Every finding on record at Seasons Rehab and Healthcare Center

Based on interview and record review, the administration of the facility failed to safeguard the medication administration of each resident. The administration failed to provide Certified Medication Technician (CMT) A his/her own sign in to pass medications once notified the sign on was not working. CMT A used Licensed Practical Nurse (LPN) A's sign in to pass medications to the facility residents. This has the potential to affect all residents. The facility census was 74 residents.Review of the facility undated Onboarding Standard Operating Procedure showed:-Interview applicant. -If an offer is made and accepted proceed to the next step.-Collect all necessary documents to run necessary background and license checks.-Start new hire onboard electronically through Hosted Time.-Preferably while they are in the office.-All new hires must complete new hire documentation electronically.-Run all necessary background checks while new hire is completing onboarding via Host Time.-All the above steps should be performed as timely as possible before a new hire leaves the facility. Review of the facility Employee Handbook dated 1/1/24 and 1/1/25 showed:-The facility expects that all personnel know and comply with the federal False Claims Act (FCA) and any state false claims laws, rules or regulations.--Examples of false claims includes falsifying records or signatures.-General Expectations for use of facility technology and equipment are.--Employees with access to computer files and records may not release or disseminate any information without authorization.--Staff may not share passwords with any unauthorized persons.--Users prohibited from attempting to access restricted files or portions of operating systems, security systems, or administrative systems to which they have not been given authorization and/or access, including electronic mail, data, programs, or information protected under state or federal laws. 1.Review of the facility undated Acknowledgment of Receipt and Review of Facility Handbook showed:-CMT A and LPN A had received a copy of the Employee Handbook and acknowledge they were responsible for reading and complying with the Handbook.-They agreed to comply with the policies in the Handbook.-By their signature below, they confirm that he/she had read and understood the above statements and that they received a copy of the facility's Employee Handbook.-Was signed by CMT A on 12/17/24.-Was signed by LPN A on 4/14/25. During an interview on 2/11/26 at 3:25 P.M., Director of Nurses (DON) said:-Human Resources (HR) does the staff credentials and sets up the employees sign in to the computer for medical records.-He/She can reset an employee's password if locked out of the computer.-He/She was not aware CMT A was having trouble with his/her sign in and was using LPN A's sign in to pass medications to the residents.-LPN A went as needed (PRN) in November 2025.-LPN A's last shift was 11/28/25 and had not worked since then.-He/she would not ask a new hire to use another employee's sign in to chart in resident's medical records.-Staff can contact him/her or HR 24 hours; seven days a week by texting or calling, if there in problems signing in to the computer. During a phone interview on 2/11/26 at 4:06 P.M., HR said:-He/She sets up the new hire's sign in for the computer once the background checks comes back and the new hire accepts the offer the facility had made.-He/She always tells the staff to never give out his/her sign in information to anyone.-He/She would expect staff to follow the employee handbook that they read and sign at the time of hire.-CMT A was a Certified Nursing Aide (CNA) before getting his/her CMT license in 10/2025 and already had a sign in.-CMT A was transferred over from the CNA credentials, so he/she could pass medications. -He/She had reset CMT A's password a couple of times.-CMT A said he/she could use another staff members sign in to pass medications until his/her sign in worked.-He/She told CMT A he/she could not use another employee's sign in to pass medications.-He/She was not aware that CMT A was still having problems and was using LPN A's sign in to pass medications.-If an employee terminates employment from the facility, he/she was responsible for deleting the employee from the system.-He/She does not delete the employee the same day sometimes it is a couple of days before he/she gets the deleting done.-If an employee was PRN, then the employee's sign in stays active all the time and is not shut off in-between shifts.-The DON can reset passwords, but he/she cannot change the credentials.-LPN A would have had to give CMT A his/her sign in to use, that was the only way CMT A could have gotten the sign in from LPN A. During an interview on 2/11/26 at 4:43 P.M., CMT A said:-He/She had told the Administrator, HR, DON and Assistant Director of Nursing (ADON) he/she was still having problems signing in to the computer to pass medications on several occasions but noting was every done to correct the problem.-The DON said he/she could not fix his/her sign in only HR could fix the problem.-He/She could sign in as a CAN but not as a CMT.-HR kept assigning him/her shifts to pass medications even though HR knew he/she was having problems getting into the resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR).-He/She and LPN A had worked a shift together and he/she could not chart that he/she had passed medications, so LPN A let him/her sign in with his/her sign in to chart in the resident's medical records.-He/She kept using LPN A' sign in to pass medications after LPN A went PRN.-He/She quite working at the facility because the administration could not get his/her sign in fixed, and he/she knew it was wrong to keep using LPN A's sign in to pass medications.-He/She would sign out the controlled substance medications in the book with his/her name and then use LPN A's sign in to chart the medication was given to the resident with LPN A initials. During an interview on 2/11/26 at 5:01 P.M., Administrator said:-LPN A went PRN in November and had not worked at the facility since.-He/She was not aware that CMT A was having problems with their sign in and did not know CMT A was using LPN A's sign in to pass medications. During an interview on 2/11/26 at 5:01 P. M., Regional Nurse said:-HR was responsible for entering the staff members information into the facility computer to get a sign in for the staff member.-Housekeeping would be given a sign in for housekeeping duties, and nurse would be given a sign in for nursing duties and a CMT would be given a sign in to pass medications and CNA duties as they can work both positions.-He/she would expect every staff member to have his/her own sign in to work.-Staff members shouldn't work if there is a problem with his/her sign in because they would not be able to chart in the resident's medical records.-If there is a problem with signing in, staff need to notify HR, DON or ADON of the problem.-Staff should not give another staff member his/her sign in for the computer.-He/she was not aware that CMT A was using LPN A's sign in to pass resident medication.-A PRN staff member who had not worked in over three months should be put in-active in the computer and sign in shut off until scheduled to work again.-He/she would never tell another staff member to sign in under another staff member to document in resident's medical records. During an interview on 2/18/26 at 11:09 A.M., LPN A said:-He/She was not aware of CMT A was using his/her sign in to pass medications to the residents.-He/She did not give CMT A permission to use his/her sign in and did not give CMT A his/her sign in information.-He/she had not worked since 11/28/25 and went PRN.-When he/she would come on shift, the computer was already on.-All he/she had to do was click on the drop-down box and click on his/her name and he/she was signed in to work under his/her name.-Sometime the computer would ask for his/her password to sign in and other times the computer would show the password.-One time the computer showed a password, and it was not his/her password, and he/she clicked go and the computer signed him/her in even though it was the wrong password.-The whole time he/she worked at the facility he/she was never asked to change his/her password. 2724968

Based on interview and record review, the facility failed to ensure staff-maintained documentation of medications as provided on the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for eight sampled residents ( Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9), when Certified Medication Technician (CMT) A used Licensed Practical Nurse (LPN) A's electronic sign in when he/she administered resident's medications for three months for eight of the nine sampled residents. The facility census was 74 residents.Review of the facility revised Medication Administration Policy dated 10/24/22 showed:-Purpose.--To provide practice standards for safe administration of medications for the residents in the facility.-Procedure.--The Licensed Nurse or CMT will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR.-Documentation.--The time dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment.--Recording will include the date, time, and dosage of the medication or type of the treatment.--Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. 1. Review of Resident #1's undated admission Record showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:-Dementia (a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). -Chronic Kidney Disease Stage 3 (a progressive loss of kidney function, sometimes over years, leading to permanent kidney failure).-Hyperlipidemia (HDL - high levels of lipids (fats) in the blood).-Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest).-High Blood Pressure. 2. Review of Resident #2's undated admission Record showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:-Dementia.-Major Depressive Disorder.-High Blood Pressure.-Thrombotic Pulmonary Emboli (a blockage in the lung's arteries, usually caused by a blood clot that travels from the legs or pelvis). 3. Review of Resident #3's undated admission Record showed the resident was admitted to the facility on [DATE] with the following diagnosis:-Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks).-Chronic Obstructive Pulmonary Disease (COPD - a lung disease that restricts airflow and makes breathing difficult).-Dementia.-Delusion Disorder (a serious mental illness characterized by holding one or more false, persistent, and unshakable beliefs).-Major Depressive Disorder.-Anxiety.-Chronic Kidney Disease Stage 3B. 4. Review of Resident #5's undated admission Record showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:-Chronic Kidney Disease Stage 3A.-Dementia.-Anxiety.-Hypothyroidism (is when the thyroid gland doesn't make enough thyroid hormones to meet the body's needs causing the metabolism to slow down).-Chronic Pain.-Neuropathy (is nerve damage causing symptoms like numbness, tingling, burning pain and muscle weakness often in the hands and feet).-Peripheral Vascular Disease (PVD - a circulatory condition causing narrowed blood vessels outside the heart/brain, often affecting the legs). 5. Review of Resident #6's undated admission Record showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:-COPD.-Alzheimer's Disease.-High Blood Pressure.-Chronic Kidney Disease.-Dementia.-Hyperlipidemia.-Diabetes Type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar). -Cerebrovascular Disease (CVD - a group of disorders affecting the heart and blood vessels).-Stroke. 6. Review of Resident #7 undated admission Record showed the resident was admitted to the facility on [DATE] with the following diagnosis:-Hypothyroidism.-Dementia.-Major Depressive Disorder.-Anxiety.-Malignant neoplasm (cancer) of the head, face, and neck. 7. Review of Resident #8's undated admission Record showed the resident was admitted to the facility on [DATE] with the following diagnosis:-Alzheimer's Disease.-High Blood Pressure.-Major Depressive Disorder.-Anxiety.-Diverticulosis (a common condition where small, non-inflamed pouches form in the colon wall). 8. Review of Resident #9's undated admission Record showed the resident was admitted to the facility on [DATE] with the following diagnosis:-High Blood Pressure.-Chronic Kidney Disease Stage 3.-Dementia.-Depression.-Delusional Disorder. 9. Review of the facility Timecard record showed LPN A's last shift worked was on 11/28/25. Review of the facility Timecard Detail Report dated 10/1/25 to 2/14/26 showed CMT A worked 11/29/25, 11/30/25, 12/1/25 to 12/9/25, 12/11/25 to 12/13/25, 12/16/25,12/19/25 to 12/22/25, 12/26/25 to 12/28/25, 12/31/25, 1/1/26 to 1/4/26, 1/6/26 to 1/11/26, 1/13/26, 1/14/26, 1/17/26, and 1/18/26. Review of the facility's November 2025 MAR and TAR showed LPN A administered medications and treatments:-On 11/29/25 to Resident #1, Resident #3.-On 11/30/25 to Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5, Resident #6 and Resident #7. Review of the facility's December 2025 MAR and TAR showed LPN A administered medications:-On 12/1/25 to Resident #9.-On 12/4/25 to Resident #2 and Resident #7.-On 12/5/25 to Resident #4, Resident #5, Resident #6 and Resident #9.-On 12/6/25 to Resident #1 and Resident #3.-On 12/7/25 to Resident #1 and Resident #3.-On 12/8/25 to Resident #3.-On 12/12/25 to Resident #2, Resident #7, Resident #8 and Resident #9.-On 12/16/25 to Resident #2, Resident #7 and Resident #8.-On 12/19/25 to Resident #4, Resident #5, Resident #6 and Resident #9.-On 12/20/25 to Resident #3.-On12/21/25 to Resident #1 and Resident #3.-On 12/27/25 to Resident #4, Resident #5, Resident #6 and Resident #9.-On 12/28/25 to Resident #4, Resident #5, Resident #6 and Resident #9.-On 12/31/25 to Resident #1 and Resident #3. Review of the facility's January 2026 MAR and TAR showed LPN A administered medications to:-On 1/2/26 to Resident #4, Resident #5, Resident #6 Resident #8 and Resident #9.-On 1/3/26 to Resident #1, Resident #2 and Resident #3.-On 1/4/26 to Resident #2 and Resident #7.-On 1/6/26 to Resident #2 and Resident #7.-On 1/7/26 to Resident #3.-On 1/9/26 to Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7, Resident #8 and Resident #9.-On 1/10/26 to Resident #2 and Resident #7.-On 1/11/26 to Resident #2 and Resident #7.-On 1/13/26 to Resident #2 and Resident #7.-On 1/17/26 to Resident #1 and Resident #3.-On 1/18/26 Resident #4, Resident #5, Resident #6, Resident #8 and Resident #9. During a phone interview on 2/11/26 at 4:06 P.M., Human Resources (HR) said:-CMT A was a Certified Nursing Aide (CNA) before getting his/her CMT license in 10/2025 and already had a sign in.-CMT A was transferred over from the CNA credentials, so he/she could pass medications. -He/She had reset CMT A's password a couple of times.-CMT A said he/she could use another staff members sign in to pass medications until his/her sign in worked.-He/She told CMT A he/she could not use another employee's sign in to pass medications.-He/She was not aware that CMT A was still having problems and was using LPN A's sign in to pass medications.-If an employee terminates employment from the facility, he/she was responsible for deleting the employee from the system.-He/She does not delete the employee the same day sometimes it is a couple of days before he/she gets the deleting done.-If an employee was PRN, then the employee's sign in stays active all the time and is not shut off in-between shifts.-The DON can reset passwords, but he/she cannot change the credentials.-LPN A would have had to give CMT A his/her sign in to use, that was the only way CMT A could have gotten the sign in from LPN A. During an interview on 2/11/26 at 4:43 P.M., CMT A said:-He/She had told the Administrator, HR, Director of Nursing (DON) and Assistant Director of Nursing (ADON) that he/she was still having problems signing in to the computer to pass medications on several occasions, but nothing was ever done to correct the problem.-The DON said he/she could not fix his/her sign in only HR could fix the problem.-He/She could sign in as a CNA not a CMT.-HR kept assigning him/her shifts to pass medications even though HR knew he/she was having problems getting into the resident's Medication Administration Records (MAR) and Treatment Administration Records (TAR).-He/she and LPN A had worked a shift together and he/she could not chart in the resident's medical record that he/she had passed medications, so LPN A let him/her sign in with LPN A's sign in to chart in the resident's medical records.-He/She kept using LPN A' sign in to pass medications after LPN A went PRN.-He/She quite working at the facility because the administration could not get his/her sign in fixed, and he/she knew it was wrong to keep using LPN A's sign in to pass medications.-He/She would sign out the controlled substance medications in the book with his/her name and then use LPN A's sign in to chart the medication was given to the resident with LPN A initials. During an interview on 2/11/26 at 5:01 P.M., the Administrator said:-LPN A went PRN in November and had not worked at the facility since.-He/She was not aware that CMT A was having problems with their sign in and did not know CMT A was using LPN A's sign in to pass medications.-Staff were not share passwords. During an interview on 2/18/26 at 11:09 A.M., LPN A said:-He/She was not aware of CMT A was using his/her sign in to pass medications to the residents.-He/She did not give CMT A permission to use his/her sign in and did not give him/her his/her sign in information.-He/she had not worked since 11/28/25 and went PRN.-When he/she would come on shift the computer was already on.-All he/she had to do was click on the drop-down box and click on his/her name and he/she was signed in to work under his/her name.-Sometime the computer would ask for his/her password to sign in and other times the computer would show the password.-One time the computer showed a password, and it was not his/her password, and he/she clicked go and the computer signed him/her in even though it was the wrong password.-The whole time he/she worked at the facility he/she was never asked to change his/her password. 2724968

Based on observation, interview and record review, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift in locations throughout the facility for view by residents, family members and visitors. The facility census was 74 residents. Record review of the facility Staffing, Schedule and Postings policy dated 10/24/2022 showed: -The facility would post the current date, the total number and the actual hours worked by licensed (RNs and LPNs) and unlicensed (CNAs) nursing staff directly responsible for resident care per shift, and the facility resident census. 1. Record review of the Staffing Ratio and Census Reports dated 12/27/24 through 1/27/25 showed: -The number of RNs, LPNs, CNAs and CMTs for each 24 hour period, rather than for each eight hour shift. -The staffing sheets did not show the total number of hours for RNs, LPNs, CNAs and CMTs for each eight hour shift. Observation of the posted Staffing Ratio and Census Report on 1/28/25 at 11:45 A.M. showed: -The number of RNs, LPNs, CNAs and CMTs for each 24 hour period, rather than for each eight hour shift. -The staffing sheets did not show the total number of hours for RNs, LPNs, CNAs and CMTs for each eight hour shift. -The date of the form was 1/27/25. During an interview on 1/28/25 at 1:35 P.M. the facility Staffing Coordinator said: -The posted staffing sheets showed the number of nurses, CNAs and CMTs for one 24 hour period. -It did not show the hours worked. -He/she was responsible for completing and posting the facility staffing sheets. During an interview on 1/31/25 at 12:00 P.M. the Director of Nursing (DON) said: -Up until 1/28/24 the total hours worked for licensed and unlicensed staff was not included on staffing sheets and the staffing sheets covered a 24 hour period rather than each eight hour shift. -After a meeting on 1/28/25 and going forward the total hours for each category of licensed and unlicensed staff for each shift would be included on staffing sheets. -The Staffing Coordinator was responsible for posting of staffing. -He/she and the Administrator were responsible for monitoring the posting of staffing. -Staffing sheets were posted at the reception desk and on the resident living units at the nurse's stations.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the needs of two sampled residents (Residents #49 and #176) who didn't like to go to group activities and were dependent upon staff to provide activities for mental, physical, and psychosocial stimulation out of 18 sampled residents. Additionally, the facility failed to ensure there was a way to easily access daily activity participation over time. The facility census was 74 residents. Review of the facility's Activities Program policy, revised 10/24/22, showed: -The purpose of the policy was to encourage resident participation to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable residents to maintain the highest attainable social, physical, and emotional functioning. -After completion of the initial Activity Assessment and the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), an Individualized Care Plan will be developed and implemented for each resident. -The Activity care plan will be reviewed and up-dated at least quarterly and with any change of condition. -Activities are tailored to meet the needs of residents with cognitive impairment or other special needs. -The facility will provide equipment and supplies for independent and group activities and for residents with special needs. -No less than quarterly the Director of Activities or designee will make a progress note as part of the resident's health record that includes the resident's level of participation, perceived benefit, response to interventions outlined in the Care Plan, progress made toward goals and recommendations for activities. -The Activity Department will maintain accurate records of each resident's participation in group, independent, and room visit involvement. Participation will be documented daily. 1. Review of Resident #49's admission MDS, dated [DATE], showed the resident: -Was diagnosed with non-traumatic brain dysfunction (a condition in which the brain is damaged by internal factors rather than external force to the head) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Had adequate hearing (could hear normal conversation) and adequate vision (could see fine detail such as newsprint). -Was severely cognitively impaired. -Had difficulty concentrating nearly every day. -Liked snacks. -Was unable to communicate what activities he/she liked. Review of the resident's Activity care plan, initiated 8/19/24 showed: -Encourage the resident's participation. -Allow the resident to leave activities at any time. -Provide assistance and escort to activity functions. Note: The care plan did not show activities that were meaningful for the resident. Review of the resident's quarterly Activity Interview for Daily Preferences, dated 10/14/24 showed the resident liked snacks but was unable to verbalize other activities of interest. Review of the resident's Activities Quarterly and Annual Participation Review, dated 1/2/25 showed the resident: -Enjoyed walking around, 1:1 visiting with staff, people-watching, sensory activities, listening to music, having snacks, reading, coloring, and bird watching. -Had good hearing and good vision with glasses. Review of the resident's annual MDS, dated [DATE] showed it was somewhat important for the resident to have magazines to read, listen to music, be around animals, and go outside for fresh air. It was very important to have snacks. Review on 1/30/25 of the resident's Activities care plan (initiated 8/19/24) showed it was never updated to include activities that were meaningful for the resident given he/she didn't like group activities. Review on 1/30/25 of the resident's progress notes for 10/1/25 through 1/29/25 showed no Activities progress notes. Daily participation documentation was not found in the resident's electronic record. Daily participation documentation was requested and not provided. Observation of the resident on the following dates and times showed: -On 1/27/25 between 7:20 A.M. and 8:00 A.M. and 8:45 A.M. and 9:20 A.M. the resident was in bed. There was no music or other stimulating activity on the resident's hall or in the resident's room. -On 1/28/25 from 10:05 A.M. to 10:30 A.M. the resident was in bed. At 12:30 P.M. the Activity Aide came on the unit and told staff he/she would take one of the residents to the bird cage while he/she cleaned the cage. The resident was in bed and wasn't asked if he/she would like to go. -On 1/29/25 at 10:15 A.M. residents were observed in the Day Services/Multipurpose Room while an outside entertainer was playing music. The resident was not at the activity. At 10:20 A.M. the Activity Aide said the resident was not at the music activity. At 10:25 P.M. the resident was observed in bed. No activity was taking place and music was not being played on the unit or in the resident's room. -Observation on 1/30/25 at 1:32 P.M. showed the resident in his/her room sitting on the side of his/her bed. There was no activity taking place or music playing on the living area or in the resident's room. During an attempt to interview on 1/30/25 at 1:35 P.M., when asked if he/she liked music, the resident said he/she didn't know. When asked if he/she liked to walk or be outside the resident did not respond. He/She nodded yes when asked if he/she liked activities on the unit where food was served. During an interview on 1/30/25 at 1:57 P.M. Certified Nursing Assistant (CNA) A said: -He/She had never seen the resident out of his/her room except at meal times. -The resident used to like a roommate, but that resident was no longer at the facility. -The resident might come out of his/her room for a food-related activity. Activities did not bring and Nursing did not pass juice or coffee mid-morning or mid-afternoon. The Activities Director had coffee and donuts sometimes in the activity room, but did not bring that to the resident halls. During an interview on 1/30/25 at 2:13 P.M. CNA B said: -The resident kept to himself/herself. -He/She didn't watch television. -He/She used to follow his/her former roommate around, but that resident was no longer at the facility. -He/She thought the resident would hover around if there was a birthday party or Valentine's Day party on the unit because he/she liked to eat. He/She was diabetic so he/she would need a sugar-free Kool-Aid or soda and a less-sweet snack. -When spoken to by familiar staff the resident would smile so he/she thought the resident would benefit from socials on the hall and 1:1 interaction. During an interview on 1/31/25 at 10:56 A.M. the Activities Director said: -He/She couldn't find daily documentation for the resident in his/her electronic record. Any activity the resident would have participated in would have been entered on the day he/she participated, but he/she wasn't able to see all daily activities for the entire week, month, or quarter. He/She could only enter the activity on the Kardex for the day. -Activities the resident had participated in included going down the main hall to look at the bird cage and sitting in front of the television on his/her living hall during a [NAME] movie. -They had taken the resident to live music activities before and the resident left the area and needed staff to get back onto his/her hall. -The resident liked the Missouri Conservation magazine and would take it if handed to him/her, but would lose the magazine. The resident used to hunt and fish so he/she tried to find an article the resident would like to stimulate his/her interest. 2. Review of Resident #176's Admission Activity Assessment, dated 12/27/24 showed the resident: -Was admitted to the facility on [DATE]. -Had adequate hearing and poor vision. -Had memories of hunting and fishing in the Ozarks. -Liked to be around animals and watch sports. Review of the resident's Activity Interview for Daily and Activity Preferences, dated 12/27/24 showed the resident's primary respondent said: -It was very important for the resident to have snacks between meals and to go outside for fresh air when the weather was good. -It was somewhat important for him/her to listen to music, be around animals and pets, and participate in religious services. Review of the resident's Comprehensive care plan, initiated 12/28/24 showed the resident had no Activities care plan. Review of the resident's Admission MDS, dated [DATE] showed the resident: -Had a primary diagnosis of a stroke and had dementia. -Had continuous inattention and disorganized thinking. -Had adequate hearing and vision (this contrasted with the poor vision noted on the Admission Activity Assessment.) -Found it very important to have snacks and be outside when the weather permitted and somewhat important to listen to music, be around animals, and attend religious services. Review on 1/30/25 of the resident's progress notes for 10/1/24 through 1/29/25 showed no Activities progress notes. Review on 1/30/25 of the resident's Comprehensive care plan showed no Activities care plan had been added after 12/28/24. Observation of the resident on the following dates and times showed: -On 1/27/25 between 7:20 A.M. and 8:00 A.M. the resident was at the dining room table. No stimulating activity such as soft background music was taking place during breakfast. Between 8:45 A.M. and 9:20 A.M. the resident was in bed with eyes closed. No activity was going on in the living area. -On 1/28/25 from 10:05 A.M. to 10:30 A.M. the resident was in bed with eyes closed. No activity was taking place on the living area. -On 1/29/25 at 10:15 A.M. residents were observed in the Day Services/Multipurpose Room where an outside entertainer was playing music. The resident was not at the activity. At 10:20 A.M. the Activity Aide said the resident was not at the music activity. At 10:27 P.M. the resident was observed in bed. No activity was taking place and no music was being played on the unit or in the resident's room. -Observation on 1/30/25 at 1:30 P.M. showed the resident was in bed with eyes closed. No activity was taking place on the living area. During an interview on 1/30/25 at 2:03 P.M. CNA A said: -Staff could get the resident to come out of his/her room as long as they offered the resident a coffee or Coca Cola. The resident would attend food-related activities on the living area. -The resident did sometimes read the Daily Chronicle newsletter and had watched part of a football game within the past month. -He/She didn't know if the resident liked music. During an interview on 1/30/25 at 2:11 P.M. CNA B said: -The resident liked to drink coffee. -There was no radio on the unit and nursing staff didn't play vintage music for the residents. He/She didn't know if the resident liked music. -The resident liked talking with staff and had funny sarcasm when he interacted. During an interview on 1/31/25 at 10:56 A.M. the Activities Director said: -He/She was still working on figuring the resident out. He/She spoke with a family member, but got little information about the resident's interests. -It was best to try to grab the resident right after a meal before he/she went back to bed. -The resident had watched a [NAME] movie on the resident hall and seemed to like that. 3. Review of the facility's Activity calendars for October, 2024 through January, 2025 showed: -In October one-to-one visits were listed for the five Tuesdays during the month. It didn't show which of the six halls the one-to-one visits took place on any given Tuesday. All other activities were group activities. -In November, 2024 and December, 2024 there were no one-to-one activities or room visits scheduled. -In January, 2025 room visits took place on Resident #49 and #176's hall on 1/6/25 and 1/22/25. -No scheduled activities were shown on the activity calendars for Saturdays or Sundays. Independent resident activities of choice and an activity cart were shown as available on weekends. During an interview on 1/27/25 at 9:35 A.M. the Activity Aide said: -They had Coffee Club scheduled in the Activity Room on 1/27/25 at 9:45 A.M. -Residents who wanted to attend came to the Activity Room. -There was no coffee and snack brought to the resident halls for residents who couldn't or didn't want to leave their living area. -Almost all the scheduled activities took place off the living halls. During an interview on 1/30/25 at 2:13 P.M. CNA A said: -The Activities Department encouraged residents to go to activities scheduled off the resident halls. -There were no activities done on the resident halls, except when Activities staff left printed coloring pictures and puzzles for residents to do on their own. -There was nothing for residents to do on the weekends except for coloring pictures and puzzles available on the activity cart. -He/She had never seen Activities do one-to-one activities with residents who couldn't or didn't want to leave their living area. -He/She wasn't sure if there were oldies music stations on the television so residents could listen to music on the living area. During an interview on 1/31/25 at 10:56 A.M. the Activities Director said: -Documentation of activity assessments and care plans were done through the resident's electronic record. He/She didn't do progress notes, but documented activity participation daily in the Kardex and quarterly on review forms. They only documented when residents actively participated. They didn't record when residents were encouraged to participate, but refused. -Almost all activities reflected on the monthly calendars were done in the main hallway, the activity room, or the multipurpose room. Sometimes activities were brought to the halls. On Halloween staff dressed up and treats were brought to the resident halls. -Activities tried to do one-to-one activities on each hall twice monthly. -There were radios on the halls that could be used by nursing staff for resident activities. -There were no scheduled activities on the weekend. Each hall had an activity cart with coloring pictures and table activities and residents pursued activities on their own. During an interview on 1/31/25 at 12:51 P.M. the Director of Nursing (DON) said: -All activities should be documented in the resident's electronic record. -He/She thought they were documented in Activity progress notes. -Staff should have access to daily activity participation documentation either through the resident's electronic record or through paper charting. -For residents who don't go to group activities or don't initiate activities on their own, one-to-one activities of interest should be provided by either the Activities or the Nursing staff.

