**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment by not maintaining the indoor air temperatures of resident rooms in the facility between 71.0 F. (degrees Fahrenheit) and 81.0 F. for 19 sampled residents on the east wing of the facility (Residents #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #18, #19, #20, #21, #22 and #23) with room temperatures ranging from 82.0 degrees Fahrenheit ( F.) to 90 F. The facility failed to have a comprehensive monitoring system including documentation of resident room temperatures and each resident's condition. The facility census was 69.The Administrator was notified on 6/23/25 at 5:15 P.M., of the Immediate Jeopardy (IJ) which began on 6/23/25. The IJ was removed on 6/24/25, as confirmed by surveyor onsite verification. Review of the facility's undated, Emergency Cooling Plan for the Facility showed the following:-A portable air unit will be installed in each occupied resident room on the East Unit, one portable air unit will be installed in the East Unit dining room, and one portable unit will be installed in the office area at the entrance of the East Unit;-Temperatures will be monitored and recorded by staff hourly in the resident rooms on the East Unit, the resident core area and resident dining room on the East Unit to ensure areas are between 71.0 F. and 81.0 F.;-If temperatures rise to 81.0 F staff will contact the administrator, Director of Nursing (DON), and the maintenance supervisor immediately and residents will be moved to the [NAME] Core and Dining areas temporarily while other emergency cooling measures are implemented.1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 5/29/25, showed the following:-The resident was cognitively intact;-The resident had diagnoses that included medically complex conditions, diabetes (a condition that occurs when your blood sugar is too high), congestive heart failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should and can cause shortness of breath with exertion), kidney failure, and coronary artery disease;-The resident required partial to moderate assistance from staff for transfers;-The resident used a wheelchair for ambulation.During an interview on 6/23/25 at 1:59 P.M., the resident said the following:-The air conditioning in the facility did not work;-Staff brought a portable unit to his/her room, but he/she did not remember when it was placed in the room;-As long as he/she sat fairly close to the air conditioning unit he/she was comfortable;-The portable air conditioning unit worked just ok.Observation on 6/23/25 at 1:59 P.M., showed the resident sat in his/her wheelchair in his/her room. The temperature in the resident's room was 88 F., taken with a dial stem thermometer, with a portable air conditioner in the room running and set at 72 F. Observation on 6/23/25 at 3:56 P.M., showed the following:-The resident sat in the common area watching television;-The common area temperature was 84 F., taken with a dial stem thermometer. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included CHF and diabetes;-The resident was dependent on staff for transfers;-The resident used a wheelchair for ambulation.During an interview on 6/23/25 at 1:42 P.M., the resident said the following:-He/She had a portable air conditioner in his/her room, but still got hot later in the day;-If staff left his/her door open it made the temperature rise in his/her room and staff did not always keep the door closed;-He/She was not able to get up on his/her own. Staff used a mechanical lift to get him/her out of bed;-He/She would prefer the temperature to be 72 F;-Staff had not offered to move the resident to another room.Observation on 6/23/25 at 1:42 P.M., showed the following:-The resident was in bed with no blanket or sheet on;-The resident's room had a portable air conditioner running with the temperature set at 73 F.;-The resident's room temperature was 78 F., taken with a dial stem thermometer. 3. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/13/25, showed the following:-The resident was cognitively intact;-The resident had diagnoses that included CHF, kidney failure, diabetes, dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning), and respiratory failure.During an interview on 6/23/25 at 1:24 P.M., Resident #9 said the following:-His/Her portable air conditioner said 61 F but it did not feel 61 F;-It took a lot to cool him/her down, he/she was hot natured;-He/She used a wheelchair and could not always get his/her room door shut when leaving the room and it caused his/her room to get hot;-Staff had not offered to move the resident to another room.Observation on 6/23/25 at 1:24 P.M., showed Resident #9's room was 80 F., taken with a dial stem thermometer. 4. Observation on 6/23/25 at 1:53 P.M., showed the following:-The east hallway for resident rooms 20-29 was 84 F., taken with a dial stem thermometer; -room [ROOM NUMBER] was the only unoccupied room on this hallway;-Two residents propelled their wheelchairs in the hallway; -A 30 (inch) pedestal fan blew air in the hallway.5. Observation on 6/23/25 at 1:57 P.M., showed the East Wing hallway for resident rooms 30-39 was 90 F., taken with a dial stem thermometer (no residents were present). Rooms 30, 31, 34, 35, 38, and 39 were occupied. 6. During an interview on 6/23/25 at 5:40 P.M., Resident #10 said his/her room was hot and uncomfortable.Observation on 6/23/25 at 5:40 P.M., showed the temperature in the resident's was 88 F., taken with a dial stem thermometer.7. Observation on 6/23/25 at 5:47 P.M., showed Resident #14's room temperature was 92 F., taken with a dial stem thermometer. 8. Observation on 6/23/25 at 5:58 P.M., showed Resident #6's room temperature was 80 F. taken with a dial stem thermometer. The resident was in bed asleep with a fan blowing on him/her9. Review of Resident #19's quarterly MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included cancer, stroke, and medically complex conditions.During an interview on 6/23/25 at 6:08 P.M., Resident #19 said the following: -His/Her room, had been warm;-He/She would like to move to a room that was not as warm;-Staff had not offered to move the resident to another room. Observation on 6/23/25 at 6:08 P.M., showed the resident's room had two fans that blew air, the portable air conditioning unit was running and set at 61 F.; the room temperature was 80 F., taken with a dial stem thermometer.10. Review of Resident #20's admission MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included medically complex conditions, seizure disorder, atrial fibrillation (A-Fib - an irregular and often very rapid heart rhythm that can lead to blood clots and increases the risk of stroke, heart failure and other heart-related