**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper infection control techniques were followed for five residents (Resident #27, #29, #59, #501, #502 and #503) in a sample of 23 residents. The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for Resident #27 and #29 when staff failed to appropriately sanitize the glucometer machine (machine that tests a drop of blood for the amount of sugar it contains) after use. Review showed Resident #29 had Hepatitis C (a virus that attacks the liver and leads to inflammation and is spread by contact with contaminated blood). Staff documented performing an accucheck on one resident, Resident #59, with the same glucometer that was not properly disinfected, after using it on Resident #29. The facility identified staff utilized this multi-resident use glucometer for five residents who resided on the 300 hall. Additionally, staff failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infection causing contaminants, and when indicated by professional standards of practice, during incontinence care for two residents (Resident #12 and #27). The facility census was 95. The administrator was notified on 04/04/24 at 2:55 P.M. of an Immediate Jeopardy (IJ) which began on 03/20/24. The IJ was removed on 4/5/24 as confirmed by surveyor on-site verification. Review of the facility's policy for Standard and Transmission Based Precautions from the Nursing Guidelines Manual dated 2007 showed the following: -Standard precautions would be used in the care of all residents regardless of their diagnoses or suspected and/or confirmed infection status. Standard precautions presume all blood, body fluids, secretions, and excretions, non-intact skin, and mucous membranes that may contain transmissible infectious agents; -Hand hygiene referred to handwashing with soap or using alcohol-based hand rubs that do not require access to water; -Hands should be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such, and before eating and after using the restroom; -In the absence of visible soiling of hands, alcohol-based hand rubs were preferred for hand hygiene; -Wash hands after removal of gloves; -Wear gloves when you anticipate direct contact with blood, body fluids, mucous membranes non-intact skin, and other potentially infected materials; -Wear gloves when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms; -Change gloves as necessary during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one); -Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Review of the facility's undated policy, Blood Glucometer Disinfecting, showed the following: -Purpose: to prevent the spread of infection; -Equipment: approved wipes with 10% bleach or comparable product; -Wash hands and put on gloves; -Provide a clean field in which to place the glucose meter (a paper towel worked well); -Clean the blood glucose meter prior to using with approved wipes with 10% bleach or comparable product, place on clean field and let air dry according to the manufacturer's directions. Do not touch the clean field with gloves including the test port. Glucometer may be wrapped in another wipe and stored; -Remove gloves and wash hands. Review of the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) recommendations, dated August 2010, showed the following: -Blood contamination is often evident on glucometers even if one cannot see it; -Facilities must use an EPA-registered disinfectant to clean glucometers; -Rubbing alcohol is not an effective disinfectant against Hepatitis B and should not be used; -It is important to use a glucose monitoring device designed for institutional use that can be disinfected frequently; -The manufacturer's instructions should say which cleaning solution a device can withstand; -If the manufacturer's instructions do not specify steps for cleaning and disinfecting between uses of glucose monitoring devices, the devices generally should not be shared among residents according to CMS; -Environmental surfaces such as glucometers should be decontaminated regularly and anytime contamination with blood or body fluids occurs or is suspected; -Glucometers should be assigned to individual patients. If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected. Review of the Evencare G3 blood glucose monitoring guidelines from medline.com showed the following: -Cleaning and Disinfecting Procedures: -The meter should be cleaned and disinfected between each patient; -The following products have been approved for cleaning and disinfecting the meter: Dispatch® Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8), Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10), Clorox Healthcare® Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12), Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1); -Steps to cleaning/disinfecting a meter: -Step 1. Wash hands with soap and water; -Step 2. Put on single-use medical protective gloves; -Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter; -Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port; -Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Caring for the meter: -Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry; -Step 6. Remove gloves. Review of the EvenCare G3 (glucometer) manufacturer guidelines from medline.com, testing a resident's glucose, showed the following: -Users need to adhere to standard precautions when handling or using this device; -All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. Review of a resident list, provided by the facility, showing which residents used the multi-resident use glucometer for the 300 hall, showed the list included Resident #29, #59, #501, #502, and #503. 1. Review of Resident #29's face sheet showed the following: -He/She resided on the 300 hall; -His/her diagnoses included Type 2 diabetes mellitus with hyperglycemia (elevated blood sugar (the amount of sugar in the blood)), and chronic viral Hepatitis C. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks (finger stick procedure where a droplet of blood is obtained for sampling to determine the amount of sugar in the blood) two times a day and as needed (PRN). Observation on 3/20/24 at 7:03 A.M. showed the following: -Licensed Practical Nurse (LPN) H removed a universal (multi-resident shared) blood glucose monitoring machine from the locked 300 hall medication/treatment cart and cleaned it with an alcohol wipe; -LPN H washed his/her hands and applied gloves; -LPH N placed a glucose test strip into the glucometer; -LPN H cleaned the resident's finger with an alcohol wipe and used a lancet to stick the resident's finger to obtain a blood droplet; -LPN H wiped the first drop of blood from the resident's finger and then obtained another drop of blood from the resident's finger and drew it up into the glucometer test strip to check the resident's blood sugar; -LPN H removed his/her gloves and washed his/her hands; -With his/her bare hands, LPN H cleaned the glucometer with an alcohol wipe and laid the glucometer on a tissue on top of the medication/treatment cart to dry. -LPN H did not disinfect the multi-resident shared blood glucose monitor with the proper disinfectant wipes. During an interview on 3/20/24 at 7:03 A.M. and 7:30 A.M. and 4/4/24 at 2:30 P.M., LPN H said the following: -He/She was taught to clean the multi-resident use glucometers with alcohol wipes; -He/She used this glucometer on all residents requiring blood glucose checks assigned to that cart (300 hall); -The way he/she cleaned the glucometer was how the facility instructed him/her to do so; -He/She was taught years ago to clean with alcohol wipes and that's the way he/she has always done it; -He/She could have found bleach wipes to use and didn't; -The bleach wipes were available for use; -He/She was aware Resident #29 had Hepatitis C. 2. Review of Resident #59's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks three times daily with meals. Review of the resident's electronic medical record, specifically vital sign results, showed LPN H documented he/she obtained the resident's accucheck on 3/20/24 at 7:30 A.M. 3. Review of Resident #501's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks twice daily, before breakfast and at bedtime. 4. Review of Resident #502's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for daily accuchecks. 5. Review of Resident #503's face sheet showed the following: -He/She resided on the 300 hall; -His/Her diagnoses included diabetes mellitus. Review of the resident's physician orders, dated March 2024, showed an order for accuchecks twice daily with meals. 6. Review of Resident #27's undated continuity of care document (CCD) showed his/her diagnoses included diabetes (elevated blood sugars), dementia, and urinary tract infections (UTI). He/She resided on the 400 hall. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/20/24, showed the following: -Cognition was severely impaired; -He/She was always incontinent of bowel and bladder; -He/She was dependent on staff for toileting hygiene. Review of the resident's physician's orders, dated March 2024, showed an order for accuchecks three times a day. Review of the resident's care plan, last reviewed/revised on 3/20/24, showed the following: -He/She required assistance with toileting and personal hygiene; -Provide incontinence care after each incontinent episode. Observation on 3/20/24 at 6:30 A.M. showed the Nurse Aide (NA) A and NA E entered the resident's room to assist the resident with morning cares. Without performing hand hygiene, NA D and NA E put on gloves and walked over to the resident. The resident was incontinent of bladder. NA D cleaned the resident's perineal area, assisted the resident onto his/her left side and NA E cleaned the resident's buttocks. Without changing gloves and performing hand hygiene after providing incontinence care, NA E placed a clean bed pan under the resident, rolled the resident to his/her right side and NA D removed the soiled linens from under the resident, pulled the clean bed pad under the resident, removed the resident's soiled gown, obtained a clean shirt from the resident's closet, and placed it on the resident. Without removing his/her gloves and performing hand hygiene after providing incontinence care, NA E opened the door and exited the room to discard the soiled linens to the dirty utility room. NA E returned to the resident's room with a new package of incontinence briefs. NA E did not wear gloves when he/she returned to the room. During an interview on 3/20/24 at 7:10 A.M., NA E said he/she was to wash and/or sanitize his/her hands between gloves changes, when entering a room, before exiting a room, and anytime gloves became contaminated. He/She should not touch anything clean with contaminated gloves and/or hands. Observation on 3/20/24 at 7:30 A.M. showed LPN H removed the glucometer from the treatment cart, cleaned it with an alcohol wipe, obtained the blood sample from the resident and then placed it on the strip in the glucometer, returned to the treatment cart, placed hand sanitizer on a tissue and wiped the glucometer with the tissue, removed his/her gloves, sanitized his/her hands, and finished cleaning the glucometer with an alcohol wipe. 7. Review of Resident #12's MDS, dated [DATE], showed the following: -Dependent for personal hygiene; -Always incontinent of bladder and bowel. Review of the resident's progress notes, dated 3/14/24 at 3:38 P.M., showed the resident had a new order to insert a 16 French/10 cubic centimeter (cc) urinary catheter due to wound on the coccyx (tailbone). Review of the resident's care plan, last revised 3/20/24 showed the following: -Poor mobility and incontinence; -Provide incontinence care after each incontinent episode. Observation on 3/20/24 at 8:30 A.M. showed the following: -The resident lay on his/her back in the bed; -Certified Nurse Assistant (CNA) W entered the room, donned gloves, emptied the resident's urinary drainage bag into a urinal and emptied it into the toilet; -Without removing his/her gloves, CNA W pulled the bed linens down from the resident and assisted the resident to turn onto his/her right side, touching the linens and the resident's hip with contaminated gloves; -Using a wet washcloth, he/she removed formed feces from between the resident's buttocks, threw this in the trash can nearby, and used a clean cloth to clean the resident's buttocks. He/She removed his/her gloves, and without performing hand hygiene, put on new gloves; -He/She tucked the soiled pad under the resident, placed a clean, cloth pad under the soiled pad and rolled the resident onto his/her left side; -He/She pulled the soiled linens out from under the resident, placed them in a plastic bag on the bed and pulled the clean linens through and beneath the resident; -Without removing his/her gloves, CNA W used a wet, clean cloth and wiped the large urinary catheter drainage tubing and then used the same area of the cloth to wipe the resident's groin area. With the same cloth, he/she wiped from the urinary catheter insertion site outward three times with the same area of the cloth. 8. During an interview on 3/21/24 at 7:35 A.M., 4/4/24 at 11:27 A.M., the Director of Nurses (DON) said the following: -Staff were to clean the glucometer with bleach wipes because they were a better disinfectant. Alcohol wipes were not good enough; -She would expect staff to clean the glucose monitor after each use with bleach wipes; -She was unaware of any resident having Hepatitis C or any bloodborne virus that received routine accuchecks; -The facility has one glucose monitor for each hall, so one at each nurse's station/cart; -There are approximately five to ten residents that received accuchecks on each hall; -Staff identify that a resident has a bloodborne virus by it being listed on their diagnoses list with ICD-10 codes; -She would expect the following measures to be in place if a resident has a bloodborne virus and is receiving accuchecks: gloves/proper PPE, handwashing and ideally, they would have their own glucose monitor; -Staff were to wash their hands and change their gloves when they become contaminated; -Staff were to wash hands when entering a resident's room, exiting a resident's room, and in between dirty to clean surfaces. Staff should not touch clean surfaces with contaminated gloves and/or hands; -Staff were to remove soiled gloves and wash hands after emptying a urinary drainage bag and before beginning perineal/catheter care. During an interview on 4/4/24 at 11:37 A.M., the Administrator said the following: -There were five glucose monitors in the building; -There are five residents on the 300 hall that receive accuchecks from the same multi-resident use glucose monitor (Residents #29, #59, #501, #502, and #503); -She expected the DON and nurse managers to do walking rounds to ensure staff are cleaning the glucose monitors properly; -The infection preventionist can pull a report with those residents having a diagnosis of any bloodborne virus; -She would expect staff to manage a resident with Hepatitis C and accuchecks with proper PPE including gloves and to clean the blood glucose monitor properly with bleach wipes and according to manufacturer's guidelines; -She was not aware the resident had Hepatitis C and received routine accuchecks. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents (Residents #1 and #12), in a sample of 16 residents, were free from significant medication errors. Staff failed to correctly transcribe an admission order for metoprolol tartrate (a medication used to treat high blood pressure), writing instead the order as haloperidol (an antipsychotic medication used to treat mental health disorders) for Resident #1. Staff administered the incorrect medication, haloperidol, to the resident for 97 days, with no doses of metoprolol tartrate administered. As a result of the error, the resident experienced difficulty swallowing, excessive drooling and pocketing food, lethargy (drowsiness and an unusual lack of energy and mental alertness), and slurred speech which required a hospital transfer to evaluate his/her condition. Additionally, staff failed to correctly transcribe an order for Ozempic (a medication used to treat diabetes) correctly, which resulted in Resident #12 receiving two additional doses in error when the medication was to be administered weekly and was administered daily. The facility census was 87. The administrator was notified on 4/25/23, at 4:20 P.M., of an Immediate Jeopardy (IJ), which began on 1/6/23. The IJ was removed on 4/25/23 as confirmed by the surveyor's on-site verification. On 5/1/23, at 2:23 P.M., the administrator reported via email, the facility did not have a policy for following physician orders or transcribing physician orders. Review of the facility policy, Medication Administration Guidelines, dated March 2015, showed the following: -It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; -Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician orders, giving the individual does to the proper resident, and promptly recording the information; -If there is doubt concerning the administering of medications, the physician's order must be verified before the medication is administered; - A current drug reference is available at each nurse's station. Review of the online reference Drugs.com showed the following regarding haloperidol (Haldol): -Haldol is an antipsychotic medication that is used to treat schizophrenia (a mental health disorder in which people may interpret reality abnormally and may result in some combination of hallucinations, delusions, paranoia and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling); -The average dose of this medication for oral forms for mental conditions for older adults at first is 0.5 milligrams (mg) to 2 mgs, two or three times a day; the physician may increase the dose if needed, however the dose is not usually more than 100 mgs a day; -Side effects of Haldol can include difficulty with speaking or swallowing, dizziness, and confusion and unusual tiredness or weakness. 1. Review of Resident #1's face sheet showed the following: -admission date 1/6/23 at 1:10 P.M.; -Diagnoses include paranoid schizophrenia and essential primary hypertension (high blood pressure). Review of the resident's order summary report, dated 1/5/23, from a receiving facility, showed the following medication orders: -Metoprolol Tartrate 50 mg by mouth two times a day related to essential hypertension; -No order noted for haloperidol 50 mg twice a day. Review of the resident's January 2023 physician order sheets (POS) showed an order for haloperidol 10 mg twice a day with a start date of 1/6/23 and haloperidol 20 mg, 2 tablets, twice a day with a start date of 1/6/23 for a total of haloperidol 50 mg twice a day. Review of the resident's January 2023 Medication Administration Record (MAR) showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 1/8/23 through 1/20/23. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/20/23, showed the resident was cognitively intact. Daily antipsychotic given seven of seven days during observation period. Review of the resident's pharmacy medication review, dated 1/20/23, showed based upon the information available, at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's January 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 1/21/23 through 1/22/23. Review of the resident's history and physical, dated 1/22/23 showed the following: -History/Medication List: reviewed, updated and signed in POS or computer record in nursing home electronic medical record (EMR); -Follow-up on any medical complications related to current psychiatric medications and the patient is also followed by psychiatry; -He/She will need psychiatry to continue following up since he/she is on high doses of Haldol which has been routine for him/her. Review of the resident's January 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 1/23/23 through 1/31/23. Review of the resident's February 2023 POS showed an order for haloperidol 10 mg twice a day with a start date of 1/6/23 and haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23 for a total of haloperidol 50 mg twice a day. Review of the resident's February 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 2/1/23 through 2/9/23. Review of the resident's interdisciplinary team (IDT) meeting progress note on 2/9/23 showed the resident is on a significant dose of Haldol, no overt signs or symptoms of over sedation or adverse effects. Review of the resident's February 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 2/10/23 through 2/14/23. Review of the resident's pharmacy medication review, dated 2/14/23, showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's February 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 2/15/23 through 2/28/23. Review of the resident's March 2023 POS showed an order for Haloperidol 10 mg twice a day with a start date of 1/6/23 and Haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23 for a total of Haloperidol 50 mg twice a day. Review of the resident's March 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 3/1/23 through 3/21/23. Review of the resident's pharmacy medication review, dated 3/21/23, showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's 3/21/23 physician progress note showed the following: -History/Medication list: reviewed, updated and signed in POS or computer record in nursing home EHR (electronic health record); -Resident has underlying schizophrenia, there have been no behavioral reports since he/she has been at the facility; -He/She does remain on Seroquel (quetiapine) and Haldol as well as Depakote (a medication used to treat certain psychiatric conditions). Review of the resident's March 2023 MAR showed staff documented administering Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 3/22/23 through 3/31/23. Review of the resident's April 2023 POS showed the following: -Haloperidol 10 mg twice a day with a start date of 1/6/23; -Haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23. Review of the resident's April 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 4/1/23 through 4/6/23. Review of the resident's IDT progress noted, dated 4/6/23, showed the resident is more lethargic, eating less, and spends most of the time in bed. Review of the resident's April 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 4/7/23 through 4/11/23. Review of the resident's nursing progress note, dated 4/11/23, showed the resident appeared lethargic; slow to respond. Blood pressure 87/68 (normal blood pressure range -systolic: less than 120 mm Hg diastolic: less than 80 mm Hg) and pulse was 62 (normal range between 60-100 beats per minute) beats per minute. Contacted psych for medication evaluation related to increased drowsiness and lethargy. Review of the resident's April 2023 MAR showed staff documented they administered Haldol 50 milligrams twice a day, between 6:30 A.M. to 10:00 A.M. and 3:00 P.M. to 6:00 P.M., to the resident from 4/12/23 through 4/15/23. Review of the resident's nursing progress note, dated 4/15/23, showed the following: -Medication Error Documentation; -On 4/14/2023 at approximately 10:45 P.M., the nurse received in report that the resident said he/she has been very tired and believes he/she is being over medicated. Nurse then updated another nurse it was probably the Haldol resident is on. Nurse had passed medications before on evenings and remembered the high dosage. Resident has been taking 100 mg a day since arrival. Upon investigation, nurses both found the resident never had an order for Haldol but had another order for metoprolol for the same dosage; -In the resident chart, the resident never had an order for metoprolol in which the resident should have been on. Nurses did note no order had been put in for metoprolol tartrate. The medications on the paper showed they were verified with the medical director (MD) (also the resident's physician) on the day of admission on the paperwork provided by a different nurse than the nurse putting in the Haldol order; -Nurses both noted that resident never had the order for Haldol. Nurses called the Director of Nursing (DON) and asked for advice. Nurses then saw that the resident did have a medication error and nursing has been giving this medication for three months now; -Nurses called the on call physician regarding the medication error. On call Nurse Practitioner (NP) said that was too much Haldol for an elderly person to receive every day; nursing is to monitor vital signs every shift and stop medications immediately; -Nurse asked if the facility should taper the dosage; our DON would like a tapering of the dosage; -NP said, No, the resident is not even supposed to be on that medication and there was too much psychiatric medication he/she was on anyway. Hold the medication and clarify the order as soon as the resident's physician gets in his office on Monday. Review of the resident's April 2023 POS showed the following: -Haloperidol 10 mg twice a day with a start date of 1/6/23 and a discontinue date of 4/15/23; -Haloperidol 20 mg, 2 tablets, twice a day with a start dated of 1/6/23 and a discontinue date of 4/15/23. Review of the resident's pharmacy medication review, dated 4/17/23, showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it was the pharmacist's professional judgement that at such time, the resident's medication regimen contained no new irregularities. Review of the resident's progress notes, dated 4/21/23 at 2:22 P.M., showed the nurse was informed by the speech therapist, the assistant director of nursing (ADON), as well as certified nursing assistants (CNAs) this shift, that the resident has had a major decline in condition as of today. Resident was lethargic, unable to swallow, pocketing food, has excessive saliva and is unable to hold self up in his/her wheelchair. Assessment of the resident showed he/she was not responding well and was lethargic. Message left with the group providing medical services for the facility. Review of the resident's progress note, dated 4/21/23 at 4:09 P.M., showed the resident's physician was made aware of the medication error this shift. After giving an update on the resident's current well-being, the physician sent the resident to the emergency room for evaluation and treatment related to his/her change in condition. Resident has been slurring words more than normal. Resident having trouble with swallowing saliva and even voiced difficulties. Resident was noticed pocketing lunch this shift. Review of the resident's hospital emergency room notes shows the resident presented with slurred speech and weakness. Review of the resident's progress note, dated 4/23/23 at 1:06 A.M., showed the resident remains in a trance state this shift. Resident will look at staff members and tried to mumble words. Resident was seen by emergency room (ER) staff yesterday. This is not the resident's normal. Resident is able to talk clearly. Resident is now declining. Resident has not been asleep so far this shift. Nursing noted his/her blood pressure (BP) being 106/68, CNAs have been updating nurse worrying about the resident. Physician is made aware. Psychiatric NP was here this morning and said if the resident continues getting worse, she will call the physician and ask for another hospital evaluation. Review of the resident's progress note, date 4/23/23 at 7:18 A.M., showed nurse giving report and nurses went to check on resident. Resident is now alert and oriented to self. Resident still tries to talk to staff but only comes in mumbles. Resident will be closely monitored at this time. Nurse contacted resident's physician regarding resident and condition. Resident has a new order for Haldol 10 mg twice a day for five days and then decrease to Haldol to 10 mg daily. Review of the resident's April 2023 POS showed the following: -Haloperidol 10 mg twice a day from 4/23/23 through 4/27/23; -Haloperidol 10 mg daily with a start date of 4/28/23. During an interview on 4/25/23, at 12:06 P.M., the resident said the following: -Staff gave him/her quite a bit of Haldol but he/she doesn't remember for how long; -The Haldol was discontinued after staff found out he/she was taking too much of it; -He/She does not think he/she has taken Haldol in the past; -Quite a few of the nurses gave him/her the wrong medication, he/she thinks it was given for about three months or so; -He/She was feeling better now and was not as sleepy since not taking the Haldol. During an interview on 4/25/23, at 1:07 P.M., Licensed Practical Nurse (LPN) E said the following: -The resident was noted to have excessive saliva and was pocketing food, head leaning to the side that was not his/her normal baseline and was not remembering specific dates; -He/She was aware of a medication error related to the resident receiving Haldol that he/she was not supposed to ever get; -He/She had not seen a Haldol dose of 50 mg and does not specifically remember seeing the Haldol order; -He/She would notify a physician if he/she had a question about a medication, but did not question the Haldol order for the resident. During an interview on 4/25/23, at 1:16 P.M. and 1:45 P.M., LPN D said the following: -The resident was noted to be very lethargic and was sent to the emergency room due to a change in condition at the change of shift on April 15th; -The resident had a transcription error that resulted in a medication error for Haldol; -He/She was unsure how the error happened; -He/She did notice the resident had a high dose of Haldol and reported it to the Director of Nurses (DON) but he/she wasn't sure when he/she had reported it; -He/She did admit the resident and verified the orders against pending orders; -He/She did not feel comfortable putting the Haldol order in and told the DON; -He/She called the nurse practitioner with psychiatry to verify the medication and was told the resident was not his/her patient and to fax the face sheet and Continuity of Care (CCD) document to psychiatry; -The CCD and face sheet was faxed to psychiatry; -He/She did not