Based on interview and record review, the facility failed to document behaviors and develop a care plan that included target behaviors (specific behaviors of the resident), and relevant non-pharmacological approaches for one sampled resident (Residents #49) who was prescribed a psychotropic medication (a drug that affects brain activities associated with mental processes and behaviors). The facility census was 74 residents. Review of the facility's Behavior Management policy, undated, showed key components of behavior management included: -Identifying residents whose behaviors may pose a risk to self or others. -Develop individualized and practical care strategies based on assessed needs. -Implement a behavior management program. -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including effectiveness of psychoactive drugs. -Nursing staff will document the response to medication, including behaviors and the side effects on the Medication Administration Record (MAR). -The facility will re-asses continued use of psychotherapeutic drug interventions. 1. Review of Resident #49's admission Record showed: -The resident was admitted to the facility on [DATE] with a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's Psychotropic Medication care plan, initiated 8/19/24 showed: -The resident used psychotropic medications. -Staff were to administer medications as ordered. -Every shift will monitor for side effects (unsteady gait, shuffling gait, ridged muscles, shaking, frequent falls, blurred vision, fatigue, loss of appetite, vomiting, and behavioral symptoms not usual for the resident). Note: The care plan did not mention resident target behaviors or symptoms indicating the need for the psychotropic medication. Review of the resident's Medication Review Report showed the physician ordered medication Quetiapine Fumarate oral tablet 25 milligrams (mg) at bedtime for mood disorder was started on 8/23/24. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff and used for care planning), dated 10/15/24, showed the resident: -Was severely cognitively impaired. -Had fluctuating inattention and continuous disorganization. -Felt down and depressed half or more days. -Had no verbal or physical behaviors directed toward others or other behaviors (e.g.: self-injurious behaviors, disrobing, smearing bodily wastes, making disturbing noises). -Was not diagnosed with a psychiatric or mood disorder such as anxiety, depression, schizophrenia, or psychotic disorder. -Was prescribed a routine antipsychotic medication. Review of the resident's Medication Administration Record (MAR) dated November 2024 behavioral documentation showed: -There were no behaviors on the day shift. -Behaviors occurred six times on the evening shift and twice on the night shift, including hitting, kicking, pushing, entering other residents' personal space, restlessness, and refusing cares. -Interventions used included redirection, removing from the situation, reapproaching, and offering food. Staff documented outcomes of behavioral interventions as either the behavior remained the same or staff were unable to determine if the behavior improved. Review of the resident's November 2024 progress notes showed there were no progress notes in November addressing details of any of the resident's behaviors such as the duration or intensity of the behaviors, possible predisposing causes of the behaviors, or details about the intervention effectiveness which could be helpful for future behavioral care planning and psychotropic medication adjustment. Review of the resident's MAR dated December 2024 showed: -There was one behavior on the day shift and four behaviors on the evening shift. Behaviors included grabbing, hitting, kicking, cursing at others, expressing frustration or anger, threatening others, entering other residents' space, and refusing cares. -Interventions included providing a calm environment, removing from the situation, engaging in a meaningful activity, and reapproaching. -The night shift documented RU thirteen times on the form. The form legend showed R stood for rummaging and U stood for Unable to determine if the intervention attempt was successful. Review of the resident's December 2024 progress notes showed: -A note was written on 12/18/24 at 8:19 P.M. showing the resident continued to remove clothing from his/her roommate's closet and wear them which greatly upset his/her roommate. Staff redirected the resident, but the behavior repeated soon after related to dementia. -No other progress notes in December addressed details of the resident's behaviors, possible predisposing causes of the behaviors, or details about each intervention's effectiveness. During an interview on 1/30/25 at 1:57 P.M. CNA A said: -He/She didn't know how the resident acted when his/her mood was down or what staff were to do to address that. -He/She had never seen the resident out of his/her room except for meals and didn't know if staying in his/her room related to his/her mood. -He/She hadn't seen any behaviors on the day shift. During an interview on 1/31/25 at 12:13 P.M. Licensed Practical Nurse (LPN) A said: -Everyone on a psychotropic medication should be monitored every shift for behaviors. -The resident's care plan should show the diagnosis, target behaviors, and symptoms related to the reason they are on a psychotropic medication. There should be non-pharmacological interventions to address the behavioral issues for all residents on a psychotropic medication such as redirection or whatever usually helped that resident. -Residents on psychotropic medications had a generic order to identify behaviors. -All behaviors should be documented on the MAR and documented in detail in the resident's progress notes. If a resident behavior was documented on the MAR, the resident's electronic record should trigger the charge nurse to write a detailed progress note. -The care plan should reflect target behaviors staff should be monitoring. -The resident used to have more episodes of resisting cares, combativeness, and arguing with a former roommate, but those behaviors had recently decreased while wandering had increased. -Justification for an antipsychotic medication should be documented on a care plan and include target behaviors and symptoms associated with the diagnosis for which the antipsychotic was ordered. During an interview on 1/31/25 at 12:37 P.M. the MDS Coordinator said: -The psychiatrist or psychiatric nurse practitioner saw all the residents who were on psychotropic medications. -If a resident was on a psychotropic medication nurses should chart behaviors on the MAR every shift and document details of behaviors in a progress note. -The care plan should explain why a resident was on an antipsychotic medication and describe target behaviors and symptoms the resident was having such as hallucinations (a perception of something that isn't actually there) or delusions (a belief that is persistently held despite evidence to the contrary). During an interview on 1/31/25 the Director of Nursing (DON) said: -The resident's target behaviors and symptoms should be identified on the care plan. -Psychotropic medications should relate to the resident's diagnosis, behaviors, and symptoms and be reviewed monthly by the pharmacist and physician. -The charge nurse should document behaviors on the resident's MAR and in their progress notes. -Behavioral documentation was used in deciding if psychotropic medications needed adjusting.

Based on interview and record review, the facility failed to ensure two sampled residents (Residents #40 and #55) out of three sampled residents, who were notified their Medicare Part A coverage would likely end and had benefit days remaining, were provided the Quality Improvement Organization (QIO) contact name and toll free phone number on their Notice of Medicare Non-Coverage (NOMNC), Centers for Medicare (CMS)-10123 form. On 1/31/25 the Administrator was notified of the past non-compliance which took place for a period of months that started on or before 7/9/24 and went through 12/31/24. On 1/2/25 the Social Services Director was given an updated Form CMS-10123 containing the QIO contact name and toll-free number so residents could appeal the decision to end services. On 1/2/25 the Social Services Director received education from Regional Nurse Consultant A on providing the QIO contact name and phone number to residents with benefit days remaining whose services were expected to end. The deficiency was corrected on 1/2/25. Review of the facility's Medicare Denial Process policy, dated April, 2024, showed: -The NOMNC, Form CMS-10123, is required to be delivered to the resident or his/her representative at least two calendar days before Medicare covered services end. -The beneficiary or representative will sign and date the notice acknowledging it was received. -Information provided must include the last covered day of service, the phone number of the QIO, and the time frame for appeal. 1. Review of Resident #40's Form CMS 10123 - NOMNC showed: -The resident started services on 7/5/24 and services were expected to end on 7/11/24. -The resident's representative acknowledged the notice on 7/9/24. -Under the section How to Ask for an Immediate Appeal the form showed the beneficiary must make request to the Quality Improvement Organization (QIO), the independent reviewer authorized by Medicare to review the decision to end services. The request for an appeal should be made no later than noon the day before the effective date of services ending. The beneficiary was to call his/her QIO to appeal or with questions. -Above the signature line was the sentence I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. -No QIO name or toll-free number was provided on the form for the beneficiary to use should he/she decide to appeal. 2. Review of Resident #55's Form CMS 10123 - NOMNC showed: -The resident's effective date of coverage started 9/3/24 and services were expected to end on 11/26/24. -The resident's representative acknowledged the notice on 11/23/24. -Under the section How to Ask for an Immediate Appeal the form showed the beneficiary must make request to the QIO. The request for an appeal should be made no later than noon the day before the effective date of services ending. The beneficiary was to call his/her QIO to appeal or with questions. -Above the signature line was the sentence I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. -No QIO name or toll-free number was provided on the form for the beneficiary to use for an appeal. During an interview on 1/31/25 at 10:09 A.M., the Social Services Director said: -He/She was unaware the QIO contact information was not on the NOMNC forms that were presented to Resident's #40 and #55. -On 1/2/25 Regional Nurse Consultant A provided an updated Form CMS-10123 that he/she could type on which contained the QIO contact name and toll-free number.

Based on interview, and record review, the facility failed to assess a resident who had fallen before moving him/her and did not call Emergency Medical Services (EMS) in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 77 residents. The Administrator was notified on 8/26/24 of Past Non-Compliance (PNC) which occurred on 8/20/24. On 8/20/24 facility administration identified the resident was moved after a fall prior to being assessed by a licensed nurse and the delay in emergency services being notified to transfer the resident to the hospital. The facility completed the investigation, and the facility staff were in-serviced by 8/21/24. Review of the facility's policy, Response to Falls, dated October 24, 2022 showed: -Residents who have experienced a fall would have been promptly assessed and treated for injuries. -After each fall, a Licensed Nurse would have completed a Post-Fall Assessment and Investigation. -Immediate Post Fall Response: -Upon finding a resident in a position indicating a fall, stay with the resident and send another staff member to notify a Licensed Nurse if the first responder was not licensed personnel. -Do not move the resident initially until after an assessment was completed. -Call for assistance. -The Licensed Nurse should have assessed the resident and taken the resident's vitals. -Assess the resident's level of consciousness, position, possible injuries, head injuries, pain, tenderness, swelling, bruising, alignment and range of motion. -If the Licensed Nurse suspects a fractured hip, back or other injury, the Licensed Nurse should have made the resident comfortable until emergency medical services arrived. -The Licensed Nurse would have also completed the Neurological Flow Sheet for any un-witnessed fall, or witnessed fall with known head injury for 72 hours following the fall. 1. Review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). -Dementia (a group of thinking and social symptoms that interferes with daily functioning). -Spinal Stenosis (when the spaces inside the bones of the spine get too small). -Lumbago with Sciatica, left side (anything that causes narrowing of the spinal canal has the potential to compress nerve roots and cause a bulging disc). -Muscle weakness. -Lack of coordination. -Cognitive communication deficit (having trouble reasoning and making decisions while communicating). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 6/21/24 showed: -He/She was moderately cognitively impaired. -He/She did not have any impairment to lower extremities (hip, knee, leg, or foot). -He/She used a walker. -He/She used a cane or crutch. -He/She had prior falls with no major injury. Review of the resident's undated Care Plan showed: -He/She had a self-care performance deficit, required supervision to limited assistance by staff for transfer as necessary. -He/She had impaired cognitive function. -He/She has had actual falls related to poor balance and unsteady gaits; 6/5/24, 6/10/24, 8/5/24, and 8/20/24 (fall with hip fracture). -He/She was at risk for falls and staff needed to follow facility fall protocol. Review of the Nurses Progress Notes dated 8/20/24 at 6:47 A.M. written by Licensed Practical Nurse (LPN) A showed: -He/She was notified by a staff member of the resident sitting on the floor next to a chair. -He/She arrived to room to see the resident sitting on the floor next to a chair. -Upon assessing the resident he/she noticed there was no bruising but his/her left leg had pain when moving it. -The resident stated he/she had lost his/her balance, fell and hurt his/her leg. -He/She did a full body assessment, gathered vital signs (blood pressure, pulse, respirations,neurological assessment). -The resident was experiencing left leg pain. -An X-ray was ordered for the resident's left leg. -He/She notified the Director of Nursing (DON), Assistant Director of Nursing (ADON), Physician, and Durable Power of Attorney (DPOA -legal statement authorizing another person to make decisions for someone who mentally was not able to). -There was no documentation showing a Certified Nurses Assistant (CNA) moved the resident prior to being assessed by a licensed nurse Review of the facility's undated fall investigation showed: -Statement from CNA D on 8/20/24 showed: -He/She was notified by the resident's roommate that Resident #1 needed help. -He/She entered the resident's room and observed the resident laying on the floor. -He/She asked the resident if he/she was hurt. -The resident responded yes, his/her leg was hurt. -The resident reached out to him/her and grabbed his/her hand to sit up. -Additional staff entered the room to assist with the fall so he/she stepped out. -Review of the witness statement dated 8/20/24 written by Restorative Aide/CNA A on 8/20/24 showed: -A night shift CNA approached him/her stating the resident had fallen. (The RA did not know the CNAs name). -When he/she entered the room, the resident was in a seated position with his/her legs in front of him/her. -Several other staff members responded to the room. -The resident complained of leg pain. -He/She assisted the resident to a nearby chair for his/her comfort. -Review of the witness statement dated 8/20/24 written by LPN A showed: -A CNA notified him/her the resident had fallen in his/her room. -Several staff had responded to the room. -He/She had completed an initial assessment and initiated fall procedures. -The resident's family was notified. -The family had requested the resident be sent to the hospital. -Review of the witness statement dated 8/20/24 written by LPN B showed: -When he/she had arrived to work he/she had received a report from the off-going shift that the resident had fallen. -The resident's family would like him/her sent to the hospital. -He/She entered the resident's room and observed him/her sitting up in a chair. -An assessment revealed the resident had pain in his/her left shoulder and hip. -The Paramedics arrived and transported the resident to a nearby hospital. -Review of the Investigation Summary dated 8/20/24 showed: -At about 6:20 A.M. CNA D was informed the resident had an unwitnessed fall in his/her room. -The resident was attempting to get up off the floor independently while awaiting clinical assessment secondary to impaired mentation and impulsivity related to a dementia diagnosis. -Clinical staff assisted the resident to a nearby chair to prevent greater potential injury. -The Nurse was informed of the incident and a complete head to toe assessment with no visualized injuries noted. -The resident complained of left hip and shoulder pain. -The resident's Physician was notified of the fall and an order was received for a STAT (immediate) X-ray. -The DON was notified. -The DPOA was notified via phone and requested the resident be sent to the hospital and not to wait for an in house radiology (X-ray). -911 was called. -Paramedics arrived at the facility. -The resident was taken to the nearby hospital. Review of the video of the resident's fall on on 8/20/24 showed: -At 6:17 A.M. on 8/20/24 the resident was walking in his/her room toward the bathroom when he/she fell backwards into his/her left side. -His/Her roommate was in the room at the time and went to find a staff member to help. -At 6:22 A.M. CNA D entered the room. -The CNA asked if the resident was OK. -CNA D then sat the resident up on the floor as he/she had been laying flat on the floor. -The resident groaned and said he/she was in pain as he/she was moved to a sitting position on the floor. -He/She left the room to find the nurse. -He/She came right back to the resident and asked the resident if his/her leg was ok. -The resident said, No it's not ok. -At 6:23 A.M. Restorative Aide (RA)/CNA A and three other staff members entered the room. -The RA/CNA A asked the resident if he/she was ok, was he/she hurt. -The resident said, I'm hurt alright, my hip and my arm. -The RA/CNA A put a gait belt (a safety assistance device used to help transfer a person) around the resident's waist and with the assistance of one other staff member they assisted the resident up and into a chair. -One of the CNAs put shoes on the resident. -The RA/CNA A put a sweat shirt on the resident and told the resident they will go get some coffee and wait for breakfast. -The RA/CNA A said they would see how well he/she was walking. -At 6:26 A.M. RA/CNA A assisted the resident up with the gait belt and gave the resident his/her walker to walk him/her into the dining room. -The resident was not able to take more than a step and sat the resident back down into the chair. -The RA/CNA A pushed the chair the resident was sitting in forward and the resident's left leg didn't move, it was dragged under the chair. -The RA/CNA A left the resident sitting up in the chair and left the room with the door shut. -At 6:36 A.M. a CNA came into the room to make the bed, he/she did not speak to the resident. -At 6:38 A.M. a male staff member walked in and looked at the resident, went to walk out then turned around and asked the resident if he/she fell . -The resident said yeah I fell . -The male staff member walked out of the room and shut the door. -At 7:49 A.M. the door opened and the roommate left the room. -The LPN B came into the room and assessed the resident. -LPN B asked the resident how he/she was doing, are you hurt? -The resident said yes on his/her left side. -LPN B did a full head to toe assessment. -LPN B looked at the resident's arms and left shoulder. -The resident said it hurts (left shoulder). -LPN B assessed the resident's left leg. -The resident said it's real sore (left leg). -LPN B assessed the residents blood pressure and vital signs. -LPN B left the room. -At 8:03 A.M. EMS were seen in the resident's room taking him/her out to the hospital. During an interview on 8/26/24 at 9:10 A.M. CNA B said: -He/She would notify the nurse if he/she had found a resident on the floor. -He/She would not move the resident. -The Nurse would have done an assessment then he/she would do a set of vital signs. -The Administrator and DON have done education on not moving a resident until they were assessed by a Nurse in the last 30 days. During an interview on 8/26/24 at 9:20 A.M. LPN B said: -If a resident was on the floor staff should have contacted a nurse. -The nurse would have done a head to toe assessment and neuro checks on the resident. -If a resident was in pain he/she would have notified the physician. -The physician would have given an order for an X-ray or to have sent the resident to the hospital. -He/She was scheduled to work the day shift on 8/20/24. -The night shift CNA told him/her that the resident had fallen. -The night shift nurse called him/her and gave report. -The night shift nurse had called the physician and had received orders for a portable X-ray. -The family member had called him/her and requested that the resident to go to the hospital. -The family member called him/her and requested the resident go to the hospital. -He/She went to see the resident. -The resident was sitting in a chair. -The resident had a flat affect, (no emotion) on his/her face. -The resident appeared to be in pain. -He/She did a range of motion evaluation on the resident's left shoulder, which was painful (resident verbalized). -He/She was unable to extend the resident's left leg out straight. -The resident said it hurt to move his/her leg. -He/She called the resident's Nurse Practitioner to get an order to send the resident to the hospital, which he/she received. -He/She called 911 to activate Emergency Services (EMS- Emergency Medical Services). -EMS arrived and took the resident to the hospital. -The reporter was notified the resident had been sent out to the hospital. -The night nurse should have stayed with the resident. -He/She did not think the night nurse had called 911. During an interview on 8/26/24 at 10:00 A.M. CNA C said: -During report at the change of shift at 7:00 A.M., the night CNA (name unknown) reported to him/her that the resident had fallen. -If a resident was on the floor you should get the nurse. -The nurse would do an assessment on the resident. -He/She would not move the resident until the nurse told him/her to. -When he/she first came to work he/she saw the resident sitting in a chair with LPN B doing an assessment on him/her. During an interview on 8/26/24 at 10:10 A.M. the family member said: -The family has a video camera in the resident's room. -At 6:30 A.M. the camera dinged notifying him/her that the resident was moving in the room. -He/She reviewed the video which showed the resident laying on the floor. -He/She reviewed the video at an earlier time which showed at 6:17 A.M. the resident got up and was walking to the bathroom without his/her walker when he/she stumbled over his/her own feet and fell to the floor. -At 7:07 A.M. a nurse(night shift) called him/her and told him/her they were going to do an in-house X-ray. -He/She told the nurse to call an ambulance and send the resident to the hospital. -He/She called the nurse a second time and told him/her to send the resident to the hospital. -At 7:45 A.M. he/she called and talked to (LPN) B and asked him/her to open the resident's door which had been closed. -LPN B said he/she was going to call for an in-house X-ray. -The family member asked the day nurse to call an ambulance to send the resident to the hospital. -At 7:50 A.M. LPN B went into the resident's room to assess him/her. -The resident said it was sore. -At 8:03 A.M. the EMS arrived and took the resident to the hospital. -The resident had previous falls. -The resident was taken to a nearby hospital where he/she had surgery the next morning to repair his/her broken hip. -He/She was very upset because he/she had told the nurses three different times to call EMS to transfer the resident to the hospital. -It was almost two hours after the fall before EMS came to transport the resident to the hospital. -The staff sat the resident up before he/she was assessed by a nurse. -The staff had attempted to walk the resident to breakfast before he/she was assessed by a nurse then sat him/her in a chair with the door closed. -He/She had showed the video to the DON and Administrator. During a telephone interview at 12:35 P.M. on 8/26/24 LPN A said: -He/She was the night nurse when the resident fell . -The resident fell between 6:00 A.M. and 7:00 A.M. on 8/20/24. -A CNA notified him/her that the resident had fallen. -He/She had went into the resident's room and completed an assessment. -The resident said he/she had hip pain. -He/She had documented the assessment on the computer system. -He/She had called the family and the physician to let them know about the fall. -The physician had ordered an X-ray. -The family member wanted the resident to go to the hospital. -He/She did not call 911, but passed it onto the day shift nurse in report. -He/She did not move the resident. -The facility has provided education before and after the fall, not to move the resident until a nurse completes an assessment. -He/She was the only nurse in the building at the time of the fall. During a telephone interview at 2:05 P.M. on 8/26/24 RA/CNA A said: -His/Her shift starts at 6:00 A.M. and he/she was there at that time. -Night shift staff asked him/her if he/she could help with the resident as he/she had fallen. -CNA D asked him/her to help get the resident up into a chair, which he/she did. -He/She was not sure what was wrong with the resident. -He/She was not sure if a nurse had assessed the resident before he/she was moved. -The resident did not have any signs of pain when he/she moved him/her. -He/She saw the nurse when he/she left the room but did not talk to him/her. -He/She knew that the resident went out to the hospital. During an interview on 8/26/24 the DON said: -If a CNA found a resident on the floor (unwitnessed fall) he/she would have expected him/her to go get help from a nurse and then stay with the resident. -The nurse should have done an assessment prior to moving the resident to determine injuries. -He/She would have expected the nurse to have done an assessment before staff moved the resident. MO00240919

