Please see deficiency cited at F689 in Event ID 533H12. This citation is uncorrected. See the narrative at Event ID 533H11. This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 3/14/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1), with a known history of suicidal ideation, high risk of suicide and frequent self-harming behavior received adequate supervision. The facility determined the resident required close supervision, defined as supervision from three to five feet, to ensure the resident's safety and well-being. Per the resident's care plan, the resident was to receive 1:1 monitoring. On 3/3/25, staff assigned to provide 1:1 supervision for the resident were reassigned to other duties and left the resident unsupervised in his/her room with the door closed. The resident broke the window in his/her room and used the glass to cut himself/herself resulting in multiple deep cuts requiring medical intervention. The sample size was eleven. The census was 106. The Administrator was notified on 3/13/25 at 2:20 P.M., of an Immediate Jeopardy (IJ) which began on 3/3/25. The IJ was removed on 3/13/25, as confirmed by surveyor onsite verification. Review of the facility's Supervision Types, no date, showed: Close Supervision: Supervise resident from a distance of three to five feet. Review of the facility's Accidents and Supervision Policy, revised 5/18/24, showed: -Purpose: Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: -Implementing interventions to reduce hazard(s) and risk(s); -Monitoring for effectiveness and modifying interventions when necessary; -Definitions: -Hazards: Elements of the resident environment that have the potential to cause injury or illness; -Risk: Any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident; -Supervision/Adequate Supervision: Intervention and means of mitigating risk of an accident; -Implementation of Interventions: Using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: -Communicating the interventions to all relevant staff; -Assigning responsibility; -Providing training as needed; -Ensuring that the interventions are put into action; -Interventions are based on the results of the evaluation and analysis of information about hazards and risks; -Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully; -Monitoring and Modification: Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: Ensuring that interventions are implemented correctly and consistently; -Supervision: Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: -Defined by type and frequency; -Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the facility's Suicide Prevention policy, revised 5/14/24, showed: -Purpose: It is the policy of this facility to assess residents for suicidality. Additionally, it is the policy of this facility to act quickly and appropriately if a resident expresses thoughts of suicide; -Definitions: -Protective Factors: Personal and environmental characteristics that help protect people from suicide. It's important to note that protective factors may not counteract significant suicidal risk; -Suicidal Ideation: Self-Reported thoughts about engaging in suicide-related behaviors; -Suicidality: The tendency of a person to commit suicide; -Suicide Prevention: The resident will not be left alone. One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/22/24, showed the following: -Cognitively intact; -Used wheelchair; -No impairment to upper extremities; -Diagnoses included: major depressive disorder (Serious mental health condition characterized by persistent sadness, hopelessness, and loss of interest or pleasure in activities), anxiety disorder (mental heal disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances). Review of the resident's care plan, initiated on 1/29/25 and revised on 2/05/25, showed: -Problem: The resident's Columbia Suicide Severity Rating Scale (C-SSRS, suicide risk assessment tool) assessment deems the resident is at high risk for suicide; -Desired outcomes included: To keep the resident in a safe protective environment. To provide proper tools and coping skills to reduce suicidal ideation. To reduce the amount of times resident experiences suicidal ideation; -Interventions included: Begin behavior monitoring. Begin 1:1 monitoring. Remove items from room that could be used in his/her plan. Safety Planning Interventions: -Safety Planning Intervention: -Warning Signs for impending crisis: left blank; -Internal coping strategies or Activities that distract from suicidal ideations (specify); -Person or place that helps distract them from suicidal thoughts: left blank; -Identify person that they can talk to (specify); -Unique hopes for the future and reason for living: left blank; -Seek professional help from counselor or psychologist. Review of the resident's physician order sheet in use at the time of the investigation, showed an order, dated 12/23/24, for: Behaviors, Monitor for the behaviors of binging and purging, every shift related to personal history of suicidal behavior. Review of the resident's medical record, showed: -On 1/12/25 at 11:01 P.M., staff documented they were made aware of the resident trying to self-harm. The resident had two sharpened pieces of a can lid. The resident said he/she was trying to cut himself/herself; -Mental Status Exam, Date of service: 1/16/25. History from nursing/family. On 1/12/25, resident attempted to self-harm with two sharpened pieces of a can lid, attempting to cut himself/herself. Resident stated if he/she didn't get a cigarette he/she would find something else to do it with it; -On 1/20/25 at 9:22 P.M., staff documented the resident said he/she cut himself/herself because his/her anxiety pushed him/her to it. The resident had blood on his/her pants and sleeves, but refused to let staff assess the wound. The resident claimed to have stopped the bleeding. The resident clutched an object in his/her hand. Emergency Medical Services (EMS) was called. EMS arrived with the police. After speaking with the resident, the officer was able to get the piece of glass the resident used to self-harm. Review of the resident's C-SSRS assessment, dated 1/29/25, showed: -Scoring is as follows: low risk 0-4, moderate risk 5-10, high risk 11-50; -Category: High Risk; -Score: 43.0; -In the past month, have you wished you were dead or wished you could go to sleep and not wake up, Yes; -In the past month, have you had any thoughts about killing yourself, Yes; -Have you been thinking about how you might kill yourself, Yes; -Have you had these thoughts and had some intention of acting on them, Yes; -Have you started to work out or worked out the details of how to kill yourself, Yes; -Do you intend to carry out this plan, No; -Have you ever done anything, started to do anything, or prepared to do anything to end your life, Yes. Review of the resident's progress notes, showed on 2/4/25 at 8:33 A.M., staff documented they found the resident with a laceration to his/her left arm. The resident said he/she was in his/her room and up all night having emotional issues. The resident wanted to cut himself/herself to release emotional pain. The resident said this helped him/her cope. The resident used glass from a bottle of make-up Review of the resident's Psychosocial Post-Incident Impact Questionnaire, dated 2/4/25, showed: -Description: Incident; -Why were you trying to hurt yourself or others: Patient stated he/she was angry with himself/herself. He/She stated cutting helps him/her cope with emotional and physical pain; -What do you feel the facility can do or change to allow your coping skill to be more effective: Patient stated he/she needs himself/herself back. He/She does not do good with sitting alone. He/She feels like he/she is a burden. Review of the resident's C-SSRS assessment, dated 2/10/25, showed: -Category: High Risk; -Score: 46.0; -In the past month, have you wished you were dead or wished you could go to sleep and not wake up, Yes; -In the past month, have you had any thoughts about killing yourself, Yes; -Have you been thinking about how you might kill yourself, Yes; -Have you had these thoughts and had some intention of acting on them, Yes; -Have you started to work out or worked out the details of how to kill yourself, Yes; -Do you intend to carry out this plan, Yes; -Have you ever done anything, started to do anything, or prepared to do anything to end your life, Yes. Review of the resident's mental status exam, showed: -Date of service, 2/13/25; -An order was placed for Abilify (medication used to treat schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors)) 400 milligrams intramuscular (IM, administration directly into the muscle tissue) every 28 days for the management of schizophrenia, and the patient agreed to the treatment plan. Additionally, an order was given for 15-minute safety checks to closely monitor him/her well-being and intervene promptly if needed. They patient will continue to be observed for any changes in symptoms, mood, or behavior; Review of the resident's progress notes, showed: -On 3/1/25 at 9 P.M., staff documented it was reported to this LPN (Licensed Practical Nurse) C that resident stated he/she was very upset, and he/she had been self-harming himself/herself. Body inspection done. The resident has what appeared to be cuts on his/her arms and legs. His/her roommate said that the resident had been doing this for a couple of days. Resident called his/her family. Resident stated to other staff members that he/she was going to keep cutting himself/herself. Ambulance called; -On 3/3/25 at 12:48 A.M., the resident broke the window in his/her room and cut his/her left arm with a piece of glass. The door to the resident's room was closed at that time. Staff discovered the resident cut himself/herself while doing rounds. The resident told staff the act of cutting takes the pain away. During an interview on 3/3/25 at 9:04 A.M., the Director of Nursing (DON) said on 3/3/25 at 12:48 A.M., the resident broke the window in his/her room and cut his/her left arm with a piece of glass. The door to the resident's room was closed at that time. Staff discovered the resident cut himself/herself while doing rounds. The resident told staff the act of cutting takes the pain away. During an interview on 3/10/25 at 2:35 P.M. and on 3/11/25 at 4:50 P.M., the resident said he/she was on 1:1 supervision on 3/3/25. The resident said they took the 1:1 staff away because the facility was short staffed. He/She took advantage of the opportunity and broke the window. The resident said he/she was without his/her 1:1 staff for maybe 15 to 20 minutes. He/She was able to bust the window out within the 15-20 minutes the 1:1 staff was gone. He/She tried to use his/her hairbrush, but that didn't work. Then he/she wrapped a towel over his/her hand and hit the window in the corner. Most of the window broke when he/she hit the glass. The glass fell out in different size pieces. The glass fell inside the room. He/She used a medium size piece. He/She held up both index fingers, pulled them apart to approximately 5 inches to represent the medium size piece of glass used to cut his/her right arm. He/She got steri-strips on his/her right arm. During a telephone interview on 3/11/25 at 2:28 P.M., Activity Aide (AA) F said he/she was assigned to a different resident for 1:1 on 3/3/25. He/She saw the resident's door was shut. AA F opened the door to the resident's room and saw the resident was shaking. AA F told LPN G the resident had cut himself/herself. He/She saw the resident's arm bleeding. LPN G wrapped the resident's arm up. The resident was taken to the nurse's desk to wait for the ambulance. During an interview on 3/11/25 at 10:41 A.M., and 5:59 P.M., LPN G said he/she reassigned the 1:1 staff that was with the resident to help clean other residents due to short staffing. He/She didn't remember the name of the 1:1 staff. LPN G was going to be the 1:1 staff for the resident. LPN G and AA F went back to the resident's room. LPN G said he/she was only gone 5 minutes or less from the resident. He/She said the resident was on his/her phone playing games when he/she first went into his/her room. The resident had on long sleeves, so he/she didn't see the blood at first. After LPN G raised the resident's sleeve, he/she saw blood on the resident's right arm. He/She said the resident's arm looked like [NAME] or [NAME] Scissor Hands cut the resident's arm up. LPN G said it was horrible. LPN G said a couple of the cuts were so deep, he/she thought the resident would need stitches. During an interview on 3/12/25 at 3:13 P.M., Certified Medication Technician (CMT) B said staff were never supposed to leave a 1:1 resident unattended. If staff needed to go to the bathroom, lunch, break, or anything else, they had to pass the 1:1 supervision to another staff member. During an interview on 3/12/25 at 3:20 P.M., LPN N said staff should never leave a 1:1 resident. The resident should be within arm's reach. If the assigned staff had to leave, they must get a relief staff member. During an interview on 3/12/24 at 3:32 P.M., LPN C said staff should never leave an assigned 1:1. If he/she had to do something, he/she would take the assigned 1:1 resident with him/her. It has happened before but it was easy to get a replacement. During an interview on 3/11/25 at 5:13 P.M., the Social Service Director said she thought the 1:1s gave the resident personal attention. She knew the resident was 1:1s when he/she broke the glass, but she wasn't aware of the particulars. During an interview on 3/12/25 at 11:01 A.M. and 11:17 A.M., the Administrator said she expected the resident to have more opportunities to participate in activities and for family to be more involved. She expects staff to listen, pay attention, ask questions, provide help, and be 1:1 companion for the resident when he/she was having thoughts of self-harm. The Administrator expected staff to be within arm's length of resident's who needed 1:1s. She expected staff to stand outside of the bathroom door during toileting. She expected staff to be with their assigned 1:1 resident at all times. The Administrator said she didn't think the resident was on 1:1s when he/she broke the window. Both the Administrator and Assistant Director of Nursing (ADON) said they didn't know the resident had a 1:1 staff assigned to him/her or that the 1:1 staff had been removed due to short staff. Both said having a 1:1 staff member assigned to the resident would reduce opportunities for self-harm. The Administrator expected staff to find coverage for the resident if they have some other task to do. During a telephone interview on 3/12/25 at 11:43 A.M., the Medical Doctor (MD) said he had planned to stop by to see the resident today. He read from the resident's psych note, dated 2/15/25, which said the resident was experiencing depression and anxiety. Due to being a high risk of suicide, other precautions were necessary. The resident had a conscious desire to inflict harm. The resident scored 46.0 on the suicide evaluation assessment and was considered high risk. The MD said 1:1 staff should never leave the resident alone; especially based on the psych note showing high risk of self-harm. He said the resident was 1:1 until he/she could be reassessed this month. The MD said 1:1 removal left the resident unattended, and if the resident committed self-harm, it would not be noticed right away, and more damage can be done. 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 onsite visit, it was determined the facility had implemented corrective actions 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). MO00250594 MO00250414

See the narrative at event ID WGJ612 Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated 9/13/24, for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on 1/13/25, staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on 1/17/25. The sample was 10. The census was 110.

Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated 9/13/24, for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on 1/13/25, staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on 1/17/25. The sample was 10. The census was 110. The Administrator was notified on 1/30/25 at 12:23 P.M. of an Immediate Jeopardy (IJ) which began on 1/13/25. The IJ was removed on 1/30/25, as confirmed by surveyor onsite verification. Review of the facility's Explanation of Diets dated, 2024 showed: -Mechanical Soft: This consistency modified diet is for individuals with limited or difficulty in chewing regular textured food; -The diet consists of food of nearly regular textures but eliminated very hard, sticky, crunchy or hard to chew foods; -Foods should be moist and fork tender; -Meat is ground or chopped into bite-sized pieces (1/2 inch or smaller). Review of the facility's Diets Policy dated 1/29/25, showed: -The facility will provide each resident with a regular or therapeutic diet as ordered by the physician; the consistency of the diet shall also be ordered; -A therapeutic diet is defined as any deviation from the regular diet; -Diets available in the facility included regular mechanical soft diet. -Regular mechanical soft diet consists of soft fruits, vegetables and ground meat. Review of Resident #7's physician's progress note dated 12/12/24, showed: Noted: Provincial dyskinesia (ODK, a movement disorder that causes involuntary, repetitive, and sometimes painful movements of the face, mouth, and can directly cause swallowing problems (dysphagia) because the involuntary movements affecting the face and mouth muscles can interfere with the coordinated movements needed for chewing and swallowing food, leading to difficulties transferring food to the throat and potential choking hazards). Review of the mechanical soft lunch menu for 1/13/25, showed: -Ground chicken with onions; -Stuffing with gravy; -Soft vegetable medley; -Apple streusel cake. Review of the facility's dietary spread sheet, dated 2024, showed a ham and cheese sandwich for mechanical soft diet should be made with ground ham and cheese. It was on the menu as an alternate food selection. Review of Resident #7's care plan dated 10/9/24, and updated on 1/24/25 (the resident expired on 1/17/25) showed: -Problem: At risk for aspiration related to mechanically altered diet and resident swallows chewing tobacco; -Desired outcome: Resident will have no choking episodes when eating; -Interventions included: -All staff to be informed of the resident's special dietary and safety needs; -Alternate small bites and sips. Use a teaspoon for eating, do not use a straw; -Diet to be followed (No documentation on type of diet); -Instruct the resident to eat in an upright position, to eat slowly and to chew each bite thoroughly. Review of the resident's progress note dated, 1/13/25, showed: -Resident in dining room eating lunch; -Certified Nursing Assistant (CNA) Q and Director of Nursing (DON) observed resident choking, staff intervened and provided Heimlich maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe (throat) in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) and mouth sweeps; -The resident was without a pulse; -Cardiopulmonary resuscitation (CPR, an emergency treatment that's done when someone's breathing or heartbeat has stopped.); -Police and Emergency Medical Services (EMS) arrived and took over; -At 12:40 P.M., resident transported to hospital. Review of the EMS trip sheet, dated 1/13/25, showed: -Responded to facility for a cardiac arrest; -Took over CPR; -The resident was connected to a monitor and it displayed asystole (no heartbeat); -EMS removed an obstruction in the resident's airway; -Resident transported to hospital. Review of the resident's hospital record dated 1/17/25, showed: -Patient Active Problem List: -Acute respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues); -Aspiration pneumonia of both lower lobes; -Anoxic brain injury (caused by a complete lack of oxygen to the brain); -1/13/25, resident presents with pulseless electrical activity (PEA, a condition where a person is unresponsive and has no pulse, but there is some electrical activity in the heart) arrest; -Acute respiratory failure, and aspiration pneumonia with shock; -Onset of symptoms was abrupt. The resident has dysphagia. He/She was eating a sandwich at his/her nursing home when he/she began choking, aspirated, and went into PEA arrest and was in asystole when EMS arrived; -The resident received CPR, intubated (tube put down throat for artificial breathing), and central line placed (a catheter placed into a vein for medication administration); -1/17/25, remains comatose. Resident extubated (breathing tube removed) at 3:17 P.M. and died at 3:33 P.M. During an interview on 1/29/25, at 7:20 A.M., Dietary Staff (DS) A said on 1/13/25, the resident was served a mechanical soft lunch. The resident refused the meal. A short time later Certified Medication Technician (CMT) B came to the kitchen window and asked for two sandwiches. CMT B did not say he/she needed mechanical soft sandwiches. Dietary staff gave CMT B two ham and cheese sandwiches with some cheese puffs. The sandwiches were not mechanical soft. During an interview on 1/29/25 at 7:18 A.M., CMT B said on 1/13/25, the resident refused his/her meal tray and asked for sandwiches. CMT B got the sandwiches from dietary. The sandwiches were mechanical soft. During an interview on 1/29/25 at 7:27 A.M., the DON said he/she was walking past the resident in the dining room and noticed the resident was choking. He/She called a Code Blue (medical emergency) and attempted the Heimlich Maneuver. At that time the resident became unresponsive. Staff lowered the resident to the floor and CPR was initiated. He/She swept the resident's mouth, but only got chewed up cheese puffs. He/She said the resident's dietary card showed he/she was on a mechanical soft diet. EMS arrived and took over CPR. The resident was transported to the hospital. The resident expired on 1/17/25. During interviews on 1/29/25 at 9:50 A.M. and 11:21 A.M., the Dietary Manager (DM) said he/she was not in the facility when the incident occurred. He/She knew the resident refused his/her meal tray. Staff came and asked for two sandwiches, but did not say who the sandwiches were for and/or if they needed mechanical soft sandwiches. DS A called the DM and said the resident was given two regular diet sandwiches, choked and had to have CPR. When the DM returned to the facility and interviewed the dietary staff, they confirmed the resident was provided two regular textured ham and cheese sandwiches. He/She told the Administrator what the dietary staff said. During an interview on 1/29/25 at 9:54 A.M., Licensed Practical Nurse (LPN) C said he/she worked the day the resident choked on a sandwich and he/she saw what looked like bread when the DON performed the mouth sweep. During an interview on 1/29/25 at 10:07 A.M., DS D said he/she worked the day the resident choked. Nursing staff asked for two sandwiches. They did not say who the sandwiches were for or what diet consistency was needed. Dietary staff gave the nursing staff two regular ham and cheese sandwiches. The ham had not been ground up. During an interview on 1/29/25 at 10:10 A.M., DS A said DS E made sandwiches in advance of the meal as substitutes if residents did not want the chicken. All the sandwiches were regular consistency. No mechanical soft sandwiches were made. CMT B asked for two sandwiches. He/She did not say who the sandwiches were for and/or what consistency the sandwiches should be. Dietary staff did not ask who the sandwiches were for and/or if they should be mechanical soft. During an interview on 1/29/25, at 11:32 A.M., DS E said he/she made the sandwiches, but did not give the sandwiches to CMT B. He/She did not know who gave the sandwiches to the CMT, but he/she had not prepared any mechanical soft sandwiches. If the nursing staff gave the resident sandwiches that DS E made, the sandwiches were regular consistency. During an interview on 1/29/25 at 11:39 A.M., the Registered Dietitian said if a resident was on a mechanical soft diet, all lunch meat should be ground up. Staff should never serve sliced meat to a resident with orders for a mechanical soft diet. He/She was aware the resident choked on a sandwich. He/She was told the resident was provided a regular sandwich with sliced ham. Nursing staff should have identified who they wanted the sandwich for and dietary staff should have asked what consistency sandwich was needed. During an interview on 1/29/25, at 11:07 A.M., the Speech Therapist said he/she worked with the resident for intelligibility of speech (articulation) and communication cognitive skills. He/She did not work on swallowing problems with the resident. The resident had an order for a mechanical soft diet. He/She was admitted with the order for a mechanical soft diet. Speech Therapy screened the resident, but did not request Skilled Speech therapy for swallowing. The resident was at risk for aspiration. If a resident had an order for a mechanical soft diet, the deli meat on the sandwich should be ground up. The dietary staff did not always grind up the deli meat. He/She worked the day the resident choked, but was in the assisted dining area and had his/her back to the resident. During an interview on 1/29/25 at 11:53 A.M., the Medical Director's Nurse Practitioner said he/she was notified by facility staff the resident aspirated on food while in the dining room and was sent to the hospital. Facility staff did not provide any details about what the resident aspirated on. The resident had dysphagia. Staff did not report the resident might have been provided the wrong diet consistency. The resident was on a mechanical soft diet. He/She should have been served a mechanical soft meal and should have been supervised at each meal. The facility should always follow physician's order when it came to the consistency of a resident's diet. During an interview on 1/29/25 at 12:19 P.M., the Chief Medical Officer from EMS said he/she responded to the facility for a chief complaint of resident in cardiac arrest. He/She suctioned the resident's mouth and pulled out multiple large pieces of thinly sliced deli meat. During an interview on 1/29/25 at 12:52 P.M., CNA F said he/she saw EMS pull sliced ham out of the resident's mouth. During an interview on 1/30/24, at 9:08 A.M., the DON and Administrator both said they were not aware the resident was served two regular consistency sandwiches. If a resident requested an alternate food, they expected nursing staff to tell dietary staff who the resident was and what their diet order was. The DON said after EMS left, she noticed the resident's dietary card showed he/she was on a mechanical soft diet. She did not see a meal tray or left over food. Staff had already removed the resident's plate, so she didn't know the resident had been served regular consistency sandwiches. She assumed the resident had been provided a mechanical soft diet. During an interview on 1/30/25 at 1:21 P.M., the Speech Therapist said each resident should be assessed for the amount of supervision required when they were eating and drinking. The level of supervision should be on the resident's care plan. Each resident was different and needed to be assessed individually for the amount of supervision required. 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 onsite visit, it was determined the facility had implemented corrective actions 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). MO00248025 MO00248163

Based on observation, interview, and record review, the facility failed to provide adequate supervision to one of five sampled residents with a history of elopement, hallucinations/delusions, behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management, and limited insight and judgement. Facility staff failed to make visual observations of the resident hourly, staff failed to follow up after not seeing the resident to administer ordered medications, and failed to ensure exit doors were working properly. Resident #1 left the building without staff's knowledge on 6/10/24 at 6:37 AM. Facility staff responsible for conducting visual checks- failed to do so, although they were documented as completed. The resident remained gone from the facility for over 24 hours before staff realized the resident was missing on 6/11/24 at 8:00 AM. The resident was not located until 6/13/24 at approximately 2:00 P.M. by another area police department at a gas station. The census was 107. The Administrator was notified on 6/14/24 at 5:36 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 6/10/24. The facility conducted an investigation and immediately in-serviced staff prior to the start of their shift regarding the following: Code white (facility's elopement code), secured doors, shift reports and rounds, falsifying documentation; completed elopement assessments on all residents to make sure appropriate placement, monitored exit doors one on one until they verified all working properly, charge nurses do two hour checks and document, management audits face check documentation, and the Administrator created a department head rotation schedule for completing random rounds in the facility at various times, other than regular daily rounds, to include evening and night shift. The IJ was corrected on 6/11/24. Review of the facility's Elopement and Wandering Residents policy, updated 6/12/24, showed: -Purpose: This facility ensures that residents who exhibit behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or eloping risk; -Definitions: - Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e, an order for discharge or leave of absence) and/or any necessary supervision to do so; -Policy: -Preventing Elopements: -The facility is equipped with door locks/alarms to help avoid elopements; -Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner; -The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risks, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. -Monitoring and managing residents at risk for elopement or unsafe wandering; -Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team; -The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan; -Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff; -Adequate supervision will be provided to help prevent accidents or elopements; -Charge nurses and unit managers will monitor the implementation of interventions, responses to interventions, and document accordingly. Review of the facility's Intensive Monitoring Policy, revised on 4/24/24, showed: -Procedure: -Residents who require more intensive monitoring due to crisis, behavior/psychiatric symptoms will be monitored by the facility staff. -Intensive monitoring: -Intensive monitoring is provided as periodic (e.g. hourly, every two hours, or every shift) check by a facility staff member; -Residents may require more intensive monitoring based on their crisis, behavior, psychiatric issues. The level of intensive monitoring shall be identified by the specific situation or resident assessment; -Residents who are showing poor impulse control including crisis, behavior, psychiatric issues, such as, verbal/ physical aggression/elopement ideations, suicidal/homicidal ideations, and decompensation mental or crisis may be placed on intensive monitoring or one to one or two to one (within eyesight of staff) monitoring at the discretion of the facility staff or the facility supervisor; -The facility staff will document the intensive monitoring in the resident's electronic medical record; -Documentation: -All documentation of intensive monitoring will be done in the electronic medical record under the task. During an interview on 6/14/24 at 5:36 P.M., the Administrator said she expected for face checks to be done hourly on all residents on all shifts Review of Resident #1's preadmission screening and resident review (PASRR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in medicaid certified beds in a nursing facility regardless of payment source), dated 9/27/23, showed the resident had a history of elopement, hallucinations/delusions, medical treatment and/or monitoring for chronic conditions, behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management, and limited insight and judgement. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/9/24, showed the following: -admitted to the facility: 9/29/23; -Cognitively intact; -Independent for eating, hygiene, dressing, walking in room and corridor, locomotion on unit; -No physical impairments of either upper and/or lower extremities; -Wandering not exhibited; -Diagnoses of anxiety disorder, depression (other than bipolar), and schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly). Review of the resident's elopement assessments showed the following: -On 9/29/23, elopement evaluation: The resident was an elopement risk; --On 4/26/24 elopement evaluation: The resident was an elopement risk; -On 5/15/24, elopement evaluation: The resident was an elopement risk; -On 6/11/24, elopement evaluation: The resident was an elopement risk. Review of the resident's care plan, dated 10/12/23, showed: -Focus: The resident is at risk of elopement due to he/she has a history of elopement from prior facility; -Goal: The resident will be monitored closely and remain safe through next review; -Interventions: Complete elopement assessments on admission, readmission, and quarterly. Face checks/intensive monitoring will be completed per facility protocol. Resident's photo and information will be kept in elopement book; -Focus: The resident is at risk of elopement related to history of leaving previous facility; -Goal: The resident's safety will be maintained through the review date; -Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television book. Monitor location frequently. Document wandering behavior and attempted diversional interventions in behavior log. Provide structured activities: Toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of the facility's May 2024 documentation of exit door maintenance checks showed: -Dates of 5/18/24, 5/19/24, and 5/25/24 missing from sheet; -Date of 5/27/24 showed a line drawn through all the exit doors; -Patio exit door documented as checked 5/1/24 to 5/17/24, 5/20/24 to 5/24/24, and 5/26/24 to 5/31/24. Review of the facility's June 2024 documentation of exit door checks showed the patio exit door checked 6/1/24 to 6/12/24. Review of the facility's video footage, dated 6/10/24 at 6:37 A.M., showed Resident #1 standing in the open, fully dressed with a hoodie on. He/She looked around, walked to the patio (exit door), pushed it open then walked out the door. The back side of the resident's body could be observed climbing over the fence. Review of Resident #1's hourly face check documentation completed on 6/10/24 showed: -Hourly face check completed; resident in the building at the following times: 6:58 A.M. (logged two times), 6:59 A.M. (logged six times), 12:59 P.M., 1:00 P.M., 1:02 P.M., 1:04 P.M., 2:30 P.M., 6:02 P.M., 6:03 P.M., 6:05 P.M., 9:15 P.M., 9:17 P.M., 9:43 P.M.; -No hourly face checks logged from: 7:00 A.M. to 12:00 P.M., 3:30 P.M. to 5:30 P.M., 7:00 P.M. to 8:00 P.M.; -No hourly face checks logged over the evening and overnight shifts from: 9:45 P.M. (6/10/24) to 10:00 A.M. (6/11/24). Review of the resident's progress notes, dated 6/11/24, showed: -At 11:10 A.M., (Late entry); the resident was noticed missing upon rounds by Certified Nurse Aide (CNA) D on A hall. Staff alerted the DON the resident was not in his/her room. Staff began searching and the night shift nurses were contacted to see if the resident was sent out without knowledge. At 8:30 A.M., a code white was called. All staff, department heads, Administrator and DON continued to search every room, closets, and bathrooms. The department heads and staff searched room to room for resident, as well as a ground search. All emergency exits and doors were checked ensuring they were closed completely. After facility search yielded no results, all department heads began searching local areas, local bars, liquor stores, convenient stores, and placed calls to local hospital and shelters. Some department heads stayed behind to review footage for resident. Local authorities contacted at 9:06 AM. A police officer (PO) from the local police department showed up on scene and a missing person's report was filed. DHSS, Physician and psychiatric Nurse Practitioner (NP) were notified. Guardian was notified with no answer, and no available voice mail. The resident's other family member was then called and said he/she was updating the guardian at 9:15 AM. The other family member said he/she had worried the resident was feeling cooped up on B unit (closed unit) and stopped taking him/her out for a while, because he/she would become aggressive with him/her and not want to return to the facility. He/She knew the resident wanted to leave and had said so previously. The family member recently spoke with Social Services Director (SSD) about room moves with Guardian approval, requesting the resident be taken off the locked unit and given a chance in the main area of the facility. The family member did not communicate the resident's anxiety or the resident's statements about wanting to leave the facility until yesterday while speaking to the DON and SSD. Family was aware of the resident's past elopement history at other facilities and his/her assessment scores, but no recent elopement attempts. The family member was educated to report any and all concerns regarding the resident's safety to the facility. The family member said he/she didn't think to tell anyone, because he/she didn't think the resident could get out, but the resident had tried at other facilities before. The resident enjoyed walking in and around the facility as a coping mechanism. DHSS was notified at 10:27 A.M. The Physician was contacted at 9:18 A.M., with no answer (message left). Psychiatric NP was contacted and the Administrator, DON, Regional Director and the local police departments were notified, and another local police department with police report for missing persons filed; -On 6/11/2024 at 11:10 A.M., (Late Entry): Social Services spoke with the resident's family member in regard to their conversation on 5/13/24 about the resident coming off the locked unit on 6/3/24. The family member left Social Worker (SW) a voice message asking for the resident to be moved to the main area of the building. SW had resident moved off the secured/locked unit on 6/4/24 back to the main area of the building. Also, the family member said the resident told him/her on several occasions that he/she was going to leave the facility, but the family member didn't notify the facility what the resident was saying. Review of the resident's June 2024 Medication Administration Record (MAR), showed from 6/10/24 to 6/13/24, the resident did not receive any of his/her medications which included olanzapine (taken for schizophrenia), scheduled daily for 7:00 A.M. and 4:00 P.M., and divalproex Sodium ER tablet (taken for bipolar disorder), scheduled daily for 7:00 A.M., 11:00 A.M., and 4:00 P.M. Review of the resident's hourly face checks documentation completed on 6/11/24 showed face checks documented as resident not available beginning at 11:22 A.M. until 1:30 P.M. During interviews on 6/12/24 at 11:00 A.M. and 11:45 A.M., with the Administrator and the DON, the DON said Resident #1 had eloped and had not returned to the facility. His/Her whereabouts were still unknown. They were still investigating. Yesterday morning, CNA D realized the resident was missing, and he/she informed the DON. Police reports were made to two local police departments. The family had just requested that the resident be taken off the locked unit to give him/her an opportunity to be in the main area of the building. It was unbeknownst to the facility the family had known the resident had been feeling antsy and wanted to leave while he/she was at the facility. The resident's family member didn't want to take the resident home on passes because it was a fight taking him/her back to the facility. Another family member is the resident's Guardian. They tried contacting the Guardian yesterday. The DON called the other family member multiple times yesterday and he/she had updated the Guardian. Review of the resident's progress notes, dated 6/13/2024 at 6:35 P.M., showed around 2:10 P.M., a local area police department contacted the Administrator and said the resident had been found and was being taken to a area local hospital to be assessed. The PO told the DON he/she received a call 1:44 P.M., about an older person at a local gas station telling bystanders he/she wanted to go home but seemed very disoriented and confused. No injuries were noted. The PO said that a call came in around 6:50 A.M., in the morning from a local community member about a man/woman walking with no shoes. SSD and the other department heads went to the hospital to verify the resident's identification and once verified, the Guardian was contacted. DHSS made aware resident was found. Resident was still currently at the hospital. Review of the summary of the facility investigation, dated 6/15/24, showed: -On 6/10/24, Resident #1 was last seen by CNA B at 6:00 A.M. and at 6:33 A.M., by nursing staff in the dining room getting coffee per his/her usual routine. The camera footage showed CNA B completing his/her rounds throughout his/her shift and with the DON during the night of 6/9/24 beginning at 11 PM leading to 6/10/24. After 6:00 A.M., CNAs began rounds on residents and began getting their residents up on their halls. Residents visited the dining area by the nurses station where both Nurse K and DON were sitting and charting on residents' assessments. At 6:29 A.M., the resident walked in the dining area to get water and then returned to get coffee. At 6:35 A.M., CNA C saw the resident in the common area. There were no signs of restlessness or agitation in the residents. At 6:36 A.M., Resident #1 walked and drank his/her morning coffee, and as soon as aides went to their halls, the resident approached the door leading to the patio smoking area, and pushed the door open, where no alarm sounded. The camera footage showed the resident climbed over the chain link fence. On 6/11/24, CNA D noticed the resident was missing. Staff notified the DON the resident was not in his/her room. Staff began searching and the night shift nurses were contacted to see if the resident was sent out without knowledge. At 8:30 A.M., a code white was called. All staff, department heads, Administrator and DON continued to search every room, closet and bathroom. The department heads and staff searched room to room for resident, as well as an exterior ground search. All emergency exits and doors were checked to ensure they were closed completely. After facility search yielded no results, all department heads began searching local areas, local bars, liquor stores, convenient stores and placed calls to local hospitals and shelters. Some department heads stayed behind to review footage for the resident. Residents and staff were interviewed about any knowledge of the resident's whereabouts, as well as residents' feelings of safety, staff monitoring and if residents felt if they are being treated with dignity and respect. Doors leading to exits with alarms were immediately checked for proper functioning. A one to one monitor was placed on smoking hall patio door and other exits until they were checked to be in good working condition. Alarm boxes were checked for any and all alerts. -On 6/13/24 around 2:10 P.M., the Administrator was contacted by a local police department stating the resident had been found and was being taken to a local area hospital to be assessed. At 9:18 P.M., the resident returned to the facility via stretcher. Physical and neurological assessments were performed and assessment reported to psychiatric NP. Resident, upon return to facility, was placed back on a locked unit, with Guardian approval of the room move. During an interview on 6/12/24 at 3:30 P.M., Resident #7 said he/she lived at the facility for five or six years. A code white was called yesterday at the beginning of the first shift. The aides on A Hall were asleep and not on the hall on Sunday 6/9/24. The staff don't check on the residents at night. Observation and interview on 6/12/24 at 4:05 P.M., showed Hall Monitor (HM) G sat at the patio exit door. The patio door was shut. A crack, approximately 2 1/2 inches, could be observed at the top and the bottom of the door. When the door was opened the alarm did not sound. HM G said he/she has worked at the facility for about one year and four months. He/She was familiar with Resident #1. Today was HM G's first day back at work since last Thursday 6/6/24. When the resident lived on B hall, he/she had never verbalized wanting to leave the facility or showed signs that he/she wanted to leave. He/She only wanted to smoke and drink coffee all day. HM G was watching the door until maintenance fixed the door because they can't leave the door unattended. The door is not always secured (closed) when it is shut. He/she wasn't sure of how long the door had been like that. During an interview on 6/12/24 at 4:18 P.M., the Administrator said the video footage showed Resident #1 left out of the patio exit door at 6:37 A.M. on 6/10/24. The patio door does alarm and lock, but if it is not pulled closed, it may stay propped opened. During an interview on 6/14/24 at 1:25 P.M., CNA C said he/she worked the 11:00 P.M. to the 7:00 A.M. shift. He/She was new to the facility. Saturday night, 6/8/24 to 6/9/24 was his/her first shift and Sunday night, 6/9/24 to 6/10/24 was his/her second shift (the morning the resident eloped). He/She was with another staff on 6/8/24 to 6/9/24 at which time he/she orientated. When he/she went in to work on 6/9/24 to 6/10/24, he /she was with another person, but he/she did not orientate. On 6/9/24/to 6/10/24 shift, CNA C last saw the resident at about 6:30 A.M., that morning. The resident was walking with a walker and had a Styrofoam cup saying he/she was wanted some coffee. The resident was walking away from his/her room and toward the dining room area, where the residents watch television. There was nothing out of the ordinary with the resident. CNA C said he/she got off work at 7:00 A.M. on 6/10/24. Staff conduct rounds on the residents and document in the computer, but the system wouldn't let him/her in. He/She had tried to get in contact with someone regarding the matter. CNA C did his/her checks like he/she was supposed to. On that Monday night (6/10-6/11/24) CNA C said he/she went to work, but did not know where he/she worked at. During an interview on 6/13/24 at 1:58 P.M., CNA B said he/she had worked at the facility for about three years and was familiar with Resident #1. CNA B worked on the the A hall on the 11:00 P.M.- 7:00 A.M. shift on 6/9/24 to 6/10/24. CNA B said the resident had left on 6/10/24 at about 6:30 A.M. He/She last saw the resident at 6:00 A.M. on 6/10/24. The resident had come from out of his/her room and was walking down the hallway as CNA B was doing his/her rounds. He/She does his/her rounds every hour, but they could be done every two hours. Rounds are documented in the electronic medical record. CNA B documented the rounds in real (actual) time. Staff have to actually put eyes on the resident during rounds. The resident was asleep when CNA B reported to work at 11:00 P.M. The resident slept the entire time. It was a normal night. The resident was in his/her room during every round, with the exception of the 6:00 A.M. round, when the resident left his/her room. The resident woke up to get his/her coffee. The resident used a walker, so CNA B didn't have any indications the resident wanted to leave. The resident is alert and oriented. During an interview on 6/13/24 at 2:37 P.M., CNA A said he/she had worked at the facility for about one year and a couple of months. He/She was familiar with Resident #1 and was one of the resident's regular CNAs. Resident #1 just moved from the B Hall to his/her assignment on the A hall. During the short time on A hall, the resident never gave any indication that he/she would leave. He/She was naturally a wanderer and walked the halls a lot. He/She would also go to the dining room and sit outside of the dining room and drink coffee. Prior to this, CNA A last worked with the resident on Friday 6/7/24 on the 7-3 shift. The resident gave CNA A no indication on Friday (6/7/24) that he/she was going to leave. The CNAs do rounds every hour and the nurses do rounds every 30 minutes, so technically rounds are done every 30 minutes. When rounds are done, staff document them in the computer. CNA A takes a laptop around with him/her and walks and charts at the same time. The resident left Monday 6/10/24 at early morning. On Monday 6/10/24, CNA A didn't see the resident at all. CNA A did document in the electronic medical record that he/she saw the resident, but he/she realized he/she made a mistake. He/She really saw another resident on B hall. He/She tried to document as much as possible as he/she goes, because it does get hectic when you trying to document at the end. The resident did the same thing every day and was never in his/her room. The resident would get up to get his/her coffee and then roamed the halls. Since the resident was never in his/her room, when CNA A got in on 6/10/24, he/she thought the resident was already walking around getting his/her coffee. CNA A saw another resident, Resident #8, sitting in the dining area and thought he/she was Resident #1. CNA A worked a double on 6/10/24. He/she worked the 7-3 shift and 3-11 shift. CNA A documented the entire day and evening that he/she had seen Resident #1. CNA A knew that he/she messed up. Prior to this, CNA A was not aware of anything wrong with the smoking patio door. During an interview on 6/13/24 at approximately 3:15 P.M., CNA D said he/she started at the facility in February of 2024. He/She worked the 7:00 A.M. to 3:00 P.M. shift. He/She was not too familiar with the resident because he/she was new to the A Hall. The resident was not on CNA D's assignment. The last time he/she saw the resident was Sunday (6/9/24) right before lunch, about 11:15 A.M. The resident is alert and totally independent. He walked on his/her own. CNA D worked Monday (6/10/24), but the resident was not on his/her assignment. He/She discovered the resident was gone on Tuesday 6/11/24 at about 8:05 A.M., right before the 8:15 A.M. smoke break. CNA D and Certified Medication Technician (CMT) H were walking down the hallway and noticed the resident's bed was untouched. That wasn't normal, so CNA D went to check the dining room to see if the resident was in there. CNA D didn't see the resident in there, so he/she checked the resident's bathroom and didn't see him/her. CNA D asked the DON if the resident was in the hospital. That's when they all started looking for him/her. The DON called a code white. The resident had eloped. The staff searched everywhere. They went to the metro station, the gas station, and he/she thinks someone went to the apartments too (adjacent to the facility). CNA D would normally just see the resident when he/she would leave out of his/her room to go and get his/her coffee. The staff do rounds every hour. CNA D does face checks every hour, but he/she couldn't speak for anyone else. He/she documents in the electronic medical record in real time. It is possible to go back and document later. With the face checks you have to document if in the building, or if you didn't see them, there are other options like resident out for appointments, resident outside privileges/Leave of absence (LOA) or resident at the hospital. CNA D was not aware of anything wrong with the patio door. It doesn't shut all the way and you have to push it hard for it to open. On the outside, it is kind of hard to open, but you won't be able to get out without putting a code in. The resident didn't put a code in to get out so CNA D's only speculation was that the door wasn't closed all the way. During an interview on 6/14/24 at 2:56 P.M., CMT H said he/she has worked for the facility for about twelve and half years, normally on the 7:00 A.M. to 3:00 P.M. shift. He/She was familiar with Resident #1. The resident had not received any medication on 6/10/24. He/She looked for the resident thinking he/she hadn't taken his/her medications. The resident's roommate told him/her the resident was in the bathroom. This had happened at about 10:00 A.M. on 6/10/24. He/She then had gotten called to another hall. He/She had gotten tied up on another hall and had forgotten about it. CMT H left at 3:00 P.M. It hadn't dawned on him/her that he/she still had not seen the resident. CMT H left a memo for the oncoming CMT, advising that he/she had not seen the resident. CMT H said he/she left on the memo that he/she thought the resident was on LOA with his/her family member because one of his/her family members goes and gets the resident. He/She didn't see the resident at all on 6/10/24. CMT H said typically when he/she arrived to work, he/she tried to get a report. He/She would ask about people deceased , hospitalizations, LOAs, or so forth. CMT H asked the nurse and he/she wasn't aware of anything. During an interview on 6/12/24 at 3:10 P.M., Resident #6, said he/she was roommates with Resident #1. Resident #6 really didn't know that much about Resident #1. Resident #1 left a couple of days ago. Resident #6 was unsure of the last time he/she saw Resident #1 prior to him/her leaving. They had been roommates for maybe a day or two. Resident #1 hadn't mentioned anything about wanting to leave the facility. During an interview on 6/13/24 at 2:27 P.M., the DON said Resident #1 had been found. The police were taking him/her to a local area hospital. Once the resident was checked over, he/she would return to the facility. During observation and interview on 6/14/24 at 11:18 A.M., Resident #1 said he/she did not feel like talking and declined speaking with the surveyor. During an interview on 6/14/24 at 11:35 A.M., with Maintenance Assistants (MA) I and MA J, MA I said on Monday 6/10/24, he/she noticed the patio door was hard to catch. He/She called the Maintenance Director (MD) and he contacted an area lock company on Monday 6/10/24. The lock company came out to the facility on 6/11/24 and 6/12/24. They looked at the door and said they had to come back. A little metal box was needed which would make the lock catch when the door was shut. Right now, the door is locked, but if the door was not slammed, it would not lock like it was supposed to. With the elopement incident, the last person who went out the door didn't make sure the door was secure. You have to make it connect with the box so that it connects with the magnet. During an interview on 6/12/24 at 4:24 P.M., the MD said MA I called him on Monday, 6/10/24 a little after 7:00 A.M., and told him he/she had to slam the smoking patio door to get it to shut. MD went in to work about 9 AM. He called a local lock company. That is when the MD became aware of the problem with the door. They routinely checked the patio smoking door. There had not been any problems with the smoking patio door prior to this. They checked all the exit doors daily. The lock company was called on 6/10/24 but they couldn't come out to the facility until today (6/12/24). That is why they have a staff person by the door around the clock. All the exit doors have alarms on them, so if residents try to bust through them, the alarms will sound. If the door was opened without a code, it would alarm. The resident didn't put a code in. When MA I arrived at work, he/she discovered the door was messed up. The issue with the door was that the door had to be pulled really hard to shut it completely. Door alarm drills were done monthly. During an interview on 6/14/24 at 2:13 P.M., the resident's Guardian said the resident had eloped from the facility on 6/10/24. The resident was tired of being at the facility. The resident had told a family member this before. There were no indication given to the Guardian the resident was going to leave. The resident had gone to the hospital and was released yesterday. The resident is not able to take care of him/herself. The resident needs around the clock care. It was not safe for the resident to be out by him/herself. The resident had been at other facilities in the past. He/She had left four or five times prior from other facilities. The Guardian did not know if the facility was aware of this or not. The Guardian was not aware the resident had been recently moved off the locked unit. The facility had placed him/her on the locked unit for supposedly 90 days. The resident's 90 days were up, so the resident was upset he/she had to stay on locked unit. The Guardian thought his/her other family member had said something to the facility about the resident moving off the locked unit. During an interview on 6/14/24 at 4:44 P.M., the DON said they were aware on admission that Resident #1 did have elopement attempts at other facilities, but the resident had been doing well at this facility. The DON got to the facility in February 2024, so she is still getting to know the residents. The resident has an elopement history and had been on the behavioral unit. It was very normal for him/her to walk up and down the halls with his/her coffee. The resident's family member asked the Social Worker for the resident to come off the locked unit because he/she felt the resident was getting a little more antsy and needed more freedom, and being on the behavioral unit was causing him/her anxiety. The DON worked overnight from 6/9/24 to 6/10/24. No alarms sounded. The resident was doing his/her usual morning walks in the dining room. The resident had gotten coffee and water. She wasn't working the resident's hall but was rounding the entire building with CNA B. There was nothing outside the resident's normal that morning. The resident was normally quiet. Regarding the elopement evaluation, he/she was an elopement risk. They don't have an explicit face check policy. She would have expected face checks to have been done on all residents hourly and documented appropriately in PCC. Sometimes the staff would get caught u [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** See the deficiency cited at Event 6lBE12. Based on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, revised 1/5/23, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by Administrator. Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations, the following steps will occur; the licensed nursing staff, team leader, Resident Care Coordinator (RCC), nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The Director of Nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. Review of the Crisis, Alleviation, Lessons and Methods (CALM, staff assisted therapeutic hold) Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively intact; -Diagnoses included major depressive disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed, implement plans to change inappropriate behavior, and pharmaceutical interventions as needed. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. Registered Nurse (RN) J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (Emergency Room) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of Resident #1's readmission skin assessment following hospitalization, dated 1/1/24, showed the resident did not have any skin injuries on the face or body. Review of the facility's investigation, dated 1/3/24, showed: -Initial Investigation: On 12/31/23 at approximately 8:00 P.M., the Director of Nursing (DON) and Administrator were notified an altercation had occurred between Resident #1 and Resident #2; -Investigative Narrative: Resident#2 propelled his/her wheelchair and attempted to strike Resident #1, but Hall Monitor A was able to intervene and stated no contact was made. Resident #1 believed he/she was hit in his/her face during the commotion but was unsure what happened; -Initial Intervention: The residents were separated by Hall Monitor A. Both Hall Monitor A and Resident #1 were interviewed. Resident #1 was sent out to the ER for a psychiatric evaluation. Resident #1 was placed on one-on-one supervision after coming back from the hospital. Resident #2 was moved to a different hallway; -Hall Monitor A's written statement, dated 12/31/23, showed Resident #2 was in his/her wheelchair propelling past Resident #1 when Resident #2 attempted to hit Resident #1, but Hall Monitor A intervened in time to stop an injury from occurring; -Resident #1's written statement, dated 1/2/24, showed he/she had just come back from the hospital after being sent out for a psychiatric evaluation on 12/31/23 and was in the hallway. He/She said Resident #2 came at him/her and Hall Monitor A broke up the altercation, and he/she did not know what happened. During interviews on 1/24/24 at 9:19 A.M., 9:30 A.M. and 9:49 A.M., Resident #1 said on 12/31/23, he/she returned from the hospital. Resident #1's bed was in the hallway because staff were in the process of moving him/her to a private room. Hall Monitor A stood close by, but Resident #1 did not want Hall Monitor A near him/her and was upset from the first altercation earlier in the day on 12/31/23. Resident #2 and Resident #1 started to get into an altercation and Hall Monitor A stepped in between them both before it could get physical. In the process of Hall Monitor A breaking up the altercation, he/she grabbed Resident #1 around the neck in a head lock, which knocked his/her glasses off his/her face. The resident said Hall Monitor A hit him/her in the jaw while putting him/her in the head lock. Resident #1 swung at Hall Monitor A in anger, attempting to hit him/her. Hall Monitor A then grabbed Resident #1 by the front of his/her shirt and slammed him/her on the bed. Hall Monitor A held him/her down and the resident was positioned on his/her back with his/her hands behind his/her back. The resident said it hurt him/her physically and made his/her heart hurt. It made him/her feel humiliated to be held down in the hallway. The resident said a female nurse came and called an ambulance to send him/her to the hospital. The resident said he/she told the DON everything. Hall Monitor A was still working at the facility, even after the resident reported being hit. Hall Monitor A still worked on Resident #1's hallway, but he/she tried not to talk to him/her. The resident did not want Hall Monitor A around him/her anymore since the incident, due to not feeling safe. During an interview on 1/25/24, at 8:55 P.M., Hall Monitor A said the following: -On 12/31/23, he/she was working on Resident #1 hall; -Resident #1 had returned from the hospital and staff were in the process of moving Resident #1's belongings into another room. Resident #1's bed was located in the hallway; -Resident #1 sat on his/her bed in the hall and Hall Monitor A stood in the hall a few feet away, on the left side of Resident #1, near the entry of the hall; -Resident #2 was in his/her wheelchair, a few feet away from where Resident #1 sat. Resident #2 was on the right side of Resident #1, at the opposite side of the hall; -Resident #2 called out to Hall Monitor A that Resident #1 was staring at him/her, and he/she thought Resident #1 was going to attack him/her; -Hall Monitor A told Resident #2 that it was okay, to just go to his/her room; -Resident #2 rolled his/her wheelchair past Resident #1 while Hall Monitor A walked towards Resident #1 and Resident #2; -Resident #1 stood up and Hall Monitor A said it looked like he/she was going to hit Resident #2, so Hall Monitor A got in between Resident #1 and Resident #2 and intervened; -Hall Monitor A pushed Resident #1 back onto the bed, using both hands on the resident's chest and then held the resident down, by placing both of his/her hands on the resident's upper chest; -Resident #2 was not struck by Resident #1 and continued to advance down the hall while Hall Monitor A held Resident #1 on the bed; -Resident #1 was swinging and kicking at Hall Monitor A, while Hall Monitor A held the resident down on the bed; -Hall Monitor A thought about swinging on (hitting) Resident #1, but didn't because Resident #1 was little; -Hall Monitor A grabbed Resident #1's right arm below the elbow to try to prevent the resident from hitting him/her; -Resident #1 did hit the back of Hall Monitor A's head with his/her hand. Hall Monitor A balled up his/her fist and was going to strike Resident #1 but then thought better of it; -Hall Monitor A restrained Resident #1 by holding the resident's right arm with one hand and holding the resident down with the left hand that was placed on the resident's chest until another unknown staff member came to the scene; -Hall Monitor A knew it was the facility's policy to not hit a resident, even if they hit staff or other residents. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included schizophrenia and Post Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). During an interview on 1/25/24 at 9:36 A.M., Resident #9 said on 12/31/23, a Code [NAME] (behavior emergency) was called, and the incident happened pretty fast. He/She said he/she saw Resident #1 start swinging, trying to punch Hall Monitor A after Hall Monitor A got close to Resident #1's bed in the hallway. Hall Monitor A grabbed Resident #1 by the front of the shirt and flung Resident #1 on the bed outside of Resident #1's room. Resident #9 said he/she did not see Hall Monitor A hit or punch Resident #1. Hall Monitor A held Resident #1 down for approximately two minutes until other staff came to assist. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/25/24 at 9:37 A.M. Resident #10 said the incident was on 12/31/23. The altercation happened after Resident #1 had returned from the hospital on [DATE]. Resident #10 said Resident #1 stood at his/her bed located in the hallway and Hall Monitor A was standing 4-5 inches away from Resident #1. Resident #1 was mumbling under his/her breath and all of a sudden, swung his/her arm out at Hall Monitor A to strike him/her. Hall Monitor A grabbed Resident #1 by the shirt and flung him/her to the bed and held the resident down until other staff arrived. Review of the time cards for Hall Monitor A, showed he/she continued working after the incident on 12/31/23, every day until 1/24/24. During an interview on 1/25/24 at 11:32 A.M., Resident #1 told the DON that he/she did not initially report to her that Hall Monitor A hit him/her and he/she was slammed to the bed, because he/she did not want the DON or other staff to be mad at him/her. During an interview on 1/25/24 at 11:11 A.M. and at 11:42 A.M., the DON said after the 12/31/23 incident, Resident #1 told her nothing had happened. Then on 1/1/24 the resident changed his/her story and said that in the process of Hall Monitor A breaking up the altercation, he/she hit Resident #1 in the jaw. Hall Monitor A should not have held the resident down by the shoulders and should have followed the CALM technique protocols. She said other staff are to be present and involved when the CALM technique is being used. Review of the facility's employee discipline notice, dated 1/29/24, showed: -Reason for disciplinary action: Hall Monitor A was on a suspension pending investigation for a resident abuse allegation. It was found that Hall Monitor A had held the resident on the bed, and didn't follow proper protocol for behavior de-escalation procedure. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included bipolar disorder (disorder associated with mood swings from depressive lows to manic highs) and dementia. Review of Resident #13's care plan, dated 7/20/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Behaviors include verbally abusive, hallucinations, delusions, insomnia, suspicion, and agitation with a history of aggressiveness with staff and peers; -Desired outcomes: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed, CALM technique if needed, non pharmaceutical interventions: one-on-one supervision interventions as needed. Review of Resident #13's progress notes, showed: -On 12/21/23 at 7:53 P.M., Licensed Practical Nurse (LPN) H, arrived to work and Code [NAME] was in process. He/She responded to C hall and the resident had been involved in a resident-to-resident altercation. Resident #13 was the aggressor in the altercation. LPN H asked the resident what happened. He/She said, Resident #14 went in his/her drawer taking his/her stuff and got two cigarettes. Resident #13 asked Resident #14 to give them back, and (he/she) said [expletive] me, so Resident #13 started punching Resident #14. LPN H asked the resident how many times he/she hit the other resident and where. The resident said he/she hit the resident four to five times in the face and (his/her) helmet fell off. LPN H educated the resident that he/she should always inform a staff member when he/she has a problem with a staff member or a resident. LPN H informed the resident that he/she can always ask to speak to a nurse as well. (Emergency Medical Service) EMS was called so that resident could go out for evaluation. -On 12/22/23 at 12:56 P.M., a Social Worker note, showed Administrator alerted social worker that Resident #13 was in an altercation with Resident #14 last night. Resident #13 is currently on 1:1 pending the investigation. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and diabetes. Review of the resident's care plan, dated 1/16/24, showed -Behavior care plan for pulling the fire alarm (not for resident to resident aggression); -Interventions included: one-on-one supervision, CALM technique if needed, and pharmaceutical interventions as needed. Review of Resident #14's progress notes showed: -On 1/27/24 at 6:56 A.M., LPN I, was called to C hall by staff because this resident was in an altercation with Resident #13 in the hallway. The residents were separated. A skin assessment was done and no injury noted at this time. An ambulance was called for transportation to the hospital. Awaiting arrival. DON notified; -On 1/27/24 at 3:23 P.M., the resident returned to the facility at approximately 10:34 A.M., no new orders, at this time. Voicemail was left on the guardian's phone to make him/her aware of the incident; -On 1/29/24 at 6:45 A.M., the DON documented, upon reading statements, it is unclear who initiated the altercation. Both employees were in rooms getting residents up when commotion was heard in the hall. A Code [NAME] was called. An altercation between Resident #13 and Resident #14 was in progress. The residents were separated verbally after asking several times. Resident #14 appears to have punched the other resident in the face. No injuries were noted upon initial assessment. EMS was called. The resident was sent to the hospital for evaluation and treatment. Returned quickly with no new orders. Resident is nonverbal and unable to make needs known. During an interview on 1/31/24 at 3:08 P.M. Certified Nurse's Assistant (CNA) E said he/she was in a room assisting a resident when he/she heard a lot of commotion coming from the hallway. He/She went out to the hallway and witnessed Resident #13 and Resident #14 fighting. He/She, along with another staff member, broke up the fight. He/She did not see who the aggressor was but they know that Resident #13 has a history of behaviors. He/She said he/she is not aware of any interventions used for Resident #13 to prevent behaviors and altercations. During an interview on 1/31/24 at 3:18 P.M., Licensed Practical Nurse (LPN) F said he/she was on a different hallway when he/she was asked by another staff member to assist on the C hallway. While LPN F was in the resident's room, he/she heard a commotion in the hallway. He/She went into the hallway to find Resident #13 and Resident #14 fighting. He/She got in the middle of the residents to stop the fight. He/She said both residents were sent out to the hospital and once they got back, both were placed on one to one with staff. During an interview on 1/27/24 at 9:41 A.M. the DON said Resident #13 was walking down the hallway using his/her walker when he/she suddenly came at Resident #14 and attempted to strike the resident with his/her walker. Resident #14 started to fight back when staff intervened and separated the residents. Resident #13 was injured with a black eye under his/her left eye. Resident #13 had been having altercations in January, which they believe to be due to his/her dementia progression. She said the only interventions that had been put in place before the altercation had been redirection when ever the resident had an altercation. 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 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 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). MO00229569 MO00229571 MO00230921 MO00230160 MO00229886

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent abuse between staff and Resident #1, and failed to protect Resident #1 and other residents by not following their policy and immediately removing the alleged staff member from the facility. The alleged staff member worked every day, for an additional 24 days after the alleged abuse. The resident said he/she felt unsafe and the alleged staff member caused the resident physical harm and humiliation. The facility also failed to ensure Residents #13 and #14 were free of resident to resident abuse. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M. of an Immediate Jeopardy (IJ) which began on 12/31/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, revised 1/5/23, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Protection of residents: Employees of this facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the facility pending the results of the investigation and review by Administrator. Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations, the following steps will occur; the licensed nursing staff, team leader, Resident Care Coordinator (RCC), nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The Director of Nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. Review of the Crisis, Alleviation, Lessons and Methods (CALM, staff assisted therapeutic hold) Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively intact; -Diagnoses included major depressive disorder and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed, implement plans to change inappropriate behavior, and pharmaceutical interventions as needed. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. Registered Nurse (RN) J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (Emergency Room) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of Resident #1's readmission skin assessment following hospitalization, dated 1/1/24, showed the resident did not have any skin injuries on the face or body. Review of the facility's investigation, dated 1/3/24, showed: -Initial Investigation: On 12/31/23 at approximately 8:00 P.M., the Director of Nursing (DON) and Administrator were notified an altercation had occurred between Resident #1 and Resident #2; -Investigative Narrative: Resident#2 propelled his/her wheelchair and attempted to strike Resident #1, but Hall Monitor A was able to intervene and stated no contact was made. Resident #1 believed he/she was hit in his/her face during the commotion but was unsure what happened; -Initial Intervention: The residents were separated by Hall Monitor A. Both Hall Monitor A and Resident #1 were interviewed. Resident #1 was sent out to the ER for a psychiatric evaluation. Resident #1 was placed on one-on-one supervision after coming back from the hospital. Resident #2 was moved to a different hallway; -Hall Monitor A's written statement, dated 12/31/23, showed Resident #2 was in his/her wheelchair propelling past Resident #1 when Resident #2 attempted to hit Resident #1, but Hall Monitor A intervened in time to stop an injury from occurring; -Resident #1's written statement, dated 1/2/24, showed he/she had just come back from the hospital after being sent out for a psychiatric evaluation on 12/31/23 and was in the hallway. He/She said Resident #2 came at him/her and Hall Monitor A broke up the altercation, and he/she did not know what happened. During interviews on 1/24/24 at 9:19 A.M., 9:30 A.M. and 9:49 A.M., Resident #1 said on 12/31/23, he/she returned from the hospital. Resident #1's bed was in the hallway because staff were in the process of moving him/her to a private room. Hall Monitor A stood close by, but Resident #1 did not want Hall Monitor A near him/her and was upset from the first altercation earlier in the day on 12/31/23. Resident #2 and Resident #1 started to get into an altercation and Hall Monitor A stepped in between them both before it could get physical. In the process of Hall Monitor A breaking up the altercation, he/she grabbed Resident #1 around the neck in a head lock, which knocked his/her glasses off his/her face. The resident said Hall Monitor A hit him/her in the jaw while putting him/her in the head lock. Resident #1 swung at Hall Monitor A in anger, attempting to hit him/her. Hall Monitor A then grabbed Resident #1 by the front of his/her shirt and slammed him/her on the bed. Hall Monitor A held him/her down and the resident was positioned on his/her back with his/her hands behind his/her back. The resident said it hurt him/her physically and made his/her heart hurt. It made him/her feel humiliated to be held down in the hallway. The resident said a female nurse came and called an ambulance to send him/her to the hospital. The resident said he/she told the DON everything. Hall Monitor A was still working at the facility, even after the resident reported being hit. Hall Monitor A still worked on Resident #1's hallway, but he/she tried not to talk to him/her. The resident did not want Hall Monitor A around him/her anymore since the incident, due to not feeling safe. During an interview on 1/25/24, at 8:55 P.M., Hall Monitor A said the following: -On 12/31/23, he/she was working on Resident #1 hall; -Resident #1 had returned from the hospital and staff were in the process of moving Resident #1's belongings into another room. Resident #1's bed was located in the hallway; -Resident #1 sat on his/her bed in the hall and Hall Monitor A stood in the hall a few feet away, on the left side of Resident #1, near the entry of the hall; -Resident #2 was in his/her wheelchair, a few feet away from where Resident #1 sat. Resident #2 was on the right side of Resident #1, at the opposite side of the hall; -Resident #2 called out to Hall Monitor A that Resident #1 was staring at him/her, and he/she thought Resident #1 was going to attack him/her; -Hall Monitor A told Resident #2 that it was okay, to just go to his/her room; -Resident #2 rolled his/her wheelchair past Resident #1 while Hall Monitor A walked towards Resident #1 and Resident #2; -Resident #1 stood up and Hall Monitor A said it looked like he/she was going to hit Resident #2, so Hall Monitor A got in between Resident #1 and Resident #2 and intervened; -Hall Monitor A pushed Resident #1 back onto the bed, using both hands on the resident's chest and then held the resident down, by placing both of his/her hands on the resident's upper chest; -Resident #2 was not struck by Resident #1 and continued to advance down the hall while Hall Monitor A held Resident #1 on the bed; -Resident #1 was swinging and kicking at Hall Monitor A, while Hall Monitor A held the resident down on the bed; -Hall Monitor A thought about swinging on (hitting) Resident #1, but didn't because Resident #1 was little; -Hall Monitor A grabbed Resident #1's right arm below the elbow to try to prevent the resident from hitting him/her; -Resident #1 did hit the back of Hall Monitor A's head with his/her hand. Hall Monitor A balled up his/her fist and was going to strike Resident #1 but then thought better of it; -Hall Monitor A restrained Resident #1 by holding the resident's right arm with one hand and holding the resident down with the left hand that was placed on the resident's chest until another unknown staff member came to the scene; -Hall Monitor A knew it was the facility's policy to not hit a resident, even if they hit staff or other residents. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included schizophrenia and Post Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). During an interview on 1/25/24 at 9:36 A.M., Resident #9 said on 12/31/23, a Code [NAME] (behavior emergency) was called, and the incident happened pretty fast. He/She said he/she saw Resident #1 start swinging, trying to punch Hall Monitor A after Hall Monitor A got close to Resident #1's bed in the hallway. Hall Monitor A grabbed Resident #1 by the front of the shirt and flung Resident #1 on the bed outside of Resident #1's room. Resident #9 said he/she did not see Hall Monitor A hit or punch Resident #1. Hall Monitor A held Resident #1 down for approximately two minutes until other staff came to assist. Review of Resident #10's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/25/24 at 9:37 A.M. Resident #10 said the incident was on 12/31/23. The altercation happened after Resident #1 had returned from the hospital on [DATE]. Resident #10 said Resident #1 stood at his/her bed located in the hallway and Hall Monitor A was standing 4-5 inches away from Resident #1. Resident #1 was mumbling under his/her breath and all of a sudden, swung his/her arm out at Hall Monitor A to strike him/her. Hall Monitor A grabbed Resident #1 by the shirt and flung him/her to the bed and held the resident down until other staff arrived. Review of the time cards for Hall Monitor A, showed he/she continued working after the incident on 12/31/23, every day until 1/24/24. During an interview on 1/25/24 at 11:32 A.M., Resident #1 told the DON that he/she did not initially report to her that Hall Monitor A hit him/her and he/she was slammed to the bed, because he/she did not want the DON or other staff to be mad at him/her. During an interview on 1/25/24 at 11:11 A.M. and at 11:42 A.M., the DON said after the 12/31/23 incident, Resident #1 told her nothing had happened. Then on 1/1/24 the resident changed his/her story and said that in the process of Hall Monitor A breaking up the altercation, he/she hit Resident #1 in the jaw. Hall Monitor A should not have held the resident down by the shoulders and should have followed the CALM technique protocols. She said other staff are to be present and involved when the CALM technique is being used. Review of the facility's employee discipline notice, dated 1/29/24, showed: -Reason for disciplinary action: Hall Monitor A was on a suspension pending investigation for a resident abuse allegation. It was found that Hall Monitor A had held the resident on the bed, and didn't follow proper protocol for behavior de-escalation procedure. 2. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included bipolar disorder (disorder associated with mood swings from depressive lows to manic highs) and dementia. Review of Resident #13's care plan, dated 7/20/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting. Behaviors include verbally abusive, hallucinations, delusions, insomnia, suspicion, and agitation with a history of aggressiveness with staff and peers; -Desired outcomes: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed, CALM technique if needed, non pharmaceutical interventions: one-on-one supervision interventions as needed. Review of Resident #13's progress notes, showed: -On 12/21/23 at 7:53 P.M., Licensed Practical Nurse (LPN) H, arrived to work and Code [NAME] was in process. He/She responded to C hall and the resident had been involved in a resident-to-resident altercation. Resident #13 was the aggressor in the altercation. LPN H asked the resident what happened. He/She said, Resident #14 went in his/her drawer taking his/her stuff and got two cigarettes. Resident #13 asked Resident #14 to give them back, and (he/she) said [expletive] me, so Resident #13 started punching Resident #14. LPN H asked the resident how many times he/she hit the other resident and where. The resident said he/she hit the resident four to five times in the face and (his/her) helmet fell off. LPN H educated the resident that he/she should always inform a staff member when he/she has a problem with a staff member or a resident. LPN H informed the resident that he/she can always ask to speak to a nurse as well. (Emergency Medical Service) EMS was called so that resident could go out for evaluation. -On 12/22/23 at 12:56 P.M., a Social Worker note, showed Administrator alerted social worker that Resident #13 was in an altercation with Resident #14 last night. Resident #13 is currently on 1:1 pending the investigation. Review of Resident #14's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and diabetes. Review of the resident's care plan, dated 1/16/24, showed -Behavior care plan for pulling the fire alarm (not for resident to resident aggression); -Interventions included: one-on-one supervision, CALM technique if needed, and pharmaceutical interventions as needed. Review of Resident #14's progress notes showed: -On 1/27/24 at 6:56 A.M., LPN I, was called to C hall by staff because this resident was in an altercation with Resident #13 in the hallway. The residents were separated. A skin assessment was done and no injury noted at this time. An ambulance was called for transportation to the hospital. Awaiting arrival. DON notified; -On 1/27/24 at 3:23 P.M., the resident returned to the facility at approximately 10:34 A.M., no new orders, at this time. Voicemail was left on the guardian's phone to make him/her aware of the incident; -On 1/29/24 at 6:45 A.M., the DON documented, upon reading statements, it is unclear who initiated the altercation. Both employees were in rooms getting residents up when commotion was heard in the hall. A Code [NAME] was called. An altercation between Resident #13 and Resident #14 was in progress. The residents were separated verbally after asking several times. Resident #14 appears to have punched the other resident in the face. No injuries were noted upon initial assessment. EMS was called. The resident was sent to the hospital for evaluation and treatment. Returned quickly with no new orders. Resident is nonverbal and unable to make needs known. During an interview on 1/31/24 at 3:08 P.M. Certified Nurse's Assistant (CNA) E said he/she was in a room assisting a resident when he/she heard a lot of commotion coming from the hallway. He/She went out to the hallway and witnessed Resident #13 and Resident #14 fighting. He/She, along with another staff member, broke up the fight. He/She did not see who the aggressor was but they know that Resident #13 has a history of behaviors. He/She said he/she is not aware of any interventions used for Resident #13 to prevent behaviors and altercations. During an interview on 1/31/24 at 3:18 P.M., Licensed Practical Nurse (LPN) F said he/she was on a different hallway when he/she was asked by another staff member to assist on the C hallway. While LPN F was in the resident's room, he/she heard a commotion in the hallway. He/She went into the hallway to find Resident #13 and Resident #14 fighting. He/She got in the middle of the residents to stop the fight. He/She said both residents were sent out to the hospital and once they got back, both were placed on one to one with staff. During an interview on 1/27/24 at 9:41 A.M. the DON said Resident #13 was walking down the hallway using his/her walker when he/she suddenly came at Resident #14 and attempted to strike the resident with his/her walker. Resident #14 started to fight back when staff intervened and separated the residents. Resident #13 was injured with a black eye under his/her left eye. Resident #13 had been having altercations in January, which they believe to be due to his/her dementia progression. She said the only interventions that had been put in place before the altercation had been redirection when ever the resident had an altercation. 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 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 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). MO00229569 MO00229571 MO00230921 MO00230160 MO00229886

Based on observation, interview, and record review, the facility failed to provide protective oversight for one resident (Resident #1) who had a history of elopement and a diagnosis of schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) when staff failed to provide supervision during a smoke break, failed to conduct a head count after the smoke break, failed to conduct hourly face checks, and did not discover the resident was missing until nine hours after the resident left the building. The resident sample was 4. The census was 114. The Administrator was notified on 12/10/23 at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on 12/8/23. The IJ was removed on 12/11/23, as confirmed by surveyor onsite verification. Review of the facility's Intensive Monitoring/Visual Checks policy, revised on 6/30/23, showed: -Purpose: To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues; -Procedure: Residents who require more intensive monitoring due to medical behavioral/psychiatric symptoms will be monitored on visual face checks by the Licensed Nurse and/or designee, and Certified Nurse's Aide (CNA) and/or designee. The Licensed Nurse monitoring shall include a visual assessment of clinical symptom changes or abnormalities; -Definition of Intensive Monitoring: Periodic (e.g. hourly, every two hours or shiftly) check by a Licensed Nurse or one to one monitoring by the designated employee assigned by the Licensed Nurse. A face check is defined by the employee visually seeing the face of the resident; -Residents may require more intensive monitoring based on their medical and behavioral/psychiatric needs; -One to one monitoring: Residents who are showing poor impulse control including verbal/physical aggression, elopement ideations or suicidal/homicidal ideations may also be placed on one to one or two to one (within eyesight of staff at all times) monitoring at the discretion of the administrative staff; -Face checks: *All residents on each unit will be monitored by visual checks at least every two hours or may be provided more intensive monitoring every hour; *Special units will not be left unattended at any time; -Documentation: All documentation of face checks, one on one, or other intensive monitoring will be done in electronic monitoring. Review of the facility's Elopement Protocol, revised on 1/19/22, showed: -Purpose: An elopement will be defined as anytime a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown; -Procedure: The first person aware of an elopement will call a Code White (this is the alert that a resident is missing and staff need to start a search for that resident) to the area of the believed elopement, if known; -If the resident is believed to possibly still be inside the facility, the first person to be aware of the missing resident is to page for all units to search room to room for the resident. All rooms, closets, bathrooms and work areas are to be searched; -If the resident has in fact left the facility, notify the resident's family or guardian. The person to notify the family or guardian will be designated by the Administrator; -The facility will notify the local police; -The Charge Nurse on duty will initiate facility grounds search; -Notification of state agencies will be at the discretion of the Administrator/designee. Review of the facility's Smoking Safety Regulation policy, revised on 6/29/23, showed: -The facility will follow all smoking regulations; -The facility will provide direct supervision for smoking by patients classified as not responsible. Review of the B Hall Smoke Break Checklist, in use at time of the elopement, showed: -Only seven residents at a time can smoke; -Must be two staff members present in order to conduct smoke break, one on the hall and one in the smoke area during smoke break; -A column with smoke break times, showed 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M. listed; -A column with 100% head count completed and Yes/No listed adjacent to each smoke time; -A column with a line for staff initials adjacent to each smoke time. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/19/23, showed: -admission date 8/5/22; -Cognitively intact; -Wandering: Not exhibited; -Independent in self-care tasks; -Diagnosis of schizophrenia. Review of the elopement assessment, dated 10/31/23, showed: -History of elopement at home: Yes; -History of attempted leave of the facility without notifying staff: Yes; -Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes; -Wanders: Yes; -Wandering behavior a pattern or goal directed: Yes; -Wanders aimlessly or non-goal directed: No; -Wandering behavior likely to affect the safety or well-being of self/others: Yes; -Wandering behavior likely to affect the privacy of others: No; -Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No; -Problem: Risk for Wandering/Elopement Identified; -Clinical Suggestions: Review current medication regimen. Monitor location frequently. Review of the resident's care plan, dated 11/5/23, showed: -Problem: Resident had a long history of mental illness and frequent psychiatric hospital admissions related to Schizophrenia; --Interventions: Pharmaceutical (medications) interventions as needed; -Problem: Risk for harm. Self directed or other directed; --Interventions: Administer medications as prescribed; -Problem: Resident had a history of aggressive behavior towards others; --Interventions: Administer medications as ordered. Monitor/Document/Report; -Problem: Resident was not allowed to come off unit and dine in dining room for lunch except on days when the Administrator is present in the building/Resident was not allowed to go out with activities for any reason related to high risk for elopement per guardian's request; --Interventions: Follow guardian's restrictions as indicated and continue to monitor whereabouts frequently. Notify guardian of any changes along with physician; -Problem: Resident is high risk of elopement due to elopement from the facility on 8/27/22. Resident resides on special care unit; --Desired Outcome: Resident will be monitored closely and remain safe. Resident will not elope from facility; ---Interventions: Monitor resident whereabouts every hour and document that you are aware he/she is safe. Inform charge nurse immediately of any attempts to exit the unit or facility unsupervised. Resident resides on a locked unit to provide protective oversight. Staff to complete hourly face checks; -Problem: Resident had an episode of elopement from facility and returned on 4/30/23; --Desired Outcome: Resident will be located by staff/Police department safely; --Interventions: One on one for four days, new orders per psych, staff to continue face checks per protocol. Review of the resident's hourly face checks, showed: -On 12/8/23, a face check documented at 3:30 P.M. Observation of camera footage and interview with the Administrator on 12/11/23 at 2:15 P.M. showed: -On 12/8/23 at 9:47 P.M., three staff members gathered at the back of B hall. Several residents stood in the area in front of the back door waiting to go outside to smoke; -One of the staff members opened the door and began to light the cigarettes for the residents as they went outside; -The Administrator pointed out Resident #1 and said he/she was dressed in a coat and boots. The administrator said this was different from the earlier times the resident went out to smoke when he/she wore flip flops and a sweater; -All of the staff members stayed inside at the table while the residents went outside. There were more than 10 residents outside at this time. The residents continued to come to the back door and staff would light their cigarettes and allow them to go outside unsupervised. The three staff members eventually got up one by one and went out the back door, leaving the hall unsupervised; -The smoke break lasted approximately 20 minutes. During this time, residents wandered back one by one into the facility. Other residents wandered from the hall to the back door area; -Approximately 20 minutes after the smoke break began, the last staff member came back in. The unidentified staff member shut the door. The resident was not observed returning into the building; -There were no obvious face checks completed after residents came back into the facility after the smoke break. Review of the resident's hourly face checks, showed: -On 12/9/23, face checks documented at 1:31 A.M., 1:34 A.M., 3:08 A.M., 4:21 A.M., 5:14 A.M., 5:42 A.M., and 9:50 A.M. Review of the resident's progress notes, showed on 12/9/23: -At 8:10 A.M.: Staff received hand over report from the night shift nurse that the resident was not seen in his/her room. Staff checked all the rooms and a search was done throughout the building. Staff called the resident's guardians and left a voicemail; -At 2:05 P.M.: The resident was noted to be missing at 7:10 A.M. to 7:15 A.M. The day shift nurse and Director of Nursing (DON) were made aware during shift change. A code white was called. An investigation was started. Facility staff searched for the resident. They were unable to locate him/her at this time. The nurse was unable to locate the guardian after multiple attempts. The police filed a missing persons report. Review of the facility's self-report investigation, dated 12/9/23, showed: -Summary of incident: The resident was noted to be missing by 7:00 A.M. to 3:00 P.M. staff on 12/9/23. Review of camera footage showed the resident last seen on 12/8/23 at 9:45 P.M., going out the door of the smoke patio for a designated smoke break on B hall. The resident did not come back into the facility from the smoke break. At approximately 7:15 A.M., the DON was notified of the missing resident. The DON immediately notified the Administrator. The facility initiated a code white and started a search for the resident immediately. The police were notified. The resident was still missing. The police have a missing person report initiated and they are looking for the resident. Staff failed to follow the following policy and procedures: Failed to follow residents during smoke break times, failed to ensure the residents were all accounted for before and after smoke break times, and failed to complete face checks per policy and procedure; -Written statement by Hall Monitor (HM) K dated 12/9/23, showed the last time he/she saw the resident was when he/she went on break at 8:10 P.M.; -Written statement by HM M dated 12/9/23, showed he/she worked from 11:00 P.M. to 7:00 A.M. on B Hall and he/she did not do his/her face checks and did not see the resident; -Written statement by HM J, undated, showed he/she was on B Hall from 3:00 P.M. to 7:00 A.M. and last saw the resident around 8:00 P.M. He/She was no longer on the hall starting at 10:00 P.M., because he/she was called off the hall. During an interview on 12/10/23 at 3:00 P.M., HM M said he/she worked 11:00 P.M. to 7:00 A.M. that night. When he/she got to work, he/she completed rounds with the other staff. When he/she did not see the resident, HM M thought the resident was in the restroom. HM M got busy mopping and cleaning the halls and did not make any more checks. HM M documented he/she made the checks, because he/she thought the resident went back to bed. HM M knew he/she was supposed to do physical face checks and document these checks. No one on the earlier shift said anything about the resident missing. HM H helped search for the resident when he/she heard the resident was missing. He/She was shocked when the Administrator said the resident had been gone since the night before. During an interview on 12/17/23 at 12:30 P.M., HM J said he/she worked 3:00 P.M. to 7:00 A.M. the night the resident eloped. He/She had only been a HM for about two months. He/She knew staff were supposed to go out with the residents when they smoked, but did not know the person who lit their cigarettes was supposed to supervise. The Administrator did not tell him/her that until after the incident. It was not in the policy. The other two staff he/she was working with said they would supervise the residents outside if he/she lit the cigarettes. So, he/she lit all the cigarettes and then they let the residents go outside by themselves. HM J finally got up and went outside with the residents and then the other staff went outside too. They left the residents inside unsupervised. He/She knows they should not have let more than seven residents out at one time. It was the end of the night. As one resident came back in, another resident could go out. They were not paying good enough attention that night and more than seven residents were outside. They were supposed to count them when everyone came back in. The DON called HM J off the floor right at the end of the smoke break so he/she did not make a count of all the residents when they came back in. HM J did not know the resident did not come back into the building. HM J agreed to work the double shift and his/her co-workers agreed to do the checks. He/She did not have a working code for the app to document the face checks. There was some kind of technical issue and they were still trying to work it out. The staff told him/her to use someone else's code, but he/she won't do it because that would be fraudulent documenting. HM J thought his/her co-workers were making the checks, because he/she was getting up and walking down the hall. HM J should have made face to face checks himself/herself. Observation on 12/10/23 at 12:15 P.M., of the B Hall outside smoke break area, showed a large patio area bordered by a large wooden fence. To the left of the door, the patio led to a pathway that ran along the side of the building. The pathway ended at a gate that was locked. The fence from the door to the gate was approximately 12 feet in height. To the right of the door, the pathway ran around the building into a large open area that was bordered by the fence and ended at a gate with a lock. The height of the fence varied in different areas from approximately 9 feet to 12 feet. Some of the boards of the fence, including the area around the gate, were broken or missing. There was a table and several chairs on the patio. There were several chairs throughout the area on both sides of the patio, in the yard. Neither area beside the building could be seen from the B hall door. During an interview on 12/11/23 at 1:45 P.M., the DON said he/she came in to work that night because a nurse had gone home. He/She called HM J off the hall around 10:10 P.M., but sent him/her right back and told him/her to make his/her hourly face checks. He/She did not make checks on that hall because he/she was working on an investigation and managing the halls for the nurse that left. She did not find out about the missing resident until about 7:10 A.M., when a staff member told her they might have a code white. She told staff to do a head count, at which time they realized the resident was missing. They searched the perimeter of the building and some of the staff got in their cars and searched the immediate area. When they could not find the resident, she notified the Administrator and the police. She interviewed the night staff who admitted to not making checks on the resident throughout the night. She viewed the camera footage and saw the resident go out for the 10:00 P.M. smoke break and did not see him/her return. The staff did not make their face checks even though she reminded them to do so several times during the night. The night staff have to lay eyes on the residents and make sure they are breathing. This may mean they have to talk to the resident or turn on the lights. She told the oncoming nurse to notify the resident's physician and guardian. During an interview on 12/15/23 at 10:00 A.M., the resident's guardian said no one at the facility contacted her regarding the resident's elopement. She called and spoke to the administrator on 12/14/23 and was not told about the elopement. This was concerning as the resident had eloped from the facility before and this was why he/she was on the locked unit. The facility had contacted him/her recently about the resident refusing his/her medication, but there was no note about the elopement. The resident could be a danger to himself/herself if not on his/her medication and unsupervised. The resident was hyperreligious and could be aggressive toward others if provoked. The staff should have been making hourly face checks on the resident and should not have allowed the resident to go outside to smoke unsupervised. During an interview on 12/10/23 at 12:20 P.M., HM N said when there are two staff on the unit, one is supposed to stay inside with the residents who do not smoke and one is supposed to stay outside and supervise the residents who do smoke. They are only supposed to let seven residents out to smoke at a time. When one comes back in then another one can go out. They are supposed to do a head check when everyone is done smoking. This is documented on the smoke break checklist. They are supposed to fill this out on every smoke break and turn it in at the end of the day. B Hall is a special care unit and they are supposed to do hourly checks on all of the residents. They have an app on their phones and they enter the checks into their phones as they make them. This goes into the resident's electronic chart. The residents do not have smoke breaks on the night shift. The staff usually just make beds, fill ice buckets, make face checks and help those residents who might need a little extra help. Staff are supposed to go in the resident's room and look at the resident. There is usually enough light from the hallway to see the resident or staff can call their name. Staff check to see if they are breathing and document the check in the app. During an interview on 12/11/23 at 3:00 P.M., the Administrator said staff did not follow policy and protocol prior to and after the resident's elopement. They allowed more than seven residents to go out during the smoke break. Staff allowed the residents to go outside unsupervised and left the hall unsupervised when they all went outside. Staff did not make a head count when the residents returned from the smoke break and did not fill out a smoke break check list for the entire shift. They did not make hourly face checks or document they made hourly face checks for the rest of the 3:00 P.M. to 11:00 P.M. shift and they did not make face checks on the 11:00 P.M. to 7:00 A.M. shift. During an interview on 12/11/23 at 10:00 A.M., the resident's physician said he had not been notified the resident was missing from the facility. The resident could be a danger to himself/herself if he/she was out on the street. If the resident did not get his/her medication he/she could start having hallucinations. If the resident was on a secured unit the staff should have been making regular checks on him/her. MO00228538 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 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 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).

Based on interview and record review, the facility failed to ensure the provision of treatment and services for one resident (Resident #1), diagnosed with a mental health disorder and post-traumatic stress disorder (PTSD, a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety) to attain the highest practicable mental and psychosocial well-being. The facility failed to provide or arrange for mental health services, and failed to notify psychiatric services of suicide attempts and of the contents of the suicide note authored by the resident. Facility staff also did not follow the facility's program for a proper therapeutic hold while the resident had a behavior emergency. The sample was 14. The census was 111. The Administrator was notified on 1/29/24 at 12:53 P.M., of an Immediate Jeopardy (IJ) which began on 12/27/23. The IJ was removed on 1/29/24, as confirmed by surveyor onsite verification. Review of the facility's Behavioral Emergency policy, dated revised 1/5/23, showed: -Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience; -Procedure: It is the policy of management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident-resident altercations the following steps will occur; the licensed nursing staff, team leader, and nursing administration will assess the resident who is exhibiting such behaviors, ensuring that safety of resident and others is the first priority. A one-to-one monitoring of resident will be initiated immediately. The director of nurses or designee and the Administrator or designee and Regional Director will be notified regarding assessment findings. The Director of Operations or Chief Operating Officer will review the resident's plan of care with the Regional Director and Administrator/designee and will determine if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility; -The licensed nurse and team leader will follow direction from the management team member on call, Resident Care Coordinator and the Administrator or designee. The guardian will be notified at this time and imposed limitations may be placed on the resident, including hospitalization or other specific directives. The physician will be notified of the licensed nurse, team leader, assessment and orders will be followed. The licensed nurse and team leader will will follow all physician orders and will notify the management team member on call regarding the new orders from the physician. If the management team member on call and Administrator or designee decide that resident's needs cannot continue to be safely met, or that the resident is not appropriate for placement at the facility, the physician (primary psychiatrist, house psychiatrist, or medical director) will be notified by the licensed nurse requesting for a psychiatric evaluation, at this time an immediate discharge notice may be sent with the resident. The legal guardian will be notified of the immediate discharge and reason for the notice; -The Administrator, Director of Nursing (DON), designee will complete an administrative investigation within 24 hours of the behavioral emergency. This may include a (as needed) PRN Intervention Form and notification of state agencies in the event that criteria are met. In the event that the resident is unable to be redirected or is requesting a PRN medication for mood stabilization, the resident will be given PRN medication per physician's orders. If the resident receives a (by mouth) PO or (Intramuscular) IM PRN mood stabilizing medication, the licensed nurse must complete the PRN Intervention Form in the electronic medical record. The licensed nurse will document the behavioral emergency in the medical record by utilizing the BIRPEEEE documentation guidelines (which means define behaviors, interventions for behaviors, reaction/response, plan continued plan of care, evaluate, evaluate, evaluate, evaluate.) -After every Code [NAME] (behavior emergency) that required the utilization of approved Crisis, Alleviations Lessons and Methods program (CALM, staff assisted therapeutic hold) hold techniques, the administrator, DON, or designated employee will complete an administrative investigation of the occurrences regarding the resident's behavior and the staff responses. Remember that any Resident who requires approved CALM hold techniques must meet the criteria, which must be documented and that physical or chemical interventions are never used to as a punishment for discipline or staff convenience. Review of the CALM Program Workbook, revised 2021 edition, showed the following techniques for adults: -Five person control take down included the following: -Staff form a V-shape; -The team leader is responsible for maintaining the client's head during the take down and provides direction during the take down; -The first two people to respond after the team leader are responsible for controlling the arms. Hold the client at the wrist and above the shoulders; -(The other two staff) kneel down behind the client. Place the outside hand above the client's knee. Place the inside hand at the client's ankle. Place shoulder on the back of the client's thigh. When all staff members are in position, the team members responsible for the legs will drive their shoulders forward. -Two person Escort included the following: -Only to be used with cooperative clients; -Person escorting puts their arm underneath the client's armpits and hold their arm at the wrist; -Secure the hold with the other arm; -Walk the client to a safe location. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/7/23, showed: -Cognitively Intact; -Diagnoses included major depressive disorder, PTSD, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, dated 12/7/23, showed: -Problem: Resident has a history of behavioral challenges that require protective oversight in a secure setting; -Desired outcome: Resident will have no serious injuries due to behaviors; -Interventions: CALM technique if needed. Implement plans to change inappropriate behavior, pharmaceutical interventions as needed; -Problem: Resident has a history of PTSD. PTSD affects resident symptoms and may flare up without any known trigger. Altercations in reactivity from the traumatic event including aggressiveness and self destructive behavior; -Desired outcome: Resident will be able to identify triggers. Resident will learn and utilize positive coping strategies. Resident will demonstrate control of emotions and relaxation techniques. Resident will be free from injury; -Interventions: Administer medication appropriately and monitor for side affects, encourage resident to express emotions in a safe environment, encourage resident to verbally identify current ineffective coping techniques, and help resident understand that their current behaviors that may be preventing effective healing or treatment, provide counseling services when needed. Review of the resident's progress note, dated 12/27/23, showed Certified Medication Technician (CMT) alerted (Licensed Practical Nurse) LPN K, that the resident refused his/her medications. LPN K went to speak with the resident regarding why he/she was refusing his/her meds. Upon entry to his/her room, observation showed the resident with a sheet wrapped around his/her neck. The resident was instructed to remove it immediately and he/she complied. The resident was allowed to vent his/her frustrations. He/She stated that he/she felt suicidal. He/She was asked why he/she felt that way and he/she said he/she didn't know. The resident stated he/she wanted their medication shot and to go to the hospital. The resident was educated on the importance of taking his/her medication and the psychiatric doctor would be alerted. He/She agreed to take his/her medication if he/she could get it. Physician was notified, new order was obtained for Zyprexa (antipsychotic) 10 milligrams (MG) IM every eight hours PRN (as needed). IM medication was administered to left deltoid (shoulder muscle) without difficulty. Shortly after the resident went to his/her room and started moving his/her items around the room. He/She was placed on a one on one supervision for safety. The resident was placed in the hallway for a while to help him/her de-escalate his/her behaviors. He/She eventually calmed down and went into his/her room to sleep. Guardian was called and a message was left. Administrator, DON, Social Worker were made aware. Will continue to monitor for protective oversight. During an interview on 1/26/24 at 12:30 P.M., Resident #1 said on the morning of 12/31/23 he/she was hearing voices. He/She was also aggravated because his/her roommate was using the room light and he/she wanted the light off. He/She placed the sheet around his/her neck in attempt to kill himself/herself. The resident said his/her roommate noticed the resident had a sheet around his/her neck and told him/her to take it off. The resident's roommate called staff into the room to tell them what Resident #1 was doing with the sheet. Resident #1 said he/she was asked by nursing staff if he/she wanted to go to the hospital and he/she said yes. The resident said he/she was feeling like he/she wanted to kill himself/herself due to the voices. Review of Resident #1's progress notes, showed: -A progress note, dated 12/31/23 at 2:30 P.M., the resident was medicated earlier for agitation. (Registered Nurse) RN J was called to B hall by Hall Monitor. Resident #1 was tearing up the room and throwing things about, turning over the night stand and throwing everything in the room. The resident blocked the door and staff were unable to enter. The door was finally cracked open enough and the resident was informed he/she could not destroy property and some property was the resident's roommate's property. Tried unsuccessfully to communicate with resident and 911 was called to take the resident to the hospital; -A progress note, dated 1/1/24, late note from 12/31/24, resident stated he/she was struck in the face by another resident. The Administrator was called. Call was placed to resident's guardian. Also called ambulance and sent to (Emergency Room) ER. Police were called, and the witness said there was no contact. Neurological assessment was done on the resident. Skin assessments were completed on both residents. -No progress note regarding the resident's return from the hospital. Review of the resident's progress note, dated 1/7/24 showed RN J called to resident room. Resident was trying to remove room air conditioner. Tried to redirect resident and resident started swinging at staff. Resident was lying on bed and he/she got up and was lying on the floor. Resident up on own and the police came and the officer and RN J asked the resident why. Emergency Medical Services (EMS) came and the resident was taken to the hospital. During an interview on 1/26/24 at 11:35 A.M., the resident said he/she wanted to use parts of the air conditioner unit to cut and hurt himself/herself. He/She was sent to the emergency room following this incident. Review of the resident's progress note, dated 1/9/24, showed Code [NAME] called to resident's room via overhead announcement. LPN I, and several other staff members responded to the code. Upon arrival, patient was being restrained by two staff members, one restraining each hand/wrist and patient biting onto pillow lying face down on bed. A verbal explanation was given that patient tied the bed sheet around his/her neck and attempting to strangle himself/herself, along with a clothes hanger. The resident refused to talk to nursing staff about the incident. LPN I initiated a 911 call for assistance with a suicide attempt. The second nurse stayed at the bedside to assist. At that time, a hand written suicide note was given to the second nurse at the scene by a staff member who was at beside for one-on-one monitoring. EMS arrived to facility and transferred resident to the hospital. Police department responded and filed police report. DON notified. Physician answering service left call, waiting return call. Guardian left voicemail, awaiting return call. During an interview on 1/25/24 at 3:53 P.M., Resident #1 said prior to the incident on 1/9/24, he/she was feeling very anxious. When the staff held him/her down on the bed, he/she knew that the staff were trying to help him/her. His/Her anxiety took over and he/she started to feel like the staff were attacking him/her. The resident was held down on his/her stomach with his/her hands behind his/her back. His/Her head was in a pillow and to the side. He/She continued trying to hit and kick the staff members and it was hard to breathe with all of the staff holding him/her down. Review of the resident's Electronic Medical Records (EMR) showed: -On 1/19/24 Resident #1 was readmitted to the facility after being at the hospital and was placed on one on one supervision; -A depression scale assessment, completed by the Social Worker on 1/20/24 at 1:11 P.M., showed Resident #1 reported feeling down, depressed, or hopeless two to six days per week, had thoughts of wanting to harm himself/herself or that that he/she would be better off dead two to six days a week. -On 1/22/24 Resident #1 was taken off of one on one supervision after being deemed safe. During an interview on 1/26/24 at 9:24 A.M., the Social Worker said she has been completing depression assessments on Resident #1 in attempt to help him/her. She said the facility does not currently have a contract with a counseling service. She said after each documented suicide attempt Resident #1 was placed on one-on-one supervision until he/she was determined to be safe. She had been in communication with the resident's guardian due to how many suicide attempts the resident was having. During an interview on 1/26/24 at 12:41 P.M., Hall Monitor B said Resident #1 gets agitated sometimes. His/Her interventions include going to the charge nurse to see if the resident has an as needed medication they can take. He/She said the hall monitors will buy the resident sodas sometimes to help the resident. He/She said if the behavior is something they can manage without nursing staff they will, but that if they need nursing staff, the charge nurse is the first place they go. He/She said the hall monitors don't always know what interventions to use or what the residents' care plans say. He/She was unaware of what Resident #1's care plan said. During an interview on 1/26/24 at 12:59 P.M., Licensed Practical Nurse (LPN) C said whatever interventions staff come up with for residents should be documented in a nurse's note and on the care plan. He/She said he/she is not sure if hall monitors are able to access a resident's care plan. He/She said nursing staff walk around every shift and relay information about the residents to the oncoming shift. He/She believed the care plan was the plan, but there was no written down intervention plan for Resident #1. Restraining Resident #1 is not the first step hall monitors should take, and they should at first, attempt to talk with the resident. During an interview on 1/25/24 at 1:06 P.M., the resident said he/she does not like loud noises or crowds. These are triggers for his/her emotions and he/she gets mad quickly. He/She would like a staff member he/she could trust, to talk with him/her weekly about his/her triggers and give him/her coping skills to use. Review of the resident's care plan, dated 12/7/23, showed the care plan had not been updated to include specific personalized interventions to address the resident's PTSD and suicide attempts on 12/27/23 and 1/9/24. During an interview on 1/26/24, at 1:06 P.M. the Psychiatrist said the following: -She expected the facility to notify her or her office of any suicide attempts, as their protocol was to send residents to the hospital for evaluation and then to see them after the incident; -She could not remember if the facility had notified her of any suicide attempts; She would have made a note in the resident's file and was not able to access the resident's medical record at the time of interview; -She expected the facility to provide counseling to residents with PTSD and/or suicide ideation on a weekly or biweekly basis, as well as care plan for both with meaningful interventions; -She expected the facility to follow up with her after a resident had a suicide attempt as it may alter plan of care; -She was new to the resident's care team, she had started approximately three weeks ago. During an interview on 1/26/24, at 2:23 P.M., the resident's Guardian said the following: -The facility did not inform her of any suicide attempts made by the resident; -She was not told the resident was sent to the hospital for suicide attempts. She and her office were only asked by the hospital for consent to admit and to discharge; -She expected the facility to notify her or her office of any suicide attempt; -She expected the facility to provide counseling to the resident for PTSD and suicide ideation; -She asked the facility social worker in the beginning of January, if they provided psychiatric counseling and she was told the facility did not provide the service and to move the resident to a different facility; -She expected the facility to develop a care plan for PTSD and suicide ideation with appropriate interventions to address the resident's psychiatric needs. During an interview on 1/26/24 at 3:04 P.M., the Psychiatrist Nurse Practitioner, said the following: -He only saw the resident on 12/28/23; -The Psychiatrist saw the resident on 1/3/24 and 1/24/24, via TeleHealth (virtual visit), which are meetings that generally take 15 to 20 minutes; -He was not aware the resident had any suicide attempts while the resident was in the facility; -His protocol was to send a resident out to the hospital immediately following a suicide attempt and would have followed up with the resident once the resident returned from the hospital to reevaluate the plan of care; -He reviewed the medical records on the resident and found there was no record that he or his office was notified by the facility on 12/27/23, 12/31/23 or 1/9/24 of the resident's suicide attempts. During an interview on 1/25/24 at 1:51 P.M., the DON said she was never made aware of the resident's suicide attempt on 1/9/24 or that the resident was restrained with his/her face in a pillow. She said this event was not investigated. She said the facility should have investigated the suicide note and kept the note. She said the resident should not have been held down with his/her face in a pillow and that it is unsafe. 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 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 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).

Based on observations, interviews, record reviews, facility policy reviews, and review of a manufacturer's user's guide, the facility failed to ensure a multi-use blood glucose meter was cleaned and disinfected after each use for three (Residents #4, #28, and #35) of six sampled residents reviewed for medication administration. The facility also failed to ensure staff did not touch medication with their bare hands for one (Resident #24) of six sampled residents reviewed for medication administration. Further, the facility failed to ensure staff washed their hands before and after gloves were removed during wound care for one (Resident #211) of twenty seven sampled residents. In addition, the facility failed to follow their infection control policy when staff failed to complete the second step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests for five employees. The census was 108. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 Infection Control at a scope and severity of J. The IJ began on 09/20/2023 when Licensed Practical Nurse (LPN) #1 failed to clean and disinfect the blood glucose meter between use for Residents #4, #28, and #35. The previous Administrator (Administrator #2), the current Administrator (Administrator #3), and the Facility Nurse Advisor (FNA) were notified of the IJ on 09/20/2023 at 6:25 P.M. The IJ was removed on 09/21/2023. Noncompliance remained at the lower scope and severity of D, isolated harm that was not immediate jeopardy. Findings included: 1. Review of the EvenCare G2 Blood Glucose Monitoring System Users Guide, with a copyright date of 2015, indicated, Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Further review of the user's guide specified, Cleaning and Disinfecting Your Meter and Lancing Device 1. Wash hands with soap and water and dry thoroughly. 2. Inspect for blood, debris, dust, or lint anywhere on the meter or lancing device. 3. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. 4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Per the user's guide, one of the validated disinfecting wipes listed was Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes. The user's guide further specified, Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. 5. Wipe meter dry or allow to air dry. 6. Wash hands with soap and water and dry thoroughly. Review of a facility policy titled, Cross Contamination of Equipment, with a revision date of 06/29/2023, indicated, The purpose of this policy is to define procedures to prevent the spread of infection/diseases when utilizing multiple use equipment. Procedure: 1. Examples of multiple use equipment include: a. Pulse-Oximetry b. Accucheck [blood glucose meter] machine c. Thermometer d. Scissors 2. Multiple use equipment will be cleaned after each use and allowed to dry before being placed back into its place of storage. 3. All multiple use equipment will be cleaned with a disinfectant wipe, bleach wipe and/or as recommended by the Manufacturer. Review of a facility policy titled, Handwashing, with a revision date of 06/29/2023, indicated, To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infection. The policy specified, 2. The use of gloves does not replace handwashing. 3. Hands are to be washed before and after gloving. 4. A waterless antiseptic solution may be used as an adjunct to routine handwashing. 5. Appropriate ten (10) to fifteen (15) second handwashing must be performed under the following conditions: a. Whenever hands are obviously soiled; b. Before performing invasive procedures; c. Before preparing or handling medications; d. After having prolonged contact with a resident; e. After handling used dressings, specimen containers, contaminated tissues, linens, etc.; f. After contact with blood, body fluids, secretions, excretions, mucous membranes, or broken skin; g. After handling items potentially contaminated with a resident's blood, body fluids, exertions and secretions; h. After removing gloves. A review of Resident #28's admission Record indicated the facility admitted the resident on 08/18/2022 with a diagnosis to include type 2 diabetes mellitus. Further review of the admission Record revealed the resident received a diagnosis of acute hepatitis C on 04/06/2023. A review of Resident #28's Order Summary Report revealed a physician's order, dated 09/20/2023, that directed staff to conduct finger stick blood glucose checks twice a day related to diabetes mellitus. A review of Resident #35's admission Record indicated the facility admitted the resident on 12/29/2022 with a diagnosis to include type 2 diabetes mellitus. A review of Resident #35's Order Summary Report revealed a physician's order,, dated 09/20/2023 that directed staff to conduct fingerstick blood glucose checks four times a day related to diabetes mellitus. A review of Resident #4's admission Record indicated the facility admitted the resident on 09/28/2012 with a diagnosis to include type 2 diabetes mellitus. A review of Resident #4's Order Summary Report revealed a physician's order, dated 09/20/2023, that directed staff to conduct fingerstick blood glucose checks with meals related to diabetes mellitus. Observation on 09/20/2023 at 8:05 A.M., showed Licensed Practical Nurse (LPN) #1 obtained a blood glucose level for Resident #28. LPN #1 placed the blood glucose meter on top of the medication cart and did not clean or disinfect the machine. At 8:18 A.M., LPN #1 was observed to wipe the top of the blood glucose meter with an alcohol wipe. LPN #1 then obtained a blood glucose level for Resident #35 using the same blood glucose meter. At 8:24 A.M., LPN #1 wiped the blood glucose meter with a disinfectant wipe; LPN #1 did not allow the blood glucose meter to dry before she checked the blood glucose level of Resident #4. During an interview on 09/20/2023 at 9:31 A.M., LPN #1 stated the blood glucose meter should be cleaned with bleach wipes after every use. LPN #1 stated she thought the dwell time (time spent in the same position) was 10 or 20 seconds, but she was not sure. During an interview on 09/20/2023 at 9:28 A.M., Registered Nurse (RN) #19 stated when a resident's blood glucose level was obtained, she would put on gloves, clean the resident's finger with an alcohol pad, stick the resident's finger with a lancet to retrieve the blood sample. Per RN #19, she would change her gloves if she needed to give insulin. RN #19 stated she would clean the blood glucose meter with an antiseptic wipe after every use and allow the blood glucose meter to air dry. During an interview on 09/20/2023 at 9:40 A.M., Resident Care Coordinator (RCC) #15 stated the blood glucose meters were to be cleansed and/or disinfected with a disinfectant between each resident. She stated gloves should be worn and hand sanitizer or hand washing should occur between glove changes. During an interview on 09/20/2023 at 10:13 A.M., RN #19 confirmed the blood glucose meters used by the facility were Even Care G2 and the wipes used for cleaning the machines were Micro-Kill One germicidal wipes. During an interview on 09/23/2023 at 8:53 A.M., Director of Nursing (DON) #51, the current DON stated that when a nurse performed a blood glucose check, the nurse should perform hand hygiene, gather the needed supplies, and set up clean and dirty fields. She stated the blood glucose meter should be cleaned and then the nurse should remove their gloves, conduct hand hygiene, and then re-glove. DON #51 stated the nurse should clean the resident's finger with alcohol and let the resident's finger dry and then obtain the sample. She stated the nurse should remove their gloves and put on new gloves, clean the blood glucose meter with a disinfectant wipe and place the meter on the clean field to air dry. She stated that once it was dry, then it would be put in the bag that was used for storage. During an interview on 09/23/2023 at 11:51 A.M., Administrator #3, the current Administrator, stated cleaning and disinfecting blood glucose meters and obtaining blood glucose levels should be performed according to the facility policy. 2. During medication administration observation on 9/20/2023 at 8:08 A.M., Certified Medication Technician (CMT) #17 removed one capsule of Vitamin D3 from a bottle with her bare hand, CMT #17 then placed the capsule in a medication cup to administer to Resident #24. During an interview on 09/22/2023 at 12:13 P.M., Resident Care Coordinator (RCC) #15 stated nurses and CMTs should not touch medications with their bare hands. During an interview on 09/23/2023 at 8:53 A.M., Director of Nursing (DON) #51, the current DON, stated medications should not be touched with bare hands and if they were, the medication should be discarded. DON #51 stated if CMT #17 touched the medication, the medication should have been discarded. 3. Review of a facility policy titled, Handwashing, with a revision date of 06/29/2023, indicated, To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infection. The policy specified, 3. Hands are to be washed before and after gloving. During wound care observation on 09/21/2023 beginning at 6:42 P.M., Registered Nurse (RN) #19 did not wash her hands before she put gloves on to provide wound care for Resident #211. During wound care, RN #19 removed her gloves three times, and each time she did not wash her hands before she put on new gloves. During an interview on 09/22/2023 at 12:13 P.M., Resident Care Coordinator (RCC) #15 stated hand hygiene should occur before gloves are put in and in between glove changes. During an interview on 09/23/2023 at 8:53 A.M., Director of Nursing (DON) #51, the current DON, stated hand hygiene should be performed before putting on gloves and in between every glove change. 4. Review of the facility's Tuberculosis Testing policy, revised dated 6/29/23, showed the following: -Purpose: To ensure each resident and employee of the facility is tested for TB after entering the facility to prevent the spread of the infection; -Procedure: 1. Upon hire, a new employee will receive a two-step purified protein derivative skin test (PPD, used in a skin test to help diagnose TB). Each employee will also have an annual one step TB test to ensure that any possible infections can be triggered proactively to prevent further spread; 2. If the new hire has had a positive reaction history to a previous TB test, a chest x-ray will be done. If the resident has a history of positive TB test, the physician will be notified and a chest x-ray will be done; 3. All TB test and chest x-ray records will be kept on file in the employee files. 5. Review of Staff Member A's employee file showed the following: -Hire date: 3/29/23; -First step: 3/29/23, Read date: 3/31/23; -No documentation of a second step. 6. Review of Staff Member B's employee file showed the following: -Hire date: 5/10/23; -First step: 5/10/23, Read date: 5/12/23; -No documentation of a second step. 7. Review of Staff Member C's employee file showed the following: -Hire date: 6/7/23; -First step: 6/7/23, Read date: 6/9/23; -No documentation of a second step. 8. Review of Staff Member D's employee file showed the following: -Hire date: 8/16/23; -First step: 8/16/23, Read date: 8/18/23; -No documentation of a second step. 8. Review of Staff Member E's employee file showed the following: -Hire date: 8/24/23; -First step: 8/24/23, Read date: 8/26/23; -No documentation of a second step. During an interview on 9/26/23 at 11:22 A.M., the Administrator said she expected the TB policy to be followed as written. The Administrator said the DON should monitor the employee TB tests. The Administrator said the DON were new and just started in September 2023. The Administrator did not know there was an issue with the second step TB test.