Every finding on record at Rocky Ridge Manor

Based on observation, interview, and record review, the facility failed to prevent misappropriation of resident property when one staff member (Business Office Manager (BOM) A) took money from four residents (Resident #1, #2, #3, and #4) without their permission and not for resident use. The facility census was 49.Review of the facility's Guidelines for Maintaining the Resident Trust Fund Account, revised 08/04/22, showed the facility will establish and maintain a system that assures full, complete, and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf. 1. Review of the probable cause statement from the [NAME] County Sherriff's Office, dated 03/17/26, showed the following:-The officer had probable cause to believe that BOM A committed one or more criminal offenses including theft of $750.00 or more;-On 03/12/26, at approximately 10:32 A.M., the deputy was dispatched to the facility for a report of theft. Dispatch advised the deputy the Administrator needed to make a report about missing money, and the Administrator believed it was an employee. The deputy responded to the location to get a complaint and paperwork from the Administrator. The deputy then turned the case over to investigations;-The Administrator said the highlighted receipts were the ones from which funds were missing. There is also a copy showing where the money should have been deposited. The only funds taken were when customers paid in cash;-The Administrator said that he called and spoke with BOM A about the incident. BOM A would continue to have excuses for each question. BOM A told him $3000.00 was in the safe. The Administrator said the money was not in the safe and they were the only two who had access to it;-Administrator said it was not normal practice to put money in the safe, it should have all been deposited. It is company protocol that, if someone pays in cash, they must have a witness sign as well. They also make a copy of the cash;-The Administrator provided the deputy with a signed complaint form. On the complaint, it was signed alleging that BOM A was taking cash for services and not depositing it into accounts. The complaint said that this has affected the facility and residents in various ways;-Receipt 122233, paid $248 on 12/05/23. The bank records show there was no deposit of $248 on or around 12/05/23;-Receipt 122234, paid $248 on 01/04/24. The bank records show there was no deposit of $248 on or around 01/04/24;-Receipt 122235, paid $248 in February 2024. The bank records show there was no deposit of $248 in February.-Receipt 122237, paid $40 on 02/22/24. The bank records show there was no deposit of $40 on or around 02/22/24;-Receipt 122240, paid $10.50 on 05/09/24. The bank records show there was no deposit of $10.50 on or around 05/9/24;-Receipt 122249, paid $306 on 12/03/24. The bank records show there was no deposit of $306 on or around 12/03/24;-Receipt 122250, paid $30 on 12/06/24. The bank records show there was no deposit of $30 on or around 12/06/24;-Receipt 122252, paid $20 on 01/02/25. The bank records show there was no deposit of $20 on or around 01/02/25;-Receipt 122270, paid $40 on 02/03/25. The bank records show there was no deposit of $40 on or around 02/03/25;-Receipt 122257, paid $4000 on 04/28/25. The bank records show that only a partial payment of$ 1,000 was made to the bank on 05/29/25.-The amount of $4,190.50 is believed to be missing from the accounts. It was later determined that $744.00 was put back into the accounts by BOM A, who had taken the money.Review of the Sheriff's Office interview with BOM A dated 03/16/26, at 5:20 A.M., showed the following: -BOM A said that if he/she signed receipts for the cash it should have been deposited however, he/she was not sure what to do with the money if insurance was involved;-Regarding receipt 122257, for which $4,000.00, he/she signed, however the bank records showed that only $1,000.00 was deposited. BOM A said he/she put $3,000.00 in the safe;-When asked about the other missing money, he/she said, The resident was notorious for paying cash and coming back later in the day asking for it back. BOM A said he/she should have written void on the receipt when he/she gave the resident the money back;-BOM A admitted that he/she took $20.00 on receipt number 122252. When asked why he/she took the money, he/she said he/she needed gas money;-When adding the small amounts from receipt numbers 122250, 122252, 122237, 122240, and 122270, the total was $140.50. He/she was asked If that money was for gas, and he/she said yes;-BOM A admitted to taking $306 from receipt number 122249.-During the interview, he/she admitted to taking all the money listed, except for the missing $3,000.00 on receipt number 122257. 1. Review of Resident #1's face sheet showed the following:-admission date of 04/04/16;-Diagnoses of intracranial (brain) injury, epilepsy (seizure disorder), quadriplegia (paralysis of arms and legs), and pain.Review of the facility cash receipt book a copy of a cash receipt, dated 12/03/23, showed the facility received $248.00 in cash for room and board for December 2023 from the resident. The money was received by BOM A. Review of the facility's December 2023 petty cash account monthly transaction/balance sheet, dated 12/31/23, from the bank showed no record of deposit for the resident's $248.00. Review of the facility cash receipt book showed a copy of a cash receipt, dated 01/04/24, where the facility received $248.00 in cash for room and board for January 2024from the resident . The money was received by BOM A. Review of the facility's January 2024 petty cash account monthly transaction/balance sheet, dated 01/31/24, from the bank no record of deposit of the resident's $248.00. Review of the facility cash receipt book a copy of a cash receipt, dated February 2024, showed the facility received $248.00 in cash for room and board for February 2024 from the resident. The money was received by BOM A. Review of the facility's February 2024 petty cash account monthly transaction/balance, dated 02/29/24, from the bank showed no record of deposit for the resident's $248.00. Review of the facility's cash receipt book a copy of a cash receipt, dated 05/24/24, for $744.00 in cash received for room rent for December 2023, January 2024, and February 2024, received from the resident. The money was received by BOM A. Review of the facility's May 2024 petty cash account monthly transaction/balance sheet, from bank showed the following:-Disbursement on 05/24/24 facility surplus for the resident = $744.00-Deposit on 05/31/24 for the resident surplus = $744.00; Review of the facility's cash receipt book showed a copy of a cash receipt, dated 04/28/25, for $4000.00 in cash received for private therapy, received from the resident. The money was received by BOM A. Review of a photocopy of a checking deposit slip, dated 05/29/25, showed the following:-The facility deposited $1000.00 in cash into the local bank;-The facility was unable to account for the remaining $3000.00 in cash. Review of a photocopy of check, dated 05/31/25, written on the local bank account to the facility signed by BOM A for $1000.00. The memo notation showed the resident private pay therapy. Review of the facility's May 2025 petty cash account monthly transaction/balance sheet, from the bank, showed the following:-Disbursement on 05/31/25 for the resident's private pay therapy = $1000.00;-Deposit on 05/31/24, for resident's private pay therapy = $1000.00. During an interview on 03/27/26, at 10:33 A.M, the current Business Office Manager (BOM) B said the following:-Approximately one week ago, the resident's responsible party approached BOM B and asked about his/her account balance;-BOM B asked the corporate financial consultant who was in the building training BOM B;-The resident's responsible party then told BOM B and the financial consultant, he/she had paid BOM A $4000.00 in cash for private (occupational) therapy sessions for the resident;-BOM B and the corporate financial consultant reviewed the resident's account activity and saw BOM A had deposited $1000.00 in cash, but did not mention the other $3000.00;-At that point, the corporate financial consultant and BOM B decided to conduct an audit of the resident's account and found three cash receipts for $248.00 (where the family member had paid former BOM A in cash);-These three cash amounts were to be used to pay the resident's monthly surplus owed but were not deposited into the account to pay for the room and board;-A few months later, in May 2024, BOM A made a cash deposit for the resident for all three months of back owed surplus (rent), totaling $744.00; -The administrator contacted former BOM A and asked about the missing $3000.00 in cash. He/she said he/she had placed $3000.00 in cash in the facility;-The Administrator and BOM B checked the safe for the $3000.00 and it was not in the safe. During an interview on 03/27/26, at 11:34 A.M., the Social Service Director (SSD) said the following:-BOM A would ask staff to sign the bottom of her his/her distribution ledgers and even ask them to sign blank ones in the past;-BOM A insisted residents notified him/her of any requests for money by 10:00 A.M. each weekday and at approximately 1:00 P.M., BOM A would give out money to the residents. The residents were only allowed to request money once per day and if they came to her later in the day, they would have to wait until the following business day to get money out of their account. During an interview on 03/30/26, at 1:44 P.M., the Regional Financial Consultant said the following:-While training the new BOM, the resident's responsible party came in to inquire about a recent statement he/she received from the facility;-The responsible party said he/she paid BOM A $4000.00 in cash for private pay therapy, through the facility's contracted therapy company;-Review of the facility cash receipt book showed the former BOM received $4000.00 in cash from the resident's responsible party, but the resident trust deposits showed only $1000.00 deposited into the resident's account;-When a resident or responsible party pays the facility in cash, the BOM should give the person a cash receipt, deposit the cash in the facility's local bank into the petty cash account, and write a check out of the account to deposit into the resident's trust account or apply to the resident's account for room/board or other bills;-He/she would not have accepted $4000.00 in cash from a resident or responsible party, but rather he/she would have asked the responsible party to bring in a cashier's check or money order for the amount;-The Administrator called BOM A and he/she alleged he/she placed the $3000.00 dollars into the facility safe and forgot about it, but the money was not in the safe;-BOM A should not have placed cash in the facility safe unless a resident needed the facility to place it overnight or after hours for emergency safety. Any cash placed in the safe should be taken to the bank on the next business day for deposit. During an interview on 03/27/26, at 1:00 P.M., the Administrator said the following:-BOM A claimed he/she put $3000.00 in cash from the resident's responsible party in the facility safe and forgot about it, but upon searching, the money was not in the safe;-BOM A admitted to the police stealing $248.00 dollars in cash from the resident's responsible party for the resident's room and board surplus on three different occasions during 2023 and 2024 and then paying the money back at one time a few months later in 2024 in the amount of $744.00. During a phone interview on 03/27/26, at 3:00 P.M., the resident's responsible party said the following:-Sometime in the Fall of 2025, he/she brought $4000.00 in cash and gave the money to BOM A so the resident could have some private pay therapy;-Approximately one year ago, he/she received a bill from the facility stating he/she had not paid the resident's monthly surplus (owed rent) for three months;-The responsible party said he/she thought this was odd, because he/she never failed to pay the monthly amount due each month;-The responsible party said during that time, he/she paid the resident's rent in cash, but after that happened, he/she started paying the surplus with a check;-The responsible party questioned BOM A about the bill and was told not to worry about it, because the company had probably just not posted the money to the resident's account yet. 2.Review of Resident #2's face sheet showed the following:-admission date of 05/11/16;-Diagnoses of schizoaffective disorder (a mental disorder characterized by psychosis and mood disorder), type 2 diabetes mellitus, lack of coordination, unsteadiness on feet, history of falls, general anxiety disorder, and major depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/19/26, showed the resident was cognitively intact. Review of a photocopied shoe store receipt, dated 09/27/25, showed the following:-One pair of grey Skecher go walks, price $52.49;-On pair of natural max cushioning Skecher endeavors, price $57.49;-Total for both pairs of shoes with tax = 120.33, paid for with cash;-BOM A name printed on the receipt;-The resident's name handwritten at the top of the receipt. During an interview on 03/27/26, at 12:28 P.M., Registered Nurse (RN) C said the following:-The resident said he/she did not have any new Skechers brand tennis shoes in the fall of 2025;-The resident said the Administrator was the only one that purchased shoes for the resident, and they were not Skechers;-The resident said BOM A never purchased him/her any shoes. During an interview on 03/27/26, at 1:00 P.M., the Administrator said the following:-The Administrator found a cash receipt, dated 09/27/25, for the purchase of two pairs of Skechers brand tennis shoes totaling $120.33, the receipt showed paid in cash by BOM A, and a resident name handwritten at the top of the receipt;-None of the staff interviewed saw the resident wearing these tennis shoes, but the former BOM did have this exact type of shoe and came to work talking about purchasing the shoes for him/herself;-The resident told the Administrator that he (the Administrator) was the only employee that had purchased shoes for the resident in the last year, and they were not that brand;-The Administrator said he/she did purchase shoes for the resident at Wal-Mart;-A search of the resident's belongings by facility staff, showed the resident did not have any Skechers brand tennis shoes;-According to the Administrator, the resident did not go anywhere outside of the facility, and the resident could not have spent that amount of money. During an interview on 03/27/26, at 2:29 P.M., Certified Nurse Assistant (CNA) D said he/she cared for the resident and the resident never had any Skecher brand shoes. Observation and interview of the resident on 03/27/26, at 2:45 P.M., showed the following:-The resident sat in the dining room playing bingo with some of the other residents;-The resident said no one had ever purchased him/her a pair of Skechers;-The resident said BOM A had never purchased him/her any shoes. During an interview on 03/27/2,6 at 5:02 P.M., RN F said BOM A never bought shoes for the resident. If the resident needed something the resident's family would buy it for him/her. 3. Review of Resident #3 face sheet showed:-admission date of 04/29/24;-Diagnoses of hemiplegia (severe neurological condition causing paralysis on one side of the body) affecting the right dominant side, adjustment disorder with depressed mood ( a temporary, excessive reaction to a specific stressor causing sadness, hopelessness, and crying), dysphagia (difficulty swallowing) following cerebral infarct (stroke), history of injury to left Achilles tendon (back of heel). Review of the resident's is quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the facility withdrawal report, dated 10/01/25 to 10/31/25, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 10/02/25, 10/14/25, 10/17/25, 10/23/25, 10/28/25, and 10/31/25.Review of the facility's withdrawal report, dated 11/01/25 to 11/30/25, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 11/04/25, 11/07/25, 11/11/25, 11/14/25, 11/18/25, 11/24/25, and 11/25/25.Review of the facility withdrawal report, dated 12/01/25 to 12/31/25, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 12/02/25, 12/03/25, 12/04/25, 12/08/25, 12/09/25, 12/12/25, 12/16,25, 12/19/25, 12/23/25, 12/30/25, and 12/31/25. Review of the facility withdrawal report, dated 01/01/26 to 01/31/26, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 01/05/26, 01/08/26, 01/09/26, 01/10/26, 01/13/26, 01/16/26, 01/20/26, 01/22/26, 01/23/26, 01/27/26, 01/29/26, and 01/30/26.Review of the facility withdrawal report, dated 02/01/26 to 02/20/26, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 02/03/26, 02/06/26, 02/09/26, 02/10/26, 02/13/26, 02/16/26, 02/17/26, and 02/19/26. Review of BOM A's employment record showed his/her last day of employment was 02/20/26. Review of the facility withdrawal report, dated 02/21/26 to 03/24/26, showed no requests for personal spending money from the resident's account. During an interview on 03/27/26, at 12:42 P.M., the resident's family member said on several occasions, the resident asked BOM A for money from the resident's own account, but BOM A told the resident he/she did not have any money in his/her account. During an interview on 03/27/26, at 12:51 P.M., the resident said the following:-Frequently, when he/she asked for money BOM A would tell the resident he/she did not have any money;-The resident attended a local church three times a week;-The resident was embarrassed about not having any money for tithing at church;-Occasionally, the resident wanted a snack from the vending machine, but frequently did not have money for that either;-The resident did not tell anyone about not having money because he/she was ashamed;-The resident said his/her tennis shoes were worn out and were hurting his/her feet, but when he/she asked BOM A for money out of his/her account for tennis shoes, the BOM A said the resident did not have money for shoes;-In the past week, the Administrator informed the resident he/she did have money in his/her account. During an interview on 03/27/26, at 1:00 P.M., the Administrator said the following:-The resident was his/her own responsible party;-The facility was the resident's payee (the facility received the resident's social security income benefits);-The Administrator reviewed the resident's account and found $2445.00 taken out of it over the last six to eight months;-The resident currently had over $14,000.00 in his/her account;-The resident said BOM A told the resident he/she did not have any money;-The facility should have allowed the resident to withdraw up to $50 a day. During an interview on 03/27/26, at 2:29 P.M., CNA D said he/she had overheard BOM A tell the resident he/she did not have any money in his/her account for tobacco, so the resident quit chewing. During an interview on 03/27/26, at 5:02 P.M., RN F said the following:-The resident reported not having any money to take to church and the resident said BOM A told the resident he/she did not have any money;-Some of the staff bought tobacco for the resident because BOM A told the resident and staff that the resident did not have any money for tobacco. 4.Review of Resident #4's face sheet showed:-admission date of 09/25/25;-Diagnoses of schizoaffective disorder, bipolar disorder, difficulty in walking, and arthritis. Review of the facility withdrawal report, dated 10/01/25 to 10/31/25, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 10/07/25, 10/10/25, 10/14/25, 10/17/25, 10/23/25, 10/28/25, and 10/30/25.Review of the facility withdrawal report, dated 11/01/25 to 11/30/25, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 11/07/25, 11/18/25, and 11/25/25 and and a withdrawal in the amount of $40.00 in cash on 11/26/25. Review of the facility withdrawal report, dated 12/01/25 to 12/31/25, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 12/02/25, 12/08/25, 12/12/25, 12/16/25, 12/19/25, 12/23/25, and 12/30/25. Review of the facility withdrawal report, dated 01/01/26 to 01/31/26, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 01/05/26, 01/08/26, 01/13/26, 01/16/26, 01/20/26, 01/22/26, 01/23/26, 01/27/26, 01/29/06, and 01/30/26.Review of the facility withdrawal report, dated 02/01/26 to 02/20/26, showed the following requests for personal spending money:-Withdrawals in the amount of $50.00 in cash on 02/03/26, 02/06/26, 02/09/26, 02/10/26, 02/16/26, and 02/17/26. Review of BOM A's employment record showed his/her last day of employment was 02/20/26. Review of the facility withdrawal report, dated 02/21/26 to 03/24/26, showed no requests for personal spending money from the resident's account. Observation and interview of the resident on 03/26/26, at 2:10 P.M., showed the following:-The resident lay on his/her bed;-The resident said he/she never asked for money from his/her account;-The resident did not know if he/she had any money or not.During an interview on 03/27/26, at 1:00 P.M., the Administrator said the following:-The resident lays in his/her bed and goes to the dining room for meals;-The resident did not ever come to the business office or ask for money;-A review of the resident's account showed approximately $2000.00 in withdrawals over the last 8 months;-The Administrator said BOM A signed off on these withdrawals. During an interview on 03/27/26, at 2:29 P.M., CNA D said the following:-The resident spent all his/her time in his/her room or in the dining room;-He/she did not go out of the facility and did not go to the vending machine;-The resident did not ever have spending money. During an interview on 03/27/26, at 4:48 P.M., Certified Medication Technician (CMT) E said the following:-He/she had never heard the resident ask for any money;-The resident did not eat sweets or go to the vending machine;-The resident only comes out of his/her room to go to the dining room for meals. During an interview on 03/27/26, at 5:02 P.M., RN F said the following:-The resident never used the vending machines;-The resident never had any money and never asked for any money;-BOM A was secretive and never wanted other staff to know about his/her job or how things were supposed to work with resident money;-BOM A would frequently bring a resident cash ledger to one of the staff at the end of the day and ask them to sign or have someone sign as a witness to a resident signature, after the resident had allegedly already signed their name for cash withdrawals. 5. During an interview on 03/27/26, at 5:27 P.M., the Administrator said the following:-When he/she started working at the facility, BOM A told the Administrator how things worked with resident money and BOM A just continued with that process;-He signed the ledger at the end of the day with BOM A and frequently the ledger would be blank and BOM A would say none of the residents wanted any money that day;-BOM A would have staff co-sign as a witness after the fact to a resident's signature, even when the staff did not witness the resident sign or the resident receive the money;-No one was auditing the cash receipt book or comparing it to the amount of money deposited or withdrawn from the resident accounts;-The BOM was responsible for ensuring the cash receipts were the same as the bank accounts;-The Administrator said BOM A taking resident money would be considered misappropriation of resident property. During a telephone interview on 03/30/26, at 1:44 P.M., the Regional Financial Consultant said the following:-The Administrator should have been auditing the resident money/accounts;-The BOM should have had a witness to the cash transactions and that person should have signed as a witness;-The second person (witness) should not sign unless they witness the transaction of money;-Residents are generally allowed to withdraw $50.00 per day from their accounts. During a phone interview on 03/30/26, at 3:28 P.M., the police sergeant said the following:-The former BOM admitted to stealing resident money;-Police suspected the former BOM stole approximately $4100.00 from residents and their responsible parties.Complaint 2802385

