Every finding on record at Lewis & Clark Gardens

Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) worked in the facility completing the duties of the DON and did not work as a charge nurse when the facility had an average daily occupancy of over 60 residents. The facility census was 86.Review of the facility's Director of Nursing Job Description, dated May 2006, showed the following:-The primary purpose of the job position is to plan, organize, develop and direct the overall operation of our nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern our facility, and as directed by the Administrator and facility policies to ensure that the highest degree of resident care is maintained al tall times;-The DON must be in the facility or involved in other work-related activities, a minimum of eight hours per day, Monday through Friday. 1. Review of the facility's daily census recapitulation, dated March 2026, showed the total daily census for the month of March 2026 was 83 to 91 residents. Review of the facility staffing sheets, dated March 2026, showed the following:-On 03/02/26, the DON worked the floor as the charge nurse on the evening shift (2:00 P.M. to 10:00 P.M.)-On 03/07/26, the DON worked the floor as the charge nurse on the night shift (10:00 P.M. to 6:30 A.M.)-On 03/08/26, the DON worked the floor as the charge nurse on the night shift;-On 03/09/26, the DON worked the floor as the charge nurse on the evening shift;-On 03/10/26, the DON worked the floor as the charge nurse on the evening shift;-On 03/16/26, the DON worked the floor as the charge nurse on the evening shift;-On 03/17/26, the DON worked the floor as the charge nurse on the day shift;-On 03/17/26, the DON worked the floor as the charge nurse on the evening shift;-On 03/20/26, the DON worked the floor as the charge nurse on the night shift;-On 03/21/26, the DON worked the floor as the charge nurse on the evening shift;-On 03/21/26, the DON worked the floor as the charge nurse on the night shift;-On 03/22/26, the DON worked the floor as the charge nurse from 4:00 A.M. to 6:00 A.M on the night shift;-On 3/23/26, the DON worked the floor as the charge nurse on the evening shift;-On 3/27/26, the DON worked the floor as the charge nurse on the night shift;-On 3/28/26, the DON worked the floor as the charge nurse on the night shift;-On 3/29/26, the DON worked the floor as the charge nurse on the evening shift. During an interview on 04/01/26 at 1:15 P.M., the DON said the following:-She worked the floor on the evening and night shifts since December 2025 since the facility was short of licensed nursing staff;-She was unaware the DON could not cover the floor routinely with a census over 60 residents;-It was difficult to work the floor and complete her DON duties. She was unable to review and audit charts, such as falls and interventions that were put in place. Some days, she worked a few hours completing the DON duties on days she worked the floor, but it was exhausting. During an interview on 4/1/26 at 12:20 P.M., the Administrator said she was unaware the DON could not work the floor routinely with a census over 60. She expected the facility to follow the regulatory requirement regarding the DON and coverage on the floor.

Based on observation and interview, the facility failed to provide a comfortable and homelike environment free from the presence of persistent urine and fecal odors with the carpet maintained in good repair. The facility census was 86.Review of the facility policy, Housekeeping Department, Seven Steps of Cleaning a Resident Room, undated showed no dust, no spots, no smudges, no smells equaled clean. 1. Observations on 03/20/26 from 9:30 A.M. to 4:30 P.M. showed the following:-Upon entry to the facility, there was a very strong smell of air freshener throughout the lobby area;-C hallway carpeted with several areas of stained carpet and a strong smell of air freshener;-room [ROOM NUMBER] there was a strong urine smell;-room [ROOM NUMBER] there was a strong urine smell;-B hall way carpet with several areas of stained carpet and a faint smell of urine covered up by a strong smell of air freshener. Observations on 3/31/26 at 9:45 A.M. to 4:30 P.M. showed the following:-Upon entering the facility, a strong odor of urine was noted throughout the lobby area;-The A hallway was noted to have a strong odor of urine throughout the entire hall;-The B hallway was noted to have a strong odor of urine and feces close to the nurses station;-room [ROOM NUMBER] had a strong odor of urine and feces and there were several areas of stained carpet. Observations on 3/31/26 at 7:45 A.M. through 2:00 P.M. showed the following:-Upon entering the facility an odor of urine covered up by air freshener was noted in the lobby area;-A hallway was noted to have a strong odor of urine throughout the entire hall;-B hallway was noted to have an odor of urine covered up by a strong odor of air freshener. During an interview on 4/1/26 at 9:35 A.M. the Housekeeping Supervisor said the following:-There were two floor technician staff, and they rotated cleaning the carpets daily. A floor extractor was used and an odor cleaning agent to clean the carpets;-The carpets on each hall were cleaned every two to three days;-The odors in the facility were usually related to the floors;-One resident on the A hall would not allow staff in his/her room and that room had very strong odors;-Certain residents spilled their urinals often and cleaning the floors was a constant battle;-Some of the aides always sprayed some type of spring time air freshener spray to help with the odors. During an interview on 4/1/26 at 12:20 P.M. the Administrator said the following:-The facility did not have a policy specific to odors;-She would expect staff to find the source of any odor and eliminate it;-Carpets were cleaned daily with carpet extractors on a rotation of each hall and as needed for spills;-She would expect the facility to be homelike which included being odor free. 2963297

Based on interview, and record review, the facility failed to consistently complete an investigation following falls to identify the root cause for the falls and failed to consistently evaluate the effectiveness of interventions and identify/revise interventions to prevent falls for two residents (Resident #5 and #1), in a review of 10 sampled residents. Staff failed to immediately report Resident #1's fall to the nurse per facility policy prior to assisting the resident off the floor following a fall. The facility census was 86. Review of the undated facility policy, Event Investigation, showed the following:-Purpose: to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. To identify any injuries after a resident sustains an event;-Any staff member who discovers, witnesses or is involved in an event should immediately report the event to the nurse in charge. The charge nurse is responsible for completion of the Report of Event form and forwarding to the Director of Nursing as soon as possible.-Description of the event: describe (known, factual details) the event and include pertinent comments made by the person involved and any witness comments;-Describe the exact location of the event: describe precisely where the event occurred;-Describe the type of event, the outcome of the event, any injures, vital signs, mental status, neurological (neuro, anything related to the nervous system, which includes the brain, spinal cords and nerves)status, range of motion and any pain;-Document any first aid that was given;-Actions taken to prevent recurrence: what was done immediately to prevent the event from happening again. Review of the undated guidelines for the facility's Fall Champion Program showed the following:-After the primary portion of the morning meeting is completed, every fall event should be reviewed to ensure appropriate interventions were implemented and documentation was complete;-This should include review of progress notes, fall event, neuro check information, labs, medications, therapy and/or restorative documentation where applicable;-An Interdisciplinary Team (IDT) note will be completed in the progress notes and should consist of the circumstances surrounding the fall, interventions already in place and new interventions;-Prior to the conclusion of the meeting, a fall risk assessment will also be completed for the resident. The care plan and the resident's care card must also be updated;-After 72 hours is complete, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff) Coordinator will review the fall event and ensure all documentation is complete. The event must be closed until you have reviewed all the documentation. Progress notes, neuro checks and the care plan;-The community's IDT will meet weekly and discuss the community's falls and interventions put into place and their effectiveness. The fall champion will collaborate with the MDS Coordinator to ensure the resident's care plan was updated;-Post fall guidelines included stay close to the resident, provide emergency care as needed, take vital signs and assess condition of the resident, notify the physician, fall champion, and administrator, notify family and responsible party and document such in the fall event. The charge nurse will initiate preventative fall interventions immediately and document those in the resident's care plan. 1. Review of Resident #5's undated face sheet showed the following:-The resident was admitted to the facility on [DATE];-Diagnoses included repeated falls, dementia, cerebral infarction (stroke), difficulty walking and muscle weakness. Review of the resident's care plan, dated 11/28/25, showed the resident had a history of falling. Staff were to keep the resident's bed in the lowest position and brakes on. Review of the resident's event report, dated 2/23/26 at 4:25 A.M., showed the following:-The resident had an unwitnessed fall. The resident was found on the floor next to his/her bed. The resident had redness to his/her right knee and left hip;-Possible contributing factors included cardiac/respiratory disease, orthopedic condition and dementia;-Interventions included rest and hospice to order a fall mat. Review of the resident's care plan, dated 2/23/26, showed the following:-Initiated on 2/23/26, the resident rolled out of bed. Ordered fall mats and bolster mattress (mattress with raised sides to help prevent rolling out);-Initiated on 2/23/26, analyze resident's fall to determine pattern and trend. Review of the resident's event report, dated 03/06/26 at 10:30 A.M., showed the following:-The resident had an unwitnessed fall. The resident lay on the floor next to his/her bed and was face down. The resident had redness to the left side of his/her rib cage;-Complaint of pain to lower back. Pain observation: excruciating pain;-Possible contributing factors present were none;-Immediate measures taken were none;-Mat on floor and bed was in the low position. Review of the resident's care plan showed no documentation staff updated the care plan following the resident's fall on 03/06/26 and no documentation to show staff reviewed or revised current interventions to prevent additional falls.Review of the resident's progress note, dated 3/7/26 at 5:02 A.M., showed staff went to the resident's room at 1:15 A.M. and found the resident on the floor by the bed. On assessment, the resident had a skin tear on the right hand. Staff cleaned the skin tear and applied antibiotic ointment. Staff assisted the resident back to bed and administered as needed (PRN) medication for pain and anxiety.Review of the resident's medical record showed no documentation staff completed an event report, including possible contributing factors or analyzed for patterns or trends as directed by the resident's care plan.Review of the resident's care plan showed no documentation staff reviewed or revised the care plan interventions to address falls following the resident's fall on 03/07/26. Review of the resident's event report, dated 03/11/26 at 9:00 A.M., showed the following:-The resident had a witnessed fall from his/her wheelchair. The resident had a skin tear to left inner arm below the elbow;-The resident complained of back pain. Pain observation showed severe to horrible intense pain;-Immediate intervention was first aid;-Fall mat already in place next to bed;-No interventions used;-Called hospice to see if a Broda chair (specialized wheelchair that tilts and reclines) could be obtained. Review of the resident's medical record showed no evidence staff reviewed or revised the care plan or analyzed for patterns or trends following the fall on 03/11/26. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Short and long-term memory impairment;-Cognitive skills for daily decision making was severely impaired, never or rarely made decisions;-Dependent on staff for ADLs;-The resident had falls since the previous assessment;-The resident had two or more falls without injury and one fall with injury (except major) such as skin tears, lacerations, and abrasions. Review of the resident's event report, dated 03/16/26 at 6:56 A.M., showed the following:-The resident had an unwitnessed fall in his/her room;-The resident exhibited moderate pain in the right hip and right side;-The resident had redness to his/her right hip and the right side of his/her back;-Immediate measures taken: analgesics;-Preventative interventions implemented: adjust bed to the lowest level;-Interventions effective. Review of the resident's medical record showed no documentation staff reviewed or revised the care plan or analyzed for patterns or trends following the resident's fall on 03/16/26. Review of the resident's event report, dated 03/18/26 at 6:25 P.M., showed the following:-The resident had an unwitnessed fall. The CNA reported he/she found the resident on the floor. There was no fracture or injury noted;-Contributing factors, interventions taken, and preventative interventions implemented were not completed on the event report. Review of the resident's progress notes, dated 3/18/26 at 8:51 P.M., showed the resident had an unwitnessed fall at 6:00 P.M. The CNA reported he/she entered the resident's room and found the resident on the floor. There were no fractures or injury noted.Review of the resident's medical record showed no documentation staff reviewed or revised the care plan or analyzed for patterns or trends following the resident's fall on 03/18/26. Review of the resident's progress note, dated 3/20/26 at 5:35 P.M., showed the following:-The resident had an unwitnessed fall. An aide found the resident on the floor next to his/her bed and notified the nurse;-Upon arrival, no new injuries were noted. Review of the resident's medical record showed no documentation staff completed an event report, including any contributing factors and interventions, reviewed or revised the care plan or analyzed for patterns or trends following the fall on 03/20/26.Review of the resident's progress note, dated 03/25/26 at 6:35 P.M., showed an aide found the resident at 6:15 P.M. on the floor mat in his/her room. No new injuries noted at this time.Review of the resident's medical record showed no evidence staff completed an event report, including any contributing factors and interventions, or reviewed or revised current interventions that were in place or analyzed for patterns or trends following the fall on 03/25/26. During an interview on 4/1/26 at 9:50 A.M., Licensed Practical Nurse H said the following:-The resident had a lot of falls, and most of his/her falls were unwitnessed;-The only interventions in place to prevent falls were a fall mat, a low bed and bolsters, and staff tried to keep an eye on the resident;-The MDS Coordinator updated the care plans with any new interventions. During an interview on 4/1/26 at 11:20 A.M., the MDS Coordinator said the following:-Residents at risk for falls should have a care plan in place related to falls. The interventions should be individualized to each resident;-He/She was to add all falls to the care plan;-He/She was off work for a few weeks and was not aware Resident #5 had multiple falls in March;-He/She had not reviewed or revised any care plans with falls or new interventions related to falls for a while;-The facility did not have routine interdisciplinary meetings to discuss falls. During an interview on 4/1/26 at 1:15 P.M., the Director of Nursing (DON) said the following:-She was covering on the floor and was unable to review and audit charts for falls and interventions that were put in place. Also, routine interdisciplinary (IDT) meetings were not taking place to discuss and review falls;-Licensed nursing staff should review the residents' care plans after each fall and revise as needed. 2. Review of Resident #1's medical record showed no documentation to show staff completed a fall risk assessment.Review of the resident's nurse's note, dated 03/02/26 at 6:34 A.M., signed by Registered Nurse (RN) A, showed the resident had an unwitnessed fall in his/her room at 5:30 A.M. Staff assessed the resident and there were no fractures, but the resident complained of mild pain on his/her left shoulder. Staff administered pain medication.Review of the resident's medical record showed no documentation staff completed an event report with interventions to prevent falls after the resident fell on [DATE]. During an interview on 03/20/26 at 4:30 P.M., Registered Nurse (RN) A said the following:-He/She was the resident's nurse on 03/02/26;-When he/she returned from a break, a staff member told him/her the resident fell out of bed;-CNA C had already put the resident back into bed before he/she found out about the fall;-CNA C told him/her the resident fell out of bed and there were no injuries, so CNA C and CNA B put the resident back in bed. During an interview on 03/27/26 at 3:07 P.M., CNA C said he/she could not find RN A and the resident was asking to get off the floor, so he/she moved the resident's arms and legs and asked if the resident was hurt. He/She saw a lot of nurses do the assessment after a resident fell, and the resident did not complain of any pain. He/She and CNA B assisted the resident off the floor.Review of the resident's care plan showed no documentation staff developed a care plan with interventions to prevent falls after the resident fell on [DATE].Review of the resident's nurse's note, dated 03/18/26 at 6:36 A.M., showed another resident called staff to the resident's room. The resident was on the floor near the window. The resident could not say exactly what happened. On assessment, staff did not identify any injury.Review of the resident's medical record showed no documentation staff completed an event report with interventions to prevent falls after the resident fell on [DATE]. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 03/23/26, showed the following:-Moderate cognitive impairment;-Dependent upon staff for activities of daily living (ADLs);-Diagnoses of Alzheimer's disease and non-Alzheimer's dementia (various neurodegenerative diseases causing cognitive decline that are not caused by Alzheimer's disease) and spinal stenosis (a chronic, degenerative condition where the spaces within the spine narrow, compressing the spinal cord or nerves);-At risk for falls. Review of the resident's care plan, dated 03/24/26, showed there was no care plan developed for falls. There was no documentation of the fall that occurred on 03/18/26 and no interventions were in place to help prevent future falls. 3. During interviews on 04/01/26 at 8:00 A.M. and 2:15 P.M., the Administrator said the following:-It was not appropriate for CNAs to get up a resident after a fall before a nurse assessed the resident;-She expected staff to follow the facility event/accident policy for falls;-Any nurse can update the care plans with interventions after a resident fell;-Staff should update the care plans with each fall. Staff should review the interventions after each fall and implement new interventions as needed;-The facility did not conduct routine IDT meetings to review falls. 27946112966988

Based on interview and record review, the facility failed to report allegations of abuse immediately and no later than two hours to the state survey agency after an allegation was made of physical abuse towards one resident (Resident #1) in a review of seven sampled residents. The facility census was 85. Review of the undated facility policy for Abuse and Neglect showed the following:-It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion-All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property by facility employees, contract employees, volunteers, contract services, consultants, physician, visitors, family members or other individuals will be reported immediately but no later than the following timeframes. If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made;-Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator;-The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal Requirements. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/6/26 showed the following:-Able to make self-understood and able to understand others;-BIMS (Brief Interview for Mental Status, a quick cognitive screening tool used in long-term care to assess orientation, memory, and recall) with a score of 13 (indicates a cognitively intact or normal mental status, meaning the individual has good orientation and memory);-Dependent upon staff for Activities of Daily Living (ADL's);-No behaviors;-Diagnoses of hemiparesis, (weakness on one entire side of the body, affecting the arm, leg, and sometimes the face, often resulting from a stroke or brain injury, causing difficulty with movement, coordination, balance, and grasping objects), respiratory failure and Traumatic Spinal Cord Dysfunction (damage to the spinal cord from an external force, like car accidents or falls, causing loss of motor, sensory, or autonomic function below the injury level, leading to paralysis, impaired sensation, bowel/bladder issues, and other systemic complications). Review of the resident's care plan for behaviors dated 04/16/2025 showed the following:-Problem: I'm followed by a mental health professional as I become very easily angered, yell at staff, yell at my family. I cause for the other residents to be disturbed especially at night;Goal: I will be able to express myself without yelling at staff and loved ones.Interventions: My family member who is my Emergency Contact is aware of my behavior and can at times help me de-escalate, I call him/her regardless of the time, another family member is also helpful. With encouragement from staff, help from mental health provider, and if needed medication as last resort I will be able to express myself clearly without yelling at staff/family. Review of the resident's care plan for Behavioral Symptoms dated 10/12/23 showed the following:-Problem: I have impaired mobility, cannot bear weight on my legs, can really use my right arm and require for staff to preform my mobility/turning ADL's, I also push against the staff, scream at them and demand they pull on me in unsafe ways.-Goal: I will relax and allow for staff to take care of me, stop pushing against them and becoming angry/verbal loud outburst/telling staff how to do my mobility/movements/turning in inappropriate way.-Interventions: Please attempt to re-direct me when I start to scream out loud and demand you re-position me the way I want you to do (pulling on my arms/shoulders), remind me this is not a safe manner and that it could lead to physical concerns for myself as well as for potential injuries for both me and the staff. When I requested to be re-positioned, please remind me that pulling on me (which I request to have my arms pulled) is not good for myself or for the provider. Since I'm in bed a lot more due to my wound I require little more re-positioning than if I were up out of bed for a while. During an interview on 1/14/26 at 9:00 A.M. the Administrator said the following:-Last week or possibly Monday, January 12th, Resident #1 told Certified Nurse Aide (CNA) B a staff member who the resident called Firehead was rude to him/her;-CNA B had reported this to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) either on Friday last week or Monday, January 12, 2026, she could not remember the exact date;-After talking with the resident and describing several staff members, the resident identified CNA A as the identified staff;-The resident told CNA B that CNA A had squeezed her face and told him/her to shut up;-At first she thought this could be abuse, but when she interviewed the resident with CNA A in the room, the resident denied the allegation; -She could not remember the exact date on when this was reported to her;-She did not report this to the state agency or complete an investigation as the resident denied the allegation. During an interview on 1/14/26 at 10:37 A.M. CNA B said the following:-On Friday, January 9th, he/she and the Activity Director were in the resident's room providing care and the resident told them that a staff member he/she called Firehead told him/her to shut up and squeezed his/her cheeks;-He/She reported this to the DON. During an interview on 1/14/26 at 11:15 A.M. the Activity Director (AD) said the following:-He/She and CNA B went to Resident #1's room to provide care;-He/She thinks this was Monday, January 12th, but could have been last week;-The resident told them that he/she felt like he/she was falling out of bed and began to scream when a staff member the resident called Firehead came into his/her room and squeezed his/her cheeks;-He/She and CNA B reported this to the Administrator;-On Monday, the 12th, the Administrator said the DON and ADON had talked with the resident and the resident denied CNA A had squeezed his/her cheeks. During an interview on 1/14/26 at 1:10 P.M. Resident #1 said the following:-Last week, Firehead, he/she did not know the staff member's real name, came into his/her room and squeezed his/her face; it really hurt;-He/she felt like he/she was falling out of the bed, and he/she began yelling for help;-A staff member he/she calls Firehead came into the room and yelled at him/her to shut up, it scared him/her. The then staff member came over and put his/her hands on his/her face and squeezed his/her cheeks real hard and told him/her to be quiet. During an interview on 1/14/26 at 1:20 P.M. and again at 3:00 P.M. the ADON said the following:-Upon interview at 1:20 P.M. the ADON said that the incident between Resident #1 and CNA A was reported on 1/12/26, then after thinking about the days and reviewing the schedule, he/she stated that the incident was reported to him/her and the Administrator on 1/9/26 by CNA A and the AD;-The resident told him/her and the DON that he/she felt like he/she was falling out of the bed and was yelling when CNA A came into his/her room and told him/her to be quiet and squeezed his/her cheeks and it hurt;-After reporting this to the Administrator, the Administrator walked CNA A in front of the resident's door and the resident identified CNA A as the staff member who yelled at him/her;-The administrator then brought CNA A into the residents' room and in front of the resident asked the resident if this was the staff member who yelled at him/her. The resident said yes, it was the staff member who yelled at him/her. During an interview on 1/14/26 at 1:45 P.M. the DON said the following:-She was at the nurses' station when CNA B and the AD came to her and said they wanted to report potential abuse;-She took CNA B and the AD to the Administrator's office;-She heard CNA B, and the AD tell the Administrator that Resident #1 reported to them that a staff member who he/she calls Firehead yelled at him/her and grabbed his/her face;-She left the office to get the schedules to see who had worked and inform the ADON of the allegations;-She and the ADON went to the resident's room and the Administrator walked CNA A by the resident's door and the resident identified CNA A as Firehead;-The administrator brought CNA A into the resident's room and began asking the resident and CNA A questions about the allegations;-She left the room and did not hear all the questions or answers;-Upon initial interview the DON said this was reported on 1/12/26, but then stated it was reported on 1/9/26. During a telephone interview on 1/15/26 at 10:30 A.M. the Administrator said the following:-The incident was reported to her on Friday, January 9th, not 1/12/26 as initially said;-She did not report the allegation, as the resident denied staff yelled at him/her;-She did interview and asked questions with CNA A in the room with the resident;-She did not feel any abuse occurred or that the allegations needed to be reported since the resident denied the allegations. 2719121

Based on interview and record review the facility failed to conduct a timely and thorough investigation of an allegation of abuse involving one resident (Resident #1), in a review of seven sampled residents. Resident #1 made an allegation of verbal and physical abuse on 1/9/26, involving a staff identified by the resident as Certified Nurse Aide (CNA) A. The facility census was 85.Review of the undated facility policy for Abuse and Neglect showed the following:-It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion;-It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated;-The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately;-The investigation will include who is involved, resident statements, resident roommate statements (if applicable), interviews from residents who received care from the alleged staff, interviews from different department staff, involved staff and witness statements of events;-Steps taken to protect residents-Immediate assessment of the alleged victim and provision of medical treatment if necessary; evaluation of whether the alleged victim feels and safe and if he/she does not feel safe, taking immediate steps to protect the resident; if the alleged perpetrator is a facility staff member, removal of the alleged perpetrator's access to the alleged victim and other residents and assurance that ongoing safety and protection is provided to the alleged victim and other residents. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/6/26 showed the following:-Able to make self-understood and able to understand others;-BIMS (Brief Interview for Mental Status, a quick cognitive screening tool used in long-term care to assess orientation, memory, and recall) with a score of 13 (indicates a cognitively intact or normal mental status, meaning the individual has good orientation and memory);-Dependent upon staff for Activities of Daily Living (ADL's);-No behaviors;-Diagnoses of hemiparesis )weakness on one entire side of the body, affecting the arm, leg, and sometimes the face, often resulting from a stroke or brain injury, causing difficulty with movement, coordination, balance, and grasping objects), respiratory failure and Traumatic Spinal Cord Dysfunction (damage to the spinal cord from an external force, like car accidents or falls, causing loss of motor, sensory, or autonomic function below the injury level, leading to paralysis, impaired sensation, bowel/bladder issues, and other systemic complications). During an interview on 1/14/26 at 9:00 A.M. the Administrator said the following:-Last week or possibly Monday, January 12th, Resident #1 told Certified Nurse Aide (CNA) B that a staff member who the resident calls Firehead was being rude to him/her;-CNA B had reported this to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) either on Friday last week or Monday, January 12, 2026, she could not remember the exact date;-After talking with the resident and describing several staff members, the resident identified CNA A as Firehead;-The resident told CNA B that CNA A squeezed his/her face and told him/her to shut up;-At first she thought this could be abuse, but when she interviewed the resident with CNA A in the room, the resident denied the allegation;-She could not remember the exact date on when this was reported to her;-She did not report this to the state agency or complete an investigation as the resident denied this allegation. During an interview on 1/14/26 at 1:10 P.M. Resident #1 said the following:-Last week, Firehead (CNA A), came into his/her room and squeezed his/her face, it really hurt; /she began yelling for help;-CNA A came into the room and yelled at him/her to shut up, it scared him/her. The staff member then came over and put his/her hands on his/her face and squeezed his/her cheeks real hard and told him/her to be quiet. Review of the facility documentation showed there were no interviews or statements from the alleged perpetrator or any other witnesses, residents or staff members. There was no evidence the facility completed a thorough investigation. During a telephone interview on 1/15/26 at 10:30 A.M. the Administrator said the following:-The incident was reported to her on Friday, January 9th, not 1/12/26 as initially said;-She had not completed an investigation and will complete one and sent to the state agency. 2719121

