Every finding on record at Sunset Home

Based on interview and record review, the facility failed to protect one Special Care Unit resident (Resident #2 ), who was unable to give consent, the right to be free from sexual abuse, when Resident #1 touched and squeezed the chest of Resident #2. The facility census was 34.On 08/24/26, the Administrator was notified of the past noncompliance incident which occurred on 08/19/26. On 08/20/26, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented to include Resident #1 room was moved, Resident #1 with 1:1 monitoring, and staff education to include de-escalation of behavior, abuse, neglect and sexual behaviors training. The noncompliance was corrected on 08/24/26 prior to the onsite visit. Review of the facility undated policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy showed: -It is the policy of this facility that each resident will be free from abuse; -Sexual abuse is defined as non-consensual sexual contact of any type with a resident;-Sexual abuse includes but not limited to unwanted intimate touching of any kind, especially of breasts. 1. Review of Resident #1's Significant Change Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 08/19/26 showed:-Brief Interview of Mental Status (BIMS) of 3 indicated significant cognitive loss; -Used a wheelchair for mobility;-No behaviors; -Needed substantial staff assistance for Activities of Daily Living (ADLs: activities completed in a day to care for oneself); -Diagnoses of dementia with anxiety, delirium (a sudden severe change in brain function that causes confusion, disorganized thinking and shifting awareness), restlessness, and agitation.Review of the resident's Comprehensive Care Plan dated 08/03/26 showed: -He/She had behaviors directed at staff: if behaviors occurred staff should walk away and approach at a later time; -Followed by Psychiatric Physician or Nurse Practitioner as needed; -Behavior included inappropriately touching another resident: He/She was moved to the other hall; redirect as needed; use distraction such as food, activity and conversation. Review of the resident's Nurse Progress Notes dated 08/19/2026 at 3:21 P.M., showed:-Resident #1 had inappropriately touched another resident's chest; The Primary Care Physician (PCP) was notified and ordered psychiatric consultation; Durable Power of Attorney (DPOA: a legal agreement with a trusted person to manage medical care/money if a person becomes unable to make decisions) was notified.2. Review of Resident #2's Quarterly MDS dated [DATE] showed: -BIMS of 3, indicated the resident had severe cognitive impairment; -Wandered daily; -Diagnoses of restlessness, anxiety, disorientation, non-traumatic brain disfunction (when internal medical events disrupt the brain's normal activity) and cognitive impairment. Review of the resident's Comprehensive Care Plan dated 8/18/26 showed: -He/She had cognitive loss: Provide support and reassurances; Provide verbal cues and supervision as needed; -He/She wandered: Avoid overstimulation; Provide visual cues; Maintain a calm environment; Maintain calm approach.-He/She was inappropriately touched by another resident; Monitor for safety every 15 minutes.Review of the resident's Nurse Progress notes dated 08/19/2026 at 3:13 P.M. showed: -Another resident was seen touching Resident #2's chest; -PCP was notified and said Resident #2 was not able to make decisions so the touching was not consensual; PCP to review medications.Review of the resident's Skin assessment dated [DATE] at 3:22 P.M., showed:-No findings.During an interview and observation on 08/24/26 at 11:20 A.M. Resident #1 said: -He/She did not think he/she had touched anyone;-He/She was laughing and mumbling nonsensical words.During an interview on 08/24/26 at 11:32 A.M., Licensed Practical Nurse (LPN) A said:-He/She had seen him hold Resident #2's hand before; -He/She had not seen any inappropriate touching between Resident #1 and #2 before; -Resident #2 was very affectionate and would hug and touch anyone,; -Resident #1 was moved to the other hall immediately after the incident; -Resident #1 was placed on 1:1 monitoring by staff;-He/She had education on de-escalation of behavior, abuse, neglect and sexual behaviors.During an interview on 08/24/26 at 11:47 A.M. showed Certified Medication Technician (CMT) A said: -Resident #2 wandered and gets in other people's personal space; -Resident #1 often called Resident #2 by his/her spouse's name; -He/She had seen Resident #1 and #2 hold hands;-He/She had not seen any inappropriate touching between Resident #1 and #2;-Resident #1 was moved off the Special Care Unit (SCU);-He/She had education on abuse, and behaviors.During an interview and observation on 08/24/26 at 12:03 P.M. Resident #2 said:-He/She felt safe; -He/She laughed and was not understood when he/she talked;-He/She smiled; -He/She patted and touched a visitor.During an interview on 08/24/26 at 12:30 P.M. the Social Service Director (SSD) said:-He/She was not aware of Resident #1 or #2 displaying any sexual behaviors; -Resident #2 gets in other people's personal space; -Resident #1 and #2 would sometimes hold hands; -He/She sent admission referrals for Resident #1 after 08/19/24;-He/She visited with Resident #2 daily to monitor behaviors and emotions; - Resident #1 was moved off the SCU;-All staff education on sexual behaviors and reporting incidents was completed.During an interview on 08/24/26 at 2:42 P.M. the Director of Nursing said:-He/She saw Resident #1 sitting in a wheelchair, in the hallway of the SCU, Resident #1 standing in front of him/her; Resident #1 had his/her arms raised up and his/her hands under Resident #2's shirt; as the DON approached, he/she could see Resident #1 making squeezing movement's with his/her hands under Resident #2's shirt; -He/She removed Resident #1 from Resident #2 and took Resident #1 to the other hall of the facility;-Resident #1 was immediately placed on 1:1 observation; -Skin assessments were completed for both residents; -Education was done with staff on abuse, sexuality in nursing homes, and referrals were sent for Resident #1;-Staff had made a previous allegation of inappropriate touching by Resident #1 previously but it could not be proven. During an interview on 08/24/26 at 2:45 P.M. the Administrator said:-Resident #1 did wink, smile and kiss staff hands often; -Resident #1 was moved immediately to the other side of the facility and placed on 1:1 observation by staff; -Resident #2 was placed on 15 minute checks for safety; -Training was completed for staff on abuse, reporting, and sexuality in long term care. Intake 3170213

Based on observation, interview, and record review, the facility failed to prevent one of the three sampled residents, (Resident #1) from accidents and hazards when Resident #1 eloped from the facility and was found by a nearby business laying on the ground. The resident was transported to the hospital and found to have fractured in his/her left arm. The facility census was 29. Review of the facility's Elopement Protocol, dated April 2006 showed:Elopement, for the purpose of these guidelines is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs, and therefore at risk for injury outside the confines of the facility, has left the facility without knowledge of staff. The definition of elopement does not include a resident who is at risk for elopement, but whose exit from the facility is known to staff who is responding to the exit. Furthermore, the definition of elopement does not include residents: who are not at risk for elopement due to their cognitive abilities. Who leave the facility with the intent to return within a short period of time. Who have the ability to leave and return safely. Residents who fit this description, are requested to sign in and out or in some similar manner, to let staff know of their departure and anticipated time of return. The purpose of the elopement guidelines is to: identify residents at risk for elopement, protect residents that are not capable of protecting themselves and provide the techniques and equipment to minimize safety risks. A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. Door alarms are tested at least once a month. The results of the test are recorded. Testing of the system includes not only the alarm's function, but also the staff's appropriate response to the alarms. Only the Administrator may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarms. All new employees are in-serviced on elopement guidelines during orientation. All employees will be in-serviced on elopement procedures annually.The Charge Nurse (CN) is responsible for coordinating a building search followed by an immediate search of the facility grounds if a resident is discovered missing or an elopement is evident. The CN will take the following steps: search the facility in teams. If non-nursing personnel are present, they initiate a search outside the building; otherwise, nursing will initiate the search. CN is to remain in the facility coordinating the search. Prepare to provide a picture and description of the resident, including clothing, height, weight, hair and eye color, etc. Administrator and Director of Nursing (DON) are to be notified within 20 minutes of the discovery. Administrator or designee calls in the off-duty department heads or staff as needed to assist with the search. Narrow the time frame in which the resident was last noted in the facility. Assign a staff member to complete a search of places in the community frequented by the resident. Call 911 for law enforcement assistance to aid in the search (if not found during facility and grounds search). Notify family/responsible party and physician within two hours of discovery. When found, assess for injuries and document. Make sure a plan has been developed to ensure protective oversight. Notify all those involved in search that the resident has returned. The care plan is to be revised to include further preventative interventions to prevent re-occurrence. In-service staff on the plan of care that will be implemented within 48 hours of incident and address to all personnel involved in direct care of the resident and alerting non-nursing staff of precautions and elopement guidelines. The Department of Health and Senior Services may be notified if there is reason to believe the resident is likely to be in harm or danger. Review of the facility's undated policy for Elopement- Missing Resident showed:Guidelines: Determine: when the resident was last seen and by whom, description of clothing and where the resident was last seen.Notify all departments and begin a thorough search of the facility and grounds, including bathrooms, closets, storage areas and crawl spaces. Search streets and neighborhood adjacent to the facility.Notify DON and Administrator.Notify attending physician.Notify responsible party. Request notification if resident makes contact with them.If absence exceeds 30 minutes, notify local law enforcement agency. Give dispatcher the following information: resident's name, sex, age, time discovered missing, where last seen, physical description (height, weight, race, hair, eyes, etc.), physical impairments, mental conditions, description of clothing, if harmful to self or others, home address, address of known relatives or friends and photograph of resident.When located, be certain to notify all appropriate people/agencies. Assess for injuries. Review of the facility's undated policy for Resident Condition Change (Observing, Recording, and Reporting) (Includes Fall or Injury) showed:The purpose is to observe, record, and report any condition change to the attending physician so that proper treatment can be implemented. After all resident falls, injuries or changes in physical or mental function, monitor the following: Observe for lacerations. Observe for swelling and discoloration. If present chart size, site, amount and color. Observe for convulsions. Observe and inquire if resident has headache or pain. Observe for personality changes. Observe for alterations in consciousness. Observe for incontinence. Observe for sensory disorder. Observe for generalized weakness. Observe for speech disorder. Observe for gait, posture or balance disorder. Observe for still neck. Observe for proper reflexes (response to painful stimuli). Take vital signs and include temperature. Observe for abdominal spasm or pain. Observe for bleeding from ears, nose, and throat. Observe for unequal pupils. Observe for dyspnea or variations in respiration (irregular). Observe for flushing or cyanosis. Observe for pain. Observe for abduction, adduction, shortening or improper position of extremities. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director for emergency situations. Complete an incident, accident or risk management report per facility guidelines. Notify resident's responsible party.Monitor resident's condition frequently until stable. Notify physician of condition change, need for treatment orders and/or medication order changes. 1.Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 5/23/25 showed:Cognitive skills severely impaired.No behaviors or wandering.No impairment to upper or lower extremities.Independent with eating, oral care, toilet use, showers, dressing and transfers.Occasionally incontinent of urine. Always continent of bowel.Diagnoses included dementia, Parkinson's disease (a movement disorder of the nervous system that worsens over time), anxiety, depression, bipolar (a mental health condition that causes extreme mood swings), psychotic disorder ( a mental health condition characterized by a loss of contact with reality, leading to symptoms like hallucinations, delusions, and disorganized thinking and speech), schizophrenia (a serious brain disorder that causes a person to have difficulty distinguishing what is real from what is not), and post-traumatic stress disorder (PTSD).No pain.No falls.The resident had antipsychotic, antianxiety, antidepression and anticonvulsant medications in the last seven days.The resident received antipsychotic medication on a routine basis.On 3/26/25, the physician documented the gradual dose reduction as contraindicated. Review of the resident's elopement/wandering assessment form dated 9/12/25 showed the resident scored a 9 which indicated the resident was a high risk for elopement. Review of the resident's care plan, dated 9/12/25 showed: The resident had increased need for guidance redirection related to dementia. Avoid assuming an overly protective attitude. Provide special environmental stimuli: directional markers, calendars, clocks, phots, and written schedules. Provide support and reassurance when the resident becomes anxious about what he/she is supposed to be doing. provide verbal cues and supervision when the resident forgets what he/she is supposed to be doing. Structure daily programs around the physical aspects of the resident's life. Encourage the resident to attend activities. The resident has experienced trauma. He/she may need assistance to address the physical, behavioral and /or social impacts of the trauma. 15 minute checks were initiated for risk for elopement when exit seeking behaviors are noted. Review of the resident's admission MDS, dated [DATE] showed:Cognitive skills severely impaired.No behaviors or wandering.No impairment to upper or lower extremities.Independent with eating, oral care, toilet use, dressing and ambulation.Supervision with showers.Partial to moderate assistance from staff for personal hygiene.Occasionally incontinent of urine. Always continent of bowel.Diagnoses included schizophrenia, dementia, anxiety, depression, and PTSD.No pain.No falls.The resident had antipsychotic, antianxiety, antidepression and anticonvulsant medications in the last seven days.Review of the Sheriff's Department incident report, dated 10/28/25 at 7:26 A.M., showed:He/she was advised a [AGE] year-old male/female had walked away from the nursing home and the resident was unable to care for him/herself. The resident is 5 foot 4 inches, weigh 163 pounds with medium length braided grey hair wearing dark pants and a long sleeve shirt and first responders were sent out. While enroute, dispatch notified the resident was found behind the Dollar General. The resident was on a backboard and was loaded into the ambulance and transferred to the ER for evaluation and treatment. LPN B gave an account of the morning's events.Review of the resident's progress notes, dated 10/28/25 at 12:27 P.M., showed:At 6:50 A.M., Licensed Practical Nurse (LPN) B went to give Resident #1 his/her Clonazepam (used to treat seizure and panic disorders), and the resident was not in his/her room, located on the [NAME] Hall of the memory care unit. He/She looked for the resident in each room on the East Hall of the memory care unit and did not see the resident. He/She checked the dining room on the memory care unit, checked the resident's room and the bathroom and did not see the resident. He/She checked all the rooms on the South Hall and notified the South Hall staff he/she was unable to find the resident. Certified Medication Technician (CMT) B said he/she saw the resident at the nurse's station at 6:00 A.M., when he/she started the medication pass. Certified Nurse Aide (CNA) C said he/she observed the resident at the courtyard door about 6:30 A.M. All staff were notified to look for the resident at 7:00 A.M. and a full building search began. The Director of Nursing (DON) arrived at this time and notified of the situation. The Administrator was notified of the situation. At 7:25 A.M. The Sheriff's department was called and reported the resident as missing from the facility. Staff continued to search the building and grounds. Off duty staff was called in and they began to search the neighborhoods and surrounding areas. At 8:00 A.M., he/she received a phone call that a staff member had found the resident behind the Dollar General and the resident had fallen. The DON and Administrator was notified. 911 was notified. At 8:20 A.M., the resident was loaded into the ambulance. Report was given to the Sheriff's Department. At 8:55 A.M., left a message for the resident's Public Administrator (PA) and left a message for the resident's physician. At 9:05 A.M., spoke with the PA and was updated on the events and the resident's condition and transferred to the emergency room (ER). At 9:09 A.M., the physician called back was updated on the resident's condition and current situation. At 11:45 A.M., the ER called and stated the resident's tests were clear and the resident was ready to be discharged back to the facility and transportation was notified. 10/28/25 at 1:20 P.M., the resident returned to the facility from ER via the facility van. The resident complained of generalized pain and aches all over and was cold. When asked what happened, the resident stated, He/She had a car accident when he/she was going to his/her mom's house. The resident was taken to the secured unit and 15-minute checks were started. Review of the resident's elopement/wandering assessment form dated10/28/25 showed the resident scored a 7 which indicated the resident was a high risk for elopement. Review of the resident's care plan, dated 10/28/25 showed:The resident had an actual elopement and rates a 7 (high risk) on elopement observation. Primary care physician and Psychiatrist was notified of resident's elopement with no changes made at this time. Resident is on 15-minute checks for 72 hours then will be on 2-hour location and safety checks. Resident was sent by ambulance to be evaluated after he/she was found and returned to the facility. Staff educated on elopement policy and procedures, 15-minute checks, door locks and lights.Review of the resident's progress notes, dated 10/29/25 at 3:07 A.M. showed:Noted swelling to left wrist and bruising to left thumb. Resident stated it was painful to touch rating pain a five out of 10. Tylenol as needed given for pain to left wrist. The physician was notified via fax.Review of the resident's progress notes, dated 10/29/25 at12:35 P.M. showed:The resident returned from the ER. Keep sling in place, keep splint dry. Return to the ER if there are any issues. See ortho on 11/5/25 at 9:45 A.M. for follow-up. Denied pain at this time. Review of the facility's field portal equipment showed the Maintenance Director verified all magnetic door locks are locking and releasing properly, verified proper signage is posted, explaining to hold doors for 15 seconds for time release, verified doors are free of any damage, checked the security and integrity of the privacy fence and verified all keypads are working properly on the following dates: 10/9/25, 10/16/25, 10/22/25 and 10/28/25. During an interview on 11/5/25 at 8:49 A.M., the Administrator said:The resident was at his/her ortho appointment and would return shortly.On 10/28/25 she sent out a message in the group chat for a code purple (missing resident). CNA B found the resident across the street behind the Dollar General and reported that the resident was found lying on the ground on his/her side. The resident said he/she was just sitting there talking to the girls, when he/she was actually lying on the ground and there were no girls around.CNA B did not move the resident but covered the resident with his/her coat and with blankets from his/her car until the ambulance arrived.The resident was wearing shoes, pants and a long sleeve shirt.The resident stated his/her left arm hurt and the ambulance personnel were informed when they arrived on the scene.CNA B rode with the resident in the ambulance to the hospital.When the resident went to the hospital, they drew labs, did a chest x-ray and a computed tomography (CT) of the head, (an imaging test that uses X-rays and a computer to create detailed cross-sectional images of the head, including the brain, skill and blood vessels), but did not do an X-ray of the resident's left arm.When the resident returned to the facility, he/she did not use his/her left arm. The next morning, it was noticeably swollen, the resident was not using it and was guarded with it. The resident did not complain of any pain. The resident's left hand was bruised, and the staff applied an ice pack. The physician was notified and received an order for an X-ray. The facility van transferred the resident to the hospital for the X-ray. When the results showed it was broken, the physician was notified and gave an order to take the resident to the ER. The ER staff put a splint with ace wrap and a sling on his/her left arm.Observation on 11/5/25 at 9:49 A.M., showed he Administrator and the surveyor checked the door alarms on the North Hall and staff responded within seconds.Observation and interview on 11/5/25 at 10:00 A.M. showed:The Administrator and the surveyor checked the door alarms on the memory care unit and the staff responded immediately.The Administrator had the Maintenance Director add three new stop sign alarms to the doors that were loud enough to be heard on the North Hall. The Administrator said the staff checked all the door alarms when they found the resident missing and there were no door alarms going off and all the door alarms worked. Observation and interview on 11/5/25 at 10:09 A.M. showed:Resident #1 returned from his/her orthopedic appointment in a wheelchair, and he/she had a brace on his/her left arm. The Administrator assisted the resident from the wheelchair to his/her bed.The resident said he/she was already outside and was walking down the street and went off from it, fell and broke his/her arm. The resident denied any pain.The Administrator said the resident's cognition is at his/her baseline.Observation on 11/5/25 at 10:27 A.M., of the South dining room door on the memory care unit showed: The Administrator put an Alzheimer's door deterrent on the door which looked like a brick wall with greenery.It's made out of thick vinyl and is fire retardant.The door did not have a keypad lock on it but had one of the loud stop sign alarms on it.Observation and interview on 11/5/25 at 10:41 A.M., of the kitchen door on the South side on the memory care unit showed:They changed the keypad lock and put a doorknob on the door, and it locked automatically. If the staff needed anything, they could ring the doorbell, and the dietary staff would answer it.As you go through the kitchen door from the memory care unit and turn there's a hallway that has a service entry exit door. It does not have an alarm on it. The key is hanging by the door but blends in with the door frame and is difficult to see. You can go out the door, but if the door is locked, you cannot come back inside.The Administrator believed this was the door Resident #1 went out. Observation on 11/5/25 at 11:04 A.M., showed Resident #1 sat in the wheelchair at the nurse's station. During an interview on 11/5/25 at 11:07 A.M., LPN A said:He/She has worked at the facility for 15 years and worked on the North Hall and on the memory care unit.He/She was not working the day Resident #1 eloped.Resident #1usually walked independently but in the last couple of weeks, he/she used a wheelchair. Resident #1 has never been combative. He/she had a history of saying his/her sister, who had passed away, was coming to pick him/her up. HIs/Her delusions usually consisted of his/her sister picking him/her up and either going shopping or going home.He/She has not had any issues with the door alarms not working.Observation on 11/5/25 at 11:12 A.M., showed staff propelled the resident to the dining room for lunch. During an interview on 11/5/25 at 11:29 A.M., CNA A said:He/She has worked for the facility for 28 years and worked on the North Hall and on the memory care unit.He/She was working on the North Hall the day Resident #1 eloped. LPN B notified the staff on the North Hall they were unable to locate Resident #1.He/She looked for the resident on the North Hall and did not find him/her.He/She did not hear any door alarms going off. Resident #1 was found behind Dollar General.They had a staff meeting that afternoon and discussed the elopement. Resident #1 was placed on 15-minute checks, and all residents were placed on two-hour visual safety checks. They added three new louder door alarms on the memory care unit and changed the door lock on the kitchen door on the memory care unit.Resident #1is easy to get along with. He/She always thinks his/her sister is coming to pick him/her up. He/She is not resistive with cares or combative. He/She is easily redirected. They currently do not have any residents who exit seek, besides Resident #1.Staffing on the unit is usually 1 aide and the CMT and the CN are for the entire building.Observation on 11/5/25 at 11:29 A.M., showed Resident #1 sati in his/her wheelchair in the dining room waiting on lunch. During an interview on 11/5/25 at 12:29 P.M., CMT A said:He/She worked on the North Hall and on the memory care unit.Resident #1 usually required stand by assistance with cares but sometimes he/she required assistance with toileting due to incontinent episodes. The resident is delusional and always thinks his/her sister, who has passed away is coming to pick him/her up. The resident is easily redirected. He/She was not working the day Resident #1 eloped. They had an in-service and discussed the elopement, Resident #1 on 15-minute checks, all residents on two-hour visual safety checks, the additional alarms on the doors on the memory care unit. If unable to locate a resident, he/she would report it to the CN and then call Code Purple (missing resident). During an interview on 11/5/25 at 12:40 P.M., Dietary [NAME] A said:He/She only worked four days a week and was not working the day Resident #1 eloped.He/She has never seen any resident go through the kitchen. During an interview on 11/5/25 at 1:35 P.M., CNA B said:He/She worked on the North Hall and on the memory care unit.He/She was off the day the message went out for the Code Purple.When he/she arrived at the facility, he/she was informed of which resident was missing. He/She started driving around looking for Resident #1.He/She parked in the parking lot of the Dollar General and did not see anyone. He/She parked in the parking lot and went behind the building and found the resident on his/her side with his/her right arm under him/her trying to hold him/herself up. The resident was wearing a long-sleeved shirt, dark pants and tennis shoes. He/She did not recall the resident being covered in leaves. Where his/her body was touching ground was wet. The resident said he/she had been out with the girls, hit his/her head on a rock and his/her arm hurt. He/She covered the resident with his/her coat then removed blankets from his/her car and placed them on the resident. He/She called the facility and informed the CN Resident #1 had been found. The Police arrived and the ambulance arrived. The ambulance staff were aware the resident's left arm was hurting, and they did not obtain any vital signs from that side. He/She rode in the ambulance to the hospital with the resident. He/She informed the hospital staff about the resident's left arm hurting. The resident was settled in the hospital bed when he/she left the ER. They had a staff meeting that afternoon and discussed the elopement, 15-minute checks, and two-hour visual safety checks on all residents, changing the doorknob on the kitchen door on the memory care unit and adding additional alarms. During an interview on 11/5/25 a 2:08 P.M., Kitchen Aide A said:He/She has worked at the facility for a little over a month.A little after 6:30 A.M., he/she was outside the deliver entrance door taking a break when he/she observed a figure walking past the propane tanks.He/She was not aware Resident #1 was missing at the time. Looking back, he/she thought that it very well could have been Resident #1 but not really for sure. they had a meeting that afternoon and were informed what to do if a resident went missing, also discussed changing the doorknob and the additional alarms. During an interview on 11/5/25 at 2:30 P.M., the Dietary Manager said:He/She had been in the position for about two weeks or maybe a month.He/She had no idea how Resident #1 eloped.Between 6:00 A.M. to 6:30 A.M., he/she opened the door to the dining room of the memory care unit. He/She had a conversation with the staff member working on the memory care unit and hung the menus then returned to the kitchen. Resident #1 was in the dining room at that time. He/She thought the door to the kitchen was shut but does not remember and also did not remember if it was locked or not. He/She did not observe the resident going through the kitchen door, did not observe the resident in the hallway and did not hear the back delivery door open.They had an in-service that afternoon and discussed the elopement, , changing the lock on the kitchen door, adding a doorbell and adding additional alarms. Intake 2654580 Intake 2654882