feel comfortable about the Haldol order from day one but did not approach the DON again. During an interview on 4/25/23, at 1:35 P.M., LPN A said the following: -When a resident is admitted to the facility, after hospitalization or new admission, orders are compared and put into the computer as pending; -The admitting nurse will check the pending orders for comparison, activate and send to the pharmacy; -He/She put in the pending orders for the resident; -New admission medication should be checked by two nurses; -He/She made a transcription error and entered Haloperidol 50 mg twice a day and it should have been metoprolol tartrate 50 mg twice a day; -He/She put the orders in the computer; -He/She was not sure who the admitting nurse was; -A normal dose of Haldol is a lot lower, more like 5 mg, it triggered in his/her mind to verify the order but he/she did not go back and check the order; -There should have been a Registered Nurse (RN) that did an audit of the orders and should have caught the error; -He/She was not sure if the audit was done; -There are a whole lot of fail safes or double checks that are supposed to be put in place to prevent errors, like two nurses checking the admission medications, an RN audit, physician reviews and pharmacy reviews; they all failed. During an interview on 4/25/23, at 5:22 P.M., LPN H said the following: -He/She was the second nurse the day the resident was admitted ; -He/She did not recall doing any of the orders and did not send anything to pharmacy; -He/She did not recall any specifics about the resident's Haldol order. During an interview on 4/26/23, at 9:58 A.M., LPN I said the following: -He/She was made aware that the resident was more lethargic during report on 4/14/23; -He/She, along with Registered Nurse (RN) K, investigated the resident's medications and noted there was not supposed to be an order for Haldol, but should have been Metoprolol. During an interview on 4/25/23, at 6:05 P.M., RN K said the following: -Haldol dosage is usually less than 10 mg; -On 4/15/23 he/she first noticed the Haldol dose for the resident being a large dose; -He/She, along with LPN I, investigated the resident's medication orders and found a medication error for the resident's Haldol. During interview on 4/26/23, at 11:23 A.M., RN F said the following: -He/She was made aware of the Haldol error for the resident on 4/25/23; -A typical dose of Haldol should be 20-30 mg twice a day and feels like 50 mg twice a day would be a large dose; if he/she found that order, he/she would question it with the DON. During interview on 4/26/23, at 10:39 A.M., the Quality Assurance Nurse said the following: -The IDT (interdisciplinary team) progress notes for 2/6/23 identified the resident was on a significant does of Haldol; -She did not notify the physician due to the fact the resident was exhibiting paranoid symptoms and was not showing adverse effects from the Haldol dose; -The dose appeared reasonable to her due to the residents' behavior; -For some residents 100 mg a day of Haldol is a normal dose; -She knew that ultimately the physician did not have any concerns with the dose due to the physician not changing anything with the medications; -She had not talked to the physician about the Haldol orders. During interview on 4/25/23, at 4:34 P.M., the consultant pharmacist said the following: -She completed the resident's pharmacy reviews in January, February, March and the last review of the resident's medications was on 4/17/23; that would have included the Haldol order; -She had not asked for a gradual dose reduction yet due to the resident being a new resident; -Haldol 50 mg twice a day is considered a high dose, but not over the maximum dose allowed. 2. Review of Resident #12's Continuity of Care (CCD) document showed a diagnosis of diabetes (a medical condition with too much sugar in the blood system). Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderately impaired cognition. Review of the resident's April 2023 POS showed an order for Ozempic (a once-weekly injection given to residents with type 2 diabetes) 0.25 mg subcutaneous injection daily with an order start date of 4/20/23. Review of the resident's April 2023 MAR showed staff documented administering the following: -On 4/22/23, 6:30 A.M., Ozempic 0.25 mg by RN F; -On 4/23/23, 6:30 A.M., Ozempic 0.25 mg by LPN J; -On 4/24/23, 6:30 A.M., Ozempic 0.25 mg by LPN J. Review of the resident's April 2023 POS showed the following: -Ozempic 0.25 mg subcutaneous injection daily with an order start date of 4/20/23 and a discontinue date of 4/25/23; -Ozempic 0.25 mg subcutaneous injection weekly on Monday with an order start date of 4/25/23. During an interview on 4/26/23 at 12:00 P.M., the resident said the following: -He/She was started on a new medication for diabetes; -He/She thinks the medication is Ozempic; -He/She got a shot two mornings in a row by LPN J. During an interview on 4/26/23, at 12:10 P.M., LPN A said the following: -He/She took the Ozempic order off for the resident and marked the weekly administration; -He/She must have hit a wrong button and the weekly order did not get saved; -He/She made a mistake. During an interview on 4/26/23, at 2:00 P.M., LPN J said the following: -He/She recalls giving the resident Ozempic on 4/23/23 and 4/24/23; -He/She had seen Ozempic orders for daily and weekly dosing so he/she did not question the order; -He/She thinks Ozempic was generally given weekly and he/she should have questioned the order. During an interview on 4/26/23, at 11:23 A.M., RN F said the following: -A few days ago he/she found a transcription error for the resident, where Ozempic was entered daily and should have been weekly; -He/She did not make the DON aware of the error and should have; he/she just corrected it. 3. During an interview on 4/26/23, at 12:50 P.M., the medical director/physician for Resident #1 and Resident #12 said the following: -He was aware of the medication errors for both residents; -He felt like the Haldol dose for Resident #1 was being monitored by psychiatry and was aware the dose was a high dose; -He felt like the high dose of Haldol should have been addressed by nursing, pharmacy, psychiatry and himself but it was not; -He was aware Resident #1 had a slight urinary tract infection (UTI) that was diagnosed at the resident's recent emergency room visit; -He felt the symptoms Resident #1 exhibited when he sent the resident to the emergency room were related to his/her increased dose of Haldol and could potentially been a little bit of both, the UTI and Haldol; -Resident #12 did receive two extra doses of Ozempic, but the dose was small enough to not cause negative side effects; -He would expect physician orders to be followed as written. During an interview on 4/26/23, at 11:15 A.M. and 2:04 P.M., the DON said the following: -A transcription error resulted in Resident #1 receiving Haldol 50 mg twice a day since 1/6/23; -Resident #1 was supposed to receive metoprolol tartrate 50 mg twice a day and was transcribed as haloperidol 50 mg twice a day; -She was not made aware of staff concerns related to haloperidol for Resident #1; -Haloperidol 50 mg twice a day was a big dose; -Long Term Psych Management (LTPM) was sent an email regarding the resident's Haldol dose on 4/6/23, related to lethargy and eating less, with no response to the email, but LTPM came in on 4/20/23; -She was made aware of another transcription error that resulted in a medication error for Resident #12's Ozempic order; -She was not sure how the transcription errors occurred, there are fail safes put in place between nursing, pharmacy, physician, nurse practitioner and herself; -The fail safes failed with Resident #1 and Resident #12. During an interview on 4/25/23 at 2:17 P.M., and 4/26/23 at 1:30 P.M., the administrator said the following: -He was made aware of the medication error for Resident #1, and that it had something to do with Haldol; -The Haldol order was too high or not supposed to be given at all; -He was aware the resident was sent to the emergency room after being lethargic and has recovered since the medication had been removed; -He would have expected the pharmacist to catch the error; -He was made aware of an additional medication error for Resident #12 that was discovered on 4/26/23 when an order was put in the computer incorrectly. 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 violations(s).

Based on interview and record review, the facility failed to provide one resident (Resident #1), who had diagnosis of schizophrenia (mental illness) and a history of elopement and exit seeking behaviors from the facility, with sufficient supervision and monitoring to ensure the resident did not leave the facility grounds without staff knowledge. Staff said they last saw the resident on 12/2/22 at approximately 9:45 P.M. in the resident smoking area outside the facility. Housekeeper A, who was responsible to supervise the residents' smoke break, did not ensure the resident returned inside the facility on 12/2/22 after the 9:30 P.M. scheduled smoke time. The resident said he/she walked away from the facility on 12/2/22 during the 9:30 P.M. smoke break. Facility staff identified the resident was missing on 12/2/22 at approximately 10:30 P.M. Staff contacted the police who located the resident on 12/2/22 at approximately 11:30 P.M. walking down a busy four lane divided highway. The facility census was 92. The administrator was notified of the Immediate Jeopardy (IJ) on 12/12/22 at 3:46 P.M. which began on 12/2/22. The IJ was removed on 12/13/22 as confirmed by surveyor onsite verification. Review of the facility's undated Smoking Policy showed the following: -Residents are supervised at all times when smoking; -An enclosed courtyard is available for residents to smoke during good weather. A staff person will supervise them; -Smoking times were 8:30 A.M. supervised by housekeeping staff, 11:00 A.M. supervised by activity staff, 1:30 P.M. supervised by dietary staff, 3:30 P.M. supervised by nursing staff, 7:00 P.M. supervised by the floor technician, and 10:00 P.M. supervised by night shift laundry staff. 