Based on observation, interview, and record review, the facility failed to provide each resident with a palatable meal served at appetizing temperatures and texture and that conserved nutritive value and flavor. The facility census was 89.Review of the facility policy, Food Temperatures, dated April 2015, showed the following:-The Dietary Manager or designee is responsible for seeing that all food is the proper cooking temperature(s) as indicated on the standardized recipe before meal service begins;-The temperature of hot foods and beverage should be maintained no less than 135 degrees Fahrenheit (F) during the duration of the meal service;-Hot food and beverage should be at least 120 degrees F when served to the resident;-Temperature of potentially hazardous cold foods should be maintained at no more than 41 degrees F. Prepare cold items a day in advance when possible. Place in the freezer 45 minutes before serving and use ice baths when needed. Review of the undated facility policy, Menus, showed standardized recipes are available in the dietary department for all foods on the menu and should be followed to ensure nutritive values and food palatability is achieved. 1. Review of the fall/winter 2025 menus, dated 9/2025, showed the following recipes:-Hot food temperatures should be held at a minimum required temperature or higher for service;-Cold food should be held at 41 degrees F or below for service;-The recipe for old fashioned banana pudding showed to line the bottom of a pan with vanilla wafers, slice half of the amount of bananas over the vanilla wafers, spoon canned banana pudding over the wafers and bananas, top the pudding with the other half of the bananas and chill. Before serving, top each portion with one tablespoon of whipped topping;-The facility did not provide a recipe for the tossed salad upon request. Review of the Resident Council Minutes, dated 11/6/25, showed the following:-The residents complained the food on the hall trays was cold when it arrived;-The Dietary Manager was responsible for food concerns;-No resolution was documented;-The next resident council meeting was scheduled for 12/4/25. Review of the lunch menu for 11/18/25, according to the dietary menu spread sheet for Fall/Winter 2025, showed staff were to serve the following:-Hot dog on bun;-Chili Con Carne;-Crackers;-Tossed salad;-Margarine;-Old fashioned banana pudding. Review of the dietary Food Temperatures log, dated November 16-18, showed the following:-The lunch and dinner meals temperature log does not have a place to enter temperatures for a dessert;-The dinner temperature log on 11/17/25 for the starch for pureed food was 108 degrees F;-The dinner temperature log on 11/17/25 for the vegetable (broccoli) was blank;-The lunch temperature log on 11/18/25 for the vegetable was blank. During an interview on 11/18/25 at 10:20 A.M. Resident #1 said the following:-The food was not good;-The food was undercooked a lot of the time. During an interview on 11/18/25 at 11:23 A.M. Resident #3 said the following:-The food was bad;-Sometimes he/she could not tell what it was he/she had on the plate;-The food was never hot, it was sometimes warm, but not hot. During an interview on 11/18/25 at 11:34 A.M. Resident #4 said the following:-The food was bad;-The food was undercooked a lot of the time;-The food was bland and he/she did not think the kitchen staff used any seasonings. During an interview on 11/18/25 at 11:38 A.M. Resident #5 said his/her food was always cold by the time staff delivered it to his/her room and it tasted awful. Observation on 11/18/25 at 12:51 P.M. of the sample test tray showed the following:-The chili tasted very salty;-The hot dog was lukewarm and the bun was dried out on one side;-The salad was lukewarm and limp with an abundance of Italian salad dressing. Some of the dressing pooled in the bottom of the bowl;-The dessert was an individual bowl of banana pudding with whipped topping on the top, it was barely cool and had a piece of black fuzz on the outside edge of the parfait. There were no vanilla wafers or fresh bananas in the dessert;-The temperature of the hot dog was 118 degrees Fahrenheit;-The temperature of the salad was 70.7 degrees Fahrenheit;-The temperature of the banana parfait was 58.5 degrees Fahrenheit;-There was no margarine, or condiments were on the tray or offered. During an interview on 11/18/25 at 1:45 P.M. Resident #6 said the following:-The meals tasted awful;-Today he/she had a salad and it was a sloppy mess and room temperature. During an interview on 11/18/25 at 2:18 P.M. Resident # 7 said the following:-90% of the time the food was served cold;-80% of the time the food came to his/her room without any type of covering on the plate and the food was dried out. During an interview on 11/20/25 at 1:09 P.M. Dietary Aide A said the following:-He/She did not get the temperatures taken on the vegetables on 11/17/25 and 11/18/25 because he/she was so busy helping other people in the kitchen and forgot;-The tossed salad was already made for the 11/18/25 lunch and he/she did not add salad dressing to the lettuce. He/She thought the residents should choose what kind of salad dressing they would like. She usually made up cups of ranch and Italian salad dressing and let them choose;-When the salad was taken out of the refrigerator the Dietary Manager said the recipe said to add the dressing to the lettuce;-The Dietary Manager was the one who added the Italian dressing to the lettuce. During an interview on 11/18/25 at 2:53 and 11/20/25 at 11:39 A.M. the Dietary Manager said the following:-The registered dietician set up the menus and he/she followed them to prepare meals;-The tossed salad for the 11/18/25 lunch meal was prepared and placed in the refrigerator. It was taken out and then a thick Italian dressing was poured over the lettuce and placed on the serving table in a pan of ice to keep it cold;-All food temperatures were taken at the time they were placed on the serving/steam table, about 30 minutes prior to serving the residents; -Individual domes were used on heated plates for the hot portion of the meals to keep the food hot; -It was Dietary Aide A's responsibility to record food temperatures for the dinner meal on 11/17/25 and he/she did not record the temperature of the broccoli;-It was Dietary Aide A's responsibility to record food temperatures for the lunch meal on 11/18/25 and he/she did not record the temperature of the tossed salad;-She expected all food items to have temperatures recorded for each meal;-She used more dressing that the recipe required. If she only used the required amount of dressing the aids keep running back and forth to the kitchen to get more salad dressing for residents;-The old fashioned banana pudding was prepared in individual bowls but should have been prepared in a pan with vanilla wafers on the bottom. The facility was out of bananas so they could not put them in the pudding and they did not make any substitutions;-She expected staff to follow the instructions on the recipes to prepare the food;-She had received complaints from the residents that the food was cold. She was doing everything she could to keep the food hot. They had a plate warmer for metal plates that sat in a plastic bottom and then covered with a plastic dome for hall trays;-It typically took the dietary staff 10 to 15 minutes to plate the 100 hall trays and get them to the hall, less than 10 minutes to plate the 200 hall trays and get them to the hall, and five to seven minutes to plate the 300 hall trays and get them to the hall;-She was not sure why it took nearly an hour to get all the hall trays to the residents on 11/18/25. During an interview on 11/18/25 at 3:30 P.M. and 11/20/25 at 1:15 P.M. the Administrator said the following:-She expected dietary staff to serve food that was that the correct temperatures and palatable to the residents;-She expected dietary staff to follow the menus and recipes made available to them;-There were no instructions to tell the dietary staff how much salad dressing to add to the lettuce for a tossed salad;-Nothing had been brought to her attention by staff or residents that the food was cold or did not taste good. MO2623665

Based on observation, interview, and record review, the facility failed to provide bathing for four residents (Residents #1, #2, #3, and #4), who relied on staff to assist with their activities of daily living (ADLs), in a review of five sampled residents, during the time the residents were temporarily relocated to the COVID isolation unit. The facility census was 85. Review of the facility's ADL policy, dated March 2015, showed no documentation related to how often a resident should be offered and/or assisted with bathing. 1. Review of Resident #1's undated face sheet showed he/she received hospice services.Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 07/10/25, showed the following:-His/Her cognition was intact;-He/She required substantial/maximum assistance with bathing. Review of the resident's care plan, last reviewed/revised on 07/17/25, showed the following:-He/She needed some assistance with activities of daily living (ADLs);-Staff would assist him/her with bathing.(Review showed no documentation related to how frequently staff were to assist the resident with bathing.) Review of the facility's undated shower schedule showed the resident was to receive a shower on Mondays and Thursdays. Wednesday was a makeup shower day. Review of the resident's shower sheets showed he/she received a shower on 08/28/25. (Review of the shower sheets and the resident's medical record showed no documentation the resident received a shower on 08/29/25 through 08/31/25.) Review of the resident's nursing progress notes, dated 09/01/25, showed the resident tested positive for COVID and was placed on COVID isolation unit. During an interview on 09/10/25 at 4:55 P.M., the Director of Nursing (DON) said she could not locate any shower sheets completed for the resident from 09/01/25 through 09/09/25. Review of the resident's shower sheets, and medical record showed no documentation the resident received a shower on 09/01/25 through 09/10/25 (a total of 13 days since his/her last shower on 08/28/25). During an interview on 09/10/25 at 12:18 P.M., the resident said the following:-He/She was placed on the COVID isolation unit on 09/01/25;-His/Her last shower was on 08/28/25, and he/she had not changed his/her clothes; -He/She was due for a shower on 09/02/25, but no one offered or gave him/her a shower; -He/She received hospice care, but the hospice aides were not allowed to come to the COVID unit to assist him/her with a shower;-He/She asked facility staff to assist him/her with a shower. The staff always told him/her they would come back later, and then they never returned;-He/She felt bad and wanted a shower. Observation on 09/10/25 at 12:18 P.M. showed the resident's hair was greasy and disheveled. 2. Review of Resident #2's undated face sheet showed he/she received hospice services. Review of the resident's admission MDS, dated [DATE], showed the following:-His/Her cognition was intact;-He/She had occasional urinary incontinence;-He/She required partial/moderate assistance with bathing. Review of the resident's care plan, last reviewed/revised on 09/01/25, showed the following:-He/She experienced bladder incontinence at times;-He/She received hospice services.(The resident's care plan did not include the resident's need for assistance with bathing or documentation to show how often the resident was to receive bathing.) Review of the resident's progress notes, dated 09/01/25, showed the resident tested positive for COVID and was placed on the COVID isolation unit. Review of the resident's quarterly MDS, dated [DATE], showed the following:-His/Her cognition was intact;-Bathing assessment was not completed due to medical condition (the resident was on COVID isolation);-He/She had occasional urinary incontinence. Review of the facility's shower schedule showed the resident was to receive a shower on Tuesdays and Fridays. Wednesday was a makeup shower day, if needed. During an interview on 09/10/25 at 4:55 P.M., the DON said she could not locate any shower sheets completed for the resident from 09/01/25 through 09/09/25. During an interview on 09/10/25 at 1:45 P.M., the resident said the following:-He/She was placed on COVID isolation on 09/01/25 until 09/10/25;-He/She did not receive a shower the entire time he/she was on the isolation unit;-He/She received hospice services, but the hospice aides could not go on the COVID isolation unit to assist him/her with bathing;-None of the facility staff offered to assist him/her with a shower;-When he/she asked about a shower, the staff told him/her they were trying to catch up or had too many other things to do;-At one point, staff provided him/her with a washcloth to wash his/her own body, but he/she wanted a shower;-Not having a shower for nine days made him/her feel dirty. 3. Review of Resident #3's admission MDS, dated [DATE], showed the following:-His/Her cognition was severely impaired;-He/She was frequently incontinent of bladder;-He/She was always incontinent of bowel;-He/She required substantial/maximum assistance with bathing. Review of the resident's care plan, last reviewed/revised on 09/01/25, showed the resident tested positive for COVID and required contact isolation (09/01/25).(Review showed no documentation the resident needed assistance with bathing or how often the resident was to receive bathing.) Review of the facility's undated shower schedule showed the resident was to receive showers on Tuesdays and Fridays. Wednesday was a makeup shower day, if needed. Review of the resident's nursing progress note, dated 09/01/25, showed the resident tested positive for COVID and was placed on the COVID isolation unit. Review of the resident's shower sheets, dated 09/01/25 until 09/10/25, showed no documentation staff offered and/or the resident received a shower/bathing. Observation on 09/10/25 at 5:00 P.M. showed the resident had a moderate amount of facial hair on his/her face. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed the following:-His/Her cognition was moderately impaired;-He/She was always incontinent of bowel and bladder;-He/She was dependent on staff for bathing. Review of the resident's care plan, last reviewed/revised on 09/16/25, showed he/she required total care with ADLs. (Review showed no documentation the resident required assistance with bathing or how often the resident should receive bathing.) Review of the facility's undated shower schedule showed no documentation of when the resident should receive a shower. Review of the resident's shower sheets from 09/01/25 through 09/10/25 showed the following:-No documentation the resident received a shower/bathing on 09/01/25 through 09/03/25;-The resident received a shower on 09/04/25;-No documentation the resident received a shower/bathing on 09/05/25 through 09/10/25 (six days since his/her last documented shower). Observation on 09/10/25 at 5:40 P.M. showed the resident was currently located in a room on the COVID isolation unit. During an interview on 09/10/25 at 5:40 P.M., the resident said the following:-He/She had been on the COVID isolation unit for five days; -He/She was supposed to receive a shower on Tuesdays and Fridays;-He/She had not received a shower since he/she was placed on the isolation unit; -He/She felt dirty and would like to shower;-He/She had not brushed his/her teeth since arriving on the isolation unit, until today;-Staff did not have time for him/her. 5. During an interview on 09/10/25 at 4:55 P.M., the DON said the following:-Residents, including residents who were on the COVID isolation unit, were supposed to receive a shower at least twice a week;-Certified Nurse Assistant (CNA) A was the main shower aide on the COVID isolation unit, but all CNAs were to offer and assist residents with showers;-Staff followed a shower schedule which consisted of Monday/Thursday and Tuesday/Friday schedule. Wednesday was a makeup date if a resident did not receive a shower on their scheduled shower day;-Staff documented when they completed a shower on the shower sheets and turned them into the nursing office;-The Assistant Director of Nursing (ADON) audited the shower sheets;-The shower on the COVID isolation unit was not draining properly last week, but staff were to offer a bed bath and/or provide a wash basin for residents to wash off if the shower was down. During an interview on 09/10/25 at 5:30 P.M., Nurse Assistant (NA) C said the following: -There was a functional shower on the COVID isolation unit;-The shower on the COVID isolation unit was not draining properly last week but was only out of service for a few hours. During an interview on 09/15/25 at 10:30 A.M., CNA A said the following:-He/She started as shower aide on 08/04/25, but was not at the facility on 08/28/25 through 09/08/25;-He/She returned on 09/09/25 and worked in the COVID isolation unit;-He/She was able to complete one shower on 09/09/25 before the shower drain backed up and had to wait for a plumber to repair it; -Resident #1 was on hospice and the hospice aides provided showers for the resident;-Resident #1 asked him/her to assist with a shower when he/she returned on 09/09/25, but the shower was broken, and he/she was unable;-He/She did not know Resident #2;-He/She did not know if Resident #3 received showers while he/she was gone from work (08/28/25 through 09/08/25). During an interview on 09/15/25 at 10:15 A.M., the Assistant Director of Nursing (ADON) said the following:-Resident #1 and Resident #2 received hospice services. The hospice aide was to assist the residents with showers twice a week. The facility staff could provide a shower to the residents receiving hospice if the residents request a shower or if staff noticed the residents needed a shower. Otherwise, the hospice aide would complete the residents' showers; -The CNAs were responsible to assist residents with showers on the COVID isolation unit even if they were on hospice; -Staff completed shower sheets and gave them to him/her when completed;-She audited the shower sheets daily when she was at the facility, but she had been out of the facility for medical reasons. During an interview on 09/15/25 at 11:20 A.M., the Administrator said the following:-Residents, including residents who resided on the COVID isolation unit, were supposed to receive showers twice a week and as needed/requested;-The shower on the COVID isolation unit was not working properly for two days. Staff reported they gave bed baths during that time, but did not complete shower sheets for the bed baths completed;-Bathing requirement was the same for those residents who received hospice services;-Typically, there was a hospice aide who assisted with bathing. If the hospice aide did not provide the bath/shower, the facility staff were to complete the baths/showers for the hospice residents;-To her knowledge, hospice aides provided care while residents were on the COVID unit. Complaint #2610531

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of seven sampled residents, was free from abuse and neglect when Certified Nurse Aide (CNA) A while sweeping the resident's room, refused to assist the resident with his/her request to retrieve paper from the floor and grabbed the resident's left hand/arm pushing the resident back causing the resident to fall onto the foot board of the bed. The resident fell onto the bed then slid off the bed onto the floor. CNA A stood watching the resident with no attempt to prevent the fall or assist the resident. The resident then scooted on the floor towards the door of the room, while CNA A continued to sweep the floor telling the resident to stay in the room, with no attempt to call for assistance or a nurse to assess the resident. The resident had diagnosis of Huntington's Chorea (a hereditary neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain. It affects movement, cognition, and behavior) and was at risk for falls. The resident sustained a large bruise to the right buttock area from the fall and pain in the area. The facility had not assessed the resident after the fall that occured on 6/13/25 until 6/23/25 when the surveyor brought the resident's complaint of pain in the area of his/her hip to the facility's attention. The facility census was 69. Review of the undated facility policy for Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy supplied by the facility and used as training for facility employees showed the following: -It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Review of the undated facility policy for Abuse Prevention and Procedure list showed: -Freedom from abuse, neglect, and exploitation: the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse; -Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of Huntington's disease, major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life), traumatic subdural hemorrhage (a condition where blood collects between the brain and its outer covering (the dura mater) due to head trauma) and anxiety. Review of the resident's Care Plan for Falls dated 6/18/24 showed the following: -The resident was at risk for falls related to impaired mobility, impaired safety awareness, unsteady gait, lower extremity weakness, and becoming angry slamming doors causing balance to be thrown off; -Remind resident to ask staff to assistance when getting things off the floor, encourage the resident to ask for assistance related to balance related to Huntington's disease; staff to assist as needed, staff to emphasize and attempt to get the resident to slow down and try not to be so upset, and to express him/herself in a calmer manner, ensure pathway was free of clutter, encourage the resident to slow down. Review of the resident's Care Plan for Behavior Symptoms dated 6/28/24 showed the following: -I sometimes have behaviors related to my frustration of having Huntington's disease process. -I will calm with staff intervention and my basic care needs will be met; -Speak to me unhurriedly and in a calm voice, talk to me upon approaching me and try to explain what you want to do for me. Review of the resident's Care Plan for Activities of Daily Living (ADL's) dated 5/27/25 showed the following: -The resident has Huntington's disease; -Staff to be aware that this is very frustrating disease for the resident; -Staff will assist with care. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 5/28/25 showed the following: -Sometimes able to make self understood and sometimes able to understand; -Difficulty with making decisions; -Requires assistance with Activities of Daily Living (ADL's); -History of falls. Review of video camera footage from the camera inside the resident's room placed by the family time stamped 6/13/25 at 5:15 P.M. with the Administrator and the Director of Nursing on 6/20/25 at 10:30 A.M. showed the following: -Certified Nurse Aide (CNA) A sweeping up trash in the resident's room. The door to the resident's room was open, the resident 'walked in the room with his/her shorts by his/her knees and underwear exposed. CNA A said, Pull your pants up and did not close the door. As CNA A swept up trash on the floor, he/she said, this is disgusting; -The resident stood up from the bed and walked over to a piece of paper on the floor, bends over and attempts to pick it up off the floor, he/she looses his/her balance and begins to fall backwards, CNA A grabs his/her left wrist and begins to push him/her back towards the bed, causing the resident to land of the foot board of the bed on his/her right buttock. The resident then lands onto the bed and then slides off the bed onto to the floor, as CNA A did not attempt to break the residents fall but continues to sweep the floor. CNA A says Listen, sit down. -The resident is then seen scooting on the floor to retrieve a piece of paper on the floor saying this is my appointment. CNA A says something, but unable to determine what is said; -CNA A continues to sweep the floor at the resident scoots on his/her bottom on the floor to the doorway of the room, CNA A continues to sweep and did not attempt to help the resident up, or call for the nurse to assess the resident. During an interview on 6/20/25 at 2:30 P.M. Resident #1 said: -He/she was mad at CNA A because he/she was throwing away his/her snacks and papers; -Stated He/she would not listen to me when I asked him/her to stop; -When asked about the fall, the resident said that he/she began to fall and CNA A put his/her hand on his/her body and pushed him/her causing him/her to fall onto the foot board of the bed and then onto the floor; -He/she did not call for the nurse, so he/she scooted on the floor as CNA A was sweeping because he/she was throwing away his/her appointment papers; -CNA A was not nice to him/her and he/she does not want CNA A to be in his/her room again. During an interview on 6/20/25 at 2:30 P.M. Family Member (FM) A said: -He/she watched the video on 6/13/25 and seen where CNA A was sweeping the floor and when Resident #1 asked him/her to stop, the CNA continued to sweep and would not listen to the resident; -It appeared that when the resident began to fall, CNA A grabbed the resident's hand and pushed him/her causing the resident to fall onto the foot board of the bed; -The resident cannot help spilling things due to his/her uncontrolled movements caused by Huntington's disease; -The staff do not take their time with the resident and he/she feels the staff does not understand the disease process. During an interview and observation on 6/23/25 at 11:33 A.M. Resident #1 said: -CNA A pushed me as I was falling and I hit my hip on the foot board of the bed. It is sore; -Licensed Practical Nurse (LPN) D performed a skin assessment of the resident's hips and found a large purple/yellow/greenish colored bruise that was approximately the size of large orange to the right hip, when LPN D pressed on the bruise, the resident said the area was very sore. During an interview on 6/20/25 at 1:44 P.M. Registered Nurse (RN) C said: -He/she became aware of Resident #1 falling and scooting on the floor when he/she walked down the hall; -CNA A was still sweeping the floor in the resident's room; -CNA A told him/her that the resident was coming out of the bathroom and lunged at him/her and fell; -The resident was very upset about something; -He/She did not do a skin assessment after he/her had helped the CNA get the resident off the floor; -Several hours later, a family member called and stated that he/she had just watched the video at home and felt CNA A had pushed the resident down, and that the resident was upset because some containers of food had been thrown away; -He/She got the containers out of the trash, they were covered with dried food, so he/she cleaned them up and returned them to the resident; -He/she informed the DON that evening when the DON came to relieve him/her. During an interview on 6/20/25 at 11:00 A.M. the Director of Nursing (DON) said; -She had been informed of the incident after the guardian had called the administrator; -After watching the video with the audio, CNA A did not call for the nurse and did not look like he/she assisted the resident to sit down. During an interview on 6/20/25 at 10:30 A.M. the Administrator said: -She was notified by the residents guardian on 6/16/25 of the video that was taken on 6/13/25 from the camera that is in the resident's room; -The guardian said that he/she was contacted by the residents family member who supplied the video footage to the facility. -In viewing the video footage, she suspended CNA A pending their investigation; -After review of the video with the audio, CNA A did not call for the nurse as he/she said, and did not assist the resident to sit down; -The investigation into the incident will need to reopened. During an interview on 6/23/25 at 4:11 P.M. the Administrator said: -Abuse is not tolerated and cannot happen; -CNA A did not attempt to break the resident's fall; -She would consider this abuse; -Staff need to report any allegation or suspicion of abuse immediately for investigation; -Staff need to be aware of the resident's disease process and how to provide care for the resident. MO255918 and MO255925

Based on interview and record review, the facility failed to report an allegation of abuse when one Resident (Resident #2) of seven sampled residents, reported to staff another staff had threatened to hit him/her with a closed fist and the resident was fearful of retaliation. The facility census was 66. Review of the undated facility policy for Abuse Prohibition showed: -All staff are to report to the Administrator and/or Designees any alleged (all allegations) violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -The Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later that 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury; 1. Review of Resident #2's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnosis of Parkinson's disease (a progressive neurological disorder that primarily affects movement. It's characterized by symptoms like tremors, stiffness, and slowness of movement). Review of the resident's care plan for physical functioning deficit dated 5/21/25 directed staff to assist with grooming and dressing needs and provide assistance of one staff member. Review of the resident's Care Plan for Falls due to Parkinson's disease dated 5/21/25 directed staff to provide individualized toileting interventions based on needs/patterns. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/25/25 showed the following: -Able to make self understood and usually understands others; -Alert and oriented and able to make some decisions; -Requires assistance with Activities of Daily Living (ADL's), standing, transfers and ambulation; -Diagnosis of Parkinson's disease. During an interview on 6/20/25 at 11:00 A.M. the resident said the following: -Last week he/she told a therapy aide that on the night shift an aide came in and answered his/her call light; -When he/she asked the aide to get the urinal because he/she could not walk to the bathroom as his/her legs locked up from his/her Parkinson's disease; -The aide handed him/her the urinal. He/she told the aide his/her hands were not working and he/she needed some help with the urinal. The aide walked away. The resident picked up the urinal and threw it at the aide. The aide then came toward him/her, drew back his/her fist, got up in his/her face and said do it yourself before walking out of the room; -He/she was afraid that the aide was going to hit/him. During an interview on 6/23/25 at 1:27 P.M. Family Member B said the following: -Last week, either Thursday, June12 or Friday, June 13, the resident reported problems on the midnight shift with an aide. The resident said he/she threw a urinal at the aide because the aide member refused to help him/her with the urinal. The aide raised his/her fist and threatened the resident; -The resident had reported this to staff, but could not remember who; -Family Member B reported this to the Social Services Director last week; -The SSD said she was aware of the incident. During an interview on 6/20/25 at 12:20 P.M. the Therapy Program Manager said the following: -Resident #2 had come to therapy and told him/her that last week an aide on the midnight shift accused him/her of throwing the urinal at the aide, the aide drew his/her arm or fist back and threatened to hit the resident; -He/She reported this to the Social Services Director who said she was already and had taken care of it. During an interview on 6/20/25 at 12:18 P.M. the Social Services Director (SSD) said the following: -Last week she overheard a couple of aides at the nurses station talking about the resident and how a staff member on the midnight shift refused to help the resident, had raised his/her fist at the resident and threatened the resident; -The therapy manager also told her that the resident had reported this to her; -She tried to talk to the resident, but he/she was using the bathroom so she went and reported the incident to the Director of Nursing and the Assistant Director of Nursing. During an interview on 6/20/25 at 12:28 P.M. Licensed Practical Nurse(LPN)/Assistant Director of Nursing (ADON) said the following: -Last night before the SSD left, the SSD reported the resident's family member told her the resident said an aide on the midnight shift had raised his/her fist to the resident; -He/She worked the midnight shift and did not do anything with this information until about 15 minutes ago when he/she reported this to the Administrator. During an interview on 6/20/25 at 10:45 A.M. the Director of Nursing said he was not aware of any incident of possible abuse involving the resident and a staff member. During an interview on 6/20/25 at 1:00 P.M. and 6/23/25 at 4:11 P .M. the Administrator said the following: -She was just told what Resident #2 had reported; -She was beginning an investigation. -Abuse was not tolerated; -Staff should report any allegation or suspicion of abuse immediately for investigation. MO255941

Based on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one resident (Resident #1), of seven sampled residents, to address care of a resident with diagnosis of Huntington's disease (a hereditary neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain. It leads to a decline in cognitive function, mood disturbances, and uncontrolled movements). The facility census was 69. Review of the facility policy for Care Planning Guidelines dated 10/1/2015 showed the following: -It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published interim RA manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, Care Area Assessments (CAA) and resident care planning. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of Huntington's disease, traumatic subdural hemorrhage (a condition where blood collects between the brain and its outer covering (the dura mater) due to head trauma) and anxiety. Review of the resident's Care Plan for Behavior Symptoms dated 6/28/24 showed the following: -I sometimes have behaviors which include aggression toward staff and refusal of care related to my frustration of having Huntington's disease process. I have actually attacked staff before or chased staff down the hallway because they could not give me what I wanted, example Ibuprofen; -I have a recording device in my room; make sure I am not in pain or uncomfortable; my behaviors may include refusal of care. Notify my physician and family if/when my behavior interferes with staff's ability to address my basic needs; administer medications as orders; speak to me unhurriedly and in a calm voice, talk to me upon approaching me and try to explain what you want to do for me. Review of the resident's Care Plan for Activities of Daily Living (ADL's) dated 5/27/25 showed the following: -The resident has Huntington's disease; -Staff to be aware that this was a very frustrating disease; -Staff will assist with care. Review of the resident's Care Plan for Communication dated 5/27/25 showed the following: -The resident makes decisions but they are not always in the best interest or something that staff cannot meet: -Approaches in part: Most of the time the resident will not listen to reason, he/she is delusional and when he/she has something in his/her head and he/she request it whether it is rationale or not he/she will not work with staff, he/she becomes frustrated, yells, lunges at other and very violently slams the door multiple times; -The staff try to keep him/her from falling and offer to help with ADL's. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 5/28/25, showed the following: -Sometimes able to make self understood and sometimes able to understand; -Has delusions, verbal behaviors occur daily, other behaviors four to six days and rejection of care. -Difficulty with making decisions; -Requires assistance with Activities of Daily Living (ADL's); -History of falls. Review of the resident's care plans showed no care plan specific to Huntington's disease, including symptoms and care to address the symptoms and resident exerience of living with this disease. During an interview on 6/20/25 at 1:55 P.M. Resident #1 said the following: -The staff do not listen to him/her; -He/She could not help that he/she spilled things, it is my disease. During an interview on 6/20/25 at 2:00 P.M. Certified Medication Technician (CMT) B said the following: -Staff were afraid of the resident; -The resident was mean to everyone, he/she has been hit by the resident before; -The resident will not let staff clean his/her room; -He/She did not kwow what Huntington's disease was. During an interview on 6/23/25 at 1:00 P.M. Housekeeper E said the following: -He/She will go in and attempt to clean the resident's room and the resident frightened him/her; -He/She does not know what Huntington's disease was or how to approach or communicate with the resident. During an interview on 6/23/25 at 2:30 P.M. the Director of Housekeeping said the following: -Staff were afraid of the resident; -He/She had heard of Huntington's disease, but was not aware of what a resident would experience with the disease. During an interview on 6/20/25 at 2:30 P.M. Family Member (FM) A said the following: -Staff do not know how to care for a person with Huntington's disease; -Everyone thought the resident had control over his/her movements and emotions and thinks the resident was mean and having behaviors; -Staff do not take the time and talk with the resident; -He/She has watched the camera footage from the resident's room and staff do not knock on the door, will just barge in and begin to pick up things, or sit food down on the table without talking with the resident and explaining what they are doing. During an interview on 6/23/25 at 3:15 P.M. Registered Nurse (RN) C said the following: -He/She was responsible for the development of the care plan; -After review of the resident's care plans, there was no care plan for Huntington's disease process. There should be a plan specific to this to educate staff and to direct staff when providing care to the resident and to understand the disease process. During an interview on 6/23/25 at 4:11 P.M. the Administrator said: -She would expect staff to develop care plans to address the residents disease process with interventions that are appropriate; -She would expect staff to be aware of what Huntington's disease is and how to care for the resident. MO255918 MO255925