Based on interview and record review, the facility staff failed to complete and document a full investigation of all allegations of abuse with steps taken to protect residents during the investigation documented when staff failed to fully investigate one allegation of abuse made by one resident (Resident #1) alleging abuse by one staff member (Restorative Nurse Aide (RNA)) E. The facility census was 48.Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, undated, showed the following:-Each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse;-All employees who have been alleged to commit abuse will be suspended immediately, pending investigation;-Facility will complete an investigation. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 06/26/25;-Diagnoses included metabolic encephalopathy-acute (brain suddenly isn't working right because of a chemical imbalance or problem with the body's metabolism), restlessness and agitation, acute pain due to trauma, schizophrenia (serious, chronic brain disorder that disrupts how a person thinks, feels and behaves, making it hard to tell what's real from what isn't), generalized anxiety disorder (excessive, persistent, and hard to control worry about everyday things), and impulse disorder (individual struggles to control sudden, powerful urges to do things that might harm themselves or others). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information:-Cognitively intact;-Physical behaviors symptoms directed towards others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others occurred one to three days of the lookback period. Review of the resident's care plan, last revised on 12/29/25, showed the following:-History of cussing, yelling, agitation with staff and other residents;-History of lying about staff behavior or other residents;-History of using manipulative tactics to gain attention or avoid certain actions;-Hits objects and threatens to hit staff or others;-Speak softly and avoid confrontational or punitive language;-Identify triggers such as frustration, or miscommunication;-If resident becomes physically aggressive attempt redirection;-Always ask for help if the resident becomes abusive or resistive;-Keep environment calm and relaxed as possible;-Remove resident from public area when behavior is unacceptable;-Encourage diversional activities;-Administer as needed medications;-Resident takes medications to treat schizophrenia, anxiety, and impulse disorder. Review of the resident's progress note dated 01/06/25, at 9:05 A.M., showed the Director of Nursing (DON) documented the following;-Resident came to his/her office first thing this morning, stating Restorative Nurse Aide (RNA) E was making the resident suck his/her boob and play with him/her. DON asked when this had happened, and the resident stated for a while;-DON called RNA E and Certified Medication Tech (CMT) F for witness into the DON's office;-DON asked the resident to repeat his/her accusation. The resident quietly without looking at anyone repeated his/her accusation;-RNA E stated that the resident had just left the therapy room after urinating on the floor, and blaming RNA E. The resident then became angry when RNA E told the resident he/she did it and would need to go change his/her clothes. The resident told RNA E that he/she was going to get RNA E fired. Resident denied this;-RNA E and Resident agreed to have no contact, and the RNA left the room;-CMT F still present and the resident stated see, I knew RNA E would get his/her way, she didn't get fired.Review of DHSS records showed the facility did not provide a documented, complete, and timely investigation of the allegation of abuse.During an interview on 01/13/26, at 1:30 P.M., Certified Medication Technician (CMT) F said the following:-If a staff asked a resident to suck their boob or play with them, it would be considered sexual abuse and should be reported;-He/she was pulled into the DON's office on 01/06/26, where the DON, RNA E, and the resident were located. The resident was asked about the allegation and the resident said RNA E asked him her to suck his/he boob and play with RNA E, but did not look at RNA E when saying this;-RNA E was not sent home, and worked the remainder of his/her shift;-The allegation should have been investigated.During an interview on 01/13/26, at 11:23 A.M., Certified Nurse's Aide (CNA) A said the following:-If a resident said a staff asked them to suck their boob, he/she would let the charge nurse know about the accusation;-He/she would take into consideration if the resident had a history or past of accusing staff of abuse, but he/she would still tell the charge nurse about the accusation;-If a resident was asked by staff to suck a staff's boob or play with them, it would be considered sexual abuse;-The facility sends the accused staff home, and they do an investigation. During an interview on 01/13/26, at 11:33 A.M., CNA B said the following:-If staff asked a resident to suck their boob and play with them, that would be considered sexual abuse, he/she would tell the charge nurse;-The facility does an investigation on allegations of abuse and the accused staff is sent home. During an interview on 01/13/26, at 11:38 A.M., Registered Nurse (RN) C said the following:-If a resident makes allegations of abuse, the facility begins an investigation and suspends the accused employee;-If a staff asked a resident to suck their boob and play with them, this would be considered sexual abuse. During an interview on 01/13/26, at 1152 A.M., RN D said the following:-If staff asked a resident to suck their boob and play with them, this would be allegations of sexual abuse;-The DON or Administrator completes the investigation and sends the accused staff home.During an interview on 01/13/26, at 12:36 P.M., the MDS Coordinator said he/she didn't know if the accused staff was sent home after abuse allegations. He/she knew the Administrator or DON did an investigation. During an interview on 01/13/26, at 12:46 P.M., the Social Service Director (SSD) said the following:-He/she assumed an accusation of a resident being asked by staff to suck on the staff's boob, or play with them, would be sexual abuse;-The accused staff would be sent home, pending investigation;-He/she, the DON and the Administrator usually work together to complete an investigation on abuse;-The DON told him/her that the resident said RNA E asked the resident to suck his/her breasts and play with him/her;-He/she believed the DON investigated the situation and he/she knew RNA E continued to work and was not suspended.During an interview on 01/13/26, at 11:57 A.M., DON said the following:-If staff asked a resident to suck their boob and play with them, it would depend on the circumstances as to whether it would be abuse;-With the resident and RNA E, the resident made the accusation because the resident was upset with RNA E. RNA E asked the resident to change his/her clothes after the resident urinated. Resident came straight to the DON's office and said RNA E had asked the resident to suck his/her boob and play with RNA E. DON had CMT F in the room for a witness and called RNA E to the office. When the resident was asked to repeat the accusation, the resident did repeat the accusation but with his/her head down and in a low voice. RNA E said he/she only asked the resident to change his/her pants and did not ask the resident to do anything inappropriate;-RNA E was not sent home after the accusation, but he/she and the resident were told to stay separated;-DON did not complete a full investigation as he/she only interviewed the resident and RNA E and no other staff or residents. During an interview on 01/13/26, at 12:22 P.M., the Administrator said the following:-He/she would consider a staff asking a resident to suck their boob, or play with them to be a sexual abuse allegation;-He/she would suspend the accused staff, begin and investigation immediately;-He/she was aware of an incident where the resident got made at RNA E because the resident had gone to the bathroom and RNA E asked the resident to change his/her clothes. The resident went to the DON and told the DON to fire RNA E, and the resident knew how to get RNA E fired. The resident said if he/she made the accusation of a staff wanting the resident to suck their boob and play with them.-He/she was not told the resident accused the staff of doing this. When the note from the resident's record was read to the Administrator, he/she agreed the accusation should have been reported as sexual abuse;-He/she didn't know if RNA E was sent home after the accusation;-He/she didn't know if a full investigation was completed.-He/she has received abuse training every three to four months. Complaint 2713651

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to Administrator and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of abuse involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 48.Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, undated, showed the following:-Each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse;-All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources, and misappropriation of resident property by facility employees, contract employees, or volunteers 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;-All employees of the facility are mandated reporters:-The facility will ensure that all reports are made within two hours if abuse or serious bodily injury. 1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 06/26/25;-Diagnoses included metabolic encephalopathy-acute (brain suddenly isn't working right because of a chemical imbalance or problem with the body's metabolism), restlessness and agitation, acute pain due to trauma, schizophrenia (serious, chronic brain disorder that disrupts how a person thinks, feels and behaves, making it hard to tell what's real from what isn't), generalized anxiety disorder (excessive, persistent, and hard to control worry about everyday things), and impulse disorder (individual struggles to control sudden, powerful urges to do things that might harm themselves or others). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information:-Cognitively intact;-Physical behaviors symptoms directed towards others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed towards others occurred one to three days of the lookback period. Review of the resident's care plan, last revised on 12/29/25, showed the following:-History of cussing, yelling, agitation with staff and other residents;-History of lying about staff behavior or other residents;-History of using manipulative tactics to gain attention or avoid certain actions;-Hits objects and threatens to hit staff or others;-Speak softly and avoid confrontational or punitive language;-Identify triggers such as frustration, or miscommunication;-If resident becomes physically aggressive attempt redirection;-Always ask for help if the resident becomes abusive or resistive;-Keep environment calm and relaxed as possible;-Remove resident from public area when behavior is unacceptable;-Encourage diversional activities;-Administer as needed medications;-Resident takes medications to treat schizophrenia, anxiety, and impulse disorder. Review of the resident's progress note dated 01/06/25, at 9:05 A.M., showed the Director of Nursing (DON) documented the following;-Resident came to his/her office first thing this morning, stating Restorative Nurse Aide (RNA) E was making the resident suck his/her boob and play with him/her. DON asked when this had happened, and the resident stated for a while;-DON called RNA E and Certified Medication Tech (CMT) F for witness into the DON's office;-DON asked the resident to repeat his/her accusation. The resident quietly without looking at anyone repeated his/her accusation;-RNA E stated that the resident had just left the therapy room after urinating on the floor, and blaming RNA E. The resident then became angry when RNA E told the resident he/she did it and would need to go change his/her clothes. The resident told RNA E that he/she was going to get RNA E fired. Resident denied this;-RNA E and Resident agreed to have no contact, and the RNA left the room;-CMT F still present and the resident stated see, I knew RNA E would get his/her way, she didn't get fired.Review of DHSS records showed the facility did not report the allegations of abuse.During an interview on 01/13/26, at 1:30 P.M., CMT F said the following:-He/she would report any abuse to the charge nurse, and they report to the DON;-If a staff asked suck their boob or play with them, it would be considered sexual abuse and should be reported;-He/she was pulled into the DON's office on 01/06/26, where the DON, RNA E, and the resident were located. The resident was asked about the allegation and the resident said RNA E asked him her to suck his/her boob and play with RNA E, but did not look at RNA E when saying this;-The allegation should have been reported to the state within two hours.During an interview on 01/13/26, at 11:23 A.M., Certified Nurse's Aide (CNA) A said the following:-If a resident said a staff asked them to suck their boob, he/she would let the charge nurse know about the accusation;-He/she would take into consideration if the resident had a history or past of accusing staff of abuse, but he/she would still tell the charge nurse about the accusation;-If a resident was asked by staff to suck a staff's boob or play with them, it would be considered sexual abuse;-The facility is supposed to report abuse allegations to the state within two hours. During an interview on 01/13/26, at 11:33 A.M., CNA B said the following:-If staff asked a resident to suck their boob and play with them, that would be considered sexual abuse. He/she would tell the charge nurse;-The facility was supposed to call the state in four hours when allegations of abuse were made by a resident. During an interview on 01/13/26, at 11:38 A.M., Registered Nurse (RN) C said the following:-He/she would report abuse allegations to the DON or Administrator;-The state was notified within two hours of any abuse allegation;-If a staff asked a resident to suck their boob and play with them, this would be considered sexual abuse. During an interview on 01/13/26, at 1152 A.M., RN D said the following:-If staff asked a resident to suck their boob and play with them, this would be allegations of sexual abuse. It should be reported to the DON;-The state should be notified within two hours.During an interview on 01/13/26, at 12:36 P.M., the MDS Coordinator said the following:-If a resident said a staff asked them to suck their boobs and play with them, this would be considered sexual abuse, and he/she would report this to the Administrator or the DON;-The resident had a history of making accusations and threatening to get staff fired;-The state should be notified of abuse allegations within two hours.During an interview on 01/13/26, at 12:46 P.M., the Social Service Director (SSD) said the following:-If a resident accused staff of sexual abuse, he/she would tell the DON or Administrator;-He/she assumed an accusation of a resident being asked by staff to suck on the staff's boob, or play with them, would be sexual abuse and should be reported to the state;-DON told him/her that the resident said RNA E asked the resident to suck his/her breasts and play with him/her;-He/she believed it was reported to the state. During an interview on 01/13/26, at 11:57 A.M., the DON said the following:-If staff asked a resident to suck their boob and play with them, it would depend on the circumstances as to whether it would be abuse;-With the resident and RNA E, the resident made the accusation because the resident was upset with RNA E. RNA E asked the resident to change his/her clothes after the resident urinated. Resident came straight to the DON's office and said RNA E had asked the resident to suck his/her boob and play with RNA E. -He/she had CMT F in the room for a witness and called RNA E to the office. When the resident was asked to repeat the accusation, the resident did repeat the accusation but with his/her head down and in a low voice;-RNA E said he/she only asked the resident to change his/her pants and did not ask the resident to do anything inappropriate;-He/she did not report the allegations of sexual abuse to the state. During an interview on 01/13/26, at 12:22 P.M., the Administrator said the following:-He/she would consider a staff asking a resident to suck their boob, or play with them, to be a sexual abuse allegation;-He/she would call the state immediately;-He/she was aware of an incident where the resident got made at RNA E because the resident had gone to the bathroom and RNA E asked the resident to change his/her clothes. The resident went to the DON and told the DON to fire RNA E and that he/she knew how to get RNA E fired. The resident said if he/she made the accusation of a staff wanting the resident to suck their boob and play with them;-He/she was not told the resident accused the staff of doing this;-When the note from the resident's record was read to the Administrator agreed the accusation should have been reported as sexual abuse;-He/she did not know if the accusation was turned into the state within two hours. Complaint #2713651

Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner, when one staff member (Social Services Director (SSD)) would not allow one resident (Resident #1) to smoke after the resident displayed behaviors. The facility census was 49. Review of the facility policy titled Resident's Rights, undated, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States; -The resident has the right to be free of interference, coercion, discrimination and reprisal form the facility in exercising his/her rights, and be supported by the facility in the exercise of his/her rights. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included transient cerebral ischemic attack (disruption of blood flow to the brain), dementia (loss of memory), major depressive disorder, severe with psychotic symptoms (person experiences sadness and a loss of contact with reality), anxiety disorder (feelings of worry and fear), post-traumatic stress disorder (PTSD - mental health condition that can develop after experiencing or witnessing a traumatic event). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information: -Moderate cognitive impairment; -Behaviors; -Independent with eating and required set up with oral hygiene; -Substantial assistance required with toileting hygiene, showers, and upper/lower body dressing; -Dependent on staff for personal hygiene. Review of the resident's care plan, last revised on 04/01/25, showed the following: -Resident had history of verbal and physical aggression towards staff related to underlying psychiatric disorder and cognitive impairment. Staff to speak softly and avoid confrontational or punitive language, and redirect if the resident becomes physically aggressive; -Resident ad diagnosis of dementia, persistent mood (affective) disorder as evidence by persistent forgetfulness and disorientation. Have anxiety, fear and paranoia associated with memory loss; -Resident had chronic pain in back, knees, and ankles. Also muscle spasms. He/she takes narcotics; -Resident was unable to perform all activities of daily living (ADL) functions without extensive assistance of one to two staff due to weakness and impaired use of left leg, arm, and hand. Review of the resident's progress note dated 04/16/25, at 2:40 P.M., showed the SSD documented he/she and another staff took the resident to the social security office. The resident was throwing a fit in the social security office. The resident blurted out he/she had gotten two facilities closed down and was working on the current facility next. The resident would not quit with his/her yelling so staff could write down what paperwork the resident needed from the facility in order to get the resident's money to come to the facility. Workers and clients in the office could hear the resident yelling and causing an ugly scene. We were outside and the resident yelled give me my goddamn cigarette. The SSD replied the resident would not get a cigarette because he/she caused a whole scene in the building and outside the building. The resident's smoke breaks were taken away for the rest of the day. During interviews on 04/30/25, at 9:17 A.M. and 1:30 P.M., the resident said the SSD took away his/her smoke breaks. During an interview on 04/30/25, at 12:15 P.M., the SSD said the following: -If a resident had a guardian and the guardian has given permission, one smoke break can be withheld from the resident for having bad behaviors; -The resident was having behaviors at the social security office and missed his/her 11:00 A.M., cigarette, but had them the rest of the day. During an interview on 04/30/25, at 11:40 A.M., Certified Nurse's Aide (CNA) A said the following: -Staff can't take away a resident's smoke breaks if they don't have a guardians; -Taking away a resident's privileges, such as smoking, is against their rights; -The resident was his/her own person. He/she was not aware of staff taking away the resident's smoke breaks. During an interview on 04/30/25, at 11:50 A.M., CNA B said the following: -When a resident had a guardian and the guardian gave permission, the resident's smoke breaks could be taken if they have behaviors; -If the resident was their own person, staff were not allowed to take away their smoke breaks; -Taking away a resident's smoke break as a punishment would be against their rights; -He/she didn't know if the resident had smoke breaks taken away. During an interview on 04/30/25, at 12:05 P.M., Certified Medication Tech (CMT) D said the following: -Staff were not allowed to take away a resident's smoke breaks when the resident misbehaves. That would be taking away their rights; -He/she knew of one occasion when the resident's smoke break was taken away. During an interview on 04/30/25, at 12:25 P.M., Registered Nurse (RN) E said the following: -It would not be appropriate to withhold a resident's smoke break as punishment. This would be against their rights; -He/she knew they tried to withhold the resident's cigarette break at least once, but staff was told they couldn't do that. He/she didn't know the date. During an interview on 04/30/25, at 12:50 P.M., the Business Office Manager (BOM) said the following: -If a resident had a guardian, and it was okay with the guardian, a resident's smoke break could be withheld; -If a resident was their own person, like the resident, staff can not take the smoke break; -He/she was not aware of the resident missing any smoke breaks. During an interview on 04/30/25, at 12:30 P.M., the Director of Nursing (DON) said the following: -Staff didn't have the right to take away a resident's smoke break when they have behaviors. That would be against their rights; -It did happen one time with the resident, but it was a miscommunication as one side of the building didn't know the resident was his/her own person and did not have a guardian; -All staff know that only those with guardians, that give permission to withhold smoke breaks, can have those smoke breaks taken away; -Only social services, administration, or nurses can decide when a smoke break was taken; -It was not appropriate for the SSD to withhold the resident's smoke break on 04/16/25. During an interview on 05/01/25, at 10:15 A.M., the Administrator said the following: -He/she had told staff when residents are their own person, they can not withhold smoke breaks; -He/she was not aware of the resident missing any smoke breaks; -On 04/16/25, the SSD encouraged the resident to get into the vehicle as they were on a time frame and it there wasn't a scheduled smoke break. The resident did smoke when he/she arrived back to the facility. MO00253134

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report two allegations of abuse involving one resident (Resident #1) to management and DHSS in a timely fashion. The facility census was 49. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources 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 involved abuse or resulted in injury. -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Physical abuse is defined as hitting, slapping, pinching, kicking, biting, etc. It also includes controlling a resident's actions through personal punishment; -Report immediately, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included transient cerebral ischemic attack (disruption of blood flow to the brain), dementia (loss of memory), type II diabetes, (body doesn't produce enough insulin), major depressive disorder, severe with psychotic symptoms (person experiences sadness and a loss of contact with reality), anxiety disorder (feelings of worry and fear), post-traumatic stress disorder (PTSD - mental health condition that can develop after experiencing or witnessing a traumatic event). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information: -Moderate cognitive impairment; -Behaviors; -Independent with eating with set up assistance with oral hygiene; -Substantial assistance with toileting hygiene, showers, and upper/lower body dressing; -Dependent on staff for personal hygiene. Review of the resident's care plan, last revised on 04/01/25, showed the following: -Resident had history of verbal and physical aggression towards staff related to underlying psychiatric disorder and cognitive impairment. Staff to speak softly and avoid confrontational or punitive language, redirect if becomes physically aggressive, -Resident had diagnosis of dementia, persistent mood (affective) disorder as evidence by persistent forgetfulness and disorientation. Resident had anxiety, fear, and paranoia associated with memory loss; -Resident had chronic pain in back, knees, and ankles and muscle spasms. Resident takes narcotics; -Resident was unable to perform all ADL functions without extensive assistance of one to two staff due to weakness and impaired use of left leg, arm, and hand. Review of the resident's progress note dated 03/31/25, at 11:54 A.M., showed SSD documented he/she went to the resident and sat down to list to what the resident had to say. The resident said that two staff members were abusing him/her and he/she had bruising all over his/her body. SSD replied well I have to take a look at your complaint and see bruising and SSD had the charge nurse look as well. There was no bruising found by the SSD or the charge nurse. The two staff members the resident accused had not been at work. (The SSD did not document notification of facility administration or DHSS of the allegation of abuse.) Review of DHSS records showed the facility did not report the allegations of abuse. Review of the resident's progress note dated 04/16/25, at 2:40 P.M., showed the SSD documented he/she and another staff took the resident to the social security office. The resident was throwing a fit in the social security office. The resident blurted out he/she had gotten two facilities closed down and was working on the current facility next. The resident said we abuse him/her and leave residents in the floor. (The SSD did not document notification of facility administration or DHSS of the allegation of abuse.) Review of DHSS records showed the facility did not report the allegation of abuse. During an interview on 04/30/25, at 12:15 P.M., the SSD said the following: -When staff are told a resident is being abused, they come to him/her; -He/she talked to the resident to see what's going on and what type of abuse was being alleged; -On 03/31/25, the resident came to him/her and said staff were hitting and abusing him/her and he/she had bruises on his/her body; -He/she got the charge nurse and they assessed the resident and he/she did not have bruises on him/her; -He/she went to the Administrator and let him/her know what was going on; -The charge nurse documented in the chart an assessment of the skin was completed; -The resident did not know the names of the staff that abused him/her; -He/she didn't know if the incident was reported to the state, but should be reported in either 24 or 2 hours; -On 04/16/25, he/she took the resident to the social security office. The resident yelled in the office that staff abused him/her, don't do anything for the resident, and they were starving the resident. The resident had never been abused at the facility; -The Administrator looked into the allegations, but the SSD didn't know if the allegations were reported to the state. During an interview on 04/30/25, at 11:40 A.M., Certified Nurse's Aide (CNA) A said the following: -If a resident accuses staff of abuse, and he/she was in the room and believes it's a misunderstanding, he/she would speak to the resident to explain that it wasn't abuse; -If he/she witnessed abuse, or was told by the resident they've been abused, he/she would speak to the SSD and the charge nurse; -Allegations of abuse are to be reported to the state in less than 24 hours. During interviews on 04/30/25, at 11:50 A.M., CNA B said the following: -If a resident reported abuse, he/she told the charge nurse and the nurse called the state within two hours. -The resident accused him/her of abuse. He/she didn't recall when that was, but he/she wasn't working the day the resident made the accusations; -The resident has said staff hit him/her. During an interview on 04/30/25, at 12:00 P.M., Certified Medication Technician (CMT) C said the following: -If a resident reported abuse, he/she notified the charge nurse; -He/she assumed it should be reported to the state, possibly in two hours. During an interview on 04/30/25, at 12:05 P.M., CMT D said the following: -When a resident reported abuse, he/she told the charge nurse; -The charge nurse tells the Administrator and Director of Nursing (DON) and the state is called within two hours. During an interview on 04/30/25, at 12:25 P.M., Registered Nurse (RN) E said the following: -If a resident reported abuse, he/she reported it to the DON or the Administrator. The state is notified in two hours; -They have training on abuse at most in-services; -The resident had not reported abuse to him/her. He/she heard other staff talk about the resident accusing staff of abuse that wasn't working or no longer worked at the facility; -He/she didn't know if the allegations were reported to the state. During an interview on 04/30/25, at 12:50 P.M., the Business Office Manager (BOM) said the following: -Allegations of abuse were reported to the DON and Administrator, or the supervisor; -The Administrator reported to the state in two hours. During an interview on 04/30/25, at 12:30 P.M., the DON said the following: -Abuse allegations should be reported to the charge nurse, DON, and Administrator; -The allegations of abuse are reported to the state if the abuse allegations are valid. He/she didn't know for sure what the time frames of reporting the abuse; -The resident had made allegations of abuse; -Skin assessments were completed and there was no bruising; -On 3/31/25, he/she believed the Resident accused the two evening shift people, the SSD talked to the staff, the next time they were in the building. He/she doesn't know if the SSD documented anything. It was not reported to the state; -On 4/14/25, he/she was not aware of the resident made allegations of abuse on this date. During an interview on 05/01/25, at 10:15 A.M., the Administrator said the following: -He/she did remember the one event, possibly from 03/31/25, where the SSD and a nurse interviewed the resident saying an aide put him/her to bed too hard. A skin assessment was done and they did not find anything; -He/she was not aware of allegations of abuse from 04/16/25; -When abuse is alleged, staff are to tell him/her and he/she investigates, speaks with the resident, and other residents and staff, and calls the state within two hours; -The two incidents were not reported to the state. MO00253134

