**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one cognitively impaired resident's (Resident #1) right to be free from abuse when staff found Resident #2 in Resident #1's bed with his hand on Resident #1's genital area. This deficient practice affected one of three residents sampled. The facility census was 78. The administrator was notified on 8/6/25 at 2:04 P.M. of an Immediate Jeopardy (IJ) which began on 7/31/25. The IJ was removed on 8/6/25 as confirmed by surveyor on-site verification.Review of the facility provided Policy Abuse Prevention Program, dated 2001 and revised 2011, showed:-Residents have the right to be free of abuse, neglect, misappropriation, and exploitation. This includes but is not limited to verbal, mental, sexual, or physical abuse; -As part of the resident abuse prevention, the administration will: protect residents from abuse by anyone including facility staff, other residents, consultants, and visitors;-Our facility will not condone any form of resident abuse or neglect;-Abuse is the willful infliction of injury, unreasonable confinement, or intimidation with resulting physical harm, pain, or mental anguish. 1.Review of Resident #1's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 7/15/25, showed: -Significant cognitive impairment, clear speech, usually understood, physical symptoms (such as hitting, kicking and pinching) directed at others 1-3 days of 7 days, and rejected care 1-3 days of 7 days, no wandering.-Diagnoses included: Dementia (a disease that affects the brain causing memory loss), without behavior disturbance, asthma, high blood pressure, psychosis (seeing /hearing and believing things that are not based in reality), anxiety, and Alzheimer's Disease. Review of the resident's Comprehensive Care Plan, dated 7/15/25, showed: -The resident had impaired cognitive function and/or impaired thought processes related to Alzheimer's Dementia;-She had difficulty making decisions, and had long and short term memory loss;-Staff should use the resident's preferred name, identify themself at each interaction, face the resident when speaking and make eye contact;-Reduce any distractions, such as turn off the television/radio, and close the door;-The resident understands consistent, simple, direct sentences. Provide the resident with necessary cues; stop and return if he/she became agitated;-Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Present just one thought, idea, question or command at a time.Review of the resident's July 2025 progress notes showed: -On 7/31/2025 at 6:07 A.M.: The night shift nurse called to report that a male resident had been found by the Certified Medication Technician (CMT) in Resident #1's room, lying in bed with her and his hand in Resident #1's pants, but outside of the brief. Resident #1 was not observed to be alarmed or in distress at the time. The residents were quickly separated and Resident #2 was removed from Resident #1's room and redirected. A physical exam of Resident #1 was immediately completed to ensure safety and no injury; with no signs of bruising, swelling or other sign of injury. The spouse and the doctor were to be notified this morning as well as other resident family and doctor. Staff were increasing monitoring for this resident to ensure safety and mental/emotional wellness;-7/31/2025 at 7:22 A.M.: It was reported from the previous shift, that a resident of the opposite sex was found in this resident's bed lying next to her. It was stated that Resident #2 had his hand down Resident #1's pants, moving it in a back & forth motion. It was reported the nurse on the previous shift examined Resident #1's bikini area and found no abrasions, bruising, or any other injuries. Resident #1 showed no distress/agitation. Resident #1 was very calm, resting quietly with eyes closed; -7/31/2025 at 10:41 A.M.: Resident #1's spouse notified of the incident;-7/31/2025 at 12:03 P.M.: Notified the resident's Primary Care Physician office nurse of incident.Review of Resident #2's Quarterly MDS, dated [DATE], showed: -Significant cognitive impairment, no behaviors, and partial/moderate assist of staff with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-Diagnoses included: Respiratory failure, dementia with behavioral disturbance, high blood pressure, anxiety, bipolar disorder (a mental illness with significant shifts in mood, energy and function), and tremor. Review of the resident's Comprehensive Care Plan, dated 6/26/25, showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to his/her cognitive deficits; -He wound wander around the unit, as he was disoriented to place, with impaired safety awareness; -Staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books;-Provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. -The resident resided on the secure SCU; -The resident may become inappropriate, such as excessive groping/touching with other female residents/care staff. He will be monitored with no unwanted/undirected episodes of groping/feeling behaviors towards others by review date;-Administer medications as ordered and monitor/document for any side effects and effectiveness;-Staff to intervene as necessary to protect the rights and safety of others;-Approach and speak to him in a calm manner;-Divert his attention;-Remove him from the situation and take him to an alternate location as needed; -Monitor his behavior episodes and attempt to determine any underlying cause;-Consider the location, time of day, persons involved, and situations, when behaviors occur;-Document his behavior and potential causes; -One on one activities should be held in public, open areas such as in the dining room or day room of the SCU; -Staff were to have a second person with them whenever private care is required for the resident.Review of the resident's July- August 2025 Progress Notes showed: -On 7/31/2025 at 6:03 A.M.: the night shift nurse reported the resident had been found by the CMT in another resident's room, lying in bed with her and his hand down the other resident's pants, on the outside of the brief. The other resident was not observed to be alarmed or in distress at the time. The residents were quickly separated and Resident #1 was removed from the other resident's room and was easily redirected. He was placed on 15-minute checks for closer monitoring to ensure safety;-On 7/31/2025 at 11:13 A.M.: the resident's Primary Care Physician was notified of the incident that occurred during the night shift.-On 8/1/2025 at1:57 P.M.: the resident began to question the staff about something that happened; asked what was going on, and said it was not good. Also said something happened that was not very good. The nurse sat with the resident and he began to calm down and was in good spirits at the end of conversation.During an interview on 8/5/25 at 3:53 P.M., CMT A said:-He/She assisted Resident #2 to get ready for the day at 5:30 A.M. and the resident laid back in his bed; -He/She then took linen and trash out, noting that Resident #1 was in bed at approximately 5:35 A.M.; -When he/she returned to the SCU, he/she found Resident #2 in Resident #1's bed;-He/She found Resident #2 in bed with Resident #1 at approximately 5:45 A.M. on 7/31/25;-Resident #1 was on her back and Resident #2 was on his right side facing Resident #1;-Resident #2 had his hand on the brief on Resident #1's private areas, rubbing in a circular motion;-Resident #1's brief was intact and she was barely awake and drowsy; -Resident #1 was not speaking or crying; -CMT A said stop, we need to leave the room; -Resident #2 got up and walked to him/her saying he was sorry and did not know; -He/She took Resident #2 back to her room and notified the charge nurse of the incident;-On 7/29/25 he/she was working with Resident #2 when he became aggressive and attempted to pull his/her uniform pants down and he/she left the area and another staff member assisted Resident #2. During an interview on 8/6/25 at 3:15 PM Licensed Practical Nurse (LPN) A said:-He/She was the day shift Charge Nurse on 7/31/25; -He/She was informed Resident #2 was found in bed with Resident #1 and staff could not tell if Resident #2's hand was inside the brief of Resident #1, but Resident #2 was moving his hand in Resident #1's bikini area; -The night nurse had done a skin assessment on Resident #1 and found no injuries.During an interview on 8/6/25 at 1:12 P.M., LPN B said:-He/She was on call 7/31/25 and was notified at 5:57 A.M. of the incident between Resident #1 and #2; -He/She was notified by the charge nurse, Resident #2 had been removed from Resident #1's room, returned to his room and another nurse was completing Resident #1's skin assessment.During an interview on 8/5/25 at 2:50 P.M., Certified Nurse Aide (CNA) A said: -Resident #2 did not usually go into other rooms; -Resident #2 would hold hands with other residents once in a while; -Resident #2 was kind of handsy when he would give hugs, like rubbing his hands up and down your back; he was a feely person, like when he walked up to you, he would rub your arm or hold your hand, but never saw him touch anyone inappropriately. During an interview on 8/6/25 at 2:00 P.M., the Administrator said:-He/She interviewed CNA A and CNA B in regard to the incident between Resident #1 and Resident #2; -He/She did not believe it was abuse as he/she was unsure why Resident #2 had gotten into bed with Resident #1. During a follow up interview on 8/6/25 at 2:30 P.M., CNA B said:-On 7/31/25 there were two CNAs (CNA A and CNA B) and one CMT on the SCU;-On the day shift there are two CNAs and a CMT scheduled on the SCU.During an interview on 8/5/25 at 1:29 P.M., Resident #1's Family Member A said: -He/She was notified the morning the incident occurred;-He/She did not understand how another resident got into Resident #1's room to the point of getting into bed with her and having his hand down the resident's pajamas; -When Resident #1 moved in he/she told the facility three things; one - the resident must be kept clean, two - he/she wanted the resident safe, and three - do not abuse the resident., but that is what happened. The facility did not keep Resident #1 safe;-The Administrator and Director of Nursing (DON) said nothing happened, because the other resident's hand was not inside her clothes, and that the other resident was only in there maybe 10 minutes. A lot can happen in 10 minutes;-He/She did not feel like there was enough staff to prevent this kind of incident from happening again;-Resident #1 was abused. She never would have allowed that if she was in her right mind. During an interview on 8/5/25 at 2:44 P.M., Resident #1 said: -She did not like when the other resident was in bed with her; -Resident #2 had touched down her waist, it did not hurt much and she did not like it; -She was a little bit afraid.During an interview on 8/5/25 at 2:56 P.M. Resident #2 said:-He/She was not sure if he/she had the right bed or the wrong one;-He/She did not know if he/she had gotten into another resident's bed;-He/She did not know where he/she was; -He/She did not know if something happened.During an interview on 8/5/25 at 3:27 P.M., the Interim DON said:-The MDS Coordinator was on call and notified of the incident between Resident #1 and #2; -He/She was told Resident #2 had been found lying in bed with Resident #1; Resident #2 had his hand on Resident #1's front bikini area on top of the resident's brief; -A skin assessment was completed on Resident #1 and nothing was found; -Resident #2's room is across the hall from Resident #1, so he may have been confused and went to the wrong room; -Both residents remained in the same rooms after the incident; -The police were not notified of the incident;-He/She spoke with Resident #2's Primary Care Physician (PCP) on 8/5/25 and requested a medication review; -The PCP adjusted Resident #2's medication on 8/5/25. During an interview on 8/6/25 at 2:35 P.M., Resident #2's PCP said:-He/She was called Monday August 4, 2025, in regards to the incident between Resident #1 and Resident #2.-He/She saw Resident #2 early morning on 8/5/25, and medication adjustments were made; -Resident #2 did not remember any of the incident on 7/31/25.-He/She believed residents on Special Care Communities need closer monitoring for safety and behaviors. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the 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). 2577793

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision of one cognitively impaired resident (Resident #1) with a known elopement risk and history. On 7/18/24, the resident became combative when staff attempted to redirect the resident back inside the facility from an outside activity, made multiple attempts to leave the facility unassisted, reached the facility parking lot in one attempt, and threw objects out the dining room window. On 7/20/24, the resident eloped out of a dining room window (six feet from the bottom of the windowsill to the grass below) around 4:00 P.M. and was brought back into the facility. The resident was placed on one-on-one at that time until the dining room windows could be secured. The facility staff did not continue the one-on-one or secure the resident's bedroom window. The resident removed his/her window screen and went out his/her second story window (approximately 13 feet 5 inches above the paved sidewalk below) between 8:15 P.M. - 8:23 P.M. on 7/20/24, resulting in sustained fractures to both heels and his/her lumbar spine 1 (L1). The facility census was 58. The Director of Nursing was notified on 7/24/24 at 3:23 P.M. of an Immediate Jeopardy (IJ) which began on 7/20/24. The IJ was removed on 7/24/24 as confirmed by surveyor onsite verification. Review of facility policy, Accidents and Incidents - Investigating and Reporting, revised July 2017, showed: -All accidents or incidents involving residents, employees, visitors, vendors, etc , occurring on facility premises shall be investigated and reported to the administrator. Review of facility policy, Wandering and Elopements, revised March 2019, showed: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety; -If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving in a courteous manner, get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. Review of facility policy, Safety and Supervision of Residents, undated, showed: -Supervision/Adequate supervision: refers to the intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident; -The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; -When accident hazards are identified, the Quality Assurance Performance Improvement (QAPI)/Safety committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible; -The care team will target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices; -Implementing interventions to reduce accident risks and hazards shall include, communicating specific interventions to all relevant staff, assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented, documenting interventions; -Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 1. Review of Resident #1's admission face sheet, dated 7/24/24, showed: -He/She was admitted to the facility on [DATE]; -Diagnoses included dementia (condition involving loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and infection of the bladder. Review of the resident's progress notes, dated 7/15/24-7/17/24, showed staff documented: -On 7/15/24, resident was admitted to the facility; -On 7/16/24, Licensed Practical Nurse (LPN) D wrote the resident was wandering on the unit, but easily redirected; -On 7/17/24, LPN C wrote the resident was exit seeking frequently throughout the day. Review of the resident's baseline care plan, dated 7/17/24, showed: -The resident was at risk for falls; -He/She was cognitively impaired; -He/She was independent with mobility, transfers, and ambulating; -He/She required assistance with personal hygiene, dressing, eating, and toilet use. Review of the resident's Elopement Risk Evaluation, dated 7/17/24, showed facility staff assessed the resident as having a score of 18.0, indicating he/she was a high risk to wander. Review of the resident's fall risk assessment, dated 7/17/24, showed facility staff assessed the resident as having a score of 8.0, indicating he/she was a low risk to fall. During an interview on 7/24/24 at 8:54 A.M., LPN B said he/she spoke with resident's daughter when the resident was admitted to the facility who told him/her they had a hard time keeping the resident inside at home and they could not figure out how to keep the resident inside and was barricading the resident inside while at home. During an interview on 7/23/24 at 3:52 P.M., Certified Medication Technician (CMT) C said: -He/She met the resident when he/she first arrived at the facility on 7/15/24 and noted the resident was very active for a resident with dementia and had been very exit seeking; -When he/she worked with the resident on the unit, the resident would follow him/her around while he/she passed medications. During an interview on 7/24/24 at 4:00 P.M., the Activity Aide said: -He/She worked on 7/18/24 in the activity department and was doing a water balloon fight with the residents; -Resident #1 went out the special care unit courtyard door during the activity, so he/she tried to incorporate the resident into the activity; -The resident initially participated, but then said, 'oh cars' and he/she was going home and started walking towards the cars in the parking lot; -He/She and Certified Nurse Aide (CNA) B went after the resident and redirected the resident into the facility front door, because when they tried redirecting the resident into the building via the courtyard gate, the resident became combative; -After the resident initially attempted to elope into the parking lot from the balloon fight, he/she observed the resident elope from the special care unit into the courtyard two more times with the resident stating he/she was going home. This occurred within a few minutes of the resident being escorted back into facility, as he/she was still outside with other residents engaged with the balloon fight. During an interview on 7/23/24 at 2:09 P.M., CNA B said: -He/She worked the special care unit a lot; -On 7/18/24 the resident went to the door to attempt to get out. He/She was standing next to the activity assistant to help block the resident and the resident bulled (pushed) his/her way through CNA B and other the staff to go out the door; -The resident walked out of the courtyard door on 7/18/24 during an activity. During an interview on 7/24/24 at 10:48 A.M., LPN C said: -On 7/18/24 there was an activity that occurred outside and the resident went out with the rest of the residents. It took three staff members to redirect the resident back through the front doors of the facility due to the resident being combative and staff had to use their bodies as a block to try and guide the resident back inside the facility; -On 7/18/24 during the day shift the resident pushed on the courtyard door three times and the door at the end of the hallway to the main nursing unit one to two times. Review of the resident's progress notes, dated 7/18/24 at 4:24 P.M., showed LPN C wrote the resident had been exit seeking for the last hour. He/She had been pushing the alarmed doors open and rushing out of the door into the courtyard. He/She opened windows and attempted to get out the various windows. The resident did not redirect easily. He/She became aggressive and combative when redirected back into the unit. The primary care physician (PCP) made aware of exit seeking and elopement plus behaviors. New orders were received for Depakote and as needed Trazodone. The resident received medication and it made him/her calmer. Contact made with the family. Review of the resident's physician's orders, dated July 2024, showed: -Order started 7/18/24, Depakote Sprinkles oral capsule delayed release sprinkle 125 mg, give 125 mg by mouth three times a day for agitation and anxiety related to dementia with agitation; -Order started 7/18/24, Trazodone HCL tablet, give 50 mg by mouth every 12 hours as needed for agitation and anxiety related to dementia with agitation. Review of the resident's Medication Administration Record (MAR), dated July 2024, showed: -Order started 7/18/24 at 4:00 P.M., Depakote Sprinkles 125 mg was administered on 7/18 at P.M. dose, 7/19 at A.M., Midday, and P.M. dose, and on 7/20 at AM, Midday, and P.M. dose. -Order started 7/18/24 at 4:15 P.M., Trazodone HCL Tablet 50 mg as needed medication was administered on 7/18/24 at 7:15 P.M., on 7/19/24 at 7:04 P.M., and on 7/20 at 3:38 P.M. During an interview on 7/23/24 at 1:44 P.M., CMT A said: -He/She worked with Resident #1 on 7/18/24 and 7/19/24; -The resident had been exit seeking on 7/18/24 by going to doors; -The resident had to be redirected away from the doors; -The resident bulled (pushed) his/her way through the courtyard door to go out with activity staff into the courtyard; -The resident also got one window open on Thursday (7/18/24) on the south wall in the dining room next to the kitchenette, he/she threw a stuffed animal out the window. At that time, the south window did not have a screen on it; -When the family was called about opening the dining room window and throwing stuff out, the family stated the resident had the same type of windows in his/her home; -After the resident's three attempts to exit the building and making it to the parking lot on 7/18/24, staff contacted the physician and got an order for Depakote and Trazodone and kept a close eye on the resident.; -The resident had not been placed on one on one supervision on 7/18/24. During an interview on 7/23/24 at 1:37 P.M., CNA A said: -On 7/18/24, the resident was observed throwing things out the South window in the dining room next to the kitchenette and staff moved a table in front of that window to deter the resident. During an interview on 7/23/24 at 2:18 P.M., CNA C said: -He/She was working on the special care unit the day Resident #1 moved into the facility; -The family had indicated the resident had been trying to exit seek at home; -On 7/18/24, CNA C saw the resident remove the screen to the dining room window, and throw blankets and shoes out the open window. The staff redirected the resident. During an interview on 7/24/24 at 10:48 A.M., LPN C said: -He/She had been working with the resident since he/she admitted to the facility; -The resident had been observed to be exit seeking when he/she pushed on doors a few times and went to windows in the dining room; -On 7/18/24, he/she observed the resident get the window open in the dining room that was next to the kitchenette. That window had a sign on it that said do not open; -He/She immediately called the Administrator on 7/18/24 and advised that they needed to get maintenance, because the resident was going to get out through the window; -He/She saw the Administrator and DON come into the unit and check the windows on 7/18/24, including pushing on the resident's room window. The Administrator and DON could not get the bedroom window to open when they pushed on it; -To prevent the resident from going to the window next to the kitchenette, he/she pushed a table over in front of it. During an interview on 7/23/24 at 1:37 P.M., CNA A said: -He/She last worked with the resident on 7/19/24 and the resident slept most of the day; -The resident would go around and touch the window curtains, but did not attempt to open the curtains; -The resident would wander and he/she would go in and out of other resident rooms and over by the door to the courtyard. During an interview on 7/23/24 at 1:44 P.M., CMT A said he/she worked with the resident on 7/19/24 and the resident displayed no exit seeking behaviors. Review of the resident's progress notes, dated 7/20/24 at 4:04 P.M., showed LPN B wrote the resident was exit seeking. CNA heard a noise and saw the resident making it out the dining room window. The resident was initially seen laying on the ground outside of the window. The resident immediately got to his/her feet and started walking away. The nurse remained inside and kept the resident in line of sight while CNA staff went outside after him/her and were able to redirect the resident back inside. Once inside, the resident had 3 skin tears to his/her left hand, side of his/her palm, tip of index finger, and base of ring finger on the underside of his/her palm. The resident was alert and orientated to baseline. He/She moved all extremities with no expression of discomfort. He/She denied pain. Neurological assessments were initiated. The resident's PCP, and family were notified. The DON was notified. One-on-one care started and as needed Trazodone was given to the resident. Review of the resident's 15 minute check log, dated 7/20/24, showed documentation of fifteen minute checks began at 4:00 P.M. and ended 8:30 P.M. During an interview on 7/23/24 at 2:09 P.M., CNA B said: -On 7/20/24, the resident went to every window and attempted to open the window in the dining room; -On 7/20/24, he/she heard a noise and looked over and saw the resident slip out of the window that was to the right of the bird cage in the dining room around lunch time; -He/She ran outside into the courtyard and out of the gate to intercept the resident; -The resident was found with a cut on his/her hand; -When the resident went out of the window, he/she had taken the screen off; -After the resident made it out of the dining room window, the resident was placed on one-on-one supervision by the Director of Nursing with CNA C designated as his/her specific staff; -On 7/20/24, CNA C sat with resident the rest of the shift until 6:30 P.M. During an interview on 7/23/24 at 2:18 P.M., CNA C said: -He/She was working with the resident on 7/20/24 and the resident paced in the dining room and kept touching or messing with the windows and staff would redirect him/her; -He/She did not see the resident go out the window the afternoon of 7/20/24, but CNA B notified him/her the resident went out of the dining room window, and he/she went outside with CNA B to get the resident back in; -He/She noted the resident had cut his/her hand; -After the resident went out the window CNA C had to do 15-minute checks on the resident and he/she sat with the resident in his/her room until he/she woke up. The DON put the 15-minute checks in place until the maintenance staff secured the window in the dining room. - He/She was assigned to stay with resident until the end of his/her shift at 6:30 P.M. During an interview on 7/24/24 at 8:54 A.M., LPN B said: -He/She worked with the resident on the day shift on 7/20/24 around 4:00 P.M. when the resident went out the window the first time. CNA B took off running and called for CNA C. Both CNA B and CNA C took off outside the building through the courtyard door; -He/She went to the dining room window and observed the resident, was right outside the window and in the process of standing up; -The resident went out the window to the right of the bird cage in the dining room; -He/She completed an assessment of the resident and found injuries to his/her index finger, ring finger, and cuts to his/her hand. He/She notified the DON. The DON instructed him/her to start one on one checks on the resident and he/she completed the neurological checks. The DON also said maintenance staff was coming out to see what he/she could do to prevent the incident; -One-on-one meant, one staff was designated to monitor and observe only one resident and this was done until the maintenance staff had been in the facility to secure the windows in the dining room; -He/She administered an as needed medication of Trazodone to the resident and he/she got sleepy; -He/She and other staff rearranged the dining room and he/she parked his/her medication cart in front of the windows; -CNA C was the staff member assigned to be with the resident for one-on-one supervision until the maintenance man was able to secure the windows in the dining room. Then the resident went to 15-minute checks; -The facility did not have a one-on-one form, so he/she issued a 15-minute check sheet for staff to document the resident observations during the one on one with resident. -The resident slept for thirty minutes after administering the as needed medication, then got up and wandered around and touched and attempted to push on the dining room windows to open them. -Maintenance staff came while he/she was there as he/she remembered seeing the maintenance staff's cart out and heard maintenance drilling. -He/She did not know if maintenance secured the resident's bedroom window. During an interview on 7/24/24 at 9:30 A.M., the DON said: -He/She was notified of the first elopement by LPN B when the resident went out of the dining room window at 4:09 P.M -He/She had advised staff during the initial call received after the first elopement on 7/20/24, the resident needed to be one on one until windows were secured; -He/She notified maintenance staff to come fix and secure the dining room windows after he/she was notified the resident got out on the afternoon on 7/20/24; -The maintenance staff only secured the dining room windows; -He/She expected one on one supervision to include one staff to one resident and to maintain visual observation of resident; -He/She expected the one-on-one supervision to end after maintenance secured the dining room windows and go to 15-minute checks. During an interview on 7/24/24 at 10:12 A.M., Maintenance said: -He/She received a phone call from the DON at 4:30 P.M. (on 7/20/24) and was asked to secure all the dining room windows; -He/She found four metal brackets and screwed them into the windows in the dining room. He/She was not sure what time he/she secured the dining room windows; -He/She was not told to and did not secure the bedroom window at that time. Observation on 7/24/24 at 10:05 A.M. showed the facility regional administrative staff measured the window in the dining room to the right of the bird cage. The measurement read six feet from the bottom of the windowsill to the grass below. During an interview on 7/23/24 at 3:40 P.M., LPN A worked the evening shift, but on a different hall and said he/she had been told in shift change report that a resident on the unit had got out a window in the dining room area earlier in the day and had bandages to his/her finger. Observation on 7/24/24 at 10:05 A.M. showed the facility regional administrative staff measured the window in the dining room to the right of the bird cage. The measurement read six feet from the bottom of the windowsill to the grass below. During an interview on 7/24/24 at 9:18 A.M., CNA E said: -He/She started his/her shift on 7/20/24 at 6:30 P.M. -The resident was a newer resident that he/she had met briefly and was told the resident had been a wanderer; -He/She had been told during shift report the resident had gotten out the window earlier in the day and he/she had been put on one on one until the windows had been fixed; -Maintenance staff had been to facility and fixed windows prior to him/her starting the shift by bolting the windows in the dining room; -He/She had been told the resident was well versed in the facility's type of windows, because the resident had the same type at home; -The resident was on 15-minute checks from the time he/she started his/her shift at 6:30 P.M., -He/She completed 15-minute checks on the resident at 8:15 P.M. The resident had been out in the hallway where he/she could see the resident; -He/She was in with another resident for approximately fifteen minutes when he/she received a phone call from CNA D who had been working on the other hall about the resident being found outside on the ground and his/her bedroom window being open; -He/She hurried to Resident #1's room. He/she looked out of the resident's window that did not have a screen and saw the resident laying on the ground; -All of the resident's belongings were laying around the resident; -Maintenance came in to secure the dining room windows prior to their shift starting at 6:30 P.M.; -The resident was sitting up on top of clothes laying with his/her legs half in grass and his/her upper body half on pavement. During an interview on 7/23/24 at 3:40 P.M., LPN A said: -The evening of 7/20 (around 8:23 PM), he/she had stepped outside and found the resident laying on top of clothing with shoes scattered around him/her. He/She checked his/her phone log and had called the administrator at 8:23 P.M. -The resident was positioned on his/her left side laying underneath an exterior sprinkler piping; -He/She immediately called the administrator and emergency medical responders; -When he/she looked up, the window above the resident was open on the second floor; -The resident had band aids on his/her arm from the previous elopement, that he/she was picking at and had a skin tear to the resident's forearms and blood on the forearms; -The resident began kicking at staff, so he/she removed the resident's shoes; -CNA E called to alert staff that was working on the special care unit; -He/She had not seen the resident before. He/she was working on the floor off the unit; -CNA E told him/her that he/she had been doing fifteen minute checks on the resident due to the elopement attempt from earlier in the day, and last saw the resident at 8:15 P.M.; -The resident tried to get up; -CMT C came down to assist and some dietary staff also came out to courtyard. During an interview on 7/23/24 at 3:20 P.M., CNA D said: -He/She found the resident laying on his/her left side with elbow propped up on ground when he/she went outside facility to smoke at back patio while working on the evening of 7/20/24 (the second time the resident went out the window); -The resident appeared loopy and disorientated and was not able to tell him/her what had happened; -He/She was with LPN A when he/she discovered the resident. LPN A called the facility administrator and 911; -He/She stayed with resident; -He/She noted the bedroom window above was completely open; -He/She called CNA E who had been working on the unit and CNA E came to the window and the CNA stuck his/her head out of the window; -The resident was observed to have a skin tear and a little bit of blood; -He/She was not responsible for the resident and did not know if the resident was on one-on-one observations. CNA E told him/her the resident had been on fifteen-minute checks after getting out a different window and jumping up and running earlier in the day. During an interview on 7/23/24 at 3:52 P.M., CMT C said: -He/She had observed the resident going to locked doors and try to push the locked doors open; -He/She had worked two to three shifts with the resident, but was not working on the special care unit on 7/20/24; -He/She received a call from LPN A about the situation where the resident was outside on the ground and went to the courtyard to assist; -When he/she first observed Resident #1 in the courtyard the resident was laying on ground with his/her top half laying in the grass and his/her legs on the cement; -He/She observed the resident was bleeding from his/her left arm; -He/She knelt down to assess injuries with LPN A and ensure the resident did not close his/her eyes or attempt to get up; -He/She had been aware from shift report that the resident had gone out the window earlier in day; -On 7/20/24 he/she observed the resident's window above to be completely open and there was no screen in the window; -He/She had not observed the resident successfully exit the special care unit while working with him/her previously on the special care unit; -He/She was aware the facility had bolted all the windows in the dining room and of fifteen minute checks until the windows were secured in place after the resident had eloped through the dining room window earlier in the day. The 15 minute checks were in place until the resident was found on the ground in the courtyard. -He/She did not know what time the windows were secured, but stated it was after 5:30-6:00 P.M. that the resident went from being one on one observation to every fifteen minute checks. Review of the resident's progress notes, dated 7/21/24 at 11:03 P.M., showed Registered Nurse (RN) A wrote the resident was transported to the emergency room (ER) after he/she was found outside last night. Review of the hospital medical record, dated 7/23/24, showed: -7/20/24, Patient seen in ER with abrasions on hands and skin tear on left arm, skin tear measuring 5 centimeters (cm) with abrasion and left index finger, and mild bruising and swelling of left index finger; -He/She was admitted to hospital on [DATE] at 9:07 P.M.; -A computerized tomography scan (CT scan) showed the resident had a comminuted (a fracture that often splinters) fracture involving the L1 vertebra, comminuted fracture of the left calcaneus (heel of the left foot) and severely comminuted fracture of the anterior (front), central, posterior (back) portions of right calcaneus (heel) on the right foot. Observation on 7/23/24 at 11:51 A.M., showed: -Maintenance staff measured the base of the resident's windowsill to ground to measure 13 feet 5 inches; -The resident's room was on the second level at the back of the facility and his/her bedroom window was located at the corner of the building; -Beneath the resident's window was a paved sidewalk next to patch of grass and green metal piping that jutted out from the building. During an interview on 7/24/24 at 10:12 A.M., Maintenance said: -He/She received a call at 8:26 P.M. to come back to facility to secure the bedroom window. During an interview on 7/24/24 at 9:30 A.M., DON said: -He/She was notified of the second elopement out of his/her bedroom window by the administrator at 8:23 P.M.; -Staff on the unit assessed the other window in the bedroom and observed the window was not an issue and was not able to be opened when pushed on or attempted to turn the hand crank without the knob. The screen was in place; During an interview on 7/23/24 at 11:51 A.M., Maintenance said: -The windows in the resident's rooms did not have cranks to turn to open the windows, the cranks had been removed from all the windows prior to his/her start of employment with the facility a year ago. -The resident's bedroom window did have a screen in the window that was clipped in with clips that fasten the screen to the window frame. During an interview on 7/23/24 at 1:36 P.M., the DON said: -No windows on the special care unit had cranks to open the windows; -The window screen in Resident #1's room was secured with four clips; -Resident #1's room was at the corner of the building on the second level looking down over the courtyard and grass. During an interview on 7/23/24 at 2:31 P.M., the hospital social worker said: -The resident incurred fractures to the lumbar region and both feet. -The resident was going on hospice and was now bed bound as a result of the injuries from going out the window;. -The resident had significant change in status and was barely talking. During an interview on 7/23/24 at 2:35 P.M., the hospital physician said: -Based on Resident #1's fractures the resident's injuries would have been incurred from a jump or fall from a greater height; -The resident was at high risk for Achilles rupture and required surgery; -The resident was not able to bear weight and was currently bed bound. -Anticipate and meet resident needs; -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the 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). MO239409, MO239285, MO239283, and MO239364

Based on observation, interview, and record review, the facility failed to keep one resident (Resident #1) free from abuse when a staff member used his/her cell phone to answer a video call through Snapchat with multiple other people who he/she did not know. During the call, the staff member flipped the camera from himself/herself to the resident who stood naked in the shower room. One of the people on the call recorded this. The resident did not give consent to the video and the resident's family said the resident would be embarrassed and angry if he/she knew someone had taken a video of him/her in the shower and then proceeded to post it to a social media platform and feared that if the resident were to be notified of the video, it would be harmful to his/her mental health and the resident's anxiety and depression would increase to the point of needing hospitalization. The facility census was 57. The administrator was notified on 2/9/23 at 5:26 P.M., of an Immediate Jeopardy (IJ) which began on 2/4/23. The IJ was removed on 2/10/23 as confirmed by surveyor on-site. Review of the facility's Abuse and Neglect Policy-Prevention Program, dated April 2021, showed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone, including: facility staff. 2. Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. 4. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Review of the facility's Phones, Faxes and Mail Systems policy, dated December 2018, showed: - Cellular phones and/or wireless communication devices should be off or on silent during working hours and are not to be used, unless approved by the Administrator and then only for work purposes. - All personal phone calls and messages must be handled during breaks unless approved by the Administrator. Review of the facility's Social Media policy, dated December 2018, showed: - Social media includes all means of communicating or posting information or content of any sort on the Internet, including to an employee's own or someone else's web log/blog, journal or diary, personal web site, social networking or affinity web site, web bulletin board or chat room, whether or not associated or affiliated with the facility, as well as any other form of electronic communication. - Employees are forbidden to comment in any way or post pictures of a current or previous residents and/or potential referrals. - Social media platforms will be used only within the legal, ethical and professional boundaries established by state and federal privacy laws, professional standards and facility policy. - Improper use of email and Internet services is strictly prohibited. Examples of improper use include, but are not limited to: d. Posting or sharing any unauthorized images of the facility, residents, family or events on social media or a public forum. h. Using language or conveying information on a social media or a public forum that violates the privacy or dignity of any resident or patient, or group of residents/patients. Review of the facility's Cameras and Other Recording Devices in the Workplace policy, dated December 2018, showed: - The facility prohibits employee possession or use of cameras and audio/video recording devices in the workplace and requires that employees turn off all cameras and audio/video recording functions on any personal electronic communication device anytime they are in any organization work area. Taking pictures or making audio/video recordings at organization events or work-related activities off premises is also prohibited. - Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities. - Resident image means the likeness of a resident captured through still photography, videotaping, digital imaging, scans, audio recording, etc. - Staff may not take or release images or recordings of any resident without express written consent obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies. - Transmitting unauthorized images of any resident through email, Internet, or social media is considered a violation of resident rights. Any image or recording taken that may be construed as humiliating or demeaning to a resident or residents is considered resident abuse and will be reported and investigated as such. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 11/7/22, showed: - Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15. This score indicates no cognitive impairment. - Independent with activities of daily living (ADLs), such as dressing, eating and personal hygiene. - Requires only supervision and oversight for bathing. - No behaviors noted. - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), panic disorder (an anxiety disorder where a person regularly has sudden attacks of panic or fear), insomnia (persistent problems falling and staying asleep), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's comprehensive care plan, dated 11/9/22, showed: - Required stand by assistance in the shower, as he/she was a risk for falling. He/she was able to shower without assistance from staff. - Experiences episodes of anxiety and insomnia. Takes medication for anxiety and depression. Review of the undated video recording showed: - The video posted to Snapchat on an unknown date. It was six seconds. - At 0:00 seconds, the video starts with an image of a person wearing a yellow face mask, a pink and white shirt with REDSKINS in black letters. A shower curtain rod and shower curtain are partially visible behind this person. - At 0:03 seconds, the video then shows the resident, standing in a shower room. He/she was not wearing any clothing. - The resident was speaking in the video, but unable to determine what he/she said. During an interview on 2/8/23 at 11:15 A.M., the Social Services Designee said: - Identified the individual shown in the beginning of the Snapchat video as NA A. - Confirmed the resident shown in the Snapchat video was Resident #1. - The resident would be mortified and angry if he/she knew NA A had recorded him/her in the shower and posted to a social media platform. During an interview on 2/8/23 at 11:15 A.M., the Administrator said: - Identified the individual shown at the beginning of the Snapchat video as NA A. - Confirmed the resident shown in the Snapchat video was Resident #1. - NA A worked the day shift, 6:00 A.M. to 6:00 P.M. - The administrator said the resident would be angry and embarrassed by the video. Review of staffing sheets and schedules for 2/4/23 showed NA A worked on 2/4/23 from 6:00 A.M. to 6:00 P.M. Review of the shower sheet for 2/4/23 showed Certified Nurse Aide (CNA) B signed the shower sheet indicating he/she provided a shower to the resident on 2/4/23, not NA A. During an interview on 2/9/23 at 4:36 P.M., NA A said: - Did not know how long he/she had worked at the facility, but since at least December 2022. - He/she worked 12 hours shifts, usually 6:00 A.M. to 6:00 P.M. - He/she gave showers and assisted residents with other care, such as dressing. - He/she had worked with the resident multiple times, including assisting in the showering. - He/she assisted the resident in the shower on 2/4/23. - He/she took the video of the resident in the shower. - He/she confirmed the video was taken on 2/4/23. - He/she had his/her phone in his/her pocket and it kept ringing. The resident asked him/her to stop the phone from ringing. NA A took the phone from his/her pocket and answered it. It was as group call from Snapchat. He/she did not know how many people or the identities of the persons on the call with him/her. After answering the call, he/she realized the phone was recording the call and tried to turn it off as soon as possible. He/she did not realize the video had posted to Snapchat. - An unknown person who was also on the call recorded the video from Snapchat. - He/she did not fill out a shower sheet after assisting the resident with a shower, and asked another CNA, CNA B, to fill out the shower sheet. During an interview on 2/10/23 at 11:10 A.M., Licensed Practical Nurse (LPN) B said: - He/She worked on 2/4/23 from 6:00 A.M. to 6:00 P.M. - He/she was assigned to North Hall and NA A was assigned to [NAME] Hall. - NA A came over to North Hall a few times during the shift. - He/she knew the resident and had worked with him/her several times. The resident would be sad and embarrassed if he/she knew someone took a video of him/her in the shower then posted it to a social media platform. The resident struggled with anxiety and the knowledge of the video would cause the resident's anxiety to increase to the point he/she may need an increase of medication or hospitalization. During an interview on 2/9/23 at 11:45 A.M., LPN A said: - He/she knew the resident and had worked with him/her multiple times. - The resident would be so embarrassed to know a staff member recorded him/her in the shower then posted it to a social media platform. - The resident had a lot of anxiety. He/she would most likely not trust staff to assist him/her again if he/she knew about the NA taking the video. During an interview on 2/9/23 at 4:00 P.M., the resident's family member said: - The resident would be embarrassed and angry if he/she knew someone had taken a video of him/her in the shower and then proceeded to post it to a social media platform. - The resident had a long history of anxiety and depression. The family member feared that if the resident were to be notified of the video, it would be harmful to his/her mental health and the resident's anxiety and depression would increase to the point of needing hospitalization. - The resident had resided at the facility for six years and would no longer be able to trust the staff to assist him/her with care. During an interview on 2/10/23 at 12:50 P.M., the Administrator said: - She expected staff not have their cell phones on them while working. - She expected employees to abide by the abuse and neglect and social media policies. - Staff are not to take pictures or videos of residents and are not to post them to social media. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO213689