Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice when staff failed to keep the ice machine clean, failed to ensure the dishwasher chemicals tested at the recommended levels, and did not wear proper hair coverings. The facility census was 28. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/23, at 8:59 AM., showed the deflector shield on the inside of the ice machine had five black spots and a black substance along most of the bottom of the deflector shield. Review of the facility's weekly cleaning schedule, dated October 2023, showed the following: -Ice machine listed as being cleaned weekly; -Staff did not indicate cleaning of the ice machine in the month of October 2023. Review of the facilities' monthly cleaning schedule, dated October 2023, showed the following: -Ice machine-sanitize; -Staff did not indicate sanitizing of the ice machine in the month of October 2023. During an interview on 11/01/23, at 1:32 P.M., Dietary Aide (DA) A said the following: -The ice machine is everyone's responsibility to clean; -He/she was not sure if there is a schedule telling how often to clean it on the inside or outside; -It would not be appropriate to use the ice if there are black spots on the inside of the ice machine. During an interview on 11/01/23, at 1:41 P.M., DA B said the following: -Staff have a cleaning schedule that hangs on the door; -He/she does not know who is in charge of cleaning the ice machine; -He/she would tell the Dietary Manager if there were black spots inside of the ice machine; -He/she said the night kitchen staff do wipe down the outside of the ice machine. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -Staff have a cleaning schedule on the door and the ice machine is listed on it; -The Maintenance Manager cleaned the ice machine out a couple of months ago; -He/she said the ice machine has not been cleaned in a couple of months; -He/she would let the Dietary Manager know if there were black spots on the inside of the ice machine. During interviews on 11/01/23, at 1:56 P.M. and 2:20 P.M., the Dietary Manager said the following: -He/she and the maintenance person is responsible for cleaning the ice machine. It is completed one time per month; -The ice machine was not cleaned last month; -The maintenance person usually cleans the deflector shield; -He/she would not use the ice machine if there's black spots on the inside and would expect staff to not use it either; -He/she would clean the ice machine if he/she saw black spots. During an interview on 11/01/23, at 2:28 P.M., the Maintenance Manager said he/she does not clean the inside of the ice machine, that's is the responsibility of the kitchen staff. During an interview on 11/01/2023, at 2:33 P.M., with the Administrator said the following: -Maintenance is responsible for cleaning the inside and outside of the ice machine; -If dietary staff see an issue such as black spots on the inside, they should not use the ice, and the machine should be taken apart and cleaned. 2. Review of the 2013 Missouri Food Code showed the following: -Chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, should be completed as specified. Review of the facility's policy titled, Dietary Personnel Guidelines, dated May 2015, showed the following: -Chemically sanitized machines should be checked daily with test strip; -Dip end of test strip into waster in the reservoir, immediately after machine is completely finished with the cycle; -Compare strip to chart on test strip container; -Document on log; -Desired reading 50 to 100 ppm (parts per million). Review of the manufacture's recommendation, showed the following: -The black or gray wheel controls the sanitizer; -The sanitizer wheel is adjustable; -Set the sanitizer concentrations 50 ppm's, not to exceed 100 ppm's; -Monitor chlorine levels by using chlorine test strips. During an observation and interview on 10/31/23, at 8:59 A.M., with the Dietary Manager showed the following: -He/she had ran a set of dishes through the low temp dishwasher; -He/she dipped the test strip at the appropriate time and it showed a light purple color indicating under 10 ppm chemical solution; -He/she ran two more wash cycles, testing at the appropriate times each time and the test strip showed no chemical solution; -He/she said the test strip should show 200 ppm; -When they have issues, he/she messages the chemical provider; -The staff monitor the chemical solution by documenting the solution amounts on a clipboard that hung near the dishwasher. Review of the Dish Machine Temperature and Test Strip Log, dated October 2023, showed the following: -The dishwasher chemicals are tested at each meal; -The dishwasher chemicals tested at 200 ppm 13 days of October at each meal; -The dishwasher chemicals were not tested 14 days during October; -On 10/29/23, the dishwasher chemicals tested at 145 ppm for breakfast, 145 ppm for lunch, and was not tested at dinner; -On 10/30/23, the dishwasher was tested at breakfast and showed 145 ppm. During an interview on 11/01/23, at 1:32 P.M., DA A said the following: -All staff check the chemicals on the dishwasher two times per week; -The chemicals should register at 200 ppm each time they're tested; -The chemical tests are documented on the clipboard that hangs by the dishwasher; -He/she would tell the dietary manager if the chemicals didn't test at the right level; -He/she wouldn't use the dishwasher if it doesn't test correctly, he/she would use the three compartment sink. During an interview on 11/01/23, at 1:41 P.M., DA B said the following: -The chemicals on the dishwasher are tested daily and all staff are responsible for testing; -He/she would not use the dishwasher if it did not read at the required level; -He/she is not sure what the chemical levels should be; -He/she would tell the Dietary Manager or the Maintenance Manager if the chemical levels in the dishwasher were not reading properly. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -The Dietary Manager and the Maintenance Manager keep an eye on the dishwasher chemicals; -The staff working nights test the chemicals and documents the results on the clipboard; -The chemical levels should be 200 ppm; -If staff test the chemicals and they're not at the proper level, they would clean the dishes by hand. During an interview on 11/01/23, at 1:56 P.M., with the Dietary Manager said the following: -All staff are responsible for checking the chemicals for the dishwasher; -The chemicals should be checked daily and written on the clipboard by the dishwasher; -The reading should be in the green color, 200 ppm, but no less than 150 ppm; -If the dishwasher chemicals don't read properly, staff shouldn't use the machine and would hand wash in the three sink compartments. During an interview on 11/01/23, at 2:33 P.M., the Administrator said the following: -Chemicals are tested daily; -He/she is not sure of what the ppm's should read, but would start with the manufacturer's recommendations; -He/she is not sure which staff have been trained to test the dishwasher chemicals; -After staff test the chemicals, the person should be documenting the chemical levels on the clipboard; -Maintenance and the Dietary Manager are responsible for making sure the chemicals are tested; -The staff testing the chemicals should know the range and the dietician would adjust accordingly; -If the chemicals are not registering the proper numbers, staff should see what the issues are and let the Dietary Manager know, the staff shouldn't use the dishwasher if the chemicals don't test appropriately; -The three sink compartment should be used in place of the dishwasher when it's not working properly. 3. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Review showed the facility did not provide a policy regarding facial hair in the kitchen. Observations of the kitchen on 11/01/23, at 12:30 P.M. and 1:41 P.M., showed the following: -DA B had facial hair around his/her mouth, chin, and upper lip; -DA B was not wearing a hair net to cover the facial hair; -DA B was mixing a powdery substance with milk, then poured this into the cup for a resident. During an interview on 11/01/23, at 1:32 P.M., DA A said the following: -Staff with facial hair are supposed to wear hair nets; -Staff should not be in the kitchen without a hair net covering all hair. During an interview on 11/01/23, at 1:41 P.M., DA B said he/she was told that a hair net did not have to be wore on a beard if the hair was shorter than his/her eyebrows. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -He/she isn't sure what the policy says on beard or facial hair; -He/she said in the past staff with a stubble of hair on their face were supposed to wear nets to cover; -Staff should wear hair nets to cover all hair when in the kitchen. During an interview on 11/01/23, at 1:56 P.M., with the Dietary Manager said the following: -He/she was told staff no longer needed to wear beard nets if the hair was no longer than the eye browns; -If the hair is longer, the staff would need to wear a hair net when in the kitchen. During an interview on 11/01/23, at 2:33 P.M., with the Administrator said the dietician recommendations are if facial hair is shorter than the eye brows no hair net is worn, if the hair is longer than the eye brows, a hair net is to be worn in the kitchen. During an interview on 11/01/2023, at 4:25 P.M., with the Registered Dietician said the he/she was told staff did not need to wear beard nets if the hair on the face was no longer than the eyebrows.

Based on observation, record review, and interview, the facility failed to provide a sanitary environment for all residents, staff, and visitors when staff failed to ensure fans and areas around fans located in the walk-in refrigerator and the vents on the ice machine were cleaned; failed to replace a missing vent cover on the side of the ice machine; and failed to repair the vent cover broken the other side of the ice machine. The facility census was 28. 1. Review showed the facility did not provide policies related to cleaning related to the fans in the refrigerator. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/2023, at 8:59 AM., showed two fans located at the back of the refrigerator had fuzzy gray lint and a build-up of lint above the fan on the left side. During an interview on 11/01/23, at 1:32 P.M., Dietary Aide (DA) A said maintenance staff cleans the fans in the refrigerator and around the fans. During an interview on 11/01/23, at 1:41 P.M., DA B said if the fans in the refrigerator have lint or dirt on them, he/she would clean them. He/she knows the fans are on the cleaning schedule, but was not sure how often. During an interview on 11/01/23, at 1:47 P.M., DA C said maintenance staff cleans the fans in the refrigerator and around the fans. If he/she sees lint, he/she would let the Dietary Manager (DM) or maintenance know. . During an interview on 11/01/23, at 1:56 P.M., the DM said maintenance staff cleans the vents in the refrigerator. -He/she tries to wipe down the fan covers and if unable to get them clean will tell the maintenance staff. During an interview on 11/01/23, at 2:28 P.M., the Maintenance Manager said kitchen staff should be cleaning the outside and around the fans in the refrigerator. He/she cleans the inside of the fans and makes sure they run. 2. Review showed the facility did not provide policies related to cleaning or maintenance of the ice machine. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/23, at 8:59 AM., showed the following: -The vent cover on the side of the ice machine had fuzzy lint on it and the bottom portion of the vent cover was broken/missing; -The vent on the other side of the ice machine had the vent cover missing. During an interview on 11/01/23, at 1:32 P.M., DA A said the following: -He/she does not know who cleans the vents on the outside of the ice machine; -Maintenance replaces the vent covers; -He/she does not know if the maintenance staff knows one of the vent covers is missing and one is broken. During an interview on 11/01/23, at 1:41 P.M., DA B said the following: -He/she wipes down the vents nightly on the outside of the ice machine; -If the vents have lint, he/she takes them off and rinses with water; -If no vent cover, would tell the dietary manager; -He/she doesn't know if the maintenance staff is aware one of the vent covers are missing and one is broken. During an interview on 11/01/23, at 1:47 P.M., DA C said the following: -He/she doesn't know about vents on the ice machine; -Maintenance takes care of anything broken so he/she would tell maintenance if there was something broken on the ice machine; -He/she doesn't know if the maintenance staff is aware that one of the vent covers are missing and the other one is broken. During an interview on 11/01/23, at 1:56 P.M., the DM said the following: -He/she would knock the lint off if he/she saw lint on the ice machine vent covers; -He/she would let the maintenance person know if the vent covers were missing or broken. During an interview on 11/01/23, at 2:28 P.M., the Maintenance Manager said the following: -Dietary staff are responsible for cleaning the grills/vent covers and the exterior of the machine; -He/she was aware the vent cover was missing on the side of the ice machine and the other vent cover is broken; -He/she has been unable to find replacement vent cover parts. During an interview on 11/01/23, at 2:33 P.M., the Administrator said maintenance staff are responsible for keeping the vents on the outside of the machine clean and repaired if they're missing parts. He/she did not know the vent cover on the side was missing, or the other one was broken.

Based on interview, and record review, the facility failed to report allegations of abuse to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of staff becoming aware of the allegation of abuse when one resident (Resident #5) made allegations of physical and sexual abuse. The facility census was 28. Record review of the facility's abuse policy titled, Reporting, from Section 1 of the Abuse Prohibition Manual, undated, showed the following: -It is the policy of this facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse; -The nursing home administrator or designee will report abuse to the state agency per state and federal requirements; -If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made and policy provides the Missouri state elder abuse hotline number. 1. Record review of Resident #5's significant change minimum data set (MDS - a federally-mandated, comprehensive assessment tool completed by facility staff), dated 5/7/21, showed the following: -Entered the facility on 11/3/20 from the hospital; -Severe cognitive impairment; -Exhibited delusions; -Physical and verbal behaviors directed toward others one to three days in the past week; -Required extensive assistance of one or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, anxiety, depression, and schizophrenia (mental disorder in which people interpret reality abnormally). Record review of the resident's nurse's note dated 2/10/21, at 8:51 P.M., showed Registered Nurse (RN) F documented the following: -Behaviors: The resident continues to get up and down unassisted. The resident became agitated with staff when attempting care. A male aide entered the resident's room with a female aide to assist and the resident became very aggressive toward the male aide. This nurse had the aides leave the room and visited with the resident who said the boy pulled the resident's hair and threw the resident across the room. The resident said he /she had enough and needed to go to his/her Grandma's house. The female aide said the male aide had only attempted to help the resident with his/her walker. Female staff assisted the resident for the rest of the evening in an attempt to decrease the resident's agitation. The resident also became angry when asked if staff could assist the resident with changing out of his/her dirty clothes and into pajamas before bed. Staff administered Ativan (an antianxiety medication) and Seroquel (an antipsychotic medication) to the resident with very little improvement. (Staff did not document reporting the allegation of abuse to DHSS.) Record review of DHSS records showed the facility did not report the allegation of abuse to DHSS. During an interview on 5/12/21, at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 2/10/21, at 8:51 P.M., where in the nurse documented the resident alleged a male aide pulled the resident's hair and threw the resident across the room. The administrator said