Based on interview and record review, the facility staff failed to complete and document a full investigation of all allegations of abuse with steps taken to protect residents during the investigation documented when staff failed to fully investigate two allegations of abuse made by one resident (Resident) alleging abuse by staff. The facility census was 49. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property; -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Physical abuse is defined as hitting, slapping, pinching, kicking, biting, etc. It also includes controlling a resident's actions through personal punishment; -During an investigation, if a staff member is accused, that person will be suspended immediately, pending investigation, and all staff on duty need to complete witness statements and cannot leave until they complete one. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included transient cerebral ischemic attack (disruption of blood flow to the brain), dementia (loss of memory), type II diabetes, (body doesn't produce enough insulin), major depressive disorder, severe with psychotic symptoms (person experiences sadness and a loss of contact with reality), anxiety disorder (feelings of worry and fear), post-traumatic stress disorder (PTSD - mental health condition that can develop after experiencing or witnessing a traumatic event). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/03/25, showed the following information: -Moderate cognitive impairment; -Behaviors; -Independent with eating and required set up help with oral hygiene; -Required substantial assistance with toileting hygiene, showers and upper/lower body dressing; -Dependent on staff for personal hygiene. Review of the resident's care plan, last revised on 04/01/25, showed the following: -He/she had a history of verbal and physical aggression towards staff related to underlying psychiatric disorder and cognitive impairment. Staff to speak softly and avoid confrontational or punitive language, and redirect if resident becomes physically aggressive, -He/she had diagnoses of dementia and persistent mood (affective) disorder as evidence by persistent forgetfulness and disorientation. Resident had anxiety, fear, and paranoia associated with memory loss; -He/she had chronic pain in back, knees, and ankles and muscle spasms. He/she took narcotics; -He/she was unable to perform all ADL functions without extensive assistance of one to two staff due to weakness and impaired use of left leg, arm, and hand. Review of the resident's progress note dated 03/31/25, at 11:54 A.M., showed the SSD documented he/she went to the resident and sat down to listen to what the resident had to say. The resident said that two staff members were abusing him/her and he/she had bruising all over his/her body. The SSD replied well I have to take a look at your complaint and see bruising and SSD had the charge nurse look as well. There was no bruising found by the SSD or the charge nurse. The two staff members the resident accused had not been at work. Review of the facility records shows the facility did not provide a documented full investigation, to include interviewing other residents and staff. Review of the resident's progress note dated 04/16/25, at 2:40 P.M., showed the SSD documented he/she and another staff took the resident to the social security office. The resident was throwing a fit in the social security office. The resident blurted out he/she had gotten two facilities closed down and was working on the current facility next. The resident said the staff abuse him/her and leave residents in the floor. Review of the facility records shows the facility did not document an investigation of the allegations of potential abuse. During an interview on 04/30/25, at 12:15 P.M., the SSD said the following: -When staff are told a resident is being abused, they come to him/her; -He/she talked to the resident to see what's going on and what type of abuse was being alleged; -On 03/31/25, the resident came to him/her and said staff were hitting and abusing him/her and he/she had bruises on his/her body; -He/she got the charge nurse and they assessed the resident and he/she did not have bruises on him/her; -He/she went to the Administrator and let him/her know what's going on; -The charge nurse documented in the chart an assessment of the skin was completed; -The resident did not know the names of the staff that abused him/her; -If the Administrator knew the names of the accused staff, he/she will suspend them pending an investigation; -On 04/16/25, he/she took the resident to the social security office, the resident yelled in the office that the facility abused him/her, don't do anything for the resident, and were starving the resident; -The Administrator looked into the allegations. During an interview on 04/30/25, at 11:40 A.M., Certified Nurse's Aide (CNA) A said the following: -If a resident accused staff of abuse, and he/she was in the room and believed it was a misunderstanding, he/she would speak to the resident to explain that it wasn't abuse; -If he/she witnessed abuse, or was told by the resident they had been abused, he/she would speak to the SSD and the charge nurse; -The accused staff would be suspended pending the outcome of the facility investigation. During an interview on 04/30/25, at 11:50 A.M., CNA B said the following: -If a resident reported abuse, he/she told the charge nurse and the nurse; -He/she didn't know if the accused staff was suspended. He/she did know the facility was supposed to investigate;. -The resident accused him/her of abuse. He/she didn't recall when that was but he/she wasn't working the day the resident made the accusations; -He/she was not suspended, however the Director of Nursing (DON) did ask him/her questions. During an interview on 04/30/25, at 12:00 P.M., Certified Medication Technician (CMT) C said the following: -If a resident reported abuse, he/she notified the charge nurse; -He/she believed the facility suspended the staff that's been accused and investigates. During an interview on 04/30/25, at 12:05 P.M., CMT D said the following: -When a resident reported abuse, he/she told the charge nurse; -The charge nurse told the Administrator and DON, and they begin an investigation. During interviews on 04/30/25, at 12:25 P.M., Registered Nurse (RN) E said if a resident reported abuse, he/she reported it to the DON or the Administrator, and they complete an investigation. The accused staff was sent home. During an interview on 04/30/25, at 12:50 P.M., the Business Office Manger said the following: -The administrator investigates allegations of abuse; -He/she didn't know of any physical or verbal abuse allegations the resident had made against staff. During an interview on 04/30/25, at 12:30 P.M., the DON said the following: -Abuse allegations should be reported to the charge nurse, DON, and Administrator; -The resident is interviewed to find out what's going on, as well as the roommate, and the staff member; -The accused staff is suspended, an investigation is completed, including interviews with other staff and residents; -The resident has made allegations of abuse. Skin assessments were completed and there was no bruising; -On 03/31/25, he/she believed the resident accused the two evening shift people and the SSD talked to the staff, the next time they were in the building. He/she didn't know if the SSD documented anything. The two staff were not suspended; -On 04/14/25, he/she was not aware of the resident making allegations of abuse on this date. During an interview on 05/01/25, at 10:15 A.M., the Administrator said the following: -He/she had not completed an investigation for abuse on the resident. He/she knew the SSD did one or two. He/she was not certain the dates on those; -He/she was not aware of allegations of abuse from 04/16/25; -When abuse is alleged, staff are to tell him/her and he/she investigates, speaks with the resident and other residents and staff. If he/she knew the names of the staff, he/she would suspend them; -He/she was not aware of whether the two incidents were investigated. MO00253134

Based on interview, and record review, the facility failed to protect all residents right to be free from sexual abuse by other residents when staff failed to care plan and implement new interventions when one resident (Resident #1) exhibited sexually abusive behaviors towards two residents (Resident #2, Resident #3) and sexually verbal behaviors toward one resident (Resident #4). The facility census was 49. Review of the facility policy, titled Abuse Prohibition Protocol Manual, revised 11/28/2016, showed the following: -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -The facility must thoroughly investigate the alleged violation, prevent further abuse while the investigation is in progress, and take appropriate corrective action; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident that includes all unwanted intimate touching of any kind especially of breasts or perineal area and nudity. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 08/01/24; -Diagnoses included schizoaffective disorder (mental health condition including delusions and hallucinations), anxiety, and bipolar disorder (mood swings ranging from depressive lows to manic highs), alcohol abuse and pyelonephritis (chronic kidney infections). Review of the resident's progress note dated 09/11/24, at 4:04 P.M., showed the following information: -The Director of Nursing (DON) documented the resident had been sexually inappropriate several times since admission; -The resident was treated for a urinary tract infection (UTI) the previous month; -The the resident's family wished for the resident to be moved closer to them. Referrals had been sent to multiple homes and none [NAME] accepted the resident. Review of the resident's progress note dated 10/18/24, at 3:17 P.M., showed the Social Services Director (SSD) documented the resident had behaviors of exposing himself/herself to other residents. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/08/24, showed the following information: -Cognitively intact; -Independent with bed mobility, transfer, dressing, toilet use, and personal hygiene; -Used walker or wheelchair for ambulation; -Physical behavioral symptoms directed at others exhibited. Review of the resident's care plan, revised 11/14/24, showed the following information: -The resident had a history of being sexually inappropriate with peers; -Staff will accompany the resident when going outside; -The resident may need additional monitoring at times; -The resident may become sexually inappropriate at times; -Remove the resident from public area when behavior is unacceptable. Review of the resident's progress note dated 11/18/24, at 8:46 A.M., showed the following information: -Staff observed Resident #1 grabbing Resident #3's genitals; -Resident #3 said this has happened four times this weekend; -The Resident #1 had been redirected multiple times since admission for inappropriate behaviors with staff and residents. The resident did not respond or even act like he/she had been told not to do this; -The resident has had UTI's with behaviors which exacerbate the sexual behaviors, however, the behaviors are ongoing. (Staff did not document any new interventions to address the resident's sexual behaviors and abuse of other residents.) Review of the resident's current care plan showed staff did not care plan the reported behaviors/resident abuse and did not care plan any new interventions to prevent future episodes. Review of the resident's progress note dated 11/20/24, at 1:21 P.M., showed the following information: -The nurse documented that Resident #3 reported that Resident #1 propelled his/her wheelchair up to Resident #3 and asked him/her if he/she could touch his/her private area; -Resident #3 reported this immediately to staff and appeared to be upset by the behavior; -The nurse spoke with Resident #1 asking him/her if this happened. Resident #1 said yes it did, I'm horny. The resident was educated not to speak to other residents in that manner. (Staff did not document any new interventions to address the resident's sexual behaviors and abuse of other residents.) Review of the resident's current care plan showed staff did not care plan the reported behaviors/resident abuse and did not care plan any new interventions to prevent future episodes. Review of the resident's progress note dated 12/01/24, at 7:40 P.M., showed the following information: -The nurse documented that Resident #1 was observed standing in Resident #2's room, naked from the waist down; -The nurse redirected Resident #1 back to his/her room and reeducated the resident not to go in other residents' rooms and not to leave his/her room without clothing; -Resident #1 denied the behavior; -Staff notified the DON; -Staff notified the physician and orders received to send to hospital for psych evaluation and possible UTI; -Staff notified family; -The resident was transported to hospital for evaluation. Review of the resident's medical record showed the resident tested negative for a UTI. Review of the resident's current care plan showed staff did not care plan the reported behaviors/resident abuse and did not care plan any new interventions to prevent future episodes. Review of the resident's progress note dated 12/09/24, at 4:45 P.M., showed the following information: -The nurse documented that another resident (Resident # 3) reported that while at supper in the dining room, Resident #1 propelled his/her wheelchair up to his/her table and asked Resident #3 if he would fuck him/her. Resident #3 told him/her no and Resident #1 went on his/her way; -The nurse spoke to Resident #1 who admitted to saying the above statement and didn't care or see why it was inappropriate; -Resident #1 ate his/her supper then stayed the remainder of the evening in his/her room. (Staff did not document any new interventions to address the resident's sexual behaviors and abuse of other residents.) Review of the resident's current care plan showed staff did not care plan the reported behaviors/resident abuse and did not care plan any new interventions to prevent future episodes. Review of the resident's progress note dated 12/15/24, at 2:47 A.M., showed the following information: -The nurse documented that a guest of another resident reported that the resident had been inappropriate and grabbed his/her groin; -The nurse spoke with the resident who denied the incident. Review of the resident's current care plan showed staff did not care plan the reported behaviors/resident abuse and did not care plan any new interventions to prevent future episodes. Review of the resident's progress note dated 12/17/24, at 4:42 P.M., showed the following information: -The resident propelled his/her wheelchair up to Resident #3, reached out and grabbed his/her genitals; -Resident #3 began to scold Resident #1, until staff removed Resident #1; -Resident #3 was very upset and requested anxiety medication. (Staff did not document any new interventions to address the resident's sexual behaviors and abuse of other residents.) Review of the resident's current care plan showed staff did not care plan the reported behaviors/resident abuse and did not care plan any new interventions to prevent future episodes. Review of the resident's progress note dated 01/06/25, at 6:10 A.M., showed the following information: -Staff observed Resident #1 in Resident #2's room, sitting on top of Resident #2 with his/her pants down and his/her hands down Resident #2's pants; -Staff immediately went in the room and removed Resident #1 off Resident #2; -The nurse assisted with pulling up Resident #1's pants and walked the resident back to his/her room; -The resident was redirected and educated that he/she should not be in other residents' rooms; -The resident was placed on 15-minute checks; -The DON and the Administrator was notified. Review of the facility's follow-up investigation report, dated 01/08/25, showed the following information: -The victim was Resident #2, and the alleged aggressor was Resident #1; -Resident #1 was found on top of Resident # 2, in Resident #2's room; -Resident #1 had his/her pants pulled down with his/her hands down Resident #2's pants; -Resident #2 was not able to give consent; -Resident #1 was taken back to his/her room; -Resident #1 was currently on 15-minute checks; -Resident #2 continued to yell out; -Resident #1 sat in his/her doorway and said I want to come to you, but they won't let me; -Resident #1 was moved to another hall further away from Resident #2; -The DON, Administrator, physician and guardians were notified, 2. Review of Resident #2's face sheet showed the following information: -admission date of 05/14/24; -Diagnoses included schizophrenia (a disorder that affects the ability to think, feel and behave clearly), anoxic brain damage (occurs when the brain is deprived of oxygen, resulting in brain cell death and impairment), metabolic encephalopathy (brain dysfunction caused by chemicals in the blood) and dysphagia (difficulty speaking). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/21/24, showed the following information: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Unclear speech with slurred or mumbled words; -Physical behavioral symptoms directed at others exhibited. Review of the resident's care plan, revised 11/20/24, showed the following information: -Provide resident with supportive care and services; -Provide resident with a safe and secure environment on an ongoing basis. Review of the resident's progress note dated 01/06/25, at 08:26 A.M., showed the following information: -Resident had been laying on his floor mat per his request; -Staff observed Resident #1 in Resident #2's room, sitting on top of Resident #2 with his/her pants down and his/her hands down Resident #2's pants; -Staff immediately went in the room and removed Resident #1 off Resident #2; -Staff notified the nurse, who assisted with pulling up Resident #1's pants and walked the resident back to his/her room; -Resident #1 was redirected and placed on 15-minute checks; -Resident #2 was assessed and no injuries noted; -Resident #2 had been previously medicated with Zyprexa (antipsychotic) and oxycodone (opioid pan medication), therefore, no additional medications were administered; -Staff notified the DON and the Administrator. 3. Review of Resident #3's face sheet showed the following information: -admission date of 11/01/24; -Diagnoses included bladder cancer, brain cancer, prostate cancer, heart failure, and anxiety. Review of the resident's annual MDS, dated [DATE], showed the following information; -Cognitively intact; -Independent with bed mobility, transfer, mobility/walking, dressing, toilet use, and personal hygiene; -Verbal behavioral symptoms directed at others exhibited; -Daily wandering exhibited. Review of the resident's care plan, revised 10/24/24, showed the following information: -Provide resident with supportive care and services; -Provide resident with a safe and secure environment on an ongoing basis; -Redirect resident when possible. Review of the resident's progress note dated 11/18/24, at 8:46 A.M., showed the following information: -Staff observed Resident #1 grabbing Resident #3's genitals; -Resident #3 said this has happened four times this weekend; -Resident #1 has been redirected multiple times since admission for inappropriate behaviors with staff and residents. Review of the resident's progress note dated 11/20/24, at 1:21 P.M., showed the following information: -The nurse documented that Resident #3 reported that Resident #1 propelled his/her wheelchair up to Resident #3 and asked him/her if he/she could touch his/her private area; -Resident #3 reported this immediately to staff and appeared to be upset by the behavior; -The nurse spoke with Resident #1 asking him/her if this happened. Resident #1 said yes it did, I'm horny. The resident was educated not to speak to other residents in that manner. During an interview on 01/15/25, at 11:10 A.M., Resident #3 said that Resident #1 has been sexually inappropriate and liked to grab his/her groin as he/she walked by. Resident #1 grabbed Resident #3's groin one time when outside on smoke break and one time while at the nurses' station. Both times Resident #3 said he/she pushed Resident #1's hand away and told him/her to stop and then reported it to the nurse. They punish him/her Resident #1 by taking away his/her smoke breaks or send him/her out (to the hospital), but he/she always comes back. Resident #3 said that Resident #1 touches other residents too, not just me. Resident #3 said that he/she doesn't like Resident #1 touching him/her and doesn't want Resident #1 touching him/her. Resident #3 said that he/she has told staff to keep him/her away from me. 4. Review of Resident #4's face sheet showed the following information: -admission date of 08/05/24; -Diagnoses included schizoaffective disorder (mental health condition including delusions and hallucinations), bipolar (mood swings ranging from depressive lows to manic highs), anxiety. Review of the resident's quarterly MDS, dated [DATE] showed the following information: -Cognitively intact; -Independent with bed mobility, transfer, mobility/walking, dressing, toilet use, and personal hygiene; -No behaviors exhibited. Review of the resident's care plan, revised 10/23/24, showed staff to provide resident with a safe and secure environment on an ongoing basis. Review of the resident's progress note dated 12/09/24, at 4:45 P.M., showed the following information: -The nurse documented that Resident # 3 reported that while at supper in the dining room, Resident #1 propelled his/her wheelchair up to his/her table and asked Resident #3 if he would fuck him/her. Resident #3 told him/her no and Resident #1 went on his/her way; -The nurse spoke to Resident #1 who admitted to saying the above statement and didn't care or see why it was inappropriate. During an interview on 01/15/25, at 11:50 A.M., Resident #4 said that Resident #1 would tell him/her that he/she wanted to fuck him/her. The resident said he/she would demand it. He/she would say it a lot, too many times to count. The resident said he/she would always tell him/her no and report it to the nurse. The resident said it has been happening for months (not sure how many months). The resident said that it made him/her feel uncomfortable and did not like to hear those words. The resident said that he/she would try to keep his/her distance from Resident #1 because she would tell him/her that she wanted to fuck him/her every time he/she would see him/her. 5. During an interview on 01/15/25, at 9:51 A.M., Certified Nurse Aide (CNA) H said that he/she had witnessed Resident #1 being sexually inappropriate with staff. The resident had tried to grab his/her groin on multiple occasions. CNA H reported this to his/her charge nurse and the DON. He/she also witnessed Resident #1 on top of Resident #2. Resident #1 had a brief on and had his/her hands down Resident #2's pants. Resident #2's eyes were big and he/she was yelling when CNA H went into the room and pulled Resident #1 off Resident #2. He/she notified the nurse immediately. Resident #1 was on 15-minute checks and staff know to watch him/her when he/she leaves his/her room. During an interview on 01/15/25, at 10:15 A.M., CNA F said Resident #1 was on 15-minute checks and can only go outside to smoke with staff because he/she was known to be sexually inappropriate. During an interview on 01/15/25, at 10:00 A.M. CNA E said the resident was on 15-minute checks because of inappropriate sexual behaviors. The resident was known to be inappropriate towards staff and residents. The resident liked to grab groins and butts. During an interview on 01/15/25, at 9:44 A.M., Certified Mediation Tech (CMT) D said the following: -Abuse and neglect (A/N) is any kind of hitting or yelling at residents. Inappropriate touching and verbal comments are also considered sexual abuse; -He/she would report any abuse immediately to the charge nurse; -He/she had witnessed Resident #1 grab Resident #3's crotch area and reported it to the DON immediately. Resident #3 was upset and began yelling at Resident #1. During an interview on 01/09/25, at 9:50 A.M., Registered Nurse (RN) A said the following: -Resident #1 normally only comes out of his/her room to smoke or eat; -The resident had chronic UTI's and is on antibiotics daily because his/her family member claims that he/she only has behaviors when he/she has a UTI; -Staff must watch the resident every time he/she comes out of his/her room because he/she has had so many behaviors; -The resident often grabs residents by the groin and makes inappropriate sexual comments to residents and staff; -Resident #3 reported to him/her that Resident #1 wheeled up to him/her and asked if he/she could touch his/her private area. Resident #3 reported this to the RN immediately. RN A spoke with Resident #1 asking if this happened. Resident #1 admitted that this occurred stating I'm horny. RN A educated the resident to not speak to other residents in this manner and said that the resident went to his/her room; -RN A said this was sexual abuse; -RN A said the physician was aware of Resident #1's behaviors as well as the Administrator;. -RN A said that the resident has been on 15-minute checks since he/she has been a resident at the facility. During an interview on 01/09/25, at 12:45 P.M., Licensed Practical Nurse (LPN) C, who also updates care plans, said the following: -Resident #1 tried to touch the other residents at the facility. The resident tried to touch their butts or grab at their crotches or tells them I want to fuck you; -The resident targeted Resident #2 and Resident #3; -Staff have it care planned and have the resident on 15-minute checks. Someone was always watching the resident every time he/she came out of his/her room. The resident only came out to smoke or eat, and only came out to eat if he/she didn't have any snacks in his/her room. The resident could only go outside to smoke with staff present. -The resident was sexually inappropriate and very impulsive. -The aides had been directed to redirect the resident when he/she exhibited this type of sexually inappropriate behavior. -The resident's family member said that the resident was sexually inappropriate when he/she had a UTI, but that is not accurate. The last two times staff have sent him/her to the hospital, he/she tested negative for a UTI. Staff have kept him/her on antibiotics for this reason. -Staff always notify the physician when the resident has inappropriate sexual behaviors. They also notify the DON and the Administrator and document the behavior. -LPN C said that it should have been reported to DHSS by either the DON or the Administrator. LPN C said that staff receives abuse and neglect training but not sure how often. During an interview on 01/15/25, at 11:35 A.M., the Social Services Director (SSD) said the following: -He/she had not witnessed any inappropriate sexual behaviors from Resident #1, but had been told about them; -There have been many episodes documented in the resident's chart and he/she has had many conversations with the resident about his/her inappropriate behaviors. He/she had told the resident that he/she cannot tell another resident that he/she wants to have sex with them and cannot touch them, especially on their butt or groin areas. He/she told the resident that was considered abuse. The resident would close his/her eyes and pretend to go to sleep during these conversations. During an interview on 01/09/25, at 1:45 P.M., the Director of Nursing (DON) said the following: -Resident #1 has been on 15-minute checks since admission; -The resident's inappropriate behaviors started almost immediately. The resident had been inappropriate with staff and residents and staff know to keep an eye on him/her when he/she is out of his/her room. -Resident #1 had patted butts and groped groins and asked other residents to have sex;. -Resident #1's family member said that these behaviors only come out if the resident has a UTI. Staff have relayed that information to the physician and have sent the resident out to the hospital numerous times. The first time the resident was sent out, he/she tested positive for a UTI, but every time after that he/she has tested negative for a UTI. The resident is on antibiotics prophylactically (intended to prevent) but the behaviors have continued; -The resident's actions are considered abuse. During an interview on 01/15/25, at 12:43 P.M., the Nurse Practitioner said that he/she was at the facility at least once per week and was aware of the continued inappropriate sexual behaviors of Resident #1. Resident #1 had been on 15-minute checks for a while due to inappropriate behaviors and the facility was not able to provide the resident with one-on-one care due to staffing. The Nurse Practitioner said that the resident had a history of inappropriate sexual behaviors prior to admitting to the facility. They are in the process of finding better suited placement for the resident. During an interview on 01/15/25, at 2:51 P.M., the Physician said that he/she had been notified of the inappropriate sexual behaviors of Resident #1. The resident had been on 15-minute checks for quite some time due to the inappropriate behaviors. The resident had been sent to the emergency room several times due to inappropriate behaviors and the facility has been looking for other placement. The physician said that if he had known Resident #1's behaviors were this bad, the facility would not had accepted him/her. The physician said that Resident #1's inappropriate sexual behaviors are beyond what the facility is capable of handling. During an interview on 01/15/25, at 11:50 A.M., the Administrator said that Resident #1 had been having inappropriate sexual behaviors for a couple of months. The resident has been on 15-minute checks since having inappropriate behaviors. The facility was currently looking for other placement for the resident. The facility had sent the resident out to the emergency room on at least three different occasions and no hospital would admit her for a psych evaluation. The sexual verbal comments from the resident to other residents at the facility is verbal abuse. They were doing everything they knew to do and didn't have any other options besides making Resident #1 a one-on-one, which was unrealistic due to not having the staff for that. MO00247542, MO00247576, MO00247787