1. Review of Resident #1's face sheet showed the following: -Original admission date of 7/28/22; -Diagnoses included anxiety, seizures, altered mental status, schizophrenia, major depressive disorder, and stroke. Review of the resident's care plan, dated 8/20/22, showed the following: -The resident had impaired decision making related to schizophrenia; -Calm the resident if signs of distress develop during the decision making process; -Determine if decisions made by the resident endanger the resident or others; -Encourage the resident to verbalize feelings, concerns, and fears, and clarify misconceptions; -Give objective feedback when inappropriate decisions are made; -Set expectations and limits; -Support and reassure the resident in new situations; -The resident was a supervised smoker. He/She would smoke in a safe environment with supervision. Review of the resident's care plan, updated 10/11/22, showed the following: -On 10/11/22 at 1:23 A.M. the Certified Nurse Aide (CNA) alerted the nurse the resident was not on the special care unit and the exit door at the end of the hall was alarming; -The facility contacted the police who assisted in searching for the resident; -On 10/11/22 the resident was located at the church next to the facility; -Assess the resident for signs of restlessness, anger, or distress, and report to the physician; -The resident would reside on the secured unit with monitoring of whereabouts; -Possible evaluation for discharge to a more appropriate and secure environment. Review of the resident's smoking assessment, dated 10/30/22, showed the resident required supervision from staff while smoking. Review of the resident's Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 11/10/22, showed the following: -Diagnoses included non-traumatic brain dysfunction, stroke, seizure disorder, and schizophrenia; -Cognition was intact; -Independent with activities of daily living. Review of the resident's elopement risk assessment, dated 11/22/22, showed the resident was at high risk for elopement. Review of the facility's undated investigation showed the following: -Elopement 12/2/22; -The resident managed to escape the facility and was found by police walking down the road; -Staff realized the resident was missing right after change of shift (2nd to 3rd shift) and they started elopement procedures; -The resident was last seen during resident supervised smoking (approximately 9:45 P.M.) by Housekeeper A; -Housekeeper A did not recall seeing the resident after smoking due to another resident causing a disturbance during the break; -Summary: During or after resident supervised smoking, the resident managed to get away from supervision unnoticed. The resident claims to have left during smoking time. Review of a written statement from Housekeeper A, obtained by the facility, dated 12/6/22 at 9:30 P.M. showed the following: -Housekeeper A took the smokers out for smoke break; -Housekeeper A did not remember if Resident #1 came back inside. During an interview on 12/12/22 at 1:35 P.M. Housekeeper A said he/she took residents out to smoke like he/she usually did on 12/2/22 around 9:30 P.M. There were about seven or eight residents, including Resident #1, outside during the smoke break. Housekeeper A had to assist some of the residents in wheelchairs over the threshold of the door and then pass out cigarettes and ensure residents who needed smoking vests had them on. Housekeeper A also had to assist residents back into the facility as they finished smoking. Resident #1 would have had plenty of time to walk off undetected while Housekeeper A was assisting others. Housekeeper A was not aware Resident #1 was at risk for elopement. Housekeeper A did not recall Resident #1 coming back inside after the smoke break. Housekeeper A said he/she should have double checked, but got busy with something else and forgot. Typically, Housekeeper A would watch the residents walk back to the unit and let themselves in through the unit doors which did not require a code. Review of a written statement from CNA B, obtained by the facility and dated 12/8/22 at 3:44 P.M., showed the following: -Around 9:30 P.M., Housekeeper A came back (to the special care unit) to clean and took Resident #1 out to smoke; -CNA B assisted Resident #1's roommate at approximately 10:15 P.M. While assisting the roommate, CNA B heard the toilet and figured Resident #1 was in the bathroom. CNA B did not open the bathroom door due to privacy; -CNA B gave report to the oncoming aide and left. During an interview on 12/12/22 at 3:00 P.M. CNA B said he/she saw Housekeeper A take Resident #1 off the unit to go out and smoke about 9:45 P.M. CNA B never saw the resident come back to the unit. CNA B assisted the resident's roommate about 10:15 P.M. and could hear the toilet running and assumed Resident #1 was in the bathroom. CNA B did not open the door to the bathroom to verify the resident was in the bathroom. CNA C arrived about 10:20 P.M. CNA B gave report and left. CNA B got a call about 11:00 P.M. from staff saying the resident was missing. The last time CNA B saw the resident was when Housekeeper A had taken him/her outside to smoke at 9:45 P.M. CNA B said he/she should have gone back to check to ensure Resident #1 was actually back on the unit, but didn't. CNA B felt there should be better communication between the aides and the staff who supervise the smokers when they take residents off the unit and when they bring them back. It would be nice to know when the residents leave the unit and when they come back because the staff on the unit don't always see this happen if they are in a room with another resident. During an interview on 12/12/22 at 1:30 P.M. CNA C said he/she arrived at the facility around 10:20 P.M. on 12/2/22. The evening shift aides told CNA C they had just done rounds and everything was fine. CNA C noticed Resident #1's room door was open, which was unusual, about 10:30 P.M. CNA C looked and did not see the resident in his/her room or anywhere else on the unit. CNA C alerted the charge nurse who looked for the resident off the unit and did not find him/her. The charge nurse contacted the off going aide staff to find out when they had last seen the resident and contacted the police. The police located the resident and returned him/her to the facility around 11:40 P.M. The resident told CNA C he/she walked off during the smoke break. The resident was calm at that time, but it appeared he/she had been crying. During an interview on 12/12/22 at 3:45 P.M. Registered Nurse (RN) D said Resident #1 went out for a smoke break on 12/2/22 around 9:30 P.M. After shift change, CNA C reported the resident was missing. RN D notified the administrator and Director of Nursing (DON) and called 911. The police located the resident walking down the highway. It was typically housekeeping and dietary staff that took the residents to smoke. RN D said all residents who required supervision for smoking should be monitored closely, regardless of their elopement risk, during smoke times to ensure everyone who goes outside comes back in to the facility. During an interview on 12/12/22 at 1:18 P.M. the resident said he/she walked away during the smoke break. The resident did not want to be in this facility or any facility. Housekeeper A was outside with the resident during the smoke break and must not have seen him/her walk off. The resident said he/she walked down to the highway, but did not remember how far he/she walked. The police picked the resident up and returned him/her to the facility. The resident said he/she did not have a plan in place when he/she left. The resident just wanted to get away from the facility. During an interview on 12/27/22 at 3:30 P.M. police department staff said the call log showed officers picked up the resident on 12/2/22 who was walking north bound along the highway approximately a half mile away from the facility. Review of www.wunderground.com showed the weather on 12/2/22 at 11:00 P.M. in the town the facility is located the temperature was 56 degrees Fahrenheit and there was no precipitation. The sun set at 5:11 P.M. The sky was overcast with low visibility. Observation on 12/12/22 at 4:30 P.M. showed the highway where the resident was located was a high traffic, four lane, divided highway. The speed limit was 60 miles per hour. There was a grassy slope with a slight decline that led to the highway, approximately an eighth of a mile from the facility. Observation on 12/12/22 at 1:50 P.M. showed dietary staff E was outside with residents during the scheduled smoke times. During an interview on 12/12/22 at 1:50 P.M. dietary staff E said he/she was not aware of which residents were at risk for elopement. During an interview on 12/12/22 at 3:40 P.M. the DON said anyone from the special care unit should be considered at risk for elopement. The DON expected staff who took residents off the unit to escort them back to the unit and they should also communicate with staff on the unit when leaving with residents and upon returning them to the unit. The DON expected staff to lay eyes on the residents during rounds to ensure there whereabouts. It was most likely that Resident #1 walked off during the smoke break undetected by staff. Police did locate the resident walking down the highway and returned him/her to the facility. During an interview on 12/12/22 at 12:40 P.M. and 3:10 P.M. the administrator said the resident went out for smoke break on 12/2/22 at 9:30 P.M. with Housekeeper A. There was another resident causing a disturbance about wanting to be an unsupervised smoker. Resident #1 said he/she snuck away during the smoke break. Staff realized the resident was missing at shift change between second and third shifts (10:30 P.M.). Staff contacted the police who found the resident walking along the highway, and returned the resident to the facility before midnight. Housekeeping and dietary staff usually supervised the resident's smoking as not to pull nursing staff away from their duties. The administrator expected any staff supervising residents' smoking to monitor them closely and ensure the residents come back inside the facility. The administrator figured everyone knew Resident #1 was at risk for elopement because of his/her history of elopement. The administrator expected Housekeeper A to ensure Resident #1 came back inside and expected Housekeeper A to walk with the resident back to the special care unit. The administrator said staff who supervise smoking should communicate with the staff working on the special care unit when they take residents off the unit and when they bring them back. Staff should also visually see residents when conducting rounds. 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 to be taken to address Class I violation(s). MO210789

