**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included alcohol use and verbal/physical aggression, for one resident (Resident #2). The facility failed to address the behaviors and inform staff how to handle the resident's escalating behaviors. The sample was eight. The census was 62. The Administrator was informed on [DATE] of an Immediate Jeopardy (IJ), which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's Substance Use Disorder policy dated [DATE], showed: -Residents admitted to the facility with substance use disorder (SUD) will receive the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being, provided by the facility and in accordance with the comprehensive assessment and care plan; -SUD is defined as recurrent use of alcohol and/or drugs which causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home; -The behavioral health care needs of those with SUD or other serious mental health disorders are evaluated as part of the facility assessment. During the facility assessment, the facility determines whether the capacity, services and staff skills are available to meet the needs of those with SUD or other serious mental health disorders; -All residents are screened for serious mental health disorders, intellectual disabilities, and related conditions prior to admission to determine if specialized services under the Preadmission Screening and Resident Review (PASARR) requirements are necessary; -If the resident does not qualify for specialized services under PASARR, but requires more intensive behavioral health services, the facility will provide for and/or arrange for these services; -The specific services needed by the resident are identified during the comprehensive assessment; -The care plan will address the individualized needs the resident may have related to the mental disorder or the SUD. For example: -Activity needs that are different from other residents; -Access to group counseling; -Access to medication assisted treatment, if applicable; -The resident's history of substance use disorder and risk for using substances which could lead to an overdose while in the facility are identified to the extent possible and documented in the medical record; -In addition, safety, and health concerns specific to the resident and his/her history are identified. Health and safety considerations related to substance use disorder may include: -Risk of respiratory depression and fatal overdose; -Increased risk of falls and other accidents; -Potential for wandering and elopement; -Potential for resident-to-resident altercations and other disruptive behaviors; -Constipation and fecal impaction; -Skin infections; -Weight loss and malnutrition; -Potential for cognitive decline and mood disorders; -Care plan interventions are directed at maintaining the safety of the resident, staff, and other residents and not necessarily on addressing the underlying addictive behaviors. Examples of appropriate care interventions for a resident with SUD include: -Monitoring the resident for signs and symptoms of substance use (changes in behavior, unexplained lethargy, odors, new needle marks, slurred speech, lack of coordination, etc.) and overdose, especially after returning from a leave of absence or during/after visitation; -Increasing supervision of the resident and, if needed, the resident's visitors; -Supporting the resident's efforts to prevent substance use such as coordinating behavioral health services, medication assisted treatment, and 12-step meetings; -Facility staff are trained on the signs and symptoms of opioid overdose and emergency interventions (the administration of opioid reversal agents (i.e., naloxone and cardiopulmonary resuscitation (CPR)) when drug overdose is suspected; -Behavioral contracts may be initiated to address behaviors which could endanger the resident, other residents, and staff and to encourage residents to follow their plan of care; -Behavioral contracts are only used with residents who have the capacity to understand them; -Examples of appropriate uses of behavioral contracts include: -A behavioral contract that communicates the resident's right to have a leave of absence and explains the health and safety risks of leaving without facility knowledge or leaving against medical advice (AMA). The contract does not restrict a resident's right to leave the facility, but can distinguish between a leave of absence, elopement, and leaving AMA; -A behavioral contract which clarifies the facility response to suspected illegal substance abuse. If substance abuse is suspected, a behavioral contract may stipulate: -Monitoring and supervision in the facility may be increased to maintain the health and safety of the resident suspected of substance abuse, as well as the other residents; -Visitation may be restricted or supervised if the resident's visitors are deemed to be a danger to the resident, other residents, or staff; -Voluntary drug testing may be conducted