Based on interview and record review, the facility failed to report all allegations of resident-to-resident abuse to the State Survey Agency (Department of Health and Senior Services- DHSS) within the required two hours when staff did not report multiple allegations of sexual abuse by one resident (Resident #1) towards other residents to DHSS. The facility census was 49. Review of the facility policy, titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources 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 involved abuse or resulted in injury. -All residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident that includes all unwanted intimate touching of any kind especially of breasts or perineal area and nudity. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admission date of 08/01/24; -Diagnoses included schizoaffective disorder (mental health condition including delusions and hallucinations), anxiety, and bipolar disorder (mood swings ranging from depressive lows to manic highs), alcohol abuse and pyelonephritis (chronic kidney infections). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/08/24, showed the following information: -Cognitively intact; -Independent with bed mobility, transfer, dressing, toilet use, and personal hygiene; -Used a walker or wheelchair for ambulation; -Physical behavioral symptoms directed at others exhibited. Review of the resident's care plan, revised 11/14/24, showed the following information: -The resident had a history of being sexually inappropriate with peers; -Staff will accompany the resident when going outside; -The resident may need additional monitoring at times; -The resident may become sexually inappropriate at times; -Remove the resident from public area when behavior is unacceptable. Review of the resident's progress note dated 11/18/24, at 8:46 A.M., showed the following information: -The nurse documented observing Resident #1 grabbing Resident #3's genitals; -Resident #3 said this has happened four times this weekend; -The resident has been redirected multiple times since admission for inappropriate behaviors with staff and residents. The resident does not respond or even act like she has been told not to do this; -The resident has had UTI's with behaviors which exacerbate the sexual behaviors, however, the behaviors are ongoing. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 11/18/24. Review of the resident's progress note dated 11/20/24, at 1:21 P.M., showed the following information: -The nurse documented that Resident #3 reported that Resident #1 propelled his/her wheelchair up to Resident #3 and asked him/her if he/she could touch his/her private area; -Resident #3 reported this immediately to staff and appeared to be upset by the behavior; -The nurse spoke with Resident #1 asking him/her if this happened. Resident #1 said yes it did, I'm horny. The resident was educated not to speak to other residents in that manner. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 11/20/24. Review of the resident's progress note dated 12/01/24, at 7:40 P.M., showed the following information: -The nurse documented that Resident #1 was observed standing in Resident #2's room, naked from the waist down; -The nurse redirected Resident #1 back to his/her room and reeducated the resident not to go in other residents' rooms and not to leave his/her room without clothing; -Resident #1 denied the behavior; -Staff notified the Director of Nursing (DON); -Staff notified the physician notified and received orders to send resident to hospital for psych evaluation and possible urinary tract infection (UTI); -Staff notified family; -The resident was transported to the hospital for evaluation. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 12/01/24. Review of the resident's progress note dated 12/09/24, at 4:45 P.M., showed the following information: -The nurse documented that another resident (Resident # 3) reported that while at supper in the dining room, Resident #1 propelled his/her wheelchair up to his/her table and asked Resident #3 if he would fuck her. Resident #3 told her no and Resident #1 went on his/her way; -The nurse spoke to Resident #1 who admitted to saying the above statement and didn't care or see why it was inappropriate; -Resident #1 ate his/her supper then stayed the remainder of the evening in his/her room. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 12/09/24. Review of the resident's progress note dated 12/17/24, at 4:42 P.M., showed the following information: -The nurse documented that the resident propelled his/her wheelchair up to Resident #3, reached out and grabbed his/her genitals; -Resident #2 began to scold Resident #1, until staff removed Resident #1; -Resident #2 was very upset and requested anxiety medication. (Staff did not document reporting the allegation of abuse to DHSS.) Review of DHSS records showed the facility did not self-report the allegation of abuse on 11/18/24. During an interview on 01/15/25, at 10:15 A.M., Certified Nurse Aide (CNA) F said he/she would report any inappropriate behaviors to the charge nurse immediately and the charge nurse should report to state within two hours. During an interview on 01/15/25, at 10:00 A.M., CNA E said he/she would report any inappropriate behaviors to the charge nurse immediately so it could be reported to state within two hours. During an interview on 01/15/25, at 9:51 A.M., CNA H said when he/she saw abuse he/she notified the nurse immediately. He/she knew they [NAME] two hours to report to state. He/she considered Resident #1's sexually inappropriate behavior abuse. During an interview on 01/15/25, at 9:44 A.M., Certified Medication Tech (CMT) D said that abuse and neglect (A/N) is any kind of hitting or yelling at residents. Inappropriate touching and verbal is also considered sexual abuse. He/she would report any abuse immediately to the charge nurse and the charge nurse should report to DHSS within two hours. CMT D said that it is not his/her responsibility to report to DHSS, that only the charge nurse, DON or Administrator reports to DHSS. During an interview on 01/09/25, at 9:50 A.M., Registered Nurse (RN) A said he/she reported the sexual inappropriate behavior to the DON and did not think that he/she needed to report it to DHSS. Resident #1's behaviors was sexual abuse. During an interview on 01/09/25, at 12:45 P.M., Licensed Practical Nurse (LPN) C said Resident #1 was sexually inappropriate and very impulsive. Staff notify the physician when the resident has inappropriate sexual behaviors. They also notify the DON and the Administrator and document the behavior. LPN C said that it should have been reported to DHSS by either the DON or the Administrator. He/she considered the behaviors abusive. During an interview on 01/09/25, at 1:45 P.M., the said the Resident #1 had been inappropriate with staff and residents and staff know to keep an eye on him/her when he/she is out of his/her room. Resident #1 had patted butts and groped groins and asked other residents to have sex. This is considered abuse, and it should have been reported to DHSS. During an interview on 01/15/25, at 11:35 A.M., the Social Services Director (SSD) said he/she had told the resident that he/she cannot tell another resident that he/she wants to have sex with them and cannot touch them, especially on their butt or groin areas. The SSD told the resident that is considered abuse. He/she was not sure if these allegations were reported to DHSS or not, but said they should have been and if he/she had been told, he/she would have made sure they were reported to DHSS as he/she is aware that they have two hours to report. The SSD said that the Administrator is responsible for reporting all abuse and neglect allegations. During an interview on 01/15/25, at 11:50 A.M., the Administrator said that Resident #1 had been having inappropriate sexual behaviors for a couple of months. The sexual verbal comments from the resident to other residents at the facility was verbal abuse and that the comments should have been reported to DHSS. MO00247542, MO00247576, MO00247787

Based on interview and record review, the facility failed to complete performance reviews of every certified nurse aide (CNA) at least once every 12 months when staff failed to document competency evaluation and performance review for two staff (CNA N and CNA M). The facility census was 39. Review showed the facility did not provide a written policy pertaining to nurse aide competency reviews. 1. Review of personnel records showed the following CNAs had been employed for more than one year: -CNA N - Hire date of 12/20/22; Re-hire date of 04/26/23; -CNA M - Hire date of 01/27/23; Re-hire date of 06/28/23; -Staff did not have documentation of a yearly performance review for CNA N and CNA M. During an interview on 09/11/24, at 9:08 A.M., the Director of Nursing (DON) said the facility did scheduled monthly in-services for all staff, with some specific to nursing and the CNAs. They did not have documentation on annual performance reviews. During an interview on 09/12/24, at 3:30 P.M., the corporate Quality Assurance Registered Nurse (QARN) said the corporation did not have a specific written policy pertaining to the completion of CNA annual competencies. The facility should complete the competencies for all CNAs and include skills such as catheter care, transfers, peri-care (perineal; genital) with incontinence or toileting, hand washing, and glove use. During an interview on 09/12/24, at 4:13 P.M., the Administrator said the facility should be completing annual competencies for the CNAs with documentation on the performance reviews. The competencies should include skills such as catheter care, peri-care, toileting, assisted transfers and mechanical lifts.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities based on residents' interests and abilities when the staff failed to provide a complete activity schedule with a variety of daily activities, failed to complete activities as scheduled, and failed to document steps taken to provide meaningful activities for nine residents (Resident #13, #17, #14, #39, #9, #16, #7,#40, and #16) out of a sample of 20 residents. The facility had a census of 39. Review of the facility policy titled, Activity/Recreational Therapy Manual last reviewed on 03/2012, showed the following: -The purpose was for the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident; -To enhance the quality of the residents daily life; -Upon admittance, annually, and upon significant change, an initial assessment was to be completed including background information, preference interviews, activity pursuit patterns, and additional pertinent information; -Quarterly assessments will be completed to evaluate the resident's current activity program and determine if changes need to be made; -The quarterly assessments include participation in activities, socialization patterns, resident preferences, and other factors; -The Activity Director charts progress notes in the residents' charts upon admission, quarterly, and with significant changes; -The progress notes should include resident interests, based on their feedback, response to activity, and activity involvement; -Resident participation is documented in the clinical record, on a daily basis by the Activity Director or designee and should include the resident's attendance, participation, refusal, and level of participation; -Activity Director should develop a monthly calendar based on resident's needs and interests; -Calendar should list the time of the activity; -Monthly calendar should be provided to each resident; -Plans and promotes meaningful activities based on the resident's interests and desires to provide a more homelike atmosphere in the facility; -Schedule activities that will involve as many residents as possible; -Care plan will address resident's interests and needs. 1. Review of the residents' activities sign in sheets, dated January 2024, showed the following: -Bingo held on 01/04/24, 01/09/24, and 01/30/24; -No other documented activities. Review of the residents' activities sign in sheets, dated February 2024, showed the following: -Bingo held on 02/08/24, 02/12/24, 02/20/24, 02/23/24, and 02/27/24; -No other documented activities. Review of the residents' activities sign in sheets, dated March 2024, showed the following: -Bingo held on 03/05/24, 03/08/24, 03/12/24, 03/19/24, and 03/26/24; -No other documented activities. Review of the residents' activities sign in sheets, dated April 2024, showed the following: -Bingo held on 04/04/24, 04/09/24, 04/16/24, 04/19/24, 04/24/24, and 04/26/24; -No other documented activities. Review of the residents' activities sign in sheets, dated May 2024, showed the following: -Bingo held on 05/09/24, 05/14/24, 05/21/24, 05/24/24, and 05/31/24; -No other documented activities. Review of the residents' activities sign in sheets, dated June 2024, showed the following: -Bowling held on 06/03/24; -Bingo held on 06/05/24; -Corn Hole held on 06/06/24, eight resident participated; -Karaoke held on 06/07/24, twelve residents participated; -Movies held on 06/10/24, ten residents participated; -Bingo held on 06/11/24; -Ring toss held on 06/12/24, ten residents participated; -Movies held on 06/17/24, ten residents participated; -Leisure time, read a book held on 06/19/24, five residents participated; -Bingo held on 06/21/24; -Movies held on 06/24/24, ten residents participated; -Bingo held on 06/25/24; -No other documented activities. Review of the residents' activities sign in sheets, dated July 2024, showed the following: -Bowling held on 07/01/24, eight residents participated; -Bingo held on 07/02/24; -Firework's display held on 07/04/24, 27 residents participated; -Karaoke held on 07/05/24, nine residents participated; -Bingo held on 07/09/24, 07/12/24, 07/19/24, 07/23/24, 07/26/24, and 07/30/24; -No other documented activities. Review of the residents' activities sign in sheets, dated August 2024, showed the following: -Bingo held on 08/27/24, seven residents participated; -Bingo held on 08/30/24, ten residents participated; -No other documented activities. Review of the residents' activities sign in sheets, dated 09/01/24 to 09/11/24, showed the following: -Bingo held on 09/03/24, nine residents participated; -Bingo held on 09/11/24, twelve residents participated. 2. Review of the facility activity calendar, posted in the television room at the facility, showed on 09/09/24, at 1:30 P.M., corn hole scheduled. Observation on 09/09/24, at 1:30 P.M., showed no corn hole activity was being done at the facility. 3. Review of the facility calendar posted in the television room at the facility, showed the following: -On 09/01/24, televised church, no time listed; -On 09/02/24, at 10:00 A.M. hydration; 10:30 A.M. phone calls; 12:00 P.M. lunch; 1:00 P.M. mail; and 1:30 P.M. movie; -On 09/03/24, Bingo, no time displayed; -On 09/04/24, at 10:00 A.M. hydration; 12:00 P.M. lunch; and podiatrist; -On 09/05/24, at 10:00 A.M., hydration; 12:00 P.M. lunch; 1:00 P.M., mail; and 1:30 P.M., leisure time; -On 09/06/24, Bingo, no time listed; -On 09/07/24, Activity of choice, no time listed; -On 09/08/24, televised church, no time listed; -On 09/09/24, at 1:30 P.M., corn hole; -On 09/10/24, no activity, in-service; -On 09/11/24, at 10:00 A.M. hydration; 12:00 P.M. lunch; and 1:30 P.M. basketball; -On 09/12/24, volley balloon, no time listed; -On 09/13/24, bingo, no time listed; -On 09/24/24, happy birthday; -On 09/15/24, televised church, no time listed; -On 09/16/24, hydration at 10:30 A.M.; phone at 12:00 P.M.; lunch at 1:00 P.M.; mail at 1:30 P.M.; and movie; -On 09/17/24, bingo, no time listed; -On 09/18/24, leisure time; -On 09/19/24, resident council, no time listed; -On 09/20/24, bingo, no time listed; -On 09/21/24, activity of choice; -On 09/22/24, televised church, no time listed; -On 09/23/24, hydration, phone calls, lunch, bowling for prizes, no times listed; -On 09/24/24, bingo, no time listed; -On 09/25/24, treats at activity and foosball, no times listed; -On 09/26/24, read a book, no time listed; -On 09/27/24, bingo, no time listed; -On 09/28/24, activity of choice, no time listed; -On 09/29/24, televised church, no time listed; -On 09/30/24, games for prizes, no times listed. 4. Observation on 09/10/24, at 9:49 A.M., of the activity room showed the following: -The room contained a basketball goal and foosball; -A shelf with various games; -A door with a sign on it that said remain locked at all times. Observation on 09/12/24, at 11:45 A.M., showed a lower cabinet in the 100 hall TV room contained three editions of Reader's Digest and three romance novels. The cabinet was at floor level and covered with a door. 5. Observation and interview on 09/11/24, starting at 10:34 A.M., showed the following: -Nurse Aide (NA) I passed out various drinks on 200 hall; -NA I said the hydration listed on the calendar was what he/she was doing. It consisted of going around to each resident who can have drinks and providing them Kool-aide, coffee, water or tea. This was done at 10:00 A.M. and 8:00 P.M. 6. Review of Resident #13's face sheet showed the following: -admitted [DATE]; -Diagnoses included above the knee amputation, diabetes, insomnia, schizoaffective disorder (combination mental disorder including delusions, hallucinations, depressed/manic periods), anxiety, limitation of activities due to disability, pain, and major depressive disorder. Review of the resident's Activity Assessment - Comprehensive, dated 07/03/24, showed the following: -Most common use of time: sleeping in his/her chair in his/her room; -Average time involved in activities (when awake and not receiving treatments or care): Some - from 1/3 to 2/3 of time; -Preferred activity settings: none of the above listed; -Hobbies: watching television; -Preferred program style: Refuses to participate; -Program time preference: does not like to participate in activities; -Participation barriers: none; -Participation strengths: social skills; -General activity preferences: reading/writing, watching TV; -Past interests included: animals/pets, board games, cooking, current events, dining out, drawing/painting, movies/theater, quilting/crochet, outdoor activities, resident council, and woodworking; -Focus of programming: no interest at all. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/11/24, showed the following: -Cognition intact; -Sometimes socially isolated. Review of the resident's care plan, last updated 07/11/24, showed the following: -Psychosocial well-being: Right leg amputated above the knee. Resident has constant worry that he/she may lose the other leg. Resident has episodes of depression related to these events; -Mood state: Loss of interest in things due to worrying and anxiety about health. Resident is anxious and depressed at times. Staff to encourage resident to get out of bed and come out of the room to socialize with others. Staff to spend 1:1 time with resident and allow resident to vent feelings. During interviews on 09/09/24, at 11:15 A.M., and on 09/10/24, at 1:43 P.M., the resident said he/she had been a resident for a long time and was tired of Bingo and Scrabble. He/she would be interested in doing something new, otherwise he/she would just stay in his/her room. The facility does not have enough activities, they play bingo a lot and they sometimes cancel the activities. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the resident could have money for activities, but he/she spends money on food instead. 7. Review of Resident #17's face sheet showed the following: -admitted [DATE]; -Diagnoses included schizoaffective disorder (combination mental disorder including delusions, hallucinations, depressed/manic periods), heart disease, diabetes, and presence of right artificial hip joint. Review of the resident's Activity Assessment- Comprehensive, dated 10/03/23, showed the following: -The resident was most active in the afternoon; -The resident was involved in some activities from 1/3 to 2/3 of the time; -Preferred setting was the day/activity room; -Preferred small groups; -Participated twice weekly; -No participation barriers; -Participation strengths included being self-motivated and social skills; -General activity preferences include watching television and talking/conversing; -Past interests include animals/pets, board games, cooking, current events, dining out, movies, outdoor activities, woodworking; -Focus of programming included outdoor activities and talk-oriented activities. Review of the resident's MDS, dated [DATE], showed the following: -Severely cognitively impaired; -The resident's activity preferences listed as somewhat important to have books, newspapers, and magazines to read, listen to music, be around animals, keep up with the news, do thing with groups of people, and go outside to get fresh air when the weather was good. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately cognitively impaired; -Preferences were not completed; -Required partial to moderate assistance with activities of daily living (ADL's) including dressing, toilet use, and personal hygiene. Review of the resident's social services and activity progress notes, dated 03/01/24 through 09/12/24, showed staff did not document regarding activities for the resident. Observation on 09/10/24, at 8:55 A.M., showed the resident lay in bed awake, the room dark, with the television off. Observation and interview on 09/11/24, at 1:40 P.M., showed 11 residents in the dining room playing bingo. Observation and interview on 09/11/24, at 1:46 P.M., showed the resident lay in bed, room dark, and television not on. The resident said staff did not tell him/her bingo was being played. He/she would like a deck of playing cards, but has never been offered them. He/she has never been given a calendar of what the activities for the month are. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the following: -He/she was not aware that the resident wanted playing cards, there are cards in the back room; -No one will play with the resident, because he/she picks His/her nose and makes it bleed. Review of the resident's care plan, last revised 09/12/24, showed the following: -Resident is to participate in at least one activity a week as he/she feels able and with staff assistance; -Post a calendar in the resident's room for staff to read to the resident; -Assist the resident to activities that may be of interest to the resident; -Encourage the resident to go to activities. 8. Review of Resident #14's face sheet showed the following information: -admitted [DATE]; -Diagnoses included developmental disorders of scholastic skills, schizoaffective disorder, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and hallucinations. Review of the resident's current physician order sheet showed an order, dated 11/29/23, for resident may participate in activities as tolerated. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Mildly cognitively impaired; -Preferences were not completed; -Sometimes socially isolated. Review of the resident's record showed staff did not complete an activity assessment for the resident. Review of the resident's care plan, revised 06/26/24, showed psychosocial well-being care planned. Facility staff to monitor frequently and report any changes in mood or behaviors to charge nurse. During an interview on 09/10/24, at 1:48 P.M., the resident said bingo was about the only activity they have. He/she would like more activities and has told the nurses. He/she gets bored and wishes there was more to do besides watch television and sleep. Observation and interview on 09/11/24, at 9:18 A.M., showed the resident laying on his/her bed watching television. The resident said that he/she was bored and would like to paint, but is currently out of painting supplies. There were no painting supplies in the activity room that he/she would be interested in. 9. Review of Resident #39's face sheet showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD- refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD-A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the resident's admission MDS, dated [DATE], showed the following: -Severely cognitively impaired; -Dependent on staff for ADL's -Activity preferences showed it as somewhat important to listen to music he/she liked, to be around animals, keep up with the news, do thing with groups of people, do his/her favorite activities, go outside to get fresh air when the weather was good, and participate in religious services or practices. Review of the resident's Activity Assessment- Comprehensive, dated 06/11/24, showed the following: -The average time resident involved in activities was unknown; -The resident had no preferred activity settings; -The resident's preferred program style was 1:1; -Program time preference was afternoon; -Participation barriers included ability to understand, mental status, and physical endurance; -The resident had no participation strengths; -General activity preferences included crafts/art, music, and watching television; -Past interests included animals/pets, board games, cooking, current events, dining out, drawing/painting, movies, quilting/crochet, outdoor activities, music, resident council, woodworking, and word games; -Focus of programing included group games and outdoor activities. Review of the resident's care plan, last revised 06/18/24, showed staff did not address the resident's activity preferences or an activity plan for the resident. Review of the resident's activity progress notes, dated 06/04/24 through 09/11/24, showed staff did not document regarding activity attendance, refusals, or participation. Review of the resident's social services progress notes, dated 06/04/24 through 09/11/24, staff did not document regarding activities preferences or activity attendance for the resident. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the following: -He/she provides activities specific to residents. He/she pulled out a bag of interactive hand toys for the resident and said the resident does come to bingo. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the resident liked to play with blocks and Legos. Since the resident was in the hospital the last time, the resident does not have much of an interest in them. During an interview on 09/12/24, at 11:22 A.M., the Director of Nursing (DON) said the resident liked to do things that involve his/her hands. The resident liked to play with Legos before going to the hospital. The resident does well with sitting at the desk talking to the nurse or certified medication technician (CMT) one-on-one. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said the resident liked to be included. The resident liked to go to bingo and karaoke. His/her care plan should include things the resident likes to do. 10. Review of Resident #9's face sheet showed the following information: -admitted [DATE]; -Diagnoses included schizoaffective disorder, Type II diabetes (blood sugar is too high), generalized anxiety disorder borderline intellectual functioning (below average cognitive ability), and chronic pain. Review of the resident's Activity Assessment, dated 08/20/24, showed the following: -Average time involved in activities, some from 1/3 to 2/3's of the time; -Prefers activities in the day/activity room; -Prefers large groups and in the afternoons; -Likes music, reading/writing, watching television, and talking; -Current interests included animals, board games, dining out, drawing, movies, music. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Very important to do things with groups of people; -Very important to do favorite activities. Review of the resident's current care plan, last revised 09/06/24, showed the following: -Resident needs staff to invite him/her to activities and assist to find the location; -Staff to provide resident 1:1 to decrease episodes of restlessness; -Resident liked games; -Resident has difficulty staying focused on task and liked to be around others. Review of the resident's medical record, dated 01/01/24 to 09/12/24, showed staff did not document related to the activities the resident participated in. Observation and interview on 09/10/24, at 1:43 P.M., showed the following: -Six residents were sitting in the television room; -The resident said they did not have corn hole yesterday; -He/she would like a paper activity calendar. During an interview on 09/11/24, at 3:31 P.M., the resident said the following: -He/she goes to bingo on Tuesdays and Friday; -He/she believed someone came and told him/her they were having bingo today; -The Activities Director and the laundry person do activities; -He/she would like to do other activities. 11. Review of Resident #16's face sheet showed the following information: -Readmitted [DATE]; -Diagnoses included paranoid schizophrenia (hallucinations, delusions and unusual ways of expressing themselves). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Preferences were not completed. Review of the resident's current care plan, last revised 09/06/24, showed staff did not address the resident's activity interests. Review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not document completion of an activity assessment or quarterly reviews of activity interests. Review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not document related to activities the resident participated in. 12. Review of Resident #7's face sheet showed the following information: -Readmitted [DATE]; -Diagnoses included schizoaffective disorder, generalized anxiety disorder (excessive worry), and insomnia (difficulty falling and staying asleep). Review of the resident's Activity Assessment, dated 01/25/24, showed the following: -Average time involved in activities, some from 1/3 to 2/3's of the time; -Prefers activities in the day/activity room; -Prefers large groups and in the afternoons; -Likes crafts/arts and watching television; -Current interests include animals, board games, current events, dining out, drawing, movies, music, word games, and outdoor activities. Review of the resident's current care plan, last revised 07/22/24, showed staff did not care plan the resident's preferred activities. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Activity preferences was not completed. Review of the resident's medical record, dated 01/01/24 and 09/12/24, showed staff did not document progress notes documented related to activities the resident participated in. Observation and interview on 09/10/24, beginning at 1:43 P.M., showed the following: -Six residents were sitting in the television room; -The resident said they did not have corn hole on 09/09/24; -He/she doesn't know if they're having activities today; -He/she looks at the calendar on the wall; -Sometimes they cancel activities if there's not staff to do them; -Sometimes the Activity Director will do bingo, karaoke, and a movie if he/she has time. 13. Review of Resident #40's face sheet showed the following: -admitted [DATE]; -Diagnoses included high blood pressure, depression, insomnia, pain, and heart failure. Review of the resident's Activity Assessment- Comprehensive, dated 04/25/24, showed the following: -The resident is involved in activities most of the time, more than 2/3 of the time; -Preferred setting is the day/activity room; -Preferred program style is large groups; -Time preference is afternoon; -No participation barriers; -No participation strengths; -Activity preference is watching television; -Past interests included animals/pets, board games, cooking, dining out, movies, outdoor activities, music, resident council, and woodworking; -Program focus is outdoor activities. Review of the resident's admission MDS, date 05/1/24, showed the following: -Cognitively intact; -His/her activity preferences showed it as very important to have books, newspapers, and magazines to read, to do things with groups of people, and to get outside to get fresh air when the weather was good and somewhat important to listen to music he/she likes, to be around animals, to keep up with the news, to do favorite activities, and participate in religious services or practices. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Staff did not document activity preferences. Review of the resident's care plan, last revised 08/02/24, showed staff did not address the resident's activity preferences or interests or any plan for activities. During interviews on 09/10/24, at 9:49 A.M., and 09/12/24, at 10:32 A.M., the Activities Director said the resident knows the facility has books and where they're at. There are both fiction and non-fiction books. 14. Review of Resident #16's face sheet showed the following information: -Readmitted [DATE]; -Diagnoses included paranoid schizophrenia. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Activity preferences not completed. Review of the resident's current care plan, last revised 09/06/24, showed staff did not care plan related to activity interests. Review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not complete an activity assessment or quarterly reviews of activity interests. Record review of the resident's medical record, dated 01/01/24 through 09/12/24, showed staff did not document related to activities the resident participated in. During an interview on 09/12/24, at 10:32 A.M., the Activities Director said the resident had been asked if he/she wants to be involved and he/she doesn't. He/she also hurt a scout's feelings and he/she does not feel that is right. 15. During an interview on 09/11/24, at 3:45 P.M., CNA C said he/she does not know if they do anything different for a resident that does not want to or cannot come out their room. Activities and restorative staff go around and tell the residents about the activity for the day. 16. During an interview on 09/11/24, at 4:02 P.M., CNA D said activities were listed on the calendar in the television room. Sometimes the CNAs will tell the residents about activities, sometimes activities will, and other times they will page overhead. 17. During an interview on 09/12/24, at 12:51 P.M., CNA F said the following: -Activities are posted on the board in the television room; -The Activities Director walks around and invites residents to activities; -He/she doesn't know anything about a paper calendar; -He/she is not sure if the staff ask residents which activities they prefer. 18. During an interview on 09/12/24, at 1:09 P.M., Licensed Practical Nurse (LPN) K said the following: -The facility used to hand out fliers for the week, but now they announce the activities daily and they have the board; -There was also a daily activity sheet that listed lunch and he/she hasn't seen that in some time either; -The Activity Director is responsible for activities and he/she also has a couple of helpers; -Residents complain all of the time about activities being canceled or not having enough; -It seems like movie night gets moved a lot, or they cancel Bingo because there isn't a staff to do it; -He/she has probably seen Bingo done about 20 times in the last nine months. 19. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the following: -The activities are posted on the calendar in the television room or announced on the intercom; -CNAs will remind the residents about the activity. Activities will come and remind them as well; -No written calendars are handed out; -There is no way to know what a resident's preferences are; -A resident's preferences are not documented anywhere; -A resident's participation in activities are not documented anywhere that he/she is aware of; -Staff is not instructed to do anything different for residents who do not participate in activities. 20. During interviews on 09/10/24, at 9:49 A.M., and on 09/12/24, at 10:32 A.M., the Activities Director said the following: -When hired, he/she was not given direction on how activities should be done; -Residents used to like to exercise, but they decided they didn't want that; -He/she tried to get them involved in other activities; -Some residents come to activities, mostly Bingo; -He/she does have another aide that's appointed to help, but they use him/her as an aide on the floor a lot; -He/she sits down with residents one-on-one to see what activities they want to do; -Residents like karaoke, corn hole, but several don't want to get out of bed; -He/she asked residents what time they want to have activities; -When he/she set up church, it was in the morning and the residents decided they didn't want mornings so it was moved to the afternoon and it was their nap time and no one came; -He/she completed an activity assessment when a resident was admitted and annually thereafter; -He/she provided puzzles and word books for various residents; -Some times aren't on the activity board. The afternoon activities are held at 1:30 P.M. He/she tells residents this and goes over it on admit; -If not enough residents show up, some activities can't be done; -He/she determines what activities to do, based upon how many residents show up for the activities; -The door is kept locked in the game room because residents have stolen. One time he/she put candy bars back there and a resident stole all of them; -If residents ask staff, they will unlock the door. Someone has a key at all times; -The activities listed on the calendar, such as hydration and lunch, are on the calendar because residents wanted to know when they were held; -He/she doesn't make calendars anymore. The residents throw them away and it's a waste of paper; -He/she said they're supposed to have Bingo, which he/she showed on the calendar, but they're having in-service today so they will make it up another day; -He/she had activities usually after the resident council meeting; -If residents refused or don't participation, he/she usually makes a note; -Since January he/she hasn't been making notes in resident's records about activities; -He/she keeps a log of who attends the activities; -He/she used to print out the calendars and put them on the resident's closet doors and they tore them off and threw them away. 21. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said the following: -The residents' activities care plan should have things the resident likes to do and what they have an interest in; -The care plan should say what they do and don't like; -The care plan should say if they don't participate in activities; -All care plans should say for everyone to encourage the residents to be involved 22. During an interview on 09/12/24, at 11:22 A.M., the DON said the following: -The activities calendar is posted in the television room; -Certain activities are announced overhead; -All residents are supposed to get a calendar in their rooms; -The CNAs or activities staff will go room-to-room and remind the residents before an activity; -If the residents do not want to participate in the activity for the day, they ask them if they can get them anything else; -Some residents just do not like to do anything; -She does not think it is documented anywhere if they do or do not participate in activities. -Activities should be on the care plan. 23. During an interview on 09/12/24, at 4:18 P.M., the Administrator said the following: -Activities should be part of the resident's care plan; -The Activity Director [TRUNCATED]