she would expect the nurse to notify the administrator immediately of the resident's allegation. The administrator said she would have further questioned the resident and staff to determine if this was an allegation of abuse. Record review of the resident's nurse's note dated 3/17/21, at 1:27 P.M., showed RN F documented the following: -Behaviors: The resident has been getting up in his/her room and out into the hallway without assistance and his/her alarm is sounding. Staff attempt to assist the resident and he/she becomes angry and agitated. The resident stated, he/she Ain't no baby and I can take care of myself. The resident yelled at an aide and said the aide threatened to hit him/her. Another staff member nearby, stated the aide did not threaten the resident. The staff attempted distractive activities. Staff gave the resident Seroquel with no relief and then gave the resident Ativan. The resident later became tearful and said that his/her kids had been locked up. He/she then stated that they had not been locked up, but that they were trying to kill him/her. The resident said he/she would expect it from one family member, but not from the other. The resident's anxiety and behaviors continued throughout the shift. The resident is currently having a window visit with his/her family member. (Staff did not document reporting the allegation of abuse to DHSS.) Record review of DHSS records showed the facility did not report the allegation of abuse to DHSS. During an interview on 5/12/21, at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 3/17/21, at 1:27 P.M., where in the resident alleged that an aide had threatened to hit the resident. The administrator would expect staff to alert her immediately of this allegation. The administrator said she felt this was an allegation of abuse. Record review of the resident's nurse's note dated 5/04/2021, at 9:24 P.M., showed RN E documented the following: -Behavior: Resident became combative with staff during care and said, You're raping me. Staff (two aides present in the room) assured the resident that they were getting him/her ready for bed. The resident continued to fight staff and said, Get out of here. You are punching me. The resident also said, the roommate peed on his/her bed. Staff administered a Xanax (an antianxiety medication) to the resident. (Staff did not document reporting the allegation of abuse to DHSS.) Record review of DHSS records showed the facility did not report the allegation of abuse to DHSS. During an interview on 5/11/21, at 2:11 P.M., Certified Medication Technician (CMT) A said the following: -The resident frequently exhibited anxiety; -The resident slaps at staff and tells staff to leave him/her alone during cares; -The resident generally responds better to one staff member, but with more staff, the resident becomes anxious and overwhelmed; -In the last few weeks, the resident kept saying someone grabbed and bruised his/her hand, the CMT has reported this in the past, but unsure to whom he/she reported; -When the resident is upset and believes someone is trying to hurt him/her, staff report this to the nurses; -He/she worked on 5/4/21, from 1:00 P.M. until 9:15 P.M., passing medications. On that evening, staff were having an issue with the resident. The CMT went into the resident's room to try and calm the resident down. The resident said he/she thought staff were trying to rape him/her. Staff reported this to the nurse, RN E. The nurse instructed the CMT to give the resident a Xanax for anxiety, and the resident took the medication. During an interview on 5/11/21, at 2:34 P.M., Certified Nursing Assistant (CNA) B said the following: -On the evening of 5/4/21, the resident sat in a wheelchair in his/her room; -CNA B tried to convince the resident it was time to go to bed, but the resident did not want to go to bed. The resident had recently changed rooms and did not like his/her new roommate; -Two co-workers, CNA C and CNA D, walked in to the resident's room and assumed CNA B had convinced the resident to go to bed; -CNA C and CNA D attempted to lift the resident's arm, in order to put a gait belt around the resident. As staff raised the resident's arm, the resident said, You better not rape me. CNA B and CNA C left the room; -CNA A confirmed with the resident, again that he/she did not want to go to bed, and then left the resident's room; -CNA A immediately reported the incident to the nurse on duty, which the aide believes was RN E; -The resident had not made any prior allegations of rape, but was physically violent, at times, when staff need to change the resident's soiled clothing. In the past, the resident had punched, scratched, and kicked staff. During an interview 05/11/21, at 3:55 P.M., CNA C said the following: -He/she worked on the evening of 5/4/21, when the resident made the rape comment; -The resident said, Don't rape me, when the CNA attempted to put gait belt around the waist of the resident; -The resident then said someone was punching his/her back, when the CNA was attempting to lean the resident forward to attach the resident's personal alarm (an alarm that attaches to the back of the resident's wheelchair and to the resident's clothing to remind the resident not to stand without assistance); -Two other staff, CNA B and CNA D, were present in the room at the time; -The resident was not tearful, but was agitated and did not want to go to bed; -When the resident became agitated, staff stopped cares and left the resident's room; -CNA C immediately