Based on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The facility failed to follow their policy to complete testing to screen new employees for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for four out of ten sampled new employees sampled for TB screening. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility and the facility failed to ensure proper hand hygiene was completed during medication pass for one sampled resident (Resident #8) out of 18 sampled residents. The facility census was 76 residents. 1. Review of the facility's water management program documents provided by the Assistant Director of Nursing (ADON) from their Infection Control binder, showed the following: -There was a copy of the 31 page Centers for Disease Control (CDC) toolkit issued 6/24/21 and entitled Developing a Water Management Program to Reduce Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) Growth & Spread in Buildings, which outlined what needed to be done to develop such a program, but nothing facility-specific, and an unanswered set of eight questions on page 2. -There was a two page policy dated 10/24/22 entitled Legionella which cited the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188 and the CDC toolkit as sources, but did not include the two forms referenced for developing a program and identifying Legionnaires Disease. Review of the facility's two generic water-borne pathogen program assessments provided by the Administrator, a 27 page form dated 7/22/21 and a 22 page form dated 4/4/23, both entitled Legionella Environmental Assessment Form, with an educational section which outlined how to implement such a prevention program and mentioned some CMS requirements, showed the following: -There was no actual facility-specific risk assessment that considered the ASHRAE industry standard #188. -The diagram of the facility's complete water system was an altered generic diagram that did not match their written explanation of the water flow throughout the facility. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was no program and/or flow chart that identified and indicated facility-specific potential risk areas of growth within the building with assessments of each individual area's potential risk level. -There were no written facility-specific interventions or action plans for when testing protocols and acceptable ranges for control limits were not met. -There was no documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. Review of the facility's emergency preparedness program binder entitled Disaster Manual, last reviewed on 6/10/22 and obtained from the 400 Hall nurse station, showed the following: -There was a copy of the CDC toolkit issued 6/5/17 and entitled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, with a set of eight unanswered questions on page 2. -There were copies of the two generic water-borne pathogen program assessments provided by the Administrator and mentioned above. Observations during the kitchen inspection on 5/17/23 between 8:56 A.M. and 12:19 P.M. showed a three-sink area, a wall-mounted sink for hand washing, a chemical dish-washing machine, and an ice machine and sink in the adjacent kitchenette. Observations during the facility Life Safety Code (LSC) room-by-room inspection with the Director of Maintenance (DOM) on 5/22/23 between 9:25 A.M. and 11:22 A.M. showed the following: -There were 40 resident rooms with private and/or adjoining bathrooms. -There was a Laundry room at the western end of the building and numerous closets with water heaters throughout the facility. -There was a bathing room and two restrooms on the main center hallway. -In the main center hall's Soiled Utility closet there was a floor mounted mop hopper sink with brown residue around the water line and in the trap at the bottom indicating it had not been flushed in a while, and a sign posted above it that read, Please Flush. -In the main center hall's Janitor's Closet was a square floor mop hopper sink filled with water that was so murky the bottom could not be seen. -There were two sprinkler systems with a main drain and auxiliary drains throughout the facility. -There two restrooms in the eastern administrative section of the building. Record review of the facility's 2-page educational document provided by the Administrator entitled Legionella Water Management, with the effective date of 10/26/2018 but no review or revision dates written in, it listed the DOM as being part of the water management team at point 2.d. During an interview on 5/23/23 at 9:39 A.M. the DOM said the following: -Testing the water for chloramine (which is a secondary disinfectant most commonly formed when ammonia is added to chlorine to treat drinking water to provide longer-lasting disinfection as the water moves through pipes to consumers) levels was all he/she had been instructed to do. -He/she thought the purpose was to control listeria (Listeriosis is a serious infection caused by the germ Listeria monocytogenes which can make people become ill after eating contaminated food). During an interview on 5/23/23 at 11:07 A.M. the Administrator said that he/she had been educated on the water-borne pathogen prevention program by reading the materials he/she provided earlier. 22727 2. Review of the facility's Tuberculosis Screening policy dated 10/24/22 showed: -Facility staff were screened for TB as part of the requisite employee health examination. -There were no specific instructions on the procedure of TB screening. Review of the facility's Administration and Interpretation of TB Skin Tests (TST) policy dated 10/24/22 showed: -Screening of facility staff for TB was done upon hire. -A licensed nurse or healthcare practitioner interpreted the TST 48 to 72 hours after administration. Review of the facility's undated Onboarding Standard Operating Procedure showed: -A TST must be read and documented within 48-72 hours from when it was administered. -No employee could start working prior to the reading of the first TST. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 3/4/23. -Employee B was hired on 4/10/23. -Employee C was hired on 1/21/23. -Employee E was hired on 4/1/23. -Employee G was hired on 1/27/23. Review of the above employees' TB testing forms showed: -Employee A's first TST was administered on 3/9/23, which was five days after date of hire and was read on 3/12/23, which was eight days after hire (instead of prior to hire) and the results were negative (0 millimeters (mm)). -Employee B's first TST was administered on 4/7/23 and read on 4/10/23 and the results were negative (0 mm). -Employee B's second TST was administered on 4/14/23, which was four days after the first TST instead of seven to 21 days after the first TST. -Employee C's first TST was administered on 1/22/23, which was one day after date of hire and was read on 1/24/23, which was three days after hire and the results were negative (0 mm). -Employee E's first TST was administered on 4/1/23, which was the date of hire and the results were read on 4/3/23, which was two days after date of hire and the results were negative (0 mm). -Employee G's first TST was administered on 4/2/23, which was over two months after the date of hire and was read on 4/4/23 and the results were negative (0 mm). During an interview on 5/23/23 at 10:06 A.M., the Human Resources Director said: -One of the charge nurses or the Assistant Director of Nursing (ADON) administer and interpret the employee TSTs. -He/she takes the onboarding employee to one of the charge nurses or the ADON to take their TST and then they come back in two days for the TST to be read. -The ADON was responsible for making sure the second TST was completed. -He/she did not think employee A and C were scheduled to work until their first TST was completed. -Employee A never worked a shift. -Employee C worked on 1/21/23 which was three days prior to the completion of his/her first TST. -It was an error on their part that Employee G's TST was not done prior to hire. Employee G was just missed somehow. During an interview on 5/23/23 at 12:10 P.M., the ADON said: -He/she tries to make sure the first TSTs are done before the employee's first day working. -The Human Resources Director lets him/her know they are hiring a new employee. -The nurses do the TSTs for the new employees. -Once the first TST is completed on an employee, he/she puts the TB screening document on a clipboard in order to track when to do the second TST. -There should be seven days between the first TST and the second TST. During an interview on 5/23/23 at 1:05 P.M., the Director of Nursing (DON) said: -The ADON does all of the employee TB screening oversight. -He/she would expect the 1st TST to be done prior to hire. -The second TST should be done seven to 21 days after the first TST was completed. 46519 3. Review of the facility's policy titled Medication-Administration dated 10/24/22 showed: -The licensed Medical or Nursing Staff must wash hands before and after medication administration. -Gloves will be worn to administer medications when contact with blood or potentially infectious bodily fluid is anticipated. Review of the facility's policy titled Eye Drops dated May 2016 showed: -Staff must perform hand hygiene before the procedure and put on gloves. -When the administration was complete the person administering should remove his/her gloves and either wash or sanitize his/her hands. Review of the facility's policy titled Medication Administration Nebulizer (Updraft) dated September 2010 showed: -Staff must perform hand hygiene before the procedure. -Once the procedure was completed staff should wash hands thoroughly. Review of the facility's policy titled Hand Hygiene dated 10/24/22 showed: -Facility staff, visitors, and volunteers must wash their hands in the following circumstances: --After unprotected (ungloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood and other bodily fluids, wound drainage and soiled dressings. --In between glove changes. -Alcohol-based hand hygiene products can and should be used to decontaminate hands: --Immediately upon entering a resident occupied area. --Immediately upon exiting a resident occupied area. -Hand hygiene was always the final step after removing and disposing of personal protective equipment. Review of Resident #8's undated face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Diabetes Mellitus (DMII- a complex disorder of carbohydrate, fat, protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis). -Unspecified Glaucoma (a group of eye diseases that can cause vision loss or blindness by damaging the optic nerve). Observation of the resident's medication pass on 5/17/23 at 12:16 P.M. completed by Licensed Practical Nurse (LPN) A showed: -He/she sanitized his/her hands, put on gloves, and administered the resident's eye drops, removed his/her gloves, but did not wash/sanitize his/her hands afterwards. -He/she then went back to the medication cart and did not wash/sanitize his/her hands while prepping or giving the resident his/her oral medication. -He/she did not wash/sanitize his/her hands after giving the medication to the resident or before starting the preparation of the nebulizer (a device that produces fine mist for inhaling medication) treatment. -After the nebulizer treatment was started on the resident, he/she walked back to the medication cart and sanitized his/her hands. During an interview on 5/17/23 at 12:24 P.M. LPN A said: -He/she felt the medication pass went okay. -He/she was unsure if the nebulizer treatment was performed correctly. Observation on 5/17/23 at 12:28 A.M. showed the nebulizer mask was not working and the treatment needed to be re-done. Observation on 5/17/23 at 12:37 P.M. of the nebulizer treatment completed by LPN A showed: -He/she sanitized his/her hands and put on gloves. -He/she turned off the treatment and replaced the resident's treatment mask. -He/she then took off his/her gloves, placed a new vial of treatment in the replaced mask, and started the treatment again. -He/she went back to the medication cart and sanitized his/her hands. -After completion of the treatment he/she did not sanitize his/her hands before entering the resident's room, and put on gloves. -He/she then removed the mask from the resident, rinsed the mask off in the resident's sink, dried the mask with a paper towel, and placed the mask in a designated bag for the mask. -He/she removed his/her gloves and returned to the medication cart without washing/sanitizing his/her hands before the next medication pass. During an interview on 5/17/23 at 2:17 P.M. LPN A said: -He/she did not think that his/her hand hygiene was correct during Resident #8's medication pass. -He/she should have washed/sanitized his/her hands between each part of the medication pass: --Before and after the eye drops. --Before and after the oral medication --Before and after both attempts of the nebulizer treatment. -He/she should have washed his/her hands before administering the resident's eye drops and before the nebulizer treatment. -He/she should have sanitized his/her hands every time he/she removed his/her gloves. During an interview on 5/18/23 at 11:54 A.M. LPN B said hand hygiene during medication pass should happen before and after each resident. During an interview on 5/18/23 at 12:07 P.M. the DON said: -Before administration of eye drops he/she would expect staff to wash their hands. -He/She would also expect hand hygiene during medication pass to be completed when: --Gloves were removed. --Going from treatment to treatment on a single resident. --Going from resident to resident. -LPN A did not perform hand hygiene correctly during medication pass. -He/She expected staff to sanitize their hands before a nebulizer treatment was given and to wash their hands afterwards.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils and to ensure the proper refrigeration, and/or disposal of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 76 residents with a licensed capacity for 78 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 5/17/23 between 8:56 A.M. and 12:19 P.M. showed the following: -There was a wooden rolling pin in the center food preparation table drawer that had food residue on it. -The gasket on the door to the reach-in refrigerator was detached and torn. -In a utensil drawer a wood handled spatula's plastic red blade was chipped. -The manual can opener had paper on its blade. -The brown, red, yellow, and blue cutting boards had excessive scoring to the point of plastic bits flaking off. -In the Dry Storage room, on the bottom shelf of a rack by the door, there was a 1 gallon (gal.) jug of soy sauce approximately (appx.) 1/2 full, with a best by date (BBD) of 1/2/23 stamped on it and a label which read Refrigerate After Opening. -On the same shelf was another jug of the same kind of soy sauce, appx. 1/8 full, with no lid on it. -On the large can dispenser rack there was a 6 pound (lb.) 3 ounce (oz.) can of shredded sauerkraut that was dented on its bottom rim, and a 6 lb. 10 oz. can of mandarin orange segments that was dented on its top rim. -On the bottom shelf of the south wall rack in the Dry Storage room was an opened 138 oz. jug of salsa with a label that read Refrigerate After Opening. -There was a 4 oz. pod of strawberry yogurt, onion peels, and paper scraps under the racks in the walk-in refrigerator. -A large floor stand fan had a heavy accumulation of lint on its blades and blade guard. -There was paint peeling off of the underside of the range hood over the deep fryer and the stove. -A rubber gasket on the inside rim of the garbage disposal was torn and incomplete. -When that day's lunch was being taken from the oven to the steam table, the top tray of chicken measured at 138.7 degrees Fahrenheit (F). Record review of the kitchen food temperature log sheet for 5/17/23, taped onto the side of the reach-in refrigerator by itself, showed the hot and cold food temperatures were recorded for that day's lunch, but the previous breakfast foods' temperatures were left blank. During an interview on 5/22/23 at 12:50 P.M., the Dietary Manager said the following: -The dietary aides were responsible for cleaning the kitchen and walk-in floors every night before they leave. -He/she would expect any food stuffs that should be refrigerated would be. -Damaged food items are to be sent back to the vendor. -Any damaged food preparation items should be thrown in the trash as soon as they are noticed. -He/she would expect food to be free of foreign substances. -The dietary aides are to clean food preparation items as needed. -The cooks are to fill out the food temperature logs for each meal but they only do it occasionally.

Based on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) for 10 out of 10 sampled new staff and to follow their policy to check the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for seven out of 10 sampled new staff. The facility census was 76 residents. Review of the facility's undated Onboarding Standard Operating Procedure showed: -Instructions to run all necessary background checks (Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees)) while a new hire was completing their onboarding. -The NA registry check and the FCSR were some of the required checks under the background checks bullet point. Review of the facility's Staff Screening policy dated 10/24/22 showed: -Prior to employment, the facility would verify and document a CBC and state exclusion screening. -The facility would not employ any individual who had been found guilty of abuse, neglect, exploitation or mistreatment or misappropriation of property or who has a finding in the state NA registry. 1. Review of the facility's list of employees hired since their last annual survey showed: -Employee A was hired on 3/4/23. -Employee B was hired on 4/10/23. -Employee C was hired on 1/23/23. -Employee D was hired on 2/25/23. -Employee E was hired on 4/1/23. -Employee F was hired on 12/21/22. -Employee G was hired on 1/27/23. -Employee H was hired on 3/20/23. -Employee J was hired on 4/15/23. -Employee K was hired on 4/13/23. Record review of employees A, B, C, D, E, F, G, H, J and K's employee files showed: -A CBC was not requested or received for any of the employees. -The FCSR checks showed all the sampled employees were registered with the FCSR (The law requires that every elder care worker hired on or after January 1, 2001 to register). -All of the sampled employees' FCSR forms printed out stated on the form that the form was not a background check (requesting the background checks was a separate process). During an interview on 5/23/23 at 10:06 A.M., the Human Resources Director (HR) said: -He/she thought when he/she was checking the FCSR website that it included a CBC (he/she was only checking the section that indicated if the employee was registered or not). -He/she was doing CBCs through the highway patrol previously but stopped because he/she thought the FCSR registration check covered it. During an interview on 5/23/23 at 1:31 P.M., the Administrator said he/she was aware the CBC should be requested prior to hire and would expect it to be done prior to hire. 2. Review of the facility's list of employees hired since their last annual survey showed: -Employee C was hired on 1/23/23. -Employee D was hired on 2/25/23. -Employee E was hired on 4/1/23. -Employee G was hired on 1/27/23. -Employee H was hired on 3/20/23. -Employee J was hired on 4/15/23. -Employee K was hired on 4/13/23. Review of employees C, D, E, G, H, J and K's employee files showed NA registry checks were not conducted on them. During an interview on 5/23/23 at 10:06 A.M., the HR Director said he/she did NA registry checks on Certified Nursing Assistants (CNAs) only and did not know he/she needed to do a NA registry check on all other staff. During an interview on 5/23/23 at 1:31 P.M., the Administrator said he/she expected the NA registry check to be done on all employees prior to hire.

Based on observation, interview, and record review the facility failed to ensure parameters were in place for the nursing staff to safely administer Metoprolol (a medication used to treat high blood pressure) and other blood pressure medications for three supplemental residents, (Resident #44, Resident #74, and Resident #10), and to ensure parameters were in place for the nursing staff to safely administer Digoxin (a medication used to treat heart failure and heart rhythm problems) for one supplemental resident (Resident #44) out of three supplemental residents for medication pass. The facility census was 76 residents. Review of the Mayo Clinic precautions for Digoxin (Oral Route Precautions), dated 5/1/23 showed: -Side effects include; dizziness, fainting, fast, pounding or irregular pulse, or slow heartbeat. -The nurse should take an apical (a measurement that takes place when a person is sitting or lying down by placing a stethoscope (a medical instrument used to listen to sounds produced within the body) on the left side of the breastbone over the apex (the tip of the heart that faces the left arm) of the heart) pulse for a full minute before administering Digoxin as it could decrease the heart rate. Review of the Mayo Clinic's precautions for Metoprolol, Medical Education and Research, dated 2023 showed: -Before administering Metoprolol the nurse should always assess the patient's blood pressure and pulse. -The medication should have been held when the patient's heart rate was less than 60 beats per minute. -The medication should have been held when the patient's blood pressure was less than 100 systolic (the measurement of the pressure in your arteries when your heart beats. Review of the facility's policy, Medication - Administration, dated October 24, 2022 showed: -Medication would be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. -Testing and taking of vital signs, upon which administration of medications were conditioned, may be performed and the results recorded. -When administration of the drug was dependent upon vital signs or testing, the vital signs or testing would have been completed prior to administration of the medication and recorded in the medical record. The Physician's standing order was requested and not supplied by the end of survey. 1. Review of Resident #44's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -High blood pressure. -Paroxysmal Atrial Fibrillation (An irregular often rapid heart rate that commonly caused poor blood flow). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 4/28/23 showed: -He/she had a Brief Interview for Mental Status (BIMS) score of one out of 15 indicating he/she was severely cognitively impaired. -He/she had high blood pressure. -Atrial Fibrillation was not marked. Review of the resident's Physician's Order Sheet (POS) dated May 2023 showed: -Digox (Digoxin) tablet 0.125 microgram (mcg) one tablet by mouth in the morning for irregular heartbeat related to Paroxysmal Atrial Fibrillation, dated 7/12/22. --There were no parameters for checking the resident's heart rate before administering the medication. --There were no parameters to indicate when the medication was to be held for a slow heart rate. -Metoprolol Tartrate tablet 100 milligrams (mg) one tablet by mouth in the morning for high blood pressure. --There were no parameters for checking the resident's heart rate or blood pressure before administering the medication. --There were no parameters to indicate when the medication was to be held for a slow heart rate or low blood pressure. Observation on 5/17/23 at 9:18 A.M. of the medication pass with Licensed Practical Nurse (LPN) C showed: -LPN C administered Digoxin 0.125 mcg to the resident without checking the resident's pulse. -LPN C administered Metoprolol 100 mg tablet to the resident without checking the resident's blood pressure or pulse. 2. Review of Resident #74's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Bradycardia (slow heart rate less than 60 beats per minute). -High blood pressure. Review of the resident's Admission MDS assessment dated [DATE] showed: -The resident's BIMS score was four out of 15 indicating he/she was severely cognitively impaired. -He/she had high blood pressure. Review of the resident's POS dated May 2023 showed: -Metoprolol Succinate Extended Release (ER) 24 hour 25 MG, one tablet by mouth in the morning related to high blood pressure, dated 4/14/23. --There were no parameters to check the blood pressure before administering the medication. 3. Review of Resident #10's face sheet showed he/she admitted to the facility on [DATE] with the following diagnosis of high blood pressure. Review of the resident's POS dated May 2023 showed: -Lisinopril (a medication to treat high blood pressure) tablet 2.5 mg one tablet by mouth one time a day related to high blood pressure, dated 4/19/23. --There were no parameters to check the blood pressure before administering the medication. 4. During an interview on 5/17/23 at 9:30 A.M., LPN C said: -He/she should have checked the residents pulse before administering Digoxin. -There were no parameters in the physician's order to check the pulse before administering the medication. -If the resident's pulse was less than 60 beats per minute, Digoxin should have been held. -He/she should have checked the residents blood pressure before administering Metoprolol or other blood pressure medications. -If the systolic number was less than 100 it should have been held. -There were no parameters in the physician's order to check the blood pressure before administering the medication. -One resident had been at the facility since 2022 and parameters for checking the blood pressure before administering Metoprolol should have been in the physician's order so it would automatically pop up on the computer screen. -The parameter for Digoxin (hold if pulse was under 60 beats per minute) should have been in the Physician's order so it would automatically pop up on the computer screen. -The nurse who did the resident's admission and checked the orders for the medications should have noticed there were no parameters and clarified the order with the physician so there were parameters for staff to follow before administering the medications. -He/she did not know if anyone checked the orders. -There were at least four other residents that were on blood pressure or heart medications that the pulse or blood pressure should have been checked before administering the medications. -The computer system should have prompted him/her to check the blood pressure or pulse. -Staff had not checked the pulse or blood pressures before administering the medications like they were taught in nursing school. During an interview on 5/18/23 at 12:50 P.M. the Nurse Practitioner (NP) said: -There should have been parameters for administering Digoxin, Metoprolol, and other blood pressure medications. -The nurse should have checked the parameters before administering the medications. -The nurse who received the order should have ensured there were parameters for administering Digoxin, Metoprolol, and other blood pressure medications. -Metoprolol and other blood pressure medications should have been held if the resident's blood pressure was less 100/60. -Digoxin should have been held if the resident's pulse was less than 60. -He/She had written the parameters in other facilities but did not do that at this facility. During an interview on 5/18/23 at 1:30 P.M. the Director of Nursing (DON) said: -Staff had a standing order to check the pulse before administering Digoxin. -Staff should have checked the blood pressure before administering a blood pressure medication such as Metoprolol. -Checking the parameters was a professional standard taught in nursing school. -The parameters should pop up on the computer program. -The NP had ordered parameters at other facilities he/she did not know why he/she did not order it here. -The nurse who admitted the resident reviewed the medications and should have caught that there were no parameters for Metoprolol, other blood pressure medications, and Digoxin. -The Pharmacy reviewed the medications monthly. -Pharmacy should have caught that there were no parameters set for Metoprolol, other blood pressure medications and Digoxin before administering the medications. -If the nurse knew the residents were on these medications they should have checked and documented the blood pressure and pulse and ensured it was on the computer program.

Based on interview and record review, the facility failed to provide restorative care (a program to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) following discharge from therapy services for one sampled resident (Resident #8) out of 18 sampled residents. This deficient practice had the potential to effect all residents who were discharged from therapy services to a restorative program. The facility census was 76 residents. Review of the facility's Restorative Nursing Program Guidelines policy, dated 10/24/2022, showed: -The program focused on achieving and maintaining physical, mental and psychosocial functioning. -A resident started the Restorative Nursing Program when a resident was discharged from formalized physical, occupational or speech rehabilitation therapy. -The Director of Nursing Services (DSN) managed and directed the Restorative Nursing Program. -General restorative nursing care did not require the use of qualified professional therapists to render such care. The basic restorative nursing categories included, but not limited to: --Active range of motion (AROM). --Walking. -The Licensed Therapist documented whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (restorative nursing services that can be provided by caregivers). -An order was obtained from the attending physician as indicated for participation in the Restorative Nursing Program. -The care plan will reflect restorative needs of each resident. 1. Review of Resident #8's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/12/23, showed: -The resident scored a 13 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --The resident's score indicated the resident was cognitively intact. -The resident's diagnoses included kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -The resident was discharged from Occupational Therapy (OT) and Physical Therapy (PT) on 5/13/23. Review of the resident's care plan, undated, showed: -The resident had a restorative care program. -The resident would maintain current level of mobility through review date. -Interventions included: --Bi-lateral Upper Extremities (BUE) strength all planes, AROM 2 x 10. --Bi-lateral Lower Extremities (BLE) strength all plans, against gravity 2 x 20. --Ambulation with four wheeled walker x 250 feet twice as tolerated. Review of the resident's Nursing Restorative Care Program/Functional Maintenance Plan, dated 5/12/23, showed: -Goals/Approaches: --BUE strength: All planes, AROM 2x10. --Environmental engagement: Promote participation in facility activities. --BLE strength: All planes against gravity 20 x 2. --Ambulation: With four wheeled walker x 250 feet, twice as tolerated. Review of the resident's Physician Orders, dated 5/22/23, showed: -Restorative Care Program: --BUE strength: All planes, AROM 2x10. --BLE strength, all planes against gravity 20 x 2. --Ambulation with four wheeled walker x 250 feet twice, as tolerated. During an interview on 5/22/23 at 9:11 A.M., Certified Nursing Assistant (CNA) A said: -The resident had restorative with the Restorative Aide (RA) and had seen the resident walking with the RA. -The resident was discharged from therapy. During an interview on 5/22/23 at 9:53 A.M., the RA said: -The resident discharged from therapy two weeks ago. -He/she did not have an order yet to do restorative care with the resident. During an interview on 5/22/23 at 10:21 A.M., Licensed Practical Nurse (LPN) A said: -The resident was pulled off of skilled therapy a couple of weeks ago. -He/she had not seen orders for restorative therapy yet. During an interview on 5/22/23 at 10:52 A.M., the Director of Rehab said: -The resident was discharged from therapy due to meeting goals and exhausting the Medicare part A. -He/she wrote a restorative plan for the resident and gave it to the MDS Coordinator. -The resident should have already started the restorative care program. During an interview on 5/23/23 at 1:05 P.M., the Director of Nursing (DON) said: -The MDS Coordinator was out of the building for an emergency and not able to be interviewed. -After the resident was discharged from therapy the therapist wrote an order for restorative care. -The order went to the MDS Coordinator who input the information in the care plan and made sure the order was in place then reviewed it with the RA who would initiate the program. -The therapist wrote the order for restorative care within a couple of days of being discharged from therapy. -Ideally it would be written upon discharge to avoid a lapse in care. -He/she would have expected less time to have lapsed from 5/13/23, the date when the resident was discharged from therapy to the time the order was written on 5/22/23. -The orders went into place yesterday on 5/22/23.