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #51's admission MDS, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Cognitively intact; -Delusions (misconceptions or beliefs that are firmly held, contrary to reality); -Verbal behavioral symptoms directed towards others two to four days out of seven; -Independent with mobility. Review of the resident's Physician Orders Sheet, dated 9/14/19, showed the physician prescribed Provera (a hormone used for sexual behaviors) 5 milligram (mg) three times a day for sexual dysfunction not due to a substance or known physiological condition. Review of the resident's care plan, dated 9/27/19, showed the following: -Resident has impaired decision making and low cognitive score; -Goal: the resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed; -Calm the resident if signs of distress develop during the decision-making process (feeling overwhelmed, fatigue, agitation, restlessness, withdrawal); -Determine if decisions made by the resident endanger him/herself or others. Intervene if necessary; -Clarify misconceptions; -Give objective feedback when inappropriate decisions are made; -Discuss future options to improve decision making skills; -Respect resident's rights to make decision(s). Review of Resident #51's nurses notes, dated 10/01/19, showed staff documented the resident is in the dining room sitting with another resident. Resident was seen by this nurse putting his/her hands near the other resident's genitalia. Staff intervened, redirected the resident to his/her room and informed resident that it was inappropriate to do that in the dining room. Social Services notified. Review of the resident's Social Services note, dated 10/08/19, showed staff documented a police detective called and informed this social worker that charges were pressed against the resident regarding inappropriate touching. Needed to make sure resident was here in case anything came of it. Said he would keep us informed of all changes in the case. Review of the resident's nurses notes, dated 10/28/19, showed staff documented a staff member observed inappropriate behavior with another resident in the dining room. Review of the resident's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions; -Verbal behaviors directed towards others three to six days out of seven. Review of the resident's nurses notes, dated 12/04/19, showed staff documented the resident was noted to be seen by staff members having his/her genitalia touched by another resident in the hallway. Educated both residents on finding a private area in one of their rooms to perform sexual acts. Redirected easily. Both residents alert, consenting. Review of the resident's POS, dated 1/16/20, showed the physician increased the resident's Provera to 25 mg once a day. Review of the resident's POS, dated 1/30/20, showed the physician increased the resident's Provera to 30 mg once a day. Review of the resident's nurses notes, dated 3/07/20, showed staff documented the resident was in hallway by the smoking area while another resident touched his/her genitalia. Both residents were consenting, but in a public area. Redirected. Review of the resident's care plan, last revised 5/14/20, showed the resident has behaviors of yelling, cursing, acting like may kick, hit, refusing personal hygiene needs, and use of Provera for sexually inappropriate behaviors. Restrict access to potentially harmful items (e.g., glass, scissors, needles, razors, lighters, knives, medications). The care plan did not define any further direction for sexual behaviors, or sexual relationships for the resident. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Behavior of inattention, comes and goes; -Physical, verbal, and other behaviors towards others one to three days out of seven. Review of the resident's POS, dated 7/24/20, showed the physician decreased the resident's Provera to 20 mg once a day. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Behavior inattention, comes and goes; -Physical, verbal, and other behaviors towards others one to three days out of seven. Review of the resident's nurses notes, dated 8/26/20, showed staff documented the resident was in the television room touching another resident. It was unclear what body part he/she was touching, redirected the resident to the dining room. The resident said he/she was poking the other resident's arm. Review of the resident's nurses notes, dated 8/26/20, showed staff documented the resident has to be redirected multiple times during the meal. The resident was attempting to touch other residents. 4. Review of Resident #109's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions. Review of the resident's nurses notes, dated 10/28/19, showed the resident put his/her hands down another resident's pants while in the dining room. Both residents consented and agreeable. Review of the resident's nurses notes, dated 12/4/19 showed the resident put his/her hands down another resident's pants while in the hallway. Both residents are alert, consenting adults. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions. Review of the resident's nurses notes, dated 3/7/20 showed the resident put his/her hands down another resident's pants while in the hallway. Both residents are alert, consenting adults. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Delusions. Review of the resident's Care Plan, last revised on 7/3/20, showed the following: -Uses psychotropics for: anxiety and depression. -Followed by a psychiatric counseling service. During an interview on 10/19/20, at 9:59 A.M., Social Services (SS) P said Resident #51 and Resident #109 were in a relationship. He/She thought the residents' were consensual with the relationship. He/She did not report their relationship to the administrator or DON. He/She did not know if the residents were able to consent for sure, but he/she thought they were. He/She was contacted by the sheriff's office and Resident #51 did have charges pressed for inappropriate touching at another facility. During an interview on 10/19/20 at 10:50 A.M., LPN R said Resident #51 had a consensual relationship with Resident #109. He/She said that the incident he/she charted on 12/4/19, and 3/7/20 involved Resident #109 performing tactile sexual acts on Resident #51 in the hallway, in front of other residents. He/She did not know of any other sexual behavior for either resident with any other resident. He/She did not know if a physician deemed the residents competent to make decisions about a sexual relationship. He/She did not report the sexual actions to the administrator, Social Services or the DON. During an interview on 10/19/20 at 11:28 A.M., LPN K said on the 10/1/20 nursing note Resident #51 was touching Resident #109's genitalia, and he/she was told both the residents were consenting adults. During an interview on 10/21/20, the resident's family member said the resident would have been embarrassed if he/she was doing sexual acts in public. When the resident was in his/her right mind, he/she would have never done anything like that in public, he/she was mild mannered, kind and shy. He/She may want companionship, but not sexual behavior for all to see. 5. During an interview on 10/19/20 at 11:28 A.M., LPN K said on 8/26/20, Resident # 51 was touching Resident #45's chest. He/She said he/she could not see exactly the point of contact from the angle he/she was at, but it looked like he/she was touching Resident #45's breast. Resident #51 denied touching Resident #45's breast and said he/she was poking Resident #45's arm, but Resident #51 was not poking Resident #45's arm. At lunch, the same day, Resident #51 was going up to residents of the opposite sex in the dining room, and reached to touch Resident #33 and Resident #70 between their legs, in their groin areas in a sexual way. He/She stopped Resident #51. He/She does not work on Resident #51's hall, but he/she knows to keep an eye on him/her in the dining room and living room area. He/She said Residents #33, #45, and #70 were not able to give consent for sexual contact, they were all unable to make decisions. During an interview on 10/24/20 at 12:24 P.M., Social Services staff Q said he/she did not know of Resident #51 engaging in any sexual, or sexually inappropriate behavior. He/She did not know the resident had charges against him/her regarding inappropriate touching. He/She did not know any of these incidents occurred including incidents on 10/1/19, 10/28/20, 12/4/19, 3/7/20, 8/26/20 in the living room or the dining room. He/She would have contacted all the families, checked to see if the residents were able to consent, if the residents who could, did consent, or if it is a possible sexual abuse. Any time there was a sexual situation, the process should be followed to ensure both parties were able to consent to ensure abuse did not occur. During an interview on 10/19/20 at 10:10 A.M. and 11:39 A.M., the DON said she did not know about any resident to resident sexual alleged incidents involving Resident #51. She had not investigated any reports with Resident #51 being sexually inappropriate with any residents and he/she did not know