Based on observation, interview, and record review, the facility failed to provide housekeeping services to maintain a clean, sanitary and orderly environment for one resident, (Resident #1) out of seven sampled residents. The facility census was 69. The facility did not provide a policy for housekeeping services or clean and comfortable homelike environment. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnosis of Huntington's disease (a hereditary neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain. It affects movement, cognition, and behavior, and there is currently no cure). Review of the resident's annual Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff dated 5/28/25 showed the following: -Sometimes able to make self understood and sometimes able to understand; -Requires assistance with Activities of Daily Living (ADL's); -History of falls. Review of video footage from a camera inside the resident's room supplied by Family Member (FM) A dated 6/13/25 showed the following: -Certified Nurse Aide (CNA) A in the resident's room with a broom, sweeping up numerous Styrofoam plates, cups, plastic silverware,and napkins that covered the resident's bedroom floor; -A trash can sat next to the resident's bed and was full of Styrofoam plates with food,cups and napkins; -Dark colored stains on the resident's bed linens on the bed. Observation and interview on 6/20/25 at 1:55 P.M. showed the following: -The resident in his/her room sitting on the bed. There was dried food debris on the bed linens and the same dark colored stains remained on the linens seen in the video camera footage; -The over the bed table was caked with dried food and spilled drinks with gnats flying around the table. Several forks and knives were on the table and caked with dried food; -Disposable plates, cups and bowls with food in some were on the floor, and next to a small trash by the resident's bed; -The toilet in the resident's bathroom had a dark brown ring around the inside of the bowl with dirty toilet tissue and empty rolls of toilet tissue on the bathroom floor. The paper towel dispenser was empty and there was no trash can in the bathroom; -Dirty and clean clothing on the floor around the bathroom entrance and closet along with several clothes hangers; -The bed closest to the entrance door had dried brown debris on the sheets. The bed frame had dried brown debris on the frame and the front wheels of the bed were broken off the frame; -A water pitcher on the floor under the first bed; -The resident stood up off the bed, his/her arms moved continuously; -The resident said he/she would like some paper towels in the bathroom and proceeded to walk to the bathroom with bare feet on the trash that covered the floor. Observation on 6/20/25 at 2:30 P.M. showed FM A in the resident's room picking up the trash off the floor while the resident sat on the bed. During an interview on 6/20/25 at 2:30 P.M. FM A said the following: -The resident could not help spilling food and drinks on the floor due to Huntington's disease; -The resident will refuse to let staff clean the room, because staff do not talk to the resident and begin throwing items away including important papers without asking the resident first; -If staff would talk to the resident and ask before they start throwing items away then the resident would not be upset with staff; -He/She had asked for a bigger trash can for the resident due to the resident's uncontrollable movements, it was difficult for him/her to throw items in the trash can -Staff do not understand the resident's Huntington's disease. During an interview on 6/20/25 at 2:30 P.M. the Director of Housekeeping Services said the following: -The former administrator told his staff they did not have to go into the resident's room to clean, as the resident had attacked one of the housekeepers. They had not been in the room for over a week; -He did not know if the room has been cleaned. During an interview on 6/20/25 at 3:00 P.M. the Administrator said the following: -She was not aware staff did not clean the resident's room or that the prior administrator told housekeeping they did not have to go into the resident's room; -Staff should be picking up the trash and emptying the resident's trash can; -She was unaware of the request for the bigger trash can; -She would expect staff to clean the resident's room. MO255918 and MO255925

Based on interview and record review, the facility failed to ensure one resident (Resident #1), was free from verbal abuse when Certified Medication Technician (CMT) B yelled and cussed at the resident and told the resident to shut up and when the resident refused cares. Resident #1 said he/she was shocked CMT B treated him/her in that manner and was scared of CMT B. The facility census was 73. The administrator was notified of the past noncompliance on 5/13/25, which occurred on 5/3/25. On 5/5/25 the administrator became aware of a staff to resident abuse allegation involving Resident #1. Upon discovery, the facility suspended the staff member, conducted an investigation, and notified appropriate parties and the police. Staff members were in-serviced on the facility abuse policy, including staff to resident abuse and reporting abuse, and all facility staff was educated on the facility abuse policy and expectations on monitoring and responding to residents. The deficiency was corrected on 5/6/25. Review of the facility's undated Abuse Policy showed the following: -It is the policy of the facility that each resident will be free from abuse; -Abuse can include verbal or mental; -Residents will be protected from abuse, neglect, and harm while they are residing at the facility; -No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection; -An owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat or neglect a resident. 1. Review of Resident #1's undated face sheet showed the resident had diagnoses that included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life) with behavioral disturbances, generalized anxiety disorder (a persistent feeling of anxiety or dread that interferes with how you live your life), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/11/25, showed the following: -The resident had moderately impaired cognitive skills for making activities of daily living decisions; -The resident had verbal behaviors toward others and other behaviors directed at himself/herself; -The resident rejected cares daily; -The resident required partial to moderate assistance from staff to wheel 50 feet in his/her wheelchair and was dependent on staff to wheel 150 feet; -The resident required substantial to maximum assistance from staff to dress and transfer from the bed to a chair; -The resident was dependent on staff to get from a sitting to standing position. Review of the the resident's Care Plan, dated 3/15/25, showed the following: -The resident had behavioral symptoms and had the right to refuse any medications or treatment he/she desired; -If the resident refused care, notify the nurse; -Repeat attempts to give medications, care or therapies at least three times; -Document refusals and notify the physician if the refusals are compromising the resident's physical, mental, or hygienic health; -The resident had a potential for drug related complications associated with the use of psychotropic medications related to restlessness and agitation; -Encourage the resident to verbalize his/her feelings that are associated with anxiety, depression, hallucinations, delusions or mood swings. Review of the facility's investigation, dated 5/5/25, showed the following: -The resident reported that CMT B told the resident to shut the F up; -The resident said CMT B was mean and he/she was scared of CMT B; -The investigation concluded that CMT B used vulgar and inappropriate language with the resident; -The resident was consistent with his/her recollection of the incident regardless of a diagnosis of dementia. During an interview on 5/12/25 at 2:06 P.M. and 5/13/25 at 3:14 P.M. the resident said the following: -CMT B kept bugging him/her to change his/her incontinent brief. CMT B was mean and yelled at him/her and tossed him/her in bed; -The resident was shocked CMT B did that to him/her and treated the resident that way. During an interview on 5/12/25 at 2:13 P.M. Resident #3 said the following: -CMT B yelled at the resident a few times because he/she got frustrated when the resident needed help; -CMT B used the F word and yelled at Resident #1 when CMT B put Resident #1 in bed; -This occurred during the weekend on either 5/3/25 or 5/4/25. Review of Visitor #15's written statement, dated 5/13/25, showed the following: -He/She was visiting a resident diagonally across the hall from Resident #1; -He/She heard a commotion in the hallway and went to the doorway of the room he/she was visiting; -He/She saw CMT B screaming and cussing at Resident #1 across the hall. CMT B used very bad language and called the resident a fucking bitch. Review of a facility statement, written by Licensed Practical Nurse (LPN) C, dated 5/4/25, showed the following: -LPN C asked the resident if anything out of the ordinary happened yesterday (5/3/25); -The resident replied Yes, the person at the desk (CMT B) was mean to me. He/She always yells at me; -The resident said CMT B kept going in his/her room telling the resident he/she had to be changed. During an interview on 5/12/25 at 12:19 P.M. CMT B said the following: -CMT B went to Resident #1's room and provided care because the resident had food on him/her, had spilled coffee on the sheets, and had been incontinent; -Resident #1 yelled and cussed at CMT B to get out of his/her room and refused care; -CMT B had not encountered that type of yelling from a resident before and didn't know how to handle it; -CMT B had never cussed at the resident before, but he/she did on that day (5/3/25); -CMT B verbally abused the resident right back; -CMT B did not remember what he/she said to the resident but he/she did say something that was verbal abuse. During an interview on 5/13/25 at 3:50 P.M. the administrator said the following: -Staff should never yell or cuss at a resident; -CMT B should not have cussed at the resident; -The facility did not tolerate any type of abuse and CMT B was terminated for his/her actions. MO253752 MO253766

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) out of a sample of eight residents, received adequate supervision to prevent accidents. The facility failed to respond to a door alarm timely after the resident, who was assessed by the facility to be at risk for elopement, exited the facility through an alarmed exit door without staff knowledge. The door alarm volume was not loud enough for staff to hear until they were halfway down the resident's hall. The facility also failed to complete 15 minute checks for the resident who required 15 minute checks for aggressive behavior. The resident fell after he/she left the facility, sustaining multiple facial fractures and a subdural hemorrhage (bleeding in the brain that can put pressure on the brain, leading to a variety of symptoms and potentially life-threatening complications if not treated promptly). The facility census was 76. On 4/24/25 the administrator was notified of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 4/17/25. Upon discovery, staff conducted an investigation and notified appropriate parties including the police. In-service education was provided for all facility staff including elopement policies, 15 minute check policies and door monitoring policies. Staff completed elopement risk assessments for all residents and the elopement risk and code white procedure books were updated with current risk assessments and code white procedures. The alarmed, fire, exit door alarms were adjusted to increase the volume of the alarm for staff to recognize the alarm promptly. Alarmed door audits and 15 minute check audits were performed and ongoing. The IJ was corrected on 4/18/25. Review of the undated facility policy, Code [NAME] Guidelines, showed the following: -The purpose of the facility is to assure that resident safety and security are maintained. Identification of residents at risk for wandering or elopement is imperative; -Every resident will be assessed, using the wander and/or Elopement Assessment form, upon admission, readmission, annually and with significant change; -A nurse will complete the assessment and once completed and the determination has been made, the care plan coordinator will review and incorporate the information with the resident's care plan; -If the resident is determined to be at risk, the resident will be placed on the At Risk list and added to the Code [NAME] Program; -A listing of residents at risk with the resident identification record will be kept at each nursing station and in the front office. Review of Resident #1's Elopement/Wandering Assessment Form, dated 1/17/25, showed the following: -The resident was ambulatory or self-mobile in a wheelchair; -The resident had a history of wandering, confusion, disorientation, and was cognitively impaired; -The resident had a wandering risk score of four which put him/her at risk; -Interventions were frequent monitoring; -The resident usually just wandered around the facility and made no attempts to exit and was not exit seeking. Review of Resident #1's undated Face Sheet showed the following: -The resident had a power of attorney for health care; -The resident had diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and vascular dementia (a mental disorder in which a person has problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/19/25, showed the following: -The resident's cognition was severely impaired; -The resident used a wheelchair for ambulation; -The resident could propel himself/herself in a wheelchair 150 feet independently; -The resident had no impairments to his/her upper or lower extremities; -Walking 10 feet was not attempted due to the resident's medical conditions; -The resident wandered less than daily; -The resident required partial to moderate assistance from staff to get from sitting to lying, lying to sitting, sitting to standing and from a chair to bed positionings; -The Significant Change MDS showed a decline in communication, increased behaviors, a decrease in cognition, and risk for psychosocial isolation compared to his/her previous MDS, dated [DATE]. Review of the resident's Care Plan, dated 4/11/25, showed the following: -The resident had impaired cognition; -The resident liked to go all throughout the facility, was easily redirected, and made no attempts to push on the exit doors or speak about leaving; -The resident was at risk for wandering related to confusion; -If the resident was exit seeking, redirect him/her from doors and attempt to engage the resident in something that occupied his/her attention; -Provide the resident with increased supervision during periods of increased wandering and exit seeking behavior; -The resident had a physical functioning deficit related to dementia and weakness. Review of the resident's progress notes, dated 4/15/25, showed the following: -The resident had aggressive behavior toward another resident; -The resident was placed on 15 minute checks. Review of Resident #1's 15 minute check log, dated 4/17/25, showed the following: -On 4/17/25, the resident was in his/her bedroom from 7:00 P.M. until 8:45 P.M. -On 4/17/25, staff did not document that a 15-minute check was completed for the resident at 9:00 P.M. or at 9:15 P.M. Review of the resident's discharge MDS, dated [DATE], showed the following: -The resident wandered daily; -The resident had short term memory problems; -The resident was independent to position himself/herself from sitting to lying, lying to sitting, sitting to standing and from a chair to bed positions; -The resident could walk independently 50 feet; -The resident could propel himself/herself in a wheelchair 150 feet independently. Review of the resident's undated, facility Elopement Timeline, showed the following: -At 8:13 P.M. on 4/17/25, the resident was in the facility; -At 8:30 P.M., staff observed the resident in a wheelchair self-propelling in the hallway toward his/her room; -At 8:45 P.M., Licensed Practical Nurse (LPN) C observed the resident lying in bed; -At 9:15 P.M., the resident's call light was on, and Nursing Assistant A went to the resident's room. The resident was not in his/her room; -(no time stated) Code [NAME] was activated; the inside and outside of the building was searched and the resident was not found; -At 9:38 P.M., the Director of Nursing (DON) was notified of the missing resident; -At 9:55 P.M., the DON arrived at the facility and the search for the resident continued. Review of Resident #1's Hospital Records, dated 4/17/25, showed the following: -Upon arrival to the emergency department the resident's injuries necessitated the activation of a level 2 trauma; -A Computed Tomography (CT, a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce detailed images of the inside of the body, including the bones, muscles, fat, organs, and blood vessels) showed a subdural hemorrhage, extensive facial trauma with right and left orbital fractures (eye socket), bilateral upper jaw bone fracture, lower jaw bone fracture, nose fracture, and right cheek bone fracture; -The resident was placed in the neurological intensive care unit. During an interview on 4/23/25 at 1:08 P.M. Resident #2 (residing on the same hall), said he/she did not hear an alarm sound on the night Resident #1 went out the alarmed fire exit door. During an interview on 4/23/25 at 1:11 P.M. Resident #3 (Resident #1's roommate), said he/she did not hear an alarm sound on the night Resident #1 went out the alarmed fire exit door. During an interview on 4/23/25 at 1:22 P.M., LPN C said the following: -On 4/17/25 at 8:45 P.M., he/she checked on Resident #1 and the resident was lying in bed; -Nursing Assistant (NA) A came and told LPN C that he/she went to answer Resident #1's call light, but the resident was not in his/her room; -LPN C went to the resident's hall and did not hear the alarm until he/she got halfway down the hall; -Resident #1's wheelchair was parked in front of the alarmed fire door; -LPN C went outside and walked the perimeter of the building and did not find the resident. LPN C also went to the building behind the facility and did not see the resident; -LPN C went back inside and called 911. The 911 dispatcher told LPN C the police had the resident, and the resident was taken to the hospital; -The resident had never been exit seeking in the past. The resident would wander the halls and go to the dining room; -The resident could walk but got tired easily and used his/her wheelchair. During an interview on 4/23/25 at 1:58 P.M., LPN F said the following: -LPN C went to the A hall where LPN F was working and told him/her that Resident #1 was missing; -LPN F went to the resident's hall and did not hear the alarm until he/she got to the nurse's station (one quarter of the way down the hall); -LPN F went to the alarmed fire exit door and shut the alarm off and tested the door to see how hard it was to open. LPN F said it opened pretty easily when you held the door release and the instructions were on the door; -Resident #1 walked with his/her wheelchair, but he/she did not have a steady gait. During an interview on 4/23/25 at 2:38 P.M., NA A said the following: -NA A was making rounds on residents between 9:20 P.M. and 9:30 P.M.; -NA A saw Resident #1's call light on and went to his/her room. When NA A got to the room Resident #1 was not in his/her bed; -NA A did not hear the door alarm; -NA A went and told LPN C that Resident #1 was not in his/her room. NA A and LPN C went looking for the resident inside and outside, but did not find the resident. During an interview on 4/23/25 at 3:46 P.M., Certified Nursing Assistant (CNA) B said the following: -He/She went on break about 8:40 P.M. and when he/she returned NA A asked if he/she had seen Resident #1 because the resident was missing; -He/She did not hear an alarm when he/she was on break outside in front of the building. During an interview on 4/23/25 at 4:09 P.M., CNA E said the following: -He/She was in a resident room on the B hall assisting with cares. When he/she came out of the room CNA E heard an alarm; -He/She saw Resident #1 about an hour earlier, but did not see the resident again before he/she went missing. During an interview on 4/24/25 at 8:46 A.M., the local police department detective said the following: -Resident #1 was found at the entrance of the driveway of the building behind the facility; -A call was made to Emergency Medical Services (EMS) at 9:05 P.M. by a local citizen that found the resident on the ground; -EMS requested police assistance at 9:07 P.M. and the first officer arrived on the scene at 9:10 P.M. (EMS was already there); -EMS left the scene at 9:33 P.M. and took the resident to the hospital; -LPN C called the police department to report the resident missing at 10:08 P.M. Observation on 4/24/25 at 9:43 A.M. showed the following: -The outside of the facility where Resident #1 exited was grass and then turned into an uneven paved parking lot; -Closer to the front of the other building there was a steep slope to the drive that ended at a heavily traveled four lane road; -The distance from the facility door the resident exited from and the spot where the resident was found by police was a little over 400 feet. During an interview on 4/23/25 at 3:00 P.M., a hospital nurse said Resident #1 was stable and would have surgery that afternoon for facial fracture repairs. During interviews on 4/23/25 at 10:39 A.M. and 4/24/25 at 10:42 A.M., the DON said the following; -She was notified by LPN C that Resident #1 was missing from the facility and could not be found; -She told LPN C to call the police to report the resident missing; -Resident #1 was on 15-minute checks and was supposed to have been monitored throughout the night; -Staff did not complete the 15 minute check for Resident #1 at 9:00 P.M. on 4/17/25. During an interview on 4/23/25 at 9:55 A.M., the Administrator said the following: -Resident #1 went out the B Hall (the hall the resident resided) alarmed, fire, exit door on 4/17/25; -Resident #1 did wander the halls and would go to the Administrator's office or to the dining room. The resident had not attempted to go out a door. MO252936

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of sampled residents, remained free from misappropriation of property when Certified Nurse Aide (CNA) A took the resident's government issued debit card without the resident's knowledge and permission and used the card to withdraw cash from several ATM's totaling $864.00, used the card to pay Boost Mobile (a cell phone company) $65.00, Spectrum for $140.86, Ameren for $100.00, and for doordash food totaling $140.23. The facility census was 76 On 4/11/25 at 3:00 P.M., the administrator was notified of the past noncompliance which occurred on 4/3/25. On 4/3/25, the administrator became aware of the violation of misappropriation of the resident's government issued debit card and monies taken from the account by CNA A. Upon discovery, the facility suspended CNA A, conducted an investigation, and notified appropriate parties. Staff reviewed the facility misappropriation policy, and all facility staff were educated on the facility misappropriation policy. CNA A was terminated. The deficiency was corrected on 4/7/25. Review of the undated facility policy for Abuse and Neglect showed: -It is the policy of this facility that each resident will be free from Abuse. Abuse can include misappropriation of resident property; -The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal Requirements and law enforcement -It is the policy of this facility that reports of abuse are promptly and thoroughly investigated; -Investigation regarding misappropriation: the facility staff will complete an active search for missing items(s) including documentation of investigation. The investigation will consist of at least the following: a review of the completed complaint report; an interview with the person or persons reporting the incident; interviews with any witnesses to the incident; a review of the resident medical record if indicated; a search of the resident room with permission; an interview with staff members having contact with the resident during the relevant periods or shift of the alleged incident; -While the investigation is being conducted, accused individuals shall be immediately suspended and removed from contact with any residents. 1. Review of Resident #1's face sheet showed the resident admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 3/12/25 showed the following: -Able to make self understood and able to understand others; -Some difficulty making decisions; -Independent with Activities of Daily Living (ADL's). During an interview on 4/11/25 at 10:00 A.M. the Administrator said the following: -Resident #1 was newly admitted , his/her own person, and able to handle his/her own finances; -The resident had a government issued bank card that he/she used to purchase items out of the facility vending machine and pay bills; -At times he/she would give the card to the Activities Director to purchase cigarettes; -On 4/3/25, the resident went to the Business Office Manager (BOM) to see if she would help him/her with checking the balance on the debit card; he/she thought some money was missing; -With the resident's permission, the BOM set up an online account, checked the account balance, and noticed that several withdrawals were made from an ATM, several meals were purchased using door dash, and several utility bills had been paid; -The resident denied giving anyone permission to use his/her debit card; -Local law enforcement was notified and the resident filed a police report; -Officer A came to the facility and took the resident's statement; -Officer A came back to the facility and showed the resident footage from one of the ATM's used to withdraw money and the resident identified CNA A as the person using his/her debit card; -CNA A was placed on suspension pending the investigation per the instructions of the police officer, as he/she wanted to speak with CNA A first before the facility terminated the employee; -The Social Services Director and Director of Nursing began to interview residents to see if any other money was taken; -In-servicing for all staff on misappropriation of resident property began; -CNA A went out of town and was to return on April 5th and was supposed to meet with Officer A, but he/she did not show up to the meeting and came into work. He/she was informed that Officer A wanted to speak with him/her about some missing money, he/she said that Resident #1 gave him/her permission to use the debit card to purchase some food and pay a utility bill. During an interview on 4/11/25 at 10:30 A.M. Resident #1 said the following: -He/She did give CNA A his/her debit card a couple of weeks ago to buy him/her some cigarettes, which he/she did and brought him/her back the debit card; -He/She did not give CNA A permission to buy any food or pay any utility bills; -He/She was asked by Officer A if he/she would like to press charges against CNA A and he/she told the officer yes. During an interview on 4/11/25 at 12:50 P.M. the BOM said the following: -On 4/2/25, Resident #1 came to him/her and said he/she had called the number on the debit card to check the balance and money was missing. The resident said he/she only had $200.00 on the debit card, and that he/she had not been using the card; -He/She asked the resident permission to call the debit card so he/she could hear the amount, after hearing the amount, the resident gave him/her permission to set up an online account to view the transactions; -The resident denied making the transactions that showed up on the account. When asked if the resident had let anyone use his/her debit card or gave out the PIN number the resident said no; -It took several days to get a representative from the debit card company to call him/her to report the fraudulent charges. The dates and times were given for all of the transactions and was given to Officer A on 4/3/25; -The total cost of the fraudulent charges were $1,369.69 and began on 3/23/25; -On 4/4/25, Officer A came back to the facility with a photo from one of the ATM's of the suspect which was identified as CNA A. Review of the transaction history provided by the debit card company showed the following: -On 3/23/25 Doordash purchase for Red Lobster for a total of $68.20; -On 3/23/25 $100.00 paid to a utility; -On 3/24/25 ATM withdrawal at a pharmacy for $260.00; -On 3/27/25 utility payment of $140.46; -On 3/27/25 Doordash for coffee for $19.85; -On 3/28/25 Doordash for pizza for $45.89; -On 3/28/25 Doordash for pizza for $6.29; -On 3/29/25 cellular provider for $65.00; -On 3/31/25 ATM with drawl at a bank for $604.00. During an interview on 4/11/25 at 3:00 P.M. the Administrator said the following: -The debit card company has filed a claim and the resident should be receiving his/her money back; -CNA A has been terminated from employment from the facility; -In-servicing has began for all staff for misappropriation of resident property; -A meeting has been held with the resident council to discuss not giving staff their personal money or debit or credit cards. MO252197

Based on observation, interview, and record review, the facility failed to ensure the kitchen was clean and maintained in a manner to ensure the safe storage, preparation, and distribution of food. Staff failed to wash hands and utilize gloves appropriately during meal preparation and service, failed to properly wash dishes in the three-compartment sink and ensure sanitizer solution was available for use, failed to properly clean food preparation surfaces with sanitizing solution, and failed to ensure the temperature in one freezer was at least 0 degrees Fahrenheit or below. The facility census was 82. 1. Review of the Registered Dietician's Kitchen Observation, dated 7/22/24, showed the following: -Open food items were not stored or properly sealed and labeled and dated; -Not all food was properly covered, labeled or dated; -The stove/oven was not clean. The front of the stove needs cleaned; -The microwave was not clean; -The cooler/freezer was not clean. Food debris was on the floor of the reach-in cooler/freezer; -The walls were not clean, without damage. The wall behind the dish machine had a dark buildup. Observation on 8/5/24 between 11:35 A.M. and 6:30 P.M. showed the following: -The floor throughout the kitchen was dirty; -The door fronts and the handles to the three-door freezer were soiled; -The ceiling on the inside surface of the microwave was heavily soiled with food debris; -The fronts and handles of the drawers, located under the preparation counter with the microwave and food processor, were heavily soiled with dried debris; -The exterior surfaces of the large, rolling flour and sugar bins, located under the preparation counter with the microwave and food processor, were soiled -The wall behind and the ceiling above the food processor were soiled; -The tiled wall, located under the preparation counter with the toaster, was heavily damaged. An area of the wall, approximately 12 inches by 12 inches, had been broken away exposing the pipes behind the wall; -The door fronts and the handles to the two-door refrigerator were soiled. The floor inside the refrigerator was soiled with food debris; -The plate warmer/holder by the steam table was soiled on the top by where the plates were dispensed and on the base of the unit; -The outside surfaces of the steam table covers were soiled; -The shelf, located under the preparation table behind the steam table, contained individual serving bowls stored inverted on a tray. The tray was soiled with loose food debris that was in contact with the lips of the bowls. A second tray contained individual bowls of dry cereal that were covered with plastic wrap. The tray, the plastic wrap covering one bowl of cereal, and the floor in front of the preparation table were soiled with an oily substance. The oily substance pooled on the top of the plastic wrap on the bowl of cereal; -The plastic food cart cover, located over the metal food cart, was heavily soiled with dried food debris and dried drips/runs. Staff stored the cake for the lunch meal on the metal food cart and reached through the opening in the cover to obtain trays of cake; -The built-up concrete platform, located under the range and measured approximately 3 feet by 7 feet, had a very rough surface with chipped and peeling paint and was heavily soiled. The surface was not easily cleanable; -The built-up concrete platform, located under the steamer and measured approximately 3 feet by 4 feet, had a very rough surface with peeling paint and was soiled with debris. The surface was not easily cleanable; -The shelf under the preparation counter across from the range was soiled with loose food debris. An opened box of contact paper and trays with inverted pitchers and lids were on the shelf. The handles and fronts of the drawers in the preparation counter were soiled; -In the dry food storage room, sticky liquid was spilled on the floor under the shelving unit, and loose debris and condiment packets were on the floor throughout the room; -The exteriors and the lids on two large trash cans, located on either side of the main food preparation counter, were heavily soiled with dried debris and drips/runs; -A portion of the wall under the sink across from the dry food storage room had been cut away, leaving an opening in the wall around the pipes; -Black mold-like substance was in the grout along the wall behind the sink in the dishwashing area; -The tile floor by the dishwashing area and the walk-in cooler had broken tiles. An area approximately 2 inches by 6 inches of tile had been removed from the floor. The flooring in this area was heavily soiled with a black debris; -The shelves on the plate cover racks were soiled with loose food debris; -A buildup of grease and debris was on the oven doors and around the temperature control knobs; -A buildup of debris was on the convection oven doors; -Inside the two-door refrigerator, two opened plastic packages of hard-boiled eggs (with liquid inside the packages) lay on their side on a wire shelf above a plastic container of cheese slices. The container of cheese slices had a large crack in the lid; -A large, plastic container, approximately half full, was labeled banana pudding and had a preparation date of 7/23. The lid was not sealed on the container; -A plastic package of hamburger buns lay on the preparation table behind the steam table. The package, which contained two buns, was ripped and open to air; -A 5-pound container of peanut butter sat on the preparation counter. The lid did not fit tightly on the container and peanut butter was on the outside of the lid and along the sides of the container; 2. Review of the facility policy, Handwashing, dated April 2011, showed turn on water, wet hands and forearms with warm water, lather hands with antiseptic soap, wash hands and forearms, rinse thoroughly with warm water, wipe hands dry with a clean paper towel, turn off water with paper towel and dispose of paper towel. Review of the facility policy, Glove Use, dated May 2015, showed the following: -Utensils or tongs should be used to serve or handle foods, both raw and cooked, whenever possible. -When serving, preference is not to use gloves unless only one task is being performed. -Hand washing per guidelines should occur between each task. -Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. -Hands should be washed: (selected items included) after disposing of trash or food, after handling dirty dishes, when changing tasks, and any other time deemed necessary Review of the Food and Drug Administration (FDA) Food Code, 2022 edition, showed the following: -Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment; -If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Review of the Registered Dietician's Kitchen Observation, dated 7/22/24, showed wiping cloths were not stored in sanitizing solution while not in use. Review of an email correspondence from the Administrator, dated 8/23/24, showed staff were to completely submerge cleaning cloths in the sanitizer solution. Observation on 8/5/24 at 3:22 P.M. showed Dietary [NAME] W opened four large cans of pork and beans, lifted the lid on the trash can, put the cans in the trash, removed his/her gloves, put the lid back on the trash can, turned on the faucet at the preparation counter, rinsed his/her hands under the running water, wet a wash cloth under the running water, turned off the water, wiped the spilled beans from the preparation counter with the wet washcloth (did not use sanitizing solution), and then wiped the can opener with the wet wash cloth. Observation on 8/5/24 at 4:07 P.M. showed Dietary [NAME] W shredded cooked pork with his/her gloved hands. He/She removed his/her gloves, wiped down the counter with a wet washcloth from the counter (did not use sanitizer), placed the washcloth on the counter, turned on the faucet at the preparation sink, rinsed his/her hands under the running water, turned off the faucet, dumped the bones and pork scraps from the cutting board into the trash can, put the lid on the trash can, turned on the faucet, rinsed his/her hands under the running water, wiped the counter with the wet washcloth that lay on the counter (did not use sanitizer), rinsed his/her hands under the running water and put on gloves. He/She then shredded more cooked pork with his/her gloved hands and placed the pork into a pan, removed his/her gloves, put on oven mitts, opened the oven and put the pan inside. He/She rinsed items in the three-compartment sink under the hose from the soap/water dispenser in the three-compartment sink, turned on the faucet at the preparation counter, rinsed his/her hands, picked up the wet washcloth from the counter, wiped the soiled counter top (soiled with pork), rinsed his/her hands and the washcloth in the soapy water at the three-compartment sink and wiped down the counter. Observation on 8/5/24 at 4:50 P.M. showed Dietary [NAME] W washed pans and the cutting board (used to prepare the cook pork) in the soapy water in the middle compartment of the three-compartment sink. He/She rinsed the pans under running water, did not sanitize, and left the pans in the left sink compartment. He/She put on oven mitts , opened the oven, removed the pans of pork from the oven, took off the oven mitts, did not wash his/her hands and put on gloves. He/She checked the temperature of the pork with a thermometer, and then pulled the pork off the thermometer with his/her gloved hand. He/She put on an oven mitt over his/her gloved hand, picked up the pan of barbeque sauce on the stovetop and poured it onto the meat. He/She removed his/her gloves, opened the trash can lid, threw away his/her gloves, turned on the water faucet at the preparation counter and quickly rinsed his/her hands under the running water. He/She then opened a bag of pasta, put it into a pan, turned on the water faucet at the preparation counter, filled a pitcher of water and poured it over the pasta in the pan. Observation on 8/5/24 between 5:18 P.M. and 5:45 P.M., during the dinner meal services, showed Dietary [NAME] W wore gloves and picked up buns with his/her gloved hands. He/She held one side of the bun in his/her hand, placed barbeque pork on the bun with a utensil, then picked up the other side of the bun with his/her gloved hand and placed it on top. He/She opened the utensil drawer with his/her gloved hand, obtained a scoop, closed the drawer and continued to pick up the buns with his/her gloved hands and serve other items from the steam table with utensils. Observation on 8/5/24 at 5:46 P.M. showed the Dietary Manager took over serving the dinner meal. He/She wore gloves and picked up buns with his/her gloved hands. He/She placed barbeque pork on the bun with a utensil, then picked up the other side of the bun with his/her gloved hand and placed it on top. He/She touched resident meal cards and utensils with his/her gloved hands in between making the sandwiches. During the meal service, the Dietary Manager wore gloves and opened the refrigerator and took a second pan of three-bean salad from the refrigerator. He/She continued serving the meal wearing the same gloves, including handling the bread with his/her gloved hands and touching the meal cards. He/She opened the refrigerator with his/her gloved hand, took out a container of jelly, closed the refrigerator, opened a bag of bread, held the bread in his/her gloved hand, opened the peanut butter container and put peanut butter on the bread with a spatula. He/She placed the spatula with peanut butter on it into the jelly and finished making the sandwich by holding the sandwich in his/her hand. 3. Review of the facility's undated policy, Sanitizing the Three-Compartment Sink, showed the following: -Ensure the sanitizing water is at the appropriate level, is being monitored, documented, and used correctly; -Fill the third compartment of the three-compartment sink with water to the line as indicated on the sink; -Add premeasured sanitizing solution; -Dishes should be submerged in sanitizing solution for 1 to 2 minutes and allowed to air dry. Review of the Registered Dietician's Kitchen Observation, dated 7/22/24, showed the three-compartment sink was not properly set up. Observation on 8/5/24 at 12:36 P.M. showed the floor under the three-compartment sink and the adjoining counter was heavily soiled with wet and dried food debris. The tiles surrounding the floor drain had been removed and soapy, dirty water from the drain pooled in this area of the floor. The floor drain and the PVC pipe from the sink to the floor drain were heavily soiled. The floor drain grate was rusted with peeling paint. The sanitizer solution bottle, located on the three-compartment sink and connected to the sanitizer hose in the three-compartment sink, was empty. The tube running from the sanitizer to the dispenser was dry. Observation on 8/5/24 at 2:23 P.M. showed Dietary Aide V washed dishes in the middle compartment of the three-compartment sink. He/She washed two large pans in the dirty water, did not rinse, turned on the sanitizer hose (no sanitizer in the sanitizer solution bottle connected to the sanitizer hose) and wet each pan with the water from the hose, and then put the pans on the dish rack to dry. He/She washed utensils in the dirty water, did not rinse, placed them in the empty sink to his/her left, and quickly sprayed them with water from the sanitizer hose. He/She then placed the six utensils (spoodles and a spatula) on the wet soiled towel on the side of the three-compartment sink. Dietary Staff V then pulled a lever under the middle sink to open the sink drain. As the water drained from the sink, water quickly backed out of the floor drain and onto the floor under the sink. Dietary Aide V closed the drain, waited a couple of seconds, and then opened the drain on the sink again. Water immediately backed out of the floor drain and ran out onto the floor approximately 8 feet under the counter and across the walkway and under a metal shelving unit on the opposite wall. Dry food items were stored on this shelving unit. The water on the floor was dirty with food debris. Dietary Aide V quickly mopped the floor, however, the floor was still soiled with food debris and dirty water. During interview on 8/5/24 at 2:25 P.M., the Maintenance Supervisor said the plumbers had been to the facility approximately seven times and said the floor drain was not big enough to handle the water when all three sinks were drained. He was not aware the sink overflowed when only a portion of the water from one sink was drained. During interview on 8/5/24 at 2:27 P.M., the Dietary Manager said the sink had been like this since she started working at the facility in May 2024. She directed staff to slowly drain the sink. If water came out of the floor drain, they were to close the sink drain. Observation on 8/5/24 at 2:39 P.M. showed the sanitizer solution bottle, located on the three-compartment sink and connected to the sanitizer hose in the three-compartment sink, was empty. The tube running from the sanitizer to the dispenser was dry. Observation on 8/5/24 at 3:40 P.M. showed Dietary [NAME] W turned on the water/soap dispenser at the three-compartment sink, ran the water over two pans to wash them in the middle compartment of the three-compartment sink. He/She rinsed the pans under running water but did not sanitize the pans. Observation on 8/6/24 at 12:45 P.M. showed the sanitizer bottle, located under the three-compartment sink, remained empty. Observation on 8/7/24 at 12:19 P.M. showed Dietary Aide V washed a pan in the middle compartment of the three-compartment sink. The water was dirty and contained very little soap. Dietary Aide V rinsed the pan with water from the sanitizer hose and placed the pan on the drying rack. The sanitizer bottle connected to the sanitizer hose was empty. Observation on 8/8/24 at 12:37 P.M., showed washed serving scoops, spoons and a whisk lay on a soiled, wet towel at the end of the three-compartment sink next to the drying rack. Observation on 8/8/24 at 2:07 P.M. showed the sanitizer bottle, located under the three-compartment sink, remained empty. 4. Review of the facility policy, Refrigerator and Freezer Temperatures, dated April 2011, showed the temperature of freezers should be 0 degrees Fahrenheit (F) or below. Observation on 8/5/24 at 11:37 A.M., showed the external thermometer on the three-door freezer showed the internal temperature was 15 degrees F. The internal thermometer showed 20 degrees F. Ice was melting in a small pool of water on the floor of the freezer. A sign was posted on the freezer to keep these doors closed. The freezer contained boxes of frozen food items, including beef and pork. Observation on 8/5/24 at 2:20 P.M. showed the external thermometer on the three-door freezer showed the internal temperature was 10 degrees F. The internal thermometer showed 15 degrees F. Ice had melted in a pool of water on the floor of the unit. Observation on 8/6/24 at 11:54 A.M. showed the external thermometer on the three-door freezer showed the internal temperature was 15 degrees F. The internal thermometer showed 28 degrees F. 5. During interviews on 8/5/24 at 2:20 P.M. and on 8/8/24 at 1:30 P.M., the Dietary Manager said the following: -She went over the RD's report (RD Kitchen Observations) with staff and came up with a method to determine how often staff were to clean and who would be in charge of cleaning these areas; - The staff were staying on top of cleaning in the kitchen but had not over the last couple of weeks. The deep cleaning was not done like it should due to staffing and illness; -When she cooked, she cleaned the surfaces thoroughly, but some staff were not doing this; -The dietary department had a cleaning list that she implemented a couple months ago and posted at the preparation counter, but staff were not following it due to staffing issues. -Staff were to sweep the floor in the kitchen between meals and mop the floors at the end of the evening shift; -The three-compartment sink should be set up with a basin for detergent, rinse and sanitizer. Staff should allow items to sit in the sanitizer before drying; -The two outside sinks in the three-compartment sink do not hold water, so staff are to fill the middle sink with water and detergent, rinse in the left basin and then allow the sanitizer to run in the right basin and let it run over the dishes prior to air drying; -The three-compartment sink had been like this since she started working in May 2024. She had discussed her concern with the sinks not holding water with the Maintenance Supervisor and the Administrator. They had discussed getting drain stoppers for the basins but she never received any; -Staff fill the sanitizer buckets with sanitizer from the three-compartment sink. Staff are to keep the washcloths in the sanitizer buckets and to use these washcloths to clean the surfaces. -There have been problems with the three-door freezer thawing quickly if the doors are open so staff are to get what they need and then close the door quickly. There is a sign on the door to close the door completely. The freezer had been like this since she started in May. She had not told the Maintenance Supervisor or the Administrator about this issue; -Staff were to wash their hands by scrubbing for 20 seconds with soap, dry hands with a paper towel and turn off the sink with the paper towel; -If touching food, staff should wear gloves that haven't touched anything else. During an interview on 8/22/24 at 3:40 P.M., the Administrator said she was not aware two of the sinks in the three-compartment sink did not drain. She expected staff to clean the kitchen. The Dietary Manager was to address the Registered Dietician's concerns identified during the monthly RD report with the dietary staff. The dietary staff were to follow the cleaning schedules, and the Dietary Manager was to monitor to ensure staff were cleaning per the schedule.

Based on observation and interview, the facility failed to ensure hazardous materials were kept secured and inaccessible to residents. The facility capacity was 142 and the census was 82. Observation on 8/5/24 from 11:28 A.M. to 6:58 P.M., during the life safety code tour of the facility, showed the following: -Six containers of chafing fuel were in an unlocked cabinet in the 200 hall dining and activity room; -A bottle of nail polish remover was in an unlocked lower cabinet in the ice cream/popcorn area located near the resident sitting area. The nail polish remover bottle label read '100% pure acetone, Warning: Keep away from children, Danger! Extremely flammable!; -A bottle of commercial surface disinfectant was in a lower unlocked cabinet in the 100/200 wing dining room. The label on the bottle read 'Keep out of reach of children'; -An unlabeled spray bottle containing purple liquid was in an unlocked cabinet near the lobby restrooms and resident sitting area; -An unlabeled spray bottle containing yellow liquid and a bottle of liquid starch were in an unlocked cabinet below the television in the main dining room. During interviews on 8/5/24 at 5:08 P.M. and on 8/7/24 at 2:30 P.M., the Maintenance Supervisor said he was unaware of the items found unsecured during the life safety code tour and he expected the items to be secured from access by residents. He recognized the yellow liquid as a cleaner and the purple liquid a deodorizer - both liquids were products utilized at the facility. He expected liquids such as these to be labeled. The nail polish remover, and starch were likely used by the activities staff. During an interview on 8/7/24 at 2:01 P.M., the Activities Director said she had only worked at the facility for a couple of weeks and was unaware the items found during the life safety code tour needed to be secured from resident access.

Based on interview and record review, the facility failed to implement an ongoing activities program designed to meet individual interests for two residents (Resident #2 and #5), in a review of 10 sampled residents and four additional residents (Resident #15, #18, #19 and #20). The facility also failed to provide activities in the evenings and on the weekends. The facility census was 85. Review of the facility policy, Role of the Activity Director, dated March 2012, showed the following: -The Activity Director provides a key role in enhancing the quality of a resident's daily life; -The Activity Director plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility. 1. Review of the facility's activity calendar, dated September 2024, showed the following: -No activities scheduled after 3:00 P.M.; -No activities scheduled on Saturdays and Sundays. 2. Review of the resident council minutes, dated 09/11/24, showed the residents requested more crafts and Bingo. 3. Review of the facility's activity calendar, dated October 2024, showed the following: -No activities scheduled after 4:00 P.M.; -No activities scheduled on Saturdays and Sundays. 4. Review of Resident #20's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/11/24, showed the following: -Cognitively intact; -Very important to do favorite activities. Review of the resident's care plan, revised 08/28/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/02/24 at 11:49 A.M., the resident said the following: -There were not enough activities; -There were no activities on the weekends. 5. Review of Resident #15's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Very important to do favorite activities; -Diagnoses of stroke and depression. Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/03/24 at 11:45 A.M., the resident said nothing goes on in the facility on the weekend. There were no weekend activities. 6. Review of Resident #18's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Very important to do favorite activities; -Diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/03/24 at 11:45 A.M., the resident said nothing goes on in the facility on the weekend. There were no weekend activities. 7. Review of Resident #5's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Very important to do favorite activities; -Diagnoses of cancer and depression. Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/08/24 at 1:36 P.M., the resident said the following: -There was a new Activity Director that had no experience; -At times they had Bingo or a movie on the weekends; -There were no church services offered; -The residents used to get ice cream as an activity three times a week, but not anymore. 8. Review of Resident #19's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Very important to do favorite activities; -Diagnosis of depression. Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/02/24 at 12:15 P.M., the resident said there were no evening or weekend activities. 9. Review of Resident #2's Significant Change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of anxiety disorder. Review of the resident's care plan, last revised 09/01/24, showed no documentation regarding activities. During an interview on 10/2/24 at 1:57 P.M., the resident said the following: -There were not enough activities at the facility; -There was nothing to do at the facility, especially on the weekends. 10. During an interview on 10/03/24 at 1:15 P.M., the Activity Assistant said the following: -She helped with activities, passed ice water and also helped in the kitchen; -She worked 12:00 P.M. to 8:00 P.M. Sunday-Thursday; -She helps pass lunch and supper trays and assists in the dining room; -There was a resident that often does Bingo on the weekends; -In the evenings, she usually played cards with a group of four residents; -Sometimes she will walk around and talk to residents, depending on how much time she has; -Sometimes on Sundays, she will do coloring or put on a movie. During an interview on 10/08/24 at 3:58 P.M. the Activity Director said the following: -She started at the facility in July 2024; -Her hours were Monday-Friday 8:00 A.M.-4:30 P.M.; -There was an Activity Assistant that worked some evenings; -The Activity Assistant helps serve supper and then plays cards with a few of the residents; She does not have documentation of this; -There was no activity staff in the building on Saturdays; -The Activity Assistant was in the facility on Sundays; Sometimes the activity assistant will serve ice cream; -Some of the residents like to do Bingo on the weekends; -There was no documentation for evening and weekend activities for the month of September; -The only documentation she had for October was for a movie and cards on 10/3/24 (Thursday). During an interview on 10/02/24 at 11:50 A.M., Licensed Practical Nurse E said the following: -He/She worked as a charge nurse on day shift every other weekend; -There were no activities on the weekends; -There was one resident who would do Bingo around 2:30 P.M. on Saturday and Sunday for those residents that can go. During an interview on 10/09/24 at 1:36 P.M., the Administrator said the following: -She would expect activities to be offered to the residents in the evenings and on weekends; -The Activity Assistant helps pass meal trays in the kitchen at meal time; -The Activity Assistant does some evening activities and works on Sundays; -The Activity Director usually tells the Activity Assistant what to do; -The Activity Assistant was supposed to do 1:1 with the cognitively impaired residents; -Activity participation should be documented. MO 242022

Based on interview and record review, the facility failed to implement an ongoing activities program designed to meet individual interests for two residents (Resident #2 and #5), in a review of 10 sampled residents and four additional residents (Resident #15, #18, #19 and #20). The facility also failed to provide activities in the evenings and on the weekends. The facility census was 85. Review of the facility policy, Role of the Activity Director, dated March 2012, showed the following: -The Activity Director provides a key role in enhancing the quality of a resident's daily life; -The Activity Director plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility. 1. Review of the facility's activity calendar, dated September 2024, showed the following: -No activities scheduled after 3:00 P.M.; -No activities scheduled on Saturdays and Sundays. 2. Review of the resident council minutes, dated 09/11/24, showed the residents requested more crafts and Bingo. 3. Review of the facility's activity calendar, dated October 2024, showed the following: -No activities scheduled after 4:00 P.M.; -No activities scheduled on Saturdays and Sundays. 4. Review of Resident #20's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/11/24, showed the following: -Cognitively intact; -Very important to do favorite activities. Review of the resident's care plan, revised 08/28/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/02/24 at 11:49 A.M., the resident said the following: -There were not enough activities; -There were no activities on the weekends. 5. Review of Resident #15's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Very important to do favorite activities; -Diagnoses of stroke and depression. Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/03/24 at 11:45 A.M., the resident said nothing goes on in the facility on the weekend. There were no weekend activities. 6. Review of Resident #18's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Very important to do favorite activities; -Diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/03/24 at 11:45 A.M., the resident said nothing goes on in the facility on the weekend. There were no weekend activities. 7. Review of Resident #5's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Very important to do favorite activities; -Diagnoses of cancer and depression. Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/08/24 at 1:36 P.M., the resident said the following: -There was a new Activity Director that had no experience; -At times they had Bingo or a movie on the weekends; -There were no church services offered; -The residents used to get ice cream as an activity three times a week, but not anymore. 8. Review of Resident #19's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Very important to do favorite activities; -Diagnosis of depression. Review of the resident's care plan, revised 08/19/24, showed the following: -The resident attends activities that he/she enjoys with encouragement from staff; -Discuss with the resident, activities offered while visiting with him/her; -Encourage the resident to socialize during group activities; -Give the resident an activities calendar and remind him/her of upcoming activities. During an interview on 10/02/24 at 12:15 P.M., the resident said there were no evening or weekend activities. 9. Review of Resident #2's Significant Change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of anxiety disorder. Review of the resident's care plan, last revised 09/01/24, showed no documentation regarding activities. During an interview on 10/2/24 at 1:57 P.M., the resident said the following: -There were not enough activities at the facility; -There was nothing to do at the facility, especially on the weekends. 10. During an interview on 10/03/24 at 1:15 P.M., the Activity Assistant said the following: -She helped with activities, passed ice water and also helped in the kitchen; -She worked 12:00 P.M. to 8:00 P.M. Sunday-Thursday; -She helps pass lunch and supper trays and assists in the dining room; -There was a resident that often does Bingo on the weekends; -In the evenings, she usually played cards with a group of four residents; -Sometimes she will walk around and talk to residents, depending on how much time she has; -Sometimes on Sundays, she will do coloring or put on a movie. During an interview on 10/08/24 at 3:58 P.M. the Activity Director said the following: -She started at the facility in July 2024; -Her hours were Monday-Friday 8:00 A.M.-4:30 P.M.; -There was an Activity Assistant that worked some evenings; -The Activity Assistant helps serve supper and then plays cards with a few of the residents; She does not have documentation of this; -There was no activity staff in the building on Saturdays; -The Activity Assistant was in the facility on Sundays; Sometimes the activity assistant will serve ice cream; -Some of the residents like to do Bingo on the weekends; -There was no documentation for evening and weekend activities for the month of September; -The only documentation she had for October was for a movie and cards on 10/3/24 (Thursday). During an interview on 10/02/24 at 11:50 A.M., Licensed Practical Nurse E said the following: -He/She worked as a charge nurse on day shift every other weekend; -There were no activities on the weekends; -There was one resident who would do Bingo around 2:30 P.M. on Saturday and Sunday for those residents that can go. During an interview on 10/09/24 at 1:36 P.M., the Administrator said the following: -She would expect activities to be offered to the residents in the evenings and on weekends; -The Activity Assistant helps pass meal trays in the kitchen at meal time; -The Activity Assistant does some evening activities and works on Sundays; -The Activity Director usually tells the Activity Assistant what to do; -The Activity Assistant was supposed to do 1:1 with the cognitively impaired residents; -Activity participation should be documented. MO 242022

Based on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for wound care for two residents (Resident #2 and Resident #1), in a review of ten sampled residents. The facility census was 85. Review of the undated facility policy titled, Physician Orders, showed the following: -Physician's orders must be signed by the physician and dated when such order was signed; -Physician orders must be reviewed and renewed; -The policy did not address following physicians orders. Review of the undated facility policy titled, Wound Care and Treatment, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -There must be a specific order for the treatment. 1. Review of Resident #2's Significant Change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 08/26/24, showed the following: -Surgical wound; -Application of non-surgical dressing other than to feet; -Diagnoses of anxiety disorder and arthritis. Review of the resident's care plan, revised 09/01/24, showed the following: -The resident has a chronic right hip wound; -The resident has an alteration in skin integrity, non-pressure related, to an old dehisced (a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing) wound from surgery; -Right hip dressing with packing as ordered. Review of the resident's physician's orders, dated 09/01/24 - 09/22/24, showed an order for Santyl (ointment used to remove damaged tissue from chronic skin ulcers) 250 unit/gram. Cleanse right hip wound with normal saline (a sterile salt water solution that is used to clean wounds and promote healing), apply Santyl to wound bed, pack with two inch Iodosorb packing strips (impregnated with iodoform, which is an antimicrobial solution. Iodoform packing strips are used to drain exudate (fluid that leaks from blood vessels into nearby tissues during the wound healing process) from tunneling wounds (a chronic wound that forms a channel or tunnel that extends from the skin's surface into deeper tissue, such as muscle or skin layers) that are open and/or infected). Cover with dry dressing. Change daily. Review of the resident's wound care consultant note, dated 09/20/24, showed the following: -New consult for open wound to right trochanter (a bony prominence on the top of the thighbone) from a cyst (a closed, sac-like pocket of tissue that can form anywhere in the body and can be filled with fluid, air, pus, or other material) removal three years prior; -Resident said wound has been draining a lot; -Recommend Iodosorb packing daily. Review of the resident's progress notes, dated 09/22/24 at 11:44 P.M., showed the following: -The resident was noted to have severe chest pain and shooting chest pain; -The resident requested to go to the hospital. Review of the resident's progress notes, dated 09/23/24 at 8:07 A.M., showed the resident was admitted to the hospital. Review of the resident's progress notes, dated 09/29/24 at 6:04 P.M., showed the following: -The resident returned from the hospital; -Nurse practitioner (NP) called. Review of the resident's hospital discharge orders, dated 09/29/24, showed an order for Santyl 250 unit/gram topical daily. Nickel thickness topical daily, cleanse right hip wound with normal saline and apply Santyl to wound bed. Pack with two inch Iodosorb packing strips. Cover with dry dressing. Change daily. Review of the resident's physician's orders, dated 09/29/24 - 10/02/24 showed no treatment order for the resident's right hip wound. Review of the resident's Treatment Administration Record (TAR), dated 09/29/24 - 09/30/24, showed no documentation of a treatment order, or that staff had completed a treatment, for the resident's right hip wound. Review of the resident's physician's orders, dated 10/01/24 - 10/02/24, showed no treatment order for the resident's right hip wound. Review of the resident's TAR, dated 10/01/24 - 10/02/24, showed no documentation of a treatment order, or that staff had completed a treatment, for the resident's right hip wound. During an interview on 10/02/24 at 1:54 P.M. and 10/03/24 at 9:05 A.M., the resident said the following: -He/She came back from the hospital on [DATE]; -He/She has an open wound on his/her hip that drains; -He/She tried to show the dressing to staff (unknown names), but staff didn't look at it; -Facility staff had not changed his/her dressing since he/she returned from the hospital on [DATE]; -His/Her dressing was last changed at the hospital prior to returning to the facility; -His/Her dressing was changed daily at the facility prior to going to the hospital; -He/She had asked staff (unknown names) about changing his/her dressing and no one has changed it yet. During an interview on 10/03/24 at 9:10 A.M., Licensed Practical Nurse (LPN) D said the following: -The resident does not have any current wound care orders to his/her right hip wound; -He/She was told by staff the Assistant Director of Nursing (ADON) was notified the resident did not have wound care orders; -Prior to the resident's most recent hospital stay, staff packed the resident's wound with Iodosorb packing strips, covered it with a dry dressing and secured the dressing with tape. During an interview on 10/08/24 at 5:28 P.M., LPN C said the following: -He/She was the charge nurse on duty when the resident was readmitted to the facility; -He/She called the NP to verify the resident's orders with the NP on call; -The NP said it was okay to resume all the resident's previous orders; -He/She was familiar with the resident and was aware of the pre-existing wound to the right hip; -The treatment order to the resident's right hip wound should have been restarted, but he/she may have missed resuming the treatment; -He/She was unsure if anyone audited or reconciled hospital readmission orders with previous orders on readmission as he/she works on the weekends only. Observation on 10/03/24 at 11:15 A.M., in the resident's room, showed the following: -The resident lay on his/her left side in bed; -There was an undated, large tan dressing present on the resident's right hip; -The ADON removed the dressing that was saturated with a pink/tan drainage and a mucous-like appearing texture (normal drainage is a thin, watery fluid that is clear or slightly yellow in color); -The periwound (the skin surrounding a wound) was reddened approximately ½ inch around the wound; -The ADON discarded the soiled dressing, performed hand hygiene and cleansed the wound; -The ADON measured the wound with a cotton applicator; -The cotton applicator was covered with tan drainage; -The wound bed was covered with tan slough (a layer of non-viable tissue in a wound) and pink granulation tissue (a new connective tissue that forms in a wound during the healing process); -The ADON applied Santyl to the wound bed and packed the wound with plain non-medicated packing strips (not the ordered two inch Iodosorb packing strips); -The ADON covered the wound bed with a gauze dressing and Mepilex dressing (bordered foam dressing) (there was no order for a Mepilex dressing). During an interview on 10/03/24 at 9:20 A.M.,10:30 A.M. and 12:10 P.M., the ADON said the following: -When a resident was discharged to the hospital the resident's medication and treatment orders are discontinued in the computer; -The charge nurse was responsible for reinstating previous orders upon readmission unless changed by the NP or physician; -The charge nurse on duty when the resident was readmitted should have resumed the resident's previous treatment orders and did not; -She was not aware the resident did not have current treatment orders; -She reinstated the resident's previous treatment orders today; -The resident's treatment order as of today, 10/03/24, was Santyl and Iodosorb packing strips; -She didn't have Iodosorb packing strips for today's (10/03/24) treatment, so she used plain packing strips; -Iodosorb packing strips activate the Santyl; -Iodosorb packing strips are wet and plain packing strips are dry. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of cancer; -No skin or ulcer treatments. Review of the resident's care plan, last revised 09/20/24, showed the following: -The resident was at risk for pressure ulcer due to impaired mobility; -No direction to staff regarding care and treatment of the right hip wound. Review of the resident's physician's orders, dated 10/01/24 - 10/09/24, showed an order for right hip wound to cleanse wound with normal saline/wound cleanser, pat dry with 4 X 4 gauze, pack wound with Iodosorb gauze using cotton-tip applicator, cover with 4 X 4 gauze, then an ABD pad (a highly absorbent dressing used to treat large wounds and heavy drainage) and secure with tape. Change daily (09/24/24). Observation on 10/03/24 at 10:35 A.M., in the resident's room, showed the following: -The resident lay in his/her bed; -With gloved hands, LPN D removed the soiled dressing and cleaned the wound; -LPN D used a cotton applicator and packed plain non-medicated packing strips into the wound bed and covered the wound with a gauze dressing (LPN D did not use the ordered Iodosorb gauze or apply an ABD pad as ordered); -LPN D secured the gauze dressing with tape. During an interview on 10/03/24 at 1:20 P.M., LPN D said the following: -He/She did not have the Iodosorb packing strip for the resident's treatment; -He/She went to the ADON's office and got the plain packing strip and that's what he/she used to pack the resident's treatment; -The resident's treatment order is to pack the resident's wound with Iodosorb packing strips, but all he/she had was the plain packing strips. 3. During an interview on 10/08/24 at 3:42 P.M., LPN B said the following: -When a resident was readmitted from the hospital, the charge nurse calls the physician's office to notify of the readmission, and faxes over the orders and face sheet for review; -The charge nurse then changes the start date of the medication and treatment orders in the computer; -Whoever does the admission is responsible for ensuring the orders are accurate; -The facility used to have an Admissions Champion (a staff member who double checked admission/readmission orders for accuracy). He/She is not sure if the facility currently has an Admissions Champion. During an interview on 10/09/24 at 1:20 P.M., the Director of Nursing said the following: -She would expect staff to follow physician's orders; -She would expect staff to follow hospital discharge orders; -The charge nurse on duty is responsible for reviewing the hospital discharge orders, comparing them to the previous orders, reconciling the orders and getting the approval from the physician or nurse practitioner. During an interview on 10/09/24 at 1:36 P.M., the Administrator said the following: -She would expect all previous orders to be resumed on re-admission unless told otherwise by the primary care physician (PCP); -She would expect staff to follow hospital discharge orders; -She would expect staff to follow wound care orders as per the physician's order. During an interview on 10/09/24 at 11:20 A.M., the wound care consultant NP said the following: -She would expect previous treatment orders to be resumed after hospitalization unless they come with new hospital discharge orders; -Resident #2's dressing should be changed daily as the wound has a lot of drainage; -She would expect staff to follow wound care treatment orders as written; -The Iodoform gauze is used to fill the wound bed and absorb drainage; -She would expect staff to notify her or the primary care provider (PCP) if wound care supplies are not available. During an interview on 10/09/24 at 1:10 P.M., the residents' physician (for both Resident #2 and Resident #1) said the following: -He would expect staff to follow hospital discharge orders; -He would expect staff to provide wound treatments as ordered. MO 242022

Based on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for wound care for two residents (Resident #2 and Resident #1), in a review of ten sampled residents. The facility census was 85. Review of the undated facility policy titled, Physician Orders, showed the following: -Physician's orders must be signed by the physician and dated when such order was signed; -Physician orders must be reviewed and renewed; -The policy did not address following physicians orders. Review of the undated facility policy titled, Wound Care and Treatment, showed the following: -It is the purpose of the facility to prevent and treat all wounds; -There must be a specific order for the treatment. 1. Review of Resident #2's Significant Change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 08/26/24, showed the following: -Surgical wound; -Application of non-surgical dressing other than to feet; -Diagnoses of anxiety disorder and arthritis. Review of the resident's care plan, revised 09/01/24, showed the following: -The resident has a chronic right hip wound; -The resident has an alteration in skin integrity, non-pressure related, to an old dehisced (a partial or total separation of previously approximated wound edges, due to a failure of proper wound healing) wound from surgery; -Right hip dressing with packing as ordered. Review of the resident's physician's orders, dated 09/01/24 - 09/22/24, showed an order for Santyl (ointment used to remove damaged tissue from chronic skin ulcers) 250 unit/gram. Cleanse right hip wound with normal saline (a sterile salt water solution that is used to clean wounds and promote healing), apply Santyl to wound bed, pack with two inch Iodosorb packing strips (impregnated with iodoform, which is an antimicrobial solution. Iodoform packing strips are used to drain exudate (fluid that leaks from blood vessels into nearby tissues during the wound healing process) from tunneling wounds (a chronic wound that forms a channel or tunnel that extends from the skin's surface into deeper tissue, such as muscle or skin layers) that are open and/or infected). Cover with dry dressing. Change daily. Review of the resident's wound care consultant note, dated 09/20/24, showed the following: -New consult for open wound to right trochanter (a bony prominence on the top of the thighbone) from a cyst (a closed, sac-like pocket of tissue that can form anywhere in the body and can be filled with fluid, air, pus, or other material) removal three years prior; -Resident said wound has been draining a lot; -Recommend Iodosorb packing daily. Review of the resident's progress notes, dated 09/22/24 at 11:44 P.M., showed the following: -The resident was noted to have severe chest pain and shooting chest pain; -The resident requested to go to the hospital. Review of the resident's progress notes, dated 09/23/24 at 8:07 A.M., showed the resident was admitted to the hospital. Review of the resident's progress notes, dated 09/29/24 at 6:04 P.M., showed the following: -The resident returned from the hospital; -Nurse practitioner (NP) called. Review of the resident's hospital discharge orders, dated 09/29/24, showed an order for Santyl 250 unit/gram topical daily. Nickel thickness topical daily, cleanse right hip wound with normal saline and apply Santyl to wound bed. Pack with two inch Iodosorb packing strips. Cover with dry dressing. Change daily. Review of the resident's physician's orders, dated 09/29/24 - 10/02/24 showed no treatment order for the resident's right hip wound. Review of the resident's Treatment Administration Record (TAR), dated 09/29/24 - 09/30/24, showed no documentation of a treatment order, or that staff had completed a treatment, for the resident's right hip wound. Review of the resident's physician's orders, dated 10/01/24 - 10/02/24, showed no treatment order for the resident's right hip wound. Review of the resident's TAR, dated 10/01/24 - 10/02/24, showed no documentation of a treatment order, or that staff had completed a treatment, for the resident's right hip wound. During an interview on 10/02/24 at 1:54 P.M. and 10/03/24 at 9:05 A.M., the resident said the following: -He/She came back from the hospital on 09/29/24; -He/She has an open wound on his/her hip that drains; -He/She tried to show the dressing to staff (unknown names), but staff didn't look at it; -Facility staff had not changed his/her dressing since he/she returned from the hospital on 09/29/24; -His/Her dressing was last changed at the hospital prior to returning to the facility; -His/Her dressing was changed daily at the facility prior to going to the hospital; -He/She had asked staff (unknown names) about changing his/her dressing and no one has changed it yet. During an interview on 10/03/24 at 9:10 A.M., Licensed Practical Nurse (LPN) D said the following: -The resident does not have any current wound care orders to his/her right hip wound; -He/She was told by staff the Assistant Director of Nursing (ADON) was notified the resident did not have wound care orders; -Prior to the resident's most recent hospital stay, staff packed the resident's wound with Iodosorb packing strips, covered it with a dry dressing and secured the dressing with tape. During an interview on 10/08/24 at 5:28 P.M., LPN C said the following: -He/She was the charge nurse on duty when the resident was readmitted to the facility; -He/She called the NP to verify the resident's orders with the NP on call; -The NP said it was okay to resume all the resident's previous orders; -He/She was familiar with the resident and was aware of the pre-existing wound to the right hip; -The treatment order to the resident's right hip wound should have been restarted, but he/she may have missed resuming the treatment; -He/She was unsure if anyone audited or reconciled hospital readmission orders with previous orders on readmission as he/she works on the weekends only. Observation on 10/03/24 at 11:15 A.M., in the resident's room, showed the following: -The resident lay on his/her left side in bed; -There was an undated, large tan dressing present on the resident's right hip; -The ADON removed the dressing that was saturated with a pink/tan drainage and a mucous-like appearing texture (normal drainage is a thin, watery fluid that is clear or slightly yellow in color); -The periwound (the skin surrounding a wound) was reddened approximately 1/2 inch around the wound; -The ADON discarded the soiled dressing, performed hand hygiene and cleansed the wound; -The ADON measured the wound with a cotton applicator; -The cotton applicator was covered with tan drainage; -The wound bed was covered with tan slough (a layer of non-viable tissue in a wound) and pink granulation tissue (a new connective tissue that forms in a wound during the healing process); -The ADON applied Santyl to the wound bed and packed the wound with plain non-medicated packing strips (not the ordered two inch Iodosorb packing strips); -The ADON covered the wound bed with a gauze dressing and Mepilex dressing (bordered foam dressing) (there was no order for a Mepilex dressing). During an interview on 10/03/24 at 9:20 A.M.,10:30 A.M. and 12:10 P.M., the ADON said the following: -When a resident was discharged to the hospital the resident's medication and treatment orders are discontinued in the computer; -The charge nurse was responsible for reinstating previous orders upon readmission unless changed by the NP or physician; -The charge nurse on duty when the resident was readmitted should have resumed the resident's previous treatment orders and did not; -She was not aware the resident did not have current treatment orders; -She reinstated the resident's previous treatment orders today; -The resident's treatment order as of today, 10/03/24, was Santyl and Iodosorb packing strips; -She didn't have Iodosorb packing strips for today's (10/03/24) treatment, so she used plain packing strips; -Iodosorb packing strips activate the Santyl; -Iodosorb packing strips are wet and plain packing strips are dry. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of cancer; -No skin or ulcer treatments. Review of the resident's care plan, last revised 09/20/24, showed the following: -The resident was at risk for pressure ulcer due to impaired mobility; -No direction to staff regarding care and treatment of the right hip wound. Review of the resident's physician's orders, dated 10/01/24 - 10/09/24, showed an order for right hip wound to cleanse wound with normal saline/wound cleanser, pat dry with 4 X 4 gauze, pack wound with Iodosorb gauze using cotton-tip applicator, cover with 4 X 4 gauze, then an ABD pad (a highly absorbent dressing used to treat large wounds and heavy drainage) and secure with tape. Change daily (09/24/24). Observation on 10/03/24 at 10:35 A.M., in the resident's room, showed the following: -The resident lay in his/her bed; -With gloved hands, LPN D removed the soiled dressing and cleaned the wound; -LPN D used a cotton applicator and packed plain non-medicated packing strips into the wound bed and covered the wound with a gauze dressing (LPN D did not use the ordered Iodosorb gauze or apply an ABD pad as ordered); -LPN D secured the gauze dressing with tape. During an interview on 10/03/24 at 1:20 P.M., LPN D said the following: -He/She did not have the Iodosorb packing strip for the resident's treatment; -He/She went to the ADON's office and got the plain packing strip and that's what he/she used to pack the resident's treatment; -The resident's treatment order is to pack the resident's wound with Iodosorb packing strips, but all he/she had was the plain packing strips. 3. During an interview on 10/08/24 at 3:42 P.M., LPN B said the following: -When a resident was readmitted from the hospital, the charge nurse calls the physician's office to notify of the readmission, and faxes over the orders and face sheet for review; -The charge nurse then changes the start date of the medication and treatment orders in the computer; -Whoever does the admission is responsible for ensuring the orders are accurate; -The facility used to have an Admissions Champion (a staff member who double checked admission/readmission orders for accuracy). He/She is not sure if the facility currently has an Admissions Champion. During an interview on 10/09/24 at 1:20 P.M., the Director of Nursing said the following: -She would expect staff to follow physician's orders; -She would expect staff to follow hospital discharge orders; -The charge nurse on duty is responsible for reviewing the hospital discharge orders, comparing them to the previous orders, reconciling the orders and getting the approval from the physician or nurse practitioner. During an interview on 10/09/24 at 1:36 P.M., the Administrator said the following: -She would expect all previous orders to be resumed on re-admission unless told otherwise by the primary care physician (PCP); -She would expect staff to follow hospital discharge orders; -She would expect staff to follow wound care orders as per the physician's order. During an interview on 10/09/24 at 11:20 A.M., the wound care consultant NP said the following: -She would expect previous treatment orders to be resumed after hospitalization unless they come with new hospital discharge orders; -Resident #2's dressing should be changed daily as the wound has a lot of drainage; -She would expect staff to follow wound care treatment orders as written; -The Iodoform gauze is used to fill the wound bed and absorb drainage; -She would expect staff to notify her or the primary care provider (PCP) if wound care supplies are not available. During an interview on 10/09/24 at 1:10 P.M., the residents' physician (for both Resident #2 and Resident #1) said the following: -He would expect staff to follow hospital discharge orders; -He would expect staff to provide wound treatments as ordered. MO 242022

Based on interview and record review, the facility failed to prevent sexual abuse between two residents (Resident #1 and Resident #2), who engaged in sexual intercourse and whose capacity to consent to sexual activity had not been determined, in a review of 13 sampled residents. Resident #1 was assessed as severely cognitively impaired and had diagnoses including Alzheimers Disease, dementia, herpes viral infection, and human immunodeficiency virus disease. Resident #2 had diagnoses including vascular dementia and depression. When Resident #2 talked to his/her responsible party after the incident, he/she told the responsible party he/she did not want the sexual activity to occur, he/she was scared, and did not want to be around Resident #1. The facility census was 85. The administrator was notified on 5/10/24 at 4:13 P.M. of an Immediate Jeopardy (IJ) which began on 5/2/24. The IJ was removed on 5/11/24 as confirmed by surveyor on-site verification. Review of the facility's abuse prohibition protocol manual, undated, showed the following: -Establish a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as, identify when, how, and whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; -The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict, such as sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; -Examples of sexual abuse: unwanted sexual attention or touching, sexual touching of the body of a resident who cannot make decisions for themselves; -Training included teaching the staff to look for changes in residents' behavior, mood, or social interactions. Review of the facility's policy Resident and Tenant Sexual Expression, dated 10/21/22, showed the following: -Sexual expression is defined by language, gestures, conduct, or activities that indicate a desire for sexual gratification (hugging, kissing, hand holding, flirting, masturbation, touch, signs of romance or companionship, viewing of sexual-explicit materials); -Some residents who exhibit diminished decision-making capacity (example dementia, Alzheimer's disease, coma) who have a brief interview for mental status (BIMS) score of seven or below will not be allowed to consent; -The facility staff will conduct a thoughtful review of accounts of sexual expression among residents to determine a solution that best meets the needs of and protects those involved; -Outcomes of the reviews will be shared with the resident and interdisciplinary team and documented in the care or service plan. 1. Review of Resident #1's face sheet, undated, showed the following: -The resident had a power of attorney; -Diagnoses included Alzheimer's disease (type of dementia that affects memory, thinking and behavior), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizoaffective disorder (bipolar type) (episodes of mania and sometimes depression), herpes viral infection, major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and human immunodeficiency virus disease. Review of the resident's Preadmission Screening and Resident Review level II (PASARR Level II) (confirms the indicated diagnosis noted in the Level I Screen and determines whether placement or continued stay in a Nursing Facility is appropriate), dated 12/7/22, showed due to the resident's cognitive impairment, ongoing paranoid and delusional ideation, the resident required close supervision 24 hours a day to maintain safety. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/16/24, showed the following: -The resident had a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment; -No behaviors documented. Review of the resident's care plan, last updated 2/28/24, showed the following: -He/She had a PASARR; -He/She had impaired cognition; -Ask open ended questions requiring only a yes/no response; -Explain all routines and procedures as they occur. Review of the resident's physician orders, dated May 2024, showed the following: -Biktarvy (antiviral combination medication) 50-200-25 milligrams (mg), give one tablet orally daily for human immunodeficiency virus disease; -Valtrex (antiviral) 500 mg, give one tablet orally daily for herpes viral infection. Review of the resident's nurse's note, dated 5/2/24 at 8:10 P.M., showed the following: -Staff observed the resident lying in Resident #2's bed without clothing; -Resident #2 was not wearing bottoms/underwear; -Staff immediately separated both residents; -The nurse called the resident's power of attorney to inform him/her of the incident. Review of the resident's nurse's note, dated 5/2/24 at 11:23 P.M., showed the following: -Staff contacted the on-call nurse practitioner regarding the incident; -The nurse practitioner prescribed labs in the morning; -Staff moved the resident to another hall away from Resident #2. During an interview on 5/9/24 at 1:31 P.M., Resident #1's next of kin said the facility notified him/her that Resident #1 was found having sex with Resident #2. Review of the resident's care plan, last revised on 2/28/24, showed it did not include documentation of interventions regarding contact between Resident #1 and Resident #2, or the resident's capacity to consent to a sexual relationship. 2. Review of Resident #2's face sheet, undated, showed the following: -admitted [DATE]; -The resident had a responsible party; -Diagnoses included depression (common and serious medical illness that negatively affects how you feel, the way you think and how you act), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain) with anxiety (feeling of fear, dread, and uneasiness), and mild agitation. Review of the resident's nurse's note, dated 4/19/24 at 2:50 P.M., showed the following: -The resident was oriented to self, very confused, and needed frequent redirection and cueing; -He/She was ambulatory with steady gait; -Recent hospitalization for worsened depression, confusion, and suicidal ideation. Review of the resident's nurse's note, dated 4/19/24, showed the resident had family members that were very abusive towards him/her in the past and had not been in the resident's life for a long time. Review of the resident's care plan, last updated 4/26/24, showed the following: -The resident had the potential for drug related complications associated with the use of psychotropic medications related to cognitive impairment; -Encourage the resident to verbalize the feelings he/she had that were associated with anxiety, depression, hallucinations/delusions, or mood swings; -The resident was at risk for wandering related to cognitive impairment and took medication to suppress thought process; -Evaluate the resident's ability to understand his/her surroundings and give him/her cues and redirection as needed to promote activities of daily living participation and reduce wandering behavior; -Please provide the resident increased supervision during periods of increased wandering and exit seeking behavior; -The care plan did not include the resident's history of abuse. - It did not include documentation of interventions regarding contact between Resident #1 and Resident #2, or the resident's capacity to consent to a sexual relationship. Record review showed the resident was a new admission and the MDS, including the BIMS, had not yet been completed. Review of the resident's nurse's note, dated 5/2/24 at 8:10 P.M., showed the following: -Staff observed the resident in bed with Resident #1; -Resident #2 wore a shirt with no bottoms/underwear; -Resident #1 was nude; -The staff separated both residents; -Attempted to notify the resident's responsible party with no success; -Call made four times to contact responsible party, no answer; -Will notify oncoming shift of incident and need to inform responsible party of incident if call is returned. Review of the resident's nurse's note, dated 5/2/24 at 11:20 P.M., showed the following: -The staff called the on-call nurse practitioner regarding the incident; -The nurse practitioner ordered staff to monitor the resident and assess his/her emotional state and call the primary physician in the morning; -The resident told the Director of Nursing (DON) that Resident #1 said he/she loved him/her and thought he/she loved Resident #1 as well. Review of the resident's nurse's note, dated 5/3/24 at 2:53 A.M., showed the following: -Immediately following the incident the resident had high anxiety and was combative with staff when trying to be redirected back to his/her room; -As staff members tried to get the resident dressed and back to his/her room, the resident hit staff with a cane and choked a staff member. That was not typical behavior for the resident; -The nurse called the on-call nurse practitioner and received an order for Haldol (antipsychotic) five milliliters (ml) now and repeat in eight hours as needed. Review of the resident's nurse's note, dated 5/3/24 at 10:23 A.M., showed staff contacted the primary care physician regarding the incident and received new orders for lab work and new medications. Review of the resident's nurse note, dated 5/3/24 at 4:34 P.M., showed the responsible party was informed of the incident and the primary care physician was notified due to the resident having unprotected sex. Review of the resident's nurse note, dated 5/10/24 at 1:05 P.M., showed the primary care physician ordered an antibiotic based on urine culture results. Review of the resident's physician orders, dated May 2024, showed the following: -Emtricitabine-tenofovir (antiviral) 200-300 mg, give one tablet orally daily for exposure to human immunodeficiency virus (started on 5/3/24); -Tivicay (antiviral) 50 mg, give one tablet orally daily for exposure to human immunodeficiency virus (started on 5/3/24); -Lab work included urinanalysis, hepatitis panel and HIV. During an interview on 5/9/24 at 1:09 P.M., Resident #2's responsible party said the following: -The resident was a very private person with a lifetime of physical, sexual, and verbal abuse; -The resident was upset about being placed in a nursing home, the placement made the resident feel worthless; -After the incident, the resident said he/she and Resident #1 spoke in the hallway, touched each other's arms, but it was not okay to have sex; -After the incident, the resident told the responsible party he/she was uncomfortable with Resident #1 around, was fearful of him/her, and did not speak with him/her or make conversation. During an interview on 5/9/24 at 1:50 P.M., Resident #2 said the following: -There was sexual contact with another resident, but nothing had happened since; -He/She felt it would be easier (than living) if he/she dropped dead; -He/She did not want Resident #1 around and was scared of him/her; -He/She had nothing positive to think about. During an interview on 5/9/24 at 11:45 A.M. and 5:53 P.M., Certified Nurse Aide (CNA) C said the following: -Resident #1 hung around Resident #2 for a couple days prior to both residents being caught having sex; -He/She found Resident #1 in Resident #2's room approximately five days before the incident. They were standing in the room talking; -He/She told the night shift staff Resident #1 was in Resident #2's room and they needed to do something about it; -He/She saw a staff member enter Resident #2's room and lead Resident #1 out of the room. During an interview on 5/10/24 at 12:40 P.M., Certified Medication Technician (CMT) D said the following: -On 5/2/24, at approximately 8:00 P.M., he/she knocked on Resident #2's door with the intention of administering medication; -A wheelchair had been placed in front of the door, making it difficult to open; -He/She pushed the door open to find Resident #1 on top of Resident #2 in bed. The two residents were having sexual intercourse; -Resident #1 was upset CMT D had entered the room and yelled for him/her to get out; -It took the staff 30 minutes to get Resident #1 out of Resident #2's room; -Resident #2 was upset after the incident and continued to look for Resident #1 and hoped he/she was not in trouble. During an interview on 5/9/24 at 2:30 P.M., Registered Nurse (RN) E said the following: -On 5/2/24, Resident #2's door was blocked by a wheelchair. RN E was not sure where it came from because neither resident used a wheelchair and Resident #2 did not have a roommate; -A staff member reported Resident #1 and Resident #2 were having sex in Resident #2's room; -Resident #1 was naked and Resident #2 did not have bottoms on; -Both residents were separated immediately; -Resident #1 had behaviors towards staff members after the incident, which was not typical; -After the incident, Resident #2 said he/she did not want Resident #1 to get in trouble. During an interview on 5/15/24 at 2:20 P.M., the Maintenance Director said the following: -He/She witnessed Resident #1 and Resident #2 holding hands while walking down the hall prior to the incident on 5/2/24; -He/She decided to monitor what was happening and saw Resident #1 pointing to his/her room; -Both residents entered Resident #1's room still holding hands, so the Maintenance Director stopped both residents and redirected Resident #1 to come out of the room; -Resident #1 and Resident #2 left the room still holding hands; -He/She reported this issue to the charge nurse at the time, who was agency staff. During an interview on 5/10/24 at 8:25 A.M., the Assistant Director of Nursing said the following: -Resident #1 and Resident #2 sat together in the common area with Resident #2 laying his/her head on Resident #1's shoulder a day or two prior to the sexual intercourse on 5/2/24; -He/She was aware the Maintenance Director found Resident #2 in Resident #1's room previously and had redirected Resident #2 out of the room; -He/She was unaware Resident #1 was found in Resident #2's room prior to the incident on 5/2/24 but learned about it after the incident (on 5/2/24) occurred. During an interview on 5/10/24 at 10:10 A.M., the DON said the following: -Staff did not notify her the Maintenance Director found Resident #2 in Resident #1's room or Resident #1 was found in Resident #2's room prior to the incident on 5/2/24; -She expected staff would report it to her and/or the Administrator; -On the day of the incident on 5/2/24, she saw Resident #1 and Resident #2 sitting together in the common area and thought they were having a conversation; -Both residents were quiet and stayed to themselves. She was aware they were developing companionship; -The intervention prior to the incident on 5/2/24 was staff were supposed to supervise the residents while they were together to ensure their interactions were appropriate, however, this did not get passed along to the staff; -When the staff separated the residents on 5/2/24, Resident #1 had behaviors towards staff while they were trying to get him/her dressed; -After the incident, Resident #2 was upset because he/she did not want Resident #1 to get into trouble; -Resident #2 tried looking for Resident #1 after the incident; -The staff moved Resident #1 to another hall; -After Resident #1 moved to another hall, Resident #2 approached other residents of the opposite sex, who have now complained because they did not want Resident #2 bothering them. During an interview on 5/15/24 at 2:45 P.M., the Administrator said staff were to report any time they witnessed residents holding hands, going to other resident's rooms, or any other intimate contact immediately to the charge nurse and/or the Director of Nursing or Administrator. During an interview on 5/10/24 at 1:06 P.M., the primary care physician for both residents said neither resident had the cognitive ability to consent to sexual activity. The physician was unaware staff had observed the residents in each others' rooms, holding hands and showing affection to one another. Staff should monitor and report those situations as they occurred. NOTE: At the time of the complaint investigation, the violation was determined to be 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 the 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). MO235588

Based on interviews, record reviews, and facility policy review, it was determined the facility failed to honor an advance directive for one resident (Resident #174) of 13 residents reviewed for code status. Resident #174 had a Durable Power of Attorney (DPOA) advance directive indicating the resident's wish for do not resuscitate (DNR) if the resident was found unresponsive. On [DATE], the facility called 911 and initiated cardiopulmonary resuscitation (CPR), despite Resident #174's advance directive. Subsequently, Resident #174 received CPR for 17 minutes against the resident's wishes. It was determined the facility's non-compliance 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, 483.10 (Resident Rights) at a scope and severity of J. The IJ began on [DATE] when Licensed Practical Nurse (LPN) #2 failed to honor Resident #174's advance directive by administering CPR when the resident was a DNR. The Administrator was notified of the IJ and provided with the IJ template on [DATE] at 2:43 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 3:12 PM. The IJ was removed on [DATE] at 8:20 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at a lower scope and severity of isolate, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F578. Findings included: A review of the facility's undated policy titled, Advanced Directive, revealed, The facility will respect advanced directives in accordance with state law. The policy indicated guidelines included: - 1. Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. - 2. Upon admission of a resident, the social services designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. -3. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. Further review of the policy revealed, Staff will be in-serviced annually to ensure they remain informed about the resident's rights to formulate advance directives and facility policy governing such rights. Inquiries concerning advance directives should be referred to the social services designee. An interview on [DATE] at 12:30 P.M. with the Director of Nursing (DON) revealed during admission, the facility asked residents and residents' families if they would like to be designated as a full code (CPR should be provided) or a DNR, and paperwork was signed and placed in the residents' charts. The DON said if the resident did not have a signed DNR form, the resident was designated as a full code. According to the DON, even if a resident had a signed DPOA that indicated the resident wished to not to be resuscitated, the resident/POA had to sign a DNR form. The DON said it was the facility's responsibility to facilitate ensuring the resident and family were aware this form was required, getting the DNR formed signed, and ensuring DNR status was documented in the resident's medical record. A review of a Resident Face Sheet revealed the facility admitted Resident #174 on [DATE] and readmitted the resident on [DATE]. According to the face sheet, the resident had diagnoses that included Alzheimer's disease, chronic kidney disease, and chronic diastolic (congestive) heart failure. The face sheet indicated Resident #174 had a living will, but did not indicate whether a copy was on file. Further review revealed Resident #174 was a full code [indicated CPR should be provided]. A review of the physician's active orders for Resident #174 revealed an order with a start date of [DATE], for a full code. A review of Resident #174's care plan, initiated on [DATE], revealed the resident chooses to be a full code. Interventions included in the event of no pulse or no respirations, to start CPR and call 911. A review of a discharge Minimum Data Set (MDS) for Resident #174, dated [DATE], revealed the staff assessment for mental status (SAMS) indicated the resident had moderately impaired cognition. A review of hospital Transfer Orders For Receiving Facility revealed Resident #174 was discharged from a hospital on [DATE], and the resident's code status was DNR. Further review of the advance directive information on the transfer orders revealed Resident #174 had a DPOA for Healthcare and the DPOA was activated. A review of DPOA documents, dated [DATE], included in Resident #174's medical record at the facility, revealed the resident wanted health care providers to withhold or withdraw heart-lung resuscitation (CPR). A review of Resident Progress Notes revealed a progress note, dated [DATE] at 1:35 A.M. The note revealed the resident did not eat or drink that shift and was unresponsive to verbal and tactile stimuli. The nurse called Family Member (FM) #1 (who was the POA) at approximately 7:25 P.M. and explained the resident's condition. The nurse explained CPR and the damage it could cause. FM #1 arrived at the facility at approximately 8:45 P.M. FM #1 stated, he/she did not want the resident to have CPR and he/she would like to sign a DNR. The note further indicated FM #1 was informed social services would reach out to them in the morning regarding DNR. A review of Resident Progress Notes revealed a progress note, dated [DATE] at 9:26 PM. The note revealed Licensed Practical Nurse (LPN) #2 found Resident #174 with low vital signs, mottling (skin has a red or purple marble appearance and occurs when the heart is no longer able to pump blood effectively), and a period of apnea (not breathing). LPN #2 notified the physician, who stated to call paramedics if CPR was needed. According to the note, the facility called paramedics at 1:54 A.M. and initiated CPR at 1:55 A.M., due to the resident becoming unconscious. After paramedics arrived, the physician called back and instructed them to stop CPR. The facility contacted the POA and confirmed Resident #174's wished to be DNR, and the POA did not want CPR to continue. The POA told the nurse and EMT that he/she wanted the DNR. Resident #174 was pronounced deceased at 2:12 A.M. An interview on [DATE] at 1:55 PM with LPN #2 revealed he/she looked in a resident's EMR (electronic medical record) at the face sheet to check a resident's code status. He/She said there was probably another place to look for code status information, but he/she did not remember where else to look. LPN #2 said staff could also contact the physician regarding code status. According to LPN #2, if CPR was initiated, one staff would notify the physician and the other staff would start CPR. LPN #2 said if there was a change to a resident's code status, the information would be communicated through the end of shift report he/she assumed that other people did their job and updated the face sheet correctly. LPN #2 said he/she was an agency employee and the facility never provided training regarding residents' code status. LPN #2 said he/she remembered the incident that occurred when they provided CPR for Resident #174. He/She said he/she thought the family was in the process of getting a DNR order in place, but he/she did not remember there being any official documentation in the computer system. LPN #2 said if there was no DNR documentation in place, Resident #174 would have been designated as a full code, which should have been documented in the resident's medical record. LPN #2 said he/she was unaware there was a DPOA on file indicating Resident #174 did not want to be resuscitated (DNR). An interview on [DATE] at 2:13 P.M. with FM #1 revealed he/she could not be certain if the family provided Resident #174's DPOA paperwork during the admission process, but FM #1 was certain that when the facility discussed advance directives during the admission process, the family informed the facility they wanted Resident #174 to be a DNR. FM #1 said the DPOA paperwork was provided to the facility prior to Resident #174's death. FM #1 said he/she was aware what CPR did to a fragile senior citizen and did not want that at all for Resident #174. An interview on [DATE] at 12:30 P.M. with the Social Services Director (SSD) revealed when a resident was admitted to the facility, he/she reached out to the SSD at the transferring facility to ask about the resident's advance directive status. The SSD said during the admission process, he/she explained formulating an advance directive to the family and resident, and once the resident and family had decided, he/she would notify the nurse on duty at the time, the Assistant Director of Nursing, Director of Nursing, Administrator, Business Office Manager, and MDS staff there was an advance directive on file for that resident. The SSD said staff documented in the resident's medical record regarding the advance directive; however, if there was not a signed DNR form on file, the resident was automatically designated as a full code. The SSD said when a resident was readmitted to the facility, he/she checked with the resident's nurse about transfer orders. He/She said he/she did not look at the orders because he/she did not have a medical background and would not be able to identify a change in code status on the transferring orders. The SSD reviewed Resident #174's DPOA document and hospital transfer orders and said that according to that information, the resident should have been designated as a DNR. He/She said he/she did not know why CPR was initiated when the resident was found unresponsive, but it should not have been. An interview on [DATE] at 8:18 A.M. with LPN #19 revealed a resident's code status was documented on the spine of a binder that contained a resident's medical record chart. LPN #19 said there should also be signed papers in the chart. According to LPN #19, staff initiated CPR for a resident, then the resident's physician instructed them to stop CPR. An interview on [DATE] at 12:30 P.M. with the Director of Nursing (DON) revealed code status should be discussed during admission, all residents should have a designated code status. The DON said when a resident was readmitted from the hospital, nursing staff completing the re-admission should review the hospital discharge paperwork and ensure any code status reflected in the transfer paperwork was followed up on and changed in the facility's medical record. According to the DON, this process should be completed immediately during readmission. The DON reviewed Resident #174's hospital discharge paperwork and the resident's DPOA document and said CPR should not have been initiated when the resident was found unresponsive. The DON said staff should have followed up on the hospital transfer orders to ensure the correct code status was on file with the facility for Resident #174. An interview on [DATE] at 2:05 P.M. with the Assistant Director of Nursing (ADON) revealed a resident's code status should be documented on a physician order, the face sheet, and the spine of the resident's hard chart. The ADON said she was not sure if the SSD documented that advance directives were discussed with residents/families, but said all residents should have a code status identified on their advance directive. According to the ADON, some residents had them and others did not, but did not elaborate on what that meant. An interview on [DATE] at 3:58 P.M. with the Administrator revealed a resident's right to formulate an advance directive was covered in the admission packet and discussed during admission to the facility. The Administrator said all staff should be aware of residents' advance directives and if there was not one in place, staff should contact the physician and get an order. The administrator said that nursing staff should ensure they were reconciling hospital readmission orders to ensure any change in code status was corrected in the facility's medical records. Onsite Verification of Removal Plan: The IJ was removed on [DATE] at 8:20 P.M. after the survey team performed onsite verification that the Removal Plan had been implemented. A review of 70 residents' medical records revealed the face sheets, care plans, and physician orders matched the DNR or full code status on file. No discrepancies were identified with code status. A review of 25 residents' medical records, who chose DNR status, revealed a signed DNR form copied on purple paper was included in the front of each medical record. A review of training logs revealed 11 nurses had been educated on the advance directive protocol. Interviews with five Registered Nurses, one LPN, and one physician revealed they were knowledgeable of the facility's advance directive protocol. A review of the facility's Quality Assurance/Performance Improvement (QAPI) plan revealed the advance directive protocol would be discussed at the next QAPI meeting. An interview with the facility physician revealed he was aware of the IJ and stated that advance directives would be monitored in QAPI going forward. All corrections were completed on [DATE]. The immediacy of the IJ was removed on [DATE]. At the time of exit, the severity of the deficiency was lowered to the D level.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) remained free from sexual abuse, when another resident with sexual and wandering behaviors (Resident #2), sexually abused Resident #1 on more than one occasion. The facility also failed to ensure two residents (Resident #5 and #6) remained free from physical and verbal abuse by Certified Nurse Assistant (CNA) E in a review of 29 sampled residents. The facility census was 73. The administrator was notified on 11/12/21, of the Immediate Jeopardy (IJ) which began on 4/26/21. The IJ was removed on 11/15/21, as confirmed by the surveyor onsite verification. Record review of the facility's Abuse Prohibition Protocol Manual, dated November 2016, showed the following: - It is the purpose of this facility to assure the residents have the right to be free from all types of abuse and neglect. The facility prohibits abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, and abuse, misappropriation of resident's property and exploitation of any resident; - The residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardian/representatives, friends or any other individuals; - The facility will identify residents whose personal history render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis; - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition (even coma), cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology, willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Sexual abuse is non-consensual sexual contact of any type with a resident. It is not limited to, sexual harassment, sexual coercion or sexual assault; - Verbal abuse is defined as any use of oral, written or body language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. (examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to his/her family again); - Physical abuse is defined as hitting slapping, kicking etc. it all includes controlling behavior through corporal punishment. 1. Record review of Resident #1's care plan revised 1/13/20 showed the following: - Problem start date 1/13/20: The resident had impaired communication due to not always understanding others, attempt to anticipate my needs; - Listen to me carefully, validate my verbal and nonverbal expressions, and please encourage me to express my needs and desires; - Allow a calm and unhurried environment as much as possible. Record review of the resident's revised care plan, dated 7/8/21, showed the following: - Problem start date 7/8/21: The resident is at risk for wandering due to confusion; - Evaluate my ability to understand my surroundings and give me cues and redirection as needed to promote activities of daily living (ADL) participation and reduce wandering behavior. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/21, showed the following: - Moderate cognitive impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Setup help of one staff member for bed mobility, walking in room and corridor; - Required one staff assistance for dressing and walking on and off unit; - No behaviors; - Mobility devices included a wheelchair. Record review of the facility's investigation dated 9/13/21 (completed by the administrator) showed the following: - Licensed Practical Nurse (LPN) A reported to the administrator that Resident #2 had inappropriately touched Resident #1's chest; - The administrator asked social service to interview the two residents, made sure the residents were separated, and the police were called; - Statements were gathered and Resident #1 was questioned about the incident and verified statements; - Resident #1 said Resident #2 had adjusted his/her heat, and told the Resident #1 he/she had nice titties but didn't touch him/her; - The officer interviewed Resident #1 and asked if there was any unwanted touching and the resident responded no; - The police officer then asked if the resident felt safe and his/her response was yes, he/she felt safe; - The police officer counseled Resident #2 on inappropriate comments. Record review of Certified Nurse Aide (CNA) B's written statement dated 9/13/21 (completed during the facility's investigation) showed the following: - CNA B walked into Resident #1's room to make sure he/she was eating; - When CNA B entered the room, he/she observed Resident #1 and Resident #2 facing each other; - Resident #1's incontinence brief and pants were off; - Resident #2 walked out of the room; - CNA B reported this observation to the Social Service Director and LPN A. During an interview on 10/26/21 at 12:15 P.M., LPN A said the following: - On 9/13/21 CNA B dressed Resident #1 and five minutes later observed Resident #1 was undressed; - CNA B reported he/she went into Resident #1's room and observed the resident sitting on the side of the bed and Resident #2 was standing in front of Resident #1; - Resident #2 said he/she was adjusting the heat; - LPN A questioned Resident #1 and he/she whispered Resident #2 touched his/her chest; - The resident was upset and tearful; - Resident #1 said Resident #2 touched him/her without permission; - LPN A provided emotional support and told the resident the facility would take the steps to handle it and report it; - He/She reported the incident to the administrator and social services; - Both residents were placed on 15 minute checks and the staff were to keep track of Resident #2's location; - Resident #2 was constantly in and out of other residents' rooms and staff would redirect him/her; - Resident #2 was alert and oriented to person, place and often the time; - Before Resident #2 was discharged from the facility, he/she was requiring frequent redirection, he/she would stare at other residents and they would request staff get him/her away. Record review of Resident #1's nursing note dated 9/13/21 at 10:38 A.M., showed the following: - Called the resident's physician to inform him/her of an incident that happened between the resident and another resident this morning; - Initially it was reported as physically inappropriate touching, but upon investigation it was found to be verbal in nature (inappropriate sexual comment). Record review of Resident #1's care plan revised 9/13/21 showed the resident prefers to be in various stages of undress while in his/her room, the resident will be appropriately dressed when out of his/her room. The resident undresses in his/her room and can take her brief off when he/she has had an accident. Record review of Resident #1's nursing note dated 10/13/21 at 6:35 P.M., completed by LPN J, showed the following: - Resident #1 was in his/her room with the call light on. LPN J went to answer the call light and Resident #2 was walking out of the room; - LPN J asked Resident #2 What was he/she doing in there? ; - Resident #2 said just turning down the heat. LPN J told Resident #2 that's another resident's bedroom, and you are not to be going in there; - LPN J asked Resident #1 if he/she was okay, and why Resident #2 was in his/her room; - Resident #1 said, He/She was feeling me up; - LPN J asked Resident #1 again if he/she was okay, and he/she stated yes; -Resident #1 was asked, Did he/she want this to happen and Resident #1 said No; - He/She informed Director of Nursing (DON) and administrator. Record review of the resident's nursing note dated 10/13/21 at 8:09 P.M. showed the following: - At around 6:35 P.M., the resident had an uninvited guest (Resident #2) come into his/her room and make unwanted sexual advances; - Resident #1 reported that Resident #2 did stop right away when he/she asked him/her to; - The police, physician and the state agency were notified. During an interview on 10/26/21 at 1:55 P.M. and 10/27/21 at 1:10 P.M., Resident #1 said the following: - Resident #2 came in his/her room on three or four occasions; - Resident #2 fondled his/her chest and put his/her hands between his/her legs and rubbed his/her private area, this made him/her mad; - Resident #1 was embarrassed and angry and told Resident #2 he/she should not be in his/her room; -The nurses found out and placed Resident #2 on 15 minute checks. Even after 15 minute checks Resident #2 came into his/her room when he/she wasn't supposed to; -The facility called the police; - He/She felt Resident #2 abused him/her and it upset him/her a lot; - He/She told the police Resident #2 didn't touch him/her on the first occasion, because he/she was so embarrassed by what had happened to him/her and didn't want them to know. Record review of Resident #1's Annual MDS 10/7/21 showed the following: - Moderate cognitive impairment; - No behaviors. Record review of Resident #1's care plan last revised 10/15/21 showed the following: - Problem start date 10/14/21: the resident allows other residents into his/her room and only reports invasion of privacy when noted by staff. On 10/13/21 a resident was seen coming out of Resident #1's room. The resident said Resident #2 sexually touched him/her; - The resident will be monitored every 15 minutes by staff for 72 hours following the incident on 10/13/21. 2. Review of Resident #2's admission MDS dated [DATE] showed the following: - Moderate cognitive impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - No behaviors; - Independent with bed mobility, transfers, dressing, walking in room and corridor and locomotion on and off the unit; - No mobility devices. Record review of Resident #2's care plan, revised 7/2/21, showed the following: - The resident has impaired communication due to not always understanding others; - Encourage the resident to express needs and desires, allow a calm and unhurried environment as much as possible; - Ask questions requiring only yes or no response, and explain all routines and procedures as they occur. Record review of the resident's care plan, revised 7/8/21, showed the following: -The resident was at risk for wandering due to dementia; - Evaluate resident's ability to understand his/her surroundings and give him/her cues and redirection to promote activities of daily living participation and reduce wandering. Record review of Resident #2's nursing note, dated 8/9/21 at 9:15 P.M., and completed by Registered Nurse (RN) N showed the following: - RN N was notified per a certified medication technician (CMT) that he/she witnessed Resident #2 coming out of an unidentified resident's room; - The unidentified resident was sleeping. When confronted, Resident #2 said he/she was adjusting the room temp; - A nurse from another hall said he/she saw Resident #2 going into an unidentified resident's room, while he/she was sleeping. The resident awakened and asked him/her to leave; - RN N stopped Resident #2 while passing the nursing station to remind him/her that he/she could not enter another resident's room, and Resident #2 was reminded of the common areas which included the dining room, television room, and smoking area; - Resident #2 said he/she was only changing the other resident's room temperature because it was hot. RN N informed Resident #2, again, that each resident's room temperature was comfortable for them; - Resident #2 said again he/she was just adjusting the room temperature; - RN N told Resident #2 not to enter anyone's room other than his/her own; - Resident #2 said, Wow, there's a lot of [OBSCENITY] ing jack offs that work here. RN N told him/her there were rules in place to protect people, and it was not unfair for residents to expect a safe environment in which other residents would not be entering their room, and that he/she could expect the same standards. Resident #2 said, Ahh, [OBSCENITY] off, and walked to his/her room mumbling the entire time; - Will continue to monitor. Record review of Resident #2's nursing note, dated 8/23/21 at 1:56 P.M., completed by LPN A, showed the following: -The resident was observed by LPN A attempting to go into a room, upon asking where the resident was going he/she said, I have to use the bathroom.; -The resident was educated that he/she needed to use his/her bathroom in his/her own room; - Notified the Assistant Director of Nursing (ADON) as this was not the first time the resident had walked into another resident's room (without consent and/or permission) and/or a room that was not his/her's, despite numerous attempts of education. Record review of Resident #2's nursing note, dated 10/07/2021 at 1:48 A.M., showed the following: - Resident #2 was found in another, unidentified, resident's room, the door was closed to the room, both residents were fully dressed and several feet apart; - The resident seemed unaware of Resident #2; - Resident #2 said I came in to turn the heat down; - The resident was escorted from the room, and the resident remained in the common area and/or in his/her room; - Close monitoring of his/her location continued. During an interview on 10/26/21 at 3:30 P.M., Resident #9 said the following: - He/She was Resident #2's previous roommate; - Resident #2 wandered into other resident's rooms; - Resident #2 wandered into Resident #1's room, he/she observed him/her coming out Resident #1's room a lot. During an interview on 10/26/21 at 4:25 P.M., Certified Medication Technician (CMT) I said the following: - He/She observed Resident #2 leaving Resident #1's room on one occasion, it didn't make sense that Resident #2 was turning the heat down in Resident #1's room; - He/She just redirected him/her; - Often when Resident #2 was observed leaving Resident #1's room, Resident #1 was asleep; - He/She felt Resident #2 was not invited into Resident #1's room. During an interview on 10/26/21 at 11:20 A.M., the Social Service Director said the following: - Resident #1 and #2 were both alert to person and place; - Resident #1 had to be asked direct and straight forward questions; - Resident #1 could not consent to a sexual relationship; - He/She said if Resident #2 touched Resident #1's chest or touched the resident inappropriately, in-between the resident's legs, it would be considered sexual abuse; - He/She took Resident #1 out to the smoking area, Resident #2 sought Resident #1 out when in the smoking area; - Resident #2 would stare at him/her (Resident #1) and try to sit next to Resident #1; - He/She (social service director) always positioned him/herself in between the two residents when in the smoking area; - Resident #1 wasn't aware Resident #2 was staring at him/her when in the smoking area; - Resident #2 entered Resident #1's room uninvited two or three times after hours (later in the evening). During an interview on 10/26/21 at 2:30 P.M., the DON said the following: - He/She heard on 9/13/21 Resident #2 went into Resident #1's room and asked Resident #1 about his/her chest and kissed him/her; - After the the 9/13/21 incident, staff put Resident #2 on 15 minute checks for 72 hours to monitor if the resident went to another hall, and, if so, what he/she needed on the other hall; - Other interventions were not put into place because the administrator considered the encounter consensual; - Resident #2 claimed he/she was turning down the thermostat; - In October a nurse saw Resident #2 walk out of Resident #1's room and Resident #2 claimed he/she was adjusting the heat; - If Resident #2 touched Resident #1 inappropriately, it would be considered sexual abuse; - Redirecting Resident #2 only worked short term; - If a resident was uncomfortable in a situation they need to report it to staff; - Resident #1 didn't want anyone to know what Resident #2 had done. During an interview on 10/26/21 at 10:45 A.M., the administrator said the following: - On the first occasion (9/13/21) Resident #1 said Resident #2 might have touched him/her but when the police came to the facility to interview Resident #1, he/she said Resident #2 hadn't touched him/her, but made a comment about his/her chest; - Nothing was done differently after the first incident on 9/13/21, as he felt it was consensual and there wasn't necessarily an issue; - The administrator said he thought Resident #1 was fixing up and doing his/her nails more. He said the resident was his/her own person so therefore it was consensual; - After the second incident on 10/13/21, Resident #1 said it was wrong what Resident #2 did in his/her room; - Resident #1 said that Resident #2 did stop when he/she told him/her to; - The administrator did not feel it was sexual abuse, because Resident #2 stopped touching Resident #1 inappropriately when asked; - If Resident #2 had not stopped that would be abuse. 3. Record review of Resident #5's annual MDS assessment dated [DATE], showed the following: - Moderate cognitive impairment; - No behaviors; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - No rejection of cares; - Extensive assistance of one staff member with transfers; - Limited assistance of one staff member with dressing and personal hygiene; - Total assistance of one staff member for toileting; - Impairment on one side of functional limitation of range of motion; - Mobility devices included a wheelchair. Record review of the resident's care plan last revised 3/25/21 showed the following: - The resident was at risk for falling related to non-weight bearing on his/her left lower leg and [CONDITION(S)]; - Give resident verbal reminders not to ambulate /transfer without assistance; - The resident needs assistance of one staff member with activities of daily living ADLs and setup help for meals; - Assist of one staff member with pivot transfers maintain non weight bearing to left low extremity, wheelchair for mobility, assist of one staff member with dressing, bathing, hygiene and toilet use, set up for meals. During an interview on 9/22/21 at 11:35 A.M., Resident #5 said the following: - A few months ago an agency staff aide (CNA E) from outside of the facility was working; - CNA E told me to Get up!; - He/She explained to CNA E he/she couldn't walk without assistance; - CNA E hit him/her two times in the face; - He/She told CNA E he/she had to help him/her; - CNA E was very rough and grabbed him/her under the arms hard, and put him/her into bed rough; - CNA E told him/her to dress herself/himself, he/she felt like CNA E abused him/her, it made him/her cry and he/she was afraid; - He/She cried himself/herself to sleep, he/she was afraid to turn on his/her call light again, as CNA E would come back; - CNA E threatened to torture him/her if he/she turned the call light on again. 4. Record review of Resident #11's MDS dated [DATE] showed the following: - Cognition moderately impaired; - Adequate hearing and vision; - Makes self understood and understands others. During an interview on 9/22/21 at 12:00 P.M., Resident #11 said the following: - He/She was Resident #5's roommate for a while; - Months back, around 10:00 P.M., an unidentified aide came into to answer his/her roommate's light; - The aide talked ugly (hateful comments) and spoke down to Resident #5.; - The aide yelled at Resident #5 about turning on his/her call light; - Resident #11 said he/she would not want an aide like that caring for him/her; - He/She would not want the aide to come back, the aide was mean. During an interview on 9/23/21 at 7:45 A.M., CNA B said the following: - Around 2:00 A.M. on 4/26/21, Resident #5 turned on his/her call light and said the aide last night that put him/her to bed, abused her/him; - The resident said CNA E threatened him/her and told him/her not to turn on his/her light again; - He/She questioned Resident #5 about what he/she meant by abuse; - The resident said he/she wanted to lay down, and CNA E said for him/her get up and to do it himself/herself; - CNA E told the resident not to turn his/her call light on again; - It scared the resident, and he/she was afraid to turn his/her call light on again; - The resident said he/she wished that he/she was dead (after the aide spoke to him/her in that manner); - He/She (CNA B) went straight to Registered Nurse (RN) L to report the incident, and he/she (RN L) said he/she didn't want to hear it, Resident #5 was making it up; - CNA B went to another nurse and tried to report the allegation to him/her; - CNA E over heard the conversation and spoke up and said he/she did say that; - CNA E said he/she told the resident to get up and do it himself/herself, and to not turn his/her call light on again for anything. Review of the written statement for the facility investigation undated, completed by CNA B, showed the following: - At 2:15 A.M. he/she answered the call light and asked the resident what was wrong, the resident said he/she was abused last night, the resident said he/she was sliding down in the chair and he/she wanted to be laid down in bed and changed; - The resident said he/she asked the CNA E to help him/her; - The aide (CNA E) told the resident to walk to bathroom and use it himself/herself; and to call his/her family member and tell him/her to come and get him/her; - The resident tried to explain what happened to RN L and he/she kept cutting him/her off, and said maybe what happened was a dream; - CNA E spoke up and said no it's not a dream. He/she told the resident to change himself/herself, call his/her daughter and tell her to come get him/her. When he/she layed the resident down he/she told the resident to not press the light for anything; - Resident #5 was very upset most of the night and threatened to hurt himself/herself. Record review of the witness statement for the facility investigation, completed by Social Services Director (SSD), dated 4/26/21 at 7:45 A.M., showed the following: - Resident #5 approached him/her saying he/she was abused.; - He/She asked the resident who abused him/her and what they looked like, Resident #5 could not remember; - He/She asked the resident when this happened, and Resident #5 said last night; - The aide told the resident to get his/her ass upand go to the bathroom. Resident #5 proceeded to say that he/she could not walk and needed assistance; - He/She told Resident #5 the facility would investigate the allegation and call it to the hotline; - She took the information to the DON and the administrator. Review of the witness statement for the facility investigation (completed by the administrator) dated 4/26/21 at 7:45 A.M., showed the following: - When the administrator arrived at work this morning the SSD informed him/her that Resident #5 had just made some claims of abuse; - He asked if that was what the Social Worker thought was abuse. The SSD said Resident #5 said an aide told him/her to put himself/herself to bed; - When the administrator talked to the resident's family member he/she said the resident had concerns about not being laid down timely and a CNA not being nice; - Resident #5 said the aide was working right now and pointed him/her out, it wasn't the same aide as the night before, but the two had the same build and features; - After seeing the other CNA, the aide Resident #5 was talking about was an agency staff, CNA E; - CNA E was put on a do not return list, as the facility felt that his/her attitude was offensive and not acceptable, no physical harm was found but actions were not acceptable. During interview on 10/3/21 at 12:35 P.M., the administrator said the following: - He felt CNA E was neglectful, threatening the resident to not turn on his/her call light was on the line of abuse; - The facility told the nursing agency, they wanted CNA E placed on the do not return list, and he/she was not to come back to work at the facility; - Staff should report any allegation of abuse immediately to him. 5. Record review of Resident #6's face sheet showed the following: - admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident's admission MDS assessment dated [DATE] showed the following: - Moderate cognitive impairment; - No behaviors; - No rejection of care; - Extensive assistance of one staff member for bed mobility, dressing, toilet use and personal hygiene; - Extensive assistance of two staff member for transfers; - Total dependence one staff member for locomotion on and off the unit; - Mobility devices used wheelchair and walker. Record review of the resident's care revised 7/21/21 showed the following: - Assess my grooming and dressing needs and provided assistance of one staff member; - The resident had a physical functioning deficit related to weakness, the resident needed assistance of two with transfers; - Locomotion via wheelchair with one staff assistance. Record review of the resident's nursing note dated 7/1/21 2:56 P.M., and completed by LPN D, showed the following: - At around 8:30 P.M. on 6/29/21, the resident told this nurse that the aide (CNA E) who put him/her to bed was rough with him/her and he/she said CNA E threw his/her legs into bed and made him/her hit the left side of his/her head on the wall; - CNA E pulled the oxygen tubing hard, hard enough to pull out the hearing aid that he/she wore in his/her left ear; - He/She questioned the aide about this. CNA E said he/she had to use strength to put the resident's legs in to bed because they were heavy. CNA E said he/she was unaware that the resident hit his/her head on the wall, he/she did not try to make the resident hit his/her head. This nurse instructed him/her not to enter the resident's room anymore that night; - A skin assessment was completed and the resident did not have an injury to his/her person at this time. During an interview on 9/22/21 at 10:50 A.M., the resident said the following: - On 6/30/21 at approximately 9:30 P.M., a CNA came in his/her room to assist him/her to bed; - The CNA became abusive after assisting him/her to bed; - CNA E grabbed his/her legs to get his/her body into bed and threw his/her legs and body into bed so the resident hit his/her head against the wall; - He/She yelled at the aide and said you hit my head on the wall and it was painful; - The CNA yelled at him/her and said lay down, I know what I'm doing!; - He/She told the CNA Get the hell out of my room.; - A professional does not act that way, it made the resident feel disgusted, to be treated in that manner; - LPN J came in to speak with him/her about what happened and he/she gave LPN J the description of abuse; - CNA E stood outside the door and listened and denied what happened; - He/She went to the administrator the next morning and reported the abuse. During an interview on 10/13/21 at 2:00 P.M., LPN D said the following: - He/She was the charge nurse on 6/30/21 and CNA E was working under him/her that shift; - He/She heard yelling from Resident #6, Get out of here, get out of here! - He/She heard Resident #6 yelling out he/she (CNA E) was being rough with him/her and he/she hit his/her head on the wall, LPN D told CNA E he/she would care for the resident the rest of the shift; - The resident said CNA E pulled on him/her and treated him/her in a rough manner; - LPN D assessed the resident and there was no bruising or injury. During an interview on 9/22/21 at 12:45 P.M., 10/13/21 at 12:35 P.M., and 10/27/21 at 1:45 P.M., the administrator said the following: - The way CNA E transferred the resident to bed felt rough, as the resident was a bigger person; - Lifting the resident's legs was more difficult; - Resident #6 didn't use the term abuse or neglect when he/she described the incident; - The resident wasn't injured; - It was poor customer service, and the facility did not want CNA E coming back to the facility to work; - If the resident said the aide threw him/her into bed, and the resident hit his/her head on the wall, staff should immediately report that to him so he could investigate; - CNA E was placed on the do not return list, and the staffing agency was instructed to not allow him/her back at the facility; - The facility had a short list of staff who was on the do not return list, he thought CNA E was put on the list to not return after the previous incident with Resident #5; - He was not sure what happened or why CNA E was allowed to return to work at the facility after the incident (with Resident #5), it was difficult to find enough staff to work. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s). MO 9 MO 1 MO 5 MO 5

Based on interview and record review, facility personnel failed to provide basic life support, including cardio-pulmonary resuscitation (CPR), an emergency procedure that is performed when a person's heartbeat or breathing has stopped), for one resident (Resident #6) requiring such emergency care in a sample of ten residents, as ordered by the physician. Facility census was 105. The administrator was notified on [DATE] of the Immediate Jeopardy (IJ) Past Non- Compliance which occurred on [DATE]. On [DATE] the administrator became aware of the violation of the facility cardio-pulmonary resuscitation policy. The staff member was suspended pending investigation and later terminated. The Assistant Director of Nurses (ADON) inserviced the staff on [DATE], [DATE] and [DATE] regarding the facility cardio-pulmonary resuscitation policy. The facility identified all other hospice residents and audited charts for documentation of code status. The IJ was removed and corrected on [DATE]. 1. Record review of the facility's policy for CPR, undated, showed the following: -Each resident has the right to pre-determine events at the time of their death. This information is recorded in their medical record in the following manner; -The resident may sign an advanced directive identifying No CPR or Full CPR -cardiac and respiratory; -The physician's orders [REDACTED].>-The resident's chart will have in the very front, a green or red sheet in a plastic sleeve; -The green sheet will state Full Code (start CPR); -The red sheet will state DNR (do not start CPR) start CPR and call 911; -The code status will also be identified under the Advanced Directives tab; -See CPR procedure; -Important points, if there is no red or green sheet available in the front of the chart, then you must look for the signed sheet under advanced directives for code status; -If no code status is available -start CPR and call 911; -If a resident appears to have been deceased for a while and is a designated full code, the nurse cannot make a judgement call, but must follow full code orders and start CPR immediately. -The nurse must continue until the ambulance arrives and takes over; -The nurse cannot make a determination not to start CPR if the resident has a full code order. 2. Record review of Resident #6's care plan, dated [DATE], showed the following; -The resident will receive the help he/she needs to sustain daily living; -The resident was a full code; -The resident received hospice services. Record review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment tool required to be completed by facility staff, dated [DATE], showed the resident was moderately cognitively impaired. Record review of the resident's face sheet, dated [DATE], showed the following: -The resident received hospice services from an area hospice provider; -The resident's advanced directives were full code. Record review of the resident's nurse's notes, dated [DATE], showed staff documented the resident continued on hospice care and was dependent on staff for total care. Record review of the resident's physician's orders [REDACTED]. -The resident's [DIAGNOSES REDACTED]. -The resident was a full code (initiate CPR). During interview on [DATE] at 12:15 P.M., the Social Services Designee said: -The resident was a full code; -The resident was his/her own person; -The resident was alert when admitted . During an interview on [DATE] at 12:47 P.M., Licensed Practical Nurse (LPN) D said: -LPN D gave LPN E report on [DATE]; -LPN D and LPN E went to the resident's room at about 2:30 P.M. during walking rounds; -All the nurses knew what the resident's code status was, because his/her condition was so poor; -This was discussed among the nurses; -There was a green name plate/tag on his/her chart indicating the resident was a full code. Record review of the resident's nurse's notes, dated [DATE] at 6:27 P.M., showed staff documented: -The resident was noted in bed with his/her eyes closed and no heart rate or respirations; -The resident's skin was warm to touch; -The resident's extremities were flaccid; -A call was made to the hospice nurse; -At 6:35 P.M., a call was placed to the resident's family; -At 6:47 P.M., the Nurse Practitioner returned the call and was made aware of the resident's condition. During interview on [DATE] at 2:00 P.M., Certified Nurse Assistant (CNA) B said: -CNA B had just left the resident's room and was in the hall way; -LPN E called the CNA to the resident's room; -The resident had no respirations; -The resident had not been gone long (deceased ); -Staff did not do CPR on the resident; -CNA B is CPR certified; -Staff should go to the chart and look for the DNR to determine if they should do CPR. Record review of a written statement, dated [DATE] (no time), showed CNA B documented: -Around 6:25 P.M. to 6:27 P.M. (on [DATE]), he/she was walking up the hall from attending to another resident, when the nurse (LPN E) stepped out of the resident's room and asked CNA B to step in the room; -That's when LPN E told him/her the resident had expired. During an interview on [DATE] at 10:00 A.M., LPN E said: -LPN E went to the resident's room after 6:00 P.M. (on [DATE]); -The resident had no respirations; -The resident was stiff and his/her eyes were closed; -LPN E called a CNA into the resident's room; -The CNA said the resident was gone (deceased ) for quite some time; -The CNA said he/she had repositioned the resident recently; -LPN E called the hospice nurse, the family, the physician and the supervisor; -LPN E was CPR certified; -LPN E does not remember talking about the CPR policy during orientation; -LPN E saw the resident's code status on the resident's face sheet after he/she found the resident with no respirations and he/she was going to document the resident was found with no respirations or heart rate; -LPN E did not see a red sheet or a green sheet, but saw the code status on the face sheet; -LPN E knew the facility policy was to initiate CPR if the resident was a full code after checking the chart; -LPN E knew the resident received hospice care and was declining; -He/she thought the resident's code status had been changed; -He/she had already called the physician, hospice and the Director of Nurses (DON) (after finding the resident deceased ); -The DON did not tell her to start CPR and he/she did not know if he/she could; -He/she couldn't remember if he/she had already talked to the physician and didn't know how much time went by from the time he/she discovered the resident deceased to the time he/she discovered the resident was full code. Record review of a written statement, dated [DATE] (no time), showed LPN E documented the following: -Coming on for his/her shift (shift began at 6:00 P.M.), LPN E found the resident had already passed away; -The resident had no respirations and no heart rate; -The resident's skin was pale and his/her eyes were closed; -The resident had no response to pain stimuli and all his/her extremities were flaccid (limp); -The CNA on duty was in the hall and also noted the resident had passed away; -LPN E was aware the resident was on hospice with a recent growth to the tumor on his/her brain; -Speaking with the resident's family during visits, the resident's condition was terminal; -LPN E immediately called the physician's exchange and hospice to make them aware the resident had passed away. During interviews on [DATE] at 11:15 A.M. and [DATE] 1:20 P.M., the ADON said: -Residents' DNR status is listed on the chart; -The resident's medical record was labeled with the resident's name and green for full code; -On [DATE] (after 6:00 P.M.), he/she got a call from the administrator saying the ADON needed to go to the facility as staff did not perform CPR on the resident; -When he/she arrived at the facility, the hospice nurse was already there and they were waiting for arrival of the funeral home; -LPN E said he/she did not start CPR as he/she knew the family had been talking about changing the resident's code status; -He/she had LPN E write a statement and relieved him/her of his/her duties. Record review of LPN E's employee counseling notice, dated [DATE], showed: -LPN E failed to start CPR on a full code resident; -LPN E was suspended. During interview on [DATE] at 12:45 P.M., the DON said: -The resident was a full code; -Staff should check the resident's code status to see if CPR is to be initiated then call 911; -LPN E called the DON and said he/she did not do CPR; -LPN E said he/she talked to the resident's family and thought the family would change the resident's code status; -LPN E said he/she thought the resident was a DNR; -The nurse said the family was present in the facility as well as the hospice nurse after the resident was found; -The DON instructed LPN E to always check the resident's code status; -The DON notified the administrator; -All the facility nurses are CPR certified; -CPR policy is reviewed with nurses during orientation; -If a resident has stopped breathing, the staff should check the resident's code status; -The staff should call 911 and initiate CPR if the resident is a full code; -If the resident's CPR status cannot be determined, staff should start CPR. During interviews on [DATE] at 1:15 P.M. and 1:55 P.M., the administrator said: -LPN E did not do CPR on the resident; -The nurse assumed the resident was a DNR; -The ADON got a statement from the nurse; -The ADON took over as charge nurse; -The administrator suspended the nurse; -The nurse said he/she did not think to get the chart and look at the code status; -All the facility nurses, including the ADON and DON are CPR certified; -When the nurses are hired they receive information on the facility CPR policy; -The facility obtains a copy of the nurse's CPR card; -The facility tracks when the certification expires; -The nurses who are CPR certified are highlighted on the daily staffing sheet; -The expectation is that staff will call for the chart to look at the resident's code status; -Staff should initiate CPR until 911 arrives; -If there was confusion or there was no code status, the nurse should automatically start CPR. MO# 8

Based on observation, interview, and record review the facility failed to ensure Cardiopulmonary Resuscitation (CPR) certified staff were on duty in the facility at all times. The facility failed to follow their policy and procedure to maintain and document a minimum of one CPR certified staff member per shift on duty, not including any staff members needed to provide transportation services. This failure affected 56 residents who were identified as full code status, (CPR required in the event of cardiac or respiratory arrest). The facility census was 110. 1. Review of the Facility Cardiopulmonary Resuscitation (CPR) policy dated [DATE], showed the following: -The purpose was to ventilate and establish circulation on a resident with absence of respirations and pulse; -Facility must maintain and document a minimum of one CPR certified staff member per shift on duty, not including any staff members needed to provide transport services; -Staff members who were CPR certified would provide documentation to the facility's Director of Nursing (DON) and/or designee, and annually thereafter; -Records of CPR certification would be maintained and available for surveyor review; -Administrator would monitor for compliance; -CPR certification must be designed for healthcare providers to be acceptable (i.e., must include mouth breathing); -On-line only first aid and CPR was not accepted; -The course should be face-to-face or a hybrid course that includes hands-on skills practice and assessment from a certified instructor prior to certification. During interview on [DATE] at 1:20 P.M., administrator AA said the facility currently cared for 56 Full Code residents. During interview on [DATE] at 7:20 A.M., the administrator said the facility did not keep track of which staff were CPR certified. She was not sure if human resources (HR) personnel kept track of CPR certifications for staff or not. During interview on [DATE] at 9:58 A.M., Human Resource/payroll staff KK said neither he/she nor anyone in the business office kept track of nursing staff CPR certifications. She was not sure who was responsible for verifying CPR certifications for employees. During interview on [DATE] at 3:50 P.M., staffing coordinator Certified Medication Technician (CMT) N said: -He/she has worked at the facility since [DATE], as the staffing coordinator; -He/she was responsible for scheduling all Registered Nurse (RNs), Licensed Practical Nurse (LPN)s, CMTs, Certified Nursing Assistants (CNAs), and restorative staff to work all shifts; -He/she was not sure which staff were CPR certified and which staff were not CPR certified; -He/she did not schedule staff to ensure all shifts were covered with at least one CPR certified employee; -He/she thought most of his/her long term nurses were CPR certified; -The facility did have full code residents, but he/she was not sure how many. During interview on [DATE] at 9:09 A.M., CMT N/staffing coordinator said the DON reviewed the staffing schedule on a daily basis. During interview on [DATE] at 2:00 P.M. and 5:30 P.M., the Director of Nurses (DON) said the following: -Current employee CPR certification cards were kept in the employee files; -The employee files did not contain all staff's CPR certifications; -She started the process of getting CPR certification status after she was notified that the CPR certifications were not being monitored. During interview on [DATE] at 9:15 A.M. the DON said: -She reviewed the staffing schedule daily and as needed; -She reviewed where staff were working and would make changes as she felt appropriate based on the staff's weaknesses and strengths; -She did not know which staff or if any staff were CPR certified; -She did not assure a CPR certified staff was working each shift. Review of the facility's employee schedule for [DATE] to [DATE], and review of the time sheets provided by the facility on [DATE] at 9:46 A.M., for the same time period showed the following shifts and times the facility did not have CPR certified staff on duty: -[DATE] night shift from 10:52 P.M. until 4:02 A.M.; -[DATE] night shift from 12:25 A.M. until 5:00 A.M.; -[DATE] night shift from 1:30 A.M. until 4:01 A.M.; -[DATE] night shift from 12:05 A.M. until 5:00 A.M. Review of the personnel files for the night shift staff who were scheduled to work from 10:00 P.M. to 6:00 A.M. on [DATE], showed the following: -RN V's CPR certification expired on [DATE]; -No CPR certification for LPN X; -No evidence of CPR certifications for CNA Y, CNA Z, CNA AA, CNA BB, CNA CC, CNA EE, and CNA FF; -No evidence of CPR certification for Dietary staff A and Laundry staff U. Review and comparison of the facility's CPR certified staff lists and the [DATE], facility staffing schedule provided by the facility, showed the following: -The facility scheduled RN V, LPN X, CNA Y, CNA A, CNA AA, CNA BB, CNA CC, CNA EE, and CNA FF to provide care to the residents from 10:00 P.M. to 6:00 A.M. on [DATE] to [DATE], and were not listed on the facility's CPR certified staff list as staff who had current CPR certifications; -Further review on [DATE], of the facility's employee schedule dated [DATE] through [DATE], showed it did not include staff who were CPR certified scheduled to work night shifts on [DATE], [DATE], or [DATE]. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility initiated inservicing of staff to ensure CPR certified staff were on duty at all times, began review of staffing schedules, and audit of staff to determine CPR certification status. The facility scheduled to ensure CPR certified staff were on duty on all shifts. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

Based on observation, interview, and record review, the facility failed to provide protective oversight for four additional residents (Residents #30, #31, #35, and #36) regarding specialized evacuation plans for two residents with tracheotomy's (Resident #30 and #36) and for three bariatric residents (Resident #30, #31 and #35). Facility staff failed to develop and implement individualized resident specific evacuation plans for all four residents and failed to educate staff on the individualized evacuation plans for those residents. Staff identified Resident #¿¿30 had a tracheostomy and required suctioning of his/her secretions every two hours and identified Resident #36 also required frequent suctioning of secretions. The facility did not have a specific plan in place to identify how staff was to provide the suctioning in the event of an emergency evacuation. The facility census was 103. 1. Review of the facility's undated Emergency Evacuation Guidelines Bariatric Residents, provided by the facility on 3/30/16, showed the following: -Facility will ensure prompt and safe transfer and evacuation of all residents, including bariatric, in the event of an emergency; -If resident is mobile, walk them out; -If able to safely transfer from bed to wheelchair, transfer and then evacuate; -If unable to transfer to a wheelchair, etc., perform a sheet lift and drag with additional staff members as needed. Review of the facility's fire emergency and evacuation plans, reviewed on 3/29/16, showed no documentation regarding how to evacuate bariatric residents or how to manage residents with special needs who may required frequent suctioning of secretions during emergency evacuation transport. 2. Record review of the facility's monthly fire drill records from 04/29/15 through the most recent fire drill conducted on 03/25/16 showed no information that a simulated evacuation drill of a bariatric resident or residents with tracheostomies had been conducted, nor was there any discussion during any of the drills documented regarding evacuation of a bariatric resident or any other special evacuation needs of residents such as frequent suctioning. During an interview on 03/29/16 at 3:05 P.M., the Maintenance Supervisor said the facility had never participated in an annual simulated evacuation as required. 3. Review of the facility's layout, entitled evacuation routes, showed Residents #30 and #35 rooms were located on the C wing, Resident #31's room was located on the B wing Medicare unit, and Resident #36's room was located on the B-wing. Review showed the residents resided in three separate smoke compartments 3. Review of Resident #30's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/13/16, showed the following: -Persistent vegetative state, no discernable consciousness; -Totally dependent on staff for bed mobility and transfer; -Walk in room and locomotion on/off the unit did not occur; -Did not use a mobility device; -Weight was 257 pounds; -Height, 67 inches; -Feeding tube; -Oxygen therapy; -Suctioning; -Tracheostomy Care. Review of the resident's physician order [REDACTED]. -The resident was admitted on [DATE]; -[DIAGNOSES REDACTED]. -Resident requires a bariatric bed; -Tube feeding, continuously; -Flush gastrostomy tube ([DEVICE]; a tube inserted through the abdomen that delivers nutrition directly to the stomach) with 100 milliliters (ml) water every four hours; -Suction as needed (PRN). Review of the resident's care plan, dated 01/21/16 and updated through 03/29/16, showed the following areas: -Activities of Daily Living (ADL) Functional/Rehabilitation Potential: The resident had an anoxic injury resulting in him/her being unresponsive at this time. He/she was on oxygen and has a tracheotomy and also has a [DEVICE]. The resident was a total care patient and needed assistance with all ADLs; he/she was unable to do anything for himself/herself. -Feeding Tube: Resident required a feeding tube related to unresponsiveness resulting from an anoxic injury; -Potential for complications related to tracheostomy: Suction as ordered, and as needed, per physician order. Review of the resident's care plan showed no documentation of a specific emergency evacuation plan to address how to evacuate this resident in the event of an emergency. Observation on 03/30/16 at approximately 10:50 A.M., showed the resident in his/her room. The resident lay in a bariatric bed that measured 42 inches across at the widest part of the bed. The measurement of the doorway into the room was 40 inches wide. During interview on 03/30/16 at 10:50 A.M., the Director of Nursing (DON) said the following: - There had not been any formal inservices regarding bariatric resident evacuation and there had been no discussion regarding how to evacuate Resident #30 in the event of an emergency; - Would expect staff to use a sheet lift with a minimum of six staff to transfer the resident; - This was general instruction only, however, for this resident, since he/she had a trach collar, continuous oxygen and a peg tube, staff would need to disconnect those things and would need a battery operated suction device during transport; - Was not sure if the facility had a portable suction device; -He/She wasn't aware if the resident had required any suction since he/she came to work at the facility two weeks ago and he/she didn't know how often the resident needed suctioned; - The DON had meant to look into whether or not the facility had a suction machine but just hadn't done it yet. Review of nursing assignment sheets for 03/18/16 through 03/31/16, for day and evening shifts, showed an average of approximately 12 to 13 nursing and Certified Nurse Aide (CNA) staff scheduled to work. In order to evacuate the resident using a minimum of six staff, half of the facility nursing staff would be required to assist in an evacuation of the resident leaving only half of the nursing staff to evacuate the other bariatric resident and all other 101 residents. Night shift staffing showed approximately six to seven staff scheduled to work. An evacuation of bariatric residents would require most all nursing staff scheduled on the night shift. During an interview on 03/30/16 at 10:50 A.M., Certified Nurse Assistant (CNA) G said he/she had not had any training regarding bariatric evacuation and no specific instruction on how to evacuate Resident #30. CNA G said he/she would most likely use two staff, or maybe three or four staff and then drag the resident to the nearest exit. During an interview on 03/30/16 at 10:55 A.M., Registered Nurse (RN) H said Resident #30 was comatose and unable to be transferred to a wheelchair. He/she was not aware of a specific plan to evacuate the resident. RN H said the only way he/she would know to evacuate the resident would be to transfer him/her from the bariatric bed to the regular size bed in the room and then out through the door and to safety. RN H said there was no bariatric sized geri chair in the facility. During an interview on 03/30/16 at 2:15 P.M., CNA C said he/she just started to work at the facility in March. CNA C said no one gave him/her any special instruction on how to evacuate a bariatric resident and didn't know how he/she would evacuate Resident #30. During an interview on 03/30/16 at 2:20 P.M., CNA D said he/she worked on all the halls throughout the facility. CNA D said he/she had not been given training on evacuating non-ambulatory residents, but would lower the bed all the way to the floor and then by using at least four people, would drag the resident on a sheet out of the affected area. CNA D said there had not been any specific training regarding how to evacuate Resident #30. During an interview on 03/31/16 at 10:12 A.M., CNA Y said the resident's bed was so big. In order to evacuate the resident, staff would have to get a lot of people and do the sheet carry with three people on each side. CNA Y said he/she learned this years ago in CNA class, but had not received any training from the facility regarding how to evacuate Resident #30. During an interview on 03/31/16 at 3:06 P.M., the DON said the facility's current suction machine for Resident #30 did not have a battery backup on the device, and only worked when plugged into an electrical outlet. During an interview on 03/31/16 at 11:05 A.M., CNA B said today (3/31/16), the DON gave him/her instructions on how to evacuate Resident #30. He/she was told to unhook his/her feeding tube and then get as many people as needed (four or more) and then pull the resident out of the room and out of the affected area by transferring using the bed sheet. CNA B said there has been no mock evacuation for the resident and had not been given any specific instruction regarding how to evacuate the resident prior to today. During a telephone interview on 03/31/16 at 2:00 P.M., RN A said he/she had worked at the facility for two years. He/she said Resident #30 required suctioning every two hours due to secretions. He/she said the DON provided an inservice to him/her yesterday regarding evacuation of bariatric residents by using a sheet with six people to carry the resident out with. He/she had general training regarding the sheet drag technique when he/she first started and at an annual training. RN A said before yesterday, he/she had not had any training regarding bariatric resident evacuation from the facility. He/she said the training yesterday was general and was not specific regarding how to evacuate Resident #30. During an interview on 03/31/16 at 2:12 P.M., CNA BB said since the resident was always in bed, he/she was bed ridden. In order to evacuate this resident, he/she would push the resident out into the hallway in his/her bed and then take him/her to a safe place. During an interview on 03/31/16 at 2:34 P.M., Certified Medication Technician (CMT) CC said staff transferred the resident with a mechanical lift. He/she said staff would have to get an aide to help transfer the resident to a chair. CMT CC said he/she had training and inservices at the facility and staff was taught in the inservice to evacuate the resident that way with two people and a Hoyer lift. During a telephone interview on 04/04/16 at 4:15 P.M., CNA HH said he/she normally worked the night shift and had done so for eight months. He/she was involved in an inservice on the night of 03/31/16 regarding evacuation of Resident #30. CNA HH said he/she had no instruction prior to this inservice as to how to evacuate this resident. He/she would have transferred Resident #30 by Hoyer to a wheelchair to evacuate. 4. Review of Resident #31's Physician order [REDACTED]. Review of the resident's annual MDS, dated [DATE], showed the following: -Ability to understand others-clear comprehension -Walk in room/corridor did not occur; -Required extensive assistance from two or more staff for bed mobility; -Staff transferred the resident only once or twice (in the seven-day review period) and required two or more staff to transfer; -Weight was 465 pounds; -Height was 67 inches. Review of the resident's care plan, dated 01/22/16, showed the following: -ADL Functional/Rehabilitation Potential: The resident was alert and able to communicate effectively. Required extensive assist of one to four with some ADLs, related to cardio pulmonary disease, neuropathy, morbid obesity, chronic kidney disease, and chronic congestive heart failure. (The resident's care plan provided no specific information on how to transfer the resident and how many staff were required to transfer the resident.) -Pressure Ulcer: Resident was at risk for skin breakdown related to several areas present, morbid obesity, and decreased mobility. Review of the resident's care plan showed no documentation of a specific emergency evacuation plan to address how to evacuate this resident in the event of an emergency. Observation on 03/30/16 at 11:20 A.M. showed the resident's oversized bed in the resident's room measured 42 inches. Further observation and measurement of the doorway width to the resident's room showed a measurement of 40 inches at the widest part of the door. The resident's wheelchair was in the room and measured 38 inches at the widest part. During an interview on 03/30/16 at 11:20 A.M., the resident said he/she stayed in bed most of the time, ate meals in bed and received bed baths every morning because it was painful to be transferred out of bed. The resident said he/she was currently unable to bear weight and was unable to assist with transfers from the bed. During an interview on 04/04/16 at 10:50 A.M., the resident said he/she knew his/her bed would not fit through the door. The resident said no one had talked with him/her about how he/she would be evacuated in the event of an emergency. The resident said he/she was completely non weight bearing and unable to assist in transfers. During an interview on 03/30/16 at 12:25 P.M., CNA E said Resident #31 has been at the facility for about six months. He/she said the facility has a Hoyer lift that would accommodate lifting the resident, however, the resident did not get into the wheelchair much anymore because it was very uncomfortable for him/her. CNA E said he/she recently inquired with some other staff about a plan to evacuate the resident but said no one knew of a plan regarding how to evacuate this resident. During an interview on 03/30/16 at 12:40 P.M., the DON said he/she did not know if the facility had a policy regarding bariatric evacuation. The DON said he/she would expect approximately six to eight staff to do a sheet carry of this type of resident in the event of evacuation. During an interview on 03/30/16 at 2:30 P.M., CNA F said to evacuate a non-ambulatory resident, he/she would get other staff to help and then lift the resident using the bed sheet. CNA F said he/she had been trained to do this while working at another facility but had not had any training regarding how to evacuate a non-ambulatory resident while working at this facility. During an interview on 03/31/16 at 10:12 A.M., CNA NN said Resident #31 would be evacuated by using four staff on each side of the bed and then transferred using the bed sheet. During an interview on 03/31/16 at 10:16 A.M., CNA B said in order to evacuate the resident they would put a sheet under the resident and carry him/her out because neither the bed or the chair would fit through the door. During an interview on 03/31/16 at 2:12 P.M., CNA BB said the resident was always in bed so staff would evacuate the resident from his/her room in the bed. He/she learned this through CNA training and through fire drills. During a telephone interview on 03/31/16 at 10:50 A.M., the DON said he/she had not done any formal inservices with staff since she came to the facility approximately two weeks ago. He/she said when first arrived to work at the facility, he/she noticed Resident #31 was in a bariatric size bed. He/she talked with a few staff about how a bed of this size would not fit through a standard room doorway so they talked about transferring this resident to a wheelchair and then out of the building in the event of an emergency. The DON said there had been no mock evacuation regarding how to evacuate a bariatric resident since he/she had been at the facility and did not know if there had been one done prior to him/her coming to work at the facility. During an interview on 03/31/16 at 1:50 P.M., the DON said the Resident #31 could be transferred by either a Hoyer lift or by sheet carry evacuation. The DON confirmed the number of staff required to execute a sheet carry evacuation would require approximately half of the normal daily staff scheduled. During an interview on 03/31/16 at 2:34 P.M., CMT CC said staff transferred the resident with a Hoyer lift. He/she said two staff would transfer the resident to a chair in the event of an evacuation. During a telephone interview on 04/04/16 at 4:15 P.M., CNA HH said he/she normally worked the night shift and had done so for eight months. He/she was involved in an inservice on the night of 03/31/16 regarding evacuation of Resident #31. He/she had no instruction prior to this inservice as to how to evacuate this resident. 5. Review of Resident #35's care plan, dated 3/14/16, showed the following: -The resident needed assistance with all activities of daily living (ADL) related to [DIAGNOSES REDACTED], decreased ADLs, weakness and confusion -The resident transferred to and from the wheelchair with a Hoyer lift and assistance from two staff; -The resident required one to two staff to assist with bed mobility. There was no documentation in the resident's care plan to address special evacuation needs for this resident. Review of the resident's MDS, dated [DATE], showed the following: -Clear comprehension; -Did not walk in room or corridor; -Locomotion on and off the unit did not occur; -Used a wheelchair for mobility; -Extensive assistance required for bed mobility and transfer; -Weight was 250 pound; -Height was 74 inches. Review of the resident's POS, dated 03/31/16, showed the following: -Resident was admitted on [DATE]; -The resident's [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 4/4/16, for evacuation of bariatric resident showed the following: -Assure the resident that he/she is safe and staff are there to help him/her; -The resident will be transferred via Hoyer lift by two staff members to his/her wheelchair to the closest secured emergency exit; -The designated staff to safely evacuate the resident will be listed on the daily assignment sheets. Observation on 04/04/16 at 11:15 A.M. showed the resident's bed measured 49 inches at the widest part and his/her doorway to the room measured 40 inches. During an interview on 04/04/16 at 2:35 P.M., the resident said he/she would not know what to expect from staff regarding emergency evacuation. He/she was transferred from his/her wheelchair to the bed by a mechanical lift. He/she said no staff had ever talked to him/her regarding evacuation procedures if he/she were to be in his/her bed when the fire alarm went off. The resident said he/she was unable to maneuver himself/herself at all and was totally dependent on staff for mobility. During an interview on 04/04/16 at 2:45 P.M., CNA DD said he/she was inserviced on Friday regarding Residents #30 and #31, but today he/she was inserviced regarding evacuation procedures for Resident #35. During an interview on 04/04/16 at 1:00 P.M., CNA EE said he/she had an inservice on Friday for Residents #30, #31 and #36 but has not had any instruction on evacuation procedures for Resident #35. During an interview on 04/04/16 at 11:50 A.M., CMT FF said he/she had not had any inservice prior to today on how to evacuate Resident #35. He/she said prior to the inservice this morning before his/her shift, he/she would not have known Resident #35 had special evacuation needs or how to evacuate this resident. During an interview on 04/04/16 at 1:55 P.M., CNA G said right after his/her shift started today, he/she received an inservice regarding Resident #35. He/she said prior to this morning, he/she would not have known Resident #35 had special evacuation needs or how to evacuate him/her. During an interview on 04/04/16 at 3:55 P.M., the administrator said only two residents, (Residents #30 and #31) were identified in the inservice given on the evening of 03/31/16. He/she said they didn't notice Resident #35 until today (4/4/16).The administrator said Resident #35 had not been identified until surveyors asked about him/her on today's date whether or not the facility had any other bariatric residents or residents with a tracheostomy. During a telephone interview on 04/04/16 at 4:15 P.M., CNA HH said he/she normally worked the night shift and had done so for eight months. He/she was involved in an inservice on the night of 03/31/16 regarding evacuation of Residents #30 and #31. He/she said there was no mention of Resident #35 in the inservice. CNA HH said he/she was not familiar with Resident #35 and would not know how to evacuate that resident. 6. Review of Resident #36's care plan, dated 11/16/15, showed the resident had a tracheostomy related to respiratory distress. (The care plan did not provide any specific evacuation procedures which would include how staff were to evacuate the resident who had a tracheostomy and required suctioning.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required extensive assistance for bed mobility with two or more persons; -Walk in room and corridor did not occur; -Locomotion on and off the unit did not occur; -Totally dependent on staff for dressing and eating; -Oxygen therapy; -Suctioning; -Tracheostomy Care. Review of the resident's POS, dated 03/31/16, showed the following: -The resident's [DIAGNOSES REDACTED]. -An order to suction as needed. Review of the resident's care plan, dated 04/04/16, showed the following: -Evacuation of a resident with a tracheotomy; -The resident has a [DEVICE] that needs to be unhooked by a nurse in the event he/she needs to be evacuated for an emergency; -The resident will have designated staff members that will safely remove him/her listed on the daily assignment sheet; -The nurse will unhook the humidifier from the resident's trach collar; -Staff will remove the resident in his/her bed with a portable suction machine to the closest secure emergency exit. During an interview on 04/04/16 at 3:20 P.M., Licensed Practical Nurse (LPN) T said the resident needed to have secretions suctioned approximately three to six times a shift but said no less than twice a shift. During an interview on 04/04/16 at 2:45 P.M., CNA DD said he/she was inserviced on Friday regarding specific evacuation procedures for Residents #30 and #31. CNA DD said this morning he/she was inserviced regarding specific evacuation procedures for Resident #36. He/She said prior to today's date there was no portable suction machine available in the facility for emergency evacuation purposes. During an interview on 04/04/16 at 11:50 A.M., CMT FF said he/she was inserviced on Friday regarding evacuation procedures for Residents #30, #31 and #36. He/she said prior to the inservice this morning before his/her shift, he/she would not have known Resident #36 had special evacuation needs or how to evacuate this resident. During an interview on 04/04/16 at 1:10 P.M., LPN J said one day last week he/she was given an inservice regarding Residents #30, #31. LPN J said just after he/she started her shift on 04/04/16 he/she was inserviced on how to evacuate resident #35 and #36. During an interview on 04/04/16 at 1:55 P.M., CNA G said today right after his/her shift started he/she received an inservice regarding Resident #36. CNA G said prior to this morning, he/she would not have known Resident #36 had special evacuation needs or how to evacuate him/her. During an interview on 04/04/16 at 3:05 P.M., CNA GG said he/she was given an inservice on Friday regarding an unnamed resident on C hall and Resident #36. He/she said would have known how to get Resident #31 out in the event of an emergency but would not have known what to do for resident #30 or #36 prior to the inservices given. CNA GG said he/she knew there was another bariatric resident (resident #35) in the building but said that resident was not mentioned in the inservice given to him/her. During an interview on 04/04/16 at 3:10 P.M., CNA F said he/she came to work at 2:00 P.M. on today's date and had been inserviced regarding how to evacuate Residents #30 and #31. CNA F said no staff have talked to him/her about evacuation instruction regarding Residents #35 or #36 and he/she was not aware of any specific evacuation plan for either. During a telephone interview on 04/04/16 at 4:15 P.M., CNA HH said he/she normally worked the night shift and had done so for eight months. CNA HH said he/she was involved in an inservice on the night of 03/31/16 regarding evacuation of Residents #30 and #31. He/she said there was no mention of Resident #36 but said he/she was familiar with Resident #36. He/she said although the resident was unconscious, he/she would have used a Hoyer lift to transfer him/her to a wheelchair then moved to a place of safety. He/she said Resident #36 required suction two to three times each night by nursing staff. 7. During an interview on 04/04/16 at 3:55 P.M., the administrator said the facility started inservices with staff regarding how to evacuate Residents #30 and #31 on Thursday evening, 03/31/16. He/she said they identified Resident #36 on Friday as needing a evacuation plan but they had not identified Resident #35 until today's date (04/04/16 around approximately 10:45 A.M.) and would have to inservice staff again regarding Resident #35. During an interview on 04/04/16 at 11:30 A.M., the DON said the facility had acquired two portable battery operated suction machines for emergency evacuation use with Residents #30 and #36. He/she said all nursing staff had been inserviced along with a few dietary staff regarding evacuation procedures regarding Residents #30, #31, #35 and #36. He/she said staff were instructed to transfer Resident #30 with two people and to evacuate the resident and his/her bed to an area of safety as the resident was now in a regular size bed and to take the portable suction machine with them. The DON said Resident #31 was to be transferred with three staff via Hoyer lift to his/her wheelchair and then to an area of safety. Resident #35 was to be transferred from his/her bariatric size bed to his/her wheelchair with two people using a Hoyer Lift and for Resident #36 staff was instructed to transfer the resident in his/her bed since he/she was not alert, to unhook his/her trach and then take the portable suction machine with them as they evacuated to an area of safety. He/she said they had not yet done a mock evacuation of the identified residents with specialized evacuation plans to ensure staff were able to execute evacuation. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility developed and implemented individualized resident specific evacuation plans for Residents #30 and #31. The facility immediately obtained portable suction machines for residents who required suctioning. The facility evaluated other residents to identify others that may have been affected by the deficient practice. The facility began inservicing all staff immediately regarding the individualized evacuation plans and devised a system to ensure specific staff were identified on the daily staffing sheets to assist in the resident specific evacuations. The remainder of staff were to be inserviced prior to the beginning of their next working shift until all staff had received this inservice. The facility revised their emergency evacuations procedures to include bariatric residents and residents with special care needs. The facility will inservice any newly hired staff on the facility's evacuation policy and resident specific evacuation plans and will monitor to ensure existing staff are knowledgeable of the individualized evacuation plans in place for the identified residents with special evacuation needs. 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address class I violations. `1`

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable, mental and physical well-being, to comprehensively assess pain and provide as needed pain medication for one resident (Resident #1), of nine sampled residents who required pain management. The facility census was 93. 1. Review of the facility's pain policy and procedure, untitled and undated, showed the following: -Pain Management was a very important aspect of the quality of life for our residents; -It can affect all aspects of their life-mobility, appetite, mood, behaviors, and of course their day-to-day comfort and happiness; -It is our responsibility to ensure that each resident's pain is promptly identified and addressed with an individualized pain management program; -This will be addressed through promptly notifying the physician and then monitor until they have achieved acceptable relief by utilizing both pharmacological and non-pharmacological methods; -Anytime a resident not already monitored for pain expresses pain or has non-verbal signs of pain, we need to immediately assess their level of pain and contact the physician; -We will also be monitoring pain on all residents on the Medication Administration Record [REDACTED] -This will trigger you to assess their pain further or administer a medication for the pain they are experiencing; -If the resident is having pain, please address promptly. 2. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/14/16 showed the following: -Ability to understand others; -Makes self-understood; -Moderately impaired with daily decision making; -Limited assist of one staff member for bed mobility, transfers and toilet use; -Always incontinent of stool; -No presence of pain; -At risk for pressure ulcers; -Presence of two Stage III pressure ulcers (full thickness skin loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss); -Presence of two Stage IV pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Stage IV ulcers can extend into muscle and/or supporting structures making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable); -Presence of two unstageable pressure ulcers (known but not stageable due to non-removable dressing/device). Review of the resident's care plan dated 1/22/16 showed the following: -Problem: hospice; -Goal: to help the resident sustain daily living and to keep comfortable; -Approaches: comfort measure only and monitor for presence of pain/intolerance during activities of daily living, report to nurse/physician as needed; -Problem: requires moderate/extensive assist of one to two with activities of daily living related to weakness, [MEDICAL CONDITIONS] joint disease, [MEDICAL CONDITION] and dementia; -Approaches: monitor for presence of pain/intolerance during activities of daily living and report to nurse/physician as needed. Review of the resident's Pain Evaluation, dated 1/22/16, showed the following: -The resident had pressure ulcers which would give reason to believe he/she would be in pain; -The resident had noisy labored breathing; -Repeated troubled calling out, loud moaning or groaning and/or crying; -Facial grimacing; -Tense, distressed, pacing, fidgeting; -Pain was relieved by medication; -The resident's acceptable pain level was 8 (on a scale of 0-10); -The resident received as needed [MEDICATION NAME] (narcotic pain medication); -Interdisciplinary Team (IDT), note showed the resident's pain was controlled by current pain regimen. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -[MEDICATION NAME] ([MEDICATION NAME]), 500 mg tablet every four hours as needed for fever/mild pain; -[MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) (used to relieve moderate to severe pain) (narcotic [MEDICATION NAME]), 5-325 one tablet by mouth every four hours as needed. -On 2/23/16, an order to treat to all wounds (left heel, right heel, left lower leg, coccyx, posterior trunk, left buttock ischial, right buttocks and left anterior ankle) cleanse with Dankin's solution (antiseptic solution), Iodosorb (cleansing and protecting wounds) and ABD (abdominal) pad (absorbent breathable dressing). Review of the resident's Medication Administration Record [REDACTED] -Assess pain each shift, rate 0-10; -The resident's acceptable level of pain was 4. -On 2/6/16 at 8:00 A.M., the resident was given [MEDICATION NAME] 5/325 mg for pain; -The resident's pain was rated zero on the day, evening and night shift. Review of hospice's Plan of Care Review, dated 2/10/16, showed the resident had multiple pressure ulcers and received Tylenol and [MEDICATION NAME] as needed. The resident complained of pain when his/her blankets were moved. Review of the resident's Medication Administration Record [REDACTED] -On 2/11/16 at 6:00 P.M., the resident complained of pain and staff gave [MEDICATION NAME] 5/325 mg; -The resident's pain was rated a zero on the day and night shift, the resident's pain was not rated on the evening shift; -On 2/12/16 at 8:00 P.M., staff gave the resident [MEDICATION NAME] 5/325 mg for complaints of pain; -The resident's pain was rated zero on the day, evening and night shift. Review of the physician progress notes [REDACTED]. He/she had multiple ulcers and was seeing a wound physician. The resident was now on hospice. He/she complained of 5 out of 10 (pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain), which was a dull and constant generalized pain that was managed with medications. The resident was on supportive care with hospice. Review of the resident's Medication Administration Record [REDACTED] -On 2/15/16 at 5:00 A.M., staff gave the resident Tylenol ([MEDICATION NAME]) for complaints of pain; -The resident's pain was rated zero on the day, evening and night shift; -On 2/19/16 at 9:30 A.M., staff gave the resident [MEDICATION NAME] 5/325 mg for complaints of foot pain; -On 2/19/16 at 10:30 P.M., the resident received [MEDICATION NAME] 5/325 mg for complaints of foot and leg pain; -The resident's pain was rated zero on the day, evening and night shift; -On 2/21/16 at 10:00 A.M., staff gave the resident [MEDICATION NAME] 5/325 mg for complaints of pain; -The resident's pain was rated zero on the day, evening and night shift. Review of the resident's wound assessment, dated 2/23/16 showed the following: -Unstageable pressure ulcer to the resident's left lower leg measuring 8 cm x 9 cm, the color was pink, yellow and black with moderate thick greenish drainage with odor and infection. The area was digressing; -Stage IV pressure ulcer to the coccyx measuring 2.5 cm x 2.5 cm x 1 cm, the ulcer was tunneling; -Stage III pressure ulcer to the posterior trunk measuring 1.5 cm x 1.5 cm [MEDICAL CONDITION] cm; -Stage IV pressure ulcer to the buttock/ischial (lower and back part of the hip bone), measuring 1.7 cm x 1.8 cm x 1 cm with tunneling, the area was digressing; -Unstageable pressure ulcer to the left anterior ankle measuring 1 cm x 0.6 cm, the color was pink and black, this was a new area to the ankle and covered with eschar (a slough or piece of dead tissue); -Unstageable pressure ulcer to the left heel measuring 4.3 cm x 5.5 cm, the color was pink, yellow and black with moderate, greenish, odorous drainage and infection; -Unstageable pressure area to the right heel measuring 4 cm x 1.5 cm, the color was pink, yellow and black with a moderate, odorous, greenish thick drainage and infection. During interview on 2/25/16, the resident said the following: -At 8:00 A.M., staff asked the resident if he/she was in pain and he/she said yes, my feet. Asked the resident to rate his/her pain on a scale of 0-10 and he/she said 10; -At 9:20 A.M., the resident said he/she was in pain when he/she was touched or moved. His/her toenails hurt and were painful; he/she had been waiting on someone to come and cut them. His/her toenails had hurt for a long time; -At 12:55 P.M., the resident said he/she had pain when staff turn and reposition him/her. It kills him/her when they change the dressing to his/her feet and back. Observation on 2/24/16 at 1:35 P.M. showed the following: -The resident lay in bed; -Certified Nurse Assistant (CNA) A and CNA B lowered the head of the resident's bed; moved his/her legs and he/she loudly hollered, Ow! (used especially as an expression of intense or sudden pain) and displayed facial grimacing; -The resident told the staff to be careful as they turned him/her; -The resident moaned loudly, yelled Ow! and exhibited facial grimacing while the staff turned him/her toward his/her left side; -Staff removed the pillow from under the resident's legs and she yelled out, Ow, ow, ow! and continued to moan; -Staff turned the resident on his/her right side and the resident yelled out Ow!; -The resident yelled out in pain; displayed facial grimacing and said, Oh girls, oh girls! when staff lifted his/her legs onto the pillow; Staff did not ask the resident if he/she was in pain; -The surveyor asked the resident if he/she was in pain and he/she said, yes, when asked to rate his/her pain on a scale of 0-10 he/she said 10. During interview on 2/24/16, CNA A said the resident wasn't in pain; he/she yelled out in pain and displayed facial grimacing during care and this was normal for the resident. The resident used to get out of bed and couldn't get up now because he/she had a, bunch of wounds. He/she said the resident always yelled out when his/her legs were touched. If the resident was in pain he/she would tell the nurse right away. During interview on 2/24/16 at 2:00 P.M., Licensed Practical Nurse (LPN) C said the resident was only in pain when he/she was turned other than that he/she was not in pain. Staff had not reported the resident was in pain. Observation on 2/24/16 at 5:40 P.M. showed the following: -The resident lay in bed; -The resident said his/her pain was an 8 on a scale of 0-10; -CNA D said the resident was normally in pain when staff turned and repositioned him/her; -The CNA continued with care and did not let the charge nurse know the resident was in pain; -He/she rolled the resident toward his/her left side and the resident moaned, Oh, oh, oh; -CNA D lifted the resident's feet and removed them off the pillow; the resident yelled loudly Ow, ow, ow!; -CNA D rolled the resident toward his/her right side and the resident yelled, Ow, ow! and had facial grimacing; -CNA D picked up the resident's legs; placed them on the pillow and the resident yelled out Ow, ow, ow!; -The resident's left great toenail was long and growing away from the nail bed; the fourth and fifth toenail of the right foot was growing up and over the nail bed; the left great toenail was missing and his/her toenails were dry, brittle, thick and yellow; -The CNA asked the resident is he/she was okay and the resident said, I don't know; -The resident yelled loudly, Ow, ow my toenails hurt! when the covers were placed over his/her feet; -The resident continued to moan softly; -The CNA said this was good, the resident normally screamed in pain very loud during care; -The CNA left the resident's room and reported to the charge nurse the resident's dressing came off during care but did not mention the resident was in pain. During interview on 2/24/16 at 5:40 P.M., CNA D said if a resident was having pain he/she was to notify the charge nurse. During interview on 2/25/16 at 7:35 A.M., LPN F said the resident had no pain unless you touched certain areas of his/her feet and legs or turned him/her in certain ways. He/she received [MEDICATION NAME] as needed and assessed for pain every shift. The resident was very alert and vocal and could tell you if he/she was in pain. If the resident was in pain while turning and repositioning he/she would expect the staff to stop care and ask him/her if he/she was hurting and get the charge nurse. The charge nurse would ask him/her if he/she was hurting. He/she did not receive report the resident was in pain on 2/24/16. During interview on 2/25/16 at 1:28 P.M., LPN E said if staff tells the resident what they were doing he/she wouldn't be in pain, if staff surprised him/her he/she would yell. The resident was in pain at various times so staff would not know if he/she needed pain medication prior to care. The resident was not on a scheduled pain medication. During interview on 2/25/16 at 2:35 P.M., LPN C said staff did not tell him/her the resident was in pain on 2/24/16. When the resident was being changed the resident would be asked for a pain pill. The resident would only say he/she was in pain if he/she was in pain. The Certified Medication Technician should ask the resident if he/she was in pain. Observation on 2/25/16 at 9:18 A.M., showed the following: -The resident lay in bed; -The wound care nurse touched the resident's right foot and the resident yelled Ow!; -The wound care nurse said it looked like the resident's right big toe nail fell off; -He/she removed the resident's heel protector from his/her right heel; the resident moaned and said, ow; -The wound care nurse had asked the resident if he/she was in pain and the resident said Yes; -The wound care nurse stopped; left the room and obtained a pain pill for the resident; -He/she removed the dressing from the resident's right heel, the right heel dripped blood; -He/she cleansed the resident's right heel pressure ulcer and the resident yelled out in pain Ow, ow, ow! and had facial grimacing. During interview on 2/25/16, at 8:07 A.M. the wound treatment nurse said the resident occasionally yelled out in pain when his/her feet were touched, if you asked him/her to raise his/her feet he/she wouldn't yell. His/her toenails did hurt. The resident's family member was concerned about his/her toenails and he/she explained the facility did not have an in-house podiatrist and he/she would have to take the resident out to a podiatrist. The resident's family member did not think it was necessary and just wanted the resident comfortable. During interview on 2/25/16 at 7:40 P.M., the MDS Coordinator said the resident's toenails were sensitive and growing out but a podiatrist does not come to the facility. During interview on 2/25/16 at 12:05 P.M., the Care Plan Coordinator/Pain Champion said the resident received wound treatments and when they moved his/her legs he/she had pain but didn't rate the resident's pain. When the resident got out of bed to smoke he/she wasn't in pain. He/she was not told the resident was in pain when turned side to side. He/she addressed pain under the resident's activities of daily living and if staff noticed he/she was in pain they were to let the charge nurses know and he/she had pain medication which could be given. The reason the resident didn't have a pain care plan was because he/she only received as needed pain medication and pain was not triggered as a care area. During interview on 2/25/16 at 10:30 A.M., the Director of Nursing (DON) said he/she was told the resident's family member was taking the resident to the podiatrist. He/she was unable to find anything in the resident's medical record regarding the resident's toe nails. He/she would have expected staff to contact the resident's physician and get an order for [REDACTED].>During interview on 2/25/16 at 10:45 A.M., the DON said the resident was on a low air flow mattress (helps prevent the formation of pressure ulcers), because he/she couldn't be turned and repositioned because he/she was in pain when you touched him/her. During interview on 2/25/16 at 1:15 P.M., the DON said: -If a resident complains of pain the MAR indicated [REDACTED] -If the resident had pain he/she expected staff to contact the physician and pain champion, the pain champion was to evaluate the resident and ask the doctor for pain medication to be scheduled; -The pain champion was not notified the resident was in pain; -The staff said the resident was in pain when they turned him/her but at other times he/she was not in pain which made the resident difficult to pre-medicate; -He/she expected the wound nurse to ask the resident 20 minutes prior to doing his/her treatments; -Sometimes the resident would ask for pain medication and he/she did not know how much of it was pain or how much was behaviors; -The CNAs would not be expected to let the nurse know prior to providing care to the resident but if the resident yelled out during care they would be expected to let the nurse know at that time. During interview on 2/25/16 at 1:55 P.M., the administrator said the resident was always in pain and getting an as needed pain medication. He/she would expect staff to be assessing the resident and making changes to his/her plan of care to make sure he/she was kept comfortable.

Based on observation, interview and record review, the facility failed to assess a resident with history of dementia for footrests and the resident's inability to hold his/her feet up when being propelled by staff in a wheelchair. The facility also failed to evaluate complaints from staff regarding difficulty propelling residents in a wheelchair across the threshold located between resident's rooms and the hallway. One of 19 sampled residents fell forward from a wheelchair while crossing a threshold to the resident's room and sustained a fractured nose and bruising to the face. (Resident #2) The census was 108. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/28/11, showed the following: -Short and long term memory loss; -Moderately impaired decision making; -Extensive dependence on staff for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of the resident's care plan dated 2/9/11, showed the following: -[DIAGNOSES REDACTED]. -Alert and oriented times two (aware of his/her name and date/or place); -Generally up ad lib (up as desired) with a walker for mobility. He/she would use a wheelchair and self propel if tired; -Did not show the wheelchair as the resident's primary mode of mobility. Review of the Nurse Practitioner (NP) O's physical assessment dated [DATE], showed the following: -Assistive gait devices: walker and wheelchair; -The resident has some edema (swelling), his/her legs are not wrapped today. Resume all wraps and monitor. During an interview on 4/11/11 at 9:19 A.M., NP O said the resident had been progressively declining and had stopped walking at Christmas. Review of the resident's nurse's notes dated 4/2/11at 5:10 A.M., showed a Certified Nurse Aide (CNA) informed the nurse that a resident fell out of his/her wheelchair that morning. When asked what happened the CNA said he/she pushed the resident's wheelchair (with the resident in it) out of the resident's room into the hallway. The wheelchair was stopped by the metal taping at the door, the metal stripping on the floor. The resident's foot rolled under the wheelchair and the wheelchair stopped abruptly and forced the resident out of the wheelchair onto the floor. The resident landed on his/her face. He/she sustained a 1 inch laceration across the bridge of his/her nose. The nose appeared discolored, swollen, bleeding and extremely painful. Upon assessment, the resident was alert and oriented times two to three (aware of his/her name and date and/or place) with periods of confusion, this was normal for the resident. He/she complained of pain and requested something for pain. The nurse administered Acetaminophen (used to treat mild to moderate pain) at that time. At 5:46 A.M., paramedics transported the resident to the emergency room . Review of a post fall nursing assessment dated [DATE] at 5:10 A.M., showed a CNA informed the nurse that the resident fell out of the wheelchair that morning. When the nurse asked the CNA what happened, the CNA said he/she pushed the resident in the wheelchair from the room into the hall when the gold metal stripping caught the resident's left foot. The foot was lodged under the wheel on the left side of the wheelchair. From there the resident was abruptly thrown from the wheelchair onto the floor and landed on the front of his/her face. Review of hospital emergency room record dated 4/2/11, showed the following: -Resident came in with complaint of falling out of a wheelchair, his/her feet got tangled up; -Obviously swollen nose and superficial abrasion to top of his/her nose; -Dried blood in his/her mouth, lip laceration, swollen, deformed nose; -[DIAGNOSES REDACTED]. Observation on 4/4/11 at 2:40 P.M., showed the resident sat in a geri-chair (a high back reclining wheelchair used to provide greater positioning support than a regular wheelchair) asleep. Red and purple bruising surrounded both of the resident's eyes and the bridge of the resident's nose. Review of the resident's medical record, showed no assessment for the resident's wheelchair use. Review of the resident's physician order [REDACTED]. -4/4/11, Roxanol (used to treat severe pain, administered in a liquid form) 5 milligrams (mg) every two hours as needed for pain; -4/6/11, Give Roxanol 10 mg now and continue every two hours as needed (no indication noted); -4/6/11, Ativan Intensol (used to treat anxiety, administered in a liquid form) 1 mg every fours as needed (no indication noted). During an interview on 4/8/11 at approximately 9:00 A.M., the Director of Nursing (DON) said she investigated the resident's fall and found the CNA pushed the resident while in a wheelchair over the lip of the threshold and the resident placed his/her foot down. The resident became stuck and fell forward out of the wheelchair. The resident's family member was aware that the resident put his/her feet down while being propelled by staff at times. The resident did cooperate most of the time. On bad days the resident would put his/her feet down while being propelled by staff. During an interview on 4/8/11 at 12:35 P.M., with Physical Therapist N and Occupational Therapist M said the following: -The resident was last seen by therapy in September 2010, at that time the resident ambulated ad-lib; -If the nursing department thinks a resident needs to use a wheelchair they can make that decision without therapy involvement; -The resident's daughter was concerned so she and the nursing staff made a decision for the resident to use a wheelchair as the primary mode of transportation; -Foot rests are used on a wheelchair for residents who have more difficulty self propelling and to assist with the resident's transport. They can be used to elevate edematous extremities and to prevent tripping. During an interview on 4/8/11 at 12:40 P.M., CNA Q said before the resident became sick staff would toilet the resident every two hours and take him/her to activities in his/her wheelchair. He/she ate in the main dining room and would do things for him/herself. When he/she propelled the resident, he/she would have to stop and let the resident rest. Sometimes the resident would drop his/her feet down if he/she were tired. The resident would only propel him/herself if he/she really wanted to get somewhere, normally staff would transport him/her around. After the resident became sick he/she became a total, full assist with care, staff kept him/her comfortable, fed him/her and encouraged the resident to eat. When asked by the surveyor what he/she meant by when the resident became sick, CNA Q stated after the resident's fell . During an interview on 4/8/11 at 12:45 P.M., Nurse R said the resident would self propel depending on how he/she felt. The resident's legs were heavy. When he/she propelled the resident in a wheelchair Nurse R would ask the resident to lift his/her feet up. The resident would lift his/her feet and drop them back down. The resident's legs were large. During an interview on 4/8/11 at 2:35 P.M., the DON said the following: -The resident experienced more tired spells; -The resident began using a wheelchair more frequently around 2/23/11; -The resident was having a slow decline; -The Nurse Practitioner ordered the Roxanol and Ativan Intensol because the resident was not taking his/her pills. Staff knew the resident was in discomfort and could tell he/she was in pain. Staff wanted the resident to be comfortable; -Staff noticed over the weekend (of the fall) the resident was not taking his/her pills. Observations throughout the entire survey conducted 4/4/11 through 4/8/11, showed Resident #2's room had a tile floor with a burgundy threshold strip leading to a carpeted hallway. During a telephone interview on 4/11/11 at 8:19 A.M., CNA L said he/she was pushing the resident out of his/her room and before the resident could say his/her foot was stuck, the resident fell . No other staff witnessed the fall. It is difficult to push residents out of their rooms, because of the strip in the door way. CNA L tried to get the wheelchair over the strip (in the doorway) and the resident's foot became stuck. He/she had previously told the DON about the difficulty in getting the resident over the threshold strip, it has been brought to the DON's attention several times. He/she only worked at the facility two days a week and seldom worked with Resident #2. He/she would be informed of resident's care needs during report and/or by looking at the resident's care plan. The resident had on Velcro strapped tennis shoes at the time of the fall, there were no footrests on the wheelchair. CNA L said he/she did not know the resident dropped his/her feet when being propelled by staff. During a telephone interview on 4/11/11 at 12:30 P.M., Nurse P said on 4/2/11, a CNA notified him/her of the resident's fall. Sometimes there is a problem with the stripping in the doorway of resident's room. He/she has tripped over the stripping before. Sometimes the stripping can catch your shoe. Nurse P could not recall if the resident could hold his/her feet up while staff propelled the resident, he/she was not familiar with the resident. During a telephone interview on 4/11/11 at 12:05 P.M., the DON said the following: -The resident would slouch when in a wheelchair at times; -A geri-chair was available for the resident's use prior to the fall but not used; -The resident was having more episodes of lounging back; -Staff had reported problems with propelling residents across the threshold stripping; -Staff would report problems with the threshold stripping every now and then (she was unable to identify specific rooms); -When staff reported a problem with propelling staff across the threshold stripping she would get maintenance involved to repair the threshold. -No one had reported a problem with Resident #2's threshold stripping prior to the fall; -At 1:05 P.M., the DON said she would have the Maintenance Director call with a list of threshold stripping's repaired in resident's rooms. During an interview on 4/11/11 at 2:09 P.M., the Maintenance Director said he has never replaced any threshold stripping to a resident's room and no one has ever mentioned to him there was a problem with the thresholds. During an interview on 4/11/11 at 3:28 P.M., the Administrator said staff never complained to her about the threshold between the resident's room and hallway being a problem.