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 23.Review of the facility's Cleaning of Workspaces policy, dated May 2015 showed:-Walls, doors, vents and ceiling must be free from chipped and/or peeling paint and must be kept in good repair;-Walls, doors, vents and ceilings must be washed at least twice a year;-Heavily soiled surfaces must be cleaned more frequently;-Cabinets should be washed with detergent solution and warm water every week and more often if needed.Review of the facility's Storage of Food and Supplies, dated May 2025, showed:-Dry storage rooms must be neat and clean;-Open boxes are to effectively re-sealed;-Date food with open date and use by date;-Food is to be stored a minimum of six inches above the floor.Review of the facility's, General Dish Room Sanitation Policy, dated May 2015, showed:-Dish room work surfaces must be maintained in a clean and sanitary condition;-A test trip should be used and noted on the dish washer log before each meal's dishwashing.Observation of the kitchen on 07/21/25 at 10:46 A.M., showed: - The floors of the kitchen sticky, covered in dirt and debris;- A black rubber mat under the stove and oven area covered with a black sticky substance;- Area under the three compartment sink covered with food debris;- Cabinets under the counter with peeling paint and black spots the size of quarters;-The floor under the prep table covered with dirt and debris;-A metal storage rack above the prep table covered in dirt and dust;-A cake uncovered sat under the dirty and dusty metal storage rack;-The handles of the refrigerator caked with a sticky substance;-The widow by the three compartment sink covered in food debris, dust and cobwebs;- The wall under the dishwasher covered in a black substance;- A black substance along the drain on the floor in the dish room;-The legs of the dishwashing area rusted with peeling paint;-The window in the dish room covered in food debris, dust and cobwebs;-An open gallon of milk in the refrigerator with an expiration date of 07/16/25.Observation of the kitchen on 07/23/25 at 11:12 A.M., showed: -The bottom half of the refrigerator covered in liquid spatter and food debris;-The vent on the wall behind the toaster oven caked in dust with a thick layer of grease;-The storage rack above the food prep table still covered with dust and debris;-Two broken tiles at the exit door of the kitchen;- The floors of the kitchen still sticky and covered in dirt and debris;- A black rubber mat under the stove and oven area still covered with a sticky substance;- Area under the three compartment sink still dirty with food debris;- Cabinets under the counter still with peeling paint and black spots the size of quarters;-The floor under the prep table still covered with dirt and debris;-The metal storage rack above the prep table still covered in dirt and dust;-The widow by the three compartment sink covered in food debris, dust and cobwebs.- The wall under the dishwasher still covered in a black substance;- A black substance still along the drain on the floor in the dish room;-The legs of the dishwashing area still rusted with peeling paint;-The window in the dish room still covered in food debris, dust and cobwebs.Walk in freezer:-A screwdrive held the freezer door shut;-The floor of the freezer covered in water and ice;-A 20 pound turkey sat on the floor;-Two unopened boxes of link sausage sat on the floor;-The unopened boxes of sausages covered in water and chunks of ice;-An open and undated bag of French fries;-An open and undated bag of okra;-An open and undated bag of sausage patties; -Chucks of ice the size of golf balls sat on top of boxes of food and on the floor;Dry Storage:-The floor covered with a sticky substance, dirt and debris.Review of the dishwasher sanitization log dated July 2025, on 7/23/25 at 12:32 P.M., showed: -Instructions, record sanitizer concertation before each meal before washing dishes;-The log should be filled in and signed by those who are directly involved in the dishwashing process;-7/01/25, no documentation indicating the sanitizer level had been checked;-7/02/25, no documentation indicating the sanitizer level had been checked;-7/07/25, no documentation indicating the sanitizer level had been checked;-7/10/25, no documentation indicating the sanitizer level had been checked;-7/12/25, no documentation indicating the sanitizer level had been checked;-7/14/25, no documentation indicating the sanitizer level had been checked;-7/15/25, no documentation indicating the sanitizer level had been checked;-7/16/25, no documentation indicating the sanitizer level had been checked;-7/17/25, no documentation indicating the sanitizer level had been checked;-7/18/25, no documentation indicating the sanitizer level had been checked;-7/19/25, no documentation indicating the sanitizer level had been checked;-7/20/25, no documentation indicating the sanitizer level had been checked.Observation and interview on 07/23/25 at 12:45 P.M., showed:-Dietary Aide (DA) B loaded dishes into the dishwasher;-DA B removed the dishes from the dishwasher after the cycle was finished;-DA B did not check the sanitizer before he/she ran the through the dishwasher;-DA B said he/she ran the breakfast dishes through the dishwasher after breakfast and the Dietary Manager (DM) ran pans through dishwasher after breakfast;-DA B said he/she was taught how to use the strips when he/she started but could not remember how to check the sanitizer in the dishwasher;-DA B said he/she worked several shifts a week;-DA B said he/she was not sure how many parts per million (PPM, measurement used to ensure the quality, safety and compliance of products or processes) the strips should read.During an interview on 07/23/25 at 12:58 P.M., the DM said:-All staff in the kitchen should know how to check the sanitizer in the dishwasher;-She was not aware that DA B did not know how to check the sanitizer in the dishwasher;-The sanitizer should be checked at every meal and recorded on the log;-There should be no blank spaces on the sanitizer log;-The PPM should be recorded three times a day;-The PPM should be around 150;-She expects the kitchen to be clean and sanitary and in good repair;-She had put in work orders for maintenance last week for repairs and cleaning of the vents;-All expired food should be disposed of and not in the refrigerator;-No food should be setting on the floor;-All foods should be sealed and dated;-Vents, floors, windows and cabinets should be clean and in good repair;-The kitchen staff is responsible for cleaning the kitchen;-Maintenance cleans the vents in the kitchen;-She said the kitchen staff tried to keep up on the cleaning but there was not enough time.During an interview on 07/23/25 at 01:10 P.M., the Maintenance Supervisor said:-He was in charge of any repairs to the kitchen;-He was not aware of any repairs that needed to be done in the kitchen;-He does not clean the vents in the kitchen;-The kitchen was responsible for cleaning the vents in the kitchen;-The kitchen should be maintained and in good repair. During an interview on 07/23/25 at 01:25 P.M., the Registered Dietitian said:-He expects the kitchen to be clean and in good repair;-He expects the sanitizer to be checked and recored before each each meal service daily;-He expects food to be dated and stored properly;-He expects expired food to be discarded. During an interview on 07/23/25 at 01:35 P.M., the Administrator said:-She expects the kitchen to be clean and in good repair;-She expects the sanitizer to be checked and recorded before each meal service daily;-She expects food to be dated and stored properly;-She expects expired food to be discarded;-She said there should not be ice on the floor of the walk in freezer and no wet boxes;-She said the cooler is keeping foods frozen at the correct temperature;-She has had repairs made to the cooler recently;-She did not know why there was a screw driver in the freezer door. During an interview on 07/30/25 at 03:28 P.M., the Eco Lab Territorial Manger said:-He/She came once a month to inspect and service the dishwasher;-The ppm should be between 50-100;-The sanitizer ppm should be checked before breakfast, lunch and supper to ensure the dishes are sanitized properly;-The dietary staff should know how to check the sanitizer in the dishwasher.

Based on observations, interviews, and record review, the facility failed to accurately label medication and to facilitate consideration of precautions and safe administration, when nursing staff failed to write the opened date on three insulin pens for two of the 12 sampled residents (Resident #6, #9) The facility census was 23.Review of the facilities Diabetic Infection Control policy, not dated, states:- All multiple dose insulin vials will be assigned to individual residents, labeled appropriately, and dated when opened. Review of NovoLog injection flexpen manufacture guidelines states:- The NovoLog(R) FlexPen(R) you are using should be thrownaway after 28 days, even if it still has insulin left in it. Review of instructions for use of Lantus prefilled pen states:- Only use the pen for up to 28 days after its first use. Throw awaythe LANTUS SoloStar pen you are using after 28 days, even if it stillhas insulin left in it. Review of instructions for Humalog KwikPen states:- The HUMALOG Pen should be thrown away after 28 days, even ifit still has insulin left in it. 1. Review Resident #6's July physician's order sheet showed:Novolog Flexpen U-100 Insulin (insulin aspart u-100)insulin pen; 100 unit/mL (3 mL); amt: Per Sliding Scale; subcutaneousIf Blood Sugar is less than 60, call MD.If Blood Sugar is 120 to 150, give 2 Units.If Blood Sugar is 151 to 200, give 4 Units.If Blood Sugar is 201 to 250, give 6 Units.If Blood Sugar is 251 to 300, give 8 Units.If Blood Sugar is 301 to 350, give 10 Units.If Blood Sugar is 351 to 400, give 12 Units.If Blood Sugar is greater than 400, call physician. Lantus Solostar U-100 Insulin (insulin glargine)insulin pen; 100 unit/mL (3 mL); amt: 30 units; subcutaneousFrequency: At Bedtime Observation on 7/22/25 at 11:02 A.M. showed Lantus insulin pen and Novolog flexpen was undated and unlabeled laying open in the medication cart. During an interview on 7/22/25 at 11:05 A.M. LPN A said both insulin pens should have been labeled and dated when opened. 2. Review of resident #9's July physician's order sheet showed:insulin lispro (Humalog)insulin pen, half-unit; 100 unit/mL; amt: 5 units; subcutaneous Observation on 07/22/2025 at 11:02 A.M. noted two insulin pens for resident #6 were in the top shelf of the medication cart. Both pens were not inside a box with the residents name and had been opened and were not dated. Observation on 07/22/2025 A.M. at 11:08 A.M. noted one insulin pen sitting in the top shelf of the medication cart, outside of it's prescription box, open and not dated for resident #9. During an interview on 07/22/2025 at 2:16 P.M. LPN A said that insulin pens should be dated when opened. During an interview on 07/23/2025 at 8:57 A.M. the DON (Director of Nursing) said that he/she expects insulin pens to be dated when opened. During an interview on 07/23/2025 at 12:18 at P.M. the Administrator said that insulin pens are to be dated when opened.

Based on observation, interview and record review the facility failed to post the daily staffing sheets to included the amount of hours scheduled to work for both licensed and non-licensed nursing staff and additionally failed to have it in an area unobstructed from the public view. The facility census was 23. The facility did not have a policy regarding the posting of daily census and staffing sheets. Observation on 7/22/25 at 2:15 P.M., showed the daily census and staffing sheets were hung on a clip board on a wall and behind a decorative tall Christmas tree in the front lobby which was obstructing the view from the public to see the daily census and staffing sheets of the facility. Review of daily census and staffing sheets attached to the clip board on 7/22/25., showed for the months of June and July no staff hours were posted for licensed or non-licensed staff in view for the public to see. During an interview on 7/22/25 at 3:10 P.M the Administrator said, she new that the daily staffing and census sheets should be posted in view of the public and that the decorative Christmas tree would need to be moved from in front of the clip board holding the daily staffing and census sheets. She was unaware that the daily staffing and census sheets should also include the number of hours worked for both licensed and unlicensed nursing staff.

Based on interview and record review the facility failed to ensure there was a Registered Nurse (RN) providing services at least 8 consecutive hours a day, 7 days a week consistently for the months of January, February, and March 2025. The facility census was 23.A facility staffing policy was requested and none was provided. Review of the Payroll Based Journal (PBJ) Staffing Data Report showed the facility is responsible for submitting staffing data through the PBJ .This data is available through facility's PBJ Staffing Data Report that can be obtained through CMS' survey system. This report must be utilized by surveyors on at least every recertification survey. The report contains information about overall direct care staffing levels as well as if an RN was onsite for 8 hours a day. Review of the facility's PBJ staffing report for 2025., showed for the months of January, February, and March of 2025- No RN Hours on, 01/01 (WE); 01/04 (SA); 01/05 (SU); 01/18 (SA); 01/19 (SU) 02/01 (SA); 02/02 (SU); 02/08 (SA); 02/09 (SU) 03/01 (SA); 03/02 (SU); 03/15 (SA); 03/16 (SU); 03/29 (SA); 03/30 (SU) Review of the facility's staffing sheets for January, February, and March of 2025., showed- No RN coverage in the month of January on 1/1/25, 1/4/,25, 1/5/25, 1/11/25,1/12/25, 1/18/25, 1/19/25. No RN coverage in the month of February on 2/1/25, 2/2/25, 2/8/,25, 2/9/25, 2/25/25, 2/26/25. No RN coverage in the month of March on 3/1/25. 3/2/25. 3/15/25, 3/16/25, 3/26, 253/27/25, 3/29/25, 3/30/25. During an interview on 7/23/25 at 1:35 P.M., the Administrator said she was aware of the regulation regarding RN coverage 8 hours a day, seven days a week, was aware of days and weekends when there was no RN in the building. She was now working on a plan to ensure there was RN coverage on the weekends, and through the week in the facility going forward.

Based on observation, interview and record review the facility failed to ensure that all services being provided met professional standards of quality of care for one resident (Resident #3) out of the 12 sampled residents. When CMT A failed to clarify medication parameters of when to hold digoxin (an antiarrhythmic medication) if the resident's heart rate dropped below a certain number (standards of quality of care recommend holding this medication for a pulse rate of 60 or below), and additionally failed to clarify with the charge nurse if a dose of digoxin should be administered or held while the resident had a heart rate of 54 (normal heart rate for adults is 60-100 beats per minute); placing the resident at risk for negative impact to their safety and well-being. The facility census was 23. Review of the facilities medication administration policy date 02/07/2013 showed:For administration of digitalis/digoxin and other medication that alter pulse rate: count the pulse for one minute before administration of medication. If the pulse rate is below 60 or above 100 notify the nurse. 1. Review of resident #3's care plan, dated 6/11/2025; showed:- The resident was admitted on [DATE].- Diagnosis of Congestive heart failure.-The use of long term (current) anticoagulants.- The resident has a cognitive deficit. - The resident will be free from complications of cardiac problems.- The care plan did not address parameters in monitoring of digoxin. Observation on 07/22/2025 at 8:48 A.M. showed CMT A was preparing digoxin medication for resident #3. CMT A checked the residents blood pressure, which resulted in 138/60 and heart rate which resulted in 54 beats per minute. CMT A failed to notify the nurse of the residents heart rate. CMT A prepared digoxin into a medication cup and prepared to provide the medication to the resident. During and interview on 07/22/2025 at 8:49 A.M. CMT A was asked by surveyor if he/she would do anything differently with administering the digoxin since the residents heart rate was low. CMT A said that there is not a parameter for this dose of digoxin, the resident gets a different dose tomorrow and there is a parameter on that order to not give the medication if the heart rate is below 60. Then CMT A said he/she would not notify the charge nurse, that the nurse would tell he/she to do what he/she thinks was best. During an interview on 07/22/2025 at 2:16 P.M. LPN (Licensed practical nurse) A said, that if a CMT needs to hold a medication the CMT would notify the nurse and the nurse will double check the order and the computer would also flag abnormal vital signs so the nurse could see it. During an interview on 07/23/2025 at 8:57 A.M. the DON (Director of Nursing) said she would expect CMT A to notify the charge nurse if a medication was held. During an interview on 07/23/2025 at 12:18 P.M., the Administrator said that a CMT is to notify the charge nurse if a medication needed to be held. The Administrator said that nurses are expected to question an order if parameters are not given on a medication that requires vital signs to be checked before administrating the medication.