if there are concerns that suspected drug use could adversely affect the resident's condition; -Voluntary inspections may be conducted if there is reasonable suspicion of possession of illegal drugs, weapons, or other unauthorized items which could endanger the resident or others; - Local law enforcement will be notified if there is suspicion of a crime in accordance with state laws, such as possession of illegal substances, paraphernalia, or weapons; -Refusal to accept or non-adherence to the terms of a behavioral contract will not be the sole basis for a denial of admission, a transfer or discharge; -Non-adherence to the contract will be treated as a care plan intervention that needs attention or needs to be altered to meet the needs of the resident. The interdisciplinary team (IDT) will work with the resident and resident representative to revise the care plan and contract. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -No behaviors exhibited; -Diagnoses included high blood pressure, high cholesterol, and depression. Review of the resident's progress notes, dated [DATE] at 6:00 A.M., showed the resident arrived back to the facility at 5:10 A.M. after checking him/herself out the facility at 2:50 P.M. on [DATE]. The resident's speech was slurred, and he/she was loud. His/Her gait was unsteady, and he/she was belligerent due to inebriation (drunk or intoxicated). The resident's physician was notified. He/She gave order to hold all medications and give fluids. Review of the resident's hospital discharge paperwork, dated [DATE], showed: -Diagnosis: Alcohol intoxication delirium; -Drugs of abuse screen completed; -Zofran (used to treat nausea or vomiting) four milligrams given. Review of the resident's care plan, in use during the survey, showed: -Problem Onset [DATE]: The resident placed him/herself in unsafe situations when away from the facility. He/She was a danger to him/herself due to polysubstance abuse. He/She had poor decision-making skills. He/She was educated and agreed to leave of absence (LOA) with supervision; -Approaches: Place resident in area with frequent observation. Alert staff of unsafe behavior. Provide diversion activities. Approach in calm and accepting manner. Monitor and document behaviors. -The care plan did not list who is designated to monitor the resident's behaviors, the frequency of monitoring, which behaviors would be monitored, and specific diversional activities. Review of the resident's progress notes, showed: -On [DATE], time unknown, the resident went into another resident's room and cursed at him/her. Staff deescalated the situation; -On [DATE] at 11:00 P.M., the resident told the nurse he/she was going to sign out of the facility. He/She was encouraged to stay inside. He/She refused, put on his/her coat, and exited the front door. The Administrator and Director of Nursing (DON) were notified; -On [DATE] at 12:15 A.M., the resident returned to the facility; -On [DATE] at 6:15 P.M., the nurse reported the resident had a falling out spell (passed out). The resident was wheeled back to his/her room. Staff notified the physician; -On [DATE] at 1:00 A.M., the resident tried to leave the facility. Staff redirected him/her. His/Her speech was slurred, and his/her eyes rolled up/down and side to side rapidly. Nurse practitioner notified. No new orders given. Review of the resident's physician progress note, dated [DATE] and [DATE], showed: -History of polysubstance abuse; -The resident reported depression and anxiety; -Alcohol and cocaine abuse in early remission; -No documentation of resident's aggressive behaviors or intoxication. Review of the resident's progress note, dated [DATE] at 5:37 P.M., showed the resident was physically aggressive with another resident. Review of the resident's medical record on [DATE], showed no documented Social Services notes. During an interview on [DATE] at 8:38 A.M., LPN E said he/she has worked at the facility since [DATE]. The resident would get drunk and bully staff and other residents. On [DATE], the resident asked to speak to LPN E. He/She refused to talk to the resident. The resident was drunk and made irrational statements. The resident grabbed him/her by the neck and pushed him/her in the corner. He/She filed a grievance against the resident immediately. He/She did not document the incident in the nurse's notes. He/She did not notify the resident's physician. Staff were aware the resident was getting drunk. He/She did not know what staff are supposed to do when residents return to the facility intoxicated. The resident got physical when he/she did not get his/her way. The DON said she would have a meeting with the resident and LPN E. They did not have a meeting. Review of the facility's complaint/grievance report, dated [DATE], showed: -Resident #2 was under the influence of alcohol; -He/She cursed at Licensed Practical Nurse (LPN) E and grabbed him/her by the collar; -Plan to resolve investigation: Social Worker will have a discussion with Resident #2; -Results of actions taken: The Administration team set up a meeting with Resident #2. Review of the resident's physician progress note, dated [DATE], showed: -History of cocaine and alcohol abuse. Improved, in early remission; -No complaints and anxiety was better; -No documentation of resident's verbal and physical aggression towards staff and other residents; -No documentation of resident's recent alcohol abuse. Review of the resident's progress note, dated [DATE] at 12:18 A.M., showed the receptionist asked the nurse to come to the lobby for a fight. The resident was in the lobby with blood on his/her hands and shirt. His/Her speech was slurred, and he/she smelled of alcohol. The resident told the nurse he/she tried to talk to Resident #1, and he/she disrespected him/her. Staff called the police. During an interview on [DATE] at 12:18 P.M., Certified Medication Technician (CMT) A said Resident #2 would come back to the facility drunk. He/She was combative and verbally aggressive. He/She usually drank between 2:00 P.M. and 8:00 P.M. CMT A notified the nurse. The nurse did not find alcohol in Resident #2's room. Resident #2 has had altercations with other residents. When residents are under the influence of alcohol or drugs, staff just tells the nurse. During an interview on [DATE] at 12:40 P.M., CNA C said the resident returned to the facility intoxicated at least two or three times per week. He/She reported it once to a nurse eight months ago. He/She is not sure if the Administrator is aware. If a resident comes back to the facility intoxicated, he/she would report it to a nurse. During an interview on [DATE] at 12:46 P.M., CMT B said the resident was very aggressive. He/She would often return to the facility drunk. He/She has reported the instances to the nurse. They could not find any alcohol on him/her. He/She did not document the incidents. If a resident returns to the facility under the influence, staff are supposed to notify the Charge Nurse. During an interview on [DATE] at 1:05 P.M., LPN D said the resident has returned to the facility intoxicated. He/She would stumble around and had slurred speech. The facility did not have a policy for intoxicated residents. He/She would go to his/her room and go to sleep. During an interview on [DATE] at 2:08 P.M., the Social Worker said the resident was having substance use issues. She was made aware in April. She offered him/her Alcohol Anonymous and counseling services. He/She refused the services. The resident would get drunk on the weekends. He/She attacked LPN E on [DATE]. She met with the resident on [DATE], time unknown. after he/she attacked LPN E. She is not sure if the resident was on a behavior contract. He/She should have been put on a behavior contract after the first incident. The nursing staff was supposed to initiate the behavior contract. During interviews on [DATE] at 11:14 A.M., [DATE] at 1:21 P.M. and [DATE] at 1:45 P.M., the DON said she has been at the facility since [DATE]. The resident had a history of being verbally and physically aggressive. He/She returned to the facility intoxicated. He/She denied drinking alcohol. He/She had an altercation with another resident in April and he/she attacked LPN E in May. She thought the Administrator talked to the resident about the incident with LPN E. LPN E said the resident smelled like alcohol. She was not aware of the problem in his/her care plan. The resident did what he/she wanted to do. The resident's physician was aware of his/her substance use and behaviors. The physician did not address the issues with the DON. The facility does not have a substance abuse assessment. Substance abuse is covered under the facility assessment. She thinks 80% of the residents drink alcohol or have a history of substance abuse. She tried to initiate an Alcohol Anonymous group at the facility. The residents came in, got snacks, and left. She is not sure if Resident #2 was on the attendance list. The facility is not allowed to search residents' rooms or person. Resident #2 should have been on a behavior contract. She was not sure who initiated behavior contracts. During an interview on [DATE] at 8:10 A.M., the Administrator said staff would meet with the resident when possible. He does not have control over what residents do when they sign out. Staff will address the situation when residents return. He never saw the resident intoxicated. The resident did not trigger a PASARR. When residents are intoxicated, staff should contact the physician and send them out. The facility puts residents on behavior contracts when deemed necessary. Resident #2 should have been on a behavior contract. He thought the DON or Social Services was responsible for initiating behavior contracts. He did not know why the resident was not on a behavior contract. During an interview on [DATE] at 10:01 A.M., Resident #2's physician said staff notified him/her of the resident being intoxicated on [DATE]. He/She told staff to hold the resident's medications. He/She was not aware the resident assaulted another resident. If the resident was getting drunk and being aggressive, the facility should have contacted his/her office. The resident should have been on a behavior contract and discharged from the facility sooner. MO00238048 MO00238149 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site 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 the exit, the deficiency was lowered to the D level. This statement does not denote 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, facility staff failed to monitor one resident (Resident #1), in accordance with facility stated standards of practice to ensure the health and safety of residents, when facility staff failed to check on the resident at shift change and every two hours. Facility staff reported administering medications to and speaking to the resident on [DATE] at 9:00 P.M. On [DATE] at 9:00 A.M., the resident was found on the floor, with a coat on. The resident did not have signs of life, and he/she had rigor mortis (stiffening of the joints and muscles of a body a few hours after death). The night shift nurse left the facility at approximately 6:00 A.M. without checking on residents with the day shift nurse. A certified medication technician (CMT) documented medication administration and a blood pressure reading at 8:00 A.M. without administering/observing the resident. Facility staff noted the resident was not at breakfast, which was uncharacteristic, however did not check on the resident. The sample was 4. The census was 50. The administrator was notified on [DATE] at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's documentation of medication administration policy, dated 2001 and revised [DATE], showed the following: -The facility shall maintain a medication administration record to document all medications administered; -A nurse or certified medication aide shall document all medications administered to each resident on the resident's MAR; -Administration of medication must be documented immediately after (never before) it is given. During an interview on [DATE] at 3:00 P.M., the Administrator said the following: -She expects nursing staff to make rounds when they came on and off shift and every two hours for resident safety; -She expects nursing staff to stay at their assignment until their relief came and they were able to give report. During an interview on [DATE] at 3:00 P.M., the Regional Nurse said the following: -Nursing staff were expected to make rounds on their residents when coming on and off shift and at every two hours during their shift to ensure resident safety; -Making frequent rounds on residents was considered a professional standard of care. During an interview on [DATE] at 4:14 P.M., the Primary Care Physician (PCP) said he expects nursing staff to round on residents at least two times a shift, but ideally every couple of hours. Review of Resident #1's care plan, undated, showed the following: -Problem: The resident was at risk for falls and fall related injury due to abnormalities of gait and mobility; Interventions included: Remind the resident to keep his/her area free of clutter, including the path to the bathroom. Assist as needed; -Problem: At risk for respiratory infection/illness due to choosing to smoke cigarettes; Interventions included: Monitor for any changes in mental status and report changes to the physician; -Full code (provide resuscitation procedures). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -Cognitively intact; -Independent with activities of daily living (ADLs); -Walked without devices; -Diagnoses included heart failure, high blood pressure, diabetes mellitus, chronic obstructive pulmonary disease (COPD, lung disease) and schizophrenia. Review of the resident's physician order sheets, dated [DATE] through [DATE], showed the resident was full code. (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive.) Review of the facility's investigation, received on [DATE] at 5:20 P.M., showed the Director of Nursing (DON) wrote a document titled Nursing progress note, dated [DATE], no time noted, detailing the time line of events of that morning: -At 9:04 A.M., the DON received a call from the Certified Medication Technician (CMT) on the third floor reporting a resident was found on the floor and appeared dead. -Upon arriving to the floor, the psychiatric (psych) Nurse Practitioner (NP) and CMT were kneeled next to the resident. The resident was on the floor at the foot of the bed, fully clothed to include coat and gloves. -Further noted, resident's extremities (arms and legs) were in rigor mortis with swelling to his/her face, legs and arms. The resident was unresponsive. -Calls were placed to the Primary Care Physician (PCP) for further instruction. The Regional Registered Nurse was notified. -The resident's temporal (artery that runs across the forehead) temperature was 35.6 C (equal to 96.0 Fahrenheit) (The average body temperature is 98.6 F (37 C)- but can range between 97 F (36.1 C) and 99 F (37.2 C)Celsius, equal to 96.0 degrees Fahrenheit); -A statement, undated, from the psych NP. On the morning of [DATE], he/she was doing rounds at the facility. When he/she arrived to the resident's room, he/she noticed a person lying face down on the floor. He/she immediately notified the nursing staff who was standing just outside the resident's room near his/her medication cart. They entered the room together and checked for the resident's pulse. The resident had no pulse. The resident was very stiff, but they managed to turn the resident over and immediately noticed rigor mortis in the resident's face muscles. The resident's skin was very cold to the touch. The nursing staff immediately called for assistance and the nursing facility staff responded promptly; -An investigation statement, dated [DATE], no time noted, signed by CMT A. He/she was on his/her way to give the resident his/her morning medications when the psych NP found the resident face down on the floor. They entered the room and the psych NP checked the resident arm for a pulse, which was absent. They turned the resident around to see if he/she was alright. The CMT saw the resident was unresponsive and called the DON to inform her what was happening; -A statement, dated [DATE], signed by Nurse D. He/she worked on the third floor on [DATE] on the 11:00 P.M. to 7:00 A.M. shift. The resident was in bed under the covers during his/her rounds; -A statement, undated, signed by CMT E. On [DATE], the CMT entered the resident's room around 8:50 P.M. The resident was asleep. CMT E woke the resident to give him/her medications. The resident woke up, took his/her medications, said thank you and went back to sleep; -There were no other statements found. -There was no final summary or conclusion of the investigation provided by the facility. During an interview on [DATE] at 11:41 A.M., CMT E said the following: -He/she worked on the third floor as a CMT on [DATE] during the evening shift from 3:00 P.M. to 11:00 P.M.; -He/she last saw the resident around 9:20 P.M. when he/she administered medications to him/her; -The resident was in bed when the CMT went in the bedroom. The resident was easily roused, sat up in the bed, took the medications from the CMT, said thank you and went back to sleep; -He/she did not notice anything different with the resident; -The resident went to bed a little earlier than usual that evening; -He/she left at approximately 11:00 P.M. when Nurse D came to relieve him/her; -He/she remembered Nurse D coming on shift. He/she gave the nurse report. They did not do rounds together. During an interview on [DATE] at 3:53 P.M., Nurse D said the following: -He/she worked the night shift on [DATE] from 11:00 P.M. to 7:00 A.M. on [DATE]; -He/she was assigned to the third floor; -There were no other staff working with him/her that shift; -He/she would do rounds on his/her residents to check to make sure they were all stable, make sure all the beds were in the low position, take report from the off-going nurse and count the narcotics on the medication cart when he/she started his/her shift; -He/she could not recall if he/she did rounds at the start of the shift; -The resident was already in bed when he/she started his/her shift; -He/she thought the last time he/she saw the resident was maybe around 4:00 A.M. The resident was in bed asleep under the covers; -He/she left between 6:00 A.M. and 7:00 A.M. that morning; -He/she gave report to Registered Nurse XX (RN-XX); -He/she did not do rounds before he/she left his/her assignment; -He/she did not do rounds with RN-XX or see RN-XX do rounds before leaving the third floor; -There were no other staff on the third floor when he/she left his/her assignment; -He/she often worked on the third floor without any other staff; -He/she often worked on the second floor during night shift and was responsible for both the second and third floor assessments and medication pass; -The third floor was often staffed with just a CNA during the night shift; -He/she found it challenging to cover both floors by him/herself to ensure the residents safety. During an interview on [DATE] at 1:03 P.M., RN-XX said the following: -She worked on [DATE]; -She did not see the resident down on the first floor for breakfast that morning, which was unusual; -RN-XX did not follow up on this unusual behavior by checking on the resident; -She was alerted by CMT A the resident was deceased at approximately 9:16 A.M.; -She went upstairs to the third floor and entered the resident's room and saw the psych NP kneeling next to the body. He/she told RN-XX he/she could not find a pulse; -The body had rigor mortis and appeared a little swollen; -She called the PCP and the family to alert them of the resident's death; During an interview on [DATE] at 11:36 A.M., the psych NP said the following: -He/she was on the third floor at approximately 9:00 A.M. on [DATE] to visit residents; -He/she normally walked around the floor, popping into rooms to say hello to his/her residents before he/she started his/her assessments; -At approximately 9:20 A.M., he/she went to the resident's room and saw him/her lying on the floor next to his/her bed, face down; -He/she went to the door and saw CMT A outside in the hall with the medication cart. He/she asked the CMT to come into the room; -He/she knelt down beside the resident and felt for a pulse. Finding none, he/she had the CMT assist him/her in rolling the resident over to his/her back; -The resident was cold to the touch, the body was stiff with rigor mortis and his/her face was distorted; -The CMT left the room to alert other staff and he/she stayed with the body; -He/she attempted a few rounds of chest compressions. The body was cold, lifeless and stiff and did not respond to the compressions; -RN-XX and another nurse came in and said the resident was dead, it was apparent from the presence of rigor mortis. During an interview on [DATE] at 11:49 A.M., CMT A said the following: -He/she worked on the third floor as a CMT on [DATE]; -He/she was running late that day and didn't arrive on the floor until approximately 7:40 A.M.; -There were no other staff on the third floor when he/she arrived. He/she retrieved the keys to the medication cart from Nurse C, the night nurse on the second floor; -He/she did not receive report from anyone; -The third floor usually was not staffed with certified nurse assistants (CNAs); -Nurse D worked the night shift, but was not there when he/she started his/her shift; -The facility usually staffed a CMT for the evening shift (3:00 P.M. to 11:00 P.M.); -CMT E worked the evening shift and had left the previous night at 11:00 P.M.; -He/she did not do rounds on the residents at the beginning of his/her shift; -He/she began passing out medication at approximately 8:00 A.M. to residents on the hall on the other side of the floor from the resident's room; -The psychiatric NP came on the floor around 9:18 A.M.; -The psych NP was checking on his/her patients when he/she entered the resident's room at approximately 9:20 A.M.; -The psych NP exited the resident's room and called out to the CMT, who was on the resident's hall, to come and check on the resident as there was something wrong; -The CMT entered the room with the psych NP and saw the resident was on the floor, near his/her bed, face down. The psych NP knelt down beside the resident, checked for a pulse, and found none; -Both the CMT and the psych NP rolled the resident over onto his/her back. The resident was cold to the touch, there was a knot on his/her forehead, and the left side of the resident's face looked smooshed in. The resident's arms were stiff, bent at the elbow, to his/her chest and there was dried spit around the resident's mouth; -The resident's body was stiff and unbending when they rolled the resident onto his/her back; -The resident was wearing street clothes, a coat and socks with no shoes; -The CMT left the room to call RN-XX; -RN-XX came up to the resident's room with Nurse B to assess the resident; During an interview on [DATE] at 12:33 P.M., Nurse B said the following: -Nurses were expected to round when they first got on shift and then every two hours with the CNAs; -Breakfast was served between 7:00 and 7:30 A.M.; -He/she was present the day the resident passed away. He/she was told a CMT found the resident on the floor and he/she was not breathing; -RN-XX asked him/her to go up with her to assess the resident; -The resident was lying on his/her back, arms were contracted up and bent at the elbow. The resident's face was puffy; -Rigor mortis had set in as the resident was not normally contracted. During an interview on [DATE] at 11:30 A.M., Nurse B said the following: -He/she would do rounds on the residents with the off-going nurse or by him/herself, before starting his/her assignment to ensure the safety of the residents; -If there was not a nurse scheduled on the third floor, the DON or Assistant Director of Nursing (ADON) were responsible for the third floor; -RN-XX was assigned to the third floor on [DATE] during the day shift; -Nurse B worked as the nurse on the second floor during the day shift on [DATE]; -He/she did not make rounds on the third floor, as it was not part of his/her assignment. During an interview on [DATE] at 12:00 P.M. CNA G said the following: -He/she was assigned to work the second floor on [DATE] during the day shift; -CMT A was the only staff member working on the third floor when CNA G came on shift at 7:00 A.M.; -CNA G normally made rounds on residents every two hours and when coming on and off shift to ensure safety. Review of the resident's MAR, dated [DATE] through [DATE], showed the following: -On [DATE], CMT A initialed he/she administered one medication at 8:00 