any of these incidents occurred. She said if it was reported she would have had Social Services look into if the residents were able to consent and talked to their physicians and families. She did not know Resident #51 had charges pressed at a previous facility for sexually touching another resident. Review of Resident #45's Care plan, last updated 6/20/20, showed the following: -Progressed Alzheimer's dementia with hallucinations, delusions, with anxiety and occasional aggressive behaviors; -Difficulty focusing attention and communicating discomforts and needs related to Alzheimer's disease; -Yells out in German/English, wandering, disruptive sounds, cursing, hitting, kicking, biting, throwing body waste, inappropriate urination, etc.; -Rejecting of care at times; -Receives psychotropic medications; -Provide a quiet, well-lit, calm environment; -Surround the resident with familiar objects. Review of the resident's quarterly MDS, dated [DATE], showed: -Diagnosis of Alzheimer's disease; -Severe cognitive impairment; -Dependent on staff for bed mobility, transfers, and locomotion on the unit; -Uses a wheelchair. Review of the resident's medical record did not show any documentation about an alleged incident on 8/26/20. During an interview on 11/10/20, at 8:45 A.M., the resident's guardian said the resident would have been very angry if someone touched his/her chest or anywhere on his/her body. He/She did not like people to touch him/her without his/her permission. He/She said the facility did not notify him/her, but he/she expects them to always notify him/her so that he/she can make sure the resident is alright. 6. Review of Resident #70's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnosis of Alzheimer's; -Limited physical assistance of one staff member for bed mobility and locomotion; -Extensive physical assistance of one staff member for transfers. Review of the resident's care plan, last updated 8/20/20, showed the following: -Cognitive decline related to a stroke; -Resident has a court appointed guardian. Review of the resident's medical record did not show any documentation about an alleged incident on 8/26/20. During an interview on 10/21/20, the resident's guardian said he/she was not notified of an incident on 8/26/20 that another resident attempted to touch the resident. 7. Review of Resident #40's (undated) care plan, showed on 5/19/18, the facility identified staff was to engage the resident in conversation that was meaningful to the resident. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Adequate hearing; -Makes self understood; -Understands others; -Cognitively intact; -No issues with memory recall; -No documented behaviors; -Required extensive assistance of one staff for bed mobility; -Required total dependence of two staff for transfers; -Functional limitation in range of motion in the lower extremities; impairment on both sides; -Diagnoses included paraplegic, depression and manic depression. During interview on 10/11/20 at 4:45 P.M., the resident said the following: -CMT U came into his/her room on 10/8/20 around 8:00 P.M. to 9:00 P.M. and was yelling at him/her about talking about him/her and causing rumors; -CMT U was saying things that were not true; -CMT U looked mean and mad; -The incident with CMT U made him/her mad and scared at the same time; -He/She was fearful of CMT U; -While standing close to his/her bed, CMT U reached his/her arm out, pointing and acted like he/she was going to strike out and hit or slap him/her; -CMT U was forceful with his/her hand motion; -He/She was scared, because he/she could not defend him/herself; -LPN V protected him/her from CMT U the evening of 10/8/20; LPN V blocked CMT U's arm with his/her arm; -LPN V told CMT U to leave the room and stop yelling and arguing with him/her several times before CMT U finally left the room; -LPN V sent CMT U home after the incident. Review of the resident's written statement, obtained by the facility, dated 10/11/20 (no time) showed the following: -The evening of 10/8/20, around 8:30 - 9:00 P.M., CMT U came into his/her room and was yelling at him/her, because other staff told him/her he/she was bad mouthing CMT U; -LPN V was in the room when this happened; -LPN V and CMT U were standing at the end of his/her roommate's bed; (the foot of the roommate's bed was observed to be near the head of the resident's bed); -LPN V was trying to turn CMT U to leave the room and CMT U brushed LPN V off and came closer to him/her; -CMT U was talking fast and loud; -CMT U was flailing his/her hands around. During interview on 10/11/20 at 4:32 P.M., LPN V said the following: -On 10/8/20, he/she was the charge nurse and CMT U was assigned to work Resident #40's hall; -Resident #40 had voiced a concern to him/her that CMT U had not cared for his/her roommate properly; -He/She called CMT U to the resident's room to check on Resident #40's roommate; -While in the resident room, CMT U was yelling, saying Resident #40 was a nosey person and always on everyone's case; -At some point, CMT U raised his/her hand/arm and stretched it out, pointing in Resident #40's direction; -He/She could recall blocking CMT U's arm with his/her arm, or got hold of it, and was telling CMT U to leave the room; -He/She had tried to get CMT U to leave the room verbally multiple times because CMT U was yelling and being inappropriate; -CMT U was calling the resident a liar, saying he/she needed to mind his/her own business and stay out of his/hers and other residents' business; he/she was sick and tired of Resident #40 reporting him/her for stuff he/she had not done; -He/She considered CMT U's behavior to be verbally abusive; -Resident #40 seemed shook up about the incident and thanked him/her for protecting him/her and making CMT U leave the room and said he/she did not want CMT U to ever be in his/her room again. Review of LPN V's written statement, obtained by DHSS, dated 10/12/20, showed the following: -On 10/8/20, he/she was the charge nurse on evening shift and CMT U was the aide for the 100 hall (the hall Resident #40 resided on); -He/She and CMT U were in Resident #40's room when CMT U and Resident #40 were yelling at each other. During interview on 10/13/20 at 12:00 P.M., CMT U said the following: -He/She worked the evening of 10/8/20 on the 100 hall; -That night there was a situation between him/her and Resident #40; -Resident #40 had accused him/her of not taking care of his/her roommate; -That made him/her mad, because he/she had taken care of the roommate; -Resident #40 was bossy and always in everyone's business; -Resident #40 makes up lies about him/her and needs to be kicked out of the facility; -He/She did not need to put up with that; -Resident #40 was yelling at him/her and accusing him/her of not doing his/her job; -That was the last straw; he/she got mad; -LPN V did tell him/her to leave Resident #40's room several times before he/she actually did; -Resident #40 tells lies. During interview on 10/11/20 at 4:00 P.M., Registered Nurse (RN) AA said the following: -He/She had worked with CMT U before; -Safety of the residents in his/her care was concerning. During interview on 11/6/20 at 1:42 P.M., the administrator said the following: -From the information he received, through speaking with Resident #40 and CMT U, he felt like CMT U's behavior was inappropriate; -CMT U was out of line to go into Resident #40's room and argue with him/her about anything and act (flailing his/her arms) like he/she did. MO#00173897, MO#00176562 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy K level. 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 an E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Based on observation, interview and record review, the facility failed to ensure one resident (Resident #33) of 27 sampled residents was free from sexual abuse when resident (Resident #92) sexually abused the resident on three known occasions. The facility also failed to implement measures to ensure facility staff were educated and able to identify sexual abuse, and prevent additional sexual abuse from occurring. As a result one additional resident (Resident #51) sexually abused four residents (Resident #33, #70, #45 and #109) when facility staff witnessed the resident attempting to grope all four residents' genital areas and Resident #51 participated in a sexual act with Resident #109 in the hallway. The facility failed to assess both residents' competence and ability to consent to sexual activity. Further review showed Certified Medication Technician (CMT) U intimidated by yelling, making belittling and demeaning remarks, and gesturing in a threatening manner one resident (Resident #40), within his/her hearing distance. CMT U's behaviors and comments made Resident #40 mad, scared and fearful of CMT U. The facility census was 111. The administrator was notified on 10/21/20 at 4:53 P.M. of an Immediate Jeopardy (IJ) which began on 10/21/20. The IJ was removed on 10/27/20, as confirmed by surveyor onsite verification. Review of the undated facility policy, titled Abuse Prohibition Protocol Manual showed the following: -It was the policy of the facility that each resident would be free from abuse. Abuse could include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. Additionally, resident would be protected from abuse, neglect and harm while they were residing at the facility. No abuse or harm of any type would be tolerated and residents and staff would be monitored for protection. The facility would strive to educate staff and other applicable individuals in techniques to protect all parties; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; -Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Examples of mental abuse include but are not limited to: demeaning remarks; - Accused residents would be isolated and monitored; -Allegations involving a sexual event (even if the event that caused the reasonable suspicion did not result in serious bodily injury), must be considered as serious bodily injury and reported to