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, did not ensure refrigerator and freezer temperatures were checked daily, did not ensure proper function of dishwasher by testing and logging it daily, did not use sanitizer solution on kitchen food preparation surfaces, staff did not practice sanitary hand washing skills, and did not ensure proper storage and labeling of foods. Additionally the facility failed to ensure food temperatures were logged and measured during meal service and cooking. The facility census was 33. Review of facility policy, handwashing, dated [DATE], showed: -If using gloves, remove gloves; -Roll down paper towels; -Turn on water and run until warm; -Wet hands and forearms with warm water; -Lather hands with antiseptic soap; -Wash hands, give particular attention to the areas between fingers, around cuticles, and under fingernails; -Wash forearms well; -Rinse thoroughly with warm water, beginning at the top of the forearm; -Wipe hands dry with clean paper towel; -Turn off water with paper towel and dispose of paper towel. Review of facility policy, glove use, dated [DATE], showed: -To ensure safe and proper food handling during food preparation and service. The food code states that food items should not be handled with bare hands. -Utensils or tongs should be used to serve or handle foods, both raw and cooked, whenever possible; -When serving, preference is not to use gloves unless only one task is being performed; -When preparing or handling food items such as meatloaf or raw chicken, gloves should be worn; -Hand washing per guidelines should occur between each task; -Gloves should be worn if handing food is necessary. Extra caution should be taken when multiple tasks are being completed; -Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. -Note: hands should be washed: -Before beginning each shift; -After breaks; -After using the restroom; -After smoking or eating; -After blowing nose; -After disposing of trash or food; -After handling dirty dishes; -After handling raw meat, poultry or eggs; -After picking up anything from the floor; -When changing tasks; -Any other time deemed necessary. 1.Review of facility policy, general dish room sanitation, dated [DATE], showed: -An associate working on the soiled end of the dish machine must wash their hands before working on the clean end of the dish machine. Observation of the kitchen during initial tour on [DATE] at 8:39 A.M. showed there was no paper towels at the handwashing sink. During an interview on [DATE] at 8:54 A.M., [NAME] A said: -He/She was out of paper towels right now. Observation of the kitchen during initial tour on [DATE] at 8:58 A.M. showed [NAME] A using a reusable cloth hand towel to dry his/her hands. During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -10:37 A.M., [NAME] A observed making puree in robot cook with gloves applied; -10:40 A.M., [NAME] A rinsed out robot coupe at dishwasher, and added container to dishwasher and ran cycle; -10:44 A.M., [NAME] A obtained robot coupe off dishwasher; -10:48 A.M., [NAME] A removed his/her gloves. He/She did not wash his/her hands. -10:48 A.M [NAME] A removed raw bags of chicken from two compartment sink and added to the trash container by hand washing sink. -10:49 A.M., [NAME] A washed his/her hands. He/She used bare hands that he/she had just washed to turn off faucet, then obtained paper towel to dry of his/her hands -10:50 A.M., Dietary Aide A washed his/her hands, turned off the faucet with his/her bare hands. He/She then obtained paper towel to dry of his/her hands. -10:51 A.M., Dietary Aide A observed applying gloves; -11:03 A.M., [NAME] A washed his/her hands, turned off faucet with his/her bare hands, then dried hands with paper towel. -11:09 A.M., [NAME] A removed dishes from clean side of dishwasher. He/She then loaded additional items into dishwasher. He/She did not wash hands prior to grabbing items from clean side of dishwasher. -11:28 A.M., [NAME] A applied gloves for meal service, he/she had not washed his/her hands. -11:47 A.M., [NAME] A observed cutting up chicken with knife from steam table, then separating the meat using his/her gloves; During an interview on [DATE] at 11:58 A.M., [NAME] A said: -He/She should turn faucet off with paper towel; -He/She did turn off faucet with bare hands when he/she washed his/her hands. During an interview on [DATE] at 12:09 P.M., the Dietary Aide A said: -He/She should wash hands every time he/she touched something different, his/her face, left the kitchen and re-entered the kitchen; -It was not sanitary to touch faucet handle with his/her bare hands; -He/She did touch faucet with bare hands when turning off the water; -He/She wore gloves when he/she made drinks and did dishes. During an interview on [DATE] at 1:03 P.M., the Administrator said: -He/She expected dietary staff to wash hands between anything clean and dirty; -He/She expected staff to glove when they were serving food, after they had touched anything they should remove gloves and wash his/her hands then re-glove; -It was unsanitary to turn faucet off with bare hands after staff had just washed his/her hands; -He/She expected paper towels to be available to staff in dietary department when drying their hands. 2. Review of facility policy, general dish room sanitation, dated [DATE], showed: -All items must be stored inverted, covered, or stacked with top of dish/tray inverted (unless stored in an enclosed cabinet). During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -10:52 A.M., Drink pitchers all stored upright on metal shelf along wall by entry, a three-tiered cart positioned by the steam table had dinner plates and bowls that were all stored in an upright position. During an interview on [DATE] at 11:58 A.M., [NAME] A said: -He/She was unsure how pitchers, bowls, and plates should be stored but thought all dishware should be stored upright. During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -Pitchers, plates, and bowls should be stored inverted; -The plates have always been stored upright since he/she had worked at facility; -He/She did not flip pitchers upside down because he/she placed their tops on them. During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected pitchers, plates, and bowls should be stored inverted. 3. Review of facility policy, cleaning schedules, dated [DATE], showed: -It was responsibility of dining services manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks. -Daily, weekly, and monthly cleaning schedules prepared by dining services manager with all cleaning tasks listed will be posted in dietary department. Review of facility policy, developing cleaning schedules, dated [DATE], showed: -Grill was to be cleaned daily if used; -Stove top to be cleaned daily; -Dishwashing area to be cleaned daily; -Stove was to be cleaned weekly; -Under shelves to be cleaned weekly -Oven was to be cleaned monthly 4. Review of facility policy, guidelines for cleaning gas stove, dated [DATE], showed: -Oven will be cleaned weekly; -Remove oven racks and place them on newspaper. Review of facility policy, guidelines for cleaning stove, dated [DATE], showed: -The stove top will be cleaned after use and the oven weekly. -Wipe off any loose food. Observation of the kitchen during initial tour on [DATE] at 8:43 A.M., showed: -The stove had dried on brown food rumbles on burners -Ledge of front of stove had grease and food crumbs; -The side of the stove had spilled drips of food down the side; -The handles of stove had grease and grime coating the handles and burner knobs. During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -11:01 A.M. showed the griddle on the oven stove top had food on it. Both side of range had food caked to it. There was drips of food running down side of oven. A stove rack was observed resting on the bare floor and leaning against the side of stove that had food crumbs spilled down side. 5. Review of facility policy, guidelines for cleaning microwave, dated [DATE], showed: -Wash out spills and splatters as they occur, using a detergent solution. -Sanitize with appropriate strength solution. Observation of the kitchen during initial tour on [DATE] at 9:01 A.M. showed the outside of microwave was covered in food debris with a sticky, grimy substance on handle and buttons. 6. Review of facility policy, cleaning floors, dated [DATE], showed: -Kitchen floor maintenance will be done after each meal. Spills need to be mopped up immediately. -Sweep the floor, pushing all debris forward, using a dustpan to remove debris. -mop one small area at a time, beginning at the rear of the room in a figure eight motion. Use a scraper to remove stubborn stains and debris on floor. Be sure to mop under and around equipment, along walls and in corners. -Rinse the area with clean warm water, use a clean mop head. -Wipe all splash and soil marks from baseboards and walls. Observation of the kitchen during initial tour on [DATE] at 9:03 A.M. showed the floors had not been swept or mopped. There was spilled brown pudding like chocolate substance on the floor. Food debris was noted under the stove and drink preparation area. During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -11:01 A.M. showed the area below the stove had not been swept or mopped. During an interview on [DATE] at 11:58 A.M., [NAME] A said: -Dietary manager did the deep cleaning of kitchen; -Dietary manager cleaned stove, oven, and griddle with a charcoal grip; -Appliances are deep cleaned every other week; -He/She tried to clean items as he/she went. During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -Sweeping and mopping of the kitchen floors was done at night; -Supervisor made him/her a cleaning map of who cleans what, he/she went through and did everything on the list except the stove; -He/She did not clean stove or oven because he/she did not want to mess anything up on it. During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected cleaning to be done every evening and clean as they go in dietary department; -Dietary department was supposed to have a monthly cleaning log; -Appliance should be moved, swept and mopped underneath 7. Review of facility policy, Refrigerator and Freezer Temperatures, dated [DATE], showed: -There should be a thermometer in all refrigerator and freezers. Thermometers should be located in the front of the unit. -Temperatures should be checked regularly in all refrigerators, at least every morning and every night. -Refrigerator and freezer temperatures will be logged twice daily. Observation of the kitchen during initial tour on [DATE] at 8:39 A.M. showed. -The refrigerator and freezer temperature log that was hanging above the handwashing sink had no entries on ,d+[DATE] and ,d+[DATE]. During an interview on [DATE] at 9:21 A.M., [NAME] A said: -The Dietary Aides were responsible for logging the temperatures of the refrigerators and freezers; During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -11:02 A.M. Observations of the cooler, refrigerator, and freezer temperature log was now completely filled out with no blanks on log. Previously the log was not filled out completely. During an interview on [DATE] at 11:11 A.M., [NAME] A said: -He/She had caught up on the logs when asked about the previous empty spaces on the logs; -He/She said Dietary Aide A filled in the log on temperature reading; -He/She did not know how staff remembered previous readings if they did not record them right away. During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected staff to check the freezer and refrigerator temperatures every shift; -He/She expected there to be no blanks on the temperature recording log. 8. Review of facility policy, Dishwashing temperatures, dated [DATE], showed: -Chemical sanitizer machine. Range to be effective ,d+[DATE] degrees F. -The dishwasher machine temperatures will be recorded for the wash and rinse cycle daily for chemical sanitized (in addition to a sanitizer test strip), or each meal for high temperature sanitized or as directed by the consultant dietician. Review of facility policy, dish machine sanitation, dated [DATE], showed: -Check the machine for the next operation; -After breakfast and lunch, refill machine and turn heaters on for the next meal; Facility did not provide a policy on dishwasher de-liming. Observation of the kitchen during initial tour on [DATE] at 8:41 A.M. showed: -The dish machine temperature log had no entries on ,d+[DATE], ,d+[DATE] and ,d+[DATE] for breakfast, lunch and dinner. During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -10:42 A.M., The dishwasher was observed with crumbs of brown substance all over the top of it, it was not clean. -11:02 A.M. observation of dish machine temperature log showed there was no blank entries. -11:11 A.M., [NAME] A ran test strip of dishwasher which showed 100 PPM. During an interview on [DATE] at 11:14 A.M. with Dietary Aide A said: -He/She did dishwasher sanitizer readings; -He/She completed the log after he/she is almost done with dishes; -He/She said that he/she checked the temperature of dishwasher before he/she washed dishes; During an interview on [DATE] at 11:58 A.M., [NAME] A said: -He/She did not know when dishwasher de-liming was performed. During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -There is someone that comes into facility one time a month to delime dishwasher and check to ensure functioning properly. -His/Her supervisor told him/her to filled in the blank spaces on the dish machine log; During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She did not know expectation of de-liming of dishwasher; -He/She would not expect the dishwasher to have brown substance covering the top of the dishwasher. 8. Review of facility policy, Food Temperatures, dated [DATE], showed: -The DSM or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled. -Keep the temperature of hot foods no less than 140 degrees F during meal services. -To ensure adequate temperatures, proper-holding techniques should be used. -Food is not placed in the steam table more than 30 minutes before meal service. Observation of the kitchen during initial tour on [DATE] at 8:47 A.M. of the food temperature logs from [DATE]-[DATE] that were on a clipboard on kitchen counter next to stove, showed: -There was no log that had been started for breakfast that had already been served on ,d+[DATE]; -There was no food temperatures recorded for supper on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] -There was only one entry for lunch on ,d+[DATE]; During an interview on [DATE] at 9:21 A.M., [NAME] A said: -He/She did not temperature check breakfast that morning due to breakfast being late; -The cook was responsible for documenting cooking temperatures; During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed no cooking or holding temperature logs had been taken at supper on ,d+[DATE] and ,d+[DATE] meals; During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -10:38 A.M., Food observed already covered on steam table included cut up potatoes, au gratin potatoes, parmesan chicken breast, and peas; -10:41 A.M., [NAME] A removed a bag of cooked hot dogs in boiling water from stove top, empties hot dogs into a metal container and poured hot water from boiling container into metal container with hot dogs; -10:43 A.M., [NAME] A added hot dogs added to steam table, no cooking temperatures were taken of hot dogs; -10:48 A.M., [NAME] A obtained au gratin potatoes from robot coupe and added to steam table; -10:51 A.M. Dinner rolls were added to steam table; -10:59 A.M., [NAME] A had not temperature checked any food items since entry into the kitchen at 10:36 A.M.; -11:16 A.M. No food temperatures had been observed since entering kitchen at 10:36 A.M.,, observation on clip board for temperature log showed cooking temperatures and holding temperatures had already been recorded for lunch. The meat temperature was recorded at 200 degrees F with a holding was 197, the starch was recorded at cooking temperature of 214 F and a holding was 212 degrees F, and the vegetable cooking temperature was recorded at 210 degrees F with a holding was 205 degrees F. -11:30 A.M., [NAME] A served up first lunch plate, no food temperatures taken from items that were on steam table. During an interview on [DATE] at 11:58 A.M., [NAME] A said: -He/She should temperature check foods when he/she pulled items out of the oven to obtain cooking temperature and right before he/she served food; -He/She did not temperature check foods prior to serving on [DATE]; During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -Food temperatures are done before food was served; -Food is temperature checked right after it came out of oven or stove top and right before it went on steam table; -Cook A did not temperature check food on steam table today. During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected staff to temperature check foods prior to placing foods on steam table and prior to serving foods. 9. Facility did not provide a policy on sanitizer solution. Observation of the kitchen during initial tour on [DATE] at 8:47 A.M. showed there was no sanitizer solution out in kitchen. Observation of the kitchen during initial tour on [DATE] at 9:09 A.M. showed there was hot soapy water in two compartments sink and dish soap sitting out by the faucet. Observation of the kitchen during initial tour on [DATE] at 9:21 A.M. showed washcloth sitting out on counter. During an interview on [DATE] at 9:21 A.M., [NAME] A said: -He/She used hot water with soap to wipe off surfaces in the kitchen; -He/She did not use sanitizer on kitchen surfaces; -He/She used sanitizer water out in the dining room to sanitize tables; During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -10:37 A.M., empty bags of raw chicken and raw pieces of chicken were observed in the 2 compartment sink where dish soap was previously observed and used to sanitize kitchen surfaces; -10:40 A.M., There was two red sanitizer buckets out and filled with water on counter tops in kitchen. One located by two compartment sink and a second located by drink preparation counter. -10:48 A.M [NAME] A removed raw bags of chicken from two compartment sink and added to the trash container by hand washing sink. -10:51 A.M., a washcloth was laying on surface of steam table, not in sanitizer water; -10:54 A.M., [NAME] A removed his/her gloves and placed in trash can, he/she then grabbed sanitizer water and washcloth out of bucket and started wiping off surfaces by robot coupe; -10:55 A.M., [NAME] A put a test strip in sanitizer bucket which showed it was white showing no parts per million (PPM) of solution) -10:56 A.M., [NAME] A dumped out sanitizer solution bucket and refilled bucket with solution from hose on wall by dishwasher; -10:57 A.M., [NAME] A dipped a second test strip into refilled bucket which showed it was white, revealing the solution tested 0 PPM. The bucket of sanitizer solution was observed to have suds in it. -10:58 A.M., [NAME] A used a washcloth dipped in the second refilled sanitizer solution bucket to wipe off the kitchen preparation surfaces table located behind the steam table. -10:58 A.M. raw pieces of chicken remain laying in drain of two compartment sink. During an interview on [DATE] at 10:55 A.M., [NAME] A said: -He/She did not test sanitizer buckets solution; -He/She normally did not test the sanitizer solution buckets; -He/She just placed sanitizer solution in the bucket directly from the solution on wall by dishwasher; During an interview on [DATE] at 11:58 A.M., [NAME] A said: -He/She had never set up sanitation buckets since he/she started working in kitchen; -He/She usually put water in the sink, added soap, and plugged up the drain; -Washcloths should be stored in the water when they were not in use During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -He/She sanitized surfaces in kitchen with sanitizer in red bucket and use of a washcloth; -Sanitizer buckets are set up depending on who is working; -Day shift normally sat out sanitizer solution; -He/She did not test sanitizer buckets for proper PPM During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected kitchen surfaces to be sanitized using sanitizing solution and a washcloth; -Washcloths should be stored in sanitizing solution; -He/She expected staff to test sanitizer solution for proper parts per million; -He/She did not expect staff to document sanitizer solution test strips. 10. Facility did not provide a policy on trash cans. Observation of the kitchen during initial tour on [DATE] at 8:39 A.M. showed: -the trash can lid by hand washing sink was in the up position and did not close. During a continuous observation of the kitchen on [DATE] from 10:36 A.M.-12:09 P.M., showed: -11:35 A.M. Trash can in dishwasher area had no lid on it; During an interview on [DATE] at 11:58 A.M., [NAME] A said: -Trash cans in the kitchen should have lids on them; During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -The trash cans in the kitchen should have lids on them. During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected trash cans in the kitchen to be covered. 11. Facility did not provide a policy on dating and labeling of foods. Observation of the kitchen during initial tour on [DATE] at 9:05 A.M., showed -In the Refrigerator in the kitchen: -Outdated meat sauce showed dated ,d+[DATE], throw out date of ,d+[DATE]; -In the kitchen: -Opened and undated package of hamburger buns; -Opened and undated whole wheat loaf of bread; -Opened and dated [DATE] package of potato chips; -On the spice shelf: -Opened and outdated [DATE] 16oz whole celery seed; -Opened and outdated [DATE] 6oz rosemary leaves; -Opened and undated 22 oz original chili container almost gone; -Opened and unsealed package of 64 oz sugar with no opened date and a received [DATE]; -Opened and unsealed package of 32 oz flour, dated [DATE]; -Opened with no open date, 64 oz Mediterranean style oregano leaves dated received [DATE]; -Walk in cooler showed: -Opened Hawaiian punch dated [DATE]; During an interview on [DATE] at 11:58 A.M., [NAME] A said: -He/She did not know how long spices could be maintained before expiring; -He/She dated food when it was made and then labeled it with a 3 day life span; -If he/she made something on [DATE] then he/she would mark it as expired 3 days later; -Dietary manager labeled food when it was received and then he/she was responsible for labeling food with the date that it was opened. During an interview on [DATE] at 12:09 P.M., Dietary Aide A said food should be labeled and dated as soon as it was opened and when stored for leftovers. During an interview on [DATE] at 1:03 P.M., Administrator said: -He/She expected food to be dated when it was received and when it was opened; -He/She expected spices to be thrown out after one year of opened date. 12. During an interview on [DATE] at 8:38 A.M. [NAME] A said: -He/She had worked in kitchen for almost a year; -Meals were served at 7:00 A.M., 11:30 A.M., and 5:00 P.M.; -He/She started serving to north dining room then transitioned to south dining room; -He/She usually worked evening meals; -He/She was working double shifts while the dietary manager was on vacation; During an interview on [DATE] at 11:58 A.M., [NAME] A said he/she had not had any training or in-services from the dietary manage. During an interview on [DATE] at 12:09 P.M., Dietary Aide A said: -He/She had been worked in the kitchen since September. -He/She had one day of training in kitchen; -He/She had to ask supervisor to train him/her on more stuff; -He/She worked full time in the kitchen;

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. This deficiency had the potential to affect all residents. The facility census was 33. The facility did not provide a policy regarding RN coverage. Review of the facility staffing and time sheets showed no RN in the facility within a 24 hour time period on: -July: 20th and 21st. -August: 3rd and 4th. During an interview on 08/14/24 at 11:30 A.M. the Administrator said: -The facility had a waiver for RN coverage so she did not worry about not having a RN in the facility on those days. -There facility used two staffing agencies that provided RN coverage at times. -There was an add on-line for a RN. -There was a RN on call 24 hours a day, 7 days a week, either the Director of Nursing or a Corporate Nurse. -There is no care that requires a RN. -The facility did admit residents on Medicare services. -She filed for a waiver for RN coverage on June 24, 2024 and has not received approval from CMS to waive RN coverage.

Based on record review and interview, the facility failed to provide competency assessments in accordance with their facility assessment, when they failed to ensure 7 of 7 randomly selected nurse aides, had competency assessments at hire and every 6 months thereafter. This potentially effected all residents. The facility census was 33. The facility did not provide a policy for competency and education. Review of the Facility assessment dated [DATE] showed: -Competencies will be tested every 6 months and those indicated by star will be tested at hire, for nursing staff. -Person Centered Care -Activities of Daily Living* -Disaster Procedures* -Infection Control* -Medication Administration* -Wound Care* -Measurements* -Resident assessments and observations -Caring for residents with all forms of dementia* -Specialized care-such as catheter insertion (a tube inserted into the bladder to drain urine), colostomy care (an artificial opening in the stomach to drain feces), etc. -Caring for residents with mental and psychological disorders- (including Trauma and Post Traumatic Stress Disorder (PTSD: a mental health condition that's caused by an extremely stressful or terrifying event )- implementing nonpharmacological (non medication) interventions* Review of employee files and education records showed: -Certified Nurse Aide (CNA) F - Date of hire 10/21/2014 -No competency completed for 2024 -CNA G -Date of hire 5/7/22 -No competency completed for 2024 -CNA E -Date of hire 7/17/23 -No competency completed for 2024 -CNA D -Date of hire 12/27/23 -No competency completed for 2024 -Nurse Aide A -Date of hire 7/6/23. -No competency completed for 2024 -Nurse Aide B -Date of hire 3/14/24 -No competency at time of hire -No competency for 2024 -Nurse Aide C -Date of hire 7/16/24 -No competency at the time of hire During an interview on 8/14/24 at 3:19 P.M. with the Director of Nursing (DON) and Administrator: The DON said: -Competency assessments were to be completed annually or more often as needed. -If there is a concern with care, a competency would be completed, such as a rise in urinary tract infections . -She was not aware the Facility Assessment showed competency was to be done every 6 months. The Administrator said: -Most education is based on findings from the quarterly Quality Assurance meeting. -Competency should be completed annually and as needed. -She did not know the Facility Assessment showed competency was to be done every 6 months and at the time of hire.

Based on interview and record review, the facility failed to ensure two nurse aides (NA) completed a nurse aide training program within four months of his/her employment in the facility. The census was 33. The facility did not provide a policy on education and Certified Nurse Aide training. Review of the Facility Assessment, completed by facility staff, dated 6/27/24 showed: -Nursing staff must have a license/certification current and verifiable with the State of Missouri. NA's will be hired with the certainty they will be in a Certified Nursing Assistant class within 120 days. Review of employee files showed the following: -Nurse Aide (NA) A date of hire 7/6/2023 -no competency evaluation -Certification issued 5/24/2024 -NA B date of hire 3/14/2024 -no competency evaluation -no certification issued Review of the Missouri CNA Registry on 8/14/24 showed: -NA A certification was issued 5/24/24 -NA B was not found During an interview on 8/14/24 at 11:30 A.M. the Administrator said: - There were two NA's working in the facility and one that was certified in the last 90 days. -The 2 NA's are in Certified Nurse Aide training on line. -She is unsure if the Director of Nursing provides a competency evaluation before NA's have contact with residents. -NA A and B did not finish classes in the 4 month time frame because of missed classes. -She was aware the staff did not finish in the allotted time. -Staff should understand that missing class would mean they cannot work. -She is unsure why the staff were still employed after 4 months.

Based on observation, record review, and interview, the facility failed to ensure staff obtained and followed complete and accurate physician orders for the administration of continuous positive airway pressure (CPAP: a type of ventilator that uses mild air pressure to keep breathing airways open while you sleep) for one resident . Additionally, the facility failed to label, date and clean the CPAP machines for 2 residents (Resident #30 and Resident #28) and failed to label and date open containers of distilled water for use in the CPAP machines for one resident (Resident #28) out of 12 sampled residents. The facility census was 33. Review of the undated facility provided policy on Oxygen Equipment Cleaning Guidelines showed: -Oxygen equipment will be cleaned to ensure safety in handling and administering oxygen. -Connectors must be cleaned after each resident use. Review of the undated facility provided policy CPAP Administration showed: -Check the physician orders for pressure setting and method of administration; -Fill the humidifier with distilled water to appropriate level; -Tubing should be cleaned weekly, the mask and nasal pillows connection wiped daily, clean the water holding tank with a damp cloth and mild soap weekly. For disinfecting the holding tank, use vinegar and water , let set for 30 minutes, rinse thoroughly and air dry. Review of the ResMed Manufacturer's guidelines for cleaning CPAP machines showed: -Clean the mask every day, or after each use. 1. Disassemble the mask components. 2. Thoroughly hand-wash the separated mask components by gently rubbing in warm water with mild detergent. 3. Rinse all the components well. 4. Allow to air dry out of direct sunlight and/or heat. -Clean the device weekly as described. 1. Wash the water tub and air tubing in warm water using only mild detergent. 2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. 3. Wipe the exterior of the device with a dry cloth. 1. Review of Resident #30 Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff ) dated 7/30/24 showed: -Brief Interview of mental status (BIMS) of 15, indicated no cognitive loss; -Set up assistance of staff for Activities of Daily Living (ADLs: activities done in a day to care for oneself); -Diagnoses of : Chronic Obstructive Pulmonary Disease (COPD: A lung disease that causes breathing problems and restricted airflow.)Obstructive Sleep Apnea (Intermittent airflow blockage during sleep caused by partial or complete collapse of the airway) Chronic Atrial Fibrillation (Afib: a heart condition that causes rapid, irregular heart beats) Post Traumatic Stress Disorder (PTSD:A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.) Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety (a feeling of dread, fear, or uneasiness) Review of the Resident's Care Plan showed no care plan for the use of the CPAP machine. Review of the Resident's physician orders for August 2024 showed: -No order for the use of the CPAP machine. -No orders for cleaning/changing tubing/masks. Observation on 08/12/24 at 9:52 A.M. showed: -Resident lying in bed. -Large gift bag sitting on the floor at beside. -CPAP mask was in the large gift bag lying on top of a purse. -Condensation in the tubing to the mask. Observation on 08/13/24 at 8:44 AM showed: -He/She had complaints of difficulty breathing. -His/Her CPAP was lying on top of a purse, in a large shopping bag at bedside. During an interview on 8/13/24 at 8:46 A.M. the resident said: -He/She puts the mask on at night . - Staff had cleaned the machine and tubing before, but not daily. 2. Review of Resident #28 Quarterly MDS, dated [DATE]., showed: -BIMS of 15, indicated no cognitive loss. -Partial to maximum assistance of staff for ADLs. -Diagnoses of: Combined Congestive Heart Failure (the heart muscle weakens and enlarges, making it difficult for the heart to pump enough blood), Atrail Fibrillation, Depression, Hypertension (high blood pressure) and morbid Obesity (A disorder that involves having too much body fat, which increases the risk of health problems.) Obstructive Sleep Apnea. Review of the Resident's Comprehensive Care Plan dated 5/31/24 showed: -Use of CPAP at night; the resident frequently refused staff to assist with placement. Review of the Resident's August physician orders showed: -CPAP with 2 liters of O2 on at bedtime and off in AM every shift. Order date of 5/25/24 -No orders for cleaning or changing tubing/masks Observation on 8/12/24 at 9:32 A.M. showed: -The CPAP machine was sitting on the nightstand, the mask was laying on the overbed table, condensation in the mask tubing. -The tubing was not dated. -The humidifier was not dated. -Three partial gallons of distilled water sitting on floor , open and undated. Observation and interview on 8/13/24 at 9:22 A.M. showed: -The CPAP machine was sitting on the nightstand, the mask was laying on the overbed table, condensation in the mask tubing. -The tubing was not dated. -The humidifier was not dated. -Three partial gallons of distilled water sitting on the floor, open and undated. -The resident said -Staff assisted him/her to put the CPAP on when he/she wanted it on. -The gallons of distilled water were for his/her CPAP machine. -He/She was not sure when the gallons of water had been opened. -He/She was not sure when the machine is cleaned. -The mask and tubing were maybe changed once a month. During an interview on 8/19/24 at 10:30 A.M. Licensed Practical Nurse A said: -The residents take the CPAP masks off themselves, and he/she checks them at morning rounds. -He/She did not clean the masks daily. -He/She was not aware the masks needed to be cleaned daily. -Tubing and masks are changed monthly . During an interview on 8/14/24 at 3:19 P.M. the Director of Nursing said: -There should be a physician order for use of CPAP machine. -CPAP cleaning should be done by manufacturers guidelines or weekly. -Distilled water should be dated when opened and was only usable for 30 days once opened. -The Charge Nurse is responsible for cleaning and care of the CPAP machines.