A.M.; -On [DATE], CMT A initialed he/she administered eight medications at 9:00 A.M.; -On [DATE], CMT A initialed he/she administered metoprolol tartrate (used to lower blood pressure) 25 mg at 9:00 A.M. with a blood pressure listed. There was a dark mark drawn over the blood pressure reading making the numbers difficult to read. During an interview on [DATE] at 10:45 A.M., CMT A said the following: -The facility was always very prompt at giving breakfast between 7:00 A.M. and 7:30 A.M.; -He/she did not see the resident go downstairs to breakfast. The resident also usually goes outside to smoke after breakfast; -He/she was not sure why he/she did not round on the residents at the beginning of his/her shift. He/she was focused on passing out the medications; -He/she did not give the resident any medication on [DATE]; -He/she was preparing to give the resident his/her medication by putting medication in a pill cup; -He/she signed his/her initials on the MAR after he/she prepared the resident's medication before administration; -He/she did not see the resident before the psych NP alerted him/her to the resident's death; -He/she was not sure why there was a blood pressure listed on [DATE] on the MAR; -If a resident did not consume the medication, he/she would circle his/her initials on the MAR and write a note on the back, explaining the medication was not consumed. During an interview on [DATE] at 3:51 P.M., NA F said the following: -He/she was assigned to work on the third floor on [DATE] during the day shift; -He/she came on shift at approximately 8:30 A.M., and got to the floor approximately 10 minutes later; -Only CMT A was working on the third floor when he/she came on shift; -He/she did not get report from anyone when he/she started his/her assignment; -He/she started to do rounds on all residents on the floor when he/she started his/her assignment; -He/she did not round on the resident as he/she did not get to the resident's side of the building before CMT A alerted him/her the resident was found dead. Review of the worksheet for nursing home deaths for the Office of the Medical Examiner, undated, showed the following: -The resident was listed as deceased at the facility; -Date/time last seen on [DATE] by a CMT; -Condition/circumstances when last seen alive: sleeping at 9:00 P.M.; -Date/time found on [DATE] at 9:20 A.M. by a CMT and psych NP. No unusual conditions noted; -No medical problems including recent illness, injury trauma or fall; -The body was found in a room, on the floor, at the foot of the bed; -Date/time pronounced: [DATE] at 9:20 A.M. During an interview on [DATE] at 9:13 A.M., the coroner said the following: -The county coroner released the body to him to perform an autopsy of the body due to the state of the body when it was found and questionable ligature (something that binds or ties) marks found on the resident's wrists; -The ligature marks found on the resident's wrists may have been caused by a coat and/or gloves the resident was reported to wear often; -The resident had a bruise on his/her right forehead and a subgaleal hemorrhage (an accumulation of blood formed between the skin and skull) at the right front of his/her scalp, showing the resident had a very recent fall, within a few hours of death. It may or may not have been significant to the resident's death; -He was not able to determine a conclusive cause of death. During an interview on [DATE] at 10:22 A.M., an anonymous resident who resided on the third floor, said the following: -The staff do not come around and check on the residents to make sure they were ok; -The facility consistently did not staff a nurse to the third floor. During an interview on [DATE] at 3:00 P.M., the Administrator said the following: -Breakfast was served between 7:15 A.M. and 7:20 A.M. It was a combination of both dining room service and hall tray service; -If residents did not eat in the dining room, the dietary aides would take breakfast trays up to the rooms for the residents who missed breakfast; -CNAs were responsible for passing out meal trays; -She expected staff to pass all room trays; -She expected staff to alert the nurse if a resident did not receive a meal so the nurse could assess the resident to see if there was a change of condition, attempt to get the resident to eat, offer an alternative and then document in progress notes if the resident refused to eat; -The third floor was generally staffed with a nurse and a CNA or a CMT and a CNA with the second floor nurse responsible for oversight; -She expected the second floor nurse to round on the third floor as appropriate or every two hours, deal with acute issues, changes of conditions, contact the PCP as needed and document in progress notes; -She expected the CMT on the third floor to pass medications to the residents and help the CNA as needed; -She expected staff to document on the resident's MAR after administering a medication for accuracy of records; -She expected the DON to investigate any death to see what occurred, what was the possible cause of death, if a change of condition was missed, if the resident could have been sent out sooner to avoid death and to provide education to staff if needed. During an interview on [DATE] at 10:03 A.M., the Administrator said the following: -RN-XX was the charge nurse responsible for the third floor on [DATE] during the day shift; -She expected RN-XX to make rounds with Nurse D before Nurse D left the building to ensure all residents were safe; -CMT A and CNA G were assigned to work on the third floor on [DATE] during the day shift; -She expected CMT A and CNA G to make rounds when they first came on shift; -She expected CMT A and CNA G to make sure all residents either went down to the dining hall on the first floor or received a breakfast tray in their room; -She expected the DON to begin an investigation on the resident's death on the day he/she had passed; -She expected the investigation to include interviews with all nursing staff who were assigned to the third floor on [DATE] night shift and on [DATE] during the day shift in order to determine a timeline of when the resident was last seen by staff and his/her last known condition to give a broader picture of what might have occurred leading up to and after the resident's death; -The DON was responsible for starting the investigation within 24 hours of the incident and to complete it with a summary of findings within 72 hours; -The Administrator was responsible to follow up on the investigation to check it for completeness; -The facility did not provide any education to staff regarding monitoring of residents during their shift. During an interview on [DATE] at 9:37 A.M., the Administrator said the facility did not have a list for residents who received hall trays; if a resident did not go to the dining room for a meal, the dietary staff would prepare a meal tray and send it to the resident's floor. There was no documentation the resident received a breakfast tray on the morning of [DATE]. During an interview on [DATE] at 9:53 A.M., the resident's family member, said the following: -He/she was notified of the resident's death on [DATE] between 11:00 and 11:45 A.M.; -The DON met the family member at the lobby and brought the family member up to the third floor; -The DON said they had given the resident his/her medications the night before and then put the resident to bed. The DON did not say what time, just specified last night; -The DON said the last time the resident was seen by staff was at 9:00 P.M. when nursing staff gave him/her medication; -The DON said when she arrived to the facility that morning, she noticed the resident was not in the dining room or in the lobby. She said the resident was always downstairs and always so friendly .(he/she) didn't come to breakfast .we just thought (he/she) was sleeping in. -The DON said the psych NP found the resident when he/she was doing rounds and the resident was already dead. During an interview on [DATE] at 3:00 P.M., the Regional Nurse said the following: -The facility did not have a policy on rounding; -Nursing staff were expected to make rounds on their residents when coming on and off shift and at every two hours during their shift to ensure resident safety; -Making frequent rounds on residents was considered a professional standard of care. During an interview on [DATE] at 4:14 P.M., the PCP said the following: -He expected nursing staff to round on residents at least two times a shift, but ideally every couple of hours; -The facility told him the resident was found dead on the floor, next to his/her bed, lying face down with significant amount of rigor mortis found in his/her limbs and face; -Rigor mortis sets into a body within six to seven hours after death; -If the resident had fallen trying to get out of bed, the nursing staff could have intervened if they had performed frequent rounding and found the resident on the floor; -He expected the facility to check on a resident's status if they miss a meal; -He expected the facility to find the deceased resident's body much sooner, during rounds, on-coming/off-going rounds or, at the very least, after the resident missed breakfast; -There was an autopsy performed on the resident due to some questions by the county coroner and the family of the resident; -He listed CHF as the cause of death based on the resident's diagnoses although he was not sure if that was the reason yet; -He expected facility staff to document after they administered medications to a resident for accuracy of records. It was obvious the resident could not have consumed medication at 8:00 A.M. or at 9:00 A.M. given the facility found him/her dead with rigor mortis between 9:00 and 9:20 A.M. MO00208478 Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site 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. Note: At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).