Based on interview and record review, the facility failed to ensure that one sampled resident (Resident #4) was treated with dignity and respect when Agency Certified Nurse Aide (CNA) G preformed karate type movements in front of the resident while he/she was trying to hit and kick the staff out of four sampled residents. The facility census was 75 residents. Record review of the facility's Abuse Prevention Policy, dated 11/1/06 showed the facility prohibits mistreatment, neglect, and abuse of its residents and is committed to protecting residents from abuse by staff, other residents, consultants, volunteers, agency staff, family members or legal guardians and friends. 1. Record review of Resident #4's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Delusional Disorders (fixed false beliefs). Record review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/8/22 showed: -The resident: --Was severely cognitively impaired. --Had disorganized thinking. --Had difficulty concentrating four or more days. --Had physical behavioral symptoms directed toward others (e.g. hitting, kicking, scratching, and grabbing) one to three days within the past week. --Had verbal behavioral symptoms directed toward others (e.g. cursing and/or screaming at and threatening others) one to three days within the past week. --Had other behavioral symptoms not directed toward others (e.g. scratching self, rummaging, pacing, and yelling) one to three days within the past week. -Behaviors did not significantly put the resident or others at significant risk for physical injury and did not significantly intrude on the privacy or activity of others or significantly disrupt the living environment. -Behaviors included rejection of care one to three days within the past week. -Required extensive two-person physical assistance with toileting and was always incontinent of bowel and bladder. Record review of the resident's Resistance to Staff Assistance Care Plan, initiated 4/1/22 showed the following interventions: -Allow the resident to make decisions about treatment regime to provide a sense of control, initiated 4/8/22. -Encourage as much participation/interaction by the resident during care activities, initiated 4/8/22. -Give clear explanation of all care activities prior to and as they occur during each contact, initiated 4/8/22. Record review of the facility's internal investigation, started 4/26/22 with a final report date of 4/29/22, showed: -Agency CNA G on 4/27/22 said: --The resident was kind of feisty, hitting and kicking. --He/she was playing around and pretended to do karate moves. --Agency CNA G said he/she realized later he/she shouldn't have been playing around and doing karate moves. -The resident was assessed with no signs of bruising, discoloration or injury. During an interview on 4/27/22 at 3:25 P.M. Licensed Practical Nurse (LPN) C said: -At approximately 6:30 P.M. Agency CNA F informed him/her that Agency CNA G was making motions with his/her hands toward the resident whom was actively resistant during resident care. -Agency CNA G said he/she was rolling his/her closed fists in a circular motion in front of the resident, but was only teasing the resident. -He/she checked the resident for injuries throughout the evening shift and he/she saw no red marks or bruising on the resident. -The resident was assessed for signs of being upset throughout the shift. During an interview on 4/27/22 at 3:50 P.M. Agency CNA F said: -He/she and Agency CNA G were in the resident's bathroom to provide care for the resident. -Agency CNA G was standing in front of the resident facing him/her while he/she sat on the commode and reached out and was moving with his/her arms with closed fist. -He/she stepped in front of the resident to protect the resident with his/her back to the resident and faced Agency CNA G. -The resident had put his/her fist up at shoulder level as if to fight Agency CNA G. Agency CNA G put his/her fists up to his/her shoulder level. -He/she was told on 4/26/22 it was usual for the resident to have behaviors of aggression. -He/she was unable to find the Administrator's phone number so he/she walked to another section of the facility and reported the incident to LPN C. During an interview on 4/27/22 at 4:30 P.M. Certified Medication Technician (CMT) A said: -He/she heard Agency CNA F say You just can't do that two or three times. He/she figured Agency CNA F was talking to the resident. -When Agency CNA F came out of the resident's room a few to eight minutes later he/she pulled him/her to the side and Agency CNA F reported that Agency CNA G said hateful things to the resident and made hand motions to the resident. -Agency CNA F reported the incident directly to LPN C. -Agency CNA G asked if Agency CNA F was telling on him/her and asked if Agency CNA F told them he/she hit the resident? Agency CNA G denied hitting the resident and said he/she was just playing around with the resident. -If staff don't have a soft approach with the resident his/her behaviors are worse. -If staff are bossy or short with the resident he/she will become combative. During a telephone interview on 4/28/22 at 9:03 A.M. Agency CNA G said: -The resident was taken to the bathroom to be changed. He/she was very agitated and sat on a shower chair next to the toilet with his/her pants still up. -He/she and Agency CNA F tried to stand the resident up to change him/her, but the resident was swinging and kicking and they couldn't get his/her pants down. -He/she was trying to be funny and was making karate moves within a few feet of the resident. He/she never touched the resident. He/she was making karate moves into the air with his/her hands and not with his/her feet. He/she didn't touch the resident's head or kick his/her legs out. -Agency CNA F said he/she couldn't do that. He/she was just playing around and making his/her karate moves. Sometimes if residents were in a bad mood being silly like dancing will bring them out of their bad mood. -CNA F walked out after saying he/she couldn't behave that way. They both left the resident's bathroom at the same time leaving the resident sitting on the shower chair. -LPN C and LPN D both came onto the unit and told him/her he/she had to leave. -He/she had received training from the agency he/she worked for in dealing with resident behaviors. He/she had been trained if a resident was very agitated to leave the resident alone and come back later to see if the resident will accept cares. It would have been better to have left the resident alone rather than doing karate chops into the air. He/she didn't know if the resident might have thought he/she was mocking or threatening him/her. The resident just looked at him/her with no emotion on his/her face while he/she was doing his/her karate moves. -Nobody had ever told him/her how to interact with this particular resident when he/she became agitated. -CMT A had told him/her to let the resident sit and he/she would give the resident some medication that would calm him/her down, but CMT A did not say how long it would take for the medication to affect the resident's behavior. Looking back, he/she should have left the resident alone longer and given the medication time to take effect. During an interview on 4/28/22 at 10:45 A.M. the resident's responsible party said: -The Administrator called him/her right after the incident happened the evening of 4/26/22. -The Administrator said staff were either trying to bathe the resident or change his/her pants. -The resident becomes very hyper and combative, especially in the evening. He/she will hit or kick out and push people away. -The resident did better when staff of the same sex take care of him/her. He/she thought it might embarrass him/her when staff of the opposite sex changes or bathes him/her. He/she thought the resident felt humiliated all the time when he/she had to be changed. -He/she thought if staff were doing karate moves in the air in front of him/her the resident would think the staff was trying to strike him/her and probably thought he/she had to defend himself/herself. It would make the resident feel very angry. He/she thought the resident would feel overtaken. -He/she thought karate moves in the air near the resident would agitate him/her further and was definitely inappropriate. He/she would think a staff person would try to calm an agitated resident down. During an interview on 4/28/22 at 12:30 P.M. the resident's primary physician said: -The resident was with Hospice (end of life care) related to senile degeneration of the brain. -The Administrator communicated with him/her that the resident has outbursts. He/she had seen the resident only once since his/her admission and the resident was docile at the time. -He/she said the karate moves in the air and/or moving or rolling one's fists in front of a resident would be inappropriate and unprofessional. During an interview on 5/2/22 at 12:38 P.M. the Administrator said: -Agency CNA G said he/she was making karate moves in front of the resident. The resident was unable to relate what happened. -When the nurse assessed the resident the resident did not appear to be upset and did not remember what had just happened. -Agency CNA G said he/she realized doing karate moves was not the right way to handle the resident, but did not say why he/she knew it was inappropriate. -What Agency CNA G admitted to was not appropriate or professional. Agency CNA G said he/she thought he/she was being funny. A resident with dementia may not understand a staff person's intention such as someone making karate moves. -Should Agency CNA G have been a facility employee the facility would have educated him/her on working with combative residents. Since he/she was an agency employee, he/she will be on a permanent do not return status. MO00200402

Based on observation, interview and record review, the facility failed to ensure one sampled resident's safety by failing to ensure monitoring of the resident was in place to prevent elopement from the facility (Resident #1) out of four sampled residents. The facility census was 75 residents. Record review of the facility's Wandering and Elopement policy and procedure dated March 2019, showed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. Record review of Resident #1's Face Sheet showed he/she was admitted on [DATE], with diagnoses including Alzheimer's disease, depression, heart disease, high cholesterol, high blood pressure, kidney disease and glaucoma. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/25/22, showed the resident: -Had severe cognitive impairment. -Ambulated independently without an assistive device. -Did not have any wandering within the lookback period. Record review of the resident's Wandering assessment dated [DATE], showed he/she: -Was alert, ambulatory and could communicate, but was unable to follow instructions and had a history of wandering. -Had wandered within the facility, most of the day through the unit and had been known to try and exit by following people out. It showed the resident was re-directed and at times had difficulty due to his/her dementia and confusion. Record review of the resident's Care Plan dated 8/10/20, showed he/she was an elopement risk and had prior attempts of trying to leave the facility unattended. It showed the resident had previously climbed through a window opening. It showed the resident's triggers for wandering/elopement were related to his/her dementia. The resident felt locked up and wants to go look for his/her family. The resident's behavior was de-escalated by reassurance and re-direction. Initiatives showed staff would: -Provide one to one companionship and distraction. -Distract the resident from wandering by offering diversions, structured activities, food, conversation, television and reading activities. -Do not allow the resident to watch staff enter door codes or follow them out of secured exits. -Modify the exits and keep the window to 3 inches wherever the resident has access. -Provide structured activities, toileting, walking inside and outside, reorientation strategies including room signs, pictures and memory boxes. Record review of the facility Investigation Summary dated 4/20/22, showed the resident was last seen on 4/20/22 at 6:45 A.M., wandering the halls which is normal behavior for the resident. At about 7:20 A.M., the resident was found outside of the building at the east of the facility at the Hospice building. It was suspected that the resident went off of the unit through a double door which was alarmed, and then out of the service doors, which was a staff entrance/exit and were not alarmed or locked. The resident was wearing a sweatshirt and pants without socks or shoes. The resident was placed on 15 minute checks and a staff person was assigned to the staff exit doors while the facility was getting assessments on alarming and locking the staff exit doors. Observation and interview on 4/20/22 at 10:42 A.M. during a tour of the facility exits showed: -The facility had two entrances to the facility. The main entrance had two sets of double doors that were not locked/coded or alarmed entrances and was staffed by a receptionist upon entry. The staff entrance also had two sets of doors that were not locked/coded or alarmed entrances. These doors were down the hall from the unit doors. -There were two emergency exit doors in the corridor of the staff entrance/exit doors. These doors were locked and required pushing them for 15 seconds before they would open. These doors were alarmed and sounded when pushed but did not open. At the end of the corridor was the unit doors. -The unit doors were locked and required a code to enter/exit. The door alarm sounded when trying to open them without using the code. These doors led one onto the resident living areas. -Once on the unit, there were six resident halls. Each hall had an exit that was coded and alarmed which led to an enclosed and fenced in patio area. All of these doors were tested and sounded without entering the codes to release the doors. -The Maintenance Director said at 7:45 A.M., he/she and his/her assistant tested all of the doors and ensured all of the windows were secured once he/she was made aware that the resident had gotten out of the facility. He/she said all of the doors that had alarms were working appropriately and the codes were all working. He/she said they thought that the resident may have followed someone out of the locked unit doors and went out of the staff exit doors. He/she said they were trying to find a way to secure the first set of doors at the staff exit so they would alarm when exiting without a code, but not restrict entering. During an interview on 4/20/22 at 11:20 A.M. the Receptionist said he/she came to work at 6:30 A.M. through the main entrance and she did not see any of the residents outside in the parking lot or inside in non-resident areas. He/she did not see the resident and did not hear any door alarms sounding since he/she came in to work. During an interview on 4/20/22 at 11:23 A.M., Licensed Practical Nurse (LPN) A said: -He/she was the night shift nurse and was covering the 100 and 200 halls. -He/she completed his/her medication pass at 5:00 A.M. and at that time, the resident was wandering in the main hall area, which is the resident's normal behavior, but he/she was not trying to go off of the unit. -He/she did not see the resident after this time, but there was a Certified Nursing Assistant (CNA) on the 100 unit (the unit the resident resided on). -When he/she spoke with CNA E he/she said the resident had slept through the night, woke up and he/she last saw the resident on the unit at 5:45 A.M. on 4/20/22. -All of the nursing staff were supposed to check the residents every two hours. -They have residents that wander on and off of their halls and that is allowed because it is less restrictive and the unit is locked, so the residents are not supposed to be able to exit unattended. -Since all of the doors on the unit is alarmed, if/when the door is pushed, they all will alarm unless you put the door code in. -He/she did not hear any alarms sound at any time during the shift or during the day shift. -When the nursing staff enter and exit out of the unit doors, they were supposed to check to ensure none of the residents were around the doors when they enter the code or when they exit, to ensure no resident follows them out of the doors. They should ensure the door is closed and secured when the exit. -When the door closes, it will automatically lock, but staff should stay until the door closes. -After the resident came back into the facility, he/she was brought back onto the unit and placed on one to one observation. -He/she started in-servicing the staff immediately and all current staff have been in-serviced on elopement and ensuring the safety of the residents. He/she said they will continue to in-service staff who work the evening and night shift staff until everyone has been in-serviced. Observation and interview on 4/20/22 at 11:37 A.M. showed the Maintenance Assistant: -Sitting in the corridor outside of the locked unit. -He/she came to work at 8:00 A.M., and was informed of the resident's elopement. -He/she and the Maintenance Director went to every exit in the facility to ensure all doors that were supposed to be locked or on a locking mechanism were working. He/she said they also checked all of the windows on the unit to ensure none of them were opened. He/she said all of the doors were working properly and there were no windows that were opened. -He/she was assigned to sit in the corridor to ensure no residents come out of the unit unassisted until they can have a coded alarm system placed on the staff exit doors. -He/he was informed that they thought the resident had exited the locked unit doors, walked down the corridor and exited out of the staff exit doors. Observation on 4/20/22 at 11:49 A.M., showed the resident was dressed for the weather with adequate shoes on and was up ambulating on the 100 hall with staff. The resident walked with staff off of the 100 hall and onto the main hall. The resident was friendly but was confused. During an interview on 4/20/22 at 11:50 A.M., CNA A said: -He/she usually worked on 100 hall and cared for the resident on the day shift from 7:00 A.M. to 3:00 P.M. -This morning he/she arrived to the facility at 6:50 A.M. he/she did not see the resident outside in the parking lot or upon entering the facility. -When he/she came onto the unit, he/she had to enter the code before opening the door and the doors were alarmed (the light on the code pad was red). -He/she did not see the resident on the unit and he/she did not hear any alarms once inside. -CNA E was sitting in a chair on the 100 hall and he/she received report from him/her. He/she said CNA E did not say anything about Resident #1. -After assisting with some resident care on 100 hall, he/she went to the 200 hall at 7:05 A.M., to assist staff with resident care. When he/she came back to the 100 hall, he/she was informed that Resident #1 was found in the Hospice building and they were bringing the resident back to the locked unit. -When the resident returned, he/she behaved the same (at baseline) and the resident was assigned a staff to provide one to one observation. -The resident normally was up when he/she came to work and he/she liked to wander on the halls and on the main hall. -The resident was exit seeking and often went to the unit doors and occasionally push on them, setting off the alarm, and staff has to redirect the resident from the doors. -He/she did not know how the resident got off of the unit because the doors were locked and alarmed, but he/she heard that the resident followed someone out of the doors. During an interview on 4/20/22 at 12:00 P.M., CNA B said: -He/she came to work at 5:50 A.M. and did not see the resident outside or inside the facility upon entering. -He/she entered the locked unit and had to put the code in before entering because the doors were locked. -Upon entering onto the unit, he/she did not see the resident. He/she went to his/her work station and began working. -He/she never heard any door alarms sounding after coming to work. -He/she was familiar with the resident and the resident often wandered on the unit and he/she saw the resident would go to the unit doors to try to get out but the doors require a code before they would open (or else an alarm would sound). -Usually when they see residents who wander and go to the unit doors, they will try to redirect the resident away from the doors and back to their hall or other areas on the unit. -When the staff exit they are supposed to check to make sure there are no residents by the door and if they are, they are supposed to redirect them away from the doors before exiting. -When they exit the unit, they are supposed to check to ensure no resident follows them out of the unit. -He/she did not know how the resident got out of the unit doors. During an interview on 4/20/22 at 12:05 P.M., CNA C said: -He/she came in to work at 7:05 A.M., this morning and he/she did not see the resident outside or in the parking lot. He/she said he/she did not see the resident inside the facility upon entering. -He/she had to enter the door code to come onto the unit and the doors were locked when he/she came in. -He/she never heard any alarms sounding once he/she came into the building or afterward. -He/she was familiar with the resident and they have other residents on the unit that wander and are exit seeking also. -The resident wanders all over the unit, wandered to the unit doors and was exit seeking. -If staff saw the residents who are exit seeking at the unit doors, they were supposed to redirect them to either their hall or to other areas on the unit. -Nursing staff was supposed to check each resident every two hours, but he/she usually checks the residents that are exit seeking more frequently so that he/she knows where the residents are at all times. -If they saw a resident at the unit doors, they were supposed to redirect the resident away from the doors. -When they exit the unit they were supposed to ensure there were no residents around because some of the residents would try to follow them out of the doors. -He/she did not know how the resident was able to walk off the unit without the door alarm sounding unless he/she knew the door code, or followed someone off of the unit who was not checking to ensure the resident was not by the door. During an interview on 4/20/22 at 12:20 P.M., CNA D said: -He/she came to work at 7:00 A.M., this morning and he/she did not see the resident in the parking lot or on the facility property upon entering the facility. -He/she did not see the resident once he/she came inside the building and he/she never heard any door alarm sound after he/she came onto the unit. -He/she had to enter the door code to come onto the unit because the doors were locked and alarmed. -He/she did not see the resident once he/she came onto the unit and he/she went to his/her assigned area. -He/she was familiar with the resident and the resident liked to wander on the halls and in the main hallway. -They have to watch for the residents who wander so that they do not go towards the unit doors. -Some of the residents will go to the unit doors and push on them to get off the unit, but the door will alarm when they push on them and the staff will silence the alarm and redirect the resident back to their hall. -The protocol for staff is that upon entering the unit they were supposed to open the doors slowly because they have residents who may be by the doors. Upon exiting the unit they are supposed to observe for any resident around or by the unit doors so that they will not try to follow the staff out of the doors once the door code is entered. -There is a sign by the unit doors that reminds them that no resident should exit the unit unattended. During an interview on 4/20/22 at 12:38 P.M., LPN B said: -He/she arrived at the facility around 6:30 A.M. and when he/she came in to the unit, he/she did not see the resident outside and once he/she came into the building, he/she did not see any residents on the main hall or by the unit doors. -There were residents that wandered and were exit seeking that lived on the unit and the resident was one who wandered and had a history of prior elopement and he/she was exit seeking. -The unit doors were locked and required a code to enter and exit. -The doors were operating correctly when he/she came onto the unit and he/she did not hear them alarm at anytime after he/she came to work. -Staff was supposed to ensure no staff exited the unit unattended and when they see residents at the doors, they usually redirected them away from the doors and if/when staff was exiting the unit they were to ensure that none of the residents were by the door. They were supposed to ensure the doors closed behind them and no resident had followed them out. -The resident wandered on the unit and was an elopement risk. -The resident had tried to get out of the facility before and he/she should have been monitored more closely when he/she is up wandering. During an interview on 4/20/22 at 2:07 P.M., Hospice Business Office Manager said: -He/she had come to work at around 7:00 A.M. and unlocked the front door at 7:05 A.M. and went to make coffee. -He/she heard someone in the front office area and when he/she went to that area, he/she saw the resident who was dressed in a top and pants was not wearing socks or shoes. -The resident was friendly but was obviously very confused. -He/she called over to the facility and asked if they were missing the resident and informed them that the resident had come into their building. -The nursing staff did not seem to know that the resident was gone, but he/she brought the resident back to the facility. -The staff told him/her they did not know how the resident got out of the facility. During an interview on 4/22/22 at 2:39 P.M., CNA E said: -He/she was an agency CNA who was assigned to work on the 100 hall on the night shift (11:00 P.M. to 7:00 A.M.) on 4/20/22. -He/she was not very familiar with the resident but when he/she arrived to work at 10:45 P.M., he/she went to the 100 hall and received report from the nursing staff he/she was replacing. -He/she completed rounds and the resident was in his/her room in bed and he/she slept through the night. -He/she did not remember when the resident got up, but the resident was ambulatory and he/she remembered the resident standing next to him/her and talking about the weather. -He/she saw the resident walk off of the 100 hall while he/she was charting. -The residents were allowed to roam on the unit, off of their halls. -He/she did not remember if he/she completed rounds again before he/she left the unit at 7:00 A.M. -The CNA who was relieving him/her came onto the unit and she gave report to him/her and then he/she left the unit. -There were several residents in the main hallway when he/she left the unit, but he/she did not remember seeing the resident. During an interview on 4/20/22 at 12:59 P.M., the interim Director of Nursing (DON) said: -His/her expectation was for no resident to be able to exit the unit unattended. -Staff should monitor the residents known to wander, exit seek or who are an elopement risk more frequently than every two hours to ensure the resident's location. -Staff upon exiting the unit are expected to make sure there are no residents by the doors to see them enter the door code or to follow them out of the doors. -Staff should ensure the unit doors are completely shut upon exiting them and look around to make sure no resident got outside of the unit doors. -After speaking with LPN A, and upon their current information about the incident, the resident was last seen this morning on the 100 hall at around 6:45 A.M. -The resident had a history of wandering and was exit seeking and was an elopement risk. -They received a call from the receptionist at the Hospice building stating the resident had come to their building and they would bring him/her back over to the facility. (The Hospice building is next door to the facility and on the same property). -Once the resident arrived back in the facility, they placed the resident on one to one monitoring and began interviewing staff regarding how the resident got out of the building. -Based on their interviews, no one heard any door alarms sounding, including the unit doors, and no one was aware the resident had gotten off of the unit. -They believe the resident followed someone out of the unit around 7:00 A.M. because all of the doors were operating as they should. -They are completing in-services with all staff on elopement and are currently trying to put a coded alarm system on the staff doors so that an extra safety measure is in place and they are rotating staff to sit in the corridor outside of the unit doors until they have the new coded alarm placed on the staff doors. MO002000093