Based on observation, interviews and record review the facility failed to provide meaningful activities for five of 12 sampled residents (Resident #17, #21, #2, #13, #20). The facility census was 33. Review of the undated activity policy said: - Activities services will plan, organize and carry out a program of activities to meet the individual needs of the residents; - The Activities Director (AD) plans and organizes individual activities and group activities; - A calendar of events will be posted on the activity bulletin board; - All staff are responsible to assist residents to the activity - The AD will develop an activity calendar to include a wide variety of activities to include spiritual, physical, emotional, cognitive, sensory, recreational, and work service related activities; - Activities will be planned for men and women and large and small groups. 1. Review of Resident #17's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 6/7/24 showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment; - He/She required stand by assistance to get dressed and shower; - Diagnoses included: Bipolar with psychotic features, vascular dementia (impairment of reason and memory sustained after a stroke), and Diabetes Mellitus Type II ( a disorder in which the body does not process blood sugar properly). Review of the resident's activity care plan dated 3/14/19 showed: - The resident enjoyed watching television in his/her room with his/her parent; - The staff were supposed to encourage him/her to attend activities which improve self esteem; - Allow the resident to voice his/her feelings and fears. During an interview on 8/12/24 at 8:47 A.M. the resident said: - He/She did not participate in activities because nothing interests him/her that is offered; - If they did different activities he/she would participate more; - The staff do not invite him/her to activities; - He/She would like to be invited to activities; - He/She did not know what activities there were to choose from; - It made him/her feel bad no being invited to participate in activities. Observation on 8/13/24 at 11:00 A.M. showed - No activity calendar in the common area or in the resident's room. Observation and interview on 8/14/24 at 10:00 A.M. showed: - The Activity Director (AD) setting up Bingo in the dining room; - The resident was not in the dining room; - At 10:01 the AD starts Bingo; - At 10:07 the resident was observed lying in his/her bed watching television; - At 10:10 A.M. the resident said he/she was not told Bingo was in the dining room, the resident got out of bed and walked to the dining room to attend the activity; - At 10:20 A.M. The activity concluded and residents left the dining room; - The resident returned to his/her bed; - The resident said he/she was sad he/she missed most of Bingo. During an interview on 8/14/24 at 10:10 A.M. Certified Medication Technician (CMT) A said: - The AD usually assisted the resident to the activities; - If the AD needed assistance with a resident, he/she told the staff and they helped get residents to the activity. 2. Review of Resident #21's quarterly MDS dated [DATE] showed: - BIMS score of 8, indicating moderate cognitive impairment; - He/She required assistance with transfers, bathing, toilet care, and getting dressed; - Diagnoses included: Bipolar disorder, weakness and psychosis. Review of the activity care plan dated 4/30/24 showed: - The resident was able to be involved in recreational and social activities that interest him/her; - He/She rarely participated in activities; - The staff were supposed to encourage the resident to participate in activities; - The staff were supposed to inform the resident of upcoming activities. During an interview on 8/12/24 at 9:14 A.M. the resident said: - He/She enjoyed playing Bingo; - He/She would like to participate in other activities; - He/She would like to have more music activities. 47195 3. Review of Resident #2's Quarterly MDS., dated 5/13/24, showed: -He/She had moderate cognitive impairment; -He/She had clear speech and was able to make-self understood and understand others; -He/She was dependent on a wheelchair and walker for mobility; -He/She needed partial to moderate assistance with toileting, personal hygiene, rolling left and right and sit to lying; -He/She needed substantial/maximal assistance with moving from lying to sitting on side of bed; -Diagnoses included: Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body controlled by the nerves), high blood pressure, chronic pain, tendency to fall, reduced mobility, need for assistance with personal care, history of falling, generalized muscle weakness, unsteadiness on feet, and cognitive communication deficit (a condition affecting a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident #2's Annual MDS, dated [DATE], showed: -It was very important to choose what clothes to wear, have snacks, take care of personal belongings, choose bedtime, have family or close friend involved in discussions about care, -Activity preferences included have books, newspapers, magazines to read, listen to music, be around animals as pets, keep up with the news, do things with groups of people, do favorite activities, go outside and get fresh air, participate in religious services. Review of care plan, dated 7/5/24, showed: -His/Her care plan did not address resident's activity preferences. Review of the residents electronic medical record showed: -He/She had no activity notes documented in progress notes. During an interview on 8/12/24 at 10:38 A.M. Resident #2 said: -He/She enjoyed playing bingo and jeopardy; -He/She did not think the facility had enough activities to interest him/her; -He/She would like to see the facility offer book reviews; -He/She did not have any activity calendar available in his/her room. Observation on 8/12/24 at 10:38 A.M. showed no activity calendar available in resident's room. Review of the facility activity calendar showed: -8/12/24 at 10:00 A.M. bingo was scheduled; -8/12/24 at 2:00 P.M. spay day was scheduled; -8/13/24 at 10:00 A.M. exercise was scheduled; -8/13/24 at 2:00 P.M. manicures were scheduled; -8/14/24 at 10:00 A.M. bingo was scheduled. Observation on 8/12/24 at 10:00 A.M. showed no activities offered. Observation on 8/12/24 at 2:00 P.M. showed no activities offered. Observation on 8/13/24 at 2:00 P.M. showed no activities offered. Observation on 8/14/24 at 9:49 A.M., showed: -Activity Director reminded resident of upcoming activity of bingo at 10:00 A.M.; -Resident observed wheeling out of his/her room to go towards end of hall to participate in Bingo activity. Observation on 8/14/24 at 10:03 A.M. showed resident engaged in activity of bingo in south dining room. 4. Review of Resident #13's Quarterly MDS, dated [DATE], showed: -His/Her cognition was intact; -He/She had clear speech; -He/She was able to make self-understood and understand others; -He/She was dependent on a wheelchair for mobility; -He/She required substantial assistance with moving from lying to sitting, toileting, and bathing; -He/She required partial/moderate assistance with personal hygiene, rolling left and right, sit to stand transfers, chair to bed transfers; -Diagnoses included: Muscle weakness, anxiety, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), polyneuropathy (a decreased ability to move and feel sensation because of nerve damage), low back pain, and edema (a condition when tiny blood vessels in the body leak fluid). Review of Resident #13's Annual MDS, dated [DATE], showed: -He/She found it very important to go outside to get fresh air when weather was good, important to do his/her favorite activities, keep up with the news, and to listen to music he/she liked; -Care area's triggered included activities. Review of care plan, dated 11/12/24 showed: -He/She had potential for social isolation due to lack of interest; -Allow him/her the opportunity to voice his/her feeling & fears; -Encourage him/her to attend activities which improve self esteem; -Introduce him/her to other residents; -Staff to make contact on the 1st & 2nd shift daily; -To the extent possible, offer his/her favorite activities. During an interview on 8/13/24 at 1:11 P.M., Resident said: -He/She felt activities were never geared towards men; -All activity groups were more women's groups; -He/She was made aware of activities by looking at white board in hallway; -He/She did not have access to an activity schedule in his/her room. Review of facility activity calendar showed: -8/12/24 at 10:00 A.M. bingo was scheduled; -8/12/24 at 2:00 P.M. spay day was scheduled; -8/13/24 at 10:00 A.M. exercise was scheduled; -8/13/24 at 2:00 P.M. manicures were scheduled; -8/14/24 at 10:00 A.M. bingo was scheduled. Observation on 8/12/24 at 10:00 A.M. showed no activities offered. Observation on 8/12/24 at 2:00 P.M. showed no activities offered. Observation on 8/13/24 at 2:00 P.M. showed no activities offered. Observation on 8/14/24 at 9:49 A.M. showed Activity Director going to resident room to invite to bingo. Observation on 8/14/24 at 10:01 A.M. showed resident was in dining room but did not participate in bingo. 5. Review of Resident #20's quarterly MDS, dated [DATE], showed: -He/She had moderate cognitive impairment; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair for mobility; -He/She required set up or clean up assistance with eating, personal hygiene, and bathing; -Diagnoses included: Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), depression, asthma, cellulitis of right lower limb (a skin infection caused by bacteria), pain, polyneuropathy, generalized muscle weakness, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of Resident #20's Annual MDS, dated [DATE], showed: -It was very important to him/her to have books, newspapers, and magazines to read, listen to music he/she liked, keep up with the news, to do things with groups of people, to participate in his/her favorite activities, and to go outside to get fresh air when weather was good. -Care area's triggered included activities. Review of care plan, dated 6/28/24, showed: -He/She had no activity preferences care planned. Review of facility activity calendar showed: -8/12/24 at 10:00 A.M. bingo was scheduled; -8/12/24 at 2:00 P.M. spay day was scheduled; -8/13/24 at 10:00 A.M. exercise was scheduled; -8/13/24 at 2:00 P.M. manicures were scheduled; -8/14/24 at 10:00 A.M. bingo was scheduled. Observation on 8/12/24 at 10:00 A.M. showed no activities offered; Observation on 8/12/24 at 2:00 P.M. showed no activities offered; Observation on 8/14/24 at 9:49 A.M. showed Activity Director going to resident room to invite to bingo. Observation on 8/14/24 at 10:01 A.M. showed resident participated in bingo. During an interview on 8/14/24 at 12:23 P.M., Resident said: -The facility did not have much for activities to do here; -There was not enough staff to help offer resident individual activities; -There was not enough activities that met his/her interest levels; -He/She liked to have outside activities; -He/She liked to play baseball and kickball; -Activity Director sometimes came around and invited him/her to activities; 6. During an interview on 8/13/24 at 1:13 P.M., Activity Director said: -He/She completed activity assessments with residents upon admission and annually; -He/She did not track activities that he/she did with each resident; -He/She did offer one on one activities like coloring, playing card games like UNO or phase 10; -He/She did not offer specific activities geared towards men but all activities except manicures were inclusive to men; -He/She offered bingo, exercise, and sweet treats; -He/She offered one on one activities by putting a music cd on in those resident's rooms; -Activity calendar was posted on bulletin boards on each hall for residents to see; -He/She did not have a way for resident's who were in their rooms or bed bound to see activities offered each day; During an interview on 8/14/24 at 8:14 A.M., Certified Nurse Aide (CNA) C said: -Activity Director takes residents to south hall for activities; -He/She was aware of activities of bingo and exercise occurring regularly; -Activity director offered activities 90% of time as scheduled. During an interview on 8/14/24 at 9:30 A.M., CNA B said: -Facility offered ice cream days, popcorn, movies, fingernail painting, and fake tattoos; -Facility offered a lot of bingo; -Residents are aware of activities by the activity calendar in hallway or activity director goes through halls to remind residents. During an interview on 8/14/24 at 10:29 A.M. the Director of Nursing (DON) said: - She would expect more activities to be completed than currently occur; - The AD had several other tasks assigned to him/her and was not able to complete more activities; - She would expect the large activity calendars on the wall to be up to date; - She would expect an activity calendar to be provided to each resident; - She expected all staff to help resident to activities; - She would expect all residents to be invited to activities.

Based on observations, interview, and record review, the facility failed to ensure staff developed and updated care plans consistent with resident's specific conditions and needs which affected one of 12 sampled residents (Resident #2). Additionally, the facility failed to conduct quarterly care plan meetings to discuss the residents plan of care. This deficient practice affected two of 12 sampled residents, (Resident #13 and #17). The facility census was 33. Review of the facility policy, MDS and Care Planning guidelines, dated September 2013, showed: -It was the policy of facility to use the most current guidelines for Centers for Medicare and Medicaid services (CMS) regarding the Minimum Data Set (MDS) Resident assessment Instrument manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, CAAs, and resident care planning. 1. Review of Resident #2's Quarterly minimum data set (MDS), A federally mandated assessment tool completed by facility staff, dated 5/13/24, showed: -He/She had moderate cognitive impairment; -He/She had clear speech and was able to make-self understood and understand others; -He/She was dependent on a wheelchair and walker for mobility: -He/She required set up or clean up assistance with eating; -He/She was on a mechanically altered diet; -Diagnoses included: Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body controlled by the nerves), high blood pressure, chronic pain, tendency to fall, reduced mobility, need for assistance with personal care, history of falling, generalized muscle weakness, and unsteadiness on feet. Review of the resident's care plan, dated 5/14/24, showed: -He/She required special utensils at meals related to Parkinson's and was a potential for weight loss; -He/She was to use built up silverware with meals; -Care plan did not reflect discontinued use of weighted utensils. Review of physician's orders dated 7/1/24 to 8/31/24, showed: -He/She was on a regular diet; -He/She had no orders for weighted utensils. Review of discontinued physician's orders showed: -On 2/27/23, he/she had an order to start regular diet with built up silverware; -On 8/7/23, he/she had orders for built up silverware to be discontinued. Review of occupational therapy notes showed: -On 6/21/24, He/She was independent with eating with no assistance from helper. Observation at lunch on 8/12/24 at 1:35 P.M. showed resident was using plastic silverware and did not have weighted utensils. Observation at breakfast on 8/14/24 at 8:02 A.M. showed resident was using regular silverware and did not use weighted utensils. During an interview on 8/14/24 at 8:04 A.M., Resident said he/she did not use weighted utensils anymore. During an interview on 8/14/24 at 8:12 A.M., CNA C said: -He/She did not think resident used weighted utensils anymore; -Resident use to have weighted utensils with his/her meals. During an interview on 8/14/24 at 8:50 A.M., Licensed Practical Nurse (LPN) A said: -Resident used to use weighted silverware; -He/She was not sure if resident still had orders for weighted utensils; -He/She knew occupational therapy had originally wrote resident's orders for weighted utensils. During an interview on 8/14/24 at 1:03 P.M., the Administrator said: -He/She expected that the resident's care plan would be updated when a resident's occupational therapy orders for weighted spoon was discontinued. -He/She expected resident's care plans to be updated with changes, after an incident occurred, and quarterly. During an interview on 8/14/24 at 1:21 P.M., Director of Nursing (DON) said: -He/She expected a resident's care plan to be updated when his/her weighted spoon orders were discontinued; -Care plans should be updated quarterly and as needed with any resident or order changes; -He/She was not aware that he/she was responsible for updating care plans when he/she was hired. 2. Review of Resident #13's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 8/4/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - He/She required substantial assistance to get dressed, use the toilet and to bathe; - Diagnoses included: Bipolar disorder (mood swings that range from depression to very happy), Atrial Fibrillation ( a disorder in which the heart does not beat correctly), epilepsy (seizure disorder), and Chronic Obstructive Pulmonary Disease (COPD). Review of there resident's care plan showed: - 6/13/24 the resident received anti psychotic medications (medications to treat bipolar disorder); - 11/1/17 the resident had a guardian and the guardian will be encouraged to attend all care plan meetings; - 11/1/17 encourage the resident to participate in activities. During an interview on 8/12/24 at 9:50 A.M. the resident said: - He/She had never been invited to a care plan meeting; - He/She would like to know what was going on for his/her plan of care; - He/She would like to be invited and participate in his/her plan of care. 3. Review of Resident #17's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 3, indicating severe cognitive impairment; - He/She required stand by assistance to get dressed and shower; - Diagnoses included: Bipolar with psychotic features, vascular dementia (impairment of reason and memory sustained after a stroke), and Diabetes Mellitus Type II ( a disorder in which the body does not process blood sugar properly). Review of the resident's care plan showed: - 6/13/24 the resident receives medication to treat his/her bipolar disorder; - 12/16/19 the resident had a guardian and invite the guardian to care plan meetings and involve them with the plan of care changes. During an interview on 8/12/24 at 8:51 A.M. the resident said: - He/She did not know what a care plan was; - He/She would like to be a part of his/her care planning and would like to be invited to his/her care plan meeting. 4. During an interview on 8/13/24 at 9:18 A.M. the DON said: - He/She was in charge of writing the resident's care plans; - He/She was in charge of coordinating care plan meetings; - He/She was aware that each resident should have a care plan meeting quarterly; - He/She was employed at the facility in April of 2023 and had not held a care plan meeting since his/her time of hire.

Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of the 12 sampled residents (Residents #2, #20 #30,). The census was 33. The facility did not provide a policy on Care Plans. 1. Review of Resident #30's Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff ) dated 7/30/24 showed: -Brief Interview of mental status (BIMS) of 15, indicated no cognitive loss -Set up assistance of staff for Activities of Daily Living (ADLs: activities done in a day to care for oneself) -Diagnoses of : Chronic Obstructive Pulmonary Disease (COPD: A lung disease that causes breathing problems and restricted airflow.) Chronic Atrial Fibrillation (Afib: a heart condition that causes rapid, irregular heart beats) Post Traumatic Stress Disorder (PTSD:A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.) Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety (a feeling of dread, fear, or uneasiness) Review of the resident's Initial, undated, Care Plan, showed- no care plan for the diagnosis of PTSD, use of Oxygen, use of Continuous Positive Airway Pressure(CPAP) ( A machine that uses mild air pressure to keep breathing airways open while you sleep) or a diagnosis of COPD. Review of the physician's order sheet for August 2024 showed: -Oxygen (O2) 2-5 Liters per minute (LPM) per nasal cannula, continuous every shift -No order for the c pap Observation on 08/13/24 at 8:44 AM showed: -The resident was sitting up on his/her bed with oxygen on at 3 liters per minute per nasal cannula. -Respirations are forceful and shallow -He/she cried at times -He/she ran hands through his/her hair over and over -His/her hands were shaking During an interview with the resident on 8/13/24 at 8:45 A.M. the resident said: -He/she was very short of breath -Staff assist him/her in putting on the cpap machine at night. -He/she wears O2 at all times -He/She does have a diagnosis of PTSD -He/she has nightmares at times -He/she felt as if his/her anxiety and depression were through the roof -He/She does not see a professional such as a Psychologist, Counselor or Psychiatrist. -The nurses will sit with him/her sometimes when he/she feels like he/she needs to talk. During an interview on 8/13/24 at 9:02 A.M. showed Certified Nurse Aide (CNA) D said: -He/she was not aware Resident #30 had PTSD. -He/she was aware the resident wore O2 -Information for the residents could be found in the care plan 44993 47195 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed: -He/She is moderately cognitive impaired; -He/She had clear speech and was able to make-self understood and understand others; -He/She was dependent on a wheelchair and walker for mobility; -He/She needed partial to moderate assistance with toileting, personal hygiene, rolling left and right and sit to lying; -He/She needed substantial/maximal assistance with moving from lying to sitting on side of bed; -Diagnoses included: Parkinson's disease (a progressive disorder that affects the nervous system and parts of the body controlled by the nerves), high blood pressure, chronic pain, tendency to fall, reduced mobility, need for assistance with personal care, history of falling, generalized muscle weakness, unsteadiness on feet, and cognitive communication deficit (a condition affecting a person's ability to think, learn, remember, use judgement, and make decisions). Review of Resident #2's Annual assessment, dated 11/11/23, showed: -It was very important for the resident to choose what clothes to wear, have snacks, take care of personal belongings, choose a bedtime, have family or close friend involved in discussions about care, -Activity preferences included: Having access to books, newspapers, magazines to read, listen to music, be around animals as pets, keep up with the news, do things with groups of people, do favorite activities, go outside and get fresh air, and participate in religious services. Review of the residents care plan, dated 7/5/24, showed his/her care plan did not address the resident's activity preferences. During an interview on 8/12/24 at 10:38 A.M. the resident said: -He/She enjoyed playing bingo and jeopardy; -He/She did not think the facility had enough activities to interest him/her; -He/She would like to see the facility offer book reviews. Review of the electronic resident medical record showed he/she had no activity notes documented in progress notes. 3. Review of Resident #13's Quarterly MDS, dated [DATE], showed: -His/Her cognition was intact; -He/She had clear speech; -He/She was able to make self-understood and understand others; -He/She was dependent on a wheelchair for mobility; -He/She required substantial assistance with moving from lying to sitting, toileting, and bathing; -He/She required partial/moderate assistance with personal hygiene, rolling left and right, sit to stand transfers, chair to bed transfers; -Diagnoses included: muscle weakness, anxiety, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), polyneuropathy (a decreased ability to move and feel sensation because of nerve damage), low back pain, and edema (a condition when tiny blood vessels in the body leak fluid). Review of Resident #13's Annual MDS, dated [DATE], showed: -He/She found it very important to go outside to get fresh air when weather was good, important to do his/her favorite activities, keep up with the news, and to listen to music he/she liked; -Care area's triggered included activities. Review of the care plan, dated 11/12/24 showed: -He/She had potential for social isolation due to lack of interest; -Allow him/her the opportunity to voice his/her feeling & fears; -Encourage him/her to attend activities which improve self esteem; -Introduce him/her to other residents; -Staff to make contact on the 1st & 2nd shift daily; -To the extent possible, offer his/her favorite activities. During an interview on 8/13/24 at 1:11 P.M., Resident said: -He/She felt activities were never geared towards men; -All activity groups were just women's groups; Review of resident's electronic medical record showed he/she had no activity notes documented in progress notes. 4. Review of Resident #20's Quarterly MDS, dated [DATE], showed: -He/She had moderate cognitive impairment; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on a wheelchair for mobility; -He/She required set up or clean up assistance with eating, personal hygiene, and bathing; -Diagnoses included: Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), depression, asthma, cellulitis of right lower limb (a skin infection caused by bacteria), pain, polyneuropathy, generalized muscle weakness, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of resident's Annual MDS, dated [DATE], showed: -It was very important to him/her to have books, newspapers, and magazines to read, listen to music he/she liked, keep up with the news, to do things with groups of people, to participate in his/her favorite activities, and to go outside to get fresh air when weather was good. -Care area's triggered included activities. Review of care plan, dated 6/28/24, showed he/she had no activity preferences care planned. During an interview on 8/14/24 at 12:23 P.M., Resident said: -The facility did not have much for activities to do here; -There was not enough staff to help offer resident individual activities; -There was not enough activities that met his/her interest levels; -He/She liked to have outside activities; -He/She liked to play baseball and kickball; -Activity Director sometimes came around and invited him/her to activities; Review of the resident's electronic medical record showed he/she had no activity notes documented in progress notes. During an interview on 8/13/24 at 1:13 P.M., the Activity Director said: -He/She completed activity assessments with residents upon admission and annually; -He/She did not track activities that he/she did with each resident; -He/She did offer one on one activities like coloring, playing card games like UNO or phase 10; -He/She did not offer specific activities geared towards men but all activities except manicures were inclusive to men; -He/She offered bingo, exercise, and sweet treats; -He/She offered one on one activities by putting a music on in resident's rooms; -Activity calendar was posted on bulletin boards on each hall for residents to see; -He/She did not have a way for resident's who were in their rooms or bed bound to see activities offered each day; During an interview on 8/14/24 at 1:03 P.M., the Administrator said: -He/She expected activity preferences to be care planned when a resident had special interest or an activity that he/she liked. -He/She expected PTSD to be care planned. During an interview on 8/14/24 at 1:21 P.M., the Director of Nursing said: -He/She expected care plans to be updated with any changes and quarterly with the MDS; -He/She expected resident activity preferences to be care planned. -PTSD should be care planned.