Based on observation, record review, and interview, the facility staff failed to ensure the facility was maintained in a sanitary and comfortable fashion when staff failed to keep the outside of the ice machine clean and failed to keep all light fixtures, vents, and ceiling areas clean. The facility census was 39. 1. Review of the facility's policy titled Ice Maker, dated May 2015, showed staff would clean the outside of the machine week. Staff would wash the outside of the ice machine monthly with a soft brush or cloth and dry. Review of the facility's Ice Machine Cleaning Schedule showed the machine was to be cleaned monthly. Staff last documented cleaning the ice machine on 08/31/24. Observations on 09/09/24, beginning at 9:13 A.M., of the ice machine in the kitchen showed the following: -The outside had white and brown buildup along the crevasses of the machine at the top; -The right side of the machine had three long streaks of white; -The left side of the machine had much of it covered with white streaks and a crusty white substance; -Above the door opening there was a dirty substance. Observations on 09/11/24, beginning at 8:50 A.M., of the ice machine in the kitchen showed the following: -Outside of the ice machine had white and brown buildup along the crevasses of the machine at the top; -The left side of the machine had much of it covered with white streaks and a crusty white substance. During an interview on 09/11/24, at 1:39 P.M., Dietary Aide (DA) A said the following: -Evening shift staff are responsible for cleaning the outside of the ice machine at the end of their shift; -Kitchen has a cleaning schedule for daily, weekly, and monthly items; -The ice machine is listed on the cleaning schedule. During an interview on 09/11/24, at 1:49 P.M., DA B said the following: -When he/she remembers, he/she wipes down the outside of the ice machine with a sanitizing rag nightly; -He/she will also clean above the door, but not as often. During an interview on 09/11/24, at 1:44 P.M., the Dietary Manager (DM) said the following: -Staff have a cleaning schedule for the kitchen, but cleaning the outside of the ice machine is not on the cleaning schedule; -Staff should be cleaning the outside of the ice machine once a day; -He/she is responsible for ensuring staff clean the ice machine. During an interview on 09/11/24, at 2:02 P.M., the Maintenance Director said dietary staff were responsible for cleaning the outside of the ice machine. During an interview on 09/11/24, at 1:56 P.M., the Administrator said the following: -He wasn't sure whose responsible it to clean the outside of the ice machine; -He would expect staff to keep the outside clean. The ice machine should not have white streaks or crust or grime on it; -The DM was responsible for making sure the ice machine was cleaned regularly. 2. Observations on 09/09/24, beginning at 9:13 A.M., and on 09/11/24, at 1: 39 P.M., of the kitchen showed the a florescent light, and ceiling around the light, located in front of the stove and above the table, had brown spots present. During an interview on 09/11/24, at 1:49 P.M., DA B said maintenance cleans the ceiling and lights on the ceiling. During an interview on 09/11/24, at 2:02 P.M., the Maintenance Director said the following . -He/she cleans the fluorescent lights in the kitchen when he/she changes out the bulbs. It is not on his/her cleaning schedule; -He/she doesn't clean the ceiling in the kitchen. During an interview on 09/11/24, at 1:44 P.M., the DM said the following: -Maintenance cleans the lights and the ceiling; -When kitchen staff find an issue, they write the issue on the clip board located at the nurses' station; -He/she doesn't know how often maintenance cleans the lights or ceiling; -He/she didn't notice the brown spots on the light or ceiling. During an interview on 09/11/24, at 1:56 P.M., the Administrator said the following: -He knew maintenance changed the bulbs out, but he wasn't sure if maintenance cleaned the lights and the ceiling; -He would expect the lights and ceiling to be clean; -Maintenance has a book at the nurses' station where any issues should be noted. 3. Observations on 09/09/24, beginning at 9:13 A.M., and on 09/11/24, at 11:42 A.M. and 1: 39 P.M., of the kitchen showed the ceiling vent, just before entering the kitchen, had fuzzy lint hanging from it. During an interview on 09/11/24, at 1:39 P.M., DA A said the following: -Maintenance was responsible for cleaning the ceiling vents; -He/she didn't think about looking at the ceiling and didn't notice the fuzzy lint on the vent. During an interview on 09/11/24, at 1:49 P.M., DA B said he/she doesn't do anything with the ceiling vents and doesn't know who is supposed to clean them. During an interview on 09/11/24, at 2:02 P.M., the Maintenance Director said he/she doesn't clean the vents and doesn't know who is supposed to clean them. During an interview on 09/11/24, at 1:44 P.M., the DM said the following: -He/she wasn't sure who was supposed to clean the vents on the ceiling; -He/she didn't realize the vent had fuzzy lint. During an interview on 09/11/24, at 1:56 P.M., the Administrator said maintenance should be taking care of the vents, ensuring they don't have fuzzy lint.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of need for one resident (Resident # 39) when staff did not place the resident's call light where it could be accessed by the resident. The facility census was 39. Review of the facility policy titled, Use of Call Light, dated March 2015, showed the following: -Answer all call lights in a prompt, calm, courteous manner; -When providing care to the residents, be sure to position the call light conveniently for the resident's use; -Tell the resident where the call light is and show him/her how to use the light; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included stroke. Review of the resident's care plan, dated 06/04/24, showed the following: -Resident had a diagnosis of flaccid hemiplegia (a condition that occurs after a stroke and is characterized by a complete lack of voluntary movement in one side of the body) affecting left nondominant side that limit abilities, required maximum assistance with most activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Make sure the resident's call light is within reach at all times. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/10/24, showed the following: -Resident was severely cognitively impaired; -Resident was dependent on all other ADL's including dressing, toilet use, and personal hygiene; -Impairment on one side of the body; -Diagnosis of stroke. Observation on 09/10/24, at 10:16 A.M., showed the resident lay in bed with the call light clipped to the head of the bed on the resident's left side of the body (not accessible to the resident). Observation on 09/10/24, at 10:36 A.M., showed the resident's call light was clipped to the head of the bed on the resident's left side of the body (not accessible to the resident). Observation on 09/11/24, at 1:55 P.M., showed the resident's call light was clipped to the head of the resident's bed on the resident's left side of the body (not accessible to the resident). reach. During an interview on 09/11/24, at 3:45 P.M., Certified Nurse Aide (CNA) C said the following: -Call lights should be next to a resident; -He/She would pin them on the resident's chest; -Everyone should have a call light. During an interview on 09/11/24, at 4:02 P.M., CNA D said the following: -He/She would connect the call light to a resident or a resident's bed where a resident can reach it; -Everyone should have a call light; -He/She would give the resident his/her call light or connect it to his/her bed where he/she could reach it, not at the head of the bed. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the following: -Call lights should be attached to a shirt or a sheet where a resident can reach them; -The resident's call light should be on his/her shirt where he/she can reach it with his/her right hand because that is the resident's non-affected side; -The resident's call light should not be placed at the head of the bed. During an interview on 09/12/24, at 11:22 P.M., the Director of Nursing (DON) said the following: -Call lights should be pinned to a resident's chest or on the bed on a resident's non affected side; -All residents should have a call light in reach, or have it addressed in the care plan if they are not safe to have them. During an interview on 09/12/24, at 4:13 P.M., the Administrator said the following: -Call lights should be in reach; -All residents should have a call light; -Call lights should not be clipped to the head of the bed.

Based on record review and interview, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission) prior to or upon admission to the facility for one resident (Resident #42). The facility census was 39. Review of the facility's Admission Packet showed a checklist showing Obtain DA 124C (preadmission screening related to psychological diagnoses). Review showed the facility did not provide a written policy pertaining to PASARRs. 1. Review of Resident #42's face sheet (gives brief profile information) showed the following: -admitted [DATE]; -Diagnoses included personal history of suicidal behavior with attempted self-injury, burn of unspecified degree of head, face, and neck, anxiety disorder, paranoid schizophrenia with acute exacerbation (mental disorder with symptoms of distrust, suspicion, and fear of others without reason, delusions - belief in something unreal, hallucinations -hearing or seeing things not present, and confused thoughts), insomnia, high blood pressure, and type 2 diabetes. Review of the resident's care plan, last revised on 08/17/24, showed the following information: -Takes medications to treat paranoid schizophrenia and anxiety disorders. Staff to monitor for side effects. Resident to see tele-psych (virtual psychologist appointments); -History of confusion due to diagnoses of paranoid schizophrenia and anxiety. Resident able to make needs known. Resident has minimal socialization outside of his/her room. Staff to re-orient to the day/time/season etc. as necessary, encourage involvement in activities, monitor for signs/symptoms, and monitor for abnormal behaviors. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 08/17/24, showed the following information: -Cognition intact; -Diagnoses included anxiety disorder and schizophrenia; -Medications included anti-psychotic (given routinely only) and antianxiety. Review of the resident's Level I Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability or Related Condition, dated and submitted by the hospital on 05/06/24, showed the following: -Major mental illness diagnoses included schizophrenia, psychotic disorder, schizoaffective disorder, and bipolar disorder (fluctuating depressed/manic episodes); -Impairment regarding Adaptation to Change: serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interactions, agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, self-injurious, self-mutilation, suicidal (thoughts, gestures, threats, or attempts), physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability, or requires intervention be mental health or judicial system; -Within the last 2 years, the individual experienced one psychiatric treatment episode that was more intensive than routine follow-up care (such as had inpatient psychiatric care; was referred to a mental health crisis/screening center; had attended partial care/hospitalization or had received Program of Assertive Community (PACT) or Integrated Case Management Services); -Within the last 2 years, due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials; -Initial admission (to the hospital) on 04/14/24 for self-inflicted burns to face; -Corrections were requested by the state agency on 05/09/24; -Corrections made by the submitter on 05/10/24; -Correction requested on 05/13/24; -Application locked due to correction not made to the online application. During an interview on 09/12/24, at 9:31 A.M., the Director of Nursing (DON) said the MDS Coordinator is fairly new and only does MDS duties several days per week. The DON has a background in MDS completion and continues to help out while the MDS Coordinator is learning. The facility missed the email requesting further correction to the resident's Level I submission. During an interview on 09/12/24, at 3:30 P.M., the Corporate QA RN (Quality Assurance Registered Nurse) said the corporation did not have a policy pertaining to PASARRs. Staff was told to follow the regulations for completing them. During an interview on 09/12/24, at 4:13 P.M., the Administrator and the QA RN said the Level I PASARR should be completed prior to the nursing facility admission (usually by the hospital). The MDS Coordinator and DON would be responsible for submitting corrections or completing new assessments as soon as possible.