Based on observation, interview and record review, the facility failed to complete fall investigations and put individualized interventions in place for one sampled resident (Resident #1) who sustained a fractured nose on 11/19/21 from a fall, sustained a laceration to the head requiring staples on 12/12/21 from a fall, and had black, bruised eyes and a hematoma (blood filled) to the head after a fall on 12/30/21; and to completed fall investigations and put individualized interventions in place for two sampled residents (Resident #3 and #4) after a fall out of three sampled residents for falls. The facility census was 74 residents. Record review of the facility's Falls and Fall Risk, Managing policy dated 12/2007 showed: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize the complications from falling. -Prioritizing approaches to managing falls and fall risk: --The staff along with the attending physician will identify appropriate interventions to reduce the risk of falls. --The consulting pharmacist, nursing staff and attending physician will identify and adjust medications that might be associated with an increased risk of falls. --If falls recur despite initial interventions, staff will implement additional interventions, based on assessment of the nature of falling, until falling is reduced of stopped, or until the reason for the continuation of the falling is identified as unavoidable. Record review of the resident's untitled, undated neurological checks form showed: -The staff were to complete neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) after a fall as follows: --Every fifteen minutes four times. --Every thirty minutes four times. --Every hour four times. -Every four hours four times. -Every shift (3 shifts) for 72 hours. Record review of the Nurse Incident Checklist showed: -The nurses were to complete the following when a fall occurs: --Complete a risk assessment including skin. --Initiate neurochecks. --Notify physician, responsible party and Director of Nursing (DON). -Complete incident note with intervention. -Statements from staff. -Assessment signed. -User-defined assessments completed. --Communication tab. -Treatments and medications as ordered. Record review of the undated Assistant Director of Nursing (ADON) and Director of Nursing (DON) checklist showed: -The ADON and DON were to complete/review the following after a fall: --Complete a risk assessment including skin. --Initiate neurochecks and complete neurochecks. --Notify the physician, responsible party, and DON. --Completed incident note with interventions. --Statements form staff. --Physician's Orders Sheet (POS). --Care plan-old and new. --Assessments signed. --User defined assessments. --Communication tab. --72 hour follow up charting complete. -Treatments and medications as ordered. 1. Record review of Resident #1's Admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -[CONDITION(S)] (a condition of increased pressure inside the eye which could lead to [CONDITION(S)]). Record review of the resident's Care Plan dated 6/20/20 showed: -The resident had impaired cognitive function related to Alzheimer's disease. -The resident was at risk of falls related to wandering. --The staff needed to anticipate and meet the needs of the resident. --The staff needed to ensure proper footwear when the resident was ambulating. --Ensure the resident's call light was in reach. -The fall care plan was last revised 7/22/20. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment required to be completed by facility staff for care planning) dated 9/22/21 showed he/she: -Was severely cognitively impaired. -Needed supervision with walking and transfers. -Had one injury fall and one non-injury fall since the last assessment. Record review of the resident's Nursing Note dated completed by Licensed Practical Nurse (LPN) C 11/19/21 showed: -The resident had been very combative and aggressive. -The resident fell on the unit at 7:58 P.M. and would not let this nurse assess him/her. -Every time this writer would try to look at the bump on the top of the resident's head, the resident would get combative, yell at the top of his/her lungs, and run off. -The physician was notified and gave physician's orders to send the resident to the emergency room . -The family was notified. -The resident returned from the hospital at 10:14 P.M. with no new physician's orders. -The resident was resting in bed with his/her baby doll. -There was no investigation, and no individualized interventions were put in place after this fall. Record review of the resident's Neurological Assessment (level of consciousness, pupil response, motor functions-hand grasps/extremities, pain response, and vital signs) Flow Sheet dated 11/19/21 showed the resident had neurological checks once per shift, for three shifts per day, for three days. Record review of the resident's hospital final report record dated 11/19/21 showed: -The resident had an episode where he/she was agitated, may have fallen, and hit the back of his/her head. -The resident's family member reported the resident had recently had medication changes with altered mental status. -The resident had a neurological assessment and no concerns were found. -The resident had a fractured nose. -The resident was sent back to the facility and was asked to return for worsening symptoms or further concerns. Record review of the resident's Nursing Note dated 12/12/21 showed no nursing notes related to a fall. Record review of the resident's untitled incident report completed by LPN D dated 12/12/21 showed: -The resident had an unwitnessed fall. -A Certified Nursing Assistant (CNA) retrieved the nurse and stated the resident had blood on the back of his/her head. -The nurse observed a bleeding hematoma to the back of the resident's head. -The nurse applied pressure while the other nurse called 911. -The resident was taken to the hospital. -The resident had a hematoma to the back of the head, and laceration to the back of the head. -There were no witnesses found. -There were no predisposing environmental factors or predisposing factors. -The resident was confused and had memory impairment. -The physician and family were notified. -There was no investigation completed, no individualized interventions were put in place after this fall, and no neurochecks were completed. Record review of the resident's hospital final report record dated 12/12/21 showed: -The resident had an unwitnessed fall with a contusion on the right side of his/her head. -The resident could not answer questions and was cognitively impaired. -A neurological assessment was completed and there were no concerns. -The resident had a Computed tomography (CT scan an X-ray image made using a form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces the image) of his/her head and no concerns were found. -The resident had a 0.5 centimeter (cm) laceration to the back right of his/her head and a staple was placed. -The resident needed to return to the emergency department after seven days to remove the staples. -The assessment was a closed head injury, fall with laceration with staple placement. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired. -Needed supervision with walking and transfers. -Had two injury falls since the last assessment. Record review of the resident's Nursing Note completed by LPN A dated 12/30/21 at 10:58 A.M. showed: -The CNA wet to get the resident dressed for breakfast and found the resident walking in his/her room with blood on his/her fingers and nose. -There was a 6.5 cm by 6.0 cm lump in the center of the resident's forehead. -The resident was assessed and had a steady gait, was ambulating independently, his/her pupils were equal and reactive to light and his/her hand grips were good. The physician was notified and told the nurse to monitor and if the resident's condition changed to call him/her back. -The family was notified. Record review of the resident's untitled incident report completed by LPN A dated 12/30/21 showed: -The resident had an unwitnessed fall. -The resident was found walking in his/her room with blood on his/her fingers and right nostril. -The resident had a lump on his/her forehead. -There were no predisposing environmental factors or predisposing factors. -The resident was confused and had memory impairment. -The physician and family were notified. -The resident had been wandering. -There was no incident report competed, no investigation, and no individualized interventions were put in place after this fall. Record review of the resident's Neurological Assessment Flow Sheet dated 12/30/21 showed: -Four neurochecks were completed every fifteen minutes. -Two neurochecks were completed every 30 minutes. -Four neurochecks were completed every hour. -Seven neurochecks were completed on three shifts for three days. Record review of the resident's Nursing Note dated 1/17/22 showed the resident had old bruising to forehead, around eyes, and coming down cheeks as a result of his/her fall on 12/30/21. Observation on 2/4/22 at 11:00 A.M. showed: -The resident was ambulating in his/her room brushing his/her hair. -The resident's bed was in a lower position. -The resident had slippers on his/her feet. During an interview on 2/4/22 at 11:05 A.M. CNA A said: -The resident did use a low bed for falling out of bed. -He/she was unsure if the resident was a fall risk because the resident could walk. -He/she was not aware of any other fall interventions. -He/she had not known the resident had fallen recently. -He/she did watch the resident but the resident could ambulate very fast. During an interview on 2/4/22 at 11:25 A.M. CNA B said: -He/she was aware the resident had fallen in the past. -The resident would wander down to this unit. -The resident was ambulatory. -When the resident was on this unit, he/she would try to get the him/her to sit down and do an activity to get him/her off his/her feet. During an interview on 12/4/22 at 11:37 P.M. LPN A said: -The resident did fall but not often. -The resident did fall and blacken both of his/her eyes but this was on a weekend. -The resident was ambulatory and wore slippers. -The resident was just like anyone else and could stumble and fall. During an interview on 12/4/22 at 12:28 P.M. the DON said: -He/she could not locate a fall investigation for the resident's fall on 11/19/21. -The resident had been sent to the hospital after the nurse was unable to assess the resident. -All fall interventions should be on the care plan. -He/she had educated the nurse on completing incident reports prior to the fall investigaiton for falls. During an interview on 2/4/22 at 12:30 P.M. the Social Services Designee (SSD) said: -He/she was responsible for medical records. -He/she could not locate the hospital medical records for the resident's falls. -He/she would request them from the hospital. During an interview on 2/4/22 at 1:55 P.M. LPN A said: -On 12/30/21, the resident was found walking around in his/her room with a bump on his/her forehead and blood on his/her fingers, hand and nostril. -He/she was unsure if he/she found the resident or if a CNA found the resident. -He/she assessed the resident and notified the family and physician. -The physician stated to monitor the resident and did not sent the resident to the hospital. -The resident was placed on neurochecks to monitor and had no significant injury. -The nurses were responsible for completing the incident report prior to fall investigations. -He/she would notify the DON of the fall and the Interdisciplinary Team (IDT) would put interventions in place and complete the investigation. -He/she was not sure where the interventions were documented or if they were updated on the care plan. -He/she was responsible for gathering witness statements but he/she did not do this. -The nurse could put in an immediate intervention in. -An example would be if the floor was wet or the resident needed shoes on. During an interview on 2/4/22 at 3:00 P.M. LPN C said: -During the end of his/her shift a CNA had come to him/her and stated the resident had fallen down. -He/she went to the resident and he/she was combative, hitting, yelling and screaming and would not let him/her assess the resident. -The resident kept trying to get away from the him/her but the resident had hit his/her head and was bleeding. -He/she called the physician and was told to send the resident to the hospital to be evaluated. -He/she was responsible for completing incident reports and he/she had not completed the incident report prior to the fall investigation. -He/she was responsible for completing an incident report for every fall. -He/she called the resident's responsible party. -Nurses could add interventions after a resident fell . -He/she had not added an intervention after this fall. -He/she was unsure if nurses could add fall interventions to the care plans. -After the resident returned from the hospital full sets of neurochecks should have been completed. -He/she thought the ADON and DON would follow up and investigate the fall looking at causes for the fall. -He/she tried to keep a close eye on the resident, keep him/her occupied with his/her baby dolls when anxious. -The resident could ambulate independently and was cognitively impaired. -The resident later returned from the hospital and he/she was not aware of any injuries for this resident. During an interview on 2/7/22 at 8:25 A.M. the DON said: -He/she could not locate any more documentation related to falls for the resident. -No investigations had been done for the falls. -The resident's fall care plan was last updated on 7/22/20. -The resident had injury falls on 11/19/21 and on 12/12/21. -The resident fell on [DATE] and had black eyes. During an interview on 2/7/22 at 8:51 A.M. the ADON/MDS Coordinator said: -He/she had just updated the resident's care plan for falls on 2/4/22. -The resident was ambulatory and independent. -A fall intervention for this resident would be going to the hospital after he/she fell . -It was difficult to put interventions in place for the resident. During an interview on 2/7/22 at 10:20 A.M. CNA C said: -He/she was there the day the resident fell on [DATE]. -He/she did not see the resident fall but had heard about it. -When he/she came back for his/her next shift, the resident had a bump on his/her head and was bruised all over his/her eyes. -He/she knew how to review the resident's care plan and had accessed the care plan. -He/she had looked for fall interventions on the care plan but there was nothing updated. 2. Record review of Resident 3's Admission Record showed he/she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of the resident's significant change MDS dated [DATE] showed he/she: -Was severely cognitively impaired. -Had one major injury fall and one non-injury fall since the last assessment. -Needed the limited assistance of one staff member with ambulating, transfers and dressing. Record review of the resident's Fall Care Plan last updated showed: -The resident was at risk of falls and had a history of falls. -The staff were to ensure the resident was wearing proper footwear. -Ensure the resident's call light was in reach. -Anticipate and meet the needs of the residents. -The resident needed assistance with ambulation from staff. -The resident used a wheelchair for mobility. Record review of the resident's Nursing Note dated 11/22/21 showed: -The CNA stated he/she heard the resident yell out and found the resident sitting on the bedroom floor beside his/her bed. -The resident was assessed with no injuries. -The resident denied hitting his/her head. -The resident's physician and family were notified. Record review of the resident's untitled incident report dated 11/22/21 showed: -This was an unwitnessed fall. -The CNA stated he/she heard the resident yell out and found the resident sitting on the bedroom floor beside his/her bed. -The resident denied hitting his/her head. -The resident was assessed with no injury and did not have pain. -There were no environmental factors that contributed to the fall. -The resident was incontinent, had gait imbalance, was cognitively impaired and had weakness. -There were no witnesses found. -The resident's physician and family were notified. -There was no investigation completed, no neurochecks, and no individualized interventions were put in place after this fall. Observation on 2/7/22 at 11:20 A.M. showed: -The resident was lying in bed under the covers. -The resident's wheelchair was beside the resident's bed. 3. Record review of Resident #4's Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Localized related partial idiopathic [CONDITION(S)] (a genetic condition; a central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness) with seizures (a hyper excitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles). Record review of the resident's Admission MDS dated [DATE] showed he/she: -Was independent with transfers and walking in his/her room. -Required supervision when walking in the corridor or on the unit. -Had no prior history of falls before admission. Record review of the resident's Nursing Note dated 12/1/21 showed: -The resident was found on the floor by staff in a bent kneeling position with both knees to the ground. -The resident was unable to give a logical explanation as to how he/she fell . -It was unknown if the resident hit his/her head. -The resident had chafing and redness to both knees. -The resident was assessed with no injuries. Record review of the resident's untitled incident report dated 12/1/21 showed: -This was an unwitnessed fall. -The resident was found on the floor by staff in a bent kneeling position with both knees to the ground. -The resident was fully dressed. -The resident had redness and dry chafing noted to both bilateral knees but no open areas or bruising. -The resident did not have pain. -The physician and family were notified. -The predisposing environmental factor was poor lighting. -The predisposing physiological factors were the resident was confused, had a gait imbalance, and had memory impairment. -Predisposing situation factors were the resident had improper footwear and was ambulating without assistance. -The resident wandered. -There was no investigation completed, no neurochecks, and no individualized interventions were put in place after this fall. Observation on 2/4/22 at 11:22 A.M. showed the resident was ambulating independently out of his/her bathroom in a house robe. 4. During an interview on 2/4/22 at 10:45 A.M. LPN B said: -When a resident fell , the nurse was responsible for completing Range of Motion (ROM - the range on which a joint can move), check the pain level and assess the resident. -The resident's physician and responsible party were notified. -Neurochecks were started for all unwitnessed falls every fifteen minutes four times, every 30 minutes four times, every hour four times, every four hours four times, then every shift for 72 hours. -If the fall was witnessed he/she would ask the CNA who saw the fall and get information. -He/she did not ask for witness statements from the staff. -The DON was responsible for completing the fall investigations. -He/she did not add interventions after a fall occurred or update the resident's care plan. -The MDS Coordinator would add interventions on the care plan after a fall. During an interview on 2/7/22 at 8:25 A.M. the DON said: -He/she could not locate any more documentation related to falls for the residents. -No investigations had been done for the falls. -The nurses had a checklist that was supposed to be completed when a fall occurred and none of the nurses knew about the required Nurse Incident Checklist. -Everything on the Nurse Incident Checklist was required to be completed by the nurse for every fall. -The nurses were responsible for gathering witness statements at the time the fall occurred. -The nurses should always continue and complete full neurochecks for the residents according to the neurological checks form. -Neurochecks were required for all un-witnessed falls. -The nurses were responsible for putting in immediate interventions after a fall. -The incident report would flag to him/her in the medical records for follow-up. -He/she looked at the incident reports and review but had not been following up to ensure the investigations were done. -The IDT team would review the fall at daily morning meetings. -The ADON/MDS Coordinator was responsible for completing the fall investigations and updating the care plan with individualized interventions based on root cause analysis. -This was ultimately his/her responsibility to ensure the fall investigations and interventions were completed. -He/she was unsure of who found the residents' when they fell . During an interview on 2/7/22 at 8:51 A.M. the ADON/MDS Coordinator said: -If a fall occurred, the nurses were responsible for completing the Nurse Incident Checklist. -He/she was responsible to review for the completion of the nurses progress notes, care plan updates and ensuring interventions were in place. -The DON was responsible for completing the fall investigations including completing a root cause analysis to determine fall interventions. -He/she was involved in the IDT team meetings. -The IDT team meets as well to go over falls but nothing was documented from the meetings. -He/she just helped out with the falls but was not responsible for the investigations. During an interview on 2/7/22 at 9:01 A.M. the Infection Preventionist said: -He/she was involved in the IDT meetings. -He/she was not involved with fall investigations. -Falls were brought up in the meetings and sometimes, if they were struggling with an intervention, they would go over interventions. -Mainly they would go over who fell . During an interview on 2/7/22 at 9:07 A.M. the Administrator said: -The ADON/MDS Coordinator was responsible for completing fall investigations and putting interventions in place. -Nursing was responsible for falls. -The ADON/DON MDS Coordinator were responsible for following up on the falls and reviewing for root cause interventions and making sure these were in place. -The DON was responsible for the falls and process of falls. -The CNAs were probably agency staff and there was no way to know who witnessed the residents' falls or found the residents' when they fell . During a telephone interview on 2/8/22 at 2:22 P.M. the Medical Director (also the resident's physician) said: -The staff should have investigated the falls to see if they were avoidable. -The DON should be reviewing the falls and looking for root cause interventions to prevent further falls and falls with injury. -The DON was responsible for completing the investigations and ensuring completion and follow through. -He/she reviewed the falls during Quality Assurance (QA) meetings. -There should be interventions put in place to prevent falls and injury falls. -Resident #1 was cognitively impaired and ambulatory and it was hard to put interventions in place but the investigations and interventions should still be completed. -Resident #1 had falls with injury including a broken nose and lacerations to the head requiring staples. MO 394

Based on observation, interview, and record review, the facility failed to ensure resident safety for one sampled resident (Resident #1) when he/she eloped from the facility during a fire alarm test; staff was not aware the resident had eloped from the locked unit and was found three quarters of a mile from the facility by a staff member going out to lunch, out of three sampled residents. The facility census was 73 residents. Record review of the facility's undated policy, Fire Response Plan, showed: -The Fire Response Plan provides for the safety of and reduces risk to employees, residents, physicians, and visitors. -Fire drills were one method of training staff in what to do in case of fire or smoke. -Fire drills were designed so staff can practically apply what they had learned in fire orientation and training. -During fire drills, the staff was expected to react the same as they would in an actual fire situation. -Fire drills would be conducted once per quarter per shift in all parts of the facility annually. -It was the policy of the facility to pre-plan for all anticipated hazards with a goal to minimize the stress and danger to our residents and staff. Record review of the facility's policy titled, Elopement Prevention, dated [DATE] showed: -Elopement occurs when a resident leaves the facility without the expressed knowledge or approval of the facility or an authorized representative of the facility to prevent an elopement from occurring. -Wandering was random or repetitive locomotion. -This movement may be goal directed (example the person appears to be searching for something such as an exit). -Residents identified as being at risk would have an individualized plan of care developed and implemented that attempts to reduce their elopement of flight risk. -When a resident has been identified as being at risk interventions would be implemented. -Increased monitoring of the resident's whereabouts to assure he/she remains in the facility (example every one-half hour checks). -Placement on a secure unit. -If door alarms would have been turned off, the exit would be directly supervised during the period in which the alarm was disabled. -Staff would be in-serviced on the facility's elopement prevention and response procedures upon hire, bi-annually, and at the discretion of the Safety Committee. 1. Record review of Resident #1's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). -Anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). -[CONDITION(S)] (a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to go back to sleep). -Major depressive disorder (a mental health disorder characterized by persistently depressed moods or loss of interest in activities, causing significant impairment in daily life). -Restlessness and agitation (a sense of inner tension and restlessness). Record review of the resident's care plan dated [DATE] showed: -The resident had a history of exit seeking behaviors. -The staff was to intervene as necessary to protect the rights and safety of others. -The resident was physically aggressive at times related to fear, anger, and dementia. -The resident had a communication problem. -The resident spoke Spanish only. -The resident did understand some English. -The resident had impaired cognitive function related to dementia. -The resident was at risk for falls related to dementia and lack of safety awareness, dated [DATE]. -The resident needed supervision with all decision making, dated [DATE]. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by the facility for care planning) dated [DATE] showed: -The resident would need an interpreter to communicate with the physician or staff. -The resident's preferred language was Spanish. -The resident was able to make self understood. -The resident was able to understand others. -The resident's Brief Interview for Mental Status (BIMS - a structured evaluation aimed at evaluating cognition in elderly patients) score was 99 (the resident was not able to complete the interview). -The resident's ability to make decisions was severely impaired. -The resident had wandering tendencies ,d+[DATE] times during the two week look-back period. During an interview on [DATE] at 2:00 P.M. the Administrator said: -On [DATE] at 9:30 A.M. the facility started to conduct a sprinkler system (a system that releases water during a fire to control the fire) test. -This test was preformed every six months. -The Maintenance Department and fire equipment company would check each sprinkler head and dampers (a mechanical device that regulates air flow). -Certified Nursing Assistant (CNA) A went out for lunch and saw the resident walking on the road about ,d+[DATE] mile away from the facility. -CNA A called out to the resident and was able to get him/her into his/her car. -About 11:20 A.M. CNA A walked the resident back into the facility. -A full head to toe assessment was preformed on the resident and he/she wasn't injured. -The resident appeared to be very happy. -The resident spoke only Spanish. -The resident understand some English. -The facility did not have any security cameras. -He/she thought the resident went out the front main doors. -The Receptionist who was stationed in front of the main door to screen everyone who came into the facility for COVID (a new disease caused by a novel (new) coronavirus) had left his/her desk during the sprinkler test to use the restroom. -The resident also could have gone out the laundry room door. -The resident's physician and family had been notified. -A head count of all residents in the facility was conducted between 11:20 A.M. and 12:20 P.M. --All residents were accounted for, including the resident who had left the facility. -The resident was placed on 1:1 monitoring between 11:30 A.M. and 1:30 P.M. with the Administrator and the DON alternating who was with the resident. -The resident was placed on 15 minute checks from [DATE] at 1:30 P.M. to [DATE] at 7:00 A.M. with the staff on the resident's unit. -He/she and the DON were conducting in-services with the staff about elopements that included staff responsibilities during a fire drill/sprinkler check when they were not physically with the resident. During an interview on [DATE] at 2:27 P.M. the resident (via translator on the telephone) said: -He/she did not remember going outside. -His/her grandmother had told him/her to do something so he/she went outside to do it. -(The Grandmother was deceased ). Record review of the resident's Nurse's Progress Notes dated [DATE] at 2:32 P.M., written by the Director of Nursing (DON) showed: -At approximately 11:15 A.M. he/she was approached by CNA A in regards to the resident being found at the roadside. -The resident was returned to the nursing unit by the Administrator and Assistant Director of Nursing (ADON) while he/she (the DON) had the CNA show him/her where the resident was exactly found. -Upon returning to the building the DON went to the unit to ensure the resident was unharmed and to ensure necessary steps were in place. -The Administrator had initiated a building head count to ensure all residents were accounted for. -The DON directed a head to toe assessment of the resident as well as vital signs. -The DON informed the resident's physician. -The DON was not able to reach the resident's family at that time. -The resident was placed on 1:1 observation and remained in the front offices throughout the next few hours. -The resident's family member arrived at the facility. -The DON explained to the family member why he/she had tried to call him/her. -The family member verbalized understanding. -The family member was Spanish speaking with minimal English but seemed to understand. -The DON remained with the resident until he/she was returned to his/her unit. Observation on [DATE] at 3:00 P.M. of the facility's outside doors showed: -There were two sections of the building. -The front side of the building and the back side of the building which was the secured locked area where the residents lived. -The front side of the building had the following outside doors unlocked; --The double doors at the main lobby where the Receptionist was stationed. --The kitchen door. --The side door where the family came into visit in the community room. --The door by the offices. --The door by the laundry room. -Between the front and back section of the facility there was a set of double doors that needed a code to be entered into the keypad to disengage the alarm between the two areas. -The code was needed going into the secured unit or to come out of the secured unit. -There were six pods in the back section where the resident's rooms were. -Each pod had a door that opened to a patio with a gate that opened to the outside. -The doors and the gates were locked, they needed a code to enter into the keypad to disengage the locks. -If anyone went out the doors without using the code an alarm would sound. During an interview on [DATE] at 3:20 P.M. the Administrator said: -The alarms on the doors in the secured area were off for the fire alarm test. -Each pod had a locked/alarmed door that went out to a fenced patio. -The patio gate was kept locked and alarmed. -The door and gate alarms were off for the test. -The Administrator thought the resident had left out the double doors while they were off for the test then exited through the laundry room door to the outside. -The resident may have went out the double doors past where the Receptionist sat then exited through the main door. -The Receptionist left to use the restroom during the test. -The Receptionist should have had someone cover for him/her when leaving the area to use the restroom. -The Receptionist has now been educated not to leave the area without having someone cover the area. -The administrative team was now educating staff and doing an investigation. -The resident had exit seeking behaviors two to three times a week. -The fire alarm/sprinkler test was announced via telephones. -The test was announced via walkie talkies to the staff. -Each staff member had a walkie talkie. -All nursing staff and the activity staff were responsible to watch the doors in the secured area. -There were seven CNA's working in the secured area. -The was one CNA scheduled for each pod plus one extra. -There were three nurses scheduled to work in the secured area. -There were three activity staff members scheduled to work. -There were four courtyard exits, one exit by the laundry room, and the front exit that the resident could have left by. -During the fire/sprinkler test the doors would have released (were unlocked and alarm deactivated). -Each CNA was responsible for watching their pod. -The staff was not assigned to a specific door to watch. -The Receptionist would have been responsible for watching the front entry. -Some of the residents would try to follow staff out of the secured area. -There were signs to remind staff to make sure to look behind them so they were not followed out of the secured area when they go through the doors. -The resident's physician and family had been notified of the elopement. -The Administrator was currently doing a 1:1 with the resident sitting in his/her office. -The fire/sprinkler testing started at 9:30 A.M. -The resident was returned to the facility at 11:20 A.M. the same day. Record review of a statement by the Receptionist dated [DATE] showed: -During the time of the resident's elopement he/she went to the restroom. -He/she had also helped transport a resident to and from the halls. During an interview on [DATE] at 9:20 A.M. the DON said: -The staff were to watch the exit doors to ensure residents did not leave. -If a resident needed assistance, staff should notify someone to watch that exit door and area. -They routinely did a head count after the fire/sprinkler test. -Head counts were not done during the fire/sprinkler test. -The resident was returned to the facility before the count would have been done. During an interview on [DATE] at 10:10 A.M. the Maintenance Director said: -He/she was doing a fire alarm/sprinkler test on [DATE]. -There was an overhead notification to the staff that the test was going to take place. -The front desk and the Administrator were notified in person of the test. -The test started about 8:30 A.M. -During the first part of the test the doors would not have been disengaged. -After lunch part two of the test was preformed. -At 1:00 P.M. he/she verbally told the CNA's to watch the doors to ensure no one got out a door. -About 1:30 P.M. the doors to the patio were disengaged (not locked and no alarm would sound if someone went through them). -The gates to the outside on the patios were also disengaged. -The CNA's could see the doors to the patios while in the unit, unless they were busy with a resident such as changing them. -They could have used more staff in the back to watch the doors. -The test lasted from 8:30 A.M. to 1:00 P.M. -He/she not absolutely sure of the time frame as he/she was busy doing the test. During an interview on [DATE] at 10:45 A.M. CNA A said: -On [DATE] he/she left the facility about 11:10 A.M. for lunch. -He/she was driving down the road when he/she saw the resident walking on the left side of the road about a ,d+[DATE] mile away from the facility. -There was no sidewalk. -The resident would have had to cross the road to get to the left side of the roadway. -The resident was spotted by the red barns and the ponds on the farm along the road. -He/she stopped in the middle of the road and put his/her emergency flashers on in his/her car. -He/she got out of his/her car held up his/her hands to stop the traffic to get to the resident. -There were three cars coming from one side and four coming from the other side. -The cars stopped as he/she ran across the road to the resident. -He/she called the resident's name and the resident recognized him/her. -He/she was able to get the resident into his/her car and return the resident to the facility about 11:20 A.M. -He/she took the resident to the DON's office. -The resident had exit seeking behaviors before such as going to the door between the front and secured unit and beating on the door to get out. -The resident attempted to get out of the secured area weekly. -Almost daily a resident would try to get out of the secured care unit. -He/she has had education on what to do when a resident was trying to elope. -The staff was to redirect the resident such as get them involved in an activity. -He/she was not told to watch the exit doors on the day of the fire/sprinkler test. -The Activities Director had taken some of the residents outside on the patio during the test. -During a certain part of the test the alarms on the doors to the patio and the gate from the patio were disengaged. -He/she thought that was about 11:10 A.M. as he/she left the facility. -The residents wander from their pod into other pods. -The resident wander out into the main hallway. -He/she did not think they had done a head count of the residents after a fire/sprinkler test in the past. -In the past the Maintenance Director would direct the staff to be at a certain place and to do a head count afterwards. -He/she was not working on the pod the resident lived on, he/she was not responsible for the resident. -During the fire drills and during any time the door alarms were disengaged, staff were instructed to watch the doors on the pod they were assigned. Observation on [DATE] at 12:35 P.M. showed: -The resident was at the door between the secured unit and the front beating and pushing on it attempting to get out of the secured unit. -The alarm sounded, staff responded and redirected the resident. During an interview on [DATE] at 12:40 P.M. CNA B said: -He/she had education on elopement and fire drills during orientation. -The facility would tell staff when there would be a fire/sprinkler test. -Education about elopement was done during orientation and in inservices. -The staff were to watch the doors to ensure the residents didn't leave. -The staff would put the residents in the dining area when the door alarms were disengaged. -The staff were to count the residents after the test. During an interview on [DATE] at 12:55 P.M. Licensed Practical Nurse (LPN) A said: -He/she has had education on elopement and fire drills during orientation. -The CNA's would monitor the residents during a fire drill to make sure they did not go out a door. -The CNA's should count the residents after a fire drill. During an interview on [DATE] at 3:00 P.M., the DON said: -On [DATE] the facility had tested the fire alarms and dampers. -At that time the outside door locks/alarms were disengaged. -Because of COVID this was the first test since he/she had been employed at the facility. -The resident was seen by staff at 10:40 A.M. on [DATE]. -They were not sure which door the resident had exited from. -This was also the first fire/sprinkler test at this facility for the Maintenance Director as they were also new. -During orientation education was done regarding monitoring the residents during fire drills/sprinkler tests. -Inservices were done throughout the year and monitoring the residents during fire drills/sprinkler tests was part of that education. -The staff should watch to ensure none of the residents go out the doors during the tests. -One staff member should have watched the courtyard. -The residents should have been counted after the test. -The resident who left would not have known how to get back to the facility. Observation on [DATE] showed: -The mileage from the facility to the red barns on the highway was ,d+[DATE] of a mile. -The area on the left side of the road (across the road) had been mowed. -The area on the right side of the road was filled with bushes. -There was no sidewalk or shoulder on either side of the road. -There was a large curve in the road where the road separated. -At the place where the roadway separated there was a stop sign. -The road coming from the facility and the road that had the stop sign were hard to see oncoming traffic as the view was obstructed with bushes. During a telephone interview on [DATE] at 8:30 A.M., the Receptionist said: -He/she was working at the Receptionist desk during the time the resident had eloped. -He/she had been educated during orientation on what to do if a resident eloped. -He/she was to use the walkie/talkie to tell administration someone had eloped. -He/she had left the desk to use the restroom during the fire drill. -He/she had left the desk to assist a resident who was coming back into the facility after going out with their family during the fire drill. -He/she had not been told he/she could not leave the desk area unattended prior to the resident elopement. During an interview on [DATE] at 12:00 P.M. CNA C said: -He/she had worked the day the resident had eloped. -He/she had to leave early due to an issue at home. -He/she left work about 10:15 A.M. -He/she had helped the resident get dressed that morning. -The resident had passed him/her several times walking in the hall going to the other pods. -He/she last saw the resident about 9:30 A.M. that morning. -The Maintenance man had told him/her that they were doing a fire alarm test that morning before breakfast about 8:30 A.M. -He/she had worked at the facility about seven months. -He/she has had education about what was expected of staff during a fire alarm or when an resident had eloped. -Education was provided during orientation. -Recent education was provided during an inservice in the last month or so about fire drills and elopements. -The first thing staff was to do if a resident had eloped was to alert the charge nurse. -The charge nurse would alert the rest of the staff over their walkie talkies. -The staff was to do a head count. -The staff was to look in every room/area of the facility. -During a fire drill the staff was to stand at the exits to watch them so the residents did not leave. -There was one CNA per pod, about 10 residents per pod. -One nurse would work two pods. -The nurse on his/her pod worked the ,d+[DATE] halls (pods) to give the residents their medications and treatments. -There was one nurse working that morning between the ,d+[DATE] halls. -During the fire alarm test he/she had 10 residents to watch. -He/she was responsible to watch the one door that lead to the patio area. -The patio area had a wooden fence around it with a locked and alarmed gate at the end of the fence. -The resident would daily try to push through the main door from the locked unit to the front of the building. -The alarms on the main door would sound and he/she would redirect the resident away from the door. -He/she was not aware of any time the resident had made it through the main door. -The door to the patio was kept locked and alarmed. -During the fire drill that door was not locked or alarmed. -When it was relocked there would be a loud click noise heard. -He/she did not hear the click before he/she left. -Part of the test was completed before he/she left. -A man along with the Maintenance man were still walking around the halls so he/she thought they were still doing the fire alarm test. -At the end of the fire alarm test the Maintenance man would walk around telling the staff the test had ended by saying to them all clear. -They also announced all clear over the walkie talkies when the test was done. -He/she had not heard the all clear, before he/she went home. -Staff needed to check the residents often during the fire drills. -If you needed to do cares with a resident or use the restroom you would tell the other CNA or the charge nurse so they could watch your area. -He/she was able to see both doors from his/her pod. -There were times when both CNA's from both pods were needed to move or change a resident, the Nurse would have to watch both areas. -The nurse would have to watch the residents if he/she took a lunch break. -There was one resident that had tried to go outside four or five times since February. -The doors would alarm and the staff was able to intercept the resident before he/she left the building. -During the fire drill the Social Worker took some of the residents outside to the gated patio area, none of his/her residents went with the Social Worker. -The resident would go to the other pods to visit he/she likes to talk. -He/she had left the pod to tell the DON that he/she had a family issued and would need to leave work. -He/she told the nurse that he/she needed to talk to the DON. -He/she was gone about four minutes from the pod. -He/she went back to talk to the DON a second time for about five minutes. -The nurse was in the dining room watching the resident while he/she was gone from the pod. -He/she had been inserviced about what he/she was to do during a fire. -He/she was responsible to stand near the exits to ensure none of the residents left. -He/she was to do a head count after the drill. -He/she can speak a few phrases in Spanish. -He/she also uses the translator on his/her phone to speak to the resident. -He/she did not know the resident was missing. -He/she had been educated on what to do if a resident had eloped. -After an elopement the resident would have been placed on 15 minute checks. -The resident had a poor attention span and was unsure if the resident could have found his/her way back to the facility if he/she left the building. -If the resident was tired or anxious he/she stumbled. -When the resident stumbled he/she would redirect him/her to sit down and rest. -If there was an elopement alert the staff were to count the residents by checking in each room. -He/she had seen times when the receptionist was not at his/her desk. -The receptionist has had to deliver a package from a resident's family. -The receptionist has had to accompany a resident to or from their pod. -He/she has seen the receptionist's desk empty a couple of times a week. During a telephone interview on [DATE] at 1:15 P.M. LPN B said: -He/she was an agency staff. -This was not the first time he/she had worked at the facility. -He/she had worked with the resident before. -The resident was his/her usual self and did not appear to be upset about anything. -He/she was not aware the resident was missing. -He/she had not had any education on what to do during fire drills from the facility. -He/she did not know that during a fire alarm/drill that the locks and alarms to the front door and patio doors would be turned off. -As of [DATE] the new policy said the resident were to be in their pods. -The CNA's were to watch the doors. -The nurse was to watch the unit. -The DON and nurses were ultimately responsible for the residents. -He/she communicated with the resident using hand gestures and a few words of Spanish. -When the resident was returned to the unit he/she did a head to toe assessment as well as a set of vital signs. -The staff did a 1:1 with the resident the rest of the day. -He/she was responsible for both 300 and 400 hallways/pods. -The door alarms were not off for that long. -The alarms were off a couple of times before lunch which was served about 12:30 P.M. -He/she had not seen exit seeking behaviors from the resident. -He/she did not think the resident would have been able to find his/her way back to the facility if he/she had left. -During the fire alarm his/her CNA had left for lunch. -He/she was responsible for the resident while the CNA was gone. -A different CNA came to replace the one that went home. -If the CNA had to do cares during the time the alarms were off he/she would watch the doors. -He/she had not heard an all clear on the walkie talkie. -He/she thought the test was done about 1:00 P.M. -The test was not done when the resident was back inside the facility. -The staff did a head count after the resident was returned. -The DON called the resident's physician and family to notify them that the resident had eloped but was now back in the facility. -He/she has had education from the facility on elopement. -The charge nurse would be notified if a resident was missing. -Staff was to look in every room and outside for the missing resident. -If the resident was found an all clear would be announced. -If the resident was not found the police would be notified. -When the resident was found a head to toe assessment and vital signs would be done. -The nurse did not have prior education prior to the elopement related to the fire drill. -He/she didn't know if the gates on the patio were locked or alarmed during the fire alarm. -He/she had seen the receptionists' desk unmanned once when the receptionist had went to the restroom. -The facility had provided education after the fire alarm about watching the doors. During an interview on [DATE] at 2:20 P.M. Certified Medication Technician (CMT)A said: -He/she had seen the resident at 10:40 A.M -The resident was sitting in the hallway outside of the 400 pod. -The resident was his/her usual self. -The resident speaks only Spanish and he/she communicated with him/her through hand gestures. -He/she went to lunch at 11:30 A.M. -The nurse knew he/she was going for lunch break. -He/she had not been aware the resident was missing. -The facility had been doing a fire alarm test which started about 9:45 A.M. -The Maintenance man had come around to tell them about the fire alarm test before it started. -The fire alarm test last a couple of hours. -When the test was over the Maintenance man told them when the test was completed. -During a fire alarm test he/she was to watch the doors to the main hallway and the doors to the patio to ensure the residents did not go out a door. -If he/she had to do cares with the residents the nurse would watch the doors. -During the fire alarm test the doors and locks to the patio were disengaged. -The gate to the outside would still be locked and alarmed. -He/she did not remember education from the facility regarding fire drills or elopement prior to the resident elopement. -The facility had provided education since the elopement starting as soon as the resident was returned to the facility. -He/she had seen the resident go to the door securing the locked unit and shake it. MO 902

Based on observation, interview, and record review the facility failed to ensure residents were tested and/or screened for [CONDITION(S)] (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five sampled residents (Residents #14, #21, #27, #55 and #56) out of five residents sampled and to wash or sanitize hands between glove changes during wound care for one sampled resident (Resident #50) out of 18 sampled residents. Additionally, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 73 residents. Record review of the facility's Policy for [CONDITION(S)] Screening-Residents, dated June 2017, showed: -All new residents who were admitted from home would receive a two-step [MEDICATION(S)] Skin Test (TST used to screen for TB) within seven days of their admission. -A TB screening (signs and symptoms review) only would be required for those who had documentation of a previous two-step TST with negative results. -Residents would be screened annually in October. 1. Record review of Resident #56's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Annual [CONDITION(S)] Screening Questionnaire, dated 10/16/19, showed: -The resident was screened for TB on 10/16/19. -The resident screening result was no active TB suspected. Further review of the resident's record showed no Annual [CONDITION(S)] screening Questionnaire since 10/16/19. During an interview on 6/22/21 at 10:50 A.M., the Director of Nursing (DON) said he/she contacted corporate and was unable to locate a TB screening form since 10/16/19. 2. Record review of Resident #21's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Annual [CONDITION(S)] Screening Questionnaire, dated 10/16/19, showed: -The resident was screened for TB on 10/16/19. -The resident had no symptoms checked. -The resident screening result was not marked. Further review of the resident's record showed no Annual [CONDITION(S)] screening Questionnaire since 10/16/19. During an interview on 6/22/21 at 10:50 A.M., the DON said he/she contacted corporate and was unable to locate a TB screening form since 10/16/19. 3. Record review of Resident #55's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Annual [CONDITION(S)] Screening Questionnaire, dated 10/16/19, showed: -The resident was screened for TB on 10/16/19. -The resident screening result was no active TB suspected. Further review of the resident's record showed no Annual [CONDITION(S)] screening Questionnaire since 10/16/19. During an interview on 6/22/21 at 10:50 A.M., the DON said he/she contacted corporate and was unable to locate a TB screening form since 10/16/19. 4. Record review of Resident #14's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Immunization tab in the facility's electronic health records system showed there was no record of a TB test and/or screening for the resident. During an interview on 6/22/21 at 10:50 A.M., the DON said he/she contacted corporate and was unable to locate a TB screening form or testing for the resident. 5. Record review of Resident #27's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's immunization tab in the facility's electronic health records system showed: -Step one of a TST was administered on 3/14/2021 with a negative result (date of result was not documented). -No other information was recorded. During an interview on 6/22/21 at 10:50 A.M., the DON said: -He/she can only assume the second step was not completed. -He/she contacted corporate and was unable to locate a TB screening form for this resident. 6. During an interview on 6/28/21 at 11:36 A.M., Licensed Practical Nurse (LPN) C said: -The nurse admitting the resident to the facility is supposed to administer a TST for the resident. -A nurse is supposed to read the TST three days later. -The order for the administration and reading of TST's is supposed to be on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The second TST is also supposed to be included in the orders on the MAR. -TB screenings for residents are supposed to be done yearly. During an interview on 6/28/21 at 2:01 P.M., the DON said: -They did the annual screening for the residents in 2020. -The Assistant Director of Nursing (ADON) said they did the annual resident TB screenings in 2020 and gave them to the previous medical records associate who no longer works there and they cannot find them. -The admitting nurse administers the first TST and enters it into the MAR. -The second TST would be administered by the nurse working when due and he/she would enter it into the MAR. 7. Record review of the facility's Hand Hygiene policy, dated September 2017, showed: -Employees must wash their hands for 10-15 seconds using soap and water after contact with blood, body fluids, secretions, mucous membranes or non-intact skin. -If hands are not visibly soiled, employees must use an alcohol based hand rub/gel: --Before direct care with residents. --Before putting on gloves. --Before handling clean or soiled dressings, gauze pads, etc. --Before moving from a contaminated body site to a clean body site during resident care. --After contact with a resident's intact skin. --After handling used dressings, contaminated equipment, etc. --After removing gloves. -The use of gloves does not replace handwashing/hand hygiene. Record review of Resident #50's quarterly Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 5/11/21, showed the following staff assessment of the resident: -Had short-term and long-term memory impairment. -Had severely impaired cognitive skills for decision-making. -Had two stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear). Record review of the resident's care plan, dated 5/21/21, showed the resident had a stage II pressure ulcer on his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). Record review of the resident's June 2021 Treatment Administration Record (TAR) showed: -6/8/21 Cleanse coccyx (tailbone) wound with normal saline, apply Triad cream (a [MEDICATION(S)]-based [MEDICATION(S)] paste that absorbs moderate levels of wound exudate) to granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) and cover with foam dressing. -Change every three days every day shift every Tuesday, Friday, and Sunday and as needed when soiled or missing for coccyx wound. -1/16/21 Apply [MEDICATION(S)] (a multipurpose moisture barrier) to buttock every shift and as needed for soiling until resolved. Observation on 6/23/21 at 10:45 A.M., of the resident's wound care with LPN C showed: -LPN C removed his/her gloves after removing the old dressing. LPN C did not perform hand hygiene. -LPN C applied new gloves, applied the Triad cream and took his/her gloves off. LPN C did not perform hand hygiene. -LPN C applied new gloves, applied [MEDICATION(S)] lotion and took his/her gloves off. LPN C did not perform hand hygiene. -LPN C put the resident's disposable brief and pants on and washed his/her hands. During an interview on 6/23/21 at 11:00 A.M., LPN C said he/she should have washed his/her hands when he/she changed gloves. During an interview on 6/28/21 at 11:14 A.M., LPN A said: -They should wash or sanitize their hands after each glove change. -They have received education on hand hygiene. During an interview on 6/28/21 at 2:01 P.M., the DON said: -There has been education provided to the staff about hand hygiene. -He/she would expect staff to wash or sanitize hands after glove changes. 8. The Centers for Disease Control (CDC) Toolkit for Legionella (which is officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective; -Legionella grows best at 77-108 degrees Fahrenheit (F); -Disinfectants (one way to prevent Legionella) are only effective in certain pH levels (usually 6.5 - 8.5); -How often to check depends on several factors (which should be determined by the facility from its Water Management Program); -The water temperatures and pH levels should be checked at regular intervals. Record review of the facility's Emergency Preparedness (EP) plan binders entitled Disaster Manual, last reviewed and updated on 8/13/19 and obtained from the old nurse station room and the 200 hall nurse station, showed there was no section covering waterborne pathogens such as Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing [CONDITION(S)] (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever). Record review of the undated Facility Needs Assessment binder provided by the Administrator, under Addendum G: Infection Control Check List, showed the following: -A 5-page document that included the subheadings Policy Requirement and Outcome Measures to Be Developed or Reviewed. -Four pages all included the facility's name, but the dates of any assessments or points and standards having been Reviewed in Place on each page were left blank. -Each page carried a disclaimer at the bottom that Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance. Record review of the facility's undated binder entitled Legionella, provided by the Administrator, showed the following: -A copy of the Centers for Disease Control (CDC) toolkit outlining what needs to be done to develop a water management program to reduce Legionella growth and spread. -There was an absence of any of the requirements for a waterborne pathogen program including: -A completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing [CONDITION(S)] (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other waterborne pathogens. -A program and flowchart that identifies and indicates specific potential risk areas of growth within the building. -Assessments of each individual potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any cleanings, sanitizing, descalings, and inspections mentioned. -A flow chart of the facility's water system. -A written description of the facility's water system. -Explanatory guidance from a United [NAME] agency. -General recommendations and information on Legionella and Pontiac fever. -A 2-page Legionella - What You Need to Do document. -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standards. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was no program and flowchart that identified and indicated specific potential risk areas of growth within the building with assessments of each individual potential risk level. -There were no facility-specific interventions or action plans for when control measure limits are not met. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. Observations during the facility Life Safety Code (LSC) room-by-room inspection with the Maintenance Director on 6/21/21 through 6/24/21 showed the following: -There were approximately 40 resident rooms with private and/or adjoining bathrooms. -There was a laundry room at the western end of the building and numerous rooms with water heaters throughout the facility. -There was a bathing room and two restrooms on the center main hallway. -There were two sprinkler systems with a main drain and auxiliary drains throughout the facility. -There was a kitchen and two restrooms in the eastern section of the building. During an interview on 6/23/21 at 1:34 P.M., the Maintenance Director said his/her only role in the Legionella program was to do monthly checks of Chloramines (also known as secondary disinfection, are disinfectants used to treat drinking water and they: are most commonly formed when [MEDICATION(S)] is added to chlorine to treat drinking water. They can provide longer-[MEDICATION(S)] disinfection as the water moves through pipes to consumers.) in the water system. During an interview on 6/24/21 at 1:05 P.M., the Administrator said the following: -He/She was instructed to implement the Legionella program by telling the department heads what to look for. -Maintenance was also to check the water monthly.

Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry for two out of ten sampled employees to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 73 residents. 1. Record review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A, a housekeeping supervisor, was hired on 12/21/20. -Employee C, a dietary worker, was hired on 2/22/21. Record review of the above employees' employee files showed no check of the NA Registry to ensure they did not have a Federal Indicator prohibiting them to work in a certified facility. During an interview on 6/28/21 at 10:00 A.M., the Administrator said: -The Human Resources employee was responsible for completing the NA registry checks. -He/she didn't know NA registry checks were required on non-nursing staff. During an interview on 6/28/21 at 10:11 A.M., the Human Resources employee said he/she didn't know NA registry checks were required on non-nursing staff.

Based on observation, interview, and record review, the facility failed to ensure the resident's medications were kept in a clean, sanitary, and secured medication cart or medication room, to ensure expired medications were destroyed/discarded, to ensure opened medications had the date they were opened written on the container, failed to ensure there was no food stored in with the medications, to ensure there were no cleaning supplies being stored/kept in the medication drawer, to ensure medications were removed from the medication cart when a resident discharged from the facility in two out of four medication carts, one treatment cart, and one medication room, and failed to ensure medications were labeled and matched the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 73 residents. Record review of the facility's policy titled Medication Storage in the Facility, dated 11/18 showed: -Medications and biologicals were stored safely, securely, and followed the manufacturer's recommendations or those of the supplier. -Potentially harmful substances such as cleaning supplies or disinfectants would be stored in a locked area separately from medications. -Outdated, contaminated, or deteriorated medications and those in containers that were soiled or without secure closures were immediately removed from inventory, disposed of according to procedures for medication disposal. -Medication storage areas were kept clean and free of clutter. -Medication storage conditions were monitored at least quarterly. -When the original seal of a manufacturer's container or vial was initially broken, it was recommended that a nurse write the date opened on the medication container or vial. -The nurse would check the expiration date of each medication before administering it. -No expired medication would be administered to a resident. -All expired medications would be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 1. Observation on 6/23/21 at 8:30 A.M. of the medication room with Licensed Practical Nurse (LPN) B showed: -There were two vials of Influenza vaccine type A and B, in the refrigerator that had expired on 5/4/21. -There was one container of stock control solution (Ultra Trak) (a control solution for a blood sugar monitoring device) a 4 milliliter (ml) box that had expired 11/18. -There was one container of stock control solution (Ultra Trak) a 4 ml box that had expired 11/24/19. -There was a case of stock control solution (Ultra Trak) that had expired 3/31/20. -There was a case of stock control solution (Ultra Trak) that had expired 8/31/20. -The only handwashing sink in the medication room was dirty with brown colored rust around the drain. 2. Observation on 6/23/21 at 10:10 A.M. of the 300/400 hall medication cart with LPN B showed: -A resident's bottle of liquid [MEDICATION(S)] (a narcotic used to treat severe pain) 30 ml prescribed by a physician was opened without an opened date written on it. -A resident's Polyethylene [MEDICATION(S)] (laxative) 510 grams (g) prescribed by a physician was opened without an opened date written on it. -A resident's Geri [MEDICATION(S)] (cough syrup) 473 ml bottle prescribed by a physician was opened without an opened date written on it. The bottle was sticky. The medication had expired 2/21. -There was a resident's half eaten chocolate bar in with the medications. -One of the drawers in the medication cart was sticky with an orange colored substance. -One of the drawers had a brown melted substance in it. -One of the drawers had bleach wipes in with the medications. 3. Observation on 6/23/21 at 10:20 A.M. of the 300/400 hall treatment cart with LPN B showed: -One of the drawers had a set of dentures from one of the residents (not in a bag). -There was a container of [MEDICATION(S)] Pixie Dust powder (a numbing medication) a prescription medication for a resident not in a bag. -The treatment cart was not locked. 4. During an interview on 6/23/21 at 10:30 A.M. LPN B said: -There should not have been any expired medications in the medication carts. -The expired medications should have been discarded. -The sink in the medications room should have been cleaned. -The nurse did not know who was responsible for cleaning the sink. -There should not have been candy in the medication cart. -Medications that had been opened should have had an opened date written on the container. -The medication containers should have been clean not sticky. -There should not have been bleach wipes in with the medications. -The drawers should be kept clean. -The treatment cart should have been locked. -There was no reason to have a resident's dentures in the cart. -The nurses were responsible for cleaning and checking the medication carts and the medication room. 5. Observation on 6/24/21 at 6:55 A.M., of the 500/600 hallway Licensed Nurses medication cart showed: -There was a red pill crusher that had pill residue in the bottom and top of the container. -The pill splitter had a piece of pink pill in it. -There was an uncapped razor and an open large nail clipper in the top drawer. -There was a small nail clipper in the open position in the second drawer. -There was a red pill, two pink pills, and half a white pill loose in drawer four. During an interview on 6/24/21 at 6:55 A.M. LPN A said: -The medication cart should be clean and the pill crusher and pill splitter should not have residue on or in them. -There should not be loose pills in the medication cart. -There should not be nail clippers in the medication cart in the open position as no one would know who they were for and should not be used on multiple residents. -There should not be an uncapped razor in the medication cart. -He/she has not had time to clean the medication cart. 6. Observation on 6/24/21 at 6:55 A.M. of the 500/600 Licensed Nurses medication cart showed: -There were multiple medications that were brought from home for a resident (Resident #500) -One of the medications was [MEDICATION(S)] HCl 10 milligram (mg) (Aricept used to treat dementia and is given at night because of its side effects of low heart rate and possible [CONDITION(S)] and when given at night, patients were able to sleep through the side effects without difficulty) give one tablet at bedtime was printed on the medication label. -The word bedtime had a line drawn through it and the word morning was hand-written on the label. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/24/21 at 6:55 A.M., LPN A said: -The medication bottle was from the resident's home. -Nursing would only follow what was on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Staff would not follow what was written on the label. -It was possible that the family had written the change of time on the bottle. During an interview on 6/24/21 at 1:05 P.M., the Director of Nursing (DON) said: -There was no defined schedule for cleaning medication carts. -He/she expected staff to clean the medication carts as they go. -Any medication that was not labeled properly should be removed from the medication cart and a new order should be written. -Occasionally when a new resident came in to the facility, the use of home medications may be needed until pharmacy delivered the medication. 7. During an interview on 6/28/21 at 11:14 A.M. LPN A said: -The Nurse or the Certified Medication Technician (CMT) was responsible for keeping the medication carts and medication room clean. -The medications that were expired should have been thrown away. -If a medication had been opened it should have had the date it was opened written on the container. -There should not have been anything like candy or teeth in the medication carts. -The bleach wipes should not have been in the drawer with the resident's medications. -The medication carts, treatment carts, and medication rooms were to be locked at all times. During an interview on 6/28/21 at 2:01 P.M. the DON said: -There should not have been expired medications on the medication carts or in the medication room. -There should have been an opened date on the medications that had been opened. -The sink in the medication room should have been cleaned by staff. -There should not have been anything extra in with the medications.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator floor clean; to retain a thermometer in the walk-in freezer to confirm correct temperatures; to safeguard plastic cutting boards were in good condition to avoid food safety hazards; to separate damaged food stuffs; and to ensure the proper refrigeration or disposal of food products. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 73 residents with a licensed capacity for 78. 1. Observations during the initial Kitchen inspection on 6/21/21 between 9:05 A.M. and 1:31 P.M. showed the following: -On a large can dispenser rack in the Dry Storage room there was a 6 pound (lb.) 6 ounce (oz.) can of white diced potatoes dented on the bottom rim and a 7 lb. 5 oz. can of baked beans dented on a lower back side. -In the walk-in refrigerator, there was a plastic lid under a rack. -There was no thermometer in the walk-in freezer. -The brown, red, white, and green cutting boards heavily scored to the point of plastic bits hanging off. -There was an open, nearly empty 1-gallon jug of soy sauce on a shelf under a side table next to the sugar and flour bins that read refrigerate after opening on the label. -On the same shelf there was a 1-quart (qt.) bottle of egg shade (yellow) food coloring that read Best By 12/9/19 on the label. During interview on 6/21/21 between 9:49 A.M. and 1:35 P.M. the Dietary Manager said the following: -They would have to get a thermometer for the freezer because they sure don't see it, it's usually hanging right there, pointing to an upper rack by the door. -He/She saw the cutting boards being examined so they changed them out with new ones. -The jug of soy sauce was disposed of for the same reason. 2. Observations during the follow-up Kitchen inspection on 6/22/21 at 10:34 A.M. showed the following: -On a large can dispenser rack in the Dry Storage room there was a 6 lb. 6 oz. can of white diced potatoes dented on the bottom rim and a 7 lb. 5 oz. can of baked beans dented on a lower back side. -In the walk-in refrigerator, there was a plastic lid under a rack. -On a shelf under a side table next to sugar and flour bins there was a 1 qt. bottle of egg shade food coloring that read Best By 12/9/19 on the label. During an interview on 6/23/21 at 2:17 P.M., the Dietary Manager said: -The cutting boards were thrown out because they were too heavily scored. -The jug of soy sauce was disposed of because it was supposed to have been refrigerated. -He/She tries to have the cooks keep an eye out for those sorts of things. -If foodstuffs have a Best By date, they need to be discarded after then. -He/She puts away deliveries from their food vendor for the Dry Storage room and the walk-in freezer and the Day Cook does the walk-in refrigerator. -There is an area set aside in the Dry Storage room for any damaged foodstuffs. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. -In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.

Based on observation, interview and record review, the facility failed to keep one sampled resident (Resident #1) free from physical abuse when two staff members forced the resident out of bed resulting in bruising to his/her right and left lower forearms and to his/her right upper forearm out of three sampled residents. The facility census was 77 residents. Record review of the facility policy for Abuse Prevention dated (MONTH) 2008 showed: -The policy was developed as a mechanism to reduce the risk of abuse. -The definition of abuse meant any physical or mental injury inflicted upon a resident. -Facility staff were required to attend training according to the facility policy, regarding abuse prevention, and -Outside independent contractors working within the facility were provided with a written notice/letter outlining their reporting obligations upon initiation of work within the facility. 1. Record review of Resident #'1's undated Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION]-(a severe mental health disease which causes abnormal thinking, causing a loss of touch with reality). Record review of the resident's Care Plan dated 6/4/19 showed: -The resident had the potential of exhibiting verbally aggressive/belligerent behaviors towards staff and other residents. -The facility staff was to anticipate the resident's needs and provide care accordingly. -The facility staff was to give the resident time to express himself/herself. -The facility staff was to give the resident choices and -If the resident became agitated in response to staff, the staff member was to walk calmly away and approach the resident later. Record review of resident's Significant Change Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff and used for care planning) dated 6/25/19 showed he/she: -Was moderately cognitively intact. -Had delusions. -Had episodes of behaviors such as threatening, screaming or cursing at others one to three days per week. -Rejected cares one to three days per week. -Needed limited assistance of one staff member for bathing, hygiene, transferring, bed mobility and dressing, and -Needed supervision for walking. Record review of resident's Registered Nurse Practitioner's (RNP) Note dated 6/17/19 and 6/18/19 showed: -The resident's skin was overall good, warm and dry with good color, and -There was no documentation of any bruising or discoloration. Record review of resident's RNP Note dated 6/20/19 showed there was no documentation regarding the status of the resident's skin in the note. Record review of resident's RNP Note dated 7/8/19 and 7/10/19 showed: -The resident's skin was clear, and -There was no documentation of any bruising or discoloration. Record review of resident's Progress Notes dated 7/18/19 at 11:37 [NAME]M., showed: -The resident was very upset about bruising on his/her arms. -The resident's family came to visit the morning after the incident and the resident told him/her that a black lady had done this to him/her early in the morning when the resident did not want to get up out of bed. -The staff explained to the resident that it was his/her right and he/she should not be made to do something that he/she did not want to do, and -The resident's family was very upset about the resident's yelling so they left the facility. Record review of Certified Nursing Assistant (CNA) A's written statement dated 7/18/19 showed: -Around 6:15 [NAME]M., on 7/18/19 he/she entered the resident's room and was dressing the resident's roommate. -Resident #1 started yelling to turn the light off. -He/she informed the resident that he/she was doing rounds and getting residents up for breakfast. -The resident was wet and his/her gown was wet. -He/she informed the resident that he/she was wet and needed to go to the restroom to be changed. -The resident began fighting and stated that he/she was not wet, and -The resident stated that he/she bruised easily and was going to sue him/her if he/she got a bruise. During an interview on 7/19/19 at 10:30 [NAME]M., the Administrator said: -He/she knew that one CNA had been suspended and they were investigating the abuse allegation and -Someone told him/her that he/she should have called the incident to the hotline. During an interview on 7/19/19 at 10:40 [NAME]M., the Director of Nursing (DON) said: -The other CNA involved in the incident did not show up for his/her last scheduled shift. -The DON attempted to reach him/her by phone to suspend him/her pending the investigation. -The resident was assessed after the incident occurred. -The resident's skin was very fragile. -The resident had bruises on both forearms. -He/she saw no finger print bruising on either of the resident's forearms, and -The resident had a history of [REDACTED]. During an interview on 7/19/19 at 11:00 [NAME]M., Licensed Practical Nurse (LPN) A, said: -The incident occurred while CNA A and CNA B were getting the resident out of bed on 7/18/19 between 5:00 [NAME]M., and 6:00 [NAME]M. -There was no other staff present during the incident. -He/she was told by the night shift nurse, while receiving report that there was an incident involving the resident and CNA A and CNA B. -He/she did not assess the resident because he/she thought the night shift nurse did an assessment. -One of the resident's family members was in to see the resident the morning on 7/18/19. -LPN A called the resident's family. -The resident was on medication that caused him/her to bruise easily. -The resident's physician was in the see the resident on the morning of 7/18/19 after the incident and the physician was notified at that time. -The resident told him/her, his/her family and the physician that he/she got his/her bruises from two black facility staff members who grabbed his/her arms when he/she did not want to get up, and -The resident had a history of [REDACTED]. During an interview on 7/19/19 at 11:45 [NAME]M., the resident said: -He/she was asleep in his/her bed. -Two large black ladies came into his/her room and yanked him/her out of bed. -The two ladies wanted him/her to get up and get dressed for breakfast, and -They grabbed him/her by the arms. Observation on 7/19/19 at 11:55 [NAME]M., showed: -The resident had two large purple bruises measuring approximately 5.0 centimeters (cm) by 5.0 cm on his/her right lower forearm that were beginning to merge into one large bruise. -He/she had three small finger print sized purple bruises measuring approximately 3.0 cm by 3.0 cm above the large bruises on his her right upper forearm. -He/she had three large purple bruises measuring approximately 4.0 cm by 4.0 cm on his/her left lower forearm in a triangular pattern, and -The resident pointed to these bruises to show where he/she was grabbed by the CNA A & CNA B. During an interview on 7/22/19 at 11:00 [NAME]M., the Administrator said: -He/she believes he/she was the first to be notified of the incident, and -He/she was making rounds the morning of 7/18/19 and was informed of what happened by CNA A before the aide left the facility. During an interview on 7/22/19 at 11:10 [NAME]M., the DON said he/she was told of the incident by the resident while making morning rounds on 7/18/19 around 10:00 [NAME]M. During an interview on 7/22/19 at 11:25 [NAME]M., the DON said: -If a resident does not want to get up out of bed, the facility staff should have left the resident alone and approached the resident at a later time, or send another staff member in later, and -The staff should never force a resident to do anything as this is their home and they should not have to do something they do not want to do. During an interview on 7/22/19 at 12:00 P.M., CNA A said: -He/she and CNA B went into the resident's room. -They first cared for the resident's roommate and while doing so, the resident began to holler for the light to be turned off. -He/she and CNA B told the resident that they were performing cares for his/her roommate and would turn the light off as soon as they were done. -After finishing cares for the roommate, they discovered that the resident was wet and needed to go into the bathroom to get his/her clothes changed for breakfast. -The resident did not want to get up yet. -As him/her and CNA B were trying to get the resident up to the bathroom, the resident pulled his/her arms away while he/she and CNA B were holding on to the resident and walked back to his/her bed. -He/she was on the resident's left side holding onto the resident's forearm at the time the resident pulled his/her arms away. -The resident told him/her and CNA B that he/she bruised easily and if they bruised him/her, he/she was going to sue them. -After they got the resident's clothes changed, he/she noticed bruising beginning on the resident's forearms. -The resident was the last resident they had to get up. -He/she did not think of leaving the resident alone since he/she was resisting getting up as they were afraid to leave the resident wet. -Maybe he/she and CNA B should have left the resident alone since he/she did not want to get up. -He/she did not know if the resident had any bruises before they had a hold of him/her arms. - He/she went and told LPN B what happened. -He/she did not know if they caused the bruises or not, and -The resident told other residents that he/she had a tussle with him/her and CNA B. During an interview on 7/22/19 at 12:55 P.M., CNA B said: -During the morning on 7/18/19, he/she was assisting CNA A with getting residents up and dressed for breakfast. -The resident was screaming to turn off the light in the room. -He/she told the resident that they would leave him/her alone but he/she was wet and needed to have his/her clothes changed. -CNA A and him/her asked the resident to stand up so they could get him/her to the bathroom. -The resident continued to resist and scream. -From the left side, he/she took the resident under his/her right arm with one arm and by the forearm with the other hand and pulled the resident up from the bed while the resident continued to scream. -CNA A and him/her attempted to get the resident into the bathroom, but he/she did not want to go and pulled away from them saying they could change him/her in his/her room. -While CNA A and him/her attempted to change the resident's clothes, the resident continued to try to pull away. -He/she continued to hold the resident under his/her arm and by his/her wrist while the resident tried to pull away. -The resident said CNA A and him/her were abusing him/her, and -After getting the resident's clothes changed, the resident said that they had given him/her bruises. During an interview on 7/22/19 at 1:40 P.M., LPN B said: -He/she had worked the night shift on 7/18/19. -CNA A came and told him/her that the resident was resisting care and after getting him/her dressed, he/she had bruises on his/her forearms. -He/she did not go and assess the resident stating that the resident already had bruises present. -He/she never documented anything about the resident having any bruises in the medical record and -When he/she mentioned the issue to LPN A, he/she said the resident already had bruises. During an interview on 7/22/19 at 2:00 P.M., LPN A said the resident did not have any bruises that he/she was aware of, however the resident frequently wore long sleeved shirts so he/she was not sure. During an interview on 7/22/19 at 2:05 P.M., CNA C said he/she had never seen any bruises on the resident and worked with the resident often. During an interview on 7/22/19 at 2:10 P.M., CNA D said: -He/she took care of the resident almost every day. -He/she never noticed any bruises on the resident before 7/18/19. -CNA A and CNA B who worked the early morning of 7/18/19 should have left the resident alone and not have forced him/her to get up as he/she would get up when he/she wanted to, and -Breakfast is not even served until between 8:00 [NAME]M., and 8:30 [NAME]M., so there would have been plenty of time to get the resident cleaned up for breakfast. During an interview on 7/22/19 at 2:15 P.M., Resident #1's family member said: -When the resident was seen on the morning of 7/18/19 it was evident that something traumatic had happened to him/her, and -The resident was very upset saying he/she had been bruised by the CNA A& and CNA B. During an interview on 7/22/19 at 4:15 P.M., CNA [NAME] said: -He/she had never noticed any bruising on the resident and -The resident could be combative, but if staff just walk away and come back later, there would be no issues. MO 472

Based on interview and record review the facility failed to ensure seven cognitively impaired residents (Resident # 1, #2, #4, #5, #6, #7, and #8) out of twenty sampled residents were free from sexual abuse and implement interventions to prevent further occurrences. In addition, the facility failed to ensure four cognitively impaired residents (Resident #1, #8, #9 and #17) out of twenty sampled residents were free from resident to resident abuse and implement interventions to prevent further occurrences. The facility census was 70 residents. Record review of the facility's Abuse and Neglect policy dated 6/1/08 with revision 1/12, showed the facility affirmed the right of their residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility therefore prohibited acts of mistreatment, neglect, abuse and or crimes from being committed against its residents. The facility would implement the following system and or practices: -Identify occurrences and patterns of potential mistreatment; -Immediately protect residents involved in identified reports of possible abuse; -Defined physical abuse as hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. -Defined sexual abuse as not limited to sexual harassment, sexual coercion or sexual assault. -The facility would identify concern and provide follow up. -The facility would screen and assess residents: -Residents would be screened prior to admission in order to identify any history that may put other residents at risk for abuse or violence. -As part of the RAI assessment staff would identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to contact. -When managing an aggressive or violent outburst by a resident the staff person should call for help and not leave the resident unsupervised until the resident is safe. -Residents who allegedly abuse another resident should be removed from contact with other residents until such time that reasonable clinical judgment determines that their behavior no longer poses a significant risk to other residents or until the investigation is concluded. Interventions may include and are not limited to: 1) more frequent observations; 2) room or inter-facility transfers; 3) hospitalization ; 4) sitters or one to one observation; 5) as needed medications as ordered by a physician or practitioner; 6) diversional activity; 7) medical or clinical evaluations. 1. Record review of Resident # 2's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -[MEDICAL CONDITION] (an infection of deep skin tissue); -Hypertension; -Muscle weakness; -History of falls. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff and used for care planning, dated 6/14/17, showed: -Severe impaired cognitive skills for daily decision making. -No behaviors. -Required supervision by facility staff, encouragement and or cueing with transfer, walking, locomotion, dressing, eating, toileting, and personal hygiene. -Required one staff person to assist with bathing. Record review of the resident's progress note dated 6/28/17 at 2:15 P.M. showed: -A Certified Nurse Aide (CNA) reported to a Certified Medication Technician (CMT) that the resident had tried to put his/her hands on a male/female resident's chest. -The resident was redirected and became aggressive with the CNA. -The incident was isolated and resident would be monitored. Record review of the resident's facility incident report dated 8/3/17 showed: -On 8/3/17 at 10:00 P.M., he/she was found without clothes laying on top of Resident #7 in Resident #7's bed. Resident #7 had on his/her night shirt and brief, and was covered up to his/her waist. -The CNA pulled Resident #2 off of Resident #7 who was asking for help. -Resident #2 was provided one to one staff supervision while awake and then moved to fifteen minute checks while sleeping, with the facility staff person sitting in the resident doorway. -The medical director ordered [MEDICATION NAME] (a medication for sexual inappropriateness) 10 milligrams (mg) and recommended placement to a male/female unit. Record review of the resident's incident written witness statement dated 8/3/17, by CNA B showed he/she was on a different hall providing a break for another CNA at 7:30 P.M., and did not hear the incident on 8/3/17. Record review of the resident's incident written witness statement completed by Certified Medication Technician (CMT) A, dated 8/3/17, showed he/she was on break when the incident occurred. Record review of the resident's incident report written witness statement completed by CNA C dated 8/3/17 at 7:50 P.M., showed: -Had went to the bathroom and on return heard a resident asking for help. -He/she found Resident #2 with no clothes on laying on top of Resident #7 who had his/her night gown and brief on. -He/she had to pull Resident #2 off of Resident #7. -He/she had went and found Licensed Practical Nurse (LPN) A who told him/her to find his/her nurse and report it. -He/she was unable to find his/her nurse for his/her hall to report the incident. Record review of the resident incident report written witness statement completed by LPN B dated 8/3/17 showed: -Observed CNA C talking to another CNA on the hall between units about Resident #2 being found on top of Resident #7 naked. -CNA C reported to LPN A. -LPN B contacted the Medical Director who ordered [MEDICATION NAME] 10 mg daily and for placement to be sought in an all male/female unit for Resident #2. -At 9:00 P.M., Resident #2 was moved to fifteen minute checks while sleeping. Record review of the resident's word document titled root cause analysis, inappropriate sexual behavior dated 8/3/17 showed: -Resident #2 found naked lying on top of a Resident #7, after Resident #7 was heard yelling for help. -Resident #7 was dressed in his/her nightshirt, brief and was partially covered to above the waist with a blanket. -The Medical Director was notified and said the hospital could not help with the behavior, ordered [MEDICATION NAME] 10 mg and advised the facility to seek placement in a male/female unit. -Staff were instructed to do fifteen minute checks while the resident was sleeping and one on one when out of his/her room. -He/she was transferred to another nursing facility on 8/12/17. Record review of the resident's progress note dated 8/3/17 at 9:57 P.M., showed: -He/she was found by a CNA without clothes and laying on top of Resident #7 in Resident #7's bed. -Resident #7 was fully clothed and asking for help. -The CNA pulled Resident #2 off of Resident #7 and removed him/her from the room. -The resident was placed on one to one status with a facility staff member and then moved to fifteen minute checks while sleeping. Record review of the resident's behavior monitoring sheet dated 8/3/17, showed he/she was monitored with checks by a facility staff person every fifteen minutes from 6:30 A.M. to 4:15 P.M. and 8:00 P.M. to 6:15 A.M. on 8/4/17. Record review of the resident's behavior monitoring sheet dated 8/4/17, showed he/she was monitored with checks by a facility staff person every fifteen minutes from 4:30 P.M. to 6:45 P.M. Record review of the resident's progress note dated 8/4/17 at 4:15 P.M., showed: -The resident was on continued monitoring for inappropriateness and had been on one to one supervision since the incident happened. -The resident was up in the common area. Record review of the resident's medical record showed: -No one to one behavior monitoring from 8/3/17 to 8/12/17. -No fifteen minute behavior monitoring from: --8/3/17 4:15 P.M. to 8:00 P.M. --8/4/17 6:15 A.M. to 4:30 P.M. --8/14/17 6:45 P.M. to 8/12/17. -There was no care plan for behaviors related to sexual inappropriateness. 2. Record review of Resident # 7's Face Sheet showed the resident was admitted to the facility on [DATE], with the following Diagnosis: [REDACTED].>-Dementia; -Diabetes; -Depression; -Hypertension; -Muscle Weakness. Record review of the resident's admission MDS dated [DATE], showed: -Had severe impaired cognitive skills for daily decision making skills. -Required total dependence of one staff person for positioning, transfer, locomotion, dressing, eating, toileting, personal hygiene, and bathing. -Incontinent of bowel and bladder. Record review of the resident's care plan dated 6/30/17 showed: -He/she had limited physical mobility related to the dementia disease process, generalized muscle weakness, and was non-ambulatory. -Required total staff assistance by one staff person for locomotion. Record review of the resident's facility incident report dated 8/3/17, showed: -Resident #7 was lying in bed with a gown and brief on. A CNA found Resident #2 laying on top of him/her without clothes on. -Resident #7 was saying help. -He/she was changed into pajamas and provided frequent checks throughout the night. -The Medical Director was notified and no new orders were provided. Record review of the resident's progress note dated 8/3/17 at 10:07 P.M., showed: -He/she was saying help when the CNA entered the resident room and found Resident #2 on top of Resident #7 without clothes. -He/she had his/her gown and brief on. Record review of the resident's medical record showed: -Thee was no fifteen minute behavior monitoring or security checks from the incident on 8/3/17. During an interview on 12/21/17 at 1:15 P.M., LPN A said: -He/she was responsible to make sure facility staff were where they are supposed to be as clinical coordinator. -He/she was familiar with the resident to resident incident between Resident #2 and Resident #7. -Resident #2 was found in Resident #7 room unclothed and on top of Resident #7. -Resident #7 was in his/her nightgown with blankets pulled up to his/her waist. -CNA C discovered the incident about 8:00 P.M. at bedtime, CNA C left the room, found LPN A who went to get LPN B for CNA C. -CNA C with the assistance of LPN B was able to remove Resident #2 from Resident #7's room. -He/she went back to his/her own tasks at the facility since CNA C and LPN B took care of it. -Resident #2 was monitored by a CNA assigned to do fifteen minute security checks. -The medical director was contacted and prescribed medication for Resident #2. During an interview on 12/26/17 at 3:54 P.M., CNA C said: -He/she had been doing cares when he/she returned to the main common area on the unit and noticed Resident #7's room door ajar. -He/she had gone into Resident #7's room and found Resident #2 naked on top of Resident #7. -Resident #7 could not yell out, he/she could not talk. -Resident #2's clothes and shoes were on the floor in Resident #7's room. -Resident #7 had his/her night gown and brief on with the top blanket pulled down. -He/she tried to separate the residents, but Resident #2 became combative and was punching at him/her. -He/she left the room to get the nurse who was at the nurse's station between the units on the hall. -He/she spoke to LPN A who said he/she would get the nurse and to go back to the room. -Resident #2 was cussing and fighting at the separation. -Resident #2 remained in the building after the incident. -Resident #2 did not receive one to one supervision. -Resident #2 did not receive fifteen minute monitoring. -Resident #2 was redirected, if observed wandering into resident rooms. -He/she was unable to watch Resident #2 when providing care to other residents and the nurse was off the unit or with another resident. -He/she denied writing a written statement when it was reviewed with him/her. -He/she had not received education or training on what to do with a resident engaged in sexually inappropriate activity. During an interview on 12/26/17 at 4:20 P.M., CMT A said: -He/she acted as a charge nurse for the 300 and 400 unit. -He/she had not received training to act as charge nurse. He/she was trained to be a CMT. -He/she was on break when the incident occurred between Resident #2 and Resident #7. -He/she had not told the CNA he/she was on break, he/she let the other nurse know. -It was impossible to watch residents at all times. -CNA C and CNA D found Resident #2 and Resident #7 in bed together. -He/she was not a witness to the incident, wrote no investigation, or notes on the incident. -He/she had not received any education or training on what to do or how to deal with resident behaviors or sexual activity from the facility. During an interview on 12/27/17 at 11:00 A.M., LPN B said: -He/she was aware of an incident where Resident #2 was in bed with Resident #7. -He/she was not a witness, he/she arrived after Resident #2 had been removed from Resident #7's room. -Resident #2 was placed on one to one supervision with the CNA float working the evening. -Resident #2 was then placed on fifteen minute checks before the shift ended. -He/she discovered the incident after he/she heard the CNAs talking in the hallway. -He/she was assigned to the 300 and 400 unit. -CNA C reported to LPN A. -He/she had no idea how long Resident #2 could have been in Resident #7's room. -He/she received no education or training for what to do with resident to resident incidents when sexually inappropriate. During an interview on 12/27/17 at 2:45 P.M., Resident #7's family member said: -He/she was notified that a resident had come in Resident #7's room and had taken off his/her clothes and laid on top of him/her. -Resident #7 was heard yelling for help. -Resident #7 was unable to position him/herself and could not have resisted another resident's advances. -He/she was told the other resident would have a close eye kept on him/her. -Resident #7 never spoke, he/she would mouth words and on occasion make a whisper. -Resident #7 in his/her younger years, before dementia, would have been afraid and told the other resident off. -Resident #7 had a prior history of an assault when younger. -He/she was worried Resident #7 mixed up the incident with the past. -He/she observed Resident #2 wander into Resident #7 room and he/she would ask staff to keep Resident #2 out of Resident #7 room. The aides responded that they did the best they could. 3. Record review of Resident # 5's Face Sheet showed the resident was admitted to the facility on [DATE], with the following Diagnosis: [REDACTED]. -[MEDICAL CONDITIONS]; -Diabetes; -Depression; -[MEDICAL CONDITION] (a chronic nervous disease characterized); -Hypertension; -Heart Failure; -[MEDICAL CONDITION]; -Kidney Disease. Record review of the resident's admission MDS dated [DATE], showed: -Severe impaired cognitive skills for daily decision making skills. -No mood or behaviors. -Required supervision, encouragement and cueing with staff assistance of one for transfer, walking, locomotion, eating, personal hygiene. -Required extensive assistance of one staff person for bathing. Record review of the resident's progress note dated 10/31/17 showed: -He/she engaged in inappropriate sexual conduct with a female resident. -The CNA interrupted the activity when checking on residents. -The Registered Nurse (RN) requested and encouraged the residents to dress and return to the common area. -The residents joined other residents at the table in the common area and continued in conversation. Record review of the resident's undated word documented titled root cause analysis showed: -On 10/31/17 it was reported the resident was observed engaged in oral sex with another resident. -The CNA interrupted the activity when checking on residents. -Neither resident were rejecting the interaction. -Residents were encouraged to dress and go to the common area. -Both residents were placed on fifteen minute security checks and were kept in constant observation, as it was meal time. -The Medical Director gave orders to send Resident #5 to the hospital. -On 10/14/17 the resident was noted to have behaviors of cursing and demanding another resident to sit with him/her. Resident #5 was following the other resident. -He/she readmitted to the facility on [DATE]. -He/she tried to reconnect with the resident of previous encounter and force his/her way into the other resident's room. Upon redirection the resident became combative. -Resident was to be discharged to another facility related to sexual aggression. Record review of the resident's progress note dated 11/9/17 showed: -At 2:56 P.M., Resident #5 was readmitted from the hospital. -At 4:19 P.M., he/she attempted to reconnect with Resident #6 and force his/her way into Resident #6's room. -Resident #5 become combative with redirection. Record review of the resident's medical record showed: -No care plan for behaviors related to sexual inappropriateness. -No fifteen minute behavior monitoring from the time of the incident 10/31/17. 4. Record review of Resident # 6's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -[MEDICAL CONDITION]; -[MEDICAL CONDITION]; -Cardiac Pacemaker (a small device placed in the chest or abdomen to help control abnormal heart rhythms); -Depression; -Mood Affective Disorder (a variety of conditions characterized by a disturbance in mood as the main feature); -Hypertension. Record review of the resident's admission MDS dated [DATE], showed: -Severe impaired cognitive skills for daily decision making skills. -No mood or behaviors. -Required supervision by facility staff,encouragement or cueing with mobility, transfer, walking, locomotion, eating and personal hygiene. -Required limited assistance of one staff person for dressing, toileting and bathing. Record review of the resident's care plan dated 10/31/17 showed: -He/she had been observed in the past week to display socially inappropriate or disruptive behavior symptoms of disrobing in public. -Goal: He/she would respond to redirection and staff monitoring and exhibited no unacceptable sexual activity. -Interventions to include: -Explain the resident's limits of sexual advances within the facility. -Close monitoring to protect residents. -Staff education for behavior approaches designed to effectively manage unacceptable sexual activity by avoiding discussions, sexual implications, magazines and books. -Discuss with him/her in a matter of fact manner that the behavior is unacceptable. -Assist with keeping covered and to a private area. -Review facility policy and procedure for resident to resident abuse. Record review of the resident's progress note dated 10/31/17 at 6:19 P.M., showed: -He/she was engaged in sexual conduct with Resident #5 in Resident #5's room. -He/she was encouraged to dress and return to the common area. -Both residents joined in conversation at a table in the dining room with other residents. Record review of the resident's progress note dated 11/4/17 at 12:42 A.M., showed; -He/she was found in another resident's room with his/her pants down and without his/her brief sitting in a recliner chair. -He/she screamed he/she was waiting on the other resident when CNA tried to assist. Record review of the resident's medical record showed: -No facility incident report was used to record an investigation of inappropriate sexual behavior on 10/31/17. -There were no fifteen minute behavior monitoring from the incident. During an interview on 12/21/17 at 3:35 P.M., CNA D said: -He/she witnessed the incident with Resident #5 and Resident #6. -He/she received report and began to go in and out of resident rooms to pull back the resident beds to be ready after supper. -Resident #5 and Resident #6 were observed watching television. -He/she had just turned down the adjoining rooms bed to Resident #5's room and saw in the bathroom mirror Resident #6 on his/her back with no pants on and Resident #5 on his/her knees with no pants on laying between Resident #6 legs. -Resident #5 had his/her brief on, Resident #6 had no brief on. -He/she stepped into the adjoining bathroom to make sure what he/she had seen and observed Resident #5 performing oral sex on Resident #6. -He/she did not intervene or make contact, he/she did not know what to do, left the room and went to find a nurse. -He/she went and found RN A and a CMT. -He/she tried the walkie talkie and was unable to reach anyone. -He/she returned to Resident #5's room with RN A and the residents were still engaged in sexual activity. -RN A broke it up, told the CMT and CNA to clean up the residents. -The residents were upset they were interrupted and it took time to get them out of the room. -Both residents were seated at the table with other residents and he/she was instructed to provide fifteen minute security checks for the residents. -Had not received education or training on what to do when an incident where residents are engaged in sexual activity, he/she knew he/she should get the nurse. During an interview on 12/26/17 at 9:05 A.M., RN A said: -He/she walked in on Resident #5 and Resident #6 having oral sex after a CNA hollered for him/her to come to the unit you got to see this I don't know what to do. -He/she entered Resident #5's room on the 200 unit from the adjoining bathroom with the CNA. -Resident #6 was lying on his/her back on Resident #6's bed with no pants on and Resident #5 had his/her pants unbuttoned around his/her knees or ankles and was on his/her knees on the bed. -He/she had to convince the residents to stop and move to the common area so they could talk there. -He/she did not believe it was consensual with the resident's dementia diagnosis. -The residents were kept in the common area where they could talk and facility staff could have an eye on both of them. -The residents were heard talking to other residents saying the stupid ladies had interrupted them. -Staff were unaware Resident #6 had entered Resident #5's room and it was unknown how long they were in the room together. -Each resident on a unit was typically laid eyes on once every two hours for toileting. -Nurses were between the units or at the nurses station located between the units on the hall by the 300 unit and 400 unit. -Nurses did not have a schedule to check on residents and usually laid eyes on each resident on the units assigned during a shift. -He/she had not received any education or training of expectation for reporting or investigating or provide one to one monitoring for resident to resident incidents at the facility. During an interview on 12/27/17 at 7:00 P.M., Resident #6's family member said: -He/she received a phone call that stated Resident #6 was found with another resident and they were separated. -He/she had an obligation to know details even when he/she did not want to, as the decision maker for Resident #6. -Resident #6 would not have approved of the indiscretion before diagnosis. During an interview on 1/2/18 at 2:00 P.M., the DON said: -The incident on 11/4/17 where Resident #6 was found with no pants and no brief on had taken place in Resident #5's room. Resident #6 returned to Resident #5's room while he/she was in the hospital for their previous encounter. -The facility did not complete a incident report for the incident on 11/4/17 with Resident #6 as no other resident was involved, he/she was seeking someone who was not in the building, making no need for follow up monitoring. 5. Record review of Resident # 4's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -Depression; -[MEDICAL CONDITION] (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability); -Hypertension. Record review of the resident's significant change in status MDS dated [DATE], showed he/she: -Had severe impaired cognitive skills for daily decision making. -Had no behaviors. -Required set-up assistance of one staff person for eating. -Required limited assistance of one staff person for ambulation. -Required extensive assistance of one staff person assistance with transfer, dressing, bathing, personal hygiene and toileting. Record review of the resident's undated word document titled inappropriate sexual behavior showed: -He/she had been in long term placement since admission on 12/24/13. -He/she had exhibited a decline over the past three years with transportation, increased falls, and change in mood and behavior. - (MONTH) (YEAR) he/she had begun to attempt to touch other incoherent residents in an inappropriate way (the inappropriate was not defined by the writer). -On 12/9/16, he/she was ordered [MEDICATION NAME] a medication for inappropriate sexual behavior. - On 5/12/17, he/she was sent to the hospital for touching a resident inappropriately. - On 5/13/17, he/she was sent to the hospital for sexual inappropriateness with male/female residents. - He/she was to be monitored by the facility staff when in the common area with other residents. -On 6/15/17, he/she was observed attempting to touch another residents' leg. -On 10/2/17, a CNA entered Resident #4's room and observed the resident with his/her hand down another resident's pants, who was laying in his/her bed. -Resident #4 was placed on every fifteen minute security checks for two hours after the incident on 10/2/17. -On 10/3/17, the Medical Director ordered his/her [MEDICATION NAME] (a medication for depression) increased to 25 milligrams to be taken by mouth twice daily, to continue fifteen minute security checks indefinitely and for the facility to assist the resident's durable power of attorney in finding the resident an all-male/all-female facility to discharge to. Record review of the resident's behavior monitoring sheet dated 10/2/17, showed he/she was monitored with checks by a staff person every fifteen minutes from 4:30 P.M. to 7:00 P.M. Record review of the resident's facility progress notes dated 10/2/17 at 4:35 P.M., showed: -Resident #4 was found by a CNA in the resident room with his/her hands down another resident's pants who was laying in his/her bed. Record review of the resident's facility progress notes dated 10/3/17 at 5:07 P.M., showed: -He/she continued on fifteen minute checks which had begun at 9:00 A.M., and were to continue indefinitely. -The facility Medical Director was contacted about the repeated concerns of inappropriate sexual behaviors by the resident. -The facility Medical Director ordered the resident to have [MEDICATION NAME] increased to 25 mg to be taken by mouth twice daily and to discharge to an all-male/all-female unit at another nursing facility. Record review of the resident's behavior monitoring report dated 10/3/17, showed he she was monitored with checks by a facility staff person every fifteen minutes from 3:00 P.M. to 10/4/17 at 7:00 A.M. Record review of the resident's facility progress notes dated 10/6/17 at 5:57 P.M., showed he/she discharged to another nursing facility. Record review of the resident's medical record showed there was: -No facility incident report used to record investigations of inappropriate sexual behavior on 10/2/17. -No care plan for behaviors related to sexual inappropriateness. -No fifteen minute behavior monitoring from 10/4/17 7:15 A.M. to 10/6/17 at 5:57 P.M. During an interview on 12/21/17 at 2:00 P.M., CNA E said: -He/she had witnessed the incident on the 200 unit with Resident #4. -Resident #4 was rubbing Resident #1's genital area. -Resident #1 was awake and redirected to engage in exercise. -Resident #4 remained in his/her room. -Was aware Resident #4 had history of sexual inappropriate behaviors and had not witnessed any before the incident with Resident #1. -Resident #4 was never placed on a one to one with a facility staff person. -Resident #4 preferred to remain in his/her room and slept a lot. -Resident #4 was watched closely when he/she was in the common area to make sure he/she was not engaging in inappropriate sexual activity. During an interview on 12/21/17 at 3:35 P.M., CNA D said: -He/she had worked the 200 unit with Resident #4 and was aware he/she would seek out other residents who were not able to resist and try to place his/her hand in the other residents' brief. -Was told to take the residents Resident #4 would seek out to their rooms to prevent Resident #4 from touching them. -Was told to have Resident #4 sit at a table with the same gender when in the common area closest to the back of the room so he/she could easily return to his/her room. -Had not been asked to provide fifteen minute security checks for Resident #4. During an interview on 12/21/17 at 1:15 P.M., LPN A said: -Aware Resident #4 located on the 200 unit was touchy with other residents. -Had found Resident #4 about to touch other residents chests or grabbing at other residents arms; and provided redirection. -Resident #4 was monitored when he/she was not in his/her room. -Resident #4 was never placed on one to one supervision. -The facility policy when a resident to resident incident occurred was to contact the physician on call or medical director, provide monitoring to the residents involved, do one to one supervision and checks, and report to the facility administration. During an interview on 12/21/17 at 2:23 P.M., CNA F said: -Was aware Resident #4 was touchy with other residents especially the ones who could not move. -He/she had to catch Resident #4 before he/she placed his/her hands where they were not supposed to be. Resident #4 liked one resident whose hands were contracted up and would catch Resident #4's hands working their way up the other resident's leg area. -He/she would try to peep out during cares to check in on Resident #4 to provide redirection when he/she knew Resident #4 was in the common area. -Resident #4 was more likely to try to be touchy when staff were busy with other residents. -Was given papers in (MONTH) with instruction to notify the charge nurse and make a witness statement when a resident was sexual. 6. Record review of Resident # 1's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -Depression (a state of intense sadness or despair); -[MEDICAL CONDITION] (a [MEDICAL CONDITION] disease of the bones and joints); -Hypertension (HTN- high blood pressure); -Diabetes (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin); -[MEDICAL CONDITION]. Record review of the resident's quarterly MDS, dated [DATE], and showed he/she: -Was rarely or never able to be understand and be understood by others. -Had severe impaired cognitive skills for daily decision making. -Was inattentive, easily distractible and had difficulty keeping track of what was said. -Required supervision by facility staff, encouragement and or cueing with transfer, and walking. -Required extensive one staff person assistance with dressing, personal hygiene and eating. -Required extensive two staff person assistance with toileti

Based on observation, interview, and record review, facility staff failed to provide adequate supervision and monitoring to a severely cognitively impaired resident (Resident #1), who was at high risk for elopement and wandering, during a fire alarm. Resident #1 left the facility unattended and was returned to the facility by a neighbor who found the resident in a wooded field approximately 100 yards behind the facility. The resident was dressed in an undershirt, hooded sweatshirt, a cardigan sweater, pants, and socks with no shoes. The temperature at the time of the elopement was 2 degrees Fahrenheit with a wind chill of -8 degrees Fahrenheit. The sample size was eight residents. The facility census was 63 residents. Record review of the undated Facility Elopement Policy showed: -All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans; -All staff are responsible; -Residents who are at risk for elopement shall be provided at least one of the safety precautions by the facility: --Door alarms on facility exits; and/or --A personal safety device that will alert facility staff when the resident has left the building without supervision; and/or --Staff supervision either by visual contact or by video camera, of facility exits; -All door alarms will be checked for proper function on a weekly basis; -At no time shall a personal safety alarm or door alarm be turned off without the continual supervision of the exit. The person responsible for turning off the personal safety alarm or door alarm shall be responsible for resetting the alarm and ensuring that it is in working condition; -Using the Minimum Data Set Resident Assessment (MDS- a federally mandated assessment instrument), all residents shall be reviewed for safety concerns and precautions, while a resident is in the facility. Residents at risk for elopement shall be identified and documented in the individual care of plan; -Residents at risk for elopement shall be identified on a Resident Watch List as well as in the clinical record. This list shall be updated whenever new resident safety issues are identified and shall be located at nursing stations and the reception area. 1. Record review of Resident #1's Facesheet showed he/she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -Dementia with behavioral disturbance. Record review of the resident's Wander Data Collection Tool, dated 12/5/16, showed staff assessed the resident as: -A wander and elopement risk; -had a history of [REDACTED].>-Cognitively impaired; -Ambulated independently; -Sought to find a spouse or family; -Was admitted at 5:00 P.M., was up ad lib (ability to walk independently) wandering around the unit aimlessly with no focus on where he/she was going; -Interventions were frequent monitoring and staff awareness. Record review of the resident's Wandering Risk Scale, dated 12/5/16 at 10:38 P.M., showed staff assessed the resident at high risk of wandering. Record review of the resident's interim care plan, dated 12/5/16, showed staff were instructed to: -Treat and eliminate causes of elopement; -Provide companionship and/or supervision; -Document elopement behaviors. Record review of the resident's Progress Notes, dated 12/7/16, showed staff documented the resident was alert to person only, wandered, was confused and up all night. Record review of the resident's Progress Notes, dated 12/8/16, showed staff documented the resident: -Wandered about the facility, in and out of other resident rooms; -Was combative and confused. Record review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Wandered daily; -Required staff supervision with walking in the corridor, in his/her room, and throughout the unit; -Required facility staff set-up assistance for bed mobility, transfers, eating, toileting, and personal hygiene; -Required one facility staff person to assist with dressing and bathing. Record review of the resident's Progress Notes, dated 12/18/16 at 3:56 P.M., showed staff documented the resident: -Eloped during the episode of the fire alarm activated on another hall by another resident at 11:45 A.M.; -Was returned to the facility by a neighbor; -Wore a T-shirt, a thick hooded sweatshirt and thick sweater; -Wore only socks on his/her feet; -Investigation found he/she went out a window after removing the screen in an empty room; -There were footprints leading away from the window; -Wet socks were removed from his/her feet and a three centimeter (cm) superficial (surface) scratch on top of the left foot was found; -Staff applied a heating pad to his/her feet; -Feet were cold to the touch, pink in color; -Inspection of the skin was found to be normal and intact; -Maintenance was onsite reinforcing the windows to prevent further opening. Record review of the resident's incident/accident report, undated, showed staff documented: -At approximately 11:45 A.M., the resident eloped out of an empty resident room window wearing layered clothing and socks on his/her feet; -His/her feet were unprotected; -The resident was gone form the building approximately 30 minutes; -He/she did not have any serious injuries; -The resident had a three cm scratch on top of the left foot; -First aid was administered, family was notified at 1:00 P.M., and the physician was notified at 1:10 P.M. During an interview on 12/20/16 at 9:00 A.M., the Administrator and the Director of Nurses said: -The elopement happened in the new addition of the building; -All windows in the new addition had safety devices installed, which limited opening the windows to six inches; -The resident broke the safety device on the window; -The entire building is locked with 6 units, the new addition included the 500 and 600 unit; -Prior to the elopement a resident on another hall pulled a fire alarm; -They believe the resident was outside the facility for 20-30 minutes based on information obtained during their investigation; -The resident exhibited wandering while on the unit; -The resident's room is on the 500 unit and the resident spends much of his/her time on the 600 unit; -The resident eloped from an empty resident room on the 600 unit on 12/18/16; -A neighbor of the facility brought the resident back to the facility; -The resident's vitals and temperature were taken; -The resident had layers of clothing on, a hat and a sweater, but the resident did not have shoes on, because he/she does not like shoes. Observation of the 500 and 600 hall units on 12/20/16 at 10:00 A.M., showed: -The left window of room 610 had the safety device latch broken on each side with one plastic piece found on the floor; -The screen was in place in the window; -Both windows in room 610 had screws installed limiting the window to open to six inches; -The window was located on the back of the building and faced a field with a wooded area in the distance; -There were footprints in the snow outside the window; -Room 605 and room 606 were found to not have screws in place. During an interview on 12/20/16 at 10:18 A.M. Certified Nurses Aide (CNA) D said: -He/she worked the 600 hall on 12/18/16; -The fire alarm went off just before 11:30 A.M.; -He/she saw the resident wandering by the back empty resident rooms (including the empty resident room 610); -Resident #1 and another resident were bickering; -Resident #1 tried to go into the empty rooms to figure out the alarm and the other resident wanted to stop him/her; -During a fire alarm, CNA D was instructed to have residents out of their individual rooms in the main common area, once the room was emptied a trash can was placed in front of the door; -In the headcount during the fire drill, two residents (Resident #1 was not one of them) on the unit were found unaccounted for and needed to be brought into the common area for the headcount; -He/she described the headcount as a visual of each resident on the unit and did not include a document or checklist to account for residents on the unit; -He/she knew which residents were supposed to be on the 600 hall unit; -One resident was in bed and had to be dressed and changed before bringing him/her out to the common area, the other was soiled and had to be changed; -The charge nurse was at the nurses station watching residents on the 600 hall unit; -When all residents on the unit were in the common area and accounted for with a headcount, the charge nurse said CNA D could take a break; -He/she did not see Resident #1 go into the back rooms, he/she only saw Resident #1 wandering at the end of the unit in front of the back rooms; -He/she checked the two back rooms before leaving for break at about 11:52 A.M. and did not see any residents in the rooms; -CNA D assumed the resident went back to the 500 unit for the headcount when CNA D did not see him/her; -CNA D was relieved for break when all 600 unit residents were accounted for; -When he/she returned from break at about 12:05 P.M., he/she saw a nurse wheeling the resident back to the unit and told CNA D the resident had gone outside. Observation on 12/20/16 at 10:27 A.M., showed the resident: -Sat in a recliner in the common area; -Wore an undershirt with a sweatshirt and cardigan sweater, pants, socks, slippers and a fisherman's hat; -Was unable to communicate the events of the elopement. During an interview on 12/20/16 at 10:30 A.M., CNA E said: -He/she worked the 500 unit on Sunday 12/18/16; -The fire alarm went off about 11:25 A.M. or 11:30 A.M.; -He/she was told the fire alarm was a drill, a resident pulled the alarm, and that someone smelled smoke on the 400 unit; -He/she and the charge nurse checked rooms on the unit, moved residents into the common area, and when resident rooms were cleared, they placed a trash can in front of the door; -During the headcount two residents were missing including Resident #1; -The headcount was described as placing eyes on each resident; -He/she said there was no form or checklist to document the headcount; -One resident was found and returned from the common hall between the units; -Resident #1 was seen about 11:40 A.M. on the 600 unit through the window of the closed fire doors sitting on a chair on the left side of the room; -The alarm was off and the charge nurse, who also viewed Resident #1 on the 600 unit, said the resident could stay on the 600 unit; -CNA E returned to the 500 unit and remained in the common area with residents until about 12:00 P.M. when the fire department cleared the 400 unit; -He/she was then relieved for break; -He/she saw Resident #1 at about 12:15 P.M. and the charge nurse was trying to warm Resident #1's feet with a heating pad from the therapeutic room; -CNA E was told the resident went outside. During an interview on 12/20/16 at 11:08 A.M., Licensed Practical Nurse (LPN) C said: -He/she was the charge nurse for the 500 and 600 hall units; -The resident as always on a mission, moving in and out of other rooms; -The house supervisor was with him/her when the fire alarm went off and instructed him/her to clear all rooms with residents redirected to the common area and trash cans placed in front of the rooms once the residents were out of their rooms; -He/she was on the 500 unit when the alarm sounded; -Once the 500 unit was cleared, he/she then went to the 600 unit make sure all residents were in the main common area and rooms were cleared; -Resident #1 prefers to walk on the 600 unit and he/she instructed the CNA to leave the resident on the 600 unit to prevent agitation; -He/she was told that another resident on another hall pulled the alarm; -When the rooms were cleared, she let the CNA on 600 unit go on break when everyone was accounted for by a headcount; -The headcount included each resident on the hall unit and knowing how many residents should be on the hall unit; -When he/she last saw the resident, he/she was with another resident near the back of the unit and both thought they knew how to solve the problem (fire alarm) and would fix it as the other resident worked for a fire department in younger years; -He/she did not have a good time frame as to when the last time he/she saw Resident #1 since he/she was between the 500 and 600 unit halls throughout the event of the fire alarm; -He/she sat down at the nurses station to begin documentation on charts; -When the neighbor brought Resident #1 back, LPN C began to check rooms on the back of the unit where the resident had been; -He/she found the window open, the latch broken and screen out in room 610; -He/she shut the window; -The resident had a cut on his/her foot, and he/she called the physician for an order; -The resident had layered clothing on, he/she was more concerned with his/her feet because they were covered only in socks; -The physician said to give the resident hot tea or cocoa and notify him/her if the body temperature was not in the normal range; -The resident's temperature was 96.3 degrees; -The week before the incident, another resident in room 604 complained it was cold because his/her window was open ; -Two to three windows were observed opened the evening of 12/18/16 (after Resident #1's elopement and return), but it was not observed who opened them. During an interview on 12/20/16 at 11:30 A.M., Resident #3 said: -He/she found his/her window open the week before and it was cold; -He/she was glad the windows were being checked. Observation on 12/20/16 at 11:30 A.M., showed Resident #3's window was closed, safety devices were intact, but not in position to be effective. During an interview on 12/20/16 at 12:25 P.M., Registered Nurse (RN) A said: -He/she was the house supervisor on 12/18/16; -A resident on the 400 hall unit pulled the fire alarm so we had a fire drill; -Someone thought they smelled electrical smoke on the 400 hall unit, so the fire department had to clear the 400 hall unit residents and all 400 hall unit residents were moved; -Charge nurses and staff were to be on the units taking headcounts to account for all residents; -It was sometime just after noon when it was reported Resident #1 had been outside the facility and was returned by a neighbor; -The 500/600 hall unit charge nurse found an open window and footprints outside the window, showing where the elopement occurred. During an interview on 12/20/16 at 1:30 P.M., the Administrator and the Director of Maintenance said: -The fire alarm went off only three minutes before the fire panel was addressed, silenced and put back into service; -The fire department came out and checked the electrical on the 400 hall unit, found no problems, and said the smell was furnace lint; -The fire watch procedures were not put into place as the system was never out of service; -A fire drill was planned for Monday, but when a resident pulled the fire alarm we went ahead and put the drill into action; -Protocol for the drill was followed, doors were closed to resident rooms with trash cans placed in front of the doors, residents were accounted for on their units in the common area and had a CNA present with them; -During the fire drill Resident #1 was accounted for and seen by the Director of Maintenance and nursing staff ; -When the drill was over and all residents were accounted for, the time was approximately 11:45 A.M.; -The facility does not have videos on the doors; -The estimated time of return of Resident #1 to the facility is 12:05 P.M.; -The new addition (the 500 and 600 hall units) was opened in July 2016; -The administrator said when the building was finished he/she was told the safety devices were in place on the windows and assumed them to be permanent; -Neither the Administrator nor the Director of Maintenance checked the safety devices to make sure they were in the on position to be effective throughout the new addition from July 2016 to the present; -The Administrator said he/she was unaware the safety devices could be bypassed; -Staff did not report to him/her that any windows were opened prior to the incident. During an interview on 12/20/16 at 2:40 P.M., Neighbor 1 said: -12/18/16 was a bitter cold day; -His/her family members decided to go for a walk; -He/she has eight acres and the facility is the back door neighbor; -His/her family found the resident disoriented and wearing socks without shoes in one of the fields; -The resident had to pass over two fences approximately 100 yards from the facility into the wooded area past the field; -It would have taken about 20 minutes to walk that distance. During an interview on 12//20/2016 at 5:30 P.M., LPN A said he/she: -Worked at the facility for about three months; -Was not working when the elopement occurred; -Received education on monitoring of residents before the incident; -Was not given any set guidelines for frequency of monitoring of residents; -Nursing staff is to monitor residents when they toilet them at least every two hours; -Monitoring of residents is not documented anywhere;. -If a resident was missing, then facility staff are supposed to do a building sweep and look everywhere for the resident; -If staff are unable to locate a resident after checking the building, then the Charge Nurse notifies the family, the physician, and the Director of Nursing immediately; -Staff should document the incident in the progress notes. During an interview on 12/20/16 at 5:41 P.M., LPN B said: -He/she heard about the elopement from coworkers, but had not received any formal training pertaining to the process for increased monitoring of residents deemed to be at high risk for elopement; -Residents at the facility are visualized all the time by staff and there are no set parameters for monitoring; -Staff are supposed to document in the computer progress notes if they are checking on someone more. During an interview on 12/20/16 at 6:00 P.M., the facility Medical Director said: -He/she was aware of the elopement at the facility; -Staff told him/her the resident was found by a neighbor in proper attire; -The resident had a blister on the foot and was given a treatment on Monday; -The on-call physician did not feel it was necessary to send the resident to the hospital; -Proper attire was defined as a coat and shoes or something between the resident and the ground; -Staff did not inform the Medical Director the resident was not wearing shoes when he/she eloped; -The resident would be fine for a couple of minutes if only wearing socks while outside; -Staff told him/her the resident went out a window; -The fire alarm could have easily frightened any of the residents; -A fire would initiate a chaotic situation; -During a fire drill, he/she would expect facility staff to keep a headcount of all residents and respond when someone was unaccounted for; -He/she would expect for the facility staff to notice if a resident had been missing for 20 to 30 minutes; -He/she was not aware a neighbor found the resident and returned him/her to the facility; -He/she thought facility staff found the resident and returned him/her to the facility. During an interview on 12/20/2016 at 6:23 P.M., the Director of Maintenance said: -He/she was in the facility when the elopement occurred; -Another resident pulled the fire alarm and the fire department responded to the alarm; -He/she checked all the resident rooms at the time of the resident elopement and found the window open where the resident exited the facility; -The resident lifted the window and busted the lock on it; -He/she checked the plastic window security device and it was broken; -The security devices can be broken easily. During an interview on 12/20/2016 at 6:38 P.M., CNA A said he/she: -Worked at the facility for about three months; -Was not working when the elopement occurred; -Has not been instructed on a specific time frame for monitoring residents who are at an increased risk of elopement; -Has not been educated on communicating with other staff when a resident wanders off his/her hall to another hall. During an interview on 12/20/16 at 6:55 P.M., Neighbor 2 said: -He/she found the resident in the flat field. The family has seven fields and four of the pastures touch the facility fence and two pastures border the backside of the facility property; -The resident would have had to come through two barbed wire fences to get to the field he/she was in; -The resident had on a shirt and a cardigan sweater, pants and socks. He/she had no shoes on and was carrying slippers; -They were closer to the facility than to their home so they walked the resident back to the facility in about 15 minutes; -The resident was found due to the neighbor dogs barking to alert him/her that someone was on the property; -The resident seemed tired and confused; -He/she was unable to find facility staff when they arrived at the facility; -He/she took off the resident's socks and placed the slippers on his/her feet; -It was approximately 12:15 P.M. before he/she left the facility after finding facility staff. MO 238 Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began immediately training the staff on elopement monitoring and documentation, identifying and reporting residents at risk of behaviors and began completing facility elopement risk assessments on all the residents. 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 the state law (Section 198.026.1RSMo) requiring that prompt remedial action be taken to address class I violations.