Based on interviews and record review the facility failed to document and provide two residents (Resident #13 and #14), with a notice of bed hold policy when the residents were transferred to local hospitals. The facility census was 33. Review of the undated bed hold policy showed: - All residents and guardians will be notified of bed hold guidelines; - Notification will be given upon admission and at the time of transfer to the hospital. 1. Review of Resident #13's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 8/4/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - He/She required substantial assistance to get dressed, use the toilet and to bathe; - Diagnoses included: Bipolar disorder (mood swings that range from depression to very happy), Atrial Fibrillation ( a disorder in which the heart does not beat correctly), epilepsy (seizure disorder), and Chronic Obstructive Pulmonary Disease (COPD). During an interview on 8/12/24 at 9:55 A.M. the resident said: He/She was in the hospital after he/she fell around the beginning of the year; - The facility staff did not give him/her a bed-hold policy form before he/she went to the hospital. Review of the resident's record showed the following: - He/She returned from the hospital on 1/4/24 after being hospitalized after he/she fell and broke his/her hip; - There was no documentation of a bed-hold policy form in the resident's record. 2. Review of Resident #14's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 11, indicating moderate cognitive impairment; - He/She was dependent on the staff to use the toilet, get dressed and to shower; - Diagnoses included: Stroke, anxiety, pneumonia (an infection of the lungs), and frequent falls. Review of the resident's record showed the following: - Licensed Practical Nurse (LPN) A documented on 7/5/24 at 3:23 P.M. he/she was called to the resident's room by staff; - The resident had difficulty breathing with his/her oxygen on, and the resident was shaking; - The resident blood pressure was 170/120 (high), pulse was 150 beats per minute (high), respirations were 28 per minute (high) and the resident oxygen saturation was 76% while receiving 4 liters of oxygen (low); - The resident was sent to the hospital emergency room for further evaluation; - The resident was admitted to the hospital for pneumonia; - There was no bed-hold policy form documented in the resident's record. 3. During an interview on 8/13/24 at 11:25 A.M. the Social Services Director said: - The bed-hold policy was signed with each resident upon admission if they want their bed held or not, but not completed again when the resident transfers transferring to the hospital; - He/She did not know why bed-hold policy was not completed with each hospitalization . During an interview on 8/13/24 at 12:56 P.M. the Administrator said: - Resident #13 and #14 should have bed-hold policy form completed and sent with them with each hospitalization ; - The bed-hold policy form should be provided to the resident and the guardian in language that can be understood; - She expected the bed-hold policy form to be documented in the resident's chart.

Based on interviews and record review the facility failed to document and provide two residents (Resident #13 and #14), with written notice of transfer when the residents were transferred to local hospitals. the facility census was 33. The facility staff did not provide a policy regarding transfers. 1. Review of Resident #13's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 8/4/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - He/She required substantial assistance to get dressed, use the toilet and to bathe; - Diagnoses included: Bipolar disorder (mood swings that range from depression to very happy), Atrial Fibrillation ( a disorder in which the heart does not beat correctly), epilepsy (seizure disorder), and Chronic Obstructive Pulmonary Disease (COPD). During an interview on 8/12/24 at 9:55 A.M. the resident said: He/She was in the hospital after he/she fell around the beginning of the year; - The Facility staff did not provide him/her with written notice regarding the transfer before he/she went to the hospital. Review of the resident's record showed the following: - He/She returned from the hospital on 1/4/24 after being hospitalized after he/she fell and broke his/her hip; - There was no documentation of a transfer form in the resident's record. 2. Review of Resident #14's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 11, indicating moderate cognitive impairment; - He/She was dependent on the staff to use the toilet, get dressed and to shower; - Diagnoses included: Stroke, anxiety, pneumonia (an infection of the lungs), and frequent falls. Review of the resident's record showed the following: - Licensed Practical Nurse (LPN) A documented on 7/5/24 at 3:23 P.M. he/she was called to the resident's room by staff; - The resident had difficulty breathing with his/her oxygen on, and the resident was shaking; - The resident blood pressure was 170/120 (high), pulse was 150 beats per minute (high), respirations were 28 per minute (high) and the resident oxygen saturation was 76% while receiving 4 liters of oxygen (low); - The resident was sent to the hospital emergency room for further evaluation; - The resident was admitted to the hospital for pneumonia; - There was no transfer form documented in the resident's record. 3. During an interview on 8/13/24 at 11:25 A.M. the Social Services Director said: - Normally he/she completed the transfer notices, however, if the resident was transferred on the weekend, or after hours, the nurse would complete the transfer form; - Sometimes the transfer form not completed; - Resident #13 and #14 should have had a transfer form completed prior to going to the hospital. During an interview on 8/13/24 at 12:56 P.M. the Administrator said: - Resident #13 and #14 should have a transfer form completed and sent with each hospitalization ; - The transfer form should be provided to the resident and the guardian in a language that can be understood; - She expected the transfer form to be documented in the resident's chart.

Based on interviews and record review, the facility failed to follow the written policy to check the Nurses Aide (NA) registry prior to hire for three of 5 sampled staff members. The facility census was 33. Review of the undated abuse and neglect policy showed: Before a prospective employee is allowed to work with the residents, a complete background check will be completed; The facility will not employ an individual who has a finding entered on the state nurse aide registry. 1. Review of Dietary Aide (DA) B personnel file showed the following: - He/She was hired 6/22/23 to work as a DA in the kitchen; - No completed NA registry check. 2. Review of Nurses Aide (NA) A's personnel fie showed the following: - He/She was hired 7/6/23 to work as an NA; - No completed NA registry check. 3. Review of the Director of Nurses (DON) personal file showed the following: - He/she was hired 4/17/23 to work as the DON; - No completed NA registry check. During an interview on 8/14/24 at 8:27 A.M. the administrator said: - The Business Office Manager (BOM) completes the NA registry checks prior to a staff member being hired; - All staff regardless if they are nursing or not are checked on the NA registry. During a follow up interview on 8/14/24 at 9:18 A.M. the Administrator said: - She expected the NA checks to be completed and in the the staff's personnel files; - She expected the NA checks to be completed prior to the staff members first day of employment.

Based on record review and interview, the facility failed to accurately show the residents' correct code status in the resident's medical record when the code status did not match in all areas of the resident's medical record. This affected two of the 12 sampled residents (Residents #185 and #28). The facility census was 33. Review of facility policy, Advance Directive, undated, showed: -The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; -Upon admission of a resident, the social services designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Review of Resident #185's entry tracking minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed he/she entered from a short term general hospital stay. Review of resident's baseline care plan, dated [DATE], showed: -He/She was a do not resuscitate (DNR- no life saving measures) code status -Diagnoses included: A fracture of lower end of left radius (long bone of the arm), respiratory failure, unsteadiness on feet, weakness, and chronic pain. Review of physician's orders dated [DATE] to [DATE], showed he/she had a DNR code status. Review of resident's paper medical record showed he/she had a green sheet that stated he/she was a full code. During an interview on [DATE] at 1:17 P.M., Social Services director said: -Resident was a full code; -He/She saw that resident had wrong code status on his/her physician's orders and on their care plan; -He/She went in and changed the code status on resident's orders on [DATE] after learning they did not match. During an interview on [DATE] at 9:30 A.M., Certified Nurse Aide (CNA) B said: -He/She knew the code status by looking at the resident's paper chart and the stickers on resident's doors; -A red sticker meant the resident was a DNR and a green sticker meant he/she wanted to be full code status which meant facility would initiate cardio-pulmonary-resuscitation (CPR); -He/She would find a nurse if resident had green status since he/she was not CPR certified; 44395 2. Review of Resident #28 Quarterly MDS dated [DATE] showed: -BIMS of 15, indicated no cognitive loss -Partial to maximum assistance of staff for ADLs. -Diagnoses of Combined Congestive Heart Failure (the heart muscle weakens and enlarges, making it difficult for the heart to pump enough blood), Atrail Fibrillation, Depression, Hypertenstion (high blood pressure) and morbid Obesity (A disorder that involves having too much body fat, which increases the risk of health problems.) Obstructive Sleep Apnea. Review of the resident's August Physician Orders showed a Code Status as DNR and dated [DATE]. Review of the resident's paper medical record showed a green FULL CODE paper in the front of the chart. Review of the resident's electronic medical record showed: -The admission checklist dated [DATE] was not completed. -The outside the Hospital DNR paperwork in the admission packet was not signed or dated by the resident or the physician Observation and interview on [DATE] at 10:22 A.M. showed a green sticker on the resident's name plate. The resident said he/she had not changed his/her code status recently. During an interview on [DATE] at 9:58 A.M. CNA A said: - [NAME] stickers on the name plate meant the resident was a full code, and red meant DNR. -If the resident had nothing on their name plate the sticker may have fallen off. -All residents should have a red or green indicator on their name plate. -The other place he/she would look for code status was in the paper chart, on top when the chart is opened. During an interview on [DATE] at 9:59 AM CNA B said: -The Resident's chart had a paper in front when opened for code status. -Resident #28 has a green sticker on his/her nameplate and would be a full code. During an interview on [DATE] at 10:30 AM the SSD said: -She was responsible for code status paperwork and signs. -Resident #28 was a full code, not a DNR. -She was not aware there was a physician's order for DNR status. During an interview on [DATE] at 10:42 AM Licensed Practical Nurse A said: -He/She would have to look at the resident's chart for code status. -Green dots on name plates mean full code and red dots mean DNR, it was the same for the paper in the resident's chart. -SSD would get the DNR signed and give it to him/her. -He/She would notify the physician, get the order and place it in the computer. During an interview on [DATE] at 1:03 P.M., Administrator said he/she expected the code status to be the same on physician's orders, electronic records, and paper chart with everything matching. During an interview on [DATE] at 3:19 P.M., Director of Nursing said: -The nurse puts the orders in the electronic records for advance directives and code status; -The social service staff was responsible for completing the code status paperwork; -A resident's code status should match in all places of their medical record; -Staff should be knowledgeable of each resident's code status; -He/She was aware that their was two residents code status that did not match in all areas of the resident's record.

Based on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, and additionally failed to complete quarterly assessments side rail and entrapment assessments (Resident #20, #13, #14, and #21), and failed to obtain a physician's order prior to installation (Resident #20, #13, and #14), failed to obtain informed consent (Resident #13, #14, and #21) for four of the 12 sampled residents (Resident #20, #13, #14, and #20). The facility census was 33. Review of facility policy, bed rails, undated, showed: -Once bed rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative. After review is complete, the resident and/or resident representative will sign the consent line and nurse will sign as well. -Develop a care plan that outlines the medical factors necessitating bed rails and an explanation of how the use of a bed rail is intended to treat the specific resident's condition. -When installing or maintaining bedrails, staff should follow manufactrer's recommendations and specifications for applicable bed rails, mattresses, and bedrames. -Staff will conduct regular inspections of all bedframes, mattresses, and bed rails, to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses, and bedframes that are compatible. -Overview of FDA potential zones of entrapment with FDA dimension recommendations: -Zone 1: within the rail -Any open space between the perimeters of the rail can present a risk of head entrapment. FDA recommended space: less than 4 and 3/4 inches -Zone 2: Under the Rail, Between the Rail supports or next to a signle rail support -The gap under the rail between the mattress, may allow for dangerous head entrapment. FDA recommended space: less than 4 and 3/4. -Zone 3: Between the rail and the mattress -The area is the space between the inside surface of the bed rail and the mattress, and if too big it can cause a risk of head entrapment. FDA recommended space: less than 4 and 3/4 inches; -Zone 4: Under the rail at the ends of the rail. -A gap between the mattress and the lowermost portion of the rail poses a risk of neck entrapment. FDA recommended space is less than 2 and 3/8 inches. -Zone 5: Between split bed rails -When partial length head and split rails are sued on the same side of the bed, the space between the rails may resent a risk of either neck or chest entrapment. -Zone 6: Between the end of the rail and the side edge of the head or foot board -A gap between the end of the bed rail and the side edge of the headboard or footboard can present the risk of resident entrapment. -Zone 7: Between the head or foot board and the end of the mattress -When there is too large of space between the inside surface of the headboard or footboard and the end of the mattress, the risk of head entrapment increases. -Prior to use of bed rails the facility should complete the matrix bed rail observation including the following: 1. Observation detail 2. Clinical Assessment 3. Alternatives attempted prior to bed rail implementation. 4. Bed rail details. 5. Assessment of potential entrapment zones. 6. Review of risk and benefits with resident and resident representative 7. Obtain informed consent with resident and/or resident representative signature 8. Obtain physician order for medical symptom assessed requiring bed rail use Review of the undated bed rail policy showed: - Bed rail use was to be care planned; - Bed rails should have regular inspections of the bed frames, mattresses and bed rails to identify possible areas of entrapments; - Prior to the installation of bed rails the facility staff should complete the bed rail observation in the Electronic Medical Record (EMR) that includes observation detail, clinical assessment, alternatives attempted prior to bed rail installation, assessment of potential entrapment zones, obtain informed consent with the resident, and obtain a physician's order for the bed rail use. 1. Review of Resident #20's Quarterly minimum data set (MDS), A federally mandated assessment tool completed by facility staff, dated 6/25/24, showed: -He/She had moderate cognitive impairment; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on staff for bed mobility and positioning; -He/She had 1 fall with no injury since prior assessment dated [DATE]; -He/She was taking antidepressant, anticoagulant, antibiotic, diuretic, opiod, and hypoglycemic medication; -Diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), coronary artery disease (a condition resulting in narrowing coronary arteries limiting blood flow to the heart), hypertension, renal insufficiency (condition in which the kidneys lose the ability to remove waste and balance fluids), depression, asthma, cellulitis of right lower limb (a skin infection caused by bacteria), pain, polyneuropathy, generalized muscle weakness, sleep apnea, neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of care plan, dated 9/19/18, showed: -Resident required assistance with ADLS due to increased weakness related to his/her disease progression; -He/She had quarter bed rail to aid with positioning and transfers. Review of physician's orders, dated 8/12/24, showed: -He/She did not have orders for any side rail. Observation on 8/12/24 at 9:48 A.M. showed resident had a side rail up on his/her left side of the bed. During an interview on 8/14/24 at 12:23 P.M., Resident said he/she had side rails on right side to help boost him/her up in bed. Review of electronic medical record showed: -On 12/27/23, one bed rail facility assessment was incomplete with missing zone information and the only assessment completed in the medical record. -A quarter side rail would be used to assist with positioning and transfers; -Frequency of use was while in bed to assist with positioning; During an interview on 8/14/24 at 9:30 A.M., CNA B said: -He/She did not know why resident has side rails on his/her bed During an interview on 8/14/24 at 1:03 P.M., the Administrator said: -He/She expected side rails to be assessed quarterly for entrapment assessments; -The Director of Nursing (DON) was responsible for completing entrapment assessments; -Side rails should have physician's orders. During an interview on 8/14/24 at 1:21 P.M., DON said: -A physician's order must be obtained for side rails; -He/She did not know he/she was responsible for doing entrapment assessments until this week; -He/She was aware the MDS Coordinator had done some of the entrapment assessments for side rails; -Side rail and entrapment assessments should be completed quarterly; -Measurements of bed frame, mattresses, and side rails should be done with quarterly assessments; -He/She had not done side rail assessments. During an interview on 8/14/24 at 1:36 P.M., the Maintenance staff said: -He/She had never installed any side rails at the facility; -He/She did not complete any measurements on side rails, mattresses, or bed frames. 44993 2. Review of Resident #13's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 8/4/24 showed: - The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment; - He/She required substantial assistance to get dressed, use the toilet and to bathe; - Diagnoses included: Bipolar disorder (mood swings that range from depression to very happy), Atrial Fibrillation ( a disorder in which the heart does not beat correctly), epilepsy (seizure disorder), and Chronic Obstructive Pulmonary Disease (COPD). Observation on 8/12/24 at 9:55 A.M. showed: - A bed rail attached to the side of the residents bed and leaning away from the bed. Review of residents record showed the following: - The care plan addressed the use of a bed rail for the resident to assist with repositioning; - No bed rail assessment; - No entrapment assessment; - No consent for the use of the bed rail; - No physicians order for the use of a bed rail. 3. Review of Resident #14's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 11, indicating moderate cognitive impairment; - He/She was dependent on the staff to use the toilet, get dressed and to shower; - Diagnoses included: Stroke, anxiety, pneumonia (an infection of the lungs), and frequent falls. Observation on 8/12/24 at 2:17 P.M. showed: - The resident was lying in bed sleeping; - The resident had a 1/2 side rail on the right of his/her bed; - The side rail was leaning away from the bed. Observation on 8/13/24 at 9:52 A.M. showed; - The resident was in bed sleeping; - The bed rail was in the up position and leaning away from the bed. Review of the resident record showed the following: - No bed rail assessment; - No entrapment assessment; - No consent for the use of bed rails; - No alternatives documented prior to the use of bed rails; - No physicians order for the use of a bed rail; - The care plan did not address the use of a bed rail. 4. Review of Resident #21's quarterly MDS dated [DATE] showed: - BIMS score of 8, indicating moderate cognitive impairment; - He/She required assistance with transfers, bathing, toilet care, and getting dressed; - Diagnoses included: Bipolar disorder, weakness and psychosis. Observation on 8/13/24 at 9:58 A.M. showed: - The resident had 1/2 bed rails to both sides of his/her bed; - Both bed rails were in the up position. Review of the residents record showed the following: - A physicians order dated 11/15/23 for the use of the left and right bed rail for transfers and repositioning; - The care plan addressed the use of the bed rails; - No bed rail assessment; - No entrapment assessment; - No bed rail consent. 5. During an interview on 8/13/24 at 10:21 A.M. the Administrator said: - She expected the use of a bed rail to have a physicians order; - She expected the care plan to address the use of bed rails; - She expected alternative methods to be documented prior to the use of a bed rail; - She expected bed rail assessments and entrapment assessments to be completed prior to the installation of the bed rail; - She expected bed rail consents to be obtained and documented prior to the installation of bed rails.