complications), and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems).Observation of the common area on 6/23/25 at 6:10 P.M., on the East Wing showed the following:-A large portable air conditioning unit vented into the ceiling;-Four residents were in the common area;-The common area temperature was 84 F., taken with a dial stem thermometer.During an interview on 6/23/25 at 6:11 P.M., Resident #20 said the following:-He/She slept in a recliner in the common area;-He/She got sweaty during the night, because it was so hot in the common area. 11. Observation on 6/23/25 at 6:13 P.M., showed the East Wing dining room had a portable air conditioner, that was running and vented into the ceiling. The temperature in the dining room was 88 F. taken with a dial stem thermometer. No residents were in the dining room at the time.12. Review of Resident #21's quarterly MDS, dated [DATE], showed the following:-The resident's cognition was moderately impaired;-The resident had diagnoses that included medically complex conditions and a need for assistance with personal care;-The resident understood others and could make himself/herself understood to others.During an interview on 6/23/25 at 6:17 P.M., Resident #21 said the following:-He/She had bladder cancer and needed to stay hydrated;-If he/she asked for water from most of the certified nurse aides (CNAs), they only brought a small Styrofoam cup of water.Observation on 6/23/25 at 6:17 P.M., showed the resident in his/her room, in bed with no blanket or sheet covering his/her body. A portable air conditioner unit was running and set at 72 F. The room temperature was 80 F., taken with a dial stem thermometer. 13. During an interview on 6/23/25 at 6:25 P.M., Resident #15 said the following:-He/She arrived at the facility today;-The resident asked his/her family member to bring a fan, because his/her room, was hot; -He/She was uncomfortable and sweaty in his/her room.Observation on 6/23/25 at 6:25 P.M., of Resident #15 and his/her room showed the resident sat on the side of his/her bed and the room temperature was 90 F., taken with a dial stem thermometer. 14. Observation on 6/23/25 at 6:31 P.M., showed Resident #16 and Resident #17's room, was 88 F., taken with a dial stem thermometer. 15. During an interview on 6/23/25 at 6:33 P.M., Resident #22 said the following:-He/She was terrible, it was hot in his/her room, -His/Her family member brought in a fan, because it was hot in his/her room;-If he/she just laid on the bed and did not move around, he/she was okay;-He/She would move to another room if it was cooler.Observation on 6/23/25 at 6:33 P.M., of Resident #22 and his/her room showed the following:-The resident was on his/her back in bed watching television;-The resident had a 24 fan blowing on him/her;-The room temperature was 86 degrees F. taken with a dial stem thermometer.Review of the resident's discharge MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included kidney failure, weakness, stroke and hardening of the arteries after a coronary artery bypass graft (CABG- a procedure to treat a blockage or narrowing of one or more of the coronary arteries).16. Observation on 6/23/25 at 6:38 P.M. of unoccupied room [ROOM NUMBER], showed the temperature was 92 F. taken with a dial stem thermometer. A portable air conditioner in the room was running and set on 62 F. Observation on 6/23/25 at 6:40 P.M. of unoccupied room [ROOM NUMBER], showed the temperature was 90 F. taken with a dial stem thermometer. A portable air conditioner in the room was running and set on 65 F. 17. During an interview on 6/23/25 at 6:41 P.M., Resident #11 said the following:-He/She was hot;-He/She kicked the blanket and sheet off to the floor and did not want them on the bed;-He/She would move to cooler room if he/she could.Observation on 6/23/25 at 6:41 P.M., of Resident #11 and his/her room showed the following:-The resident lay on his/her bed with no blankets or sheet and wore only an incontinent brief;-The resident's blanket and sheet were on the floor;-The resident's room was 90 F., taken with a dial stem thermometer.18. Review of Resident #3's admission MDS, dated [DATE], showed the following:-The resident was cognitively intact;-The resident had diagnoses that included diabetes and medically complex conditions.During an interview on 6/23/25 at 6:52 P.M., Resident #3 said the following:-The resident only had a sheet covering him/her because he/she just finished eating supper; -It was hot in his/her room and it was going to get hotter;-He/She really suffered from the heat, sometimes it made him/her nauseated;-It was ridiculous it was so hot in his/her room.Observation on 6/23/25 at 6:52 P.M., of Resident #3 and his/her room showed the following:-The resident lay in bed with a sheet covering him/her up to his/her waist;-The temperature in the resident's room was 89 F. taken with a dial stem thermometer;-A portable air conditioning unit was in the room running and set on 61 F. 19. Review of Resident #18's admission MDS, dated [DATE], showed the following:-The resident's cognition was moderately impaired;-The resident had diagnoses that included traumatic brain injury, coronary artery disease, arthritis, hemiparesis (weakness of one entire side of the body), and a need for assistance with personal care. During an interview on 6/23/25 at 7:00 P.M., Resident #18 said the following:-It was hot in his/her room;-He/She was hot and sweaty.Observation on 6/23/25 at 7:00 P.M., of the resident and his/her room showed the following:-The resident lay in bed with a small fan clamped to the bed rail blowing air on the resident's face;-The resident's room temperature was 92 F;-A portable air conditioning unit in the room was running and set on 70 F. 20. Review of weatherunderground.com showed the high temperature for 6/23/25 was 93 F. with a heat index of 98 F.21. During an interview on 6/30/25 at 4:30 P.M. Certified Medication Technician (CMT) E said the following:-On June 21st and June 22nd it was very hot on the east wing in the resident rooms, the dining room, common area, and hallways;-He/She did not use a thermometer to monitor the resident room temperatures, or any other area of the east wing;-Residents were uncomfortable during that weekend. During an interview on 6/23/25 at 12:43 P.M., the Director of Nursing (DON) said the following:-She was not sure when the air conditioning went out on the East wing;-There were portable air conditioning units in each occupied resident room on the East wing;-Staff had not monitored residents more frequently or monitored room temperatures since the air conditioning unit went out on the East wing;-She never saw anything in the emergency preparedness binder that related to a heat plan;-The residents on the East wing continued to use the East wing dining room since the air conditioner went out.During interviews on 6/23/25 at 12:43 P.M., 2:48 P.M., 4:10 P.M., and 6/30/25 at 1:42 P.M., the Administrator said the following:-The facility's air conditioner went down on the East unit the week of 6/3/25;-Portable air conditioners were installed in all occupied resident rooms after the facility air conditioner went out; -Staff had not monitored residents or resident room temperatures since the facility air conditioner on the East wing of the facility went out. The maintenance staff installed portable air conditioning units in their rooms;-Staff usually passed water two times a day. Staff had not been directed to pass water to the residents on the East wing more than twice a day since the facility air conditioner went out; -She had an emergency cooling plan for the facility that was drafted in 2022 specific to the East wing of the facility when the facility had air conditioning problems that was kept in her office;-The staff had not followed the emergency plan to monitor temperatures hourly in resident rooms, core areas, and the dining room;-The staff had not followed the emergency plan to assess residents as appropriate in order to help determine safe room temperatures;-She was responsible for the emergency preparedness policies and keeping the binders up to date;-She did not feel she needed to have a detailed plan in the emergency preparedness binder at the nurse's station because she would expect staff to call her and she would give them instructions;-She did not expect nursing staff to implement a full emergency plan;-It should be general nursing knowledge to monitor residents in the summer for dehydration and excessive heat;-She expected staff to offer fluids throughout the day during the summer and when there was excessive heat.During an interview on 6/30/25 at 2:32 P.M., the Medical Director said the following:-He was aware the air conditioning was broken and there were portable air conditioning units in each resident room;-He would expect staff to monitor residents for excessive heat;-If the facility had a policy but it was not followed, it did not do anyone any good.NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO256298

Based on observation, interview, and record review, facility staff failed to identify signs and symptoms of hyperglycemia (an excess of glucose in the bloodstream) on 4/25/23 for one resident, (Resident #32), who had a diagnosis of diabetes, when the resident presented with shaking and excessive thirst. The resident's care plan instructed staff to be alert to signs of high blood sugar and contact the physician as indicated. Facility staff did not check the resident's blood sugar or call the resident's physician to report the noted signs and symptoms. On the morning of 4/26/23, the facility failed to obtain a fasting blood sugar as ordered. On the afternoon of 4/26/23, the facility notified the resident's physician the resident had become lethargic, unresponsive and pale. The resident's physician instructed staff to check the resident's blood sugar and the reading on the facility meter resulted high. The resident was sent to the hospital and assessed with a blood sugar of 797 (normal range 80-120 mg/dl). The resident was admitted to the hospital under ICU (intensive care unit) care and placed on an insulin drip (insulin given through an IV (access to the vein) to lower his/her blood sugar. Interview with the resident's physician showed he would have wanted to be notified on 4/25/23 of the resident's condition and he/she would have instructed for the resident's blood sugar to be checked. The facility census was 76. The administrator was notified of the Immediate Jeopardy (IJ) on 4/27/23 at 5:00 P.M. which began on 4/25/23. The IJ was removed on 5/1/23 as confirmed by surveyor onsite verification. Review of the facility policy, Diabetes Clinical Protocol, revised November 2020, showed the following: -The staff will identify and report issues that may affect, or be affected by, a resident's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia; -Urgent notification may be indicated if the individual has not eaten well or consumed sufficient fluids for two or more days and has fever, hypotension (low blood pressure), lethargy or confusion; -The physician will help the staff clarify and respond to these episodes. Review of the facility policy, Regarding Physician Orders, revised August 2021, showed the following: -It is the responsibility of each charge nurse to assess, document, provide and initiate interventions and to consult with that resident's Primary Care Physician with any/all abnormal findings regarding the resident; -The charge nurse is held accountable and responsible for keeping not only the family informed of potential issues found upon the resident assessment but to also keep the Primary Care Physician informed of ALL issues found concerning the resident. 1. Review of Resident #32's Care Plan, dated 10/23/18, showed the following: -Be alert to signs of high blood sugar including flushed, dry skin, drowsiness, nausea/vomiting, abnormal pain, soft sunken eye balls, red lips, decreased blood pressure, acetone breath, and increased respirations (hyperglycemia). Contact physician as indicated; -Make sure the resident's needs are met such as hunger and thirst; -Anticipate his/her needs and pay attention to nonverbal cues. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/31/23, showed the following: -Severely impaired cognition; -Diagnosis of diabetes mellitus; -No insulin orders. Review of the resident's April 2023 physician orders showed the following: -Accucheck (blood sugar check) three times a week before breakfast on Monday, Wednesday, and Friday. Notify the physician if the blood sugar is below 70 or above 400; -Push water/fluid intake when awake; -Assist with feeding with every meal and snack. Observation on 4/25/23 at 4:04 P.M., showed the resident was in main living room on the [NAME] hall. He/She was pale, had facial grimacing and a clenched mouth. He/She was gritting his/her teeth, his/her hands were in fists, and he/she was shaking. During an interview on 4/25/23 at 4:06 P.M., Licensed Practical Nurse (LPN) N said the following: -The resident was not diabetic; -The resident had not been eating much the past couple of days; -Yesterday, the resident ate breakfast, but not much lunch or dinner; -Today, the resident didn't eat much at breakfast and didn't eat any lunch; -The resident appears in pain, so he/she was going to give him/her some Tylenol. During an interview on 4/25/23 at 4:12 P.M., LPN N (after he/she reviewed the resident's medical record) said the resident was a diabetic, but was not insulin dependent. Review of the resident's Nurse's Note dated 4/25/23 at 4:16 P.M., showed the following: -Resident refused breakfast and lunch, showing signs and symptoms of pain and discomfort with facial grimace and hands in fists. Provided as needed pain medication. Observation on 4/25/23 at 4:20 P.M. showed the following: -LPN N crushed Tylenol and mixed it with applesauce and fed it to the resident; -The resident's lips and mouth were dry/crusty, and his/her tongue was covered with a white film; -LPN N provided the resident an 8-ounce cup of water, and the resident gulped it very quickly through a straw; -LPN N provided the resident a second 8-ounce cup of water, and the resident gulped it through a straw so quickly that he/she began to cough. During an interview on 4/27/23 at 1:19 P.M., LPN N said the following: -He/She didn't check the resident's blood sugar because he/she just thought the resident was thirsty since he/she had missed a meal; -The resident was not insulin dependent; -The resident normally sat with his/her hands clenched; -Excessive thirst, dry mouth, and shaking are all signs of hyperglycemia; -He/She was still trying to learn resident's baselines; -He/She did not notify the resident's family or physician because the resident didn't continue to show signs and symptoms after the pain medication was given. Review of the resident's medical record for 4/26/23 (Wednesday) showed no documentation staff checked the resident's blood sugar before breakfast as directed in his/her physician's order. Review of the resident's progress note, dated 4/26/23 at 1:55 P.M., showed the following: -The resident became lethargic during his/her shower and began to appear as if he/she was becoming non-responsive; -The resident was pale in color, clenching his/her mouth and fists; -Staff notified the resident's primary care physician and he/she directed staff to check the resident's blood sugar. The results read HIGH; -The resident was sent to the hospital. Review of the resident's hospital records, dated 4/26/23 at 3:00 P.M., showed the following: -Glucose, Plasma 797 (normal range between 70-100 mg/dL); -Labs notable for leukocytosis (an increase in the number of white cells in the blood, especially during an infection), hyperglycemia (an excess of glucose in the bloodstream) and hyponatremia (a lower than normal level of sodium in the bloodstream) and acute renal failure (AKI; a condition in which the kidneys suddenly can't filter waste from the blood) concerning for significant dehydration; -Fluid boluses given and started on insulin drip (administering insulin directly into the bloodstream through a thin tube in a vein). Review of the resident's progress note, dated 4/26/23 at 7:37 P.M., showed the resident was in the hospital ICU on an insulin drip. The resident's admitting diagnoses were hyperglycemia, dehydration (a harmful reduction in the amount of water in the body), and hypernatremia. During an interview on 4/27/23 at 10:45 A.M., the resident's physician said the following: -He would expect staff to notify him with signs and symptoms of hyperglycemia. He would have expected to staff to notify him on 4/25/23 when the resident first presented with signs and symptoms; -He would expect staff to check a resident's blood sugars with signs and symptoms of hyperglycemia or would have expected staff to at least call him to get an order to check the resident's blood sugar on 4/25/23; -He would expect staff to follow physician orders. During an interview on 4/27/23 at 11:15 A.M., the Director of Nursing (DON) said the following: -She expected staff to check a resident's blood sugar when the resident has signs and symptoms of hyperglycemia, and to complete a full assessment on the resident and notify the physician; -The blood sugar checks, assessment, and physician notification should all be documented in the electronic medical record. During an interview on 5/2/23 at 7:11 P.M., the Administrator said the following: -She expected staff to use their nursing judgement for diabetic residents with no Accucheck orders and to check a blood sugar prior to giving any insulin, as well as with any change in the condition of the resident. NOTE: At the time of the recertification survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the 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 to be taken to address Class I violation(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents on the facility special care unit, including four residents (Resident #54, #59, #500 and #501), in a review of thirteen sampled residents, from verbal and sexual abuse by one resident (Resident #68). Resident #68 had a history of verbal and physical sexually inappropriate behavior. The resident exhibited inappropriate sexual behavior towards other residents on the unit which included touching or attempts to touch their bodies with his/her hands or mouth in a sexual manner and made sexual comments toward them. Resident #501, a cognitively intact resident, experienced psychosocial distress due to interactions with Resident #68 when the resident made him/her feel sexually harassed and mentally abused. Resident #501 demanded to be moved from the special care unit where he she resided with Resident #68, to another part of the facility as a result. The facility census was 73. On 07/13/23 at 5:30 P.M., the facility's administrator was notified of the immediate jeopardy which began on 12/7/22. The IJ was removed on 7/18/23 as confirmed by surveyor onsite verification. Review of the facility policy, Identifying Types of Abuse, revised September 2022 showed the following: -As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents; -Abuse of any kind against residents is strictly prohibited; -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology; -Abuse toward a resident can occur as resident-to-resident abuse; -Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation; -Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability; -Examples of mental and verbal abuse include, but are not limited to harassing a resident, derogatory statements directed to the resident; -Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area; -Generally, sexual contact is nonconsensual if the resident appears to want the contact to occur, but lacks the cognitive ability to consent or the resident does not want the contact to occur; -Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. In addition, the alleged victim may not report abuse due to shame, fear, or retaliation. Other residents may not be able to speak due to a medical condition and/or cognitive impairment (e.g., stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred; -Abuse may result in psychological, behavioral, or psychosocial outcomes; -The following situations are recognized as those that are likely to cause psychosocial harm which may take months or years to manifest, and have long-term effects on the resident and his/her relationship with others and include sexual assault, unwanted sexual touching and sexual harassment. 1. Review of Resident #68's facility face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's undated facility diagnosis page showed the resident with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, dementia and sexual dysfunction. Review of the resident's facility progress notes showed staff documented the following: -On 11/10/22 at 7:14 P.M., the resident was sexually inappropriate towards staff and was educated on expectations of behavior. Will continue to monitor; -On 11/12/22 at 7:20 P.M., during the resident's shower he/she was noted to be sexually inappropriate with the CNA, making comments about the aide rubbing his/her genitalia. Resident was informed that this behavior was inappropriate. Resident was also noted to be asking this nurse and his/her CNA if we were having sex with our boyfriends/girlfriends; -On 11/14/22 at 6:58 P.M., the resident has been hard to redirect this shift; had to be redirected multiple times for sexual statements, will continue to monitor; -On 11/18/22 at 4:53 P.M., the resident was sexually inappropriate at times. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/22/22, showed the resident had a Brief Interview for Mental Status (BIMS) (screening tool to assess cognition) of 10, indicating the resident had mild cognitive impairment. The resident had verbal behaviors on two days ( in a seven day look back period), transferred, walked and moved in the bed independently. Review of the resident's facility progress notes showed staff documented the following: -On 12/07/22 at 6:23 P.M., Resident currently sits at the dining room table talking to other residents and trying to kiss multiple (residents of the opposite sex). Resident was redirected multiple times. Resident was educated that his/her behavior was inappropriate and upsetting other residents; -On 12/8/22 at 6:39 P.M., the resident has continued to have multiple episodes of inappropriate behaviors. Noted to be sitting at the breakfast table and said (people of the opposite sex), are like whiskey, they are all good but some are better than others in bed. He/She also asked the CNA multiple times, Do you wanna take a shower with me? You can wash me and then gestured towards his/her genitals. Resident was redirected multiple times and educated that his/her behavior was inappropriate and upsetting other residents, he/she said I will try to work on it. Review of the resident's care plan dated 12/8/22 showed no evidence the resident presented with behaviors or direction for staff to address the resident's sexually inappropriate behaviors. Review of the resident's facility progress notes showed staff documented the following: -On 12/13/22 at 6:50 P.M., the resident has had five episodes of being inappropriate this shift; -On 12/16/22 at 6:03 P.M., the resident had two episodes of sexual inappropriate behavior this shift; -On 12/17/22 at 4:50 P.M., the resident had multiple episodes of sexual inappropriate behavior this shift as well as being verbal hateful, belligerent and verbally abusive to staff and residents; -On 12/18/22 5:39 P.M., the resident has been verbally sexually inappropriate and belligerent today; -On 12/30/22 at 7:11 P.M., has been verbally inappropriate this shift; -On 01/01/23 at 7:20 P.M., has been hateful, belligerent and verbally sexually inappropriate this shift. He/She looked at the table where residents of the opposite sex sat and said, Do you guys wanna get lucky tonight? Do you know what (named specific medication for sexual performance)? I use it so I get lucky; -On 01/02/23 at 6:54 P.M., the resident has been belligerent and sexually inappropriate this shift. He/She would walk around to residents of the opposite sex and try kissing them on the mouth. This nurse had to redirect him/her. Resident screamed, Damn, you just can't let me have no damn fun!; -On 01/15/23 at 7:12 P.M., was sexually inappropriate this shift with another resident. The residents were found in this resident's room on his/her bed, kissing on one another and inappropriately touching one another. The residents were separated and individually educated this was not an appropriate setting for these behaviors; -On 01/26/23 at 2:16 P.M., this resident noted to be sitting very close with another resident of the opposite sex, holding hands with each other and rubbing arms. This nurse attempted to relocate the resident, but this was unsuccessful due to this resident not wanting to move; -On 01/29/23 at 6:20 P.M., the resident grabbed hold of one of the dietary staff of the opposite sex and put his/her arms around him/her and squeezed, saying those are nice. This nurse told the resident that he/she could not be handling or vocalizing like that and it was inappropriate. The resident screamed, It is not inappropriate, he/she let me do it!; -On 01/30/23 at 6:48 P.M., orders received, resident not to be alone with staff or residents of the opposite sex. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 14 (cognitively intact), the resident had verbal behaviors one to three days of the seven day look back period, and was independent with walking, transfers and bed mobility. Review of the resident's facility progress notes showed staff documented the following: -On 02/21/23 at 9:35 A.M., the social worker documented in the last seven days, the resident had one incident of sexually inappropriate behavior. Earlier in February the resident had three incidents of sexually inappropriate behavior, in January-19 incidents, and in December-15 incidents of sexually inappropriate behavior; -On 02/22/23 at 6:22 P.M., the resident walked up to another resident of the opposite sex and asked the other resident to give him/her a kiss; -On 03/06/23 at 2:57 P.M., the resident went up to another resident and kissed that resident on the forehead; and was noted to do this twice during this shift; -On 03/08/23 at 8:20 A.M., noted to go up to another resident of the opposite sex while he/she was eating his/her breakfast and grab the collar of this resident's shirt and ask if he/she could see what was under there; -On 03/08/22 at 11:28 A.M., when another resident of the opposite sex was returning to his/her seat from the bathroom, this resident asked this resident, Can I rub them (breasts)? The other resident replied that no, Resident #68 could not rub his/her breasts. After this incident the resident was redirected; -On 03/10/23 at 1:20 P.M., the resident asked a resident of the opposite sex if they liked to have sex. Staff redirected the resident. The resident then went to another resident and asked him/her the same question. When attempting to redirect, he/she asked if staff was married and had sex; -On 03/11/23 at 10:58 A.M., the resident asked a resident of the opposite sex if he/she has had sex since he/she has been at the facility; -On 03/12/23 at 4:27 P.M., resident noted to rub another resident of the opposite sex's back and he/she asked him/her if he/she had ever had sex. This resident told the resident of the opposite sex, If you come to (resident's room), I'll rub on your breast and I'll rub down there so you will know what it feels like; -On 03/15/23 at 1:41 P.M., resident has had sexual behaviors towards other residents this shift. The resident told another resident He/She would like to have some good clean sex with (opposite sex) residents, while (opposite sex) residents sat at the table eating lunch. One of the residents told him/her he/she was a dirty old (person) and that he/she didn't appreciate the way he/she was talking to him/her, and not to speak to him/her anymore. This resident said okay and that he/she really looked good in his/her shirt. Staff informed this resident that he/she could not talk to other residents in that manner because it made them feel uncomfortable; -On 03/21/23 at 2:03 P.M., the resident has had some inappropriate remarks towards staff and other residents. This resident asked a resident of the opposite sex if he/she had sex recently while being in this nursing home and if he/she wanted to do so, then come to (resident's room) and they could have some. Resident of the opposite sex told him NO they can't do that in here; -On 03/25/23 at 3:04 P.M., this nurse witnessed this resident kiss another resident on the forehead; -On 03/26/23 at 3:07 P.M., this nurse overheard this resident tell a resident of the opposite sex that he/she could sit on his/her lap. Review of the resident's care plan, revised 03/28/23, showed the resident presented with sexual behaviors and now took estrogen (hormone) therapy related to sexual behaviors. The care plan did not identify any other action, other than monitoring for medication side effects, to address the resident's behaviors. Review of the resident's facility progress notes showed staff documented the following: -On 04/03/23 at 6:58 P.M., resident noted to make multiple sexual comments towards staff and other residents; -On 04/13/23 at 6:37 P.M., the resident made multiple sexual comments during this shift to residents and staff. Unable to redirect. During morning meal, this resident was noted to be rubbing a resident of the opposite sex's breast while the other resident attempted to push the resident's hand away. Resident #68 said, Doesn't that feel good?; -On 04/17/23 at 6:28 P.M., continues with inappropriate sexual comments to residents and staff multiple times; -On 04/23/23 at 11:35 A.M., resident exhibiting inappropriate behaviors today. Resident observed in a resident of the opposite sex's room, standing over him/her and touching him/her. This resident was redirected by CNA staff and was given education on why this was not appropriate; -On 04/23/23 at 11:42 A.M., regarding previous nurse's note - CNA defined touching as the resident had his/her hand on the other resident's lap, was rubbing his/her back, and their faces were touching; -On 04/25/23 at 6:34 P.M., resident noted to be asking multiple different residents of the opposite gender to give me a kiss. Resident redirected and reminded of possible germs & infection. Resident acknowledged understanding, but has been noncompliant; -On 04/26/23 at 7:24 P.M., resident noted to be very inappropriate sexually with other residents this shift. Resident grabbed a resident of the opposite gender's breast and told him/her he/she had very nice boobies; -On 04/27/23 at 6:30 P.M., resident has had a couple of inappropriate sexual behaviors this shift; trying to kiss other residents, and asked staff if they had been sexually active before coming to work today; -On 05/11/23 at 3:04 P.M., noted during after morning meal to have his/her hands under another resident's shirt. Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS of 10, the resident had mild cognitive impairment; -Verbal behaviors occurred on four to six days during the seven day look back period; -Independent with bed mobility, transfers and walking. Review of the resident's facility progress notes showed staff documented the following: -On 05/19/23 at 7:13 A.M., the social worker documented in the last seven days he/she had five incidents of sexually inappropriateness. Earlier in May he/she had one incident of grabbing and nine incidents of sexually inappropriateness. In April he/she had 15 incidents of sexually inappropriateness and in March, 26 incidents of sexually inappropriateness; -On 05/29/23 at 7:37 P.M., the resident stood up at the table and unzipped his/her pants and asked to feel this. Told the resident this was inappropriate to do that and asked him/her to zip his/her pants back up; -On 05/31/23 at 11:09 A.M., resident noted to have inappropriate sexual behavior toward other residents this shift; -On 06/09/23 at 5:14 P.M., staff reported that this resident and a resident of the opposite sex were in this resident's room participating in inappropriate sexual behaviors; -On 06/10/23 at 6:23 P.M., resident made frequent sexual remarks to residents of the opposite sex, and asked them if they would give him/her a kiss on the cheek; -On 06/27/23 at 5:37 P.M., resident was kissing another resident; -On 07/01/23 at 6:36 P.M., resident walked up behind a resident of the opposite sex and put his/her hands around his/her shoulders for a hug; the other resident became upset and yelled at this resident to get off of him/her; -On 07/08/23 at 6:53 P.M., resident was noted to compliment the residents and the workers frequently and requested another resident give him/her a kiss. 2. Review of Resident #501's undated face sheet showed the resident had diagnoses including mild cognitive impairment and unspecified dementia. Review of the resident's facility progress notes showed staff documented the following: -On 12/04/2022 at 6:01 P.M., this resident came to this nurse this evening and said he/she did not like another resident (of the opposite sex) and the next time the other resident came near him/her, he/she was going to hit him/her in the stomach; -On 01/04/23 at 11:44 A.M., the resident walked up to the desk while this nurse was having a conversation with another resident. He/She snapped at the other resident saying, Shut up you rude old (person of the opposite sex). This nurse told this resident, This is not a situation that involves you so let's please leave him/her alone and I will come talk to you in just a moment. This resident screamed at this nurse and CNA saying, This does involve me, I live here, he/she makes my life a living hell, I am so fed up with all of you. Review of the resident's census sheet showed he/she moved from the dementia unit (where Resident #68 resided) on 01/04/23 to a room in another part of the facility. Review of the resident's annual MDS dated [DATE] showed the following: -BIMS of 15, cognitively intact; -Adequate hearing; -No behaviors; -Has clear comprehension of others. Review of the resident's care plan, revised 05/26/23, showed the following: -He/She wanted to feel that he/she was in control of his/her life; -He/She has alteration in his/her thought process related to dementia; he/she would like to feel safe. During an interview on 7/13/23, at 2:36 P.M., Resident #501 said the following: -He/She resided on the locked unit for about a year; -He/She demanded to move off of the unit because of Resident #68; -Resident #68 would not leave him/her alone, he/she would follow Resident #501 around constantly; -Resident #68 drove me nuts; -Resident #68 would say sexual things all the time, he/she still shivers at the thought of it; -Resident #68's hands were always on somebody; -Resident #68 tried to touch Resident #501 several times; -The more Resident #501 turned Resident #68 away the more he/she tried; -If Resident #68 wasn't bugging Resident #501 he/she was staring at Resident #501; -He/She was mad at the staff because they wouldn't make Resident #68 stop, the staff would say, He/She is not hurting anyone, but the resident said, He/She was hurting me; -He/She was being sexually harassed by Resident #68, you don't have to touch someone to be sexually abused; -It is not right; -Resident #68 would try to come in his/her room; -He/She can't understand why the staff didn't make him/her leave the resident alone; -It got to the point Resident #501 was scared he/she was going to hurt Resident #68; -Even now, when Resident #68 comes out for events in the main area of the facility he/she will stare at Resident #501 from across the room; -Resident #68 hurts you in a mental way that destroys you and it turns Resident #68 on; -I wanted to pick up a chair and smash it over his/her head, like I was losing myself, I do not have those kind of thoughts; -Resident #68 knew he/she was conquering me, killing me emotionally, and following me around so much I couldn't breathe, like a prisoner; -That is why he/she demanded to move off of the unit. 3. Review of Resident #54's facility diagnosis page showed the resident had a diagnosis of dementia. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 13, (a BIMS of 15 indicates intact cognition). Review of the resident's progress notes showed staff documented on 01/15/23 at 7:14 P.M., the resident was sexually inappropriate this shift with another resident (Resident #68). They were found in the other resident's room on his/her bed, kissing on one another and inappropriately touching one another. Residents were separated and individually educated on this not being an appropriate setting for this behavior. Review of the resident's annual MDS, dated [DATE], showed the resident had a BIMS of 12; the resident had mild cognitive impairment. Review of the resident's progress notes showed the facility Social Worker documented on 02/13/23 at 8:02 A.M. that the resident's BIMS score was 13 and he/she had had one incident of being sexually inappropriate in January (2023). Review of the resident's care plan, dated 03/28/23, showed the resident has alteration in thought process related to dementia. Review of the resident's progress notes showed staff documented on 05/11/23 at 3:06 P.M., the resident was noted to have inappropriate behaviors with another resident (Resident #68). Review of the resident's quarterly MDS, dated [DATE], showed the following: -BIMS of 3 indicating severe cognitive impairment; -Had the ability to clearly comprehend; -Made self understood. Review of the resident's progress notes showed staff documented the following: -On 05/12/23 at 1:00 P.M., the Social Worker documented that the resident's BIMS score was three and he/she had two incidents of sexually inappropriate behavior in the last seven days. Earlier in May, he/she had two incidents of sexually inappropriate behavior. In April, he/she had ten incidents of sexually inappropriate behavior and in March, three incidents. -On 06/09/23 at 5:30 P.M., staff reported this resident and another resident of the opposite sex (Resident #68) were in the other resident's room participating in inappropriate sexual behavior. This resident appeared to have his/her shirt up and the other resident had his/her mouth on this resident's breast. 4. Review of Resident #500's facility face sheet showed he/she has diagnoses that include age related cognitive decline. Review of the resident's care plan, dated 06/01/21, showed the resident has alteration in thought process related to dementia, the resident will feel safe. Review of the resident's annual MDS, dated [DATE], showed the following: -BIMS of 9; the resident was cognitively impaired; -Had clear comprehension of others; -Able to make self understood. During an interview on 07/13/23 at 4:22 P.M., the resident said the following: -He/She knew who Resident #68 was; -Resident #68 had tried some hanky panky stuff with him/her before, but he/she always told him/her to get lost; he/she didn't do that kind of stuff; -Resident #68 would try and grab at his/her chest, and kiss or touch him/her. 5. Review of Resident #59's facility diagnoses page showed he/she has diagnoses that include Alzheimer's disease and other symptoms and signs involving cognitive functions and awareness. Review of the resident's significant change MDS, dated [DATE], showed the resident had a BIMS of 4; the resident was cognitively impaired. Review of the resident's quarterly MDS, dated [DATE], showed the resident had a BIMS of 99 (resident unable to complete the interview); the resident was severely cognitively impaired. During an interview on 07/13/23 at 9:45 A.M., Licensed Practical Nurse (LPN) A said the following: -The documentation in Resident #54's progress notes on 01/15/23 documented an incident between Resident #54 and Resident #68 that occurred in Resident #68's room; -He/She was sure Resident #54's progress note of 05/11/23 also documented an incident with Resident #68 that was also of a sexual nature; -The documentation in Resident #54's progress notes on 06/09/23 was again in regards to Resident #68. This was the second time the residents had been found together in Resident #68's room engaging in inappropriate behavior; -He/She had made the documentation in Resident #68's progress notes for 03/08/23 and could recall that the resident of the opposite sex was Resident #59 with that incident; -He/She had also documented in Resident #68's progress notes the incident on 03/08/23; that incident was with Resident #500; -Resident #68 flirted with several of the residents of the opposite sex as well as staff. Resident #500 Never took any stuff from Resident #68 and it always seemed to be Resident #54 that Resident #68 was more attracted to; -He/She had documented the entry in Resident #68's progress notes on 07/01/23 at 6:36 P.M., but could not recall if the other resident was Resident #54 or Resident #500. During an interview on 07/14/23 at 4:14 P.M., Registered Nurse (RN) E said he/she had made the entries in Resident #68's progress notes on 04/23/23 at 11:35 A.M. and 11:42 A.M. He/She could not recall who the resident of the opposite sex was. He/She could only recall making the documentation and that an aide had reported it to him/her. He/She would not consider this abuse. He/She did not recall checking on either resident after the reported incident. Residents in the dementia unit would not be able to give any type of consent, that is why staff needed to redirect when possible. During an interview on 07/13/23 at 10:28 A.M., LPN D said the following: -He/She made the entry in Resident #68's progress notes on 03/11/23 at 10:58 A.M. The resident she was referring to was Resident #54. Resident #68 and #54 had been found together in inappropriate acts a couple of different times. He/She was not sure if he/she would consider Resident #68's behavior abuse or not. The residents had dementia so he/she was not sure if that made a difference or not; -He/She made the entry in Resident #68's progress notes on 03/12/23 at 4:27 P.M., this incident also documented the concern between Resident #68 and #54. During an interview on 07/13/23 at 11:15 A.M., LPN B said the following: -He/She made the entry in Resident #68's progress notes on 03/15/23 at 1:41 P.M. He/She could not recall who the other resident was that was involved. He/She did document that Resident #68's behavior made other residents uncomfortable and that it was of a sexual nature, but he/she was not sure if it was abuse. He/She could not tell if Resident #68's behaviors affected other residents because they had diagnoses of dementia, he/she just knew he/she would not like to be treated that way; -He/She made the entry for 03/21/23 at 2:03 P.M. He/She could not recall the opposite sex resident who was invited back to Resident #68's room. Resident #68 was always making comments to staff in the presence of other residents who probably would feel uncomfortable if they understood what Resident #68 was saying or asking, whether it be to staff or other residents; -On 06/09/23 at 5:14 P.M., he/she made the entry in Resident #68's progress notes. The incident documented was between Resident #54 and Resident #68, Resident #54 was in Resident #68's room. Resident #54 had his/her shirt pulled up and under garment pulled down and Resident #68 had his/her mouth on Resident #54's breast. During an interview on 07/13/23 at 11:52 A.M., LPN F said the following: -He/She made the progress note entries in Resident #68's chart on 04/25/23 and 04/26/23; -On 04/26/23, the resident of the opposite sex involved was Resident #54. During an interview on 07/14/23 at 3:05 P.M., the Social Service Director said the following: -She had heard that Resident #68 had made sexually inappropriate comments and had behaviors. She heard this from staff who reported it to her, but she had been told Resident #68 was re-directable so she had no further concerns and had not reported to anyone; -She does recaps quarterly and documents in the resident progress notes. She had read the documentation that staff completed that showed the resident had sexually inappropriate behaviors; -She was aware of the incident between Resident #54 and Resident #68 that occurred on 06/09/23 when Resident #68 had his/her mouth on Resident #54's breast, but did not recall the incident when Resident #68 and #54 were found in Resident #68's bed touching and kissing; -She was not sure if these incidents were considered abuse; -She had tried to call Resident #54's power of attorney (POA) to see if it was alright for Resident #54 to engage in such behaviors if he/she wanted to; -She knew Resident #54 had a BIMS of 3; a score of three means the resident was cognitively impaired and could not make decisions for him/herself. During an interview on 07/11/23 at 5:30 P.M. and 07/12/23 at 12:22 P.M., the administrator said the following: -She was aware of Resident #68's behaviors that were both verbally and physically sexual in nature; -She had instructed staff to redirect the resident and the resident had been started on medications to help curb sexual tendencies; -She was aware Resident #54 and Resident #68 were found in bed together in January and also aware of an incident in June when Resident #68 has his/her mouth on Resident #54's breast; -She had received complaints about Resident #68 from Resident #501, and knew this resident did not like Resident #68; -She did not know there had been an incident between Resident #68 and Resident #59; -She was aware Resident #68 made advances toward Resident #500 but nothing was acted on; Resident #68 just tried to touch him/her; -She was aware there had been an order to ensure Resident #68 was not alone with staff and residents of the opposite sex. Staff ensure this with room checks every 15 minutes; -She did not consider Resident #68's behavior to be abuse; -She thought Resident #54 had sexual inappropriate behaviors towards Resident #68; specifically when he/she exposed him/herself to Resident #68 and came out of his/her room either with no clothes on or when he/she opened up his/her robe; -She did not know who the aggressor was in these incidents; -A resident with a BIMS of three and with an active power of attorney would not be able to make a determination or consent; -Sexual abuse can be both verbal and physical; -If the behavior happens over and over, it would be considered abuse. She felt like staff redirected Resident #68 and his/her behaviors were not considered abuse; -Dementia residents can be re-directed to get the unwanted behavior to stop; -She did not feel that any harm had been done so these incidents were not considered abuse; -She was not sure how the reasonable person would feel if they were exposed to Resident #68's behaviors. During an interview on 07/14/23 at 3:15 P.M., the Nurse Practitioner said the following: -Resident #68 and #54 were both residents he has seen and cared for at the facility; -He was aware of Resident #68's sexual behaviors, with both verbal and physical contacts; -Neither resident was able to give consent as they have diagnosis of dementia, are cognitively impaired and unable to make such decisions. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).