reported the incident to RN E. During an interview on 5/11/21 at 4:17 P.M., RN E said the following: -On the evening of 5/4/21, the nurse arrived to resident's room to find CNA B and CNA D in the room with the resident. The resident was screaming, 'You're raping me. The nurse assumed the resident was delusional. Staff were attempting to change the resident's pants because he/she was wet, but they had not started changing him/her at that time. The nurse said he/she believed staff taking the resident to his/her room caused the resident's behavior. The nurse directed the CNAs to leave the resident alone. The resident then accused his/her roommate of urinating on the resident's bed. The roommate was not in the room at the time; -The nurse asked the CMT to give the resident a medication for anxiety; -The nurse did not report the resident's rape comment to anyone; -The nurse said, if at any time, he/she thought the resident was making a serious abuse allegation, he/she would have reported it, but the nurse witnessed the staff not touching the resident while the resident said, You're raping me -The resident had no obvious physical injuries, but seemed very agitated with staff attempting to provide care; -The resident has days of delusions and the nurse has heard the resident yell out and become verbally aggressive with staff; -The nurse said he/she received abuse training every three months from the facility, and this training includes reporting of abuse; -The nurse said he/she is supposed to report any abuse to the Director of Nursing (DON) or the facility administrator, and they then report to DHSS within two hours, -The nurse said he/she never thought abuse was possible, in this case, because multiple staff were in the room at the time and no one was touching the resident. During an interview on 5/11/21, at 4:36 P.M., the DON said the following: -She reviewed the resident's notes a couple of days after 5/4/21, but did not report the allegation of abuse to anyone; -The DON spoke with CNA D, who reported all three aides (CNA B, CNA C, and CNA D) were in the resident's room at the time of the resident's allegations on 5/4/21; -CNA D said he/she touched the resident's arm the resident began yelling and accused the staff of raping him/her, and then the staff left the room and reported the incident to RN E; -The DON said the facility policy directs staff to report any abuse allegation, including rape and investigate; -The DON said all allegations of abuse are to be reported to DHSS within two hours. During an interview on 5/11/21, at 4:36 P.M., the administrator said the following: -She was unaware of the resident's statements on 5/4/21; -In this particular situation, the resident said, You are raping me, and since there were multiple staff in the room at the time observing the resident and the resident is demented, she expected staff to leave the resident's room and report to the charge nurse; -The administrator said she would need more information to make a determination as to whether this was an allegation of abuse or not; -The administrator said staff had notified her of the resident's statements, she would have come to the facility and interviewed the resident to determine if abuse; -If the resident made a valid allegation, such as, I have been raped or the staff have raped me then that would be an allegation of abuse and the facility would report to DHSS within two hours and the DON and/or administrator would come to the facility and do an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete full and timely investigations of allegations of abuse when one resident (Resident #5) made allegations of physical and sexual abuse. The facility census was 28. Record review of the facility's policy titled, Investigation, from Section 7 of the facility's, Abuse Prohibition Protocol Manual (undated) showed: -It is the policy of this facility that reports of abuse are promptly and thoroughly investigated; -When an incident or suspected incident of abuse is reported, the administrator will investigate the incident with the assistance of appropriate personnel. The investigation will include: Who was involved, resident statements, resident's roommate statements, interviews with three to four residents who received care from the alleged staff, interviews obtained from three to four different department staff, involved staff and witness statements of events, a description of the resident's behavior and the environment at the time of the incident, resident assessment, observation of resident and staff behaviors during the investigation, and environmental considerations; -The follow-up investigative notes will be submitted to Department of Health and Senior Services (DHSS) within five working days of the initial report. 