Based on observation, interview and record review the facility failed to provide adequate supervision, identify an elopement risk and implement safety measures and prevent one resident (Resident #1), who resided on the secure care unit, from eloping from the facility through an alarming door, and exiting from the building for approximately 18 hours with the temperature of 39 degrees Fahrenheit (F) and 14 mile per hour (MPH) wind gusts. Resident was found at a hotel 15.2 miles from the facility. The facility census was 39. The Administrator was notified on 5/3/22 at 2:09 P.M. of the Immediate Jeopardy (IJ) which began on 4/30/22. The IJ was removed on 5/5/22, as confirmed by surveyor onsite verification. Review of the Elopement Protocol; Special Care Unit Manual, dated April 2006, provided by the facility showed in part: -The following individuals may have responsibility for preventing resident elopement: -Registered Nurse (RN). -Licensed Practical Nurse (LPN). -Certified Medication Technician (CMT). -Certified Nurse Aide (CNA). -Definition: -Elopement, for the purpose of these guidelines is defined as that situation where a resident with impaired decision making ability, who is oblivious to his/her own safety needs, and therefore at risk for injury outside the confines of the facility has left the facility without knowledge of staff. -Purpose: -Identify residents at risk for elopement. -Protect residents that are not capable of protecting themselves. -Provide the techniques and equipment to minimize safety risks. -Door Alarms: -A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. -Door alarms are tested at least once a month. The result of the test are recorded. -Testing of the system includes not only the alarms' function, but also the staff's appropriate response to the alarms. -Only the administrator may authorize disabling the alarm system, and is responsible for the method of monitoring for resident's safety and resetting the alarms. Review of Resident #1's Discharge notes from an area hospital, dated 4/21/22, showed: -His/her memory is impaired. -He/she had a history of noncompliance with medications and leaving a group home. -He/she had little to no awareness of his/her severe cognitive deficits. -He/she needed assistance with complex medical decision making. -He/she required assistance with basic activities of daily living (ADLs: tasks of everyday life, including bathing, eating, dressing, using the toilet, etc). -Diagnosis of Schizophrenia (a serious mental disorder in which people interpret reality abnormally, and may have visual and auditory (hearing) hallucinations (things that seem real to the person but are not real to others)). -Public Administrator was appointed on 4/20/22. During an interview on 5/19/22 at 12:30 P.M., Hospital Social Service Designee said: -He/she sent a mass Level II referral out for placement due to resident's history of elopement. -He/she spoke with the Administrator on 3/17/22 when Resident #1 was accepted for admittance. -He/she did notify the Administrator Resident #1 was an elopement risk. Review of the resident's medical record showed: -Date of admission 4/21/22. -Elopement and wandering risk assessment, completed by LPN A dated 4/23/22 at 3:09 P.M., showed facility staff assessed the resident as follows: -Cognitively impaired (including Alzheimer's or diagnosis of dementia). -Takes medication that suppresses the thought process. -Total score of 2 indicating low risk for elopement. -Baseline care plan did not indicate any risk for elopement. -No PASRR (Preadmission Screening and Resident Review (PASARR: which is indicated for any individual who may have an intellectual disability (ID), developmental disability (DD), or mental illness (MI. It is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care)) screening on file for the resident, although the resident had a diagnosis of a mental disorder. Review of Resident #1's PASRR screening, obtained through the Central Office Medical Review Unit of the Department of Mental Health, showed the resident's PASRR evaluation was completed on 3/8/22. The screening included: - Most recent living situation included the resident walked away from his most recent placement and mentions of staying in a barn, on the concrete, and in the cold suggest that he was homeless without shelter; -Diagnoses including schizophrenia, psychotic disorder, personality disorder, antisocial personality, mild mental retardation, borderline intellectual functioning -diagnosed with dementia on 2/24/2022. -Historical symptoms- recent hospitalization was prompted by resident walking away to live on the streets until he went to Emergency Department. Guardianship is in process. - Behavorial assessment indicated wandering, uncooperative with medical/nursing care or treatments, seclusiveness and suspicious of others. -Cognitive skills/adaptive functioning: does not make good decisions. Resident operates at a below average to low average intelligence; this combined with cognitive deficits makes it very difficult for him to make good decisions or judgments; -Neurological assessment- disordered to date and time of day. Neuropsych Evaluation 2/28/22- revealed severe cognitive impairments/deficits, performing exceptionally low range on most administered cognitive tests. Review of the resident's Physician Order Sheets (POS), dated April 2022, showed: -Diagnosis of Schizophrenia. -Major Neurocognitive Disorder (disorder of cognitive function that is commonly characterized by impairments in memory, speech, reasoning and intellectual function). During an interview on 4/30/22 at 5:00 P.M., the Administrator said: -Resident #1 was in the quarantine area on the secured care unit due to 14 day quarantine for new admission. -Staff are not in the quarantine area full time, they enter that area every 2 hours and as needed. -Winds in the area were high, causing the door to catch and the alarm to sound on April 30, 2022. -Around 1:30 P.M., the door alarm to the exit door near the room of Resident #1 was sounding, staff silenced the alarm off and Resident #1 , #2, and #3 were in their rooms. -At approximately 2:30 P.M., the exit door alarm was sounding again and CNA A went to silence the alarm and found the resident was not in his/her room. -Facility staff began a search of the grounds and surrounding areas, including the town and highway. -The other residents in the quarantine area did not see Resident #1 leave. -Resident #1 had not voiced any wish to leave to him/her. -Resident #1's Public Administrator, physician, and the County Sheriff had been notified. -Alarms sound at the door and at a reset box at South Nurse's station. During an interview on 4/30/22 at 5:28 P.M., RN A said: -There were 2 CNA's responsible for the quarantine area of the building and the residents on South hall. -He/she was aware of the elopement. -He/she notified the Administrator and Sheriff's Department of the missing resident. Observation on 4/30/22 at 5:32 P.M., showed: -A plastic zipper wall at the end of South hall that reached from floor to ceiling and wall to wall. -Resident rooms 117, 119, 122, and 124 (which included the resident's room) were on one side of the zippered wall and are not visible from any of the south hall due to the opaque zipper wall. During an interview on 4/30/22 at 5:32 P.M.: - CNA B said: -Wind gusts were catching the door, causing the alarm to sound and needed to be reset by staff. -On 4/30/22 at 1:30 P.M. he/she was picking up meal trays and heard the alarm. -He/she applied Personal Protective Equipment (PPE), went to the door, reset the alarm, and checked all residents in the isolation area. -All 3 residents were accounted for in their respective rooms. -He/she then went to give a shower to Resident #4. -At 2:30 P.M. he/she was passing ice water on the unit, outside of the quarantine area, and obtaining menus for the evening meal when he/she heard the alarm sound. -CNA A came from the isolation area stating Resident #1 was not there. -He/she began checking rooms for Resident #1. -CNA A said: -Wind gusts had caused the door to catch, causing the alarm to sound every 15-20 minutes throughout the day. -He/she heard the alarm go off about 2:30 P.M. on 4/30/22. -He/she applied PPE and went to the alarming door behind the isolation area. -He/she checked outside, reset the alarm, passed ice/water to Resident #2 and #3, obtained Resident #2 and #3's menu options then moved to Resident #1's room, where he/she was found to be missing. -He/she then checked the rooms located in the isolation area. -He/she notified CNA B that Resident #1 was missing. -He/she called the facility from his/her cell phone to report the missing resident. -He/she began a search outside the building. -CNA B checked the inside rooms for Resident #1. -Resident #1 had made no statements of wanting to leave. During an interview on 5/2/22 at 9:35 A.M., CNA A said: -He/she was assisting Resident #5 with a shower, and at approximately 1:30 P.M., he/she exited the shower room to obtain supplies and heard the alarm sounding from the quarantine area. -He/she did not respond or reset the alarm at that time and he/she was not sure if staff checked the alarm at that time. -He/she finished Resident #5's shower around 2:00 P.M. and he/she did not hear the alarm at that time. -CNA B was in the second shower room assisting Resident #4 with a shower between 1:30 P.M. and 2:30 P.M. on 4/30/22. -He/she and CNA B assisted each other with the transfers for Residents #4 and #5, leaving them both in shower rooms at the same time. -LPN B was on the 100 hall while he/she and CNA B were in the shower rooms. -He/she and CNA B began passing ice water and menus around 2:00 P.M. beginning with the rooms near the quarantine area and moving to the other side of the hall. -When he/she returned to the 100 hall side of the building around 2:30 P.M., and neared the quarantine area, he/she heard the alarm sounding. -He/she applied PPE, went to the door, checked outside, noted the fence was down, checked the other resident's rooms then noted Resident #1 was missing. -He/she yelled to CNA B that Resident #1 was missing. -He/she then called the facility on his/her cell phone, telling RN A that Resident #1 was missing. During an interview on 4/30/22 at 5:47 P.M., LPN B said: -He/she did not remain on the 200 hall as there was a resident on the 100 hall who was actively dying and he/she was providing care to that resident. -CNA staff reported to him/her around 2:00 P.M. that Resident #1 was missing. -He/she was unsure of the time that the CNA's reported to him/her that Resident #1 was missing due to another resident passed away at 2:08 P.M. and staff notified him/her sometime after that. -RN A notified the administrator and the Sheriff's office and sent staff outside the building to search for Resident #1 approximately 2:30 P.M. on 4/30/22. -He/she searched inside the building for Resident #1. Review of the resident's record showed no documentation of the resident's elopement. Observation on 4/30/22 beginning at 5:59 P.M., showed: -All door alarms sounded immediately when door handle was pushed. -A corner section approximately three to four feet of the courtyard's (a fenced off area with covered patio) six foot privacy fence, to the left of the exit door of the building, was lying on the ground. -The secured court yard had a large gate with alarm key pad and magnetic lock, directly in front of the exit door of the building. During an interview on 5/1/22 at 10:03 A.M., the Administrator said: - He/she was notified by the Sheriff's department that Resident #1 was found in a nearby town at a hotel, 15.2 miles from the facility. -Resident #1 would be returning to the facility and will be on 1:1 observation. Review of the local weather history, dated 4/30/22, showed: -59 degrees F with 29 mph wind gusts at 2:52 P.M. -39 degrees F with 24 mph wind gusts at 11:52 P.M. During an interview on 5/2/22 at 8:52 A.M., the Maintenance Director said: -The missing section of fence was down when he/she started in September of 2021. -He/she fixed the fence and then during winter storms it was torn down again. -He/she was unsure of date it was town down. -He/she was not aware the door alarms were sounding over the weekend. During an interview on 5/2/22 at 11:35 A.M., the Administrator said: -He/she had spoken to Social Services at the discharging hospital and Resident #1 had no attempts to leave there. -The courtyard fence went down over the winter, was repaired and then went down again. -The SSD may not have all of Resident's hospital documentation scanned into the computer. Observation and interview on 5/2/22 at 12:02 P.M., showed: -The resident stated he/she went on a long adventure. - Resident had a large scratch approximately the length of a large paperclip to the right side of his/her nose. During an interview on 5/3/22 at 1:24 P.M., Resident #1 said: -He/she had went on an adventure. -He/she left the building, because the door was opened by the wind and he/she had seen the fence knocked down. -He/she didn't hear any alarms when the door opened. -He/she walked and spent the night by a hay [NAME]. -He/she got the scratch on his/her nose when climbing over a fence. During an observation on 5/2/22 at 12:02 P.M., Physician A evaluated resident and said: -Resident #1 needs to be in a secured unit. -Resident #1 could potentially leave again. During an interview on 5/2/22 at 12:20 P.M., LPN A said: -Resident #1 was pleasant, cooperative and had no behaviors. -Resident #1 was not assessed as an elopement risk when admitted . -Elopement risk assessment was completed on every new admission. -He/she just read in hospital records that resident eloped from his/her previous place of residence. -He/she reads the discharge orders when he/she was admitting a new resident. -Resident #1 had made no comments about leaving, or seen attempting to leave. During an interview on 5/2/22 at 1:52 P.M., the Hotel Clerk said: -He/she saw Resident #1 walking north on a street next to the hotel; -He/she saw Resident #1 enter the hotel lobby. He/she got coffee and cereal. -Another employee told him/her Resident #1 was the person the Sheriff's office was looking for. -He/she notified the Sheriff's office about 7:30 A. M. that Resident #1 was in the hotel lobby. -Sheriff's Department Corporal arrived at the hotel about 7:50 A.M. and retrieved Resident #1. During an interview on 5/2/22 at 2:12 P.M., County Sheriff Corporal said: -He/she was notified at 2:59 P.M. on 4/30/22 that Resident #1 was missing. -He/she was read information from Resident #1's chart stating Resident #1 had gone missing from his previous placement and was homeless for 9 years. -He/she was unsure which staff read the information to him/her. -He/she had significant concerns that Resident #1 had a history of elopement, was placed in a room near an exit door, with a floor to ceiling and wall to wall barrier where staff could not easily see Resident #1. -He/she saw that the door lead outside, was easily pushed open, wouldn't latch due to the wind, and a portion of the privacy fence was not intact. -The exterior door alarm sounded multiple times while he/she was onsite and he/she saw no staff, at any time, check the alarm, and reset it. -The area had sustained winds of 18-20 MPH throughout the night, not including the gusts. -When he/she picked up Resident #1 at the hotel, the resident had bruising and an abrasion to his/her nose. During an interview on 5/2/22 at 3:50 P.M., LPN A said: -He/she was not aware until today that Resident #1 had left his/her previous placement. -He/she was not the admitting nurse, but assisted the admitting nurse with the medication orders for Resident #1. -He/she did not complete an elopement assessment when the resident was admitted , he/she completed the elopement risk assessment the day after he/she was admitted . -He/she usually reads the discharge orders, determines any immediate needs and orders for a new admission. -If he/she gets the PASARR he/she makes a copy, places it in the chart and gives a copy to the SSD. -He/she usually receives report from a discharging facility for a new resident. -He/she did not take report on Resident #1. -He/she completed his/her elopement risk assessment 2 days later without reading the discharge info and thought he/she was a low risk. During an interview on 5/3/22 at 10:58 A.M., LPN B said: -On April 21, 2022 Resident #1 admitted around 5:55 P.M. and he/she was off shift at 6:00 P.M. -He/she faxed the physician, entered a computer note and faxed the orders to the pharmacy. -He/she did not receive a report from the discharging hospital. -He/she did read the discharge order, he/she left previous placement and had checked himself/herself into the hospital. -Resident #1 was placed in the secured unit due to being a new admission and needing the quarantine area. -He/she did not complete an elopement assessment; -He/she didn't do any of the assessments and passed on to the next shift to complete them. During an interview on 5/4/22 at 11:56 A.M., the Public Administrator (PA) said: -Resident #1 was placed on guardianship on 4/20/22. -He/she was working on other placement for Resident #1. -He/she was not aware that Resident #1 was found 15 miles from the facility. During an interview on 5/2/22 at 4:03 P.M., the Administrator said: -He/she would expect the admitting nurse to obtain report on a new admission, read the discharge information, initiate a care plan, and put orders in place for any immediate needs such as a secured unit. -With the information from the hospital Resident #1 should have been a higher elopement risk. At the time of the abbreviated 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 visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00200560

44993 Based on interview and record review, the facility failed to prevent the sexual abuse of two residents (Resident #2 and #3) when the facility did not put interventions in place to protect the residents from Resident #1, after he/she sexually abused Resident #2 on 2/1/22. He/she then sexually abused Resident #3 by fondling the resident's breasts on 2/20/22. The facility census was 41. The administrator was notified on 2/23/22 at 11:30 A.M. of an Immediate Jeopardy (IJ) which began on 2/20/22. The IJ was removed on 2/24/22 as confirmed by surveyor on-site. Review of the abuse policy, dated November 2017, showed: - It is the policy that each resident will be free from abuse including verbal, physical, and sexual. - Residents will be protected from abuse while living at the facility. - Abuse will not be tolerated and residents and staff will be monitored for protection. - The facility encourages residents and staff to report abuse. - The facility will educate staff techniques to protect residents from abuse. - The nursing home administrator or designee will report abuse to the state agency per state and federal requirements. 1. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Brief interview for mental status (BIMS) score of 0, indicating severe cognitive impairment. - Required extensive staff assistance for cares; - Frequently incontinent of bowel and bladder; - Diagnoses included cerebral palsy (abnormal brain development) and seizure disorder. Review of the resident's care plan, dated 12/16/2020, showed: - The resident had a guardian. - The resident was at risk for injury due to emotional excitability. - The resident had difficulty making self understood due to cognitive impairment. Review of the resident's nurses' notes, dated 2/1/22 at 9:03 A.M., showed LPN A documented he/she was informed by the DON at 8:50 A.M. the resident had been touched inappropriately by Resident #1. He/she continued to monitor the resident and ensure that he/she was not in the dining room unattended. Staff are keeping a good eye on him/her to ensure he/she does not get close to Resident #1. Resident #1 was placed on 15 minute checks after the incident. During an interview on 2/23/22 at 9:46 A.M. LPN A said: - Resident #2 acts like he/she is afraid of Resident #1 after this incident. - The incident was reported to the DON and Administrator and Resident #1 was placed on 15 minutes checks to ensure Resident #1 and #2 did not have contact with each other. Review of the resident's care plan, dated 12/16/2020, showed: - Staff did not update the resident's care plan after the alleged incident on 2/1/22. During an interview on 2/22/22 at 12:40 P.M., the Director of Nursing (DON) said: - 2/1/22 Resident #1 was placed on 15 minute checks after staff witnessed him/her touching Resident #2's breasts. Due to there having been no allegations of sexual inappropriateness in the past, and no further incidents while he/she was being monitored every 15 minutes, the 15 minute checks were allowed to expire after 24 hours. - 2/2/22 he/she told the staff to continue to monitor Resident #1 and #2 to ensure that no further incidents happened. During interviews on 2/23/22 at 1:08 P.M. and on 2/24/22 at 12:50 P.M., the administrator said: - Resident #1 was placed on 15 minute checks after the 2/1/22 incident for 24 hours. - The 15 minute checks were stopped, because the facility did not have a policy to do 15 minute checks and there were no more incidents. - He/she did not think there was anything to protect the other resident's from since no further incidents happened. 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 12/24/21 showed: - BIMS score of 15, indicating no cognitive impairment. - Diagnoses included: Parkinson's disease (a progressive disease that affects the nervous system that can cause tremors and muscle rigidity), anxiety, and muscle weakness. - He/she required the assistance of one staff to turn while in bed, dressing, transfers, and using the toilet. - He/she was dependent on an electric wheel chair for mobility. Review of the Activities of Daily Living (ADL's) care plan, dated 3/23/21, showed: - He/she required assistance with ADL's due to weakness related to Parkinson's disease. - He/she used an electric wheel chair for mobility. Review of the nurses' notes, dated 2/20/22 at 6:16 P.M., showed Licensed Practical Nurse (LPN) A documented the resident reported to him/her at 4:20 P.M. another resident went into his/her room, shut the door, and touched his/her breast. He/she told the other resident to leave his/her room several times. The other resident told LPN A that he/she did enter the resident's room and closed the door, but was asking Resident #3 to make him/her a stocking cap and denied touching the resident's breast. Review of the resident's nurse's note, dated on 2/20/22 at 7:10 P.M., showed the administrator documented a deputy from the county sheriff's office took both of the resident's statements and he/she verified what was reported earlier. Review of the facility investigation, dated 2/20/22, showed: - 4:20 P.M. Resident #3 went to the nurses' station and reported Resident #1 entered his/her room and touched his/her breast. - Resident #3 reported that he/she was in his/her closet hanging clothes when Resident #1 entered his/her room and shut the door behind him/her. - Resident #3 asked Resident #1 what he/she wanted and he/she did not reply. - Resident #3 told Resident #1 to leave his/her room, but Resident #1 did not leave. - Resident #3 moved his/her electric wheel chair, facing Resident #1 and at that time Resident #1 touched his/her breast. - He/she yelled and another resident knocked on his/her door and Resident #1 left his/her room. - 7:30 P.M. a behavioral health hospital referral was made; no beds available at this time, but sent Resident #1's demographic information. - Resident #1 was placed on one on one observation. - 2/21/22 Resident #1's demographic information was sent to a behavioral health hospital for review for placement. Review of the Sheriff's Deputy report, dated 2/20/22, showed: - The administrator reported Resident #1 had entered Resident #3's room and grabbed his/her right breast. - Resident #1 had previously been seen by staff grabbing the breast of Resident #2 on a prior occasion. - Resident #3 was visibly upset, sobbing, and appeared to be distraught. - Resident #3 said that he/she could not do this anymore and that he/she did not feel safe around Resident #1. - Resident #3 said he/she was in his/her room hanging clothing in the closet when Resident #1 entered his/her room in his/her wheel chair. - Resident #1 shut the door behind him/her. - Resident #3 asked him/her what he/she wanted and Resident #1 did not answer and continued to sit and stare at Resident #3. - Resident #1 approached Resident #3 and grabbed his/her right breast. - At that time another resident knocked on the door and Resident #1 left the room. - Resident #3 said this had happened in the past. - Resident #3 said Resident #1 had an evil look in his/her eyes, and he/she became emotional and started to cry. - Resident #1 said he/she was in another resident's room with the door shut to ask about a hat. - Later in the conversation Resident #1 said he/she brushed Resident's #3's breast with his/her hand. - The administrator said he/she was trying to get Resident #1 into an all-male unit to try to keep the sexual behavior from continuing. During an interview on 2/21/22 at 1:55 P.M., Resident #3 said: - He/she was in the closet arranging his/her clothes. - Resident #1 resident entered his/her room. - He/she said What do you want? and Resident #1 closed the door and blocked it with his/her wheel chair while he/she was sitting in it. - He/she told Resident #1 to leave his/her room; the resident did not say anything and moved toward him/her and massaged his/her right breast. - He/she told Resident #1 to stop, get out, another resident heard him/her yelling and knocked on the door. - Resident #1 then left his/her room, and he/she reported the incident to LPN A. - He/she said Resident #1 had been telling him/her that Resident #1 wanted to have sex with him/her, telling him/her to put his/her nightgown on and wait in bed for Resident #1. - Resident #1 touched his/her breast sometime before Christmas and tried to put his/her hand in his/her pants and he/she pushed the resident away. - At that time, Resident #1 told him/her that he/she wanted to have sex with him/her. During an interview on 2/21/22 at 2:25 P.M., Certified Nurse Aide (CNA) A said: - He/she was working on the behavioral unit on 2/20/22 and Resident #3 was crying at the unit's entrance. - When asked why he/she was crying, the resident told him/her that Resident #1 was in his/her room, shut the door, and touched his/her breast. - Another resident knocked on Resident #3's door and that was when Resident #1 left his/her room. During an interview on 2/22/22 at 1:45 P.M., Resident #3 said: - He/she was in the electric wheel chair at the foot of his/her bed, Resident #1 came towards him/her and placed his/her hand on Resident #3's breast. - Another resident knocked on the door and that is when Resident #1 left his/her room. - Resident #1 entered Resident #3's room one other time and put his/her hand down Resident #3's pants, but was not able to touch his/her private area. - His/her nails were sharp and Resident #3 was able to get Resident #1's hand out of his/her pants. - He/she blew a whistle and nurse aides came to his/her room. During an interview on 2/22/22 at 4:00 P.M., CNA A said: - He/she was assigned to the unit on 2/20/22. - He/she was getting residents up for the evening meal when he/she saw Resident #3 crying. - Resident #3 reported that Resident #1 had entered his/her room and fondled his/her breasts. - CNA A took Resident #3 to the nurses' desk and reported the incident to LPN A. During an interview on 2/23/22 at 9:46 A.M., LPN A said: - On 2/20/22 Resident #3 reported to him/her that Resident #1 fondled his/her breast. - He/she reported the incident to the administrator and DON and primary care physician (PCP). - One on one monitoring was started to watch Resident #1 at that time. During an interview on 2/22/22 at 4:49 P.M., the sheriff's deputy said: - He/she took Resident #3's report on 2/20/22 at around 7:00 P.M. - He/she was very upset and crying. - He/she said this had happened multiple times. - Resident #1 initially denied touching Resident #3's breast, but then said there was a previous incident and that he/she supposed he/she did it, referring to touching the resident's breast. 3. Review of Resident #1's annual MDS, dated [DATE], showed: - BIMS score of 15, indicating no cognitive impairment. - Diagnoses included: Anxiety and heterosexual behaviors (sexual attraction of the opposite gender). - He/she was independent when transferring, getting dressed, using the toilet, and performing personal hygiene. - He/she had no impairment of the upper or lower extremities, however uses a wheelchair for locomotion. - He/she has had no sexual behaviors. Review of the resident's Physician's Order Sheet (POS), dated 2/22, showed: - 12/30/21 quetiapine 100 mg per tablet, give one tablet by mouth two times per day (a medication used to treat psychosis with behaviors). - 12/30/21 Medroxyprogesterone tablet, 2.5 mg, give one tablet by mouth one time daily (a medication used to decrease sexual behaviors). Review of the resident's sexual behavior care plan, dated 2/1/22, showed: - He/she was displaying sexual inappropriateness toward others. - Placed him/her on 15 minutes checks as needed for sexual inappropriateness. - Re-direct him/her back to his/her room when inappropriate. - Remind him/her to not touch any person without their permission. - Encourage him/her to discuss his/her feelings about sexuality with an appropriate staff member. - Avoid having him/her in situations which may contribute to his/her behavior when possible. - Intervention dated 2/20/22: Staff to sit one on one with the resident. During an interview on 2/21/22 at 2:40 P.M., Resident #1 said he/she: - Has made advancements toward Resident #3 in the past, but he/she was willing then; - Brushed his/her arm/hand against Resident #3 breast yesterday; - Had made advancements to other residents in the facility, but would not provide any further information. 4. During an interview on 2/21/22 at 3:20 P.M., CNA B said: - He/she had made comments to LPN B that Resident #1 was being inappropriate with other residents. During an interview on 2/23/22 at 10:15 A.M., CNA D said: - He/she had seen Resident #1 behaving inappropriately, but does not remember when. - He/she reported the incident to the charge nurse, but unknown if the nurse did anything about it and does not remember which charge nurse the incident was reported to. - He/she reported it to LPN B and the DON, but nothing was done about the incident. - He/she did not remember the date. During an interview on 2/22/22 at 12:40 P.M., the DON said: - 2/20/22 Resident #3 reported that Resident #1 was in his/her room, shut the door behind him/her, blocked the door and touched his/her right breast. - The DON called the sheriff's department to make a report. - Resident #1 was placed on one on one monitoring shortly after the incident with Resident #3 and remained one on one since that time. - He/she denied that staff have reported incidents of sexual abuse in the past to him/her. During interviews on 2/23/22 at 1:08 P.M. and on 2/24/22 at 12:50 P.M., the administrator said: - She expected the staff member who had been told of abuse to report it to the charge nurse and the administrator immediately. - After the incident on 2/20/22, Resident #1 was placed on one to one observation and will remain that way until he/she is placed in another facility. - She expected the nurses to improve upon their documentation of resident behaviors. - If a resident had a behavior, the nurse is supposed to document a clinical note which triggers a prompt within the electronic medical record for the nurse to begin behavioral documentation. - The nurses are supposed to notify the PCP and the mental health doctor when there is a behavior that is out of the ordinary. During an interview on 2/24/22 at 1:16 P.M., Resident #1 said: - He/she had been touching the breast of Resident #2 and Resident #3 a couple of times per week for about a year. - Resident #3 had never said no, until this last time that happened a couple of days ago. - He/she has touched Resident #2 a time or two and he/she pushed him/her away. - The staff are not around when this happens, but he/she had done this in the hallway and the short hall way. During an interview on 3/1/22 at 2:26 P.M., the PCP said: - He/she had the expectation that the facility staff would report sexual abuse to him/her right away. - He/she expected the facility staff to physically distance the resident's involved in the sexual abuse. - The facility staff have not notified him/her of any incident regarding sexual abuse with Resident #1 prior to 2/1/22. - Resident #1 was admitted to the facility with the order for medroxyprogesterone. - Medroxyprogesterone is primarily given to male patients to curb sexually inappropriate behaviors. MO197471 NOTE: At the time of the abbreviated 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 visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation.