Based on record review and interview, the facility failed to ensure that each resident's written care plan was accurate and up-to-date, when staff failed to care plan hospice services for two residents (Resident #39 and Resident #2). The facility census was 39. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Resident on hospice services. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 06/04/24, for hospice evaluation and treatment. Observation on 09/12/24, at 9:36 A.M., showed a hospice book that indicated the resident received care from hospice). Review of the resident's care plan, dated 06/04/24, showed staff did not care plan related to the resident's referral for, or use of hospice services. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/10/24, showed staff did not document the resident received hospice services. During an interview on 09/12/24, at 8:54 A.M., Certified Nurse Aide (CNA) F said the resident received hospice services. He/She knew this because the hospice provider came in to give the resident baths. He/She would be able to know what the facility would provide and what hospice would provide by what was documented on the care plan. During an interview on 09/12/24, at 9:00 A.M., CNA G said the resident received hospice services and he/she knew this because the resident was in a special bed. He/she would provide the basic care that he/she provides to everyone and he/she was not sure what hospice would provide to the resident. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the resident was on hospice services and that hospice should be on the care plan. 48187 2. Review of Resident #2's face sheet showed the following information: -admitted [DATE]; -Diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave), urinary tract infection, dysphagia (difficulty speaking), and falls. Review of the resident's Patient-Specific Letter of Agreement Inpatient and Respite Care Services, dated 04/12/24, showed hospice services were provided. Review of the resident's quarterly MDS, dated [DATE], showed the resident received hospice services. Review of the resident's current nurses' progress notes showed the following: -On 08/14/24, the Weekly Summary showed the resident continued on hospice services. -On 08/28/24, the Weekly Summary showed the resident continued on hospice services; -On 09/04/24, the Weekly Summary showed the resident continued on hospice services; Review of the resident's care plan, revised 06/19/24, showed staff did not care plan related to the resident's use of hospice services. During an interview on 09/11/24, at 11:53 A.M., RN L said that the resident was currently on hospice services and is being documented on a weekly progress note that the resident is on hospice. RN L said hospice should be care planned. During an interview on 09/11/24, at 11:56 A.M., RN H said that the resident was currently on hospice. RN H said that the nurses assess and document a weekly note that includes that the resident is on hospice. Hospice should be on the care plan. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said the resident was on hospice and he/she would expect it to be on his/her care plan. During an interview on 09/11/24, at 1:28 P.M., the Director of Nursing (DON) said the care plan should be updated with hospice services. The resident was on hospice. During an interview on 09/12/24, at 4:15 P.M., the Administrator said the resident was currently on hospice and had been for a while now. 3. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said care plans should be up-dated quarterly or as needed with any significant change. The MDS Coordinator and DON are the only staff that up-date the care plans. Hospice should be on the care plan. The MDS Coordinator said that he/she doesn't get to spend a lot of time on care plans as he/she is mostly working the floor as a charge nurse. 4. During an interview on 09/12/24, at 11:22 A.M., the DON said hospice should be addressed on the facility care plan. 5 During an interview on 09/12/24, at 4:13 P.M., the Administrator said hospice should be on the facility care plan.

Based on observation, record review, and interviews, the facility failed to assist all dependent residents with activities of daily living to maintain good grooming when the facility staff failed to perform peri-care for one resident (Resident #41) following an episode of incontinence and toileting. The facility census was 39. 1. Review of Resident #42's face sheet (gives basic profile information about the resident) showed the following: -admitted [DATE]; -Diagnoses included metabolic encephalopathy (brain dysfunction that occurs due to a chemical imbalance in the blood) and congestive heart failure (CHF - irregular heart function). Review of the resident's care plan, last updated 08/15/24, showed the following: -Staff to assist with toileting; -Staff to provide changing and peri-care with each incontinent episode to keep skin clean and free from odor and breakdown; -Staff to apply barrier creams with each incontinent episode to maintain good skin integrity. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 08/21/24, showed the following: -Severely impaired cognition; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -Required substantial/maximal assistance for toileting hygiene. Observation on 09/10/24, at 2:05 P.M., showed the following: -Certified Nurse Aide (CNA) C and CNA D donned gloves and assisted the resident to walk to the toilet. The back of the resident's pants were wet. -The resident held onto the grab bar while the CNAs lowered his/her pants and wet brief; -The resident sat on the toilet. -CNA C removed his/her gloves and left the bathroom to retrieve a fresh brief and dry pants. -CNA C handed new gloves to CNA D and without performing hand hygiene, they both changed their gloves. -Without performing any peri-care, the CNAs placed the new brief and clean pants on the resident. -The CNAs ambulated with the resident back to his/her recliner. During an interview on 09/12/24, at 1:04 P.M., CNA J said staff should do peri-care whenever a resident is changed or after they use the bathroom. Staff should do peri-care regardless of whether or not there is any output. When toileting a resident staff should put gloves on, undue the brief, use two wipes to clean the resident's peri-area, take off the gloves to refasten brief or place new one. If the gloves become dirty, they should be changed. They don't do hand hygiene in between glove changes. During an interview on 09/12/24, at 12:51 P.M., CNA F said he/she would do peri-care when toileting a resident and every two hours regardless. Staff should put gloves on and use wipes to do peri-care. If the gloves get dirty, staff should wash their hands and put a new pair on. The clean, dry brief should be place using a clean pair of gloves. During an interview on 09/12/24, at 1:55 P.M., the Director of Nursing (DON) said staff should assist residents with peri-care and/or toileting. Staff should clean the front first, wiping from front to back, change gloves and sanitize their hands, and then clean the back side. Staff should sanitize their hands before touching other things, utilizing hand sanitizer, and wash their hands when they are finished caring for the resident. During an interview on 09/12/24, at 4:13 P.M., the Administrator and the corporate QA RN (Quality Assurance Registered Nurse) said staff should always perform peri-care with incontinence and/or toileting. Staff should change their gloves and sanitize their hands during care and sanitize hands before touching other things or re-dressing the resident.

Based on observation, record review, and interviews, the facility failed to ensure staff followed acceptable standards of care when staff did not change gloves or sanitize their hands during care for the indwelling suprapubic catheter (tubing inserted directly into the bladder through the abdomen to drain to an exterior collection bag) of one resident (Resident #20). The facility census was 39. 1. Review of Resident #20's face sheet (gives basic profile information) showed the following: -admitted to the facility on [DATE]; -Diagnoses included bipolar disease (mental disorder causing alternating depressive and manic episodes), generalized anxiety disorder, insomnia, muscle weakness, history of urinary tract infection (UTI), benign prostatic hyperplasia (BPH; enlarged prostate gland) with lower urinary tract symptoms, testicular hypofunction, indwelling urethral catheter, impaired cognitive function and awareness, and schizophrenia (mental disorder including hallucinations and delusions). Review of the resident's quarterly Minimum Data Set (MDS; a federally mandated comprehensive assessment tool completed by facility staff), dated 07/04/24, showed the following information: -Cognition mildly impaired; -Indwelling catheter in place; -Continent of bowel. Review of the resident's physician order sheet, current as of 09/12/24, showed the following: -an order, dated 01/06/23, for an indwelling catheter, size 14 French with 10 milliliter (ml) bulb/balloon; -an order, dated 01/06/24, to change the catheter monthly; -an order, dated 01/06/24, for catheter care every shift. Review of the resident's care plan, last updated 07/06/24, showed the following: -Problem start date: 01/13/23 -Chronic suprapubic catheter, inserted due to diagnosis of BPH and urinary retention; goal to remain free of complications from BPH and chronic UTIs; empty catheter every shift and/or as needed; monitor and record output; perform catheter care every shift and as needed. Observation on 09/11/24, at 2:25 P.M., showed RN L donned a gown, gloves, and mask while in the hallway outside the resident's room, then turned the knob to open the door and enter the room. RN L explained the procedure to the resident, who rested on his/her bed. Without changing the contaminated gloves or performing hand hygiene, RN L lowered the resident's sweatpants to expose the abdominal (SP: suprapubic) insertion site of the catheter and removed the old gauze drain sponge surrounding the insertion site. The RN went to the sink and applied soap and water to a washcloth, then used it to clean around the SP insertion site. RN L secured the catheter tubing with one gloved hand and cleaned the tubing in a motion away from the body, did not change gloves or perform hand hygiene, and dried the tubing using a dry part of cloth. Still without changing gloves or performing hand hygiene, the RN placed a new drain sponge around site, replaced the waistband of pants, and then removed his/her gloves, gown and mask and washed his/her hands. During an interview on 09/11/24, at 3:00 P.M., RN L said staff should don gloves after washing/sanitizing their hands. Staff should change gloves after cleaning the catheter insertion site, but he/she did not remember to do so during the above observed catheter care. During an interview on 9/12/24, at 4:13 P.M., the Administrator and the corporate QA RN (Quality Assurance Registered Nurse) both said staff should wash/sanitize their hand prior to donning gloves. Staff should change gloves and sanitize their hands after cleaning a catheter, before touching clean items.

Based on record review, observation, and interview, the facility failed to provide care per standards of practice when staff failed to address one resident's (Resident #39) complaints of pain in a timely manner. The facility census was 39. Review of the facility's policy Pain Management Guidelines, dated January 2017, showed the following: -The goal of pain management will be to control pain so it will not interfere with the ability to have restful sleep patterns, perform activities of daily living (ADL's- dressing, grooming, bathing, eating, and toileting), participate in usual activities, or cause problems with mood or behaviors; -A licensed nurse or certified nurse aide (CNA) may assess and communicate degrees of pain to the person administering the pain medications to the residents; -Hospice residents will be provided pain medications according to the hospice program and physician orders; -The resident's description of his/her pain will be documented in the nurses progress notes/aide charting and/or on the MAR of the resident's medical record. 1. Review of Resident #39's face sheet (brief resident profile sheet) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), stroke, depression, anxiety, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Resident on hospice services. Review of the resident's care plan, dated 06/04/24, showed the following: -Alert with episodes of fluctuating orientation related to behaviors with diagnoses of PTSD, anxiety, depression, and stroke; -Complains of pain and try to get pain medication, even when they are not due yet; -Goal of adequate pain control; -Staff to monitor for control of pain; -Staff to offer the resident as needed (PRN) pain medications with complaints of break-through pain; -Staff to offer non-pharmacological interventions, such as position changes or massage; -Staff to do quarterly and PRN pain assessments. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/10/24, showed the following: -The resident did not receive scheduled pain medications; -The resident had frequent pain; -The resident's pain frequently affected sleep patterns; -The resident's pain frequently affected his/her ability to complete day to day activities. Review of the resident's pain assessment and evaluation, dated 06/13/24, showed the following: -Resident had frequent pain in the last five days; -Pain made it frequently difficult for the resident to sleep over the last five days; -Pain frequently limited the resident's day-to-day activities; -The resident expressed pain through anxiety, agitation/restlessness, anger, sleep disturbance, and verbal reports; -The resident rated his/her pain as severe over the last five days; -The resident described his/her pain as shooting, stabbing, and throbbing; -The resident reported pain all times of the day; -Resident made vocal complaints of pain; -Resident was not on a scheduled pain regimen. Review of the resident's current Physician Order Sheet (POS) showed the following: -An order dated 07/12/24, for hydrocodone/acetaminophen (a narcotic that treats pain) 10/325 milligrams (mg), one tablet by mouth, every six hours, as needed; -An order, dated 07/12/24, for morphine concentrate (narcotic that can treat moderate to severe pain)100 mg/5 milliliters (ml), 0.25 ml by mouth, every two hours, as needed. Review of the resident's September 2024 Medication Administration Record (MAR) showed the following: -On 09/10/24, at 7:15 A.M. staff administered morphine concentrate for leg pain rated 7 out of 10. Staff documented resident resting after administration ; -On 09/10/24, at 11:15 A.M., staff administered morphine concentrate for leg pain rated 8 out of 10. Staff documented resident resting after administration. Observation on 09/10/24, of the resident, showed the following: -At 2:36 P.M., the resident yelled out. The resident lay in the bed complaining of pain to his/her left arm, both leg, and knees. The resident had a blanket and sheet placed across his/her midsection, but not covering his/her legs; -At 2:38 P.M., the resident began yelling for pain medication. The resident said, Nurse! I need something for pain; -At 2:42 P.M., the resident began moaning loudly in pain and rubbing his/her legs together. The resident said, I can't hardly stand it; -At 2:44 P.M., a staff member walked past the door and the resident began yelling for help; -At 2:46 P.M., the resident continued to moan loudly while still rubbing his/her legs together; -At 2:48 P.M., the resident began yelling, Nurse!; -At 2:53 P.M., the resident said, I'm still hurting bad, worse; -At 2:55 P.M., the resident yelled out, I'm freezing, I'm freezing, bring another blanket; -At 2:58 P.M., the resident began repeatedly saying please. He/she then said, sometimes you have to wait a minute, it feels like it's been 30; -At 3:00 P.M., the resident told a staff member in the hall, Nurse, that pain medicine didn't work, I'm still hurting like crazy; -At 3:06 P.M., the resident lay in bed rubbing his/her left arm and muttering to self; -At 3:14 P.M., the resident said he/she continued to hurt in his/her legs, knees, and arms; -At 3:17 P.M., the resident lay in bed talking to self. No staff entered in the room to check on him/her. -At 3:24 P.M., the resident said loudly he/she had pain in all his/her joints, hurts about every day. The resident complained of being cold. Certified Nurse Aide (CNA) C entered the room. CNA C said he/she heard the resident say he/she was cold. The CNA covered the resident with a blanket. The resident told the aide he/she had pain in his/her joints. CNA C said he/she thought the resident was on scheduled pain medication and did not know for sure if he/she could have anything right now. The CNA said he/she would check with the nurse and left the room. During an interview on 09/10/24, at 3:24 P.M., the resident said sometimes he/she could get up and do stuff. The pain did not usually affect or prevent him/her from doing daily activities. Sometimes, the pain affected his/her sleep. The resident said the pain was better. During an interview on 09/10/24, at 3:40 P.M., Registered Nurse (RN) H said he/she did not know the resident had complained of pain. The CNA did not tell him/her about the resident's complaints of pain. The resident was not on scheduled pain medication. The nurse said he/she could go give the resident something for pain. Review of the resident's September 2024 MAR showed the following: -On 09/10/24, at 4:00 P.M., staff administered morphine concentrate, for leg pain rated 7 out of 10. Staff documented the dose was not effective; -On 09/10/24, at 5:45 P.M., staff administered hydrocodone/acetaminophen for leg pain rated at 8 out of 10. Staff documented the dose was effective. During an interview on 09/11/24, at 2:41 P.M., Certified Medication Technician (CMT) E said the following: -No one reported the resident's pain to him/her on 09/10/24, or he/she would have given the resident a pain pill; -He/She gave the resident hydrocodone/acetaminophen on 09/10/24, at 5:45 P.M., when the resident sat at the desk yelling out that his/her legs hurt; -He/she said would assess a resident for pain when giving a pain pill, but he/she assumed the nurses were responsible for assessing pain. During an interview on 09/11/24, at 3:45 P.M., CNA C said the following: -He/She would report pain to the CMT and nurse immediately; -Staff can tell when the resident is in pain by nonverbal cues and other time he/she can verbally tell; -Regardless of the way the pain is communicated, he/she would report it; During an interview on 09/11/24, at 4:02 P.M., CNA D said that he/she would report a resident's complaint of pain immediately to the nurse or CMT. The resident can voice complaints of pain verbally. During an interview on 09/12/24, at 8:54 A.M., CNA F said the following: -He/She would report pain to the nurse or CMT immediately; -He/She knows when the resident is having pain because he/she yells out; -Pain pills do help the resident and normally work within 30 minutes; -The resident's pain affects him/her from getting up/going to meals; -The resident's pain affects his/her sleep. During an interview on 09/12/24, at 9:00 A.M., CNA G said the following: -He/She would reposition a resident complaining of pain to see if that relieves the pain. He/She would also report the pain to the nurse and the CMT immediately; -He/She knows the resident has pain because the resident yells out; -The resident's pain sometimes affects him/her going to meals; -Pain pills seem to help the resident sometimes, but if he/she has already been yelling for a long time they don't seem to work as well. During an interview on 09/12/24, at 9:36 A.M., Registered Nurse (RN) H said the following: -The nurses only assess pain when they give a PRN medication; -There is no routine pain assessments; -If a resident can verbally describe pain, he/she would use a pain scale of 1 to 10; -If a resident cannot verbally describe pain, he/she would look for nonverbal cues such as crying, grimacing, yelling, or rubbing a body part; -The resident can verbalize his/her pain; -The resident also has non verbal cues such as yelling and crying; -The pain medication helps sometimes; -Sometimes the morphine does not help, sometimes the Norco does better; -All of the resident's pain medications are PRN; -The resident's pain sometimes effects his/her ability to attend meals; -The resident's pain sometimes effects his/her sleep as the resident will yell out more when he/she is in pain. During an interview on 09/12/24, at 10:47 A.M., the resident's primary physician said the following: -Since the resident is on hospice, he would expect staff to give him/her pain medication; -The resident is on a starting dose of morphine, which he would consider low, and could be increased if not effective; -He would expect staff to notify him if the resident's pain medication was not effective. During an interview on 09/12/24, at 1:15 P.M., the MDS Coordinator said she would expect pain management to be on the care plan and that she would expect staff to follow the care plan. During an interview on 09/12/24, at 11:22 A.M., the Director of Nursing (DON) said the following: -The nurses assess for pain; -The residents should be assessed for pain when a resident says they are in pain, during the weekly skin assessment, and before and after a PRN medication is given; -If a resident has chronic pain, they should be assessed every shift; -The nurses document the pain assessment on the MAR or in the nurse's notes; -If a resident is verbal, they should be assessed using a 1 to 10 scale; -If a resident is non verbal, they should be assessed by looking for grimacing, crying, rubbing legs together, or holding body parts; -Staff can tell when the resident has leg pain because the resident will move his/her legs and cry out; -To assess the resident's pain, staff should ask him/her where if it hurts and where, and look for nonverbal cues; -When the resident is crying out or if he/she asked for pain medication, he/she would give it immediately; -The pain pills do a good job controlling his/her pain most of the time; -The resident's pain does not keep him/her from getting up for meals as far as she is aware; -The resident's pain does effect his/her sleep. During an interview on 09/12/24, at 4:13 P.M., the Administrator said nurses should be assessing pain, that it should be documented in a progress note, and he would expect pain to be treated in a timely manner.