1. Record review of Resident #5's significant change minimum data set (MDS - a federally-mandated, comprehensive assessment tool completed by facility staff), dated 5/7/21, showed the following: -admitted to the facility on [DATE] from the hospital; -Severe cognitive impairment; -Exhibited delusions; -Physical and verbal behaviors directed toward others, 1-3 days in the past week; -Required extensive assistance of one staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, anxiety, depression, and schizophrenia (mental disorder in which people interpret reality abnormally). Record review of the resident's nurse's note dated 2/10/21, at 8:51 P.M., showed Registered Nurse (RN) F documented the following: -Behaviors: The resident continues to get up and down unassisted. The resident became agitated with staff when attempting care. A male aide entered the resident's room with a female aide to assist and the resident became very aggressive toward the male aide. This nurse had the aides leave the room and he/she visited with the resident. The resident said the boy pulled the resident's hair and threw the resident across the room. The resident said he/she had enough and needed to go to his/her Grandma's house. The female aide said the male aide had merely attempted to help the resident with his/her walker. For the remainder of the evening, female staff assisted the resident to try to decrease the resident's agitation. The resident also became angry when staff asked the resident if they could remove the resident's dirty clothes and assist the resident in putting on his/her pajamas before bed. The resident has had Ativan (an antianxiety medication) and Seroquel (an antipsychotic medication) with very little improvement. Record review of DHSS records showed facility staff did not provide an investigation summary or notes regarding the allegation of abuse. During an interview on 5/12/21, at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 2/10/21, at 8:51 P.M., where in the nurse documented the resident alleged a male aide pulled the resident's hair and threw the resident across the room. The administrator said she would expect the nurse to notify her immediately of the resident's allegation. The administrator said she would have further questioned the resident and staff to determine if this was an allegation of abuse; -The administrator would have investigated this allegation of resident abuse. Record review of the resident's nurse's note dated 3/17/21, at 1:27 P.M., showed RN F documented the following: -Behaviors: The resident has been getting up in his/her room and out into the hallway without assistance and his/her alarm is sounding. Staff attempt to assist the resident and he/she becomes angry and agitated. The resident stated, he/she Ain't no baby, and I can take care of myself. The resident yelled at an aide and said the aide threatened to hit him/her. Another staff member nearby, said the aide did not make the comment. Staff attempted distractive activities with the resident. Staff gave the resident Seroquel with no relief and then gave the resident Ativan. The resident later became tearful and said that his/her kids had been locked up. The resident then stated that they had not been locked up, but that they were trying to kill the resident. The resident said that he/she would expect it from one family member, but not from the other. The resident's anxiety and behaviors continued throughout the shift. Resident is currently having a window visit with his/her family member. Record review of DHSS records showed facility staff did not provide an investigation summary or notes regarding the allegation of abuse. During an interview on 5/12/21 at 4:19 P.M., the administrator said the following: -Until today, the administrator was unaware of the resident's nurse's note dated 3/17/21, at 1:27 P.M., where in the resident alleged that an aide had threatened to hit the resident. The administrator would expect staff to alert her immediately of this allegation. The administrator said she felt this was an allegation of abuse. -The administrator would have investigated this allegation of resident abuse. Record review of the resident's nurse's note dated 5/04/2021, at 9:24 P.M., showed RN E documented the following: -Behavior: Resident became combative with staff during care and said, You're raping me. Staff (two aides present in room) assured the resident that they were getting him/her ready for bed. The resident continued to fight staff and said, Get out of here. You are punching me. Resident #5 also said, the roommate peed on Resident #5's bed. Staff administered a Xanax to the resident. Record review of DHSS records showed facility staff did not provide an investigation summary or notes regarding the allegation of abuse. During an interview on 5/11/21, at 2:11 P.M., Certified Medication Technician (CMT) A said the following: -The resident frequently exhibited anxiety; -The resident slaps at staff and tells staff to leave him/her alone during cares; -The resident generally responds better to one staff member, but with more staff, the resident becomes anxious and overwhelmed; -In the last few weeks, the resident kept saying someone grabbed and bruised his/her hand, the CMT has reported this in the past, but unsure to whom he/she reported; -When the resident is upset and believes someone is trying to hurt him/her, staff report this to the nurses; -He/she worked on 5/4/21 from 1:00 P.M. until 9:15 P.M. passing medications. On that evening, staff were having an issue with the resident and he/she went into the resident's room to try and calm the resident down. The resident said he/she thought staff were trying to rape him/her. Staff reported this allegation to the nurse, RN E. The nurse instructed the CMT to give the resident a Xanax for anxiety, and the resident took the medication. During an interview on 5/11/21, at 2:34 P.M., Certified Nursing Assistant (CNA) B said the following: -CNA B worked on the evening of 5/4/21; -On the evening of 5/4/21, the resident sat in a wheelchair in his/her room; -CNA B tried to convince the resident it was time to go to bed, but the resident did not want to go to bed. Staff had recently placed the resident in a differed room and did not like his/her new