Based on observation, interview, and record review, the facility failed to provide protective oversight and supervision for one of three sampled resident's (Resident #1), who had a history of [REDACTED]. The sheriff found the resident 4.25 miles from the facility walking down the highway at 1:15 A.M., in the dark. The facility census was 55. Review of the facility's policy for elopement - missing resident guidelines, dated March 2015, showed: - Determine when the resident was last seen. - Notify all departments and begin a thorough search of the facility and grounds. - Notify the director of nursing (DON), administrator, physician, and the responsible party. - If absence exceeds 30 minutes, notify the local law enforcement. - When located, be certain to notify all appropriate people/agencies. - The policy did not indicate any timeframe in which staff should notify the appropriate people or agencies. Review of the facility's policy for resident smoking, dated March 2015, showed: - The facility shall establish and maintain safe resident smoking practices. - Any smoking-related privileges, restrictions, and concerns (need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. - Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking according to the facility smoking schedule. Review of the undated south smoking schedule assigned department to supervise showed: - 7:00 A.M. maintenance; - 8:30 A.M. housekeeping; - 10:30 A.M. laundry; - 1:00 P.M. social services; - 3:00 P.M. certified nurse aide (CNA); - 6:30 P.M. CNA; - 9:00 P.M. certified medication technician (CMT). 1. Review of Resident #1's admission elopement/wandering assessment form, dated 1/19/17, showed the resident at risk for elopement. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/17, showed: - Moderate cognitive impairment; - Felt down, depressed or hopeless nearly every day; had trouble falling asleep or staying asleep; - Wandering not present; no prior assessment to compare wandering behaviors to; - [DIAGNOSES REDACTED]. Review of the care plan, updated 2/17/17, showed staff listed a problem of being at risk for elopement due to the resident's desire to return home and his/her cognitive deficit, with a goal of remaining safe over the next 90 days. Staff listed the following approaches implemented on 1/31/17: - Allow resident to voice feelings and fears; - Staff education on icons on the door; - Keep guardian and physician informed of his/her desire to return home; - Monitor whereabouts at all times; - Picture and brief description of resident in elopement risk book; - Provide emotional support and socialization; - Remind the resident of the need to stay in the facility unless accompanied by a staff member. Review of the psychiatrist's admission assessment, dated 2/26/17, showed: - The resident admitted from another facility after he/she eloped. - Safety concern: resides on the secured unit and has a history of elopement. Review of the resident's nurse's notes dated 3/4/17, showed staff documented they observed the resident attempting to climb out the window in his/her room. The resident placed on 15 minute observation. Review of the resident's care plan showed staff did not develop new approaches or interventions to address the resident's recent elopement attempt on 3/4/17. During an interview on 7/31/17 at 3:15 P.M., the DON said: - Staff nailed the resident's window shut after he/she attempted to climb out of the window on 3/4/17. - Resident placed on 15 minute observations for 72 hours. - The 15 minute observations were discontinued after the 72 hours and no further attempts of eloping. Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - [DIAGNOSES REDACTED]. - No wandering behavior exhibited. Review of the resident's quarterly elopement/wandering assessment form, dated 5/4/17, showed: - The resident at risk for elopement. - No documentation of the attempt to climb out of the window on 3/4/17. Review of the resident's nurse's notes dated 6/13/17, showed: - The MDS coordinator (MDSC) took the residents from the secured unit to an unsecured smoke area at 9:00 P.M. for the scheduled smoke break. - MDSC turned to open the door to the facility on ce everyone had finished smoking and Resident #1 opened the gate and ran down the driveway. - CNA A was exiting the building and redirected the resident back into the facility. - Resident placed on 15 minute observation. - Responsible party and physician on-call notified. Review of the care plan updated 6/13/17, showed the resident placed on 15 minute observations. The plan did not indicate how long staff needed to do 15 minute observations and did not list any other approaches or interventions to keep the resident from attempting to elope. Review of the resident's nurse's notes dated 6/15/17, showed staff documented the resident had no further behaviors or elopement attempts and they discontinued the 15 minute observations. During an interview on 8/1/17 at 11:35 P.M., the MDSC said: - He/She did not know the resident attempted to elope prior to 6/13/17. - He/She did not know anything about the resident's attempt to leave the facility through his/her window on 3/4/17. - He/She reviews nurses' notes to assist in the completion of the care plan and MDS. - He/She relies on staff to inform him/her of change in the resident's condition or an elopement attempt. - On 6/13/17, he/he took the residents on the secured unit to the unsecured smoke area for the 9:00 P.M. smoke break. - Resident #1 shows a flat affect and rarely talks with staff or other residents. - Resident #1 exited out the gate and began running down the driveway when he/she turned to open the door for the residents to return into the facility. - CNA A was leaving the facility and assisted the resident into the facility and notified the DON, physician, and responsible party. During a telephone interview on 8/3/17 at 10:15 A.M., CNA A said: - On 6/13/17, he/she had finished his/her shift and was leaving the facility. - He/she saw Resident #1 running down the driveway of the facility after exiting the gate of the unsecured smoke area. - He/she assisted MDSC in redirecting the resident back into the facility. - He/she did not know anything about the resident ever attempting to exit the building prior to 6/13/17. - Staff can look at the care plans at the nurses' station or on the electronic chart to know how to provide care to the resident. - Staff communicated significant changes and elopement attempts verbally during shift change and monthly staff meetings. Review of the resident's nurse's notes dated 7/30/17 at 7:16 A.M., showed: - At 12:30 A.M., Licensed Practical Nurse (LPN) A received report from CNA B and CNA C that Resident #1 was not in his/her room or bathroom and no door alarms sounded. - Staff searched the facility and the grounds. - LPN A notified the DON, administrator, and the sheriff's department. - The facility received a call from the sheriff's department at 1:15 A.M., that Resident #1 had been found walking down the highway. - Resident #1 assessed and placed on 1:1 (one on one) observation. - Responsible party and physician notified. Observation and interview on 7/31/17 at 1:00 P.M., Registered Nurse (RN) A said: - Resident #1 shows a flat affect and does not speak to him/her. - He/she did not know about Resident #1 attempting to elope prior to 7/29/17. - Staff look at the care plans at the nurses' station or on the electronic chart to know how to provide care to the resident. - Staff know of significant changes and elopements through verbal report and shift change. - After Resident #1 eloped on 7/29/17, staff were only instructed to take all residents in the facility to the secured courtyard area to smoke with two staff members at all times. Review of the care plan, updated 6/13/17, showed staff did not implement any new approaches or interventions after the resident eloped from the facility on 7/29/17. Observation with RN A on 7/31/17 at 1:00 P.M., showed no care plan books located at the nursing station. RN A attempted to locate the care plans in the facility's electronic medical record system, but could not locate them there either. During an interview on 7/31/17 at 1:30 P.M., Resident #1 said: - On 7/29/17, he/she went outside to the unsecured smoke break area with CMT A and other residents for the 9:00 P.M. smoke break. - CMT A opened the door after the break and helped other residents back into the building and left him/her outside. - He/she wanted to go back home, opened the gate, and started walking down the highway towards home. - He/she had eloped from another facility in his/her home town and that is why his/her family will not allow him/her to live alone. - The resident repeatedly said he/she wanted to go home. Observation on 7/31/17, showed the area the resident was found, by the sheriff office, on a two lane highway with a posted speed limit of 55 miles. During an interview on 7/31/17 at 1:50 P.M., CNA D said: - The resident stays in his/her room and does not speak to others. - He/she assists residents on the secured unit during smoke breaks. - Did not know anything about Resident #1 attempting to elope from the facility prior to 7/29/17. During an interview on 7/31/17 at 2:00 P.M., Housekeeper A said: - He/she assists residents on the secured unit during smoke breaks at 7:00 A.M. and 8:30 A.M. - He/she did not know anything about Resident #1 attempting to elope from the facility prior to 7/29/17. During an interview on 7/31/17 at 2:10 P.M., CMT A said: - On 7/29/17, he/she took the residents from the secured unit to the unsecured some area for the 9:00 P.M. smoke break. - The residents preferred to smoke in the unsecured area due to a shorter distance to walk. - After all the residents finished smoking, he/she assisted them back into the building. - He/she looked around the smoke area, did not see anyone else outside and assumed everyone had returned into the building. - He/she believed Resident #1 was the 3rd person back into the building. - Resident #1 must have left the unsecured smoke area without him/her being aware, since the resident had been found on the highway 4.25 miles from the facility at 1:15 A.M - Staff had no monitoring system for counting the residents who entered and left the building during smoke breaks. - He/she did not know Resident #1 had attempted to elope prior to 7/29/17, but had heard that he/she might have tried to elope one other time during a smoke break. - The resident has a flat affect and rarely speaks to staff or other residents. During an interview on 7/31/17 at 4:05 P.M., the resident's physician said: - He/she expects staff to provide a safe and secure environment for the residents in the secure unit. - A conference meeting needs to occur, to include all departments, to discuss how Resident #1 is getting out of the facility and what interventions should be put in place. - He/she did not know about the resident eloping or attempting to elope prior to 7/29/17. Observation and interview on 8/1/17 at 11:00 A.M., RN B said: - Resident #1 displays a flat affect, wants to go home, and stays in his/her room. - He/she did not know about the resident eloping or attempting to elope prior to 7/29/17. - Staff know how to care for the residents by the care plans at the nurses' station and through verbal report during shift change. - RN B could not locate the care plan books at the nurses' station and could not locate the care plans in the e-chart. - All residents in the secured unit are considered an elopement risk. - He/She did not know why the residents on the secured unit smoked on the unsecured smoke area, but knew the lock on the courtyard gate had a history of [REDACTED]. During a telephone interview on 8/1/17 at 4:30 P.M., CNA B said: - On 7/30/17 at 12:00 A.M. bed checks, Resident #1 was not in his/her room or bathroom. - CNA B and CNA C began looking for the resident and notified the charge nurse. - No door alarms sounded during the evening. - He/she thought Resident #1 had been in his/her chair around 10:00 P.M., but was unsure. - The sheriff's department found the resident 4.25 miles away from the facility walking on the side of the highway. During a telephone interview on 8/2/17 at 9:55 A.M., LPN A said: - He/she was on the north hall on 7/30/17 at 12:30 A.M., when CNA B informed him/her that Resident #1 was not in his/her bedroom or bathroom. - He/She had staff begin a search for the resident and he/she started the elopement protocol. - He/she notified the DON, administrator, sheriff's department, responsible party, and physician. - He/she last saw the resident when he/she administered the resident's bedtime medication at 8:30 P.M - The sheriff's department found the resident 4.25 miles from the facility walking on the side of the highway at 1:15 A.M - The resident returned to the facility at 1:40 A.M., the resident was assessed and noted to be anxious, alert and oriented, limp to the left foot, left wrist pink and not swollen. Resident reluctant to allow a thorough assessment. - The resident pleaded with the officer to take him/her home. - Physician ordered an X-ray of left foot and found nothing broken. - He/she placed the resident on 1:1 observation for 6 hours and then 15 minute observations. - He/she did not know about the resident ever attempting to exit the building prior to 7/30/17. During an interview on 7/31/17 at 3:15 P.M., the DON said: - Every resident on the secured unit is considered an elopement risk. - Staff should place a resident on 15 minute observation when an elopement attempt occurs until 72 hours and no further attempts. - Staff should update care plans with new interventions with a significant change or elopement. - Staff should ensure all residents are accounted for on the secured unit when leaving and entering the building. During an interview on 8/1/17, at 11:35 P.M., the MDSC said: - Every resident on the secured unit is considered an elopement risk. - An elopement/wandering assessment is completed on all new admissions and quarterly. - He/she reviews nurses' notes to assist in the completion of the care plan and MDS. - He/she relies on staff to inform him/her of change in the resident's condition or an elopement attempt. - Care plans and elopement risk assessments should be updated upon an elopement attempt and significant changes. - Staff provide care to the residents and receive information on how to provide care for them through verbal report during shift change and through the care plans located at the nurses station and electronic medical record. During an interview on 8/1/17, at 12:30 P.M., the cooperate nurse said: - He/she did not know about Resident #1 attempting to elope from the facility prior to 7/29/17. - Staff should update care plans with new interventions with a significant change or elopement. - All the residents on the secured unit are considered an elopement risk. During an interview on 8/1/17, at 12:40 P.M., the administrator said: - Every resident on the secured unit is considered an elopement risk. - Staff should place a resident on 15 minute observation when an elopement attempt occurs until no further attempts. - Staff should update care plans with new interventions with a significant change or elopement. - She did not know why staff take the residents on the secured unit to an unsecured smoke area. - Staff should ensure all residents are accounted for on the secured unit when leaving and entering the building. - Staff provide care to the residents and receive information on how to provide care for them through verbal report, during shift change, and through the care plans located at the nurses station and electronically. MO 3 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observations, record review, and interviews completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility had ensured the residents on the secured unit smoked in the secured courtyard and were monitored by two staff members. The courtyard gates will be checked by the charge nurse or designee before and after each smoke break to ensure the gates remain secure. Staff will do a head count to ensure all residents are accounted for after the break. All residents were reassessed by the Elopement/Wander Assessment tool to identify others who may be at risk for elopement. After staff receive shift report, charge nurses will meet with the direct care staff to communicate any resident-specific issues necessary for safety. A 5-minute report form will be utilized for report to the direct staff for on-going communication to other shifts, and will be maintained readily available for staff. The facility began in-servicing all staff on the elopement policy, accounting for each resident, and resident smoking. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity level was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. ******************** The facility was found to be in substantial compliance during a re-visit conducted on 9/25/17 by Sue Johnson FS II.

Based on record review, observation and interview the facility failed to identify, develop and implement appropriate interventions to assist two residents (Resident #2 and #5), who voiced fears about one resident (Resident #3) who was verbally and sexually inappropriate towards them. Staff failed to assure residents were able to maintain their highest level of mental and psychosocial functioning. Staff failed to provide appropriate intervention for one resident (Resident #1) who stole medications from the facility medication cart and hoarded the medication and continued the behavior after the behavior was identified by facility staff. The facility census was 54. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 2/6/15, showed: - Resident's scored a 13 on his/her brief interview for mental status (BIMS), indicating the resident was cognitively intact. During an interview on 2/19/15, at 2:15 P.M., the resident said: - He/she felt scared of Resident #3, who made frequent sexual comments when he/she walked by the resident's room and in common areas; - Resident #3 blocked him/her in his/her bedroom with a wheelchair and stared at him/her; - Resident #3 would not move until he/she yelled for help and another resident came and told Resident #3 to move; - Resident #3 exposed him/herself to others by showing his/her genitals when others walked by Resident #3's room; - He/she reported concerns about Resident #3 to staff but staff did not seem to care. 2. Review of Resident #5's MDS dated [DATE], showed: - BIMS score of 15, indicating the resident's cognitively intact. During an interview on 2/17/15, at 12:30 P.M., the resident said: - He/she felt terrified of Resident #3; - He/she walked the halls of the facility daily for exercise and Resident #3 exposed him/herself to others by showing his/her genitals; - Resident #3 used to live in the room directly across from him/her and he/she did not have anyway to avoid seeing Resident #3 exposing him/herself when he/she went to his/her own room; - Resident #3 made cat calls when he/she walked to his/her own room or by the resident's room; - Resident #3 wrote stacks of letters about sexual things and gave the letters to the Director of Nursing (DON); - The DON let him/her read the letters and they were so disgusting he/she stopped reading them; - He/she wanted to see what kind of pervert he/she lived with; - He/she felt terrified Resident #3 would try and come in his/her room and do something sexual to him/her in the middle of the night when nobody would know; - He/she told the DON and the DON told him/her to yell and turn on his/her call light; - He/she could not sleep at night because of nightmares about Resident #3; - Staff told him/her Resident #3 did have the right to do whatever he/she wanted in his/her own bedroom; - The DON told him/her just to ignore Resident #3's behavior; - Staff moved Resident #3 to another room a few months ago, but Resident #3 continued to expose him/herself in that room with the door open; - He/she walked by Resident #3's room a few days ago, when exercising and Resident #3 had his/her genitals exposed to anyone who walked by; - He/she still felt terrified of Resident #3. 3. Review of Resident #3's care plan dated 8/21/14 showed: - Displaying sexual behaviors toward females; - Fifteen minute checks as needed; - Allow him/her to voice feelings and concerns without judgment; - Encourage to discuss feelings about sexuality with appropriate staff; - Redirect to room when inappropriate; - Remind the resident he/she can not touch others without permission; - Encourage resident to use a lap blanket while up in his/her wheelchair. During an interview on 2/19/14 at 11:30 A.M., the DON said: - Resident #2 and Resident #5 did complain about Resident #3's behavior; - She did tell Resident #5 to turn on his/her call light if Resident #3 tried to come in his/her room; - She did not have concerns that Resident #3 would go into Resident #5's room because Resident #3 was a large person and dependent on a wheelchair for mobility; - Resident #3 did expose him/her self to other residents in his/her bedroom; - Resident #3 wrote stacks of sexual letters about female residents; - The letters were so graphic they were difficult to read; - She did let Resident #5 read the letters, but they were so graphic Resident #5 only read a little bit and said he/she could not read anymore; - Resident #5 wanted to know what kind of pervert they were dealing with; - She did move Resident #3 to another room in September 2014, after the resident said; he/she felt like the female resident's were taunting him/her when they took a shower at night and walked back to their bedrooms; - Resident #3 said he/she knew the female residents were naked under their pajamas and he/she wanted to grab them; - She did not know of any interventions the facility provided the female residents who were affected by Resident #3's behavior. 4. Review of Resident #1's care plan dated 12/4/14, showed: - History of verbal and physical outburst related to a mood disorder; - Risk for elopement related to desire to live at home; - Remind the resident he/she is to stay inside the facility; - Risk for harm, related to the use of smoking material; - Keep smoking materials in a secure place at the nurses' station or medication room. Review of the short term guardian directive completed 12/15/14, showed: - Problems included loaning cell phone to others who did not have phone privileges, tobacco use, isolating in room and eating in room; - Interventions included limiting loaning of cell phone, no tobacco in room; - Update 1/22/15, resident must be supervised at all times and can not leave the facility except for doctor appointments. Review of the incident report dated 12/20/114, showed: - Items found in the residents room included alcohol pads, two cans of chewing tobacco, tobacco found in cereal, four safety razors and medications including [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (muscle relaxer and [MEDICATION NAME] (antianxiety). Review of the residents Physician order [REDACTED]. - [DIAGNOSES REDACTED]. Review of the psychologist notes dated 1/18/15, showed: - Resident's reasoning for stealing medications were manipulative in nature; - Staff encouraged to take the resident's threats seriously. During an interview on 2/17/14, at 2:00 P.M., Resident #2 said: - He/she saw Resident #1 hide two empty medication bubble packs in the hall; - He/she gave the empty bubble packs to facility staff; - Resident #1 stole medications from the medication cart and hid the medication in his/her room; - Resident #1 even spit his her crushed medications in cups and froze the medications in a cup; - Resident #1 kept razors and tobacco in his/her room; - Staff found the items after they searched Resident #1's room, after he/she gave them the empty medication bubble packs; - After he/she gave the empty bubble packs to staff, Resident #1 told him/her to stay out of his/her life, or he/she would be [***] ing sorry; - Resident #1 would let other residents use his/her phone and after they used the phone, Resident #1 would ask for favors from the residents who used his/her phone; - He/she held Resident #1's body up, one day during a smoke break because the resident seemed so sedated; - Staff assisted Resident #1 back to his/her room after the break and did not seem concerned; - Resident #1 frequently seemed sedated and on some kind of drugs; - He/she felt scared of Resident #1. During an interview on 2/19/14 at 11:30 A.M., the DON said: - Resident #1 did steal medications, including narcotics that belonged to other residents off the facility medication cart; - Staff could not identify all of the medication but knew they belonged to other residents, and she had an entire bottle full of medications they found in the resident's room; - The facility did find razors and tobacco in the resident's room; - The resident even stole a small purse from a female resident and filled it with tobacco and put it under the facility vending machine; - Housekeeping found the purse when they swept under the vending machine; - She thought the resident would let other residents use his/her cell phone and then ask for favors in return; - She did not think any of the other residents gave him/her their medications; - When she asked the resident why he/she stole the medications, the resident said he/she stole the medications, to show the facility how smart he/she was and how dumb the facility staff were; - They did not know how the resident got the medications off the medication cart; - The empty bubble packs had other resident names on them; - Facility staff did allow the resident to go out of the facility with his/her family for Christmas after the incident; - The resident went to the hospital on [DATE], after the resident said he/she did have the means to hurt other residents and him/herself and if staff did not send him/her out he/she would; - When she called report to the receiving facility, the nurse told her that they found dozens of pills in the resident's socks after he/she arrived at their facility; - Because the resident was a sociopath with a criminal mind, the resident did out-think the facility staff and put others at risk for danger. MO 0