Based on record review and interview, the facility failed to ensure that all residents who were trauma survivors received care per standards of practice when staff did not address the the diagnosis of Post-Traumatic Stress Disorder (PTSD - disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) in the medication record or in the care plan, to include triggers and interventions, and failed to ensure care staff were aware of the PTSD history, to include triggers and interventions, for one resident (Resident #41). The facility census was 39. Review of the facility assessment, updated 10/25/23, showed the following information: -The facility may accept residents with, or who may develop, common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management including PTSD; -The facility will manage the medical conditions causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, and care of individuals with trauma/PTSD; -The facility will provide person-centered/directed care. Staff to find out what upsets him/her and incorporate this into he care planning process. Staff to make sure staff caring for the resident has this information. Review showed the facility did not provide a policy related to PTSD. 1. Review of Resident #41's face sheet (gives basic profile information about the resident) showed an admitted [DATE]. Review of the resident's PASARR Level II Evaluation (Preadmission Screening and Resident Review (PASARR) - a two level tool used to screen each resident in a nursing facility for mental disorder or intellectual disability prior to admission), completed by hospital staff on 05/09/24, showed the following information: -No contact with his/her three children; -He/she and spouse started using drugs/alcohol together at an early age. Spouse currently supposed to be in alcohol/drug rehab program, but recently signed out of the program. At this time the spouse is not allowed to visit, per family's request; -Resident/spouse had a house that burned to the ground last year and now living in a [NAME] house on sibling's property; -Sibling reports he/she and siblings grew up in a very abusive home environment. Parent remarried to an abusive partner with heavy drug/alcohol involvement in the home. All siblings experienced significant mental/physical abuse and witnessed significant domestic violence in the home. All siblings, including this resident, reported they were sexually abused; -Sibling reported resident attempted suicide once by hanging and once by cutting him/herself. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/21/24, showed the resident's diagnoses included traumatic brain dysfunction, seizure disorder, and anxiety disorder. Review of resident's nurses' notes showed the following: -On 07/29/24, at 2:07 A.M., the resident returned from outing with family and had been punching, pushing, trying to bite, and kicking at staff and attempting to elope. Attempts to calm resident down and redirect have not been effective. Staff gave as needed medication, but resident still wound up. Staff following him/her around to prevent elopement, but aggressive behaviors continue. Staff contacted nurse practitioner and received order for Haloperidol (an antipsychotic medication) 1 milligram (mg) IM (injected in the muscle) given now. The medication has not stopped behaviors; -On 07/29/24, at 4:28 A.M., resident continued with aggressive behaviors and refused redirection. Staff received order from nurse practitioner to send resident out for evaluation. Emergency medical services (EMS) left with resident at 3:00 A.M. Review of the resident's face sheet showed on 08/02/24 the diagnosis of post-traumatic stress disorder was added. Review of resident's nurses' notes showed on 08/03/24, at 4:45 A.M., resident arrived back at the facility at 11:00 P.M. Resident reported he/she was glad to be back and have a pleasant affect. Resident placed on 15-minute checks. Review of the resident's care plan, last reviewed 08/15/24, showed the staff did not address the new diagnosis of PTSD, the resident's triggers for PTSD, or interventions related to PTSD. Review of the resident's quarterly MDS, dated [DATE], showed the resident's diagnoses included PTSD. Review of the facility provided matrix (a form requested on survey entrance with brief details of resident care needs), completed on 09/09/24, showed the staff identified the resident had PTSD/trauma. During an interview on 09/11/24, at 1:55 P.M., the resident's sibling said they have tried to educate the facility staff on the resident's emotional triggers. The resident and his/her siblings were molested as children and agitation will escalate if staff make him/her lie down for any personal care. During an interview on 09/12/24, at 11:28 A.M., Certified Nurse Aide (CNA) P, who was the designated shower aide for the day, said the resident gets agitated sometimes. The CNA thinks the family being present often over stimulates him/her; then he/she wants them there all the time. He/she was not aware of any psychological history for the resident or a diagnosis of PTSD. During an interview on 09/12/24, at 12:55 P.M., CNA G said he/she gets a report from the previous shift on the residents. Other staff should know and pass on information regarding a resident's triggers and care needs. He/she did not know of any specific triggers for the resident or his/her psychological background. During an interview on 09/12/24, at 1:04 P.M., Licensed Practical Nurse (LPN) K said he/she was contracted staff and had worked in the facility often, but hadn't been there for the past month. A CNA said the resident's spouse had come in drunk and upset the resident. The LPN was unaware of other triggers or psychological background for the resident. During an interview on 09/12/24, at 1:40 P.M., the MDS Coordinator said he/she did not know who added the diagnosis of PTSD. A diagnosis of PTSD should be listed under behaviors in the care plan. The MDS Coordinator was unaware of the resident's history, the reason for the PTSD diagnosis, or any triggers for the resident. He/she said they didn't think they'd need to list any specific triggers, just that there is a history of traumatic event, to inform the staff. During an interview on 09/12/24, at 1:55 P.M. the Director of Nursing (DON) said staff should have carried the diagnosis over to the care plan to identify and notify staff of history and triggers. He/she was not previously aware of the resident's history of being abused/molested as a child or the house fire. During an interview on 09/12/24, at 4:13 P.M., the Administrator and the corporate Quality Assurance Registered Nurse said a diagnosis of PTSD should be noted in the resident's care plan with specifics and triggers. The Administrator was unaware of the reason for the resident's PTSD diagnosis or any triggers.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to complete appropriate hand hygiene and use PPE appropriately while providing wound care for one resident (Resident #32). Facility staff also failed to complete appropriate hand hygiene while providing indwelling suprapubic catheter (tubing inserted directly into the bladder through the abdomen to drain to an exterior collection bag) care for one resident (Resident #20). The facility census was 39. Review of the facility policy, titled Handwashing, dated 03/2015, showed the following information: -Purpose to reduce transmission of organisms from resident-to-resident, staff-to-resident, and resident-to-staff; -Wash hands with soap and water. Review of the facility policy, titled Enhanced Barrier Precautions (EBP) to Infection Control Guidance, updated 03/2024, showed the following information: -Policy purpose was to prevent broader transmission of multidrug-resistance organisms and to help protect patients with chronic wounds and indwelling devices; -EBP should be implemented until wounds have resolved or indwelling medical devices have been removed; -Staff are to use EBP when providing high-contact resident care activities such as performing wound cares; -Equipment include gloves and gown; -Conduct proper hand hygiene before starting care; -Gloves and donning and doffing of gown are required when conducting high-contact resident care activities such as wound care; -Gloves and gown should be removed and discarded after each resident care encounter; -Personal Protective Equipment (PPE) should be placed in proximity outside the resident's door and a trash can in the resident's room for disposal prior to leaving the room. Review of the facility policy, titled Wound Care and Treatment, dated 07/2015, showed the following information: -Handwashing and glove usage will be done according to guidelines; -Put on gloves; -Remove soiled dressing and place in trash bag; -Remove gloves and place in trash bag; -Wash hands and put on clean gloves; -Clean the wound according to the physician orders; -Remove gloves and place in trash bag. Put on clean pair of gloves (handwashing or alcohol gel usage if skin is contaminated when gloves removed); -Apply clean dressing; -Position resident comfortably with call light with-in reach; -Clean the environment with Sani/bleach wipes; -Discard trash; -Remove gloves and wash hands; -Document. 1. Review of Resident #32's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; Diagnoses included stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) of sacral region (the triangular bone at the base of the spine that connects the lower back to the pelvis), heart failure, hypertension (high blood pressure), and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/16/24, showed the following information: -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised 06/30/24, showed the following information: -Staff to use EBP when providing cares while in the resident's room; -Assist with repositioning and toileting; -Monitor skin for any signs of breakdown such as redness, blisters, and open areas. Review of the resident's current Physician Order Sheet showed the following information: -An order, dated 07/17/24, to cleanse wound with hypochlorous acid (no need to rinse from wound or skin, use to irrigate and scrub the wound bed, protect peri-wound with skin prep, lightly pack tunnel (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) with a long thin piece of Hydrofera Blue (antibacterial wound dressing) and cover with ABD pad (gauze) for moderate to heavy drainage. Treatment to be done every other day and as needed if soiled. -An order, dated 08/16/24, clean coccyx wound with Vashe (wound cleanser), place Puracol (collagen wound dressing) in wound, cover with gauze, then apply foam dressing to cover gauze, with skin prep around dressing, Place Suresite (transparent film dressing) over wound and surrounding area. Treatment to be done every other day. Observation on 09/11/24, at 10:38 A.M., showed the following information: -Registered Nurse (RN) L parked a treatment cart outside the resident's room with drawers facing the resident's room and gathered supplies; -RN L completed hand hygiene and donned gown, surgical mask, and gloves before entering resident's room; -RN L removed the old dressing and placed in biohazard bag; -RN L cleansed wound with wound cleanser and sterile Q-tip, then placed Q-tip in biohazard bag; -RN L changed gloves without performing hand hygiene; -RN L applied skin prep to skin around wound then placed Hydrofera Blue in wound; -RN L pulled his/her face mask down exposing his/her nose with gloved hand; -RN L changed gloves without performing hand hygiene; -RN L covered wound with ABD pad and secured with tape; -RN L changed gloves without performing hand hygiene; -The resident repositioned to left side; -RN L removed old dressing and placed in biohazard bag; -RN L cleansed wound with wound cleanser; -RN L while kneeled at the bedside near the wound, pulled his/her mask from face, fanned face with his/her hand and stated he/she was trying to get some air; -RN L applied skin prep to skin around wound; -RN L changed gloves without performing hand hygiene; -RN L applied Puracol dressing to wound; -RN L removed gloves (did not perform hand hygiene), left room with gown on, went to treatment cart to obtain ABD pad; -RN L returned to room, ABD pad placed without gloves and secured with tape; -RN L pulled mask from face, fanned face with his/her hand, and said he/she could not breath with the mask covering his/her face; -RN L removed gown and mask and washed hands. During an interview on 09/11/24, at 11:53 A.M., RN L said staff should use hand hygiene after changing gloves, but said I don't. I cleanse my hands good at the beginning and wash them again when I am all done with wound care. I change my gloves between dirty and clean and that should be good. During an interview on 09/11/24, at 11:56 A.M., RN H said staff should wash their hands or use hand hygiene before and after wound care and any time they change their gloves. During an interview on 09/11/24, at 1:28 P.M., the Director of Nursing (DON) said that staff is expected to wear gown, gloves and mask when providing cares on all EBP residents. The DON expected staff to wash hands or use hand hygiene before and after donning and doffing gloves and every time gloves are changed. The DON expected the mask to cover the nose and mouth of staff when performing cares and staff should not remove the face mask or pull the mask from the face while performing cares with a gloved hand. The DON expected staff to complete the wound care, then remove all PPE, including mask, and wash hands before leaving the resident's room. During an interview on 09/12/24, at 4:15 P.M., the Administrator said that he/she would not expect staff to pull face mask down and fan face while performing wound cares. He expected staff to wash hands or use hand hygiene after removing gloves. 2. Review of Resident #20's face sheet showed the following: -admitted [DATE]; -Diagnoses included history of urinary tract infection (UTI), benign prostatic hyperplasia (BPH - enlarged prostate gland) with lower urinary tract symptoms, and indwelling urethral catheter. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognition mildly impaired; -Indwelling catheter in place; -Continent of bowel. Review of the resident's physician order sheet, current as of 09/12/24, showed the following: -An order, dated 01/06/23, for an indwelling catheter; -An order, dated 01/06/24, to change the catheter monthly; -An order, dated 01/06/24, for catheter care every shift. Review of the resident's care plan, last updated 07/06/24, showed the following: -Chronic suprapubic catheter inserted due to diagnosis of BPH and urinary retention; -Goal to remain free of complications from BPH and chronic UTIs; -Staff to empty catheter every shift and/or as needed, monitor and record output, and perform catheter care every shift and as needed. Observation on 09/11/24, at 2:25 P.M., showed the following: -RN L donned a gown, gloves, and mask while in the hallway outside the resident's room, then turned the knob to open the door and enter the room; -RN L explained the procedure to the resident, who rested on his/her bed. Without changing the contaminated gloves or performing hand hygiene, RN L lowered the resident's sweat pants to expose the abdominal insertion site of the catheter and removed the old gauze drain sponge surrounding the insertion site; -The RN went to the sink and applied soap and water to a washcloth, then used it to clean around the SP insertion site. (The RN did not complete hand hygiene.); -RN L secured the catheter tubing with one gloved hand and cleaned the tubing in a motion away from the body without changing gloves or performing hand hygiene. RN L then dried the tubing using a dry part of the cloth; -Without changing gloves or performing hand hygiene, the RN placed a new drain sponge around site and replaced the waistband of pants. During an interview on 09/11/24, at 3:00 P.M., RN L said staff should don gloves after washing/sanitizing their hands. Staff should change gloves after cleaning the catheter insertion site, but he/she did not remember to do so during the above observed catheter care. During an interview on 9/12/24, at 4:13 P.M., the Administrator and the corporate QA RN (Quality Assurance Registered Nurse) both said staff should wash/sanitize their hand prior to donning gloves. Staff should change gloves and sanitize their hands after cleaning a catheter, before touching clean items.

Based on interviews and record review, the facility staff failed ensure all allegations of possible abuse were reported timely when staff did not report an allegation of employee to resident abuse involving one resident (Resident #1) immediately to administration and within two hours of staff becoming aware of the allegation to the state survey agency (Department of Health and Senior Services - DHSS). The facility census was 32. Review of the facility policy titled Abuse Prohibition Protocol Manual, revised 11/28/16, showed the following: -Educate all staff to report to the Administrator and/or designees any alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown sources 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 involved abuse or resulted in injury. Review of the facility policy titled Reporting, revised 11/2017, showed the following: -All allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately; -Allegations of abuse must be reported within two hours after the allegation was made; -All employees of the facility are mandated reporters. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following information: -admitted [DATE]; -Diagnoses included pervasive development disorder (delays of social and communication skills), epilepsy (seizures), anxiety, and bipolar disorder (mood swings ranging from depressive lows to manic highs). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/16/23, showed the following information: -Severe cognitive impairment; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Sometimes incontinent of bowel and bladder. Review of the resident's care plan, revised 11/16/23, showed the following information: -Provide resident with supportive care and services; -Staff will anticipate needs and ensure needs are met; -Staff will keep area around resident calm and quiet with minimal stimulation. Record review of the facility's initial facility reported incident to the Abuse and Neglect Hotline, dated 12/10/23, at 7:01 A.M., showed the following: -The Administrator reported to the Director of Nursing (DON) at 8:24 p.m. on 12/09/23 that the Dietary Manager had received a text message from Dietary Aide (DA G) that he/she believed Certified Nurse Aide (CNA) J had restrained the resident while taking him/her out of the dining room at supper time; -Later, the DA said he/she and cook, (DA H) seen this same CNA yelling at this same resident, and aggressively putting him/her to bed. Review of the facility's follow-up investigation report, dated 12/12/23, showed the following: -The victim was Resident #1 and the alleged perpetrator was CNA J; -DA G reported to his/her supervisor that he/she witnessed staff member CNA J wrap his/her arms around the resident from behind when the resident was screaming in the dining room at 6:00 P.M. Friday evening (12/08/23). CNA J quickly released the resident and then wheeled his/her wheelchair out of the dining room. DA G then witnessed CNA J helping the resident into bed at around 7:40 P.M. He/she claimed he/she felt that CNA J was being a little rough with the resident and that the resident hit his/her knee on the wall, but could not be sure; -The resident's guardian and physician were notified; -The allegation was reported to the facility Adminstrator at 8:30 P.M. on 12/09/23 (the day after the alleged abuse occurred). During an interview on 12/18/23, at 11:30 A.M., DA G said that he/she saw CNA J restraining the resident while in the dining room on Friday, 12/08/23, at approximately 5:30 P.M. CNA J was holding down the resident's arms while he/she was sitting in his/her wheelchair while in the dining room. Later that evening he/she witnessed CNA J aggressively throw the resident into the bed and yell at the resident to stay in the bed. DA G said that he/she did not report this to anyone until the next evening, Saturday, 12/09/23, at approximately 8:00 P.M. He/she notified his/her manager via text message. He/she said he/she was not aware that it should have been reported immediately. During an interview on 12/18/23, at 12:50 P.M., DA H said he/she was with DA G on 12/08/23, gathering trays from residents' rooms, when he/she heard CNA J yell at the resident to lay down and stay in bed. He/she did not see any abusive behavior in the room, stating he/she only heard the yelling from the resident's room then saw a CNA J leave the room and slam the door. He/she said he/she did not report it because he/she did not see anything to report. Abuse or neglect should be reported to the manager or the Administrator immediately. During an interview on 12/18/23, at 1:25 P.M., Dietary Manager I said that he/she received a text message from DA G on Saturday, 12/09/23, at approximately 8:09 P.M., regarding alleged abuse that had occurred the previous day. He/she immediately called the Administrator to report the allegation and forwarded him the text message. Dietary Manager I said that he/she has educated his/her staff on multiple occasions to notify him/her immediately of any abuse or neglect that is seen or heard. During an interview on 12/18/23, at 10:57 A.M., Housekeeper A said he/she was not aware of any recent allegations of abuse and has not had any recent abuse and neglect trainings or in-services. If he/she witnessed any abuse, he/she would report it immediately to his/her supervisor so that it could be reported to the state within two hours. During an interview on 12/18/23, at 10:59 A.M., Housekeeper B said that he/she has not witnessed any abuse including yelling or cussing or seen any staff being rough with the residents. He/she would report those things immediately to his/her supervisor. During an interview on 12/18/23, at 11:04 A.M., Housekeeper C said that he/she has not seen any abuse. He/she said that any abuse should be reported to all administration, including his/her Manager, Director of Nursing (DON) and the Administrator immediately. During an interview on 12/18/23, at 11:06 A.M., Registered Nurse (RN) D said that he/she has not seen any recent abuse. He/she would report any abuse immediately to the Director of Nursing and the Administrator. During an interview on 12/18/23, at 11:10 A.M., Nurses Assistant (NA) E said that if he/she witnessed any kind of abuse he/she would notify the charge nurse immediately. He/she said that the facility has two hours to report alleged abuse to the state. During an interview on 12/18/23, at 11:15 A.M., Certified Nurse's Assistant (CNA) F said that he/she has not witnessed any abuse from staff and if he/she does he/she will notify his/her charge nurse, DON, and Administrator immediately. During an interview on 12/18/23, at 1:30 P.M., the Director of Nursing (DON) said the Administrator had called him/her on Saturday, 12/09/23, at approximately 8:30 P.M., regarding alleged abuse that had occurred the previous day. The DON said that he/she lived close to the facility and came to the facility to immediately report the alleged abuse to DHSS. During an interview on 12/18/23, at 1:38 P.M., the Administrator said that he received a phone call from the Dietary Manager I on Saturday, 12/09/23, at approximately 8:25 P.M., regarding alleged abuse that had occurred the previous day. The Administrator said that he called the DON to report the abuse and the Administrator immediately started his/her investigation. He/she expects staff to notify him/her and the DON immediately of any allegations of abuse or neglect. The facility has two hours to report the allegations to DHSS. MO00228554

Based on observation, interview, and record review, the facility failed to ensure all residents were free from physical restraint for the convenience of staff when one staff (Registered Nurse (RN) A) physically restrained one resident (Resident #1) with a bed sheet against the resident's wishes and without a physician's orders. The facility census was 39. The administrator was notified on 7/28/2021, at 11:02 A.M., of an Immediate Jeopardy (IJ) which began on 7/21/2021. The IJ was removed on 7/29/2021, as confirmed by surveyor onsite verification. Review of the facility Abuse Prohibition Protocol Manual, last updated 11/28/2016, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Review of the facility restraint policy from the Nursing Guidelines Manual, dated March 2015, showed the following: -Restraints shall only be used for the safety and well-being of the residents and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls; -Physical restraints are defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body; -Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life sustaining treatment, and no less restrictive interventions are not feasible. The Director of Nursing (DON) has the authority to order the use of emergency restraints. The attending physician must be notified of such use and the reason for the order. 1. Review of Resident #1's face sheet (admission data) showed the following: -Most current admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, last review date 05/17/2021, showed the following: -[CONDITION(S)] medications to treat [CONDITION(S)] (mood disorder) and [CONDITION(S)] disorder; -Monitor for any side effects or extrapyramidal symptoms (EPS-related to or denoting nerves concerned with motor activity) and report to the doctor/psychiatrist; -Perform quarterly Abnormal Involuntary Movement (AIMS-used to assess severity scale of dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs, and torso)), and psychiatric appointments through tele-psych visits; -Psychological state will be stable by the next review date; -Used a wheelchair for mobility and can self propel; -Behavioral symptoms include delusions and untrue statements, difficulty staying on topic, and does not make sense at times; -Allow the resident to tell delusional stories and only correct if necessary; -Monitor for changes in moods and behaviors. If staff observe resident to be agitated take to quiet space and let the resident vent to you. -Alert the psychiatrist/doctor. (The care plan did not specifically say what to alert the psychiatrist/doctor of.) Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated comprehensive assessment tool completed by facility staff), dated 05/12/2021, showed the following: -Severe cognitive impairment; -Short and long-term memory problems; -Mild depression demonstrated by feeling down or depressed 7-11 days out of 14; difficulty falling asleep or staying asleep 7-11 days out of 14; and difficulty concentrating on things 2-6 days out of 14; -No behaviors exhibited; -Required extensive assistance for transfers, walking in room and corridor, eating, toileting, hygiene, and bathing; -Non-verbal signs of pain 1-2 days out of 7; -No falls; -No restraints. Review of the resident's nurses' notes showed the following: -On 7/20/2021 at 1:20 P.M., the resident continued to have behaviors. He/she was out in the hallways with facility under COVID-19 (an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([CONDITION(S)]-CoV-2)) quarantine. He/she refused to wear a mask. The resident was yelling at the top of his/her lungs that This is God's house, this is Judgement Day, and cussing at staff and other residents constantly. The resident was angry, delusional, and in a manic state. The resident was not sleeping for any length of time and was not eating. The nurse notified the psychiatrist of resident's behaviors and that the recent order of [MEDICATION(S)] (an anti-psychotic medication) did not benefit the resident. The nurse also notified the psychiatrist that the neurologist (a physician who treats diseases of the brain and spinal cord and peripheral nerves and muscles) discontinued the resident's [MEDICATION(S)] (a medication used to treat mood disorders) at his/her visit on 7/12/2021. The psychiatrist ordered [MEDICATION(S)] (an anti-psychotic medication) 5 mg by mouth or injection every six hours as needed. The psychiatrist asked the nurse to contact the neurologist and ask for suggestions. Staff notified the resident's guardian. Staff administered the resident's [MEDICATION(S)] 5 mg given at 12:00 P.M., with no change in behavior at that time. Staff will continue to monitor. (Staff did not document contacting the neurologist as directed by the psychiatrist. Staff did not document follow-up with the psychiatrist when the medication was not effective.) Record review of the resident's Physician's Order Sheet (POS), dated 6/01/21 to 7/29/2021, showed the following: -An order, dated 07/20/2021, for [MEDICATION(S)] 5 milligrams (mg) orally every six hours as needed for [CONDITION(S)] disorder; -An order, dated 07/20/2021, for [MEDICATION(S)], 5 milligrams intramuscularly (in the muscle), every six hours as needed for [CONDITION(S)] disorder; -No physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's nurses' notes showed the following: -On 07/20/2021 at 9:43 P.M., the resident propelled self around the facility refusing to go to his/her room per COVID protocol. The resident was delusional using the word [OBSCENITY] to everyone. The resident stated he/she was pregnant with God's baby, then continued with delusions and informed the nurse he/she was a child of the devil. As the night progressed the resident became worse with his/her behavior. The resident stated he/she was not going to take any more pills from staff because staff were trying to poison him/her. -On 7/21/2021 at 5:44 A.M., Registered Nurse (RN) A documented during shift report the resident came out of his/her room and sat beside the nursing desk overhearing his/her name mentioned. The resident became loud, screaming curse words, saying [OBSCENITY] You over and over. The nurse explained to the resident he/she was on COVID Protocol Room Confinement. The resident refused to go to his/her room and was delusional and paranoid. The resident's behavior escalated quickly to the point the resident was trembling all over. Staff administered one IM injection of [MEDICATION(S)] in resident's right buttock. The injection was ineffective at alleviating degree of resident's behavior as the resident's behaviors worsened over the night requiring three to one direct patient care. The resident's delusions got more detailed and cursing got louder. The staff were unable to redirect the resident. The resident kept leaving the room, attempting to go outside, and demanding a cigarette. The nurse utilized a soft restraint sheet wrapped around both upper extremities for brief period to transport the resident back to his/her room after the resident became unsafe with his/her wheelchair by shaking it and putting his/her hands in the wheels of the wheelchair when the wheelchair was being pushed by staff. The resident threw punches at staff and slapped and kicked. The nurse was unable to reason with the resident and unable to redirect the resident. The resident was unsafe to self and to staff. Other residents awakened during sleep due to resident's behaviors. Placed call to Social Services Director (SSD) D to request he/she assist with intervention by talking to the resident. SSD D arrived and spoke to the resident and by the end of their time together, the resident was conversational and laughing. The resident still refused to take the as needed [MEDICATION(S)]. After the SSD D left the resident went to sleep for about an hour and when he/she awakened he/she quickly returned to the previous behaviors. (Staff did not not document he/she had attempted to contact the Director of Nursing (DON) regarding the restraint use, or the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's investigation which was started on 7/28/2021 (seven days after the restraining of the resident occurred and was documented), beginning at 10:00 A.M., and completed on 7/29/2021, showed the following: -On 7/21/2021, at 7:30 A.M., charge nurse (RN A), applied a flat sheet around chest and upper arms of the resident; - The summary of the findings of the investigation supported RN A did place a sheet around the resident's chest and arms; -The charge nurse, RN A, suspended (7/28/2021) pending outcome of the investigation; -The findings of the investigation determined abuse did not occur. It was not RN A's intention to abuse the resident and no harm occurred to the resident. The facility determined the RN did not follow the facility policy on the use of restraints during an emergency situation. -The RN will receive on-going education regarding behavior management. Review of RN A's statement, dated 7/29/2021, showed the following: -The resident's behavior had intensified and escalated over the duration of the 10:00 P.M. to 6:00 A.M. shift; -The resident's behavior during the shift included tipping his/her wheelchair, trying to throw him/herself out of the wheelchair, jerking the wheelchair up and down while seated in the chair, and striking out at staff; -He/she attempted to contact the administrator and Director of Nursing with no success; -He/she took a flat sheet, folded it lengthwise and placed it around the resident's upper arms and held it with his/her hands on the wheelchair hand grips; -The restraint was not effective. The sheet was removed because it did not help; -The resident wheeled him/herself back to his/her room at that time; -The incident with the sheet occurred near the end of the shift; -RN A said he/she should have walked away and instructed the staff to walk away and allowed the resident to behave without interference. He/she should also have called the physician for further instruction when he/she could not make contact with the DON or administrator. During a telephone interview on 7/28/2021 at 7:31 A.M., (after finishing his/her shift) RN A said the following: -The behaviors the resident had were extreme. The resident's behaviors had escalated and the resident was combative, delusional, agitated, and paranoid. The resident thought orange people were going to kill him/her; -He/she attempted to calm the resident and talk to him/her. He/she attempted to rationalize with the resident and tried diversion because the resident was trying to hurt him/herself with the wheelchair. The resident was shaking the wheelchair kind of bouncing it and hanging on the wheels of the wheelchair as if he/she was trying to flip the wheelchair; -RN A said he/she used a soft sheet restraint later that morning after staff had been three to one with resident care. The RN said he/she did not know what else to do. The staff were unable to redirect the resident and the resident continued to curse and try to throw self from wheelchair; -He/she asked staff to get him/her a flat sheet and he/she folded it wide and placed around the resident's upper extremities while RN A held the sheet to the arms of the wheelchair; -The physical restraint soft sheet was ineffective. After the resident had been restrained the resident went back to his/her room. The RN said the sheet was on for less than two minutes and was not a good idea; -The RN said prior to using the sheet on the resident, he/she had attempted to contact the DON and Administrator and could not reach either; -At one point the social worker did respond and came in and calmed the resident, but then the resident's behaviors resumed after the social worker left; -He/she did not know for physical restraints staff had to notify the DON and obtain an order from the physician. Review of the Certified Nurse Aide (CNA) M's facility witness statement, dated 7/28/2021, showed the following: -On 7/21/2021, at approximately 7:00 A.M., the resident was taking him/herself outside and following staff into other residents' rooms; -The resident was yelling, cursing, kicking, and hitting at staff; -He/she attempted to take the resident to his/her room when the resident grabbed the wheels of his/her wheelchair to prevent it being moved; -The charge nurse obtained a flat sheet and the sheet was placed around the resident's chest and upper arms; -The resident was taken to his/her room and the sheet was removed. During an interview on 7/27/2021 at 11:20 A.M., CNA F said the following: -He/she received training on how to deal with difficult residents having behaviors. Staff should try to calm resident, re-direct, walk away, reapproach, and report to charge nurse; -It is not acceptable to use a physical restraint; -He/she saw RN A physically restrain the resident with a bed sheet last week. The resident was very combative and hit the RN in the head with a full water pitcher. The resident also kicked and hit the nurse and was screaming, scratching and yelling; -RN A asked CNA F to get a sheet and bring it to him/her. The RN folded the sheet and did a soft physical restraint around the resident's upper extremities so the resident could not hit anymore; -The nurse requested he/she assist with holding the sheet around the resident's upper extremities and he/she refused; -The resident resisted the restraint, yelled, and continued to attempt to use his/her arms while restrained; -The staff got the resident calmed down so he/she was not hitting, but the resident was still angry and cussing. The staff took him/her to his/her room in a wheelchair. The sheet had been removed when he/she took the resident back to his/her room in his/her wheelchair; -He/she reported the incident to the charge nurse LPN C. He/she did not know if administration had been informed; -The sheet had been placed around the resident's upper extremities for one to two minutes. During interviews on 7/27/2021 at 10:20 A.M. and 1:50 P.M., LPN C said the following: -On 7/21/2021, the resident came up to the nurses' station and heard his/her name mentioned. At report the on-coming and off-going nurse go through each resident and discuss pertinent information about residents and events regarding the residents on previous shift; -On 7/21/2021, LPN C said RN A reported the resident had extreme behaviors including combativeness, cursing, refusal to comply with COVID-19 protocols, and kicking which could hurt the resident. The resident had been observed shaking his/her wheelchair and hitting the wall; -After the nurses finished report and completed the narcotic count the resident had gone back to his/her room; -The facility provided training on dealing with difficult residents who were having behaviors. Staff should try to redirect the resident. If after multiple attempts a staff could not calm the resident or redirect the resident staff should notify the on-call doctor to see about a medication order or to obtain an order to send the resident out for a psychiatric evaluation; -At no time were physical restraints appropriate; -The facility does not use physical restraints; -He/she read this in the progress note after report on 7/21/2021. After he/she read the progress note he/she told the DON and Administrator to read the progress note. During an interview on 7/25/2021 at 10:50 A.M., Nurse Aide (NA) B the resident had been very combative and having behaviors of cursing, hitting, and threatening staff and the resident later was sent to a psychiatric hospital on 7/22/2021. During an interview on 7/27/2021 at 10:50 A.M., NA B said the following: -He/she worked the night shift on 7/21/2021; -The resident was having extreme behaviors; -The facility provided training on dealing with difficult residents at orientation. Staff should try to calm the resident, redirect, try to change subject, walk away, reapproach; -Restraints were not allowed and could be considered a form of abuse. During an interview on 7/27/20 at 11:52 A.M., MDS/Care Plan Coordinator G said the following: -The resident was care planned for behaviors and for psychoactive medications; -Staff should not use a sheet to physically restrain a resident and the facility does not use behavior restraints; -He/she heard RN A used a soft sheet restraint around the resident's upper extremities so the resident would not hit staff; -Staff should try to take resident outside to calm him/her, get another staff to assist with the resident, could step away and reapproach later, or see if social services could speak to the resident; -The RN could have called the physician for a medication order or a request to send the resident out for a psychiatric evaluation; -It was not appropriate to use a restraint to physically restrain a resident against their wishes. During an interview on 7/28/2021 at 12:30 P.M., CNA J said the following: -CNA classes covered how to deal with residents having behaviors and believed the facility provided this training as well. The CNA said he/she would step back unless behaviors were directed at other residents, protect residents, report the behaviors to the charge nurse, try a different approach or get another staff to try to deal with the resident, or reapproach; -Restraining a resident against their wishes could be considered abuse. During an interview on 7/28/2021, at 12:10 P.M., Certified Medication Technician (CMT)/CNA K said the following: -At orientation the facility provided training on residents with difficult behaviors called Calm training. If a resident had behaviors staff should report these to the charge nurse, attempt to calm the resident, find out why the resident is upset and having behaviors, attempt to redirect, try to see if another staff can calm the resident, and reapproach; -He/she knew physical restraints were not supposed to be used; -He/she is not sure what staff had to do to get authorization for a physical restraint; -Restraining a resident with a sheet against their wishes is a form of abuse. During an interview on 7/29/2021, at 1:03 P.M., SSD D said the following: -On 7/21/2021, he/she had been notified by the RN that the resident was having extreme behaviors and asked if the SSD could come to facility and try to calm the resident down. He/she did come to facility and was able to calm the resident down and the resident went to sleep; -The resident had been having mental illness exacerbation for a while. The facility had notified the physician and psychiatrist and medication changes had been done. The medications did not seem to help; -The facility sent the resident to the neurologist to see if he/she had medical conditions to be causing the exacerbation of his/her mental illness. The neurologist took the resident off his/her [MEDICATION(S)] and it made the resident ten times worse. The resident had been cursing, screaming, delusional, hallucinating, calling staff names, and hitting staff; -He/she would have reported this to administration; -The facility does not use physical restraints; -He/she would consider using a physical restraint against a resident's wishes as a form of abuse; -Staff were trained on how to deal with residents having behaviors and on the restraint policy. During an interview on 7/25/2021 at 11:10 A.M., the DON said the following: -The resident's mental illness had been exacerbated for a while. The facility had notified his/her physician and psychiatrist and medication changes had been done and it did not help. The facility sent the resident to his/her neurologist to see if there were any medical reasons for his/her behaviors. The neurologist took the resident off his/her [MEDICATION(S)] and his/her behaviors became ten times worse. The resident had been delusional, hallucinating, screaming, cursing, calling staff names, and hitting staff; -The resident never reported to the DON that a staff personal had restrained him/her or tied him/her down; -The staff had not reported that a resident had been tied down. During an interview on 7/27/2021 at 1:20 P.M., the Medical Director, who is resident's primary physician, said the following: -He found out about the incident with the sheet today (07/27/2021); -He would have expected a call to the on-call physician regarding the resident's behaviors; -He said he had been updated throughout the week on this resident's behaviors. The behaviors became a problem after the resident saw the neurologist who stopped the residents [MEDICATION(S)]; -He was not sure if the nurse on duty called a doctor on call. He said if it was during the day the staff should contact the psychiatrist who manages the resident's mental health; -He would step in if the facility could not reach the psychiatrist quickly and something needed to be done; -The facility does not use restraints; -The nurse could have called the on-call doctor and gotten an order to send the resident out for psychiatric care instead of using a restraint. During an interview on 7/27/2021 at 10:40 A.M., the Administrator said the following: -She had read the nurses' note from 7/21/2021; -The facility never physically restrains a resident; -The nurse should have not used a soft sheet restraint and should have realized this was abuse; -Staff were provided training on how to deal with residents having behaviors at orientation and periodically throughout the year; -She would have expected the nurse to walk away and reapproach the resident unless the resident with behaviors was hurting another resident; -The nurse had called earlier that shift and got a [MEDICATION(S)] order for the residents behaviors. The [MEDICATION(S)] did not help and possibly made the resident worse; -She was not aware of the RN contacting the physician after the [MEDICATION(S)] did not help or to get an order to use a physical restraint. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 523

Based on interview and record review, the facility failed to immediately begin an investigation and take steps to protect all residents from abuse when one staff member (Registered Nurse (RN) A) was witnessed by other staff physically restraining one resident (Resident #1) with a bed sheet and the staff member (RN A) continued to work additional shifts unsupervised in the facility. The facility census was 39. The administrator was notified on 7/28/2021 at 11:02 A.M., of an Immediate Jeopardy (IJ) which began on 7/21/2021. The IJ was removed on 7/29/2021, as confirmed by surveyor onsite verification. Record review of the facility Abuse Prohibition Protocol Manual, last updated 11/28/2016, showed the following: -Immediately educate all staff to report to the Administrator and/or designees of 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 no later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury; -It is the policy of the facility to train employees, through orientation and on-going sessions on issues related to abuse and prohibition practices to include what constitutes abuse, neglect, exploitation, and misappropriation of resident property; recognizing signs of abuse and neglect; and reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown origin, and to whom and when staff and others must report their knowledge related to the alleged violation without fear of reprisal; -Annual notification of covered individuals of their obligation to comply with reporting requirements, and understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond; -The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse, neglect, or exploitation or mistreatment while the investigation is in progress; -The resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms; -The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: thoroughly investigate the alleged violation; prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and take appropriate corrective action as a result of the investigation findings; -The facility follow-up investigation notes will be submitted via fax or as directed by Department of Health and Senior Services (DHSS) within five working days of the initial report. 1. Record review of Resident #1's face sheet (admission data) showed the following: -Most current admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated comprehensive assessment tool completed by facility staff), dated 05/12/2021, showed the following: -Severe cognitive impairment; -Short and long-term memory problems; -No behaviors exhibited; -Required extensive assistance for transfers, walking in room and corridor, eating, toileting, hygiene, and bathing; -No falls; -No restraints. Record review of the resident's Physician's Order Sheet (POS), dated 6/01/21 to 7/29/2021, showed the following: -An order, dated 07/20/2021, for [MEDICATION(S)] (an anti-psychotic medication) 5 milligrams (mg) orally every six hours as needed for [CONDITION(S)] disorder; -An order, dated 07/20/2021, for [MEDICATION(S)], 5 milligrams intramuscularly (in the muscle), every six hours as needed for [CONDITION(S)] disorder; -No physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's nurse's note dated 7/21/2021, at 5:44 A.M., showed RN A documented the following: -During shift report the resident came out of his/her room and sat beside the nursing desk overhearing his/her name mentioned. The resident became loud, screaming curse words, saying [OBSCENITY] You over and over; -The nurse explained to the resident he/she was on COVID (an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([CONDITION(S)]-CoV-2)) Protocol Room Confinement; -The resident refused to go to his/her room and was delusional and paranoid; -The resident's behavior escalated quickly to the point the resident was trembling all over; -Staff administered one IM injections of [MEDICATION(S)] in resident's right buttock. -The injection was ineffective at alleviating degree of resident behavior as the resident's behaviors worsened over the night and required three to one direct patient care; -The resident's delusions got more detailed and cursing got louder. The staff were unable to redirect the resident. The resident kept leaving the room, attempting to go outside, demanding a cigarette; -The nurse utilized a soft restraint sheet wrapped around both upper extremities for brief period to transport the resident back to his/her room after the resident became unsafe with his/her wheelchair by shaking it and putting his/her hands in the wheels of the wheelchair when the wheelchair was being pushed by staff; -The resident threw punches at staff and slapped and kicked. The nurse was unable to reason with resident and unable to redirect the resident. The resident was unsafe to self and to staff. Record review of Department of Health and Senior Services (DHSS) records showed the facility did not self-report an allegation of abuse when RN A restrained the resident with a sheet. Record review of the facility's investigation which was started on 7/28/2021 (seven days after the restraining of the resident occurred and was documented), beginning at 10:00 A.M., and completed on 7/29/2021, showed the following: -On 7/21/2021, at 7:30 A.M., charge nurse (RN A), applied a flat sheet around chest and upper arms of the resident; - The summary of the findings of the investigation supported RN A did place a sheet around the resident's chest and arms; -The charge nurse, RN A, suspended (7/28/2021) pending outcome of the investigation; -The findings of the investigation determined abuse did not occur. It was not the RN A's intention to abuse the resident and no harm occurred to the resident. The facility determined the RN did not follow the facility policy on the use of restraints during an emergency situation. -The RN will receive on-going education regarding behavior management. Record review of RN A's statement, dated 7/29/2021, showed the following: -The resident's behavior had intensified and escalated over the duration of the 10:00 P.M. to 6:00 A.M. shift; -The resident's behavior during the shift included tipping his/her wheelchair, trying to throw him/herself out of the wheelchair, jerking the wheelchair up and down while seated in the chair, and striking out at staff; -He/she attempted to contact the administrator and Director of Nursing with no success; -He/she took a flat sheet, folded it lengthwise, and placed it around the resident's upper arms and held it with his/her hands on the wheelchair hand grips; -The restraint was not effective. The sheet was removed because it did not help; -The resident wheeled him/herself back to his/her room at that time; -The incident with the sheet occurred near the end of the shift; -RN A said he/she should have walked away and instructed the staff to walk away and allowed the resident to behave without interference. He/she should also have called the physician for further instruction when he/she could not make contact with the DON or administrator. During a telephone interview on 7/28/2021 at 7:31 A.M., (after finishing his/her shift) RN A said the following: -He/she received abuse and neglect training at hire that covered types of abuse, when to report, and how to report. He/she did not recall an annual training on abuse and neglect or training on how to deal with difficult residents; -The behaviors the resident had were extreme. The resident's behaviors escalated and the resident was combative, delusional, agitated, and paranoid. The resident thought orange people were going to kill him/her; -He/she attempted to calm the resident and talk to him/her. He/she attempted to rationalize with the resident and tried diversion because the resident was trying to hurt him/herself with the wheelchair. The resident was shaking the wheelchair kind of bouncing it and hanging on the wheels of the wheelchair as if he/she was trying to flip the wheelchair; -RN A said he/she used a soft sheet restraint later that morning after staff had been three to one with resident care. The RN said he/she did not know what else to do. The staff were unable to redirect the resident and the resident continued to curse and was trying to throw self from wheelchair; -He/she asked staff to get him/her a flat sheet and he/she folded it wide and placed around the resident's upper extremities while RN A held the sheet to the arms of the wheelchair; -The physical restraint soft sheet was ineffective. After the resident had been restrained the resident went back to his/her room. The RN said the sheet was on for less than two minutes and was not a good idea; -The RN said prior to using the sheet on the resident, he/she had attempted to contact the DON and Administrator and could not reach either; -At one point the social worker did respond and came in and calmed the resident, but then the resident's behaviors resumed after the social worker left; -He/she did not know for physical restraints staff had to notify the DON and obtain an order from the physician. Record review of the Certified Nurse Aide (CNA) M's facility witness statement, dated 7/28/2021, showed the following: -On 7/21/2021, at approximately 7:00 A.M., the resident was taking him/herself outside and following staff into other residents' rooms; -The resident was yelling, cursing, kicking, and hitting at staff; -He/she attempted to take the resident to his/her room when the resident grabbed the wheels of his/her wheelchair to prevent it being moved; -The charge nurse obtained a flat sheet and the sheet was placed around the resident's chest and upper arms; -The resident was taken to his/her room and the sheet was removed. Record review of the facility's staffing schedule from July 16, 2021 through July 31, 2021, showed RN A scheduled to work the following days: -On 7/21/2021, 6:00 P.M. to 6:00 A.M.; -On 7/24/2021, 6:00 P.M. to 6:00 A.M.; -On 7/25/2021, night shift (hours not listed); -On 7/26/2021, night shift (hours not listed). Record review of RN A's Employee Counseling Notice, dated 7/29/2021, showed on 7/21/2021 RN A utilized a soft sheet restraint on the resident without following emergency restraint protocol. RN A suspended pending the facility investigation. During an interview on 7/27/2021 at 11:20 A.M., CNA F said the following: -He/she had received abuse and neglect training when hired and periodically throughout the year. He/she said the abuse and neglect training covered what abuse is, signs and symptoms of abuse, types of abuse, how to report, and when to report allegations of abuse; -He/she received training on how to deal with difficult residents having behaviors. Staff should try to calm resident, re-direct, walk away, reapproach, and report to charge nurse; -It is not acceptable to use a physical restraint; -He/she saw RN A physically restrain the resident with a bed sheet last week. The resident was very combative and hit the RN in the head with a full water pitcher. The resident also kicked and hit the nurse and was screaming, scratching and yelling; -RN A asked CNA to get a sheet and bring it to him/her. The RN then folded the sheet and did a soft physical restraint around the resident's upper extremities so the resident could not hit anymore; -The nurse requested he/she assist with holding the sheet around the resident's upper extremities and he/she refused; -The staff got the resident calmed down so he/she was not hitting, but the resident was still angry and cussing. The staff took him/her to his/her room in a wheelchair. The sheet had been removed when he/she took the resident back to his/her room in his/her wheelchair; -He/she reported the incident to the charge nurse LPN C. He/she did not know if administration had been informed; -The sheet had been placed around the resident's upper extremities for one to two minutes. During interviews on 7/27/2021 at 10:20 A.M. and 1:50 P.M., LPN C said the following: -He/she had been provided abuse and neglect training at orientation and through periodic in-services on abuse and neglect. The training covered types of abuse, and how and when to report abuse and neglect; -On 7/21/2021, the resident came up to the nurses' station and heard his/her name mentioned. At report the on-coming and off-going nurse go through each resident and discuss pertinent information about residents and events regarding the residents on previous shift; -On 7/21/2021, LPN C said RN A reported the resident had extreme behaviors including combativeness, cursing, refusal to comply with COVID-19 protocols, and kicking which could hurt the resident. The resident had been observed shaking his/her wheelchair and hitting the wall; -The facility does not use physical restraints; -He/she read this in the progress note after report on 7/21/2021. After he/she read the progress note he/she told the DON and Administrator to read the progress note; -He/she did not report the nurse physically restrained a resident because it had been hearsay; -He/she did not think CNA F reported to him/her that the RN had physically restrained the resident. It was very chaotic and several staff talking so maybe he/she did report the incident and LPN C did not hear him/her. During an interview on 7/27/2021 at 10:50 A.M., NA B said he/she had heard hearsay about the incident with the sheet, but did not report this since he/she did not see it. He/she had heard RN A used a sheet to wrap it around the resident's arms so staff could push the resident in his/her wheelchair back to his/her room. NA B said physically restraining a resident against their wishes could be considered abuse. During an interview on 7/27/2021, at 11:52 A.M., MDS/Care Plan Coordinator G said the facility provided abuse and neglect training at hire and at least annually as well as on-line training's on abuse and neglect. The training covers types of abuse, signs or symptoms of abuse, how to report, and when to report. He/she heard RN A used a soft sheet restraint around the resident's upper extremities so the resident would not hit staff. He/she would consider using a physical restraint against a residents wishes as a form of abuse. During an interview on 7/29/2021 at 1:03 P.M., SSD D said the facility provided abuse and neglect training at orientation and several times a year. He/she said this training would have covered abuse and neglect signs and symptoms, what abuse is, how to report and when to report abuse. He/she would have reported the restraint to administration and would have considered the restrain abuse. The facility should investigate allegations of abuse. If the facility received an allegation of abuse against an employee, the employee should be suspended pending investigation and if cleared the employee would be allowed to return to work. If he/she received an allegation of abuse against an employee he/she would send the employee out of the building immediately. During an interview on 7/25/2021 at 11:10 A.M., the DON said the resident never reported to the DON that a staff person had restrained him/her or tied him/her down. Staff had not reported any abuse or that a resident had been tied down. If he/she had been informed of the RN physically restraining a resident he/she would have report this to state as abuse. If the facility received an allegation of abuse against an employee the employee should be suspended and an investigation completed. During an interview on 7/27/2021, at 10:40 A.M., the Administrator said the nurse should have not used a soft sheet restraint and should have realized this was abuse. He/she had not been able to get in touch with the nurse at this time. Staff were provided training on abuse and neglect and how to deal with residents having behaviors at orientation and periodically throughout the year. If the facility had an allegation of abuse against an employee the facility should suspend the employee and start an investigation. During an interview on 7/27/2021, at 9:55 A.M., the Corporate Nurse said he/she did not think the facility connected that this was an allegation of abuse and did not start an investigation. At this time the facility has started an investigation, suspended RN A, and were completing staff and resident interviews. (Six days after the nurse restrained the resident with a sheet). The facility should suspend an employee immediately if there is an allegation of abuse against a resident. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 523