roommate; -Two co-workers, CNA C and CNA D, walked in to the resident's room and assumed CNA B had convinced the resident to go to bed; -CNA C and CNA D attempted to lift the resident's arms, in order to put a gait belt around the resident. As staff raised the resident's arms, the resident said, You better not rape me. CNA B and CNA C then left the room; -CNA A confirmed with the resident, again that he/she did not want to go to bed, and then left the resident's room. -CNA A immediately reported the incident to the nurse on duty, which the aide believes was RN E; -The resident had not made any prior allegations of rape, but was physically violent with staff, at times, when staff need to change the resident's soiled clothing. In the past, the resident had punched, scratched, and kicked staff during cares. During an interview 05/11/21, at 3:55 P.M., CNA C said the following: -He/she worked on the evening of 5/4/21, when the resident made the rape comment; -The resident said, Don't rape me, when the CNA attempted to put a gait belt around the waist of the resident; -The resident then said someone was punching his/her back, while the CNA was attempting to lean the resident forward to attach the resident's personal alarm (an alarm that attaches to the back of the resident's wheelchair and to the resident's clothing to remind the resident not to stand without assistance); -Two other staff, CNA B and CNA D, were present in the room at the time; -The resident was not tearful, but was agitated and did not want to go to bed; -When the resident became agitated, staff stopped cares and left the resident's room; -CNA C immediately reported the incident to RN E. During an interview on 5/11/21, at 4:17 P.M., RN E said the following: -On the evening of 5/4/21, the nurse arrived to the resident's room to find CNA B and CNA D in the room with the resident. The resident was screaming, 'You're raping me. The nurse assumed the resident was delusional. Staff were attempting to change the resident's pants because he/she was wet, but they had not started changing the clothing at that time. The nurse said he/she believed the staff taking the resident to his/her room caused the resident's behavior. The nurse directed the CNAs to leave the resident alone. The resident then accused his/her roommate of urinating on the resident's bed. The roommate was not in the room at the time; -The nurse asked the CMT to give the resident a medication for anxiety; -The nurse did not report the resident's allegation of rape to anyone; -The nurse said, if at any time, he/she thought the resident was making a serious abuse allegation, he/she would have reported it, but the nurse witnessed the staff not touching the resident while the resident said, You're raping me; -The resident had no obvious physical injuries, but seemed very agitated with staff attempting to provide care; -The resident had periods of delusions and the resident yells out and becomes verbally aggressive with staff at times; -The nurse said he/she received abuse training every three months from the facility, and this training includes reporting of abuse; -The nurse said he/she is supposed to report any abuse to the Director of Nursing (DON) or the facility administrator; -The nurse said he/she never thought abuse was possible, in this case, because multiple staff were in the room at the time and no one was touching the resident. During an interview on 5/11/21, at 4:36 P.M., the DON said the following: -She reviewed the resident's notes a couple of days after 5/4/21, but did not report the allegation of abuse to anyone; -The DON spoke with CNA D, who reported all three aides (CNA B CNA C, and CNA D) were in the resident's room at the time of the resident's allegations on 5/4/21; -CNA D said he/she touched the resident's arm the resident began yelling and accused the staff of raping him/her, and then the staff left the room and reported the incident to RN E; -The DON did not interview any other staff involved; -The DON said, if there been just one staff in the room at the time, he/she would have interviewed staff and residents; -The DON said the facility policy directs staff to report and conduct an investigation on any abuse allegation, including rape. During an interview on 5/11/21, at 4:36 P.M., the administrator said the following: -She was unaware of the resident's statements on 5/4/21; -In this particular situation, the resident said, You are raping me, and since there were multiple staff in the room at the time observing the resident and the resident is demented, she expected staff to leave the resident's room and report to the charge nurse; -The administrator said she would need more information to make a determination as to whether this was an allegation of abuse or not; -The administrator said if staff had notified her of the resident's statements, she would have came to the facility and interviewed the resident to determine if abuse occurred; -If the resident made a valid allegation, such as, I have been raped, or, The staff have raped me, then that would be an allegation of abuse; -When a resident makes an allegation of abuse, the facility would report to DHSS within 2 hours and the DON and/or administrator would come to the facility to conduct an investigation.

Based on observation, interview, and record review, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to provide adequate indications for usage of an antipsychotic medication, failed to identify appropriate target behaviors for medication use, and failed to show the medication helped promote or maintain the resident's highest practicable mental, physical, and psychological well-being for one resident (Resident #6) in a selected sample of 14. The facility census was 29. Record review of the facility's policy titled, Psychoactive Drug Therapy, dated April 2006, showed the following information: -This facility will use psychoactive drugs only in the best interest of the resident, never for the convenience of the staff or to punish residents, and in conjunction with non-drug interventions and approaches whenever possible; -An unnecessary drug is any drug when used in excessive dose or excessive duration, or without adequate monitoring, without adequate indication for use, or in the presence of adverse consequences, which indicate the dose should be reduced or discontinued. Psychoactive medications are those prescribed to control mood, mental status, or behavior. These include anti-anxiety agents, sedative-hypnotic, antidepressants, anti-psychotics, and anti-manic drugs; -Physician orders for all will include: medication name and strength, route of administration, frequency of administration, and target behavior; -Documentation of medication administration will be monitored along with targeted behaviors. Record review of the facility's policy titled, Behavior Management Program, dated April 2006, showed the following information: -Each resident who is receiving a psychoactive medication will be placed on a behavior management plan; -Each resident will have a care plan identifying the reason for the medication and behavioral interventions to be implemented by each discipline; -Identification of a new problem behavior will be assessed to rule out other possible reasons for the resident's distress (i.e. environmental stressors, acute illness, medication change, etc.), prior to obtaining an order for a psychoactive medication. 1. Record review of Resident #6's face sheet (brief information sheet) showed the following information: -admission date of 2/15/18; -Diagnoses of unspecified dementia without behavioral disturbance, anxiety disorder, other schizoaffective disorders, insomnia, and cognitive communication deficit (communication disorders related to brain function). Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrumment completed by facility staff, dated 2/14/19, showed the following information: -Severely cognitively impaired; -Behavior of wandering daily; -Independent with walking, transfers, dressing, and eating. Record review of the resident's physician order sheet (POS) showed the following information: -On 4/22/18, an order for Zyprexa (an antipsychotic medication), 5 milligrams (mg), by mouth one time per day at bedtime. On 4/23/18, the physician added schizoaffective disorder (mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) to the resident's diagnoses. Record review of the resident's monthly behavioral monitoring form, started 4/23/18, showed the targeted behavior each month as wandering; no other behaviors were listed. Record review of the resident's care plan, last updated 2/14/19, showed the following information: -Document behaviors and notify physician; -Resident wanders; -Nursing interventions to avoid over stimulation, assess for pain, toileting, or hunger, offer other activities, and redirect. Observation on 2/19/19, at 10:30 A.M., showed the resident asleep in his/her room in a recliner. Observation on 2/20/19, at 2:45 P.M., showed the resident asleep in a common area in a recliner. During observation and interview on 2/21/19, at 11 40 A.M., on a couch in a common area of the facility, the resident said he/she likes to walk and be outside. The resident was very pleasant, but confused. During observation on 2/22/19, at 8:50 A.M., showed the resident asleep in a recliner in the dining area. During an interview on 2/22/19, at 8:55 A.M., Certified Nurse Aide (CNA) A said the resident is pleasant, and not combative. The resident does not have hallucinations or delusions. The resident is easy to redirect. During an interview on 2/22/19, at 9:05 A.M., CNA B said the resident is not combative, and does not have negative behaviors. The resident will try to exit the facility, but is easy to redirect. During an interview on 2/22/19, at 9:10 A.M., Registered Nurse (RN) C said antipsychotic medications are used for residents with hallucinations or delusions. The resident is usually pleasant. The resident wanders, and is easy to redirect. The resident does not have hallucinations, delusions, or negative behaviors. During an interview on 2/22/19, at 11:10 A.M., the Director of Nurses (DON) said antipsychotic medications are used with residents with hallucinations, delusions or combative behaviors. All behaviors are tracked on the behavioral monitoring forms. The resident had behaviors when he/she was admitted . He/she was exit seeking and difficult to redirect. The resident wandered into other resident rooms and could be difficult to redirect. These behaviors should be on the monitoring form and detailed in the nurses notes. During an interview on 2/22/19, at 11:30 A.M., the administrator said antipsychotics are used with certain diagnoses, and must have appropriate target behaviors. Wandering is not a target behavior by itself. It should be shown the resident is in distress or has behaviors that effect care or other residents. The resident wandered frequently upon admission and became more difficult to redirect. Behavioral interventions were tried and should have been documented.