Based on interview and record review, the facility staff failed to thoroughly assess and intervene when one of three sampled residents (Resident #1) displayed signs and symptoms of a significant change in condition. The resident fell on [DATE], and sustained a head injury. On [DATE], the resident started vomiting, became lethargic and non-responsive. Facility staff failed to notify the physician when the resident developed headaches, nausea, vomiting and became non-responsive. The facility sent the resident to the hospital on [DATE], and he/she was diagnosed with [REDACTED]. The resident died [DATE]. The facility census was 57. 1. Review of the facility's policy titled Condition Change, Resident (observing, recording, and reporting) included fall or injury, dated [DATE], showed the purpose of the policy was to observe, record and report any condition change to the attending physician so that proper treatment can be implemented. The guidelines showed after all resident falls, injuries or changes in physical or mental function, monitor the following: - Observe and inquire if resident has a headache or pain - Observe for personality changes - Observe for alterations in consciousness - Observe for incontinence - Observe for sensory disorder - Observe for generalized weakness - Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director for emergency situations. Complete an incident, accident, or risk management report per facility guidelines. Notify resident's responsible party. Monitor resident's condition frequently until stable. Review of Resident #1's nurses' notes dated [DATE], at 10:45 A.M., showed Resident #1 was in an altercation with another resident. The other resident pushed Resident #1 and he/she fell on floor. The resident hit the right side of his/her head and had a laceration with a raised bump on the right side of his/her head. The nurse documented he/she cleansed the laceration with wound cleanser and applied triple antibiotic ointment. The nurse called the resident's family (who is the resident's legal guardian) and faxed the physician regarding the resident's fall. The nurse documented he/she started neurological checks (assessments performed to determine if the resident had a head injury, which included vital signs, checking level of consciousness, pupil response, motor function, pain response, and observation of the resident). Review of Resident #1's current Minimum Data Set (MDS), a federally mandated resident assessment completed by facility staff, dated [DATE], included the following information: - Brief Interview for Mental Status (BIMS) score of 15 (a score of 15 indicates the resident is cognitively intact). - The resident was independent with all activities of daily living, including bed mobility, transfers, walking in room, eating, and toilet use. - The resident was not steady but he/she was able to walk with a walker. - Occasionally incontinent of urine and never incontinent of bowel. - had a history of [REDACTED]. Review of the resident's nurse's note, dated [DATE], at 3:30 A.M., showed the resident was resting well. Right eye remains bruised deep purple, bump remains to back of head. Neurological checks within normal limits. Review of nurse's notes, dated [DATE], at 1:52 P.M., the Director of Nursing (DON) wrote the resident's physician saw the resident and reviewed the resident's chart and medications without giving any new orders. Review of the physician progress notes [REDACTED]. eyes. The physician documented the resident was alert and oriented to person, place and time. The resident was well-groomed and cooperative. The physician wrote "head - contusions face and head." Review of the resident's medical record showed no nurses's notes from [DATE], until [DATE]. Review of nurses notes, dated [DATE], at 2:30 P.M., showed the staff received an order for [REDACTED]. Review of the Medication Administration Record [REDACTED].M. for headache. She then documented there was not relief. On [DATE], at 3:05 A.M., the DON documented she gave the resident another dose of Tylenol for a headache. She documented at 4:00 A.M., the resident was sleeping. Any other Tylenol given during the month was for general pain or bilateral knee pain. During an interview on [DATE], at 9:50 A.M., the DON said she worked the night shift on [DATE]. The DON said she gave the resident Tylenol twice during that shift because the resident complained of a slight headache. The resident was alert and oriented. The resident was also anxious that night so the DON also gave the resident an anti-anxiety medication with the second dose of Tylenol. The resident was incontinent a couple of times during the night but the aides told the DON this was not unusual. The resident was able to walk to the bathroom independently. Review of nurses notes, dated [DATE], at 4:00 P.M., showed the resident saw his/her physician. New orders written to discontinue one stomach medication and ordered a different one. The nurse documented he/she called the resident's family with UA results and new medication orders. During an interview on [DATE], at 11:10 A.M., Physician A said he/she did not see Resident #1 on [DATE]. He/she checked his/her records and was able to verify he/she did not see the resident on that day. The physician said he/she made a progress note whenever he/she saw a resident and if there was not a note, then he/she did not see the resident. Review of the resident's medical record showed there was not a physician's progress note dated [DATE]. Review of the MAR indicated [REDACTED]. During an interview on [DATE], at 1:55 P.M., Certified Nurse Aide (CNA) A said he/she took care of Resident #1 two days before the resident went out to the hospital, which was [DATE]. He/she worked the evening shift. The resident put his/her call light on and when the CNA got to the room, the resident projectile vomited into the trash can. The resident probably threw up five or six times that evening. The resident eventually became non-responsive. The CNA said he/she told the charge nurse, Licensed Practical Nurse (LPN) B, about the resident throwing up. The nurse did not go to check on the resident until after the aide told the nurse he/she could not get the resident back into bed. The resident was sitting up in his/her recliner. The resident was normally independent with all cares. LPN B went to see the resident toward the end of the shift at about 9:30 P.M. LPN B called the resident's name, trying to get the resident to answer. LPN B said he/she thought the resident may have been faking. Normally the resident is on his/her call light every five minutes but that evening he/she did not use the call light except the first time he/she threw up. The resident first threw up after supper that evening. CNA A said he/she left about 10:00 P.M. and the resident was in bed asleep. He/she worked the day shift the next day and floated between the north and south halls that day. CNA A did not see the resident use his/her call light that day. During an interview on [DATE], at 2:55 P.M., CNA C said he/she worked the evening shift on [DATE], on the south hall. Normally Resident #1 was up and independent with his/her cares. When the CNA first came on duty, the resident was up and about on his/her own. The resident complained of a headache, but he/she had been complaining of a headache for about a week. When the CNA went into the resident's room, the resident would say his/her head was killing him/her. CNA C said he/she always told the charge nurse when the resident complained. He/she did not know if the nurse gave the resident anything for the headache. On the evening of the 17th, the resident complained of being nauseated early in the shift. The resident did not come out to supper but he/she had a room tray. The aide said the resident did not eat much of his/her supper. After supper, the resident said he/she vomited. The CNA did not see him/her vomit but CNA A said he/she saw it and it was projectile vomiting. As the evening progressed, the resident became more out of it. He/she was sitting up in the recliner with his/her head slumped to the side. The resident was incontinent of both bowel and urine. This was very unusual. The resident was non -responsive and the two aides had to physically lift the resident to put him/her to bed. The resident could not stand at all. CNA C said he/she had never seen the resident like this before. The aide said he/she went and told LPN B and LPN B said okay, he/she would check on the resident in a little bit. LPN B said he/she thought the resident was playing it up so the resident could get attention. LPN B did go check on the resident one time, later in the shift. During an interview on [DATE], at 2:10 P.M., Certified Medication Technician (CMT) A said he/she took care of Resident #1 after the resident's [DATE], fall. The resident had a lot of bruising all over his/her face after the fall. The resident complained a lot about having a headache. The resident would say, "my head hurts." CMT A said he/she told the nurses because the nurses are the ones who have to give all as-needed (PRN) medications. On the evening of [DATE], the resident seemed fine the first part of the shift but then he/she started throwing up. The CMT said it scared him/her when the resident vomited. The resident threw up his/her bedtime medications. The resident complained of a stomach ache and seemed pretty alert and oriented. The CMT said he/she wondered if the resident had the stomach flu because some of the other residents had the flu. CMT A said he/she told LPN B Resident #1 threw up his/her bedtime medications. The nurse went and checked on the resident after the CMT told him/her about the resident vomiting. CMT A said he/she also worked on [DATE]. The resident was not him/herself. The resident stayed in bed and did not get up for any meals. Normally the resident could tell everything that was going on and knew the CMT by name. On the 18th, the resident did not know the CMT's name and just slept most of the day. That was very unusual for the resident. The CMT said he/she could not get the resident to take any of his/her medications so the aide had to get LPN A to give the medications. He/she could not get the resident awake enough to take his/her medications. LPN A actually got the resident to take the medications. When the aide worked again on the morning of [DATE], the resident was the same as the day before. The resident did not go to breakfast on [DATE]. During an interview on [DATE], at 9:10 A.M., LPN B said he/she worked on the evening of [DATE], as the charge nurse. Resident #1 is normally alert and oriented. The resident could be a pain at times because he/she was obsessive about things. He/she used his/her call light frequently and would come to the nurses' station and want to call his/her family. On [DATE], one of the aides came to the nurse and said the resident was throwing up. He/she went down to the resident's room and all he/she saw was the resident hacking up phlegm. LPN B said he/she did not think the resident complained of a headache. He/she took the resident's temperature and it was fine, but he/she did not think he/she wrote the temperature down anywhere. The resident was awake on [DATE]. The aides never told him/her they had to lift the resident into bed or tell him/her the resident was incontinent of urine or bowel movement. The resident was occasionally incontinent of urine but not bowel. LPN B worked until the morning of [DATE]. Every time he/she checked on the resident during the night, the resident was sleeping. The resident was pretty quiet which was unusual, but LPN B thought the resident was coming down with the flu. He/she told the day shift on [DATE], that the resident had a quiet night but was not feeling too good. LPN B said he/she did not document about the resident vomiting but realized he/she should have. LPN B said he/she knew it was bad on his/her part. During an interview on [DATE], at 8:35 A.M., CNA D said he/she worked the day shift on [DATE], on the south hall. The only thing the previous shift told him/her in report that morning was that the resident was dry all night. Normally, Resident #1 was feisty, asking for help to get his/her clothes out, to go to the bathroom and to get a rag for his/her face in the mornings. The resident did not normally stay in bed all day. He/she got up and walked around in his/her room. He/she would occasionally go to the dining room, but usually ate in his/her room. He/she frequently used his/her call light, sometimes every five to ten minutes. The first time the aide saw the resident on [DATE], was when he/she took the resident's breakfast tray into the resident's room. CNA D said he/she tried to get the resident up but the resident would not move. The resident opened his/her eyes a little but then closed them right back. This was very unusual for this resident. The resident did not talk to the aide and normally the resident would talk to him/her. The resident did not eat or drink anything for breakfast that day. The CNA said he/she tried to feed the resident some but he/she could not get the resident to open their mouth. Normally the resident fed him/herself. The aide said he/she told LPN A the resident would not eat or drink anything for breakfast and would not wake up. LPN A said he/she would go check on the resident. The aide did not know if the nurse went and checked on the resident. About 9:00 or 10:00 A.M., CNA D went to the resident's room to turn and reposition him/her. He/she was dry at that time. The resident was usually continent and would get up and go the bathroom on his/her own. The aide said he/she told LPN A again that the resident was not acting like him/herself. CNA D said he/she took the resident's lunch tray into the resident's room. The resident still did not eat or drink and still did not speak to the aide. The resident did open his/her eyes a little bit. At 1:00 P.M., the aide checked the resident and he/she was wet, so the aide cleaned him/her up and turned and repositioned him/her. The resident was like dead weight when they moved him/her. The aide did not think the resident had the flu because all of the other residents could still get up and about when they had the flu and were responsive. CNA D said he/she gave report to the evening shift and told them the resident did not eat breakfast or lunch, he/she would not get up, and they needed to reposition him/her. During an interview on [DATE], at 2:45 P.M., Nurse Aide (NA) A said Resident #1 was normally awake and talking and he/she used his/her call light a lot. NA A said he/she worked [DATE] on the evening shift. He/she normally gets report from the aides on the previous shift, but he/she did not get told anything about Resident #1 that day. The resident spent the whole day in bed which was very unusual for him/her. The resident did not go to supper that evening. The resident got a room tray but only ate about two bites. The resident was pretty sleepy and he/she was incontinent which was unusual. The NA said he/she told the nurse the resident was not acting right and that the nurse needed to check on the resident. He/she did not know if the nurse went to see the resident. Resident #1 did tell NA A that his/her head hurt and the aide said he/she went and told the nurse this also. The resident complained twice about having a headache during his/her shift. Review of the Activity of Daily Living (ADL) charting, completed by the aides who provided care for the resident, showed prior to [DATE], the resident was independent with all cares. On [DATE], the aides documented the resident required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. During an interview on [DATE], at 8:15 A.M., LPN A said he/she worked [DATE], on the day shift. He/she did not see Resident #1 that day until about 1:30 P.M. The resident was tired. The resident would open his/her eyes but did not speak to the nurse. LPN A had trouble getting the resident awake to take one of his/her medications, so he/she did not give it. No one reported to him/her the resident had been vomiting. That would have been a reason to call the physician. If he/she had gotten report on this resident, he/she would have checked on the resident earlier in the day. He/she said the aides never came and told him/her the resident was not doing well. Normally, Resident #1 was alert and oriented. LPN A said he/she knew something was going on. LPN A said he/she thought the resident might have the flu. He/she did not call the physician but passed information about the resident on to the next shift. He/she told the evening shift nurse in report that the resident was lethargic. LPN A said he/she took the resident's vital signs about 1:45 P.M., but he/she did not document them anywhere. He/she passed them on to the evening shift nurse. LPN A said he/she did not have time to chart on residents. During an interview on [DATE], at 9:10 A.M., LPN B said when he/she came to work on the evening of [DATE], at 6:00 P.M., the day shift nurse said the resident had been quiet all day and that the resident did not eat breakfast or lunch. LPN B said he/she should probably have called the physician at that point. He/she did not remember when he/she first saw the resident that evening. He/she knew that he/she did not see the resident at the beginning of the shift. When he/she knew residents were not feeling well, the nurse said he/she guessed he/she should go check on the residents. LPN B said he/she did not chart about the resident on [DATE]. The nurse said he/she did check on the resident and checked the resident's vital signs. The resident had a temperature of 101 something. The nurse thought he/she wrote it down but not sure where he/she wrote it. The nurse gave the resident a Tylenol rectal suppository because the resident would not even take any water by mouth. That was unusual for the resident to not be able to drink. The aides were trying to drip water into the resident's mouth using a straw. LPN B still thought the resident might have the flu. LPN B said none of the other residents who had the flu became as debilitated as Resident #1. On the morning of [DATE], LPN B said he/she gave report to the day shift nurse. He/she told them the resident ran a temperature and he/she gave Tylenol rectal suppository to the resident and the temperature came down. LPN B said he/she did not chart anything that night about the resident not taking oral medications or not being able to drink. During an interview on [DATE], at 2:30 P.M., CNA B said he/she worked on [DATE], the day Resident #1 went out to the hospital. The resident stayed in bed all day. He/she usually went to the bathroom but on that day, the aide said the resident was incontinent and the aide had to clean him/her up. The resident usually talked to the aides, but he/she did not talk on that day. The resident would only open his/her eyes to slits and really did not wake up. The resident did not eat breakfast that day. Another aide said in report that the resident ran a temperature in the night and had been incontinent. The aide checked on the resident about 12:00 P.M. and turned the resident to clean him/her up. As he/she turned the resident, he/she bumped the resident's knee and the resident did not respond. The aide said the resident would normally have yelled at the aide. The aide said he/she went and told LPN A the resident was still not responding and the nurse went down and checked on the resident. During an interview on [DATE], at 8:15 A.M., LPN A said he/she worked [DATE], on the day shift. He/she got report that morning from LPN B who said Resident #1 had a low grade temperature and LPN B said he/she gave the resident Tylenol. The first thing LPN A did that morning was go check on the resident. He/she took vital signs but did not remember if he/she documented them anywhere. He/she remembered the vital signs were stable because he/she remembered comparing them to the ones he/she took in the afternoon. The resident was awake but lethargic. LPN A said he/she had to do a sternal rub to wake the resident up. Once in a while in the past, the resident was hard to wake up, but normally he/she was easily awakened. LPN A did not call the physician that morning because he/she still thought the resident might have had the flu. The LPN said he/she did not know the resident did not eat or drink anything on [DATE], but did know the resident did not eat anything on [DATE]. In hindsight, the nurse said he/she should have called the physician. LPN A said he/she never thought the resident was faking it. After lunch, when the nurse went to check on the resident, the resident's blood pressure was decreased and his/her pulse was elevated. LPN A said he/she could see a bump on the resident's forehead that was not there that morning. He/she had the RN on duty come check on the resident. They called the physician and got orders to send the resident to the hospital. LPN A said he/she knew signs of head trauma included nausea/vomiting and headaches. During an interview on [DATE], at 1:20 P.M., Registered Nurse (RN) A said he/she worked the day Resident #1 went out to the hospital. He/she worked on the north hall of the facility and the resident lived on the south hall. RN A said he/she went down to the south hall to get something. He/she had heard from the night shift nurse that the resident had a low grade temperature the night before. When he/she got down to the south hall about 12:30 P.M., LPN A said he/she wanted him/her to see Resident #1. RN A said he/she knew something was wrong as soon as he/she saw the resident. He/she had not seen the resident for a few days and the nurse said he/she knew the resident had not felt good for a day or two. The resident was just lying in the bed on his/her back. The resident did not talk to the nurse which was unusual. The resident opened his/her eyes just a slit. The nurse said he/she did not check the resident's pupil reaction to light. The nurse had the resident grab his/her fingers. The resident could grip with his/her right hand but could not grip with the left hand. LPN A said to look at the bump on the resident's head. The bump was about half the size of a golf ball. LPN A said that had not been there earlier in the day. The resident's heart rate was elevated. The nurses got orders to send the resident to the hospital. Review of the resident's nurses notes, dated [DATE], at 1:00 P.M., showed the nurse received an order via the telephone to send the resident to the emergency room (ER) due to lethargy, unresponsive state and temperature. Guardian contacted. At 1:40 P.M., the ambulance arrived to transport the resident to the hospital. The nurse documented he/she called and gave report to the emergency room nurse. During an interview on [DATE], at 1:00 P.M., Physician A said he/she saw Resident #1 on [DATE], and the resident was his/her normal self. The physician said he/she knew the resident was in an altercation with another resident. The resident's neurological signs were fine on [DATE]. On [DATE], the facility contacted the physician and said the resident had a significant mental status change. The physician gave the order to send the resident to the hospital. The physician said the facility should have notified him/her when the resident started having headaches, nausea/vomiting and decreased mental status. The physician said it was part of any head injury protocol to watch for signs of head trauma such as headaches, nausea/vomiting and decreased level of consciousness. He/she did not remember anyone from the facility contacting him/her on [DATE], with the resident's condition. The physician said head injuries can present with problems several weeks after the initial injury. Review of the nursing home to hospital transfer form, dated [DATE], showed the resident's primary [DIAGNOSES REDACTED]. Key resident clinical information showed non-responsive, lethargy, and temperature. At the time of the transfer, the resident's temperature was 97.9 degree Fahrenheit. Review of the SBAR (Situation, Background, Assessment, and Request) communication form, dated [DATE], showed the change in condition was the resident was lethargic, unresponsive, and had a knot on right temple and back of head. The resident had decreased consciousness and unresponsiveness. He/she also had weakness and decreased mobility. Under the assessment portion, the nurse documented the resident was lethargic, unresponsive, temperature, increased urine odor, and clammy. Nursing notes on the SBAR form showed the resident was non-responsive, had low grade temperature this morning. Gave Tylenol 650 milligram (mg) rectal suppository and the temperature came down. The resident still had bruising to the face from a fall. Also had a bump to head on temple and the back of the head on the right side. The resident had urine output one time this morning and it was a scant amount. Has not had a bowel movement today. Review of the ER record, dated [DATE], showed the chief complaint was respiratory distress, fever, and mental status change. The note showed the resident was at the ER from the nursing home with headache, lethargy, shortness of air, and bruising around the eyes. The ER [DIAGNOSES REDACTED]. Review of the hospital triage nurse assessment showed the report he/she received from the facility nurse showed the resident had a fever, congestion and mental status change/lethargy. The facility nurse told the triage nurse the symptoms started the morning of [DATE]. Review of the ER physician's record showed the resident's chief complaint was altered mental status, respiratory difficulty, fever, and head trauma two weeks ago. The local hospital transferred the resident to another hospital for neurosurgery (brain surgery) intervention for subdural hematoma. During an interview on [DATE], at 9:50 A.M., the DON said she monitored residents by looking at the 24-hour report sheets and getting report from the nurses. The DON said she did not know anything about Resident #1 vomiting on [DATE], and was not aware the resident did not eat or drink anything on [DATE]. The DON said she was not aware that LPN B gave the resident a Tylenol rectal suppository due to not being able to wake the resident. The nurses should have called the physician and the DON when the resident became non-responsive and if he/she was projectile vomiting. The staff should at the least have called her and asked what they should do. The DON said she did not know there were several residents with the flu and they should have notified the physician even if they thought it was the flu. All of the facility policies and procedures are kept at the nurses' stations, so the staff would have had access to the change of condition policy. The nurses should have been documenting in Resident #1's chart regarding his/her change in condition. 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 on [DATE], it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit of [DATE], the facility began reassessments of all residents currently residing in the facility to determine no residents were exhibiting signs and symptoms of a significant change in condition. On the same date, the facility began providing in-service education for all nursing staff on facility policies and protocols for assessing, recording, and reporting a change in a resident's condition. The facility's plan was for all nursing staff to be in-serviced prior to working their next shift. As of [DATE], the facility was still in the process of in-servicing their nursing staff and completing resident assessments. The facility DON/designee and administrator has started monitoring all falls and incidents that could result in a resident's change in condition to assure proper assessment, monitoring and physician notification. Over the next several weeks, the facility will assess staff performance and resident treatment through reviews and observations. 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 "G" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO