitor K said he/she redirected the resident, so he/she did not talk about it again. Hall Monitor K did not tell staff the resident said he/she wanted to harm him/herself. At approximately 10:00 P.M., the resident showed Hall Monitor K the cuts on his/her arm. The resident said he/she tried to harm him/herself. Hall Monitor K notified Nurse F. The resident was placed on one on one monitoring. Hall Monitor K watched the resident until 11:00 P.M. Hall Monitor K later told Nurse F that the resident talked about harming him/herself earlier that night. This was not the first time the resident talked about harming him/herself. Hall Monitor K said back in March 2016, the resident bit his/her wrist. The resident was transported to the hospital. Hall Monitor K could not remember any further details of the incident or if the resident harmed him/herself again before 7/23/16. Hall Monitor K worked on 7/24/16 at 11:00 P.M. to 7:00 A.M. The resident was calm and stayed in the television room until 11:00 P.M. The resident went to his/her room. Hall Monitor K said he/she sat outside the resident's room all night. He/she did not document the details of the incident or the interaction with the resident. During an interview on 7/25/16 at 4:00 P.M., CNA H said he/she was aware of the incident on 7/23/16. He/she worked on 7/23/16, 3:00 P.M to 11:00 P.M. shift. The resident was depressed about his/her parent's health. The resident cut his/her wrist with a pencil. Nurse F used a bandage to wrap his/her wrist. The resident was placed on one on one monitoring by staff, which was when the resident and staff are arms length from each other. Prior to the resident cutting his/her wrist, he/she wanted an extra cigarette. CNA H believed the resident harmed him/herself because he/she could not have an extra cigarette, but blamed it on his/her parent's health. During an interview on 7/25/16 4:20 P.M., Nurse F said he/she worked on the B-Hall on 7/23/16 at 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. Nurse F said CNA H notified him/her that the resident cut his/her left wrist on the night of 7/23/16. The cuts measured approximately 2 1/2 inches in length. The resident's wrist was cleaned and bandaged by another staff. The resident said he/she wanted to kill him/herself. The resident was on one on one monitoring with CNA H on 7/23/16 until 11:00 P.M. The night shift CNA stayed on one on one monitoring with the resident until the next day. Nurse F tried to call the resident's primary physician and his/her guardian, but could not reach them. Nurse F said he/she left a message. Nurse F was not sure if the psychiatrist was called. Nurse F did not document if he/she notified the resident's psychiatrist. Nurse F notified the DON. Nurse F was told to have the resident placed on one on one monitoring. Nurse F remembered he/she called the administrator twice because he/she mixed up the resident with another resident that resides on the same hall. There was another resident on the B-Hall that had [MEDICAL CONDITION]. Nurse F informed the administrator of the correct detail of the resident's wrist. Nurse F could not notify the resident's doctors or guardian, so Nurse F said he/she decided that the resident was safe in the facility and not to transport him/her to the hospital. The cut on the resident's wrist was not deep. It was an abrasion. The resident was monitored by staff until 7/24/16 at 7:00 A.M. Nurse F gave report to the nurse manager on 7/24/16. The resident had a history of [REDACTED]. During an interview on 7/26/16 at 6:10 A.M., CNA J said he/she worked on 7/23/16 at 11:00 P.M. CNA J was told by Nurse F that the resident attempted suicide. The resident had a bandage on his/her wrist. CNA J was not assigned to monitor the resident. Hall Monitor K was assigned one on one monitoring with the resident. The resident sat in the television area with Hall Monitor K for most of the night. The resident was calm for the rest of the night. CNA J said the resident was calm the next day. The resident stayed in bed most of the day on 7/24/16. CNA J said he/she did not document the details of the incident or the interaction with the resident. During an interview on 7/27/16 at 8:25 P.M., CNA D said he/she worked on 7/24/16 for 30 minutes. CNA D covered for the staff that arrived late to the facility. CNA D arrived at the same time as the late staff. CNA D did not give report or speak to anyone. He/she did not know about the resident until 7/25/16 when he/she returned to work. He/she was aware that the resident was on one on one monitoring, but did not know the reason. During an interview on 7/26/16 at 10:30 A.M., Nurse M said he/she relieved Nurse F on 7/24/16 at 7:00 A.M. Nurse M was told by Nurse F that the resident was suicidal and harmed him/herself. Nurse M said he/she looked in on the resident when he/she first arrived. The resident received one on one monitoring by Hall Monitor P. Hall Monitor P sat outside the resident's room with the door open. The resident had his/her wrist wrapped. The wounds were superficial and there was no drainage. Nurse M asked the resident if he/she was upset or wanted to harm himself again. The resident replied no. The resident was calm and cooperative. He/she was on one on one monitoring until 7/24/16 at 8:00 A.M. or 9:00 A.M. Staff always had eyes on the resident after the one on one monitoring ended. Nurse M did not contact the resident's doctor or the guardian. Nurse M was not aware that they were not contacted or needed to be contacted. Nurse M did not see any documentation in the resident's medical chart. Nurse M provided documentation, but was not sure if it made it to the resident's medical chart. During an interview on 7/25/16 at 11:50 A.M., CNA D, assigned to B hall on 7/25/16, said he/she did not have any knowledge of the resident's self harming injuries or any [MEDICAL CONDITION] that occurred over the weekend with the resident. During an interview on 7/25/16 at 11:55 A.M. and 3:05 P.M., Certified Medical Technician (CMT) E, assigned to B hall on 7/25/16, said he/she did not have any knowledge of the resident's self-harming injuries or any [MEDICAL CONDITION]. CMT E said the resident was usually vocal about any injuries he/she had. The resident did not talk about his/her wrist. During an interview on 7/25/16 at 12:00 P.M., Nurse B said he/she is the nurse responsible for the resident's care on 7/25/16. The resident did not have any recent hospitalization s. Nurse B did not have any knowledge of the resident's [MEDICAL CONDITION] or any self-harming injuries that occurred over the weekend. During an interview on 7/25/16 at 12:10 P.M., the DON said she was aware of the resident's self harming injury. The incident occurred on 7/23/16. The resident was put on one on one monitoring for 12 hours. The resident's legal guardian and psychiatrist were notified. The DON did not know if social services followed up with the resident. The DON was told by the administrator that it was not the resident's normal behavior. During an interview on 7/25/16 at 1:10 P.M., the social services manager said he/she was notified that the resident cut him/herself on 7/25/16. The social services manager notified the resident's guardian. Further review of the resident's social services notes, showed a note dated 7/25/16, it was reported today that during the weekend the resident conflicted self harm by using his/her bottom teeth and scraped them across the wrist. Social services spoke to the resident's guardian in regards to the resident's behavior. Social services let the guardian know that the resident stated he/she missed his/her family and would like to see them. Social services also let the guardian know that he/she will go to the hospital. Social services spoke to the resident about coping skills and that the next time he/she felt the need to conflict self harm that he/she should call and ask for his/her charge nurse, social services, or any one that he/she felt comfortable with. Social services will continue and follow up and support for any other concerns. During an interview on 7/25/16 at 1:20 P.M., Nurse B said he/she spoke to the resident's psychiatrist. The resident would be transported to the hospital. Nurse B said this was the first time the psychiatrist was notified. Further review of the resident's POS, showed an order, dated 7/25/16, to send the resident to the hospital for [DIAGNOSES REDACTED]. During an interview on 7/25/16 at 2:15 P.M., the DON said the event happened on 7/23/16 at 10:30 P.M. or 11:00 P.M. The resident scratched his/her wrist with an ink pen. Staff searched the resident's room and removed items that the resident could use to harm him/herself. The DON was notified by Nurse F, who was on duty. The DON did not know or remember what the resident told Nurse F, but the resident wanted to harm him/herself. The resident did not want to commit suicide. Nurse F was told to notify the resident's primary doctor and the psychiatrist. The scratches on the resident's wrist were superficial. The resident also received protective oversight. He/she did not go to the hospital because his/her needs were met. The nurses on duty over the weekend were also notified. The DON would expect staff to give report to the oncoming and outgoing shift. It should be documented on the report log. The psychiatrist did not want the resident to be transported to the hospital on [DATE]. Today, staff called and asked the psychiatrist if the resident could go to the hospital when it was reported that the resident continued to be suicidal. The resident was placed back on one on one monitoring until he/she was transported to the hospital. The administrator said the resident received upsetting news about his/her spouse. The resident made statements about harming him/herself. The resident went out to the hospital in the past. If a resident was suicidal, the nurse would conduct an interview and make sure the resident was safe. The nursing staff would check if the resident was suicidal or homicidal. Staff would make sure there was no harm. Social services is expected to get involved. The administrator would expect all staff to monitor the resident. During an interview on 7/26/16 at 8:45 A.M., the administrator said the resident should remain in the line of sight of the staff during one on one monitoring. Staff should also report if the resident had [MEDICAL CONDITION]. During an interview on 7/26/16 at 9:15 A.M., the social services manager said he/she was aware of the resident's feelings of depression. Before the resident was sent to the hospital last month, the resident said he/she was going to harm him/herself because of his/her parent and spouse. The social services manager called the resident's legal guardian and his/her guardian requested that the resident be transported to the hospital. When a resident is readmitted to the facility after having feelings of suicide, the social services manager would check on the resident three times in the first week. The social services manager was not sure if the visits with the residents were documented, but he/she made rounds on a daily basis. He/she had not spoken to the resident since the first week he/she was readmitted on [DATE]. He/she did not follow up with the nursing staff about the resident's depression or any [MEDICAL CONDITION] and the nursing staff did not follow up with social services. If a resident harms themselves, they are transported to the hospital. If a resident talks about harming themselves, they are placed on one on one monitoring, and social services contacts the guardian. The social services manager would expect staff to notify him/her about the incident that occurred on 7/23/16. During an interview on 7/26/16 at 9:40 A.M., Nurse Practitioner N said the resident's primary doctor was not on call on 7/23/16 and 7/24/16. There were two other doctors that were on call. In case of an emergency, staff should call the exchange. If a resident was suicidal or attempted suicide, staff should have called the exchange. They would have ordered the resident to be transported to the hospital for a psychiatric evaluation. He/she would expect the staff to contact the resident's psychiatrist. The office did not receive any voice messages from the facility on 7/23/16 or 7/24/16. During an interview on 7/26/16 at 12:30 P.M., the resident's legal guardian said he/she received a phone call from the facility on 7/25/16. He/she was told that the resident wanted to die and he/she bit his/her arm. The guardian did not receive a call from the facility prior to 7/25/16. The facility has the guardian's emergency line, office number, cell number and fax lines. The guardian did not receive any messages from the facility. The guardian confirmed with the deputy of the department that the facility did not call or leave a message on 7/23/16 or 7/24/16. The resident had a history of [REDACTED]. Last month, the resident expressed suicidal feelings about his/her parent and partner. He/she was transported to the hospital. If the resident expressed suicidal feelings, the facility is expected to complete an assessment and monitor him/her. If the resident harmed him/herself, the facility is expected to call 911 so the resident can be safe. If the physician cannot be reached, staff are still expected to call 911. The facility did not tell the guardian when the incident occurred. The guardian did not have any knowledge of the resident harming him/herself in the past four years since he/she was assigned as the resident's legal guardian. During an interview on 7/27/16 at 7:15 A.M., Hall Monitor P said he/she worked on 7/23/16 at 11:00 P.M. to 7:00 A.M. Hall Monitor P was told by a nurse that the resident tried to commit suicide. The resident said he/she was sad because he/she missed his/her parent. There were two other times the resident was suicidal this year. The first time was when his/her parent had a stroke and was put in a coma. The second time was when his/her spouse left him/her. Hall Monitor P said the resident scratched his/her wrist only one time in the past. Hall Monitor P believed they were attention wounds. Hall Monitor P calmed the resident down and he/she went to his/her room. On 7/23/16, Hall Monitor P was assigned one on one monitoring with the resident until the DON took the resident off of it. Hall Monitor P said the resident was on one on one monitoring the entire shift. If a resident was placed on one on one monitoring, staff would be their own personal servant. If the resident wanted to smoke, staff would go with them. If the resident wanted food or drink, staff would provide it. Hall Monitor P had a long conversation with the resident. The resident was calm at first, but began to cry when he/she talked about his/her parent. The resident and Hall Monitor P stayed in the main area of the B-Hall until the resident went to bed around 5:00 A.M. Hall Monitor P filled out the five minute check sheet. CNA D relieved Hall Monitor P at the end of the shift. CNA D was already aware of the incident. During an interview on 7/25/16 at 3:05 P.M., Psychiatrist I said he/she was first notified on 7/25/16 that the resident scratched him/herself. The facility received orders to send to the resident out to the hospital on [DATE]. The resident had a history of [REDACTED].