law enforcement agency and the State Survey Agency- Immediately. All precautions would be put in place to secure and protect the resident and /or items as to not interfere with or contaminate and allow for a thorough investigation by said entities; - Abuse prohibition alone did not relieve the nursing home of its reasonability to assure the resident was free from abuse. The nursing home must provide ongoing oversight and supervision of staff in order to assure that its policies were implemented as written; -Identification section in part. All staff were to monitor residents and would know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that might constitute abuse would be investigated. All staff would receive education about how to identify signs and symptoms of abuse. Residents would be monitored for possible signs of abuse. Because some cases of abuse were not directly observed, understanding resident outcomes of abuse could assist in identifying whether abuse was occurring or had occurred; - It was the policy of the facility that the residents would be protected from the alleged offender. Immediately upon receipt of a report of alleged abuse, the Administrator and or designee would coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and support to the resident, their roommate, if applicable and other residents with the potential to be affected would be provided. Procedures must be in place to provide the resident with a safe, protected environment during the investigation. If the alleged perpetrator was a facility resident, the staff member would immediately remove the perpetrator from the situation and another staff member would stay with alleged perpetrator and wait for further instruction from administration, if possible. 1. Review of Resident #33's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/20 showed the following: -Diagnosis of Alzheimer's disease, anxiety disorder and depression; -Severely impaired cognition; -No behavioral symptoms; -Independent in Activities of Daily Living (ADLs), required set up help with dressing and personal hygiene. Review of the resident's nurses' notes showed the following: -On 8/11/20 at 2:19 A.M. another resident was caught in Resident #33's room with his/her hand down Resident #33's pants; -On 8/12/20 at 2:12 A.M. staff documented Certified Nurse Aide (CNA) staff came to the desk and informed the nurse he/she heard a banging noise coming from the resident's room and when he/she went into the room he/she found the resident under another resident attempting to have sex. Resident #33's pants were partly down and the other resident's pants were partly down. The other resident was rubbing his/her genitals on Resident #33 perineal area/genitals. Two CNA staff separated the two residents. When asked about the incident, Resident #33 stated I don't know what you're talking about. You are thinking of someone else, when asked if the contact was consensual. The resident's physician was notified and the resident's responsible party. Staff documented the responsible party said the resident had never behaved in this manner. The resident was moved to the 100 hall. Review of the resident's care plan dated 8/12/20 showed the following: -Diagnosis of Alzheimer's disease, anxiety disorder, and depressive disorder; -The resident had behaviors of hoarding, sitting personal items on the floor in a pattern and rearranging them throughout the day. Confused at times and anxious. Goal was the resident would not harm self or others. Staff should assess if behavior endangered others and intervene, assist with effective coping mechanisms, maintain a calm environment and calm approach. He/She no longer resided on the secure Special Care Unit to remove him/her from another resident; -The resident was independent with ADLs and required supervision with showers; -The resident had memory and recall problems related to Alzheimer's disease. Goal was the resident would remain safe from injuries from cognitive loss; -The resident's care plan did not include any documentation regarding another resident attempting to have sexual intercourse with the resident. 2. Review of Resident #92's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 6/9/20 showed the following: -Moderately impaired cognition; -Independent in all activities of daily living; -Delusional; -Verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). Review of the resident's care plan updated 8/12/20 showed the following: -Diagnosis of Alzheimer's disease, bipolar disease (psychiatric disease of severe mood swings), and dementia; -The resident had behaviors of staff manipulation, attempting to elope, aggression towards others, yelling at others, obsession over smoke breaks and making inappropriate sexual remarks to staff members without physical attempts. Complexity of mental condition was severe. Staff should monitor for increased anxiety, depression and for adverse effects of medications. Staff should monitor for behaviors, (yelling, physical aggression, sexually inappropriate, wandering affecting others, delusions, hallucinations) and chart if occurred; -The resident had behaviors of wandering, yelling, cursing, hitting at times, inappropriate sexual comments towards female staff and manipulation of staff or attempts to intimidate. Attempted physical sexual contact with female resident on 8/12/20. Goal was resident would not harm self and/or others. If occurred would be reviewed for cause and interventions. Staff should provide new order for Provera (female hormone medication), assess if behaviors endanger others, intervene if necessary, assist to identify effective coping mechanisms, maintain a calm environment and approach, provide outlets for expression of hostility and anger, and reside on locked unit (Special Care Unit) for smaller environment to decrease crowds, noise and availability to exit doors. Review of the resident's nurses' notes showed the following: -On 8/11/20 at 2:19 A.M. staff documented the resident was caught in another resident's room with his/her hand down the other resident's pants. The resident was told not to enter the other resident's room again; -On 8/12/20 at 12:31 A.M. staff documented a CNA came to the desk and said he/she heard a banging noise coming from the other resident's room and when he/she went into the room he/she found the resident on top of the other resident attempting to have sex. Resident #92's pants were down and the other resident's pants were partly down. Resident #92 was rubbing his/her genitals on the other resident's perineal area/genitals. Two CNA staff separated the two residents. When asked about the incident, Resident #92 said we never discussed it, when asked if the contact was consensual. The physician was notified, and every ten minute checks were started on the resident to ensure the safety of the resident and others. Provera (female hormone medication) 10 milligrams daily was scheduled for administration when arrived from the pharmacy; -On 8/12/20 at 12:19 P.M. staff documented they spoke with Registered Nurse/Nurse Practitioner (RN/NP) W regarding the event that occurred last night. RN/NP W said he/she would speak with the resident's family regarding the new medication order of Provera to curb sexual behaviors. RN/NP was agreeable with use of the medication pending family consultation. RN/NP W said medication may be held per the responsible party's preference until a consultation was completed by telehealth visit; -On 8/12/20 and 3:41 P.M. staff documented RN/NP W spoke with the resident's responsible party and Provera administration was refused. The responsible party said staff just needed to do more checks on Resident #92 and make sure he/she was not in other residents' rooms. Staff documented the resident was difficult to monitor due to history of elopement, impulsiveness, manipulation of staff, and self-ambulating. The resident's physician and medical director were made aware of the resident's responsible party refusal of Provera 10 mg daily. The physician said it would be appropriate to look for discharge to a facility that could accommodate sexual behaviors. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Independent in all activities of daily living; -Delusional; -Physical and verbal behavioral symptoms directed toward other (hitting, kicking, pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others and cursing at others) occurred and put others at risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or living environment; -The change in behavior status, care rejection or wandering was worse when compared to previous assessments. Review of the resident's care plan showed no additional update regarding the resident's sexual behaviors and interventions to prevent additional sexual behaviors. Observation of the Special Care Unit (SCU) on 10/13/20 showed Resident #92 in the common areas, walking independently in the hallways and back and forth to his/her room without staff supervision. Observation of the SCU on 10/14/20 showed the following: -At 12:20 P.M. Resident #92 sat in the common area with three additional residents without staff supervision. The resident ate lunch independently, walked around the common area without assistance or staff supervision and watched television; -At 8:45 P.M. Resident #92 sat outside smoking with numerous residents from the SCU and general population of the facility. Nurse Aide (NA) D and CNA JJ were on the SCU hallway talking. NA D left the hall; -At 8:55 P.M. Resident #92 returned to the SCU from smoking outside, walked independently down the hallway into his/her room; -At 9:30 P.M. CNA JJ remained the only staff member on the SCU hall. During interview on 10/13/20 at 7:55 P.M. NA D said the following: -He/She worked the evening and night shifts usually on the 300 hall or the SCU; -On 8/12/20 at about 8:30 P.M. or 9:00 P.M. he/she and CNA X sat in the SCU office room and heard a banging noise from the room next door (Resident #33's room ). Resident #92 was on top of Resident #33 b[TRUNCATED]